Seniors' and People with Disabilities' Experiences with Mandatory Medicaid Managed Care in California: Populations to Target for Additional Support during Transitions.

With more states moving people with disabilities and complex care needs into managed care, it is important to target beneficiaries for additional anticipated support before specific needs arise. In a survey of 1,521 seniors and people with disabilities in California who moved into Medicaid managed care six-16 months previously, the majority reported neutral or positive experiences with managed care continuity, access, and quality, compared with fee-for-service. Beneficiaries most likely to have negative experiences included those with poor self-rated health, functional impairment, cognitive impairment, frequent ED visits, and claims for back / osteoarthritis and cancer. Those with no specialty visits and those who had been continuously enrolled in Medicaid longer term before the transition also were more likely to report negative experiences. These populations can be targeted for assistance by health plans and Medicaid agencies. More specialty visits and longer time in Medicaid managed care also seems to improve beneficiaries' experiences.

Online smoking cessation program for Korean Americans: Randomized trial to test effects of incentives for program completion and interim surveys.

INTRODUCTION: Smoking is prevalent among Korean American men. Quitting is Winning, an Internet-based, cognitive-behavioral smoking cessation program, was developed using community-based participatory research principles. METHODS: A randomized controlled trial was used to evaluate whether participants were more likely to complete the program and quit smoking at 6-months of follow-up with additional reinforcement. The main outcomes were the proportion of participants who completed the online program and the proportion who quit smoking for at least 30days, 26weeks after enrollment, among those randomized into the high-reinforcement (HR) condition compared with those in the low-reinforcement (LR) condition. RESULTS: The study achieved a final enrollment of 403 participants including 56 women. Program completion was greater for the HR as compared to the LR condition (17% vs. 10%, p=.035). There was no significant difference in 30-day smoking cessation (intent-to-treat [ITT]) between the HR and LR conditions (9% vs. 8%, ns). Smoking cessation was greater among program completers as compared to those who did not complete the program (28% vs. 5%, p<.001). CONCLUSIONS: The addition of interim surveys and financial incentives for interim survey completion and program completion significantly increased the likelihood of program completion. Moreover, program completers were significantly more likely to quit smoking. Although smoking cessation rates did not significantly differ between the HR and LR conditions, the results suggest that future studies should explore the efficacy of larger financial incentives for program completion (Clinical Trial #NCT02584127).

Medicaid beneficiaries in california reported less positive experiences when assigned to a managed care plan.

In 2011 California began transitioning approximately 340,000 seniors and people with disabilities from Medicaid fee-for-service (FFS) to Medicaid managed care plans. When beneficiaries did not actively choose a managed care plan, the state assigned them to one using an algorithm based on their previous FFS primary and specialty care use. When no clear link could be established, beneficiaries were assigned by default to a managed care plan based on weighted randomization. In this article we report the results of a telephone survey of 1,521 seniors and people with disabilities enrolled in Medi-Cal (California Medicaid) and who were recently transitioned to a managed care plan. We found that 48 percent chose their own plan, 11 percent were assigned to a plan by algorithm, and 41 percent were assigned to a plan by default. People in the latter two categories reported being similarly less positive about their experiences compared to beneficiaries who actively chose a plan. Many states in addition to California are implementing mandatory transitions of Medicaid-only beneficiaries to managed care plans. Our results highlight the importance of encouraging beneficiaries to actively choose their health plan; when beneficiaries do not choose, states should employ robust intelligent assignment algorithms.

An internet-based smoking cessation program for Korean Americans: results from a randomized controlled trial.

