Self-Check-In Kiosks Utilization and Their Association With Wait Times in Emergency Departments in the United States.

BACKGROUND: Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied. OBJECTIVES: To assess the association between patient wait time and utilization of self-check-in kiosks in EDs. To investigate a series of other patient-, ED-, and hospital-level predictors of wait time in EDs. METHODS: Using data from the 2015 and 2016 National Hospital Ambulatory Medical Care Survey, we analyzed 40,528 ED visits by constructing a multivariable linear regression model of the log-transformed wait time data as an outcome, then computing percent changes in wait times. RESULTS: During the study period, about 9% of EDs in the United States implemented kiosks. In our linear regression model, the wait time in EDs with kiosk self-check-in services was 56.8% shorter (95% confidence interval ̶ 130% to ̶ 6.4%, p < 0.05) compared with EDs without kiosk services. In addition to kiosks, patients' day of visit, arrival time, triage assessment, arrival by ambulance, chronic medical conditions, ED boarding, hospitals' full-capacity protocol, and hospitals' location were significant predictors of wait time. CONCLUSIONS: Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care.

Mobile Health Application and e-Health Literacy: Opportunities and Concerns for Cancer Patients and Caregivers.

Health literacy is critical for cancer patients as they must understand complex procedures or treatment options. Caregivers' health literacy also plays a crucial role in caring for cancer patients. Low health literacy is associated with low adherence to medications, poor health status, and increased health care costs. There is a growing interest in the use of mobile health applications (apps) to improve health literacy. Mobile health apps can empower underserved cancer patients and their caregivers by providing features or functionalities to enhance interactive patient-provider communication and to understand medical information more readily. Despite the potentiality of improving health literacy through mobile health apps, there exist several related concerns: no equal access to mobile technology, no familiarity or knowledge of using mobile health apps, and privacy and security concerns. These elements should be taken into account for health policy making and mobile apps design and development. Importantly, mobile apps should be developed with the goal of achieving a high range of user access by considering all health literacy level and various cultural and linguistic needs.

A Journey in Capacity Building: Revisiting the Mullins Framework for Meaningfully Engaging Patients in Patient Centered Outcomes Research.

This paper reviews the implementation of the UNITE for Better Health Outcomes Eugene Washington PCORI Engagement Award project using Mullins and colleagues' Framework for Meaningfully Engaging Patients in Patient Centered Outcomes Research (PCOR) and the advantages and disadvantages of this framework. We combine Mullins' framework with the ten themes for guiding future studies in PCOR also developed by Mullins' research group. We interviewed patient stakeholders at the end of the engagement award and include patient stakeholder perspectives of how well we performed each of these steps. Despite some breakdowns in trust, which were eventually repaired, we successfully identified patient and family stakeholders; built partnerships with patients, researchers, providers, and community groups; explained the purpose of our project and the importance of PCOR; developed training materials for patients and providers; and updated our key constituents throughout the process. Overall, we believe combining Mullins' framework with the ten themes provides a solid roadmap for implementing a PCORI engagement award. Our main challenge was recruiting and keeping hard-to-reach patients and caregivers involved in the project. We believe this was due to our limitations more so than the framework. Based on the lessons we learned, we provide concrete recommendations for others who want to engage hard-to-reach patients using the Mullins framework.

National Trends in Hospital Emergency Department Visits among Those with and without Multiple Chronic Conditions, 2007-2012.

Emergency department (ED) visits and the number of adults with multiple chronic conditions (MCC) have been increasing over the last decade, but little is known about the trends in ED use for patients with MCC. This study examined national trends in ED use for those with MCC compared with one chronic condition and no chronic conditions and used data from the 2007-2012 National Emergency Department Sample, limited to patients 45 years old or older. ED visits for encounters with one chronic condition and MCC increased at significantly greater rates than for those with no chronic conditions both overall and for all subgroups examined.

Plain Language and Health Literacy for the Oncology Family Caregiver: Examining an English/Spanish mHealth Resource.

OBJECTIVES: To explore an mHealth resource to support the limited-English-proficient cancer family caregiver. DATA SOURCES: Structured interviews with oncology clinic providers to assess a nurse-delivered resource to support health literacy and decision-making along the cancer trajectory. CONCLUSION: Limitations in communicating about oncology care with limited-English caregivers is evident. The mHealth resource examined here shows promise to improve relational health literacy between the oncology nurse and family caregiver. IMPLICATIONS FOR NURSING PRACTICE: Communicating with limited-English-proficient family caregivers invites oncology nurses to seek out resources to create shared understanding.

