Cognitive mapping as an approach to facilitate organ donation among African Americans.

Making up 13.4% of the United States population, African Americans (AAs) account for 28.7% of candidates who are currently waiting for an organ donation. AAs are disproportionately affected by end-organ disease, particularly kidney disease, therefore, the need for transplantation among this population is high, and the high need is also observed for other solid organ transplantation. To this end, we worked with the AA community to derive an empirical framework of organ donation strategies that may facilitate AA decision-making. We used a cognitive mapping approach involving two distinct phases of primary data collection and a sequence of data analytic procedures to elicit and systematically organize strategies for facilitating organ donation. AA adults (n = 89) sorted 27 strategies identified from nominal group technique meetings in phase 1 based on their perceived similarities. Sorting data were aggregated and analyzed using Multidimensional scaling and hierarchical cluster analyses. Among 89 AA participants, 68.2% were female, 65.5% obtained > high school education, 69.5% reported annual household income ≤ $50,000. The average age was 47.4 years (SD = 14.5). Derived empirical framework consisted of five distinct clusters: fundamental knowledge, psychosocial support, community awareness, community engagement, and system accountability; and two dimensions: Approach, Donor-related Information. The derived empirical framework reflects an organization scheme that may facilitate AA decision-making about organ donation and suggests that targeted dissemination of donor-related information at both the individual-donor and community levels may be critical for increasing donation rates among AAs.

Factors associated with the provision of inpatient care in hospices.

BACKGROUND: Hospices provide end-of-life care to patients who have complex health care needs and whose symptoms are difficult to control. Understanding why some hospices offer inpatient hospice care to patients could bring more evidence for policy makers and researchers to focus on the role of inpatient care in hospice. PURPOSE: The purpose of this study was to examine market and organizational factors that are associated with the provision of hospice inpatient care. METHODOLOGY: This study used a retrospective, longitudinal design (2009-2013). The study sample was drawn from three data resources: the Area Health Resources Files, the Provider of Services files, and Hospice Cost Reports from Centers for Medicare & Medicaid Services. The sample size was 2,391 hospices or 10,999 hospice observations over 5 years. A generalized linear mixed-effects model was used to examine the association between market and organizational factors and hospice inpatient services offering. RESULTS: On average, 94.59% of hospices offer inpatient services to patients. Proportion of adults who were over 65 years old (OR = 1.12) and Medicare-managed care penetration (OR = 1.02) were positively associated with the provision of hospice inpatient services. The number of hospitals with hospice program was negatively related to hospice inpatient services offering (OR = .95). Other factors such as nursing skill mix, volunteer dependence, and census region were also associated with inpatient services offering. PRACTICE IMPLICATIONS: The age demand of hospice care and Medicare-managed care penetration are related to hospice inpatient services offering. Hospices located in the market with more competition from hospitals that offer hospice program are less likely to offer inpatient care.

Hospice inpatient services provision, utilization, and financial performance.

BACKGROUND: Hospice performance is an overlooked area in the health care field due to the difficulty of measuring quality of care and the infrequent quality inspection. Based on the daily reimbursement mechanism for different levels of hospice care, inpatient services provision could influence both hospice-level length of stay (LOS) and financial performance. PURPOSE: The objective of this study was to explore the relationship between hospice inpatient services provision and hospice utilization and financial performance. METHODOLOGY/APPROACH: A longitudinal secondary data set (2009-2013) was merged from three sources: (a) Hospice Cost Reports from the Centers for Medicare & Medicaid Services, (b) the Provider of Services files, and (c) the Area Health Resources Files. The dependent variable in this study was hospice average LOS and financial performance measured by total operating margin (TOM) and return on assets. The independent variable was hospice inpatient services' offering. Mixed-effects regression models were used in the multivariate regression analyses. RESULTS: When comparing to hospices not providing inpatient services, offering inpatient services by staff was negatively related to average LOS (b = -0.063, p < .05) and TOM (b = -0.022, p < .05). The combination method with providing inpatient services by staff and under arrangement was negatively associated with return on assets (b = -0.073, p < .05). CONCLUSION: Hospice inpatient services provision was associated with average LOS and financial performance. PRACTICE IMPLICATIONS: Offering the inpatient services to patients by staff decreased average LOS and TOM. Hospice agencies may seek strategies to maintain their financial sustainability through outsourcing.

Patient assessment of primary care physician communication: segmentation approach.

