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Background: Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments. Objective: To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments. Design: Retrospective cohort study. Participants: Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018. Main Measures: Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments. Key Results: The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5–1.8) for outpatient appointments, 1.9 (1.7–2.1) for gastroenterology appointments, and 3.1 (2.9–3.4) for adherence with bowel preparation kits, respectively. Conclusions: Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available. [ABSTRACT FROM AUTHOR]

Purpose: Because social conditions such as food insecurity and housing instability shape health outcomes, health systems are increasingly screening for and addressing patients' social risks. This study documented the prevalence of social risks and examined the desire for assistance in addressing those risks in a US-based integrated delivery system.Methods: A survey was administered to Kaiser Permanente members on subsidized exchange health insurance plans (2018-2019). The survey included questions about 4 domains of social risks, desire for help, and attitudes. We conducted a descriptive analysis and estimated multivariate modified Poisson regression models.Results: Of 438 participants, 212 (48%) reported at least 1 social risk factor. Housing instability was the most common (70%) factor reported. Members with social risks reported more discomfort being screened for social risks (14.2% vs 5.4%; P = .002) than those without risks, although 90% of participants believed that health systems should assist in addressing social risks. Among those with 1-2 social risks, however, only 27% desired assistance. Non-Hispanic Black participants who reported a social risk were more than twice as likely to desire assistance compared with non-Hispanic White participants (adjusted relative risk [RR] 2.2; 95% CI, 1.3-3.8).Conclusions: Athough most survey participants believed health systems have a role in addressing social risks, a minority of those reporting a risk wanted assistance and reported more discomfort being screened for risk factors than those without risks. Health systems should work to increase the comfort of patients in reporting risks, explore how to successfully assist them when desired, and offer resources to address these risks outside the health care sector.VISUAL ABSTRACT. [ABSTRACT FROM AUTHOR]

Background: Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare.Objective: Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety DESIGN: Longitudinal observational study PARTICIPANTS: Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate) MAIN MEASURES: Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion.Key Results: Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18).Conclusions: Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care. [ABSTRACT FROM AUTHOR]

PURPOSE Lower continuity of care has been associated with higher rates of adverse outcomes for persons with multiple chronic medical conditions. It is unclear, however, whether this relationship also exists within integrated systems that offer high levels of informational continuity through shared electronic health records. METHODS We conducted a retrospective cohort study of 12,200 seniors with 3 or more chronic conditions within an integrated delivery system. Continuity of care was calculated using the Continuity of Care Index, which reflects visit concentration with individual clinicians. Using Cox proportional hazards regression permitting continuity to vary monthly until the outcome or censoring event, we separately assessed inpatient admissions and emergency department visits as a function of primary care continuity and specialty care continuity. RESULTS After adjusting for covariates (demographics; baseline, primary, and specialty care visits; baseline outcomes; and morbidity burden), greater primary care continuity and greater specialty care continuity were each associated with a lower risk of inpatient admission (respective hazard ratios (95% CIs) = 0.97 (0.96, 0.99) and 0.95 (0.93, 0.98)) and a lower risk of emergency department visits (respective hazard ratios = 0.97 (0.96, 0.98) and 0.98 (0.96, 1.00)). For the subgroup with 3 or more primary care and 3 or more specialty care visits, specialty care continuity (but not primary care continuity) was independently associated with a decreased risk of inpatient admissions (hazard ratio = 0.94 (0.92, 0.97)), and primary care continuity (but not specialty care continuity) was associated with a decreased risk of emergency department visits (hazard ratio = 0.98 (0.96, 1.00)). CONCLUSIONS In an integrated delivery system with high informational continuity, greater continuity of care is independently associated with lower hospital utilization for seniors with multiple chronic medical conditions. Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs. [ABSTRACT FROM AUTHOR]

The article presents information on a study conducted to investigate whether clinicians' explicit and implicit ethnic or racial bias is linked to the perceptions of black and Latino patients in established clinical relationships. In the Primary Care Assessment Survey, a telephone survey of 2,908 patients was conducted, that addressed their clinicians' interpersonal treatment, communication, and trust. The study found that levels of explicit bias were low among clinicians.

