It takes quality improvement to cross the chasm.

Healthcare organisations in the USA rank significantly lower in quality of care compared with other developed nations. Research shows US performance emphasises expensive treatment over effective prevention programmes. This study demonstrates how a comprehensive quality improvement programme can improve health outcomes in a large county-based Medicaid health plan. The health plan serves a diverse community of members spanning racial and ethnic groups with varying levels of clinical risk and social determinants of health burdens. We used a regression discontinuity design to evaluate the impact of a comprehensive quality improvement programme vs using mainly pay-for-performance on Healthcare Effectiveness Data and Information Set (HEDIS) metrics over the course of 10 years. We found significant improvements in several HEDIS metrics that occurred after the quality improvement programme was implemented. These results demonstrate the importance of using a comprehensive quality improvement strategy along with pay-for-performance to improve health outcomes. It was determined that this research was exempt from institutional review board approval, as it used administrative healthcare data, and did not involve direct interventions with human subjects.

A higher Asthma Medication Ratio (AMR) predicts a decrease in ED visits among African American and Hispanic children.

INTRODUCTION: Higher rates of ED visits and hospitalizations for asthma among African American and Hispanic children may indicate suboptimal management of asthma, leading to a greater financial burden of healthcare. It is not well known if an association of race/ethnicity with controller medication and hospital-based care utilization exists. OBJECTIVE: This study examines whether the Asthma Medication Ratio (AMR) predicts healthcare utilization for asthma by race/ethnicity. METHODS: 4,584 Medi-Cal children (Ages 5-11) with persistent asthma in Los Angeles were identified and their AMRs (2018) were calculated based on the HEDIS criteria. Healthcare utilization data were used, including hospitalizations, ED visits, and pharmacy claims to examine whether a higher AMR predicts decreases in healthcare utilization by race/ethnicity in the subsequent 3,6, and 12 months (2019). RESULTS: The average AMR was lowest among African American children (0.401). In the subsequent 12 months, they were highest in ED visits (0.249) and hospitalizations (0.121), but lowest in outpatient visits (0.793). The results of logistic regression showed that a higher value of AMR (>0.5) contributed to decreases in ED visits in the subsequent 12 months only among African Americans (OR = 0.551, 95% CI 0.364-0.832) and Hispanics (OR = 0.613, 95% CI 0.489-0.770). No association between AMR and hospitalizations was found. CONCLUSIONS: Our findings indicate that increased use of controller medication contributes to a decrease in ED visits among African American and Hispanic children with persistent asthma. Increased use of controller medications and caregiver's efforts for medication adherence may contribute to a reduction in asthma disparities.

Determinants of racial and ethnic disparities in utilization of hospital-based care for asthma among Medi-Cal children in Los Angeles.

OBJECTIVE: We sought to identify racial/ethnic patterns of health care utilization for asthma among asthmatic children (ages 0-18) and address unequal access to optimal asthma management as a determinant of asthma disparities. METHODS: We used children Medi-Cal (California's Medicaid program) enrollees, including African American, Asian, Hispanic, and White children in Los Angeles and retrieved individual hospital utilization records of 69,118 asthmatic children (2013-2018). We applied Hierarchical Generalized Linear Models (HGMLs) to identify the patterns of health care utilization at the individual level, controlling for demographic and neighborhood characteristics. RESULTS: African American children show a higher ratio of ED to outpatient visits (OR = 1.32, 95% CI 1.08-1.62) and hospitalizations to outpatient visits (OR = 1.50, 95% CI 1.30-1.73). They also had a high ratio of ED visits (OR = 1.36, 95% CI 1.10-1.68) and hospitalizations (OR = 1.47, 95% CI 1.26-1.71) relative to PCP visits. A ratio of ED visits and hospitalizations decreased if a ratio of controller medications to total medications was greater than 0.5, but increased if children were male, under 11 years old, or living in low-income neighborhoods (Median household income < 25th percentile, $45,629) with high poverty rates (>20%). CONCLUSIONS: African American male children from disadvantaged neighborhoods are at the highest risk for higher utilization of hospital-based care for asthma. Our findings also indicate a lower ratio of controller medications contributed to increases in ED visits and hospitalizations, suggesting suboptimal management of asthma and a lack of intervention treatment through medications among minority children.

Are severe depressive symptoms associated with infertility-related distress in individuals and their partners?

