Accommodating Medical School Faculty with Disabilities

More than ten years have passed since the Americans with Disabilities Act (ADA) mandated that all employers provide “reasonable accommodations” for employees with disabilities. This mandate applies to medical schools, but no systematic information is available to assess the accommodations provided to medical school faculty with disabilities. This Issue Brief summarizes anecdotal evidence from several medical schools about the experiences of faculty with disabilities, and the barriers they face in establishing and maintaining their careers. It also recommends practical steps medical schools can take to provide a welcoming and accessible academic medical environment

Use and cost of disease-modifying therapies by Sonya Slifka Study participants: has anything really changed since 2000 and 2009?

Background:Disease-modifying therapies benefit individuals with relapsing forms of multiple sclerosis, but their utility remains unclear for those without relapses. Objective:To determine disease-modifying therapy use and costs in 2009, compare use in 2009 and 2000, and examine compliance with evidence-based guidelines. Methods:We determined the extent and characteristics of disease-modifying therapy use by participants in the Sonya Slifka Longitudinal Multiple Sclerosis Study (Slifka) in 2000 (n=2156) and 2009 (n=2361) and estimated out-of-pocket and total (payer) costs for 2009. Two multivariable logistic regressions predicted disease-modifying therapy use. Results:Disease-modifying therapy use increased from 55.3% in 2000 to 61.5% in 2009. In 2009, disease-modifying therapy use was reported by 76.5% of participants with relapsing-remitting multiple sclerosis, 73.2% with progressive-relapsing multiple sclerosis, 62.5% with secondary progressive multiple sclerosis, and 41.8% with primary progressive multiple sclerosis. Use was significantly associated with relapsing-remitting multiple sclerosis, shorter duration of illness, one to two relapses per year, non-ambulatory symptoms, using a cane, younger age, higher family income, and having health insurance. Average annual costs in 2009 were US$939-3101 for patients and US$16,302-18,928 for payers. Conclusion:Use rates were highest for individuals with relapsing-remitting multiple sclerosis, but substantial for those with progressive courses although clinical trials have not demonstrated significant benefits for them

Diagnosis-based risk adjustment for Medicare capitation payments

Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula

Behavioral health emergencies encountered by community paramedics: lessons from the field and opportunities for skills advancement

