Diversity, Inclusion, and Health Equity in Academic Family Medicine.

BACKGROUND AND OBJECTIVES: Diversity, inclusion, and health equity (DIHE) are integral to the practice of family medicine. Academic family medicine has been grappling with these issues in recent years, particularly with a focus on racism and health inequity. We studied the current state of DIHE activities in academic family medicine departments and suggest a framework for departments to become more diverse, inclusive, antiracist, and focused on health equity and racial justice. METHODS: As part of a larger annual membership survey, family medicine department chairs were asked for their assessment of departmental DIHE and antioppression activities, and infrastructure and resources committed to increasing DIHE. RESULTS: More than 60% of family medicine department chairs participating in this study rate their departments highly in promoting DIHE and antioppression, and 66% of chairs report an institutional infrastructure that is working well. Just over half of departments or institutions have had a climate survey in the past 3 years, 47.3% of departments have a diversity officer, and 26% of departments provide protected time or resources for a diversity officer. CONCLUSIONS: The majority of family medicine department chairs rate their departments highly on DIHE. However, only 50% of departments have formally assessed climate in the past 3 years, fewer have diversity officers, and even fewer invest resources in their diversity officers. This disconnect should motivate academic family medicine departments to undertake formal self-assessment and implement a strategic plan that includes resource investment in DIHE, measurable outcomes, and sustainability.

Interacting with patients' family members during the office visit.

The physician-patient relationship is part of the patient's larger social system and is influenced by the patient's family. A patient's family member can be a valuable source of health information and can collaborate in making an accurate diagnosis and planning a treatment strategy during the office visit. However, it is important for the physician to keep an appropriate balance when addressing concerns to maintain the alliance formed among physician, patient, and family member. The patient-centered medical home, a patient care concept that helps address this dynamic, often involves a robust partnership among the physician, the patient, and the patient's family. During the office visit, this partnership may be influenced by the ethnicity, cultural values, beliefs about illness, and religion of the patient and his or her family. Physicians should recognize abnormal family dynamics during the office visit and attempt to stay neutral by avoiding triangulation. The only time neutrality should be disrupted is if the physician suspects abuse or neglect. It is important that the patient has time to communicate privately with the physician at some point during the visit.

Point of care testing to improve glycemic control.

PURPOSE: The purpose of this paper is to pilot-test the feasibility and impact of protocol-driven point-of-care HbAlc testing on levels of glycemic control and on rates of diabetic regimen intensification in an urban community health center serving low-income patients. DESIGN/METHODOLOGY/APPROACH: The paper suggests a primary care process re-design, using point of care finger-stick HbA1c testing under a standing order protocol that provided test results to the provider at patient visit. FINDINGS: The paper finds that the protocol was well received by both nurses and physicians. HbA1c testing rates increased from 73.6 percent to 86.8 percent (p = 0.40, n = 106). For the 69 patients who had both pre- and post-intervention results, HbAlc levels decreased significantly from 8.55 to 7.84 (p = 0.004, n = 69). At baseline, the health center as a system was relatively ineffective in responding to elevated HbA1c levels. An opportunity to intensify, i.e. a face-to-face visit with lab results available, occurred for only 68.6 percent of elevated HbAlc levels before the intervention, vs. 100 percent post-intervention (p < 0.001). Only 28.6 percent of patients with HbAlc levels >8.0 had their regimens intensified in the pre-intervention phase, compared with 53.8 percent in the post-intervention phase (p = 0.03). RESEARCH LIMITATIONS/IMPLICATIONS: This was a pilot-study in one urban health center. Larger group-randomized controlled trials are needed. PRACTICAL IMPLICATIONS: The health center's performance as a system, improved significantly as a way of intensifying diabetic regimens thereby achieving improved glycemic control. ORIGINALITY/VALUE: This intervention is feasible, replicable and scalable and does not rely on changing physician behaviors to improve primary care diabetic outcomes.

Implementation and evaluation of a nursing home fall management program.

OBJECTIVES: To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs). DESIGN: A quality improvement project with data collection throughout FMP implementation. SETTING: NHs in Georgia owned and operated by a single nonprofit organization. PARTICIPANTS: All residents of participating NHs. INTERVENTION: A convenience sample of 19 NHs implemented the FMP. The FMP is a multifaceted quality improvement and culture change intervention. Key components included organizational leadership buy-in and support, a designated facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management. MEASUREMENTS: Process-of-care documentation using a detailed 24-item audit tool and fall and physical restraint use rates derived from quality improvement software currently used in all Georgia NHs (MyInnerView). RESULTS: Care process documentation related to the assessment and management of fall risk improved significantly during implementation of the FMP. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention NHs (a relative reduction of 44%), and decreased in the nonintervention NHs from 7.0% to 4.9% (a relative reduction of 30%). Fall rates remained stable in the intervention NHs (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end), whereas fall rates increased 26% in the NHs not implementing the FMP (from 15.0 falls/100 residents/per month to 18.9 falls/100 residents per month). CONCLUSION: Implementation was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in the use of physical restraints. In contrast, fall rates increased in NHs owned by the same organization that did not implement the FMP. The FMP may be a helpful tool for NHs to manage fall risk while attempting to reduce physical restraint use in response to the Centers for Medicare and Medicaid Services quality initiatives.

