Adolescents' Receipt of Care in a Medical Home: Results From a National Survey.

PURPOSE: Despite long-term emphasis on the medical home for children, little research focuses on adolescents. This study examines adolescent past-year attainment of medical home, its components, and subgroup differences among demographic and mental/physical health condition categories. METHODS: Utilizing the 2020-21 National Survey of Children's Health (NSCH), ages 10-17 (N = 42,930), we determined medical home attainment and its 5 components and subgroup differences utilizing multivariable logistic regression: sex; race/ethnicity; income; caregiver education; insurance; language spoken at home; region; and health conditions: physical, mental, both, or none. RESULTS: Forty-five percent had a medical home with lower rates among those who were as follows: not White non-Hispanic; lower income; uninsured; in non-English-speaking households; adolescents whose caregivers lacked a college degree; and adolescents with mental health conditions (p range = .01-<.0001). Differences for medical home components were similar. DISCUSSION: Given low medical home rates, ongoing differences and high mental illness rates, efforts are needed to improve adolescent medical home access.

Radiotherapy Deserts: The Impact of Race, Poverty, and the Rural-Urban Continuum on Density of Providers and the Use of Radiation Therapy in the US.

PURPOSE: Prior efforts to characterize disparities in radiation therapy access and receipt have not comprehensively investigated interplay between race, socioeconomic status, and geography relative to oncologic outcomes. This study sought to define these complex relationships at the US county level for prostate cancer (PC) and invasive breast (BC) cancer to build a tool that facilitates identification of "radiotherapy deserts"-regions with mismatch between radiation therapy resources and oncologic need. METHODS AND MATERIALS: An ecologic study model was constructed using national databases to evaluate 3,141 US counties. Radiation therapy resources and use densities were operationalized as physicians to persons at risk (PPR) and use to persons at risk (UPR): the number of attending radiation oncologists and Medicare beneficiaries per 100,000 persons at risk, respectively. Oncologic need was defined by "hot zone" counties with ≥2 standard deviations (SDs) above mean incidence and death rates. Univariable and multivariable logistic regressions examined links between PPR and UPR densities, epidemiologic variables, and hot zones for oncologic outcomes. Statistics are reported at a significance level of P < .05. RESULTS: The mean (SD) PPR and UPR densities were 2.1 (5.9) and 192.6 (557.6) for PC and 1.9 (5.3) and 174.4 (501.0) for BC, respectively. Counties with high PPR and UPR densities were predominately metropolitan (odds ratio [OR], 2.9-4.4), generally with a higher percentage of Black non-Hispanic constituents (OR, 1.5-2.3). Incidence and death rate hot zones were largely nonmetropolitan (OR, 0.3-0.6), generally with a higher percentage of Black non-Hispanic constituents (OR, 3.2-6.3). Lower PPR density was associated with death rate hot zones for both types of cancer (OR, 0.8-0.9); UPR density was generally not linked to oncologic outcomes on multivariable analysis. CONCLUSIONS: The study found that mismatch between oncologic need with PPR and UPR disproportionately affects nonmetropolitan communities with a higher percentage of Black non-Hispanic constituents. An interactive web platform (bit.ly/densitymaps) was developed to visualize "radiotherapy deserts" and drive targeted investigation of underlying barriers to care in areas of highest need, with the goal of reducing health inequities in this context.

Community paramedic hospital reduction and mitigation program: study protocol for a randomized pragmatic clinical trial.

BACKGROUND: New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization. METHODS: This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment. DISCUSSION: This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov NCT05232799. Registered on 10 February 2022.

Evaluating Patient and Family Experience Among Spanish-Speaking and LatinX Patients: a Scoping Review of Existing Instruments.