PURPOSE: The purpose of this paper is to examine how patient assessment of primary care physician (PCP) communication is related to patient satisfaction with the PCP, patient perception of PCP professional competence, patient assessment of the relationship with the doctor and patient demographic characteristics using a segmentation approach. DESIGN/METHODOLOGY/APPROACH: The authors surveyed 514 adult patients waiting for appointments with their PCPs in two US primary care clinics. A latent class analysis was used to identify mutually exclusive unobserved homogeneous classes of patients. FINDINGS: The authors identified three distinct classes/groups with regard to patient assessment of physician communication and the physician-patient relationship. The largest group (53 percent of the sample) assessed their PCP communication and other doctor-patient relationship aspects as excellent. However, 37 percent provided mostly negative assessments, expressed high general dissatisfaction with the physician and disagreed with the statement that their PCP was well qualified to manage their health problems. These patients were on average more educated and affluent and the group included more males. About 10 percent of patients expressed generally lower satisfaction with the PCP, though their dissatisfaction was not as extreme as in the highly dissatisfied group. RESEARCH LIMITATIONS/IMPLICATIONS: Further studies are needed to help physicians develop skills to communicate with different patients. ORIGINALITY/VALUE: Patient segmentation can be an important tool for healthcare quality improvement particularly for emerging approaches to primary care such as patient-centered care.

Identification of strategies to facilitate organ donation among African Americans using the nominal group technique.

BACKGROUND AND OBJECTIVES: African Americans are disproportionately affected by ESRD, but few receive a living donor kidney transplant. Surveys assessing attitudes toward donation have shown that African Americans are less likely to express a willingness to donate their own organs. Studies aimed at understanding factors that may facilitate the willingness of African Americans to become organ donors are needed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A novel formative research method was used (the nominal group technique) to identify and prioritize strategies for facilitating increases in organ donation among church-attending African Americans. Four nominal group technique panel interviews were convened (three community and one clergy). Each community panel represented a distinct local church; the clergy panel represented five distinct faith-based denominations. Before nominal group technique interviews, participants completed a questionnaire that assessed willingness to become a donor; 28 African-American adults (≥19 years old) participated in the study. RESULTS: In total, 66.7% of participants identified knowledge- or education-related strategies as most important strategies in facilitating willingness to become an organ donor, a view that was even more pronounced among clergy. Three of four nominal group technique panels rated a knowledge-based strategy as the most important and included strategies, such as information on donor involvement and donation-related risks; 29.6% of participants indicated that they disagreed with deceased donation, and 37% of participants disagreed with living donation. Community participants' reservations about becoming an organ donor were similar for living (38.1%) and deceased (33.4%) donation; in contrast, clergy participants were more likely to express reservations about living donation (33.3% versus 16.7%). CONCLUSIONS: These data indicate a greater opposition to living donation compared with donation after one's death among African Americans and suggest that improving knowledge about organ donation, particularly with regard to donor involvement and donation-related risks, may facilitate increases in organ donation. Existing educational campaigns may fall short of meeting information needs of African Americans.

Frictions as barriers to perioperative alignment: results from a latent class analysis.

The quality of the relationship between the sterile processing department (SPD) and the operating room (OR) is an important determinant of OR safety and performance. In this article, the concept of "friction" refers to the SPD behaviors and attributes that can negatively affect OR performance. Panels of SPD professionals initially were asked to identify and operationally define different ways in which behaviors of a hospital's SPD could compromise OR performance. A national convenience sample of OR nurses (N=291) rated 14 frictions in terms of their agreement or disagreement that each had a negative effect on OR performance in their hospital. Overall, more than 50% of the entire sample agreed that 2 frictions, "SPD does not communicate effectively with the OR" (55%) and "SPD inventories are insufficient for surgical volume" (52%), had negative effect on OR performance. However, a latent class analysis revealed 3 distinct classes of nurses who varied with respect to their level of agreement that SPD-OR frictions negatively affected OR performance. The observed heterogeneity in how different groups of nurses viewed different frictions suggests that effective efforts aimed at reducing performance-limiting frictions should be customized so that resources can be used where they are most needed.

Dealing with the financial burden of cancer: perspectives of older breast cancer survivors.

PURPOSE: Financial burden among cancer survivors is often overlooked in survivorship care planning. Cancer survivors with limited incomes may be particularly affected. Yet, little data are available to address financial issues among them. Eliciting the survivors' perspectives on how to deal with this financial burden is a first crucial step to identifying the means to provide this supportive care. METHODS: In this pilot study, three nominal group technique (NGT) sessions were conducted with a convenience sample of 23 older breast cancer survivors (age 52 to 83) recruited from a county safety net hospital and a Comprehensive Cancer Center. One single NGT question was posed in these sessions, namely "What could help women deal with the financial burden that cancer brings to them and their families?" Survivors responded in an iterative fashion and then ranked the most relevant responses. RESULTS: The most relevant responses addressed the (1) need for affordable insurance; (2) need to have prompt information on treatment costs patients will face, insurance coverage, and agencies or programs that provide needed products and services; and (3) need to access social workers, navigators, support groups, or others knowledgeable about available resources. Survivors also suggested that physicians become aware of cancer costs and financial issues faced by patients and consider costs in their treatment plans. CONCLUSIONS: Older survivors face financial challenges for which there are few available resources. They suggested several avenues to address cancer-related financial issues that may be considered in developing supportive interventions.

