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Background and Aims: My Diabetes My Way (MDMW) is Scotland’s interactive website and mobile app for people with diabetes and their caregivers. It contains multimedia resources for diabetes education and offers access to electronic personal health records. This study aims to assess the cost-utility of MDMW compared with routine diabetes care in people with type 2 diabetes who do not use insulin. Materials and Methods: Analysis used the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model 2. Clinical parameters of MDMW users (n = 2576) were compared with a matched cohort of individuals receiving routine care alone (n = 11 628). Matching criteria: age, diabetes duration, sex, and socioeconomic status. Impact on life expectancy, quality-adjusted life years (QALYs), and costs of treatment and complications were simulated over ten years, including a 10% sensitivity analysis. Results: MDMW cohort: 1670 (64.8%) men; average age 64.3 years; duration of diabetes 5.5 years. 906 (35.2%) women: average age 61.6 years; duration 4.7 years. The cumulative mean QALY (95% CI) gain: 0.054 (0.044-0.062) years. Mean difference in cost: –£118.72 (–£150.16 to –£54.16) over ten years. Increasing MDMW costs (10%): –£50.49 (–£82.24-£14.14). Decreasing MDMW costs (10%): –£186.95 (–£218.53 to –£122.51). Conclusions: MDMW is “dominant” over usual care (cost-saving and life improving) in supporting self-management in people with type 2 diabetes not treated with insulin. Wider use may result in significant cost savings through delay or reduction of long-term complications and improved QALYs in Scotland and other countries. MDMW may be among the most cost-effective interventions currently available to support diabetes.

This scoping review aimed to examine telehealth-assisted case management for chronic illnesses and assess its overall impact on health care delivery. Guided by the PRISMA statement, this review included 36 empirical studies published between 2011 and 2020. This study identified three weaknesses and four strengths of telehealth-assisted case management. While the weaknesses were negative feelings about telehealth, challenges faced by patients in learning and using telehealth devices, and increased workload for case managers, the strengths included efficient and timely care, increased access to health care services, support for patients’ satisfaction, and cost savings. Future research can be designed and conducted for overcoming the weaknesses of telehealth-assisted case management. Additionally, the strengths identified by this review need to be translated from research into case management practice for chronic illness care. This review not only describes the value of such care strategy, but also provides implications for future nursing practice and research.

Novel approaches to deliver lifestyle medicine that are convenient and accessible to patients are needed. Patients generally seek medical care when they are not well, reinforcing the notion of a “sick” care health system. Conversely, health clubs represent beacons of wellness amid the mire of chronic disease. Many individuals visit health clubs with the goal of becoming or remaining healthy. Expanding health care access to these health club populations creates opportunities to engage those who do not typically seek medical care, and may also attract those who are highly motivated to make lifestyle changes to prevent, treat, and reverse chronic disease. Health club clinics could be expanded with in-person or virtual offerings that go beyond traditional models. Such offerings would stand to improve health and be mutually beneficial for the provider and health club. By decreasing the barrier to access such care and meeting highly motivated patients where they are, providers may be more successful in their efforts to deliver lifestyle medicine to patients who are ready, willing, and able to make lifestyle behaviors changes.

Nursing knowledge is housed in its paradigms, philosophies, models, and theories. This knowledge must be utilized to demark nursing’s unique contributions within healthcare, regardless of the setting. The purpose of this paper is to explore the ways in which Parse’s community model may serve as a way to think about health policies and the unique ways policies may connect to nursing knowledge. Within this paper, there is a discussion about health policy, Parse’s humanbecoming paradigm, and policy development reflected upon with change concepts within the humanbecoming community model. This exploration is important because “disciplinary knowledge is the foundation for transforming health policy and health care delivery systems” (American Academy of Nursing, 2020, para. 1).

Background Complicated acute appendicitis (CAA) has been linked to extremes of age, racial and socioeconomic disparities, public insurance, and remote residency. CAA rate has been used from 2005 to 2018 as a health care quality metric, with the assumption that delay in treatment was a main cause of perforation. We studied factors that could contribute to CAA focusing on modifiable factors which could be altered as part of a health care delivery system. Materials and Methods All primary admissions for acute appendicitis (AA) from the 2010 Nationwide Inpatient Sample were linked to 2010 state-level physician density data. CAA was distinguished by codes for perforation, generalized peritonitis, or intra-abdominal abscess. A multivariable logistic regression model for CAA prediction was built. Results A total of 288 556 patients were admitted with AA and 86 272 (29.9%) had CAA. Independent factors, linked to CAA, included age outside the 10-39 range (odds ratio (OR) = 2.1-2.4 and all P < .001), male gender (OR = 1.2), malnutrition (OR = 6.2), diabetes mellitus (OR = 2.1), chronic anemias (OR = 1.9), nonprivate insurances (OR 1.2-1.5), nonmetropolitan patient’s residence (OR = 1.15), and Midwest region (OR = 1.2). Patient income and physician coverage were not significant factors after adjustment for all other covariates. Highest CAA fraction of 39.6% was noted in rural patients admitted to urban teaching facilities. Discussion Although provider coverage at the state level may seem adequate and not related to increased CAA rates, the distance patients traveled for their definitive surgical care correlated with higher rates of CAA. Adjusting physician distribution into nonurban settings closer to patients could decrease rates of CAA by diminishing time to definitive care.

