US Health Care Providers Research Articles

Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers

ObjectiveIdentify factors associated with healthcare providers' frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents. Study designWe analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year. ResultsAlthough most providers (>95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30–0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28–0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27–0.91) and family medicine (aOR 0.21, 95% CI 0.09–0.47) versus adolescent medicine, completing training ≥15 versus <5 years ago (aOR 0.27, 95% CI 0.09–0.83), and reporting that 0–24% of patients pay with Medicaid or other government healthcare assistance versus ≥50% (aOR 0.23, 95% CI 0.09–0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method. ConclusionsWhile most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents' access to contraception. ImplicationsAlthough >95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents' access to DMPA and all methods of contraception.

Real-world experience of calcipotriene and betamethasone dipropionate foam 0.005%/0.064% in the treatment of adults with psoriasis in the United States

Background: Clinical trials have established calcipotriene 0.005%/betamethasone dipropionate 0.064% (Cal/BD) foam as a well-tolerated and efficacious topical therapy for psoriasis.Methods: A chart review of 24 US healthcare providers gathered real-world information (clinical characteristics and outcomes, safety, and resource utilization) for patients (≥18 years old) prescribed Cal/BD foam between January 1 and October 31, 2016, along with healthcare provider characteristics and perceptions of Cal/BD foam.Results: Data were reported from 105 patients and 177 active psoriatic lesions. Cal/BD foam was applied once-daily; the prescription was 4 weeks for 69/177 (39%) lesions (median 4, range 1–26 weeks). Knees (n = 41; 23%) and elbows (n = 37; 20%) were the most frequently treated areas. Among 114 lesions, severity improved from “mild”/“moderate”/“severe” to “clear”/“almost clear” in 71%, and 54% had a clinically significant improvement (two-step/greater improvement) in lesion severity from baseline. Of 128 lesions with baseline itch, 90% were not itchy at the best treatment response. Most healthcare providers reported prescribing Cal/BD foam because of its overall efficacy (n = 20/23; 87%). Adverse events were reported in 1/105 patients (1%).Conclusion: Data from real clinical practice demonstrate that Cal/BD foam improves psoriasis disease severity and associated itch in patients and further extend results of clinical trials.

Perceptions of Health Practices and Interactions with the US Healthcare System among Bhutanese Refugees: A Qualitative Approach

The aim of this pilot study was to explore health practices of Bhutanese refugees and their interactions with the US healthcare system and providers.

PHP153 - What US Healthcare Providers Value in Genomic Precision Medicine: A Discrete Choice Experiment

The current literature on physician preferences for genomic precision medicine is limited. The objective of this study was to estimate healthcare providers’ preferences for attributes that influence their recommendation of genetic tests to their patients. Using qualitative research (n=5 providers), we identified the following attributes as important to healthcare providers for test recommendation: type of information from the genetic test (disease screening vs. treatment change, or both), prevalence of genetic marker, expert agreement on recommendations, change in quality of life and life expectancy gains (with statistical uncertainty), and test cost. We used these attributes to design a stated preference discrete choice experiment and administered a web-survey on a representative sample of US healthcare providers. We used effects coding and analyzed the data using a nested logit modeling approach. The survey response rate was 67% (356 participants completed the survey). The respondents had a mean practice experience of 21.1 years and 87% had previously ordered genetic testing for their patients. Based on the relative importance of attributes, the genetic tests’ attributes ranked in the following order of decreasing importance: quality-of-life, gains in life expectancy, test cost, expert agreement in recommendations, prevalence of the genetic marker, and screening vs treatment prediction. Providers’ marginal willingness to pay (mWTP) was highest for genetic tests that lead to improvement in quality-of-life ($1199 to $5929) and lowest for tests that resolved uncertainty in life expectancy gains ($64 to $219). The mWTP for an increase in medical experts’ agreement on recommendations ranged from $134 to $1955. Providers exhibited a strong preference for the genetic tests that improved their patients’ quality-of-life, increased patients’ life expectancy, and cost less. The estimated preferences of providers over different characteristics of genetic tests in this study can help predict genetic tests’ adoption and inform patient/provider shared decision making.

