Showing papers by "RAND Corporation published in 2000"

Meta-analysis of observational studies in epidemiology - A proposal for reporting

Abstract: ObjectiveBecause of the pressure for timely, informed decisions in public health and clinical practice and the explosion of information in the scientific literature, research results must be synthesized. Meta-analyses are increasingly used to address this problem, and they often evaluate observational studies. A workshop was held in Atlanta, Ga, in April 1997, to examine the reporting of meta-analyses of observational studies and to make recommendations to aid authors, reviewers, editors, and readers.ParticipantsTwenty-seven participants were selected by a steering committee, based on expertise in clinical practice, trials, statistics, epidemiology, social sciences, and biomedical editing. Deliberations of the workshop were open to other interested scientists. Funding for this activity was provided by the Centers for Disease Control and Prevention.EvidenceWe conducted a systematic review of the published literature on the conduct and reporting of meta-analyses in observational studies using MEDLINE, Educational Research Information Center (ERIC), PsycLIT, and the Current Index to Statistics. We also examined reference lists of the 32 studies retrieved and contacted experts in the field. Participants were assigned to small-group discussions on the subjects of bias, searching and abstracting, heterogeneity, study categorization, and statistical methods.Consensus ProcessFrom the material presented at the workshop, the authors developed a checklist summarizing recommendations for reporting meta-analyses of observational studies. The checklist and supporting evidence were circulated to all conference attendees and additional experts. All suggestions for revisions were addressed.ConclusionsThe proposed checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion. Use of the checklist should improve the usefulness of meta-analyses for authors, reviewers, editors, readers, and decision makers. An evaluation plan is suggested and research areas are explored.

Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial.

Abstract: ContextCare of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.ObjectiveTo determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.DesignRandomized controlled trial initiated from June 1996 to March 1997.SettingForty-six primary care clinics in 6 US managed care organizations.ParticipantsOf 27,332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.InterventionsMatched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.Main Outcome MeasuresProcess of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.ResultsPatients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P≥.21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).ConclusionsWhen these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.

The public release of performance data: what do we expect to gain? A review of the evidence.

Abstract: ContextInformation about the performance of hospitals, health professionals, and health care organizations has been made public in the United States for more than a decade. The expected gains of public disclosure have not been made clear, and both the benefits and potential risks have received minimal empirical investigation.ObjectiveTo summarize the empirical evidence concerning public disclosure of performance data, relate the results to the potential gains, and identify areas requiring further research.Data SourcesA literature search was conducted on MEDLINE and EMBASE databases for articles published between January 1986 and October 1999 in peer-reviewed journals. Review of citations, public documents, and expert advice was conducted to identify studies not found in the electronic databases.Study SelectionDescriptive, observational, or experimental evaluations of US reporting systems were selected for inclusion.Data ExtractionIncluded studies were organized based on use of public data by consumers, purchasers, physicians, and hospitals; impact on quality of care outcomes; and costs.Data SynthesisSeven US reporting systems have been the subject of published empirical evaluations. Descriptive and observational methods predominate. Consumers and purchasers rarely search out the information and do not understand or trust it; it has a small, although increasing, impact on their decision making. Physicians are skeptical about such data and only a small proportion makes use of it. Hospitals appear to be most responsive to the data. In a limited number of studies, the publication of performance data has been associated with an improvement in health outcomes.ConclusionsThere are several potential gains from the public disclosure of performance data, but use of the information by provider organizations for quality improvement may be the most productive area for further research.

