Primary Care Access for All: A Roadmap for Addressing the Primary Care Crisis in Rhode Island.

BACKGROUND: Primary care in Rhode Island is in crisis. The dearth of primary care providers is already affecting access to services and the situation is likely to worsen unless major steps are taken. There are inadequate numbers of trainees in primary care medical residencies, nurse practitioner (NP) and physician assistant (PA) training programs who plan to practice primary care in our state. The Care Transformation Collaborative of RI (CTC-RI) has assembled a broadly representative task force of physicians, NPs, PAs, and others to build a strong and robust primary care delivery system across the state that recruits, trains, retains, and sustains primary care providers. Study Methods and Design: Program directors from all primary care medical residencies, NP, and PA programs were asked to provide data on their programs, including the number of new trainees per year, total enrollment, and information on recent year graduates, including the total number, the number entering primary care, and the number entering primary care who plan to practice in RI. PRIMARY RESULTS: Of the 106 graduates from primary care residencies in RI in academic year 2002-23, only 15 (14%) planned to provide primary care in Rhode Island. Similarly, of the 144 NP and PA graduates in primary care programs, only 48 (33%) planned to provide primary care in the state. PRINCIPAL CONCLUSIONS: Given the high rate of primary care provider burnout, reduction in patient care hours, and retirement, primary care access will be further eroded unless major steps are taken. The CTC-RI Task Force on Primary Care Provider Workforce has produced a strategic roadmap to address these issues.

The Unique Value Proposition of Pediatric Health Care.

This document provides a framework for the value proposition of pediatric health care. It is intended to provide a succinct set of principles for establishing this proposition that demonstrates the short- and long-term value to the child and family, the health care system, and society as a whole.

True self-attributions shape judgments of blame in the context of addiction-relevant crime.

In three studies, we examined how attributing the criminal actions of a drug-addicted offender to their "true self" influences perceptions of their blameworthiness. Study 1 revealed that attributing a drug-addicted offender's crime (theft) to his true self positively predicted judgments of the offender's blameworthiness for the crime. Study 2 employed an experimental design and revealed that information connecting a crime (vs. not connecting) to an addicted offender's true self led to greater judgments of blame, whereas learning that the offender had (vs. did not have) a genetic predisposition to addiction mitigated blame. In Study 3, participants read a vignette about a drug-addicted thief whose addiction began with a doctor's prescription, a drug-addicted thief whose addiction began with recreational drug use, or a thief with no mention of addiction. Participants in the prescription condition, but not the recreational use condition, attributed theft to the offender's true self less and ascribed less blame for the crime, relative to the no addiction condition. Furthermore, participants attributed the addiction less to the offender's true self and assigned less blame to the offender for his addiction in the prescription (vs. recreation) condition. Overall, our studies suggest that lay intuitions about true selves robustly guide people's judgments about blame in the context of crimes involving drug-addicted offenders.

Birth Stories, Support, and Perinatal Emotional Health among Minority Adolescent Mothers: A Mixed Methods Study.

STUDY OBJECTIVE: To explore minority, adolescent birth and perinatal experiences to inform and improve quality of care for this unique group. DESIGN: Mixed quantitative and qualitative study guided by Bourdieu's Social Fields framework. SETTING: Clinic dedicated to parenting adolescents, and a local charter school founded to serve pregnant and parenting young adults. PARTICIPANTS: Sample size for quantitative data: n = 27; qualitative data: n = 14. Average age was 16.39 years (SD = 1.29); most self-identified as Latina/Hispanic or African American/Black/Afro-Caribbean/African. INTERVENTIONS AND MAIN OUTCOME MEASURES: We used 2 validated surveys: Birth Satisfaction Scale-Revised (BSS-R), and the Postpartum Worry Scale-Revised (PWS-R). The BSS-R has 10 items, and quantifies labor and delivery experiences. The PWS-R has 20 items, and quantifies maternal, infant, and social-emotional worries. The qualitative, semistructured 30-minute interviews with a subset of survey respondents further explored perinatal mental health, labor experiences, and support networks. RESULTS: BSS-R data resulted in an average score of 25.14 (SD = 5.35), which correlated to moderate satisfaction with birth experience (range, 0-40 with 0 = most negative). The PWS-R average score of 55.79 (SD = 21.06) indicated elevated postpartum worry (range, 20-100 with 20 = most worry). Qualitative interviewees worried about relationships and newborn well-being; support networks fluctuated; distinct events, pain, and fear during labor dominated birth stories. Advice for peers included: tending to social support, stress, and self-care. Nonjudgmental communication, empathy, and emotional connection were desired attributes of their health care team. Participants had anxiety related to social networks and newborn care. Although birth experiences were moderately positive, they were also described as stressful. However, participants were resourceful, insightful, and took advantage of social supports. CONCLUSION: Birth experiences, patterns of stress, and support networks are uniquely identified and utilized by adolescent mothers. Being heard and feeling connected to providers empowered this group of young, minority adolescents. Participant advice could inform future educational courses, programs, and hospital innovations for perinatal adolescents.

