Inner-city Primary Care Clinic Research Articles

Screening for Mental Illness in Primary Care Clinics

To assess the prevalence of mental disorders in inner city outpatient clinics and to improve the diagnosis of mental illness in primary care. The Problem Oriented Patient Report (POPR), a patient self-report checklist, was administered to 362 outpatients at two inner-city Buffalo primary care clinics. Patients' completed POPR checklists were evaluated to identify those with potential mental illness diagnoses and were available for the physicians' review during the patients' visits. After the visit, clinical charts were reviewed to determine the frequency of new mental illness diagnoses among continuing and new patients. The screening checklist (POPR) revealed potential mental illnesses in 148/362 outpatients, of which 98% had not been identified by the physicians who had reviewed the patients' completed POPR forms. Only five new diagnoses of mental illnesses were independently made by clinics' physicians-all in follow-up (continuing) patients. The physicians in the two clinics did not diagnose mental illnesses in their patients, even when written checklists of self-reports were available to them. Differences in staff attitudes may influence the data collection process, and patients' as well as physicians' responses. A weakness of this study is that the POPR might generate false positive results. Even if this were the case, the rate of previous diagnoses was still extremely low.

P.2.124 Neural correlates of rivastigmine treatment in schizophrenia: An fMRI study

Patient literacy affects many aspects of medication use and may influence the measurement of adherence. The aim of the study is to design and evaluate a medication adherence scale suitable for use across levels of patient literacy.The Adherence to Refills and Medications scale (ARMS) was developed, pilot tested, and administered to 435 patients with coronary heart disease in an inner-city primary care clinic. Psychometric evaluation performed overall and by literacy level, included an assessment of internal consistency, test–retest reliability, and factor analysis. Criterion-related validity was evaluated by comparing scores with Morisky's self-reported measure of adherence, medication refill adherence, and blood pressure measurements. Lexile analysis was performed to assess the reading difficulty of the instrument.The final 12-item scale had high internal consistency overall (Cronbach's α = 0.814) and among patients with inadequate (α = 0.792) or marginal/adequate literacy skills (α = 0.828). Factor analysis yielded two subscales, which pertained to taking medications as prescribed and refilling medications on schedule. The ARMS correlated significantly with the Morisky adherence scale (Spearman's rho = −0.651, P < 0.01), and it correlated more strongly with measures of refill adherence than did the Morisky scale. Patients with low ARMS scores (which indicated better adherence) were significantly more likely to have controlled diastolic blood pressure (P < 0.05), and tended to have better systolic blood pressure control. Lexile analysis demonstrated that the instrument had a favorable reading difficulty level below the eight grade.The ARMS is a valid and reliable medication adherence scale when used in a chronic disease population, with good performance characteristics even among low-literacy patients.

The effect of low blood pressure goals on achieved blood pressure in high risk hypertensives

OR-69 Key Words: Diabetes, Target Organ Damage, Blood Pressure Goals

Conceptual models of psychological distress among low-income patients in an inner-city primary care clinic.

Although depression and anxiety syndromes are common in primary care, many depressed and anxious patients fail to receive effective treatment. Little attention has been given to the role of illness beliefs in shaping these patients' treatment preferences and decisions. Using semistructured interviews, this study examined conceptual models of depressive symptoms among patients in an inner-city clinic. A theoretical taxonomy of patients' conceptual models of distress was developed: each category was associated with a unique pattern of treatment preferences. We conclude that patients' models of distress may play an important role in treatment-seeking decisions, and deserve further investigation.

Identification of Cardiovascular Risk Factors in Homeless Adults

Cardiovascular disease is an important health problem among homeless adults; however, the common cardiac risk factors present in this population are unknown. This study was undertaken to identify the reversible cardiovascular risks present in the homeless. A retrospective chart review was performed randomly on 100 patients who were seen at a homeless clinic in New Orleans, Louisiana. These patients were compared with 200 matched nonhomeless patients who attended an inner-city primary care clinic. Each chart from the 2 groups was reviewed for the presence of hypertension, diabetes mellitus type 2, cigarette smoking, and hypercholesterolemia. Statistical comparisons were made between the homeless and the control subjects. Hypertension was present in 65% of the homeless but only 52% of the nonhomeless [P < 0.05; odds ratio 1.78 (CI, 1.09 to 2.9)]. Smoking was far more common in the homeless than the nonhomeless, 75 versus 57%, respectively [P < 0.005; odds ratio 2.22 (CI, 1.27 to 3.88)]. There was no difference in the prevalence of diabetes or total cholesterol. Compared with national data hypertension, smoking and diabetes seem to be represented excessively in the homeless population. Smoking and hypertension are significantly more prevalent in the homeless population than in a matched cohort. Educational and preventive programs are needed to reduce the prevalence of cardiovascular disease and reduce the overutilization of expensive healthcare resources.

Predictors of Older Primary Care Patients' Participation in a Submaximal Exercise Test and a Supervised, Low-Impact Exercise Class

Objectives. This study is an investigation of physical activity promotion among a nonvolunteer sample of community-dwelling, older, urban primary care patients. Our primary interest was in the rates of exercise test and class participation. Of secondary interest were the medical record and baseline survey predictors of test and class participation.Methods. The first 500 nonterminally ill women ages 50 years or more with a visit at one of two predominantly African-American, inner-city primary care clinics received a physician screen, a referral to a submaximal exercise test, and, subsequently, a free, supervised exercise program located in a nearby community center.Results. Eighty-one percent were eligible for the exercise test per provider screen. Of these, 29% completed the exercise test and 28% attended at least one exercise class. After 1 year, 9.2% were attending the exercise classes. Higher exercise outcome expectations, not smoking, and clinic site were associated with exercise test and class participation.Conclusions. Providing free, traditional exercise classes and a primary care referral to the classes resulted in limited physical activity participation among older, urban primary care patients. More development and testing of physical activity promotion programs are needed in this population.

