Journal of general internal medicine
-
Observational Study
Perceived discrimination, patient trust, and adherence to medical recommendations among persons with sickle cell disease.
Adults with sickle cell disease (SCD) report experiencing discriminatory behavior from some healthcare providers. The impact of discrimination on health outcomes in SCD, including adherence to physician recommendations, is not known. ⋯ SCD patient perceptions of discriminatory experiences from healthcare providers are associated with greater nonadherence to physician recommendations, and may be a potential factor contributing to disparities in health and health quality among this patient population. Perceived discrimination appears to affect adherence behaviors through the pathway of patient trust. Improving relationships between healthcare providers and SCD patients may improve the trust that SCD patients have in medical professionals, which in turn may improve other outcomes among this underserved patient population.
-
In 2011, the Veterans Health Administration (VHA) released the Acute Ischemic Stroke (AIS) Directive, which mandated reorganization of acute stroke care, including self-designation of stroke centers as Primary (P), Limited Hours (LH), or Supporting (S). ⋯ The AIS Directive brought focused attention to reorganizing stroke care across a wide range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique addition of the LH designation presented some challenges. S facilities tended to report a lack of a coordinated stroke team and champion to drive process changes.
-
Statins are the cornerstone of lipid-lowering therapy for cardiovascular disease prevention. The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines represent a fundamental shift in how statins will be prescribed. The new guidelines recommend statins for nearly all older patients up to age 75 years, including healthy adults with low normal lipid levels and no atherosclerotic cardiovascular disease (ASCVD) risk factors other than age. ⋯ Based on the new guidelines, one could term these older adults as having "statin deficiency," a condition warranting statin treatment. We call this putative condition of age-related statin deficiency "statinopause." After careful examination of the trial evidence, we find very little support for the new recommendations for primary prevention. The lack of evidence underscores the need for clinical trials to determine the risks and benefits of statin therapy for primary prevention among older adults.
-
Clinical performance measurement has been a key element of efforts to transform the Veterans Health Administration (VHA). However, there are a number of signs that current performance measurement systems used within and outside the VHA may be reaching the point of maximum benefit to care and in some settings, may be resulting in negative consequences to care, including overtreatment and diminished attention to patient needs and preferences. Our research group has been involved in a long-standing partnership with the office responsible for clinical performance measurement in the VHA to understand and develop potential strategies to mitigate the unintended consequences of measurement. ⋯ Next steps include working with VHA leaders to develop and test implementation approaches to help ensure that the next generation of PMs motivate truly patient-centered care and are clinically meaningful.
-
Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death. ⋯ Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.