Biomedical subjects

Elizabeth M Yano

Publications and source records attributed to Elizabeth M Yano.

33 records · Page 2Linked to original sources

PubMed2004

Primary care practice and facility quality orientation: influence on breast and cervical cancer screening rates.

BACKGROUND: Despite the importance of early cancer detection, variation in screening rates among physicians is high. Insights into factors influencing variation can guide efforts to decrease variation and increase screening rates. OBJECTIVES: To explore the association of primary care practice features and a facility's quality orientation with breast and cervical cancer screening rates. STUDY DESIGN: Cross-sectional study of screening rates among 144 Department of Veterans Affairs (VA) medical centers and for a national sample of women. METHODS: We linked practice structure and quality improvement characteristics of individual VA medical centers from 2 national surveys (1 to primary care directors and 1 to a stratified random sample of employees) to breast and cervical cancer screening rates determined from a review of random medical records. We conducted bivariate analyses and multivariate logistic regression of primary care practice and facility features on cancer screening rates, above and below the median. RESULTS: While the national screening rates were high for breast (87%) and cervical cancer (90%), higher screening rates were more likely when primary care providers were consistently notified of specialty visits and when staff perceived a greater organizational commitment to quality and anticipated rewards and recognition for better performance. CONCLUSIONS: Organization and quality orientation of the primary care practice and its facility can enhance breast and cervical cancer screening rates. Internal recognition of quality performance and an overall commitment to quality improvement may foster improved prevention performance, with impact varying by clinical service.

Breast Neoplasms↗

PubMed2002

What patient population does visit-based sampling in primary care settings represent?

BACKGROUND: Evaluations of outpatient interventions often rely on consecutive sampling of clinic visitors, and assume that study results generalize to the population of patients cared for. OBJECTIVE: The representativeness of such visit-based sampling compared with the population of patients seen during the same year, in terms of sociodemographic and clinical characteristics of the user groups that visit-based sampling yielded were assessed. METHODS: One thousand five hundred forty-six continuing patients visiting the primary care firms in an urban VA medical center were consecutively sampled, and visit frequencies were compared for these patients with subsets of the patient population. Administrative and survey data was then used to describe the types of patients visit-based sampling most represented compared with the types of patients sampled less frequently. RESULTS: The average sampled patient visited the firms significantly more often than patients in the reference population (18.7 vs. 9.5). Sampled patients were significantly older (>55 years), in poorer health (higher prevalence of cancer, stroke, hypertension), less likely to smoke, and more likely to be single than the average patient visiting the firms (P<0.05). Adjusting for age and sickness, frequent visitors were more apt to have experienced continuity of care during the prior year, to prefer VA care, and to be unemployed. CONCLUSIONS: Consecutive visit-based sampling actually selected patients with a visit pattern more typical of the patient population visiting four or more times a year. Studies using sampling of consecutive visitors will typically under-represent low users of care and should account for the degree to which results may not generalize to the broader practice population.

Adult↗

PubMed2002

Primary care practice management in rural and urban Veterans Health Administration settings.

Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care. The authors used survey and administrative data from 1999 from the Veterans Health Administration (VHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally. Rural VHA hospitals were smaller, less likely to be academically affiliated, and had fewer integrated specialty care services. Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services. However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals. Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received. Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones. This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings. Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings.

Female↗

PubMed2002

Use of general medical services by VA patients with psychiatric disorders.

