Shawna V. Hudson

The Meanings of Self-Ratings of Health A Qualitative and Quantitative Approach

Self-ratings of health are central measures of health status that predict outcomes such as mortality and declines in functional ability. Qualitative and quantitative data are used to test the hypothesis that definitions of health that are narrowly biomedical are associated with underestimates of self-ratings relative to respondents’medical histories, while definitions that are broad and inclusive are related to relatively better self-ratings. A sample of 159 elderly African Americans rates their health and reports “what went through your mind.” Analysis of variance shows that respondents who overestimate their health are more likely to report ratings based on social activities and relationships, or psychological, emotional, or spiritual characteristics, rather than biomedical criteria. The authors conclude that inclusive definitions of health facilitate more positive self-ratings of health, given a fixed health status; methodologically, they conclude that this is a promising method for exploring self-ratings of health.

Principles of the Patient-Centered Medical Home and Preventive Services Delivery

PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services. METHODS We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling. RESULTS Higher global PCMH scores were associated with receipt of preventive services (β=2.3; P <.001). Positive associations were found with principles of personal physician (β=3.7; P <.001), in particular, continuity with the same physician (β=4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (β=5.6; P <.001), particularly, having a well-visit within 5 years (β=12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (β = 8.0; P <.001) and use of clinical decision-support tools (β = 5.0; P = .04) were also associated with receipt of preventive services. CONCLUSIONS Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.

Quality of Diabetes Care in Family Medicine Practices: Influence of Nurse-Practitioners and Physician’s Assistants

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician’s assistants (PAs), or neither, and which practice attributes contribute to any differences in care. METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs. RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤ .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices. CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.

Adult Cancer Survivors Discuss Follow-up in Primary Care: ‘Not What I Want, But Maybe What I Need’

BACKGROUND Nearly one-third of office visits for cancer are handled by primary care physicians. Yet, few studies examine patient perspectives on these physicians’ roles in their cancer follow-up care or their care preferences. METHODS We explored survivor preferences through qualitative, semistructured, in-depth interviews drawing on patients recruited from 2 National Cancer Institute–designated comprehensive cancer centers and 6 community hospitals. We recruited a purposive sample of early-stage breast and prostate cancer survivors aged 47 to 80 years, stratified by age, race, and length of time from and location of cancer treatment. Survivors were at least 2 years beyond completion of their active cancer treatment RESULTS Forty-two survivors participated in the study. Most participants expressed strong preferences to receive follow-up care from their cancer specialists (52%). They described the following barriers to the primary care physician’s engagement in follow-up care: (1) lack of cancer expertise, (2) limited or no involvement with original cancer care, and (3) lack of care continuity. Only one-third of participants (38%) believed there was a role for primary care in cancer follow-up care and suggested the following opportunities: (1) performing routine cancer-screening tests, (2) supplementing cancer and cancer-related specialist care, and (3) providing follow-up medical care when “enough time has passed” or the survivors felt that they could reintegrate into the noncancer population. CONCLUSION Survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Research interventions to address these issues are necessary to enhance the quality of care received by cancer survivors.

Self-report versus Medical Records for Assessing Cancer-Preventive Services Delivery

Accurate measurement of cancer-preventive behaviors is important for quality improvement, research studies, and public health surveillance. Findings differ, however, depending on whether patient self-report or medical records are used as the data source. We evaluated concordance between patient self-report and medical records on risk factors, cancer screening, and behavioral counseling among primary care patients. Data from patient surveys and medical records were compared from 742 patients in 25 New Jersey primary care practices participating at baseline in SCOPE (supporting colorectal cancer outcomes through participatory enhancements), an intervention trial to improve colorectal cancer screening in primary care offices. Sensitivity, specificity, and rates of agreement describe concordance between self-report and medical records for risk factors (personal or family history of cancer, smoking), cancer screening (breast, cervical, colorectal, prostate), and counseling (cancer screening recommendations, diet or weight loss, exercise, smoking cessation). Rates of agreement ranged from 41% (smoking cessation counseling) to 96% (personal history of cancer). Cancer screening agreement ranged from 61% (Pap and prostate-specific antigen) to 83% (colorectal endoscopy) with self-report rates greater than medical record rates. Counseling was also reported more frequently by self-report (83% by patient self-report versus 34% by medical record for smoking cessation counseling). Deciding which data source to use will depend on the outcome of interest, whether the data is used for clinical decision making, performance tracking, or population surveillance; the availability of resources; and whether a false positive or a false negative is of more concern. (Cancer Epidemiol Biomarkers Prev 2008;17(11):2987–94)

