Showing papers in "BMC Health Services Research in 2004"
TL;DR: The objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach.
Abstract: A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.
975 citations
TL;DR: This framework can be used by patients and health care practitioners to determine what styles of practice meet their needs and by policy makers, healthcare managers and researchers to document the evolution of team practices over time.
Abstract: Background: "Integrative health care" has become a common term to describe teams of health care providers working together to provide patient care. However this term has not been welldefined and likely means many different things to different people. The purpose of this paper is to develop a conceptual framework for describing, comparing and evaluating different forms of teamoriented health care practices that have evolved in Western health care systems. Discussion: Seven different models of team-oriented health care practice are illustrated in this paper: parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary and integrative. Each of these models occupies a position along the proposed continuum from the nonintegrative to fully integrative approach they take to patient care. The framework is developed around four key components of integrative health care practice: philosophy/values; structure, process and outcomes. Summary: This framework can be used by patients and health care practitioners to determine what styles of practice meet their needs and by policy makers, healthcare managers and researchers to document the evolution of team practices over time. This framework may also facilitate exploration of the relationship between different practice models and health outcomes.
300 citations
TL;DR: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.
Abstract: Background: Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. Discussion: We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. Summary: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.
151 citations
TL;DR: There is a large unmet need for temporary methods of contraception in urban areas of China, and all available studies documenting pregnancy and induced abortion among unmarried Chinese women attending premarital examinations are summarized.
Abstract: Until recently, premarital examination for both men and women was a legal requirement before marriage in China. Researchers have carried out surveys of attendees' sexual activity, pregnancy and abortion before their marriages, trying to map out reproductive health needs in China, according to this unique population-based data. To systematically identify, appraise and summarise all available studies documenting pregnancy and induced abortion among unmarried Chinese women attending premarital examinations. We searched the Chinese Biomedical Literature Index from 1978 to 2002; PUBMED; and EMBASE. Trials were assessed and data extracted by two people independently. Nine studies, of which seven were conducted in the urban areas, one in the rural areas, and one in both urban and rural areas, met the inclusion criteria. In the seven studies in urban areas, the majority of unmarried women had experienced sexual intercourse, with estimates ranging from 54% to 82% in five studies. Estimates of a previous pregnancy ranged from 12% to 32%. Abortion rates were high, ranging between 11 to 55% in 8 studies reporting this, which exclude the one rural study. In the three studies reporting both pregnancy and abortion, most women who had become pregnant had an induced abortion (range 86% to 96%). One large rural study documented a lower low pregnancy rate (20%) and induced abortion rate (0.8%). There is a large unmet need for temporary methods of contraception in urban areas of China.
107 citations
TL;DR: While technology contributes to improving the patients' health, it also imposes significant constraints on their lives and policies aimed at developing home care must clearly integrate principles and resources supporting the appropriate use of technology.
Abstract: Background
The delivery of technology-enhanced home care is growing in most industrialized countries. The objective of our study was to document, from the patient's perspective, how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. Understanding what makes a technology user-friendly should help improve the design of home care services.
101 citations
TL;DR: While the strategy was well received by the physicians involved, there was no change in prescribing patterns and the project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained.
Abstract: The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting. Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis. Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69–14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up. While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained.
100 citations
TL;DR: Patients studied want their physicians to be highly professional and expert clinicians and show humaneness and support, but their first priority is for the physician to respect their autonomy.
Abstract: It is not currently known what is the patient's viewpoint of a "good" physician. We set out to define patient's priorities regarding different physician's attributes in 3 domains important in medical care. Patients hospitalized or attending clinics at a large teaching hospital selected the 4 attributes that they considered most important out of 21 listed arbitrarily in a questionnaire. The questionnaire included 7 items each in the domains of patient autonomy, professional expertise and humanism. Participating patients (n = 445, mean age 57.5 ± 16 years) selected professional expertise (50%), physician's patience and attentiveness (38% and 30%, respectively), and informing the patient, representing the patient's interests, being truthful and respecting patient's preferences (25–36% each) as the most essential attributes. Patient's selections were not significantly influenced by different demographic or clinical background. Selections of attributes in the domain of patient's autonomy were significantly more frequent and this was the preferred domain for 31% and as important as another domain for 16% – significantly more than the domain of professional expertise (P = 0.008), and much more than the domain of humanism and support (P < 0.0005). Patients studied want their physicians to be highly professional and expert clinicians and show humaneness and support, but their first priority is for the physician to respect their autonomy.