Background The number of people living with stroke has increased demand for rehabilitation. A potential solution is telerehabilitation for health care delivery to promote self-management. One such approach is the Augmented Community Telerehabilitation Intervention (ACTIV). This structured 6-month program uses limited face-to-face sessions, telephone contact, and text messages to augment stroke rehabilitation. Objective To investigate whether ACTIV improved physical function compared with usual care. Methods This 2-arm, parallel randomized controlled trial was conducted in 4 New Zealand centers. Inclusion criteria were patients with first-ever stroke, age >20 years, and discharged home. A blinded assessor completed outcome measurement in participants’ homes at baseline, postintervention, and 6 months postintervention. Stratified block randomization occurred after baseline assessment, with participants allocated to ACTIV or usual care control. Results A total of 95 people were recruited (ACTIV: n = 47; control: n = 48). Postintervention intention-to-treat analysis found a nonsignificant difference between the groups in scores (4·51; P = .07) for physical function (measured by the physical subcomponent of the Stroke Impact Scale). The planned per-protocol analysis (ACTIV: n = 43; control: n = 48) found a significant difference in physical function between the groups (5·28; P = .04). Improvements in physical function were not maintained at the 12-month follow-up. Conclusions ACTIV was not effective in improving physical function in the ACTIV group compared with the usual care group. The per-protocol analysis raises the possibility that for those who receive more than 50% of the intervention, ACTIV may be effective in preventing deterioration or even improving physical function in people with stroke, in the period immediately following discharge from hospital.

Purpose Physicians work increasingly in larger organizations across different health care delivery systems. This systematic review examines the published empirical literature on organizational commitment among physicians within an international context. Design A systematic, PRISMA-guided review examining studies of organizational commitment among physicians published over time. Four article databases and a combination of appropriate search terms aided in identifying relevant articles. Findings Key findings include: (a) physicians, regardless of country, personal characteristics, type of job, or place of employment generally have lower levels of organizational commitment than other health care workers; (b) work- and job-related variables, particular age and job satisfaction, shape physicians’ organizational commitment; and (c) organizational commitment and the factors that shape it are similar across physicians working in different health systems. Review implications: Organizational commitment should remain central for researchers to study in most health systems internationally. Larger samples, longitudinal research, and greater use of theory are design improvements that will strengthen the extant research. The findings imply that if healthcare organizations create workplaces that make physicians feel in control, do not overwhelm them with work, provide a supportive culture, enhance their ability to give input, and keep them job satisfied, they may gain enhanced organizational commitment. Originality and value: To our knowledge, this is the first review of research examining organizational commitment among physicians. It is a resource for researchers and managers interested in learning more about aligning physician thinking and behavior with health care organizations.

Rapid growth of Medicare Advantage (MA) plans has the potential to change clinical practice for both MA and fee-for-service (FFS) beneficiaries, particularly for high-need, high-cost beneficiaries with multiple chronic conditions or a costly single condition. We assessed whether MA growth from 2010 to 2017 spilled over to county-level per capita spending, emergency department visits, and readmission rates among FFS beneficiaries, and how much this varied by the comorbidity burden of the beneficiary. We also examined whether the association between MA growth and per capita spending in FFS varied in beneficiaries with specific chronic conditions. MA growth was associated with decreased FFS spending and emergency department visits only among beneficiaries with six or more chronic conditions. MA growth was associated with decreased FFS spending among beneficiaries with 11 of the 20 chronic conditions. This suggests that MA growth may drive improvements in efficiency of health care delivery for high-need, high-cost beneficiaries.

Chronic diseases pose many challenges to health care providers and the health care system from a human capital, logistic, and financial perspective. To overcome these challenges, efficient and effective health care delivery models that address multiple chronic conditions need to be leveraged. Shared medical appointments are one potential solution to address these issues. This article offers a brief history of group visits and shared medical appointments and reviews the available data regarding their outcomes. It describes the benefits of using lifestyle medicine as the primary therapeutic modality within a shared medical appointment to treat, reverse, and prevent chronic disease. Key considerations and action steps for the implementation of lifestyle medicine shared medical appointments (LMSMAs) are outlined and the potential delivery of these services via telehealth is explored.