The Memory Quilt: Heart-and-Hands Learning for Palliative Care.

Nursing students' learning of adult and pediatric palliative care is a daunting experience. An effective initial teaching strategy using a Memory Quilt activity can improve nursing students' interpersonal and communication skills and help prepare them for end-of-life caring. These skills help students meet patient and family needs, as they transition to care settings.

Redesigning Health Care Practices to Address Childhood Poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Partnering for health: collaborative leadership between a community health center and the YWCA central Massachusetts.

BACKGROUND: A collaborative partnership among community-based organizations (CBOs)-a community-health center, a YWCA, and 2 academic health centers-developed and implemented open access to physical activity for health center patients. OBJECTIVE: To describe partnership approach taken by 2 CBOs; determine staffs' views of this unique partnership, highlight aspects of the partnership that contributed to its success, identify challenges and mechanisms for overcoming them, and note lessons learned. Assess health center patients' use of YWCA facility. METHODS: Usage data were obtained from YWCA records. Staff were interviewed using primarily open-ended questions. Inductive approach was used to analyze qualitative data. RESULTS: The approach to partnership was largely organic, without formal working documents; nevertheless, the partnership reflected the organizations' missions. Over 4 years, 1134 health center patients made more than 23 000 visits to the YWCA. Responses of health center staff and provider interviewees about partnership processes sorted into the following categories: partnership description and results, partnership benefits, challenges, lessons learned, and advice to other CBOs. YWCA staff interviewee responses reflected the categories: staffing, clientele, and public face. Comments also included challenges, lessons learned, and advice to other YWCAs. CONCLUSIONS: This partnership achieved notable successes largely because (a) it formed to serve a specific purpose that met both agencies' goals, (b) leaders made sustained commitments, and (c) it managed conflict. The partnership has taken on new projects over time; new ideas for improving access and service to underserved patients continue to emerge. Interorganizational trust and allegiance have been key to addressing challenges; nevertheless, the organic nature of the partnership's origins and the challenges of success have meant that the partnership has restructured its agreement and, to avoid being overwhelmed, limited new patient use.

Low vitamin D status among obese adolescents: prevalence and response to treatment.

PURPOSE: To explore the prevalence of low vitamin D status among obese adolescents and to examine the effect of current management of low vitamin D status in these patients. METHODS: A retrospective chart review of obese adolescents who had been screened for vitamin D status by serum total 25-hydroxyvitamin D (25(OH)D) level. Vitamin D deficiency was defined as 25(OH)D level of <20 ng/mL, vitamin D insufficiency as 25(OH)D level of 20-30 ng/mL, and vitamin D sufficiency as 25(OH)D level of >30 ng/mL. Adolescents with vitamin D deficiency were treated with 50,000 IU of vitamin D once a week for 6-8 weeks, whereas adolescents with vitamin D insufficiency were treated with 800 IU of vitamin D daily for 3 months. Repeat 25(OH)D was obtained after treatment. RESULTS: The prevalence rate of low vitamin D status among 68 obese adolescents (53% females, 47% males, age: 17 ± 1 years, body mass index: 38 ± 1 kg/m(2), Hispanic: 45%, African American: 40%, Caucasian: 15%) was 100% in females and 91% in males. Mean (±SE) 25(OH)D level was significantly higher in summer (20 ± 8 ng/mL) than in spring (14 ± 4 ng/mL, p < .02), and significantly lower in winter (15 ± 7 ng/mL) than in fall (25 ± 15 ng/mL, p < .05). Although there was a significant (p < .00001) increase in mean 25(OH)D after the initial course of treatment with vitamin D, 25(OH)D levels normalized in only 28% of the participants. Repeat courses with the same dosage in the other 72% did not significantly change their low vitamin D status. CONCLUSIONS: Increased surveillance and possibly higher vitamin D doses are warranted for obese adolescents whose total 25(OH)D levels do not normalize after the initial course of treatment.