INTRODUCTION: Smoking is quite prevalent among Korean Americans (KAs). Quitting is Winning was developed using community-based participatory research principles as an online self-help smoking cessation program for KAs in response to feedback from our community partner who felt that most KAs prefer to quit "on their own." METHODS: A randomized controlled trial was used to evaluate this cognitive-behavioral program. The main outcome was the proportion of participants who had quit for at least 30 days, 50 weeks after enrollment, among those randomized into the Internet intervention compared with those receiving a similar program via booklet. The study had 11 online surveys administered every 5 weeks. RESULTS: The study took place between September 2005 and April 2009 and had a final enrollment of 1,112. Based on the outcome assessed at 50 weeks, there was no significant difference in 30-day smoking cessation between the Internet (11%) and booklet (13%) groups (intent-to-treat [ITT] difference = -2%, 95% CI = -6% to 2%). In post-hoc analysis, quitting was higher among participants in the Internet intervention (n = 562) who completed the online program: 26% quit compared with 10% who did not complete the program (ITT difference = 16%, 95% CI = 3%-29%). CONCLUSIONS: The Internet self-help smoking cessation program appears to help KA smokers quit, although not more than a similar program delivered via booklet. If we can get people engaged, online cessation programs have potential to reach smokers who would not or cannot participate in more traditional interventions.

Relationships between household smoking restrictions and intention to quit smoking among Korean American male smokers in California.

This cross-sectional study examined the relationships between household smoking restrictions and intentions to quit smoking among Korean American male smokers in California. We used data from the California Korean American Tobacco Use Survey (CKATUS), which was conducted in 2004 using computer-assisted telephone interviewing. Among the 2,545 respondents who participated in the CKATUS, the 387 male smokers who answered a question assessing their intention to quit smoking were included in the final analyses. In univariable analyses, smokers who reported having household smoking restrictions were more likely to intend to quit smoking as compared with those who did not (P<0.01). Other independent correlates of having an intention to quit smoking were being less than 50 yr of age, having spent more than 50% of one's life in the US, being assimilated, and having other smokers in the household. In a multiple logistic regression analysis, the significant correlates of having an intention to quit smoking were household smoking restrictions (complete or partial restriction vs. no restriction on smoking; odds ratio, 2.54; 95% confidence interval, 1.22-5.28) and absence of other smokers in the household. In conclusion, smoking restrictions in the household are associated with an intention to quit smoking among Korean American male smokers in California.

Mobile phone use and risk of tumors: a meta-analysis.

PURPOSE: Case-control studies have reported inconsistent findings regarding the association between mobile phone use and tumor risk. We investigated these associations using a meta-analysis. METHODS: We searched MEDLINE (PubMed), EMBASE, and the Cochrane Library in August 2008. Two evaluators independently reviewed and selected articles based on predetermined selection criteria. RESULTS: Of 465 articles meeting our initial criteria, 23 case-control studies, which involved 37,916 participants (12,344 patient cases and 25,572 controls), were included in the final analyses. Compared with never or rarely having used a mobile phone, the odds ratio for overall use was 0.98 for malignant and benign tumors (95% CI, 0.89 to 1.07) in a random-effects meta-analysis of all 23 studies. However, a significant positive association (harmful effect) was observed in a random-effects meta-analysis of eight studies using blinding, whereas a significant negative association (protective effect) was observed in a fixed-effects meta-analysis of 15 studies not using blinding. Mobile phone use of 10 years or longer was associated with a risk of tumors in 13 studies reporting this association (odds ratio = 1.18; 95% CI, 1.04 to 1.34). Further, these findings were also observed in the subgroup analyses by methodologic quality of study. Blinding and methodologic quality of study were strongly associated with the research group. CONCLUSION: The current study found that there is possible evidence linking mobile phone use to an increased risk of tumors from a meta-analysis of low-biased case-control studies. Prospective cohort studies providing a higher level of evidence are needed.

Effects of Web- and computer-based smoking cessation programs: meta-analysis of randomized controlled trials.

