Background

Serum cholesterol is one of the most important modifiable risk factors for coronary artery disease. There are conflicting data on racial and ethnic variation in the treatment of high cholesterol.

Methods

We analyzed data from the Third National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey conducted between 1988 and 1994. Participants included 7679 white, 4467 African American, and 4113 Mexican American adults older than 25 years who completed the household adult questionnaire. The adjusted odds of serum cholesterol screening and of taking a prescription medication to lower serum cholesterol among African Americans and Mexican Americans were compared with those of whites, controlling for differences in age, sex, income, educational level, insurance status, comorbid illness, and having a regular source of health care.

Results

African Americans and Mexican Americans were significantly less likely than whites to report ever having had their blood cholesterol checked (odds ratio, 0.7 for both; P<.001). Among individuals with high cholesterol who were told to take a medication, African Americans (P<.001) and Mexican Americans (P =.05) were less likely than whites to be taking a cholesterol-lowering agent (odds ratios, 0.3 and 0.5, respectively). Individuals who reported being told they had high cholesterol had significantly higher serum cholesterol measurements (from the laboratory examination) than those who reported being told their cholesterol was not high (234 vs 198 mg/dL [6.05 vs 5.12 mmol/L]; P<.001).

Conclusions

African Americans and Mexican Americans were less likely to report serum cholesterol screening than whites. Even when identified as having high cholesterol that required medication, African Americans and Mexican Americans were less likely than whites to be taking cholesterol-lowering agents.

Context

Women from racial and ethnic minorities in the United States have higher rates of cervical cancer and present with later stage disease compared to whites. Delays in care for abnormal Papanicolaou (Pap) smears can lead to missed cases of cervical cancer or late-stage presentation and may be one explanation for these differences.

Objective

To determine if race and ethnicity, health beliefs, and cancer knowledge are associated with delays in care for abnormal Pap smears.

Design, participants, and setting

We conducted a mailed survey with telephone follow-up of all women with an abnormal Pap smear who received care at Kaiser Permanente Los Angeles Medical Center between October 1998 and October 1999 (n = 1,049).

Measurements and main results

A delay in care was defined as not attending the first scheduled clinic visit to follow up on an abnormal Pap smear, or requiring multiple contact attempts, including a certified letter, to schedule a follow-up visit. Our response rate was 70% (n = 733) and the sample was 51% Latina. Spanish-speaking Latinas and women of Asian descent were more likely to endorse fatalistic beliefs and misconceptions about cancer. Thirteen percent of the sample delayed follow-up on their abnormal Pap smear. Women who delayed care were more fatalistic and endorsed more misconceptions about cervical cancer. Delays in care were not independently associated with race and ethnicity.

Conclusions

Health beliefs and cancer knowledge differed by race and ethnicity among women in a large managed care organization. Fatalistic health beliefs and misconceptions about cancer, but not race and ethnicity, were independently associated with delays in care.

Purpose

To describe the characteristics of participants who completed a mailed survey, compared to those initial non-responders who completed the same survey over the telephone. STUDY DESIGN AND PATIENT POPULATIONS: We conducted a mailed survey, in both Spanish and English, among women with abnormal Pap smears, who were members of a large managed care organization. Telephone follow up for non-responders was performed by a bilingual interviewer. A 20-minute long distance telephone card was offered as an incentive to individuals who completed the telephone survey. We used bivariate and multivariate analyses to describe the population characteristics of respondents who replied by mail, as compared to those who completed the survey by telephone.

Results

Of the 1049 potentially eligible participants, 733 women completed the survey, for an overall response rate of 70%. Fifty-six percent (N=411) of the surveys were received by mail, and 44% (N=322) were completed by telephone. Thirty-four percent of the telephone surveys were completed in Spanish, compared to 13% of the mailed surveys (P<.001). Telephone respondents were less satisfied with their health care than were those who responded by mail.

Conclusions

Among this insured cohort of women, Latinas who completed the survey in Spanish were more likely to participate in a telephone survey that offered an incentive, than in a mailed survey. These findings should be considered when planning health surveys in this population.

Objective

It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes.

Data source

Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization.

Study design

Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013.

Principal findings

A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits.

Conclusions

In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.

Background

Few studies have examined the effects of Institutional Review Board (IRB) requirements to contact potential research participants.

Objective

To examine the association between requirements to contact potential research subjects and participation rates in a multisite health services research study. RESEARCH DESIGN, SUBJECTS: Prospective observational study of survey participation by 2673 individuals with diabetes and 1974 individuals with congestive heart failure treated at 15 clinical sites in the United States that had implemented a quality improvement intervention.

Main outcome measures

Telephone survey response rates.

