Medical Care最新文献

Objectives: To estimate the prevalence of adverse childhood experiences (ACEs) among a population-based sample of adults in the United States by their primary source of health care.

Background: Debate continues around the effectiveness and implementation of health care-based screening of ACEs. However, it is unclear how the burden of ACEs would be distributed across different sources of health care (ie, what a health system might expect should it implement ACEs screening).

Methods: Data are from 8 U.S. states that include optional modules for ACEs and health care utilization in their 2019 or 2020 Behavioral Risk Factor Surveillance System survey. The analytic sample includes respondents with completed interviews (n = 45,820). ACEs were categorized into ordinal categories of 0, 1, 2, 3, or ≥4; and the prevalence of ACEs was summarized across 5 sources of health care: (1) employer-based or purchased plan; (2) Medicare, Medicaid, or other state programs; (3) TRICARE, Veterans Affairs, or military (ie, military-related health care); (4) Indian Health Service; or (5) some other source. All estimates were weighted to account for the complex sampling design.

Results: Across all health insurance types, at least 60% of individuals reported at least one ACE. The greatest prevalence of patients reporting ≥4 ACEs occurred for military-related health care (21.6%, 95% CI = 18.2-25.5) and Indian Health Service (45.4%, 95% CI = 22.6-70.3).

Conclusions: ACEs are extremely common across sources of health care, but some health systems have greater proportions of patients with high ACE exposures. The unique strengths and challenges of specific health care systems need to be integrated into the debate about clinical ACEs screening.

The concepts of health and well-being are deeply intertwined and interdependent. Situating both health and well-being within a unified framework is important to ensure their inclusion in the full spectrum of health research and to achieve the crucial task of building a body of basic, translational, and clinical studies to guide the implementation of whole-person health care. This commentary proposes such a framework where an individual's own assessment of their physical, emotional, and spiritual well-being complements objective measures of their physical and psychological function and where social, environmental, economic, educational, and vocational well-being are located within positive determinants of health.

A cultural transformation is underway at the Veterans Health Administration and other health care systems to address the well-being of the whole person and not just their disease states. A part of this evolution is to develop a measurement paradigm because the existing ones are generally disease-specific; however, the International Statistical Classification of Diseases and Related Health Problems (ICD)-10th Revision-Clinical Modification does include codes for social determinants of health (SDOH). The ICD coding system is an internationally recognized system to identify and classify diseases, injuries, health encounters, and inpatient procedures. Medical and social service providers, researchers, health information managers, public health and health care system professionals, policymakers, and coders use these codes to conduct surveillance, such as on the existence of diseases and their outcomes, health care utilization, and health care-associated adverse events, and for billing and claims reimbursement. The ICD coding system has been the backbone of health care systems' clinical documentation and coding practices on an international level since 1909. Clinical documentation and coding have an immense influence on what can be measured in medical records. The current ICD guidance needs to undergo a cultural transformation to have parity between codes for medical and nonmedical conditions, such as supporting the standard use of SDOH as primary diagnoses for outpatient encounters, expanding its list of SDOH codes, and incorporating a wellness perspective. Developing a measurement paradigm that assesses the well-being of the whole person must involve in tandem revising the ICD coding system to include this same perspective.

There is growing interest in moving away from a reductionistic view of the person and the health services they need to focus on improving the health of the whole person. However, there needs to be agreement about what this focus entails and how to measure its achievement. From this perspective, we offer suggestions for moving the measurement discussion forward. Our key suggestion is to separate the measurement of whole person health (WPH)-that is, the end goal or ultimate outcome we want to improve and/or maintain-from the measurement of WPH determinants-that is, the things that can be intervened upon to maximize WPH. We also offer some next steps toward developing a measure of WPH.

Countries around the world have large aging adult populations. There is wide public health concern about the health and well-being of aging adults, and a movement to transform healthcare systems to become age-friendly. The concept of "successful aging" recognizes the importance of aging and expands the goal beyond the absence of disease to functioning and well-being. In this perspective, we discuss aging as a part of life that should be considered in whole person health and cite work with the US veteran population as an example of how successful aging and age-friendly practices can be incorporated into whole person health for adult populations. We also review studies of successful aging that may offer important ways to define and measure whole person health and discuss how it might be instructive to assess successful aging with multiple indicators across the adult life span, particularly in underserved populations at-risk of premature aging and poor health. Finally, we conclude with a discussion of the "life course perspective" that may serve as a useful model for the interplay between successful aging and whole person health.

Objectives: (1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity.

Background: An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR.

Methods: Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity.

Results: Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR.

Conclusions: Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

Background: Measuring patient well-being during clinical care may enhance patient-centered communication and treatment planning. The Veterans Health Administration (VHA) piloted the use of the Well-Being Signs (WBS), a self-report measure of psychosocial well-being, in clinical care.

Objective: To understand early WBS implementation and health care team member experiences with its use before developing detailed support materials and finalizing the measure.

Methods: We conducted a mixed-methods evaluation of the WBS implementation pilot at 4 VHA facilities, including surveys of (n=4) Whole Health (WH) leaders/clinical leads, and semi-structured interviews with (n=11) clinical leads and team members. Survey data were characterized using descriptive statistics; interview data were analyzed using rapid qualitative analysis.

Results: Facilities supported WBS implementation by disseminating information to clinical team members, primarily during staff meetings (3/4 facilities), individual discussions (3/4), and email (3/4); only half provided training sessions. In interviews, some care team members expressed the need for more training on using the WBS in clinical care. Some interviewees also provided suggestions for changes to the draft measure, including response option format and question look-back period.

Conclusions: Although there have been growing calls for attention to patient well-being in clinical care, our results suggest barriers to the implementation of well-being measures in this context. Findings were used to inform the development of enhanced training materials and make modifications to enhance the acceptability of the WBS to providers. Other identified barriers will need to be addressed in future implementation efforts, including bolstering leadership support and easing the added time and burden of administration.

Background: Despite numerous calls for standardized collection of sexual orientation and gender identity (SOGI) data in clinical settings, uptake of this practice still lags.

Objectives: This study conducted a preimplementation assessment of staff attitudes toward SOGI data collection within an adult primary care practice in an urban academic medical center in the northeastern United States.

Research design: We created a process map of the flow of patient data from the point of registration to the clinical encounter to identify all staff roles associated with registration and patient demographic data collection. We purposively sampled staff members across these roles and conducted semistructured virtual interviews between November 2021 and February 2022. The research team used deductive and inductive coding and conducted a thematic analysis to identify barriers and facilitators to implementation.

Subjects: Nine clinical staff and eleven nonclinical staff were interviewed.

Measures: Participants were asked about their general experiences with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients, their perspectives on collecting this data, and potential barriers and facilitators to incorporating this into the workflow.

Results: The main themes that emerged were the relevance of SOGI data to the clinical practice; concerns about patient acceptability; the prevalence of cis-gender, heteronormative assumptions; and concerns about linguistic, cultural, and generational differences. Differences were noted between clinical and nonclinical staff.

Conclusions: Greater education is needed to help both clinical and nonclinical staff understand how patients' SOGI demographics can be used to provide affirming, patient-centered care. Implementation strategies can be tailored to address specific barriers at the individual, organizational, and social levels.