Showing papers in "Medical Care in 2007"
TL;DR: The NIHPROMIS network derived a consensus-based framework for self-reported health, systematically reviewed available instruments and datasets that address the initial PROMIS domains, and began testing of item banks covering 5 broad domains of self- reported health.
Abstract: Background:The National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Roadmap initiative (www.nihpromis.org) is a 5-year cooperative group program of research designed to develop, validate, and standardize item banks to measure patient-reported outcomes
2,179 citations
TL;DR: An overview of the methods used in the PROMIS item analyses and proposed calibration of item banks is provided and recommendations are provided for future evaluations of item Banks in HRQOL assessment.
Abstract: Background: The construction and evaluation of item banks to measure unidimensional constructs of health-related quality of life (HRQOL) is a fundamental objective of the Patient-Reported Outcomes Measurement Information System (PROMIS) project. Objectives: Item banks will be used as the foundation for developing short-form instruments and enabling computerized adaptive testing. The PROMIS Steering Committee selected 5 HRQOL domains for initial focus: physical functioning, fatigue, pain, emotional distress, and social role participation. This report provides an overview of the methods used in the PROMIS item analyses and proposed calibration of item banks. Analyses: Analyses include evaluation of data quality (eg, logic and range checking, spread of response distribution within an item), descriptive statistics (eg, frequencies, means), item response theory model assumptions (unidimensionality, local independence, monotonicity), model fit, differential item functioning, and item calibration for banking. Recommendations: Summarized are key analytic issues; recommendations are provided for future evaluations of item banks in HRQOL assessment.
1,251 citations
TL;DR: Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) and lower odds of hospitalrelated mortality and adverse patient events and patient and hospital characteristics, including hospitals’ commitment to quality of medical care, likely contribute to the actual causal pathway.
Abstract: (OR, 0.49; 95% CI, 0.36‐0.67), respiratory failure (OR, 0.40; 95% CI, 0.27‐0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62‐0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79‐0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62‐0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55‐0.86). Conclusions: Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals’ commitment to quality of medical care, likely contribute to the actual causal pathway.
1,091 citations
TL;DR: Even in an environment with universal access to free short-term psychotherapy and basic health services, most students with apparent mental disorders did not receive treatment and initiatives to improve access to mental health care for students have the potential to produce substantial benefits.
Abstract: Background: University students represent an important population in which to study access to mental health care. Understanding their unmet needs will enhance efforts to prevent and treat mental disorders during a pivotal period in life. Objective: To quantify mental health service use and estimate how various factors are associated with help-seeking and access in a university student population. Design: A Web-based survey was administered to a random sample of 2785 students attending a large, public university with a demographic profile similar to the national student population. Nonresponse bias was accounted for using administrative data and a nonrespondent survey. Measures: Mental health was measured using the Patient Health Questionnaire screens for depressive and anxiety disorders. Mental health service utilization was measured as having received psychotropic medication or psychotherapy in the past year. Results: Of students with positive screens for depression or anxiety, the proportion who did not receive any services ranged from 37% to 84%, depending on the disorder. Predictors of not receiving services included a lack of perceived need, being unaware of services or insurance coverage, skepticism about treatment effectiveness, low socioeconomic background, and being Asian or Pacific Islander. Conclusions: Even in an environment with universal access to free short-term psychotherapy and basic health services, most students with apparent mental disorders did not receive treatment. Initiatives to improve access to mental health care for students have the potential to produce substantial benefits in terms of mental health and related outcomes.
897 citations
TL;DR: The systematic process wherein items are classified for subsequent statistical processing by the PROMIS investigators is described, wherein items successfully screened through this process were sent to field testing and will be subjected to innovative scale construction procedures.
Abstract: One of the PROMIS (Patient-Reported Outcome Measurement Information System) network's primary goals is the development of a comprehensive item bank for patient-reported outcomes of chronic diseases. For its first set of item banks, PROMIS chose to focus on pain, fatigue, emotional distress, physical function, and social function. An essential step for the development of an item pool is the identification, evaluation, and revision of extant questionnaire items for the core item pool. In this work, we also describe the systematic process wherein items are classified for subsequent statistical processing by the PROMIS investigators. Six phases of item development are documented: identification of extant items, item classification and selection, item review and revision, focus group input on domain coverage, cognitive interviews with individual items, and final revision before field testing. Identification of items refers to the systematic search for existing items in currently available scales. Expert item review and revision was conducted by trained professionals who reviewed the wording of each item and revised as appropriate for conventions adopted by the PROMIS network. Focus groups were used to confirm domain definitions and to identify new areas of item development for future PROMIS item banks. Cognitive interviews were used to examine individual items. Items successfully screened through this process were sent to field testing and will be subjected to innovative scale construction procedures.
