Examining trends in substance use disorder capacity and service delivery by Health Resources and Services Administration-funded health centers: A time series regression analysis.

BACKGROUND: The opioid epidemic and subsequent mortality is a national concern in the U.S. The burden of this problem is disproportionately high among low-income and uninsured populations who are more likely to experience unmet need for substance use services. We assessed the impact of two Health Resources and Services Administration (HRSA) substance use disorder (SUD) service capacity grants on SUD staffing and service use in HRSA -funded health centers (HCs). METHODS AND FINDINGS: We conducted cross-sectional analyses of the Uniform Data System (UDS) from 2010 to 2017 to assess HC (n = 1,341) trends in capacity measured by supply of SUD and medication-assisted treatment (MAT) providers, utilization of SUD and MAT services, and panel size and visit ratio measured by the number of patients seen and visits delivered by SUD and MAT providers. We merged mortality and national survey data to incorporate SUD mortality and SUD treatment services availability, respectively. From 2010 to 2015, 20% of HC organizations had any SUD staff, had an average of one full-time equivalent SUD employee, and did not report an increase in SUD patients or SUD services. SUD capacity grew significantly in 2016 (43%) and 2017 (22%). MAT capacity growth was measured only in 2016 and 2017 and grew by 29% between those years. Receipt of both supplementary grants increased the probability of any SUD capacity by 35% (95% CI: 26%, 44%) and service use, but decreased the probability of SUD visit ratio by 680 visits (95% CI: -1,013, -347), compared to not receiving grants. CONCLUSIONS: The significant growth in HC specialized SUD capacity is likely due to supplemental SUD-specific HRSA grants and may vary by structure of grants. Expanding SUD capacity in HCs is an important step in increasing SUD access for low income and uninsured populations broadly and for patients of these organizations.

Impact of oral health service expansion funding at health centers in the United States.

OBJECTIVES: This study aims to assess the impact of Health Resources and Services Administration (HRSA) investment in oral health through the HRSA FY16 Oral Health Service Expansion (OHSE) funding on workforce, access, and quality in health centers (HCs) from 2015 to 2017. METHODS: Analyses were conducted using data from the Uniform Data System from 2015 and 2017, and the 2015 Area Health Resource File. Change in indicators of oral health workforce, access, and quality of care by the receipt of OHSE funding received by HCs in 2016 were examined. Regression models for 1,345 HCs were developed to conduct a difference-in-difference analyses of the comparative change from 2015 to 2017 in the dependent variables among OHSE and non-OHSE awardees while controlling for confounders. RESULTS: OHSE awardees showed a significant difference in the oral health workforce with a higher mean number increase by 0.6 full time equivalent (FTE) dentists, 0.4 dental hygienists, 1.1 dental assistants, and 2.3 for other dental staff compared to non-OHSE awardees. Compared to non-OHSE awardees, OHSE awardees showed a mean increase of 712 dental patients served who received 1,402 dental visits, representing a 9-percentage point increase in the percentage of HCs that had an oral health program and a 3-percentage point increase in the ratio of dental patients to total patients. CONCLUSIONS: Funding dedicated to oral health service expansion in HCs may result in outcomes ranging from increasing workforce to reduction in access and financial barriers. Retrospective analysis demonstrated improved capacity for oral healthcare delivery attributable to HRSA support to HCs.

Racial/ethnic variations in weight management among patients with overweight and obesity status who are served by health centres.