OBJECTIVE: Patients with psychiatric disorders, particularly those with severe mental illnesses, have high rates of undetected and untreated medical problems and substantially elevated mortality rates due to medical illness. The authors sought to develop a better understanding of the demographic, medical, and psychiatric characteristics of this population to inform efforts to improve the medical care of these persons. METHODS: Using Department of Veterans Affairs (VA) databases, the authors examined use of medical services by 175,653 patients who were treated in Southern California and Nevada during fiscal year 2000. Multivariate regression models were used to examine factors affecting receipt of any medical care and the number of medical visits. RESULTS: Patients with psychiatric diagnoses had fewer medical visits than other VA patients; the largest differences were seen for patients with severe mental illnesses. Patients who were younger and male had few visits. Patients with diabetes or hypertension who had been diagnosed as having schizophrenia, bipolar disorder, or an anxiety disorder had substantially fewer visits than those who did not have these psychiatric diagnoses. Patients older than 50 years were less likely to have any medical care if they had a diagnosis of a substance use, depressive, bipolar, or anxiety disorder or posttraumatic stress disorder. CONCLUSIONS: Use of medical care varies by psychiatric diagnosis. Young adults with schizophrenia and posttraumatic stress disorder and adults of all ages with bipolar disorder have an especially high risk of not receiving general medical services. Interventions to improve medical care may need to be tailored to the population being targeted.

Diabetes Mellitus↗

PubMedDate not supplied

Gender differences in smoking cessation services received among veterans.

INTRODUCTION: Smoking is the leading preventable cause of death among women in the United States. It is a particular problem for women using the Veterans Health Administration (VA), where the prevalence of smoking among women is 30%. We compared the baseline characteristics of male and female smokers and then assessed the smoking cessation services they received to determine whether there are important gender differences in care. METHODS: As part of a study of implementing national guidelines for smoking cessation taking place at 18/23 VA centers in the southwestern and western United States, we conducted a baseline survey of a random sample of 1,941 smokers in primary care (129 women, 1,812 men) to assess the smoking cessation services received by female and male veterans. Subjects were followed 1 year later (73 women, 1007 men). Results for men and women were compared using chi-square tests and analysis of variance. Logistic regression analyses were conducted to determine factors that were independently associated with receipt of smoking cessation services. RESULTS: Female smokers were younger, more educated, and less likely to be married than male smokers. Women were equally likely to report being advised to quit smoking or referred to a smoking cessation program but were much less likely to report receiving a prescription for nicotine patches (OR .5, 95% CI .3-.9). One year later, female smokers were less likely to have successfully quit smoking. CONCLUSION: Women were less likely to report receiving nicotine patches for smoking cessation. Future interventions to increase use of smoking cessation medications for female smokers will also hopefully increase their quit rate.

Adult↗

PubMedDate not supplied

VA emergency health care for women: condition--critical or stable?

BACKGROUND: Veteran's Affairs (VA) facilities have reconfigured themselves to address the health care needs of the growing number of women veterans. However, the challenge of providing comprehensive care to a group that is an extreme minority within VA may still leave gaps in the delivery of necessary health care services. OBJECTIVES AND METHODS: We sought to assess the availability of women's health care specialists for emergency gynecologic problems (emergency-GYN) and for emergency mental health conditions specific to women (emergency-WMH), we surveyed the Chief of Staff and senior clinician at each VA site serving 400 or more women veterans. RESULTS: Emergency-GYN expertise was usually available at all times for 39.8% of sites, and only during usual clinic hours for 24.6% of sites. An emergency-WMH specialist was available at all times for 51.7% of sites, and only during usual clinic hours for 31.0% of sites. VA sites that had a separate women's health clinic were more likely to have emergency-GYN expertise available. Sites in regions with higher managed care penetration were less likely to have emergency-WMH specialist availability. CONCLUSIONS: Our data suggest a limited availability of specialists for gynecologic and women's mental health emergencies at some VA sites. How this may affect overall quality of care for women in the VA system is unknown. Further work is needed to determine actions clinicians take when expertise is emergently needed for health care issues unique to women. Options for expanding VA availability of such expertise include internal development of women's health expertise and telemedicine access to experts to aid in emergency women's health care decision making.

Emergency Service, Hospital↗

PubMedDate not supplied

Diffusion of innovation in women's health care delivery: the Department of Veterans Affairs' adoption of women's health clinics.

