Studies comparing quality of care by specialty: valid, relevant, or neither?
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Humans↗
Biomedical subjects
Ann S O'Malley
Publications and source records attributed to Ann S O'Malley.
Immunization disparities in older Americans: determinants and future research needs.
BACKGROUND: Marked racial disparities persist in influenza and pneumococcal vaccinations among Medicare beneficiaries. This study sought to assess the contribution that patient, physician, health system, and area-level characteristics make to these racial disparities in immunization. METHODS: Cross-sectional and decomposition analyses were performed on a nationally representative sample of 18,013 non-institutionalized Medicare beneficiaries who responded to the Medicare Current Beneficiary Survey (MCBS) in 2000 to 2002. The physician characteristics of interest included specialty type, accessibility, information-giving skills, perceived quality, and continuity of care. Health system characteristics included HMO enrollment and numbers of primary care physicians per elderly. The outcomes were receipt of influenza vaccine in the past year and ever having received a pneumococcal vaccine. RESULTS: Immunization rates were below recommended levels for all Medicare beneficiaries. Disparities between white and black beneficiaries in the receipt of vaccinations were large-an absolute 17% difference for each vaccine. After adjusting for patient, physician, health system, and area-level characteristics, white beneficiaries had significantly higher odds of vaccination than did black beneficiaries: adjusted odds ratio (aOR) = 1.52 (95% confidence interval [CI] = 1.35-1.71) for influenza vaccination, and aOR = 1.82 (95% CI = 1.61-2.07) for pneumococcal vaccination. Beneficiaries with a usual physician that they rated as having good information-giving skills and whose practice was more accessible, had higher immunization rates. Beneficiaries with a primary care generalist as their usual physician had higher odds of immunization than those with a specialist as their usual physician. At the county level, a higher number of primary care physicians per elderly resident was associated with higher odds of immunization. Only 7% of the racial disparity in influenza immunization was explained by the measured characteristics of beneficiaries and their health systems. CONCLUSIONS: Despite similar insurance coverage and presence of a usual physician, black beneficiaries were significantly less likely than their white counterparts to receive influenza and pneumococcal vaccinations. The implications for future research are discussed, including the need for system-based interventions that make the offering and discussion of vaccination routine.
Aged↗
Barriers and facilitators of colorectal cancer screening among Mid-Atlantic Latinos: focus group findings.
OBJECTIVE: To examine patient and provider barriers and facilitators of colorectal cancer (CRC) screening among mid-Atlantic Latinos seeking care at urban primary care clinics and describe implications for the design of interventions in primary care. DESIGN AND METHOD: Nine focus groups were conducted with 70 Latino patients and 27 primary care providers. Content analysis of focus group transcripts was performed using established qualitative techniques. RESULTS: Comments on CRC screening fell into 10 content areas: primary care site or provider characteristics (25% patient/21% provider comments); knowledge (18% patient/12% provider comments); cost/insurance coverage (10%/25%); attitudes (14%/7%); ordering of priorities (10%/11%); language (12%/7%); procedural issues regarding screenings (8%/10%); discrimination (2%/1%); and issues related to being a new immigrant (.2%/6%). Patient lack of understanding of the screening test procedures, inadequate knowledge about colorectal cancer, inadequate numbers of Spanish-speaking providers, and the cost of screening were most often cited as barriers by patients. Both providers and patients repeatedly mentioned the lack of funding and referral sources for colonoscopy as a key barrier to performing screening, even with lower-cost fecal occult blood tests, as colonoscopy follow-up would not be available. Patients favored receiving CRC screening recommendations from their usual continuity physician, but were open to receiving information on test procedures and indications from a Spanish-speaking health educator. CONCLUSIONS: Efforts to improve funding and availability of colonoscopy for low-income persons could proceed in tandem with linguistically and culturally appropriate clinic-based efforts to improve CRC screening among Latinos.
Aged↗
No exodus: physicians and managed care networks.
After remaining stable since 1996-97, the percentage of U.S. physicians who do not contract with managed care plans rose from 9.2 percent in 2000-01 to 11.5 percent in 2004-05, according to a national study from the Center for Studying Health System Change (HSC). While physicians have not left managed care networks in large numbers, this small but statistically significant increase could signal a trend toward greater out-of-pocket costs for patients and a decline in patient access to physicians. The increase in physicians without managed care contracts was broad-based across specialties and other physician and practice characteristics. Compared with physicians who have one or more managed care contracts, physicians without managed care contracts are more likely to have practiced for more than 20 years, work part time, lack board certification, practice solo or in two-physician groups, and live in the western United States. The study also found substantial variation in the proportion of physicians without managed care contracts across communities, suggesting that local market conditions influence decisions to contract with managed care plans.
