Publications by authors named "Minal R Patel"

58 Publications

Elevating Health Disparities Education among Trainees and Physicians.

J Allergy Clin Immunol Pract 2022 Jan 13. Epub 2022 Jan 13.

Mayo Clinic Rochester, Rochester MN.

Health disparities disproportionately effect patients in racial and ethnic minority groups, and these disparities are linked to economic, environmental, and social disadvantage. It is widely known that health disparities impact patients with allergic and immunologic conditions, yet universal and comprehensive training in health disparities is lacking. More robust educational opportunities are needed to fully equip trainees with tools to recognize and develop effective strategies to reduce the burden of health disparities. Also, there are no universal standards or requirements for professional medical boards in their respective maintenance of certification programs that will ensure ongoing training for practicing providers that will help them identify and manage individual or societal issues such as social determinants that contribute to health disparities. Further, the long-term impact of systematic discrimination, implicit and overt bias, and medical mistrust among populations most often effected by disparities compounds the complexity of the methods and types of training that is desperately needed to overcome health disparities. We provide a commentary on important topics that should be addressed during Allergy and Immunology training and beyond. We further highlight strategies and tools that should be utilized to tackle this important issue effecting millions of patients under our specialty care. It is past time for us to go beyond the bedside and comprehensively integrate health disparities training in our fellowship programs and in our practices.
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http://dx.doi.org/10.1016/j.jaip.2022.01.003DOI Listing
January 2022

Impacts of the COVID-19 pandemic on unmet social needs, self-care, and outcomes among people with diabetes and poor glycemic control.

Prim Care Diabetes 2021 Oct 29. Epub 2021 Oct 29.

Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States. Electronic address:

Aims: The purpose of this study was to examine whether pandemic exposure impacted unmet social and diabetes needs, self-care behaviors, and diabetes outcomes in a sample with diabetes and poor glycemic control.

Methods: This was a cross-sectional analysis of participants with diabetes and poor glycemic control in an ongoing trial (n = 353). We compared the prevalence of unmet needs, self-care behaviors, and diabetes outcomes in successive cohorts of enrollees surveyed pre-pandemic (prior to March 11, 2020, n = 182), in the early stages of the pandemic (May-September, 2020, n = 75), and later (September 2020-January 2021, n = 96) stratified by income and gender. Adjusted multivariable regression models were used to examine trends.

Results: More participants with low income reported food insecurity (70% vs. 83%, p < 0.05) and needs related to access to blood glucose supplies (19% vs. 67%, p < 0.05) during the pandemic compared to pre-pandemic levels. In adjusted models among people with low incomes, the odds of housing insecurity increased among participants during the early pandemic months compared with participants pre-pandemic (OR 20.2 [95% CI 2.8-145.2], p < 0.01). A1c levels were better among participants later in the pandemic than those pre-pandemic (β = -1.1 [95% CI -1.8 to -0.4], p < 0.01), but systolic blood pressure control was substantially worse (β = 11.5 [95% CI 4.2-18.8, p < 0.001).

Conclusion: Adults with low-incomes and diabetes were most impacted by the pandemic. A1c may not fully capture challenges that people with diabetes are facing to manage their condition; systolic blood pressures may have worsened and problems with self-care may forebode longer-term challenges in diabetes control.
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http://dx.doi.org/10.1016/j.pcd.2021.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8590528PMC
October 2021

Rural Michigan Farmers' Health Concerns and Experiences: A Focus Group Study.

J Prim Care Community Health 2021 Jan-Dec;12:21501327211053519

University of Michigan, Ann Arbor, MI, USA.

Objectives: Rural residents comprise approximately 15% of the United States population. They face challenges in accessing and using a health care system that is not structured to meet their unique needs. It is important to understand rural residents' perceptions of health and experiences interacting with the health care system to identify gaps in care.

Methods: Our team conducted focus groups with members of the Michigan Farm Bureau during their 2019 Annual Meeting. Topics explored included resources to manage health, barriers to virtual health care services, and desired changes to localized healthcare delivery. Surveys were used to capture demographic and internet access information.

Conclusion: Analysis included data from 2 focus groups (n = 14). Participants represented a wide age range and a variety of Michigan counties. The majority were full-time farm owners with most-93% (n = 13)-reporting they had access to the internet in their homes and 86% (n = 12) reporting that their cellphones had internet capabilities. Participants identified challenges and opportunities in 4 categories: formal health care; health and well-being supports; health insurance experiences; and virtual health care.

Conclusion: The findings from this study provide a useful framework for developing interventions to address the specific needs of rural farming residents. Despite the expressed challenges in access and use of health care services and resources, participants remained hopeful that innovative approaches, such as virtual health platforms, can address existing gaps in care. The study findings should inform the design and evaluation of interventions to address rural health disparities.
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http://dx.doi.org/10.1177/21501327211053519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8554574PMC
October 2021

Predictors of screening for cervical and colorectal cancer in women 50-65 years old in a multi-ethnic population.

Prev Med Rep 2021 Jun 19;22:101375. Epub 2021 Apr 19.

Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA.