647 citations
TL;DR: In this article, a large body of empirical data exists on the prediction of patient adherence from subjective and objective assessments of health status and disease severity, which can be summarized with meta-analysis.
Abstract: Background:A large body of empirical data exists on the prediction of patient adherence from subjective and objective assessments of health status and disease severity. This work can be summarized with meta-analysis.Objectives:Retrieval and summary analysis of r effect sizes and moderators of the re
470 citations
TL;DR: The interventions were associated with improved physician and patient communication behaviors and the challenge for future research is to design effective patient and physician interventions that can be integrated into practice.
Abstract: Objective:We sought to synthesize the findings of studies examining interventions to enhance the communication behaviors of physicians and patients during outpatient encounters.Methods:We conducted searches of 6 databases between 1966 and 2005 to identify studies for a systematic review and synthesi
458 citations
TL;DR: This article describes how this propensity score-based method can be used to compare the effectiveness of 2 or more treatments and provides a conceptual explanation of inverse probability-weighted estimation.
Abstract: Inverse probability-weighted estimation is a powerful tool for use with observational data. In this article, we describe how this propensity score-based method can be used to compare the effectiveness of 2 or more treatments. First, we discuss the inherent problems in using observational data to assess comparative effectiveness. Next, we provide a conceptual explanation of inverse probability-weighted estimation and point readers to sources that address the method in more formal, technical terms. Finally, we offer detailed guidance about how to implement the estimators in comparative effectiveness analyses.
457 citations
TL;DR: Six HRQoL measures show similar but not identical trends in population norms for older US adults, and provide reference values for 6 self-reported generic health-related quality-of-life indexes.
Abstract: Background—A number of indexes measuring self-reported generic health-related quality-of-life (HRQoL) using preference-weighted scoring are used widely in population surveys and clinical studies in the US Objective—To obtain age-by-gender norms for older adults on 6 generic HRQoL indexes in a crosssectional US population survey and compare age-related trends in HRQoL Methods—The EQ-5D, HUI2, HUI3, SF-36v2™ (used to compute SF-6D), QWB-SA and HALex were administered via telephone interview to each respondent in a national survey sample of 3,844 non-institutionalized adults aged 35-89 Persons aged 65 to 89 and telephone exchanges with high percentages of African Americans were over-sampled Age-by-gender means were computed using sampling and post-stratification weights to adjust results to the US adult population Results—The six indexes exhibit similar patterns of age-related HRQoL by gender; however, means differ significantly across indexes Females report slightly lower HRQoL than do males across all age groups HRQoL appears somewhat higher for persons age 65-74 compared to people in the next younger age decade, as measured by all indexes
414 citations
TL;DR: Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension, and differences in preferences are unlikely to explain regional variations in EOL spending.
Abstract: Objective
We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care.
392 citations
TL;DR: The REALM-SF provides researchers a brief, validated instrument for assessing patient literacy in diverse research settings and provides excellent agreement between REALm-SF and REALM instrument grade-level assignments when dichotomized at the 6th grade.
Abstract: Background:Although prior studies used the 66-item Rapid Estimate of Adult Literacy in Medicine (REALM instrument) for literacy assessment, researchers may require a shorter, validated instrument when designing interventions for clinical contexts.Objective:To develop and validate a very brief litera
TL;DR: Nurse working conditions were associated with all outcomes measured and will most likely promote patient safety, and future researchers and policymakers should consider a broad set of working condition variables.
Abstract: Background:System approaches, such as improving working conditions, have been advocated to improve patient safety. However, the independent effect of many working condition variables on patient outcomes is unknown.Objective:To examine effects of a comprehensive set of working conditions on elderly p
TL;DR: The Safety Organizing Scale (SOS), a 9-item unidimensional measure of self-reported behaviors enabling a safety culture, was found to have high internal reliability and reflect theoretically derived and empirically observed content domains.
