Heather Klusaritz

Short‐ and Long‐Term Mortality after an Acute Illness for Elderly Whites and Blacks

OBJECTIVE To estimate racial differences in mortality at 30 days and up to 2 years following a hospital admission for the elderly with common medical conditions. DATA SOURCES The Medicare Provider Analysis and Review File and the VA Patient Treatment File from 1998 to 2002 were used to extract patients 65 or older admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia. STUDY DESIGN A retrospective analysis of risk-adjusted mortality after hospital admission for blacks and whites by medical condition and in different hospital settings. PRINCIPAL FINDINGS Black Medicare patients had consistently lower adjusted 30-day mortality than white Medicare patients, but the initial survival advantage observed among blacks dissipated beyond 30 days and reversed by 2 years. For VA hospitalizations similar patterns were observed, but the initial survival advantage for blacks dissipated at a slower rate. CONCLUSIONS Racial disparities in health are more likely to be generated in the posthospital phase of the process of care delivery rather than during the hospital stay. The slower rate of increase in relative mortality among black VA patients suggests an integrated health care delivery system like the VA may attenuate racial disparities in health.

Is lower 30-day mortality posthospital admission among blacks unique to the Veterans Affairs health care system?

Background:Several studies have reported lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) health care system, particularly for those age 65 and older. This finding may be a result of the VAs integrated health care system, which reduces barriers to care through subsidized comprehensive health care services. However, no studies have directly compared racial differences in mortality within 30 days of hospitalization between the VA and non-VA facilities in the US health care system. Objective:To compare risk-adjusted 30-day mortality for black and white males after hospital admission to VA and non-VA hospitals, with separate comparisons for patients younger than age 65 and those age 65 and older. Research Design:Retrospective observational study using hospital claims data from the national VA system and all non-VA hospitals in Pennsylvania and California. Subjects:A total of 369,155 VA and 1,509,891 non-VA hospitalizations for a principal diagnosis of pneumonia, congestive heart failure, gastrointestinal bleeding, hip fracture, stroke, or acute myocardial infarction between 1996 and 2001. Measures:Mortality within 30 days of hospital admission. Results:Among those under age 65, blacks in VA and non-VA hospitals had similar odds ratios of 30-day mortality relative to whites for gastrointestinal bleeding, hip fracture, stroke, and acute myocardial infarction. Among those age 65 and older, blacks in both VA and non-VA hospitals had significantly reduced odds of 30-day mortality compared with whites for all conditions except pneumonia in the VA. The differences in mortality by race are remarkably similar in VA and non-VA settings. Conclusions:These findings suggest that factors associated with better short-term outcomes for blacks are not unique to the VA.

The concentration of hospital care for black veterans in Veterans Affairs hospitals: implications for clinical outcomes.

&NA; Where minorities receive their care may contribute to disparities in care, yet, the racial concentration of care in the Veterans Health Administration is largely unknown. We sought to better understand which Veterans Affairs (VA) hospitals treat Black veterans and whether location of care impacted disparities. We assessed differences in mortality rates between Black and White veterans across 150 VA hospitals for any of six conditions (acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal hemorrhage, and pneumonia) between 1996 and 2002. Just 9 out of 150 VA hospitals (6% of all VA hospitals) cared for nearly 30% of Black veterans, and 42 hospitals (28% of all VA hospitals) cared for more than 75% of Black veterans. While our findings show that overall mortality rates were comparable between minority‐serving and non‐minority‐serving hospitals for four conditions, mortality rates were higher in minority‐serving hospitals for acute myocardial infarction (AMI) and pneumonia. The ratio of mortality rates for Blacks compared with Whites was comparable across all VA hospitals. In contrast to the private sector, there is little variation in the degree of racial disparities in 30‐day mortality across VA hospitals, although higher mortality among patients with AMI and pneumonia requires further investigation.

Public Libraries As Partners for Health

Introduction Public libraries are free and accessible to all and are centers of community engagement and education, making them logical choices as partners for improving population health. Library staff members routinely assist patrons with unmet health and social needs. Methods We used a 100-question, self-administered web survey sent to all library directors listed in the Pennsylvania Library Association database (N = 621), to investigate staff interactions with library patrons to address social determinants of health. We conducted statistical comparisons of quantitative responses and a content analysis of open-ended responses. Results Respondents (N = 262) reported frequently interacting with patrons around health and social concerns — well beyond those related to literacy and education — including help with employment (94%), nutrition (70%), exercise (66%), and social welfare benefits (51%). Acute emergencies were not uncommon in Pennsylvania’s public libraries, with nearly 12% of respondents having witnessed a drug overdose at the library in the past year. Most respondents felt that their professional training left them inadequately prepared to assist patrons with health and social issues. Although at least 40% of respondents offered some health programming at their library branch, their offerings did not meet the high level of need reflected in common patron inquiries. Conclusion The challenges library staff members experience in meeting their patrons’ information needs suggest opportunities for public libraries to advance population health. Library staff members need additional training and resources and collaboration with public health and health care institutions to respond to community needs through effective, evidence-based public health programming.

