Unmet health-related needs of community-dwelling older adults during COVID-19 lockdown in a diverse urban cohort.

BACKGROUND: Shelter-in-place orders during the COVID-19 pandemic created unmet health-related and access-related needs among older adults. We sought to understand the prevalence of these needs among community-dwelling older adults. METHODS: We performed a retrospective chart review of pandemic-related outreach calls to older adults between March and July 2020 at four urban, primary care clinics: a home-based practice, a safety net adult medicine clinic, an academic geriatrics practice, and a safety net clinic for adults living with HIV. Participants included those 60 or older at three sites, and those 65 or older with a chronic health condition at the fourth. We describe unmet health-related needs (the need for medication refills, medical supplies, or food) and access-related needs (ability to perform a telehealth visit, need for a call back from the primary care provider). We performed bivariate and multivariate analyses to examine the association between unmet needs and demographics, medical conditions, and healthcare utilization. RESULTS: Sixty-two percent of people had at least one unmet need. Twenty-six percent had at least one unmet health-related need; 14.0% needed medication refills, 12.5% needed medical supplies, and 3.0% had food insecurity. Among access-related needs, 33% were not ready for video visits, and 36.4% asked for a return call from their provider. Prevalence of any unmet health-related need was the highest among Asian versus White (36.4% vs. 19.1%) and in the highest versus lowest poverty zip codes (30.8% vs. 18.2%). Those with diabetes and COPD had higher unmet health-related needs than those without, and there was no change in healthcare utilization. CONCLUSIONS: During COVID, we found that disruptions in access to services created unmet needs among older adults, particularly for those who self-identified as Asian. We must foreground the needs of this older population group in the response to future public health crises.

Predictors of All-Cause 30-Day Readmissions in Patients with Heart Failure at an Urban Safety Net Hospital: The Importance of Social Determinants of Health and Mental Health.

Introduction: Heart failure (HF) is a frequent cause of readmissions. Despite caring for underresourced patients and dependence on government funding, safety net hospitals frequently incur penalties for failing to meet pay-for-performance readmission metrics. Limited research exists on the causes of HF readmissions in safety net hospitals. Therefore, we sought to investigate predictors of 30-day all-cause readmission in HF patients in the safety net setting. Methods: We performed a retrospective chart review of patients admitted for HF from October 2018 to April 2019. We extracted data on demographics and medical comorbidities and performed patient-specific review of social determinants and mental health in 4 domains: race/ethnicity, housing status, substance use, and mental illness. Multivariable Poisson regression modeling was employed to evaluate associations with 30-day all-cause readmission. Results: The study population included 290 patients, among whom the mean age was 59 years and 71% (n = 207) were male; 42% (120) were Black/African American (AA), 22% (64) were Hispanic/Latino, and 96% (278) had public insurance; 28% (79) were not housed, 19% (56) had a diagnosis of mental illness, and active substance use was common. The 30-day readmission rate was 25.5% (n = 88). Factors that were associated with increased risk of readmission included self-identifying as Black/AA (relative risk 2.28, 95% confidence interval 1.00-5.20) or Hispanic/Latino (2.53, 1.07-6.00), experiencing homelessness (2.07, 1.21-3.56), living in a shelter (3.20, 1.27-8.02), or intravenous drug use (IVDU) (2.00, 1.08-3.70). Conclusion: Race/ethnicity, housing status, and substance use were associated with increased risk of 30-day all-cause readmission in HF patients in a safety net hospital. In contrast to prior studies, medical comorbidities were not associated with increased risk of readmission.

Risk factors for reporting poor cultural competency among patients with diabetes in safety net clinics.

BACKGROUND: The Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set assesses patient perceptions of aspects of the cultural competence of their health care. OBJECTIVE: To determine characteristics of patients who identify the care they receive as less culturally competent. RESEARCH DESIGN: Cross-sectional survey consisting of face-to-face interviews. SUBJECTS: Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care. MEASURES: Participants completed the Consumer Assessment of Healthcare Providers and Systems Cultural Competency and answered questions about their race/ethnicity, sex, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and comorbidities. RESULTS: In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication--Positive Behaviors domain [odds ratio (OR) 1.73, 95% confidence interval, 1.11-2.69]. African Americans were less likely than whites to report poor cultural competence in the Doctor Communication--Positive Behaviors domain (OR 0.52, 95% CI, 0.28-0.97). Participants who reported a longer relationship (≥ 3 y) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication--Health Promotion (OR 0.35, 95% CI, 0.21-0.60) and Trust domains (OR 0.4, 95% CI, 0.24-0.67), whereas participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 95% CI, 0.30-0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined. CONCLUSIONS: Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups.