98 citations
TL;DR: This study demonstrates the importance of possible predictors of LOS, in an acute care Psychiatric department and shows the proposed indicator can be readily used to detect inefficiencies.
Abstract: Length of stay (LOS) is an important indicator of efficiency for inpatient care but it does not achieve an adequate performance if it is not adjusted for the case mix of the patients hospitalized during the period considered. After two similar studies for Internal Medicine and Surgery respectively, the aims of the present study were to search for Length of Stay (LOS) predictors in an acute psychiatric department and to assess the performance of the difference: observed-predicted length of stay, as an indicator of inpatient care inefficiencies. Retrospective case-series of patients discharged during 1999 from the Psychiatric Department from General Hospital "Hermanos Ameijeiras" in Havana, Cuba. The 374 eligible medical records were randomly split into two groups of 187 each. We derived the function for estimating the predicted LOS within the first group. Possible predictors were: age; sex; place of residence; diagnosis, use of electroconvulsive therapy; co morbidities; symptoms at admission, medications, marital status, and response to treatment. LOS was the dependent variable. A thorough exam of the patients' records was the basis to assess the capacity of the function for detecting inefficiency problems, within the second group. The function explained 37% of LOS variation. The strongest influence on LOS came from: age (p = 0.002), response to treatment (p < 0.0001), the dummy for personality disorders (p = 0.01), ECT therapy (p = 0.003), factor for sexual and/or eating symptoms (p = 0.003) and factor for psychotic symptoms (p = 0.025). Mean observed LOS is 2 days higher than predicted for the group of records with inefficient care, whereas for the group with acceptable efficiency, observed mean LOS was 4 days lower than predicted. The area under the ROC curve for detecting inefficiencies was 69% This study demonstrates the importance of possible predictors of LOS, in an acute care Psychiatric department. The proposed indicator can be readily used to detect inefficiencies.
62 citations
TL;DR: 'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals, in the midst of a crisis such as SARS.
Abstract: Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, amplifies the difficulties of hospital priority setting. The purpose of this study is to describe and evaluate priority setting in a hospital in response to SARS using the ethical framework 'accountability for reasonableness'. This study was conducted at a large tertiary hospital in Toronto, Canada. There were two data sources: 1) over 200 key documents (e.g. emails, bulletins), and 2) 35 interviews with key informants. Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation. Participants described the types of priority setting decisions, the decision making process and the reasoning used. Although the hospital leadership made an effort to meet the conditions of 'accountability for reasonableness', they acknowledged that the decision making was not ideal. We described good practices and opportunities for improvement. 'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals. In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.
53 citations
TL;DR: The relatively low cost method of sending a pre-warning letter had a modest impact on increasing response rates to a postal questionnaire sent to a group of patients for whom a low response rate was anticipated.
Abstract: Background
A systematic review identified a range of methods, which can influence response rates. However, analysis specific to a healthcare setting, and in particular, involving people expected to be poor responders, was missing, We examined the effect of pre-warning letters on response rates to a postal survey of sedentary patients whom we expected a low rate of response.
49 citations
TL;DR: Investigation of the feasibility and desirability of using mathematical programming techniques that allow weights to vary across countries to reflect their varying circumstances and objectives finds them not very sensitive to changes in weights.
Abstract: In 2002, the World Health Organization published a health system performance ranking for 191 member countries. The ranking was based on five indicators, with fixed weights common to all countries. We investigate the feasibility and desirability of using mathematical programming techniques that allow weights to vary across countries to reflect their varying circumstances and objectives. By global distributional measures, scores and ranks are found to be not very sensitive to changes in weights, although differences can be large for individual countries. Building the flexibility of variable weights into calculation of the performance index is a useful way to respond to the debates and criticisms appearing since publication of the ranking.