BACKGROUND: The effects of Web- and computer-based smoking cessation programs are inconsistent in randomized controlled trials (RCTs). We evaluated those effects using a meta-analysis. METHODS: We searched MEDLINE (PubMed), EMBASE, and the Cochrane Review in August 2008. Two evaluators independently selected and reviewed eligible studies. RESULTS: Of 287 articles searched, 22 RCTs, which included 29 549 participants with 16 050 enrolled in Web- or computer-based smoking cessation program groups and 13 499 enrolled in control groups, were included in the final analyses. In a random-effects meta-analysis of all 22 trials, the intervention group had a significant effect on smoking cessation (relative risk [RR], 1.44; 95% confidence interval [CI], 1.27-1.64). Similar findings were observed in 9 trials using a Web-based intervention (RR, 1.40; 95% CI, 1.13-1.72) and in 13 trials using a computer-based intervention (RR, 1.48; 95% CI, 1.25-1.76). Subgroup analyses revealed similar findings for different levels of methodological rigor, stand-alone vs supplemental interventions, type of abstinence rates employed, and duration of follow-up period, but not for adolescent populations (RR, 1.08; 95% CI, 0.59-1.98). CONCLUSION: The meta-analysis of RCTs indicates that there is sufficient clinical evidence to support the use of Web- and computer-based smoking cessation programs for adult smokers.

Adherence to Pap test guidelines: variation among Asians in California.

OBJECTIVES: To compare Pap screening in the previous 3 years among subgroups of Asian American women, aged 18 to 65 years. DESIGN: Analysis of data from the 2001 and 2003 California Health Interview Survey (CHIS), a cross-sectional population-based telephone survey. MAIN MEASURES: The survey elicited information from major Asian subgroups, including Chinese, Filipina, Japanese, Korean, South Asian, and Vietnamese. Surveys were administered in several languages, including Mandarin, Cantonese, Korean, and Vietnamese. Employing the Andersen behavioral model of health services utilization, this study fits logistic regression models to identify correlates of Pap screening within and across Asian American subgroups. These analyses use time living in the United States and English proficiency as acculturation measures. RESULTS: There were different independent correlates of Pap test receipt for the six Asian subgroups. English proficiency and income were independently associated with Pap screening among only one subgroup; education, time in the US, and insurance among three; and age and usual source of care among four subgroups. Unmarried women were more likely to report not having a Pap test in the past three years across all six subgroups. CONCLUSIONS: Based on these differences, programs and policies targeting the health of Asian American women should consider tailoring interventions to match the needs of different ethnic groups. Specifically, program materials should strive to be both culturally sensitive and linguistically appropriate for all target populations.

Risk factors for Chlamydia among young women in a northern california juvenile detention facility: implications for community intervention.

OBJECTIVES/GOAL: Chlamydia infections are increasing in California, with rates highest in young women aged 15 to 24. Juvenile detention facilities are important venues for screening high-risk youth who may not otherwise access care. We, therefore, sought to identify risk factors for urogenital chlamydia among young women in a county juvenile detention facility between 2002 and 2005. STUDY DESIGN: With the state Chlamydia Screening Project (ClaSP), young women booked into the county detention facility were offered urine-based screening for urogenital chlamydia. Demographics, sexual history, and behavioral risk factors were self-reported through questionnaires completed during specimen collection. RESULTS: Nine hundred and thirty-nine young women were screened for chlamydia. The 5% positivity rate remained steady over the 33-month study. Vaginal sex was reported by 82% of women, oral sex by 50%, and anal sex by 30%. Only 9% reporting anal sex always used condoms. In multivariate analysis, little distinguished those with urogenital chlamydia. Women from the southern region of the county (adjusted odds ratio, 3.5; 1.4-8.7) and surrounding urban centers (3.7; 1.2-11.4) had higher odds of infection, as did those with 2 to 3 lifetime partners (3.2; 1.2-8.2)-although there was no linear relationship between partner number and infection. Those who had been in drug/alcohol treatment had lower odds of infection (0.1; 0.01-0.6). CONCLUSIONS: Our findings support universal chlamydia testing of young women detainees. The high prevalence of unprotected anal sex highlights an important modifiable HIV risk behavior in these adolescents. Risk factors reported here should inform the integration of prevention and treatment services in correctional settings and substance abuse treatment centers.

Cancer coverage in a mainstream and Korean American online newspaper: lessons for community intervention.

