Measuring Primary Care Across 35 OECD Countries.

PURPOSE: To examine the psychometric properties and scores of the Person-Centered Primary Care Measure (PCPCM) in 28 languages and 35 Organisation for Economic Co-operation and Development (OECD) countries. METHODS: Using a paid online sampling service, we requested age- and sex-representative samples of 360 adults in each country. We administered the Person-Centered Primary Care Measure-a previously validated 11-item, patient-reported measure that was developed using what patients and clinicians said is most important about primary care. We also assessed construct validity through associations with demographics, the Patient-Enablement Instrument, number of years the person had been with their primary care physician and practice, whether the patient thought the doctor knowing the results would improve their care, and whether it was hard to complete the survey. We assessed the psychometric properties of the PCPCM in each country and report the summative and item-specific PCPCM scores for each country. RESULTS: The PCPCM exhibited solid psychometric properties across all languages and countries, with Cronbach's alphas ranging from 0.88 to 0.95, and corrected item-total correlations ranging from 0.47 to 0.81, with the vast majority of countries ranging from the low 0.50s to the high 0.70s. Multiple analyses showed strong evidence of concurrent validity. With a potential range from a low of 1 to a high of 4, the overall mean score was 2.74, with a standard deviation of 0.19. Mean PCPCM scores ranged from the lowest in Sweden (2.28) to the highest in Turkey (3.08), with Germany ranking second (3.01), and the United States third (2.99). CONCLUSION: The internal consistency and concurrent validity of the PCPCM across multiple countries provides strong evidence of the coherence of the breadth of primary care functions that patients and clinicians say are important. The diversity of total and item-specific scores across countries provokes interesting hypotheses about the influence of each different country's policies, practices, demographics, and culture on primary care, and provides a strong impetus for further ecological and individual data analyses using the Person-Centered Primary Care Measure. Annals "Online First" article.

A New Comprehensive Measure of High-Value Aspects of Primary Care.

PURPOSE: To develop and evaluate a concise measure of primary care that is grounded in the experience of patients, clinicians, and health care payers. METHODS: We asked crowd-sourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts in a 2½ day international conference to provide additional insights. A multidisciplinary team conducted a qualitative analysis of the combined data to develop a parsimonious set of patient-reported items. We evaluated items using factor analysis, Rasch modeling, and association analyses among 2 online samples and 4 clinical samples from diverse patient populations. RESULTS: The resulting person-centered primary care measure parsimoniously represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, advocacy, community context, comprehensiveness, continuity, coordination, family context, goal-oriented care, health promotion, integration, and relationship. Principal axes factor analysis identified a single factor. Factor loadings and corrected item-total correlations were >0.6 in online samples (n = 2,229) and >0.5 in clinical samples (n = 323). Factor scores were fairly normally distributed in online patient samples, and skewed toward higher ratings in point-of-care patient samples. Rasch models showed a broad spread of person and item scores, acceptable item-fit statistics, and little item redundancy. Preliminary concurrent validity analyses supported hypothesized associations. CONCLUSIONS: The person-centered primary care measure reliably, comprehensively, and parsimoniously assesses the aspects of care thought to represent high-value primary care by patients, clinicians, and payers. The measure is ready for further validation and outcome analyses, and for use in focusing attention on what matters about primary care, while reducing measurement burden.

Development of a Measure of Incremental Behavior Change Toward Smoking Cessation.

