Analysis of Cost Variation in Endourological Procedures throughout the United States Using a National Database.

INTRODUCTION: We examined geographic variations in the direct costs of endourological procedures, including percutaneous nephrolithotomy, shock wave lithotripsy and retrograde intrarenal surgery/ureteroscopy, as well as the impact of hospital factors on costs using Vizient™, a national clinical database. METHODS: We performed statistical analysis on 44,379 cases (percutaneous nephrolithotomy in 8,395, shock wave lithotripsy in 12,979 and retrograde intrarenal surgery/ureteroscopy in 23,005) from 2015 to 2018 augmented with information from the 2017 American Hospital Directory to determine the impact of hospital factors on the direct costs of endourological procedures across American Urological Association geographic sections. RESULTS: We found a mean±SD direct cost of $5,040±$1,578 for percutaneous nephrolithotomy, $1,994±$642 for shock wave lithotripsy and $2,291±$1,077 for retrograde intrarenal surgery/ureteroscopy nationally. The South Central region had the highest costs for shock wave lithotripsy (mean±SD $3,022±$815), while the Western region had the highest costs for percutaneous nephrolithotomy and retrograde intrarenal surgery/ureteroscopy ($5,610±$1,460 and $3,207±$1,338, respectively). The Northeastern region had the lowest mean±SD costs for percutaneous nephrolithotomy ($4,368±$1,613), shock wave lithotripsy ($927±$234) and retrograde intrarenal surgery/ureteroscopy ($1,824±$1,238). For percutaneous nephrolithotomy and retrograde intrarenal surgery/ureteroscopy high volume institutions had greater costs compared to low volume institutions ($5,318 vs $5,092, p <0.01 and $2,579 vs $2,246, p <0.01, respectively). This finding was not replicated for shock wave lithotripsy ($2,096 vs $2,119, p=0.9). CONCLUSIONS: Significant geographic variation exists regarding direct costs of endourological procedures, with higher volume hospital systems having greater costs for percutaneous nephrolithotomy and retrograde intrarenal surgery/ureteroscopy regardless of location.

Factors influencing medical student self-competence to provide weight management services.

This study aimed to identify factors associated with high obesity care self-competence among US medical students. The authors performed a cross-sectional analysis of 2014 survey data on fourth year medical students collected online as part of the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES). Independent variables included quality and quantity of interaction with patients and peers with obesity; hours of communication and partnership skills training; negative remarks against patients with obesity by supervising physicians, and witnessed discrimination against patients with obesity. The dependent variable was self-competence in providing obesity care. Of 5823 students invited to participate, 3689 (63%) responded and were included in our analyses. Most students were white (65%), half were women and 42% had high self-competence in caring for patients with obesity. Factors associated with high self-competence included increased interaction with peers with obesity (39% vs. 49%, P < 0.001) and increased partnership skills training (32% vs. 61%, P < 0.001). Increased partnership skills training and quantity of interactions with peers with obesity were associated with high student self-competence in providing obesity-related care to patients. Medical schools might consider increasing partnership skills training to improve students' preparedness and skill in performing obesity-related care.

Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.

The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer-reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.

A trial of education, prompts, and opinion leaders to improve prescription of lipid modifying therapy by primary care physicians for patients with ischemic heart disease.

BACKGROUND: Recent clinical trials indicate that treatment with lipid modifying therapy improves outcomes in patients with ischemic heart disease (IHD) and low levels of high density lipoprotein (HDL) cholesterol. The results of these trials, however, have not been widely implemented in clinical practice. OBJECTIVES: To develop and test an intervention designed to increase the rate of prescription of lipid modifying therapy and to determine the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart reminders). METHODS: The study was conducted in 11 US Department of Veterans Affairs Medical Centers. The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy was compared between five intervention sites and six matched control sites using a controlled before and after study design. Additionally, 92 providers within the intervention clinics were randomized to receive one of the three prompts. Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data. RESULTS: At the intervention sites the prescription rate increased from 8.3% during the pre-intervention period to 39.1% during the intervention (OR = 6.5, 95% CI 5.2 to 8.2, p<0.0001) but remained unchanged at the control sites. The interaction between group (control v intervention) and time period was highly significant (p<0.0001). The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites (95% CI 2.1 to 4.7). Overall, there was no significant difference in prescription rates among the three prompt groups. However, there was a significant interaction between prompt group and site, indicating that the efficacy of the prompts differed by site. CONCLUSION: An intervention for primary care providers consisting of an educational workshop, opinion leader influence, and prompts substantially increased the prescription rate of lipid modifying therapy.

Partner violence and medical encounters: African-American women's perspectives.

