How different governance models may impact physician-hospital alignment.

BACKGROUND: Hospitals utilize three ideal type models for governing relationships with their physicians: the traditional medical staff, strategic alliances, and employment. Little is known about how these models impact physician alignment. PURPOSE: The study compares the level of physician-hospital alignment across the three models. APPROACH: We used survey data from 1,895 physicians in all three models across 34 hospitals in eight systems to measure several dimensions of alignment. We used logistic equations to predict survey nonresponse and differential physician selection into the alliance and employment models. Controlling for these selection effects, we then used multiple regression to estimate the effects of alliance and employment models on alignment. RESULTS: Physicians in employment models express greater alignment with their hospital on several dimensions, compared to physicians in alliances and the traditional medical staff. There were no differences in physician alignment between the latter two models. CONCLUSIONS: Employment models promote greater alignment on some (but not all) dimensions, controlling for physician selection. The impact of employment on alignment is not large, however. PRACTICE IMPLICATIONS: Hospitals and accountable care organizations that rely on employment may achieve higher physician alignment compared to the other two models. It is not clear that the gain in alignment is worth the cost of employment. Given the small impact of employment on alignment, it is also clear that they are not identical. Hospitals may need to go beyond structural models of integration to achieve alignment with their physicians.

Prevalence of Substance Use Among Patients of Community Health Centers in East Los Angeles and Tijuana.

BACKGROUND: Given the increased use of psychoactive substances on the United States-Mexico border, a binational study (Tijuana, Mexico-Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings. OBJECTIVES: To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use. METHODS: This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March-October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms. RESULTS: Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico. CONCLUSIONS: Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.

Individual- and Neighborhood-Level Determinants of Fear of Violent Crime Among Adolescents.

Fear of violent crime is common among adolescents in urban settings; however, little is known about individual- and neighborhood-level determinants of fear. A generalized ordered logit model was used to analyze individual- and neighborhood-level variables among 2474 adolescents. Seeing violence significantly reduced the probability of feeling unafraid, as did higher levels of social disorder. The more block faces where police were visible, the higher the probability of feeling unafraid and lower the probability of feeling very afraid. Reducing fear could affect more people than just reducing crime. Fear-reduction strategies should target those most at risk of becoming fearful.

VA health service utilization for homeless and low-income Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles.

BACKGROUND: The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing. OBJECTIVES: We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans. RESEARCH DESIGN: We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status. RESULTS: HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group. CONCLUSIONS: Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

Barriers to drug use behavior change among primary care patients in urban United States community health centers.

In 2011 and 2012, 147 patients in urban United States Community Health Centers who misused drugs, but did not meet criteria for drug dependence, received a brief intervention as part of a National Institute on Drug Abuse-funded clinical trial of a screening and brief intervention protocol. Potential study participants were identified using the World Health Organization (WHO) Alcohol, Smoking, and Substance Involvement Screening Test. Data gathered during brief interventions were analyzed using grounded theory strategies to identify barriers patients believed inhibited drug use behavior change. Numerous perceived barriers to drug use behavior change were identified. Study implications and limitations are discussed.

Chronic disease management for recently homeless veterans: a clinical practice improvement program to apply home telehealth technology to a vulnerable population.

BACKGROUND: Although vulnerable populations may benefit from in-home health information technologies (HIT) that promote disease self-management, there is a "digital divide" in which these groups are often unlikely to use such programs. We describe the early phases of applying and testing an existing Veterans Affairs (VA) HIT-care management program, Care Coordination Home Telehealth (CCHT), to recently homeless Veterans in the US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Peers were used to support patient participation. METHODS: CCHT uses in-home messaging devices to provide health education and daily questions about clinical indicators from chronic illness care guidelines, with patient responses reviewed by VHA nurses. Patients could also receive adjunctive peer support. We used medical record review, Veteran interviews, and staff surveys to "diagnose" barriers to CCHT use, assess program acceptability, explore the role of peer support, and inform future quality improvement. SUBJECTS: Fourteen eligible Veterans in HUD-VASH agreed to CCHT participation. Ten of these Veterans opted to have adjunctive peer support and the other 4 enrolled in CCHT usual care. RESULTS: Although barriers to enrollment/engagement must be addressed, this subset of Veterans in HUD-VASH was satisfied with CCHT. Most Veterans did not require support from peers to engage in CCHT but valued peer social assistance amidst the isolation felt in their scattered-site homes. CONCLUSIONS: HIT tools hold promise for in-home care management for recently housed Veterans. Patient-level barriers to enrollment must be addressed in the next steps of quality improvement, testing and evaluating peer-driven CCHT recruitment.