PCV47 - Extended Thromboprophylaxis With Betrixaban Is Cost-Effective In Acutely ILL Medical Patients

The APEX trial demonstrated that prophylaxis of venous thromboembolism (VTE) with betrixaban from hospital admission through post-discharge (35-42 days) in acutely ill medical patients reduced VTE events without significant increase in major bleeding vs standard-duration prophylaxis (6-14 days) with enoxaparin. Here, we analyzed the cost-effectiveness of this new thromboprophylaxis regimen with betrixaban versus standard-duration enoxaparin. We adopted our previously published decision-tree model to compare two thromboprophylaxis strategies from a US health care provider perspective among a hypothetical cohort of 10,000 acutely ill medical patients who are at risk of VTE: betrixaban (160 mg loading dose followed by 80 mg once daily for 35 days; $396) versus enoxaparin (40 mg daily for 9 days; $284). To estimate VTE-related deaths within 35 days that might have been averted by thromboprophylaxis, the model incorporated a clinical care path, including primary and secondary VTE prophylaxis as well as treatment of thromboprophylaxis-related adverse events. Parameter values and costs were estimated for each node in the decision tree based on publically available health data. All costs were converted to 2017 USD based on the US medical care consumer index. For the base-case scenario, among a hypothetical cohort of 10,000 acutely ill medical patients at increased VTE risk, betrixaban was estimated to reduce risk of death by 0.16% and save nearly $1.8M (or $178.27 per patient treated). One-way sensitivity analyses indicated that betrixaban would dominate enoxaparin assuming: a) the cost of 35-day betrixaban was <$15.94 per dose (<$574 per 36 doses); b) the clinically relevant recognized bleeding rate was ≤3.8% or c) the VTE rate was ≤7.2%. Based on the rates of clinical events reported in the APEX study, thromboprophylaxis with betrixaban from admission through post-discharge in acutely ill medical patients is likely to prevent additional deaths and reduce costs compared with standard-duration thromboprophylaxis with enoxaparin.

Abstract 135: Extended Thromboprophylaxis With Betrixaban is Cost-effective in Acutely Ill Medical Patients

Objectives: The APEX trial demonstrated that prophylaxis of venous thromboembolism (VTE) with betrixaban from hospital admission through post-discharge (35-42 days) in acutely ill medical patients reduced VTE events, including symptomatic VTEs, without significant increase in major bleeding versus standard-duration prophylaxis (6-14 days) with enoxaparin. Based on these data, betrixaban has been approved by the FDA for prophylaxis of VTE in adult patients hospitalized for an acute medical illness who are at risk for thromboembolic complications. Here, we analyzed the cost-effectiveness of this new thromboprophylaxis regimen with betrixaban versus standard-duration thromboprophylaxis with enoxaparin. Methods: We adopted our previously published decision-tree model to compare two thromboprophylaxis strategies from a US health care provider perspective among a hypothetical cohort of 10,000 acutely ill medical patients who are at risk of VTE: betrixaban (160 mg loading dose followed by 80 mg once daily for 35 days; $396) versus enoxaparin (40 mg daily for 9 days; $284). To estimate VTE-related deaths within 35 days that might have been averted by thromboprophylaxis, the model incorporated a clinical care path, including primary and secondary VTE prophylaxis as well as treatment of thromboprophylaxis-related adverse events. Parameter values and costs were estimated for each node in the decision tree based on publically available health data. All costs were converted to 2017 USD based on the US medical care consumer index. Results: For the base-case scenario, among a hypothetical cohort of 10,000 acutely ill medical patients at increased VTE risk, betrixaban was estimated to reduce risk of death by 0.16% and save nearly $1.8M (or $178.27 per patient treated). One-way sensitivity analyses indicated that betrixaban would dominate enoxaparin assuming: a) the cost of 35-day betrixaban was &lt;$15.94 per dose (&lt;$574 per 36 doses); b) the clinically relevant recognized bleeding rate was ≤3.8% or c) the VTE rate was ≤7.2%. Conclusions: Based on the rates of clinical events reported in the APEX study, extended-duration thromboprophylaxis with betrixaban from hospital admission through post-discharge in acutely ill medical patients is likely to prevent additional deaths and reduce costs compared with standard-duration thromboprophylaxis with enoxaparin.