Alabama Physicians and Accountable Care Organizations: Will What We Don't Know Hurt Us?

Accountable care organizations (ACOs) were designed to improve the quality of care delivered to Medicare beneficiaries while also halting the growth in Medicare spending. Many existing health systems in the Northeast, Midwest, and West have formed ACOs, whereas implementation in Southern states has been slower. The study team conducted a survey of all physician members of the Medical Association of the State of Alabama to determine the likelihood of their participation in an ACO and their attitudes toward some of the characteristics, such as quality measures, regulations, and risks versus rewards. The team found that many physicians reported a lack of knowledge about these areas. Physicians who reported that they were either likely or not likely to participate overwhelmingly held unfavorable attitudes about ACOs. It would be advantageous for Alabama physicians to become more knowledgeable about ACOs in the case that they become a more predominant form of care delivery in the future.

Use of information technology for medication management in residential care facilities: correlates of facility characteristics.

The effectiveness of information technology in resolving medication problems has been well documented. Long-term care settings such as residential care facilities (RCFs) may see the benefits of using such technologies in addressing the problem of medication errors among their resident population, who are usually older and have numerous chronic conditions. The aim of this study was two-fold: to examine the extent of use of Electronic Medication Management (EMM) in RCFs and to analyze the organizational factors associated with the use of EMM functionalities in RCFs. Data on RCFs were obtained from the 2010 National Survey of Residential Care Facilities. The association between facility, director and staff, and resident characteristics of RCFs and adoption of four EMM functionalities was assessed through multivariate logistic regression. The four EMM functionalities included were maintaining lists of medications, ordering for prescriptions, maintaining active medication allergy lists, and warning of drug interactions or contraindications. About 12% of the RCFs adopted all four EMM functionalities. Additionally, maintaining lists of medications had the highest adoption rate (34.5%), followed by maintaining active medication allergy lists (31.6%), ordering for prescriptions (19.7%), and warning of drug interactions or contraindications (17.9%). Facility size and ownership status were significantly associated with adoption of all four EMM functionalities. Medicaid certification status, facility director's age, education and license status, and the use of personal care aides in the RCF were significantly associated with the adoption of some of the EMM functionalities. EMM is expected to improve the quality of care and patient safety in long-term care facilities including RCFs. The extent of adoption of the four EMM functionalities is relatively low in RCFs. Some RCFs may strategize to use these functionalities to cater to the increasing demands from the market and also to provide better quality of care.

Relative financial burden of health care expenditures.

Out-of-pocket health expenditures potentially have a large impact on patients, particularly those with low incomes, leading to reduced utilization of health services and even bankruptcy. This analysis examines the burden of out-of-pocket spending, relative to total income, across several demographic groups. Rural residents had a higher relative burden than urban residents, as did women and Whites. Important policy implications are discussed.

Cognitive and behavioral characterization of the Potocki-Lupski syndrome (duplication 17p11.2).

OBJECTIVE: To describe the cognitive and behavioral phenotypic features of the Potocki-Lupski syndrome (duplication 17p11.2), a recently recognized syndrome with multiple congenital anomalies and developmental delays. METHOD: Fifteen subjects were enrolled in an extensive multidisciplinary clinical protocol. Cognitive and behavior evaluations included a parent-report medical and psychological history form, intellectual assessment and assessments of adaptive behavior, executive functioning, and maladaptive behavior and emotions. Eight of the families completed an Autism Diagnostic Interview-Revised and Autism Diagnostic Observation Schedule-Generic. RESULTS: The majority of patients (13 of 15) presented with intellectual disability. Moreover, the majority of patients also had moderate to severe behavioral difficulties, including atypicality, withdrawal, anxiety, and inattention. Many patients characterized also presented with autistic symptom pictures, some of whom (10 of 15) met diagnostic criteria for an autistic spectrum disorder, namely autistic disorder or pervasive developmental disorder not otherwise specified. CONCLUSION: This work expands on the behavioral phenotype of duplication 17p11.2 (Potocki-Lupski syndrome). Further phenotypic analysis will aid in clinical diagnosis, counseling, and management of this newly characterized microduplication syndrome. The association between this syndrome and autistic spectrum disorder may contribute to further understanding the etiology of the pervasive developmental disorders.

Continuity of health insurance coverage and perceived health at age 40.