TL;DR: Mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs, after adjusting for confounding.
Abstract: It has been proposed that greater availability of primary medical care practitioners (GPs) contributes to better population health. We evaluated whether measures of the supply and structure of primary medical services are associated with health and health care indicators after adjusting for confounding. Data for the supply and structure of primary medical services and the characteristics of registered patients were analysed for 99 health authorities in England in 1999. Health and health care indicators as dependent variables included standardised mortality ratios (SMR), standardised hospital admission rates, and conceptions under the age of 18 years. Linear regression analyses were adjusted for Townsend score, proportion of ethnic minorities and proportion of social class IV/ V. Higher proportions of registered rural patients and patients ≥ 75 years were associated with lower Townsend deprivation scores, with larger partnership sizes and with better health outcomes. A unit increase in partnership size was associated with a 4.2 (95% confidence interval 1.7 to 6.7) unit decrease in SMR for all-cause mortality at 15–64 years (P = 0.001). A 10% increase in single-handed practices was associated with a 1.5 (0.2 to 2.9) unit increase in SMR (P = 0.027). After additional adjustment for percent of rural and elderly patients, partnership size and proportion of single-handed practices, GP supply was not associated with SMR (-2.8, -6.9 to 1.3, P = 0.183). After adjusting for confounding with health needs of populations, mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs.
TL;DR: Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.
Abstract: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16–0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.
TL;DR: Hospitalization, perceived seriousness of condition, and concerns about the risks of medications were found to be associated with patient trust in physicians or the medical profession, highlighting the salience of trust in serious physician-patient encounters.
Abstract: Patients' trust in physicians and in the medical profession is vital for a successful patient-physician relationship. Trust is especially salient in critical medical situations, such as serious side-effects, hospitalizations, and diagnoses of serious medical conditions, but most trust studies have been done with the general population or in routine primary care settings. This study examines the association between patient-physician encounters in such critical medical situations and patients' trust in their physician and in the medical profession in general. A random national telephone survey was conducted using validated multi-item questionnaire measuring trust and satisfaction with physicians and with the medical profession. A seven item questionnaire measured the patient-physician encounters in critical medical situations. A total of 1117 subjects aged 20 years and older with health insurance were included for analyses. Spearman rank order correlations were used to determine the association of encounter variables with trust in physicians and the medical profession. Prescription of medications by primary care physicians that patients believed might have side effects was negatively correlated with trust in physician (ρ = -0.12, p < 0.001, n = 1045) in multivariate analysis. A primary care physician evaluating the patient for a condition the patient believed was serious was positively correlated with trust in physician (ρ= 0.08, p < 0.01). Being hospitalized was positively correlated with trust in the medical profession (ρ = 0.12, p < 0.01, n = 475). Hospitalization, perceived seriousness of condition, and concerns about the risks of medications were found to be associated with patient trust in physicians or the medical profession. These findings highlight the salience of trust in serious physician-patient encounters and the role that patient vulnerability plays in determining patient trust.
TL;DR: This RCT, using a large community based sample, found that the offer of entry into a lottery style draw for £100 of High Street vouchers has no effect on response rates to a postal health questionnaire.
Abstract: Background
Postal questionnaires are an economical and simple method of data collection for research purposes but are subject to non-response bias. Several studies have explored the effect of monetary and non-monetary incentives on response. Recent meta-analyses conclude that financial incentives are an effective way of increasing response rates. However, large surveys rarely have the resources to reward individual participants. Three previous papers report on the effectiveness of lottery incentives with contradictory results. This study aimed to determine the effect of including a lottery-style incentive on response rates to a postal health survey.
TL;DR: A cross-sectional analysis of California hospital discharges for two age groups – non-newborns 0–17 years old, and seniors, finds a poorer fit of the traditional geographic system for children.