Results

Of 15 IRBs, seven required sites to obtain authorization from participants to release contact information to the study team. Five required oral and two required written advance permission. The response rate was 58% (913/1571) at sites where no advance permission was required, 39% (989/2530) from sites that required oral advance permission and 27% (145/546, P <0.001) at sites requiring written advance permission. Although 85% of eligible participants contacted directly by the study team consented to complete the survey, only 43% of individuals at sites requiring written advance permission allowed the release of contact information to the study team.

Conclusions

Many potential participants did not grant advance permission to be contacted by the study team. Requiring advance permission reduced participation rates, especially at sites requiring written authorization.

Health care systems face challenges providing accessible health care across geographically disparate sites. The Veterans Health Administration (VHA) developed regional telemedicine service focusing initially on primary care and mental health services. The objective of this study is to describe the program and progress during the early implementation. In its first year, the Clinical Resource Hub program provided 244 515 encounters to 95 684 Veterans at 475 sites. All 18 regions met or exceeded minimum implementation requirements. The regionally based telehealth contingency staffing hub met early implementation goals. Further evaluation to review sustainability and impact on provider experience and patient outcomes is needed.

BACKGROUND: The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VAs Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. METHODS: The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluations overall goal is to assess CRHs return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. DISCUSSION: Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Objective

To identify factors associated with contraceptive nonuse and use of less effective methods among obese women in the US.

Study design

We analyzed data from sexually active obese women (body mass index >30 kg/m²) age 20-44 using the 2006-2010 National Survey of Family Growth. We conducted multinomial logistic regression to assess associations between current contraceptive use and demographic, reproductive and health services factors. Specifically, we compared contraceptive nonusers, behavioral method users (withdrawal and fertility awareness) and barrier method users (condoms) to prescription method users (pill, patch, ring, injection, implant and intrauterine device).

Results

Of 1345 obese respondents, 21.5% used no method, 10.3% behavioral methods, 20.8% barrier methods and 47.4% prescription methods. Only 42.4% of respondents overall and 20.4% of nonprescription method users reported discussing contraception with a provider in the past year. Similar to findings in the general population, behavioral method users were more likely to have previously discontinued a contraceptive method due to dissatisfaction [adjusted RR (aRR), 1.93; 95% confidence interval (CI), 1.09-3.44], and nonusers were more likely to perceive difficulty becoming pregnant (aRR, 3.86; 95% CI, 2.04-7.29), compared to prescription method users. Respondents using nonprescription methods were significantly less likely to have discussed contraception with a healthcare provider (nonusers: aRR, 0.16; 95% CI, 0.10-0.27; behavioral methods: aRR, 0.13; 95% CI, 0.06-0.25, barrier methods: aRR, 0.15; 95% CI, 0.09-0.25) than prescription method users.

Conclusions

Obese women who discuss contraception with a provider are more likely to use effective contraception and may be less likely to experience unintended pregnancy; however, over half report no recent discussion of contraception with a provider.

Implications

Efforts are needed to increase contraceptive counseling for obese women, who face increased risks of morbidity from unintended pregnancy.

Primary care clerical staff may experience burnout if not adequately prepared and supported for patient-facing customer service tasks. Guided by the Job Demands-Resources (JD-R) model, we use national survey data from 707 primary care clerks at 349 VA clinics (2018; response rate: 12%) to evaluate associations between clerks' perceptions of tasks, work environment, training, and burnout. We found challenges with customer-facing tasks contribute to higher burnout, and supportive work environment was associated with lower burnout. Although perceptions of training were not associated with burnout, our results combined with the JD-R model suggest that customer service training may protect against burnout.

Purpose of the study

To compare the number of chronic conditions among a list of 12 and their association with physical function among postmenopausal non-Veteran and Veteran women with diabetes.

Design and methods

Among women with diabetes from the Women's Health Initiative, we compared the average number of chronic conditions between non-Veterans and Veterans and the association between total number of chronic conditions on subsequent RAND-36 physical function. To examine associations between each condition and subsequent physical function, we compared women with diabetes plus one chronic condition to women with diabetes alone using linear regression in separate models for each condition and for non-Veterans and Veterans.

Results

Both non-Veterans (N = 23,542) and Veterans (N = 618) with diabetes had a median of 3 chronic conditions. Decreases in physical function for each additional condition were larger among Veterans than non-Veterans (-6.3 vs. -4.1 points). Decreases in physical function among women with diabetes plus one chronic condition were greater than that reported for diabetes alone for all combinations and were more pronounced among Veterans (non-Veterans: -11.1 to -24.2, Veterans: -16.6 to -40.4 points). Hip fracture, peripheral artery disease, cerebrovascular disease, and coronary disease in combination with diabetes were associated with the greatest decreases in physical function.

Implications

Chronic conditions were common among postmenopausal women with diabetes and were associated with large declines in physical function, particularly among Veterans. Interventions to prevent and reduce the impact of these conditions and facilitate coordination of care among women with diabetes may help them maintain physical function.