While a lack of health insurance or interrupted coverage has been shown to lead to poorer health status among preretirement populations, this phenomenon has not been examined among a large population of younger, working-age adults. We analyzed a nationally representative data set of persons born between 1957 and 1961, the National Longitudinal Survey of Youth-1979, to examine the links between insurance continuity and self-assessed physical and mental health at age 40. Among respondents turning 40 in 1998 or 2000, 59.8% had been continuously insured during the decade before they reached age 40. In unadjusted analysis, persons who were continuously covered had the highest scores for both physical and mental health. After controlling for respondent characteristics, insurance coverage was not significantly associated with perceived physical or mental health.

Early alcohol use, rural residence, and adult employment.

OBJECTIVE: Rural residence was once perceived as protective regarding youthful alcohol use and its effects. Our study examined whether the relationship between alcohol use in youth and early adulthood and subsequent employment outcomes differed for rural and urban youth. METHOD: Data from a 20-year panel survey, the National Longitudinal Survey of Youth 1979, were used to address the association between alcohol use between the ages of 17 and 26 and employment outcomes during adulthood. Early drinking experiences and misuse symptoms were used as drinking behavior measures. Rural was defined as living outside any Metropolitan Statistical Area. Employment outcomes were defined using employment status and employment quality. Analyses were weighted to reflect the stratified sample design (N = 8,399). RESULTS: Drinking behaviors did not differ by residence. In bivariate analysis, alcohol use measures during youth were consistently associated with working more than 40 hours per week and earning irregular compensation. For three of seven employment quality measures examined, interactions between residence and alcohol use were observed in multivariable analysis. Rural youth were more likely to suffer adverse employment consequences. CONCLUSIONS: Rural residence does not appear to provide protection from the effects of drinking during youth on adulthood employment and was associated with adverse outcomes. Further research is needed to ascertain whether such differences stem from different availability of services or other characteristics of the rural environment.

Race and ethnicity differences in reporting of depressive symptoms.

Our study explored race and ethnicity differences in reporting of symptoms to physicians and other practitioners among respondents to the 1999 National Health Interview Survey who screened positive for depression. Respondents were asked if they had told a doctor or another practitioner (nurse, social worker, psychologist, clergy, other) about their problems. Whites and Hispanics were significantly more likely to communicate with a physician or other practitioner than were African Americans, even with personal characteristics held constant. Practitioners should actively elicit descriptions of feelings and mood, especially with African Americans, and be prepared to treat or refer patients appropriately.

Rural-urban differences in depression prevalence: implications for family medicine.

BACKGROUND AND OBJECTIVES: Rural populations experience more adverse living circumstances than urban populations, but the evidence regarding the prevalence of mental health disorders in rural areas is contradictory. We examined the prevalence of depression in rural versus urban areas. METHODS: We performed a cross-sectional study using the 1999 National Health Interview Survey (NHIS). In face-to-face interviews, the NHIS administered the Composite International Diagnostic Interview Short Form (CIDI-SF) depression scale to a nationally representative sample of 30,801 adults, ages 18 and over. RESULTS: An estimated 2.6 million rural adults suffer from depression. The unadjusted prevalence of depression was significantly higher among rural than urban populations (6.1% versus 5.2% ). After adjusting for rural/urban population characteristics, however, the odds of depression did not differ by residence. Depression risk was higher among persons likely to be encountered in a primary care setting: those with fair or poor self-reported health, hypertension, with limitations in daily activities, or whose health status changed during the previous year. CONCLUSIONS: The prevalence of depression is slightly but significantly higher in residents of rural areas compared to urban areas, possibly due to differing population characteristics.

Trends in colon cancer screening procedures in the US Medicare and Tricare populations: 1999-2001.

BACKGROUND: This study examined trends in the numbers of double contrast barium enemas, flexible sigmoidoscopies, and colonoscopies and trends in the choices of colorectal cancer screening service providers. METHODS: Descriptive statistics were used to examine Medicare and Tricare data for the years 1999 to 2001. RESULTS: The total volume of procedures increased 5% and 14%, respectively, in Tricare and Medicare. Tricare and Medicare, respectively, saw 32% and 33% reductions in barium enemas and 28% and 41% reductions in flexible sigmoidoscopies. Colonoscopies increased by 45% and 34% in Tricare and Medicare, respectively. Gastroenterologists provided the majority of colonoscopies for both groups each year. CONCLUSIONS: The volume of colonoscopies increased from 1999 to 2001 for both groups while the volumes of barium enemas and flexible sigmoidoscopies decreased. Gastroenterologists appear to be the preferred providers of colonoscopies.