BACKGROUND: In response to concerns about the availability and quality of women's health services in Department of Veterans Affairs (VA) medical centers in the early 1990s, Congress approved landmark legislation earmarking funds to enhance women's health services. A portion of the appropriation was used to launch Comprehensive Women's Health Centers as exemplars for the development of VA women's health care throughout the system. We report on the diffusion and characteristics of VA women's health clinics (WHCs) 10 years later. METHODS: In 2001, we surveyed the senior women's health clinician at each VA medical center serving > or =400 women veterans (83% response rate) regarding their internal organizational characteristics in relation to factors associated with organizational innovation (centralization, complexity, formalization, interconnectedness, organizational slack, size). We evaluated the comparability of WHCs (n = 66) with characteristics of the original comprehensive women's health centers (CWHCs; n = 8). RESULTS: Gender-specific service availability in WHCs was comparable to that of CWHCs with important exceptions in mental health, mammography and osteoporosis management. WHCs were less likely to have same-gender providers (p < .05), women's health training programs (p < .01), separate women's mental health clinics (p < .001), separate space (p < .05), or adequate privacy (p < .05); however, they were less likely to have experienced educational program closures (p < .001) and staffing losses (p < .05) compared to CWHCs. CONCLUSIONS: Diffusion of comprehensive women's health care is as yet incomplete. More research is needed to examine the quality of care associated with these models and to establish the business case for managers faced with small female patient caseloads.

Diffusion of Innovation↗

PubMedDate not supplied

Availability of comprehensive women's health care through Department of Veterans Affairs Medical Center.

Despite increased numbers of women veterans, little is known about health services delivery to women across the Department of Veterans Affairs (VA). To assess VA availability of women's health services, we surveyed the senior clinician at each VA site serving 400 or more women veterans. We found that virtually all sites have developed arrangements, either directly or through off-site contracts, to ensure availability of comprehensive women's health care. On-site care, however, is routinely available only for basic services. Future work should evaluate cost and quality trade-offs between using non-VA sites to increase specialized service availability and using VA sites to enhance continuity of care.

Ambulatory Care↗

PubMedDate not supplied

The organization and delivery of women's health care in Department of Veterans Affairs Medical Center.

Congressional eligibility reforms have profoundly changed the array of services to be made available to women veterans in Department of Veterans Affairs (VA) health care facilities. These include access not only to primary and specialty care services already afforded VA users, but also to a full spectrum of gender-specific services, including prenatal, obstetric, and infertility services never before provided in VA settings. The implications of this legislative mandate for delivering care to women veterans are poorly understood, as little or no information has been available about how care for women veterans is organized. This article reports on the first national assessment of variations in the organization of care for women veterans.

Ambulatory Care↗

PubMedDate not supplied

The impact of primary care resources on prevention practices.

Organizational factors influence the quality of preventive care. Combining facility-level data from a national organizational survey and centrally available, externally abstracted chart review data on prevention performance, we assessed the relationship between structural features of primary care departments and the quality of preventive care delivered. Primary care practice resources were significantly and positively associated with the delivery of 6 of 9 preventive services. Adjusting for facility size and academic affiliation, these resource arrangements accounted for substantial variation in 8 of 9 services. Assuring high-quality prevention performance requires ongoing investment in primary care-based infrastructure.

Cross-Sectional Studies↗

PubMedDate not supplied

Early adoption of human immunodeficiency virus quality improvement in Veterans Affairs medical centers: use of organizational surveys to measure readiness to change and adapt interventions to local priorities.

