County Health System Research Articles

Patients’ Adherence to Recommended Follow-up Eye Care After Diabetic Retinopathy Screening in a Publicly Funded County Clinic and Factors Associated With Follow-up Eye Care Use

The public health success of diabetic retinopathy (DR) screening programs depends on patients' adherence to the timetable of follow-up eye care recommended by the screening program. African Americans are among those at highest risk for DR and have one of the lowest rates of eye care use. To assess the rate of adhering to recommended follow-up eye care in a DR screening program administered in a safety-net health care facility and to examine factors associated with follow-up eye care use. Prospective follow-up study of persons with type 1 or type 2 diabetes. The setting was an internal medicine clinic of a publicly funded health system in Alabama, serving a population largely uninsured and African American, that had implemented a DR screening program using a nonmydriatic camera for ocular imaging and remote reading centers for evaluation of images. Patients with physician appointments between January 26 and July 24, 2012, were eligible for screening if they had a diagnosis of type 1 or type 2 diabetes and were 19 years or older. Data from the county health system's administrative database were obtained from January 26, 2012 (date of first enrollee), through May 1, 2015, to establish participants' eye care use in the ophthalmology clinic after screening. Adherence to the recommended interval of follow-up eye appointments in the facility's ophthalmology service as determined by administrative records, as well as factors associated with adherence. Diabetic retinopathy screening was completed in 949 adults with diabetes, of whom 84.5% (802 of 949) were African American, 64.5% (612 of 949) were women, and 71.7% (680 of 949) lacked health insurance. Participants ranged in age from 21 to 95 years, and their mean (SD) age was 53.9 (10.4) years. The mean (SD) age at diabetes diagnosis was 44.3 (12.5) years, and the mean (SD) duration of diabetes was 9.6 (9.4) years. Across interval recommendation types, 29.9% (284 of 949) adhered to obtaining comprehensive follow-up eye care within the recommended time frame. Two years after a participant's screening date, 50.9% (483 of 949) had no record of having received eye care. Factors associated with adhering to interval appointments were having an advanced age (odds ratio, 1.02; 95% CI, 1.01-1.04) and knowing one's glycated hemoglobin level (odds ratio, 2.00; 95% CI, 1.34-2.97). Agreeing to assistance in making a follow-up eye care appointment was associated with nonadherence (odds ratio, 0.67; 95% CI, 0.45-0.99). After a DR screening program in a public clinic largely serving an African American population, only one-third of participants adhered to interval recommendations for follow-up eye appointments, even though cost and accessibility were minimized as barriers to care. Our findings suggest that DR screening programs are not likely to meet their public health goals without incorporation of eye health education initiatives successfully promoting adherence to recommended comprehensive eye care for preventing vision loss.

Strengthening Strategic Reward Framework in Health Systems: A Survey of Narok County, Kenya

BACKGROUND: Rewards are used to strengthen good behavior among employees based on the general assumption that rewards motivate staff to improve organizational productivity. However, the extent to which rewards influence motivation among health workers (HWs) has limited information that is useful to human resources (HRs) instruments. This study assessed the influence of rewards on motivation among HWs in Narok County, Kenya. METHODS: This was a cross-sectional study done in two sub-counties of Narok County. Data on the rewards availability, rewards perceptions and influence of rewards on performance, as well as motivation level of the HWs, was collected using a self-administered questionnaire with HWs. SPSS version 21 was used to analyze descriptive statistics, and factor analysis and multivariate regression using Eigen vectors was used to assess the relationship between the reward intervention and HWs’ motivation.RESULTS: A majority of HWs 175 (73.8%) had not received a reward for good performance. Only 3 (4.8%) of the respondents who received rewards were not motivated by the reward they received. Overall, reward significantly predicted general motivation (p-value = 0.009).CONCLUSION: In Narok County, the HR’s instruments have not utilized the reward system known to motivate employees. In the study area, hard work was not acknowledged and rewarded accordingly. In addition, there were not sufficient opportunities for promotion in the county. An increased level of reward has the potential to motivate HWs to perform better. Therefore, providing rewards to employees to increase motivation is a strategy that the Narok County health system and its HR management should utilize.