Filling the patient–provider knowledge gap: a patient advocate to address asthma care and self-management barriers

Abstract Introduction: In an ongoing study, a new clinical role adapted from a patient navigator called the patient advocate (PA) met with patients before medical visits, attended appointments and afterwards reviewed provider instructions. This qualitative analysis examines the perspectives of PAs and providers regarding their experiences with patients to understand how a PA can help patients and providers achieve better asthma control. Methods: PAs recorded journal entries about their experiences with patients. Provider focus groups and interviews were conducted by researchers and transcribed. Analysis was based on the Grounded Theory approach for qualitative research, using open and then focused coding. Two researchers independently coded these sources until intercoder agreement was achieved. Results: Upon review of 31 journal entries on PA experiences with 24 patients and transcripts from 2 provider focus groups and 12 provider interviews, 5 themes emerged surrounding asthma care and self-management: medication adherence, follow-up, communication, social determinants of health and time. While patients shared with PAs specific socioeconomic barriers to medication adherence and follow-up, providers often did not know about these problems and cited barriers to communication. Time restrictions on medical visits further limited communication. Conclusions: Perspectives reported here illustrate a gap in knowledge and understanding between patients and providers. The PA’s unique relationship with patients and presence inside and outside of medical visits allowed them to learn contextual patient information unknown to providers. PAs and providers cited numerous ways PAs can help to improve patient–provider mutual understanding.

Public Library Staff as Community Health Partners: Training Program Design and Evaluation:

Public libraries are free and open to all—and accessed at high rates by vulnerable populations—which positions them to be key public health allies. However, library staff themselves often feel ill-equipped to address the health and social concerns of their patrons. To fill this gap, we developed a case-based training curriculum to help library staff recognize, engage, and refer vulnerable patrons to appropriate resources. Topics addressed in the training, including homelessness, mental health and substance use disorders, immigration, and trauma, were selected based on findings from a prior community needs assessment. Using a modified measure of self-efficacy, participants (n = 33) were surveyed before and after each session. Several participants (n = 7) were also interviewed 4 months after the training was completed. Overall, staff reported significant increases in comfort, confidence, and preparedness in assisting vulnerable patrons across all topic areas. Qualitative findings reflected positive perceived impact and value of the trainings. Staff felt training resources should be made more readily accessible. Improving library staff capacity to address the health and social needs of their patrons can further establish public libraries as partners in improving population health.

Engaging With the Community to Promote Physical Activity in Urban Neighborhoods

Purpose: To describe perceptions of physical activity, opinions, on intergenerational approaches to physical activity and a vision for increasing physical activity in an underresourced urban community. Approach: Focus groups embedded in a large Community-Based Participatory Research Project. Setting: West and Southwest Philadelphia. Participants: 15 parents, 16 youth, and 14 athletic coaches; youth were 13 to 18 years old and attended West Philadelphia schools; parents’ children attended West Philadelphia schools; and coaches worked in West Philadelphia schools. Methods: Six focus groups (2 youth, 2 parent, and 2 coach) were conducted guided by the Socio-Ecological Model; transcriptions were analyzed using a rigorous process of directed content analysis. Results: Factors on all levels of the Socio-Ecological Model influence the perception of and engagement in physical activity for youth and their families. Future strategies to increase engagement in physical activity need to be collaborative and multifaceted. Conclusion: When physical activity is reframed as a broad goal that is normative and gender-neutral, a potential exists to engage youth and their families over their lifetimes; with attention to cross-sector collaboration and resource sharing, engaging and sustainable intergenerational physical activity interventions can be developed to promote health in underresourced urban communities.

A Monte Carlo simulation approach for estimating the health and economic impact of interventions provided at a student-run clinic

Background Student Run Clinics (SRCs) are a common aspect of medical education, present at more than half of US medical schools, and noted for providing care to communities that might otherwise lack access, including the uninsured and underinsured. To date, few studies have rigorously quantified the health and economic benefits of SRCs, and the present study remedies that. Methods and findings We used Monte Carlo simulations to estimate the health impact of common preventive health interventions applied to individuals in quality-adjusted life-years (QALYs). We then used those measurements to estimate the health and economic impact of United Community Clinic (UCC), a student-run clinic in Philadelphia, PA. We found that with an annual operating budget of

How nurse-led practices perceive implementation of the patient-centered medical home

50,000, UCC saves 6.5 QALYs, corresponding to over

Capsule Commentary on Liss et al., Specialty Use Among Patients with Treated Hypertension in a Patient-Centered Medical Home

850,000 saved. Conclusions Using Monte Carlo simulation methods, the health and economic impact of SRCs can be reasonably estimated to demonstrate the utility of SRCs and justify their growing importance in the healthcare delivery landscape of the US.