HIV and STI risk behaviors, knowledge, and testing among female adult film performers as compared to other California women.

A cross-sectional structured online survey was self-administered to a convenience sample of current female adult film performers via the Internet; bivariate analyses compared HIV and other STI risk behaviors, knowledge, and testing in female adult performers to California Women's Health Survey respondents. 134 female adult film performers (mean age 27.8 years) were compared to the 1,773 female respondents (mean age 31.3 years) to the 2007 CWHS. Female performers initiated sex on average 3 years younger and had 6.8 more personal sexual partners in the prior year than other California women. The majority of performers reported HIV and Chlamydia testing (94 and 82%, respectively) in the prior 12 months. They more likely to use condoms consistently in their personal life than other California women (21 vs 17%), though this difference disappeared after controlling for other variables. Adult performers are routinely tested for HIV and Chlamydia, yet they have multiple sexual partners and use condoms inconsistently.

Personality-related factors as predictors of help-seeking for depression: a population-based study applying the Behavioral Model of Health Services Use.

BACKGROUND: Although the prevalence of mental disorders and the demand for mental health services are increasing, little is known about the impact of personality-related factors on help-seeking among depressive individuals. We, therefore, investigated the relationship between the "Big Five" personality traits, resilience, alexithymia, childhood neglect or abuse, and help-seeking among depressive individuals. METHODS: We used data from 354 persons with a diagnosis of major depression from the population-based cohort study of health in Pomerania within the theoretical framework of the Andersen Behavioral Model of Health Services Use. RESULTS: Using stepwise regression techniques, we found that older age, higher education, more perceived social support, presence of childhood abuse, higher levels of conscientiousness, lower levels of resilience, and more severe depression were associated with help-seeking for depression. In contrast, gender, extraversion, openness, agreeableness, neuroticism, and alexithymia did not significantly predict help-seeking. In addition, no evidence for gender-specific effects was observed. CONCLUSION: Personality-related predisposing factors are important predictors of help-seeking. The influence of resilience on help-seeking among depressed individuals merits further exploration.

Self-reported use of eye care among Latinos: the Los Angeles Latino Eye Study.

PURPOSE: To identify the prevalence and determinants of self-reported eye care use in Latinos. DESIGN: Population-based ocular epidemiologic study in Latinos aged 40+ years living in La Puente, California. PARTICIPANTS: A total of 5455 participants. METHODS: Univariate, multivariable, and stepwise logistic regression analyses were conducted to identify predisposing, enabling, and need variables associated with self-reported eye care use. MAIN OUTCOME MEASURES: Prevalence of self-reported use: eye care visit, having had a dilated examination in the past 12 months, ever having had a dilated examination, and odds ratios for factors associated with self-reported use. RESULTS: Overall, 36% of participants reported an eye care visit and 19% reported having a dilated examination in the past year. Fifty-seven percent reported ever having had a dilated eye examination. Greater eye care use was associated with older age, female gender, bilingual language proficiency (English and Spanish), more education, having health insurance, having a usual place for care, having a regular provider of care, a greater number of comorbidities, visual impairment, and lower vision-specific quality of life scores. CONCLUSIONS: Multiple modifiable factors are associated with greater use and access to eye care for Latinos. Modification of these factors should be a priority because visual impairment has significant impacts on well-being and mortality.

Health and health care disparities among homeless women.

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

Psychiatric comorbidity and mortality among veterans hospitalized for congestive heart failure.

