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PubMedDate not supplied

A model immunization demonstration for preschoolers in an inner-city barrio, San Diego, California, 1992-1994.

An immunization demonstration project was conducted in an inner-city Latino neighborhood in San Diego to address underimmunization of children of preschool age. The project attempted interventions on consumer, provider, and system levels to reduce barriers to immunization and raise immunization rates. Free walk-in immunization clinics with emphasis on cultural sensitivity and that incorporated computerized reminder/recall were established. An educational series was offered to community health center (CHC) providers, and extensive community-based outreach and education took place in schools, churches, a WIC site, etc. Evaluation activities included preintervention and postintervention provider knowledge, attitudes, and practice surveys, CHC chart audits, and household surveys in the intervention ZIP code area and a control ZIP code area. Immunization coverage for 4DPT, 3OPV, and 1MMR (4:3:1) among two-year-olds increased significantly from 37% to 50% overall, and to 59% in the 1991 birth cohort in the intervention area compared to a one percentage point overall increase in the control area. Coverage improved significantly and missed opportunities decreased in one intervention CHC that participated most actively in educational inservices. While the Year 2000 U.S. Public Health Service objective of 90% 4:3:1 coverage for two-year-olds was not achieved over the 21-month course of the project, the results approached the 1996 single-antigen objectives. This demonstration underscores the importance of multilevel interventions including low cost, no appointment, and culturally appropriate immunization services for the indigent; the use of computerized reminder systems; and provider assessment, education, and feedback in the effort to raise preschool immunization levels. Medical Subject Headings (MeSH): immunization, preschool-age children, health promotion, provider education, immunization monitoring and follow-up systems, pediatric immunization standards, household surveys.

California↗

PubMed2001

Physician credentials and practices associated with childhood immunization rates: private practice pediatricians serving poor children in New York City.

Private practice physicians in New York City's poorest neighborhoods are typically foreign trained, have generally substandard clinical practices, and have been accused of rushing Medicaid patients through to turn a profit. However, they also represent a sizable share of physician capacity in medically underserved neighborhoods. This article documents the level of credentials, systems, and immunization-related procedures among these physicians. Furthermore, it assesses the relationship between such characteristics and childhood immunization rates. The analysis utilizes a cross-sectional comparison of immunization rates in 60 private practices that submitted 2,500 or more Medicaid claims for children. Immunization data were gathered from medical records for 2,948 randomly selected children under 3 years of age. Half of sampled physicians were board certified (55%), and half were accepted by the Medicaid Preferred Physicians and Children (PPAC) program (51.7%). Of physicians, 43% saw patients only on a walk-in basis, while only 17% scheduled the next appointment while the patient was still in the office. There were 75% of the physicians who reported usually immunizing at acute care visits. Immunization rates were higher among PPAC physicians compared to others (41% vs. 29% up to date for diphtheria and tetanus toxoids and pertussis [DTP]/Haemophilus influenzae type b [Hib], polio, and measles-mumps-rubella [MMR], P = .01), and board-certified physicians showed a trend toward better immunization rates (39% vs. 30%, P =.07). Physicians who reported usually immunizing at acute care visits also had higher rates than those who did not (38% vs. 27%, P = .05). Scheduling a date and time for the next immunization showed a trend toward association with immunization coverage (37% vs. 28%, P= .10). Private practice physicians who provide high volumes of care reimbursed by Medicaid have improved their credentials and affiliations over time, thereby expanding reimbursement options. Credentials and affiliations were at least as effective in distinguishing relatively high- and low-performing physicians, as were immunization-related practices, suggesting that they are useful markers for higher quality care. The relative success of the PPAC program should inform efforts to improve the capacity and quality of primary care for vulnerable children. Appointment and reminder systems that effectively manage the flow of children back into the office for immunizations and the vigilant use of acute care visits for immunizations go hand in hand. Opportunity exists for payers and plans to encourage and support these actions.

Certification↗

PubMedDate not supplied

Improving the follow-up of patients with abnormal Papanicolaou smear results.

A review of the literature on adherence with recommended follow-up after an abnormal screening Papanicolaou smear result reveals that many women do not receive adequate follow-up. Primary care providers can influence the number of women who undergo timely colposcopy or a subsequent Papanicolaou smear by addressing common barriers to follow-up. Physicians should anticipate fears commonly experienced by women when they learn of abnormal Papanicolaou smear results, including fear of cancer, fear of pain during colposcopy, and fear of loss of sexual or reproductive function. An awareness that certain populations are at especially high risk of inadequate follow-up, including black and Hispanic women, women with less than a high school education, and women of low socioeconomic status, can help physicians target their efforts. Practical strategies for improving follow-up include speaking directly with the patient about results, emphasizing the precancerous nature of most lesions, actively preparing the patient for colposcopy by describing the procedure and its complications, and addressing fears about the common treatment options for cervical intraepithelial neoplasia. Office-based reminder systems and educational materials may also be used as adjuncts to personal contact.

