Jessica R. Schumacher

Alterations in Brain and Immune Function Produced by Mindfulness Meditation

Objective: The underlying changes in biological processes that are associated with reported changes in mental and physical health in response to meditation have not been systematically explored. We performed a randomized, controlled study on the effects on brain and immune function of a well‐known and widely used 8‐week clinical training program in mindfulness meditation applied in a work environment with healthy employees. Methods: We measured brain electrical activity before and immediately after, and then 4 months after an 8‐week training program in mindfulness meditation. Twenty‐five subjects were tested in the meditation group. A wait‐list control group (N = 16) was tested at the same points in time as the meditators. At the end of the 8‐week period, subjects in both groups were vaccinated with influenza vaccine. Results: We report for the first time significant increases in left‐sided anterior activation, a pattern previously associated with positive affect, in the meditators compared with the nonmeditators. We also found significant increases in antibody titers to influenza vaccine among subjects in the meditation compared with those in the wait‐list control group. Finally, the magnitude of increase in left‐sided activation predicted the magnitude of antibody titer rise to the vaccine. Conclusions: These findings demonstrate that a short program in mindfulness meditation produces demonstrable effects on brain and immune function. These findings suggest that meditation may change brain and immune function in positive ways and underscore the need for additional research.

Right Frontal Brain Activity, Cortisol, and Withdrawal Behavior in 6-Month-Old Infants

Although several studies have examined anterior asymmetric brain electrical activity and cortisol in infants, children, and adults, the direct association between asymmetry and cortisol has not systematically been reported. In nonhuman primates, greater relative right anterior activation has been associated with higher cortisol levels. The current study examines the relation between frontal electroencephalographic (EEG) asymmetry and cortisol (basal and reactive) and withdrawal-related behaviors (fear and sadness) in 6-month-old infants. As predicted, the authors found that higher basal and reactive cortisol levels were associated with extreme right EEG asymmetry. EEG during the withdrawal-negative affect task was associated with fear and sadness behaviors. Results are interpreted in the context of the previous primate work, and some putative mechanisms are discussed.

Physician Assistants and Nurse Practitioners as a Usual Source of Care

PURPOSE To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. METHODS Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). FINDINGS Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (beta=-0.22, 95% CI =-0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. CONCLUSIONS Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.

Undiagnosed hypertension among young adults with regular primary care use.

Objective: Young adults meeting hypertension diagnostic criteria have a lower prevalence of a hypertension diagnosis than middle-aged and older adults. The purpose of this study was to compare the rates of a new hypertension diagnosis for different age groups and identify predictors of delays in the initial diagnosis among young adults who regularly use primary care. Methods: A 4-year retrospective analysis included 14 970 patients, at least 18 years old, who met clinical criteria for an initial hypertension diagnosis in a large, Midwestern, academic practice from 2008 to 2011. Patients with a previous hypertension diagnosis or prior antihypertensive medication prescription were excluded. The probability of diagnosis at specific time points was estimated by Kaplan–Meier analysis. Cox proportional hazard models (hazard ratio; 95% confidence interval) were fit to identify predictors of delays to an initial diagnosis, with a subsequent subset analysis for young adults (18–39 years old). Results: After 4 years, 56% of 18–24-year-olds received a diagnosis compared with 62% (25–31-year-olds), 68% (32–39-year-olds), and more than 70% (≥40-year-olds). After adjustment, 18–31-year-olds had a 33% slower rate of receiving a diagnosis (18–24 years hazard ratio 0.66, 0.53–0.83; 25–31 years hazard ratio 0.68, 0.58–0.79) compared with adults at least 60 years. Other predictors of a slower diagnosis rate among young adults were current tobacco use, white ethnicity, and non-English primary language. Young adults with diabetes, higher blood pressures, or a female provider had a faster diagnosis rate. Conclusion: Provider and patient factors are critical determinants of poor hypertension diagnosis rates among young adults with regular primary care use.

Potentially Preventable Use of Emergency Services: The Role of Low Health literacy

Background:Limited health literacy is a barrier for understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored. Objective:To examine the relationship between health literacy, access to primary care, and reasons for ED use among adults presenting for emergency care. Methods:Structured interviews that included health literacy assessment were performed involving 492 ED patients at one Southern academic medical center. Unadjusted and multivariable logistic regression models assessed the relationship between health literacy and (1) access to a personal physician; (2) doctor office visits; (3) ED visits; (4) hospitalizations; and (5) potentially preventable hospital admissions. Results:After adjusting for sociodemographic and health status, those with limited health literacy reported fewer doctor office visits [odds ratio (OR)=0.6; 95% confidence interval (CI), 0.4–1.0], greater ED use, (OR=1.6; 95% CI, 1.0–2.4), and had more potentially preventable hospital admissions (OR=1.7; 95% CI, 1.0–2.7) than those with adequate health literacy. After further controlling for insurance and employment status, fewer doctor office visits remained significantly associated with patient health literacy (OR=0.5; 95% CI, 0.3–0.9). Patients with limited health literacy reported a preference for emergency care, as the services were perceived as better. Conclusions:Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes toward primary care services.

The impact of a patient's concordant and discordant chronic conditions on diabetes care quality measures.

AIMS Most patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality. METHODS Logistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics. RESULTS A higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions. CONCLUSIONS Having more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patients comorbidities, including the absence of comorbidities, especially concordant comorbidities.

Preventive service gains from first contact access in the primary care home.

