Urban Safety-net Clinic Research Articles

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.

Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups. The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics. Randomized controlled trial. Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited. The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy). The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013). The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening. The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Collaboration between Pharmacists and Physicians Can Improve Patient Care

There are currently an estimated 56 million patients in the United States who do not have adequate access to primary health care. Pharmacists play an essential role in team-based patient care because of patients' reliance on medications to reduce disease-related complications. This article presents data from an ongoing evaluation of a collaborative practice model among physicians and pharmacists that provides care for patients with chronic disease in an urban safety net clinic.

Racial Discrimination in Health Care Settings: Does Insurance Matter?

As physicians at urban safety net clinics, we read the study by Cuffee et al.1 with great interest. In New York City, where we practice, perceived racial/ethnic discrimination is likely tied to insurance status. Among academic medical centers, a two-tier clinic system is often implemented with a faculty practice for privately insured patients and a trainee-focused practice for publicly insured and uninsured patients. Because racial/ethnic minorities are more likely to be uninsured or publicly insured, clinics are largely racially segregated, de facto.2 To examine this, and foster a dialogue with patients around this issue, we conducted a brief survey of primary care patients at three Federally Qualified Health Centers (Bronx, NY). The survey contained an oral informed consent, demographic questions, and two “yes/no” questions: (1) “Have you ever felt that the doctor or medical staff you saw judged you unfairly or treated you with disrespect because of your race or ethnic background?,” and (2) “Do you think there was ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?”3 Responses to questions on discrimination were compared by insurance status (abstracted from the medical record) by using the χ2 test; a P ≤ .05 was considered significant. Inclusion and exclusion criteria, and survey administration, are detailed in previous reports.4,5 The Albert Einstein College of Medicine Committee on Clinical Investigation approved this survey. Among the 248 respondents (Table 1), 8.1% felt that a doctor or medical staff member judged them unfairly or treated them with disrespect because of their race or ethnic background. Those with public insurance were more likely to report this compared with those with private insurance (15.0% vs 5.2%; P = .05). Of respondents, 13.3% thought there was a time when they would have gotten better medical care if they had belonged to a different race or ethnic group, with no significant difference between publicly and privately insured patients (10% vs 5.2%; P = .4). Analysis of uninsured patients was limited by small sample size. TABLE 1— Sociodemographic Characteristics of Survey Respondents (n = 248): Bronx, NY, 2011 In summary, patients with public insurance more often reported discrimination than did those with private insurance. This is potentially attributable to experiences in the clinic system for the publicly insured. Further research is needed to examine the role of insurance status, and the effect that dismantling the two-tier clinic system could have on perceived racial/ethnic discrimination and outcomes.

Factors shaping effective utilization of health information technology in urban safety-net clinics

Urban safety-net clinics are considered prime targets for the adoption of health information technology innovations; however, little is known about their utilization in such safety-net settings. Current scholarship provides limited guidance on the implementation of health information technology into safety-net settings as it typically assumes that adopting institutions have sufficient basic resources. This study addresses this gap by exploring the unique challenges urban resource-poor safety-net clinics must consider when adopting and utilizing health information technology. In-depth interviews (N = 15) were used with key stakeholders (clinic chief executive officers, medical directors, nursing directors, chief financial officers, and information technology directors) from staff at four clinics to explore (a) nonhealth information technology-related clinic needs, (b) how health information technology may provide solutions, and (c) perceptions of and experiences with health information technology. Participants identified several challenges, some of which appear amenable to health information technology solutions. Also identified were requirements for effective utilization of health information technology including physical infrastructural improvements, funding for equipment/training, creation of user groups to share health information technology knowledge/experiences, and specially tailored electronic billing guidelines. We found that despite the potential benefit that can be derived from health information technologies, the unplanned and uninformed introduction of these tools into these settings might actually create more problems than are solved. From these data, we were able to identify a set of factors that should be considered when integrating health information technology into the existing workflows of low-resourced urban safety-net clinics in order to maximize their utilization and enhance the quality of health care in such settings.

Autonomy Versus Automation: Perceptions of Nonmydriatic Camera Choice for Teleretinal Screening in an Urban Safety Net Clinic

Teleretinal screening with nonmydriatic cameras has been presented as a means of increasing the number of patients assessed for diabetic retinopathy in urban safety net clinics. It has been hypothesized that automated nonmydriatic cameras may improve screening rates by reducing the learning curve for camera use. In this article, we examine the impact of introducing automated nonmydriatic cameras to urban safety net clinics whose photographers had previously used manual cameras. We evaluated the impact of manual and automated digital nonmydriatic cameras on teleretinal screening using a quantitative analysis of readers' image quality ratings as well as a qualitative analysis, through in-depth interviews, of photographers' experiences. With the manual camera, 68% of images were rated "adequate" or better, including 24% rated "good" and 20% rated "excellent." With the automated camera, 61% were rated "adequate" or better, including 9% rated "good" and 0% rated "excellent." Photographers expressed frustration with their inability to control image-taking settings with the automated camera, which led to unexpected delays. For safety net clinics in which medical assistants are already trained to take photographs for diabetic retinopathy screening with a manual camera, the introduction of automated cameras may lead to frustration and paradoxically contribute to increased patient wait times. When photographers have achieved a high degree of aptitude with manual cameras and value the control they have over camera features, the introduction of automated cameras should be approached with caution and may require extensive training to increase user acceptability.