STUDY QUESTION: Are severe depressive symptoms in women and men associated with individual and dyadic infertility-related stress in couples undergoing infertility treatment? SUMMARY ANSWER: Severe depressive symptoms were significantly associated with increased infertility-related distress at both the individual and partner level. WHAT IS KNOWN ALREADY?: An infertility diagnosis, the stress of medical treatments and a prior history of depression are risk factors for future depression in those undergoing fertility treatments. Studies examining the impact of severe depressive symptoms on infertility-related distress in couples are lacking. STUDY DESIGN, SIZE, DURATION: This cross-sectional study included 1406 couples who were consecutively referred patients undergoing fertility treatments in Denmark in the year 2000. A total of 1049 men and 1131 women were included in the study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were consecutively referred patients undergoing a cycle of medically assisted reproduction treatment at five Danish public and private clinics specializing in treating fertility patients. Severe depressive symptoms were measured by the Mental Health Inventory 5 from the Short Form Health Survey 36. Infertility distress was measured by the COMPI Fertility Problem Stress Scales. Multilevel modelling using the actor-partner interdependence model was used to study the couple as the unit of analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Severe depressive symptoms were reported in 11.6% of women and 4.3% of men, and were significantly associated with increased infertility-related distress at the individual and partner level. There was no significant interaction for gender indicating that men and women did not differ in how severe depressive symptoms were associated with infertility distress. LIMITATIONS, REASON FOR CAUTION: Because of the cross-sectional study design, the study findings only show an association between severe depressive symptoms to individual and partner distress at a single point in time; however, nothing is known about causality. WIDER IMPLICATIONS OF THE FINDINGS: This study adds to the growing body of literature using the couple as the unit of analysis to study the relationship between depression and infertility distress. Recommendations for medical and mental health professionals that underscore the potential risk factors for depressed men and women who are pursuing infertility treatments are provided. Additional studies using a longitudinal study design to track the impact of depression on distress over the course of the infertility treatment cycle would be valuable for increasing our understanding of the complex relationship that exists between these psychosocial factors. STUDY FUNDING/COMPETING INTERESTS: Authors Brennan Peterson and Matthew Pirritano have no financial disclosures for this study. Camilla Sandal Sejbaek and Lone Schmidt have received research grants from the Danish Health Insurance Foundation (J. nr. 2008B105) and Merck Sharp & Dohme. The funders had no influence on the data collection, analyses or conclusions of the study.

Fertility awareness and parenting attitudes among American male and female undergraduate university students.

BACKGROUND: In the USA, the postponement of childbearing reflects contemporary social norms of delaying marriage, pursing educational goals and securing economic stability prior to attempting conception. Although university students are more likely to delay childbearing, it is unclear to what extent they are aware of age-related fertility decline. The current study is the first of its kind to assess fertility awareness and parenting attitudes of American undergraduate university students. METHODS: Two-hundred forty-six randomly selected undergraduate university students (138 females and 108 males) completed an online self-report survey adapted from the Swedish Fertility Awareness Questionnaire. Students were evenly distributed between the freshman, sophomore, junior and senior classes with a mean age of 20.4 years. RESULTS: Participants wanted to have their first and last child within the window of a woman's fertility. However, participants demonstrated a lack of fertility awareness by vastly overestimating the age at which women experience declines in fertility, the likelihood of pregnancy following unprotected intercourse and the chances that IVF treatments would be successful in the case of infertility. Nearly 9 in 10 participants want to have children in the future and viewed parenthood as a highly important aspect of their future lives. CONCLUSIONS: Delaying childbearing based on incorrect perceptions of female fertility could lead to involuntary childlessness. Education regarding fertility issues is necessary to help men and women make informed reproductive decisions that are based on accurate information rather than incorrect perceptions.

Marital benefit and coping strategies in men and women undergoing unsuccessful fertility treatments over a 5-year period.

OBJECTIVE: To assess the relationship between infertility, marital benefit, and coping in a sample of men and women undergoing unsuccessful fertility treatments. DESIGN: Prospective longitudinal cohort design using multilevel modeling. SETTING: Danish public and private hospitals (n = 5) specializing in treating fertility patients. PATIENT(S): Participants were Danish men and women about to start a cycle of medically assisted reproduction treatment who were followed for a 5-year period of unsuccessful treatments. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The Copenhagen Multicenter Psychosocial Infertility research program Coping Strategy Scales and Marital Benefit Measure. RESULT(S): Compared with men, a greater percentage of women reported high levels of marital benefit. For active-avoidance coping, there was a significant partner effect by gender interaction. Meaning-based strategies increased between 1 and 5 years for men and women. The use of meaning-based coping had a significant positive actor effect with marital benefit for both men and women. CONCLUSION(S): Approximately one-third of participants undergoing unsuccessful fertility treatments reported high marital benefit as a positive consequence of the infertility experience. Partner effects for men and women related to active-avoidance coping may be related to the degree of emotional support that each spouse can offer the other, whereas differences in meaning-based coping indicate a possible timing effect related to gender.

Impact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system.

The Medical Services Initiative program--a safety net-based system of care--in Orange County included assignment of uninsured, low-income residents to a patient-centered medical home. The medical home provided case management, a team-based approach for treating disease, and increased access to primary and specialty care among other elements of a patient-centered medical home. Providers were paid an enhanced fee and pay-for-performance incentives to ensure delivery of comprehensive treatment. Medical Services Initiative enrollees who were assigned to a medical home for longer time periods were less likely to have any emergency room (ER) visits or multiple ER visits. Switching medical homes three or more times was associated with enrollees being more likely to have any ER visits or multiple ER visits. The findings provide evidence that successful implementation of the patient-centered medical home model in a county-based safety net system is possible and can reduce unnecessary ER use.

A randomized trial of methods to help clinicians learn motivational interviewing.

The Evaluating Methods for Motivational Enhancement Education trial evaluated methods for learning motivational interviewing (MI). Licensed substance abuse professionals (N = 140) were randomized to 5 training conditions: (a) clinical workshop only; (b) workshop plus practice feedback; (c) workshop plus individual coaching sessions; (d) workshop, feedback, and coaching; or (e) a waiting list control group of self-guided training. Audiotaped practice samples were analyzed at baseline, posttraining, and 4, 8, and 12 months later. Relative to controls, the 4 trained groups showed larger gains in proficiency. Coaching and/or feedback also increased posttraining proficiency. After delayed training, the waiting list group showed modest gains in proficiency. Posttraining proficiency was generally well maintained throughout follow-up. Clinician self-reports of MI skillfulness were unrelated to proficiency levels in observed practice.