Middle Eastern/North Africa (MENA) women are often not identified in cancer screening studies. The aim of this study was to determine the rates and predictors of cervical and colorectal cancer (CRC) screening for women 50-65 years of three race/ethnicities. White, black and MENA women of Southeast Michigan were surveyed once in 2019 for demographics, health care barriers, chronic diseases, and cancer screening updates using in-person, telephone, and online methods. Descriptive statistics and multivariate multinomial logistic regression were used to predict up-to-date colorectal cancer and cervical cancer screening. All analyses were adjusted by local population weights for comparability and generalizability. 394 women participated with 54% up-to-date on both screenings, 21% for cervical cancer screening alone, and 12% for CRC alone. Women more likely to be up-to-date for only cervical cancer screening compared to both cancer screens are younger (aOR 0.83 (95% CI 0.76, 0.92), are of MENA descent (7.97 (2.46, 25.76) and have no insurance (9.41 (1.07, 82.92). There are no predictors for women being up-to-date for CRC screening alone compared to both screens. Among women 50-65 years old, being up-to-date in cervical cancer screening is unrelated to being up-to-date for CRC screening. Compared to Healthy People 2020, there are significant gaps in cervical and CRC screening among women 50-65 years old of all races, but particularly among women of MENA descent who are even less likely to have CRC screening than cervical cancer screening.
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http://dx.doi.org/10.1016/j.pmedr.2021.101375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086134PMC
June 2021

A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship.

Popul Health Manag 2021 Dec 14;24(6):710-721. Epub 2021 May 14.

Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA.

Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.
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http://dx.doi.org/10.1089/pop.2021.0043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8713277PMC
December 2021

Awareness and Preferences for Health Care Chaplaincy Services Among US Adults.

J Am Board Fam Med 2021 Mar-Apr;34(2):368-374

From the Department of Health Behavior & Health Education, University of Michigan, Ann Arbor.

Purpose: Health care chaplains intervene on unmet religious/spiritual (R/S) needs in health care settings that are associated with poor outcomes. Little is known about demand for their services. The purpose of this study was to describe population-level awareness and perceptions of health care chaplains and preferences for their services.

Methods: Data came from a cross-sectional survey of a nationally representative sample of US adults ≥ 18 years of age (n = 1020). Participants were asked about preferences for chaplain services, previous experience and awareness of chaplains, and level of importance on having R/S needs and sources of meaning addressed.

Results: Mean age of the sample was 47.6. Although the majority were aware of chaplains (85%), only 15% indicated they had previous experience with one. Adults who were unaware were younger (38 vs 49 years, < .001), male ( = .007), non-white race/ethnicity ( < .001), and had lower educational attainment ( = .01). Seventy percent reported an interest in having R/S or existential needs met in the context of health care.

Conclusions: The majority of the US population say they are aware of chaplains and desire their services, yet few report previous experience with them in health care. More behavioral interventions are needed to better connect patients to chaplains.
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http://dx.doi.org/10.3122/jabfm.2021.02.200396DOI Listing
September 2021

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study.

J Public Health Dent 2021 Mar 22. Epub 2021 Mar 22.

University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.

Objective: To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan.

Methods: This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim.

Results: Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability.

Conclusion: Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.
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http://dx.doi.org/10.1111/jphd.12447DOI Listing
March 2021

A Snapshot of Social Risk Factors and Associations with Health Outcomes in a Community Sample of Middle Eastern and North African (MENA) People in the U.S.

J Immigr Minor Health 2021 Mar 11. Epub 2021 Mar 11.

Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA.

Social factors (e.g. housing, food security, etc.) contribute significantly to health. The purpose of this study is to describe social risk and social exclusion factors in one of the largest Middle Eastern and North African (MENA) populations in the U.S. and their association with health outcomes. We conducted a cross-sectional study with a community convenience sample of 412 adults who self-identify as MENA. Weighted, adjusted linear regression models were used to examine relationships of interest. Prevalent social risks included transportation barriers to healthcare (33%), food insecurity (33%), and financial strain (25%). In adjusted models, perception of being treated unfairly (Estimate (SE) 0.08 (0.04), p < 0.05) and fear of deportation (0.26 (0.06), p < 0.001) were associated with more social risk factors. More social risk factors were associated with worse self-reported health (0.09 (0.03), p < 0.01), more chronic conditions (0.11 (0.03), p < 0.004), and more mental health symptoms (0.34 (0.14) p < 0.01).Social risk is high among those perceiving unfairness and fear deportation. Those with more social risk factors reported worse health. These findings have implications for social needs screening and referral models that can best serve U.S. MENA sub-populations.
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http://dx.doi.org/10.1007/s10903-021-01176-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948165PMC
March 2021

Lung Cancer Screening Knowledge, Perceptions, and Decision Making Among African Americans in Detroit, Michigan.

Am J Prev Med 2021 01;60(1):e1-e8

Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan. Electronic address:

Introduction: Previously, a web-based, patient-facing decision aid for lung cancer screening, shouldiscreen.com, was developed and evaluated. An initial evaluation was completed before the Medicare coverage decision and recruited a nondiverse sample of mostly former smokers, limiting the understanding of the potential effectiveness of the tool among diverse populations. This study evaluates shouldiscreen.com among African Americans in Metro Detroit.

Methods: Using insights obtained from participatory workshops in this population, content changes to shouldiscreen.com were implemented, and this modified version was evaluated with a before-after study. Measures included knowledge of lung cancer screening, decisional conflict, and concordance between individual preference and screening eligibility. Surveys occurred between April and July 2018. Participants were contacted 6 months after the survey to assess subsequent screening behaviors. Analysis took place in 2019.

Results: Data were collected from 74 participants aged 45-77 years, who were current/former smokers with no history of lung cancer. The average knowledge score increased by 25% from 5.7 (SD=1.94) before to 7.1 (SD=2.30) after (out of 13 points). Decisional conflict was halved between before and after. Concordance between individual preference and eligibility for screening increased from 22% (SD=41) to 35% (SD=47). Half of the participants felt uncomfortable answering surveys electronically and requested paper versions.

Conclusions: The use of the tool led to small improvements in lung cancer screening knowledge and increased concordance with current recommendations. Additional design modifications and modes of information delivery of these decision aids should be considered to increase their efficacy in helping populations with lower educational attainment and computer literacy.
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http://dx.doi.org/10.1016/j.amepre.2020.07.004DOI Listing
January 2021

Social Determinants of Poor Management of Type 2 Diabetes Among the Insured.