INTRODUCTION: LatinX populations are rapidly growing in the USA, but still report lower levels of patient centered care and satisfaction when compared to their non-LatinX white counterparts. This review encompasses literature which describes patient experience instruments that (1) evaluate LatinX experience, (2) have validated Spanish versions, or (3) measure language-concordant care experiences. METHODS: A scoping review of literature in Ovid Medline, CINAHL, and PsycINFO was conducted. Articles were excluded if they were not applicable to the health care industry, did not include a patient experience instrument, or did not include LatinX or Spanish-speaking individuals within their study population. Data extraction was performed for concepts measured, study size, population, health care setting, and languages validated. RESULTS: This review identified 224 manuscripts. Of these, 81 met full inclusion criteria and represented 60 unique instruments. These covered six categories: general patient experience (43%, n = 26/60), experiences of discrimination/mistrust (12%, n = 7/60), cultural factors (10%, n = 6/60), patient-provider relationship (10%, n = 6/60), and communication (8%, n = 5/60). The remaining instruments measured multiple categories (17%, n = 10/60). Just over one third of instruments (n = 24, 5 pediatric, 19 adult) were validated in Spanish and an additional 14 (23%) were validated in English alone. Finally, 4 (7%) instruments were identified which were developed for use in a language concordant setting. CONCLUSION: Many instruments were identified which evaluate LatinX patient experience; however, none was both validated in Spanish and measured in all key categories of experience described above. Additionally, few instruments were developed for holistic evaluation of patient experience in pediatric or language concordant care settings.

Advance Care Planning Experiences Among Sexual and Gender Minority People.

Importance: Advance care planning (ACP) can promote patient-centered end-of-life (EOL) care and is intended to ensure that medical treatments are aligned with patient's values. Sexual and gender minority (SGM) people face greater discrimination in health care settings compared with heterosexual, cisgender people, but it is unknown whether such discrimination occurs in ACP and how it might affect the ACP experiences of SGM people. Objectives: To increase understanding of barriers and facilitators of ACP facing SGM individuals. Design, Setting, and Participants: This mixed-methods national study of ACP included a telephone survey of self-identified SGM and non-SGM participants in a nationally representative sample drawn from a larger omnibus national panel by SSRS. Qualitative interviews were conducted with a subset of survey participants who identified as SGM. Data were collected from October 2020 to March 2021. Exposures: Self-identified SGM. Main Outcomes and Measures: The survey included 4 items from the validated ACP Engagement Survey, adapted to capture experiences of discrimination. Interviews asked about participants' experiences with ACP, including the appointment of medical decision-makers, sharing preferences, and experiences within the health care system more broadly. Results: A total of 603 adults participated in the survey, with 201 SGM individuals (mean [SD] age, 45.7 [18.7] years; 101 [50.2%] female; 22 [10.9%] Black, 37 [18.4%] Hispanic, and 140 [69.7%] White individuals) and 402 non-SGM individuals (mean [SD] age, 53.7 [19.2] years; 199 [49.5%] female; 35 [8.7%] Black, 41 [10.2%] Hispanic, and 324 [80.6%] White individuals). Regarding reasons for not completing ACP, SGM respondents, compared with non-SGM respondents, were more likely to say "I don't see the need" (72 [73.5%] vs 131 [57.2%], P = .006) and "I feel discriminated against by others" (12 [12.2%] vs 6 [2.6%], P < .001). Of 25 completed interviews among SGM participants, 3 main themes were identified: how fear and experiences of discrimination affect selection of clinicians and whether to disclose SGM identity; concerns about whether EOL preferences and medical decision-makers would be supported; and a preference to discuss EOL decisions and values outside of clinical settings. Conclusions and Relevance: This study found that fear of disclosing sexual orientation or gender identity information and discrimination are important barriers to ACP for SGM in clinical settings, but discussions of preferences and values still occur between many SGM people and medical decision-makers. More SGM-specific patient-centered care might better support these discussions within the health care system. Furthermore, health systems can facilitate improved engagement by supporting clinician sensitivity training, including guidance on documentation and requirements.

Embarazo subsecuente en la adolescencia: causas, consecuencias y posibles soluciones / Subsequent pregnancy in adolescence: Causes, consequences and possible solutions

Introducción: México se encuentra en los primeros lugares de embarazo en la adolescencia entre los países de la Organización para la Cooperación y el Desarrollo Económico. Por lo tanto, el embarazo de primera vez y subsecuente representa un problema sanitario con impacto negativo en el desarrollo de la adolescente y su hijo, por lo que es necesario estudiar el fenómeno a fin de prevenirlo y contribuir al mejoramiento de las condiciones de salud y vida de dos grupos vulnerables (adolescentes e hijos). Desarrollo: las causas del embarazo subsecuente son diversas, implican aspectos relacionados con el entorno familiar y comunitario, el acceso a los servicios de salud y el nivel educativo. Aunque no es exclusivo de un estrato social, se presenta con mayor frecuencia en adolescentes de bajos recursos. Las consecuencias son de índole físico, psicológico, económico y social, y agudizan las condiciones negativas de salud y las mencionadas como causas, con riesgo de que se repita y se perpetue el problema. Conclusiones: las intervenciones basadas en la atención centrada en la persona han mostrado efectos positivos en la conducta anticonceptiva de las adolescentes. Su adopción e implementación en países en desarrollo amerita la suma de esfuerzos interinstitucionales e interdisciplinares de forma vertical y transversal, con sentido bidireccional, a fin de hacer cambios significativos en la prevención de este fenómeno.

