This study demonstrates that recognition of cognitive impairment by primary care physicians is adversely influenced by important patient and disease characteristics. Results also show that use of the Mini-Cog would improve recognition of cognitive impairment in primary care, particularly in milder stages and in older adults subject to disparities in health care quality due to sociodemographic factors.

The Mini-Cog detects clinically significant cognitive impairment as well as or better than the MMSE in multiethnic elderly individuals, is easier to administer to non-English speakers, and is less biased by low education and literacy.

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BackgroundScientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR).MethodsWe searched the literature for existing measures for the 7 Inner Setting domain constructs (Culture Overall, Culture Stress, Culture Effort, Implementation Climate, Learning Climate, Leadership Engagement, and Available Resources). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states (N = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity).ResultsCFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR < 0.08, RMSEA < 0.08), with almost all factor loadings exceeding 0.40. Scale reliabilities ranged from good (0.7 ≤ α < 0.9) to excellent (α ≥ 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level.ConclusionsOur findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.

BACKGROUND.Colorectal cancer (CRC) is a leading cause of cancer mortality in the US. Surveys reveal low CRC screening levels among Asians in the US, including Chinese Americans.METHODS.A randomized controlled trial was conducted with Chinese patients to evaluate a clinic‐based, culturally and linguistically appropriate intervention promoting fecal occult blood test (FOBT) screening. The multifaceted intervention included a trilingual and bicultural health educator, bilingual materials (a video, a motivational pamphlet, an informational pamphlet, and FOBT instructions), and three FOBT cards. Patients in the control arm received usual care. Our primary outcome measure was FOBT screening within 6 months after randomization. The proportion of FOBT completion in the intervention and control arms was compared by using a chi‐square test, and logistic regression analysis was performed to adjust for the effects of sociodemographic variables and prior screening history. Potential effect modifications were also tested by using logistic regression models.RESULTS.Our intervention had a strong effect on FOBT completion (intervention group, 69.5%; control group, 27.6%), and the adjusted odds of FOBT slightly increased to over 6‐fold greater in the intervention arm compared with the control arm. No effect modification by age, gender, language, insurance, or prior FOBT was found.CONCLUSIONS.The authors' multifaceted, culturally appropriate intervention significantly increased FOBT screening in a group of low‐income and less‐acculturated minority patients. Given the large effect size, future research should determine the effective core component(s) that can increase CRC screening in both the general and minority populations. Cancer 2006. © 2006 American Cancer Society.

Chinese Americans are 10 times more likely to be diagnosed with hepatocellular carcinoma (HCC) than their white counterparts. About 80% of HCC's among Asian immigrants are associated with hepatitis B virus (HBV) infection. We used data from in-person interviews of Chinese residents in Seattle to examine factors associated with HBV testing. The survey was completed by 206 men and 236 women (cooperation rate: 58%). Less than one-half (48%) of respondents had been tested for HBV. Factors associated (p < 0.01) with ever having tested in bivariate comparisons included knowing that Chinese are more likely to be infected with HBV than Whites; individuals can be infected with HBV for life; HBV infection can cause liver cancer; not believing that HBV can be prevented by having a positive attitude; having a family member, friend, or medical doctor recommend testing; asking for testing from a medical doctor; and not needing interpreter services. In multiple regression analyses, the following factors were independently associated with testing: believing that Chinese were more likely than Whites to get HBV (p = 0.004), having a doctor recommend testing (p

There is a growing emphasis on the role of organizations as settings for dissemination and implementation. Only recently has the field begun to consider features of organizations that impact on dissemination and implementation of evidence-based interventions. This manuscript identifies and evaluates available measures for 5 key organizational-level constructs: (1) leadership; (2) vision; (3) managerial relations; (4) climate; and (5) absorptive capacity. Overall the picture was the same across the five constructs—no measure was used in more than one study, many studies did not report the psychometric properties of the measures, some assessments were based on a single response per unit, and the level of the instrument and analysis did not always match. We must seriously consider the development and evaluation of a robust set of measures that will serve as the basis of building the field, allow for comparisons across organizational types and intervention topics, and allow a robust area of dissemination and implementation research to develop.

Sign on a print shop door:BWe can do it fast, we can do it well, we can do it cheap. Pick two. 78-year-old widow with hypertension, osteoarthritis, a recent stroke, elevated cholesterol, and a 50-pack-year smoking history comes to her primary care provider for a mild cough and weight loss. She lives alone and loves to chat with her doctor. The physical examination is unrevealing. Chest xray shows a lung nodule. A CT scan is ordered. A long discussion ensues about what would happen if the CT scan shows cancer: how would she undergo evaluation and treatment with her family far away? For what became a 40-min visit, only 15 min had been allotted. Now the doctor is behind schedule. She feels guilty and gives more time to each patient, thus falling further behind. Screening issues are postponed and personal interactions are diminished. A walk-in patient is added. One waiting patient leaves angrily. At the end of the day, facing a large pile of forms and documentation needs, the doctor feels drained and questions the quality of care she provided.The Time Crunch. While Mechanic demonstrated that routine primary care visits (averaging 15-20 min) were 1 to 2 min longer than before, 1 the complexity of clinical issues addressed during these visits has increased. In 2010, the CDC reported that one-third of elderly patients had three or more chronic medical conditions, with 40 % of patients taking three or more medications. Providers may respond by cutting corners on the history and physical examination and by ordering more tests, which lead to a cascade of follow-up tests. Providers describe behind-the-scenes burdens of documentation, phone calls, emails, refills, consultations, and lab reports, while careful calculations show that guideline-driven preventive care would add 7 h to each primary care clinician's workday. 2 The work of primary care simply cannot be completed in the time allotted.Consequences for Patients. Increased work during short (<20 min) visits means appointments in which fewer health care issues are addressed and the depth of understanding is diminished. Time-consuming psychosocial determinants of health are left unaddressed. These consequences translate to decreased patient satisfaction, excess emergency room usage and non-adherence to treatment plans. 3Consequences for Providers. Fifty-three percent of primary care providers report time pressure in the clinical encounter. 4 Many providers describe emotional exhaustion and the fear of making clinical errors. Students observe harried primary care providers and choose alternative career paths.Root Causes. In the early 1990s, Medicare adopted the relative value unit (RVU) payment model. In a budgetneutral system, the introduction of new procedures at substantially higher RVU levels has resulted in the devaluing of cognitive care such as evaluation and management services. When private insurers and managed care contracts reduced compensation, providers increased daily volumes to maintain stable incomes. Health systems followed with daily visit