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No Easy Talk: A Mixed Methods Study of Doctor Reported Barriers to Conducting Effective End-of-Life Conversations with Diverse Patients

July 9, 2015 Comments off

No Easy Talk: A Mixed Methods Study of Doctor Reported Barriers to Conducting Effective End-of-Life Conversations with Diverse Patients
Source: PLoS ONE

Objective
Though most patients wish to discuss end-of-life (EOL) issues, doctors are reluctant to conduct end-of-life conversations. Little is known about the barriers doctors face in conducting effective EOL conversations with diverse patients. This mixed methods study was undertaken to empirically identify barriers faced by doctors (if any) in conducting effective EOL conversations with diverse patients and to determine if the doctors’ age, gender, ethnicity and medical sub-specialty influenced the barriers reported.

Design
Mixed-methods study of multi-specialty doctors caring for diverse, seriously ill patients in two large academic medical centers at the end of the training; data were collected from 2010 to 2012.

Outcomes
Doctor-reported barriers to EOL conversations with diverse patients.

Results
1040 of 1234 potential subjects (84.3%) participated. 29 participants were designated as the development cohort for coding and grounded theory analyses to identify primary barriers. The codes were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort (n= 996 doctors). Qualitative responses from the validation cohort were coded and analyzed using quantitative methods. Only 0.01 % doctors reported no barriers to conducting EOL conversations with patients. 99.99% doctors reported barriers with 85.7% finding it very challenging to conduct EOL conversations with all patients and especially so with patients whose ethnicity was different than their own. Asian-American doctors reported the most struggles (91.3%), followed by African Americans (85.3%), Caucasians (83.5%) and Hispanic Americans (79.3%) in conducting EOL conversations with their patients. The biggest doctor-reported barriers to effective EOL conversations are (i) language and medical interpretation issues, (ii) patient/family religio-spiritual beliefs about death and dying, (iii) doctors’ ignorance of patients’ cultural beliefs, values and practices, (iv) patient/family’s cultural differences in truth handling and decision making, (v) patients’ limited health literacy and (vi) patients’ mistrust of doctors and the health care system. The doctors’ ethnicity (Chi-Square = 12.77, DF = 4, p = 0.0125) and medical subspecialty (Chi-Square = 19.33, DF = 10, p =0.036) influenced their reported barriers. Friedman’s test used to examine participants relative ranking of the barriers across sub-groups identified significant differences by age group (F statistic = 303.5, DF = 5, p < 0.0001) and medical sub-specialty (F statistic =163.7, DF = 5, p < 0.0001).

Conclusions and Relevance
Doctors report struggles with conducting effective EOL conversations with all patients and especially with those whose ethnicity is different from their own. It is vital to identify strategies to mitigate barriers doctors encounter in conducting effective EOL conversations with seriously ill patients and their families.

CRS — The Mental Health Workforce: A Primer (April 16, 2015)

July 8, 2015 Comments off

The Mental Health Workforce: A Primer (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

Congress has held hearings and introduced legislation addressing the interrelated topics of the quality of mental health care, access to mental health care, and the cost of mental health care. The mental health workforce is a key component of each of these topics. The quality of mental health care depends partially on the skills of the people providing the care. Access to mental health care relies on, among other things, the number of appropriately skilled providers available to provide care. The cost of mental health care depends in part on the wages of the people providing care. Thus an understanding of the mental health workforce may be helpful in crafting policy and conducting oversight. This report aims to provide such an understanding as a foundation for further discussion of mental health policy.

Despite Increased Use of Electronic Medical Records, Fewer U.S. Doctors Believe It Improves Health Outcomes, Accenture Survey Shows

June 25, 2015 Comments off

Despite Increased Use of Electronic Medical Records, Fewer U.S. Doctors Believe It Improves Health Outcomes, Accenture Survey Shows
Source: Accenture

A new survey by Accenture (NYSE: ACN) found that most U.S. doctors are more proficient using electronic medical records (EMR) than they were two years ago, but fewer believe that EMR has improved treatment decisions, reduced medical errors or improved health outcomes.

The U.S. findings, part of a six-country survey of more than 2,600 physicians, including roughly 600 in the United States, found that healthcare IT use among doctors has averaged double-digit growth, since Accenture conducted a similar survey in 2012. However, despite doctors increasing their use of technology over that time, fewer physicians believe that EMR has improved treatment decisions (46 percent in 2015 vs. 62 percent in 2012), reduced medical errors (64 vs. 72 percent) and improved health outcomes for patients (46 vs. 58 percent).