In 2012, the Centers for Medicare & Medicaid Services (CMS) will introduce measures of adherence to oral hypoglycemic, antihypertensive, and cholesterol-lowering drugs into its Medicare Advantage quality program. To meet these quality goals, delivery systems will need to develop and disseminate strategies to improve adherence. The design of adherence interventions has too often been guided by the mistaken assumptions that adherence is a single behavior that can be predicted from readily available patient characteristics and that individual clinicians alone can improve adherence at the population level. Effective interventions require recognition that adherence is a set of interacting behaviors influenced by individual, social, and environmental forces; adherence interventions must be broadly based, rather than targeted to specific population subgroups; and counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers. To achieve the adherence goals set by CMS, front-line clinicians, interdisciplinary teams, organizational leaders, and policymakers will need to coordinate efforts in ways that exemplify the underlying principles of health care reform. [ABSTRACT FROM AUTHOR]

The article presents a study on the correlation of patient-centered outcomes with patient-reported and ICD-9-based morbidity measures. It discusses how the study was conducted which involved 961 people and explored nine health outcomes as a function of four variables that represent types of morbidity measures. It details the study's results which revealed that assessment of morbidity requires assessment of emotional symptoms and subjective and objective measurement of disease burden.

BACKGROUND Information comparing characteristics of patients who do and do not pick up their prescriptions is sparse, in part because adherence measured using pharmacy claims databases does not include information on patients who never pick up their first prescription, that is, patients with primary non-adherence. Electronic health record medication order entry enhances the potential to identify patients with primary non-adherence, and in organizations with medication order entry and pharmacy information systems, orders can be linked to dispensings to identify primarily non-adherent patients. OBJECTIVE This study aims to use database information from an integrated system to compare patient, prescriber, and payment characteristics of patients with primary non-adherence and patients with ongoing dispensings of newly initiated medications for hypertension, diabetes, and/or hyperlipidemia. DESIGN This is a retrospective observational cohort study. PARTICIPANTS (OR PATIENTS OR SUBJECTS) Participants of this study include patients with a newly initiated order for an antihypertensive, antidiabetic, and/or antihyperlipidemic within an 18-month period. MAIN MEASURES Proportion of patients with primary non-adherence overall and by therapeutic class subgroup. Multivariable logistic regression modeling was used to investigate characteristics associated with primary non-adherence relative to ongoing dispensings. KEY RESULTS The proportion of primarily non-adherent patients varied by therapeutic class, including 7% of patients ordered an antihypertensive, 11% ordered an antidiabetic, 13% ordered an antihyperlipidemic, and 5% ordered medications from more than one of these therapeutic classes within the study period. Characteristics of patients with primary non-adherence varied across therapeutic classes, but these characteristics had poor ability to explain or predict primary non-adherence (models c-statistics = 0.61-0.63). CONCLUSIONS Primary non-adherence varies by therapeutic class. Healthcare delivery systems should pursue linking medication orders with dispensings to identify primarily non-adherent patients. We encourage conduct of research to determine interventions successful at decreasing primary non-adherence, as characteristics available from databases provide little assistance in predicting primary non-adherence. [ABSTRACT FROM AUTHOR]

Poor engagement in HIV care is common in the United States and worsens HIV treatment outcomes. In addition, poor engagement in care is likely to drastically reduce the effectiveness of “test and treat” HIV prevention strategies.(See the editorial commentary by Lange, on pages 801–802.)For individuals with human immunodeficiency virus (HIV) infection to fully benefit from potent combination antiretroviral therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective antiretroviral therapy. Test-and-treat strategies for HIV prevention posit that expanded testing and earlier treatment of HIV infection could markedly decrease ongoing HIV transmission, stemming the HIV epidemic. However, poor engagement in care for HIV-infected individuals will substantially limit the effectiveness of test-and-treat strategies. We review the spectrum of engagement in care for HIV-infected individuals in the United States and apply this information to help understand the magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention. [ABSTRACT FROM AUTHOR]