INTRODUCTION: A reliable measure capable of detecting progression towards smoking cessation would be valuable for evaluating and optimizing the effectiveness of low- to moderate-intensity cessation interventions, such as brief advice in the primary care setting. This article presents the development and evaluation of a brief self-report measure of Incremental Behavior Change toward Smoking cessation (IBC-S). METHODS: Sequential samples of 411 and 399 adult smokers completed items representing a spectrum of behavioral and cognitive changes antecedent to smoking cessation. The dimensionality, fit, range of difficulty, and reliability of items were evaluated using factor analysis and Rasch modeling. RESULTS: The final 15-item IBC-S measure met fit criteria and demonstrated acceptable reliability. Participants with a significant change in IBC-S score were over four times more likely to report cessation at 6-week follow-up (OR 4.37, 95% CI 1.83-10.42). CONCLUSION: The IBC-S is brief, reliable and associated with self-report of smoking reduction and cessation. IMPLICATIONS: This article presents the psychometric evaluation of a measure to assess a spectrum of behaviors and cognitions antecedent to smoking cessation. The findings indicate that the items show good measurement properties and good potential as a sensitive measure to evaluate interventions. This measure provides an alternative outcome for interventions that are designed to move individuals towards cessation attempts.

Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey.

BACKGROUND: Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. OBJECTIVE: The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. DESIGN: We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. PARTICIPANTS: The study included senior medical students. MAIN MEASURES: We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. KEY RESULTS: Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. CONCLUSIONS: In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations.

Care Delivery in Community Health Centers Before, During, and After the COVID-19 Pandemic (2019-2022).

INTRODUCTION: Health centers provide primary and behavioral health care to the nation's safety net population. Many health centers served on the frontlines of the COVID-19 pandemic, which brought major changes to health center care delivery. OBJECTIVE: To elucidate primary care and behavioral health service delivery patterns in health centers before and during the COVID-19 public health emergency (PHE). METHODS: We compared annual and monthly patients from 2019 to 2022 for new and established patients by visit type (primary care, behavioral health) and encounter visits by modality (in-person, telehealth) across 218 health centers in 13 states. RESULTS: There were 1581,744 unique patients in the sample, most from health disparate populations. Review of primary care data over 4 years show that health centers served fewer pediatric patients over time, while retaining the capacity to provide to patients 65+. Monthly data on encounters highlights that the initial shift in March/April 2020 to telehealth was not sustained and that in-person visits rose steadily after November/December 2020 to return as the predominant care delivery mode. With regards to behavioral health, health centers continued to provide care to established patients throughout the PHE, while serving fewer new patients over time. In contrast to primary care, after initial uptake of telehealth in March/April 2020, telehealth encounters remained the predominant care delivery mode through 2022. CONCLUSION: Four years of data demonstrate how COVID-19 impacted delivery of primary care and behavioral health care for patients, highlighting gaps in pediatric care delivery and trends in telehealth over time.

Care Quality and Equity in Health Centers During and After the COVID-19 Pandemic.

INTRODUCTION: Federally Qualified Community Health Centers (FQHCs) are on the frontline of efforts to improve healthcare equity and reduce disparities exacerbated by the COVID-19 pandemic. This study assesses the provision and equity of preventive care and chronic disease management by FQHCs before, during, and after the pandemic. METHODS: Using electronic health record data from 210 FQHCs nationwide and employing segmented regression in an interrupted time series design, preventive screening and chronic disease management were assessed for 939,053 patients from 2019 to 2022. Care measures included cancer screenings, blood pressure control, diabetes control, and childhood immunizations; patient-level factors including race and ethnicity, language preference, and multimorbidity status were analyzed for equitable care provision. Analyses were conducted in 2023-2024. RESULTS: Cancer screening rates and blood pressure control initially declined after the onset of the pandemic but later rebounded, while diabetes control showed a slight increase, later stabilizing. Racial and ethnic disparities persisted, with Asian individuals having a higher prevalence of screenings and blood pressure control, and Black/African American individuals facing a lower prevalence for most screenings but a higher prevalence for cervical cancer screening. Hispanic/Latino individuals had a higher prevalence of various screenings and diabetes control. Disparities persisted for Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native individuals and were observed based on language and multimorbidity status. CONCLUSIONS: While preventive screening and chronic disease management in FQHCs have largely rebounded to pre-pandemic levels following an initial decline, persistent disparities highlight the need for targeted interventions to support FQHCs in addressing healthcare inequities.

Variation in multimorbidity by sociodemographics and social drivers of health among patients seen at community-based health centers.

