David Grembowski

Self-Efficacy and Health Behavior Among Older Adults*

Self-efficacy has a well-established, beneficial effect on health behavior and health status in young and middle-aged adults, but little is known about these relationships in older populations. We examined this issue as part of a randomized trial to determine the cost savings and changes in health-related quality of life associated with the provision and reimbursement of a preventive services package to 2,524 Medicare beneficiaries enrolled in Group Health Cooperative of Puget Sound. Baseline self-efficacy data were collected for all participants in five behavioral areas: exercise, dietary fat intake, weight control, alcohol intake, and smoking. Results reveal that efficacy and outcome expectations for these health behaviors are not independent. Correlational and factor analyses indicate two dimensions of efficacy expectations, one consisting of exercise, dietary fat, and weight control, and another consisting of smoking and alcohol consumption. Outcome expectations of the five behaviors form a single dimension. Older adults with high self-efficacy had lower health risk in all behaviors and better health. Regression analyses detected a positive association between socioeconomic status and health-related quality of life (p < .02), but the strength of the association declined (p < .11) after the self-efficacy measures entered the model, indicating that self-efficacy explains part of the association between socioeconomic status and health status. Interventions aimed at improving self-efficacy also may improve health status.

Reducing Oral Health Disparities: A Focus on Social and Cultural Determinants

Oral health is essential to the general health and well-being of individuals and the population. Yet significant oral health disparities persist in the U.S. population because of a web of influences that include complex cultural and social processes that affect both oral health and access to effective dental health care.This paper introduces an organizing framework for addressing oral health disparities. We present and discuss how the multiple influences on oral health and oral health disparities operate using this framework. Interventions targeted at different causal pathways bring new directions and implications for research and policy in reducing oral health disparities.

Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders.

We used data from a 4-year prospective study of 2,558 primary care patients age 65 and older in a large staff model health maintenance organization to examine the association of clinically significant depressive symptoms and eight other chronic medical conditions with quality adjusted life years (QALYs). We developed linear regression models to examine the association of clinically significant depressive symptoms as defined by a score of 16 or greater on the Center for Epidemiological Studies Depression Scale and eight common chronic medical disorders at baseline with QALYs over the 4-year study period. Estimates of QALYs were derived from Quality of Well-Being Scale scores at baseline, at 2-year follow-up, and at 4-year follow-up. Individuals with clinically significant depressive symptoms at baseline had significantly lower QALYs over the 4-year study period than nondepressed subjects, even after adjusting for differences in age, gender, and the eight other chronic medical conditions. In terms of the entire study population, only arthritis and heart disease were more strongly associated with QALYs than depression.

Managed Care, Physician Job Satisfaction, and the Quality of Primary Care

AbstractOBJECTIVE: To determine the associations between managed care, physician job satisfaction, and the quality of primary care, and to determine whether physician job satisfaction is associated with health outcomes among primary care patients with pain and depressive symptoms. DESIGN: Prospective cohort study. SETTING: Offices of 261 primary physicians in private practice in Seattle. PATIENTS: We screened 17,187 patients in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms; 2,004 patients completed a 6-month follow-up survey. MEASUREMENTS AND RESULTS: For each patient, managed care was measured by the intensity of managed care controls in the patient’s primary care office, physician financial incentives, and whether the physician read or used back pain and depression guidelines. Physician job satisfaction at baseline was measured through a 6-item scale. Quality of primary care at follow-up was measured by patient rating of care provided by the primary physician, patient trust and confidence in primary physician, quality-of-care index, and continuity of primary physician. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days. Pain and depression patients of physicians with greater job satisfaction had greater trust and confidence in their primary physicians. Pain patients of more satisfied physicians also were less likely to change physicians in the follow-up period. Depression patients of more satisfied physicians had higher ratings of the care provided by their physicians. These associations remained after controlling statistically for managed care. Physician job satisfaction was not associated with health outcomes. CONCLUSIONS: For primary care patients with pain or depressive symptoms, primary physician job satisfaction is associated with some measures of patient-rated quality of care but not health outcomes.

Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms.

AbstractOBJECTIVE: To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms. DESIGN: Prospective cohort study. SETTING: Offices of 261 primary physicians in private practice in Seattle. PATIENTS: Patients (N=17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n=942) completed follow-up surveys at 1, 3, and 6 months. MEASUREMENTS AND RESULTS: For each patient, the intensity of managed care was measured by the managedness of the patient’s health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient’s primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians. CONCLUSIONS: The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.

Group Health Cooperative's Transformation Toward Patient-Centered Access

The Institute of Medicine suggests redesigning health care to ensure safe, effective, timely, efficient, equitable, and patient-centered care. The concept of patient-centered access supports these goals. Group Health, a mixed-model health care system, attempted to improve patients’ access to care through the following changes: (a) offering a patient Web site with patient access to patient—physician secure e-mail, electronic medical records, and health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance care efficiency; (d) offering direct access to physician specialists; and (e) aligning primary physician compensation through incentives for patient satisfaction, productivity, and secure messaging with patients. In the 2 years following the redesign, patients reported higher satisfaction with certain aspects of access to care, providers reported improvements in the quality of service given to patients, and enrollment in Group Health stayed aligned with statewide trends in health care coverage.

Managed Care and Physician Referral

In the era of managed care, fundamental changes are occurring in the American health care system that are altering physician referral patterns. Faced with higher premiums that erode profits and competitiveness, employers, government, and nonprofit agencies are contracting with managed care organizations, which control costs partly by imposing constraints and incentives on physician referral behavior. As more and more Americans are covered by managed care plans, it becomes more important to understand how managed care organizations control access to specialists and how these controls affect health outcomes. The authors present a model defining the expected influence of managed care on physician referral based on social exchange theory and the empirical literature. They conclude with a discussion of the future research implications of the model.

A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.

Background:Effective healthcare for people with multiple chronic conditions (MCC) is a US priority, but the inherent complexity makes both research and delivery of care particularly challenging. As part of AHRQ Multiple Chronic Conditions Research Network (MCCRN) efforts, the Network developed a conceptual model to guide research in this area. Objective:To synthesize methodological and topical issues relevant to MCC patient care into a framework that can improve the delivery of care and advance future research about caring for patients with MCC. Methods:The Network synthesized essential constructs for MCC research identified from roundtable discussion, input from expert advisors, and previously published models. Results:The AHRQ MCCRN conceptual model defines complexity as the gap between patient needs and healthcare services, taking into account both the multiple considerations that affect the needs of MCC patients, as well as the contextual factors that influence service delivery. The model reframes processes and outcomes to include not only clinical care quality and experience, but also patient health, well being, and quality of life. The single-condition paradigm for treating needs one-by-one falls apart and highlights the need for care systems to address dynamic patient needs. Conclusions:Defining complexity in terms of the misalignment between patient needs and services offers new insights in how to research and develop solutions to patient care needs.

Socioeconomic status and exercise self-efficacy in late life

Self-efficacy, or assessments about ones ability to carry out particular tasks, has been shown to play a central role in the adoption and maintenance of exercise. The relationship between exercise self-efficacy and socioeconomic status (SES), however, has not been formally developed or tested, and the implications of SES for exercise interventions are not known. We hypothesize pathways through which income, education, and occupation affect self-efficacy and capitalize on the availability of responses from 1944 older HMO enrollees to investigate the direct and indirect associations of SES indicators with exercise self-efficacy. Direct associations of age and education are found. Indirect associations of age, income, education, and occupation operate primarily through previous exercise experience, satisfaction with amount of walking, depression, and outcome expectations. The potentially modifiable nature of exercise outcome expectations (i.e., belief in the benefits of exercise) in combination with its strong association with exercise self-efficacy argue in support of greater consideration of its role in attempts to improve exercise self-efficacy.

Patient-Centered Medical Home Initiative Produced Modest Economic Results For Veterans Health Administration, 2010–12

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided