US Health Care Providers Research Articles

Behavioral Economics Holds Potential To Deliver Better Results For Patients, Insurers, And Employers

Many programs being implemented by US employers, insurers, and health care providers use incentives to encourage patients to take better care of themselves. We critically review a range of these efforts and show that many programs, although well-meaning, are unlikely to have much impact because they require information, expertise, and self-control that few patients possess. As a result, benefits are likely to accrue disproportionately to patients who already are taking adequate care of their health. We show how these programs could be made more effective through the use of insights from behavioral economics. For example, incentive programs that offer patients small and frequent payments for behavior that would benefit the patients, such as medication adherence, can be more effective than programs with incentives that are far less visible because they are folded into a paycheck or used to reduce a monthly premium. Deploying more-nuanced insights from behavioral economics can lead to policies with the potential to increase patient engagement and deliver dividends for patients and favorable cost-effectiveness ratios for insurers, employers, and other relevant commercial entities.

Variability in the Management of Superficial Venous Thrombophlebitis Among Phlebologists and Vascular Surgeons

This study aimed to compare management patterns of patients with superficial venous thrombophlebitis (SVT) among phlebologists and vascular surgeons. A survey was provided to practitioners who attended the American Venous Forum meeting in 2011. Statistical analysis included descriptive statistics, unpaired t tests, and Friedman's test for correlation. There were 354 US or Canadian health care providers of whom 169 were phlebologists and 185 were vascular surgeons. There was a significant different in anticoagulation administration and duration (P = .034, P = .032, respectively). Friedman's test for correlation between multiple surgical treatments showed no correlation between surgical treatments tested with all treatments having an equal distribution in our data. Follow-up differed between groups with vascular surgeons following up with imaging more than phlebologists (P = .03). Our data indicate that there is no consensus between or among phlebologists or vascular surgeons as to the surgical management of superficial venous thrombophlebitis, duration of follow-up, and anticoagulation parameters.

Crossing Borders: One World, Global Health

Crossing Borders: One World, Global Health

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Introduction: Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage system. The 2010 Pediatric Emergency Mass Critical Care (PEMCC) Taskforce could not recommend any current triage model but advised further research towards this goal. Hypothesis: Providers will prefer an objective pediatric triage system for PEMCC as compared to one that includes factors such as subjective evaluation, neuro-cognitive outcome or patient age. Methods: This cross-sectional survey used an audience response system with US healthcare providers who attended a regional pediatric disaster preparation symposium in 2012 to answer ethical and logistical questions about triage. Differences in opinions between respondents’ professions and hospital type were evaluated using a Student’s t-test. Results: 112 attendees responded (89% response rate); 55% were nurses, 26% physicians and 19% other providers. Work locations included pediatric hospitals (51%) vs. clinics, non-pediatric hospitals or other areas (49%). 59% of respondents agreed that a pediatric triage system should include both objective and subjective components. 59% prioritized children predicted to have a good neuro-cognitive outcome. 70% agreed that no pediatric age group should be prioritized. When considering the effect of workplace, 63% of non-neutral responding pediatric hospital providers preferred a pediatric triage system combining both a subjective evaluation by a care provider and an objective score compared with 37% from care settings other than a non-pediatric care settings (p= 0.04). Conclusions: In this regional survey of providers, the majority of respondents agree that a pediatric triage system should: 1) include both an objective score and a subjective evaluation, 2) prioritize predicted neuro-cognitive outcome but 3) should not include patient age. However, the majority of responders from settings other than pediatric hospitals prefer a triage system that excludes subjective evaluation. Further evaluation of community and provider opinion in other regions is clearly necessary to further the development of a nationally standardized pediatric triage system.

THE DEVELOPMENT OF STEADI—A FALL PREVENTION TOOL KIT FOR US HEALTHCARE PROVIDERS

BackgroundFall injuries in the US result in over 19 000 deaths and 2.2 million emergency department visits, and cost over $28 billion. Research shows that, in a clinical setting, effective...

Changes in COPD demographics and costs over 20 years

Objective:Chronic obstructive pulmonary disease (COPD) is now the third leading cause of death in the US and responsible for significant healthcare resource use. The purpose of this study was to examine the changes in COPD costs over 20 years and assess total direct cost trends over the last 10.Methods:A cross-sectional study of a population-based survey (2007 Medical Expenditure Panel Survey compared to the 1987 National Medical Expenditures Panel Survey) of respondents aged 40 and older with COPD (ICD-9-CM codes 491.xx, 492.xx, or 496.xx) was assessed for demographic and healthcare services use characteristics and compared to reported statistics from 1987. Ten-year trends in total direct medical costs from 1997–2007 are presented.Results:In 2007, there were 416 survey respondents with COPD compared to 228 in 1987. In 1987, women were only 39% of the COPD sample, while in 2007 they made up 58% of the sample. Mean cost per COPD patient was $16,135 (2007 dollars) in 2007, which was up from $11,807 (2007 dollars) in 1987 or a 37% increase. The proportional cost of emergency department visits (183%) and prescription drugs (170%) from 1987–2007 was high compared to other healthcare services. However, the mean cost of a hospitalization was the highest actual increase ($2289). Ten-year trends show a similar gradual increase.Conclusions:The prevalence of COPD among females as well as the mean cost per COPD patient has risen sharply over the last 20 years. Cost-shifting from acute services to preventive services may allow US payers and healthcare providers to improve care and better manage costs for patients with COPD. More attention on prevention, diagnosis, and management needs to be directed to women at risk of COPD.

Global Burden of Hepatitis C: Considerations for Healthcare Providers in the United States

An estimated 2%-3% of the world's population is living with hepatitis C virus (HCV) infection, and each year, >350000 die of HCV-related conditions, including cirrhosis and liver cancer. The epidemiology and burden of HCV infection varies throughout the world, with country-specific prevalence ranging from <1% to >10%. In contrast to the United States and other developed countries, HCV transmission in developing countries frequently results from exposure to infected blood in healthcare and community settings. Hepatitis C prevention, care, and treatment programs must recognize country-specific epidemiology, which varies by setting and level of economic development. Awareness of the global epidemiology of HCV infection is important for US healthcare providers treating foreign-born patients from countries where HCV infection is endemic and for counseling patients who travel to these countries. Countries with a high burden of HCV infection also would benefit from establishing comprehensive prevention, care, and treatment programs.

Encyclopedia of Family Health

Encyclopedia of Family Health

Health Care Provider Satisfaction with Telephone Consultations Provided by Pharmacists and Physicians at the National HIV/AIDS Clinicians’ Consultation Center

The federally funded National HIV/AIDS Clinicians' Consultation Center (NCCC) offers US health care providers expert telephone consultations for managing HIV/AIDS and occupational exposures to blood-borne pathogens through 3 telephone services: the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline), the National HIV Telephone Consultation Service (Warmline), and the Perinatal HIV Hotline. Callers to the NCCC receive consultation from either a clinical pharmacist (PharmD) or a physician (MD) with HIV expertise. To compare the satisfaction of NCCC callers who received clinical consultations from clinical pharmacists and physicians with HIV expertise. We prospectively mailed 1256 satisfaction surveys to NCCC health care provider callers during a 7-month period. Survey recipients were not aware that satisfaction surveys compared PharmD and MD consultation services. Respondents rated their level of agreement with 8 statements about the quality of consultation, the quality of clinical information given, and future calls to the NCCC. Survey return rates were 43% for PEPline and 40% for Warmline and Perinatal HIV Hotline combined. Overall, caller satisfaction with the telephone consultation service was extremely high (>4 in all categories on a 1-5 Likert scale). There was no significant difference in PEPline caller satisfaction ratings between PharmD and MD consultations. Callers to the Warmline and Perinatal HIV Hotline agreed with all 8 satisfaction statements. For the following 3 statements, however, satisfaction was higher when Warmline and Perinatal HIV Hotline consultation was provided by an MD: "Overall, I was pleased with the quality of my consultation" (p = 0.04); "I would use this service again" (p < 0.02); and "I am likely to recommend this service to my colleagues" (p = 0.02). Health care provider callers to the NCCC were highly satisfied with the information obtained from this HIV/AIDS telephone consultation service. By measuring callers' survey response to PharmD and MD consultations, the importance of the clinicians' contributions to this advanced HIV/AIDS consultation service is documented.