A Comparative Review of Generic Quality-of-Life Instruments

Abstract: The assessment of health-related quality of life (HR-QOL) is an essential element of healthcare evaluation Hundreds of generic and specific HR-QOL instruments have been developed Generic HR-QOL instruments are designed to be applicable across a wide range of populations and interventions Specific HR-QOL measures are designed to be relevant to particular interventions or in certain subpopulations (eg individuals with rheumatoid arthritis) This review examines 7 generic HR-QOL instruments: (i) the Medical Outcomes Study 36-Item Short Form (SF-36) health survey; (ii) the Nottingham Health Profile (NHP); (iii) the Sickness Impact Profile (SIP); (iv) the Dartmouth Primary care Cooperative Information Project (COOP) Charts; (v) the Quality of Well-Being (QWB) Scale; (vi) the Health Utilities Index (HUI); and (vii) the EuroQol Instrument (EQ-5D) These instruments were selected because they are commonly used and/or cited in the English language literature The 6 characteristics of an instrument addressed by this review are: (i) conceptual and measurement model; (ii) reliability; (iii) validity; (iv) respondent and administrative burden; (v) alternative forms; and (vi) cultural and language adaptations Of the instruments reviewed, the SF-36 health survey is the most commonly used HR-QOL measure It was developed as a short-form measure of functioning and well-being in the Medical Outcomes Study The Dartmouth COOP Charts were designed to be used in everyday clinical practice to provide immediate feedback to clinicians about the health status of their patients The NHP was developed to reflect lay rather than professional perceptions of health The SIP was constructed as a measure of sickness in relation to impact on behaviour The QWB, HUI and EQ-5D are preference-based measures designed to summarise HR-QOL in a single number ranging from 0 to 1 We found that there are no uniformly ‘worst’or ‘best’ performing instruments The decision to use one over another, to use a combination of 2 or more, to use a profile and/or a preference-based measure or to use a generic measure along with a targeted measure will be driven by the purpose of the measurment In addition, the choice will depend on a variety of factors including the characteristics of the population (eg age, health status, language/culture) and the environment in which the measurement is undertaken (eg clinical trial, routine physician visit) We provide our summary of the level of evidence in the literature regarding each instrument’s characteristics based on the review criteria The potential user of these instruments should base their instrument selection decision on the characteristics that are most relevant to their particular HR-QOL measurment needs

Likelihood-Based Item-Fit Indices for Dichotomous Item Response Theory Models.

Abstract: New goodness-of-fit indices are introduced for dichotomous item response theory (IRT) models. These indices are based on the likelihoods of number-correct scores derived from the IRT model, and they provide a direct comparison of the modeled and observed frequencies for correct and incorrect responses for each number-correct score. The behavior of Pearson’s X2 (S-X2) and the likelihood ratio G2 (S-G2) was assessed in a simulation study and compared with two fit indices similar to those currently in use (Q1-X2 and Q1-G2). The simulations included three conditions in which the simulating and fitting models were identical and three conditions involving model misspecification. S-X2 performed well, with Type I error rates close to the expected .05 and .01 levels. Performance of this index improved with increased test length. S-G2 tended to reject the null hypothesis too often, as did Q1-X2 and Q1-G2. The power of S-X2 appeared to be similar for all test lengths, but varied depending on the type of model misspe...

Treatment Preferences Among Depressed Primary Care Patients

Abstract: OBJECTIVE: To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients.

Who Is at Risk of Nondetection of Mental Health Problems in Primary Care

Abstract: OBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians.

The concept of clinically meaningful difference in health-related quality-of-life research. How meaningful is it?

Abstract: It is generally believed that small differences in health-related quality of life (HR-QOL) may be statistically significant yet clinically unimportant. The concept of the minimal clinically meaningful difference (MCID) has been proposed to refer to the smallest difference in a HR-QOL score that is considered to be worthwhile or clinically important. However, there is danger in oversimplification in asking the question: what is the MCID on this HR-QOL instrument? We argue that the attempt to define a single MCID is problematic for a number of reasons and recommend caution in the search for the MCID holy grail. Specifically, absolute thresholds are suspect because they ignore the cost or resources required to produce a change in HR-QOL. In addition, there are several practical problems in estimating the MCID, including: (i) the estimated magnitude varies depending on the distributional index and the external standard or anchor; (ii) the amount of change might depend on the direction of change; and (iii) the meaning of change depends on where you start (baseline value).

Peer effects in private and public schools across countries

Abstract: Many argue that the composition of a school or classroom-that is, the characteristics of the students themselves-affect the educational attainment of an individual student. This influence of the students in a classroom is often referred to as a peer effect. There have been few systematic studies that empirically examine the peer effect in the educational process. In this research, we examine the peer effect with a unique data set that includes individual student achievement scores and comprehensive characteristics of the students' families, teachers, other school characteristics, and peers for five countries. The data allow an examination of peer effects in both private and public schools in all countries. Our analysis indicates that peer effects are a significant determinant of educational achievement; the effects of peers appear to be greater for low-ability students than for high-ability students. The finding is robust across countries but not robust across school type. © 2000 by the Association for Public Policy Analysis and Management.

