Development of a survey instrument to measure patient experience of integrated care.

BACKGROUND: Healthcare systems are working to move towards more integrated, patient-centered care. This study describes the development and testing of a multidimensional self-report measure of patients' experiences of integrated care. METHODS: Random-digit-dial telephone survey in 2012 of 317 adults aged 40 years or older in the San Francisco region who had used healthcare at least twice in the past 12 months. One-time cross-sectional survey; psychometric evaluation to confirm dimensions and create multi-item scales. Survey data were analyzed using VARCLUS and confirmatory factor analysis and internal consistency reliability testing. RESULTS: Scales measuring five domains were confirmed: coordination within and between care teams, navigation (arranging appointments and visits), communication between specialist and primary care doctor, and communication between primary care doctor and specialist. Four of these demonstrated excellent internal consistency reliability. Mean scale scores indicated low levels of integration. CONCLUSION: These scales measuring integrated care capture meaningful domains of patients' experiences of health care. The low levels of care integration reported by patients in the study sample suggest that these types of measures should be considered in ongoing evaluations of health system performance and improvement. Further research should examine whether differences in patient experience of integrated care are associated with differences in the processes and outcomes of care received.

Patient and clinician views on comparative effectiveness research and engagement in research.

AIMS: Describe and compare patient and primary care clinician attitudes about comparative effectiveness research (CER) and inclusion of patients and clinicians as partners in clinical research. MATERIALS & METHODS: Online survey of patients (n = 900) and primary care clinicians (n = 750) from opt-in survey panels. RESULTS: Nearly half (45%) of clinicians were not familiar with CER, but after reviewing a definition of CER, most (76%) agreed that it can improve patient care. Patients and clinicians indicated interest in engagement as research partners (66% and 55%, respectively). Lack of time was the most commonly endorsed barrier. CONCLUSION: Attitudes toward CER and engagement in clinical research were generally favorable. Identified facilitators and barriers point to strategies for enhancing patient and clinician engagement in research.

Patient perceptions of integrated care: confused by the term, clear on the concept.

PURPOSE: Health care reform in the US has introduced terms such as 'the patient-centered medical home' and 'integrated care' that are often unclear and unfamiliar to patients. This study explored patient experiences with the functional domains of integrated care. THEORY AND METHODS: Patients first wrote their definitions of integrated care and then participated in focus group discussions about their experiences with the health care system. Transcripts were analyzed for thematic content. RESULTS: Forty-four patients participated in one of seven focus groups in San Francisco, CA in English and Spanish. Many patients were not clear about the meaning of the term integrated care. However, patients described experiences largely reflected in an existing conceptual model of integrated care and the importance of coordination within and across teams and with community resources, continuity and sharing of information, and patient engagement. Patients with high medical needs described the ubiquitous challenges they faced in experiencing coordinated care. CONCLUSIONS: Patients may not understand the term integrated care but are relatively clear on what the concept of integrated care entails and support its successful implementation. Patients and their families are at the center of integrated care, and health systems need to support and empower them to successfully navigate the medical neighborhood.

The association among specialty, race, ethnicity, and practice location among California physicians in diverse specialties.

BACKGROUND: Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non-primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists. OBJECTIVE: We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities. METHODS: Using California Medical Board Physician Licensure Survey (2007) data for 48388 physicians, we geo-coded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas. RESULTS: We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22-2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non-primary care specialties. CONCLUSION: In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.

Effect of closure of a local safety-net hospital on primary care physicians' perceptions of their role in patient care.

PURPOSE We examined how the closure of a large safety-net hospital in Los Angeles County, California, affected local primary care physicians. METHODS We conducted semistructured interviews with 42 primary care physicians who practiced in both underserved and nonunderserved settings in Los Angeles County. Two investigators independently reviewed and coded transcripts. Three investigators used pile-sorting to sort the codes into themes. RESULTS Overall, 28 of 42 physicians (67%) described some effect of the hospital closure on their practices. Three major themes emerged regarding the impact of the closure on the affected physicians: (1) reduced local access to specialist consultations, direct hospital admissions, and timely emergency department evaluation; (2) more patient delays in care and worse health outcomes because of poor patient understanding of the health care system changes; and (3) loss of colleagues and opportunities to teach residents and medical students. CONCLUSIONS Physicians in close proximity to the closed hospital-even those practicing in nonunderserved settings-reported difficulty getting their patients needed care that extended beyond the anticipated loss of inpatient services. There is a need for greater recognition of and support for the role primary care physicians play in coordinating care; promoting continuity of care; and informing patients, clinic administrators and policy makers about system changes during such transitions.