Acceptability of computer assessments among ethnically diverse, low-income smokers.

To examine the acceptability of computer-based assessments among an ethnically diverse, low-income population of primary care patients. Although computers have been used to provide assessments and interventions in health care settings, members of ethnic minority and low-income households have less access to computers than other groups, and therefore the acceptability of computers as a health care assessment and delivery tool needs to be examined. We examined the acceptability of computers for providing assessments of smoking history, nicotine dependence, and other related variables among an ethnically diverse, low-income primary care population. No intervention was used in this study. Three inner-city primary care clinics located in hospitals were used as sites for this study. These hospitals were located in areas of the city where low-income and ethnic minority households are overrepresented relative to the total population. Adult male and female smokers (n = 522) were recruited while awaiting appointments in each primary care clinic. A questionnaire assessing smoking rate, patterns, history, motivation to quit smoking, and other smoking-related variables was administered using either a paper-and-pencil format or a laptop computer. Frequency counts, analysis of variance, and chi 2 tests were used where appropriate. Most subjects (78.5%) used the computer to complete the baseline survey. Almost all subjects (92%) rated the computer "very easy" or "easy" to use. Subjects who were Spanish-speaking, were born outside the United States, or were Hispanic tended to rate the program as slightly less easy to use than other subjects. Computer-based assessments appear highly acceptable to individuals in low-income populations.

Assessment of documented foot examinations for patients with diabetes in inner-city primary care clinics.

The established guidelines for a diabetes foot examination include assessing circulatory, skin, and neurological status to detect problems early and reduce the likelihood of amputation. To determine documented adherence with guidelines for foot examinations. Four clinics in underserved areas. Charts of 350 diabetic patients, identified by billing code, were reviewed for foot examination documentation. A documented foot examination was defined as assessing at least two of the three components of a foot examination. The review determined the periodicity and prevalence of foot examinations, referrals to a podiatrist or vascular surgeon during a 2-year period, and risk factors for foot complications. Stepwise logistic regression was used to determine whether risk factors for foot complications predicted foot examination status. The patients had a mean age and duration of diabetes of 57.7 and 8.8 years, respectively; 86% were black or Hispanic. There was no indication of foot examination or referral for 55.7% of the patients during the 2-year period. Patients with foot care referrals were more likely to have foot examinations by their primary care providers (P = .0001). There was almost a fourfold increase in the odds that patients with diagnosed peripheral vascular disease had foot examinations, with twofold greater odds for each 25-year increase in age. Populations at risk of diabetic complications are unlikely to have foot examinations in their primary medical care, but having peripheral vascular disease increases the likelihood. Efforts are needed to improve adherence to foot examination guidelines for patients with diabetes from underserved populations.

Accuracy of Immunization Histories Provided by Adults Accompanying Preschool Children to a Pediatric Emergency Department

Because some have advocated the use of emergency departments to administer delayed childhood immunizations, we evaluated the accuracy of immunization histories obtained in this setting by comparison with medical records of inner-city health care facilities. Questionnaires were orally administered to adults accompanying children to the emergency department. Individual medical records were reviewed. Pediatric emergency department at Wyler Children's Hospital, University of Chicago and 68 inner-city primary care clinics. Children aged 3 to 65 months registering for medical care. Of the sample, 98% were African American; 75% were Medicaid recipients. Adults' knowledge of immunization histories, immunization cards, and medical records compared with American Academy of Pediatrics/Immunization Practices Advisory Committee recommendations. Of the accompanying adults, 64% stated that their child's general immunization status was "up-to-date"; 65% of these had clinic records confirming that status. Only 8% of specific regimens stated by these adults accurately matched those found in clinic records. Moreover, 45% of adults accompanying children at least 16 months and older provided inaccurate information regarding previous receipt of measles immunization. Information provided by accompanying adults (from recall or from immunization cards) is inadequate to determine accurately which preschoolers in the pediatric emergency department are delayed in immunizations.

Factors influencing consumer receptivity to the nurse practitioner. A systems analysis.

This paper describes a methodology to delineate factors associated with consumer acceptance of the medical nurse practitioner (MNP). The MNP is a category of new health practitioners with proficiency in medical/health care functions traditionally performed only by physicians. A process model approach was developed to study the significance of selected sociodemographic cognitive, attitudinal, and clinical/medical factors that are expected to predispose consumer acceptance of the MNP. The survey population consists of predominantly elderly and indigent ambulatory patients to an inner-city primary care clinic. The data were collected from 156 primary care patients before and after the introduction of the MNP program. The results clearly demonstrate consumer support for the new health practitioner concept. This finding is further substantiated in the "after" study. From an analysis of symptoms experience, symptom severity, and type of symptoms, symptoms experience emerged as the strongest indicator of consumer receptivity to MNP concept. Additionally, exposure to MNP caused the consumer to become more aware of proper consumption and increased the demand for physician care and specialty care where appropriate.