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1.
JAMA Netw Open ; 4(7): e2118801, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34323984

RESUMO

Importance: Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. Objective: To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. Design, Setting, and Participants: This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. Interventions: The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. Main Outcomes and Measures: Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. Results: Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. Conclusions and Relevance: In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. Trial Registration: ClinicalTrials.gov Identifier: NCT03134092.

2.
J Am Board Fam Med ; 34(3): 571-578, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34088817

RESUMO

BACKGROUND: Timely access to primary care is important, particularly among patients with acute conditions and patients seeking gateways to specialty care. Due to concerns that expanded Medicaid eligibility would compromise access to primary care among new Medicaid beneficiaries, an experimental study was conducted to test the ability to obtain timely appointments. Although access to primary care appointments for simulated Medicaid patients significantly increased, wait times also increased. This study explores the determinants of wait times and whether they pose greater barriers to Medicaid beneficiaries. METHODS: We conducted linear regressions to determine the association between the number of days to scheduled appointments and the simulated patient's clinical scenario, practice-level characteristics, and county-level measures of primary care supply. RESULTS: Simulated Medicaid patients faced 1.3 days longer wait times than commercially insured ones. Participation in accountable care organizations and integrated health systems was associated with longer wait times but did not seem to reduce wait time disparities across insurance types. Notably, the presence of Federally Qualified Health Centers in a given county was associated with lower wait times for simulated Medicaid patients. CONCLUSIONS: These findings highlight the complexity of access disparities for Medicaid patients and provide insight for future waves of health care reform.


Assuntos
Medicaid , Listas de Espera , Acesso aos Serviços de Saúde , Humanos , Cobertura do Seguro , Patient Protection and Affordable Care Act , Atenção Primária à Saúde , Estados Unidos
3.
Ann Emerg Med ; 77(1): 103-109, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32534834

RESUMO

STUDY OBJECTIVE: The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED). METHODS: This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past-year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians' perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport. RESULTS: Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport. CONCLUSION: We found support that video is considered an enhancement by physicians overseeing a community paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home.


Assuntos
Auxiliares de Emergência , Serviço Hospitalar de Emergência , Telefone , Comunicação por Videoconferência , Idoso , Idoso de 80 Anos ou mais , Comunicação , Feminino , Humanos , Masculino , Estudos Retrospectivos , Transporte de Pacientes/estatística & dados numéricos
5.
JMIR Res Protoc ; 9(9): e19496, 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32969832

RESUMO

BACKGROUND: Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative-enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain. OBJECTIVE: Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain. METHODS: This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative-enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge. RESULTS: A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms. CONCLUSIONS: This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19496.

6.
Health Aff (Millwood) ; 39(8): 1443-1449, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32525713

RESUMO

New York City has emerged as the global epicenter for the coronavirus disease 2019 (COVID-19) pandemic. The city's public health system, New York City Health + Hospitals, has been key to the city's response because its vulnerable patient population is disproportionately affected by the disease. As the number of cases rose in the city, NYC Health + Hospitals carried out plans to greatly expand critical care capacity. Primary intensive care unit (ICU) spaces were identified and upgraded as needed, and new ICU spaces were created in emergency departments, procedural areas, and other inpatient units. Patients were transferred between hospitals to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and Department of Defense medical personnel. Supplies needed to deliver critical care were monitored closely and replenished to prevent interruptions. An emergency department action team was formed to ensure that the experience of front-line providers was informing network-level decisions. The steps taken by NYC Health + Hospitals greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases.


Assuntos
Infecções por Coronavirus/prevenção & controle , Cuidados Críticos/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Unidades de Terapia Intensiva/organização & administração , Avaliação de Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Recursos Humanos/estatística & dados numéricos , COVID-19 , Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/epidemiologia , Feminino , Pessoal de Saúde/organização & administração , Humanos , Masculino , Cidade de Nova Iorque/epidemiologia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Medição de Risco
7.
J Interpers Violence ; 34(7): 1428-1460, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-27271981

RESUMO

The study examines the similarities and differences between China and the United States with regard to rape myths. We assessed the individual level of rape myth acceptance among Chinese university students by adapting and translating a widely used measure of rape myth endorsement in the United States, the Illinois Rape Myth Acceptance (IRMA) scale. We assessed whether the IRMA scale would be an appropriate assessment of attitudes toward rape among young adults in China. The sample consisted of 975 Chinese university students enrolled in seven Chinese universities. We used explorative factor analysis to examine the factor structure of the Chinese translation of the IRMA scale. Results suggest that the IRMA scale requires some modification to be employed with young adults in China. Our analyses indicate that 20 items should be deleted, and a five-factor model is generated. We discuss relevant similarities and differences in the factor structure and item loadings between the Chinese Rape Myth Acceptance (CRMA) and the IRMA scales. A revised version of the IRMA, the CRMA, can be used as a resource in rape prevention services and rape victim support services. Future research in China that employs CRMA will allow researchers to examine whether individual's response to rape myth acceptance can predict rape potential and judgments of victim blaming and community members' acceptance of marital rape.