Selection for early surgery in asymptomatic mitral regurgitation: A Markov model

BackgroundCurrent guidelines propose mitral valve repair in asymptomatic chronic mitral regurgitation (MR) when the likelihood of repair is 90% or more. As this figure is not evidence-based, we sought whether the results of a decision-analytic model could facilitate the selection between early surgery (ES) and watchful waiting (WW) based on current guidelines. MethodsA Markov model was developed to reflect the anticipated health states in MR (pre-operative, post-operative, post-complication and death). Risks and transitions were informed by the literature. Implications of the strategies for survival, quality-adjusted life years (QALYs), cost and cost-effectiveness were calculated from a US healthcare provider perspective. ResultsIn the reference case (90% repair), QALY with ES was superior to WW (11.2 [0.4–21.3] vs 10.7 [95%CI: 1.0–21.3]) at an incremental cost-effectiveness of $54,659 ($45,030–$64,288) per QALY. Sensitivity analyses of health benefit showed the main variables influencing outcome were repair rate, operative mortality and risks of heart failure and death with medical management. At the registry repair rate (50%), outcomes of ES were worse than WW, and threshold analysis showed that a repair rate of 84% was required for ES to be superior. High medical risk (yearly heart failure risk 5.6±6.6% and mortality 2.5±4%) was the most favorable scenario for surgery; ES was more effective when mortality in the WW group was >3.5%/year. ConclusionA Markov model might be used to guide the selection of asymptomatic patients for mitral repair, based on local variations in risk and complications as well as repair rate.

Catching a wave: auto‐ethnographic notes on love and war in Hawaii

This is an autoethnographic account of a research visit to Hawaii in the spring and summer of 2003. The substantive research, of which conventional reports have been published, was an exploratory study of implementing new information technology in a large US health care provider organisation. However, the fieldwork opened a door onto the wider culture of Hawaii, as different from our English culture as from that of northern California, our temporary home. This is my attempt to record that experience in the context of our year abroad.

Dietary Vitamin K in Oral Anticoagulation Patients: Clinician Practices and Knowledge in Outpatient Settings

Background: Dietary vitamin K is a recognized variable associated with oral anticoagulant therapy. However, current practices of dietary education and instruction regarding vitamin K, as well as factors influencing related decision-making, are unknown. Research has examined healthcare providers' ability to identify a meal containing vitamin K, but the ability to classify portions of specific vegetables according to vitamin K content has not been evaluated. Objective: To characterize dietary evaluation and instructional methods provided to patients receiving warfarin therapy, assess factors influencing instructional methods, and evaluate clinician knowledge of vitamin K content for specific vegetable portions. Methods: A cross-sectional online survey of US healthcare providers involved with management of outpatient oral anticoagulation therapy was conducted. Results: One hundred twenty-two responses were received. Seventy-four percent of respondents collected initial dietary history from all patients and 52% asked all patients for dietary history at follow-up visits. Taking a verbal dietary history from all patients was significantly associated with larger clinic size and managing patients in person. Eighty-two percent of respondents reported providing dietary vitamin K education to all patients. Low patient literacy was a common factor influencing instruction to avoid foods high in vitamin K. Overall mean score reflecting the ability to classify vegetable portions by vitamin K content was 64.6 ± 10.9%. Conclusions: Acquisition of dietary history by anticoagulation providers is not always completed at initial and follow-up patient visits. Provision of patient education at initial visits is relatively high. Patient factors such as low literacy may influence a clinician's decision to provide a specific method of dietary instruction, including avoidance of foods high in vitamin K. Clinicians are least likely to correctly identify vegetable portions containing vitamin K in the range of 10–99 μg and should consider portion size when assessing dietary history.

US Nurses’ Perceptions of Their Role in Diabetes Care

The purpose of this study was to examine nurse and physician perceptions of nurse involvement and roles in diabetes care. The study used a cross-sectional design with face-to-face or telephone interviews of diabetes health care professionals in 13 countries from Asia, Australia, Europe, and North America. This article focuses on the data from US health care providers. The US sample included 51 generalist nurses, 50 diabetes specialist nurses, 166 generalist physicians, and 50 diabetes specialist physicians. Nurses and physicians agreed that nurses should take a larger role in managing diabetes. Most common differences identified between nurses and physicians were that nurses provide better education, spend more time with patients, were better listeners, and knew their patients better than physicians. All nurses had a high perceived need for better understanding of psychosocial issues and were more likely than physicians to suggest helping patients to take responsibility for their care. Nurses more than physicians also said better communication was needed. Generalist nurses report that they act as intermediaries and facilitate patient appointment keeping. Specialist nurses talk to patients about self-management, teach medication management, have a higher level of involvement in medication prescribing, and are more willing to take on additional responsibilities than generalist nurses. There is an increased need for more involvement by nurses, particularly specialist nurses, in diabetes care.