This study sought to examine racial/ethnic variations in receipt of provider recommendations on weight loss, patient adherence, perception of weight, attempts at weight loss and actual weight loss among patients with overweight/obesity status at Health Resources and Services Administration-funded health centres (HC). We used a 2014 nationally representative survey of adult HC patients with overweight/obesity status (PwOW/OB) last year and reported the HC was their usual source of care (n = 3517). We used logistic regression models to assess the interaction of race/ethnicity and having obesity in (1) provider recommendations of diet or (2) exercise, (3) patient adherence to diet or (4) exercise, (5) perceptions of weight and (6) weight loss attempts. We used a multinomial regression model to examine (7) weight loss or gain vs no change and a linear regression model to evaluate (8) percent weight change. We found Black PwOW/OB (OR = 1.65) experienced greater odds of receiving diet recommendations than Whites. We found limited racial/ethnic disparities in adherence. Black (OR = 0.41), Hispanic/Latino (OR = 0.45), and American Indian/Alaska Native (OR = 0.41) PwOW/OB had lower odds of perceiving themselves as overweight. Black (OR = 1.68) and Hispanic (OR = 1.98) PwOW/OB had a greater odds of reporting weight gain, and Asian PwOW/OB (OR = 0.42) had lower odds of reporting weight loss than Whites. Disparities in provider diet recommendations among Blacks and Hispanics indicated the importance of personalized weight management recommendations. Understanding underlying reasons for discordance between self-perception and observed weight among different groups is needed. Overall increase in weight, despite current interventions, should be addressed through targeted racially/ethnically appropriate approaches.

Improving Outcomes of Care for HRSA-Funded Health Center Patients Who Have Mental Health Conditions and Substance Use Disorders.

The rising prevalence of mental health conditions and substance use disorders (MH/SUD) underscores the important role of health centers (HCs) in caring for low-income and uninsured MH/SUD patients. This study used the 2014 Health Center Patient Survey and 2014 Uniform Data System to determine the independent association between delivery of MH/SUD integration and related interventions to patients that reported a MH/SUD condition (n=2714) with the number of HC visits, emergency department (ED) visits, and hospitalizations last year. Results showed that health education was associated with fewer predicted ED visits (1.8 vs. 2.3) and lower likelihood of hospitalizations (16% vs. 24%) among MH patients. Medical enabling services was associated with lower rates of ED visits (0.3 vs.1.9) and hospitalizations (< 1% vs. 13%) among SUD patients. The results indicate the utility of integration and related intervention services in primary care settings to improve service use and reduce ED and hospitalization among MH/SUD patients.

HRSA-funded Health Centers Are an Important Source of Care and Reduce Unmet Needs in Primary Care Services.

BACKGROUND: Evidence indicates the unmet need for primary care services including medical, mental health, and dental care is greater among uninsured and Medicaid beneficiaries than privately insured individuals, many of whom use Health Resources and Services Administration-funded health centers (HRSA HCs). OBJECTIVE: We examined differences in rates of unmet need between low-income uninsured and Medicaid patients of HRSA HCs and safety-net clinics in general or private physicians. RESEARCH DESIGN: We used logistic regression models to compare the predicted probabilities of unmet need for uninsured and Medicaid individuals whose usual source of care is HRSA HCs versus clinics in general or private physicians. SAMPLE: We used a nationally representative survey of low income, adult patients who identified HRSA HCs as their usual source of care. We used the National Health Interview Survey to independently identify low-income individuals whose usual source of care was clinics (National Health Interview Survey clinics) or physicians (National Health Interview Survey physicians) in the general population. MEASURES: Dependent variables were unmet need and delay in medical care, and unmet need for prescription medications, mental health, and dental care. The primary independent variable of interest was the usual source of care. We controlled for potential confounders. RESULTS: We found the probability of unmet need for medical and dental care to be lower among HRSA HC patients than individuals whose usual source of care were not HRSA HCs. CONCLUSIONS: HRSA HC patients have lower probabilities of unmet need for medical and dental care. This is likely because HRSA HCs provide accessible, affordable, and comprehensive primary care services. Expanding capacity of these organizations will help reduce unmet need and its consequences.

Enabling Services Improve Access To Care, Preventive Services, And Satisfaction Among Health Center Patients.