A Behavioral Model of Health Services Utilization approach was used to examine the impact of comorbid mental illness on mortality of veterans admitted to Veterans Affairs medical centers in fiscal year 2001 with a primary diagnosis of congestive heart failure (n = 15,497). Thirty percent had a psychiatric diagnosis, 4.7% died during the index hospitalization, and 11.5% died during the year following discharge. Among those with mental illness, 23.6% had multiple psychiatric disorders. Multivariable logistic regression models found dementia to be positively associated with inpatient mortality. Depression alone (excluding other psychiatric disorders) was positively associated with one-year mortality. Primary care visits were associated with a reduced likelihood of both inpatient and one-year mortality. Excepting dementia, VA patients with a mental illness had comparable or higher levels of primary care visits than those having no mental illness. Patients with multiple psychiatric disorders had more outpatient care than those with one psychiatric disorder.

Ethnic differences in the correlates of mental distress among homeless women.

BACKGROUND: Homeless women experience high rates of mental distress. We sought to determine whether ethnic differences exist in the relationship between the predisposing and enabling domains of the Gelberg-Andersen Behavioral Model for Vulnerable Populations and mental distress. METHODS: We selected 821 homeless women in the Los Angeles area using a representative probability sampling design and invited them to participate in face-to-face interviews. The sample was 67% African American, 17% Hispanic, and 16% White. RESULTS: We identified a number of ethnic differences in the correlates of mental distress. Being partnered or married was associated with greater distress among African American and White women, and experiencing competing needs was predictive of distress for African Americans and Hispanics. CONCLUSION: A variety of factors contribute to mental distress among different ethnic groups of homeless women; these differences should be considered in the development of culturally appropriate services designed to address mental health problems among homeless populations.

Correlates of self-diagnosis of chronic medical and mental health conditions in under-served African American and Latino populations.

OBJECTIVE: This study examines the correlates of self-diagnosis of chronic medical and mental health conditions in under-served minority populations. The Behavioral Model for Vulnerable Populations was employed to compare the predisposing and enabling characteristics of two groups: the first group consisted of individuals who self-reported their medical conditions without a presumptive or definitive physician diagnosis, while the second group consisted of individuals who self-reported their medical conditions with a presumptive or definitive physician diagnosis of their condition. STUDY SETTING: The sample consisted of 287 African American and Latino heads of household. This sample was obtained from a geographically defined random sample of 418 households from three urban public housing communities in Los Angeles County, California. STUDY DESIGN: This study was a cross-sectional, face-to-face, semistructured interview survey. RESULTS: Using logistic regression techniques and controlling for demographic characteristics, the results indicate that accessibility, affordability, continuity of medical care, and financial strains were the core concepts that explain the gap between self vs physician diagnosis of medical conditions. CONCLUSION: This study identifies unique characteristics of minority persons who claimed that their medical conditions had not been presented to or diagnosed by a medical provider in comparison to those who are formally diagnosed by medical providers. The study provides an entry point for further examination of correlates and sequels of self-diagnosis and its resultant effects on professional treatment-seeking in minority populations with certain medically important chronic conditions.

Reforming dental education: faculty members' perceptions on the continuation of pipeline program changes.

In 2002-03 the Robert Wood Johnson Foundation (RWJF) established the Pipeline, Profession, and Practice: Community-Based Dental Education program to change dental education in the United States. In partnership with The California Endowment, the RWJF awarded grants to fifteen U.S. dental schools that would support them in efforts to recruit more underrepresented minority/low-income (URM/LI) students, add cultural competence training, and increase extramural rotations to sixty days. As the program evaluator, the University of California, Los Angeles, School of Public Health (UCLA-SPH) conducted a survey of dental faculty in 2006 related to the goals of the Pipeline program. In this article, we report faculty perceptions pertaining to the extramural rotations and URM/LI recruitment. The survey was conducted in fourteen U.S. dental schools that received Pipeline grants and had an overall response rate of 60 percent (n=1,027) from the 1,713 faculty members who received the survey. A majority (57 percent) of faculty members strongly agreed that extramural rotations should continue as an integral part of students' education; 51 percent felt the same about the continuation of URM/LI recruitment programs. Multivariate logistic regression analyses revealed that faculty type, perception of extramural rotations being a positive experience, increased student productivity, and school culture were significant determinants of support for continuation of the extramural rotation programs. Determinants of support for continuation of the URM/LI recruitment programs were faculty type, perception of URM/LI recruitment effectiveness, perception of students from diverse backgrounds improving educational experience, and having a school mission statement that supports URM/LI recruitment. Pipeline schools should ensure that their extramural faculty remain key players in the Pipeline programs, widely publicize the programs' successes, and develop a service-oriented culture in order to build and sustain faculty perceptions that these programs should continue as integral parts of the schools' educational mission.