Latinos are the largest minority group in the United States, yet there is currently a lack of Web sites that focus on Latino health. This article shares qualitative research results obtained from Latinos, with a focus on creating a culturally sensitive, bilingual, interactive, computer-based cardiovascular disease risk assessment and behavioral goal-setting program. This project is a substudy of the Latinos Using Cardio Health Actions to Reduce Risk (LUCHAR) grant, a 5-year trial, funded by the National Heart, Lung, and Blood Institute, whose primary aim is the primary prevention of cardiovascular disease in Latinos. Ten focus groups, five in English and five in Spanish, were conducted at six community sites with trained, bilingual facilitators in Denver, Colorado. Results from the focus groups are used to make recommendations on how to develop a culturally sensitive cardiovascular health care Web site for Latinos. [ABSTRACT FROM AUTHOR]

Objectives. We assessed the distribution of immunization records among 3 health care delivery sectors and the impact of a regional immunization registry on "up to date" rates. Methods: Immunization registry records in 2 regions were categorized as having originated in private practices, community health centers, or public health clinics. "Up to date" rates were calculated after we sequentially added immunization records from the 3 sectors. Results. The percentage of children with immunizations documented in multiple sectors increased with age from 7 to 24 months, and children who were seen in multiple sectors were more likely to be up to date. There were relative increases in "up to date" rates of 50% for children aged 24 months. Conclusions. The regional immunization registry is a powerful public health tool for increasing documented "up to date" rates and providing insights into patterns of immunization delivery. (Am J Public Health. 2004;94:967-972). [ABSTRACT FROM AUTHOR]

Background: Primary care physicians are caring for increasing numbers of persons with comorbid chronic illness. Longitudinal information on health outcomes associated with specific chronic conditions may be particularly relevant in caring for these populations. Our objective was to assess the effect of certain comorbid conditions on physical well being over time in a population of persons with chronic medical conditions; and to compare these effects to that of hypertension alone. Methods: We conducted a secondary analysis of 4-year longitudinal data from the Medical Outcomes Study. A heterogeneous population of 1574 patients with either hypertension alone (referent) or one or more of the following conditions: diabetes, coronary artery disease, congestive heart failure, respiratory illness, musculoskeletal conditions and/or depression were recruited from primary and specialty (endocrinology, cardiology or mental health) practices within HMO and fee-for-service settings in three U.S. cities. We measured categorical change (worse vs. same/better) in the SF-36® Health Survey physical component summary score (PCS) over 4 years. We used logistic regression analysis to determine significant differences in longitudinal change in PCS between patients with hypertension alone and those with other comorbid conditions and linear regression analysis to assess the contribution of the explanatory variables. Results: Specific diagnoses of CHF, diabetes and/or chronic respiratory disease; or 4 or more chronic conditions, were predictive of a clinically significant decline in PCS. Conclusions: Clinical recognition of these specific chronic conditions or 4 or more of a list of chronic conditions may provide an opportunity for proactive clinical decision making to maximize physical functioning in these populations. [ABSTRACT FROM AUTHOR]

Presents a study that assessed adequacy of reimbursement for childhood vaccinations in two rural regions in Colorado by comparing medical practice costs of providing childhood vaccinations with reimbursement. Effect of cost and reimbursement considerations on physicians' provision of childhood vaccinations; Background on the efforts of the Colorado Immunization Services Project to improve early childhood vaccination rates in rural areas; Methodology; Results and implications.

This article presents an analysis of the 1993 National Health Interview Survey (NHIS) in the U.S. which was related to the immunization services in rural and urban areas. Although immunization rates have improved overall for children and adults in recent years, substantial problems remain in providing immunization services. To assess the extent of immunization problems in non-metropolitan areas, the 1993 NHIS was analyzed. In this survey, parents were asked to report on the immunization status of one child in their family and asked adults to report whether they had received an influenza immunization in the previous year and whether they had ever received pneumococcal vaccine. Across all immunizations and age categories, immunization rates were lower than goals set forth in Healthy People 2000, this was particularly true for HIB immunization in children and pneumococcal immunization in adults. The rate of influenza and pneumococcal immunization among adults aged 50 to 64 years was substantially lower than the rate among adults aged 65 and older. These findings highlight the need for continued efforts in health policy, public health practice and primary care to improve immunization coverage in both urban and rural areas.