Family Practice↗

PubMedDate not supplied

Prescribe for health. Improving cancer screening in physician practices serving low-income and minority populations.

OBJECTIVE: To evaluate a health maintenance organization (HMO)-sponsored intervention to improve cancer screening in private physician practices serving low-income, minority populations. DESIGN: A randomized controlled trial with preintervention and postintervention measurements. Measurements were obtained by abstracting information from independent random samples of medical charts (N = 2316 at preintervention and 2238 at postintervention). SETTING: Forty-seven primary care physician practices located in low-income and minority urban neighborhoods in Chicago, Ill. INTERVENTION: Practices were encouraged to adopt an office chart reminder system and to use a patient health maintenance card. Activities to facilitate the adoption of these items and for compliance with cancer screening guidelines included on-site training and start-up assistance visits, a physician continuing medical education seminar, and quality assurance visits with feedback to physicians. MAIN OUTCOME MEASURES: The proportions of patients with a chart-documented mammogram, clinical breast examination, Papanicolaou smear, or fecal occult blood slide test in the 2 years before preintervention and postintervention chart abstractions. RESULTS: Between baseline and postintervention, there was a net increase in the proportion of HMO members in the intervention, compared with the control practices, who received in the preceding 2 years a Papanicolaou smear (11.9%) and a fecal occult blood slide test (14.1%). There was a net increase in the proportion of non-HMO patients in the intervention compared with the control practices who received a clinical breast examination (15.3%) and a fecal occult blood slide test (20.2%). CONCLUSIONS: Implementation of an HMO-mediated, multicomponent intervention to improve cancer screening was feasible and effective for the Papanicolaou smear, fecal occult blood slide test, and the clinical breast examination, but not for mammography.

Adult↗

PubMed2006

Adoption of patient-centered care practices by physicians: results from a national survey.

BACKGROUND: Little is known about the extent to which primary care physicians (PCPs) practice patient-centered care, 1 of the Institute of Medicine's 6 dimensions of quality. This article describes the adoption of patient-centered practice attributes by PCPs. METHODS: Mail survey; nationally representative physician sample of 1837 physicians in practice at least 3 years postresidency. RESULTS: Eighty-three percent of PCPs surveyed are in favor of sharing of medical records with patients. Most physicians (87%) support team-based care. But, only 16% of PCPs communicate with their patients via e-mail; only 36% get feedback from their patients. Seventy-four percent of PCPs still experience problems with availability of patients' medical records or test results; less than 50% have adopted patient reminder systems. Thirty-three percent of physicians practicing in groups of 50 or more have adopted 6 to 11 of the 11 patient-centered care practices targeted in the survey compared with 14% of solo physicians. CONCLUSION: Although some patient-centered care practices have been adopted by most PCPs, other practices have not yet been adopted as broadly, especially those targeting coordination, team-based care, and support from appropriate information systems.

Aged↗

PubMed1998

Do pediatricians counsel families about sun protection?: a Massachusetts survey.

BACKGROUND: Pediatric visits during summer months may be especially opportune times for sun protection counseling for children and their parents. Few data exist on the extent of such counseling. OBJECTIVE: To begin to assess this, we surveyed practicing Massachusetts pediatricians to examine current attitudes and practices of sun protection counseling. DESIGN AND SETTING: Surveys mailed to Massachusetts pediatricians. RESULTS: We received surveys from 756 (60%) of 1263 eligible Massachusetts pediatricians. Almost 70% indicated that they recommended safe sun practices to more than 50% of their patients and their parents during the summer months. Counseling regarding seat belt use, bicycle helmet use, and smoking prevention were ranked higher in priority than sun protection counseling by pediatricians; nutritional guidelines were noted by pediatricians to be a parent's most frequent concern. Four variables were independently associated with a practitioner's providing safe sun recommendations to more than 50% of parents and children: (1) private setting and health maintenance organization practitioners as opposed to academic physicians, (2) high ranking of patients' safe sun knowledge, (3) high priorities of both parents and physicians for sun protection counseling and parental knowledge of safe sun practices relative to other recommendations, and (4) pediatrician interest in receiving instructional materials. CONCLUSIONS: For the most part, summer sun protection counseling among Massachusetts pediatricians seems well integrated into standard practice. Most pediatricians rated their confidence level as high for discussing sun protection and only a few cited inadequate training or poor reimbursement as barriers toward improved counseling. Small steps, such as providing more instructional materials to patients and using office-based reminder systems, may improve the quality of sun protection counseling practices. Incorporating sunburn prevention into the list of routinely recommended injury prevention guidelines for pediatricians should be considered.