Contracts↗
Disparities despite coverage: gaps in colorectal cancer screening among Medicare beneficiaries.
BACKGROUND: Despite its effectiveness in reducing mortality, colorectal cancer (CRC) screening rates are low, especially among low-income and minority groups; however, physician recommendation can increase screening rates. METHODS: We performed a multilevel analysis of the Medicare Current Beneficiary Survey data linked to Medicare claims and the Area Resource File to identify determinants of racial and socioeconomic disparities in CRC screening among 9985 Medicare Parts A and B beneficiaries with a usual physician. Recent CRC screening was defined as receipt of either a home fecal occult blood test, flexible sigmoidoscopy, or colonoscopy at recommended intervals. RESULTS: Unadjusted rates of screening were 48% for white and 39% for black beneficiaries (P<.001). Racial differences in CRC screening receipt were eliminated after adjustment for socioeconomic status as measured by income and education. Socioeconomic status disparities decreased but remained significant after adjustment for personal and health system factors. Awareness of CRC (adjusted odds ratio, 2.76; 95% confidence interval, 2.29-3.33) and having a primary care generalist (vs another specialist) as one's usual physician (adjusted odds ratio, 1.31; 95% confidence interval, 1.12-1.53) were associated with higher odds of screening, controlling for other factors. The odds of screening were also higher among those whose usual physician was rated more highly on information-giving skills. CONCLUSIONS: Racial differences in CRC screening rates among Medicare beneficiaries with a usual physician are explained by differences in socioeconomic status. Beneficiaries with a primary care generalist as their usual physician had higher rates of CRC screening receipt. Increased efforts to make Medicare beneficiaries aware of the benefits of CRC screening may capitalize on the associations found in this study between CRC knowledge, physician information giving, and timely screening.
Aged↗
Rising pressure: hospital emergency departments as barometers of the health care system.
Pressures--ranging from persuading specialists to provide on-call coverage to dealing with growing numbers of patients with serious mental illness--are building in already-crowded hospital emergency departments (EDs) across the country, according to findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. As the number of ED visits rises significantly faster than population growth, many hospitals are expanding emergency department capacity. At the same time, hospitals face an ongoing nursing shortage, contributing to tight inpatient capacity that in turn hinders admitting ED patients. In their role as hospitals' "front door" for attracting insured inpatient admissions, emergency departments also increasingly are expected to help hospitals compete for insured patients while still meeting obligations to provide emergency care to all-comers under federal law. Failure to address these growing pressures may compromise access to emergency care for patients and spur already rapidly rising health care costs.
Delivery of Health Care↗
The role of trust in use of preventive services among low-income African-American women.
BACKGROUND: This study explored factors that predict higher trust in primary care providers, and examined the role of patient trust on the use of preventive services for low-income African-American women. METHODS: We conducted a cross-sectional, population-based telephone survey of 961 African-American women over age 40 in Washington, DC. Two dimensions of trust were examined: overall trust in one's regular primary care provider, and trust that the regular provider had no financial conflict of interest. Self-reported use of mammography, Pap tests, clinical breast exams, colorectal cancer screening, blood pressure, height and weight measurement, diet counseling, and depression screening, as delivered by one's primary care provider, were assessed. An index summarizing overall use of these interventions was the main outcome variable. RESULTS: More than two-thirds of respondents reported high trust in their physician. Older respondents (>65) were more trusting of their physicians overall than were younger respondents (P < 0.01). Primary care characteristics (continuity of care, accessibility of the practice, coordination of specialty care by one's regular provider) were more strongly associated with having high trust than were sociodemographic, health status, and insurance characteristics. Higher trust was significantly associated with greater use of recommended preventive services (OR: 2.3, 95% CI: 1.3, 4.0), controlling for the effects of insurance status, primary care, and patient characteristics. CONCLUSIONS: Trust is associated with use of recommended preventive services in low-income African-American women. Stronger patient-provider relationships, with high levels of trust, may indirectly lead to better health through adherence to recommended preventive services for low income African-American women.
Black or African American↗
Clinical practice guidelines and performance indicators as related--but often misunderstood--tools.