What Do Test Scores in Texas Tell Us

Abstract: We examine the results on the Texas Assessment of Academic Skills (TAAS), the highest-profile state testing program and one that has recorded extraordinary recent gains in math and reading scores. To investigate whether the dramatic math and reading gains on the TAAS represent actual academic progress, we have compared these gains to score changes in Texas on another test, the National Assessment of Educational Progress (NAEP). Texas students did improve significantly more on a fourth-grade NAEP math test than their counterparts nationally. But, the size of this gain was smaller than their gains on TAAS and was not present on the eighth-grade math test. The stark differences between the stories told by NAEP and TAAS are especially striking when it comes to the gap in average scores between whites and students of color. According to the NAEP results, that gap in Texas is not only very large but increasing slightly. According to TAAS scores, the gap is much smaller and decreasing greatly. Many schools are devoting a great deal of class time to highly specific TAAS preparation. While this preparation may improve TAAS scores, it may not help students develop necessary reading and math skills. Schools with relatively large percentages of minority and poor students may be doing this more than other schools. We raise serious questions about the validity of those gains, and caution against the danger of making decisions to sanction or reward students, teachers and schools on the basis of test scores that may be inflated or misleading. Finally, we suggest some steps that states can take to increase the likelihood that their test results merit public confidence and provide a sound basis for educational policy.

Appropriateness of the decision to transfer nursing facility residents to the hospital.

Abstract: OBJECTIVES: To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers. DESIGN: A structured implicit review (SIR) of medical records. SETTING AND PARTICIPANTS: Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals. MEASUREMENTS: Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate. RESULTS: In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization. CONCLUSIONS: Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals. J Am Geriatr Soc 48: 154–163, 2000.

Dying with Lung Cancer or Chronic Obstructive Pulmonary Disease: Insights from SUPPORT

Abstract: CONTEXT: Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient. OBJECTIVE: To compare the course of illness and patterns of care for patients with non-small cell lung cancer and severe COPD. DESIGN: Prospective cohort study of seriously ill, hospitalized adults. SETTING: Five teaching hospitals in the United States. PATIENTS: Patients with Stage III or IV non-small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008). MAIN OUTCOME MEASURES: Patients' preferences for pattern of care and for ventilator use; symptoms; life-sustaining interventions; and survival prognoses. RESULTS: Sixty percent in each group wanted comfort-focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28% of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2-month and 6-month survival prognoses, even days before death. CONCLUSIONS: Hospitalized patients with lung cancer or COPD preferred comfort-focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life-sustaining interventions.

Defining and measuring quality of care: a perspective from US researchers.

Abstract: The modern quality field in medicine is about one-third of a century old. The purpose of this paper is to summarize what we know about quality of care and indicate what we can do to improve quality of care in the next century. We assert that quality can be measured, that quality of care varies enormously, that improving quality of care is difficult, that financial incentives directed at the health system level have little effect on quality, and that we lack a publicly available tool kit to assess quality. To improve quality of care we will need adequate data and that will require patients to provide information about what happened to them and to allow people to abstract their medical records. It also will require that physicians provide patient information when asked. We also need a strategy to measure quality and then report the results and we need to place in the public domain tool kits that can be used by physicians, administrators, and patient groups to assess and improve quality. Each country should have a national quality report, based on standardized comprehensive and scientifically valid measures, which describes the country's progress in improving quality of care. We can act now. For the 70-100 procedures that dominate what physicians do, we should have a computer-based, prospective system to ensure that physicians ask patients the questions required to decide whether to do the procedure. The patient should verify the responses. Answers from patients should be combined with test results and other information obtained from the patient's physician to produce an assessment of the procedure's appropriateness and necessity. Advanced tools to assess quality, based on data from the patient and medical records, are also currently being developed. These tools could be used to comprehensively assess the quality of primary care across multiple conditions at the country, regional, and medical group level.