Associations between aspects of culturally competent care and clinical outcomes among patients with diabetes.

BACKGROUND: Culturally competent care may be associated with clinical outcomes in diabetes management, which requires effective physician-patient collaboration. The recent development and validation of the Consumer Assessment of Healthcare Providers and Systems Cultural Competence tool enables investigation of possible associations. OBJECTIVE: To assess whether 3 aspects of culturally competent care are associated with glycemic, lipid, and blood pressure control among ethnically diverse patients with diabetes. DESIGN: Survey and chart review study of patients recruited from urban safety net clinics in 2 cities. SUBJECTS: A total of 600 patients with type 2 diabetes and a primary care physician. MEASURES: We used multivariate logistic regression to assess the independent relationships between the 3 domains of the Consumer Assessment of Healthcare Providers and Systems Cultural Competence (Doctor Communication-Positive Behaviors, Trust, and Doctor Communication-Health Promotion) and glycemic, lipid, and systolic blood pressure control after adjusting for sociodemographic and clinical factors. RESULTS: In adjusted analysis, high Trust was associated with lower likelihood of poor glycemic control (odds ratio, 0.59; 95% confidence interval, 0.41-0.84) and high Doctor Communication-Health Promotion was associated with a higher likelihood of poor glycemic control (odds ratio, 1.49, 95% CI, 1.02-2.19). None of the 3 aspects of culturally competent care examined were associated with lipid or systolic blood pressure control after adjustment. DISCUSSION: Trust in physician, a core component of culturally competent care, but not doctor communication behavior, was associated with a lower likelihood of poor glycemic control in a safety net population with diabetes. Glycemic control may be more sensitive to patient physician partnership than blood pressure and hyperlipidemia control.

Advances in measuring culturally competent care: a confirmatory factor analysis of CAHPS-CC in a safety-net population.

BACKGROUND: Providing culturally competent care shows promise as a mechanism to reduce health care inequalities. Until the recent development of the Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set (CAHPS-CC), no measures capturing patient-level experiences with culturally competent care have been suitable for broad-scale administration. METHODS: We performed confirmatory factor analysis and internal consistency reliability analysis of CAHPS-CC among patients with type 2 diabetes (n=600) receiving primary care in safety-net clinics. CAHPS-CC domains were also correlated with global physician ratings. RESULTS: A 7-factor model demonstrated satisfactory fit (χ²231=484.34, P<0.0001) with significant factor loadings at P<0.05. Three domains showed excellent reliability-Doctor Communication-Positive Behaviors (α=0.82), Trust (α=0.77), and Doctor Communication-Health Promotion (α=0.72). Four domains showed inadequate reliability either among Spanish speakers or overall (overall reliabilities listed): Doctor Communication-Negative Behaviors (α=0.54), Equitable Treatment (α=0.69), Doctor Communication-Alternative Medicine (α=0.52), and Shared Decision-Making (α=0.51). CAHPS-CC domains were positively and significantly correlated with global physician rating. CONCLUSIONS: Select CAHPS-CC domains are suitable for broad-scale administration among safety-net patients. Those domains may be used to target quality-improvement efforts focused on providing culturally competent care in safety-net settings.

Effect of a Novel, Evidence-Based, Standardized Discharge Checklist on 30-Day All-Cause Readmissions in Patients Hospitalized for Heart Failure in an Urban Safety Net Hospital.

Safety net hospitals frequently incur financial penalties for high readmission rates. Heart failure (HF) is a common driver of readmissions, but effectively lowering readmission rates in patients with HF has proved challenging. There are few evidence-based interventions validated within safety net systems. Between October 2018 and April 2019, we implemented an evidence-based discharge checklist. We evaluated the hypothesis that it would reduce 30-day all-cause readmissions in patients admitted for HF at an urban safety net hospital. We retrospectively compared all-cause 30-day readmission rates between the cohort discharged using the checklist and historical controls. Demographics were similar between the intervention (n = 103) and control (n = 187) groups and reflected the diverse and vulnerable population cared for in the safety net. The mean age was 60 years, 71% were male, 42% were Black, 22% were Hispanic/Latinx, 28% were not housed, 35% used illicit stimulants, and 73% had a left ventricular ejection fraction ≤40%. Use of the checklist was associated with a 12.4% absolute reduction in the 30-day readmission rate (29.9% vs 17.5%, p = 0.02). The intervention group was more likely to be discharged on appropriate guideline-directed medical therapy for reduced systolic function, including ß blockers (93% vs 73%, p = 0.0004), angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (92% vs 66%, p <0.0001) and mineralocorticoid receptor antagonists (50% vs 27%, p = 0.0007). Multivariable analysis demonstrated that using the discharge checklist was associated with a lower risk of 30-day all-cause readmission (risk ratio 0.54, 0.33 to 0.90). Therefore, a low-cost, novel, evidence-based discharge checklist significantly reduced 30-day all-cause readmission rates in patients hospitalized for HF at a safety net hospital.