Barriers and Facilitators for Colorectal Cancer Screening Practices in the Latino Community: Perspectives From Community Leaders

BACKGROUND Colorectal cancer (CRC) is the second-leading cause of cancer-related death in the United States and the third most commonly diagnosed cancer among Latinos. While Latinos represent one of the fastest-growing ethnic groups in the United States, their participation in cancer prevention and treatment trials is low. METHODS Thirty-six Latino community leaders participated in five focus groups that examined factors affecting CRC screening practices among Latinos. RESULTS The top four barriers identified were low knowledge and awareness of CRC, language barriers, lack of insurance, and undocumented legal status. Additional barriers included seeking health care only when sick, fatalism, fear, denial that CRC can occur, other needs more pressing than preventive care, and use of home remedies rather than biomedical care. Participants also described strategies that could be used to increase screening rates including mass media, screening reminders, educational programs using visual tools, and interventions tailored to various literacy levels. CONCLUSIONS To ensure that the specific needs and health beliefs of the Latino community are addressed, future research should incorporate community input to create more tailored and effective cancer educational programs for Latinos.

Features of the Chronic Care Model (CCM) Associated with Behavioral Counseling and Diabetes Care in Community Primary Care

Background: The Chronic Care Model (CCM) was developed to improve chronic disease care, but it may also inform delivery of other types of preventive care. Using hierarchical analyses of service delivery to patients, we explored associations of CCM implementation with diabetes care and counseling for diet or weight loss and physical activity in community-based primary care offices. Methods: Secondary analysis focused on baseline data from 25 practices (with an average of 4 physicians per practice) participating in an intervention trial targeting improved colorectal cancer screening rates. This intervention made no reference to the CCM. CCM implementation was measured through staff and clinical management surveys and was associated with patient care indicators (chart audits and patient questionnaires). Results: Overall, practices had low levels of CCM implementation. However, higher levels of CCM implementation were associated with better diabetes assessment and treatment of patients (P = .009 and .015, respectively), particularly among practices open to “innovation.” Physical activity counseling for obese and, particularly, overweight patients was strongly associated with CCM implementation (P = .0017), particularly among practices open to “innovation”; however, this association did not hold for overweight and obese patients with diabetes. Conclusions: Very modest levels of CCM implementation in unsupported primary care practices are associated with improved care for patients with diabetes and higher rates of behavioral counseling. Incremental incorporation of CCM components is an option, especially for community practices with stretched resources and with cultures of “innovativeness.”