Authors:
Minal R Patel

Curr Diab Rep 2020 11 5;20(11):67. Epub 2020 Nov 5.

Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1415 Washington Heights, SPH 1, Room 3810, Ann Arbor, MI, 48109-2029, USA.

Purpose Of Review: Even with insurance coverage increasing over time among the population with diabetes, a large proportion continues to have poorly controlled disease. The purpose of this narrative literature review is to describe the social determinants of poor management of type 2 diabetes among the insured population and illustrate drivers of poor outcomes beyond insurance coverage.

Recent Findings: Despite the provision of health insurance, social determinants play a significant role in shaping diabetes outcomes, especially for economic instability (employment, out-of-pocket expenses associated with diabetes management), food insecurity, education and literacy, access to quality health care (health systems designed to effectively manage chronic disease), neighborhood and the built environment (segregated neighborhoods, socioeconomic conditions of communities, housing), and social and community context (discrimination, social support). Multiple social determinants shape poor diabetes outcomes among the insured. These determinants are now being further exacerbated by the COVID-19 pandemic, which has created the worst economic crisis for US families since the Great Depression. The evidence of this review points to the imperative need for more multilevel intervention approaches to address these determinants in the management of diabetes.
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http://dx.doi.org/10.1007/s11892-020-01354-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641654PMC
November 2020

Development of an Ethnic Identity Measure for Americans of Middle Eastern and North African Descent: Initial Psychometric Properties, Sociodemographic, and Health Correlates.

J Racial Ethn Health Disparities 2021 Aug 24;8(4):1067-1078. Epub 2020 Sep 24.

ACCESS, 6450 Maple St., Dearborn, MI, 48126, USA.

Background: Southeast Michigan is home to the second largest Middle Eastern and North African (MENA) US population. There is increasing interest in understanding correlates of psychosocial outcomes and health behaviors in this growing population. One potentially important health correlate is ethnic identity (EI). This paper reports the development, validity, and initial correlates of a new measure of MENA identity named the MENA-IM.

Methods: We used convenience sampling at locations frequented by individuals of MENA descent in southeast Michigan. We also measured EI centrality, religiosity, cultural mistrust, substance use, and health status to assess convergent and divergent validity. Exloratory and Confirmatory Factor Analysis identified three subscales, which were valid for both Arab and Chaldean respondents and were named (1) MENA cultural affiliation, (2) MENA media use, and (3) multicultural affiliation. We also created and tested a 20-item, single-factor version.

Results: We obtained data from 378 adults, 73% of whom identified as Arab and 27% as Chaldean. MENA-IM scores were higher among older, lower-educated, lower-income, non-US born, and Arabic-speaking respondents. Arab respondents reported significantly higher scores than Chaldeans. MENA-IM scores were positively associated with EI centrality and religiosity. Higher MENA-IM scores were found among those not reporting use of marijuana, alcohol, and opiates. Higher MENA-IM scores were also found among those without a self-reported history of heart disease and among those with better mental health status.

Discussion: The MENA-IM has strong psychometric properties and demonstrated initial evidence of convergent and discriminant validity. In general, values on the measure were associated with better psychosocial and health status. How the measure performs with MENA populations outside of Michigan and how it may relate to other health outcomes merit investigation.
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http://dx.doi.org/10.1007/s40615-020-00863-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8285340PMC
August 2021

Examination of Changes in Health Status Among Michigan Medicaid Expansion Enrollees From 2016 to 2017.

JAMA Netw Open 2020 07 1;3(7):e208776. Epub 2020 Jul 1.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Evidence about the health benefits of Medicaid expansion has been mixed and has largely come from comparing expansion and nonexpansion states.

Objective: To examine the self-reported health of enrollees in Michigan's Medicaid expansion, the Healthy Michigan Plan (HMP), over time.

Design, Setting, And Participants: A telephone survey from January 1 to October 31, 2016 (response rate, 53.7%), and a follow-up survey from March 1, 2017, to January 31, 2018 (response rate, 83.4%), were conducted in Michigan, which expanded Medicaid in 2014 through a Section 1115 waiver permitting state-specific modifications. Four thousand ninety HMP beneficiaries aged 19 to 64 years with at least 12 months of HMP coverage and at least 9 months in a Medicaid health plan were eligible to participate. Data were analyzed from April 1 to November 30, 2018.

Main Outcomes And Measures: Surveys measured demographic characteristics and health status. Analyses included weights for sampling probability and nonresponse. Comparisons between 2016 and 2017 included those who responded to both surveys (n = 3097).

