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Racial and ethnic disparities in access to health care may result from discrimination. To identify differences in the rates at which patients belonging to racial/ethnic minority groups are offered primary care appointments and the number of days they wait for their primary care appointment and to understand the mechanisms by which discrimination occurs. This cross-sectional study used 7 simulated black, Hispanic, and white patient callers to request appointments from 804 randomized primary care offices in 2 urban centers in Texas from November 2017 to February 2018. Data analysis was conducted between February and December 2018. Research assistants called randomly assigned offices to schedule an appointment, supplying the same basic information. Race and ethnicity were signaled through callers' names and voices. Appointment offer rates, days to appointment, and questions asked during the call. Of the 7 callers (age range, 18-29 years), 2 (28.6%) self-identified as non-Hispanic black, 3 (42.9%) self-identified as non-Hispanic white, and 2 (28.6%) self-identified as Hispanic. Of the 804 calls they made, 299 (37.2%) were from simulated white callers, 215 (26.7%) were from simulated black callers, and 290 (36.1%) were from simulated Hispanic callers. Overall, 582 callers (72.4%) were offered appointments. In unadjusted models, black and Hispanic callers were more likely to be offered an appointment than white callers (black callers, 32.2 [95% CI, 25.1-39.3] percentage points more likely; P < .001; Hispanic callers, 21.1 [95% CI, 13.7-28.5] percentage points more likely; P < .001). However, after adjusting for whether insurance status was revealed, this statistical significance was lost. In adjusted models, black callers were 44.0 (95% CI, 36.2-51.8) percentage points more likely to be asked about their insurance status than white callers (P < .001), and Hispanic callers were 25.3 (95% CI, 17.1-33.5) percentage points more likely to be asked about their insurance status (P < .001) than white callers. Black and Hispanic callers received appointments further in the future than white callers (black callers: marginal effect estimate, 3.650; 95% CI, 0.579 to 6.721; P = .08; Hispanic callers: marginal effect estimate, 2.644; 95% CI, -0.496 to 5.784; P = .02). In this study, black and Hispanic patients were more likely to be offered an appointment, but they were asked more frequently about their insurance status than white callers. Black and Hispanic callers experienced longer wait times than white patients, indicating a barrier to timely access to primary care.

ABSTRACT BACKGROUND Rehospitalizations within 30 days of discharge are responsible for a large portion of healthcare spending. One approach to preventing rehospitalizations is early follow-up, usually defined as an office visit with a primary care physician within 7 days of discharge—an approach that is being incentivized by health plans. However, evidence regarding its effectiveness is limited. OBJECTIVE We aimed to determine whether an office visit with a primary care physician within 7 days after discharge is associated with 30-day rehospitalization. DESIGN This was an observational study set within a randomized trial. PARTICIPANTS The study included patients age 65 and older receiving care from a multi-specialty group practice and discharged from hospital to home between 26 August 2010 and 25 August 2011. To control for confounding, we identified characteristics of patients and hospital stays that are predictive of rehospitalization, and also developed high-dimensional propensity scores. Analyses used Cox proportional hazards models and took into account varying amounts of opportunity time for office visits. MAIN MEASURES We looked at 30-day rehospitalizations at any hospital. KEY RESULTS Of 3,661 patients discharged to home during the study year, 707 (19.3 %) were rehospitalized within 30 days. Patients receiving an office visit within 7 days numbered 1,808 (49.4 %), and of these, 1,000 (27.3 %) were with a primary care physician. In models predicting rehospitalization, stratified on deciles of propensity score and controlling for additional confounders, the hazard ratios associated with office visits with a primary care physician within 7 days were 0.98 (95 % CI 0.80, 1.21); for visits with any physician, the hazard ratio was HR 1.04, (95 % CI 0.87, 1.25). CONCLUSIONS We found no protective effect for office visits within 7 days. Such visits may need to be specifically focused on a range of issues related to the specific reasons why patients are rehospitalized. It is likely that outpatient visits will need to be set within comprehensive transition programs.