Potential delivery system responsiveness to quality improvement (QI) interventions is rarely assessed before implementation, although it might aid in interventional design. Preparing for a national initiative, we assessed Veterans Affairs (VA) human immunodeficiency virus (HIV) clinic organizational characteristics and attitudes toward QI interventions. Current QI activities and attitudes toward potential effectiveness of several techniques to improve antiretroviral and opportunistic infection prophylaxis therapy were assessed. These included computerized clinical reminders (CRs), group-based QI, expert advice, and facility and provider-level audit/feedback. Organizational characteristics were also examined. Respondents rated CRs and group-based QI (GBQI) interventions most highly. Western and complex facilities viewed CR and GBQI interventions more positively than less complex facilities or those in other regions, even controlling for organizational characteristics and perceived barriers to change. VA clinicians favored CR and GBQI over facility/ provider feedback. The persistence of regional variation should be further explored. Organizational surveys of attitudes toward potential QI interventions can assist in choosing interventions and targeting specific facilities.

Attitude of Health Personnel↗

PubMedDate not supplied

Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation.

Given the prevalence of smoking, its impact, and the benefits of cessation, helping smokers quit should be a top priority for health care organizations. To restructure health care delivery and guide future policy, the authors used baseline survey data from an 18-site Veterans Health Administration group randomized trial to assess the level of interest in quitting smoking for a practice population and determine what smoking cessation services they reported receiving. Among 1941 current smokers, 55% did not intend to quit in the next 6 months, and the remainder intended to quit in the next month (13%) to 6 months (32%). Forty-five percent reported a quit attempt in the prior year. While nearly two thirds of smokers reported being counseled about cessation within the past year, only 29% were referred to a cessation program, and 25% received a prescription for nicotine patches. Tobacco control efforts within this population should focus on increasing the rate of assisting patients with quitting.

Aged↗

PubMedDate not supplied

Smoking cessation care received by veterans with chronic obstructive pulmonary disease.

Smoking is the main cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the only effective intervention to slow its progression. We examined whether smokers with COPD received more cessation services than smokers without COPD. Current smokers from 18 Veterans Health Administration primary care clinics completed baseline and 12 month follow-up surveys (baseline n = 1,941; 12 month n = 1,080), composed of validated questions on smoking habits, history, and attitudes; health/functional status; and sociodemographics. Both at baseline and 12 month follow-up, smokers with COPD were more likely to report that they had been advised to quit, prescribed nicotine patches, or referred to a smoking cessation program within the last year. However, the rate of quitting smoking was the same for smokers with COPD and smokers without COPD. The increase in cessation services received by smokers with COPD was noted primarily among smokers not interested in quitting. New approaches may be required, particularly to help smokers not interested in quitting.

Chi-Square Distribution↗

PubMedDate not supplied

Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system.

PURPOSE: To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system. DESIGN: Cross-sectional survey. SETTING: Eighteen Veterans Affairs medical and ambulatory care centers. SUBJECTS: A cohort of male current smokers (n = 1606). MEASURES: Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy. RESULTS: Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34-.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28-1.08) smokers were less likely to use NRT. CONCLUSIONS: Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.

Aged↗

PubMedDate not supplied

Assessing the structure of smoking cessation care in the Veterans Health Administration.

PURPOSE: National smoking cessation practice guidelines offer recommendations regarding the processes and structure of care. Facilities routinely measure the processes of care but not the structure of care. This pilot study assessed the structure of smoking cessation care at Veterans Health Administration facilities. METHODS: Key informants at 18 sites completed a brief checklist survey adapted from national smoking cessation guidelines. Responses were compared with detailed site surveys. RESULTS: Guideline adherence was seen in identifying smokers and treating inpatient smokers. Areas of low adherence include offering incentives and defining staff responsibilities. The checklist survey showed poor correspondence with the detailed survey, with low agreement on systematic screening (kappa = .21) and higher agreement on primary care prescribing authority (kappa = .53). DISCUSSION: This pilot survey provides a potential rapid method for assessing adherence to systems recommendations from the national smoking cessation guidelines. The relatively low agreement with a more detailed survey suggests that the two surveys may have been measuring different aspects of smoking cessation care.

Ambulatory Care Facilities↗