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Showing papers on "Health care published in 2003"


Journal ArticleDOI
TL;DR: The deficits the authors have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public and strategies to reduce these deficits in care are warranted.
Abstract: background We have little systematic information about the extent to which standard processes involved in health care — a key element of quality — are delivered in the United States. methods We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores. results Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence. conclusions The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.

4,750 citations


Journal ArticleDOI
TL;DR: In this paper, the authors estimated the direct medical and indirect productivity-related costs attributable to diabetes and calculated and compared the total and per capita medical expenditures for people with and without diabetes.
Abstract: Objective Diabetes is the fifth leading cause of death by disease in the U.S. Diabetes also contributes to higher rates of morbidity-people with diabetes are at higher risk for heart disease, blindness, kidney failure, extremity amputations, and other chronic conditions. The objectives of this study were 1). to estimate the direct medical and indirect productivity-related costs attributable to diabetes and 2). to calculate and compare the total and per capita medical expenditures for people with and without diabetes. Research design and methods Medical expenditures were estimated for the U.S. population with and without diabetes in 2002 by sex, age, race/ethnicity, type of medical condition, and health care setting. Health care use and total health care expenditures attributable to diabetes were estimated using etiological fractions, calculated based on national health care survey data. The value of lost productivity attributable to diabetes was also estimated based on estimates of lost workdays, restricted activity days, prevalence of permanent disability, and mortality attributable to diabetes. RESULTS-Direct medical and indirect expenditures attributable to diabetes in 2002 were estimated at 132 billion US dollars. Direct medical expenditures alone totaled 91.8 billion US dollars and comprised 23.2 billion US dollars for diabetes care, 24.6 billion US dollars for chronic complications attributable to diabetes, and 44.1 billion US dollars for excess prevalence of general medical conditions. Inpatient days (43.9%), nursing home care (15.1%), and office visits (10.9%) constituted the major expenditure groups by service settings. In addition, 51.8% of direct medical expenditures were incurred by people >65 years old. Attributable indirect expenditures resulting from lost workdays, restricted activity days, mortality, and permanent disability due to diabetes totaled 39.8 billion US dollars. U.S. health expenditures for the health care components included in the study totaled 865 billion US dollars, of which 160 billion US dollars was incurred by people with diabetes. Per capita medical expenditures totaled 13243 US dollars for people with diabetes and 2560 US dollars for people without diabetes. When adjusting for differences in age, sex, and race/ethnicity between the population with and without diabetes, people with diabetes had medical expenditures that were approximately 2.4 times higher than expenditures that would be incurred by the same group in the absence of diabetes. Conclusions The estimated 132 billion US dollars cost likely underestimates the true burden of diabetes because it omits intangibles, such as pain and suffering, care provided by nonpaid caregivers, and several areas of health care spending where people with diabetes probably use services at higher rates than people without diabetes (e.g., dental care, optometry care, and the use of licensed dietitians). In addition, the cost estimate excludes undiagnosed cases of diabetes. Health care spending in 2002 for people with diabetes is more than double what spending would be without diabetes. Diabetes imposes a substantial cost burden to society and, in particular, to those individuals with diabetes and their families. Eliminating or reducing the health problems caused by diabetes through factors such as better access to preventive care, more widespread diagnosis, more intensive disease management, and the advent of new medical technologies could significantly improve the quality of life for people with diabetes and their families while at the same time potentially reducing national expenditures for health care services and increasing productivity in the U.S. economy.

4,014 citations


Journal ArticleDOI
TL;DR: Evidence of the effectiveness of self-management interventions is presented and a possible mechanism, self-efficacy, through which these interventions work are posited.
Abstract: Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks—medical management, role management, and emotional management—and six self-management skills—problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

3,379 citations


Journal ArticleDOI
TL;DR: Measuring pediatric HRQOL may be a way to evaluate the health outcomes of SCHIP and demonstrate the feasibility, reliability, and validity of the PedsQL 4.0 as a pediatric population health outcome.