Assuntos
Vítimas de Crime/psicologia , Características Culturais , Estupro/psicologia , Percepção Social , Estereotipagem , China , Comparação Transcultural , Análise Fatorial , Feminino , Humanos , Julgamento , Masculino , Mudança Social , Estudantes , Universidades , Adulto Jovem
8.
Health Serv Res ; 54(1): 181-186, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30397918

RESUMO

OBJECTIVE: To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act. DATA SOURCE: Ten state primary care audit conducted in 2012/2013 and 2016. STUDY DESIGN: CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type. PRINCIPAL FINDINGS: In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance. CONCLUSION: Appointment availability at CHCs improved after ACA implementation, without increased wait times.


Assuntos
Centros Comunitários de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Humanos , Patient Protection and Affordable Care Act , Estados Unidos
9.
J Interpers Violence ; 34(13): 2774-2796, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-27503325

RESUMO

Retaining participants in longitudinal studies is a unique methodological challenge in many areas of investigation, and specifically for researchers aiming to identify effective interventions for women experiencing intimate partner violence (IPV). Individuals in abusive relationships are often transient and have logistical, confidentiality, and safety concerns that limit future contact. A natural experiment occurred during a large randomized clinical trial enrolling women in abusive relationships who were also heavy drinkers, which allowed for the comparison of two incentive methods to promote longitudinal retention: cash payment versus reloadable wireless bank cards. In all, 600 patients were enrolled in the overall trial, which aimed to incentivize participants using a reloadable bank card system to promote the completion of 11 weekly interactive voice response system (IVRS) phone surveys and 3-, 6-, and 12-month follow-up phone or in person interviews. The first 145 participants were paid with cash as a result of logistical delays in setting up the bank card system. At 12 weeks, participants receiving the bank card incentive completed significantly more IVRS phone surveys, odds ratio (OR) = 2.4, 95% confidence interval (CI) = [0.01, 1.69]. There were no significant differences between the two groups related to satisfaction or safety and/or privacy. The bank card system delivered lower administrative burden for tracking payments for study staff. Based on these and other results, our large medical research university is implementing reloadable bank card as the preferred method of participant incentive payments.


Assuntos
Intoxicação Alcoólica/prevenção & controle , Mulheres Maltratadas/psicologia , Violência por Parceiro Íntimo/prevenção & controle , Entrevista Motivacional/economia , Participação do Paciente/economia , Mecanismo de Reembolso/economia , Adulto , Intoxicação Alcoólica/epidemiologia , Mulheres Maltratadas/estatística & dados numéricos , Feminino , Humanos , Violência por Parceiro Íntimo/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Motivação , Projetos de Pesquisa , Inquéritos e Questionários
10.
Psychol Violence ; 8(5): 596-604, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30555730

RESUMO

Objective: The objective of this study was to better understand the experience of coercive control as a type of IPV by examining associations between coercive control and women's experiences of particular forms of violence, use of violence, and risk of future violence. Method: As part of a larger research study, data were collected from 553 women patients at two hospital emergency departments who had experienced recent IPV and unhealthy drinking. Baseline assessments, including measures of coercive control, danger, and experience and use of psychological, physical, and sexual forms of IPV in the prior three months were analyzed. Results: Women experiencing coercive control reported higher frequency of each form of IPV, and higher levels of danger, compared to women IPV survivors who were not experiencing coercive control. There was no statistically significant association between experience of coercive control and women's use of psychological or sexual IPV; women who experienced coercive control were more likely to report using physical IPV than women who were not experiencing coercive control. Conclusions: Findings contribute to knowledge on the relationship between coercive control and specific forms of violence against intimate partners. A primary contribution is the identification that women who experience coercive control may also use violence, indicating that a woman's use of violence does not necessarily mean that she is not also experiencing severe and dangerous violence as well as coercive control. In fact, experience of coercive control may increase victims' use of physical violence as a survival strategy.