OBJECTIVE: To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Community-based, primary care center. PATIENTS: Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter. MEASUREMENTS: Patients' perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV "in the past year." RESULTS: Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers. CONCLUSIONS: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care.

The effect of patient race and socio-economic status on physicians' perceptions of patients.

Despite its potential influence on quality of care, there has been little research on the way physicians perceptions of and beliefs about patients are affected by patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of how patients' demographic characteristics influence encounter characteristics, diagnoses, treatment recommendations, and outcomes. This study uses survey data to examine the degree to which patient race and socio-economic status affected physicians' perceptions of patients during a post-angiogram encounter. A total of 842 patient encounters were sampled, out of which 193 physicians provided data on 618 (73%) of the encounters sampled. The results of analyses of the effect of patient race and SES on physician perceptions of and attitude towards patients, controlling for patient age, sex, race, frailty/sickness, depression, mastery, social assertiveness and physician characteristics, are presented. These results supported the hypothesis that physicians' perceptions of patients were influenced by patients' socio-demographic characteristics. Physicians tended to perceive African-Americans and members of low and middle SES groups more negatively on a number of dimensions than they did Whites and upper SES patients. Patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians' perceptions of patients' personality, abilities, behavioral tendencies and role demands. Implications are discussed in terms of further studies and potential interventions.

Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery.

OBJECTIVE: The study sought to determine if there were race/ethnicity or gender differences in access to coronary artery bypass graft (CABG) surgery among patients who have been designated as appropriate and as necessary for that surgery according to the RAND methodology. METHODS: RAND appropriateness and necessity criteria were used to identify a race/gender stratified sample of postangiography patients who would benefit from coronary artery bypass graft surgery. These patients were tracked for 3 months to determine if they had undergone coronary artery bypass graft surgery in New York State. Subjects were a total of 1,261 postangiography patients in eight New York hospitals in 1994 to 1996. Measures included percentages of patients for whom coronary artery bypass graft surgery was appropriate and necessary undergoing surgery by race/ethnicity and gender, as well as multivariate odds ratios for race/ethnicity and gender. RESULTS: After controlling for age, payer, number of vessels diseased, and presence of left main disease, African-American and Hispanic patients were found to be significantly less likely to undergo coronary artery bypass graft surgery than white non-Hispanic patients (respective odds ratios 0.64 and 0.60). When "necessity" was used as a criterion instead of "appropriateness," significant differences in access for African-American patients remained. The gatekeeper physician recommended surgery only 10% of the time that patients did not undergo "appropriate" coronary artery bypass graft surgery, and this percentage did not vary significantly by race/ethnicity or gender of the patient. CONCLUSIONS: Even after controlling for appropriateness and necessity for coronary artery bypass graft surgery in a prospective study, African-American patients had significant access problems in obtaining coronary artery bypass graft surgery. These problems appeared not to be related to patient refusals.

Developing effective helping relationships in health education practice.

Health educators who interact directly with the people they serve must be able to establish effective relationships. Helping relationships are effective if they facilitate clients' progress toward health-promoting goals. Health educators are usually well versed in learning activities and spend a significant proportion of their time interacting with clients. However, many health educators have never received explicit training in how to establish effective formal helping relationships. Research on social influence processes has provided a set of empirical findings that suggest interpersonal behaviors that are likely to maximize the effectiveness of formal helping relationships. This literature indicates that formal helping relationships characterized by interpersonal behaviors that enhance client self-esteem and feelings of control are most effective in helping clients achieve specific goals. Interestingly, enhancement of self-esteem and feelings of control are consistent with many definitions of personal empowerment. Since the social influence and empowerment literatures come from very different intellectual roots and have different approaches to power and influence, their convergence is especially notable. These literatures combine to establish the bases for proposing two essential components of effective helping relationships: (1) providing unconditional acceptance and positive regard for clients, and (2) sharing power and control through participatory processes.

Social support and undermining in close relationships: their independent effects on the mental health of unemployed persons.

Structural equation analyses were used to examine the impact of social support vs. social undermining (conflict) on mental health in longitudinal data from 1,087 recently unemployed respondents. The results demonstrated that social support and social undermining were not the opposite poles of the same factor, each having some impact independent of the other. Social undermining had statistically significant and strong adverse impact at each concurrent level of mental health. It also predicted improvement (but not a high level) in mental health in subsequent time waves. In contrast, social support had a significant beneficial impact on mental health only at Time 1. Compared with the volatile and extreme effects of social undermining, those of social support appear weaker but more stable. These findings are consistent with literature on the impact of life events (S. E. Taylor, 1991) and on marital interactions and satisfaction (J. M. Gottman & L. J. Krokoff, 1989).