Purpose: Understanding variation in multimorbidity across sociodemographics and social drivers of health is critical to reducing health inequities. Methods: From the multi-state OCHIN network of community-based health centers (CBHCs), we identified a cross-sectional cohort of adult (> 25 years old) patients who had a visit between 2019-2021. We used generalized linear models to examine the relationship between the Multimorbidity Weighted Index (MWI) and sociodemographics and social drivers of health (Area Deprivation Index [ADI] and social risks [e.g., food insecurity]). Each model included an interaction term between the primary predictor and age to examine if certain groups had a higher MWI at younger ages. Results: Among 642,730 patients, 28.2% were Hispanic/Latino, 42.8% were male, and the median age was 48. The median MWI was 2.05 (IQR: 0.34, 4.87) and was higher for adults over the age of 40 and American Indians and Alaska Natives. The regression model revealed a higher MWI at younger ages for patients living in areas of higher deprivation. Additionally, patients with social risks had a higher MWI (3.16; IQR: 1.33, 6.65) than those without (2.13; IQR: 0.34, 4.89) and the interaction between age and social risk suggested a higher MWI at younger ages. Conclusions: Greater multimorbidity at younger ages and among those with social risks and living in areas of deprivation shows possible mechanisms for the premature aging and disability often seen in community-based health centers and highlights the need for comprehensive approaches to improving the health of vulnerable populations.

Ethnic differences in the caregiver's attitudes and preferences about the treatment and care of advanced lung cancer patients.

OBJECTIVE: This study examined differences in attitudes and preferences between African American and White caregivers about cancer treatment and care. METHODS: There were 173 White and 26 African American caregivers of advanced lung cancer patients who were recruited as a convenience sample. A telephone interview was conducted to collect information using a semi-structured questionnaire. Using logistic regression, we examined differences between racial groups concerning therapeutic and caregiving issues controlling for socioeconomic and demographic variables. RESULTS: The regression analyses showed that African American caregivers had higher expectations for treatment outcomes (p ≤ 0.05) but poorer understanding of hospice and a stronger preference for hospice care outside the home (p ≤ 0.05). They were more likely to believe that the patient communicates with the family about cancer treatment to meet the family's expectations rather than seek emotional support (p ≤ 0.01). They were also more reluctant to endorse children's responsibility to make a treatment decision and are less likely to be fully satisfied with the decision-making process (p ≤ 0.05). CONCLUSIONS: The findings suggest some differences in beliefs and cultural values between African American and White caregivers. African American caregivers appear to believe more in the possibility of curative care for advanced lung cancer and eschew hospice care. The findings inform possible challenges regarding communication about end-of-life treatment and care with African American caregivers and a need for the provision of adequate information and education.

Performance of the Person Centered Primary Care Measure in Pediatric Continuity Clinic.

OBJECTIVE: Improvement efforts in pediatric primary care would benefit from measures that capture families' holistic experience of the practice. We sought to assess the reliability and validity of the new Person-Centered Primary Care Measure (PCPCM) in a pediatric resident continuity clinic serving low-income families. METHODS: We incorporated the 11-item PCPCM, stems adapted to reflect a parent responding about their child's visit, into a telephone survey of 194 parents presenting for care in October 2019 at a pediatric resident continuity clinic in Cleveland Ohio (64% response rate). We evaluated PCPCM items using factor analysis and Rasch modeling, and assessed associations of the PCPCM with parents' demographics and perceptions of specific elements of their child's care. RESULTS: In this sample of low-income families, the PCPCM had good reliability (Cronbach's alpha 0.85). All items loaded onto a single factor in principal axes factor analysis. Of the 11 aspects of primary care represented in the scale, "shared experience" was most difficult for parents to endorse in Rasch modeling. All 11 items contributed significantly to the total scale score with corrected item-total correlations >0.4. The PCPCM score was independent of socio demographics and was associated with parent's report that their child's clinician spends enough time with them. CONCLUSIONS: The PCPCM performs well in a pediatric continuity clinic setting, warranting consideration for its use as a parsimonious parent-reported measure of what patients and clinicians say matters most in pediatric primary care.