Abstract: In the U.S. small-area health services research studies are often based on the hospital service areas (HSAs) defined by the Dartmouth Atlas of Healthcare project. These areas are based on the geographic origins of Medicare Part A hospital patients, the great majority of whom are seniors. It is reasonable to question whether the geographic system so defined is appropriate for health services research for all ages, particularly for children, who have a very different system of healthcare financing and provision in the U.S. This article assesses the need for a unique system of HSAs to support pediatric small-area analyses. It is a cross-sectional analysis of California hospital discharges for two age groups – non-newborns 0–17 years old, and seniors. The measure of interest was index of localization, which is the percentage of HSA residents hospitalized in their home HSA. Indices were computed separately for each age group, and index agreement was assessed for 219 of the state's HSAs. We examined the effect of local pediatric inpatient volume and pediatric inpatient resources on the divergence of the age group indices. We also created a new system of HSAs based solely on pediatric patient origins, and visually compared maps of the traditional and the new system. The mean localization index for pediatric discharges was 20 percentage points lower than for Medicare cases, indicating a poorer fit of the traditional geographic system for children. The volume of pediatric cases did not appear to be associated with the magnitude of index divergence between the two age groups. Pediatric medical and surgical case subgroups gave very similar results, and both groups differed substantially from seniors. Location of children's hospitals and local pediatric bed supply were associated with Medicare-pediatric divergence. There was little visual correspondence between the maps of traditional and pediatric-specific HSAs. Children and seniors have significantly different geographic patterns of hospitalization in California. Medicare-based HSAs may not be appropriate for all age groups and service types throughout the U.S.
TL;DR: In Rome, Italy, standard optimal coronary care is underprovided, and it seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.
Abstract: Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997–2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%). Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25–0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37–0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66–0.99 when comparing low to high SES). In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.
TL;DR: The effects of home visits to elderly people by public health nurses with perceived poor health are investigated in a population of elderly with (perceived) poor health rather than the general population to test whether nurses who are qualified at a lower professional level are able to obtain convincing effects.
Abstract: Background
Preventive home visits to elderly people by public health nurses aim to maintain or improve the functional status of elderly and reduce the use of institutional care services. A number of trials that investigated the effects of home visits show positive results, but others do not. The outcomes can depend on differences in characteristics of the intervention programme, but also on the selection of the target population. A risk group approach seems promising, but further evidence is needed. We decided to carry out a study to investigate the effects in a population of elderly with (perceived) poor health rather than the general population. Also, we test whether nurses who are qualified at a lower professional level (home nurses instead of public health nurses) are able to obtain convincing effects. The results of this study will contribute to the discussion on effective public health strategies for the aged.
TL;DR: The bootstrap's advantage in dealing with skewed data was found to be outweighed by its poor confidence interval coverage when the number of clusters was at the level frequently found in cluster RCTs in practice, suggesting 24 clusters per treatment arm is the minimum number for which one would even begin to consider the bootstrap in preference to traditional robust methods.
Abstract: This work has investigated under what conditions confidence intervals around the differences in mean costs from a cluster RCT are suitable for estimation using a commonly used cluster-adjusted bootstrap in preference to methods that utilise the Huber-White robust estimator of variance. The bootstrap's main advantage is in dealing with skewed data, which often characterise patient costs. However, it is insufficiently well recognised that one method of adjusting the bootstrap to deal with clustered data is only valid in large samples. In particular, the requirement that the number of clusters randomised should be large would not be satisfied in many cluster RCTs performed to date. The performances of confidence intervals for simple differences in mean costs utilising a robust (cluster-adjusted) standard error and from two cluster-adjusted bootstrap procedures were compared in terms of confidence interval coverage in a large number of simulations. Parameters varied included the intracluster correlation coefficient, the sample size and the distributions used to generate the data. The bootstrap's advantage in dealing with skewed data was found to be outweighed by its poor confidence interval coverage when the number of clusters was at the level frequently found in cluster RCTs in practice. Simulations showed that confidence intervals based on robust methods of standard error estimation achieved coverage rates between 93.5% and 94.8% for a 95% nominal level whereas those for the bootstrap ranged between 86.4% and 93.8%. In general, 24 clusters per treatment arm is probably the minimum number for which one would even begin to consider the bootstrap in preference to traditional robust methods, for the parameter combinations investigated here. At least this number of clusters and extremely skewed data would be necessary for the bootstrap to be considered in favour of the robust method. There is a need for further investigation of more complex bootstrap procedures if economic data from cluster RCTs are to be analysed appropriately.