Abstract: Background: Evidence that medical error is a systemic problem requiring systemic solutions continues to expand. Developing a “safety culture” is one potential strategy toward improving patient safety. A reliable and valid self-report measure of safety culture is needed that is both grounded in concrete behaviors and is positively related to patient safety. Objective: We sought to develop and test a self-report measure of safety organizing that captures the behaviors theorized to underlie a safety culture and demonstrates use for potentially improving patient safety as evidenced by fewer reported medication errors and patient falls. Subjects: A total of 1685 registered nurses from 125 nursing units in 13 hospitals in California, Indiana, Iowa, Maryland, Michigan, and Ohio completed questionnaires between December 2003 and June 2004. Research Design: The authors conducted a cross-sectional assessment of factor structure, dimensionality, and construct validity. Results: The Safety Organizing Scale (SOS), a 9-item unidimensional measure of self-reported behaviors enabling a safety culture, was found to have high internal reliability and reflect theoretically derived and empirically observed content domains. The measure was shown to discriminate between related concepts like organizational commitment and trust, vary significantly within hospitals, and was negatively associated with reported medication errors and patient falls in the subsequent 6-month period. Conclusions: The SOS not only provides meaningful, behavioral insight into the enactment of a safety culture, but because of the association between SOS scores and reported medication errors and patient falls, it also provides information that may be useful to registered nurses, nurse managers, hospital administrators, and governmental agencies.
TL;DR: VA health care provides an important safety net for vulnerable populations and targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.
Abstract: Objectives: We examined the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services. Methods: We used a retrospective, cross-sectional design to identify veterans who were eligible to use VA and Medicare health care in calendar year 1999. We analyzed national VA utilization and Medicare claims data. We used descriptive and multivariable generalized ordered logit analyses to examine how patient, geographic, and environmental factors affect the percent reliance on VA and Medicare inpatient and outpatient services. Results: Of the 1.47 million veterans in our study population with outpatient use, 18% were VA-only users, 36% were Medicare-only users, and 46% were both VA and Medicare users. Among veterans with inpatient use, 24% were VA only, 69% were Medicare only, and 6% were both VA and Medicare users. Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care. Conclusions: VA health care provides an important safety net for vulnerable populations. Targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.
TL;DR: For general surgery, more limited definitions of failure-to-rescue that omit over 40% of deaths, display less reliability, and may have more questionable validity than the original FTR measure are encouraged.
Abstract: Objectives:Use of failure-to-rescue (FTR) as an indicator of hospital quality has increased over the past decade, but recent authors have used different sets of complications and deaths to define this measure. This study examines the reliability and validity of different FTR measures currently in us
TL;DR: The Patient-Reported Outcomes Measurement Information System (PROMIS) is described—its rationale, the funded network, and the network’s conceptual, analytic, empirical work, and goals.
Abstract: In a process involving hundreds of scientists in 2002, the National Institutes of Health (NIH) identified high-priority scientific opportunities and needs the agency should pursue. Criteria used to identify the most important initiatives included: goals that could not be accomplished by a single institute, but were the responsibility of the NIH as a whole; initiatives that the NIH could not afford not to do; initiatives that no other entity could or would do; and initiatives that would transform biomedical research. This “Roadmap for Medical Research” included, as 1 of 3 major theme areas, the goal of “re-engineering the clinical research enterprise.” Initiatives developed under this roadmap theme are intended to facilitate and enhance clinical research in numerous ways, including promoting integration of clinical research networks, harmonizing regulatory processes, revolutionizing clinical research training, and developing technologies to improve clinical outcomes assessment. This supplemental issue of Medical Care describes the last of these initiatives, the Patient-Reported Outcomes Measurement Information System (PROMIS)—its rationale, the funded network, and the network’s conceptual, analytic, empirical work, and goals. One clinical research issue highlighted by the roadmap process was the need for more valid, reliable, and generalizable measures of clinical outcomes that are important to patients. Conventional measures of disease status do not fully capture the ways that chronic diseases and their treatment affect individuals. Many aspects of patients’ subjective experience, such as symptom severity and frequency, emotional and social wellbeing, and perceived level of health and functional ability, are important targets for disease intervention. Measurement of patient-reported outcomes (PROs) is particularly important in clinical trials, where laboratory or imaging results may not translate into important benefit to patients, or in trials where 2 treatments may be comparably effective, but have different adverse-effect profiles that differentially affect symptoms, functioning, or other aspects of patients’ quality of life. The identified need for improved PRO measurement engendered an NIH request for applications to develop a validated, dynamic system to measure PROs efficiently in study participants with a wide range of chronic diseases and demographic characteristics. The intent was to create a collaborative group of funded investigators that would take advantage of computer technologies and advances in modern measurement theory to develop an improved tool for measuring PROs. The broad objectives outlined in the request for applications were to: (1) develop and test a large bank of items measuring PROs; (2) create a computerized adaptive testing system that will allow for efficient, psychometrically robust assessment of PROs in clinical research on a wide range of chronic diseases; and (3) create a publicly-available system that can be added to and modified periodically, and that will allow researchers to access a common item repository and a computerized adaptive test (CAT).
TL;DR: Outcomes improved when practices associated with better outcomes in PBE-CPI analyses were adopted in practice and can uncover better practices more quickly than randomized controlled trials or sophisticated statistical methods, while achieving many of the same advantages.
Abstract: Objectives:To describe a new, rigorous, comprehensive practice-based evidence for clinical practice improvement (PBE-CPI) study methodology, and compare its features, advantages, and disadvantages to those of randomized controlled trials and sophisticated statistical methods for comparative effectiv
TL;DR: Hospitals that operate at or over capacity may experience heightened rates of patient safety events and might consider re-engineering the structures of care to respond better during periods of high stress.
Abstract: Context:Hospitals are under pressure to increase revenue and lower costs, and at the same time, they face dramatic variation in clinical demand.Objective:We sought to determine the relationship between peak hospital workload and rates of adverse events (AEs).Methods:A random sample of 24,676 adult p
TL;DR: To prevent premature leaving, it is important to expand nurses' expertise, to improve working processes through collaboration and multidisciplinary teamwork, and to develop team training approaches and ward design facilitating teamwork.
Abstract: Objectives:Europe's nursing shortage calls for more effective ways to recruit and retain nurses. This contribution aims to clarify whether and how social work environment, teamwork characteristics, burnout, and personal factors are associated with nurses' intent to leave (ITL).Methods:Our sample com
TL;DR: In this example of a large database study, restricting to incident drug users, similar comparison groups, patients without contraindication, and to adherent patients was a practical strategy, which limited the effect of confounding, as these approaches yield results closer to those seen in RCTs.
Abstract: Results from pharmacoepidemiologic research often have immediate and far-reaching clinical, regulatory, and economic implications. Consequently, practitioners and policymakers must consider carefully whether any association between use of a prescription drug and health outcomes is causal. Although a variety of systematic errors may bias nonexperimental research,1 confounding bias is of particular concern in epidemiologic studies of drug effects.2
Large health care utilization data sets are an efficient data source to analyze the relation between prescription drug use patterns in clinical practice and unintended and infrequent health outcomes.3,4 Despite their advantages, pharmacoepidemiologic claims data studies have been criticized for the incompleteness of their information on potential confounders. Restricting study cohorts to patients who are homogeneous regarding their indication for the study drug will lead to more balance of patient predictors of the study outcome among exposure groups and thus will reduce confounding. Restricting study cohorts can also increase the likelihood that all included subjects will have a similar response to therapy, and therefore reduce the likelihood of effect modification. Randomized controlled trials (RCTs) commonly restrict their study population to patients with a presumed indication for the study drug and then randomly allocate the actual treatment. One might argue, therefore, that similar restriction of the study cohort in nonrandomized research can foster convergence between those findings and results from RCTs. Although restriction is based on measurable patient characteristics, selecting proxy characteristics may overcome the often-limited depth of information in health care utilization databases. The large size of such databases, however, makes it feasible to restrict on many criteria without reducing the study to a size that would meaningfully compromise the precision of effect estimates. A recent study suggested that the way investigators apply restriction varies substantially when they examine adverse drug effects in nonrandomized research, but it did not analyze the effects of different restriction strategies on the validity of findings.5
The objective of this article is to develop a structured approach to restricting patient populations in epidemiologic database studies of intended and unintended treatment effects. To illustrate how increasing restriction criteria affects the strength of an association between statin use and 1-year mortality, we used a cohort study of Medicare enrollees and compared results with those of randomized controlled trials. We used this example because statins are widely used in primary and secondary prevention of coronary heart disease and myocardial infarction (MI). It is a medication class for chronic use, and several randomized controlled trials are available in elderly patients showing a reduced risk of MI and suggesting improved mortality.