Incidence rate of primary cardiac tumors: a 14-year population study.

Incidence of primary cardiac tumors (PCTs) is not known. Literature data derive from autoptic studies or echocardiographic registries. An incidence of 1 of 1000 autoptic and 1.5 of 1000 echocardiographic study is reported but data from a general population are not available. The aim of our study was to evaluate the incidence rate of PCTs in the general population. All patients with suspected cardiac mass were evaluated with basal echocardiogram and/or transesophageal echocardiogram/cardiac magnetic resonance by Grosseto's cardiology department, the county referral center for both adult and pediatric populations. Diagnosis was confirmed at surgical excision (32), autoptic specimens (3) or by multimodal imaging when surgery was not indicated (7). The database of the county health system was interrogated to identify residents with The International Classification of Diseases-9 codes of PCT. Forty-two consecutive cases of PCTs were diagnosed from 1 January 1998, through 31 December 2011, among residents in Grosseto's county. Incidence rate of PCTs was 1.38 of 100,000 inhabitants per year. PCTs were benign in 38 patients (90.5%) and malignant in four (9.5%). Twenty myxomas were found (48%), followed by seven fibroelastomas (15%), six lipomas (15%), three rhabdomyomas (8%), two hemangioma (5%), two sarcomas (5%), one lymphoma (2%) and one pericardial hemangiopericytoma (2%). Incidence of benign PCT was 1.24 of 100,000/year; referring only to myxomas we found an incidence of 0.68 of 100,000/year. This is the first population study on PCT, a rare disease with an incidence rate of 1.38 new cases per 100,000 residents per year.

Diabetic tractional retinal detachment repair by vitreoretinal fellows in a county health system.

To investigate anatomical and functional outcomes of vitreoretinal fellow-performed vitrectomy for tractional retinal detachment secondary to proliferative diabetic retinopathy in a county hospital system. Consecutive retrospective review of patients surgically treated for diabetic tractional retinal detachment at Olive View-UCLA County Medical Center (Sylmar, CA) during a 2-year training period. Sixty-two eyes of 58 patients met inclusion criteria with a mean age of 48 ± 9 years and preoperative hemoglobin A1c of 8.4 ± 1.9%. Previous panretinal photocoagulation had been performed in 34 eyes (54.8%). Mean surgery duration was 153 ± 54 minutes. There was no significant time difference observed between first-year fellow surgeries (159.5 ± 52.3 minutes) and those performed by second-year fellows (146.8 ± 56.4 minutes, P = 0.35), although there was a trend toward longer first-year surgical times. After a mean follow-up of 11.2 months, successful retinal reattachment was achieved in 56 eyes (90.3%). Overall, mean logMAR visual acuity improved from 2.0 ± 0.5 to 1.4 ± 0.8 (P = 0.0007). Final visual acuity had improved in 33 eyes (53.2%), was unchanged in 11 eyes (17.7%), and decreased in 18 eyes (29%). Postoperative complications encountered included early vitreous hemorrhage in 10 eyes (16.1%), delayed vitreous hemorrhage in 3 eyes (4.8%), secondary rhegmatogenous retinal detachment in 11 eyes (17.7%), and neovascular glaucoma in 5 eyes (8%). Second-year fellows had a lower incidence of rhegmatogenous retinal detachment than first-year fellows (P = 0.016). Patients with diabetic tractional retinal detachment present to county hospitals with more complex retinal pathology, yet surgical outcomes as performed by vitreoretinal fellows compare favorably to previously reported series.

Transmission clustering among newly diagnosed HIV patients in Chicago, 2008 to 2011: using phylogenetics to expand knowledge of regional HIV transmission patterns.