12.
J Am Board Fam Med ; 31(5): 682-690, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30201664

RESUMO

PURPOSE: Failures of care coordination among health care providers are known to lead to poorer health outcomes for patients with complex medical needs. However, there has been limited research into the perspectives of patients who receive care from a variety of health care providers. This qualitative study sought to characterize the factors leading to emergency department (ED) patient satisfaction and dissatisfaction with their care coordination. METHODS: Semistructured telephone interviews were conducted with 25 adult patients following ED visits about their experiences with their care coordination. All patients interviewed had 2 or more ED visits and hospitalizations in the past year and/or health providers in more than one health system. Interview transcripts were coded and analyzed following a modified grounded theory approach. RESULTS: Four broad categories of themes emerged from the patient interviews covering the following: (1) perceptions of care coordination between their providers, (2) the role of electronic health records, (3) challenges with information exchange between health systems, and (4) sources of support for care coordination activities, emphasizing the important role of the primary care provider. CONCLUSIONS: Patients with multiple health care providers identified significant barriers to communication among providers and inadequate support with care coordination activities. Expansion of team-based models of primary care and prioritizing interoperable technology for sharing patient health information between providers will be critical to improving the patient experience and the safety of transitions of care.


Assuntos
Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comunicação , Registros Eletrônicos de Saúde , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto Jovem
13.
Am J Manag Care ; 24(8): 368-375, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30130029

RESUMO

OBJECTIVES: The Pennsylvania Chronic Care Initiative (CCI) was a statewide patient-centered medical home (PCMH) initiative implemented from 2008 to 2011. This study examined whether the CCI affected utilization and costs for HIV-positive Medicaid patients with both medical and behavioral health comorbidities. STUDY DESIGN: Nonrandomized comparison of 302 HIV-positive Medicaid patients treated in 137 CCI practices and 2577 HIV-positive Medicaid patients treated elsewhere. METHODS: All patients had chronic medical conditions (diabetes, chronic obstructive pulmonary disease, asthma, or congestive heart failure) and a psychiatric and/or substance use disorder. Analyses used Medicaid claims data to examine changes in total per patient costs per month from 1 year prior to 1 year following an index episode. Propensity score weighting was used to adjust for potential sample differences. Secondary outcomes included costs and utilization of emergency department, inpatient, and outpatient/pharmacy services. RESULTS: We identified an average total cost savings of $214.10 per patient per month (P = .002) for the CCI group relative to the non-CCI group. This was a function of decreased inpatient medical (-$415.69; P = .007) and outpatient substance abuse treatment (-$4.86; P = .001) costs, but increased non-HIV pharmacy costs ($158.43; P = .001). Utilization for the CCI group, relative to the non-CCI group, was correspondingly decreased for inpatient medical services (odds ratio [OR], 0.619; P = .002) and inpatient services overall (OR, 0.404; P = .001), but that group had greater numbers of outpatient medical service claims when they occurred (11.7%; P = .003) and increased non-HIV pharmacy claims (9.7%; P = .001). CONCLUSIONS: There was increased outpatient service utilization, yet relative cost savings, for HIV-positive Medicaid patients with medical and behavioral health comorbidities who were treated in PCMHs.


Assuntos
Soropositividade para HIV/economia , Medicaid/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Assistência Centrada no Paciente/economia , Comorbidade , Redução de Custos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estados Unidos
14.
Head Neck ; 40(6): 1147-1155, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29394465

RESUMO

BACKGROUND: The purpose of this study was to determine national disparities in head and neck cancer treatment package time (the time interval from surgery through the completion of radiation) and the associated impact on survival. METHODS: We conducted an observational cohort study using the National Cancer Database of 15 234 patients with resected head and neck cancer who underwent adjuvant radiotherapy from 2004-2012. Predictors of prolonged package time were identified by multivariable linear regression. Survival outcomes were assessed using a multivariable Cox model. RESULTS: Mean package time was 100 days (SD 23). Package time was 7.52 days (95% confidence interval [CI] 6.23-8.81; P < .001) longer with Medicaid versus commercial insurance. Low income and African American race also predicted for longer package times. All-cause mortality increased an average of 4% with each 1 week increase in treatment package time (hazard ratio [HR] 1.04; 95% CI 1.03-1.05; P < .001). CONCLUSION: Significant national socioeconomic disparities exist in treatment package time. Treatment delays in this setting may contribute to worse survival outcomes.