Provider practice models for and costs of delivering medication abortion — evidence from 11 US abortion care settings

Purpose Understanding practice models and provider costs for medication abortion (MAB) provision may elucidate ways to facilitate MAB integration into a larger arena of health care services. This study provides descriptive data on the diverse MAB practice models currently being utilized by US health care providers and the costs associated with the components of those models. Method Data were gathered from a sample of 11 abortion care settings, using clinic administrative records and patient satisfaction surveys. Results Practice models varied dramatically, with a wide range in the type of staff employed to provide MAB. The total episode cost for providing MAB ranged from $252 to $460, and patient satisfaction was high across all practices. Conclusion Information from this study can be used to guide decisions regarding MAB integration into practices not currently providing abortion or which provide only aspiration abortions. The information may also be useful for providers wishing to refine their MAB services.

The interpretation of “culture”: Diverging perspectives on medical provision in rural Montana

Seeking to address evident disparities in health care delivery to minority populations, researchers have developed a framework generally referred to as “cultural competency.” This framework suggests that increasing providers’ knowledge about culturally specific beliefs and behaviors will both assist providers in caring for particular, traditionally underserved groups and enhance the quality of health care delivery for all patients. Meanwhile, a number of critics have challenged the presuppositions of the “culture” concept underlying cultural competency, arguing that such well-intended efforts may merely exacerbate received stereotypes. Despite such criticism, the influence of cultural competency, along with the related categories of cultural sensitivity, cultural humility, cultural proficiency, and cultural awareness, continues to grow in medical schools, governmental agencies, and health care organizations, particularly in the United States. To better assess the varying theoretical and policy claims of proponents and opponents of the cultural competency framework, we undertook a modest qualitative, interview-based investigation. We explored how “culture” is being presented and enacted by Mexican agricultural workers and US health care providers in one rural Montana clinic. While the Mexican agricultural workers in the study emphasized structural dimensions of labor migration as the most relevant factors in shaping patient–provider interactions, the US health care providers tended to focus on the “cultural characteristics” peculiar to their patients. The discrepancy in these assessments serves to extend and complement existing criticism of cultural competency. While our study was limited to one locale with a limited number of participants, its findings highlight the paucity of empirical research in this area and suggest the need to examine the efficacy of cultural competency in settings outside conventional “needs assessment” or “outcome studies” models.

Internal supply chain performance measurement

The purpose of this article is to present one example of how the strategies of total quality management (TQM) and continuous improvement are being used by US health care providers to meet the challenges of the future. This article presents an application utilizing the strategies of TQM and continual and rapid improvement in the area of assessing internal customer satisfaction in the health care arena. Satisfaction information concerning internal processes is critically important to the health care provider, and this article presents the development and application of an instrument designed to provide timely and relevant internal customer satisfaction information to individual health care providers. This provides information on problem identification and improvement opportunities for a world-class continuous improvement program. The article finds that customer satisfaction is increasingly being recognized as an appropriate measure for determining how well a particular organization is accomplishing its mission and, while customer satisfaction surveys provide valuable information and may be used to improve the entire operation, they provide limited insight into the details of the inner workings of each cost center. Each of the measures discussed in this article is potentially equally insightful and may provide more directly usable information when applied to internal customers. This article provides useful information on providing customer satisfaction in the health care arena.

Nonhealing skin lesions in a sailor and a journalist returning from Iraq.

US health care providers who are not familiar with cutaneous leishmaniasis may now begin to encounter more patients with this challenging entity as military personnel return from rotations in Iraq or Afghanistan. Diagnosis requires a skin scraping, aspiration, or biopsy, followed by examination by an experienced microscopist or pathologist. Demonstration of the parasite DNA by PCR or culture in special media can also be used to confirm the diagnosis. Sodium stibogluconate is the mainstay of therapy, but other options for selected cases include topical thermal or cryotherapy treatment and oral triazole compounds. Assistance is available through the CDC and, for Department of Defense beneficiaries, certain military facilities.

Global emergency medicine initiative: Advancing emergency medical care in the developing nation of Honduras

Study objectives: Honduras is a Spanish-speaking country located in Central America, with a population of approximately 6.5 million. It is one of the poorest countries in the western hemisphere and was severely affected by Hurricane Mitch in 1998, which killed approximately 5,600 people and cost $1 billion in damage. Shortly thereafter, Global Emergency Medicine Initiative (GEMINI), sponsored by Rotary International, developed a program to advance emergency medicine and disaster response in Honduras. I describe 3 years of emergency medical training experience in the developing nation of Honduras. Methods: A team of 10 US health care providers and support staff traveled to Tocoa, Honduras, and surrounding communities on 3 occasions during 2002 to 2004 to provide basic health education and emergency medicine training to all levels of health care providers during a 3-day period. Course participants included physicians, nurses, midwives, first responders, administrative staff, and community health workers. Each year, a written survey was conducted to ascertain the health concerns and needs of the community. Subsequent curricula were adjusted according to the survey results. Topics included triage, splinting and immobilization, cardiopulmonary resuscitation, prenatal care and childbirth, cardiovascular emergencies, respiratory illnesses, hypertension, diabetes, HIV, malaria, and preventative medicine. Hands-on sessions for physicians included ECG training, intubation skills, and intravenous access. A woodworker taught the local firefighters how to make their own backboards. Geographically isolated community health workers were provided with Where There Is No Doctor books and instruction in basic health care. Results: Approximately 750 participants were trained during a 3-year period. They were provided with resources to others in their community with the hope of instituting a train the trainer program. The major health concerns in the communities include HIV (especially among the Afro-Honduran Garifuna population), malaria, diabetes, hypertension, diarrhea, and respiratory illnesses. Conclusion: Emergency medicine skills can be taught in developing nations incorporating out-of-community and local educators and resources.

Security: a new clinical engineering paradigm [Clinical notes

Since the tragic events of 9/11, security has become a universal concern. Clinical engineers are encouraged to get up to speed and recognize the benefit an effective security process can bring to medical technology management. The security paradigm appropriately focuses on insuring the integrity, availability, and confidentiality of information maintained and transmitted by medical devices rather than on the management of discrete devices. It is worthwhile noting that this process will soon be required for US healthcare providers. The U.S. Department of Health and Human Services has established a Security Rule (part of the Health Insurance Portability and Accountability Act's Administrative Provisions), which will require the adoption of such a security process by 21 April 2005.

US web site will publish list of "drug-free practitioners"

No Free Lunch, a group of US health care providers who “believe that pharmaceutical promotion should not guide clinical practice” (www.nofreelunch.org) is to publicize a list of practitioners who have pledged to be “drug company-free.” Doctors who sign up to the “drug-free practitioners list” must pledge to be “free of company money and influence in their clinical practice, teaching, and research.” They must also promise to practice medicine on the basis of the best available scientific evidence and in the best interest of their patients, rather than on the basis of “advertising gimmicks and promotional ploys.” The idea for the list came from a group of patients in New York who had been given free drug samples by their doctors. These patients began to question why they were given samples, believing that it was part of a marketing strategy by the pharmaceutical industry. In one recent study, doctors stated that they used free samples as a way of avoiding cost to patients who were uninsured ( Journal of General Internal Medicine 2000;15:478-483) [PubMed]. Theavailability of drug samples, however, led doctors to dispense andsubsequently to prescribe drugs that differed from their preferreddrug choice. The pharmaceutical industry gave $7.2 billion worth ofsamples to US doctors in 1999, and No Free Lunch believes that thiswas a deliberate marketing ploy. In addition to publishing thelist, No Free Lunch offers a “pen amnesty”program—doctors hand in their drug company pens and receive a NoFree Lunch pen in return. Doctors can also check their own“drug company dependence” by answering a special CAGEquestionnaire (www.nofreelunch.org/cage.html),a parody of the screening tool commonly used for alcohol dependence:“Have you ever prescribed Celebrex? Do you getAnnoyed by people who complain about drug lunches and freegifts? Is there a medication loGo on the pen you're using rightnow? Do you drink your morning Eye-opener out of a Lipitorcoffee mug?” Bob Goodman, the director of No Free Lunch,hopes that the group will help to change a medical culture that seestaking gifts from drug representatives as “anentitlement.”