Journal of general internal medicine
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Randomized Controlled Trial
Cost-effectiveness of strategies to improve HIV testing and receipt of results: economic analysis of a randomized controlled trial.
The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results. ⋯ In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.
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Clinical Trial
Electronic prescribing improves medication safety in community-based office practices.
Although electronic prescribing (e-prescribing) holds promise for preventing prescription errors in the ambulatory setting, research on its effectiveness is inconclusive. ⋯ Prescribing errors may occur much more frequently in community-based practices than previously reported. Our preliminary findings suggest that stand-alone e-prescribing with clinical decision support may significantly improve ambulatory medication safety.
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A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings. ⋯ Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.
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Adults with sickle cell disease often report poor interpersonal healthcare experiences, including poor communication with providers. However, the effect of these experiences on patient trust is unknown. ⋯ Poorer patient ratings of provider communication are associated with lower trust toward the medical profession among adults with sickle cell disease. Future research should examine the impact of low trust in the medical profession on clinical outcomes in this population of patients.
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The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the "hamster on a treadmill" problems in current medical practice. ⋯ Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.