Associations between Difficulty Paying Medical Bills and Forgone Medical and Prescription Drug Care.

Problems paying medical bills have been reported to be associated with increased stress, bankruptcy, and forgone medical care. Using the Behavioral Model for Vulnerable Populations developed by Gelberg et al as a framework, as well as data from the 2010 Ohio Family Health Survey, this study examined the relationships between difficulty paying medical bills and forgone medical and prescription drug care. Logistic regression was used to examine associations between difficulty paying medical bills and predisposing, enabling, need (health status), and health behaviors (forgoing medical care). Difficulty paying medical bills increased the effect of lack of health insurance in predicting forgone medical care and had a conditional effect on the association between education and forgone prescription drug care. Those who had less than a bachelor's degree were more likely to forgo prescription drug care than those with a bachelor's degree, but only if they had difficulty paying medical bills. Difficulty paying medical bills also accounted for the relationships between several population characteristics (eg, age, income, home ownership, health status) in predicting forgone medical and prescription drug care. Policies to cap out-of-pocket medical expenses may mitigate health disparities by addressing the impact of difficulty paying medical bills on forgone care.

The assessment and treatment of back and neck pain: an initial investigation in a primary care practice-based research network.

AIM: The purpose of this study was to conduct an exploratory examination of the current state of non-malignant acute and chronic back and neck pain assessment and management among primary care providers in a multi-site, practice-based research network. BACKGROUND: Acute and chronic pain are distinct conditions that often require different assessment and management approaches, however, little research has examined assessment and management of acute and chronic pain as separate conditions. The large majority of patients with acute and chronic back and neck pain are managed in primary care settings. Given the differences between acute and chronic pain, it is necessary to identify differences in patient characteristics, practitioner evaluation, treatment and management in primary care settings. METHODS: Over a two-week period, 24 practitioners in a multi-site practice-based research network completed 196 data cards about 39 patients experiencing acute back and neck pain and 157 patients suffering from chronic back and neck pain. Findings There were significant differences between the patients experiencing acute and chronic pain in regards to practitioner evaluation, current medication management and current treatment for depression. In addition, diagnostics differed between patients experiencing acute versus chronic back and neck pain. Further, primary care providers' review of online drug monitoring program reports during the current visit was associated with current medication management using short term opioids, long-term opioids or tramadol. Most research examining acute and chronic pain focuses on the low back. Additional research needs to be conducted to explore and compare acute and chronic pain across the whole spine.

Door-to-balloon times from freestanding emergency departments meet ST-segment elevation myocardial infarction reperfusion guidelines.

BACKGROUND: Freestanding emergency departments (FEDs) introduce a challenge to physicians who care for the patient with an ST-segment elevation myocardial infarction (STEMI) because treatment is highly time dependent. FEDs have no percutaneous coronary intervention (PCI) capabilities, which necessitates transfer to a PCI-capable facility or fibrinolysis. STUDY OBJECTIVE: Our aim was to determine the proportion of STEMI patients who arrived to an FED and were subsequently transferred for PCI and met the door-to-balloon reperfusion guidelines of 90 min. METHODS: This was a dual-center retrospective cohort review of all patients 18 years and older who were diagnosed with an STEMI and presented to the main hospital-affiliated FEDs. Electronic medical records and emergency medical services documentation were reviewed for all cases since the opening of the FEDs in July 2007 and August 2009, respectively. Key time points were abstracted and statistical evaluation was performed using Fisher's exact test. RESULTS: A total of 47 patients met inclusion criteria. Median door-to-transport time was 34 min (interquartile range [IQR] 15 min). Median transport time from the FEDs to the main hospital catheterization laboratory was 21 min (IQR 5 min). Median arrival at the catheterization laboratory-to-balloon time was 25 min (IQR 13 min). Median total door-to-balloon time was 83 min (IQR 10.5 min), with 78.7% meeting the American Heart Association's recommended guidelines of ≤ 90 min. CONCLUSION: STEMI patients initially seen at two FEDs achieved door-to-balloon time goals of < 90 min.

Professional judgments about advance care planning with community-dwelling consumers.

CONTEXT: There is limited research on how community-based long-term care (CBLTC) providers' personal characteristics and attitudes affect their decisions to initiate advance care planning (ACP) conversations with consumers. OBJECTIVES: To examine judgments by CBLTC providers as to whether a consumer was in need of ACP and to compare the relative influence of situational features of the consumer with the influence of personal characteristics of the CBLTC provider. METHODS: Factorial surveys with vignettes with randomly assigned situational features of a hypothetical consumer were obtained from 182 CBLTC providers at three Area Agencies on Aging located in the Midwestern U.S. Measures included the consumer's situational features, such as demographics, diagnosis, pain level, level of functioning, and caregiver involvement. Personal characteristics of the CBLTC provider included demographics, discipline, past experience with ACP, and attitudes toward ACP. RESULTS: Hierarchical linear models indicated that most variability in ACP decisions was the result of differences among CBLTC providers (64%) rather than consumers' situational features. Positive decisions to discuss ACP were associated with consumers who needed assistance with legal issues and had a cancer diagnosis; these variables explained 8% of the vignette level variance. Significant personal characteristics of the CBLTC provider included a nursing background, less direct contact with consumers, past experience with ACP, and positive attitudes toward ACP; these variables explained 41% of the person-level variance. CONCLUSION: This study shows the lack of normative consensus about ACP and highlights the need for consistent educational programs regarding the role of the CBLTC provider in the ACP process.

