OBJECTIVES:Recent reports of delays in receiving care among U.S. Veterans have received national attention. Such delays may have an effect on veterans' propensity to seek healthcare as well, which could be detrimental to their health. There exists no evidence at the national level of the magnitude of perceived care delay in the Veterans Affairs (VA) system and how it compares to populations with other types of insurance coverage in the U.S.STUDY DESIGN AND METHODS:This cross-sectional study analyzed a recent nationally representative survey database (n = 10,907). Descriptive and multivariate regression analyses were performed to determine how care delay for veterans compares with the general population.RESULTS:We found that 17.2% of Americans delayed seeking needed healthcare in 2010-2011, but the figure was 29% for veterans. Also, there was a significant association of care delay with VA health care coverage after adjusting for other personal factors and region of the country.CONCLUSIONS:Study results suggest a possible link between VA access problems and veterans' behavior in seeking needed healthcare, which may be creating disparities in the effectiveness of care for this vulnerable and deserving population. Our study provides evidence of self-reported care delay among veterans. More studies are necessary to further understand factors in relation to delaying seeking care among veterans.

The role of information technology (IT) remains important within the medical community. However, little is known about the extent to which practicing physicians improve practice performance by having and utilizing IT at the national level. The present study, analyzing a national physician survey (n = 4,720), seeks to explore associations of IT availability and utilization with practice performance at the national level. The multivariate regression analysis results suggest that patient information IT functionality upholds physician advantages in annual income but prescription drug IT functionality was reversely linked to annual income. We also found a negative association of patient information IT functionality with patient visit volume. Our study results revealed mixed findings. Not all IT functionalities would offer benefits to practicing physicians. Our data suggest that patient information IT functionality can moderate cost concerns related to IT investment among providers.

BACKGROUND:Physician financial conflict of interest is a concern in the delivery of medicine because of its possible influence on the cost and the quality of patient care. There has been an extensive discussion of the ethical, economic, and legal aspects of this issue but little direct empirical evidence of its magnitude or effects.METHODOLOGY:A nationally representative survey (n = 4,720) was used to empirically examine physician self-report of receipt of financial gifts from the pharmaceutical and medical devices industry and its association with their ability to provide quality care.FINDINGS:Results indicate that the vast majority of physicians receive industry gifts in various forms, and the receipt of gifts is associated with lower perceived quality of patient care. There is also an inverse relationship between the frequency of received gifts and the perceived quality of care.PRACTICE IMPLICATIONS:Physicians need to be aware of the widespread receipt of industry gifts in medical practice and the potential adverse impact of such receipts on the delivery of care.

Home health aides are one of our essential human resources in the U.S. long-term care industry but understanding whether home health aides experience racial discrimination in the workplace and, if so, which personal/organizational factors are associated at the national level has been unnoticed. Using a nationally representative sample (n=3377), we attempt to investigate the association between racial discrimination and personal and organizational factors. The study found the 13.5% prevalence rate of racial discrimination. The study findings from multiple regression analysis reveal that black home care aides are more likely than white aides to experience racial discrimination in the workplace, suggesting that racial disparity may be an additional barrier to our home health care industry. National chain affiliation and low income were also found to be associated with perceived racial discrimination.

While quality is of paramount concern in health care, there has been little research done examining physician attitudes towards quality of health care and their perceived competitiveness in the market place. Utilizing the national physician survey data ( n = 4720), we undertook a bivariate and multivariate regression analysis to explore the association between physician perceived competition and barriers to quality of care. After adjusting personal and organizational factors, two quality care measures were found to be related to increased physician perceived market competition: (1) inadequate mechanism (patient’s inability to pay for care); (2) variations in practice (medical errors and untimeliness of medical reports). Overall our findings suggest the association between perceived market competition and barriers to quality of care. In physicians’ views the current managed care market system appears to be competitive but this market competition may not benefit practicing physicians in improving quality of patient care.