Converging health inequalities in later life--an artifact of mortality selection.

Abstract: An emergent issue in the health inequalities debate is how socioeconomic status (SES) and physical health relate over the life course. Many studies indicate that the SES-health relationship diminishes in later life. The present research tests the hypothesis that this convergence in health inequalities is an artifact of mortality selection, which biases downwards the "true" association between SES and health in later life. By including respondents who had subsequently died or were loss-to-followup into the analysis, I assess the sensitivity of the age-specific association between education and health to sample selection processes. I study U.S. adults followed for approximately ten years using the NHANES I Epidemiologic Followup Study. Results based on the surviving sample are robust to the inclusion of people selected out of the sample due to mortality or attrition. Sample selection biases do not appear to explain the convergence in health inequalities in late life.

Policy analysis: a systematic approach to supporting policymaking in the public sector

Abstract: This paper describes a systematic process for examining complex public policy choices that has been developed and refined over the past 50 years and is often called policy analysis. Its purpose is to assist policymakers in choosing preferred courses of action by clarifying the problem, outlining the alternative solutions and displaying tradeoffs among their consequences. In most real-world policy situations there are many possible alternatives, many uncertainties, many stakeholders and many consequences of interest. Also, there is usually no single decisionmaker and little chance of obtaining agreement on a single set of preferences among the consequences. As a result, there is no way to identify an optimal solution. Instead, policy analysis uses a variety of tools to develop relevant information and present it to the parties involved in the policymaking process in a manner that helps them come to a decision. It is a problem-oriented approach that does not presume a model structure for assessing the consequences of a policy or ranking the alternatives. The paper provides a brief history of policy analysis, describes the most important elements of the policy analysis process, provides an illustrative example of the use of the approach and suggests directions for future developments that can enrich the approach and increase the chances for successful use of the results. Copyright © 2000 John Wiley & Sons, Ltd.

Early Predictors of Adolescent Violence

Abstract: Objectives. This study sought to identify early predictors of adolescent violence and to assess whether they vary by sex and across different types and levels of violence. Methods. Data fV'om a 5-year longitudinal self-report survey of more than 4300 high school seniors and dropouts from California and Oregon were used to regress measures of relational, predatory, and overall violence on predictors measured 5 years earlier. Results. Deviant behavior in grade 7, poor grades, and weak bonds with middle school predicted violent behavior 5 years later. Attending a middle school with comparatively high levels of cigarette and marijuana use was also linked with subsequent violence. Early drug use and peer drug use predicted increased levels of predatory violence but not its simple occurrence. Girls with low self-esteern during early adolescence were more likely to hit others later on; boys who attended multiple elementary schools were also more likely to engage in relational violence, Conciusions. Violence prevention programs for younger adolescents should include efforts to prevent or reduce troublesome behavior in school and poor academic performance. Adolescent girls may also profit from efforts to raise self-esteem; adolescent boys may need extra training in resisting influences that encourage deviant behavior. Programs aimed at preventing drug use may yield an added violencereduction bonus, {Am J Public Heaith. 2000;90:566-572) During the last decade, violence has received increasing attention as a major public health issue for Americans of all ages,' Of particular concern is the degree to which violence affects the lives of youth, either as the perpetrators or as the victims of violence. Between 1985 and 1990, arrests for murder, manslaughter, and aggravated assault rose by 60% for children younger than 18 years,^ Between 1985 and 1991, homicide arrest rates actually declined among those older than 25 years, but they doubled among younger males,' These high rates of violence are mirrored by high rates of youth victimization, and violence and victimization tend to have common antecedents,"* Moreover, despite the fact that rates of violent crime have declined across all age groups since 1994, adolescents between the ages of 12 and 19 years remain at highest risk for victimization by violent crime,'

High Prevalence of Abscesses and Cellulitis Among Community-Recruited Injection Drug Users in San Francisco