Circumstances of the COVID-19 pandemic have mandated a change to standard management of infantile spasms. On April 6, 2020, the Child Neurology Society issued an online statement of immediate recommendations to streamline diagnosis and treatment of infantile spasms with utilization of telemedicine, outpatient studies, and selection of first-line oral therapies as initial treatment. The rationale for the recommendations and specific guidance including follow-up assessment are provided in this manuscript. These recommendations are indicated as enduring if intended to outlast the pandemic, and limited if intended only for the pandemic health care crisis but may be applicable to future disruptions of health care delivery.

Structural issues in the health care delivery system can disproportionately affect language minority patients who require interpretation services. This qualitative study addresses the issues Spanish-speaking Latinos face in obtaining health care by examining the experiences of 25 Spanish speakers in California’s Central Valley, a medically underserved area. The following barriers to communication emerged in the findings: time-restricted interactions, unfriendly encounters, discrimination, issues in interpreting, miscommunication, and opposition to providers. We report participants’ recommendations for improving health care communication, including the need for friendlier and more attentive services, more Spanish-speaking providers, and more time with providers. We argue that these recommendations are in line with Latino cultural constructs: confianza (trust), familismo (family-orientation), personalismo (friendliness), respeto (respect), and simpatía (kindness). This study raises awareness about how language use and intercultural competence affect health care communication by centering the voices of Spanish speakers across numerous contextualized examples.

African American (AA) women have high prevalence of Type 2 diabetes mellitus (T2DM) and complications. No studies have been conducted about how social determinants of health and health care delivery affect their T2DM self-management. The purpose was to describe how social determinants of health and healthcare delivery may influence AA women’s T2DM self-management using qualitative descriptive methodology ( N = 10). Ten participants were interviewed. Participants’ geographical location, education, level of income, health literacy, and systemic racism, that is, healthcare delivery services, for example, inadequate healthcare services, providers’ assumptions about the patient’s knowledge of diabetes, providers’ attitudes toward patients, and stigma related to diabetes as a disease were identified. Understanding the role of social determinants of health and the health care delivery system in influencing T2DM self-management is a powerful tool for providers and practitioners for improving practice and health care policies to decrease health disparities and improve health outcomes among AA women with T2DM.

Approximately 1 in 10 of the current 26 million people who are refugees reside in high-income countries. They have commonly experienced trauma related to violence, insecurity, persecution and shortage of food and medicine. Our research suggests that COVID-19 and its health and social sequalae may be triggering past traumatic reactions, exacerbating mental health problems and undermining functioning. The purpose of this article is to promptly communicate these anecdotal findings to general health practitioners to ensure informed and sensitive health care delivery to this vulnerable population.

Clinical–community linkages enhance health care delivery and enable physician–patient partnerships to achieve better health. The Michigan State University (MSU) Model of Health Extension includes a strategy for forming these linkages by focusing on increasing primary care patient referrals and enrollment in health programs. This article shares the results of a survey of Michigan internal medicine and family medicine physicians ( n = 323) to better understand attitudes toward and familiarity with community-based education (CBE) programs and to assess the logistical requirements to make CBE referrals efficient and sustainable. Survey results showed that at most, 55% of respondents were aware of at least one CBE program implemented by Cooperative Extension. Of those who were aware, over 85% agreed that the programs have positive benefits for patients. Thirty-five percent reported at least one referral barrier, and familiarity with the CBE programs was a significant predictor for reporting all referral barriers. The results suggest that increasing physicians’ familiarity of CBE health programs is a key first step in identifying ideal strategies to overcome referral barriers. Data from this study may help determine scalable state level models for increasing awareness of chronic disease prevention and other CBE programs in efforts to improve the health of the nation.

Children with medical complexity comprise a growing population that stresses existing models of pediatric care. This report will describe a care support project that delivered shared plans of care to providers and families of children with medical complexity. This program was built around carefully constructed care support teams where each member had clearly defined roles and responsibilities. The teams worked collaboratively to improve provider communication, create SMART (Specific, Measurable, Assignable, Realistic, and Timely) goals, and perform task tracking. This process created a scaffolding to support community physicians, allowing patients to remain in their local medical homes and to access services closer to home and reducing hospital admissions and emergency room overutilization.

We constructed a novel measure of homelessness to examine differences in hepatitis C virus (HCV) prevalence across 3 categories of unstably housed and homeless veterans and across US Department of Veterans Affairs Medical Center facilities. We used Veterans Affairs administrative data to classify a cohort of 434 240 veterans as at risk of homelessness, currently homeless, or formerly homeless, and we examined variation in HCV prevalence by using descriptive measures and mixed-effect logistic regression models. HCV prevalence was highest among veterans who were formerly homeless (16.7%; 32 490 of 195 000), followed by currently homeless (12.4%; 22 050 of 178 056) and at risk of homelessness (8.2%; 5015 of 61 184). Veterans Affairs Medical Center–level prevalence ranged from 5.4% to 21.5%. Differences in HCV prevalence were significant by sex, race/ethnicity, and age. Targeting specific populations of homeless veterans for tailored HCV interventions and allocating additional resources to certain Veterans Affairs Medical Centers may be warranted.

Urgent care (UC) is one of the fastest growing venues of health care delivery for nonemergent conditions. This study compared the patient experience during virtual and in-person urgent care visits. We conducted a cross-sectional study of patients with the same diagnosis during Virtual Urgent Care (VUC) and in-person UC visits with the same diagnosis with regard to time and cost over a period of one year. We recorded and analyzed 16 685 urgent care visits: In-person UC (n = 14 734), VUC (n = 1262). Significant differences were found in the average total time for a visit in an in-person UC (70.89 minutes), and VUC (9.38 minutes). The average total cost of VUC ($49) and in-person UC ($142.657) differed significantly. Significant difference was found between UC turnaround time and VC turnaround time (Dependent variable (DV): 53.77, P < .01). We found significant differences in cost and time between in favor of virtual visits. Our findings suggest additional policy reform to expand the use of virtual care among target populations to improve access, reduce costs, meet the needs of patients, and reduce emergency department visits.

There has long been a major policy debate on the role of hospital ownership (private vs public) in medical system performance. China’s health care delivery system is mainly a public system. In 2000, a full privatization reform was implemented in the city of Suqian, offering a unique opportunity to assess possible effects of private delivery based on a major external shock to the existing system. Compared with all other cities in Jiangsu province since 2003, Suqian did not experience any greater increase either in total outpatient or inpatient expenditures. In the meantime, Suqian performed equally well as other cities in terms of changes in number of inpatient admissions and average inpatient days, and even better for mortality rate in emergency rooms. This study concludes that under appropriate public financing, private delivery can serve the public demand at least equally well as public providers in terms of cost inflations and utilizations.

Health care delivery revolves around accurate documentation, with data management free from error. A seemingly insignificant typographical error can cause short- and long-term problems that may lead to inaccurate records and misinformation. This report presents an overview of input errors in the US Food and Drug Administration Adverse Event Reporting System (FAERS). The focus is on errors and inconsistencies in reporting of drug names in the FAERS database, initiated through input of the MedWatch reporting system. The consequences from erroneous data input—in this case, drug names—can have an impact on data integrity, research, and patient safety.

In order to improve the quality and efficiency of hospitals, they can be viewed as a logistical system in which integration is a critical factor for performance. This paper describes the results of a scoping study that identifies the logistical parameters mentioned in international research on hospitals and indicates whether literature reflects system integration. When subsystems collaborate in order to accomplish the task of the entire organization, there is integration. A total number of 106 logistical parameters are identified in our study. In addition, the flow type – patients, materials and staff – and hospital subsystems were registered. The results presented in international literature show that logistics is highly fragmented in hospitals. Studies also show integration, although this takes place mainly within the subsystems of hospitals. A multi-agent perspective on hospitals is proposed, following the view that both integration and differentiation are essential for effective organizational performance. Given the widely recognised importance of controlling hospital costs and the potential of logistics to help in this process, it is important to gain more knowledge of hospitals as network organizations, as well as knowledge regarding the degree of integration and the logistical parameters that are required for better hospital performance.

Background:Comprehensive and effective multiple sclerosis (MS) health care requires understanding of patients’ needs, preferences, and priorities.Objective:To evaluate priorities of patients with MS for their MS care.Methods:Participants included 3003 Americans with MS recruited through the National MS Society and the North American Research Committee on Multiple Sclerosis patient registry. Participants completed a comprehensive questionnaire on aspects of their health-care experiences.Results:Participants identified the top 3 health-care priorities as (1) the affordability of MS health care, (2) ensuring that non-MS health-care providers have more education about MS and how it can interact with other conditions, and (3) access to an MS center or specialized MS clinic with MS health-care professionals together in one place. Participants receiving care in an MS center rated the quality and their satisfaction with care higher than those receiving care in other settings. Although having the opportunity to evaluate their health-care quality was important to the participants, only 36.4% had been provided the opportunity in the past year.Conclusions:This study identifies health-care priorities and concerns for Americans with MS.

Background: Point-of-care (POC) testing is becoming increasingly valuable in health care delivery, and it is important that the devices used meet the same quality criteria as main laboratory analyzers. While external quality assessment (EQA) provides a great tool for assessing quality, many POC devices are not enrolled in these schemes and standard laboratory evaluations are needed to assess performance. Methods: The Clinical and Laboratory Standards Institute (CLSI) protocols EP-5 and EP-9 were applied to investigate imprecision, accuracy and bias. We assessed bias using the mean of 4 certified secondary reference measurement procedures (SRMPs). Results: The Afinion2™ and the Quo-Lab had CVs of ≤1.7 and ≤2.4% respectively in IFCC SI units (≤1.2 and ≤1.7% NGSP) and a bias ≤2 mmol/mol (≤0.2% NGSP) at 48 and 75 mmol/mol (6.5 and 9.0% NGSP). Sigma for the Afinion2 was 5.8 and for the Quo-Lab 4.0. Both methods passed the NGSP criteria with 2 instruments when compared with 4 individual SRMPs. The HbA1c 501 had a CV of 3.4% and 2.7% in IFCC SI units (2.1% and 1.7% NGSP) and a bias ≤2.4 mmol/mol (≤0.2% NGSP) and passed the NGSP criteria with 2 instruments compared with 4 individual SRMPs except for instrument 2 compared with the Tosoh G8. Sigma was 2.1. The A1Care had a sigma of 1.4 and failed all criteria mainly due to a high CV (6.2% and 4.1% in IFCC SI units [4.1% and 2.9% NGSP] at 48 and 75 mmol/mol [6.5 and 9.0% NGSP]). Conclusions: The analytical performance was excellent for the Afinion2 and the Quo-Lab, acceptable for the HbA1c 501 and unacceptable for the A1Care according to different used criteria, demonstrating that whilst performance is improving there are still areas for considerable improvement.

Objectives: The cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may contribute to treatment disparities. However, few data exist on factors associated with DAA initiation. Methods: We conducted a retrospective cohort study of HCV-infected Kaiser Permanente Northern California members aged ≥18 during October 2014 to December 2016, using Poisson regression models to evaluate demographic, behavioral, and clinical factors associated with DAA initiation. Results: Of 14 790 HCV-infected patients aged ≥18 (median age, 60; interquartile range, 53-64), 6148 (42%) initiated DAAs. DAA initiation was less likely among patients who were non-Hispanic black (adjusted rate ratio [aRR] = 0.7; 95% confidence interval [CI], 0.7-0.8), Hispanic (aRR = 0.8; 95% CI, 0.7-0.9), and of other minority races/ethnicities (aRR = 0.9; 95% CI, 0.8-1.0) than among non-Hispanic white people and among those with lowest compared with highest neighborhood deprivation index (ie, a marker of socioeconomic status) (aRR = 0.8; 95% CI, 0.7-0.8). Having maximum annual out-of-pocket health care costs >$3000 compared with ≤$3000 (aRR = 0.9; 95% CI, 0.8-0.9) and having Medicare (aRR = 0.8; 95% CI, 0.8-0.9) or Medicaid (aRR = 0.7; 95% CI, 0.6-0.8) compared with private health insurance were associated with a lower likelihood of DAA initiation. Behavioral factors (eg, drug abuse diagnoses, alcohol use, and smoking) were also significantly associated with a lower likelihood of DAA initiation (all P < .001). Clinical factors associated with a higher likelihood of DAA initiation were advanced liver fibrosis, HCV genotype 1, previous HCV treatment (all P < .001), and HIV infection ( P = .007). Conclusions: Racial/ethnic and socioeconomic disparities exist in DAA initiation. Substance use may also influence patient or provider decision making about DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations.

Efforts to transform health care delivery to improve care have increasingly focused on care integration. However, variation in how integration is defined has complicated efforts to design, synthesize, and compare studies of integration in health care. Evaluations of integration initiatives would be enhanced by describing them according to clear definitions of integration and specifying which empirical relationships they seek to test—whether among types of integration or between integration and outcomes of care. Drawing on previous work, we present a comprehensive theoretical model of relationships between types of integration and propose how to measure them.

Health care expenditures, patient satisfaction, and timely access to care will remain problematic if dramatic changes in health care delivery models are not developed and implemented. To combat this challenge, a Triple Aim approach is essential; Innovation in payment and health care delivery models is required. Using the Donabedian framework of structure, process, and outcome, this article describes a nurse-led employee-centered care model designed to improve consumers’ health care experiences, improve employee health, and increase access to care while reducing health care costs for employees, age 18 and older, in a corporate environment.