HIV transmission cluster analyses can inform HIV prevention efforts. We describe the first such assessment for transmission clustering among HIV patients in Chicago. We performed transmission cluster analyses using HIV pol sequences from newly diagnosed patients presenting to Chicago's largest HIV clinic between 2008 and 2011. We compared sequences through progressive pairwise alignment, using neighbor joining to construct an unrooted phylogenetic tree. We defined clusters as >2 sequences among which each sequence had at least 1 partner within a genetic distance of ≤1.5%. We used multivariable regression to examine factors associated with clustering and used geospatial analysis to assess geographic proximity of phylogenetically clustered patients. We compared sequences from 920 patients, median age of 35 years, 75% male, 67% black, 23% Hispanic, and 8% had a rapid plasma reagin titer ≥1:16 concurrent with their HIV diagnosis. We had HIV transmission risk data for 54%; 43% identified as men who have sex with men (MSM). Phylogenetic analysis demonstrated 123 patients (13%) grouped into 26 clusters, the largest having 20 members. In multivariable regression, age <25, black race, MSM status, male gender, higher HIV viral load, and rapid plasma reagin ≥1:16 associated with clustering. We did not observe geographic grouping of genetically clustered patients. Our results demonstrate high rates of HIV transmission clustering, without local geographic foci, among young black MSM in Chicago. Applied prospectively, phylogenetic analyses could guide prevention efforts and help break the cycle of transmission.

Get Yourself Tested 2011-2012: findings and prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae at an urban public health system.

During April 2011 and April 2012 the Get Yourself Tested campaign was launched throughout the Cook County Health and Hospitals System to promote testing of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) among 15-25-year-olds in a high-prevalence urban community. Retrospective data were collected and analysed. Demographic differences by CT and GC positivity were evaluated along with factors associated with CT and GC status. A total of 2853 tests were conducted among individuals aged 15-25 years. A total of 2060 (72%) females and 793 (28%) males were tested. Of those tested, 488 (17%) individuals tested positive for either CT or GC or both; 400 (14%) were positive for CT, 139 (5%) were positive for GC. The prevalence for GC was 8.8% (n = 70) in males compared to 3.3% (n = 69) in females (p < 0.001) and the prevalence of CT was 16% (n = 127) for males compared to 13.3% (n = 273) for females (p = 0.057). Women in a high-risk population are more likely to get tested for sexually transmitted infections; however, men are more likely to test positive for CT and GC. Get Yourself Tested is an important campaign to encourage wider spread testing among populations at risk in Cook County.

Rheumatic heart disease in modern urban america: A cohort study of immigrant and indigenous patients in Chicago

It is widely reported that the natural history of rheumatic heart disease (RHD) is more aggressive in developing countries, manifesting symptoms and requiring interventions at a younger age than in industrialized nations [1–5]. As the demographics in urban America shift with growing immigrant minorities from Latin America and other developing countries, it is possible that the demographics and natural history of RHD in the U.S. are changing as well. We compared the natural history and disease burden between immigrant and indigenous patients with RHD receiving care at Cook County Health and Hospitals System, a large public health care network serving inner-city Chicago.

Incentives among Health Workers in a Remote Kenyan District: Implications for Proposed County Health System

Attracting and retaining health workers in remote rural areas is a challenge in Kenya. Devolution of the Kenyan health system may negatively affect worker retention; incentives may play a role in retaining health workers. Semi-structured questionnaires were administered to health workers and human resource data reviewed. Analysis was for descriptive and emerging themes. Health workers were employed under three different terms of service. The majority receive a monthly hardship allowance in the range of $7.5-94. Only five percent of health workers were able to engage in private practice. Available housing, water supply, electricity supply, and educational facilities were cited as inadequate. With the proposed devolution to county governments, 97.3% of respondents preferred to work in a different county. There may be need to harmonize the terms of service, improve the incentives, and amenities available to health workers in remote Kenyan counties in order to improve retention.