A crash-course in cultural competence.

America is a multi-cultural society. Yet, there are cultural dimensions to the clinician-patient relationship that have not been systematically addressed in medical education or in clinical practice. Lack of diversity and lack of cross-cultural skills in the medical profession may contribute to health disparities in America. Cultural competence for the medical profession represents a core set of skills that can be learned to respectfully and effectively communicate healthcare information with diverse patient populations. The authors blended their extensive literature review with the knowledge and experience of a culturally diverse medical team to develop the CRASH-Course in Cultural Competency training program for medical professionals. CRASH is a mnemonic for the following essential components of culturally competent health care--consider Culture, show Respect, Assess/Affirm differences, show Sensitivity and Self-awareness, and do it all with Humility. The goal of the CRASH-Course in Cultural Competency is to build confidence and competence in the clinician's ability to communicate effectively with diverse patient populations.

Disparities in Primary Care EHR Adoption Rates.

This study evaluates electronic health record (EHR) adoption by primary care providers in Georgia to assess adoption disparities according to practice size and type, payer mix, and community characteristics. Frequency variances of EHR "Go Live" status were estimated. Odds ratios were calculated by univariate and multivariate logistic regression models. Large practices and community health centers (CHCs) were more likely to Go Live (>80% EHR adoption) than rural health clinics and other underserved settings (53%). A significantly lower proportion (68.9%) of Medicaid predominant providers had achieved Go Live status and had a 47% higher risk of not achieving Go Live status than private insurance predominant practices. Disparities in EHR adoption rates may exacerbate existing disparities in health outcomes of patients served by these practices. Targeted support such as that provided to CHCs would level the playing field for practices now at a disadvantage.

Disparities in antidepressant treatment in Medicaid elderly diagnosed with depression.

OBJECTIVES: To determine whether there were racial or ethnic disparities in the use of antidepressants in low-income elderly patients insured by Medicaid. DESIGN: Examination of 1998 Medicaid claims data. SETTING: Centers for Medicare and Medicaid Services Medicaid claims data for five U.S. states. PARTICIPANTS: All Medicaid recipients aged 65 to 84 with a diagnosis of depression. MEASUREMENTS: Treatment versus no treatment; in those treated, treatment with drugs was classified as old- or new-generation antidepressants. RESULTS: In 1998, 7,339 unique individuals aged 65 to 84 had at least one outpatient encounter with depression as the primary diagnosis. Nearly one in four (24.2%) received no antidepressant drug therapy, and 22% received neither psychotherapy nor an antidepressant. African-American individuals were substantially more likely to be untreated (37.1%) than Hispanic (23.6%), white (22.4%), or Asian (13.8%) individuals. In logistic regression models adjusting for sex, state, long-term care status, and age group, African Americans with a primary diagnosis of depression were almost twice as likely as whites not to receive an antidepressant within the study period (odds ratio=1.91, 95% confidence interval=1.62-2.24). Patients in long-term care facilities and those aged 65 to 74 were less likely to receive treatment. CONCLUSION: Substantial numbers of elderly Medicaid enrollees with a primary diagnosis of depression did not receive antidepressants or behavioral therapy. This gap in care disproportionately affected African-American patients.

Re-engineering the primary care practice to eliminate adult immunization disparities.

Traditional "one-patient-at-a-time," doctor-centered primary care practice models do not achieve optimal immunization rates for pneumonia and influenza, in part because of time pressures and competing demands from a burgeoning list of clinical guidelines. Some widely used quality improvement methods (physician education, provider feedback, academic detailing, etc.) have only a modest and short-lived impact on improving immunization rates. Evidence is mounting that practices can substantially improve immunization rates by changing practice systems and processes with standing orders and algorithms, expanded nurse decision-making, patient education and incentives, and partnerships with community-based pharmacies. Quality-focused, constantly-learning practices that cultivate a culture of excellence will be most effective in adopting such changes.

Modifiable determinants of healthcare utilization within the African-American population.

BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of healthcare have focused on black-white differences rather than focusing on "within-group" analysis of African Americans. OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on healthcare utilization within the African-American population. METHODS: Secondary data analysis of 3462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally representative survey of the civilian, noninstitutionalized U.S. population in 1999. RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3462 African-American respondents who represent a U.S. population of 36,538,639 persons. Personal nonmodifiable characteristics such as age and gender were significantly related to healthcare utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of healthcare utilization for Afrcan-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors. CONCLUSIONS: The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients and could be independently targeted for intervention.

Racial and sex differences in associations between activities of daily living and cognition in community-dwelling older adults.

OBJECTIVES: To examine the association between function measured according to activities of daily living (ADLs), instrumental activ1ities of daily living (IADLs), and cognition assessed according to Mini-Mental State Examination (MMSE) scores of older African-American and non-Hispanic white community-dwelling men and women. DESIGN: Cross-sectional study assessing associations between self-reported ADL and IADL difficulty and MMSE scores for race- and sex-specific groups. SETTING: Homes of community-dwelling older adults. PARTICIPANTS: A random sample of 974 African-American and non-Hispanic white Medicare beneficiaries aged 65 and older living in west-central Alabama and participating in the University of Alabama at Birmingham Study of Aging, excluding those with reported diagnoses of dementia or with missing data. MEASUREMENTS: Function, based on self-reported difficulty in performing ADLs and IADLs, and cognition, using the MMSE. Multivariable linear regression models were used to test the association between function and cognition in race- and sex-specific groups after adjusting for covariates. RESULTS: Mini-Mental State Examination scores were modestly correlated with ADL and IADL difficulty in all four race- and sex-specific groups, with Pearson correlation coefficients ranging from −0.189 for non-Hispanic white women to −0.429 for African-American men. Correlations between MMSE and ADL or IADL difficulty in any of the race- and sex-specific groups were no longer significant after controlling for sociodemographic factors and comorbidities. CONCLUSION: Mini-Mental State Examination was not significantly associated with functional difficulty in older African-American and non-Hispanic white men and women after adjusting for sociodemographic factors and comorbidities, suggesting a mediating role in the relationship between cognition and function.

Economic impact of a Medicaid population health management program.

A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003-2004) and performance year one (2006-2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions.

Predictors of 4-year retention among African American and white community-dwelling participants in the UAB study of aging.

PURPOSE: To identify racial/ethnic differences in retention of older adults at 3 levels of participation in a prospective observational study: telephone, in-home assessments, and home visits followed by blood draws. DESIGN AND METHODS: A prospective study of 1,000 community-dwelling Medicare beneficiaries aged 65 years and older included a baseline in-home assessment and telephone follow-up calls at 6-month intervals; at 4 years, participants were asked to complete an additional in-home assessment and have blood drawn. RESULTS: After 4 years, 21.7% died and 0.7% withdrew, leaving 776 participants eligible for follow-up (49% African American; 46% male; 51% rural). Retention for telephone follow-up was 94.5% (N = 733/776); 624/733 (85.1%) had home interviews, and 408/624 (65.4%) had a nurse come to the home for the blood draw. African American race was an independent predictor of participation in in-home assessments, but African American race and rural residence were independent predictors of not participating in a blood draw. IMPLICATIONS: Recruitment efforts designed to demonstrate respect for all research participants, home visits, and telephone follow-up interviews facilitate high retention rates for both African American and White older adults; however, additional efforts are required to enhance participation of African American and rural participants in research requiring blood draws.

E-mail in patient-provider communication: a systematic review.

OBJECTIVE: To review systematically the role of e-mails in patient-provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care. METHODS: A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008. RESULTS: A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed. CONCLUSION: The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool. PRACTICE IMPLICATIONS: It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.

Presence of a community health center and uninsured emergency department visit rates in rural counties.

CONTEXT: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. METHODS: We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22). CONCLUSIONS: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

A model quality improvement program for the management of falls in nursing homes.

There is an urgent need for model programs to effectively manage fall risk in nursing homes. Such programs should use best practices and quality improvement (QI) methodology in a manner that is practical for sustained implementation in the current resource-constrained long-term care environment. The Falls Management Program (FMP) represents 13 years of fieldwork (1993-2006). It is an interdisciplinary, multifaceted approach to reducing fall risk that includes systematic screening, assessment, individualized care planning, resident monitoring, and the elimination of environmental safety hazards. The FMP is initiated by a self-assessment process that assists nursing homes in identifying areas that need improvement so that staff can tailor implementation to their own facility's needs. The FMP incorporates education on best practices and uses several QI tools designed to assist nursing homes with program implementation. Core components of the program include administrative and clinical leadership, interdisciplinary teamwork using QI methodology, support by advance practice nurses, and an 8-step fall response system to facilitate the comprehensive investigation and documentation of falls, primary care provider involvement, and development of individualized fall risk reduction strategies.

Challenges to implementing an APN-facilitated falls management program in long-term care.

Although several clinical studies have demonstrated success in reducing falls among nursing home residents, the degree of adherence to these strategies varies widely among studies and facilities, especially following the removal of external consultants or advance practice nurses (APNs). This article identified contextual factors that challenged the effective implementation of a falls reduction program. For nurses, the major problems with implementing the project involved inadequate nursing assessment and clinical decision making. APNs who influence nursing staff behavior via education and individual resident consultation may fill the critical gap in professional nursing care in nursing homes.