OBJECTIVE: Korean Americans have higher incidence of stomach, liver, and cervical cancer than most groups in CA, USA, and generally lower rates of cancer screening. To better target community interventions, we evaluated the cancer content in a leading Korean American newspaper, the Korea Daily, compared to a mainstream newspaper from the same metropolitan area, the Los Angeles (LA) Times. METHODS: Using the online versions of each newspaper for the year 2006, we counted articles mentioning cancer and evaluated the content in a random sample of 300 articles from each newspaper. Articles were categorized by relevance of cancer content and topic(s) covered. RESULTS: Although the LA Times had a higher proportion of articles mentioning cancer, the Korea Daily had more articles that primarily focused on cancer and addressed specific types of cancer. Articles in the Korea Daily were more likely to discuss prevention, while those in the LA Times more often focused on people, politics, or research. CONCLUSIONS: Smaller, ethnic newspapers may be more amenable to messages about prevention and appropriate places to target community-focused interventions. PRACTICE IMPLICATIONS: Health practitioners should consider submitting articles to ethnic newspapers and forming partnerships with journalists to cultivate this potential.

Patient satisfaction with extended release tolterodine or oxybutynin in overactive bladder.

OBJECTIVE: To evaluate the effects of individual and condition characteristics on satisfaction with extended release tolterodine or oxybutynin in overactive bladder (OAB). METHODS: Data were from the 2005 National Health and Wellness Survey, an annual, nationally representative, self-administered, internet-based survey of 40,000+ US adults (age 18+). Inclusion criteria for analysis were diagnosed OAB and using extended release tolterodine or oxybutynin but no other prescription medications for OAB. Satisfaction with extended release tolterodine or oxybutynin was rated on a five-point scale from 1 = not at all satisfied to 5 = extremely satisfied. Linear regression was used to evaluate independent effects demographics, patient perception of OAB, duration of use, requesting of medication, type of prescribing physician, medication compliance, and mental and physical health-related quality of life (Medical Outcomes Study, Eight-item Short-Form Health Survey; SF-8) on treatment satisfaction. RESULTS: There were 345 patients who met the inclusion criteria. Apparent predictors of medication satisfaction, in order of magnitude of effect, were: feelings that OAB is just an inconvenience (standardized beta = -0.28; p < 0.001); less impact of OAB on daily life (standardized beta = 0.24; p < 0.001); longer duration of use (standardized beta = 0.10; p = 0.052); overwhelming urges to urinate (standardized beta = 0.10; p = 0.061); younger age (standardized beta = -0.10; p = 0.054); and more frequent medication use (standardized beta = 0.09; p = 0.096). LIMITATIONS: Data were cross-sectional and self-reported by patients via the internet. CONCLUSIONS: Patient treatment satisfaction is affected by perceptions of OAB symptoms and impact, as well as consistent, long-term use of prescription treatments. Clinicians should reinforce to patients the importance of long-term compliance for successful treatment.

Quality of life among bipolar disorder patients misdiagnosed with major depressive disorder.

OBJECTIVE: Bipolar disorder is frequently misdiagnosed as major depressive disorder (MDD). We aim to quantify the prevalence of misdiagnosed bipolar disorder among the depression population and evaluate the quality-of-life (QOL) impact of misdiagnoses. METHOD: Data were collected from 2 self-administered, cross-sectional studies in 2003. Patients participating in The Bipolar Disorder Misdiagnosis Study (N = 1156) were previously diagnosed with depression, experienced a depressive episode within the past year, and had no previous diagnosis of bipolar disorder or schizophrenia. Patients who experienced a manic episode in the past year, based on DSM-IV criteria, were classified as misdiagnosed. Patients participating in The Bipolar Disorder Project (N = 1214) self-reported a diagnosis of bipolar disorder and were recruited through community mental health centers and support groups. Quality of life was assessed via the Psychological General Well-Being (PGWB) Index and Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8). Demographic differences between groups were controlled using linear regression models. RESULTS: Of the diagnosed MDD sample, 14.3% met criteria for misdiagnosed bipolar disorder. When controlling for demographic differences, the PGWB overall score for the misdiag-nosed averaged 12.77 (p < .001) points lower than that of MDD patients and 9.55 (p < .001) points lower than that of diagnosed bipolar disorder patients. The average SF-8 mental component summary score for the misdiagnosed was 5.85 (p < .001) points lower than that of MDD patients and 3.18 (p = .002) points lower than that of diagnosed bipolar disorder patients. CONCLUSION: Misdiagnosis is associated with poorer QOL than MDD or diagnosed bipolar disorder, which are recognized as having a considerable impact on QOL.