TL;DR: The effectiveness and cost implications of 'pharmaceutical care' provided by community pharmacists to elderly patients in the community and the cost to the NHS, patients and to society as a whole are investigated.
Abstract: Background
This trial aims to investigate the effectiveness and cost implications of 'pharmaceutical care' provided by community pharmacists to elderly patients in the community. As the UK government has proposed that by 2004 pharmaceutical care services should extend nationwide, this provides an opportunity to evaluate the effect of pharmaceutical care for the elderly.
TL;DR: It is not possible to make any firm conclusions about the effectiveness of MoM based on these early results, but it is unclear if such results would be replicated in more rigorous studies, and what the long-term performance might be.
Abstract: Background
Conventional total hip replacement (THR) may be felt to carry too high a risk of failure over a patient's lifetime, especially in young people. There is increasing interest in metal on metal hip resurfacing arthroplasty (MoM) as this offers a bone-conserving option for treating those patients who are not considered eligible for THR. We aim to evaluate the effectiveness of MoM for treatment of hip disease, and compare it with alternative treatments for hip disease offered within the UK.
TL;DR: Although limited by sample size, the preliminary analyses suggest that type (ii) responses are more likely to be the result of recall bias due to competing morbidity and age than deaths/institutionalization or item non-response.
Abstract: Self-reported information has commonly been used to monitor mammography utilization across populations and time periods. However, longitudinal investigations regarding the prevalence and determinants of inconsistent responses over time and the impact of such responses on population screening estimates are lacking. Based on longitudinal panel data for a representative cohort of Canadian women aged 40+ years (n = 3,537) assessed in the 1994–95 (baseline) and 1996–97 (follow-up) National Population Health Survey (NPHS), we examined the prevalence of inconsistent self-reports of mammography utilization. Logistic regression models were used to estimate the associations between women's baseline sociodemographic and health characteristics and 2 types of inconsistent responses: (i) baseline reports of ever use which were subsequently contradicted by follow-up reports of never use; and (ii) baseline reports of never use which were contradicted by follow-up reports of use prior to 1994–95. Among women who reported having a mammogram at baseline, 5.9% (95% confidence interval (CI): 4.6–7.3%) reported at follow-up that they had never had one. Multivariate logistic regression analyses showed that women with such inconsistent responses were more often outside target age groups, from low income households and less likely to report hormone replacement therapy and Pap smear use. Among women reporting never use at baseline and ever use at follow-up, 17.4% (95%CI: 11.7–23.1%) reported their most recent mammogram as occurring prior to 1994–95 (baseline) and such responses were more common among women aged 70+ years and those in poorer health. Women with inconsistent responses of type (i), i.e., ever users at baseline but never users at follow-up, appeared to exhibit characteristics typical of never users of mammography screening. Although limited by sample size, our preliminary analyses suggest that type (ii) responses are more likely to be the result of recall bias due to competing morbidity and age. Inconsistent responses, if removed from the analyses, may be a greater source of loss to follow-up than deaths/institutionalization or item non-response.
TL;DR: A simple approach to identifying barriers to change and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia appears to have been adequate and efficient.
Abstract: Background
We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions.
TL;DR: The care of patients with primary-care home nursing is complex and reduced functional capacity decreased and help from family members increased the chance of having received outpatient specialised medical care, raising questions concerning the medical care for patients with both medical and functional problems.