What Hispanic parents do to encourage and discourage 3-5 year old children to be active: a qualitative study using nominal group technique.

PURPOSE: Hispanic preschoolers are less active than their non-Hispanic peers. As part of a feasibility study to assess environmental and parenting influences on preschooler physical activity (PA) (Niños Activos), the aim of this study was to identify what parents do to encourage or discourage PA among Hispanic 3-5 year old children to inform the development of a new PA parenting practice instrument and future interventions to increase PA among Hispanic youth. METHODS: Nominal Group Technique (NGT), a structured multi-step group procedure, was used to elicit and prioritize responses from 10 groups of Hispanic parents regarding what parents do to encourage (5 groups) or discourage (5 groups) preschool aged children to be active. Five groups consisted of parents with low education (less than high school) and 5 with high education (high school or greater) distributed between the two NGT questions. RESULTS: Ten NGT groups (n = 74, range 4-11/group) generated 20-46 and 42-69 responses/group for practices that encourage or discourage PA respectively. Eight to 18 responses/group were elected as the most likely to encourage or discourage PA. Parental engagement in child activities, modeling PA, and feeding the child well were identified as parenting practices that encourage child PA. Allowing TV and videogame use, psychological control, physical or emotional abuse, and lack of parental engagement emerged as parenting practices that discourage children from being active. There were few differences in the pattern of responses by education level. CONCLUSIONS: Parents identified ways they encourage and discourage 3-5 year-olds from PA, suggesting both are important targets for interventions. These will inform the development of a new PA parenting practice scale to be further evaluated. Further research should explore the role parents play in discouraging child PA, especially in using psychological control or submitting children to abuse, which were new findings in this study.

Feeding style differences in food parenting practices associated with fruit and vegetable intake in children from low-income families.

OBJECTIVE: To examine the moderating effects of feeding styles on the relationship between food parenting practices and fruit and vegetable (F & V) intake in low-income families with preschool-aged children. DESIGN: Focus group meetings with Head Start parents were conducted by using the nominal group technique. Parents completed information on food parenting practices and feeding styles. Three dietary recalls were collected on each child. SETTING: Parents completed measures in Head Start centers and/or over the telephone. PARTICIPANTS: 667 parents of preschool-aged children participated. OUTCOMES: Food parenting practices and F & V intake. ANALYSIS: Mean differences in the food parenting practices across the 4 feeding styles were established through multivariate general linear modeling using MANOVA. Moderated multiple regression analysis was conducted to examine the moderating role of feeding style on food parenting practices and child F & V intake. RESULTS: The indulgent feeding style moderated the relationship between food parenting practices and child F & V intake. CONCLUSIONS AND IMPLICATIONS: This study indicates that parents' feeding styles have a moderating effect on the relationship between the food parenting practices and children's F & V intake. This finding can facilitate the development of interventions aimed at reducing childhood overweight.

Primary care patient satisfaction segmentation.

PURPOSE: The aim of this study is to examine patient satisfaction with non-physician staff as related to patient demographics, satisfaction with physician, and intentions to recommend their physicians to others. DESIGN/METHODOLOGY/APPROACH: A survey was conducted at two internal medicine primary care clinics affiliated with a major university health system. A latent class analysis was used to detect patient subpopulations based on profiles of response for five satisfaction-with-staff indicators. FINDINGS: The response rate was 86.46 percent (479 of 554). Analyses revealed four patient subpopulation segments. Segment I (n = 241) patients uniformly indicated a high level of satisfaction across the five satisfaction-with-staff indicators. These patients tended to be older and less educated, and have lower incomes relative to patients in other segments. Patients in Segment II (n = 83) expressed satisfaction with staff caring and need accommodation, but dissatisfaction with access to their physicians. Patients in Segment III (n = 51) indicated high levels of satisfaction with access and low levels of satisfaction with staff caring and need accommodation. Segment IV (n = 104) patients uniformly expressed low levels of satisfaction across all indicators and generally were younger and more educated, as well as hadhigher incomes than other patients. ORIGINALITY/VALUE: Patients have different expectations from their non-physician staff, e.g. younger, more affluent, and educated patients expressed dissatisfaction with staff. This suggests that non-physician staff should provide extra/further responsiveness to have these patients' needs met. Generally, approaches that are differentially targeted to specific patient subgroups are likely to be more efficient and patient-oriented than undifferentiated approaches.

