Anne H. Gaglioti

Access to Primary Care in US Counties Is Associated with Lower Obesity Rates

Background: Obesity causes substantial morbidity and mortality in the United States. Evidence shows that primary care physician (PCP) supply correlates positively with improved health, but its association with obesity in the United States as not been adequately characterized. Our purpose was to characterize the association between PCP supply in US counties and adult obesity. Methods: We performed a multivariate logistic regression analysis to examine the relationship between county-level PCP supply and individual obesity status. We controlled for individual variables, including sex, race, marital status, income, and insurance status, and county-level variables, including rurality and poverty. Results: Higher county-level PCP supply was associated with lower adult obesity after controlling for common confounders. Individuals living in counties with the most robust PCP supply were about 20% less likely to be obese (P ≤ .01) than those living in counties with the lowest PCP supply. Conclusions: While the observed association between the supply of PCPs and lower rates of obesity may not be causal, the association warrants further investigation. This may have important implications for restructuring the physician workforce in the context of the current PCP shortage and implementation of the Affordable Care Act and the patient-centered medical home.

Practice-based Research Networks (PBRNs) Bridging the Gaps between Communities, Funders, and Policymakers

In this commentary, we propose that practice-based research networks (PBRNs) engage with funders and policymakers by applying the same engagement strategies they have successfully used to build relationships with community stakeholders. A community engagement approach to achieve new funding streams for PBRNs should include a strategy to engage key stakeholders from the communities of funders, thought leaders, and policymakers using collaborative principles and methods. PBRNs that implement this strategy would build a robust network of engaged partners at the community level, across networks, and would reach state and federal policymakers, academic family medicine departments, funding bodies, and national thought leaders in the redesign of health care delivery.

Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach

ABSTRACT Objective: Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. Results: The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. Conclusions: At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.

Increasing Family Medicine Faculty Diversity Still Lags Population Trends

Background: Faculty diversity has important implications for medical student diversity. The purpose of this analysis is to describe trends in racial, ethnic, and gender diversity in family medicine (FM) departments and compare these trends to the diversity of matriculating medical students, the diversity of all medical school faculty, and the population in general. Methods: We used the Association of American Medical Colleges Faculty Roster to describe trends in proportions of female and minorities under-represented in medicine (URM) in FM department full-time faculty in U.S. MD-granting medical schools. Results: Among FM faculty, the proportions of female and URM faculty have grown more than 2-fold between 1980 and 2015. Increasing faculty rank was associated with lower diversity across the study period. FM departments had higher female and URM proportions than the average of all other specialties, but URM representation still lagged population trends. Conclusion: Although FM faculty diversity is growing over time, continued attention to URM representation should remain a priority.

How Socioeconomic Status Affects Patient Perceptions of Health Care: A Qualitative Study:

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.

Integrated care coordination by an interprofessional team reduces emergency department visits and hospitalisations at an academic health centre

ABSTRACT People with chronic behavioural and physical health conditions have higher healthcare costs and mortality rates than patients with chronic physical conditions alone. As a result, there has been promotion of integrated care for this group. It is important to train primary care residents to practice in integrated models of care with interprofessional teams and to evaluate the effectiveness of integrated care models to promote high-quality care for this at-risk group. We implemented an integrated, interprofessional care management programme for adults with chronic mental and physical health needs as part of a curriculum for family medicine and family medicine psychiatry residents. We then evaluated the clinical effectiveness of this programme by describing participants’ healthcare utilisation patterns pre- and post-enrolment. Patients enrolled in the programme were approximately 60–70% less likely to utilise the emergency room and 50% less likely to be admitted to the hospital after enrolment in the programme compared to before enrolment. The odds of individual attendance at outpatient primary care and mental health visits improved after enrolment. In the context of the implementation of integrated behavioural and physical healthcare in primary care, this interprofessional care management programme reduced emergency department utilisation and hospitalisations while improving utilisation of primary care and psychiatry outpatient care. Further studies should focus on replication of this model to further discern the model’s cost-savings and health promotion effects.

Neighborhood Environmental Health and Premature Death From Cardiovascular Disease

Introduction Cardiovascular disease (CVD) is the leading cause of death in the United States and disproportionately affects racial/ethnic minority groups. Healthy neighborhood conditions are associated with increased uptake of health behaviors that reduce CVD risk, but minority neighborhoods often have poor food access and poor walkability. This study tested the community-driven hypothesis that poor access to food at the neighborhood level and poor neighborhood walkability are associated with racial disparities in premature deaths from CVD. Methods We examined the relationship between neighborhood-level food access and walkability on premature CVD mortality rates at the census tract level for the city of Atlanta using multivariable logistic regression models. We produced maps to illustrate premature CVD mortality, food access, and walkability by census tract for the city. Results We found significant racial differences in premature CVD mortality rates and geographic disparities in food access and walkability among census tracts in Atlanta. Improved food access and walkability were associated with reduced overall premature CVD mortality in unadjusted models, but this association did not persist in models adjusted for census tract population composition and poverty. Census tracts with high concentrations of minority populations had higher levels of poor food access, poor walkability, and premature CVD mortality. Conclusion This study highlights disparities in premature CVD mortality and neighborhood food access and walkability at the census tract level in the city of Atlanta. Improving food access may have differential effects for subpopulations living in the same area. These results can be used to calibrate neighborhood-level interventions, and they highlight the need to examine race-specific health outcomes.

A Practical Risk Stratification Approach for Implementing a Primary Care Chronic Disease Management Program in an Underserved Community

Abstract:The use of value metrics is often dependent on payer-initiated health care management incentives. There is a need for practices to define and manage their own patient panels regardless of payer to participate effectively in population health management. A key step is to define a panel of primary care patients with high comorbidity profiles. Our sample included all patients seen in an urban academic family medicine clinic over a two-year period. The simplified risk stratification was built using internal electronic health record and billing system data based on ICD-9 codes. There were 347 patients classified as high-risk out of the 5,364 patient panel. Average age was 59 years (SD 15). Hypertension (90%), hyperlipidemia (62%), and depression (55%) were the most common conditions among high-risk patients. Simplified risk stratification provides a feasible option for our team to understand and respond to the nuances of population health in our underserved community.