Contextualizing an expanded definition of health literacy among adolescents in the health care setting.

The current emphasis on preventive health care and wellness services suggests that measures of skills and competencies needed to effectively navigate the health care system need to be better defined. We take an expanded perspective of health literacy and define it as a set of skills used to organize and apply health knowledge, attitudes and practices relevant when managing one's health environment. It is an emerging area of inquiry especially among adults and those with chronic conditions; however, it has been less studied among adolescent populations. To begin operationalizing this concept in a manner appropriate for teens in a health systems context, we explored knowledge, attitudes and practices related to health and preventive health care in 12 focus groups with publicly insured adolescents (N = 137), aged 13-17 years, as well as eight key informant interviews with physicians who serve publicly insured teens. Five dimensions emerged that provide a preliminary framework for an expanded definition of health literacy among adolescents. These include: (i) navigating the system, (ii) rights and responsibilities, (iii) preventive care, (iv) information seeking and (v) patient-provider relationship. This robust definition of health literacy contextualizes the concept in a health environment where individuals must be informed and skilled health care consumers.

Drug benefit changes under Medicare Advantage Part D: heterogeneous effects on pharmaceutical use and expenditures.

BACKGROUND: Although Medicare Part D improved drug benefits for many beneficiaries, its impact on the coverage of Medicare Advantage Part D (MAPD) enrollees depended on their pre-existing benefits and whether they had gap coverage under Part D. OBJECTIVE: To examine changes in prescription drug utilization and expenditures associated with drug benefit changes resulting from the implementation of Part D. PATIENTS: We studied 248,773 continuously enrolled MAPD patients in eight states. Patients whose insurance product or Census block could not be identified or who had atypical benefits, low-income subsidies or Medicaid coverage were excluded. MAIN MEASURES: The main outcomes were changes in prescription drug days supply and expenditures from 2005 to 2006 and 2005 to 2007. DESIGN: We linked Census data with 2005-7 MAPD claims, encounter, enrollment, and benefits data and estimated associations of the outcomes with changes in drug benefits, controlling for 2005 comorbidities, demographics, and Census population characteristics. KEY RESULTS: MAPD enrollees whose drug benefits became potentially less generous after Part D had the smallest increases in drug utilization and expenditures (e.g., drug expenditures increased by $130 between 2005 and 2006), while those who potentially gained the most from Part D experienced the largest increases ($302). The differences in benefit design changes had a stronger association with drug utilization and outcomes among patients at high risk of gap entry than among the entire sample. CONCLUSIONS: Although Medicare Part D unambiguously improved drug coverage for many elderly, it led to heterogeneous changes in drug benefits among MAPD enrollees, who already had generic and sometimes branded drug benefits. After 2006, benefits were worse for individuals who had branded drug coverage in 2005 but now had a coverage gap, but benefits may have improved for individuals who acquired branded drug coverage. Commensurate with these differential changes in benefits following Part D, changes in drug utilization and expenditures varied substantially as well.

Recruitment strategies and costs associated with community-based research in a Mexican-origin population.

PURPOSE: We describe the recruitment strategies and personnel and materials costs associated with two community-based research studies in a Mexican-origin population. We also highlight the role that academic-community partnerships played in the outreach and recruitment process for our studies. We reviewed study documents using case study methodology to categorize recruitment methods, examine community partnerships, and calculate study costs. RESULTS: We employed several recruitment methods to identify and solicit 154 female caregivers for participation in qualitative interviews and quantitative surveys. Recruitment approaches included using flyers and word of mouth, attending health fairs, and partnering with nonprofit community-based organizations (CBOs) to sponsor targeted recruitment events. Face-to-face contact with community residents and partnerships with CBOs were most effective in enrolling caregivers into the studies. Almost 70% of participants attended a recruitment event sponsored or supported by CBOs. The least effective recruitment strategy was the use of flyers, which resulted in only 7 completed interviews or questionnaires. Time and costs related to carrying out the research varied by study, where personal interviews cost more on a per-participant basis ($1,081) than the questionnaires ($298). However, almost the same amount of time was spent in the community for both studies. IMPLICATIONS: Partnerships with CBOs were critical for reaching the target enrollment for our studies. The relationship between the University of California-Los Angeles (UCLA) Resource Center for Minority Aging Research/Center for Health Improvement for Minority Elderly and the Department of Aging provided the infrastructure for maintaining connections with academic-community partnerships. Nevertheless, building partnerships required time, effort, and resources for both researchers and local organizations.

Falling into the coverage gap: Part D drug costs and adherence for Medicare Advantage prescription drug plan beneficiaries with diabetes.