BACKGROUND: Widespread variation in medical practice indicates that existing scientific evidence is often not translated into appropriate clinical care. Two tools have evolved that try to address this variation: clinical practice guidelines (CPGs) and performance indicators (PIs). TENSIONS BETWEEN CPGS AND PIS: CPGs present available evidence that is subsequently reviewed and frequently adopted by professional organizations, so that clinicians may judge whether specific management recommendations are appropriate for each patient. PIs are devised to measure and document performance to motivate organizations to improve through the use of common metrics. IMPLICATIONS OF THESE TENSIONS: The increasingly widespread use of PIs with CPGs (and clinicians' confusion of them with CPGs) risks lowering the standards of clinical care. PIs are not intended to set optimal standards of care for any individual patient. Clinicians should not restrict their quality monitoring to a focus on PIs because they could miss important opportunities to learn and to improve the care they deliver to their individual patients. CONCLUSION: Tensions between CPGs and PIs do not mean that these tools should be abandoned but rather that they need to be refined. Recognition of the imperfections of CPGs and PIs should not blind clinicians to the ultimate goals of these tools--to promote quality (through changes in practice and/or selection) and ensure that medical care is based on scientific evidence.
Humans↗
Providing health care to low-income women: a matter of trust.
BACKGROUND: Trust is an important indicator of quality in patient-provider relationships and predicts adherence to certain protective health behaviours. It has been relatively unexplored among low-income or minority women. OBJECTIVES: We explored health care experiences that influence patient trust among low-income women in the USA with respect to professionals and lay health workers (LHWs). METHODS: Focus groups were conducted with 33 prenatal and postpartum women, aged 18-45 years, recruited from community-based public prenatal care programmes. Focus groups were audio-recorded, transcribed, and independently coded by readers. A model of factors associated with trust was developed based on the major thematic categories. RESULTS: Most women were Black (67%) and had completed high school (85%). Factors related to greater trust specific to patient-provider relationships were: continuity of the patient-provider relationship, effective communication, demonstration of caring and perceived competence. Women with less trust in their physicians reported an unwillingness to follow his/her advice. Most women reported having more trusting relationships with LHWs and nurses than with physicians, probably due to greater contact with these staff. Several women with a low level of trust reported experiences of discrimination due to lack of insurance. CONCLUSIONS: Prenatal care presents a unique opportunity for providers to contribute to the elimination of health disparities among low-income women. Improving continuity with public health prenatal care providers and building strong relationships with LHWs may enhance quality of care and contribute to achieving this goal. Better patient-provider communication is also a practical area of focus towards improving patient trust.
Delivery of Health Care↗
Current evidence on the impact of continuity of care.
PURPOSE OF REVIEW: A core attribute of primary care, continuity of care, is usually viewed as the relationship between a patient and a single practitioner that extends beyond episodes of illness or care for a specific disease and is ongoing over time. The latest evidence of the effectiveness of continuity of care on outcomes for children and adolescents will be presented and placed into the context of prior literature. RECENT FINDINGS: Despite numerous changes in health care delivery systems, recent studies found that clinician continuity continues to be highly valued by patients and their families. From January 1, 2002 to July 1, 2004, five new studies on physician continuity also assessed pediatric outcomes. These studies found an association between physician continuity and lower emergency department use and costs, better coordination of care, and greater patient and parent satisfaction with care. Two new studies on continuity with a primary care practice found that it was associated with higher receipt of recommended developmental, dental, and nutritional advice, as well as up-to-date immunization coverage. SUMMARY: Organizational approaches to maximizing access while maintaining continuity require further development. Efforts to restructure provider reimbursement and information systems need to move from single encounter-based systems toward an emphasis on the provision of care over time, to reward and facilitate continuity of care and the positive patient outcomes with which it is associated.
Adolescent↗
Association between CBE, FOBT, and Pap smear adherence and mammography adherence among older low-income women.
BACKGROUND: Adherence to regular and timely mammography screening, especially in older low-income women, continues to fall below objectives. The primary aim of this study was to examine whether engaging in other cancer screenings was associated with mammography adherence for older women. METHODS: Women, ages 52 and over, without a self-reported history of breast cancer (N = 862) were selected from a larger sample of women residing in Washington, DC, census tracts with >/=30% of households below 200% of the federal poverty threshold. A computer-assisted telephone survey was used to collect data on health care system factors, demographics, cultural beliefs, clinical breast exam (CBE), Pap smear, fecal occult blood testing (FOBT), and mammography. Adherence was defined as receipt of the last two screening tests within recommended intervals for age. RESULTS: After controlling for other variables, adherence to CBE (OR = 4.15; 95% CI, 2.55-6.73) and Pap smear (OR = 1.82; 95% CI, 1.07-3.12) were highly predictive of mammography adherence. Adherence to FOBT (OR = 1.66; 95% CI, 0.97-2.84) was marginally predictive. CONCLUSIONS: Results of this study indicate that nonadherence to other cancer screenings can help identify women in need of additional interventions to improve mammography adherence.