Exploration of the psychometric properties of the Person-Centred Primary Care Measure (PCPCM) in a Chinese primary care population in Hong Kong: a cross-sectional validation study.

OBJECTIVES: To evaluate the validity and psychometric properties of the Chinese Person-Centred Primary Care Measure (PCPCM) in a Chinese-speaking population. DESIGN: A cross-sectional study. SETTING: A primary care clinic in Hong Kong. PARTICIPANTS: 300 Chinese adult patients (150 males and 150 females) were recruited from a primary care clinic to complete a questionnaire containing the PCPCM, Consultation and Relational Empathy (CARE), Patient Enablement Index (PEI) and Adult (short version) Primary Care Assessment Tool (PCAT). The Chinese PCPCM was readministered to 118 participants after 14 days for test-retest reliability. OUTCOME MEASURES: The construct validity, reliability and sensitivity of the Chinese PCPCM. RESULTS: The Chinese PCPCM was identified to have a one-factor construct, with good item fit and unidimensionality on Rasch analysis. Internal reliability was high (Cronbach's alpha >0.8) with moderate test-retest reliability (intraclass correlation coefficient=0.622, p<0.001). Significant correlations (0.58, 0.42, 0.48) between the PCPCM and CARE, PEI and Adult (short version) PCAT scores supported good convergent construct validity. PCPCM scores were higher among patients who had known their doctors for a longer period or who were more likely to be able to see the same doctor at every visit, and among those who self-reported to have 'better health' rather than 'worse health'. CONCLUSION: The Chinese PCPCM appears to be a valid, reliable and sensitive instrument for evaluating the quality of person-centred care among primary care patients in Hong Kong. Further studies are needed to confirm the utility of this instrument in other Chinese-speaking populations around the world.

Family history and perceptions about risk and prevention for chronic diseases in primary care: a report from the family healthware impact trial.

PURPOSE: To determine whether family medical history as a risk factor for six common diseases is related to patients' perceptions of risk, worry, and control over getting these diseases. METHODS: We used data from the cluster-randomized, controlled Family Healthware Impact Trial (FHITr). At baseline, healthy primary care patients reported their perceptions about coronary heart disease, stroke, diabetes, and breast, ovarian, and colon cancers. Immediately afterward, intervention group participants used Family Healthware to record family medical history; this web-based tool stratified familial disease risks. Multivariate and multilevel regression analyses measured the association between familial risk and patient perceptions for each disease, controlling for personal health and demographics. RESULTS: For the 2330 participants who used Family Healthware immediately after providing baseline data, perceived risk and worry for each disease were strongly associated with family history risk, adjusting for personal risk factors. The magnitude of the effect of family history on perceived risk ranged from 0.35 standard deviation for ovarian cancer to 1.12 standard deviations for colon cancer. Family history was not related to perceived control over developing diseases. Risk perceptions seemed optimistically biased, with 48-79% of participants with increased familial risk for diseases reporting that they were at average risk or below. CONCLUSIONS: Participants' ratings of their risk for developing common diseases, before feedback on familial risk, parallels but is often lower than their calculated risk based on family history. Having a family history of a disease increases its salience and does not change one's perceived ability to prevent the disease.

Cultural adaptation and content validity of a Chinese translation of the 'Person-Centered Primary Care Measure': findings from cognitive debriefing.