Economic impact of ambulatory care formulary restrictions at a large county health system

Study results documenting substantial cost savings achieved by an outpatient indigent-care pharmacy program through formulary modifications and optimized purchasing practices are presented. Wholesale purchasing data were retrospectively evaluated to compare drug expenditures before and after a large Florida hospital's adoption of a tiered formulary system for three ambulatory care facilities serving mostly uninsured patients. The outcomes assessed included the average cost per prescription and total medication purchases before and after implementation of the tiered formulary, which was phased in over several months and accompanied by intensive educational programs targeting physicians and pharmacy staff. Other outcomes included cost avoidance resulting from an increased emphasis on patient assistance program (PAP) enrollment and the use of "bulk replacement" arrangements for prescription replenishment. During a designated nine-month postimplementation period, the average cost per prescription declined by 4.7% (from $19.86 to $18.92) relative to the baseline value. Six-month spending decreases of 36-58% from prior-year levels were achieved in 7 of the 10 most-purchased drug classes, with an overall 25% decline in medication purchases. Cost avoidance due to more aggressive use of PAPs and bulk replacement programs also yielded substantial program savings. Formulary streamlining and other cost-control initiatives at an outpatient pharmacy program were associated with a decrease in the average cost per prescription of $0.94 over a nine-month period. The primary endpoint showed a potential annualized savings of approximately $1 million.

Advanced Primary Care in San Antonio: Linking Practice and Community Strategies to Improve Health

Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.

The Use of Combination Lipid Therapy in a County Health System

Background: With the paucity of clinical outcomes trials and guidelines to make compelling recommendations regarding the treatment of dyslipidemia beyond statin monotherapy, we present a descriptive analysis of the combination lipid-lowering therapies being used at a large county hospital system. Objective: To provide a descriptive evaluation of the comparative effectiveness and safety of various combination lipid therapies in conjunction with a statin. Methods: Patients of a county health system who received at least 3 months of combination lipid therapy in conjunction with a statin during a 1-year period were eligible for inclusion in this retrospective chart review. The main outcome was a descriptive analysis of the comparative effectiveness among combination lipid therapies, as evidenced by fasting lipid panels. Results: A total of 834 patients were included in the analysis. Approximately 88% were on 1 additional lipid-modifying agent beyond a statin; 2 or 3 additional medications were much less common. Fish oils and fibrates were the most common nonstatin agents used, comprising approximately 85% of the combination therapies. Approximately 17% of patients had all 4 lipids at goal. A majority of patients were at goal for low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol (non-HDL-C), and total cholesterol, but a large proportion were not at goal for HDL-C and triglycerides. No statistically significant differences were found among therapies for effectiveness related to lipid goals, medication adherence, or safety. The chart review did not find an appreciable number of adverse events. The overall adherence rate was subpar at 56% and varied modestly among treatments. Conclusions: This retrospective analysis found no significant differences in effectiveness, adherence, and safety among the combination lipid therapies used in a county health system. Further research is warranted to elucidate the recommended approach to using combination lipid therapies.

Diabetes Transitional Care from Inpatient to Outpatient Setting

Purpose: Diabetes transitional care from the inpatient to outpatient setting is understudied. This study evaluated the effect of inpatient pharmacist discharge counseling on outpatient diabetes medication adherence. Research methods: Prospective, randomized, controlled study compared pharmacist discharge counseling (intervention) with usual patient care (control) in 127 patients with established diabetes and an A1C ≥8% who had a provider and medications filled within the county health system. The primary outcome was diabetes medication adherence rate measured using the prescription of days covered (PDC) method. Results: Patients in the intervention, compared with control group, had greater diabetes medication adherence rate 150 days after discharge (55.2% vs 34.8%; P = .002), rate of follow-up visits (60.5% vs 43.9%; P = .01) and reduction in A1C (−1.97% vs +0.114%; P = .003). Being in the intervention group and having greater adherence with follow-up visits correlated independently with lower follow-up A1C. Conclusion: Transitional care in the form of inpatient education geared to improve self-management after hospital discharge. This may serve as a paradigm to improve outpatient adherence rate with medications, follow-up visits, and A1C reduction.

