Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost - Ensuring High-Quality Specialty Care

Tremendous health outcome inequities remain in the U.S. across race and ethnicity, gender and sexual orientation, socio-economic status, and geography—particularly for those with serious conditions such as lung or skin cancer, HIV/AIDS, or cardiovascular disease.These inequities are driven by a complex set of factors—including distance to a specialist, insurance coverage, provider bias, and a patient's housing and healthy food access. These inequities not only harm patients, resulting in avoidable illness and death, they also drive unnecessary health systems costs.This 5-part series highlights the urgent need to address these issues, providing resources such as case studies, data, and recommendations to help the health care sector make meaningful strides toward achieving equity in specialty care.Top TakeawaysThere are vast inequalities in access to and outcomes from specialty health care in the U.S. These inequalities are worst for minority patients, low-income patients, patients with limited English language proficiency, and patients in rural areas.A number of solutions have emerged to improve health outcomes for minority and medically underserved patients. These solutions fall into three main categories: increasing specialty care availability, ensuring high-quality care, and helping patients engage in care.As these inequities are also significant drivers of health costs, payers, health care provider organizations, and policy makers have a strong incentive to invest in solutions that will both improve outcomes and reduce unnecessary costs. These actors play a critical role in ensuring that equity is embedded into core care delivery at scale.Part 3: "Ensuring High-Quality Specialty Care"New efforts to mitigate provider implicit bias, establish culturally-competent care, and leverage quality improvement approaches help identify and eliminate disparities in care

Medication management in mental health: nurses’ perceptions of their work with service users and carers

Aim: This study aimed to ascertain registered mental health nurses’ perceptions of their role involving medication management interventions with clients and their carers. Medicine-related interventions include administration, assessment of therapeutic effect potential side-effects education, liaison with service users and influence in prescribing decisions. Design and methods: The study used a qualitative design. Ten registered nurses were interviewed. Findings: Three themes were identified all related to the nurse context of work, role and client and carer need: improved dialogue, information and education, and adherence issues. Practice implications: Nurses use their clinical expertise in medication management to help achieve optimum therapeutic outcomes

Pilot Study Of A Somatosensory Intervention To Improve Medical Adherence In Patients With Uncontrolled Hypertension

Background Essential hypertension is the most common primary diagnosis in the US, with myriad and serious sequelae inflicting significant morbidity upon individuals and economic losses upon society. Estimates of adherence to prescribed medication regimens range from 20% to 60%. Because hypertension is largely asymptomatic, patients may underestimate both the benefits of adherence and the costs of nonadherence. This novel educational intervention seeks to encourage adherent behavior by providing patients with a conscious manifestation of their disease severity through manipulation of pressurized balls. Methods Randomized controlled pilot trial of patients under treatment for hypertension with SBP ≥140mmHg or DBP ≥90mmHg at index visit, selected by convenience sample at a VA Primary Care Clinic. Baseline clinical, demographic, medication taking habits and motivation data obtained by surveys and chart abstraction. All subjects received a short talk on the dangers of hypertension. Intervention Group subjects simultaneously squeezed rubber balls in each hand filled to air pressures differing by the same amount that their current SBP exceeded 120mmHg. Followup medication taking habits, motivation, medication possession ratios and blood pressure measurements were determined by telephone survey, pharmacy and clinical records over 90-, 180-, 270- and 360-day time periods. Feasibility of a larger study was determined by structured interviews with a physician and nurse who employed the intervention in clinical practice. Results Thirty subjects were enrolled into Intervention and Control Groups of equal size. Immediate motivational impact by 7-point scale significantly favored the Intervention (6.3, p \u3c 0.001 vs 4.3, p = 0.164). Change in self-reported adherence on an 8-point scale at 90-days favored the Intervention but was not significant (0.5, p = 0.372 vs -0.1, p = 0.798). Change in 360-day medication possession ratio favored the Intervention and approached significance (11.3%, p = 0.088 vs 0.7%, p = 0.934). Both Groups demonstrated clinically relevant improvements in MAP with greater magnitude, duration and significance for the Intervention Group through 360 days (-12.2mmHg, p = 0.008 vs -6.0mmHg, p = 0.164). Larger improvements in adherence were significantly associated with greater baseline motivation and immediate motivational impact from the intervention while longer disease experiences were associated with less improvement. Clinicians reported favorable reception from their patients and felt that the intervention represented a simple and helpful tool that they would use in everyday practice. Conclusions The results of this pilot trial suggest that a novel, brief educational intervention designed to provide a somatosensory manifestation of an otherwise asymptomatic disease process may show promise in promoting adherent behavior and clinically useful reductions in blood pressure in patients with poorly controlled hypertension. A larger study appears feasible and is required to confirm and investigate the statistical significance of these results

Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial

Background: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. Methods: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. Results: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.ConclusionsDIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs

How to match the optimal currently available inhaler device to an individual child with asthma or recurrent wheeze

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Affirming Expectations: African American Men\u27s Perceptions Of Trust In Physicians