Results: Of the 3097 respondents to the 2017 follow-up survey, 2388 (77.1%) were still enrolled in HMP (current enrollees) and 709 (22.9%) were no longer enrolled when surveyed (former enrollees). Among all follow-up respondents, a weighted 37.5% (95% CI, 35.3%-39.9%) were aged 19 to 34 years, 34.0% (95% CI, 31.8%-36.2%) were aged 35 to 50 years, and 28.5% (95% CI, 26.7%-30.3%) were aged 51 to 64 years; 53.0% (95% CI, 50.8%-55.3%) were female. Respondents who reported fair or poor health decreased from 30.7% (95% CI, 28.7%-32.8%) in 2016 to 27.0% (95% CI, 25.1%-29.0%) in 2017 (adjusted odds ratio [AOR], 0.66 [95% CI, 0.53-0.81]; P < .001), with the largest decreases observed in respondents who were non-Hispanic black (from 31.5% [95% CI, 27.1%-35.9%] in 2016 to 26.0% [95% CI, 21.9%-30.1%] in 2017; P = .009), from the Detroit metropolitan area (from 30.7% [95% CI, 27.0%-34.4%] in 2016 to 24.9% [95% CI, 21.6%-28.3%] in 2017; P = .001), and with an income of 0% to 35% of the federal poverty level (from 37.6% [95% CI, 34.2%-40.9%] in 2016 to 32.3% [95% CI, 29.1%-35.5%] in 2017; P < .001). From 2016 to 2017, the mean number of days of poor physical health in the past month decreased significantly from 6.9 (95% CI, 6.5-7.4) to 5.7 (95% CI, 5.3-6.0) (coefficient, -6.10; P < .001), including among current (from 7.0 [95% CI, 6.5-7.5] to 5.6 [95% CI, 5.1-6.0]; P < .001) and former (from 6.8 [95% CI, 5.9-7.7] to 5.8 [95% CI, 5.0-6.7]; P = .02) enrollees, those with 2 or more chronic conditions (from 9.9 [95% CI, 9.3-10.6] to 8.5 [95% CI, 7.8-9.1]; P < .001), across all age groups (19-34 years, from 4.3 [95% CI, 3.7-4.9] to 3.0 [95% CI, 2.5-3.5]; P < .001; 35-50 years, from 8.2 [95% CI, 7.3-9.0] to 6.9 [95% CI, 6.1-7.7]; P = .002; 51-64 years, from 9.0 [95% CI, 8.2-9.8] to 7.6 [95% CI, 6.9-8.3]; P = .001), and among non-Hispanic white (from 7.5 [95% CI, 7.0-8.1] to 6.1 [95% CI, 5.6-6.6]; P < .001) and black (from 5.9 [95% CI, 5.1-6.8] to 4.4 [95% CI, 3.6-5.1]; P < .001) respondents. No changes in days of poor mental health or usual activities missed owing to poor physical or mental health were observed.

Conclusions And Relevance: These findings suggest that HMP enrollees in Michigan have experienced improvements in self-reported health over time, including minority groups with a history of health disparities and enrollees with chronic health conditions.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.8776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352154PMC
July 2020

Corrigendum to "Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes - A randomized controlled trial" [Contemporary Clinical Trials 89 (2020) 105933].

Contemp Clin Trials 2020 Apr 14;91:106025. Epub 2020 May 14.

Department of Health Behavior & Health Education, University of Michigan School of Public Health, United States of America.

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http://dx.doi.org/10.1016/j.cct.2020.106025DOI Listing
April 2020

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan.

JAMA Netw Open 2020 01 3;3(1):e1920316. Epub 2020 Jan 3.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear.

Objective: To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion.

Design, Setting, And Participants: This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018.

Main Outcomes And Measures: Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students.

Results: The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status.

Conclusions And Relevance: Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.20316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042869PMC
January 2020

Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial.

Contemp Clin Trials 2020 02 7;89:105933. Epub 2020 Jan 7.

Department of Health Behavior & Health Education, University of Michigan School of Public Health, United States of America.

Despite the burdens costs can place on adults with diabetes, few evidence-based, scalable interventions have been identified that address prevalent health-related financial burdens and unmet social risk factors that serve as major obstacles to effective diabetes management. In this study, we will test the effectiveness of CareAvenue - an automated e-health tool that screens for unmet social risk factors and informs and activates individuals to take steps to connect to resources and engage in self-care. We will determine the effectiveness of CareAvenue relative to standard care with respect to improving glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial burden. We will also examine the role of patient risk factors (moderators) and behavioral factors (mediators) on the effectiveness of CareAvenue in improving outcomes. We will recruit 720 patients in a large health system with uncontrolled Type 1 diabetes mellitus (T1DM) or Type 2 diabetes mellitus (T2DM) who engage in CRN or perceive financial burden. Participants will be randomized to one of two arms: 1) receipt of a 15-20 min web-based program with routine follow-up (CareAvenue); or 2) receipt of contact information for existing health system assistance services. Outcomes will be assessed at baseline and 6- and 12-month follow-up. Clinical Trial Registration: ClinicalTrials.gov ID NCT03950973, May 2019.
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http://dx.doi.org/10.1016/j.cct.2020.105933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242130PMC
February 2020

Association of Expanded Medicaid Coverage With Health and Job-Related Outcomes Among Enrollees With Behavioral Health Disorders.

Psychiatr Serv 2020 01 25;71(1):4-11. Epub 2019 Sep 25.

Institute for Healthcare Policy and Innovation (Tipirneni, Patel, Goold, Kieffer, Ayanian, Clark, Lee, Bryant, Kirch, Solway), School of Public Health (Patel), School of Social Work (Kieffer), Child Health Evaluation and Research Center (Clark), and Institute for Social Research (Lee), all at the University of Michigan, Ann Arbor; Department of Internal Medicine (Tipirneni, Goold, Ayanian, Bryant, Luster), Center for Bioethics and Social Sciences in Medicine (Lewallen), and Department of Psychiatry (Zivin), all at the University of Michigan Medical School, Ann Arbor; Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Zivin).

Objectives: The study objective was to assess the impact of Medicaid expansion on health and employment outcomes among enrollees with and without a behavioral health disorder (either a mental or substance use disorder).

Methods: Between January and October 2016, the authors conducted a telephone survey of 4,090 enrollees in the Michigan Medicaid expansion program and identified 2,040 respondents (48.3%) with potential behavioral health diagnoses using claims-based diagnoses.

Results: Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work. In adjusted analyses, both enrollees with behavioral health diagnoses and those without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work and made them better able to look for a job. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as those without a behavioral health diagnosis to report improved ability to work and improved job seeking after Medicaid expansion.