Exploring China’s western and central county systems performance measured by outcomes framework scores—A cross-sectional survey of routine healthcare data

This study was designed to measure the performance of county health systems in central and western China utilizing routine healthcare data. Drawing on a literature review and expert consultation, the study established a theoretical framework and an indicator system for performance review. Questionnaires were designed and disseminated to collect empirical data on health system performance in four counties of two central and western provinces. Quantitative data were subjected to descriptive statistical analysis through SPSS12.0. Three dimensions were introduced in the performance review framework-health outcomes, financial risk protection and consumer and provider satisfaction. Health outcomes were assessed from four secondary indicators: infant mortality rate; maternal mortality rate; under-5 child mortality rate; and the incidence of Class A and Class B notifiable diseases. Financial risk was assessed using two secondary indicators: the proportion of the cost of inpatient care that was reimbursed under the New Cooperative Medical System (NCMS) insurance scheme, and the rate of NCMS funds utilization. The assessment of satisfaction was made using two secondary indicators: the overall satisfaction of local residents with healthcare services, and the satisfaction of health practitioners at the township and village level. The study indicated better health system performance in the two counties in Chongqing than those in Shanxi. It was concluded that outcome framework scores can fairly reveal performance differences among county health systems in central and western China, and can provide practical evidence for optimizing the operation and inputs of county health systems. Caution needs to be exercised in generalizing such performance outcomes as many factors such as spending and organization that contribute to county health system performance were not included in the study.

Contributions of Public Hospitals to Regional Health Care: A Population-Based Analysis of the County Health Care System Serving Metropolitan Chicago

To determine the proportions of countywide expenditures and service delivery for the Cook County Health and Hospitals System (CCHHS), we obtained data from the CCHHS budget; CCHHS registration, program, and pharmacy databases; public health departments and organization reports; and federal agency estimates. The annual CCHHS budget of $1.2B represents 3.4% of total Cook County health care expenditures. Eight of the nine population-based proportions of health care services delivered by the CCHHS exceeded this proportion of health expenditures by factors of 1.3-8 times. These services include diagnosis of tuberculosis, sexually transmitted diseases, and cancers; care of very low birth weight babies; primary care for HIV and diabetes; and emergency room and ambulatory visits. This county health care system is a productive contributor to overall health service delivery in Cook County, and its contributions exceed its proportionate funding in eight of nine priority health areas.

An Academic–Community Partnership to Improve Care for the Underserved

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.

Low-Income Women with Abnormal Breast Findings: Results of a Randomized Trial to Increase Rates of Diagnostic Resolution

Timely diagnostic resolution of abnormal breast findings represents a critical step in efforts to reduce breast cancer morbidity and mortality. Yet, follow-up rates among resource poor populations are not optimal. Efforts to mitigate this disparity are needed. We report results of a randomized trial assessing the effectiveness of a patient support and navigation intervention in increasing timely diagnostic resolution of abnormal breast findings among indigent women. Women (n = 1,708) diagnosed with a breast abnormality at two public hospitals were randomized to an intervention or control group. The intervention, delivered through telephone, involved one call from a professional health worker and multiple calls from a lay health worker. The outcome, timely diagnostic resolution, defined as receipt of a definitive diagnosis (malignant or benign) within 6 months of the index referral, was assessed through medical chart audit. Intent-to-treat analyses revealed no significant effect of the intervention on timely diagnostic resolution. Diagnostic resolution rates were 55% and 56%, respectively, in the intervention and control arms. The significant predictors were method of abnormality identification (odds ratio = 1.50) and location of first scheduled appointment (odds ratio = 0.62). The intervention was not effective in creating change within the County health system. Achieving optimum diagnostic follow-up may require more intensive interventions than the one tested. In addition, system-level rather than patient-level interventions may hold more promise. There are no randomized trials reported in the literature testing interventions to increase diagnostic follow-up of breast abnormalities. Future research might test patient and system-level interventions that can be sustained beyond the study period.