Impact of Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury.

OBJECTIVE: To examine the impact of Medicare's inpatient rehabilitation facility (IRF) prospective payment system (PPS) on inpatient rehabilitation outcomes for patients with traumatic spinal cord injury (SCI). DESIGN: Retrospective study. SETTING: Twelve SCI Model Systems. PARTICIPANTS: A sample of Medicare (n=296) and non-Medicare (n=3110) patients was selected from the National SCI Statistical Center Database from 1996 to 2006. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Motor FIM score change and length of stay (LOS). RESULTS: LOS decreased by about 5.8 days a year (P<.001) for Medicare patients and about 1.3 days a year (P=.031) for non-Medicare patients after PPS implementation. However, for both groups, FIM score gains were not significantly different in the pre-PPS and PPS periods. CONCLUSIONS: Although significant decreases in LOS were observed for Medicare patients after IRF PPS implementation, Medicare patients' improvements in motor function did not decrease. Non-Medicare patients with SCI also experienced shortened stays after Medicare IRF PPS implementation, but had equivalent FIM score gains compared with their counterparts who received inpatient rehabilitation care before PPS implementation. IRF PPS implementation was associated with shorter stays, but was not associated with lower functional improvement.

What should we include in a cultural competence curriculum? An emerging formative evaluation process to foster curriculum development.

PURPOSE: To identify, prioritize, and organize components of a cultural competence curriculum to address disparities in cardiovascular disease. METHOD: In 2006, four separate nominal group technique sessions were conducted with medical students, residents, community physicians, and academic physicians to generate and prioritize a list of concepts (i.e., ideas) to include in a curriculum. Afterward, 45 educators and researchers organized and prioritized the concepts using a card-sorting exercise. Multidimensional scaling (MDS) and hierarchical cluster analysis produced homogeneous groupings of related concepts and generated a cognitive map. The main outcome measures were the number of cultural competence concepts, their relative ranks, and the cognitive map. RESULTS: Thirty participants generated 61 concepts; 29 were identified by at least two participants. The cognitive map organized concepts into four clusters, interpreted as (1) patient's cultural background (e.g., information on cultures, habits, values), (2) provider and health care (e.g., clinical skills, awareness of one's bias, patient centeredness, professionalism), communication skills (e.g., history, stereotype avoidance, health disparities epidemiology), (3) cross-culture (e.g., idiomatic expressions, examples of effective communication), and (4) resources to manage cultural diversity (e.g., translator guides, instructions, community resources). The MDS two-dimensional solution demonstrated a good fit (stress = 0.07; R² = 0.97). CONCLUSIONS: A novel, combined approach allowed stakeholders' inputs to identify and cognitively organize critical domains used to guide development of a cultural competence curriculum. Educators may use this approach to develop and organize educational content for their target audiences, especially in ill-defined areas like cultural competence.

Management of female sexual problems: perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists.

INTRODUCTION: Although approximately 40% of women report female sexual problems--and particularly sexual desire disorders, there are numerous practical, professional, and personal barriers to their diagnosis and management by treating clinicians. AIM: To identify practice patterns, perceptions, and barriers to the diagnosis and management of female sexual problems among U.S. practicing primary care physicians (PCPs) and obstetrician/gynecologists (OB/GYNs). METHODS: A random sample of practicing U.S. PCPs and OB/GYNs were sent a case-vignette survey by e-mail and fax. Response to the survey was considered consent. A regression model was analyzed to assess predictors of confidence. MAIN OUTCOME MEASURE: Frequency and variability in diagnostic tests ordered and treatment recommendations provided for a patient with diminished sexual desire. Percent of physicians who reported they were confident in treating hypoactive sexual desire disorder (HSDD) and percent who reported significant barriers to initiating a dialogue about sexual health with female patients. RESULTS: A total of 505 responses were analyzed (8.8% response rate). Of respondents, 21% of OB/GYNs and 38% of PCPs stated they were not at all confident in treating HSDD. The majority of physicians would order a thyroid panel (PCP = 63%, OB/GYN = 53%) to assess a patient's diminished desire and recommended counseling and stress management to treat a patient with sexual complaints (PCP = 48%, OB/GYN = 54%). Regression results identified time constraints, the perceived lack of effective therapies, perceptions regarding patient-physician gender discordance, years in practice, number of patients seen per week, and perceptions regarding continuing medical education and practice experience as significant and independent predictors of confidence in treating HSDD patients.