Research regarding the accuracy of estimating blood loss by anesthesia providers has been limited, generally consisting of small sample sizes with conflicting findings. We conducted a prospective study using a convenience sample of 91 anesthesia providers: 36 Certified Registered Nurse Anesthetists (CRNAs), 48 student registered nurse anesthetists (SRNAs), and 7 anesthesiologists. We applied a known volume of moulage (theater) blood to items at 4 stations and asked each participant to estimate the amount of blood present at each station. Descriptive and inferential statistical analyses were performed. Multivariate regression analysis was conducted to evaluate the association of estimation errors with covariates (provider training, gender, ethnicity, years of education, and years of anesthesia experience). We found no difference in the mean error of blood loss estimation based on provider training, gender, ethnicity, education, or experience. Although no statistically significant differences in blood loss estimations existed among provider groups, CRNAs had smaller mean errors than anesthesiologists in all 4 stations and smaller mean errors than SRNAs in 3 of 4 stations. Accuracy of estimating blood loss, measured by mean error, was not related to type of provider training, years of education or experience, gender, or ethnicity. Anesthesia providers may not estimate blood loss accurately.

Understanding practice behaviors of solo/dual physician ownership and associated factors at the national level is important information for policymakers and clinicians in response to the Affordable Care Act (ACA) of 2010, but poorly understood in the literature. We analyzed nationally representative data (n = 4,720). The study results reveal nearly 33% of the sample reported solo/two-physician practices. Male/minority/older physicians, psychiatrists, favor small practices. Greater market competition was perceived and less charity care was given among solo/two-physician practitioners. The South region was favored by small physician practitioners. Physicians in solo or two-person practices provided fewer services to chronic patients and were dissatisfied with their overall career in medicine. Small practices were favored by international medical graduates (IMGs) and primary care physicians (PCPs). Overall our data suggest that the role of solo/dual physician practices is fading away in the delivery of medicine. Our findings shed light on varied characteristics and practice behaviors of solo/two-physician practitioners, but more research may be needed to reevaluate the potential role of small physician practitioners and find a way to foster a private physician practice model in the context of the newly passed ACA of 2010.

Purpose – Performance of home health aides remains imperative in the medical community, but understanding the potential role of consideration leadership (CL) in improving performance of home health aides in the literature has gone undetected. This paper seeks to address these issues. Design/methodology/approach – The present study, using the 2007 National Home Health Aides Survey (n=3,308), aims to investigate the moderating role of consideration leadership (CL) in the relationship between injury and training among home health aides at the national level. Descriptive statistics and a hierarchical logistic regression analysis were performed. Findings – Not all consideration practices play a positive role in the relationship between training and injury. The authors found only employee-focused consideration leadership practices, when introduced together with training, may benefit home health aides in reducing injury. Research limitations/implications – To maximize training effectiveness, leaders may need to understand the importance of their own role in training transfer processes and attempt to demonstrate adequate influence behaviors such as consideration. Originality/value – This research is the first of its kind to explore the role of consideration leadership in the relationship with injury and training among home health aides.

Anesthetic management of patients who have suffered traumatic brain injuries can be challenging. We investigated the relationship between arterial to end-tidal carbon dioxide partial pressure gradients (Pa-etCO(2)) and 3 predictor variables: (1) injury severity score, (2) use of positive end-expiratory pressure, and (3) presence of rib fractures. Using a convenient sampling method, we sampled 56 patients who arrived to the operating room intubated after traumatic brain injuries between 2005 and 2011. Two groups were compared retrospectively: those with Pa-etCO(2) greater than 10 mm Hg (case group) (n = 37) and those with Pa-etCO2 gradients of 10 mm Hg or less (control group) (n = 19). Descriptive and inferential statistics were employed to identify any differences between the groups. Stepwise regression was also performed. Cross tabulation analysis revealed that injury severity score of 30 or more was a predictor of Pa-etCO(2) gradient. Stepwise regression analysis revealed the presence of rib fracture and body mass index to be significant predictors of Pa-etCO(2) gradient (P < .011). This study identified coexisting conditions in which the patients' Pa-etCO(2) gradients were large. Results showed that injury severity score of 30 or more, the presence of rib fractures, and higher body mass index were statistically significant predictors of Pa-etCO(2) gradients greater than 10 mm Hg. These observations should be considered when evaluating PetCO(2) in conjunction with arterial blood gas analysis to determine optimal ventilation status of these patients.