Unpacking Care Coordination Through a Multiteam System Lens: A Conceptual Framework and Systematic Review.

The 2016 President's Cancer Panel Connected Health report calls for thoroughly characterizing the team structures and processes involved in coordinating care for people with chronic conditions. We developed a multilevel care coordination framework by integrating existing frameworks from the teams and care coordination literatures, and used it to review evidence examining care coordination processes for patients with cancer, diabetes, cardiovascular disease, and combinations of these conditions. We searched Pubmed/MedLINE, CINAHL Plus, Cochrane, PsycINFO (December 2009-June 2016), and references from previous reviews. Studies describing behavioral markers of coordination between ≥2 US health care providers caring for adults with cancer, chronic heart disease, diabetes, or populations with a combination of these conditions were included. Two investigators screened 4876 records and 180 full-text articles yielding 33 studies. One investigator abstracted data, a second checked abstractions for accuracy. Most studies identified information sharing or monitoring as key coordination processes. To execute these processes, most studies used a designated role (eg, coordinator), objects and representations (eg, survivorship plans), plans and rules (eg, protocols), or routines (eg, meetings). Few examined the integrating conditions. None statistically examined coordination processes or integrating conditions as mediators of relationships between specific coordination mechanisms and patient outcomes. Restricted to United States, English-language studies; heterogeneity in methods and outcomes. Limited research unpacks relationships between care coordination mechanisms, coordination processes, integrating conditions, and patient outcomes suggested by existing theory. The proposed framework offers an organizer for examining behaviors and conditions underlying effective care coordination.

Listening to Communities: Mixed-Method Study of the Engagement of Disadvantaged Mothers and Pregnant Women With Digital Health Technologies.

BackgroundUS health care providers are increasingly demanding patient engagement with digital health technologies to enroll in care, access personal health information, communicate with providers, and monitor their own health. Such engagement may be difficult for disadvantaged populations who may have limited health literacy, time constraints, or competing priorities.ObjectiveWe aimed to understand the extent of adoption and use of digital health tools and to identify key perceived psychological motivators of technology use among disadvantaged first-time pregnant women and mothers of young children.MethodsWe recruited women from health organizations serving low-income communities in the Midwest and on the East and West coasts. A total of 92 women participated in 14 focus groups. During each session, we administered worksheets that measured 3 utilization outcomes: the number of recent Web-based health-seeking activities, current use of digital health-management practices (eg, accessing personal health information, communicating with providers, and scheduling appointments), and potential adoption of digital health-management tools among low users or nonusers. Responses to the worksheets and to a pre-focus group survey on demographics, technology access, and motivators of use were examined to create user profiles. Separate regression models identified the motivators (eHealth literacy, internal health orientation, and trust in digital information) associated with these outcomes. Qualitative data were incorporated to illustrate the worksheet responses. ResultsWhereas 97% of the participants reported that they had searched for health information on the Internet in the past year, 42% did not engage in digital health-management practices. Among the low users and nonusers, 49% expressed interest in future adoption of digital health tools. Web-based health information-seeking activities were associated with digital health-management practices (P<.001). When controlling for covariates, eHealth literacy was positively correlated with the number of Web-based health-seeking activities (beta=.03, 95% CI 0.00-0.07). However, an internal health orientation was a much stronger correlate of digital health-management practices (beta=.13, 95% CI 0.02-0.24), whereas trust in digital information increased the odds of potential adoption (vs no adoption) in adjusted models (OR 5.21, 95% CI 0.84-32.53). Demographic characteristics were not important drivers of digital health use and few differences distinguished use among mothers and pregnant women.ConclusionsSeeking health information on the Internet may be an important gateway toward engaging in digital health-management practices. Notably, different consumer motivators influence digital health tool use. The relative contributions of each must be explored to design tools and interventions that enhance competencies for the management of self and child health among disadvantaged mothers and pregnant women. Unless we address disparities in digital health tool use, benefits from their use will accrue predominantly to individuals with the resources and skills to use technology effectively.

