Harry Strothers

The Relationship Between Ethnicity and Advance Directives in a Frail Older Population

OBJECTIVE: To assess the relationship between ethnicity and Health Care wishes, including Advance Directives, in a group of frail older persons in PACE (Program For All Inclusive Care Of The Elderly).

E-mail in patient-provider communication: a systematic review.

OBJECTIVE To review systematically the role of e-mails in patient-provider communication in terms of e-mail content, and perspectives of providers and patients on e-mail communication in health care. METHODS A systematic review of studies on e-mail communication between patients and health providers in regular health care published from 2000 to 2008. RESULTS A total of 24 studies were included in the review. Among these studies, 21 studies examined e-mail communication between patients and providers, and three studies examined the e-mail communication between parents of patients in pediatric primary care and pediatricians. In the content analyses of e-mail messages, topics well represented were medical information exchange, medical condition or update, medication information, and subspecialty evaluation. A number of personal and institutional features were associated with the likelihood of e-mail use between patients and providers. While benefits of e-mails in enhancing communication were recognized by both patients and providers, concerns about confidentiality and security were also expressed. CONCLUSION The e-mail is transforming the relationship between patients and providers. The rigorous exploration of pros and cons of electronic interaction in health care settings will help make e-mail communication a more powerful, mutually beneficial health care provision tool. PRACTICE IMPLICATIONS It is important to develop an electronic communication system for the clinical practice that can address a range of concerns. More efforts need to be made to educate patients and providers to appropriately and effectively use e-mail for communication.

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

CONTEXT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. METHODS We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22). CONCLUSIONS The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

Ethnicity and decision-makers in a group of frail older people

OBJECTIVE: To assess the relationship between ethnicity and decision‐makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All‐inclusive Care for the Elderly (PACE).

Disparities in Antidepressant Treatment in Medicaid Elderly Diagnosed with Depression

Objectives: To determine whether there were racial or ethnic disparities in the use of antidepressants in low‐income elderly patients insured by Medicaid.

Implementation and Evaluation of a Nursing Home Fall Management Program

OBJECTIVES: To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs).

Sex, Drugs, and HIV: Does Methadone Maintenance Reduce Drug Use and Risky Sexual Behavior?

This study examined differences in drug use, sexual behavior, attitudes, and perceptions of vulnerability for AIDS between injection drug users who received methadone treatment in the previous 6 months and those who did not. Of the 123 participants assessed, 62 (50%) received methadone treatment. Methadone patients reported fewer sexual partners and greater use of condoms compared to nonmethadone patients. Methadone patients also reported fewer high-risk sexual partners than those not in treatment. Women reported more high-risk partners than men. Methadone patients reported drinking alcohol less, but smoking marijuana more than nonmethadone users. Methadone users had more positive beliefs about the efficacy of condoms for preventing AIDS and expressed less anger than nonmethadone users in situations related to condom usage. These findings have important implications for using methadone maintenance to reduce the dual risk for HIV in injection drug users.

Predictors of 4-year retention among African American and white community-dwelling participants in the UAB study of aging.

PURPOSE To identify racial/ethnic differences in retention of older adults at 3 levels of participation in a prospective observational study: telephone, in-home assessments, and home visits followed by blood draws. DESIGN AND METHODS A prospective study of 1,000 community-dwelling Medicare beneficiaries aged 65 years and older included a baseline in-home assessment and telephone follow-up calls at 6-month intervals; at 4 years, participants were asked to complete an additional in-home assessment and have blood drawn. RESULTS After 4 years, 21.7% died and 0.7% withdrew, leaving 776 participants eligible for follow-up (49% African American; 46% male; 51% rural). Retention for telephone follow-up was 94.5% (N = 733/776); 624/733 (85.1%) had home interviews, and 408/624 (65.4%) had a nurse come to the home for the blood draw. African American race was an independent predictor of participation in in-home assessments, but African American race and rural residence were independent predictors of not participating in a blood draw. IMPLICATIONS Recruitment efforts designed to demonstrate respect for all research participants, home visits, and telephone follow-up interviews facilitate high retention rates for both African American and White older adults; however, additional efforts are required to enhance participation of African American and rural participants in research requiring blood draws.

Point of care testing to improve glycemic control

PURPOSE The purpose of this paper is to pilot-test the feasibility and impact of protocol-driven point-of-care HbAlc testing on levels of glycemic control and on rates of diabetic regimen intensification in an urban community health center serving low-income patients. DESIGN/METHODOLOGY/APPROACH The paper suggests a primary care process re-design, using point of care finger-stick HbA1c testing under a standing order protocol that provided test results to the provider at patient visit. FINDINGS The paper finds that the protocol was well received by both nurses and physicians. HbA1c testing rates increased from 73.6 percent to 86.8 percent (p = 0.40, n = 106). For the 69 patients who had both pre- and post-intervention results, HbAlc levels decreased significantly from 8.55 to 7.84 (p = 0.004, n = 69). At baseline, the health center as a system was relatively ineffective in responding to elevated HbA1c levels. An opportunity to intensify, i.e. a face-to-face visit with lab results available, occurred for only 68.6 percent of elevated HbAlc levels before the intervention, vs. 100 percent post-intervention (p < 0.001). Only 28.6 percent of patients with HbAlc levels >8.0 had their regimens intensified in the pre-intervention phase, compared with 53.8 percent in the post-intervention phase (p = 0.03). RESEARCH LIMITATIONS/IMPLICATIONS This was a pilot-study in one urban health center. Larger group-randomized controlled trials are needed. PRACTICAL IMPLICATIONS The health centers performance as a system, improved significantly as a way of intensifying diabetic regimens thereby achieving improved glycemic control. ORIGINALITY/VALUE This intervention is feasible, replicable and scalable and does not rely on changing physician behaviors to improve primary care diabetic outcomes.

Racial and sex differences in associations between activities of daily living and cognition in community-dwelling older adults.

To examine the association between function measured according to activities of daily living (ADLs), instrumental activ1ities of daily living (IADLs), and cognition assessed according to Mini‐Mental State Examination (MMSE) scores of older African‐American and non‐Hispanic white community‐dwelling men and women.