OBJECTIVES: To develop an equivalent Chinese translation of the Person-Centered Primary Care Measure (PCPCM) and to establish its cultural adaptability and content validity through cognitive debriefing. DESIGN: The original English PCPCM was first translated into Chinese by double forward-translation by professional translators. The reconciliated Chinese version was then doubly back-translated into English by two other professional translators blinded to the forward-translation. On affirmation on its linguistic equivalence with the developers of the original English PCPCM, the reconciliated Chinese PCPCM was sent for cognitive debriefing with 20 Chinese-speaking primary care subjects by a trained interviewer using structured probing questions to collect their opinions on the clarity, comprehensibility and relevance of each item and response option in the Measure. SETTING: Subjects were invited from a primary care clinic in Hong Kong to undergo the cognitive debriefing interviews. The interviews were divided into four groups chronologically to allow revision of the items to be made in between. PARTICIPANTS: Ten males and 10 females above the age of 18 completed the cognitive interviews. They were all Cantonese-speaking Chinese recruited by convenience sampling. Subjects with cognitive impairment, could not read Chinese, too old or too sick to complete the interviews were excluded from the study. RESULTS: An average of 3.3 min (range 3-4 min) was required for the subjects to self-complete the Measure. All items were generally perceived to be easily understood and relevant. Modifications were made to items with the content validity index (CVI) on clarity or understanding <0.8 in each round of the interviews or if a majority of the subjects suggested rewording. Revisions were made to two items in the Chinese PCPCM throughout the whole cognitive debriefing process before the final version was confirmed. The average CVI on clarity of the Chinese PCPCM items ranged from 0.75 to 1. The average CVI on understanding ranged from 0.7 to 1. The average CVI on relevance ranged from 0.55 to 1. CONCLUSIONS: The content validity of the PCPCM was ascertained in terms of its clarity, understandability and relevance to allow further testing of its psychometric properties in a larger Chinese population.

Racial, ethnic, and socioeconomic differences in the incidence of obesity related to childbirth.

OBJECTIVES: We investigated the relationship between childbirth and 5-year incidence of obesity. METHODS: We performed a prospective analysis of data on 2923 nonobese, nonpregnant women aged 14 to 22 years from the 1979 National Longitudinal Survey of Youth Cohort, which was followed from 1980 to 1990. We used multivariable logistic regression analyses to determine the adjusted relative risk of obesity for mothers 5 years after childbirth compared with women who did not have children. RESULTS: The 5-year incidence of obesity was 11.3 per 100 parous women, compared with 4.5 per 100 nulliparous women (relative risk [RR] = 3.5; 95% confidence interval [CI] = 2.4, 4.9; P < .001). The 5-year incidence of obesity was 8.6 for primiparous women (RR = 2.8; 95% CI = 1.5, 5.0) and 12.2 for multiparous women (RR = 3.8; 95% CI = 2.6, 5.6). Among parous women, White women had the lowest obesity incidence (9.1 per 100 vs 15.1 per 100 for African Americans and 12.5 per 100 for Hispanics). CONCLUSIONS: Parous women have a higher incidence of obesity than do nulliparous women, and minority women have a higher incidence of parity-related obesity than do White women. Thus, efforts to reduce obesity should target postpartum women and minority women who give birth.

Calcium supplement use by African American women.

INTRODUCTION: Inadequate calcium intake is more common among women belonging to racial and ethnic minorities. This study examined the patterns and characteristics associated with calcium supplement use or nonuse among African American women, and the potential impact of physician recommendation on calcium supplementation. METHODS: African American women aged 19 to 65, attending community outreach activities sponsored by a multispecialty academic medical center in northeastern Ohio, completed a calcium supplement survey. Survey items included demographic and bone health-related information, and rationale for calcium supplement use or nonuse. RESULTS: Of 160 respondents, 14% of women regularly took calcium supplements, 16% were former users, and 70% never used calcium supplements. Characteristics associated with calcium use status included age, multivitamin use, and marital status. Few African American women recall discussions with their doctors about calcium intake. Most who formerly took calcium supplements and most who had never taken them were willing to do so if recommended by their physician. DISCUSSION: Calcium supplement use among African American women in this study was low. However, many of the barriers to calcium supplement use by African American women appear remediable through brief calcium intake counseling by their physician.

Measuring practice capacity for change: a tool for guiding quality improvement in primary care settings.

