Rhodes, Karin V
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Publication Limitations in Access to Dental and Medical Specialty Care for Publicly Insured Children(2011-06-24) Rhodes, Karin V; Bisgaier, JoannaMedicaid and the state-run Children’s Health Insurance Program (CHIP) cover about 42 million children, many of whom would not have access to care without public insurance. Federal law requires that this access be equivalent to that of privately insured children for covered services, and many states have implemented policies to improve longstanding disparities in primary and preventive care. Reimbursement rates are up, but significant disparities remain, especially for dental and specialty services. It is important to understand the distinct effect of provider-related barriers, because they are potentially more modifiable through health policy than patient-related ones. This Issue Brief summarizes research that directly measures the willingness of dental and medical providers to see publicly-insured children, using research assistants posing as mothers calling for an urgent appointment for their child.Publication Better Health While You Wait: A Controlled Trial of a Computer-Based Intervention for Screening and Health Promotion in the Emergency Department(2001-03-01) Rhodes, Karin V; Lauderdale, Diane S; Stocking, Carol B; Howes, David S; Roizen, Michael F; Levinson, WendyStudy objective: We evaluate a computer-based intervention for screening and health promotion in the emergency department and determine its effect on patient recall of health advice. Methods: This controlled clinical trial, with alternating assignment of patients to a computer intervention (prevention group) or usual care, was conducted in a university hospital ED. The study group consisted of 542 adult patients with nonurgent conditions. The study intervention was a self-administered computer survey generating individualized health information. Outcome measures were (1) patient willingness to take a computerized health risk assessment, (2) disclosure of behavioral risk factors, (3) requests for health information, and (4) remembered health advice. Results: Eighty-nine percent (470/542) of eligible patients participated. Ninety percent were black. Eighty-five percent (210/248) of patients in the prevention group disclosed 1 or more major behavioral risk factors including current smoking (79/248; 32%), untreated hypertension (28/248; 13%), problem drinking (46/248; 19%), use of street drugs (33/248; 13%), major depression (87/248; 35%), unsafe sexual behavior (84/248; 33%), and several other injury-prone behaviors. Ninety-five percent of patients in the prevention group requested health information. On follow-up at 1 week, 62% (133/216) of the prevention group patients compared with 27% (48/180) of the control subjects remembered receiving advice on what they could do to improve their health (relative risk 2.3, 95% confidence interval 1.77 to 3.01). Conclusion: Using a self-administered computer-based health risk assessment, the majority of patients in our urban ED disclosed important health risks and requested information. They were more likely than a control group to remember receiving advice on what they could do to improve their health. Computer methodology may enable physicians to use patient waiting time for health promotion and to target at-risk patients for specific interventions.Publication Nonprice Barriers to Ambulatory Care After an Emergency Department Visit(2008-05-01) Vieth, Teri L; Rhodes, Karin VStudy objective: Availability of timely follow-up care is essential in emergency medicine. We describe nonprice barriers to care experienced by callers reporting to be emergency department (ED) patients in need of follow-up care. Methods: This was a secondary analysis of data collected during a survey of ambulatory clinics in 9 US cities. Research assistants called a random sample of 603 ambulatory clinics, generated from actual ED referral lists. Callers identified themselves as new patients referred by the local ED. Outcome measures were the percentage of callers experiencing failed appointment attempts for a variety of reasons and inconvenience factors associated with the appointment process: number and amount of time spent on hold, voicemail, repeated calls, and total telephone time. Results: Only 242 (23%) of 1065 total calls resulted in an appointment within one week, for an ultimate caller success rate of 40% (242/603 pseudopatient scenarios). Independent of insurance status, 43% of 603 initial calls to ED referral numbers were unsuccessful: 27% of initial call failures were due to clinic closures, busy signals, voicemail, or personnel too busy to take the call; 6% wrong numbers; 4% disconnected or extended holds; and 6% out of practice scope. If they reached clinic personnel, 55% of callers were placed on hold; average hold time was 2.43 minutes (median 1.35 minutes). Answering system time averaged 1.17 minutes (median 0.68 minutes; range 0.02 to 13.90 minutes). On average, it required 1.7 calls to reach appointment