Objective:The purpose of this study was to examine the association of obstructive sleep apnea (OSA) with difficult intubation in patients undergoing general anesthesia requiring tracheal intubation.Methods:Using a retrospective, case-control study design, 90 adults with difficult tracheal intubation were compared with 81 gender-matched controls, between 2007 and 2010. Analyses included descriptive and inferential statistics, and multivariate regression was used to estimate predictors of difficult intubation while adjusting for patient demographics.Results:In the univariate analysis, OSA was not associated with difficult intubation. After patient factors were controlled for in the multivariate logistic regression, patients without OSA were more likely to have difficult intubation (odds ratio, 0.36; 95% confidence interval, 0.13-0.99; P = .048). Other predictors of difficult intubation were lower body mass index and higher Mallampati score.Discussion:In adult subjects, OSA history was not a predictor of difficult intubation. Other patient or anesthesiologist factors should be assessed for their association with difficult intubation.

This research seeks to address the home infusion therapy reimbursement gap found within Medicare Part D. In particular, the research explored the reimbursement gap's impact on home health utilization, its contribution to the national health expenditure growth, and the potential fix of the problem by restructuring Medicare Part B to include a home infusion therapy benefit under its coverage. Previous studies found that there is a great cost avoidance opportunity available through home health and home infusion treatment, because such treatment avoids the high costs associated with hospitalization and nursing home and other long-term care facilities. Future implications of this topic are unclear, as the Affordable Health Care for America Act is equipped to cut Medicare services and reimbursements, in spite of current bipartisan legislation in both houses to cover the home infusion reimbursement gap.

Little research has been done on the effects that topical intratracheal anesthesia have on the length of time required to successfully extubate patients after surgical interventions. This retrospective case-control study, using a convenience sample (n = 100 patients), explored the effects of using topical lidocaine laryngotracheal anesthesia injected into the adult trachea before insertion of the endotracheal tube on patients undergoing surgical treatment for blockage of the carotid artery. Both descriptive and inferential analyses were performed to evaluate differences among all variables. Multiple linear regression was also performed while adjusting for the confounding factors (age, gender, and smoking status). Results revealed that the use of lidocaine laryngotracheal anesthesia during induction of anesthesia prolonged the mean times for postoperative removal of the endotracheal tube by nearly 2 minutes. Extended time for removal of endotracheal tubes may lead to increased costs to the healthcare institution and to the patient, which in turn may lead to dissatisfaction within healthcare teams and possibly to patient discontent with care provided.

This policy paper investigates whether physician conflicts of interest have an effect on physicians' quality of care and whether implementation of conflict-of-interest policies will ameliorate any negative effects of divergent interests. Some government regulations are discussed in a policymaking perspective. We also suggest that healthcare organizations establish specific policies guarding against potential negative outcomes related to conflicts of interest. At the pinnacle of the conflict-of-interest debate resides the patient. One of the most important effects of disclosure is providing patients with the opportunity to make informed decisions regarding their healthcare. Research supports that conflicts of interest are inherent and oftentimes unavoidable in the healthcare setting.

Information technology (IT) is a key mechanism for improving the quality of healthcare and containing costs, but racial differences in the utilization of IT among practicing physicians are unknown. The current study, using a national physician survey (n = 6,628), investigated racial differences in the utilization of IT. White physicians and minority physicians were directly compared. We first conducted both descriptive and inferential analyses to detect the difference in IT utilization by race and then performed multiple logistic regressions to test whether race remains significant in relation to IT utilization. Results reveal racial differences in the usage of IT. Compared to their minority counterparts, white physicians underutilized a preventive service reminder system. On the other hand, white physicians favored utilizing electronic communications with patients and exchanging clinical data and images with other providers.