Background: Funding agencies and researchers increasingly recognize the importance of patient stakeholder engagement in research. Despite calls for greater patient engagement, few studies have engaged a broad-based online community of patient stakeholders in the early stages of the research development process. Objective: The objective of our study was to inform a research priority-setting agenda by using a Web-based survey to gather perceptions of important and difficult aspects of diabetes care from patient members of a social networking site-based community. Methods: Invitations to participate in a Web-based survey were sent by email to members of the PatientsLikeMe online diabetes community. The survey asked both quantitative and qualitative questions addressing individuals' level of difficulty with diabetes care, provider communication, medication management, diet and exercise, and relationships with others. Qualitative responses were analyzed using content analysis. Results: Of 6219 PatientsLikeMe members with diabetes who were sent survey invitations, 1044 (16.79%) opened the invitation and 320 (5.15% of 6219; 30.65% of 1044) completed the survey within 23 days. Of the 320 respondents, 33 (10.3%) reported having Type 1 diabetes; 107 (33.4%), Type 2 diabetes and taking insulin; and 180 (56.3%), Type 2 diabetes and taking oral agents or controlling their diabetes with lifestyle modifications. Compared to 2005-2010 National Health and Nutrition Examination Survey data for individuals with diabetes, our respondents were younger (mean age 55.8 years, SD 9.9 vs 59.4 years, SE 0.5); less likely to be male (111/320, 34.6% vs 48.4%); and less likely to be a racial or ethnic minority (40/312, 12.8% vs 37.5%). Of 29 potential challenges in diabetes care, 19 were categorized as difficult by 20% or more of respondents. Both quantitative and qualitative results indicated that top patient challenges were lifestyle concerns (diet, physical activity, weight, and stress) and interpersonal concerns (trying not to be a burden to others, getting support from family/friends). In our quantitative analysis, similar concerns were expressed across patient subgroups. Conclusions: Lifestyle and interpersonal factors were particularly challenging for our online sample of adults with Type 1 or Type 2 diabetes. Our study demonstrates the innovative use of social networking sites and online communities to gather rapid, meaningful, and relevant patient perspectives that can be used to inform the development of research agendas. [ABSTRACT FROM AUTHOR]

OBJECTIVE We wanted to characterize patient accompaniment to medical encounters and to explore the rationale and influence of the companion on the primary care medical encounter. STUDY DESIGN This was a descriptive study POPULATION Academic general internal medicine physicians, patients, and patient companion participated. OUTCOMES MEASURED We measured the frequency of waiting and examination room companions, the reasons for accompaniment, the influence on the encounter and the overall helpfulness of the companion as assessed by patients and companions. We also determined the physician's assessment of the companion's influence, helpfulness, and behavior dining the encounter. RESULTS Companions were in the examination room for 16% of visits; 93% were family members. The rationales for waiting and examination room companions were to help with transportation, provide emotional support, and provide company. Examination room companions helped communicate concerns to the physician, remember the physician's advice, make decisions, and communicate their own concerns to the physician. Patients believed that examination room companions influenced 75% of medical encounters, mainly by improving communication between physician and patient. Physicians agreed that examination room companions favorably influenced physician and patient understanding (60% and 46% of encounters, respectively). Patients indicated that waiting and examination room companions were very helpful for 71% and 83% of visits, respectively. CONCLUSIONS Companions frequently accompany patients to their primary care medical encounters. They are often family members, and they assume important roles in enhancing patient and physician understanding. [ABSTRACT FROM AUTHOR]