How did it work? An examination of the mechanisms through which an intervention for the unemployed promoted job-search behavior.

Conducted process analysis of treatment mediation effects (Judd & Kenney, 1981) on longitudinal data from a large randomized field experiment with 928 recently unemployed persons. The experimental treatment included an intervention that succeeded in promoting quality reemployment outcomes, as described in earlier reports (Caplan et al., 1989; Vinokur et al., 1991). Using Ajzen's theory of planned behavior (Ajzen, 1985, 1988), the analyses examined the mediating effects of job-search self-efficacy, attitude, norms, and intention on job-search behavior. The results provided substantial support for the theory of planned behavior and demonstrated the mediational role of job-search self-efficacy. For both 1- and 4-month posttests, job-search self-efficacy was shown to mediate the effects of the intervention through its direct effects on job-search intention and on short term job-search behavior, as well as through its indirect effects on subjective norms and attitude. However, in the longer term 4-month posttest, exposure to the intervention had a direct effect on job-search behavior. This long-term direct effect of the intervention was hypothesized to reflect the influence of inoculation against setbacks which is essential for sustaining the long-term behavioral efforts involved in job seeking.

Impact of a preventive job search intervention on the likelihood of depression among the unemployed.

Drawing on coping resources theory, we evaluate the impact of a job search intervention on depressive symptoms in a randomized field experiment at three follow-up periods covering two and one-half years. Baseline depressive symptoms, low social assertiveness, and financial hardship were identified as significant risk variables predicting depressive symptoms at follow-up. These variables then were used to identify high- and low-risk individuals in both experimental and control groups. Results indicated that the job search intervention had its primary impact on persons identified as being at higher risk for depression. Furthermore, the intervention had an impact on both the incidence and prevalence of more severe depressive symptoms among high-risk individuals.

What's the use of theory?

The barriers to the use of theory in health education practice are addressed by exposing common misperceptions of the nature and usefulness of theory. First, the mystique of theory is addressed through a discussion of theory development and the roots of theory in everyday experience. Two characteristics of theory, generalizability across settings or situations and testability, are described and linked to benefits for practice. Second, a guide for practitioners in applying theory to each stage of the intervention process is provided. A case example illustrates how theory can guide practice as well as the benefits to be gained by applying theory to program development. Finally, the bases for common negative misperceptions of theory are identified and clarified, and the beneficial nature of theory reviewed.

Long-term follow-up and benefit-cost analysis of the Jobs Program: a preventive intervention for the unemployed.

Results are reported from a 2 1/2 year follow-up of respondents who participated in a randomized field experiment that included the Jobs Program, a preventive intervention for unemployed persons. The intervention was intended to prevent poor mental health and loss of motivation to seek reemployment and to promote high-quality reemployment. The results of the long-term follow-up were consistent with those found 1 and 4 months after intervention (Caplan, Vinokur, Price, & van Ryn, 1989). The results demonstrate the continued beneficial effects of the intervention on monthly earnings, level of employment, and episodes of employer and job changes. These findings are supported by a benefit-cost analysis, which demonstrates large net benefits of the intervention to the participants and to the federal and state government programs that supported the project.

Broadening the scope of worksite stress programs: a guiding framework.

Abstract Worksite stress programs have proliferated in recent years. A large proportion of these programs focus on helping individual employees learn about stress and develop better coping skills. Few programs attempt to reduce the stressful aspects of the job or the organizational context. In order to facilitate the development of a broader array of stress reduction programs, the authors provide: 1) a conceptual framework upon which worksite stress programs should be based, 2) a guide to the variety of decision points in the program development process, 3) an exploration of the reasons why a broader range of stress programs have not heretofore been developed, and 4) suggestions for creating a context amenable to innovative worksite stress programs.

Job seeking, reemployment, and mental health: a randomized field experiment in coping with job loss.

Cognitive theories of adherence to difficult courses of action and findings from previous survey research on coping with a major life event--job loss--were used to generate a preventive intervention, tested by a randomized field experiment. The aim was to prevent poor mental health and loss of motivation to seek reemployment among those who continued to be unemployed and to promote high-quality reemployment. Ss were 928 recently unemployed adults from southeastern Michigan, representing a broad range of demographic characteristics; they were randomly assigned to either the experimental or control condition. The experimental intervention included training in job seeking with a problem-solving process emphasizing inoculation against setbacks and positive social reinforcement. A pretest was administered, followed by posttests 1 and 4 months after the experiment. The experimental condition yielded higher quality reemployment in terms of earnings and job satisfaction, and higher motivation among those who continued to be unemployed.