Aged↗
Primary care cancer control interventions including Latinos: a review.
BACKGROUND: Even though 86% of adult Latinos have a usual source of care, there is a paucity of literature on primary care-based interventions to promote cancer prevention and control in this population. This systematic review examines published primary care-based cancer control interventions that included Latinos. METHODS: MEDLINE, the Cochrane Registry, and EMBASE were searched from January 1985 to January 2003. Any primary care-based intervention using a controlled trial, quasi-experimental, or pre-post design that targeted breast, cervical, or colorectal cancer was included if at least 5% of the sample was Latino. RESULTS: A total of 14 intervention studies met inclusion criteria. Seven of the 14 studies described patient or provider reminder interventions. Other interventions incorporated into the primary care setting one of the following: community health educators, culturally sensitive videos, audit with feedback, materials from the "Put Prevention Into Practice" campaign, and vouchers for free screenings. The heterogeneity of designs and outcome variables and the low number of Latinos presented obstacles to combining data to estimate the overall effectiveness of primary care interventions for this population. Qualitatively, patient and physician reminders and management systems strategies including audit with feedback for providers appear to result in improved screening utilization. CONCLUSIONS: There is a paucity of data on the effectiveness of primary care cancer control interventions directed at Latinos. Primary care-based interventions that have been effective in non-Latinos could incorporate culturally appropriate elements and lessons from community-based research and could be applied to Latinos so that their effectiveness can be assessed in this group.
Health Promotion↗
Delivery of preventive services for low-income persons over age 50: a comparison of community health clinics to private doctors' offices.
This study focused on the use of 14 evidence-based preventive services for the low-income population over age 50: colorectal, breast and cervical cancer screening, cholesterol screening, counseling around diet, exercise, tobacco, alcohol and illicit drugs, and immunizations for influenza, tetanus and pneumonia. Population characteristics and rates of delivery of these preventive services are compared for low-income users of community health clinics vs private doctors' offices/HMOs. Three nationally representative data-files from the National Health Interview Survey--the Person-Level File, Sample Adult File, and Sample Adult Prevention File--were linked to obtain the necessary data on preventive services use in the 12,024 persons over age 50. Among the population of persons over age 50 living below 200% of the poverty threshold, those using community clinics were more likely to be younger, a racial or ethnic minority, less formally educated, in poorer health, uninsured, and more likely to face time, transportation or cost barriers to obtaining health care (p < .01 for all comparisons), than their counterparts using private doctors' offices/HMOs. Community health clinics performed as well as private doctors/HMOs in the delivery of cancer screening, cholesterol screening and immunizations to lower income persons over 50 years. Rates of counseling about diet and exercise were higher among users of private doctor's offices than among users of community health clinics users (40% vs. 31% respectively, p = .02). Despite the severe resource constraints under which they operate, and the greater vulnerability of the population they serve, community clinics deliver preventive services at rates comparable to private doctors' offices and HMOs.
Community Health Centers↗
Primary care attributes and care for depression among low-income African American women.
OBJECTIVES: We examined the association between attributes of primary care providers and care for depression, from a patients' perspective, among a sample of predominantly low-income African American women. METHODS: Computer-assisted telephone interviews were conducted among a population-based sample of 1202 women residing in Washington, DC. RESULTS: Respondents whose primary care physicians provided more comprehensive medical services were more likely to be asked about and treated for depressive symptoms than women whose providers were less medically comprehensive. Women who rated their providers as having more respect for them also were more likely to be asked about and treated for depression. CONCLUSIONS: More comprehensive primary care delivery and a physician-patient relationship focused on mutual respect are associated with greater rates of physician inquiry about and treatment for depression among vulnerable women.
Adult↗
Beyond the examination room: primary care performance and the patient-physician relationship for low-income women.