Abstract: In many states, budget constraints are prompting earlier release of prison inmates. Prior studies have demonstrated elevated mortality rates in the post-release period but little is known about the health experiences of former inmates in the transition from prison to the community. The objective of this study was to understand the health-seeking experiences, perceptions of risk, and medical and mental health needs of former prisoners in the first two months after release from prison. Participants consisted of 29 former inmates within the first two months after their release from prison to the Denver, Colorado area. Using qualitative methods, trained interviewers conducted individual, in-person, semi-structured interviews exploring participants'' experiences with health, mental health, and health care since release. Interview transcripts were coded and analyzed utilizing a team-based approach to inductive analysis. We found that health-related behavior occurred in the context of a complex life experience, with logistical problems exacerbated by emotional distress. Major themes included 1) transitional challenges; 2) cognitive responses including perceptions about personal risk, knowledge and priorities; 3) emotional responses including pronounced stress, fear, anxiety, disappointment; and 4) health behaviors. Former inmates reported multiple challenges, poor transitional preparation preceding release, and inadequate or absent continuity of mental and physical health care in the context of significant emotional distress and anxiety. Improved release planning, coordination between the medical, mental health and criminal justice systems may reduce the risk of poor health outcomes for this population. [Copyright &y& Elsevier]

Background: The systematic collection of quantitative data on structures and processes from surgical services participating in the National Surgical Quality Improvement Program (NSQIP) has not been a focus to date. Efficient collection of useful measures of structures and processes may improve understanding of surgical outcomes and strategies for improving the quality of surgical care, as NSQIP continues to expand. The purpose of this article was to describe results of a quantitative survey designed to measure surgical care structures and processes within NSQIP sites. Study Design: A cross-sectional survey was mailed to 123 Department of Veteran Affairs (VA) and 14 private sector sites participating in the Agency for Healthcare Research and Quality (AHRQ)-funded Patient Safety in Surgery (PSS) Study. The survey included questions about organizational structures and processes of preoperative, intraoperative, and postoperative general surgical care services. For this study, we included only data from 90 VA sites that returned a survey (73% response rate). We used descriptive statistics and examined the bivariate association of structures and processes items or scales with risk-adjusted observed-to-expected (O/E) ratios of surgical morbidity and mortality. Results: Examination of frequency or means and standard deviations of items and scales revealed substantial variation in the structures and processes of surgical care services in participating VA sites, with correlation analyses demonstrating that, of 35 process and structure variables, there was a statistically significant relationship with the hospital’s observed-to-expected ratio for 14 variables for morbidity, but only 4 variables for mortality. Conclusions: This descriptive analysis provides support for the potential importance of measuring organizational structures and processes of care in addition to risk-adjusted morbidity and mortality. [Copyright &y& Elsevier]

: BackgroundHealthcare systems have been challenged to ensure the timely administration of immunizations. Immunization registries have been proposed to improve the accuracy and completeness of immunization information and to promote effective practice.: MethodsComparison of randomly selected samples from two birth cohorts (1993 and 1998) from Denver Health Medical Center. Chart review and immunization registry information for these groups were compared; a composite immunization was recorded and up-to-date (UTD) status established. Registry data were compared with this composite using a sensitivity measure to assess completeness and accuracy.: ResultsAmong 818 children in the 1993 cohort and 1043 children in the 1998 cohort, there were 6386 and 6886 valid immunizations, respectively. The registry recorded 71.4% and 97.7% of these for the 1993 and 1998 cohorts, respectively (p <0.001). The apparent UTD rate, as measured with registry data alone, improved from 37% to 79% between the two time frames (p <0.001). Composite UTD status was 83.1% and 78.9% (1993 vs 1998, respectively). Accurate registry-defined UTD status improved from 44.4% to 100% between the two intervals.: ConclusionsImmunization registry accuracy improved dramatically for recorded immunizations and UTD status. However, after 3 years of registry use, the overall proportion of children who were UTD had not significantly improved. The mere presence of a registry does not ensure more complete vaccination coverage. Other registry-based strategies, including use of the data for reminder, recall, and audit, may further improve immunization coverage. [Copyright &y& Elsevier]