Jinsheng Zhu

Cancer Screening among Racial/Ethnic and Insurance Groups in the United States: A Comparison of Disparities in 2000 and 2008

Using the National Health Interview Survey, we examined associations among race/ ethnicity, insurance coverage, and cancer screening, and assessed changes in the magnitude of disparities over the past decade. Outcomes included recent cervical, breast, and colorectal cancer screening. Rates of colorectal screening increased for all racial/ethnic groups and some insurance groups from 2000 to 2008. However, rates of Pap tests and mammograms remained stagnant, and even decreased for certain groups. Some Hispanic-White and Asian-White disparities in cancer screening were reduced or eliminated over this time period. However, in 2008 Asians continued to have lower odds of Pap tests and Hispanics lower odds of colorectal cancer screening, even after accounting for potential confounders. There were no significant changes in Black-White disparities. The uninsured continued to be at a disadvantage for all three types of cancer screening, relative to the privately insured, as were publicly insured individuals with respect to colorectal cancer screening.

Patient-centered Medical Home Capability and Clinical Performance in HRSA-supported Health Centers

Objectives:To evaluate the relationship between Patient-centered Medical Home (PCMH) model adoption in health centers (HCs) and clinical performance measures and to determine if adoption of PCMH characteristics is associated with better clinical performance. Research Design:Data came from the Health Resources and Services Administration’s 2009 Uniform Data System and the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers. Clinical performance measures included 2 process measures (childhood immunization and cervical cancer screening) and 2 outcome measures (hypertension control and diabetes control). Total and subscale PCMH scores were regressed on the clinical performance measures, adjusting for patient, provider, financial, and institutional characteristics. Results:The findings showed different directional relationships, with some PCMH domains (care management, test/referral tracking, quality improvement, and external coordination) showing little or no effect on outcome measures of interest, 1 domain (access/communication) associated with improved outcomes, and 1 domain (patient tracking/registry) associated with worse outcomes. Conclusions:This study is among the first to examine the association between PCMH transformation and clinical performance in HCs, providing an understanding of the impact of PCMH adoption within safety-net settings. The mixed results highlight the importance of examining relationships between specific PCMH domains and specific clinical quality measures, in addition to analyzing overall PCMH scores which could yield distorted findings.

Racial and socioeconomic disparities in access to primary care among people with chronic conditions.

Objective: The purpose of this study was to examine racial and socioeconomic disparities in access to primary care among people with chronic conditions. Methods: Data for this study were taken from the household component of the 2010 Medical Expenditure Panel Survey. The analysis primarily focused on adults ≥18 years old. Logistic regressions were conducted among people with chronic conditions to compare primary care attributes between each minority group and their non-Hispanic white counterparts and between individuals with high, above average, or below average socioeconomic status and their low socioeconomic status counterparts, controlling for other individual factors. Results: Racial disparities were found in having usual source of care (USC), USC provider type, and USC location. However, no disparities were found in ease of contacting or getting to USC as well as the services received. Furthermore, very limited socioeconomic disparities were found after controlling for other individual characteristics, in particular race and insurance status. Conclusions: More efforts need to be devoted to racial/ethnic minorities with chronic conditions to improve their access to continuous and high-quality primary care.

Insurance, Racial/Ethnic, SES-Related Disparities in Quality of Care Among US Adults with Diabetes

Abstract Diabetes-related quality improvement initiatives are typically aimed at improving outcomes and reducing complications. Studies have found that disparities in quality persist for certain racial/ethnic and socioeconomically disadvantaged groups; however, results are mixed with regard to insurance-based differences. The purpose of this study is to investigate the independent associations between type of health insurance coverage, race/ethnicity, and socioeconomic status (SES), and quality of care, as measured by benchmark indicators of diabetes-related primary care. This study used the Diabetes Care Survey of the 2010 Medical Expenditure Panel Survey. Bivariate and multivariate logistic regressions were used to examine the association between quality of diabetes care and type of insurance coverage, race/ethnicity, and SES. Multivariate analyses also controlled for additional demographic and health status characteristics. Respondents with insurance coverage (particularly those with private insurance or with Medicare and Medicaid coverage) were more likely to receive quality diabetes care than uninsured individuals. Few significant disparities based on race/ethnicity or SES persisted in subsequent multivariate analyses. Findings suggest that insurance coverage may make the greatest impact in ensuring equitable distribution of quality diabetes care, regardless of race/ethnicity or socioeconomic status. With the implementation of Affordable Care Act under which more people could potentially gain access to insurance, policymakers should next track insurance-based diabetes care disparities.

Effects of patient-centered medical home attributes on patients' perceptions of quality in federally supported health centers.

PURPOSE We sought to assess patients’ ratings of patient-centered medical home (PCMH) attributes and overall quality of care within federally supported health centers. METHODS Data were collected through the 2009 Health Center Patient Survey (n = 4,562), which consisted of in-person interviews and included a nationally representative sample of patients seen in health centers. Quality measures included patients’ perceptions of overall quality of services, perceptions of quality of clinician advice/treatment, and likelihood of referring friends and relatives to the health center. PCMH attributes included (1) access to care getting to health center, (2) access to care during visit, (3) patient-centered communication with health care clinicians, (4) patient-centered communication with support staff, (5) self-management support for chronic conditions, (6) self-management support for behavioral risks, and (7) comprehensive preventive care. Bivariate analysis and logistic regressions were used to examine associations between patients’ perceptions of PCMH attributes and patient-reported quality of care. RESULTS Eighty-four percent of patients reported excellent/very good overall quality of services, 81% reported excellent/very good quality of clinician care, and 84% were very likely to refer friends and relatives. Higher patient ratings on the access to care and patient-centered communication attributes were associated with higher odds of patient-reported high quality of care on the 3 outcome measures. CONCLUSIONS More than 80% of patients perceived high quality of care in health centers. PCMH attributes related to access to care and communication were associated with greater likelihood of patients reporting high-quality care.