Disparities in US Healthcare Provider Screening and Advice for Cessation Across Chronic Medical Conditions and Tobacco Products.

Disparities in tobacco use are worsening in the United States, disproportionately affecting those with chronic medical conditions. One possible contributor is that physicians may not screen and advise cessation uniformly across patients and/or tobacco products. This study examined provider communications regarding cigarette and non-cigarette tobacco products among adults with chronic conditions. Cross-sectional study drawn from two waves (2013-2014) of the National Survey on Drug Use and Health (NSDUH). Adults (≥ 18years) who used tobacco in the past year. Prevalence of tobacco use included past-year use of cigarettes, cigars, or smokeless tobacco among those with and without chronic conditions. Chronic conditions included asthma, anxiety, coronary heart disease, depression, diabetes, hepatitis, HIV, hypertension, lung cancer, stroke, and substance abuse. Odds ratio of receipt of screening and advice to quit across chronic condition and tobacco product type were reported. Data were analyzed using logistic regression, controlling for basic sociodemographic factors and number of provider visits. Adults with anxiety, depression, and substance use disorders had the highest prevalence of past-year cigarette (37.2-58.2%), cigar (9.1-28.0%), and smokeless tobacco (3.1-11.7%) use. Patients with any chronic condition were more likely to receive advice to quit than those without a condition (OR 1.21-2.37, p<0.01), although the odds were lowest among adults with mental health and substance use disorders (OR 1.21-1.35, p<0.01). Cigarette smokers were more likely to report being screened and advised to quit than non-cigarette tobacco users (OR 1.54-5.71, p<0.01). Results support the need for provider training to expand screening and cessation interventions to include the growing spectrum of tobacco products. Screening and referral to interventions are especially needed for those with mental health and substance use disorders to reduce the disparate burden of tobacco-related disease and death.

Addressing the Challenges of Chagas Disease: An Emerging Health Concern in the United States.

Chagas disease is an emerging health concern in the United States. US health care providers have an unparalleled opportunity to respond to the challenges this infection poses and to provide state-of-the-art care for patients with Chagas disease. Most of the approximately 300,000 persons with Trypanosoma cruzi infection living in the United States have chronic, asymptomatic infection acquired in endemic regions in Latin America. Congenital infection is often asymptomatic and, even when symptomatic, has no features that distinguish it from other congenitally transmitted infections. Health care providers and the public have limited awareness of this infection. Recognizing risk groups and performing targeted diagnostic testing for at-risk infants, children, and adults are a health priority because early treatment can effect cure and avert the life-threatening cardiac manifestations of Chagas disease. Two medications for treatment, benznidazole and nifurtimox, are available through the Centers for Disease Control and Prevention. Although challenges exist, informed health care providers can greatly reduce the effects of Chagas disease in the United States.

CYP2C19 LOF and GOF-Guided Antiplatelet Therapy in Patients with Acute Coronary Syndrome: A Cost-Effectiveness Analysis.