Health services research (HSR) is the science of the evaluation and improvement of health care provision. HSR can be used by health care organisations to develop and understand administrative, financial and organisational processes in order to improve efficacy of clinical treatments, efficiency of their delivery, and ultimately patient outcomes. HSR applies both quantitative and qualitative methodology, utilising data collected from real-life clinical practice, rather than the confines of more controlled traditional efficacy trials. With new and developing therapies, HSR provides an opportunity to enhance the delivery of cost-effective and efficient health care. Level of evidence: Not applicable (educational article).

This study explores ethical issues raised in providing medical care to participants and communities of low-resource settings involved in a Phase II/III pediatric malaria vaccine trial (PMVT). We conducted 52 key informant interviews with major stakeholders of an international multi-center PMVT (GSK/PATH-MVI RTS,S) (NCT00866619) in Ghana and Tanzania. Based on their stakeholder experiences, the responses fell into three main themes: (a) undue inducement, (b) community disparities, and (c) broad therapeutic misconceptions. The study identified the critical ethical aspects, from the perspectives of stakeholders, of delivering health care during a PMVT. The study showed that integrating research into health care services needs to be addressed in a manner that upholds the favorable risk–benefit ratio of research and attends to the health needs of local populations. The implementation of research should aim to improve local standards of care through building a collaborative agenda with local institutions and systems of health.

Introduction: Being a primary source for health care delivery, public health personnel shall be well trained and motivated as their performance has a strong impact on overall health system performance. There is large gap in knowledge about determinants of motivation in Indian set-up; so the present study was undertaken to understand the perceptions of health workforce regarding their job conditions and their expectations. Material and methods: Cross-sectional study was conducted in District Yavatmal, Maharashtra, India. Total participants were 940 which included 96 medical officers (MOs) and 844 allied health personnels (AHPs). Data collection was completed using structured self-administered questionnaire. Results: Highest number of MOs mentioned ‘good working relationship’ (93 per cent) while among AHPs highest participant consider ‘training opportunity’ (88 per cent) as ‘more important attribute’. Among MOs difference between expected and availability of study attributes was statistically significant for 14 attributes but none in favour of availability. In AHP group, significantly higher proportion of respondents felt that good working relationships, good income, superior recognizing good work were considered as more important attributes by fewer respondents but significantly greater proportion of respondents in AHP group felt that these attributes were present in the job. Discussion and conclusions: Findings suggested that for MOs motivating factors in job was related to the independence in working and recognition from superiors and patients while AHPs’ main motivational force seemed to be recognition and clarity of work. Training opportunity and congenial environment at workplace were common desirable attributes. There were few attributes which majority of health workforce considered as ‘mostly available attribute’ in their present job which leaves much scope for improvement in job conditions for health workforce in rural area.

Anesthesia takes place in a complex, high-stakes environment where humans and technologies interact to provide medical care to patients. Providing adequate decision support for individuals and team...

Introduction: Clinician perceptions of patients with low socioeconomic status (SES) have been shown to affect clinical decision making and health care delivery in this group. However, it is unknown how and if low SES patients perceive clinician bias might affect their health care. Methods: In-depth interviews with 80 enrollees in a state Medicaid program were analyzed to identify recurrent themes in their perceptions of care. Results: Most subjects perceived that their SES affected their health care. Common themes included treatment provided, access to care, and patient-provider interaction. Discussion: This study highlights complex perceptions patients have around how SES affects their health care. These results offer opportunities to reduce health care disparities through better understanding of their impact on the individual patient-provider relationship. This work may inform interventions that promote health equity via a multifaceted approach, which targets both providers and the health care system as a whole.

As health systems seek to incentivize physicians to deliver high-value care, the relationship between physician compensation and health care delivery is an important knowledge gap. To examine physician compensation nationally and its relationship with care delivery, we examined 2012-2015 cross-sectional data on ambulatory primary care physician visits from the National Ambulatory Medical Care Survey. Among 175 762 office visits with 3826 primary care physicians, 15.4% of primary care physicians reported salary-based, 4.5% productivity-based, and 12.9% “mixed” compensation, while 61.4% were practice owners. After adjustment, delivery of out-of-visit/office care was more common for practice owners and “mixed” compensation primary care physicians, while there was little association between compensation type and rates of high- or low-value care delivery. Despite early health reform efforts, the overall landscape of physician compensation has remained strongly tethered to fee-for-service. The lack of consistent association between compensation and care delivery raises questions about the potential impact of payment reform on individual physicians’ behavior.

