Karin V. Rhodes

Appointment Availability after Increases in Medicaid Payments for Primary Care

BACKGROUND Providing increases in Medicaid reimbursements for primary care, a key provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers. The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states before policymakers had much empirical evidence about its effects. METHODS We measured the availability of and waiting times for appointments in 10 states during two periods: from November 2012 through March 2013 and from May 2014 through July 2014. Trained field staff posed as either Medicaid enrollees or privately insured enrollees seeking new-patient primary care appointments. We estimated state-level changes over time in a stable cohort of primary care practices that participated in Medicaid to assess whether willingness to provide appointments for new Medicaid enrollees was related to the size of increases in Medicaid reimbursements in each state. RESULTS The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups. CONCLUSIONS Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.).

Does Screening in the Emergency Department Hurt or Help Victims of Intimate Partner Violence

STUDY OBJECTIVE Recent systematic reviews have noted a lack of evidence that screening for intimate partner violence does more good than harm. We assess whether patients screened for intimate partner violence on a computer kiosk in the emergency department (ED) experienced any adverse events during or subsequent to the ED visit and whether computer kiosk identification and referral of intimate partner violence in the ED setting resulted in safety behaviors or contact with referrals. METHODS We conducted a prospective, observational study in which a convenience sample of male and female ED patients triaged to the waiting room who screened positive (on a computer kiosk-based questionnaire) for intimate partner violence in the past year were provided with resources and information and invited to participate in a series of follow-up interviews. At 1-week and 3-month follow-up visits, we assessed intimate partner violence, safety issues, and use of resources. In addition, to obtain an objective measure of safety, we assessed the number of violence-related 911 calls to participant addresses within a call district 6 months before and 6 months after the index ED visit. RESULTS Of the 2,134 participants in a relationship in the last year, 548 (25.7%) screened positive for intimate partner violence. No safety issues, such as calling security or a partners interference with the screening, occurred during the ED visit for any patient who disclosed intimate partner violence. Of the 216 intimate partner violence victims interviewed in person and 65 contacted by telephone 1 week later, no intimate partner violence victims reported any injuries or increased intimate partner violence resulting from participating in the study. For the sample in the local police district, there was no increase in the number of intimate partner violence victims who called 911 in the 6 months after the ED visit. Finally, 35% (n=131) reported they had contacted community resources during the 3-month follow-up period. CONCLUSION Among patients screening positive for intimate partner violence, there were no identified adverse events related to screening, and many had contacted community resources.

Intimate Partner Violence and Comorbid Mental Health Conditions Among Urban Male Patients

PURPOSE We wanted to explore the associations between intimate partner violence (IPV) and comorbid health conditions, which have received little attention in male patients. METHODS Using a computer-based self-assessment health questionnaire, we screened sequential emergency department patients who were urban, male, and aged 18 to 55 years. We then examined associations between types of IPV disclosures, co-occurring mental health symptoms, and adverse health behaviors. RESULTS Of 1,669 men seeking nonurgent health care, 1,122 (67.2%) consented to be screened, and 1,026 (91%) completed the screening; 712 (63%) were in a relationship in the past year. Of these men, 261 (37%) disclosed IPV: 20% (n = 144) disclosed victimization only, 6% (n = 40) disclosed perpetration only, and 11% (n= 77) disclosed bidirectional IPV (defined as both victimization and perpetration in their relationships). Men disclosing both victimization and perpetration had the highest frequencies and levels of adverse mental health symptoms. Rates of smoking, alcohol abuse, and drug use were likewise higher in IPV-involved men. CONCLUSIONS A cumulative risk of poor mental health and adverse health behaviors was associated with IPV disclosures. Self-disclosure by men seeking acute health care provides the potential for developing tools to assess level of risk and to guide tailored interventions and referrals based on the sex of the patient.

