Index by author

The Issue in Brief

Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries

Tammy Chang , and colleagues

Background Under the Patient Protection and Affordable Care Act (ACA), states will have the opportunity to expand Medicaid to millions of uninsured American adults. This study uses the most recent nationally representative data to examine the characteristics of individuals potentially eligible for Medicaid under ACA coverage expansion and compare them with current Medicaid beneficiaries.

What This Study Found The population potentially eligible for Medicaid coverage under the ACA is similarly healthy as--if not healthier than--the current Medicaid population. The exception is that tobacco smoking and alcohol use patterns are higher among potential Medicaid enrollees than for current Medicaid beneficiaries. Specifically, the analysis of data on 13.8 million current and 13.6 million eligible Medicaid beneficiaries indicates eligible adults are expected to have better health status than current beneficiaries. Additionally, the proportion of potentially eligible beneficiaries who are obese and with depression is significantly lower than current beneficiaries. There were no significant differences in the expected prevalence of diabetes or hypertension. Current tobacco smoking and moderate and heavy alcohol use are more common among the potentially eligible population than among current beneficiaries.

Implications

• These findings suggest that federal Medicaid expenditures for newly covered beneficiaries may not be as high as projected by the Congressional Budget Office in the short term, thereby reducing spending anticipated with implementation of the ACA.
• Given the higher prevalence of tobacco smoking and alcohol use, the authors point to the need for broad enrollment and engagement of this potentially eligible population to address their higher prevalence of modifiable risk factors for future chronic disease.

Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study

Luke Fortney , and colleagues

Background Physician burnout, as well as low job satisfaction, and its negative influence on patient care are pervasive problems. This study evaluates whether a short mindfulness training program can increase job satisfaction, quality of life, and compassion among 30 primary care clinicians.

What This Study Found Participating in a brief mindfulness course consisting of a weekend immersion and 2 short follow-up evening sessions was associated with reduction in indicators of job burnout, depression, anxiety, and stress on 3 follow-up surveys at 1 day, 2 months, and 9 months postintervention. Specifically, at 9 months postintervention, participants had significantly better scores on all Maslach Burnout Inventory subscales, emotional exhaustion, depersonalization, and personal accomplishment, as well as on the depression, anxiety, and stress subscales of the Depression Anxiety Stress Scales-21 and perceived stress assessed with the Perceived Stress Scale.

Implications

• The effect was maintained over 9 months without formal intervention booster sessions, which suggests that even limited initial training may be enough to teach fundamental mindfulness practices.
• Mindfulness training appears to be a low-cost, time-efficient tool to help support clinician health and well-being, which may have implications for patient care. The authors call for a randomized controlled trial to confirm these results.

A Multicenter Study of Physician Mindfulness and Health Care Quality

Mary Catherine Beach , and colleagues

Background Mindfulness refers to a person?s tendency to remain attentive to their own experience, thoughts and feelings. Over the past decade, it has been recommended that physicians enhance their own capacities for mindfulness when practicing medicine and interacting with patients. This study assesses whether clinician self-rated mindfulness is associated with quality of patient care.

What This Study Found Physicians rating themselves as more mindful have more patient-centered communication and more satisfied patients. Measuring the mindfulness of 45 clinicians and later assessing the quality of their interactions with patients infected with the human immunodeficiency virus, researchers found mindful clinicians were more likely to be patient-centered in their communications, more positive in their emotional tone with patients and more likely to be rated highly on communication and overall satisfaction by patients.

Implications

• Mindfulness may be an important pathway to a more humanistic, effective and satisfying practice of medicine. The highly reciprocal influence of patients and clinicians on one another, the authors add, is in itself a powerful and positive medical tool--perhaps in some situations more powerful than other interventions that can be offered to patients. They call for future research to determine whether improving clinician mindfulness can also improve patient health outcomes.

Vaccinations Administered During Off-Clinic Hours at a National Community Pharmacy: Implications for Increasing Patient Access and Convenience

Leonard E. Fensterheim , and colleagues

Background An esimtated 50,000 adults die annually from vaccine-preventable diseases in the United States, and adult vaccination rates are below national goals. Although most clinicians offer vaccinations during traditional clinic hours (9:00 am to 5:00 pm, Monday through Friday), community pharmacies often offer expanded hours that allow patients to receive vaccinations at more convenient times. This study analyzes the types of vaccines administered and patient populations receiving vaccinations during off-clinic hours in a national community pharmacy and the implications on vaccination access and convenience.