INTRODUCTION: When an individual calls 911 because of a behavioral health emergency, paramedics may be the first health care professional on scene to address that crisis. Traditionally, the paramedic profession has been educated to respond to life-threatening medical emergencies.1 Paramedics are increasingly expected to respond to behavioral health crises but may not be adequately prepared to do so. 1 There has been limited research regarding paramedics’ experiences, attitudes, and perceptions about responding to behavioral health crises, with a particular dearth of literature on this subject from the USA. 1,2,3,4,5 As the first point of contact, paramedics may influence the quality of care individuals experiencing behavioral health emergencies receive, rendering this gap in knowledge concerning. 1,4 Paramedics encounter a range of behavioral health crises, from individuals who have self-harmed, substance use, to older adults experiencing social isolation. 6,7 This study aimed to answer the following questions: Do paramedics feel well prepared to respond to behavioral health crises? How do paramedics describe the challenges and facilitators involved in responding to these situations? What are the skills they use to respond to these situations? The present study examined paramedics’ experiences and perceptions regarding behavioral health emergencies, aiming to address a significant gap in the literature on paramedics’ ability to respond to the needs of individuals experiencing behavioral health crises. BACKGROUND: Limited research based in the UK, Europe, and Australia has examined the extent to which paramedics feel equipped by their training to respond to situations of a behavioral health nature, with a marked lack of USA-based research in this area. In a survey of members of the College of Paramedics (UK), 98% of the 623 respondents endorsed the need for increased mental health education and training. 2 Paramedic training curriculums in the UK have evolved to incorporate more of an emphasis on behavioral health, yet whether or not this behavioral health training is effective has not yet been investigated. 1 Several Australian studies investigated paramedic perceptions of their mental health training and decision-making during mental health emergencies.5,8. Paramedic participants reported inadequate mental health training and indicated a need for increased education on mental illness, particularly regarding possible treatment options that are feasible as part of prehospital care.8. Paramedics described relying more on intuition than education when faced with challenging cases.5 In a mixed methods study, Australian paramedics reported the need for more education on how to adequately respond to older adults experiencing complex mental health crises including depression, social isolation, and food insecurity.7 Limited research has explored paramedic perceptions, attitudes, and experiences responding to behavioral health emergencies, but the existing research indicates that many emergency healthcare providers consider physical health emergencies more valuable or important than behavioral health emergencies.8,9,10 Studies indicate that paramedic students do not consider training in mental health issues as relevant to the profession,1 with an Australian study of paramedic undergraduate students indicating a lower level of regard for those with intellectual disabilities, substance abuse disorders, or acute mental illness compared to students studying in other health professions.11 A multi-site, qualitative study based in Paris, France and New York, New York examined how social and professional values influenced prehospital emergency workers’ responses.9 The authors found that patients deemed to have lower social value were lower priority to emergency providers, with cases involving substance use or calls from lower socioeconomic areas, for instance, regarded as less legitimate uses of emergency services.9 Notably, situations that required more complex or heroic medical or surgical actions were also attributed higher value by emergency healthcare workers.9 Greater importance was attributed to medical (versus behavioral health) emergencies across additional studies, with paramedic participants implying that behavioral health calls were not valid emergencies,5 and with paramedic participants indicating that their role is mainly to transport—not to treat—individuals experiencing behavioral health crises.8 Additionally, paramedic participants perceived their services as often used inappropriately for behavioral health emergencies due to the limited availability of more appropriate behavioral health services.8 Related research regarding the perceptions of emergency department physicians and nurses in the USA also revealed a greater value placed on physical versus behavioral health emergencies, as well as perceptions that certain crises (such as self-harm) were less valid, or less worthy of emergency treatment.10 This is particularly concerning given that emergency department healthcare providers interact with a substantial number of persons seeking behavioral health emergency care: in 2015, approximately 4.1% of visits to an emergency department were related to diagnosed mental health disorders (approximately 5,666,000 visits).12 The number of emergency department visits related to opioid overdose increased by 29.7% in the USA between July 2016 and September 2017.13 Emergency healthcare workers are treating a significant number of behavioral health emergencies, rendering improved understanding of healthcare providers’ perceptions and attitudes towards this population crucial. Existing research into the perceptions of experienced paramedic practitioners regarding behavioral health emergencies is limited.1,3,4 With the exception of a multi-site study based in New York, New York and Paris, France,9 a thorough review of the extant literature failed to unearth research on the perceptions and experiences of paramedics responding to behavioral health crises in the USA. This is a particularly significant gap, as differences in paramedic education, relevant behavioral health legislation, and culture may exist across countries. The present study used qualitative analyses of in-depth interviews of practicing paramedics to address this gap by examining paramedics’ perceptions and experiences responding to behavioral health crises in the USA. METHODS: This study was part of a Patient-Centered Outcomes Research Institute (PCORI) contract funding an examination of the Acute Community Care Program (ACCP) at Commonwealth Care Alliance (CCA). The Acute Community Care Program is a state-funded community paramedicine intervention for the patients of CCA, in conjunction with EasCare Ambulance Company. INTERVIEW GUIDE AND RECRUITMENT: The research team, which included experienced paramedics at EasCare Ambulance Company, worked together to create an open-ended guide to interview paramedics. The interview protocol consisted of six sections: (1) history of career as paramedic, (2) current skills and job experiences, (3) views of paramedic experience, (4) career goals, (5) final questions and wrap up, and (6) demographics. The research team revised the original guide after several pilot interviews and based on feedback from key informants, namely seasoned paramedic supervisors from the research team. Interviews with paramedics lasted approximately 1 h and were conducted over the phone by either the PI or Co-PI, who are experienced in qualitative research. The research team intended to interview 25 paramedics who would be identified through two large ambulance companies in the Greater Boston area of Massachusetts. The director at these ambulance companies asked their paramedics on staff if they would be willing to be interviewed and, if they agreed, the director gave us their contact information. Six paramedics who had initially agreed could not be reached, and arrangements were made with one paramedic who did not follow through with the interview. In total, the researchers conducted telephone interviews with 23 paramedics, after receiving verbal informed consent to perform and record the interview. Participants were mailed a $50 gift card to thank them for their time. Professional transcription service transcribed digital recordings verbatim, and the project manager reviewed all transcripts against the digital recording, making small corrections as needed. DATA ANALYSIS: Audiotapes of the sessions were analyzed by three research team members. A thematic analysis approach was utilized, starting with familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing a final analysis.14 The researchers worked both separately and collaboratively, working individually at each stage of the process and then coming together to compare results in order to ensure the validity of identified themes. Early readings of the transcript data allowed the researchers to develop preliminary ideas regarding potential themes. Each researcher then thoroughly analyzed the individual transcripts, generating initial codes and beginning to search for themes both within and across documents. During this stage, the researchers met frequently to compare and contrast the results of each individual’s analysis, reviewing emerging themes and collaborating to refine themes into a coherent set. To asses inter-rater reliability, two un-read transcripts were reviewed by all team members and coded independently, followed by meetings as a research team to compare coding decisions on each transcript and reconcile any discrepancies. This rigorous process helped to ensure strong inter-rater reliability as we were able to gain consensus in our coding process for all other transcripts. Researchers individually arranged transcript data verbatim into groups of initial themes, and a master document was then created collaboratively, which outlined each finalized theme and included transcript excerpts embodying each theme. Memo-writing was employed throughout the analytic process to document coding decisions.15 As a final check for validity, the two experienced paramedic supervisors from the research team reviewed the themes and subthemes and provided feedback about the findings. The paramedic supervisors confirmed that these themes were what they might have expected the data to reveal, further validating the findings. RESULTS: Table 1 shows demographic characteristics of the 23 participants. Results for this paper will focus on three themes identified in the data analysis. Namely, paramedics (1) report frequently working with patients who are having a behavioral health crisis, (2) report having inadequate behavioral health training, and (3) have many difficulties managing these patients, relying primarily on their professional experiences and/or strong interpersonal skills rather than explicit training to address patients’ needs (see Table 2).Accepted manuscrip