1,969 citations


Book
01 Jul 2003
TL;DR: Health Professions Education: A Bridge to Quality is the follow up to that summit, held in June 2002, where 150 participants across disciplines and occupations developed ideas about how to integrate a core set of competencies into health professions education.
Abstract: The Institute of Medicine study Crossing the Quality Chasm (2001) recommended that an interdisciplinary summit be held to further reform of health professions education in order to enhance quality and patient safety. Health Professions Education: A Bridge to Quality is the follow up to that summit, held in June 2002, where 150 participants across disciplines and occupations developed ideas about how to integrate a core set of competencies into health professions education. These core competencies include patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. This book recommends a mix of approaches to health education improvement, including those related to oversight processes, the training environment, research, public reporting, and leadership. Educators, administrators, and health professionals can use this book to help achieve an approach to education that better prepares clinicians to meet both the needs of patients and the requirements of a changing health care system.

1,920 citations


Journal ArticleDOI
16 Apr 2003-JAMA
TL;DR: The theory and research on the dissemination of innovations and applications of that theory to health care are examined and at least 7 recommendations for health care executives who want to accelerate the rate of diffusion of innovations within their organizations are suggested.
Abstract: Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly-if at all. Diffusion of innovations is a major challenge in all industries including health care. This article examines the theory and research on the dissemination of innovations and suggests applications of that theory to health care. It explores in detail 3 clusters of influence on the rate of diffusion of innovations within an organization: the perceptions of the innovation, the characteristics of the individuals who may adopt the change, and contextual and managerial factors within the organization. This theory makes plausible at least 7 recommendations for health care executives who want to accelerate the rate of diffusion of innovations within their organizations: find sound innovations, find and support "innovators," invest in "early adopters," make early adopter activity observable, trust and enable reinvention, create slack for change, and lead by example.

1,803 citations


Journal ArticleDOI
TL;DR: A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of racial/ethnic disparities in health and improve care for all Americans.
Abstract: OBJECTIVES: Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care. METHODS: The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers. RESULTS: Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care. CONCLUSIONS: Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

1,709 citations



Journal ArticleDOI
24 Sep 2003-JAMA
TL;DR: Increasing the supply of pragmatic or practical clinical trials will depend on the development of a mechanism to establish priorities for these studies, significant expansion of an infrastructure to conduct clinical research within the health care delivery system, more reliance on high-quality evidence by health care decision makers, and a substantial increase in public and private funding forThese studies.
Abstract: Decision makers in health care are increasingly interested in using highquality scientific evidence to support clinical and health policy choices; however, the quality of available scientific evidence is often found to be inadequate. Reliable evidence is essential to improve health care quality and to support efficient use of limited resources. The widespread gaps in evidencebased knowledge suggest that systematic flaws exist in the production of scientific evidence, in part because there is no consistent effort to conduct clinical trials designed to meet the needs of decision makers. Clinical trials for which the hypothesis and study design are developed specifically to answer the questions faced by decision makers are called pragmatic or practical clinical trials (PCTs). The characteristic features of PCTs are that they (1) select clinically relevant alternative interventions to compare, (2) include a diverse population of study participants, (3) recruit participants from heterogeneous practice settings, and (4) collect data on a broad range of health outcomes. The supply of PCTs is limited primarily because the major funders of clinical research, the National Institutes of Health and the medical products industry, do not focus on supporting such trials. Increasing the supply of PCTs will depend on the development of a mechanism to establish priorities for these studies, significant expansion of an infrastructure to conduct clinical research within the health care delivery system, more reliance on high-quality evidence by health care decision makers, and a substantial increase in public and private funding for these studies. For these changes to occur, clinical and health policy decision makers will need to become more involved in all aspects of clinical research, including priority setting, infrastructure development, and funding.