Background:The patient-centered medical home (PCMH) concept recently has garnered national attention as a means of improving the quality of primary care. Preventive services are one area in which the use of a PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign. The purpose of this study was to examine whether first-contact access characteristics of a medical home (eg, availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals who already have a longitudinal relationship with a primary care physician at a site of care. Methods:This was a secondary analysis examining data from 5507 insured adults with a usual physician who participated in the 2003 to 2006 round of the Wisconsin Longitudinal Study. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access with those without first-contact access. Results:Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate examination (odds ratio [OR], 1.62; 95% CI, 1.20–2.18), a flu shot (OR, 1.36; 95% CI, 1.01–1.82), and a cholesterol test (OR, 1.36; 95% CI, 1.01–1.82) during the past year. There was no significant difference in receipt of mammograms (OR, 1.23; 95% CI, 0.94–1.61). Conclusions:In the primary care home, first-contact accessibility adds benefit, beyond continuity of care with a physician, in improving receipt of preventive services. Amid increasing primary care demands and finite resources available to translate the PCMH into clinic settings, there is a need for further studies of the interplay between specific PCMH principles and how they perform in practice.

Patients’ Perceptions of Safety if Interpersonal Continuity of Care were to be Disrupted

Objective  To determine if patients vary in perceptions of safety if interpersonal continuity were to be disrupted. If so, which characteristics are associated with feeling unsafe?

Associations of Specific Postoperative Complications With Outcomes After Elective Colon Resection: A Procedure-Targeted Approach Toward Surgical Quality Improvement

Importance Numerous quality initiatives have been implemented in an effort to minimize the onus of postoperative complications on clinical and economic outcomes after major surgery. It is unknown which complications have the greatest overall effect on these outcomes. Objective To quantify the associations of specific postoperative complications with outcomes after elective colon resection. Design, Setting, and Participants Patients undergoing elective colon resection between January 1, 2012, and December 31, 2013, who were included in the Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program were assessed for the development of specific types of postoperative complications. The overall contributions of these complications to subsequent clinical and resource use outcomes were assessed. Main Outcomes and Measures The main outcomes were 30-day mortality, end-organ dysfunction, reoperation, prolonged hospitalization, nonroutine discharge status, and hospital readmission. Risk-adjusted population attributable fractions were estimated for each complication-outcome pair. The population attributable fractions for a specific complication represented the percentage reduction in a given outcome that would be expected if exposure to that complication was completely eliminated. Results A total of 26 682 patients undergoing elective colon resection were included for analysis; 13 870 patients were women (52.0%) and 15 088 (56.5%) were younger than 65 years. The most common index complications were ileus (n = 3140; 11.8%), bleeding (n = 2032; 7.6%), and incisional surgical site infection (n = 1873; 7.0%). Anastomotic leak was associated with the incidence of end-organ dysfunction, mortality, reoperation, and hospital readmission, with estimated population attributable fractions of 33.3% (95% CI, 29.6-36.8), 20.0% (95% CI, 14.0-25.7), 48.4% (95% CI, 45.7-51.0), and 20.6% (95% CI, 19.1-22.1) for each of these respective outcomes. The effect of complications, such as urinary tract infection, venous thromboembolism, and myocardial infarction, on these outcomes was comparatively small. Conclusions and Relevance Anastomotic leak has a large overall effect on 30-day clinical and economic outcomes after elective colon resection. The findings of our study support the adoption of a procedure-targeted approach to surgical quality improvement and describe a practical method for assessing complication effect.

Predictors of Language Service Availability in U.S. Hospitals

BACKGROUND Hispanics comprise 17% of the total U.S. population, surpassing African-Americans as the largest minority group. Linguistically, almost 60 million people speak a language other than English. This language diversity can create barriers and additional burden and risk when seeking health services. Patients with Limited English Proficiency (LEP) for example, have been shown to experience a disproportionate risk of poor health outcomes, making the provision of Language Services (LS) in healthcare facilities critical. Research on the determinants of LS adoption has focused more on overall cultural competence and internal managerial decision-making than on measuring LS adoption as a process outcome influenced by contextual or external factors. The current investigation examines the relationship between state policy, service area factors, and hospital characteristics on hospital LS adoption. METHODS We employ a cross-sectional analysis of survey data from a national sample of hospitals in the American Hospital Association (AHA) database for 2011 (N= 4876) to analyze hospital characteristics and outcomes, augmented with additional population data from the American Community Survey (ACS) to estimate language diversity in the hospital service area. Additional data from the National Health Law Program (NHeLP) facilitated the state level Medicaid reimbursement factor. RESULTS Only 64% of hospitals offered LS. Hospitals that adopted LS were more likely to be not-for-profit, in areas with higher than average language diversity, larger, and urban. Hospitals in above average language diverse counties had more than 2-fold greater odds of adopting LS than less language diverse areas [Adjusted Odds Ratio (AOR): 2.26, P< 0.01]. Further, hospitals with a strategic orientation toward diversity had nearly 2-fold greater odds of adopting LS (AOR: 1.90, P< 0.001). CONCLUSION Our findings support the importance of structural and contextual factors as they relate to healthcare delivery. Healthcare organizations must address the needs of the population they serve and align their efforts internally. Current financial incentives do not appear to influence adoption of LS, nor do Medicaid reimbursement funds, thus suggesting that further alignment of incentives. Organizational and system level factors have a place in disparities research and warrant further analysis; additional spatial methods could enhance our understanding of population factors critical to system-level health services research.