Primary Care Access for New Patients on the Eve of Health Care Reform

IMPORTANCE Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients. OBJECTIVE To assess primary care appointment availability by state and insurance status. DESIGN, SETTING, AND PARTICIPANTS We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state. MAIN OUTCOMES AND MEASURES The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured. RESULTS Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to

Differences in Female and Male Victims and Perpetrators of Partner Violence With Respect to WEB Scores

75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern. CONCLUSIONS AND RELEVANCE Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plans network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

“I Didn’t Want To Put Them Through That”: The Influence Of Children on Victim Decision-making in Intimate Partner Violence Cases

Measurements of intimate partner violence (IPV) based on acts of violence have repeatedly found substantial bilateral violence between intimates. However, the context of this violence is not well defined by acts alone. The objective of this research was to compare differences in women and men within each IPV status category (victim, perpetrator, and both) with respect to levels of battering as defined by their scores on the Womens Experience With Battering Scale (WEB), which asks gender-neutral questions about the abuse of power and control and fear in an intimate relationship. In our study, women disclosed higher levels of battering on the WEB, despite IPV status (victimization or both victimization and perpetration). In addition, female IPV victims were 5 times more likely than their male counterparts to disclose high rates of battering on the WEB. Depressive symptoms, symptoms of posttraumatic stress disorder, African American race, and IPV victimization were independently associated with higher WEB scores.

Referral Without Access: For Psychiatric Services, Wait for the Beep

For mothers, intimate partner violence (IPV) presents a concern not only for their own well-being but also for that of their children who are exposed to the violence and its aftermath. In focus groups with adult women (N = 39) across three jurisdictions who had experienced legal system intervention for IPV victimization, mothers raised unsolicited concerns about the negative effects of IPV exposure on their children. These comments were not prompted by the facilitator but were raised by women in all seven of the focus groups during discussions about motivations and barriers to participation in prosecution of their abusive partners. The overall message was that victims with children felt very conflicted. Children both facilitate and inhibit leaving the abusive relationship. Mothers wanted to spare their children from harmful effects of violence but also wanted to keep their families together and protect their children from potential agitation and instability caused by legal system involvement. Participants described how fears and threats of involvement from child protective services inhibited help-seeking while simultaneously voicing a desire for services that would help their children. More research is needed to help service providers understand the quagmire mothers who are victims of IPV encounter regarding their children’s wellbeing.

Child Injury Risks are Close to Home: Parent Psychosocial Factors Associated with Child Safety

STUDY OBJECTIVE We examine access to care for acute depression by insurance status compared to access for acute medical conditions in 9 metropolitan areas in the United States. METHODS Using an audit study design, trained research assistants posing as patients referred from a local emergency department (ED) for treatment of depression called each clinic twice, with differing insurance status. The main outcome measure was the ability to schedule a mental health appointment within 2 weeks of the ED visit. RESULTS In 45% of 322 calls to mental health clinics, the research assistant reached an answering machine compared with 8% of calls to medical clinics. As a result, only 31% of callers with depression vignettes were able to determine whether they could get an appointment versus 78% of callers with medical complaints. When they reached appointment personnel by telephone, 57% of depression callers successfully arranged an appointment (39% within 14 days). Among depression callers who reached appointment personnel, 67% of privately insured and 33% of Medicaid callers were able to make an appointment, for overall appointment rates of 22% and 12%, respectively. Appointment success for the uninsured was comparable to that of Medicaid patients. The high percentage of callers who encountered answering machines prevented us from completing the designed analysis of paired calls to individual clinics. CONCLUSION Our findings indicate that the process for obtaining urgent follow-up appointments is systematically different for patients seeking behavioral health care than for those with physical complaints. The use of voicemail, in lieu of having a person answer the telephone, is much more prevalent in behavioral than physical health settings. More work is needed to determine the effect of this practice on depressed individuals and vulnerable populations.

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial

Objective: In several populations, maternal depression has been associated with reduced child safety. In an urban pediatric Emergency Department, we examined the relationship between parental depression, social support, and domestic conflict and child safety behaviors.Methods: We studied consecutive patients in an Emergency Department. Trained interviewers used a structured instrument to assess patient, primary caregiver, and household demographics, socio-economic status, psychosocial factors, child safety behaviors (whether a gun was in the home, poisons were locked, a functioning smoke detector was present, and use of carseats or seatbelts), and whether the home was smoke-free. 1,116 patients provided adequate data.Results: Depression was associated with a modest and not statistically significant reduction in child safety behaviors in this population. Lack of social support and the presence of domestic conflict were robustly, independently, and statistically significantly associated with less safe homes. Domestic conflict was associated with more smoking in the home.Conclusion: In our population, child safety was associated less with depression and more with parental lack of social support and domestic conflict. These can be assessed in a Emergency Department and may be amenable to intervention.

Taking the Mystery out of “Mystery Shopper” Studies

BACKGROUND Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal. METHODS We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fishers exact p=0.11). CONCLUSION Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.