Adolescent↗

PubMed1999

Beliefs about Papanicolaou smears and compliance with Papanicolaou smear follow-up in adolescents.

OBJECTIVE: To explore qualitatively adolescent girls' understanding of Papanicolaou smears and barriers to compliance with Papanicolaou smear follow-up appointments. DESIGN: Qualitative analysis, using 3 focus groups and 15 in-depth, semistructured individual interviews. SETTING: Adolescent Clinic and Young Parents' Program at Children's Hospital, Boston, Mass. MAIN OUTCOME MEASURES: Beliefs and attitudes about Papanicolaou smears and barriers to compliance with Papanicolaou smear follow-up. RESULTS: The mean (+/- SD) age of the 15 interview participants was 18.7 (+/- 1.9) years. Knowledge about Papanicolaou smears and pelvic examinations was poor. Most participants believed that their peers receive Papanicolaou smear screening and perceived teenagers to be susceptible to cervical cancer. Perceived benefits to getting Papanicolaou smears were prevention and early detection or diagnosis, and reported barriers included pain or discomfort, embarrassment, fear of finding a problem, fear of the unknown, denial, poor communication or rapport with the provider, not wanting to look for trouble, lack of knowledge, and peers' advice. Participant-generated strategies for how providers could overcome barriers to Papanicolaou smear screening included education and the development of trusting, consistent relationships with providers. Participant-generated strategies for how providers could enhance appointment-keeping among adolescents included telephone and written reminders. CONCLUSIONS: These data support a behavioral theory-based model of adolescent compliance with Papanicolaou smear follow-up, which may help to develop strategies to enhance compliance with Papanicolaou smear follow-up appointments. These strategies include providing in-depth education about Papanicolaou smears, addressing barriers to Papanicolaou smear follow-up, focusing on appropriate provider behaviors, and instituting an appointment reminder system.

Adolescent↗

PubMed1999

Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial.

CONTEXT: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. OBJECTIVE: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. DESIGN AND SETTING: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). SUBJECTS: Obstetricians and their preterm delivery cases at participating hospitals. INTERVENTION: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. MAIN OUTCOME MEASURE: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). RESULTS: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. CONCLUSION: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

Anti-Inflammatory Agents↗

PubMed2001

Community-based cancer screening for underserved women: design and baseline findings from the Breast and Cervical Cancer Intervention Study.

BACKGROUND: Underutilization of breast and cervical cancer screening has been observed in many ethnic groups and underserved populations. Effective community-based interventions are needed to eliminate disparities in screening rates and thus to improve prospects for survival. METHODS: The Breast and Cervical Cancer Intervention Study was a controlled trial of three interventions in the San Francisco Bay Area from 1993 to 1996: (1) community-based lay health worker outreach; (2) clinic-based provider training and reminder system; and (3) patient navigator for follow-up of abnormal screening results. Study design and a description of the interventions are reported along with baseline results of a household survey conducted in four languages among 1599 women, aged 40-75. RESULTS: Seventy-six percent of women ages 40 and over had had at least one mammogram, and most had had a clinical breast examination (88%) and Pap smear (89%). Rates were significantly lower for non-English-speaking Latinas and Chinese women (56 and 32%, respectively, for mammography), and maintenance screening (three mammograms in the past 5 years) varied from 7% (non-English-speaking Chinese) to 53% (Blacks). Pap smear screening in the past 3 years was low among non-English-speaking Latinas (72%) and markedly lower among non-English-speaking Chinese women (24%). The strongest predictors of screening behavior were having private health insurance and frequent use of medical services. Having a regular clinic and speaking English were also important. Race/ethnicity, education, household income, and employment status were, overall, not significant predictors of screening behavior. CONCLUSIONS: These baseline results support the importance of cancer screening interventions targeted to persons of foreign origin, particularly those less acculturated.

Adult↗

PubMed1989

Worksite-screenings for hypertension with follow-up: experiences from the Munich Blood Pressure Program.