Muscle Invasive Bladder Cancer: Examining Survivor Burden and Unmet Needs

PURPOSE Although improvements in perioperative care have decreased surgical morbidity after radical cystectomy for muscle invasive bladder cancer, treatment side effects still have a negative impact on patient quality of life. We examined unmet patient needs along the illness trajectory. MATERIALS AND METHODS A total of 30 patients (26.7% women) treated with cystectomy and urinary diversion for muscle invasive bladder cancer participated in the study. Patients were recruited from the Department of Urology at Mount Sinai and through advertisements on the Bladder Cancer Advocacy Network (BCAN) website between December 2011 and September 2012. Data were collected at individual interviews, which were audiotaped and transcribed. Transcribed data were quantitatively analyzed to explore key unmet needs. RESULTS At diagnosis unmet informational needs were predominant, consisting of insufficient discussion of certain topics, including urinary diversion options and their side effects, self-care, the recovery process and medical insurance. Unmet psychological needs related to depression, and worries about changes in body image and sexual function were reported. Postoperative unmet needs revolved around medical needs (eg pain and bowel dysfunction) and instrumental needs (eg need of support for stomal appliances, catheters and incontinence). During survivorship (ie 6 to 72 months postoperatively) unmet needs centered around psychological support (ie depression, poor body image and sexual dysfunction) and instrumental support (eg difficulty adjusting to changes in daily living). CONCLUSIONS Meeting patient needs is imperative to ensure adequate patient involvement in health care and enhance postoperative quality of life. An effective support provision plan should follow changes in patient needs.

Physician perspectives on cancer clinical trials and barriers to minority recruitment.

Clinical trials provide the foundation on which advances in cancer therapies are built. Yet, relatively few in the eligible adult population participate, 3% to 5%,1 and much of the research is based on data collected from samples lacking racial and economic diversity.2 Though the research community recognizes the importance of having diverse clinical trial participants, barriers to recruitment exist at multiple levels.2-4 Cultural, structural, and psychological barriers for patients and providers have been documented.1-11 Barriers such as lack of accessible and affordable research trials5,8 and a patient’s inability to qualify for or comply with specified research protocols7,10 characterize common structural hurdles for patients, especially those who are medically underserved.2 Patient fears and mistrust of the research community also are powerful cultural barriers.2,5,8,10,12,13 Although patient barriers are important, equally challenging physician barriers have received far less attention. Structural hurdles such as physicians’ lack of awareness of available trials, problems with data management, and the absence of adequate physician compensation for time devoted to studies are considered as physician barriers.1,10,14 In addition, “cultural barriers” such as fear of losing patients and distrust of institutions conducting clinical trials exist among providers.10 Research suggests that physician referral is one of the most effective means of recruiting patients onto cancer clinical trials (CCTs).13,15 Yet, factors that affect a physician’s choice to discuss a trial with a patient, especially those who are racial and/or ethnic minorities, remain underexplored. The purpose of this study was to examine local cancer providers’ knowledge about CCTs and attitudes toward minority participation in CCTs.

Improving Outcomes for High-Risk Diabetics Using Information Systems

Background: Diabetes care requires management of complex clinical information. We examine the relationship between diabetic outcomes and practices’ use of information. Methods: We performed a cross-sectional, secondary analysis of baseline data from 50 community primary care practices participating in a practice improvement project. Medical record review assessed clinical targets for diabetes (HbA1c ≤8, LDL ≤100, BP ≤130/85). Practices’ use of information was derived from clinician responses to a survey on their use of clinical information systems for patient identification and tracking. Hierarchical linear modeling examined relationships between patient outcomes and practice use of information, controlling for patient level covariates (age, gender, hypertension, and cardiovascular comorbidities) and practice level covariates (solo/group, and electronic health record [EHR] presence). Results: Practices’ use of identification and tracking systems significantly (P < .007 and 0.002) increased odds of achieving diabetes care targets (odds ratio [OR] 1.23 95%, confidence interval [CI] 1.06 to 1.44, and OR 1.32 95% CI 1.11 to 1.59). For diabetic patients with hypertension, odds of hypertension control were higher with higher use of tracking systems (OR = 1.52, P = .0017) and reflected similar trend with higher use of identification systems (OR = 1.28, P = .1349). EHR presence was not associated with attainment of clinical targets. Conclusions: Use of relatively simple systems to identify and track patient information can improve diabetic care outcomes. Practices making investments in an EHR must recognize that this technology alone is not sufficient for achieving desirable clinical outcomes. Researchers must explore the interrelationships of organizational factors necessary for successful information use.