Abstract: The reduced number of hospital beds and an ageing population have resulted in growing demands for home nursing. We know very little about the comprehensive care of these patients. The objectives were to identify the care, in addition to primary health care, of patients with primary-care home nursing to give a comprehensive view of their care and to investigate how personal, social and functional factors influence the use of specialised medical care. One-third (158) of all patients receiving primary-care home nursing in an area were sampled, and 73 % (116) were included. Their care from October 1995 until October 1996 was investigated by sending questionnaires to district nurses and home-help providers and by collecting retrospective data from primary-care records and official statistics. We used non-parametric statistical methods, i.e. medians and minimum – maximum, χ2, and the Mann-Whitney test, since the data were not normally distributed. Conditional logistic regression was used to study whether personal, social or functional factors influenced the chance (expressed as odds ratio) that study patients had made visits to or had received inpatient care from specialised medical care during the study year. 56 % of the patients had been hospitalised. 73 % had made outpatient visits to specialised medical care. The care took place at 14 different hospitals, and more than 22 specialities were involved, but local care predominated. Almost all patients visited doctors, usually in both primary and specialised medical care. Patients who saw doctors in specialised care had more help from all other categories of care. Patients who received help from their families made more visits to specialised medical care and patients with severe ADL dependence made fewer visits. The care of patients with primary-care home nursing is complex. Apart from home nursing, all patients also made outpatient visits to doctors, usually in both primary and specialised medical care. Many different caregivers and professions were involved. Reduced functional capacity decreased and help from family members increased the chance of having received outpatient specialised medical care. This raises questions concerning the medical care for patients with both medical and functional problems.
TL;DR: A retrospective population cohort study using time series analysis to evaluate seasonal patterns of atrial fibrillation hospitalizations for the province of Ontario for the years 1988 to 2001 confirms statistical evidence of seasonality.
Abstract: Background
Atrial fibrillation is a common cardiac dysrhythmia, particularly in the elderly. Recent studies have indicated a statistically significant seasonal component to atrial fibrillation hospitalizations.
TL;DR: Black patients had a trend towards decreased 30-day mortality and were less likely to receive optimal care, which is consistent with other studies that suggest better risk-adjusted survival among blacks than among whites.
Abstract: Patients hospitalized with community acquired pneumonia (CAP) have a substantial risk of death, but there is evidence that adherence to certain processes of care, including antibiotic administration within 8 hours, can decrease this risk. Although national mortality data shows blacks have a substantially increased odds of death due to pneumonia as compared to whites previous studies of short-term mortality have found decreased mortality for blacks. Therefore we examined pneumonia-related processes of care and short-term mortality in a population of patients hospitalized with CAP. We reviewed the records of all identified Medicare beneficiaries hospitalized for pneumonia between 10/1/1998 and 9/30/1999 at one of 101 Pennsylvania hospitals, and randomly selected 60 patients at each hospital for inclusion. We reviewed the medical records to gather process measures of quality, pneumonia severity and demographics. We used Medicare administrative data to identify 30-day mortality. Because only a small proportion of the study population was black, we included all 240 black patients and randomly selected 720 white patients matched on age and gender. We performed a resampling of the white patients 10 times. Males were 43% of the cohort, and the median age was 76 years. After controlling for potential confounders, blacks were less likely to receive antibiotics within 8 hours (odds ratio with 95% confidence interval 0.6, 0.4–0.97), but were as likely as whites to have blood cultures obtained prior to receiving antibiotics (0.7, 0.3–1.5), to have oxygenation assessed within 24 hours of presentation (1.6, 0.9–3.0), and to receive guideline concordant antibiotics (OR 0.9, 0.6–1.7). Black patients had a trend towards decreased 30-day mortality (0.4, 0.2 to 1.0). Although blacks were less likely to receive optimal care, our findings are consistent with other studies that suggest better risk-adjusted survival among blacks than among whites. Further study is needed to determine why this is the case.
TL;DR: It is feasible to recruit women for a trial of NRT in pregnancy as they wait for antenatal ultrasound examinations and staff recruiting women believed that trial recruitment would be maximised if women attending the ultrasound department knew about trial recruitment before attending and greater staff resources were made available for this.