Introduction: Mexico ranks in the first places of teenage pregnancy among the countries of the Organisation for Economic Co-operation and Development. For this reason, the first and subsequent pregnancy represents a health problem with a negative impact on the development of the adolescent girl and her child, which is why it is necessary to study the phenomenon, in order to prevent it and to contribute to the improvement of health and living conditions of two vulnerable groups (adolescents and children). Development: The causes of subsequent pregnancy are diverse, involving aspects related to the family and community environment, as well as access to health services, and the educational level. Although it is not exclusive to a social stratum, it occurs more often in low-income adolescents. The consequences are of a physical, psychological, economic and social nature, and they exacerbate the negative health conditions and those mentioned as causes, with the risk of repeating and perpetuating the problem. Conclusions: Person-centered interventions have demonstrated positive effects on the contraceptive behavior of adolescents. Its adoption and implementation in developing countries deserve the sum of inter-agency and interdisciplinary efforts in a vertical and cross-cutting manner with a two-way sense of making significant changes in the prevention of this phenomenon.

Disparities of Access, Use, and Barriers to Seeking Health Care Services in Arizona.

BACKGROUND: Access to health care (HC) services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all persons. OBJECTIVES: We assess social indicators among people living in Arizona that are associated with access, use, and barriers to seeking HC services. RESEARCH DESIGN: We analyzed data (n=8073) from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) to describe demographic and health characteristics among persons by HC access and use, and for whom costs were a barrier to seeking care. RESULTS: Among Arizona adults, 13.5% reported lacking HC coverage, 28.7% reported lacking a personal doctor, and medical costs were a barrier to seeking care for 14.1%. Arizonans aged 18-34 years or with a high school education or less more often reported lacking HC coverage, a personal doctor, or not visiting a doctor because of costs. Past year medical and dental checkups were less common among less educated (≤high school) and never married persons. Hispanic persons more often reported lacking HC coverage or not visiting a doctor because of costs, and less often reported past year dental checkups. CONCLUSIONS: BRFSS can be analyzed to identify and quantify unique HC disparities, and the findings can serve as the basis for improving HC in communities. Expansion of HC services and providers may be achieved, in part, through incentives for providers to work in designated health professional shortage areas and/or leveraging telehealth/telemedicine in rural and urban underserved communities.

The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results.

BACKGROUND: Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness. OBJECTIVES: The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals. RESEARCH DESIGN: A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results. SUBJECTS: Eight primary care clinics that were engaged in PCMH reform. MEASURES: We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years. RESULTS: In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03). DISCUSSION: The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.

Association of Maternal-Clinician Ethnic Concordance With Latinx Youth Receipt of Family-Centered Care.

Importance: Disparities in medical home provisions, including receipt of family-centered care (FCC), have persisted for Latinx youths in the US. Objective: To examine the association between maternal-clinician ethnic concordance and receipt of FCC among US-born Latinx youths. Design, Setting, and Participants: A cross-sectional secondary analysis of data from the Medical Expenditure Panel Survey from January 1, 2010, to December 31, 2017, was conducted. Data analysis was performed from January 6 to February 3, 2020. Latinx youths (age, ≤17 years) born in the US who had a usual source of care and used care in the past year, their Latina mothers (age, 18-64 years), and youths' health care clinician characteristics (eg, race, ethnicity, and sex) were evaluated using χ2 tests and propensity-score matching methods. Main Outcomes and Measures: Maternal reports on whether their youths' clinician listened carefully to the parent, explained things in a way the parent could understand, showed respect, and spent enough time with the patient. Results: There were 2515 US-born Latinx youths with linked maternal characteristics during the study period; 51.67% (95% CI, 48.87%-54.45%) of the youths were male, mean (SD) age was 8.48 (0.17) years (30.86% [95% CI, 28.39%-33.44%] were between ages 5 and 9 years), 61.53% (95% CI, 57.15%-65.74%) had public insurance coverage, and 39.89% (95% CI, 32.33%-47.89%) had mothers who were ethnically concordant with the youths' medical care clinician. We found that for youths with maternal-clinician ethnic concordance, the probabilities of reporting FCC were significantly higher than they would have been in the absence of concordance: that the medical care clinician listened carefully to the parent (average treatment effect on the treated [ATET], 5.44%; 95% CI, 2.14%-8.74%), explained things in a way the parent could understand (ATET, 4.82%; 95% CI, 1.60%-8.03%), showed respect for what the parent had to say (ATET, 5.51%; 95% CI, 2.58%-8.45%), and spent enough time with the patient (ATET, 5.28%; 95% CI, 1.68%-8.88%). Conclusions and Relevance: Given the increase of Latinx populations and the simultaneous shortage of underrepresented minority health care clinicians, the findings of this study suggest that increasing the number of clinicians from underrepresented minority backgrounds and ethnic-concordant parental-clinician relationships may help reduce disparities in receipt of medical home provision among US-born Latinx youths.