Assuntos
Neoplasias de Cabeça e Pescoço/epidemiologia , Neoplasias de Cabeça e Pescoço/terapia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Afro-Americanos/estatística & dados numéricos , Idoso , Quimiorradioterapia , Estudos de Coortes , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Disparidades em Assistência à Saúde/etnologia , Humanos , Modelos Lineares , Masculino , Medicaid , Pessoa de Meia-Idade , Pobreza/etnologia , Pobreza/estatística & dados numéricos , Taxa de Sobrevida , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
15.
Acad Emerg Med ; 25(1): 6-14, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28846179

RESUMO

OBJECTIVE: Up to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore 1) whether patients making a repeat ED visit are self-referred or indirectly referred from the other ED and 2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits. METHODS: This mixed-methods study conducted over a 10-week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint. Selected patients presenting with fractures were then enrolled for semistructured qualitative interviews, which were audiotaped, transcribed, and independently coded by two team members until thematic saturation was reached. RESULTS: A total of 143 patients were identified as being recently seen at another local ED for the same chief complaint prior to presenting to the public hospital; 94% were uninsured and 61% presented with fractures. A total of 27% required admission at the public ED and 95% of those discharged required further outpatient follow-up. Fifty-one percent of patients completed a survey and qualitative interviews were conducted with 23 fracture patients. Fifty-three percent of patients reported that staff at the first hospital told them to go the public hospital ED, and 23% reported referral from a follow-up physician associated with the first hospital. Seventy-three percent reported receiving the same tests at both EDs. Interview themes identified multiple health care visits for the same injury, concern about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow-up care without insurance, loss of work, and financial strain. CONCLUSIONS: The majority of patients presenting to a public hospital ED after treatment for the same complaint in another local ED were indirectly referred to the public ED without transferring paperwork or records, incurring duplicate testing and patient anxiety.


Assuntos
Serviço Hospitalar de Emergência , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Encaminhamento e Consulta/organização & administração , Adulto , Assistência ao Convalescente , Idoso , Serviço Hospitalar de Emergência/economia , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Encaminhamento e Consulta/economia , Texas
16.
Med Care Res Rev ; 75(5): 633-650, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29148335

RESUMO

Coverage and access have improved under the Affordable Care Act, yet it is unclear whether recent gains have reached those regions within states that were most in need of improved access to care. We examined geographic variation in Medicaid acceptance among Michigan primary care practices before and after Medicaid expansion in the state, using data from a simulated patient study of primary care practices. We used logistic regression analysis with time indicators to assess regional changes in Medicaid acceptance over time. Geographic regions with lower baseline (<50%) Medicaid acceptance had significant increases in Medicaid acceptance at 4 and 8 months post-expansion, while regions with higher baseline (≥50%) Medicaid acceptance did not experience significant changes in Medicaid acceptance. As state Medicaid expansions continue to be implemented across the country, policy makers should consider the local dynamics of incentives for provider participation in Medicaid.


Assuntos
Reforma dos Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Planos Governamentais de Saúde/estatística & dados numéricos , Geografia , Humanos , Michigan , Estados Unidos
17.
Ann Emerg Med ; 70(6): 835-839, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28811121

RESUMO

STUDY OBJECTIVE: We characterize emergency department (ED) utilization among perinatal women and identify differences in risk factors and outcomes between women who use versus do not use the ED during the perinatal period. METHODS: This is a retrospective cross-sectional study comparing patients who used the ED versus did not use the ED during the perinatal period. Patient data were collected from medical chart review and postpartum interviews. RESULTS: Of the 678 participants, 218 (33%) had at least 1 perinatal ED visit. Women who used the ED were more likely than those who did not to be adolescent (relative risk [RR] 2.23; 95% confidence interval [CI] 1.38 to 3.63), of minority race (RR 1.94; 95% CI 1.46 to 2.57), and Medicaid insured (RR 2.14; 95% CI 1.71 to 2.67). They were more likely to smoke prenatally (RR 3.42; 95% CI 2.34 to 4.99), to use recreational drugs prenatally (RR 3.53; 95% CI 1.78 to 7.03), and to have experienced domestic abuse (RR 1.78; 95% CI 1.12 to 2.83). They were more likely to have delayed entry to prenatal care (RR 2.01; 95% CI 1.46 to 2.77) and to experience postpartum depression (RR 2.97; 95% CI 1.90 to 4.64). Their infants were nearly twice as likely to be born prematurely (RR 1.92; 95% CI 1.07 to 3.47). CONCLUSION: Results highlight that pregnant patients using the ED are a high-risk, vulnerable population. Routine ED screening and linkage of this vulnerable population to early prenatal care and psychosocial interventions should be considered as a public health strategy worth investigating.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Assistência Perinatal/estatística & dados numéricos , Complicações na Gravidez/epidemiologia , Adolescente , Adulto , Fatores Etários , Estudos Transversais , Violência Doméstica/estatística & dados numéricos , Feminino , Humanos , Gravidez , Complicações na Gravidez/terapia , Estudos Retrospectivos , Fatores de Risco , Fumar/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto Jovem
18.
Cancer ; 123(22): 4449-4457, 2017 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-28727136