In 1983/84, the Munich Blood Pressure Program (MBP) performed worksite screenings for arterial hypertension at 18 Munich companies. A participation of 51% (n = 7310) was achieved. After duplicate measurements of casual blood pressure 1084 participants were suspected of having actual hypertension. All suspected cases were invited for a reexamination to reduce the number of false-positive hypertensives. Individuals with persisting hypertension after this two-step-screening were predominantly male, on the average younger than 50 years and showed a low level of antihypertensive drug treatment. About 75% of all detected hypertensives saw a family physician subsequent to the screenings for further management. Referrals and patient compliance were frequently reinforced by a computer based reminder system. A follow-up examination was performed among the MBP participants after two years. It showed that in 417 confirmed hypertensives of the primary screenings a marked increase in the proportion of treated and controlled hypertensives had occurred. This was true for younger and older hypertensives.

Adult↗

PubMed1993

A nurse practitioner intervention to increase breast and cervical cancer screening for poor, elderly black women. The Harlem Study Team.

OBJECTIVE: To compare nurse practitioner (NP) and physician rates of breast and cervical cancer screening among poor, elderly black women. DESIGN: A quasi-experimental design was used to compare pre- and postintervention annual screening rates. Rates were determined by medical record audits. SETTING: Two urban public hospital primary care clinics served as the study sites. PATIENTS: All women aged 65 years or more were eligible to participate. INTERVENTIONS: Women were offered screening by a NP during a routine visit in the intervention site; a physician reminder system was used in the control site. MAIN RESULTS: Baseline annual screening rates were comparable in the two study sites. At the end of the study period, rates were significantly higher in the NP site, compared with the control. In the NP clinic, the annual rate of Pap tests increased to 56.9% from the baseline of 17.8%, and mammographies increased to 40% from 18.3%. In comparison, rates remained low in the control site, increasing only to 18.2% of women receiving Pap tests from a baseline of 11.8%, and remaining at 18% for mammography. CONCLUSIONS: Use of a NP to deliver same-day screening is an effective strategy to target poor, elderly black women for breast and cervical cancer screening. However, even with the substantial increases in rates obtained with the NP intervention, screening in this vulnerable population remains below nationally targeted levels.

Black or African American↗

PubMedDate not supplied

Diffusion of the U.S. Preventive Services Task Force recommendations into practice.

The U.S. Preventive Services Task Force's "Guide to Clinical Preventive Services" summarizes the results of a critical review of the literature pertaining to the effectiveness of 169 interventions in modifying 60 risk factors or conditions. The ultimate impact of the guide depends on the diffusion into clinical practice of its recommendations. This report reviews the factors influencing the diffusion process. Three categories of behavioral influence--predisposing, enabling, and reinforcing factors--apply to this diffusion process. Predisposing factors include knowledge and attitudes, personal health behaviors, confidence, and beliefs about patients' interests in health-promotion advice. Enabling factors include competence to perform preventive services, reimbursement for preventive services, organization of the practice setting, time to provide preventive services, a reminder system, and a coherent set of guidelines that are perceived as scientific and unambiguous. Reinforcing factors include peer support, feedback, evidence of results, and an enhanced sense of self-efficacy in fulfilling one's role as a healer. Recommendations are given for using these factors to increase the diffusion of preventive services into clinical practice.

Diffusion of Innovation↗

PubMed2001

Creation of a software application for the clinical radiologist.

PURPOSE: To create a software application that automates a significant portion of a clinical radiologist's work. METHODS: The daily workflow of clinical radiologists in a university-based department was analyzed, specifically looking for manual tasks that could be implemented in software. An application that a practicing radiologist would use in his daily work was created. RESULTS: By using speech recognition, reports could be created, edited, and verified immediately. Online medical reference information could be made instantly accessible. Billing data could be captured accurately and completely at report creation time. A radiologist could be alerted to important upcoming events by use of a reminder system. Reports could be delivered immediately to referring physicians using either the internet or telephone. CONCLUSIONS: It is possible to improve the productivity of busy practicing clinical radiologists by automating a large portion of their workflow and implementing it in an easily mastered software application.

Humans↗

PubMed1987

Effect of medical records' checklists on implementation of periodic health measures.

Recent re-evaluation of preventive health care has resulted in more limited and directed guidelines; nonetheless, physician compliance has remained poor. This study assessed whether an inexpensive reminder system of preventive care checklists would improve physician implementation of periodic health measures. Residents in internal medicine were randomly placed into two groups: one received a copy of the appropriate checklist with each patient's medical record; the other did not. After one year, 200 randomly selected records were audited to determine the proportion of recommendations implemented for each patient. Residents who received checklists performed appropriate preventive health measures at a significantly higher rate than those who did not (0.56 +/- 0.26 versus 0.39 +/- 0.22, p less than 0.002). The actual use of the checklist to record the results was associated with an even higher rate of compliance compared with instances in which the checklists were provided but not used and instances in which checklists were not received (0.70 +/- 0.21 versus 0.44 +/- 0.24 and 0.39 +/- 0.22, respectively, p less than 0.002). These data suggest that a physician's use of simple checklists can provide an inexpensive and effective means of improving implementation of periodic health maintenance.