Background: Practice-based research (PBR) is employed in the pharmacy profession to improve the quality and efficiency of health care delivery. Although widely practiced in developed countries, it is rarely used in developing countries, including Nigeria. Objectives: To determine the factors associated with Nigerian pharmacists’ interest in PBR. Methods: This is a cross-sectional study utilizing an online survey. Pharmacists currently practicing in Nigeria were invited to participate. A hyperlink to the online questionnaire was shared with members of relevant professional bodies via Facebook, WhatsApp, and Twitter. Reminders were sent to facilitate a high response rate. Factors associated with pharmacists’ interest in PBR were determined using multiple logistic regression. Results: Two hundred and three completed responses were received from the survey. The majority, 94.6% (192), expressed an interest in PBR and believed that it would enhance their pharmacy practice and role in patient care. The multivariable analysis showed that pharmacists’ interest in publishing their research findings in peer-reviewed journals (odds ratio = 0.004, 95% confidence interval = 0.00-0.05, P < .001) and their knowledge of the professional relevance of research pertaining to their area of practice within the health care system (odds ratio = 0.02, 95% confidence interval = 0.00-0.47, P = .015) were found to be independent predictors of pharmacists’ interest in PBR. Conclusion: There is an interest in PBR among practicing pharmacists in Nigeria. The provision of evidence-based pharmaceutical services in Nigeria will be enhanced by interventions that encourage the conduct of research and publication of research findings, and by improving knowledge of the professional relevance of PBR in pharmacy practice areas.

Our ability to unravel the mysteries of human health and disease have changed dramatically over the past 2 decades. Decoding health and disease has been facilitated by the recent availability of high-throughput genomics and multi-omics analyses and the companion tools of advanced informatics and computational science. Understanding of the human genome and its influence on phenotype continues to advance through genotyping large populations and using “light phenotyping” approaches in combination with smaller subsets of the population being evaluated using “deep phenotyping” approaches. Using our capability to integrate and jointly analyze genomic data with other multi-omic data, the knowledge of genotype-phenotype relationships and associated genetic pathways and functions is being advanced. Understanding genotype-phenotype relationships that discriminate human health from disease is speculated to facilitate predictive, precision health care and change modes of health care delivery. The American Association for Dental Research Fall Focused Symposium assembled experts to discuss how studies of genotype-phenotype relationships are illuminating the pathophysiology of craniofacial diseases and developmental biology. Although the breadth of the topic did not allow all areas of dental, oral, and craniofacial research to be addressed (e.g., cancer), the importance and power of integrating genomic, phenomic, and other -omic data are illustrated using a variety of examples. The 8 Fall Focused talks presented different methodological approaches for ascertaining study populations and evaluating population variance and phenotyping approaches. These advances are reviewed in this summary.

The objective of this study was to assess the psychometric properties of IntegRATE—a 4-item patient-reported measure of integration in health care delivery—under controlled conditions. Adults who reported having received health care in the previous year were exposed to a fictional health care scenario featuring good, mixed, or poor integration on 1 or 2 occasions. They were then asked to imagine themselves as a patient in the scenario and complete IntegRATE and other measures. The data collected were analyzed to assess the discriminative, concurrent, and divergent validity of IntegRATE and its test–retest reliability and responsiveness using both “sum score” and “top score” scoring approaches. Six-hundred people participated in the study with 190 taking part on 2 occasions. The IntegRATE sum score demonstrated discriminative validity, concurrent validity, divergent validity, and responsiveness and partially demonstrated test–retest reliability. The IntegRATE top score demonstrated concurrent validity, divergent validity, and responsiveness and partially demonstrated discriminative validity and test–retest reliability. We conclude that the IntegRATE sum score exhibits encouraging psychometric properties and performs more optimally than the IntegRATE top score.

Purpose. Many Americans continue to smoke, increasing their risk of disease and premature death. Both telephone-based counseling and in-person tobacco cessation classes may improve access for smokers seeking convenient support to quit. Little research has assessed whether such programs are effective in real-world clinical populations. Design. Retrospective cohort study comparing wellness coaching participants with two groups of controls. Setting. Kaiser Permanente Northern California, a large integrated health care delivery system. Subjects. Two hundred forty-one patients who participated in telephonic tobacco cessation coaching from January 1, 2011, to March 31, 2012, and two control groups: propensity-score–matched controls, and controls who participated in a tobacco cessation class during the same period. Wellness coaching participants received an average of two motivational interviewing–based coaching sessions that engaged the patient, evoked their reason to consider quitting, and helped them establish a quit plan. Measures. Self-reported quitting of tobacco and fills of tobacco cessation medications within 12 months of follow-up. Analysis. Logistic regressions adjusting for age, gender, race/ethnicity, and primary language. Results. After adjusting for confounders, tobacco quit rates were higher among coaching participants vs. matched controls (31% vs. 23%, p < .001) and comparable to those of class attendees (31% vs. 29%, p = .28). Coaching participants and class attendees filled tobacco-cessation prescriptions at a higher rate (47% for both) than matched controls (6%, p < .001). Conclusion. Telephonic wellness coaching was as effective as in-person classes and was associated with higher rates of quitting compared to no treatment. The telephonic modality may increase convenience and scalability for health care systems looking to reduce tobacco use and improve health.