PURPOSE: Capacity for change, or the ability and willingness to undertake change, is an organizational characteristic with potential to foster quality management in health care. We report on the development and psychometric properties of a quantitative measure of capacity for change for use in primary care settings. METHODS: Following review of previous conceptual and empirical studies, we generated 117 items that assessed organizational structure, climate, and culture. Using information from direct observation and key informant interviews, a research team member rated these items for 15 primary care practices engaged in a quality improvement intervention. Distributional statistics, pairwise correlation analysis, Rasch modeling, and item content review guided item reduction and instrument finalization. Reliability and convergent validity were assessed. RESULTS: Ninety-two items were removed because of limited response distributions and redundancy or because of poor Rasch model fit. The final instrument comprising 25 items had excellent reliability (alpha = .94). A Rasch model-derived capacity for change score correlated well with an independently determined, qualitatively derived summary assessment of each practice's capacity for change (rhoS = 0.82), suggesting good convergent validity. CONCLUSION: We describe a new instrument for quantifying organizational capacity for change in primary care settings. The ability to quantify capacity for change may enable better recognition of practices likely to be successful in their change efforts and those first requiring capacity building prior to change interventions.

Geriatrician training in the care of elders with intellectual and other developmental disabilities.

Adults with intellectual and other developmental disabilities (IDD) are now living to late life. Whether geriatricians are being trained to provide care for this clinically complex subpopulation of elders has not been examined. Two thirds of all geriatric fellowship directors in the United States responded to a Web-based survey of curriculum and training in this area. Forty-four percent rated training in this area as "important" or "very important," but only 26% of directors rated their graduates as moderately or highly competent in caring for elders with IDD. We report our survey findings and implications for future curricular development.

Disparities and Variables Associated With Physical Restraint for Acute Agitation in a Nonpsychiatric Emergency Department.

OBJECTIVE: To determine associations between the rate of physical restraint and demographic variables such as body mass index (BMI), ethnicity, sex, and age in the emergency department (ED) along with clinical variables such as various psychiatric diagnoses and medications. METHODS: This 6-month (October 1, 2016-March 30, 2017) retrospective chart review was conducted in the ED of a community hospital, which is also a teaching institution for medical students and residents but does not have access to psychiatry consultations via phone or in person. A total of 165 agitated patients were included in the study. Agitated patients who were restrained were compared to those who were not physically restrained. RESULTS: Of the patients, 112 (68%) were physically restrained, and those not physically restrained were included as controls (n = 53, 32%). Younger age (P = .03), lower BMI (P = .04), intoxication (P = .001), preexisting diagnosis of depression (P = .02), and antipsychotics as a home medication (P = .03) were associated with physical restraints. In the ED, administration of haloperidol and olanzapine was associated with physical restraints. Current benzodiazepine prescription (P = .001), ED administration of ketamine (P = .001), and ED administration of diazepam (P = .001) were more common in those not physically restrained. CONCLUSIONS: Risk factors for physical restraints can be used to identify high-risk patients early, and other treatments along with behavioral and environmental modifications may then be utilized. Further research to develop protocols using nonpharmacologic and pharmacologic measures to minimize use of restraints is required.

A provider-observed tool to assess Oral Hygiene Skill Mastery (OHSIM) in human immunodeficiency virus-positive (HIV+) adults.

AIMS: Periodontal diseases (PDs) affect nearly half of Americans ≥30 years old and are common in human immunodeficiency virus-positive (HIV+) adults. A validated measure of oral hygiene skill could improve tailored prevention-focused health communication. METHODS: We developed Oral Hygiene Skill Mastery (OHSIM), a provider-observed measure of toothbrushing and flossing ability. We examined OHSIM's inter-rater reliability (IRR) and concurrent validity using a blinded, cross-sectional study design with a convenience sample of HIV+/- adults. Clinical outcome measures included bleeding on probing (BOP) and abbreviated plaque and gingival indices. Analyses included IRR and, after identifying relevant predictor variables for each outcome, backward elimination regression and structural equation modeling (SEM) were used to demonstrate concurrent validity. RESULTS: We saw 173 research participants (reliability: n = 61; validity: n = 112). The average IRR was α = 0.73 for toothbrushing and α = 0.84 for flossing. Toothbrushing and flossing skill were moderately correlated (r = 0.49, P < 0.001). SEM analyses demonstrated that OHSIM toothbrushing significantly and independently predicted variance in plaque and gingival indices and BOP, while OHSIM flossing skill significantly and independently predicted plaque index and BOP. CONCLUSION: OHSIM is a provisionally reliable and valid provider-observed measure of toothbrushing and flossing skill. Most predictors of clinical outcomes were modifiable behaviors. Toothbrushing quality is a critical component of oral health.