Abstract: The prevalence of and risk factors for abscesses and cellulitis were investigated among a community sample of injection drug users (IDUs). Participants were interviewed, and those with symptoms were examined. Of 169 IDUs, 54 (32%) had abscesses ( ), cellulitis ( n= 35 n= ), or both ( ); 27% had lanced their own abscesses; and 16% had self-treated with 5 n= 14 antibiotics they purchased on the street. IDUs who skin-popped (injected subcutaneously or intramuscularly) were more likely to have an abscess or cellulitis than those who had injected only intravenously (odds ratio, 4.9; 95% confidence interval, 2.2‐11). The likelihood of abscesses and cellulitis increased with frequency of skin-popping and decreased with increasing duration of injection drug use. Abscesses are extremely prevalent among IDUs in San Francisco. Skin-popping is a major risk factor, and self-treatment is common. Abscesses and cellulitis are a common problem among injection drug users (IDUs). Few previous studies have examined the prevalence of and risk factors for abscesses among IDUs. In this cross-sectional survey of street-recruited IDUs, we estimated the prevalence of abscesses and cellulitis among IDUs by examining all participants who reported symptoms of local infection. We also examined the risk factors for these infections and estimated the prevalence of related behaviors.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection

Abstract: OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality o...

Violence victimization after HIV infection in a US probability sample of adult patients in primary care.

Abstract: OBJECTIVES: This study estimated the proportion of HIV-infected adults who have been assaulted by a partner or someone important to them since their HIV diagnosis and the extent to which they reported HIV-seropositive status as a cause of the violence. METHODS: Study participants were from a nationally representative probability sample of 2864 HIV-infected adults who were receiving medical care and were enrolled in the HIV Costs and Service Utilization Study. All interviews (91% in person, 9% by telephone) were conducted with computer-assisted personal interviewing instruments. Interviews began in January 1996 and ended 15 months later. RESULTS: Overall, 20.5% of the women, 11.5% of the men who reported having sex with men, and 7.5% of the heterosexual men reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes. CONCLUSIONS: HIV-related care is an appropriate setting for routine assessment of violence. Programs to cross-train staff in antiviolence agencies and HIV care facilities need to be developed for men and women with HIV infection. Language: en

Job Continuity Among New Mothers

Abstract: In the early 1990s, both state and federal governments enacted maternity-leave legislation. The key provision of that legislation is that after a leave of a limited duration, the recent mother is guaranteed the right to return to her preleave employer at the same or equivalent position. Using data from the National Longitudinal Survey of Youth, we correlate work status after childbirth with work status before pregnancy to estimate the prevalence, before the legislation, of returns to the preleave employer. Among women working full-time before the pregnancy, return to the prepregnancy employer was quite common. Sixty percent of women who worked full-time before the birth of a child continued to work for the same employer after the child was born. Furthermore, the labor market behavior of most of the remaining 40% suggests that maternity-leave legislation is unlikely to have a major effect on job continuity. Compared with all demographically similar women, however, new mothers have an excess probability of leaving their jobs.

The effect of syringe exchange use on high-risk injection drug users: a cohort study.

Abstract: OBJECTIVE To determine whether syringe exchange program use is associated with cessation of syringe sharing among high-risk injection drug users. DESIGN AND METHODS Between 1992 and 1996, street-recruited injection drug users were interviewed and received HIV testing and counseling semi-annually, as part of a dynamic cohort study. We examined a cohort of 340 high-risk injection drug users for whom two observations, 6-months apart, were available and who reported syringe sharing at the first interview. Multivariate logistic regression analysis was performed to determine the relationship between syringe exchange program use and cessation of syringe sharing, while controlling for confounding factors. RESULTS At follow-up interview, 60% (204 of 340) reported quitting syringe sharing. High-risk injection drug users who began using the syringe exchange program were more likely to quit sharing syringes [adjusted odds ratio (AOR), 2.68; 95% confidence interval (CI), 1.35-5.33], as were those who continued using the syringe exchange program (AOR,1.98; 95% CI, 1.05-3.75) in comparison with non-syringe exchange program users, while controlling for confounding factors. CONCLUSIONS The initiation and continuation of syringe exchange program use among high-risk injection drug users is independently associated with cessation of syringe sharing. Syringe exchange program use can be an important component in reducing the spread of blood-borne infectious diseases among high-risk injection drug users.

Anticipatory guidance: what information do parents receive? What information do they want?