Leisure-time physical activity and health-care utilization in older adults.

This study examined whether leisure-time physical activity (LTPA) was associated with health-care utilization in a racially diverse sample of rural and urban older adults. Community-dwelling adults (N = 1,000, 75.32 +/- 6.72 years old) self-reported participating in LTPA and their use of the health-care system (physician visits, number and length of hospitalizations, and emergency-room visits). After controlling for variables associated with health and health-care utilization, older adults who reported lower levels of LTPA also reported a greater number of nights in the hospital in the preceding year. There was no support, however, for a relationship between LTPA and the other indicators of health-care utilization. Our findings suggest that being physically active might translate to a quicker recovery for older adults who are hospitalized. Being physically active might not only have health benefits for older persons but also lead to lower health-care costs.

Barriers associated with the delivery of Medicare-reimbursed diabetes self-management education.

PURPOSE: The purpose of this study was to explore the barriers that practitioners face in providing diabetes self-management education (DSME) to Medicare beneficiaries, with a special focus on barriers faced by rural providers. METHODS: Using an e-mail survey, Diabetes Control Program Coordinators (DCPCs) in all US states were asked 3 open-ended questions to understand problems with obtaining American Diabetes Association (ADA) recognition for Medicare reimbursement, differences in obtaining ADA recognition by rural and urban facilities, and facility-level barriers to providing DSME to Medicare patients. Using a mail survey administered to half of ADA-recognized diabetes education centers (DECs), information was collected about perceived barriers to providing DSME in all areas and rural areas. RESULTS: Most DCPCs believed it was more difficult for rural providers to obtain ADA recognition than for urban providers; the largest barriers were costs and reporting requirements. The top barriers for rural providers mentioned by DCPCs were the shortage of designated specialists, fewer resources, and high application fees for ADA recognition. Barriers identified by DEC respondents facing rural providers include staffing/institutional support, amount of Medicare reimbursement, lack of hours covered, and transportation. DEC respondents providing care in urban areas only were more likely to perceive barriers to providing diabetes education in rural areas than were rural providers. CONCLUSIONS: Barriers to DSME are perceived to be higher for rural providers than urban providers. Urban providers perceived that many barriers to DSME are greater for rural providers. The ADA application process is perceived as expensive and laborious. Most respondents perceived Medicare reimbursement for DSME as inadequate.

Recruitment and retention of emergency medical technicians: a qualitative study.

Emergency medical technicians (EMTs) are critical to out-of-hospital care, but maintaining staff can be difficult. The study objective was to identify factors that contribute to recruitment and retention of EMTs and paramedics. Information was drawn from three focus groups of EMT-Basic, EMT-Intermediate, and EMT-Paramedic personnel recruited from participants at an annual conference. Thoughts and feelings of EMTs and paramedics were investigated using eight questions designed to explore entry into emergency medical services, what it is like to be an EMT or paramedic, and the EMT educational process. Data were analyzed at the group level for common themes using NVivo. For a majority of respondents, emergency medical services was not a primary career path. Most respondents entered the industry as an alternate or replacement for a nursing career or as a second career following military medic service. The majority of respondents believed the job was stressful yet rewarding, and although it negatively affected their personal lives, the occupation gave them a sense of accomplishment and belonging. Respondents expressed a preference for EMT education resulting in college credit or licensure versus professional certification. Job-related stress produced by numerous factors appears to be a likely contributor to low employee retention. Recruitment and retention efforts should address study findings, incorporating key findings into educational, evaluation, and job enhancement programs.

Health insurance for Americans approaching age sixty-five: an analysis of options for incremental reform.

This article provides a systematic evaluation of the options for incremental health insurance reforms aimed at older Americans nearing age sixty-five. It presents three basic arguments for giving special consideration to this age group: (1) early retirement and its effect on access to employer insurance; (2) changes in health and health care expenses associated with increasing age; (3) the vulnerability to unexpected economic or health "shocks" that will affect people throughout their retirement. The analysis of policy options begins by specifying criteria for evaluating alternative approaches to reform. The proposed criteria emphasize that reforms for this age group should be designed to fit with other financial plans and decisions made during such a transitional stage of life. Policy options should be judged according to fundamental goals such as equity and efficiency, not simply ranked according to the number of uninsured who will gain coverage. After offering a comprehensive catalog and evaluation of available options, the analysis identifies and discusses a preferred approach-which preserves choices while offering universal and subsidized access to Medicare before age sixty-five.