Applying the Gelberg-Andersen behavioral model for vulnerable populations to health services utilization in homeless women.

We applied the Gelberg-Andersen Behavioral Model for Vulnerable Populations to predict health services utilization (HSU) in 875 homeless US women. Structural models assessed the impact of predisposing (demographics, psychological distress, alcohol/drug problems, homelessness severity), enabling (health insurance, source of care, barriers) and need (illness) variables on HSU (preventive care, outpatient visits, hospitalizations). Homelessness severity predicted illness, barriers and less insurance. Distress predicted more barriers, illness and less outpatient HSU. Drug problems predicted hospitalizations. Barriers predicted more illness and less outpatient HSU. Health and homelessness indicators were worse for White women. Better housing, access to care and insurance would encourage appropriate HSU.

What enhances underrepresented minority recruitment to dental schools?

This study examined the factors influencing the proportion of underrepresented minority students (URM) in dental schools. Using a comprehensive recruitment model, it considered the relative importance of community characteristics (population demographics, oral health policies, dental care system, and university environment), dental school characteristics (Pipeline-supported, mission, and financing), and community-based dental education (CBDE) characteristics of the dental school on recruitment of URM students. Data come from a national survey of dental school seniors and a variety of publicly available sources. Three outcome variables measure URM recruitment: percent URM, percent Hispanic, and percent African American in the first year of dental school. Multivariable results revealed that the most important factors predicting a higher percent URM in first-year classes were a higher proportion of URM clinical faculty and graduating students' perceptions that their clinical rotation experience improved their ability to care for diverse groups. For percent Hispanic in the first year, a higher proportion of URM clinical faculty and students spending more time in clinical rotations predicted greater Hispanic recruitment. Graduating students' perceptions that they were less prepared to treat diverse groups were directly associated with the proportion of Hispanic students in the class. For a higher percent of African Americans in the first-year class, the most important factors were a higher proportion of blacks in the county, support from the national Pipeline program, and graduating students' perceptions of better preparedness to integrate cultural differences into treatment planning. Higher total financial aid awarded by the school was negatively associated with recruitment of African Americans. Results suggest some improved URM recruitment strategies for dental schools.

Influence of contextual environment and community-based dental education on practice plans of graduating seniors.

This study investigated senior dental students' plans to provide care to underserved racial/ethnic minority populations. Three sets of determinants were analyzed: contextual environment, community-based dental education (CBDE), and student characteristics. We analyzed data from the ADEA Survey of Dental School Seniors and administrative data sources to construct contextual variables. Multivariable results show three contextual variables predicted practice plans: greater numbers of federally qualified health centers, higher percentages of underrepresented minorities, and attending a California Pipeline dental school. Regarding CBDE predictors, it was alarming to find seniors who viewed the cultural competency curriculum as inadequate and perceived themselves as less prepared to provide oral health care to diverse populations were also those most likely to serve minority patients. Significant student characteristics included racial/ethnic minority, female gender, older age, lower parent's income, and socially conscious orientation. The study provides evidence that contextual environment, CBDE, and student characteristics were significantly associated with plans to care for underserved patients. Findings suggest if the Pipeline initiative is successful in stimulating reform in U.S. dental schools, future students will develop greater awareness regarding critical access problems and the competencies required to effectively care for diverse populations. In the long term, addressing the problem of dental care access will require the creation of policy, financial, and structural interventions to motivate providers to care for the underserved.

What influences dental students to serve special care patients?