1,675 citations


Journal ArticleDOI
TL;DR: The SCQ has modest correlations with a widely used medical record-based comorbidity instrument, and with subsequent health status and utilization, and it will be particularly useful in settings where medical records are unavailable.
Abstract: Objective To develop the Self-Administered Comorbidity Questionnaire (SCQ) and assess its psychometric properties, including the predictive validity of the instrument, as reflected by its association with health status and health care utilization after 1 year. Methods A cross-sectional comparison of the SCQ with a standard, chart abstraction-based measure (Charlson Index) was conducted on 170 inpatients from medical and surgical care units. The association of the SCQ with the chart-based comorbidity instrument and health status (short form 36) was evaluated cross sectionally. The association between these measures and health status and resource utilization was assessed after 1 year. Results The Spearman correlation coefficient for the association between the SCQ and the Charlson Index was 0.32. After restricting each measure to include only comparable items, the correlation between measures was stronger (Spearman r = 0.55). The SCQ had modest associations with measures of resource utilization during the index admission, and with health status and resource utilization after 1 year. Conclusion The SCQ has modest correlations with a widely used medical record-based comorbidity instrument, and with subsequent health status and utilization. This new measure represents an efficient method to assess comorbid conditions in clinical and health services research. It will be particularly useful in settings where medical records are unavailable.

1,440 citations


Journal ArticleDOI
TL;DR: The change in hospital funding with diagnosis related groups (DRG), medical advances as well as demographic changes will call for new quantitative and qualitative standards imposed on German hospitals.
Abstract: The change in hospital funding with diagnosis related groups (DRG), medical advances as well as demographic changes will call for new quantitative and qualitative standards imposed on German hospitals. Increasing costs and competition in the health care sector requires new and innovative strategies for resource management. Today's policy is mainly defined by rationing and intensified workload. The introduction of DRGs will presumably further constrict management perspectives on pure financial aspects. However, to ensure future development, compassionate services and continued existence of hospitals, a balance of seemingly conflicting perspectives, such as finance, customer, process, learning and growth are of utmost importance. Herein doctors and nurses in leading positions should play a key role in changing management practice. For several years the balanced scorecard has been successfully used as a strategic management concept in non-profit organizations, even in the health care sector. This concept complies with the multidimensional purposes of hospitals and focuses on policy deployment. Finally it gives the opportunity to involve all employees in the original development, communication and execution of a balanced scorecard approach.

Book Chapter
18 Nov 2003
TL;DR: This textbook provides a detailed, yet concise, explanation of both qualitative and quantitative approaches and draws upon case-study examples to illustrate how these can be used in a variety of health-care settings, with special relevance to clinical disorders, disease prevention and health promotion.
Abstract: This textbook offers an excellent introduction to the variety of research methods used within the fields of clinical and health psychology. The book provides a detailed, yet concise, explanation of both qualitative and quantitative approaches and draws upon case-study examples to illustrate how these can be used in a variety of health-care settings, with special relevance to clinical disorders, disease prevention and health promotion. Research Methods for Clinical and Health Psychology fulfils the demand for a textbook explaining how qualitative and quantitative methods can be used explicitly in a health psychology context. It will be invaluable reading for clinical and health psychology students, trainees and practitioners, as well as those in nursing, medical and other healthcare departments taking an advanced psychology option.

Journal ArticleDOI
TL;DR: It is hypothesized that race concordance is associated with higher levels of communication behaviors that are considered patient centered, higher patient ratings of physicians' participatory decision making, and higher ratings of patient satisfaction.
Abstract: When patients and physicians are of the same race, patients are more satisfied with care in the office setting. The authors found that having the same race did not affect patient-centered communica...