This research explores the association of physician conflicts of interest with quality of care. Specifically, we discuss the role of some government regulations as policy alternatives. The need for further regulation has become more apparent as improprieties in the healthcare industry have come to light. The dominating theme in current and proposed legislation, as well as institutional policies, is the idea of ensuring that conflicts of interest are transparent, thereby increasing the likelihood that appropriate relationships will be maintained between healthcare providers and industry representatives. Much of the difficulty that organizations are going to have in implementing effective policies is the resistance that will be initiated by physicians. In order to decrease the frequency of negative effects from conflicts of interest, we suggest that each organization establish a committee to create and oversee strict policies governing expectations regarding conflicts of interest.

PurposePrescription drug requests and physician denial are important aspects of medical decision making, but little research has been done to identify factors linked to prescription drug request and physician denial. This paper aims to explore factors in relation to patient prescription drug request and provider denial.Design/methodology/approachThe paper is based on a cross‐sectional study in a nationally representative database of 2,988 individuals. Descriptive and multivariate stepwise conditional logistic regression analyses were conducted.FindingsResults of multivariate regression models reveal, after adjusting for personal factors, that heart disease, allergy, anxiety, minor chronic conditions, medical seeking behaviors and direct‐to‐consumer advertising (DTCA) were found to be related to prescription drug request. The denied were individuals with arthritis, less prevalent chronic conditions, the uninsured, and African Americans. It was also found that 27.4 percent of the sample requested a prescription drug and about 24 percent of those who segmented for prescriptions were physicians.Research limitations/implicationsDTCA is positively associated with prescription drug requests but the analysis did not support any effect of DTCA on the refusal status. Patients' requests and physician decision making to refuse are somewhat complicated and vary with different medical conditions.Originality/valueThe paper, using nationally representative data, investigates the factors associated with prescription drug request and denial.

Kawasaki Disease (KD) is the leading cause of acquired cardiovascular disease among children, but management of KD has received relatively little attention. In the US alone, about 5500 cases were estimated in 2009. KD is most common among Asian and Pacific Islander children but can affect all ethnicities and races. Timely and accurate diagnosis remains critical, but difficult: the etiology of KD is unknown, and no accurate diagnostic laboratory test has been developed. Continuing medical education can help physicians, clinicians, and nurse practitioners accurately diagnose and treat KD. A registry specific to KD or a surveillance system may be necessary to increase awareness among health care professionals and to decrease complications related to misdiagnosis.

The concept of transformational leadership styles has been popular in medical communities in recent years but very limited information is available in the literature on the role of transformational leadership in relation to workplace performance among home health aides. A secondary data analysis was conducted using the 2007 National Home Health Aides Survey ( n = 1,828). A multivariate regression analysis was performed to estimate the association of transformational leadership styles with workplace performance among home health aides. Transformational leadership styles were positively linked to performance in reducing injury, increasing career satisfaction, and choosing their career again if they had to choose. Our finding suggests that introducing transformational leadership practices may benefit home health aides in improving their workplace performance.

Whereas physician support of disease management (DM) is recognized as important for improving the quality and effectiveness of care of individuals with chronic illness, little is known about physicians’ perceptions of the model or their likelihood of adoption. A multivariate regression analysis was conducted of a 2008 nationally representative sample of practising physicians in the USA who had been exposed to DM programmes (n = 1615) to determine their support for DM and how attitudes differ across physicians. Results indicated that the majority of physicians believe in the quality enhancing benefits of DM programmes, but there are systematic differences in the attitudes towards DM of different types of physicians. Physicians affiliated with health maintenance organizations (HMOs) and hospital-based practices are more likely than other physicians to agree that DM programmes improve their ability to provide high-quality care to patients with chronic conditions. Minority physicians and physicians who perceive their market as more competitive, have a more positive attitude towards DM than white physicians and physicians in less competitive markets. International medical graduates hold relatively positive attitudes about the benefits of DM programmes and older physicians are more likely than their young peers to approve of DM and physicians. Physicians with a higher percentage of patients with chronic conditions are more likely to have a favourable view of DM. Specialty physicians are more likely to have a positive view of DM, and DM-exposed physicians are more likely to perceive that DM programmes lead to improved quality of care. Future study is needed to determine the reasons for these differences in attitudes and whether they can be modified by targeted information.