This study aimed to examine the cost-effectiveness of CYP2C19 loss-of-function and gain-of-function allele guided (LOF/GOF-guided) antiplatelet therapy in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). A life-long decision-analytic model was designed to simulate outcomes of three strategies: universal clopidogrel (75mg daily), universal alternative P2Y12 inhibitor (prasugrel 10mg daily or ticagrelor 90mg twice daily), and LOF/GOF-guided therapy (LOF/GOF allele carriers receiving alternative P2Y12 inhibitor, wild-type patients receiving clopidogrel). Model outcomes included clinical event rates, quality-adjusted life-years (QALYs) gained and direct medical costs from perspective of US healthcare provider. Base-case analysis found nonfatal myocardial infarction (5.62%) and stent thrombosis (1.2%) to be the lowest in universal alternative P2Y12 inhibitor arm, whereas nonfatal stroke (0.72%), cardiovascular death (2.42%), and major bleeding (2.73%) were lowest in LOF/GOF-guided group. LOF/GOF-guided arm gained the highest QALYs (7.5301 QALYs) at lowest life-long cost (USD 76,450). One-way sensitivity analysis showed base-case results were subject to the hazard ratio of cardiovascular death in carriers versus non-carriers of LOF allele and hazard ratio of cardiovascular death in non-carriers of LOF allele versus general patients. In probabilistic sensitivity analysis of 10,000 Monte Carlo simulations, LOF/GOF-guided therapy, universal alternative P2Y12 inhibitor, and universal clopidogrel were the preferred strategy (willingness-to-pay threshold=50,000 USD/QALY) in 99.07%, 0.04%, and 0.89% of time, respectively. Using both CYP2C19 GOF and LOF alleles to select antiplatelet therapy appears to be the preferred antiplatelet strategy over universal clopidogrel and universal alternative P2Y12 inhibitor therapy for ACS patients with PCI.

Online public reactions to frequency of diagnostic errors in US outpatient care.

Diagnostic errors pose a significant threat to patient safety but little is known about public perceptions of diagnostic errors. A study published in BMJ Quality & Safety in 2014 estimated that diagnostic errors affect at least 5% of US adults (or 12 million) per year. We sought to explore online public reactions to media reports on the reported frequency of diagnostic errors in the US adult population. We searched the World Wide Web for any news article reporting findings from the study. We then gathered all the online comments made in response to the news articles to evaluate public reaction to the newly reported diagnostic error frequency (n=241). Two coders conducted content analyses of the comments and an experienced qualitative researcher resolved differences. Overall, there were few comments made regarding the frequency of diagnostic errors. However, in response to the media coverage, 44 commenters shared personal experiences of diagnostic errors. Additionally, commentary centered on diagnosis-related quality of care as affected by two emergent categories: (1) US health care providers (n=79; 63 commenters) and (2) US health care reform-related policies, most commonly the Affordable Care Act (ACA) and insurance/reimbursement issues (n=62; 47 commenters). The public appears to have substantial concerns about the impact of the ACA and other reform initiatives on the diagnosis-related quality of care. However, policy discussions on diagnostic errors are largely absent from the current national conversation on improving quality and safety. Because outpatient diagnostic errors have emerged as a major safety concern, researchers and policymakers should consider evaluating the effects of policy and practice changes on diagnostic accuracy.

Korean Immigrant Women's Taekyo Practices in the United States as a Traditional Prenatal Self-care.

The purpose of this study was to explore preserved belief system supporting Korean immigrant women's Taekyo practices and influencing factors while they observe the tradition within US sociocultural context. Leininger's exploratory focused ethnographic approach was used. Semi-structured in-depth interviews were conducted with purposive sample of sixteen Korean immigrant women who gave birth in the US within last 6 months. Researcher's observation and reflective field notes were also integrated into the interview data. Leininger and McFarland's four phases of ethnographic analysis guided data analysis process. The perceived belief system supporting Taekyo practices included Taekyo as an enculturated Korean tradition, connecting parents with fetus, and positive impacts on fetal development. And Korean immigrant women's Taekyo practices were influenced by resources of information, woman's orientation toward Taekyo, pressure from local Korean community, and child order. The findings from this research would serve as an important knowledge base to expand US health care providers' understanding of Korean traditional Taekyo practices observed by Korean immigrant women's as important prenatal self-care practices. The findings could also aid in providing more patient-centered and culturally-tailored prenatal care plan to Korean immigrant by including Korean traditional belief system supporting Taekyo practices.

The negative impact of organizational cynicism on physicians and nurses.