Using diagnoses to describe populations and predict costs

The Diagnostic Cost Group Hierarchical Condition Category (DCG/HCC) payment models summarize the health care problems and predict the future health care costs of populations. These models use the diagnoses generated during patient encounters with the medical delivery system to infer which medical problems are present. Patient demographics and diagnostic profiles are, in turn, used to predict costs. We describe the logic, structure, coefficients and performance of DCG/HCC models, as developed and validated on three important data bases (privately insured, Medicaid, and Medicare) with more than 1 million people each

Principal inpatient diagnostic cost group model for Medicare risk adjustment

The Balanced Budget Act (BBA) of 1997 required HCFA to implement health-status-based risk adjustment for Medicare capitation payments for managed care plans by January 1, 2000. In support of this mandate, HCFA has been collecting inpatient encounter data from health plans since 1997. These data include diagnoses and other information that can be used to identify chronic medical problems that contribute to higher costs, so that health plans can be paid more when they care for sicker patients. In this article, the authors describe the risk-adjustment model HCFA is implementing in the year 2000, known as the Principal Inpatient Diagnostic Cost Group (PIPDCG) model

Screening for Chronic Conditions Using a Patient Internet Portal: Recruitment for an Internet-based Primary Care Intervention

Background: Patient Internet portals have created new opportunities for assessment and management of chronic conditions. Objective: To conduct an online screening survey for a study recruitment using a secure patient Internet portal to identify primary care patients with untreated depression, chronic pain, or mobility difficulty before nonurgent office visits. Design: Internet-based screening survey for a randomized trial. Participants: Patients who were registered portal users who had scheduled primary care appointments. Approach: Electronic study invitations via the portal were sent to 4,047 patients with scheduled visits to 34 primary care physicians participating in the study. After clicking on a link in the study invitation, patients were consecutively shown the study description, consent form, and lastly, the screening survey to determine final eligibility for study participation. Results: Of the 2,113 (52%) patients who opened the study invitation, 1,001 consented online to join the study and 981 (98%) of these completed the screening survey. Of the respondents, 319 (33%) screened positive for 1 or more of the 3 conditions. Conclusions: The online screening survey conducted through the patient portal was effective in identifying patients with chronic conditions in advance of scheduled primary care visits for participation in an intervention study