This study examines factors associated with graduating dental students' motivation to deliver services to special care patients. We investigated community context and student characteristics, which would influence potential behavior. Higher percentages of older adults and low-income residents in the community were positively correlated with interest in serving special care populations. Factors which correlated with individual student characteristics included having a father with at least a college education, a higher number of weeks spent in extramural clinical rotations, preparedness to provide care to disabled patients, and service orientation and socially conscious attitudes. Frail elderly and disabled persons have limited access to dental care, which is compounded by a shortage of skilled dental professionals who are willing to treat these populations. Our findings suggest that interest in special care dentistry is partly conditioned by the dental school's demographic and dental market context. This study is important to dental educators and policymakers because the challenge of providing care to the "special patient" will increase in the future.

A pilot replication of QUIT, a randomized controlled trial of a brief intervention for reducing risky drug use, among Latino primary care patients.

BACKGROUND: QUIT is the only primary care-based brief intervention that has previously shown efficacy for reducing risky drug use in the United States (Gelberg et al., 2015). This pilot study replicated the QUIT protocol in one of the five original QUIT clinics primarily serving Latinos. DESIGN: Single-blind, two-arm, randomized controlled trial of patients enrolled from March-October 2013 with 3-month follow-up. SETTING: Primary care waiting room of a federally qualified health center (FQHC) in East Los Angeles. PARTICIPANTS: Adult patients with risky drug use (4-26 on the computerized WHO ASSIST): 65 patients (32 intervention, 33 control); 51 (78%) completed follow-up; mean age 30.8 years; 59% male; 94% Latino. INTERVENTIONS AND MEASURES: Intervention patients received: 1) brief (typically 3-4 minutes) clinician advice to quit/reduce their risky drug use, 2) video doctor message reinforcing the clinician's advice, 3) health education booklet, and 4) up to two 20-30 minute follow-up telephone drug use reduction coaching sessions. Control patients received usual care and cancer screening information. Primary outcome was reduction in number of days of drug use in past 30days of the highest scoring drug (HSD) on the baseline ASSIST, from baseline to 3-month follow-up. RESULTS: Controls reported unchanged HSD use between baseline and 3-month follow-up whereas Intervention patients reported reducing their use by 40% (p<0.001). In an intent-to-treat linear regression analysis, intervention patients reduced past month HSD use by 4.5 more days than controls (p<0.042, 95% CI: 0.2, 8.7). Similar significant results were found using a complete sample regression analysis: 5.2 days (p<0.03, 95% CI: 0.5, 9.9). Additionally, on logistic regression analysis of test results from 47 urine samples at follow-up, intervention patients were less likely than controls to test HSD positive (p<0.05; OR: 0.10, 95% CI: 0.01, 0.99). CONCLUSIONS: Findings support the efficacy of the QUIT brief intervention for reducing risky drug use.

Variations in provider conceptions of integrative medicine.

Consumers often turn to complementary and alternative medicine (CAM) and use it concurrently with conventional medicine to treat illnesses and promote wellness. However, prior studies demonstrate that these two paradigms are often not combined effectively. Consumers often do not tell physicians about CAM treatments or CAM practitioners about conventional treatments that they are using. This can lead to inefficient care and/or adverse interactions. There is also a lack of consensus about the structure and practice of integrative medicine among the various types of practitioners. This qualitative study aimed to identify key domains and develop a conceptual model of integrative medicine at the provider level, using a grounded theory approach. Purposive sampling was used to select 50 practitioners, including acupuncturists, chiropractors, internists/family practitioners, and physician acupuncturists in private practice and at academic medical centers in Los Angeles. We conducted semi-structured, in-depth interviews with practitioners and then identified core statements that describe practitioners' attitudes and behaviors toward integrative medicine. Core statements were free pile sorted to ascertain key domains of integrative medicine. Four key domains of integrative medicine were identified at the provider level: attitudes, knowledge, referral, and practice. Provider age, training, and practice setting also emerged as important factors in determining clinicians' "orientation" toward integrative medicine. "Dual-trained" practitioners, such as physician acupuncturists, exemplified clinicians with a greater orientation toward integrative medicine. They advocated an open-minded perspective about other healing traditions, promoting co-management with and making referrals to practitioners of other paradigms, and treating patients with both CAM and conventional healing modalities.