Journal Article
TL;DR: The psychological and occupational impact of this event within a large hospital in the first 4 weeks of the SARS outbreak and the subsequent administrative and mental health response is described.
Abstract: Background: The outbreak of severe acute respiratory syndrome (SARS) in Toronto, which began on Mar. 7, 2003, resulted in extraordinary public health and infection control measures. We aimed to describe the psychological and occupational impact of this event within a large hospital in the first 4 weeks of the outbreak and the subsequent administrative and mental health response. Methods: Two principal authors met with core team members and mental health care providers at Mount Sinai Hospital, Toronto, to compile retrospectively descriptions of the experiences of staff and patients based on informal observation. All authors reviewed and analyzed the descriptions in an iterative process between Apr. 3 and Apr. 13, 2003. Results: In a 4-week period, 19 individuals developed SARS, including 11 health care workers. The hospital’s response included establishing a leadership command team and a SARS isolation unit, implementing mental health support interventions for patients and staff, overcoming problems with logistics and communication, and overcoming resistance to directives. Patients with SARS reported fear, loneliness, boredom and anger, and they worried about the effects of quarantine and contagion on family members and friends. They experienced anxiety about fever and the effects of insomnia. Staff were adversely affected by fear of contagion and of infecting family, friends and colleagues. Caring for health care workers as patients and colleagues was emotionally difficult. Uncertainty and stigmatization were prominent themes for both staff and patients. Interpretation: The hospital’s response required clear communication, sensitivity to individual responses to stress, collaboration between disciplines, authoritative leadership and provision of relevant support. The emotional and behavioural reactions of patients and staff are understood to be a normal, adaptive response to stress in the face of an overwhelming event.

Journal ArticleDOI
TL;DR: The National Standards for Diabetes Selfmanagement Education (DSME) as mentioned in this paper were developed by the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA).
Abstract: Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and is necessary in order to improve patient outcomes. The National Standards for DSME are designed to define quality diabetes self-management education and to assist diabetes educators in a variety of settings to provide evidence-based education. Because of the dynamic nature of health care and diabetes-related research, these Standards are reviewed and revised approximately every 5 years by key organizations and federal agencies within the diabetes education community. A Task Force was jointly convened by the American Association of Diabetes Educators and the American Diabetes Association in the summer of 2006. Additional organizations that were represented included the American Dietetic Association, the Veteran's Health Administration, the Centers for Disease Control and Prevention, the Indian Health Service, and the American Pharmaceutical Association. Members of the Task Force included a person with diabetes; several health services researchers/behaviorists, registered nurses, and registered dietitians; and a pharmacist. The Task Force was charged with reviewing the current DSME standards for their appropriateness, relevance, and scientific basis. The Standards were then reviewed and revised based on the available evidence and expert consensus. The committee convened on 31 March 2006 and 9 September 2006, and the Standards were approved 25 March 2007. Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would …

Journal ArticleDOI
14 May 2003-JAMA
TL;DR: Although many people use the Internet for health information, use is not as common as is sometimes reported and effects on actual health care utilization are also less substantial than some have claimed.
Abstract: ContextThe Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization Available estimates of use and impact vary widely Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activitiesObjectivesTo measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care systemDesign, Setting, and ParticipantsSurvey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet usersMain Outcome MeasuresSelf-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care useResultsApproximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001 Six percent reported using e-mail to contact a physician or other health care professional About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical productsConclusionsAlthough many people use the Internet for health information, use is not as common as is sometimes reported Effects on actual health care utilization are also less substantial than some have claimed Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization

Journal ArticleDOI
12 Mar 2003-JAMA
TL;DR: The goal of this article is to articulate the 4 central challenges facing clinical research at present--public participation, information systems, workforce training, and funding; to make recommendations about how they might be addressed by particular stakeholders; and to invite a broader, participatory dialogue with a view to improving the overall performance of the US clinical research enterprise.
Abstract: Medical scientists and public health policy makers are increasingly concerned that the scientific discoveries of the past generation are failing to be translated efficiently into tangible human benefit. This concern has generated several initiatives, including the Clinical Research Roundtable at the Institute of Medicine, which first convened in June 2000. Representatives from a diverse group of stakeholders in the nation’s clinical research enterprise have collaborated to address the issues it faces. The context of clinical research is increasingly encumbered by high costs, slow results, lack of funding, regulatory burdens, fragmented infrastructure, incompatible databases, and a shortage of qualified investigators and willing participants. These factors have contributed to 2 major obstacles, or translational blocks: impeding the translation of basic science discoveries into clinical studies and of clinical studies into medical practice and health decision making in systems of care. Considering data from across the entire health care system, it has become clear that these 2 translational blocks can be removed only by the collaborative efforts of multiple system stakeholders. The goal of this article is to articulate the 4 central challenges facing clinical research at present—public participation, information systems, workforce training, and funding; to make recommendations about how they might be addressed by particular stakeholders; and to invite a broader, participatory dialogue with a viewtoimprovingtheoverallperformanceoftheUSclinicalresearchenterprise.