Conclusions: Coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.
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http://dx.doi.org/10.1176/appi.ps.201900179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939140PMC
January 2020

Knowledge of Health Insurance Terms and the Affordable Care Act in Racially and Ethnically Diverse Urban Communities.

J Immigr Minor Health 2020 Jun;22(3):456-466

Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.

Confusion around health insurance reforms persist. The purpose of this study was to assess demographic differences in Affordable Care Act (ACA) and health insurance knowledge in a multi-ethnic urban sample. Data came from 243 adults from racial/ethnic communities. Participants were asked about elements of health insurance and the ACA. Generalized linear and logistic regression models were used to examine relationships between demographic predictors and knowledge domains. Female gender (p < 0.05) and Latino/Hispanic race/ethnicity (p < 0.001) were most predictive of lower eligibility knowledge, while non-citizen with residency status (p < 0.001) and other/not declared residency status (p < 0.001) were most predictive of lower insurance coverage knowledge. No demographic factors predicted enrollment knowledge. Latino/Hispanic race/ethnicity (p < 0.01) was most predictive of not knowing that more people can get insurance because of the ACA. In conclusion, there is variation in health insurance and ACA-related knowledge in multi-ethnic populations. More compatible health communication interventions are needed to support outreach to key demographic groups.
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http://dx.doi.org/10.1007/s10903-019-00924-3DOI Listing
June 2020

Comprehensive medication reviews: Optimal delivery setting and recommendations for quality assessment.

J Am Pharm Assoc (2003) 2019 Sep - Oct;59(5):642-645. Epub 2019 Jul 12.

Objectives: To propose a metric evaluating the quality of comprehensive medication reviews (CMRs), and to discuss the optimal setting for CMR delivery.

Summary: First, we provide a current assessment of the quality of CMRs performed in community, payer, and health system/clinic settings, with recommended opportunities for improvement. Thereafter, a companion metric for CMR quality is discussed, because this is critical to ensuring that patients are not just receiving CMR services, but that CMRs reflect evidence-based recommendations supporting optimal patient outcomes.

Conclusion: Based on the data currently available, accessibility to electronic medical records would enhance patient-specific recommendations to optimize CMR delivery and patient outcomes. Future studies may help to identify additional factors, such as pharmacist-physician collaboration in clinic and use of evidence-based recommendations, that can further enhance CMR quality.
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http://dx.doi.org/10.1016/j.japh.2019.06.004DOI Listing
August 2020

Clinician Perspectives on Electronic Health Records, Communication, and Patient Safety Across Diverse Medical Oncology Practices.

J Oncol Pract 2019 06 22;15(6):e529-e536. Epub 2019 Apr 22.

3 University of Michigan School of Nursing, Ann Arbor, MI.

Purpose: We know little about how increased technological sophistication of clinical practices affects safety of chemotherapy delivery in the outpatient setting. This study investigated to what degree electronic health records (EHRs), satisfaction with technology, and quality of clinician-to-clinician communication enable a safety culture.

Methods: We measured actions consistent with a safety culture, satisfaction with practice technology, and quality of clinician communication using validated instruments among 297 oncology nurses and prescribers in a statewide collaborative. We constructed an index to reflect practice reliance on EHRs (1 = "all paper" to 5 = "all electronic"). Linear regression models (with robust SEs to account for clustering) examined relationships between independent variables of interest and safety. Models were adjusted for clinician age.

Results: The survey response rate was 68% (76% for nurses and 59% for prescribers). The mean (standard deviation) safety score was 5.3 (1.1), with a practice-level range of 4.9 to 5.4. Prescribers reported fewer safety actions than nurses. Higher satisfaction with technology and higher-quality clinician communication were significantly associated with increased safety actions, whereas increased reliance on EHRs was significantly associated with lower safety actions.

Conclusion: Practices vary in their performance of patient safety actions. Supporting clinicians to integrate technology and strengthen communication are promising intervention targets. The inverse relationship between reliance on EHRs and safety suggests that technology may not facilitate clinicians' ability to attend to patient safety. Efforts to improve cancer care quality should focus on more seamless integration of EHRs into routine care delivery and emphasize increasing the capacity of all care clinicians to communicate effectively and coordinate efforts when administering high-risk treatments in ambulatory settings.
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http://dx.doi.org/10.1200/JOP.18.00507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6804874PMC
June 2019

Insuring Good Health: Outcomes and Acceptability of a Participatory Health Insurance Literacy Intervention in Diverse Urban Communities.

Health Educ Behav 2019 06 20;46(3):494-505. Epub 2019 Feb 20.

1 University of Michigan School of Public Health, Ann Arbor, MI, USA.

Background: The U.S. uninsured rate has dropped significantly since the passage of the Affordable Care Act (ACA), yet insurance coverage remains lower in historically marginalized communities than in the overall population. New consumer engagement approaches that involve these populations are needed. The purpose of this study was to evaluate the effectiveness of the Insuring Good Health Intervention, a website and video series designed to improve engagement with health insurance and ACA reforms. The study was designed and implemented using a community-based participatory research approach.

Method: We conducted a lagged-control cluster randomized controlled trial to evaluate Insuring Good Health with racially and ethnically diverse adults seeking services in medically underserved areas within the Detroit, Michigan metropolitan area. Outcomes were assessed at baseline and at 6 and 9 months postintervention, and including self-efficacy, knowledge, beliefs, and intention to seek help with insurance navigation and care.