Given the preventable morbidity and mortality associated with atrial fibrillation (AF), increased awareness of undiagnosed AF, and advances in mobile electrocardiogram (ECG) technology, there is a critical need to assess the effectiveness of using such technology to routinely screen for AF in clinical practice. VITAL-AF is a pragmatic trial that will test whether screening for AF using a single-lead handheld ECG in individuals 65 years or older during primary care visits will lead to an increased rate of AF detection. The study is a cluster-randomized trial, with 8 primary care practices randomized to AF screening and 8 primary care practices randomized to usual care. We anticipate studying approximately 16,000 patients in each arm. During the 1-year enrollment period, practice medical assistants will screen eligible patients who agree to participate during office visits using a single-lead ECG device. Automated screening results are documented in the electronic health record, and patients can discuss screening results with their provider during the scheduled visit. All single-lead ECGs are overread by a cardiologist. Screen-detected AF is managed at the discretion of the patient's physician. The primary study end point is incident AF during the screening period. Key secondary outcomes include new oral anticoagulation prescriptions, incident ischemic stroke, and major hemorrhage during a 24-month period following the study start. Outcomes are ascertained based on electronic health record documentation and are manually adjudicated. The results of this pragmatic trial may help identify a model for widespread adoption of AF screening as part of routine clinical practice.

In children, intermittent asthma is the most common pattern and is responsible for the majority of exacerbations. Montelukast has a rapid onset of action and may be effective if used intermittently. To determine whether a short course of montelukast in children with intermittent asthma would modify the severity of an asthma episode. Children, aged 2-14 years with intermittent asthma participated in this multicenter, randomized, double-blind, placebo-controlled clinical trial over a 12-month period. Treatment with montelukast or placebo was initiated by parents at the onset of each upper respiratory tract infection or asthma symptoms and continued for a minimum of 7 days or until symptoms had resolved for 48 hours. A total of 220 children were randomized, 107 to montelukast and 113 to placebo. There were 681 treated episodes (345 montelukast, 336 placebo) provided by 202 patients. The montelukast group had 163 unscheduled health care resource utilizations for asthma compared with 228 in the placebo group (odds ratio, 0.65; 95% confidence interval, 0.47-0.89). There was a nonsignificant reduction in specialist attendances and hospitalizations, duration of episode, and beta-agonist and prednisolone use. Symptoms were reduced by 14% and nights awakened by 8.6% (p = 0.043), and days off from school or childcare by 37% and parent time off from work by 33% (p < 0.0001 for both). A short course of montelukast, introduced at the first signs of an asthma episode, results in a modest reduction in acute health care resource utilization, symptoms, time off from school, and parental time off from work in children with intermittent asthma.

In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed. To test an intervention to reduce patients' unmet concerns. Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys. Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania. A volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition. After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: \"Is there anything else you want to address in the visit today?\" (ANY condition) and \"Is there something else you want to address in the visit today?\" (SOME condition). Patients' unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys. Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients'; expression of unanticipated concerns not listed in previsit surveys. Patients' unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.

Aims/Introduction To clarify the relationship between medication use and primary care visit non‐attendance (missed appointment) among people with type 2 diabetes. Materials and Methods Data of 2,200 patients registered in the Japan Diabetes Outcome Intervention Trial‐2 Large‐Scale trial were reviewed. The intervention group received multifaceted interventions encouraging regular visits. The hazard ratios (HR) and 95% confidence intervals (CI) of oral medications relative to not taking any oral medications were estimated using the Cox proportional hazards model, adjusted for district medical association ID, intervention, insulin usage, age, sex, and HbA1c. We also investigated whether the HRs differed based on the oral medication type. Furthermore, we divided the intervention and control groups into four groups based on medication use (taking/not taking oral medications and insulin therapy) and performed survival analysis for each group. Results The HRs (95% CI) for oral medication use relative to not taking oral medications and for insulin use relative to not receiving insulin therapy were 0.178 (0.104–0.305) and 0.725 (0.378–1.352), respectively. Regardless of the type of oral medication, non‐attendance was lower in the groups taking oral medications. The HRs (95% CI) in the groups taking only oral hypoglycemic agents, only other drugs, and both relative to no oral medication were 0.229 (0.126–0.417), 0.235 (0.112–0.494), and 0.148 (0.084–0.260), respectively. Only in the control group, non‐attendance was more frequent with no medications than with oral medications, regardless of insulin (P < 0.01, respectively). Conclusions Our findings suggest that taking oral medications might be important to prevent non‐attendance among people with type 2 diabetes. Taking oral medications might prevent non‐attendance, and multifaceted interventions might prevent non‐attendance, regardless of medication use. However, no significant difference was observed in insulin usage.