Bone accretion in adolescents using the combined estrogen and progestin transdermal contraceptive method Ortho Evra: a pilot study.

OBJECTIVE: To date, there are no data regarding the effect of the transdermal combined estrogen and progestin contraceptive Ortho Evra on bone mineral content (BMC) and bone mineral density (BMD). We examined the effects of transdermally delivered ethinyl estradiol and norelgestromin on whole body (WB) BMC and BMD of the hip and lumbar spine (LS) of adolescent girls. METHODS: In a matched case-control study, girls (n = 5) who applied Ortho Evra for days 1-21 followed by days 22-28 free of medication for 13 cycles (about 12 months) were compared with 5 age- and ethnicity-matched control girls. Evaluations of calcium intake; bone-protective physical activity; bone densitometry (DXA, QDR 4500A, Hologic); bone formation markers serum osteocalcin (OC) and bone-specific alkaline phosphatase (BAP); bone resorption marker urinary N-telopeptide (uNTX); insulin growth factor-1 (IGF-1); and sex hormone binding globulin (SHBG) were carried out at initiation, 6 months, and 12 months. Changes from baseline were compared using mixed models, adjusting for follow-up comparisons using the Holm Test (sequential Bonferroni). RESULTS: There were no significant differences (SD) between groups at baseline in age, gynecologic age, WBBMC, hip BMD, and LSBMD. Girls on Ortho Evra did not change significantly in WBBMC (12-month mean increase 0.2% +/- 0.8%), whereas controls did (3.9% +/- 1.8%, P < or = .001, adjusted P = .002), with SD between the 2 groups (P = .007, adjusted P = .036). Adolescents on Ortho Evra did not change significantly in hip BMD (12-month mean increase 0.5% +/- 0.6%), whereas controls did (2.7% +/- 0.6%, P < or = .001, adjusted P = .004), with SD between the 2 groups (P = .024) prior to adjustment for multiple comparisons, but no SD after adjustment (P = .096). Similarly, although the increase in LSBMD within the control group after 12 months (mean increase 2.8% +/- 1.0%) was statistically significant (P = .009, adjusted P = .044), the change within the treatment group (12-month mean increase 0.8% +/- 0.8%) was not. However, percent LSBMD changes after 12 months did not significantly differ between the 2 groups before or after adjustment for multiple comparisons. Calcium intake and bone-protective physical activity did not significantly predict BMC and BMD changes of study participants. There was a significantly greater increase in SHBG levels in the treatment group after 6 months (P = .003, adjusted P = .013) and 12 months (P < or = .001, adjusted P < or = .001) than in controls. Changes in levels of OC, BAP, uNTX, and IGF-1 were not significantly different between the 2 groups. CONCLUSIONS: Ortho Evra use attenuates bone mass acquisition in young women who are still undergoing skeletal maturation. This attenuation may be attributed in part to increased SHBG levels, which reduce the concentrations of free estradiol and free testosterone that are available to interact with receptors on the bone. Clinical implications remain to be determined in studies with a larger number of adolescents.

Isolated low HDL cholesterol emerges as the most common lipid abnormality among obese adolescents.