Patient preferences in choosing a primary care physician.

BACKGROUND AND AIMS: Studies have identified factors important to patients in consideration of a primary care physician (PCP). Few have explored relevant differences in choosing between family medicine (FM) and internal medicine (IM) physicians. The objective of this study was to identify differences in rating of factors perceived to be important to racially diverse FM and IM patients in the selection of a PCP, and to determine patient knowledge of PCP training. SETTINGS, DESIGN, METHODS, AND MATERIAL: This observational study used self-administered questionnaires to obtain information from adult participants at 2 continuity clinics, FM and IM. Participants rated 16 factors on their importance in selecting a PCP. Demographics and information regarding participants' knowledge of PCP training were collected. STATISTICAL ANALYSES USED AND RESULTS: 857 surveys were completed. Data were analyzed using descriptive statistics, Student t test, χ(2), and multivariate logistic regression. Sixty-five percent and 32% of participants were Caucasian or African American, respectively. Combined responses from both clinics revealed good patient care as the factor ranked highest in importance for selecting a PCP, followed by good communication skills. Forty-eight percent and 35% of FM and IM participants, respectively, did not know whether their PCP was trained in IM or FM. More than 50% of participants were not familiar with the scope of their physicians' practice. CONCLUSIONS: Our results suggest that good patient care and communication are similarly important to all patients, regardless of race. Practices should maintain focus on these qualities, as well as on patient education regarding the relevant differences between FM and IM physicians. Results from this study are consistent with prior research on these issues in more racially homogenous populations.

Perfusion pressures and distal oxygenation in individuals with diabetes undergoing chronic hemodialysis.

BACKGROUND: The number of diabetic patients worldwide was estimated to be approximately 285 million in 2010. Approximately 5% of all diabetic patients have foot ulcers, often preceded by neuropathy and delayed healing resulting from peripheral vascular disease which leads to increased risk of infection. Additionally, there is a concern that blood flow to the feet may be reduced in patients with diabetes, which may be further compounded by changes in lower extremity perfusion pressure during hemodialysis. Current laser Doppler technology provides the opportunity to identify changes in vascularityin a non-invasive fashion. MATERIALS AND METHODS: A prospective, parallel-arm, comparison, pilot study was conducted. A total of 15 patients were enrolled, ten of whom had a documented history of diabetes. All patients required hemodialysis. Peripheral perfusion and oxygenation measurements were obtained before, midway and at the conclusion of three separate dialysis sessions within a 3-week interval for each subject. RESULTS: Preliminary results indicate a significant reduction in toe pressure during and after hemodialysis in the diabetic patient group compared to the non-diabetic group. Significant differences were not found in skin perfusion measurements or in the oxygenation measurements at any time in diabetic and nondiabetic patients undergoing hemodialysis. CONCLUSION: Preliminary results suggest hemodialysis may significantly affect pressure of the lower extremities in diabetic patients. Trends from these data indicate the need to further investigate the effect of hemodialysis on techniques used to heal wounds and ulcers in patients with diabetes.

Suppression of transforming growth factor-ß effects in rabbit subconjunctival fibroblasts by activin receptor-like kinase 5 inhibitor.

PURPOSE: Transforming growth factor-ß (TGF-ß) activity has been implicated in subconjunctival scarring in eyes following glaucoma filtration surgery (GFS). The purpose of this study is to determine whether an inhibitor for activin receptor-like kinase (ALK) 5 (also known as TGF-ß receptor type I) could suppress TGF-ß activity and thereby promote filtering bleb survival after GFS in a rabbit model. METHODS: An ALK-5 inhibitor, SB-505124, was used. A docking study was performed to investigate the interaction between the inhibitor and the receptor. Immunofluorescence for connective tissue growth factor (CTGF) and α-smooth muscle actin (α-SMA) was performed in cultured rabbit subconjunctival fibroblasts. Immunoblotting for phosphorylated Smad2 (pSmad2), CTGF, and α-SMA was also performed. In an in vivo rabbit GFS model, SB-505124 was delivered in a lactose tablet during surgery. Eyes were examined by slit-lamp and intraocular pressure (IOP) was measured until the time of bleb failure or up to 28 days after surgery. Tissue sections on day 5 after surgery were histologically evaluated after staining with hematoxylin and eosin. The sections were also immunostained for CTGF and α-SMA. In addition, cell outgrowth from dissected subconjunctival tissues placed in a cell culture flask with media was investigated. RESULTS: The docking study indicated hydrogen bond interactions between SB-505124 and amino acids His-283 and Ser-280 of ALK-5. Suppression of pSmad2, CTGF, and α-SMA by SB-505124 was observed in cultured fibroblasts. Filtering blebs in the GFS with SB-505124 group were maintained for more than 10 days, and the period of bleb survival was significantly longer than that in controls. IOP levels after surgery seemed to be related to bleb survival. Histologically, subconjunctival cell infiltration and scarring at the surgical site in the GFS with SB-505124 and mitomycin C (MMC) groups were much subsided compared to controls. Suppression of CTGF and α-SMA by SB-505124 was also observed by immunofluorescence. Cell outgrowth from explants dissected from eyes to which SB-505124 was applied during GFS was robust while outgrowth was poor from those treated with MMC. CONCLUSIONS: The ALK-5 inhibitor SB-505124 was efficacious both in vitro and in vivo in suppressing the TGF-ß action. The inhibitor may provide a novel therapy for preventing ocular inflammation and scarring.