Abstract: Smoking in pregnancy is a public health problem and effective methods for reducing this are required. Although nicotine replacement therapy (NRT) is effective for smoking cessation in non-pregnant people, there is no direct evidence concerning its effectiveness in pregnancy. Despite this, clinical guidelines recommend the cautious use of NRT during pregnancy. Randomised controlled trials are needed to determine the safety and efficacy of NRT when used by pregnant women for smoking cessation, but the feasibility of recruiting women to such trials is unknown. Consequently, in this study we aimed to determine i) the feasibility of recruiting women to a RCT of NRT in pregnancy as they attend hospital antenatal ultrasound examinations, ii) the proportion of such women who are eligible for and interested in trial enrolment and iii) research staff perceptions of how one method of trial recruitment could be improved. During a one month period, all women attending for antenatal ultrasound examination in an English teaching hospital were asked to complete a questionnaire which determined their eligibility to enrol in a proposed placebo controlled randomised trial investigating the effectiveness of NRT in pregnancy. Women who were eligible to participate were asked whether they would do so and those who accepted enrolment were offered an appointment with a smoking cessation advisor. Over 99% (851/858) of women agreed to complete a questionnaire about smoking habits whilst waiting for ultrasound examinations. 10.3% (88/851) of women attending for antenatal ultrasound fitted eligibility criteria for a proposed RCT of NRT in pregnancy, but only 3.6% [(31/851), 95% CI, 2.4 to 4.9%] indicated on the questionnaire that they would like to take part in a study involving randomisation to placebo or active patches. Researchers offered trial enrolment to 26 of these 31 women and 96% (25) accepted. Staff recruiting women believed that trial recruitment would be maximised if women attending the ultrasound department knew about trial recruitment before attending and greater staff resources were made available for this. It was also perceived that women generally under-reported the amount they smoked on questionnaires completed whilst waiting in ultrasound department areas. It is feasible to recruit women for a trial of NRT in pregnancy as they wait for antenatal ultrasound examinations. Using similar recruitment methods, researchers can expect to recruit between 24 and 49 women per 1000 approached.
TL;DR: The offer of a prize draw incentive to win a PDA did not significantly increase response rates to a national questionnaire survey of consultant obstetricians and gynaecologists.
Abstract: Background
Response rates to postal questionnaires are falling and this threatens the external validity of survey findings. We wanted to establish whether the incentive of being entered into a prize draw to win a personal digital assistant (PDA) would increase the response rate for a national survey of consultant obstetricians and gynaecologists.
TL;DR: Average length of stay does not differ between managed and non-managed care patients and the variation was smaller for DRGs that are easy to standardize than for other DRGs.
Abstract: In this study we examined the influence of type of insurance and the influence of managed care in particular, on the length of stay decisions physicians make and on variation in medical practice. We studied lengths of stay for comparable patients who are insured under managed or non-managed care plans. Seven Diagnosis Related Groups were chosen, two medical (COPD and CHF), one surgical (hip replacement) and four obstetrical (hysterectomy with and without complications and Cesarean section with and without complications). The 1999, 2000 and 2001 – data from hospitals in New York State were used and analyzed with multilevel analysis. Average length of stay does not differ between managed and non-managed care patients. Less variation was found for managed care patients. In both groups, the variation was smaller for DRGs that are easy to standardize than for other DRGs. Type of insurance does not affect length of stay. An explanation might be that hospitals have a general policy concerning length of stay, independent of the type of insurance of the patient.
TL;DR: The objective of this study is to evaluate the impact of two types of reminders on overtreatment by oral anticoagulant: a simple reminder of text formatted dose adjustment table and a personalized recommended dose and next date of INR control, adapted to patient data.
Abstract: Background
The quality control of oral anticoagulant therapy (OAT) during the initiation and maintenance treatment is generally poor. Physicians' ordering of OAT (especially fluindione and warfarin) can be improved by dose adjustment algorithms, taking into account the results of International Normalized Ratio (INR). Reminders at the point of care, computerized or not, have been demonstrated to be effective in changing physicians prescription behavior.
However, few studies have addressed the benefit of personalized reminders versus non personalized reminders, whereas the personalized reminders require more development to access patient record data and integrate with the computerized physician order entry system.
The Hospital Information System of George Pompidou European Hospital integrates an electronic medical record, lab test and drugs order entry system. This system allows to evaluate such reminders and to consider their implementation for routine use as well as the continuous evaluation of their impact on medical practice quality indicators.
The objective of this study is to evaluate the impact of two types of reminders on overtreatment by oral anticoagulant: a simple reminder of text formatted dose adjustment table and a personalized recommendation for oral anticoagulant dose and next date of INR control, adapted to patient data. Both types of reminders appear to the physician at the moment of drug ordering.