Impact of Psychiatric Hospitalization on Trust, Disclosure and Working Alliance with the Outpatient Psychiatric Provider: A Pilot Survey Study.

Introduction  The relationship between inpatient psychiatric experience and subsequent outpatient psychiatric care remains highly understudied. We conducted a voluntary, anonymous, self-report, pilot survey study to explore the impact of current or recent psychiatric hospitalization on patients' ability to trust their outpatient psychiatric providers, particularly with respect to the disclosure of symptoms such as suicidal thoughts. Methods  A survey was conducted in a psychiatry practice-based research network (PBRN) of six outpatient community psychiatry clinic sites within four regional agencies and at an adult inpatient psychiatry unit of a tertiary-care academic hospital in the Cleveland area. We asked patients to record characteristics of their hospitalization, perceived changes in attitudes, and complete a working alliance inventory. Sixty-two surveys were collected. Results  Most respondents had high working alliance scores with their outpatient providers and a low prevalence of coercive experiences during hospitalization. A minority (15%) experienced a reduction in trust with their outpatient provider. Nonetheless, a substantial percentage of respondents expressed a lower likelihood of disclosing various concerning psychiatric symptoms and behaviors to their outpatient provider. Thirty-six percent reported they are less likely to disclose thoughts of harming self. Percentages for subjects reporting a reduced likelihood of disclosing thoughts of harming others, hearing voices, not taking medications as prescribed, and substance use ranged from 21-29%. At the same time, there were also trust-enhancing effects: a substantial number of patients reported an increase in their ability to trust psychiatric providers and an increase in the likelihood of disclosure of psychiatric symptoms. Exploratory analyses revealed significant associations of gender, race, outpatient provider involvement in hospitalization, and involvement of police during admission with trust, disclosure, and working alliance. Conclusion  Even with a high therapeutic alliance and low perceived coercion during inpatient psychiatric hospitalization, the experience can lead to a disruption of trust and transparency with the outpatient psychiatrist in a considerable proportion of patients.

Comparison of obstructive sleep apnea patients with and without leg edema.

BACKGROUND: To determine the proportion of patients with obstructive sleep apnea (OSA) who have leg edema, and to identify differences between edematous and non-edematous OSA patients. METHODS: Retrospective, cross-sectional study of 378 patients with OSA (apnea/hypopnea index [AHI] >or=15) who had neither heart failure nor chronic lung disease. RESULTS: Thirty-five percent (133/378) of the subjects with OSA had bilateral leg edema. Eighty-one percent (108/133) of the edematous subjects had mild pitting that was 1+. Compared to the non-edematous OSA subjects, the edematous subjects were older (age=51+/-13 versus 45+/-13 years, p=0.001), more obese (body mass index=39+/-9 versus 33+/-8kg/m(2), p=0.001), had more severe OSA (AHI=46+/-71 versus 27+/-29, p=0.004), spent a greater proportion of sleep time with an oxygen saturation <90% (20+/-26 versus 11+/-18%, p=0.001), and were more likely to have diabetes mellitus (11% versus 3%, p=0.001) and hypertension (32% versus 10%, p=0.001). Age, obesity, hypertension and diabetes mellitus correlated significantly with edema status. After adjusting for these confounding variables, the AHI means remained different between the edema and non-edema groups (41+/-5 versus 28+/-3, p=0.04). CONCLUSIONS: Approximately one-third of OSA patients have edema. Edematous OSA patients are older, more obese, more likely to have diabetes mellitus and hypertension, and have more severe OSA than OSA patients who lack edema.