What This Study Found Analyzing data on 6,250,402 vaccines administered at more than 7,500 Walgreens pharmacies across the United States during a year, researchers found 31 percent were provided during off-clinic hours: 17 percent were provided on weekends, 10 percent on weekday evenings, and 3 percent on federal holidays. Younger, working-aged, healthy adults, in particular, were more likely to obtain a variety of vaccinations during off-clinic hours. Specifically, patients had significantly higher odds of off-clinic vaccination if they were younger than 65 years of age, male, resided in an urban area, and did not have any chronic conditions.

Implications

• Allowing patients to seek and receive vaccinations at times that are most convenient to them, often when medical offices are closed, could increase immunization rates in the United States.
• The authors call for expanding the ability of pharmacists to administer all vaccines in all states by standing orders coupled with expanded hours of operation.

Natural Course of Cutaneous Warts Among Primary Schoolchildren: A Prospective Cohort Study

Sjoerd C. Bruggink , and colleagues

Background Because cutaneous warts resolve spontaneously and available treatments often fail, family physicians and patients may consider a wait-and-see policy. This study examines the natural course of cutaneous warts among primary schoolchildren and decisions about their treatment.

What This Study Found In this study of 1,099 Dutch children aged 4 to 12 years, 33 percent of children had cutaneous warts at baseline. One-half of children with warts were free of warts 1 year later despite any treatment. Resolution rates were higher among younger children and children with non-Caucasian skin type. During the 15 month follow-up, 38 percent of children and their parents decided to treat the warts, a decision that was more likely when warts were bigger and bothersome. Eighteen percent used over-the counter treatment only, 15 percent used a family physician-provided treatment only, and 5 percent used both.

Implications

• These findings may be useful in shared decision making with parents and children. The authors suggest that parents and family physicians should weigh the benign natural course, adverse effects of treatments, and costs on the one hand, and the effectiveness of treatments and risk of spreading untreated warts on the other.

Toward a Simple Diagnostic Index for Acute Uncomplicated Urinary Tract Infections

Bart J. Knottnerus , and colleagues

Background Sixty percent of all women experience at least one acute uncomplicated urinary tract infection (UTI) during their life. Various medical history questions and urine investigations can be used for UTI diagnosis. This study analyzes different approaches to diagnosing acute uncomplicated urinary tract infections in women and proposes a model that reduces the number of questions asked and urine investigations needed.

What This Study Found Analyzing data on 196 women presenting with painful and/or frequent urination, researchers find that 3 questions, sometimes followed by a urine dipstick test, can provide a practical level of accuracy. Specifically, they recommend asking (1) does the patient think she has a UTI, (2) is there at least considerable pain on urination and (3) is there vaginal irritation? Asking these questions, they find, may be sufficient to correctly classify more than one-half of women with painful and/or frequent urination as having UTI risk of either less than 30 percent or greater than 70 percent. Subsequent performance of nitrite and blood dipstick tests raises this proportion to 73 percent. The percentage rises to 83 percent if a urine dipstick is performed only for patients with a UTI risk between 30 percent and 70 percent after history and avoids the possibility of a false-negative nitrate tests in patients with high UTI risk (greater than 70 percent) after history.

Implications

• Expensive and time-consuming urinary sediment and dipslide tests may add little diagnostic information. The authors call for future research to validate these recommendations.

Cinnamon Use in Type 2 Diabetes: An Updated Systematic Review and Meta-Analysis

Olivia J. Phung , and colleagues

Background Cinnamon has been studied in patients with type 2 diabetes for its effects on lowering blood glucose levels, but studies have been small and show conflicting results. This updated analysis of existing research examines cinnamon's effect on glycemia and lipids.

What This Study Found Consumption of cinnamon is associated with a statistically significant decrease in levels of fasting plasma glucose, total cholesterol, low-density lipoprotein cholesterol and triglyceride, and an increase in high-density lipoprotein cholesterol. A meta-analysis of 10 randomized controlled trials evaluating the effects of cinnamon use in 543 patients with type 2 diabetes found reduced levels of fasting plasma glucose, total cholesterol, and triglycerides. Cinnamon also increased levels of HDL-C. No significant effect on hemoglobin A1c levels was seen.