Journal ArticleDOI
TL;DR: To assess the ability of gait speed alone and a three‐item lower extremity performance battery to predict 12‐month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults.
Abstract: OBJECTIVES: To assess the ability of gait speed alone and a three-item lower extremity performance battery to predict 12-month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults. DESIGN: Prospective cohort study. SETTING: Primary care programs of a Medicare health maintenance organization (HMO) and Veterans Affairs (VA) system. PARTICIPANTS: Four hundred eighty-seven persons aged 65 and older. MEASUREMENTS: Lower extremity performance Established Population for Epidemiologic Studies of the Elderly (EPESE) battery including gait speed, chair stands, and tandem balance tests; demographics; health care use; health status; functional status; probability of repeated admission scale (Pra); and primary physician's hospitalization risk estimate. RESULTS: Veterans had poorer health and higher use than HMO members. Gait speed alone and the EPESE battery predicted hospitalization; 41% (21/51) of slow walkers (gait speed 1.0 m/s) (P < .0001). The relationship was stronger in the HMO than in the VA. Both performance measures remained independent predictors after accounting for Pra. The EPESE battery was superior to gait speed when both Pra and primary physician's risk estimate were included. Both performance measures predicted decline in function and health status in both health systems. Performance measures, alone or in combination with self-report measures, were more able to predict outcomes than self-report alone. CONCLUSION: Gait speed and a physical performance battery are brief, quantitative estimates of future risk for hospitalization and decline in health and function in clinical populations of older adults. Physical performance measures might serve as easily accessible “vital signs” to screen older adults in clinical settings.

Journal ArticleDOI
TL;DR: Two GIS-based accessibility measures into one framework are synthesized, and the sensitivity of results are analyzed by experimenting with ranges of threshold travel times in the FCA method and travel friction coefficients in the gravity model.
Abstract: This article synthesizes two GIS-based accessibility measures into one framework, and applies the methods to examining spatial accessibility to primary healthcare in the Chicago 10-county region. The floating catchment area method defines the service area of physicians by a threshold travel time while accounting for the availability of physicians by their surrounded demands. The gravity-based method considers a nearby physician more accessible than a remote one and discounts a physician's availability by a gravity-based potential. The former is a special case of the latter. Based on the 2000 Census and primary care physician data, this research assesses the variation of spatial accessibility to primary care in the Chicago region, and analyzes the sensitivity of results by experimenting with ranges of threshold travel times in the floating catchment area method and travel friction coefficients in the gravity model. The methods may be used to help the U.S. Department of Health and Human Services and state Health Departments improve health professional shortage areas designation.

Journal ArticleDOI
TL;DR: Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success, which should result in improved quality of care.

Journal ArticleDOI
TL;DR: Five questions--What should be transferred to decision makers? To whom should it be transferred? By whom? How? With what effect?--provide an organizing framework for a knowledge transfer strategy.
Abstract: Applied r esearch o rganizations i nvest a great deal of time, and research funders invest a great deal of money generating and (one hopes) transferring research knowledge that could inform decisions about health and health care. Basing these knowledge-transfer activities on our evolving understanding of the most effective approaches to knowledge transfer will help us achieve value for money in our individual and collective investments in health services and health policy research. Research organizations and research funders can probably be excused for not basing their activities on research evidence until now, however, because the variety of relevant questions, target audiences, and disciplinary perspectives and methodological approaches used in empirical studies has made the identification of take-home messages from this field of research a very difficult task. We provide an organizing framework for a knowledge-transfer strategy and an overview of our understanding of the current knowledge for each of the five elements of the framework. The framework provides an overall approach to knowledge transfer that can be evaluated as a whole over long periods of time, as well as specific elements that can be evaluated and fine-tuned over shorter periods of time. We also illustrate how opportunities for improving how research organizations transfer research