staff and 8% of clinic contacts required 4 or more attempts. Total telephone time averaged 11.1 minutes for successful appointments. Conclusion: There are important nonprice barriers to obtaining follow-up appointments for urgent conditions, independent of insurance status.Publication Primary Care Appointment Availability for Medicaid Patients: Comparing Traditional and Premium Assistance Plans(2016-07-14) Basseyn, Simon; Saloner, Brendan; Kenney, Genevieve M; Polsky, Daniel; Wissoker, Douglas; Rhodes, Karin VKey Findings: In 2014, Arkansas and Iowa expanded their Medicaid programs and enrolled many of their adult beneficiaries in commercial Marketplace plans. This study suggests that this “private option” may make it easier for new Medicaid patients to get primary care appointments.Publication Does Screening in the Emergency Department Hurt or Help Victims of Intimate Partner Violence?(2008-04-01) Hourey, Debra; Kaslow, Nadine; Kemball, Robin S; McNutt, Louise A; Cerulli, Catherine; Strauss, Helen; Rosenberg, Eli; Lu, Chengxing; Rhodes, Karin VStudy objective: Recent systematic reviews have noted a lack of evidence that screening for intimate partner violence does more good than harm. We assess whether patients screened for intimate partner violence on a computer kiosk in the emergency department (ED) experienced any adverse events during or subsequent to the ED visit and whether computer kiosk identification and referral of intimate partner violence in the ED setting resulted in safety behaviors or contact with referrals. Methods: We conducted a prospective, observational study in which a convenience sample of male and female ED patients triaged to the waiting room who screened positive (on a computer kiosk-based questionnaire) for intimate partner violence in the past year were provided with resources and information and invited to participate in a series of follow-up interviews. At 1-week and 3-month follow-up visits, we assessed intimate partner violence, safety issues, and use of resources. In addition, to obtain an objective measure of safety, we assessed the number of violence-related 911 calls to participant addresses within a call district 6 months before and 6 months after the index ED visit. Results: Of the 2,134 participants in a relationship in the last year, 548 (25.7%) screened positive for intimate partner violence. No safety issues, such as calling security or a partner’s interference with the screening, occurred during the ED visit for any patient who disclosed intimate partner violence. Of the 216 intimate partner violence victims interviewed in person and 65 contacted by telephone 1 week later, no intimate partner violence victims reported any injuries or increased intimate partner violence resulting from participating in the study. For the sample in the local police district, there was no increase in the number of intimate partner violence victims who called 911 in the 6 months after the ED visit. Finally, 35% (n131) reported they had contacted community resources during the 3-month follow-up period. Conclusion: Among patients screening positive for intimate partner violence, there were no identified adverse events related to screening, and many had contacted community resources.Publication Characterizing Emergency Department Discussions about Depression(2007-10-01) Rhodes, Karin V; Kushner, Hallie M; Bisgaier, Joanna; Prenoveau, ElizabethBackground: The reality of emergency health care in the United States today requires new approaches to mental health in the emergency department (ED). Major depression is a disabling condition that disproportionately affects women. Objectives: To characterize ED provider–patient discussions about depression. Methods: This was a secondary analysis of a database of audiotaped ED visits with women patients collected during a clinical trial of computer screening for domestic violence and other psychosocial risks. Nonemergent female patients, ages 18–65 years, were enrolled from two socioeconomically diverse academic EDs. All audio files with two or more relevant comments were identified as "significant depression discussions" and independently coded using a structured coding form. Results: Of 871 audiorecorded ED visits, 70 (8%) included discussions containing any reference to depression and 20 (2%) constituted significant depression discussions. Qualitative analysis of the 20 significant discussions found that 16 (80%) required less than 90 seconds to complete. Ten included less than optimal provider communication characteristics. Despite the brevity or quality of the communication, 15 of the 20 yielded high patient satisfaction with their ED treatment. Conclusions: ED providers rarely addressed depression. Qualitative analysis of significant patient– provider interactions regarding depression found that screening for depression in the ED can be accomplished with minimal expenditure of provider time and effort. Attention to psychosocial risk factors has the potential to improve the quality of ED care and patient satisfaction.Publication Mood disorders