Abstract: Objective To determine whether parents are receiving anticipatory guidance, whether they could use more information on anticipatory guidance topics, and how receipt of anticipatory guidance relates to satisfaction with care. Design and Sample Analysis of data from a telephone interview of 2017 respondents between July 1995 and January 1996. A stratified random-digit dialing design was used to obtain a nationally representative sample of parents with children between 0 and 3 years old. Main Outcome Measures Discussions with a physician or nurse about 6 anticipatory guidance topics and whether parents could use more information on these topics. Willingness of parents to pay extra to discuss these topics and receive additional care. Ratings of how well clinicians provide health care. Results The percentage of parents who had not discussed each subject with a clinician varied by topic: newborn care ( Conclusions Although anticipatory guidance is considered an important component of well-child care, the majority of parents reported that they had not discussed most standard topics with a clinician. Many parents could use more information on these topics. Effort is required to provide parents with the information they need to take good care of their children.

Problems in recruiting community-based physicians for health services research

Abstract: OBJECTIVE: To qualitatively determine factors that are associated with higher participation rates in community-based health services research requiring significant physician participation burden. MEASUREMENTS: A review of the literature was undertaken using MEDLINE and the Social Science Research Index to identify health services research studies that recruited large community-based samples of individual physicians and in which the participation burden exceeded that of merely completing a survey. Two reviewers abstracted data on the recruitment methods, and first authors were contacted to supplement published information. MAIN RESULTS: Sixteen studies were identified with participation rates from 2.5% to 91%. Almost all studies used physician recruiters to personally contact potential participants. Recruiters often knew some of the physicians to be recruited, and personal contact with these “known” physicians resulted in greater participation rates. Incentives were generally absent or modest, and at modest levels, did not appear to affect participation rates. Investigators were almost always affiliated with academic institutions, but were divided as to whether this helped or hindered recruitment. HMO-based and minority physicians were more difficult to recruit. Potential participants most often cited time pressures on staff and themselves as the study burden that caused them to decline. CONCLUSIONS: Physician personal contact and friendship networks are powerful tools for recruitment. Participation rates might improve by including HMO and minority physicians in the recruitment process. Investigators should transfer as much of the study burden from participating physicians to project staff as possible.

Social security, economic growth, and the rise in elderly widows' independence in the twentieth century

Abstract: The percentage of elderly widows living alone rose from 18% in 1940 to 62% in 1990, while the percentage living with adult children declined from 59% to 20%. This study finds that income growth, particularly increased Social Security benefits, was the single most important determinant of living arrangements, accounting for nearly one-half of the increase in independent living. Unlike researchers in earlier studies, we find no evidence that the effect of income became stronger over the period. Changes in age, race, immigrant status, schooling, and completed fertility explain a relatively small share of the changes in living arrangements.

Measuring underuse of necessary care among elderly medicare beneficiaries using inpatient and outpatient claims

Abstract: ContextContinuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.ObjectiveTo develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.DesignA 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.Setting and SubjectsA total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.Main Outcome MeasuresProportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).ResultsFor 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).ConclusionsThis claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data.

Coping, Conflictual Social Interactions, Social Support, and Mood Among HIV‐Infected Persons

Abstract: This study considers the interrelationships among coping, conflictual social interactions, and social support, as well as their combined associations with positive and negative mood. Research has shown that each of these variables affects adjustment to stressful circumstances. Few studies, however, examine this full set of variables simultaneously. One hundred forty HIV-infected persons completed a questionnaire containing measures of coping, social support, conflictual social interactions, and positive and negative mood. Factor analyses showed that perceived social support and conflictual social interactions formed separate factors and were not strongly related. Compared to perceived social support, social conflict was more strongly related to coping behaviors, especially to social isolation, anger, and wishful thinking. Conflictual social interactions were more strongly related to negative mood than was perceived social support. Coping by withdrawing socially was significantly related to less positive and greater negative mood. The findings point to the importance of simultaneously considering coping, supportive relationships, and conflictual relationships in studies of adjustment to chronic illness. In particular, a dynamic may occur in which conflictual social interactions and social isolation aggravate each other and result in escalating psychological distress.