Increased patient delays in care after the closure of Martin Luther King Hospital: implications for monitoring health system changes.

BACKGROUND: The safety net system remains an important part of the health care system for uninsured and minority populations, however, the closure of safety net hospitals changes the availability of care. Using community-based participatory research methods, we explored the impact of hospital closure among late middle aged and elderly racial/ethnic minorities in South Los Angeles. METHODS: Telephone survey of participants in both 2008, after hospital closure, and 2003, before hospital closure, who self-identified as African American or Latino, were over the age of 50 and lived in zip codes of South Los Angeles. We developed multiple logistic regression models on imputed data sets weighted for non-response and adjusted for self-reported measures of demographic and clinical characteristics to examine the odds of reporting delays in care. RESULTS: After adjusting for covariates known to influence access to care and distributed differently in the two survey samples, we found significantly greater delays in care. Following the closure of the Martin Luther King, Jr. safety net hospital, the adjusted odds ratios were 1.70 (95% CI 1.01, 2.87) for delays in care, 1.88 (95% Cl 1.06, 3.13) for problems receiving needed medical care, and 2.62 (95% CI 1.46, 4.67) for seeing a specialist. CONCLUSIONS: Our survey of older minority adults in South Los Angeles found increased delays in access to care for needed medical services after the closure of Martin Luther King, Jr. Hospital. As health care reform unfolds, monitoring for changes in access to care that may result from new policies will be important to address future disparities, particularly for vulnerable populations.

Do physicians with self-reported non-English fluency practice in linguistically disadvantaged communities?

BACKGROUND: Language concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP. OBJECTIVE: To investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP. DESIGN: Cross-sectional cohort study. PARTICIPANTS: A total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001-2007. MEASURES: Self-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households. METHODS: Practice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status. RESULTS: Physicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63-1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43-1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency. CONCLUSIONS: Physicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.

The vulnerability of middle-aged and older adults in a multiethnic, low-income area: contributions of age, ethnicity, and health insurance.

This community-partnered study was developed and fielded in partnership with key community stakeholders and describes age- and race-related variation in delays in care and preventive service utilization between middle-aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self-identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self-reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14-23) and problems obtaining needed medical care (APP=15%, 95% CI=12-20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33-56) and problems obtaining needed medical (APP=33%, 95% CI=22-45) and specialty care (APP=26%, 95% CI=16-39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.

Self-reported fluency in non-english languages among physicians practicing in California.

BACKGROUND AND OBJECTIVES: With increasing numbers of people with limited English proficiency in the United States, there is growing concern about the potential adverse effect of language barriers on patient care. We sought to compare the non-English language fluency of practicing physicians by physician race/ethnicity and location of medical school education. METHODS: We used cross-sectional analyses of California Medical Board Survey (2007) data of 61,138 practicing physicians. Measures examined were self-reported physician language fluency in 34 languages, race/ethnicity, and medical school of graduation. RESULTS: Forty-two percent of physicians reported having fluency in at least one language other than English. Fifty-six percent of international medical graduates (IMGs) reported fluency in a language other than English, compared to 37% of US medical graduates (USMG). Although the majority of physicians with fluency in Spanish are not Latino, fluency in Asian languages is primarily restricted to physicians who are of Asian race/ethnicity. Eighty-seven percent of physicians with fluency in Mandarin, Cantonese, or other Chinese languages are of Chinese ethnicity. A similar association between ethnicity and fluency was found for Southeast Asian languages, Pacific Island languages, and South Asian languages. IMGs constituted more than 80% of the physicians with fluency in Arabic, South Asian, and Pacific Islander languages. CONCLUSIONS: IMGs contribute to the diversity of languages spoken by California physicians.