Nurses are expected to work a variety of different shifts throughout their careers, including traditional day shifts, night shifts, and swing shifts. Research suggests that night shifts can have potentially adverse effects on a worker’s perceptual and motor capacities, circadian rhythm, and ability to function the following day. Due to the critical role that nurses play in the health care delivery system, it is worth exploring options that serve to mitigate the aforementioned consequences associated with working at night. A number of potential countermeasures are explored, including slow shift rotations, naps, melatonin supplements, and caffeine. It is concluded that implementing slow rotating shifts and allowing time for a nap during the first night shift of a new rotation could have the largest impact on maximizing worker and patient safety.

Introduction Accountable care organizations are a value-based payment model in the United States rooted in holding groups of health care providers financially accountable for the quality and total cost of care of their attributed population. To succeed in reaching their quality and efficiency goals, accountable care organizations implement a variety of care delivery changes, including workforce redesign. Patient support personnel—nonphysician staff such as care coordinators, community health workers, and others—are critical to restructuring care delivery. Little is known about how accountable care organizations are redesigning their patient support personnel in terms of responsibilities, location, and evaluation. Methods We conducted semi-structured 1-h interviews with 25 executives at 16 distinct accountable care organizations. The interviews were recorded, transcribed, and coded for themes, using a qualitative coding and analysis process. Results Accountable care organizations deployed patient support personnel to perform four clusters of responsibilities: care provision, care coordination, logistical help with transportation, and social and emotional support. Accountable care organizations deployed these personnel strategically across settings (primary care, inpatient services, emergency department, home care, and community) depending on their population needs. Most accountable care organizations used personnel with the same level of training across settings. Few accountable care organizations planned to conduct a comprehensive evaluation of their patient support personnel to optimize their value. Discussion Accountable care organization strategies in workforce redesign indicate a shift from a physician-centered to a team-based approach. Employing personnel with varying levels of clinical training to perform different tasks can help further optimize care delivery. More robust evaluation of the deployment of patient support personnel and their performance is needed to demonstrate cost-saving benefits of workforce redesign.

While few may argue about the importance of healthy lifestyle choices on the effects of chronic health conditions, many would highlight the challenge that its practical integration poses in daily clinical practice. The field of lifestyle medicine aims to assist individuals and communities to adopt and sustain healthy behaviors. It is a powerful yet often underutilized tool. This article illustrates the importance of joint multidisciplinary efforts in the effective practice of lifestyle medicine. Furthermore it stresses the importance of equipping healthcare providers with the tools and education necessary to deliver consistent, and high quality holistic care.

Objective To examine the life experiences of African American and Hispanic adults whose personal chronic illness and/or that of a family member is the biggest health problem for their families. Data source Telephone (landline and cell phone) interviews of random, nationally representative samples of 1081 African-American and 1478 Hispanic adults, age 18 and older. We evaluated the responses of 757 African-American and 697 Hispanic participants who reported a chronic illness as the biggest health problem in their families. Methods Weighted analysis of cross-sectional survey responses from African-American and Hispanic adults. Results African Americans and Hispanics with chronic illness in their families reported experiencing challenges with the health care delivery system, with financial/economic insecurity, and with their communities that may influence how they live with chronic disease. Discussion Policymakers and clinicians should be aware that some African-American and Hispanic patients face obstacles within and beyond the health care system that are relevant to how they live with chronic conditions affecting their families. Additional tools and supports may need to be identified and supplied to effectively manage chronic illness in these communities. The payment system for physicians should account for the supplementary supports and services these patients might require.

An increase in the older adult population will likely be associated with an increased need for long-term-care communities, such as assisted living. A primary goal of assisted living communities is to help residents maintain their health and well-being. To accomplish this goal, direct care workers employed in these settings are responsible for monitoring residents for cues that might signal problems and then responding appropriately. However, very little is known about these workers’ decision making. To gain a better understanding, direct care workers from assisted living facilities took part in a critical incident interview and a scenario-based interview. The interview data revealed various cues that were categorized as cognitive, physical, or emotional in nature. Specific explanations for the scenarios were primarily that the situation was the result of a cognitive/emotional/social issue or a physical health issue. The type and number of explanations varied widely from scenario to scenario. Of the actions participants described taking to handle the scenarios, gathering and using information was discussed more than any other action. This research has implications for training of formal and informal caregivers and also highlights the potential need for decision support systems in this domain.