Enabling services address a combination of social determinants of health and barriers to access to primary care and are intended to reduce health disparities. They include care coordination; health education; transportation; and assistance with obtaining food, shelter, and benefits. Empirical evidence of enabling services' potential contribution to health outcomes is limited, which impedes their widespread dissemination. We examined how the receipt of enabling services influenced patient health care outcomes based on a nationally representative survey of patients served in 2014 at health centers funded by the Health Resources and Services Administration. We compared enabling services users and nonusers and found that enabling services were associated with 1.92 more health center visits, an 11.78-percentage-point higher probability of getting a routine checkup, a 16.34-percentage-point higher likelihood of having had a flu shot, and a 7.63-percentage-point higher probability of patient satisfaction. Our results confirm the value of systematic delivery of enabling services in reducing access barriers and improving patient satisfaction.

Organizational Factors Associated with Disparities in Cervical and Colorectal Cancer Screening Rates in Community Health Centers.

INTRODUCTION: Community health centers provide care to underserved populations least likely to adhere to cancer screening guidelines, but vary in their ability to ensure eligible patients are identified and screened. This study examines organizational factors associated with cervical and colorectal cancer screening rates among health centers funded by the Health Resources and Services Administration (HRSA). METHODS: Data were drawn from the 2015 Uniform Data System and analyzed using negative binomial regression. RESULTS: On average, 53% of eligible health center patients were screened for cervical cancer and 37% for colorectal cancer. Organizational characteristics positively associated with cancer screening rates include provider-patient staffing ratios, electronic health record status, percentage revenue from public capitated managed care, and local primary care provider availability. Percentage of homeless patients was negatively associated with screening. CONCLUSION: Efforts to improve cancer screening among underserved populations should address organizational factors that may contribute to disparities in screening uptake.

Assessing the Impact of Patient-Centered Medical Home Principles on Hypertension Outcomes Among Patients of HRSA-Funded Health Centers.

BACKGROUND: Millions of Americans have uncontrolled hypertension and are low-income or uninsured populations. Health Resources and Services Administration-funded health centers (HCs) are primary providers of care to these patients and a majority have adopted the patient-centered medical home (PCMH). PCMH includes principles of care coordination or integration and care management-support important to the treatment of hypertension. We examined whether the receipt of PCMH concordant care by HC patients improved hypertension outcomes. METHODS: We used a nationally representative survey of adult HC patients with hypertension (n = 2,280) conducted between October 2014 and April 2015. We included data from the 2013 and 2014 Uniform Data System to include characteristics of the HCs where these patients received their care. Our outcome measures included flu shots, number of primary care visits, normal blood pressure at last visit, emergency department (ED) visits, confidence in self-care, and compliance with provider recommendations. The primary independent variables were (i) whether the HC coordinated and referred patients to specialists; (ii) provided counseling, health education, coaching, treatment plans, and advice on hypertension control; and (iii) helped patients to obtain government benefits, medical transportation, and basic needs such as housing and food. Logistic and negative binomial multivariate regression models were performed. RESULTS: Hypertension-focused coaching was associated with normal blood pressure at last visit (odds ratio (OR) = 1.47) and fewer ED visits (incidence rate ratio = 0.81). Behavioral health counseling was associated with increased self-efficacy in self-care management (OR = 3.20). CONCLUSIONS: Our findings suggested that increased focus on these practices may lead to better hypertension outcomes among patients who are low-income and uninsured populations.

Evaluation of Text Messaging Effects on Health Goal Adherence in the Management of Participants With Chronic Diseases.