TL;DR: Although age and the severity of side-effects remain important, patient-centered care was a primary mediator of patient adherence to ongoing cancer treatment with tamoxifen.
Abstract: Background:Among breast cancer patients, tamoxifen use is associated with reduced risk of disease relapse and death, but it is often difficult for women to sustain therapy during the 5 years required to obtain maximum benefit.Objectives:We sought to examine the influence of patient-centered care act
TL;DR: All of the ICD-10 versions of the Charlson algorithm performed satisfactorily, with the Quan version showing a trend toward outperforming the other versions in all data sets, and the distribution of comorbidity level categories was similar across the 3 translations.
Abstract: Objective:The Charlson comorbidity index has been widely used for risk adjustment in outcome studies using administrative health data. Recently, 3 International Statistical Classification of Diseases, Tenth Revision (ICD-10) translations have been published for the Charlson comorbidities. This study
TL;DR: Adherence to the guideline recommendation for active care was associated with better clinical outcomes and reduced cost, and patients receiving adherent care were more likely to have a successful physical therapy outcome.
Abstract: Background: Numerous practice guidelines have been developed for patients with low back pain in an attempt to reduce inappropriate variations and improve the cost-effectiveness of care. Guideline implementation has received more research attention than the impact of adherence to guideline recommendations on outcomes and costs of care. Objective: Examine the association between adherence to the guideline recommendation to use active versus passive treatments with clinical outcomes and costs for patients with acute low back pain receiving physical therapy. Research Design: Retrospective review of patients with acute low back pain receiving physical therapy in 2004 –2005. Adherence to the recommendation for active treatment was determined from billing records. Clinical and financial outcomes were compared between patients receiving adherent or nonadherent care. Subjects: A total of 1190 patients age 18 – 60 years old with low back pain of less than 90 days duration in 10 clinics in 1 geographic region. Measures: Clinical outcomes included the numeric pain rating and Oswestry disability questionnaire taken initially and at the completion of treatment. Financial outcomes included the number of sessions and charges for physical therapy care. Results: Adherence rate was 40.4%. Adherence was greater for patients receiving workers’ compensation (P 0.05). Patients receiving adherent care had fewer visits and lower charges (P 0.05), and showed more improvement in disability adjusted mean difference for percentage improvement 25.8%, 95% confidence interval (CI): 21.3–30.4, P 0.001 and pain (adjusted mean difference for percentage improvement 22.4%, 95% CI: 17.5–27.3, P 0.001). Patients receiving adherent care were more likely to have a successful physical therapy outcome (64.7% vs. 36.5%, P 0.001). Conclusions: Adherence to the guideline recommendation for active care was associated with better clinical outcomes and reduced cost.
TL;DR: Results suggest a 5-level classifier system has less ceiling effect and greater discriminative ability with potentially more power to detect differences between groups compared with EQ-5D-3L.
Abstract: Objective:The objectives of this study were: 1) to determine whether expanding the number of levels (ie, response categories) on the standard 3 level EQ-5D (EQ-5D-3L) to 5-levels (EQ-5D-5L) would improve the descriptive richness and ability of the measure to discriminate among different levels of he
TL;DR: Real-time surveillance combining dynamic data files, aggregation of data, and sequential analysis methods offers a useful and highly adaptable approach to early detection of adverse events after the introduction of new vaccines.
Abstract: Background:Rare but serious adverse events associated with vaccines or drugs are often nearly impossible to detect in prelicensure studies and require monitoring after introduction of the agent in large populations. Sequential testing procedures are needed to detect vaccine or drug safety problems a
TL;DR: In this article, the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors were examined. But, although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety.
Abstract: Context: Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Objectives: Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. Subjects: A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Research Design: Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Results: Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Conclusions: Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.