Comparison of injection drug users accessing syringes from pharmacies, syringe exchange programs, and other syringe sources to inform targeted HIV prevention and intervention strategies.

OBJECTIVE: To describe injection drug users (IDUs) who access syringes through different outlets to help inform the prevention needs of IDUs who underuse safe syringe sources in New York City (NYC), where syringe availability is high compared with other U.S. cities. DESIGN: Cross sectional. SETTING: NYC, 2005-2007. PARTICIPANTS: 285 IDUs. INTERVENTION: Participants were recruited using random street-intercept sampling in 36 socioeconomically disadvantaged neighborhoods. MAIN OUTCOME MEASURES: IDUs using syringe exchange programs (SEPs), pharmacies, or other outlets as a primary syringe source were compared based on sociodemographic characteristics, injection practices, and medical service use. RESULTS: Chi-square tests and polytomous logistic regression were used to compare IDUs with different self-reported primary syringe sources used in the 6 months preceding study entry. Compared with IDUs using other syringe sources, those primarily using SEPs were less likely to be black (adjusted odds ratio 0.26 [95% CI 0.11-0.57]), more likely to inject daily (3.32 [1.58-6.98]), and more likely to inject with a new syringe (2.68 [1.30-5.54]). Compared with IDUs using other syringe sources, those primarily using pharmacies were less likely to be black (0.39 [0.17-0.90]). CONCLUSION: These data suggest that pharmacies and SEPs may be reaching different populations of IDUs and highlight a subpopulation of highly marginalized IDUs (i.e., black race, infrequent injectors) who are underusing safe syringe sources in NYC. Targeted interventions are needed to reduce racial disparities and increase use of safe syringe outlets.

Individual- and neighborhood-level factors associated with nonprescription counseling in pharmacies participating in the New York State Expanded Syringe Access Program.

OBJECTIVE: To determine the individual- and neighborhood-level predictors of frequent nonprescription in-pharmacy counseling. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: New York City (NYC) during January 2008 to March 2009. INTERVENTION: 130 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey. PARTICIPANTS: 477 pharmacists, nonpharmacist owners/managers, and technicians/clerks. MAIN OUTCOME MEASURES: Frequent counseling on medical conditions, health insurance, and other products. RESULTS: Technicians were less likely than pharmacists to provide frequent counseling on medical conditions or health insurance. Regarding neighborhood-level characteristics, pharmacies in areas of high employment disability were less likely to provide frequent health insurance counseling and pharmacies in areas with higher deprivation were more likely to provide counseling on other products. CONCLUSION: ESAP pharmacy staff members are a frequent source of nonprescription counseling for their patients in disadvantaged neighborhoods of NYC. These findings suggest that ESAP pharmacy staff may be amenable to providing relevant counseling services to injection drug users and warrant further investigation.

The Power Of Access To Affordable Care.

A patient and student with severe asthma chases adequate insurance coverage until the Affordable Care Act provides something more.

Patient Engagement In Health Care Safety: An Overview Of Mixed-Quality Evidence.

Patients and caregivers play a central role in health care safety in the hospital, ambulatory care setting, and community. Despite this, interventions to promote patient engagement in safety are still underexplored. We conducted an overview of review articles on patient engagement interventions in safety to examine the current state of the evidence. Of the 2,795 references we evaluated, 52 articles met our full-text inclusion criteria for synthesis in 2018. We identified robust evidence supporting patients' self-management of anticoagulation medications and mixed-quality evidence supporting patient engagement in medication and chronic disease self-management, adverse event reporting, and medical record accuracy. Promising modes of patient engagement in safety, such as anticoagulation management and patient portal access, are not widely implemented. We discuss major implementation priorities and propose directions for future research and policy to enhance patient partnership within safety efforts.