Preventive care for low-income women in massachusetts post-health reform.

BACKGROUND: Before enacting health insurance reform in 2006, Massachusetts provided free breast, cervical cancer, and cardiovascular risk screening for low-income uninsured women through a federally subsidized program called the Women's Health Network (WHN). This article examines whether, as women transitioned to insurance to pay for screening tests after health reform legislation was passed, cancer and cardiovascular disease screening changed among WHN participants between 2004 and 2010. METHODS: We examined claims data from the Massachusetts health insurance exchange and chart review data to measure utilization of mammography, Pap smear, and blood pressure screening among WHN participants in five community health centers in greater Boston. We conducted a longitudinal analysis, by insurance type, using generalized estimating equations to examine the likelihood of screening at recommended intervals in the postreform period compared to the prereform period. RESULTS: Pre- and postreform, we found a high prevalence of recommended mammography (86% vs. 88%), Pap smear (88% vs. 89%), and blood pressure screening (87% vs. 91%) that was similar or improved for most women postreform. Screening use differed by insurance type. Recommended mammography screening was statistically significantly increased among women with state-subsidized private insurance (odds ratio [OR] 1.58, p<0.05). Women with unsubsidized private insurance or Medicare had decreased Pap smear use postreform. Although screening prevalence was high, 31% of women required state safety-net funds to pay for screening tests. CONCLUSION: Our results suggest a continued need for safety-net programs to support preventive screening among low-income women after implementation of healthcare reform.

Lessons learned obtaining informed consent in research with vulnerable populations in community health center settings.

BACKGROUND: To improve equity in access to medical research, successful strategies are needed to recruit diverse populations. Here, we examine experiences of community health center (CHC) staff who guided an informed consent process to overcome recruitment barriers in a medical record review study. METHODS: We conducted ten semi-structured interviews with CHC staff members. Interviews were audiotaped, transcribed, and structurally and thematically coded. We used NVivo, an ethnographic data management software program, to analyze themes related to recruitment challenges. RESULTS: CHC interviewees reported that a key challenge to recruitment included the difficult balance between institutional review board (IRB) requirements for informed consent, and conveying an appropriate level of risk to patients. CHC staff perceived that the requirements of IRB certification itself posed a barrier to allowing diverse staff to participate in recruitment efforts. A key barrier to recruitment also included the lack of updated contact information on CHC patients. CHC interviewees reported that the successes they experienced reflected an alignment between study aims and CHC goals, and trusted relationships between CHCs and staff and the patients they recruited. CONCLUSIONS: Making IRB training more accessible to CHC-based staff, improving consent form clarity for participants, and developing processes for routinely updating patient information would greatly lower recruitment barriers for diverse populations in health services research.

Lack of access due to costs remains a problem for some in Massachusetts despite the state's health reforms.

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer. The state needs to implement new strategies to build on the promise of universal coverage and address specific needs of vulnerable populations, such as limiting out-of-pocket spending for this group. Also, more data are needed on the social determinants of health to identify specific barriers related to cost and access for vulnerable groups that general insurance reforms may not address.

Experiences with hospital care: perspectives of black and Hispanic patients.

BACKGROUND: Significant racial and ethnic differences along several dimensions of patients'experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described. METHODS: We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients' experiences with care were most important in determining overall levels of satisfaction. RESULTS: Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff. CONCLUSIONS: Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.