PURPOSE OF THE STUDY: The study purpose was to determine whether text messaging health-related messages, questions, and reminders to community case management participants with chronic diseases increased health goal adherence. PRIMARY PRACTICE SETTING: This study was conducted by a rural community case management, hospital-affiliated program. METHODOLOGY AND SAMPLE: This pilot, quasiexperimental study measured health goal adherence, the degree to which an individual continues work toward self-identified health goals under limited supervision, before and after a text messaging intervention. All participants were receiving community case management services for chronic disease. Participants completed baseline and follow-up surveys regarding a text messaging intervention. RESULTS: Most participants were African Americans, had diabetes, with equal numbers by gender, an average age of 57.8 years, and had been in the community case management program for 3-5 years. Participants were sent a total of 1,654 messages/questions and 571 reminders. At follow-up, respondents who reported "Did you work on your health goals?" increased significantly (p = .0430). However, no differences were found for "Did you go to your health care appointments?" and "Did you take your medicines as you should?" No differences were noted in reported visits/hospitalizations overall or specifically at the research site. Lastly, study member visit/hospitalization numbers did not change significantly at follow-up. IMPLICATIONS FOR COMMUNITY CASE MANAGEMENT PRACTICE: Although text messaging is not meant to take the place of face-to-face interactions, it does provide community case managers with an additional modality of communication with patients to offer support and important care reminders, and to facilitate patient participation in his or her care.

Effect of ABCDE Bundle Implementation on Prevalence of Delirium in Intensive Care Unit Patients.

BACKGROUND: The ABCDE bundle incorporates multidisciplinary measures to improve and/or preserve patients' physical, functional, and neurocognitive status through awakening and breathing coordination, delirium prevention and management, and early physical mobility. OBJECTIVES: To quantify the prevalence and duration of delirium in patients in the intensive care unit (ICU) before and after implementation of the ABCDE bundle. METHODS: Delirium prevalence was defined as the percentage of patients who had at least 1 positive delirium score on the Intensive Care Delirium Screening Checklist (ICDSC) during the ICU stay; delirium duration was the number of days during the ICU stay that a positive ICDSC score was noted. Retrospective data were collected from before and after implementation of the ABCDE bundle. RESULTS: Of the 159 records reviewed (80 before and 79 after bundle implementation), most were for white men (mean age, 66.3 years). After implementation of the ABCDE bundle, the prevalence of delirium decreased significantly (from 38% to 23%, P = .01) and the mean number of days of delirium decreased significantly (from 3.8 to 1.72 days, P < .001). The number of patients with delirium-free stays increased after bundle implementation. CONCLUSIONS: Implementation of the ABCDE bundle led to significant decreases in the prevalence and duration of delirium in ICU patients.

Timing of Newborn Pulse Oximetry Screenings for Critical Congenital Heart Defects Before Discharge.

OBJECTIVE: To determine if there would be positive results from a second pulse oximetry screening (POS) completed for newborns at discharge at 28 to 48 hours of age in addition to the newborn POS completed at 24 to 25 hours of age. DESIGN: Prospective descriptive research study. SETTING: Rural, mid-Atlantic, 13-bed, level I hospital. PARTICIPANTS: Newborns (N = 1,002) at 35 weeks' gestation or older discharged from the newborn nursery. METHODS: Registered nurses (RNs) performed POS at 24 to 25 hours of age (POS 1) and at discharge but less than 48 hours of age (POS 2). Data related to critical congenital heart defects were collected. RESULTS: There were no positive POS results (O2 saturation ≤ 90%) at POS 1 or POS 2, and no additional diagnostic tests were ordered as a result of POS. Although one full-term newborn had negative results at POS 1 and POS 2, the RN identified a murmur, and a subsequent echocardiogram was used to detect tetralogy of Fallot and pulmonary atresia. The RNs detected concerning conditions in 14 newborns that resulted in 28 additional tests, including echocardiograms (9), chest x-ray imaging (8), laboratory testing (7), electrocardiograms (3), and ultrasound imaging (1). CONCLUSIONS: The POS-positive result rate was 0 for newborns at POS 1 and POS 2. Therefore, our study findings supported Maryland's mandate of one POS completed within 24 to 48 hours of birth. Nurses must continue to be vigilant about assessing newborns, including screening for critical congenital heart defects and congenital heart defects.

A prospective, randomized, single-blind study evaluating the effectiveness, tolerability, and cost of colonoscopy bowel preparations.

Colorectal cancer, the third most common cancer in U.S. adults, can be detected early through colonoscopy. Thorough bowel preparation facilitates successful colonoscopy. Effectiveness, tolerability, and costs of 3 bowel preparations were compared in patients undergoing outpatient screening colonoscopy. In this prospective, randomized, single-blind study, comparing three preparation protocols, 209 of 276 consented subjects completed (Protocol [N = 67] = HalfLytely© 1 L × 2 doses and bisacodyl 5 mg delayed release tablets × 2 tablets; Protocol 2 [N = 74] = MiraLAX® 5 tablespoons × 2 doses and bisacodyl 5 mg tablets × 2 tablets; and Protocol 3 [N = 68] = MoviPrep 1 L × 2 doses). Patients completed symptom diaries and a gastroenterologist rated effectiveness. Most subjects were White females, aged 59 years (mean). Protocol 1 was the most effective regimen, but Protocol 2 was the most tolerable and cost-effective. While the three bowel protocol differences were not statistically significant for all outcomes measured, there were clinically meaningful differences. As Protocol 1 was most effective, HalfLytely© and bisacodyl is recommended for patients prior to colonoscopy. For patients who cannot tolerate HalfLytely© or MoviPrep, or with financial concerns, Protocol 2 (MiraLAX® & bisacodyl) is alternatively recommended.

Sodium content of popular commercially processed and restaurant foods in the United States.

PURPOSE: The purpose of this study was to provide baseline estimates of sodium levels in 125 popular, sodium-contributing, commercially processed and restaurant foods in the U.S., to assess future changes as manufacturers reformulate foods. METHODS: In 2010-2013, we obtained ~ 5200 sample units from up to 12 locations and analyzed 1654 composites for sodium and related nutrients (potassium, total dietary fiber, total and saturated fat, and total sugar), as part of the U.S. Department of Agriculture-led sodium-monitoring program. We determined sodium content as mg/100 g, mg/serving, and mg/kcal and compared them against U.S. Food and Drug Administration's (FDA) sodium limits for "low" and "healthy" claims and to the optimal sodium level of < 1.1 mg/kcal, extrapolating from the Healthy Eating Index-2010. RESULTS: Results from this study represent the baseline nutrient values to use in assessing future changes as foods are reformulated for sodium reduction. Sodium levels in over half (69 of 125) of the foods, including all main dishes and most Sentinel Foods from fast-food outlets or restaurants (29 of 33 foods), exceeded the FDA sodium limit for using the claim "healthy". Only 13 of 125 foods had sodium values below 1.1 mg/kcal. We observed a wide range of sodium content among similar food types and brands. CONCLUSIONS: Current sodium levels in commercially processed and restaurant foods in the U.S. are high and variable. Targeted benchmarks and increased awareness of high sodium content and variability in foods would support reduction of sodium intakes in the U.S.

Evaluation of fall risk assessment tools for psychiatric patient fall prevention: a comparative study.

The Hendrich II Fall Risk Model™ (Hendrich II) is used to determine patient fall risks. However, the WilsonSims Fall Risk Assessment Tool (WSFRAT) is more specific to psychiatric patients. The current study tested the Hendrich II and WSFRAT simultaneously to determine which tool was the most predictive for patient falls in a psychiatric population. Fall risk assessments using the Hendrich II and WSFRAT tools were completed through discharge. Fall risk assessment scores, medications, and falls data were documented. Fifty patients who met eligibility criteria generated 319 observations; of the 50 patients, two (4%) experienced falls. Sensitivity was 100% for the Hendrich II and WSFRAT, with all patients properly categorized as high risk for falling. Both assessments had similar specificity (Hendrich II = 67.8%; WSFRAT = 63.1%). Both tools have similar specificity; thus, additional research is warranted.

What causes near-misses and how are they mitigated?

OBJECTIVES: The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events. BACKGROUND: Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients. METHODS: Study participants were RNs who completed a survey about a self-reported near-miss or another RN's near-miss they'd witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes. RESULTS: A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the near-misses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions. CONCLUSIONS: Hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Education about mitigating techniques for near-misses is imperative for RNs.

Exploring how nurses and managers perceive shared governance.