Despite the potentially severe consequences that might result, there is a paucity of research on organizational cynicism within US health care providers. In response, this study investigated the effect of cynicism on organizational commitment, job satisfaction, and interest in leaving the hospital for another job in a sample of 205 physicians and 842 nurses. Three types of cynicism were investigated: trait (dispositional), global (directed toward the hospital), and local (directed toward a specific unit or department). Findings indicate that all 3 types of cynicism were negatively related to affective organizational commitment and job satisfaction, but positively related to interest in leaving. In both nurse and physician samples, cynicism explained about half of the variance in job satisfaction and affective commitment, which is the type of commitment managers are most eager to promote. Cynicism accounted for about a quarter and a third of the variance in interest in leaving the hospital for nurses and physicians, respectively. Trait, global, and local cynicism each accounted for unique variance in affective commitment, job satisfaction, and interest in leaving, with global cynicism exerting the largest influence on each outcome. The implications for managers are that activities aimed at decreasing organizational cynicism are likely to increase affective organizational commitment, job satisfaction, and organizational tenure.

Cost-utility analysis of genotype-guided antiplatelet therapy in patients with moderate-to-high risk acute coronary syndrome and planned percutaneous coronary intervention.

Prasugrel is recommended over clopidogrel in poor/intermediate CYP2C19 metabolizers with acute coronary syndrome (ACS) and planned percutaneous coronary intervention (PCI), reducing the risk of ischemic events. CYP2C19 genetic testing can guide antiplatelet therapy in ACS patients. The purpose of this study was to evaluate the cost-utility of genotype-guided treatment, compared with prasugrel or generic clopidogrel treatment without genotyping, from the US healthcare provider's perspective. A decision model was developed to project lifetime economic and humanistic burden associated with clinical outcomes (myocardial infarction [MI], stroke and major bleeding) for the three strategies in patients with ACS. Probabilities, costs and age-adjusted quality of life were identified through systematic literature review. Incremental cost-utility ratios (ICURs) were calculated for the treatment strategies, with quality-adjusted life years (QALYs) as the primary effectiveness outcome. Relative risk of developing myocardial infarction and stroke between patients with and without variant CYP2C19 when receiving clopidogrel were estimated to be 1.34 and 3.66, respectively. One-way and probabilistic sensitivity analyses were performed. Clopidogrel cost USD19,147 and provided 10.03 QALYs versus prasugrel (USD21,425, 10.04 QALYs) and genotype-guided therapy (USD19,231, 10.05 QALYs). The ICUR of genotype-guided therapy compared with clopidogrel was USD4,200. Genotype-guided therapy provided more QALYs at lower costs compared with prasugrel. Results were sensitive to the cost of clopidogrel and relative risk of myocardial infarction and stroke between CYP2C19 variant vs. non-variant. Net monetary benefit curves showed that genotype-guided therapy had at least 70% likelihood of being the most cost-effective alternative at a willingness-to-pay of USD100,000/QALY. In comparison with clopidogrel, prasugrel therapy was more cost-effective with <21% certainty at willingness-to-pay of >USD170,000/QALY. Our modeling analyses suggest that genotype-guided therapy is a cost-effective strategy in patients with acute coronary syndrome undergoing planned percutaneous coronary intervention.

Physical examination instruction in US pharmacy curricula

ObjectiveCompare physical examination instruction and competency expectations between US pharmacy schools. MethodsPharmacy Practice Department Chairs or their equivalents at all US pharmacy schools were surveyed regarding physical exam instruction and evaluation within their respective curricula. Opinions were also gathered regarding physical exam competency expectations and the need to formally evaluate this skill prior to graduation and for purposes of US licensure and federal healthcare provider recognition. The survey instrument was pretested prior to dissemination. ResultsThe survey response rate was 56%. Instructional and assessment methods used in teaching and evaluating physical exam skills were similar among responding US pharmacy programs. However, there is variability in the extent of physical exam instruction and evaluation as well as opinions related to physical exam competency expectations prior to graduation and for purposes of US pharmacy licensure and federal healthcare provider credentialing. Overall, 83% of programs require students to demonstrate correct exam techniques via a competency exam; however, only 52% of schools require students to apply physical findings to therapeutic decision-making. Respondents from new schools were more likely to support formal competency evaluation of physical exam skills via objective structured clinical exam for purposes of US licensure and healthcare provider credentialing compared to established schools (p < 0.05). ConclusionDifferences in competency expectations and the extent of physical exam instruction and evaluation in US pharmacy schools illustrate the need for a minimum national standard for this pharmacy practice skill.

