Suzanne B. Cashman

The power and the promise: Working with communities to analyze data, interpret findings, and get to outcomes

Although the intent of community-based participatory research (CBPR) is to include community voices in all phases of a research initiative, community partners appear less frequently engaged in data analysis and interpretation than in other research phases. Using 4 brief case studies, each with a different data collection methodology, we provide examples of how community members participated in data analysis, interpretation, or both, thereby strengthening community capacity and providing unique insight. The roles and skills of the community and academic partners were different from but complementary to each other. We suggest that including community partners in data analysis and interpretation, while lengthening project time, enriches insights and findings and consequently should be a focus of the next generation of CBPR initiatives.

Physicians' responses to financial incentives : evidence from a for-profit ambulatory care center

Health Stop is a major chain of ambulatory care centers operating for profit. Until 1985 its physicians were paid a flat hourly wage. In the middle of that year, a new compensation plan was instituted to provide doctors with financial incentives to increase revenues. Physicians could earn bonuses the size of which depended on the gross incomes they generated individually. We compared the practice patterns of 15 doctors, each employed full time at a different Health Stop center in the Boston area, in the same winter months before and after the start of the new arrangement. During the periods compared, the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, mostly as a result of a 12 percent increase in the average number of patient visits per month. The wages of the seven physicians who regularly earned the bonus rose 19 percent. We conclude that substantial monetary incentives based on individual performance may induce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives.

Clinical prevention and population health: Curriculum framework for health professions

Abstract The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services–health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title “Clinical Prevention and Population Health” has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.

Patient health status and appointment keeping in an urban community health center

This study examines the relationship between patient health status and the likelihood of missing appointments in a community health center serving low-income patients. Medical records of 465 adult patients scheduled to be seen during one week in February 1999 were audited for an 18-month period. Seventy-three percent of patients failed to keep one or more appointments; 43% missed one or two; 30% missed three or more. Health status measures significantly associated with missing appointments included depression (p = 0.03), anxiety/panic disorder (p = 0.03), and using tobacco (p = <0.001). Linear regression analysis indicated that the number of appointments scheduled and of diagnosed psychological conditions, as well as patient age were significant predictors of missed appointments. Patient appointment keeping is predictable; definable, measurable characteristics of patients can contribute to setting priorities for customizing interventions.

The Primary Care Physician Workforce in Massachusetts: Implications for the Workforce in Rural, Small Town America

CONTEXT Small towns across the United States struggle to maintain an adequate primary care workforce. PURPOSE To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. METHODS A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. FINDINGS Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. CONCLUSIONS Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.

Physician satisfaction in a major chain of investor-owned walk-in centers

This article describes physicians at a major chain of investor-owned freestanding walk-in centers and reports on their job satisfaction. They derived satisfaction from a sense of autonomy and the corporations reliable provision of staff and supplies. Their job dissatisfaction results from the corporate emphasis on generating revenue and the lack of opportunity for professional interaction with colleagues.

Development of a brief questionnaire to identify families in need of legal advocacy to improve child health

OBJECTIVE To determine whether the medical-legal advocacy screening questionnaire (MASQ), a simple 10-item questionnaire, is able to screen families in a primary care setting for possible referral to legal services more effectively than the clinical interview alone. METHODS Family Advocates of Central Massachusetts (FACM) is a medical-legal collaboration that assists low-income families with legal issues that affect child health. A convenience sample of parents seen at each of 5 medical practices associated with FACM was recruited to complete the MASQ prior to a routine child health care visit. Physicians blinded to the result assessed family need for referral to FACM after their usual clinical encounter. The sensitivity and specificity of both the MASQ and provider assessment were calculated. RESULTS Two hundred fifty-five parents from 5 practices participated in the study. The MASQ identified 85 patients in need of legal services. Prior to reviewing the MASQ, the primary care providers identified 35 families in need of referral to the FACM. After completion of both the MASQ and the medical encounter, 37 families agreed to referral. The MASQ had sensitivity of 0.81 and specificity of 0.75 in predicting program referral. Provider assessment had sensitivity of 0.65 and specificity of 0.95 of predicting program referral. CONCLUSIONS Routine use of the MASQ would likely identify more patients in pediatric practices who would accept referral to legal assistance than reliance on provider impression alone after a routine clinical encounter.

Improving Population Health Through Integration of Primary Care and Public Health: Providing Access to Physical Activity for Community Health Center Patients

OBJECTIVES Our community health center attempted to meet public health goals for encouraging exercise in adult patients vulnerable to obesity, diabetes, hypertension, and other chronic diseases by partnering with a local YMCA. METHODS During routine office visits, providers referred individual patients to the YMCA at no cost to the patient. After 2 years, the YMCA instituted a

Roundtable Discussion and Final Comments

10 per month patient copay for new and previously engaged health center patients. RESULTS The copay policy change led to discontinuation of participation at the YMCA by 80% of patients. Patients who persisted at the YMCA increased their visits by 50%; however, more men than women became frequent users after institution of the copay. New users after the copay were also more likely to be younger men. Thus the copay skewed the population toward a younger group of men who exercised more frequently. Instituting a fee appeared to discourage more tentative users, specifically women and older patients who may be less physically active. CONCLUSIONS Free access to exercise facilities (rather than self-paid memberships) may be a more appropriate approach for clinicians to begin engaging inexperienced or uncertain patients in regular fitness activities to improve health.

The patient population of a major chain of investor-owned ambulatory care walk-in centers

I think Tom has done a really fine job in outlining nine critical dimensions that determine the success or failure of coalitions. The general topics and the more focused areas under each topic very well reflect some of the best insights about coalition formation and development. I am also tremendously impressed by the two community stories that he has included; bravo to B. L. Hathaway and Babatunde Folayemi. These stories are very clearly written and well illustrate many of the principles and ideas that are described. They also add a terrific sense of the hard work and struggle that folks take on in their efforts to use coalitions as a method of change over the long-term. All in all, this introductory material is simply outstanding. I also want to offer some ideas for consideration.