California↗

PubMed1985

Screening for hypertension: results of the Munich Blood Pressure Program.

The Munich Blood Pressure Program (MBP) is a community hypertension control program for the metropolitan area of Munich. It tries to improve "incidental screening" in doctors' offices in the city through continuing education programs for physicians and auxiliary personnel and, in addition, emphasizes worksite screening to bring high-risk hard-to-reach groups under treatment and control. Blood pressure (BP) is measured at the worksite under standardized conditions. Those with values greater than or equal to 140 mm Hg systolic BP and/or greater than or equal to 90 mm Hg diastolic BP at the first visit have BPs measured again within 1-5 days. If their BP values are still elevated, they are referred to their family physicians for further assessment. At the same time, they are given a postage-paid card on which their doctors are asked to note the BP value measured in their offices. This postcard is returned to the MBP for evaluation. A computer-based reminder system informs all MBP participants at certain time intervals to have their BP checked. The text of the letters and the time interval between them depend on the most recent BP and treatment status data available to the MBP. In 1983, screenings were performed in seven firms. Participation rates of up to 57% were achieved for this entirely voluntary examination (3,948 participants). Age- and sex-specific prevalence rates (for the pooled data of the seven firms) were similar to those of a random sample of the Munich population (Munich Blood Pressure Study I). Seventy-four percent of those with elevated BP at first visit participated in the remeasurement at a second visit. Only 58% of these showed elevated BP values the second time. More than half (n = 101) of those second-visit hypertensives (greater than or equal to 160/95 mm Hg; n = 183) returned at least one completed postcard. The examining physician confirmed the hypertensive BP values in 60 of those cases. Of the 101, 57 were under treatment, 19 controlled and 38 uncontrolled. The follow-up period considered here lasted until May 1984 and varied from 5 to 15 months according to the date of screening in the respective firm. Only the first returned card has been evaluated thus far.

Adult↗

PubMed1995

Compliance in the treatment of hypertension. A need for action.

Compliance is commonly defined as the extent to which a person's behavior coincides with medical or health advice. There is evidence that noncompliance is a common problem with many medications, including antihypertensive treatment. Since noncompliance can have serious adverse effects on patient health it is important that practitioners make use of available strategies for increasing compliance. This paper considers aspects of the literature concerning noncompliance with antihypertensive medications and presents a number of strategies that practitioners can use to increase compliance. These include strategies for increasing patient recall of information and for implementing reminder systems. There is some evidence that eliciting social support can aid compliance as can presenting information about side effects. The importance of prescribing the simplest possible dosage regimen is emphasized.

Antihypertensive Agents↗

PubMed2006

Influence of primary care practice and provider attributes on preventive service delivery.

BACKGROUND: While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors. METHODS: This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery. RESULTS: Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery. CONCLUSIONS: This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

Adult↗

PubMed2006

Persistence with bisphosphonate treatment for osteoporosis: finding the root of the problem.

Poor compliance and persistence are among the most significant reasons for failed pharmacotherapy encountered in clinical practice. Consequences of poor compliance range from minor to serious, depending on drug characteristics, disease state, and severity of disease. Compliance and persistence are particular problems for patients with a disorder such as osteoporosis, which remains asymptomatic for long periods. Poor compliance with bisphosphonate therapy for osteoporosis has been associated with a smaller decrease in the rate of bone turnover and smaller improvements in bone mineral density, and may potentially result in a higher risk of fracture and disability. The compliance problem is additive; complex dosing guidelines may contribute to poor compliance with therapy, and the failure to follow these guidelines may result in treatment-related adverse events that further reduce compliance. In the long term, these issues often result in nonpersistence with treatment. In addition to direct consequences for the patient, poor compliance is associated with significant healthcare costs. Studies suggest that less-frequent dosing regimens improve compliance; however, even among patients receiving weekly bisphosphonates, persistence may remain suboptimal. Several strategies are available to improve compliance and persistence with osteoporosis therapies. Good communication between the healthcare provider and the patient--with continuous reinforcement of the importance of treatment--is a key approach to improving persistence. Patients should receive feedback to confirm that their treatment is having an effect, and individualized reminder systems should be recommended to help the patient adhere to the treatment plan. Potentially, every patient is liable to discontinue treatment even after a long period of regular dosing. It should be assumed that every patient receiving therapy for osteoporosis needs regular reinforcement of the importance of continuing therapy.

Bone Density↗