Older immigrants from the former Soviet Union and their use of complementary and alternative medicine

The population of older immigrants in the United States is growing and they bring their health beliefs and practices with them. Older immigrants from the former Soviet Union use a variety of complementary and alternative medicine (CAM) remedies which includes in part: 1) foods to which medicinal properties are attributed, 2) herbs, 3) external treatments, and 4) pharmaceuticals manufactured in the former Soviet Union and available over-the-counter. These remedies vary in their efficacy and are often used in combination with or in lieu of prescribed allopathic (Western) medications. Health beliefs regarding medicine in the United States has led older Slavic immigrant to distrust their US health care providers and system. Nurses are in a key position to inquire and work with older Slavic immigrants to safely use their CAM and provide more information about prescribed allopathic medications and the harmful effects of combining remedies without consultation.

Characteristics of US Health Care Providers Who Counsel Adolescents on Sports and Energy Drink Consumption.

Objective. To examine the proportion of health care providers who counsel adolescent patients on sports and energy drink (SED) consumption and the association with provider characteristics. Methods. This is a cross-sectional analysis of a survey of providers who see patients ≤17 years old. The proportion providing regular counseling on sports drinks (SDs), energy drinks (EDs), or both was assessed. Chi-square analyses examined differences in counseling based on provider characteristics. Multivariate logistic regression calculated adjusted odds ratios (aOR) for characteristics independently associated with SED counseling. Results. Overall, 34% of health care providers regularly counseled on both SEDs, with 41% regularly counseling on SDs and 55% regularly counseling on EDs. On adjusted modeling regular SED counseling was associated with the female sex (aOR: 1.44 [95% CI: 1.07–1.93]), high fruit/vegetable intake (aOR: 2.05 [95% CI: 1.54–2.73]), family/general practitioners (aOR: 0.58 [95% CI: 0.41–0.82]) and internists (aOR: 0.37 [95% CI: 0.20–0.70]) versus pediatricians, and group versus individual practices (aOR: 0.59 [95% CI: 0.42–0.84]). Modeling for SD- and ED-specific counseling found similar associations with provider characteristics. Conclusion. The prevalence of regular SED counseling is low overall and varies. Provider education on the significance of SED counseling and consumption is important.

Culturally Related Health Risks: Gastric Cancer and Asian Americans

ulture influences health status. Cultural awareness on the part of health care proCviders improves both health outcomes and care quality. Gastric cancer is a leading cause of death worldwide, particularly in Eastern Asians (Chinese, Japanese, Koreans, Mongolians). The incidence rate for gastric cancer was number 1 among Eastern Asians in 2008 (30 per 100,000 populations), which is about 6 in 10 new cases. Korea has the highest rate of gastric cancer (41.4 per 100,000) among Asians, followed by Mongolia (34 per 100,000), Japan (31.1 per 100,000), and China (29.9 per 100,000). Gastric cancer in the United States is the 14th leading cancer, with 21,600 new cases and 10,990 deaths in 2013. According to the 2006-2010 California cancer incidence data, which is the only available data for individual Asians, gastric cancer is the 3rd most common cancer in both Korean American men and women in California and the 5th most common in Japanese and Vietnamese American men. Although nationwide campaigns are regularly mounted to screen for breast, cervical, and colorectal cancers in the US, gastric cancer screening is totally overlooked, perhaps because of its low incidence among non-Hispanic whites. Asian Americans have been largely neglected with regard to health status assessment, program development, and resource allocation. Absence of national guidelines for gastric cancer screening and a lack of awareness of culturally related health risks by US health care providers has hindered early detection and treatment of gastric cancer in Asian Americans. Therefore, gastric cancer is frequently diagnosed in a later stage with a lower cure rate. For example, the 5-year survival rate was 67% in Korea from 20062010, whereas the survival rate was 26.9% in America from 2002-2008. Asian Americans are the fastest growing minority population in the US, currently numbering more than 17 million (nearly 6% pecent of the population), an increase of 43% between 2000 and 2010. Asians

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.