Parenting practices are associated with fruit and vegetable consumption in pre-school children.

OBJECTIVE: Parents may influence children's fruit and vegetable (F&V) consumption in many ways, but research has focused primarily on counterproductive parenting practices, such as restriction and pressure to eat. The present study aimed to assess the association of diverse parenting practices to promote F&V and its consumption among pre-school children. DESIGN: An exploratory analysis was performed on cross-sectional data from 755 Head Start pre-school children and their parents collected in 2004-5. Data included parent practices to facilitate child F&V consumption (grouped into five categories); parent-reported dietary intake of their child over 3 d; and a number of potential correlates. K-means cluster analysis assigned parents to groups with similar use of the food parenting practice categories. Stepwise linear regression analyses investigated the association of parent clusters with children's consumption of F&V, after controlling for potential confounding factors. RESULTS: A three-cluster solution provided the best fit (R2 = 0.62), with substantial differences in the use of parenting practices. The clusters were labelled Indiscriminate Food Parenting, Non-directive Food Parenting and Low-involved Food Parenting. Non-directive parents extensively used enhanced availability and teachable moments' practices, but less firm discipline practices than the other clusters, and were significantly associated with child F&V intake (standardized beta = 0.09, P < 0.1; final model R2 = 0.17) after controlling for confounders, including parental feeding styles. CONCLUSIONS: Parents use a variety of parenting practices, beyond pressuring to eat and restrictive practices, to promote F&V intake in their young child. Evaluating the use of combinations of practices may provide a better understanding of parental influences on children's F&V intake.

Internet delivered support for tobacco control in dental practice: randomized controlled trial.

BACKGROUND: The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized. OBJECTIVE: To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings. METHODS: Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention. RESULTS: Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices' mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK. CONCLUSION: This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit. TRIAL REGISTRATION: clinicaltrials.gov NCT00627185, http://www.webcitation.org/5c5Kugvzj.

Assessing the effects of the HIPAA privacy rule on release of patient information by healthcare facilities.

The HIPAA privacy rule (HIPAA) has had both positive and negative effects on the release of patient information by healthcare facilities. Although the intention of HIPAA was to protect patient privacy and to promote security and confidentiality of patient information, it has had unintended consequences for facilities. To identify some of these unintended effects, two expert panels of health information management directors from healthcare facilities participated in the nominal group technique meetings. They identified 70 barriers related to release of patient information associated with the implementation of HIPAA. The perceived biggest barriers were increases in the public's misunderstanding about release of patient information, lack of an umbrella policy or regulation defining infractions and enforcement that allows individual institutions to make their own interpretations, and challenges to health information management professionals in controlling safeguards related to release of information given the transition to electronic health records and the increased involvement of information technology. The findings from this study suggest there is a need for additional clarification of the regulations governing HIPAA, standardized instructions, and extensive training of healthcare workers.

Racial/ethnic disparities in patient-reported nonsteroidal antiinflammatory drug (NSAID) risk awareness, patient-doctor NSAID risk communication, and NSAID risk behavior.

OBJECTIVE: Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used and frequently lead to serious adverse events. Little is known about NSAID-related ethnic/racial disparities. We focused on differences in patient NSAID risk awareness, patient-doctor NSAID risk communication, and NSAID risk-avoidance behavior. METHODS: We performed a cross-sectional analysis of survey data from the Alabama NSAID Patient Safety Study. Eligible patients were > or = 65 years old and currently taking prescription NSAIDs (Rx NSAIDS). Generalized linear latent and mixed models accounted for nesting of patients within physicians. RESULTS: Of all 404 participants, 32% were African American and 73% were female. The mean +/- SD age was 72.8 +/- 7.5 years, and 64% reported an annual household income <$20,000. African American patients were less likely than white patients to recognize any risk associated with over-the-counter (OTC) NSAIDs (13.3% versus 29.3%; P = 0.001) and Rx NSAIDs (31.3% versus 49.6%; P = 0.001), report that their doctor discussed possible NSAID-related gastrointestinal problems (38.0% versus 52.4%; P = 0.007), and take medications to reduce ulcer risk (30.5% versus 50.2%; P = 0.001). Patients with lower income and education reported significantly less risk awareness for OTC and Rx NSAIDs. Racial/ethnic differences persisted after adjusting for multiple confounders. CONCLUSION: In this community-based study of low income elderly individuals receiving NSAIDs, we identified important racial/ethnic differences in risk awareness, communication, and behavior. Additional efforts are needed to promote safe NSAID use and reduce ethnic/racial disparities.