BACKGROUND: Nurse managers have a pivotal role in the success of unit-based councils, which include direct care nurses. These councils establish shared governance to provide innovative, quality-based, and cost-effective nursing care. PURPOSE: This study explored differences between direct care nurses' and nurse managers' perceptions of factors affecting direct care nurses' participation in unit-based and general shared governance activities and nurse engagement. METHODS: In a survey research study, 425 direct care RNs and nurse managers were asked to complete a 26-item research survey addressing 16 shared governance factors; 144 participated (response rate = 33.8%). RESULTS: Most nurse participants provided direct care (N = 129, 89.6%; nurse managers = 15, 10.4%), were older than 35 (75.6%), had more than 5 years of experience (76.4%), and worked more than 35 hours per week (72.9%). Direct care nurses' and managers' perceptions showed a few significant differences. Factors ranked as very important by direct care nurses and managers included direct care nurses perceiving support from unit manager to participate in shared governance activities (84.0%); unit nurses working as a team (79.0%); direct care nurses participating in shared governance activities won't disrupt patient care (76.9%); and direct care nurses will be paid for participating beyond scheduled shifts (71.3%). Overall, 79.2% had some level of engagement in shared governance activities. Managers reported more engagement than direct care nurses. CONCLUSIONS: Nurse managers and unit-based councils should evaluate nurses' perceptions of manager support, teamwork, lack of disruption to patient care, and payment for participation in shared governance-related activities. These research findings can be used to evaluate hospital practices for direct care nurse participation in unit-based shared governance activities.

Effect of preoperative incentive spirometry patient education on patient outcomes in the knee and hip joint replacement population.

PURPOSE: This study examined the effects of preoperative incentive spirometry (IS) education (POISE) on postoperative outcomes for knee and hip total joint replacement patients. DESIGN: In this prospective study, 140 patients were randomized to Group 1 (POISE intervention = 50 completing) or Group 2 (no intervention = 56 completing) (34 dropped). METHODS: The Group 1 intervention consisted of formal instruction preoperatively for IS home use, postoperative use, and IS volumes documentation. Group 2 patients received no intervention. Patients recorded postoperative IS volumes, which were used to determine return to baseline volume. FINDINGS: One hundred six patients completed the study. Most were Caucasian females averaging 64 years. Although IS return to baseline volume time was not significantly different between groups, POISE patients had fewer postoperative complications, hospital days, and charges. POISE patients ranked the intervention as helpful. CONCLUSIONS: Although IS volumes were not significantly different between groups, POISE patients had better outcomes and ranked the intervention as helpful.

Obesity status and colorectal cancer screening in the United States.

BACKGROUND: Findings from previous studies on an association between obesity and colorectal cancer (CRC) screening are inconsistent and very few studies have utilized national level databases in the United States (US). METHODS: A cross-sectional study was conducted using data from the 2005 Medicare Current Beneficiary Survey to describe CRC screening rate by obesity status. RESULTS: Of a 15,769 Medicare beneficiaries sample aged 50 years and older reflecting 39 million Medicare beneficiaries in the United States, 25% were classified as obese, consisting of 22.4% "obese" (30 ≤ body mass index (BMI) < 35) and 3.1% "morbidly obese" (BMI ≥ 35) beneficiaries. Almost 38% of the beneficiaries had a body mass index level equivalent to overweight (25 ≤ BMI < 30). Of the study population, 65.3% reported having CRC screening (fecal occult blood testing or colonoscopy). Medicare beneficiaries classified as "obese" had greater odds of CRC screening compared to "nonobese" beneficiaries after controlling for other covariates (ORadj = 1.25; 95% CI: 1.12-1.39). CONCLUSIONS: Findings indicate that obesity was not a barrier but rather an assisting factor to CRC screening among Medicare beneficiaries. Future studies are needed to evaluate physicians' ordering of screening tests compared to screening claims among Medicare beneficiaries to better understand patterns of patients' and doctors' adherence to national CRC screening guidelines.