Impact of Patient-Centered Medical Home Assignment on Emergency Room Visits Among Uninsured Patients in a County Health System

The Medical Services Initiative program--a safety net-based system of care--in Orange County included assignment of uninsured, low-income residents to a patient-centered medical home. The medical home provided case management, a team-based approach for treating disease, and increased access to primary and specialty care among other elements of a patient-centered medical home. Providers were paid an enhanced fee and pay-for-performance incentives to ensure delivery of comprehensive treatment. Medical Services Initiative enrollees who were assigned to a medical home for longer time periods were less likely to have any emergency room (ER) visits or multiple ER visits. Switching medical homes three or more times was associated with enrollees being more likely to have any ER visits or multiple ER visits. The findings provide evidence that successful implementation of the patient-centered medical home model in a county-based safety net system is possible and can reduce unnecessary ER use.

Community‐Associated Methicillin‐ResistantStaphylococcus aureusand HIV: Intersecting Epidemics

Single-site studies have suggested a link between human immunodeficiency virus (HIV) and community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Population-level incidence of HIV-infected patients with CA-MRSA versus community-associated methicillin-susceptible S. aureus (CA-MSSA) infection was assessed in the Cook County Health and Hospitals System (CCHHS), a multi-hospital and ambulatory care center. Rates in zip codes, including those with a high density of individuals with prior incarceration (ie, high-risk zip codes), were calculated. We did a nested case-control analysis of hospitalized HIV-infected patients with S. aureus skin and soft-tissue infections (SSTIs). In CCHHS, the incidence of CA-MRSA SSTIs was 6-fold higher among HIV-infected patients than it was among HIV-negative patients (996 per 100,000 HIV-infected patients vs 157 per 100,000 other patients; P < .001). The incidence of CA-MRSA SSTIs among HIV-infected patients significantly increased from 2000-2003 (period 1) to 2004-2007 (period 2) (from 411 to 1474 cases per 100,000 HIV-infected patients; relative risk [RR], 3.6; P<.001), with cases in period 1 clustering in an area 6.3 km in diameter (P=.035) that overlapped high-risk zip codes. By period 2, CA-MRSA SSTIs among HIV-infected patients were spread throughout Cook County. USA300 was identified as the predominant strain by pulsed-field gel electrophoresis (accounting for 86% of isolates). Among hospitalized HIV-infected patients, the incidence of CA-MRSA increased significantly from period 1 to period 2 (from 190 to 779 cases per 100,000 HIV-infected patients; RR, 4.1; P<.001). Risks for CA-MRSA by multivariate analysis were residence in alternative housing (eg, shelters), residence in high-risk zip codes, younger age, and infection in period 2. HIV-infected patients are at markedly increased risk for CA-MRSA infection. This risk may be amplified by overlapping community networks of high-risk patients that may be targets for prevention efforts.

Reducing Blood Pressure Levels Effectively in Practice

Practice guidelines for the prevention of cardiovascular disease identify clear targets for risk-factor modification but often say little about the difficult objective of actually achieving them. Now, we have data on two strategies specifically designed to help patients with uncontrolled CVD risk factors reach their prevention goals. In one study from a California county health system, researchers enrolled 419 low-income patients (mean age, 55; 66% women; 85% nonwhite) who had at least moderately uncontrolled, modifiable CVD risk factors. Participants …

Metabolic Risk Factors Among Medicaid Outpatients With Schizophrenia Receiving Second-Generation Antipsychotics

Metabolic Risk Factors Among Medicaid Outpatients With Schizophrenia Receiving Second-Generation Antipsychotics