Time, costs, and clinical utilization of screening for health literacy: a case study using the Newest Vital Sign (NVS) instrument.

PURPOSE: Difficulties in identifying and caring for patients with limited health literacy have prompted interest in clinical screening to assess health literacy. Little agreement exists, however, on the utility of such screening. In this case study we explore the business and clinical cases for screening for health literacy using the Newest Vital Sign (NVS), a brief instrument specifically developed for use in primary care settings. METHODS: Data were collected in 2008 in the Morehouse School of Medicine Department of Family Medicine Primary Care Clinic, where health literacy screening was implemented as part of routine intake procedures within an ongoing quality improvement effort to improve cardiovascular disease and diabetes outcomes. Specifically, we monitored time requirements, administrative and training costs, and clinician utilization associated with the NVS. RESULTS: Results identified only small time and cost constraints associated with implementing NVS screening. Clinical utility was more problematic, however, because refresher trainings were needed to ensure continued staff and clinician buy-in, use of the NVS data, and implementation of best practices to communicate with at-risk patients. CONCLUSIONS: Though the time and cost constraints associated with screening for health literacy were small, clinician utilization of this data in decision making and care processes may require further training and/or support.

Methodologies for improving response rates in surveys of physicians: a systematic review.

Although physician surveys are an important tool in health services and policy research, they are often characterized by low response rates. The authors conducted a systematic review of 66 published reports of efforts to improve response rates to physician surveys. Two general strategies were explored in this literature: incentive and design-based approaches. Even small financial incentives were found to be effective in improving physician response. Token nonmonetary incentives were much less effective. In terms of design strategies, postal and telephone strategies have generally been more successful than have fax or Web-based approaches, with evidence also supporting use of mixed-mode surveys in this population. In addition, use of first-class stamps on return envelopes and questionnaires designed to be brief, personalized, and endorsed by legitimizing professional associations were also more likely to be successful. Researchers should continue to implement design strategies that have been documented to improve the survey response of physicians.

The use of human patient simulators: best practices with novice nursing students.

Only recently have nursing educators begun to consider the enormous implications of using high-fidelity human patient simulation in general nursing education. As a first step in exploring the potential of this new technology with novice nursing students, faculty conducted a quantitative and qualitative analysis of students' reactions to a simulation. In addition, from the analysis and the review of literature, the faculty identified specific best practices for using this educational methodology with novice nursing students.

Avoiding free care at all costs: a survey of uninsured patients choosing not to seek emergency services at an urban county hospital.

The purpose of this case study was to understand why many uninsured patients opt not to make use of a free public hospital when it is available, instead seeking emergency department care at sites where they will be billed for the services they receive. One hundred fifty seven uninsured patients were interviewed over an 8-week period at three emergency departments that bill for services near a county hospital that provides free care. Data was gathered on income, health status, and credit history. Subjects were also asked if they had previously sought care at the county hospital and, if they had, how satisfied they were with the quality of care and with the wait time. Seventy two percent of the subjects reported household incomes of <$20,000, 48% reported they were in fair or poor health, and 33% said they were unable to pay at least one medical bill at the site where they were seeking care. 65% reported they had previously received care at the county hospital, and of these 61% said they were not-too-likely or not-at-all likely to return. In a regression analysis, experience with wait time correlated with subjects willingness to return, whereas their satisfaction with quality, their income, problems with debt, and reported health status did not. Access involves more than geographic proximity and affordability. Excessive wait times can deter even patients who are poor, in ill health and in debt from making use of services that are intended for their benefit.

Use of deceptive tactics in physician practices: are there differences between international and US medical graduates?

Concerns have been raised about the medical practices of international medical graduates (IMGs) in the United States. This study examined the differences between IMGs and US-trained medical graduates (USMGs) in their attitude toward and utilization of deception in medical practices. A random sample of physicians practicing in the US was surveyed by mail in 1998. The dependent variables of interest included 11 attitudinal and behavioral indicators of deceptive tactics in medical practice. IMGs and USMGs displayed limited difference in their attitudes but some differences in their self-reported use of deceptive tactics in medical practice. IMGs were less likely than USMGs to change the patient's official diagnosis (OR, 0.557; 95% CI, 0.344-0.902) or to withhold a useful service because of utilization rules (OR, 0.612; 95% CI, 0.382-0.979). The hypothesis that IMGs have less appropriate professional standards than USMGs is not supported by this study. Alternative hypotheses, such as IMG familiarity with US health care and legal systems, warrant investigation.

Do physicians not offer useful services because of coverage restrictions?

Ethically, physicians should discuss all medically appropriate services with patients, but coverage restrictions can make these discussions difficult. In a national survey of physicians, we asked how often physicians elected not to offer their patients useful services because of health plan coverage rules. During the course of a year, 31 percent reported having sometimes not offered their patients useful services because of perceived coverage restrictions. Among these, 35 percent reported doing so more often in the most recent year than they did five years ago. It can be frustrating for doctors to discuss uncovered services with their patients, but open communication is necessary for shared decision making and to improve coverage decisions.

Measuring deception: test-retest reliability of physicians' self-reported manipulation of reimbursement rules for patients.

This study examined the test-retest reliability of physicians' self-reported manipulation of reimbursement rules for patients. The test-retest reliability of self-report of three specific tactics were examined: (1) exaggerating the severity of patients' conditions, (2) changing a patient's official (billing) diagnosis, and (3) reporting signs or symptoms that patients did not have. The reliability of a scaled summary measure of physicians' manipulation of reimbursement rules was also assessed. Overall, the authors found high levels of test-retest agreement across all three items and the summary measure. These findings suggest that self-report can be used to produce reliable data on this controversial issue. Specifically, the three items reported here can be used to produce a reliable summary measure of physicians' manipulation of reimbursement rules to help patients obtain care that physicians perceive as necessary.