The impact of anemia on quality of life and healthcare resource utilization in patients with HIV/AIDS receiving antiretroviral therapy.

OBJECTIVE: To understand the impact of anemia on health-related quality of life (HRQOL) and healthcare resource utilization (HRU) in patients with HIV/AIDS. METHODS: In 2003, adults with HIV/AIDS were recruited through 114 US STD/HIV clinics to complete self-administered questionnaires. Adults reporting anemia as a side-effect of antiretroviral therapy (ART) during the past month were considered anemic. HRU was evaluated by emergency room (ER) visits, days of hospitalization, and healthcare provider visits in the past 6 months. The SF-8 was used to measure HRQOL. Linear regression was used to evaluate independent effects of anemia on HRQOL and HRU controlling for demographics, years since HIV diagnosis, HIV viral load, CD4 + count, and ART use. RESULTS: 2044 patients were enrolled, with 498 (24%) experiencing anemia. Anemic patients had lower SF-8 summary scores (mental: 38.2 +/- 11.6 vs. 42.9 +/- 11.9, p < 0.001; physical: 40.1 +/- 10.0 vs. 45.5 +/- 10.4, p < 0.001) than nonanemic patients. HRU in the anemic group was significantly higher (p < 0.05), with respect to percentage of patients visiting ER, mean number of ER visits, mean number of days hospitalized, and mean number of total visits to providers. In linear regression models, anemic patients had mental and physical HRQOL scores more than 4 points lower than nonanemic patients (p < 0.001 for both). Additionally, anemic patients had 2.7 more visits to healthcare providers (p < 0.001). LIMITATIONS: Data were cross-sectional, self-reported by patients, and did not include clinical measures of anemia. CONCLUSION: Based on this survey, self-reported anemia appears to be associated with worsened HRQOL and greater HRU among HIV/AIDS patients using ART.

Treatment satisfaction with a transdermal contraceptive patch or oral contraceptives.

OBJECTIVE: The study was conducted to examine the influence of demographics, health-related quality of life (HRQL) and duration of use on satisfaction with the transdermal contraceptive patch or oral contraceptives (OCs). METHODS: In this cross-sectional analysis of the 2004 National Health and Wellness Survey (NHWS), women were currently using the patch (n=257) or OCs (n=1824). Outcome variable was a five-point satisfaction scale (1=not at all; 5=extremely). Satisfaction rates were computed as the percentage of patients reporting a 4 or 5. Independent variables included demographics, HRQL (SF-8), duration of use, and treatment (patch or OCs). Logistic regression evaluated association of independent variables. RESULTS: Patch use was associated with significantly higher satisfaction than OCs (OR=2.05; 95% CI=1.34-3.15; p=.001) in the logistic regression model. Months using product (p<.001), days used product in past month (p<.001) and mental well-being (p=.02) were other variables associated with satisfaction. CONCLUSION: Patch use, duration of use and mental well-being were associated with satisfaction.

Relationship between preventative physical health care and mental health in individuals with schizophrenia: a survey of caregivers.

The relationship between preventative physical health care and mental health in individuals with schizophrenia was assessed retrospectively by questionnaires completed by 504 caregivers. Psychiatric symptom severity and quality-of-life data on 332 respondents were evaluable. Suboptimal preventative physical health care was defined as absence of > or =2 examinations within a specified time: physical and dental within 12 months, eye within 24 months. Findings revealed similar use of mental health care services for all individuals, but those in the suboptimal physical health care group (n = 93 [28%]) had a lower quality of life (p < .011), more negative symptoms (p < .009), less paid employment (p < .001), and more alcohol/drug abuse (p = .02). These findings suggest that mental health care providers should play a more active role in monitoring the basic physical health care of patients with schizophrenia.