Expanding coverage: How primary care physicians are accommodating the newly insured

May 21, 2015 Comments off

Expanding coverage: How primary care physicians are accommodating the newly insured
Source: Deloitte

Are there enough physicians in the US to accommodate the millions of newly insured patients? If not, how will the health care system manage its growing (and aging) patient population?

The Deloitte Center for Health Solutions 2014 Survey of US Physicians shows that 44 percent of physicians are treating more newly insured patients – an important finding for health care stakeholders and decision makers. More primary care physicians (PCPs) (56 percent) experienced an increase in the number of newly insured patients than did surgical specialists (40 percent), non-surgical specialists (38 percent), and other physicians (33 percent). Survey respondents report that this is causing longer appointment wait times and driving PCPs to work longer hours. To cope, some PCPs are adding new physicians and hiring clinical staff to help with care coordination.

Expanding coverage: How primary care physicians are accommodating the newly insured

May 14, 2015 Comments off

Expanding coverage: How primary care physicians are accommodating the newly insured
Source: Deloitte

Are there enough physicians in the US to accommodate the millions of newly insured patients? If not, how will the health care system manage its growing (and aging) patient population?

The Deloitte Center for Health Solutions 2014 Survey of US Physicians shows that 44 percent of physicians are treating more newly insured patients – an important finding for health care stakeholders and decision makers. More primary care physicians (PCPs) (56 percent) experienced an increase in the number of newly insured patients than did surgical specialists (40 percent), non-surgical specialists (38 percent), and other physicians (33 percent). Survey respondents report that this is causing longer appointment wait times and driving PCPs to work longer hours. To cope, some PCPs are adding new physicians and hiring clinical staff to help with care coordination.

How does this compare with the Massachusetts experience with coverage expansion? What impacts will expansion of health care coverage to the newly insured have at national and state levels? What effect will it have on the role of the US safety net system and hospital emergency departments? How will growth in the insured population affect mid-level providers and retail health and urgent care clinics?

Physicians are already experiencing increased demand from a larger patient population. Adapting to that demand is one of the next challenges, not only for physicians, but for many health care stakeholders and decision makers. States and other policy makers may want to consider policy solutions to alleviate physician pressure, including increasing Medicaid primary care service reimbursement rates, sponsoring patient-centered medical homes (PCMH), advancing scope-of-practice standards, and reducing barriers to technology adoption. While physicians will continue to play a critical role in the US health care system, they will likely need to adapt to ever-growing patient numbers and demands. And, they should adapt quickly and prepare to weather the storm. Physician practices should consider redesigning care delivery models, developing new relationships, using data and analytics, and improving patient engagement.

Federal and State Standards for “Essential Community Providers” under the ACA and Implications for Women’s Health

May 13, 2015 Comments off

Federal and State Standards for “Essential Community Providers” under the ACA and Implications for Women’s Health
Source: Kaiser Family Foundation

Millions of previously uninsured Americans have gained access to health coverage through the Affordable Care Act (ACA) Marketplace plans. The provider networks of the Marketplace plans determine where enrollees can seek medical care. Many of these individuals have received their care for years from safety-net providers, such as community health centers and family planning clinics. Recognizing the important role these providers play in promoting continuity of care as people transition from being uninsured and relying on safety net clinics to private insurance, and to meet the increased demand for medical care in underserved communities, Congress established general requirements to assure that these providers have the opportunity to participate in the health plans that are offered through the Marketplaces. These safety net clinics and hospitals are referred to as Essential Community Providers (ECPs), and the ACA specifically requires that Qualified Health Plans available through the federal or state insurance Marketplaces have a “sufficient number and geographic distribution of ECPs, where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in the plan’s service area.”1 Because both the Center for Medicare and Medicaid Services (CMS) and state regulators can have the authority to decide how to implement the broad ECP standard, there is considerable variation across the country in both the categories of providers included as ECPs as well as the standards required for inclusion in plan networks. This brief reviews the definition of ECP, examines the federal and state rules that govern the extent to which plans must include these providers in their networks, identifies the variation from state to state, and discusses the particular importance of these rules and providers for women’s access to care.

UK — National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

March 27, 2015 Comments off

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
Source: University of Manchester

We found 18 deaths by suicide per year in in-patients under observation across the UK during 2006-12. We found that half of deaths examined occurred when checks were carried out by less experienced staff or agency staff who were unfamiliar with the patient. A common feature was that staff did not follow the observation plan because the ward was busy or poorly designed. We found that the current observation approach is not working safely enough. New models need to be developed and evaluated.

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