442 pre-ART, HIV-infected adults were randomized to peer support consisting of structured home visits to promote clinic attendance and preventive care intervention use or standard of care. At baseline, 62 % reported previously visiting an HIV clinic, 45 % reported taking cotrimoxazole prophylaxis, and 31 % were “care-naïve” (no previous clinic visit and not on cotrimoxazole). After 1 year, intervention participants were more likely to report being in care (92 vs 84 %; PRR 1.09, p = 0.039), on cotrimoxazole (89 vs 81 %; PRR 1.10, p = 0.047), and safe water vessel adherence (23 vs 14 %; PRR 1.64, p = 0.024). The effect was observed only among care-naïve participants (n = 139) with 83 % intervention versus 56 % controls reporting being in HIV care (PRR 1.47, p = 0.006), 78 versus 58 % on cotrimoxazole (PRR 1.35, p = 0.04), and 20 versus 4 % safe water vessel adherence (PRR 5.78, p = 0.017). Peer support may be an effective intervention to facilitate pre-ART care compliance in this important population.

To analyze the impact of different recall lengths on agreement between self-reported physician visits and those documented in health insurance data applying an experimental design. We randomly assigned 432 patients with diabetes to one of two versions of a written survey, each asking about the number of physician visits over a 3- or 6-month recall period. Health insurance data were linked individually. In both groups, the mean number of self-reported physician visits per month was lower than in the insurance data, with a larger difference in the 6-month group (−0.9; 95% CI −1.0, −0.7) than in the 3-month group (−0.5; −0.7; −0.2), difference between the two groups: 0.4 (0.1–0.7; P = 0.009). The percentage of participants with correct reporting was small and did not differ largely between the two groups (6.5% and 9.3%). However, there was more overreporting in the 3-month group (25.6% vs. 11.1%). Shorter recall periods may produce more accurate results when estimating the mean number of physician visits. However, this may be driven not by a more accurate reporting, but by a higher proportion of respondents that overreported and a lower proportion of respondents that underreported, when compared to the longer reporting period.

With depression known to impede HIV care adherence and retention, we examined whether depression alleviation improves these disease management behaviors. A sample of 1028 depressed HIV clients in Uganda enrolled in a cluster randomized controlled trial of two depression care models, and were surveyed over 12 months. Serial regression analyses examined whether depression alleviation was associated with self-reported antiretroviral therapy (ART) adherence and clinic attendance at month 12, and whether these relationships were mediated by self-efficacy and motivation. Among those with major depression, depression alleviation was associated with better ART adherence and clinic attendance at month 12; these relationships were fully mediated by self-efficacy at month 12, while adherence motivation partially mediated the relationship between depression alleviation and ART adherence. When both mediators were entered simultaneously, only self-efficacy was a significant predictor and still fully mediated the relationship between depression alleviation and adherence. These findings suggest that depression alleviation benefits both ART adherence and clinic attendance, in large part through improved confidence and motivation to engage in these disease management behaviors.

We assessed the effectiveness of the treatment supporter initiative as an intervention in improving clinic attendance for antiretroviral (ARV) drug refills and adherence to antiretroviral therapy (ART) in a cohort of HIV-infected adults. This two-arm randomized controlled trial was undertaken at an HIV clinic in a district hospital in Uganda. A total of 174 adult patients on ART were randomized 1:1 to a standard adherence intervention package plus a treatment supporter intervention (TS arm) or to a standard adherence intervention package (non-TS arm) alone. Clinic attendance for refills and adherence measurements using monthly clinic-based pill counts were monitored for both arms for 28 weeks. Baseline characteristics were similar for both arms. There was a non-significant difference in mean adherence between the TS and non-TS groups at end of follow-up [99.1% (95% CI: 98.3–99.9% vs. 96.3% (95% CI: 94.2–98.3%), P  > 0.05]. TS participants had more than four times the odds of achieving optimal adherence (≥95%) [Odds ratio (OR) = 4.51, 95% CI: 1.22–16.62, exact P  = 0.027]. TS participants were also more likely to be on time for their clinic appointments: 91.6 vs. 90.1% for TS and non-TS, respectively (OR = 1.19, 95% CI: 0.74–1.91, P  > 0.05). Use of patient-selected treatment supporters may be an effective intervention to improve ARV treatment outcomes in resource-constrained settings.