Access, interest, and attitudes toward electronic communication for health care among patients in the medical safety net.

Electronic and internet-based tools for patient-provider communication are becoming the standard of care, but disparities exist in their adoption among patients. The reasons for these disparities are unclear, and few studies have looked at the potential communication technologies have to benefit vulnerable patient populations. To characterize access to, interest in, and attitudes toward internet-based communication in an ethnically, economically, and linguistically diverse group of patients from a large urban safety net clinic network. Observational, cross-sectional study Adult patients (≥ 18 years) in six resource-limited community clinics in the San Francisco Department of Public Health (SFDPH) MAIN MEASURES: Current email use, interest in communicating electronically with health care professionals, barriers to and facilitators of electronic health-related communication, and demographic data-all self-reported via survey. Sixty percent of patients used email, 71 % were interested in using electronic communication with health care providers, and 19 % reported currently using email informally with these providers for health care. Those already using any email were more likely to express interest in using it for health matters. Most patients agreed electronic communication would improve clinic efficiency and overall communication with clinicians. A significant majority of safety net patients currently use email, text messaging, and the internet, and they expressed an interest in using these tools for electronic communication with their medical providers. This interest is currently unmet within safety net clinics that do not offer a patient portal or secure messaging. Tools such as email encounters and electronic patient portals should be implemented and supported to a greater extent in resource-poor settings, but this will require tailoring these tools to patients' language, literacy level, and experience with communication technology.

Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics

Adolescent HPV vaccination in minority and low income populations with high cervical cancer incidence and mortality could reduce disparities. Safety-net primary care clinics are a key delivery site for improving vaccination rates in these populations. To examine prevalence of HPV initiation (≥ 1 dose), completion (receipt of dose 3 within 12 months of initiation), and receipt of 3 doses in four safety-net clinics as well as individual-, household-, and clinic-level correlates of initiation. We used multilevel modeling to investigate HPV initiation among 700 adolescent females who sought primary care in four safety-net clinics in Dallas, Texas from March 2007 to December 2009. Data were abstracted from patients' paper and electronic medical records. HPV vaccine uptake varied significantly by clinic. Across clinics, initiation was 36.6% and completion was 39.7% among those who initiated. In the total study population, only 15.7% received all three doses. In multivariate, two-level logistic regression analyses, initiation was associated with receipt of other adolescent vaccines, influenza vaccination in the year prior to data abstraction, being sexually active, and having more chart documentation (presence of health maintenance questionnaire and/or immunization record). There was no association between initiation and age, race/ethnicity, or insurance status. In four urban safety-net clinics, HPV initiation rates paralleled 2008 national rates. The correlation of HPV initiation with other adolescent vaccines underscores the importance of reviewing vaccination status at every health care visit. HPV vaccine uptake in safety-net clinics should continue to be monitored to understand impact on cervical cancer disparities.

Limited Health Literacy Is a Common Finding in a Public Health Hospital's Rheumatology Clinic and Is Predictive of Disease Severity

Health literacy (HL) is associated with outcomes in many conditions, but little is known about its impact on arthritic diseases. We sought to determine whether HL is related to disease activity and severity in patients with rheumatoid arthritis (RA). English-speaking adult RA patients were recruited for this cross-sectional study. Background information was ascertained by medical record review; Disease Activity Score 28 (DAS-28) scores were determined by providers; subjects completed the Multidimensional Health Assessment Questionnaire (MDHAQ), demographic questionnaires, and validated HL instruments, including the Short Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and the single-item literacy screener. We used linear regression to assess whether HL was associated with MDHAQ and DAS-28 scores. One hundred ten subjects participated in the study. Limited HL was a common finding, especially among ethnic minorities. The single-item literacy screener results were predictive of lower MDHAQ scores by univariate regression analysis. Similar trends were observed for the Short Test of Functional Health Literacy in Adults and Rapid Estimate of Adult Literacy in Medicine. The relationship between the single-item literacy screener and MDHAQ remained statistically significant in multivariate analysis that controlled for the impact of demographic features and RA disease characteristics. Health literacy scores were not associated with DAS-28 scores. Health literacy was independently associated with functional impairment in English-speaking RA patients at an urban safety-net clinic. This new finding suggests that RA functional status might be improved by strategies that target limited HL's causal pathways.

American Indian Community Leader and Provider Views of Needs and Barriers to Mammography

Breast cancer incidence is rising and mortality is disproportionately high among American Indians and Alaska Natives, yet screening rates remain low. Using community-based participatory research, we conducted interviews with community leaders (n=13) and providers from the Indian Health Service, tribal clinics, and urban safety-net clinics (n=17). Participants in both groups identified similar needs, including culturally-appropriate mammography education, use of Native elders as patient navigators, and an emphasis on preventive care. Pertinent barriers included culturally-specific issues (e.g., historic mistrust and gender roles), cost, transportation, and fear of mammography and potential results. The results reflect the struggles of promoting mammography across diverse populations.