Obesity as a risk factor for antipsychotic noncompliance.

OBJECTIVE: Weight gain is a common side effect of antipsychotic medications and is of particular concern with most of the newer "atypical" antipsychotics. It is, therefore, increasingly important to understand the impact of obesity and perceived weight problems on compliance with these medications. METHODS: A survey of treatment and health issues was mailed to local chapters of the National Alliance for the Mentally Ill (NAMI) and National Mental Health Association (NMHA), who distributed them to people with schizophrenia. Noncompliance was defined as a self-report of missing any antipsychotic medication in the previous month. The primary independent variables were (1) body mass index (BMI; weight [kg]/height [m2])-categorized as normal (< 25, n = 73), overweight (25-30, n = 104), or obese (> 30, n = 100)-and (2) subjective distress over weight gain. Other independent variables included demographics, medication attitudes, and treatment satisfaction. RESULT: BMI status and subjective distress from weight gain were predictors of noncompliance. Obese individuals were more than twice as likely as those with a normal BMI to report missing their medication (OR = 2.5; CI 1.1-5.5). A comprehensive model suggested that the primary mediator of noncompliance was distress over weight gain. CONCLUSIONS: There appears to be a significant, positive association between obesity and subjective distress from weight gain and medication noncompliance, even when accounting for other possible confounding factors.

The impact of weight gain on quality of life among persons with schizophrenia.

Weight gain has been associated with the use of antipsychotic medications, and research has linked obesity with reduced quality of life. This study sought to assess the impact of weight gain on persons with schizophrenia who are taking antipsychotic medications. The Psychological Well-Being Index, a measure of quality of life, was distributed to individuals with schizophrenia who belonged to mental health associations. Among 286 respondents, 56 percent gained no weight over a six-month period while taking antipsychotic medications, 19 percent gained one to ten pounds, 12 percent gained 11 to 20 pounds, and 14 percent gained more than 20 pounds. When gender and use of antipsychotics were controlled for, weight gain was related to poorer quality of life and reduced well-being and vitality. Clinicians should consider the effect of weight gain on quality of life when prescribing antipsychotics and should help patients adopt weight maintenance behaviors.

The impact of symptom severity on the cost of Alzheimer's disease.

OBJECTIVES: ITo examine the economic impact of Alzheimer's disease (AD) as the disease progresses on patients' medical costs and caregivers' productivity. DESIGN: A 12-page, self-administered mail survey, fielded in November 1999. SETTING: Households with AD caregivers, selected from a nationwide (U.S.) consumer database. PARTICIPANTS: One thousand seven hundred fifteen caregivers of noninstitutionalized AD patients. MEASUREMENTS: Disease progression was measured using a scale of symptom frequency and measures of instrumental and physical functioning. Cost components included hospital days, physician visits, and emergency room visits. Lost productivity was assessed using hours per week that caregivers provided care and the number of days that they missed from work because of caregiving. RESULTS: The direct costs of caring for AD patients for 6 months totaled $3,129, whereas the indirect costs were $26,080. Patients with more-frequent symptoms used all healthcare resources, including the hospital, emergency room, and physicians, more often than those with less-frequent symptoms. Those with lower levels of physical and instrumental functioning also used the hospital and physicians more often than those with higher levels of physical and instrumental functioning. Caregivers of these more severely impaired patients spent more hours providing care and reported missing more work than those caring for higher-functioning patients. These relationships remained after controlling for potentially confounding factors. CONCLUSIONS: This large study of patients at all stages of AD shows that the direct and indirect costs of AD are considerably lower for patients with fewer symptoms. Longitudinal studies will determine the impact on the overall cost of care of interventions that reduce symptoms and maintain patients at earlier stages of the disease.