A 12-hour fasting lipid profile was obtained from 88 otherwise healthy obese (BMI > or = 95%) adolescents (age 16 +/- 1 years, BMI 36 +/- 1 kg/m(2), 55 males, 33 females, 57% Hispanic, 23% African American, 19% Caucasian, 1% Asian American). About 56% of the obese adolescents exhibited lipid abnormalities based on cutoff points established by American Heart Association (AHA) guidelines, and about 57% exhibited lipid abnormalities based on percentile values established by the Lipid Research Clinic Pediatric Prevalence Study. Isolated low high-density lipoprotein-cholesterol (HDL-C) was the most common abnormality (43% based on AHA, 36% based on the Lipid Research Clinic Pediatric Prevalence Study) among the obese adolescents with lipid disorders. While there was no significant statistical difference (SSD) between genders in the levels of total cholesterol and low-density lipoprotein-cholesterol (LDL-C), triglyceride (TG) levels were significantly higher (P = .003) in males (120 +/- 11 mg/dL) than in females (81 +/- 7 mg/dL), and levels of HDL-C were significantly higher (P = .006) in females (42 +/- 2 mg/dL) than in males (35 +/- 1 mg/dL). There was no SSD between races in total cholesterol and LDL-C levels. TG levels were significantly lower in African-American participants (81 +/- 9 mg/ dL) compared with levels in Caucasian participants (117 +/- 15 mg/dL, P

Survey of primary care pediatricians on the transition and transfer of adolescents to adult health care.

The transition and transfer from pediatrics to adult health care of youth with and without special health care needs has become a focus of professional organizations, health care insurers, national policy makers, and providers. To understand transition and transfer at a primary care practice level, all primary care pediatricians in Rhode Island were surveyed. Responses were received from 103 of 169 (60.9%) practicing pediatricians. Few responders had practice policies on transfer. Most reported that transition should begin later than recommended. Few practices communicated with adult providers at transfer. Most reported that health insurers were of little help in transfer. Many pediatric practices had young adults after age 22 and many with special needs. Responders reported adolescents left their practices by 1 of 6 methods. The survey indicates the need for further study of transition and transfer and the need for additional training and education if transfers are to be successful.

The medical genetics workforce: an analysis of clinical geneticist subgroups.

PURPOSE: Clinical geneticists with a Doctor of Medicine degree face challenges to meet the growing population demand for genetic services. This study was designed to assist the profession with workforce planning by identifying clinically relevant subgroups of geneticists and describing their professional characteristics and clinical practices. Geneticists' patient care productivity is compared across subgroups and other medical specialists. METHODS: Part of a comprehensive national study of genetic services and the health workforce, this study uses data from a 2003 survey of geneticists certified by the American Board of Medical Genetics. This study includes 610 clinical geneticists who spend at least 5% of their time in direct patient-care services. An iterative approach was used to identify five subgroups based on the types of new patients seen. We conducted a descriptive analysis of subgroups by demographic, training, professional, and practice characteristics. RESULTS: The subgroups include general (36%), pediatric (28%), reproductive (15%), metabolic (14%), and adult (7%) geneticists. Clinically relevant variations across subgroups were noted in training, professional, and practice parameters. Subgroups vary across patient care hours (median, 15-33 hours/week) and total weekly work hours (52-60 hours). New patient visits (mean, 222-900/year) are higher than follow-up patient visits (mean, 155-405) for all subgroups except metabolic geneticists. CONCLUSION: Although many geneticists practice as generalist geneticists, this study provides an evidence base for distinguishing clinically relevant subgroups of geneticists. Geneticists provide similar numbers of new patient visits and far fewer follow-up visits than other medical specialists. These findings are relevant to geneticist workforce planning.

U.S. genetics nurses in advanced practice.

PURPOSE: To describe characteristics and professional roles of genetics nurses in advanced practice. DESIGN: A cross-sectional descriptive survey administered in 2004 as one component of a comprehensive study of genetic services and the health workforce. The sample was 211 U.S. members of the International Society of Nurses in Genetics. METHODS: The survey included demographic characteristics, education, credentials, professional roles, and attitudes about genetic healthcare issues. FINDINGS: The majority of respondents had master's degrees and many had earned doctorates in nursing (20%) or other fields (12%). Thirty-one percent were certified as nurse practitioners; 57% provided direct patient care, with the largest percentage working in genetics (26%) or oncology (22%) settings. Over one-third were educators and 19% conducted genome-related research. CONCLUSIONS: Genetics nurses in advanced practice in the US focus on both genomic discoveries and clinical health care through the application of genomic knowledge into health care, research, and nursing education.