Results: Among 243 participants, mean age was 43.4 ( SD = 13) years, and all participants met federal guidelines for poverty. The study had an 86% response rate at 9-month follow-up ( n = 209). Compared with the lagged-control group, intervention participants had more positive beliefs concerning preventive care (estimate 0.51, standard error 0.16; p < .01), and intention to seek help with insurance navigation and care (estimate 0.43, standard error 0.17; p < .001) at 9-month follow-up. Hispanic participants benefitted the most from the intervention, including improved knowledge of health insurance eligibility over 9 months compared with other racial/ethnic groups (estimate -0.97, standard error 0.40, p < .01).

Discussion: Insuring Good Health was associated with increased intention to seek help with insurance navigation and care, and improved beliefs around preventive care.

Conclusions: Insuring Good Health has the potential to be an important consumer engagement tool to reduce disparities in health insurance coverage and care seeking.
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http://dx.doi.org/10.1177/1090198119831060DOI Listing
June 2019

Improving the Affordability of Prescription Medications for People with Chronic Respiratory Disease. An Official American Thoracic Society Policy Statement.

Am J Respir Crit Care Med 2018 12;198(11):1367-1374

Background: Mounting evidence indicates that out-of-pocket costs for prescription medications, particularly among low- and middle-income patients with chronic diseases, are imposing financial burden, reducing medication adherence, and worsening health outcomes. This problem is exacerbated by a paucity of generic alternatives for prevalent lung diseases, such as asthma and chronic obstructive pulmonary disease, as well as high-cost medicines for rare diseases, such as cystic fibrosis. Affordability and access challenges are especially salient in the United States, as citizens of many other countries pay lower prices for and have greater access to prescription medications.

Methods: The American Thoracic Society convened a multidisciplinary committee comprising experts in health policy pharmacoeconomics, behavioral sciences, and clinical care, along with individuals providing industry and patient perspectives. The report and its recommendation were iteratively developed over a year of in-person, telephonic, and electronic deliberation.

Results: The committee unanimously recommended the establishment of a publicly funded, politically independent, impartial entity to systematically draft evidence-based pharmaceutical policy recommendations. The goal of this entity would be to generate evidence and action steps to ensure people have equitable and affordable access to prescription medications, to maximize the value of public and private pharmaceutical expenditures on health, to support novel drug development within a market-based economy, and to preserve clinician and patient choice regarding personalized treatment. An immediate priority is to examine the evidence and make recommendations regarding the need to have essential medicines with established clinical benefit from each drug class in all Tier 1 formularies and propose recommendations to reduce barriers to timely generic drug availability.

Conclusions: By making explicit, evidence-based recommendations, the entity can support the establishment of coherent national policies that expand access to affordable medications, improve the health of patients with chronic disease, and optimize the use of public and private resources.
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http://dx.doi.org/10.1164/rccm.201810-1865STDOI Listing
December 2018

Use of Storytelling to Increase Navigation Capacity Around the Affordable Care Act in Communities of Color.

Prog Community Health Partnersh 2018;12(3):307-319

Background: Improving health insurance coverage and retention in communities of color is a national priority and new approaches are needed.

Objectives: To describe 1) the formation of Insure Detroit, a community-based participatory research (CBPR) partnership aimed at addressing health insurance and Affordable Care Act (ACA) literacy challenges in economically disadvantaged areas, 2) the development of Insuring Good Health, a novel, multimedia, health information technology-focused intervention to address the health aims of the partnership, and 3) the evaluation plan for the intervention.

Methods: Insure Detroit, a partnership between researchers and community-based organizations, was established. Principles of CBPR were followed closely in the conduct of this project. The Insure Detroit partnership developed the intervention and evaluation plan through an iterative process. The Insuring Good Health intervention is multilingual and composed of a responsive website. It includes nine short, animated videos informed by storytelling techniques that communicate key learning points pertaining to health insurance navigation and use.

Lessons Learned: Lessons learned included narrowing learning points for the intervention, balancing the volume of work to comply with the study timeline, and balancing the political climate with the development of the intervention.

Conclusions: The Insure Detroit partnership demonstrates that a CBPR approach can develop media-based health communications to address health insurance literacy. Our experiences highlight that CBPR principles that encourage shared decision making and co-learning can result in high-quality, innovative interventions that have the potential to resonate well with communities of color.
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http://dx.doi.org/10.1353/cpr.2018.0055DOI Listing
March 2019

Physician attitudes about cost consciousness for breast cancer treatment: differences by cancer sub-specialty.

Breast Cancer Res Treat 2019 Jan 26;173(1):31-36. Epub 2018 Sep 26.

Department of Radiation Oncology, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.

Purpose: High costs of cancer care place considerable burden on patients and society. Despite increasing recognition that providers should play a role in reducing care costs, how physicians across cancer specialties differ in their cost-consciousness has not been reported. We examined cost-consciousness regarding breast cancer care among medical oncologists, surgeons, and radiation oncologists.

Methods: We identified 514 cancer surgeons, 504 medical oncologists, and 251 radiation oncologists by patient report through the iCanCare study. iCanCare identified newly diagnosed women with breast cancer through the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles. We queried providers on three dimensions of cost-consciousness: (1) perceived importance of cost saving for society, patients, practice, and payers; (2) awareness of patient out-of-pocket expenses; and (3) discussion of financial burden.

Results: We received responses from 376 surgeons (73%), 304 medical oncologists (60%), and 169 radiation oncologists (67%). Overall levels of cost-consciousness were moderate, with scores ranging from 2.5 to 3.0 out of 5. After adjusting for covariates, surgeons had the lowest scores on all three cost-consciousness measures; medical oncologists had the highest scores. Pairwise contrasts showed surgeons had significantly lower scores than medical oncologists for all three measures and significantly lower scores than radiation oncologists for two of the three cost-consciousness variables: importance of cost saving and discussion of financial burden.

Conclusions: How cost-consciousness impacts medical decision-making across specialty and how policy, structural, and behavioral interventions might sensitize providers regarding cost-related matters merit further examination.
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http://dx.doi.org/10.1007/s10549-018-4976-7DOI Listing
January 2019

Improving Patient-Provider Communication and Therapeutic Practice Through Better Integration of Electronic Health Records in the Exam Room: A Pilot Study.

Health Educ Behav 2019 06 8;46(3):484-493. Epub 2018 Sep 8.

2 University of California Irvine, CA, USA.

Background: The rapid proliferation of electronic health records (EHRs) in clinics has had mixed impact on patient-centered communication, yet few evaluated interventions exist to train practicing providers in communication practices.

Aims: We extended the evidence-based Physician Asthma Care Education (PACE) program with EHR-specific communication strategies, and tested whether training providers with the extended program (EHR-PACE) would improve provider and patient perceptions of provider communication skills and asthma outcomes of patients.

Method: A pilot randomized design was used to compare EHR-PACE with usual care. Participants were providers ( n = 18) and their adult patients with persistent asthma ( n = 126). Outcomes were assessed at baseline and 3- and 6-month postintervention, including patient perception of their provider's communication skills and provider confidence in using EHRs during clinical encounters.

Results: Compared with the control group, providers who completed the EHR-PACE program reported significant improvements at 3-month follow-up in their confidence with asthma counseling practices (estimate 0.90, standard error [ SE] 0.4); p < .05) and EHR-specific communication practices (estimate 2.3, SE 0.8; p < .01), and at 6-month follow-up, a significant decrease in perception that the computer interferes with the patient-provider relationship (estimate -1.0, SE 0.3; p < .01). No significant changes were observed in patient asthma outcomes or their perception of their provider's communication skills.

Discussion: Training providers with skills to accommodate EHR use in the exam room increases provider confidence and their perceived skills in maintaining patient-centered communications in the short term.

Conclusion: Evidence-supported training initiatives that can increase capacity of busy providers to manage increased computing demands shows promise. More research is needed to fully evaluate EHR-PACE on patients' health status and their perceptions of their provider's care through a large-scale trial.
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http://dx.doi.org/10.1177/1090198118796879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465159PMC
June 2019

Cost Conversations Between Primary Care Providers and Patients with Expanded Medicaid Coverage.

J Gen Intern Med 2018 11;33(11):1845-1847

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.

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http://dx.doi.org/10.1007/s11606-018-4551-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206343PMC
November 2018

Does cross-cultural communication training for physicians improve pediatric asthma outcomes? A randomized trial.

J Asthma 2019 03 11;56(3):273-284. Epub 2018 Apr 11.

a Department of Health Behavior and Health Education , University of Michigan School of Public Health Ann Arbor , MI , USA.

Objective: Adverse cross-cultural interactions are a persistent problem within medicine impacting minority patients' use of services and health outcomes. To test whether 1) enhancing the evidence-based Physician Asthma Care Education (PACE), a continuing medical education program, with cross cultural communication training (PACE Plus) would improve the asthma outcomes of African American and Latino/Hispanic children; and 2) whether PACE is effective in diverse groups of children.

Methods: A three-arm randomized control trial was used to compare PACE Plus, PACE, and usual care. Participants were primary care physicians (n = 112) and their African American or Latino/Hispanic pediatric patients with persistent asthma (n = 867). The primary outcome of interest included changes in emergency department visits for asthma overtime, measured at baseline, and 9 and 21 months following the intervention. Other outcomes included hospitalizations, asthma symptom experience, caregiver asthma-related quality of life, and patient-provider communication measures.

Results: Over the long term, PACE Plus physicians reported significant improvements in confidence and use of patient-centered communication and counseling techniques (p < 0.01) compared to PACE physicians. No other significant benefit in primary and secondary outcomes was observed in this trial.

Conclusion: PACE Plus did not show significant benefit in asthma-specific clinical outcomes. More trials and multi-component strategies continue to be needed to address complex risk factors and reduce disparities in asthma care.

Trial Registration: ClinicalTrials.gov: NCT01251523 December 1, 2010.
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http://dx.doi.org/10.1080/02770903.2018.1455856DOI Listing
March 2019

Depression and Asthma Outcomes in Older Adults: Results from the National Health and Nutrition Examination Survey.

J Allergy Clin Immunol Pract 2017 Nov - Dec;5(6):1691-1697.e1. Epub 2017 Jun 19.

Division of Allergy and Clinical Immunology, University of Michigan Health System, Ann Arbor, Mich; Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Mich.

Background: Older adults have high rates of asthma morbidity and mortality, as well as increased rates of depression. There are no nationally representative studies describing the association of depression on key asthma outcomes such as emergency department (ED) visits among older adults.

Objective: The objective of this study was to determine the association of depression with asthma outcomes in older adults (age ≥ 55) from the National Health and Nutrition Examination Survey (NHANES).

Methods: Data from the NHANES survey (2007-2012) were analyzed. Bivariate analyses and multivariate Poisson regression models were used to examine associations between depression and asthma outcomes among adults above the age of 55.

Results: Approximately 7.01% (n = 509) of the sample reported a physician diagnosis of asthma. Older adults with asthma and depression (n = 196) had increased asthma episodes (prevalence ratio [PR], 1.53; 95% confidence interval [CI], 1.00-2.35), ED/urgent care visits for asthma (PR, 2.24; 95% CI, 1.15-4.34), sleep disturbances due to asthma (PR 2.75; 95% CI, 1.54-4.92), and activity limitation (PR, 1.77; 95% CI, 1.00-3.18; P = .05) compared with older asthmatics without depression. They also reported worse health-related quality of life measures across 4 domains including days of poor general health, physical health, mental health, and inactivity (P < .001 for all). No significant differences in spirometric values were observed.