ABSTRACT AFFIRMING EXPECTATIONS: AFRICAN AMERICAN MEN’S PERCEPTIONS OF TRUST IN PHYSICIANS by RONDRELL TAYVAN TAYLOR August 2015 Advisor: Dr. R. Khari Brown Major: Sociology (Medical) Degree: Doctor of Philosophy Trust is the foundation of the doctor-patient relationship. It promotes healing and medical efficacy. Patient trust in physicians exists when doctors act in their patients’ best interests. Moreover, trust literature demonstrates that historically (and contemporarily), African Americans are less likely than Whites to trust clinicians and the medical community due to the history of discrimination, clinical racism, unethical medical practices, implicit or unconscious racial biases, and exploitation by the health care system. This is the first study that qualitatively and exclusively examines how African American men conceptualize (define) trust in physicians. It specifically explores factors that influence trust, how trust in physicians impact medical compliance, and how the doctor-patient interaction impacts trust in physicians. Using a qualitative, grounded theory methodology, this study explored 20 African American men’s perceptions of trust in physicians. The project revealed that most of the participants were trusting patients and they viewed trust as an iterative, bi-directional process that was formed from the initial doctor’s appointment. Some of the responses that promoted trust in physicians included, caring, technical competence, thoroughness in evaluation, providing appropriate treatment and information, good communication, partnership-building, being personable or relatable, and feeling a sense of security. Respect, kindness, compassion, empathy, sensitivity, and maintaining confidentiality also increased trust in doctors. Participants who trusted their physicians also indicated feeling like they mattered, and that their lives had value. Nevertheless, apathy, disrespect, and technical incompetence emerged as the most salient factors that reduced trust the men’s physicians. The results of this study reveal that trust in physicians positively influenced medical compliance. The majority of the men in this study indicated following treatment recommendations. Moreover, trust in doctors, along with being provided information regarding medications or treatment recommendations facilitated medical compliance, which promoted trust. Furthermore, medical adherence was also based on the rapport and the well-established relationships that the men had with their doctors. Consistent with trust research, the findings of the interviews support research that physician behavior and personality are the strongest predictors of patient trust in physicians. However, this study challenges existing theoretical precepts about race and trust because the narratives reveal that almost all of the participants in this study received patient-centered care, which increased the men’s agency and control during medical interactions, which encouraged them to engage in shared decision-making. Also, many respondents viewed medical trust from a macro perspective. The men explained that examining and improving the interwoven systems of power and inequality within the health care system, is needed to increase trust. Furthermore, the narratives revealed that it was important for health care to involve connectivity and inclusivity, irrespective of an individual’s race, gender, SES, or other variables. This study may raise consciousness and encourage physicians and other health care professionals to interact and communicate differently and more effectively with Black male patients, which may reduce health disparities and increase medical compliance. Further qualitative studies are needed to gain a deeper understanding of the underlying issues, attitudes, and experiences that Black men have in medical realms

Psychoanalytic and cognitive-behavior therapy of chronic depression : study protocol for a randomized controlled trial

Background: Despite limited effectiveness of short-term psychotherapy for chronic depression, there is a lack of trials of long-term psychotherapy. Our study is the first to determine the effectiveness of controlled long-term psychodynamic and cognitive-behavioral (CBT) treatments and to assess the effects of preferential vs. randomized assessment. Methods/design: Patients are assigned to treatment according to their preference or randomized (if they have no clear preference). Up to 80 sessions of psychodynamic or psychoanalytically oriented treatments (PAT) or up to 60 sessions of CBT are offered during the first year in the study. After the first year, PAT can be continued according to the ‘naturalistic’ usual method of treating such patients within the system of German health care (normally from 240 up to 300 sessions over two to three years). CBT therapists may extend their treatment up to 80 sessions, but focus mainly maintenance and relapse prevention. We plan to recruit a total of 240 patients (60 per arm). A total of 11 assessments are conducted throughout treatment and up to three years after initiation of treatment. The primary outcome measures are the Quick Inventory of Depressive Symptoms (QIDS, independent clinician rating) and the Beck Depression Inventory (BDI) after the first year. Discussion: We combine a naturalistic approach with randomized controlled trials(RCTs)to investigate how effectively chronic depression can be treated on an outpatient basis by the two forms of treatment reimbursed in the German healthcare system and we will determine the effects of treatment preference vs. randomization

Improving Quality and Achieving Equity: A Guide for Hospital Leaders

Outlines the need to address racial/ethnic disparities in health care, highlights model practices, and makes step-by-step recommendations on creating a committee, collecting data, setting quality measures, evaluating, and implementing new strategies

MOTIVATIONAL INTERVIEWING TRAINING: IMPACT ON HEALTH CARE PRACTITIONERS’ ATTITUDES AND MOTIVATION FOR FACILITATING BEHAVIOUR CHANGE

Purpose: To investigate the impact of a one-day workshop in Motivational Interviewing (MI) on health care practitioners’ perceived competence, perceived autonomy, and experiences and attitudes towards facilitating behaviour change among patients. Methods: This single subject multiple baseline design study targeted a sample of 10 health practitioners. One-on-one interviews were conducted prior to the workshop and at one and four weeks post-training. Participants completed a series of questionnaires multiple times prior to and following the workshop. Results: Participants described improvements in their abilities to facilitate behaviour change following the workshop. Significant increases in perceived competence (Cohen’s effect size £=4.61), perceived autonomy (¿^=1.62), practitioner efficacy (d=2.22), and behaviour change in routine care (\u3c£=1.69) were reported. Discussion: Participation in the workshop was effective. Allied health care practitioners are in key positions to facilitate health behaviour changes that contribute to behaviour-related illness. The integration of MI should be explored further with a larger group

The Health Disparities Myth

Many experts today insist that bias in the doctor's office will lead to poorer treatment of minority patients. A new monograph by Jonathan Klick of Florida State University and AEI's Sally Satel, The Health Disparities Myth: Diagnosing the Treatment Gap (AEI Press, 2006) found no evidence to support the idea that racially biased doctors are a cause of poor minority health