Implications

• Despite the generally positive results, the authors advise caution in applying the results of this analysis to patient care because of the uncertainty of the dose and duration of cinnamon use and uncertainty of the ideal patient population.
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eCHAT: Lifestyle and Mental Health Screening in Primary Care

Felicity Goodyear-Smith , and colleagues

Background Developed by researchers in New Zealand, the webWeb-based eCHAT (electronic Case-Finding and Help Assessment Tool) screens patients for problematic drinking, smoking and other drug use, gambling, exposure to abuse, anxiety, depression, anger control, and physical activity, and whether they want help with these issues. This study assesses the feasibility and acceptability of systematic use of eCHAT.

What This Study Found eCHAT appears to be feasible, acceptable, and easily integrated into patients' electronic medical records. In this study, the tool was self-administered on an iPad in the waiting room by 196 consecutive patients visiting 2 primary care practices. Most patients found the iPad easy to use and the questions easy to understand and appropriate. Feedback from clinical and office staff was also generally positive. Domains where patients wanted immediate help were anxiety, depression, physical activity, and smoking. No patient requested help with more than one issue during the consultation, and physicians did not report being overwhelmed by the requests.

Implications

• eCHAT appears to be an acceptable tool for systematic finding of unhealthy behaviors and negative mood states in primary care. The authors suggest that the help question posed by the tool empowers patients to control the direction of their consultation, and call for future research to determine whether using eCHAT will lead to improved health outcomes.

Relationship Between Clinical Quality and Patient Experience: Analysis of Data From the English Quality and Outcomes Framework and the National GP Patient Survey

Nadia R. Llanwarne , and colleagues

Background Providing high-quality clinical care and a good patient experience are priorities for most health care systems, but there has been little research into the relationship between these 2 domains of quality. This study examines this relationship using data from 2 established measures of quality in primary care in England.

What This Study Found There is little correlation between quality of care assessed by clinical measures and that assessed by patient experience measures, suggesting that both are needed to get a balanced picture of quality. Analyzing patient experience and clinical performance data from 7,759 practices, researchers found although the correlations between clinical quality summary scores and patient survey scores were all positive, the strength of the associations was weak, with the highest correlation coefficient reaching 0.18, and more than one-half 0.11 or less. The strongest correlations with clinical quality were highest for patient assessments of access (ability to get through on the telephone, availability of urgent appointment, ability to book ahead, ability to see preferred doctor) and overall satisfaction. There were very low correlations between clinical quality and interpersonal aspects of care.

Implications

• The authors conclude that clinical and patient experience domains of quality need to be considered separately when assessing the overall performance of a family practice.

Being Uninsured Is Bad for Your Health: Can Medical Homes Play a Role in Treating the Uninsurance Ailment?

Jennifer E. DeVoe

Background In the United States, health insurance coverage is associated with better access to services and improved health outcomes.

What This Study Found A family physician reflects on the potential of primary care medical homes to partner with patients to reduce preventable mortality by helping them find and keep health insurance coverage. Ensuring all patients have the best and most continuous coverage available to them under existing and newly expanded programs may be as (or more) important than ensuring all patients have optimal blood pressure control, diabetes control, or timely cancer screenings. The author outlines how basic tenets of the chronic care model can be used to build systems that treat the United States' large "uninsurance" problem. Primary care clinicians are in a position to see how lack of insurance negatively affects health, and the author calls for the development of effective processes and tools within the medical home to help patients obtain health insurance, retain their coverage, or make important health insurance coverage decisions. Health care financing, she argues, should no longer be separate from the delivery of health care services.

Implications

• The author concludes that by adopting uninsurance and underinsurance as a chronic illness and applying the tenets and tools of the chronic care model to treat it, medical homes have the opportunity to improve population health and make a positive difference in the lives of patients.

Measuring Up: Musings of a Family Doctor on the Employee Time Clock

Ruth Kannai

Background A family physician in Israel reflects on how the introduction of an employee time clock at the health maintenance organization where she works influences everyday clinical decisions that affect the quality of care she provides her patients. She shares the mantra she routinely turns to with each hastened visit to reaffirm her professional integrity, pledging her allegiance first and foremost to her patients and her own standards of care.