OBJECTIVE: To compare drug costs and adherence among Medicare beneficiaries with the standard Part D coverage gap versus supplemental gap coverage in 2006. DATA SOURCES: Pharmacy data from Medicare Advantage Prescription Drug (MAPD) plans. STUDY DESIGN: Parallel analyses comparing beneficiaries aged 65+ with diabetes in an integrated MAPD with a gap versus no gap (n=28,780); and in a network-model MAPD with a gap versus generic-only coverage during the gap (n=14,984). PRINCIPAL FINDINGS: Drug spending was 3 percent (95 percent confidence interval [CI]: 1-4 percent) and 4 percent (CI: 1-6 percent) lower among beneficiaries with a gap versus full or generic-only gap coverage, respectively. Out-of-pocket expenditures were 189 percent higher (CI: 185-193 percent) and adherence to three chronic drug classes was lower among those with a gap versus no gap (e.g., odds ratio=0.83, CI: 0.79-0.88, for oral diabetes drugs). Annual out-of-pocket spending was 14 percent higher (CI: 10-17 percent) for beneficiaries with a gap versus generic-only gap coverage, but levels of adherence were similar. CONCLUSIONS: Among Medicare beneficiaries with diabetes, having the Part D coverage gap resulted in lower total drug costs, but higher out-of-pocket spending and worse adherence compared with having no gap. Having generic-only coverage during the gap appeared to confer limited benefits compared with having no gap coverage.

Medicare Part D coverage gap and diabetes beneficiaries.

OBJECTIVE: To examine drug costs and entry and exit rates into the Part D coverage gap for beneficiaries with diabetes in Medicare Advantage managed care plans. STUDY DESIGN: Cross-sectional observational study. METHODS: Study patients were Medicare Advantage Part D beneficiaries with diabetes from 2 large California health plans who were continuously enrolled in 2006 and had a drug coverage gap starting at $2250. Entry and exit into the gap, total drug costs, and out-of-pocket drug costs were determined using pharmacy databases. RESULTS: In 2006, 26% of the 42,801 beneficiaries with diabetes reached the coverage gap; 2% of beneficiaries exited the gap and qualified for catastrophic coverage. Beneficiaries incurred a mean of $2182 in total drug costs during 2006. Drug expenditures remained stable over the year for beneficiaries who did not enter the gap. For beneficiaries who entered the gap, total drug costs were higher overall and decreased at year's end as out-of-pocket expenses increased. CONCLUSIONS: Fewer diabetes patients in this study entered the coverage gap than had been previously estimated, but the entry rate was much higher than that of the general Medicare Advantage Part D population. Patients entering the gap had lower subsequent monthly drug expenditures; this may be due to lower-than-expected drug prices and greater use of generics in managed care, or it may potentially signal poorer drug adherence. Future work should examine these hypotheses and explore risk factors for entering the Part D coverage gap.

Impact of instructional practices on student satisfaction with attendings' teaching in the inpatient component of internal medicine clerkships.

OBJECTIVE: To determine the prevalence and influence of specific attending teaching practices on student evaluations of the quality of attendings' teaching in the inpatient component of Internal Medicine clerkships. DESIGN: Nationwide survey using a simple random sample. SETTING: One hundred and twenty-one allopathic 4-year medical schools in the United States. PARTICIPANTS: A total of 2,250 fourth-year medical students. MEASUREMENTS AND MAIN RESULTS: In the spring of 2002, student satisfaction with the overall quality of teaching by attendings in the inpatient component of Internal Medicine clerkships was measured on a 5-point scale from very satisfied to very dissatisfied (survey response rate, 68.3%). Logistic regression was used to determine the association of specific teaching practices with student evaluations of the quality of their attendings' teaching. Attending physicians' teaching practices such as engaging students in substantive discussions (odds ratio (OR)=3.0), giving spontaneous talks and prepared presentations (OR=1.6 and 1.8), and seeing new patients with the team (OR=1.2) were strongly associated with higher student satisfaction, whereas seeming rushed and eager to finish rounds was associated with lower satisfaction (OR=0.6). CONCLUSION: Findings suggest that student satisfaction with attendings' teaching is high overall but there is room for improvement. Specific teaching behaviors used by attendings affect student satisfaction. These specific behaviors could be taught and modified for use by attendings and clerkship directors to enhance student experiences during clerkships.

Practice characteristics and HMO enrollee satisfaction with specialty care: an analysis of patients with glaucoma and diabetic retinopathy.

BACKGROUND: The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential. OBJECTIVE: To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). SUBJECTS/STUDY SETTING: A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices. STUDY DESIGN: We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction. PRINCIPAL FINDINGS: Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction. CONCLUSIONS: Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction.