Publications

BACKGROUND

Electronic referral and consultation systems are gaining popularity, but their contribution to the patient centered medical home-neighborhood framework of coordinated care delivery is not clear. We examined how specialists leverage an electronic referral and consultation system to deliver specialty care, identified determinants of high-quality electronic specialist communication and measured the impact of feedback to specialists on communication quality.

METHODS

Referral patterns were identified for 19 specialties using eReferral in the San Francisco public health care delivery system. Primary care provider (PCP) ratings of the quality (helpfulness and educational value) of consultative communication were measured. Using logistic regression, we identified determinants of high-quality specialist communication during pre-consultative exchange or virtual co-management. Predictors included: specialty and reviewer type, referral volume, percent of referrals never scheduled and time spent by reviewers on eReferral. A pre-post analysis examined the impact of feedback on communication quality.

RESULTS

The percentage of referrals immediately scheduled (27.2-82.8%) and never scheduled (7.7-59.3%) varied by specialty, with medical reviewers (vs. surgical and women׳s health) and physician reviewers (vs. nurse practitioners) scheduling fewer referrals immediately (p<0.001). Prevalence of high-quality communication was 71%, impacted by referral volume (adjusted odds ratio=0.78, 95%CI 0.68-0.88 for each additional 1000 referrals/year) and time spent per referral (1.18, 1.04-1.35 for each additional 3min).

CONCLUSIONS

Specialists can use electronic referral and consultation systems to enhance specialty care delivery with consultative communication that is highly rated by PCPs.

IMPLICATIONS

These data can inform the structure and functionality of future electronic consultation systems to maximize care coordination.

LEVEL OF EVIDENCE

III.

BACKGROUND AND OBJECTIVES

De-normalization of smoking as a public health strategy may create shame and isolation in vulnerable groups unable to quit. To examine the nature and impact of smoking stigma, we developed the Internalized Stigma of Smoking Inventory (ISSI), tested its validity and reliability, and explored factors that may contribute to smoking stigma.

METHODS

We evaluated the ISSI in a sample of smokers with mental health diagnoses (N = 956), using exploratory and confirmatory factor analysis, and assessed construct validity.

RESULTS

Results reduced the ISSI to eight items with three subscales: smoking self-stigma related to shame, felt stigma related to social isolation, and discrimination experiences. Discrimination was the most commonly endorsed of the three subscales. A multivariate generalized linear model predicted 21-30% of the variance in the smoking stigma subscales. Self-stigma was greatest among those intending to quit; felt stigma was highest among those experiencing stigma in other domains, namely ethnicity and mental illness-based; and smoking-related discrimination was highest among women, Caucasians, and those with more education.

DISCUSSION AND CONCLUSION

Smoking stigma may compound stigma experiences in other areas. Aspects of smoking stigma in the domains of shame, isolation, and discrimination were related to modeled stigma responses, particularly readiness to quit and cigarette addiction, and were found to be more salient for groups where tobacco use is least prevalent.

SCIENTIFIC SIGNIFICANCE

The ISSI measure is useful for quantifying smoking-related stigma in multiple domains.

RATIONALE

For treatment of multidrug-resistant tuberculosis, World Health Organization (WHO) guidelines recommend four likely effective drugs plus pyrazinamide (PZA), irrespective of the likely effectiveness of PZA in an individual patient. Whether this regimen should be supplemented in the absence of likely PZA effectiveness is an open question.

OBJECTIVES

The objectives of this study were to examine (1) whether individuals receiving four likely effective drugs (based on documented susceptibility or no prior exposure) experienced higher mortality during the intensive phase of treatment than those receiving five likely effective drugs and (2) whether the WHO-recommended regimen (four likely effective drugs plus PZA) may be compromised in individuals in whom PZA is not likely effective.

METHODS

Among 668 patients, we compared the hazard of death across regimen groups characterized by the number of likely effective drugs and whether pyrazinamide was one of the likely effective drugs.

MEASUREMENTS AND MAIN RESULTS

Relative to five likely effective drugs, regimens of four likely effective drugs and the WHO-recommended regimen used in individuals in whom PZA was not likely effective were associated with higher mortality rates (respectively, adjusted hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.35-6.09 and adjusted HR, 2.76; 95% CI, 0.92-8.27). The mortality rate for a regimen of five likely effective drugs with likely effective PZA was similar to that for the regimen of five likely effective drugs without PZA (HR, 1.00; 95% CI, 0.12-8.00).

CONCLUSIONS

Mortality may be reduced by the inclusion of five likely effective drugs, including an injectable, during the intensive phase of treatment. If PZA is unlikely to be effective in an individual patient, these results suggest adding a different, likely effective drug.

OBJECTIVE

To determine Latino parents' beliefs regarding the effects of television viewing on infants and toddlers.

METHODS

We conducted interviews with 26 Latino parents of infants and toddlers. We evaluated parents' beliefs about the health effects of television viewing, sources of information on this topic and facilitators and barriers to following the American Academy of Pediatrics (AAP) screen-time guidelines.

RESULTS

Parents believed that television viewing was educational for children but were concerned that watching television could worsen children's vision. Parents would be motivated to limit television viewing by children if it were recommended by a health care provider. Most parents were confident that they could limit their children's television viewing, although some perceived logistical challenges to following guidelines.

CONCLUSIONS

Parents in our study had limited knowledge of the effects of television. Counseling on television by health care providers for Latino parents may decrease Latino infants and toddlers' television exposure.