Conclusions: Older adults with asthma and depression are nearly twice as likely to have poor asthma outcomes across several indicators, including asthma-related ED/urgent care visits compared with those without depression. Screening for depression and providing supportive resources may decrease the burden of asthma among older adults.
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http://dx.doi.org/10.1016/j.jaip.2017.03.034DOI Listing
June 2018

Pharmacists' perspectives of the current status of pediatric asthma management in the U.S. community pharmacy setting.

Int J Clin Pharm 2017 Aug 11;39(4):935-944. Epub 2017 May 11.

Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, USA.

Objective To explore community pharmacists' continuing education, counseling and communication practices, attitudes and barriers in relation to pediatric asthma management. Setting Community pharmacies in Michigan, United States. Methods Between July and September 2015 a convenience sample of community pharmacists was recruited from southeastern Michigan and asked to complete a structured, self-reported questionnaire. The questionnaire elucidated information on 4 general domains relating to pharmacists' pediatric asthma management including: (1) guidelines and continuing education (CE); (2) counseling and medicines; (3) communication and self-management practices; (4) attitudes and barriers to practice. Regression analyses were conducted to determine predictors towards pharmacists' confidence/frequency of use of communication/counseling strategies. Main outcome measure Confidence in counseling skills around asthma. Results 105 pharmacists completed the study questionnaire. Fifty-four percent of pharmacists reported participating in asthma related CE in the past year. Over 70% of pharmacists reported confidence in general communication skills, while a lower portion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen (58%), decision-making (50%) and setting short-term (47%) and long-term goals (47%) with the patient and caregiver for managing asthma at home. Pharmacists who reported greater use of recommended communication/self-management strategies were more likely to report confidence in implementing these communication/self-management strategies when counseling caregivers and children with asthma [Beta (B) Estimate 0.58 SE (0.08), p < 0.001]. Female pharmacists [B Estimate -2.23 SE (1.01), p < 0.05] and those who reported beliefs around doctors being the sole provider of asthma education [B Estimate -1.00 SE (0.32), p < 0.01] were less likely to report confidence in implementing communication/self-management strategies. Conclusion A pharmacists' confidence may influence their ability to implement recommended self-management counseling strategies. This study showed that community pharmacists are confident in general communication. However pharmacists are reporting lower confidence levels in counseling on higher order self-management strategies with patients. More appropriate and targeted continuing education programs for pharmacists around asthma self-management education are recommended.
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http://dx.doi.org/10.1007/s11096-017-0471-1DOI Listing
August 2017

Solutions to Address Diabetes-Related Financial Burden and Cost-Related Nonadherence: Results From a Pilot Study.

Health Educ Behav 2018 02 26;45(1):101-111. Epub 2017 Apr 26.

1 University of Michigan School of Public Health, Ann Arbor, MI, USA.

Background: Cost-related nonadherence (CRN) to recommended self-management behaviors among adults with chronic conditions such as diabetes is prevalent. Few behavioral interventions to mitigate CRN have been tested and evaluated.

Aims: We developed a financial burden resource tool and examined its acceptability and the preliminary effects on patient-centered outcomes among adults with diabetes or prediabetes seen in a clinical setting.

Method: We report a pre-post one-group design pilot study. From an endocrinology clinic, we recruited 104 adults with diabetes who reported financial burdens with their diabetes management or engaged in CRN behaviors. We offered participants the financial burden resource tool we developed, which provided tailored, low-cost resource options for diabetes management and other social needs. Acceptability and self-reported outcomes were assessed 2 months after use of the tool.

Results: Mean age of participants was 50.5 years ( SD = 15.3). Participants found the tool highly acceptable across 15 indicators (e.g., 93% "learned a lot," 98% "topics relevant" 95% "applicable to their lives," 98% "liked the information"). Significant improvements between baseline and 2-month follow-up were observed for discussion of cost concerns with nurses (19% to 29%, p < .05) and pharmacists (13% to 25.5%, p < .01), not skipping doses of medicines due to cost (11% to 4%, p < .03), and financial management (33.83 to 39.62, p < .007). There were no significant changes in perception of financial burden.

Conclusion: A financial burden resource tool is highly acceptable to patients, is easy to administer, and can prompt behavior change. This pilot study supports the need for well-powered trials with longer follow-up to further evaluate the effectiveness of such tools in improving CRN and key outcomes.
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http://dx.doi.org/10.1177/1090198117704683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5908467PMC
February 2018

Health Insurance Challenges in the Post-Affordable Care Act (ACA) Era: a Qualitative Study of the Perspective of Low-Income People of Color in Metropolitan Detroit.

J Racial Ethn Health Disparities 2018 02 7;5(1):78-85. Epub 2017 Feb 7.

Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, SPH 2, Ann Arbor, MI, 48109-2029, USA.

Low-income people of color are at risk of remaining uninsured due to a variety of factors. This study examined Affordable Care Act (ACA)-related and other health insurance enrollment experiences, observations, navigation needs, and experiences maintaining health insurance coverage among low-income communities of color in an economically disadvantaged community (Metropolitan Detroit). We conducted nine focus groups (n = 87) between May and June 2015. Participants were recruited through community-based organizations serving our key populations of interest. Using an inductive thematic analysis approach, codes and themes were generated. Findings from six themes demonstrated that although health insurance is perceived as important, confusion and frustration persist around health plan benefits and coverage, eligibility requirements and key provisions of the ACA, and enrollment. Individuals face difficulties justifying the cost of health insurance. More focused insurance outreach efforts are needed to achieve the ultimate goal of improving the health of low-income communities of color.
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http://dx.doi.org/10.1007/s40615-017-0344-2DOI Listing
February 2018
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