in the emergency department: the challenge of linking patients to appropriate services(2008-01-01) Rhodes, Karin VThe article by Boudreaux et al. [1] in the current issue regarding the prevalence and interest in treatment for mood disorders among ED patients raises several important concerns for acute care providers and for the health care system as a whole. Hospital emergency departments (EDs) have increasingly become a location in which mental illness first presents [2]. The result is that identification, diagnosis and referral for mental health symptoms rests, not infrequently, with ED physicians. However, neither the training of emergency physicians nor the needed support infrastructure of psychiatric and social services has kept up with national trends, leaving ED providers poorly prepared and under-resourced for the task.Publication The Future of Emergency Medicine Public Health Research(2006-11-01) Rhodes, Karin V; Pollock, Daniel AThis chapter addresses past successes and challenges and then elaborates on the potential for further advances in three areas that bridge emergency medicine and the broader public health and health services research agenda: (1) monitoring health care access; (2) surveillance of diseases, injuries, and health risks; and (3) delivering clinical preventive services. This article also suggests ways to advance policy-relevant research on systems of health and social welfare that impact the health of the public.Publication Resuscitating the Physician-Patient Relationship: Emergency Department Communication in an Academic Medical Center(2004-09-01) Rhodes, Karin V; Vieth, Teri; He, Theresa; Miller, Annette; Howes, David S; Bailey, Olivia; Walter, James; Frankel, Richard; Levinson, WendyStudy objective: We characterize communication in an urban, academic medical center emergency department (ED) with regard to the timing and nature of the medical history survey and physical examination and discharge instructions. Methods: Audiotaping and coding of 93 ED encounters (62 medical history surveys and physical examinations, 31 discharges) with a convenience sample of 24 emergency medicine residents, 8 nurses, and 93 nonemergency adult patients. Results: Patients were 68% women and 84% black, with a mean age of 45 years. Emergency medicine providers were 70% men and 80% white. Of 62 medical history surveys and physical examinations, time spent on the introduction and medical history survey and physical examination averaged 7 minutes 31 seconds (range 1 to 20 minutes). Emergency medicine residents introduced themselves in only two thirds of encounters, rarely (8%) indicating their training status. Despite physician tendency (63%) to start with an open-ended question, only 20% of patients completed their presenting complaint without interruption. Average time to interruption (usually a closed question) was 12 seconds. Discharge instructions averaged 76 seconds (range 7 to 202 seconds). Information on diagnosis, expected course of illness, self-care, use of medications, time-specified follow-up, and symptoms that should prompt return to the ED were each discussed less than 65% of the time. Only 16% of patients were asked whether they had questions, and there were no instances in which the provider confirmed patient understanding of the information. Conclusion: Academic EDs present unique challenges to effective communication. In our study, the physician-patient encounter was brief and lacking in important health information. Provision of patient-centered care in academic EDs will require more provider education and significant system support.Publication Child Injury Risks are Close to Home: Parent Psychosocial Factors Associated with Child Safety(2007-05-01) Rhodes, Karin V; Iwashyna, Theodore JObjective: In several populations, maternal depression has been associated with reduced child safety. In an urban pediatric Emergency Department, we examined the relationship between parental depression, social support, and domestic conflict and child safety behaviors. Methods: We studied consecutive patients in an Emergency Department. Trained interviewers used a structured instrument to assess patient, primary caregiver, and household demographics, socio-economic status, psychosocial factors, child safety behaviors (whether a gun was in the home, poisons were locked, a functioning smoke detector was present, and use of carseats or seatbelts), and whether the home was smoke-free. 1,116 patients provided adequate data. Results: Depression was associated with a modest and not statistically significant reduction in child safety behaviors in this population. Lack of social support and the presence of domestic conflict were robustly, independently, and statistically significantly associated with less safe homes. Domestic conflict was associated with more smoking in the home. Conclusion: In our population, child safety was associated less with depression and more with parental lack of social support and domestic conflict. These can be assessed in a Emergency Department and may be amenable to intervention.