TL;DR: Five methods of combining quality indicators scores to produce composite scores that summarize the overall performance of health care providers were compared, resulting in substantial differences in how providers scored.
Abstract: OBJECTIVE: To compare different methods of combining quality indicators scores to produce composite scores that summarize the overall performance of health care providers. METHODS: Five methods for computing a composite quality score were compared: the "All-or-None," the "70% Standard," the "Overall Percentage," the "Indicator Average," and the "Patient Average." The first 2 "criterion-referenced" methods assess the degree to which a provider has reached a threshold for quality of care for each patient (100% or 70%). The remaining "absolute score" methods produce scores representing the proportion of required care successfully provided. Each method was applied to 2 quality indicator datasets, derived from audits of UK family practitioner records. Dataset A included quality indicator data for 1178 patients from 16 family practices covering 23 acute, chronic, and preventative conditions. Dataset B included data on 3285 patients from 60 family practices, covering 3 chronic conditions. RESULTS: The results varied considerably depending on the method of aggregation used, resulting in substantial differences in how providers scored. The results also varied considerably for the 2 datasets. There was more agreement between methods for dataset B, but for dataset A 6 of the 16 practices moved between the top and bottom quartiles depending upon the method used. CONCLUSIONS: Different methods of computing composite quality scores can lead to different conclusions being drawn about both relative and absolute quality among health care providers. Different methods are suited to different types of application. The main advantages and disadvantages of each method are described and discussed.
TL;DR: Three national approaches should be considered in reforming the healthcare system in China: universal insurance Coverage, higher amounts of insurance coverage, and increasing the population's level of education.
Abstract: Objectives: To describe patterns in physician and hospital utilization among rural and urban populations in China and to determine factors associated with any differences. Methods: In 2003, the Third National Health Services Survey in China was conducted to collect information about health services utilization from randomly selected residents. Of the 193,689 respondents to the survey (response rate, 77.8%), 6429 urban and 16,044 rural respondents who were age 18 or older and reported an illness within the last 2 weeks before the survey were analyzed. Generalized estimating equations with a log link were used to assess the relationship between rural/urban residence and physician visit/hospitalization to adjust for respondents clustered at the household level. Results: About half of respondents did not see a physician when they were ill. Rural respondents used physicians more than urban respondents (52.0% vs. 43.0%, P 0.001) and used hospitals less (7.6% vs. 11.1%, P 0.001). Factor associated with increased physician utilization included residing in rural areas among majority Chinese (ie, Han) rate ratio (RR), 1.21; 95% confidence interval (95% CI), 1.16‐1.26, residing 3 km away from the medical center (RR, 1.16; 95% CI, 1.12‐1.21), or being uninsured (RR, 1.38; 95% CI, 1.30‐1.46). Rural minority Chinese visited physicians significantly less than urban minority Chinese (RR, 0.90; 95% CI, 0.83‐0.98). Hospital utilization was significantly lower among rural males (RR, 0.84; 95% CI, 0.72‐0.98), rural seniors (age, 65; RR, 0.64; 95% CI, 0.53‐0.77), rural respondents with low education (RR, 0.70; 95% CI, 0.57‐0.86 for illiterate), or rural insured respondents (RR, 0.86; 95% CI, 0.69‐0.99) than hospitalization among urban counterparts. Conclusions: Three national approaches should be considered in reforming the healthcare system in China: universal insurance coverage, higher amounts of insurance coverage, and increasing the population’s level of education. In addition, access issues in remote areas and by rural minority Chinese population should be addressed.
TL;DR: The need for continued provider education to inform prescribers of the potential risks of using certain medications in the elderly and to improve prescribing practices is emphasized.
Abstract: Background:Potentially inappropriate medication (PIM) use is a major source of drug-related problems in the elderly. Few studies have quantified the effect of PIM use on total healthcare expenditures in the United States.Objectives:We sought to determine the relationship between PIM use and healthca
TL;DR: Among older persons at increased risk of death or functional decline, multimorbidity results in better, rather than worse, quality of care.
Abstract: Background:Older patients with multiple chronic conditions may be at higher risk of receiving poorer overall quality of care compared with those with single or no chronic conditions. Possible reasons include competing guidelines for individual conditions, burden of numerous recommendations, and diff