RESUMO

BACKGROUND: Racial disparities in prostate cancer treatment and outcomes are widespread and poorly understood. In the current study, the authors sought to determine whether access to care, measured across multiple dimensions, contributed to racial differences in prostate cancer. METHODS: The Philadelphia Area Prostate Cancer Access Study (P2 Access) included 2374 men diagnosed with localized prostate cancer between 2012 and 2014. Men were surveyed to assess their experiences accessing care (response rate of 51.1%). The authors determined appointment availability at 151 urology practices using simulated patient telephone calls and calculated travel distances using geospatial techniques. Multivariable logistic regression models were used to determine the association between 5 different domains of access (availability, accessibility, accommodation, affordability, and acceptability) and receipt of treatment, perceived quality of care, and physician-patient communication. RESULTS: There were 1907 non-Hispanic white and 394 black men in the study cohort. Overall, approximately 85% of the men received definitive treatment with no differences noted by race. Black men were less likely to report a high quality of care (69% vs 81%; P<.001) and good physician-patient communication (60% vs 71%; P<.001) compared with white men. In adjusted models, none of the 5 domains of access were found to be associated with definitive treatment overall or with radical prostatectomy. All access domains were associated with perceived quality of care and communication, although these domains did not mediate racial disparities. CONCLUSIONS: To the authors' knowledge, the current study presents the first comprehensive assessment of prostate cancer care access, treatment, and patient experience, demonstrating that although access was related to overall perceived quality of care and better physician-patient communication, it did not appear to explain observed racial differences. Cancer 2017;123:4449-57. © 2017 American Cancer Society.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Neoplasias da Próstata/etnologia , Neoplasias da Próstata/terapia , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Grupos de Populações Continentais/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Philadelphia/epidemiologia , Sistema de Registros , Estados Unidos/epidemiologia
19.
Ann Fam Med ; 15(2): 107-112, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28289108

RESUMO

PURPOSE: The Patient Protection and Affordable Care Act (ACA) expanded coverage to roughly 12 million individuals by mid-2014 and 20 million by 2016, raising concern about the capacity of the primary care system to absorb these individuals. We set out to determine how justified the concern was. METHODS: We used an audit design in which simulated patients called primary care practices seeking new-patient appointments in 10 diverse states (Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas) from November 2012 through March 2013 and from May 2014 through July 2014, before and after the major ACA insurance expansions. Callers were randomly assigned to scripts specifying either private or Medicaid insurance and called only offices identified as "in network" for each plan. RESULTS: We completed 5,385 private insurance and 4,352 Medicaid calls in 2012-2013 and 2,424 private insurance and 2,474 Medicaid calls in 2014. Overall appointment rates for private insurance remained stable from 2012 (84.7%) to 2014 (85.8%) with Massachusetts and Pennsylvania experiencing significant increases. Overall, Medicaid appointment rates increased 9.7 percentage points (57.9% to 67.6%) with substantial variation by state. Across all callers, median wait times for those obtaining an appointment were 7 days in 2012 and 5 days in 2014, but the difference was not statistically significant. CONCLUSIONS: Contrary to widespread concern, we find no evidence that the millions of individuals newly insured through the ACA decreased new-patient appointment availability across 10 states as shown by stable wait times and appointment rates for private insurance as of mid-2014.


Assuntos
Agendamento de Consultas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Seguro Saúde/classificação , Patient Protection and Affordable Care Act , Humanos , Medicaid , Atenção Primária à Saúde , Distribuição Aleatória , Estados Unidos
20.
Acad Emerg Med ; 24(5): 511-522, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28146297

RESUMO

BACKGROUND: Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care. OBJECTIVE: The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy. METHODS: A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2. RESULTS: Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in five questions for the proposed measure. CONCLUSIONS: A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics.


Assuntos
Asma/terapia , Serviço Hospitalar de Emergência/normas , Letramento em Saúde , Medidas de Resultados Relatados pelo Paciente , Assistência Centrada no Paciente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pais/educação , Pais/psicologia , Alta do Paciente , Pesquisa Qualitativa , Inquéritos e Questionários
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