Effect of Medication Reconciliation at Hospital Admission on 30-Day Returns to Hospital: A Randomized Clinical Trial.

Importance: According to international recommendations, hospitals should use medication reconciliation to prevent medication errors and improve patient safety. Objective: To assess the impact of medication reconciliation at hospital admission on patient-centered health care outcomes. Design, Setting, and Participants: This parallel group, open-label randomized controlled trial used centralized randomization to the intervention group (ie, individuals with medication reconciliation) or control group (ie, individuals with only standard, physician-acquired medication history). Outcome assessors and data analysts were blinded to group allocation. Participants included 1702 patients aged 85 years or older, with more than 10 medications at hospital admission, or meeting both conditions at 2 regional secondary teaching hospitals in southern Switzerland. Study duration was 14.5 months, from November 1, 2018, to January 15, 2020. Data were analyzed from December 2018 through March 2020. Interventions: Medication reconciliation was performed at hospital admission in 3 steps: (1) the pharmacy assistant obtained the list of the patient's current medications (ie, the best possible medication history [BPMH]); (2) the clinical pharmacist led reconciliation of the BPMH with the list of home medications recorded at hospital admission by the attending physician (according to the hospital standard procedure); and (3) medication discrepancies were communicated to the attending physician, and, when necessary, medications prescribed at admission were adapted. Main Outcomes and Measures: The primary outcome was a composite postdischarge health care use variable quantified as the proportion of patients with unplanned all-cause hospital visits (including visits to the emergency department and hospital readmissions) within 30 days after discharge from the hospital when medication reconciliation took place. A time-to-event analysis was performed. Results: Among 1702 patients (median [interquartile range] age, 86.0 [79.0-89.0] years; 720 [42.3%] men), 866 patients (50.9%) were allocated to the intervention group and 836 patients (49.1%) to the control group. The primary outcome occurred among 340 participants (39.3%) in the intervention group and 330 participants (39.5%) in the control group (P = .93). In time-to-event analyses at study closeout, unplanned all-cause hospital visits to the emergency department (log-rank P = .08) and unplanned all-cause hospital readmissions (log-rank P = .10) occurred similarly in the intervention and control groups. Conclusions and Relevance: These findings suggest that medication reconciliation at hospital admission has no impact on postdischarge health care outcomes among patients aged 85 years or older, with more than 10 medications at hospital admission, or meeting both conditions. Trial Registration: ClinicalTrials.gov Identifier: NCT03654963.

Duration of medical home participation and quality of care for patients with chronic conditions.

OBJECTIVE: To examine whether the length of participation in a patient-centered medical home (PCMH), an evidence-based practice, leads to higher quality care for Medicaid enrollees with multiple co-morbid chronic conditions and major depressive disorder (MDD). DATA SOURCES: This analysis uses a unique data source that links North Carolina Medicaid claims and enrollment data with other administrative data including electronic records of state-funded mental health services, a state psychiatric hospital utilization database, and electronic records from a five-county behavioral health carve-out program. STUDY DESIGN: This retrospective cohort study uses generalized estimating equations (GEEs) on person-year-level observations to examine the association between the duration of PCMH participation and measures of guideline-concordant care, including the receipt of minimally adequate care for MDD, defined as 6 months of antidepressant use or eight psychotherapy visits each year. DATA COLLECTION/EXTRACTION METHODS: Adults with two or more chronic conditions reflected in administrative data, including MDD. PRINCIPAL FINDINGS: We found a 1.7 percentage point increase in the likelihood of receiving guideline-concordant care at 4 months of PCMH participation, as compared to newly enrolled individuals with a single month of participation (p < 0.05). This effect increased with each additional month of PCMH participation; 12 months of participation was associated with a 19.1 percentage point increase in the likelihood of receiving guideline-concordant care over a single month of participation (p < 0.01). CONCLUSIONS: The PCMH model is associated with higher quality of care for patients with multiple chronic conditions and MDD over time, and these benefits increase the longer a patient is enrolled. Providers and policy makers should consider the positive effect of increased contact with PCMHs when designing and evaluating initiatives to improve care for this population.

Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study.

Importance: Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations. Objective: To explore clinicians' experiences with the SICP 1 year after implementation. Design, Setting, and Participants: This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020. Exposures: The SICP includes clinician training, communication tools, and processes for system change. Main Outcomes and Measures: Clinicians' experiences with and perceptions of the SICP. Results: Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. Conclusions and Relevance: In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.

The patient satisfaction in primary care consultation-Questionnaire (PiC): An instrument to assess the impact of patient-centred communication on patient satisfaction.

BACKGROUND: Primary care consultation is significantly influenced by communication between the General Practitioner (GP) and their patients. Hypothesising that patient satisfaction can be tested based on an expectation-experience comparison, the aim of this article is to discuss the influence of communication on patient satisfaction. METHODS: A standardised questionnaire was developed striving for a universal primary care survey tool that focuses on patient satisfaction in the context of patient-centred-communication. The sample consisted of 14 German GPs with 80 patients each (n = 1120). Due to the inclusion in an overarching cluster-randomised-study (CRT), the medical practices to be examined were divided into intervention and control groups. The intervention was developed as a reflective training on patient-centred communication. RESULTS: The results in the present sample show no correlation between patient-centred-communication and patient satisfaction. There are also no significant differences between the intervention and control group. DISCUSSION: The results raise the question to what extent patient satisfaction can be shaped significantly through patient-centred-communication. The presented project represents part of the basic research in general medical care research and contributes to the transparent processing of theoretical assumptions. With the results described here, communication models with a focus on patient centredness can be evaluated with regard to their practical relevance and transferability.

An economic valuation technique identified different inpatient care experience as priorities for older Canadians than a traditional approach.

OBJECTIVES: To (1) estimate the relative value of older adults' healthcare experiences based on the Canadian Patient Experience Survey for Inpatient Care (CPES-IC) using an economic valuation technique, and (2) compare the results with those of a conventional key-driver analysis of healthcare experiences based on bivariate correlations. STUDY DESIGN AND SETTING: An online survey of 1,074 Canadians aged 60 and older who had been hospitalized within five years. Participants completed the CPES-IC and a best-worst scaling (BWS) valuation task. BWS data were analyzed using a conditional logit model. These results were compared to a conventional key-driver analysis that estimates importance through Spearman's correlations between experiences and a global rating of overall experience. RESULTS: The valuation approach found that the three experiences most valued by patients were: that staff seemed informed and up-to-date about their hospital care, doctors explained things in a way that they could understand, and that they got all the information they needed about their care and treatment. Three of the top five most valued experiences from the valuation approach were among the top five in the key driver analysis. However, there were noteworthy differences in rank order. CONCLUSION: The results of the valuation exercise can inform local and/or system level quality improvement efforts by identifying priorities from an economic evaluation point of view, which are different than those based on a conventional key-driver analysis. Given the degree of uncertainty in estimates both the rank order and confidence intervals should be used to guide decision-making.

ActionHealthNYC: Effectiveness of a Health Care Access Program for the Uninsured, 2016-2017.

Objectives. To evaluate the effectiveness of a novel health care access program (ActionHealthNYC) for uninsured immigrants. Methods. The evaluation was conducted as a randomized controlled trial in New York City from May 2016 through June 2017. Using baseline and follow-up survey data, we assessed health care access, patient experience, and health status. Results. At baseline, 25% of participants had a regular source of care; two thirds had visited a doctor in the past year and reported 2.5 visits in the past 12 months, on average. Nine to 12 months later, intervention participants were 1.2 times more likely to report having a primary care provider (58% vs 46%), were 1.2 times more likely to have seen a doctor in the past 9 months (91% vs 77%), and had 1.5 times more health care visits (4.1 vs 2.9) compared with control participants. Conclusions. ActionHealthNYC increased health care access among program participants. Public Health Implications. State and local policymakers should build on the progress that has been made over the last decade to expand and improve access to health care for uninsured immigrants.

Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study.

OBJECTIVE: To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. DESIGN: Quasi-experimental design with partial randomisation at the cluster level. SETTING: Seven rural districts in Zambia. POPULATION: Women delivering at 40 health facilities between June 2016 and August 2018. METHODS: Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. MAIN OUTCOME MEASURES: Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. RESULTS: We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001). CONCLUSION: The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. TWEETABLE ABSTRACT: A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.

Self-reported medication adherence among patients with diabetes or hypertension, Médecins Sans Frontières Shatila refugee camp, Beirut, Lebanon: A mixed-methods study.

INTRODUCTION: Low adherence to medications, specifically in patients with Diabetes (DM) and Hypertension (HTN), and more so in refugee settings, remains a major challenge to achieving optimum clinical control in these patients. We aimed at determining the self-reported medication adherence prevalence and its predictors and exploring reasons for low adherence among these patients. METHODS: A mixed-methods study was conducted at Médecins Sans Frontières non-communicable diseases primary care center in the Shatila refugee camp in Beirut, Lebanon in October 2018. Data were collected using the validated Arabic version of the 8-items Morisky Medication Adherence Scale (MMAS-8) concurrently followed by in-depth interviews to explore barriers to adherence in patients with DM and/or HTN. Predictors of adherence were separately assessed using logistic regression with SPSS© version 20. Manual thematic content analysis was used to analyze the qualitative data. RESULTS: Of the 361 patients included completing the MMAS, 70% (n = 251) were moderately to highly adherent (MMAS-8 score = 6 to 8), while 30% (n = 110) were low-adherent (MMAS-8 score<6). Patients with DM-1 were the most likely to be moderately to highly adherent (85%; n = 29). Logistic regression analysis showed that patients with a lower HbA1C were 75% more likely to be moderately to highly adherent [(OR = 0.75 (95%CI 0.63-0.89), p-value 0.001]. Factors influencing self-reported moderate and high adherence were related to the burden of the disease and its treatment, specifically insulin, the self-perception of the disease outcomes and the level of patient's knowledge about the disease and other factors like supportive family and healthcare team. CONCLUSION: Adherence to DM and HTN was good, likely due to a patient-centered approach along with educational interventions. Future studies identifying additional factors and means addressing the barriers to adherence specific to the refugee population are needed to allow reaching optimal levels of adherence and design well-informed intervention programs.

Herpes Zoster (Shingles) Patient-Centered Wound Outcomes: A Literature Review.

GENERAL PURPOSE: To present a comprehensive review of patient-centered outcomes of topical or systemic interventions applied to those with shingles or postherpetic neuralgia to inform clinical practice and identify related research needs. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will be able to:1. Explain the importance of early diagnosis and treatment of herpes zoster (HZ).2. Identify interventions that have resulted in documented improvement of validated patient-centered outcomes in patients with HZ or postherpetic neuralgia.3. Recognize the average per patient medical costs of HZ in the US.

One in three people endure herpes zoster (HZ; also known as shingles) during their lifetime, experiencing pain, secondary infections, postherpetic neuralgia, reduced quality of life, and considerable patient costs. These patient burdens remain to be reviewed. To perform a comprehensive review of patient-centered outcomes of topical or systemic interventions applied to those with shingles or postherpetic neuralgia to inform clinical practice and identify related research needs. The PubMed database was searched with supplementary Google Scholar searches for Medical Subject Headings "shingles" or "post-herpetic neuralgia" to find clinical studies documenting validated patient-centered outcomes: pain, secondary infection, healing, function, depression, social isolation, treatment costs, or quality of life. Six representative case studies were examined. Pertinent original and derivative clinical study references were included. Preclinical studies, reviews, or studies of non-HZ conditions were excluded. Two authors tabulated clinical efficacy evidence for interventions affecting patient-centered outcomes. Evidence supported efficacy for systemic antiviral or topical anesthetic interventions improving pain, healing, sleep, vision, or quality of life for those with HZ or postherpetic neuralgia. Patient cases reported improved pain and/or sleep using occlusive dressings. Treatment costs and secondary infections were reported only in cases or cohort studies. Randomized clinical research focused on medications improving patient pain, healing, sleep, or vision outcomes. Research is needed measuring outcomes of adding occlusive dressings to optimal care and effects on secondary infections and treatment costs.