Primary Care and Public Health Activities in Select US Health Centers: Documenting Successes, Barriers, and Lessons Learned

OBJECTIVES We examined primary care and public health activities among federally funded health centers, to better understand their successes, the barriers encountered, and the lessons learned. METHODS We used qualitative and quantitative methods to collect data from 9 health centers, stratified by administrative division, urban-rural location, and race/ethnicity of patients served. Descriptive data on patient and institutional characteristics came from the Uniform Data System, which collects data from all health centers annually. We administered questionnaires and conducted phone interviews with key informants. RESULTS Health centers performed well on primary care coordination and community orientation scales and reported conducting many essential public health activities. We identified specific needs for integrating primary care and public health: (1) more funding for collaborations and for addressing the social determinants of health, (2) strong leadership to champion collaborations, (3) trust building among partners, with shared missions and clear expectations of responsibilities, and (4) alignment and standardization of data collection, analysis, and exchange. CONCLUSIONS Lessons learned from health centers should inform strategies to better integrate public health with primary care.

Racial/ethnic differences in clinical quality performance among health centers.

More than 1100 federally funded health centers provide primary and preventive care to about 20 million underserved patients in the United States. Since 2008, the Health Resources and Services Administration has implemented a clinical quality improvement initiative to measure and evaluate the quality of care across all health centers. We assessed racial/ethnic disparities in clinical quality among US health centers, and examined whether performance on quality measures varied across 3 health center characteristics. National data came from the 2009 Uniform Data System. We examined performance across 3 indicators of clinical quality: poorly controlled hypertension among adult patients, poorly controlled diabetes among adult patients, and low birth weight among newborns. We compared results for each measure across racial/ethnic groups, as well as across 3 health center characteristics: health center patient volume, duration of health center funding, and extent of managed care penetration. Non-Hispanic Asian patients had the best results among racial/ethnic groups for 2 of the 3 measures examined: lowest rates of poorly controlled diabetes (26%) and hypertension (34%). Hispanics/Latinos had similar rates of poor hypertension control compared with non-Hispanic whites (38% for both), and lower rates of low birth weight (8% vs 10%). Poor diabetes control was more prevalent among Hispanic/Latino patients than non-Hispanic white patients, but the absolute difference was small (5 percentage points). Non-Hispanic black/African American patients had statistically worse outcomes than non-Hispanic white patients, but the absolute differences were also small (2–6 percentage points, depending on outcome). Health centers with larger patient volume fared better than their counterparts with smaller volume for all racial/ethnic groups. For Hispanic/Latino patients, more established health centers compared favorably to new health centers for all 3 outcomes. Health centers with some managed care penetration did better for diabetes and hypertension control relative to health centers without managed care penetration. Compared with national rates, health centers report minimal racial/ethnic disparities in clinical outcomes. Health center characteristics are also associated with clinical outcomes. More research is needed to determine the nature of disparities after accounting for health center patient, provider, and institutional characteristics.

Primary care and public health activities in select U.S. health centers: documenting successes, barriers, and lessons learned.

PURPOSE The goal of the current study was to examine primary care and public health activities among federally funded health centers, to better understand their successes, barriers encountered, and lessons learned. METHODS Qualitative and quantitative methods were used to collect data from nine health centers, stratified by administrative division, urban-rural location, and race/ethnicity of patients served. Descriptive data on patient and institutional characteristics came from the Uniform Data System, which collects data from all health centers annually. Questionnaires were administered and phone interviews were conducted with key informants. RESULTS Health centers performed well on primary care coordination and community orientation scales and reported conducting many essential public health activities. Specific needs were identified for integrating primary care and public health: (1) more funding for collaborations and for addressing the social determinants of health, (2) strong leadership to champion collaborations, (3) trust-building among partners, with shared missions and clear expectations of responsibilities, and (4) alignment and standardization of data collection, analysis, and exchange. CONCLUSIONS Lessons learned from health centers should inform strategies to better integrate public health with primary care.

Diabetes and medical expenditures among non-institutionalized U.S. adults

AIMS This research presents a comprehensive picture of medical spending associated with diabetes in the United States, accounting for important population characteristics. METHODS The Household Component (HC) of the 2010 Medical Expenditure Panel Survey (MEPS) was used for this study. Regression analysis was used to compare medical spending between individuals with and without diabetes. The dependent variables of interest were total and out-of-pocket expenditures related to medical care, hospital use, physician office visits, and prescription drug use. RESULTS This study reveals that individuals with diabetes experience significantly greater medical, hospital, physician office, and prescription drug expenditures compared to those without diabetes. Even after controlling for predisposing, enabling, and need factors, adults with diabetes spent

Chronic conditions and medical expenditures among non-institutionalized adults in the United States

1843 more on total medical expenditures and