OBJECTIVE: To assess whether primary care performance of low-income women's primary care delivery sites is associated with the strength of their relationships with their physicians. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold. PARTICIPANTS: Women over age 40 (N=1,205), 82% of whom were African American. MEASUREMENTS AND MAIN RESULTS: The response rate was 85%. Primary care performance was assessed using women's ratings of their systems' accessibility (organizational, geographic, and financial), continuity, comprehensiveness, and coordination. Respondents' ratings of trust in their physicians, communication with their physicians, and compassion shown by their physicians were used to operationalize the patient-physician relationship. Controlling for population and insurance characteristics, 4 primary care features were positively associated with women's trust in and communication with their physicians: continuity with a single clinician, organizational accessibility of the practice, comprehensive care, and coordination of specialty care services. Better organizational access, but not geographic or financial access, was associated with greater levels of trust, compassion, and communication (odds ratios [ORs], 3.2, 7.4, and 6.9, respectively; P < or =.01). Women who rated highest their doctor's ability to take care of all of their health care needs (highest level of comprehensiveness) had 11 times the odds of trusting their physician (P < or =.01) and 6 times the odds of finding their physicians compassionate and communicative (P < or =.01), compared to those with the lowest level of comprehensiveness. CONCLUSIONS: Primary care delivery sites organized to be more accessible, to link patients with the same clinician for their visits, to provide for all of a woman's health care needs, and to coordinate specialty care services are associated with stronger relationships between low-income women and their physicians. Primary care systems that fail to emphasize these features of primary care may jeopardize the clinician-patient relationship and indirectly the quality of care and health outcomes.
Adult↗
Adherence of low-income women to cancer screening recommendations.
BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women's adherence to cancer screening recommendations.
Adult↗
Patient and provider priorities for cancer prevention and control: a qualitative study in Mid-Atlantic Latinos.
OBJECTIVE: This study examines the cancer prevention and control priorities of uninsured Latin Americans and their primary care providers in metropolitan Washington, D.C. Patient and provider priorities are compared to identify common ground for future interventions in resource constrained primary care settings. METHODS: Ten focus groups were conducted among 88 Latin-American patients from 5 primary care clinics. Key informant interviews and a priority setting exercise were conducted among the clinicians and medical directors at these same clinics. Prompted by semi-structured open-ended questions, the key informant interviews and focus groups elicited patient and provider concerns and priorities for cancer prevention and control. All focus group sessions and key informant interviews were audiotaped, transcribed verbatim, and coded independently by 2 reviewers. Interrater reliability for the overall coding of distinct units of text into one of 4 major content areas was excellent, (Kappa = 0.95; 95% CI 0.94, 0.98). RESULTS: All comments from the patient focus groups and provider key informant interviews fell into one of 4 content areas: cancer knowledge, attitudes and beliefs, patient socioeconomic concerns, and clinic capabilities to provide services. The most frequently mentioned theme among patients was their own lack of knowledge about cancer screening, particularly about colorectal cancer screening. Other leading patient priorities were the perceived costs of screening tests and the resource constraints of the primary care clinics serving the uninsured. Leading attitudinal concerns about screening were fatalism, embarrassment about the screening test, and non-concordant clinician gender. The leading priorities among clinicians were increasing patient knowledge about screening tests, time limitations of the clinical encounter, and primary care clinic resource constraints. The areas of greatest overlap in priorities between patients and providers were the themes of low patient knowledge about cancer screening and prevention, and recognition of the resource constraints under which these "safety net" clinics operate. CONCLUSIONS: Patient knowledge level about screening, particularly colorectal cancer screening, and the impact of clinical resource constraints on the delivery of cancer screening are common priorities of uninsured Latino patients and their primary care clinicians. Stepping up efforts to improve cancer screening and prevention for Latinos requires an initial investment in developing the basic clinical infrastructure (ie, clinic capacity) of sites serving this special population. Common priorities identified from patient and provider data should be used to design evidence-based cancer prevention and control interventions within the resource limitations of the primary care settings serving the uninsured.
Adolescent↗
Feasibility of mobile cancer screening and prevention.
Many areas have high cancer mortality rates and medically underserved populations. This study describes the feasibility (acceptability and costs) of an urban multiphasic (multiple cancers) screening van. Feasibility was evaluated by literature review and informant interviews. Costs were estimated by resource use from urban mobile screening units; decision analysis estimated the costs per cancer detected for breast, cervix, colorectal, and prostate cancer screening. Acceptability of a multiphasic van varied by the informant's perspective. Feasibility and costs were most sensitive to four parameters: age, prior screening history, risk factors, and volume of simultaneous examinations. Subsidized mobile screening facilities may have the potential to reduce cancer morbidity and mortality if they target hard-to-reach underscreened groups, maintain high volume, coordinate with primary care providers, and build on an infrastructure that provides diagnostic and treatment services regardless of ability to pay. It is unclear whether the investment required will translate into a reasonable cost per year of life saved.
Cost-Benefit Analysis↗