Raymond F. Palmer

Declining Executive Control in Normal Aging Predicts Change in Functional Status: The Freedom House Study

Objectives: To assess the contribution of executive control function (ECF) to functional status.

Patient Outcomes at 26 Months in the Patient-Centered Medical Home National Demonstration Project

PURPOSE The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices’ transition to patient-centered medical homes (PCMHs). METHODS In 2006, a total of 36 family practices were randomized to facilitated or self-directed intervention groups. Progress toward the PCMH was measured by independent assessments of how many of 39 predominantly technological NDP model components the practices adopted. We evaluated 2 types of patient outcomes with repeated cross-sectional surveys and medical record audits at baseline, 9 months, and 26 months: patient-rated outcomes and condition-specific quality of care outcomes. Patient-rated outcomes included core primary care attributes, patient empowerment, general health status, and satisfaction with the service relationship. Condition-specific outcomes were measures of the quality of care from the Ambulatory Care Quality Alliance (ACQA) Starter Set and measures of delivery of clinical preventive services and chronic disease care. RESULTS Practices adopted substantial numbers of NDP components over 26 months. Facilitated practices adopted more new components on average than self-directed practices (10.7 components vs 7.7 components, P=.005). ACQA scores improved over time in both groups (by 8.3% in the facilitated group and by 9.1% in the self-directed group, P <.0001) as did chronic care scores (by 5.2% in the facilitated group and by 5.0% in the self-directed group, P=.002), with no significant differences between groups. There were no improvements in patient-rated outcomes. Adoption of PCMH components was associated with improved access (standardized beta [Sβ]=0.32, P = .04) and better prevention scores (Sβ=0.42, P=.001), ACQA scores (Sβ=0.45, P = .007), and chronic care scores (Sβ=0.25, P =.08). CONCLUSIONS After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.

Do Parenting and the Home Environment, Maternal Depression, Neighborhood, and Chronic Poverty Affect Child Behavioral Problems Differently in Different Racial-Ethnic Groups?

OBJECTIVE. To determine whether the processes through which parenting practices, maternal depression, neighborhood, and chronic poverty affect child behavioral problems are similar or different in minority and nonminority children in the United States. METHODS. Data from 884 white, 538 black, and 404 Latino families with children who were 6 to 9 years of age in the National Longitudinal Survey of Youth were analyzed. The outcome, child behavioral problems, was measured using the Behavior Problems Index externalizing and internalizing subscales. The effects of chronic poverty, neighborhood, maternal depression, and parenting on the outcome were analyzed using multigroup structural equation modeling. RESULTS. Chronic poverty affected child behavioral problems indirectly through the other variables, and parenting practices had direct effects in each racial/ethnic group. The effects of maternal depression were partially mediated through parenting in the white and Latino samples but were direct and unmediated through parenting practices in the black sample. Neighborhood effects were present in the white and black samples but were not significant for the Latino sample. CONCLUSIONS. Chronic poverty, neighborhood, maternal depression, and parenting practices have effects on child behavioral problems in white, black, and Latino children, but the processes and mechanisms through which they exert their effects differ among the groups. The differences may be related to social stratification mechanisms as well as sociocultural differences in family and childrearing practices.

Participatory Decision Making, Patient Activation, Medication Adherence, and Intermediate Clinical Outcomes in Type 2 Diabetes: A STARNet Study

PURPOSE Participatory decision making (PDM) is associated with improved diabetes control. We examine a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence. METHODS This observational study was conducted in 5 family physician offices. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their office visit. Two survey questionnaires, administered 12 months apart, elicited patients’ ratings of their physician’s PDM style at baseline and their level of activation and medication adherence both at baseline and at follow-up. Measures of glycated hemoglobin (hemoglobin A1c), systolic blood pressure, and low-density lipoprotein (LDL) cholesterol were abstracted from the medical record starting 12 months before the baseline survey to 12 months after the follow-up survey. A path analysis using a structural equation model was used to test hypotheses. RESULTS We mailed questionnaires to 236 participants; 166 (70%) returned the baseline questionnaire, and 141 (80%) returned the follow-up questionnaire. Hemoglobin A1c levels, systolic blood pressure, and LDL cholesterol values all declined significantly, and patient activation and medication adherence improved. PDM at baseline was associated with patient activation at follow-up. Patient activation at follow-up was associated with medication adherence at follow-up, and medication adherence at follow-up was associated with change in hemoglobin A1c levels and LDL cholesterol values but not with systolic blood pressure. CONCLUSIONS Participatory decision making during primary care encounters by patients with type 2 diabetes resulted in improvements in hemoglobin A1c levels and LDL cholesterol values by improving patient activation, which in turn improved medication adherence.

Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home

PURPOSE The objective of this study was to elucidate the effect of facilitation on practice outcomes in the 2-year patient-centered medical home (PCMH) National Demonstration Project (NDP) intervention, and to describe practices’ experience in implementing different components of the NDP model of the PCMH. METHODS Thirty-six family practices were randomized to a facilitated intervention group or a self-directed intervention group. We measured 3 practice-level outcomes: (1) the proportion of 39 components of the NDP model that practices implemented, (2) the aggregate patient rating of the practices’ PCMH attributes, and (3) the practices’ ability to make and sustain change, which we term adaptive reserve. We used a repeated-measures analysis of variance to test the intervention effects. RESULTS By the end of the 2 years of the NDP, practices in both facilitated and self-directed groups had at least 70% of the NDP model components in place. Implementation was relatively harder if the model component affected multiple roles and processes, required coordination across work units, necessitated additional resources and expertise, or challenged the traditional model of primary care. Electronic visits, group visits, team-based care, wellness promotion, and proactive population management presented the greatest challenges. Controlling for baseline differences and practice size, facilitated practices had greater increases in adaptive reserve (group difference by time, P = .005) and the proportion of NDP model components implemented (group difference by time, P=.02); the latter increased from 42% to 72% in the facilitated group and from 54% to 70% in the self-directed group. Patient ratings of the practices’ PCMH attributes did not differ between groups and, in fact, diminished in both of them. CONCLUSIONS Highly motivated practices can implement many components of the PCMH in 2 years, but apparently at a cost of diminishing the patient’s experience of care. Intense facilitation increases the number of components implemented and improves practices’ adaptive reserve. Longer follow-up is needed to assess the sustained and evolving effects of moving independent practices toward PCMHs

Proximity to point sources of environmental mercury release as a predictor of autism prevalence

The objective of this study was to determine if proximity to sources of mercury pollution in 1998 were related to autism prevalence in 2002. Autism count data from the Texas Educational Agency and environmental mercury release data from the Environmental Protection Agency were used. We found that for every 1000 pounds of industrial release, there was a corresponding 2.6% increase in autism rates (p<.05) and a 3.7% increase associated with power plant emissions(P<.05). Distances to these sources were independent predictors after adjustment for relevant covariates. For every 10 miles from industrial or power plant sources, there was an associated decreased autism Incident Risk of 2.0% and 1.4%, respectively (p<.05). While design limitations preclude interpretation of individual risk, further investigations of environmental risks to child development issues are warranted.

Ethnic Differences in Mini‐Mental State Examination (MMSE) Scores: Where You Live Makes a Difference

OBJECTIVES: To examine differences in correlates of the Mini‐Mental State Examination (MMSE) in a population‐based sample of older Mexican Americans and European Americans and to provide empirical validation of the MMSE as an indicator of cognitive impairment in survey research in older Mexican Americans by comparing MMSE classification against performance on timed tasks with varying levels of cognitive demand.

Executive control mediates memory's association with change in instrumental activities of daily living: the Freedom House Study.

Objectives: To assess the relative independent contribution of changes in executive control function (ECF) and memory to changes in functional status.

Methods for Evaluating Practice Change Toward a Patient-Centered Medical Home

PURPOSE Understanding the transformation of primary care practices to patient-centered medical homes (PCMHs) requires making sense of the change process, multilevel outcomes, and context. We describe the methods used to evaluate the country’s first national demonstration project of the PCMH concept, with an emphasis on the quantitative measures and lessons for multimethod evaluation approaches. METHODS The National Demonstration Project (NDP) was a group-randomized clinical trial of facilitated and self-directed implementation strategies for the PCMH. An independent evaluation team developed an integrated package of quantitative and qualitative methods to evaluate the process and outcomes of the NDP for practices and patients. Data were collected by an ethnographic analyst and a research nurse who visited each practice, and from multiple data sources including a medical record audit, patient and staff surveys, direct observation, interviews, and text review. Analyses aimed to provide real-time feedback to the NDP implementation team and lessons that would be transferable to the larger practice, policy, education, and research communities. RESULTS Real-time analyses and feedback appeared to be helpful to the facilitators. Medical record audits provided data on process-of-care outcomes. Patient surveys contributed important information about patient-rated primary care attributes and patient-centered outcomes. Clinician and staff surveys provided important practice experience and organizational data. Ethnographic observations supplied insights about the process of practice development. Most practices were not able to provide detailed financial information. CONCLUSIONS A multimethod approach is challenging, but feasible and vital to understanding the process and outcome of a practice development process. Additional longitudinal follow-up of NDP practices and their patients is needed.

An introduction to geriatrics for first-year medical students

OBJECTIVE: To prepare medical students to better serve their older patients while raising awareness of geriatrics as a career choice.