Journal ArticleDOI
TL;DR: Racial and ethnic disparities in pain perception, assessment, and treatment were found in all settings and across all types of pain and the literature suggests that the sources of pain disparities among racial and ethnic minorities are complex.
Abstract: CONTEXT: Pain has significant socioeconomic, health, and quality-of-life implications. Racial- and ethnic-based differences in the pain care experience have been described. Racial and ethnic minorities tend to be undertreated for pain when compared with non-Hispanic Whites. OBJECTIVES: To provide health care providers, researchers, health care policy analysts, government officials, patients, and the general public with pertinent evidence regarding differences in pain perception, assessment, and treatment for racial and ethnic minorities. Evidence is provided for racial- and ethnic-based differences in pain care across different types of pain (i.e., experimental pain, acute postoperative pain, cancer pain, chronic non-malignant pain) and settings (i.e., emergency department). Pertinent literature on patient, health care provider, and health care system factors that contribute to racial and ethnic disparities in pain treatment are provided. EVIDENCE: A selective literature review was performed by experts in pain. The experts developed abstracts with relevant citations on racial and ethnic disparities within their specific areas of expertise. Scientific evidence was given precedence over anecdotal experience. The abstracts were compiled for this manuscript. The draft manuscript was made available to the experts for comment and review prior to submission for publication. CONCLUSIONS: Consistent with the Institute of Medicine's report on health care disparities, racial and ethnic disparities in pain perception, assessment, and treatment were found in all settings (i.e., postoperative, emergency room) and across all types of pain (i.e., acute, cancer, chronic nonmalignant, and experimental). The literature suggests that the sources of pain disparities among racial and ethnic minorities are complex, involving patient (e.g., patient/health care provider communication, attitudes), health care provider (e.g., decision making), and health care system (e.g., access to pain medication) factors. There is a need for improved training for health care providers and educational interventions for patients. A comprehensive pain research agenda is necessary to address pain disparities among racial and ethnic minorities.

Journal ArticleDOI
TL;DR: Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health, and few OECD countries have improved essential features of their primary care systems as assessed by the scale used here.
Abstract: Objective To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Journal Article
TL;DR: A review of previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations can be found in this article, where the authors suggest a series of performance measurements as a means to evaluate infection-control efforts.
Abstract: The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions. This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.

Journal ArticleDOI
TL;DR: The A5- item scale is a useful indicator of health care decision regret at a given point in time and was greater among those who changed their decisions than those who did not.
Abstract: Background.As patients become more involved in health care decisions, there may be greater opportunity for decision regret. The authors could not find a validated, reliable tool for measuring regret after health care decisions.Methods.A5- item scale was administered to 4 patient groups making different health care decisions. Convergent validity was deter- mined by examining the scale's correlation with satisfaction measures, decisional conflict, and health outcome measures.Results.The scale showed good internal consistency (Cronbach's = 0.81 to 0.92). It correlated strongly with decision satisfaction (r = -0.40 to -0.60), decisional conflict (r = 0.31 to 0.52), and overall rated quality of life (r = -0.25 to - 0.27). Groups differing on feelings about a decision also differed on rated regret: F(2, 190) = 31.1, P < 0.001. Regret was greater among those who changed their decisions than those who did not, t(175) = 16.11, P < 0.001.Conclusions.The scale is a useful indicator of health care decision regret at ...

Journal ArticleDOI
Lucy Gilson1
TL;DR: This paper considers what the debates on trust have to offer health policy analysis by exploring the meaning, bases and outcomes of trust, and its relevance to health systems, and presents a synthesis of theoretical perspectives on the notion of trust.

Journal ArticleDOI
TL;DR: This analysis will provide the nursing profession with the conceptual basis to effectively develop, implement, evaluate, and compare peer support interventions while also serving as a guide for further conceptual and empirical research.

Journal ArticleDOI
TL;DR: A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status.
Abstract: Background Self-management interventions improve various outcomes for many chronic diseases. The definite place of self-management in the care of chronic obstructive pulmonary disease (COPD) has not been established. We evaluated the effect of a continuum of self-management, specific to COPD, on the use of hospital services and health status among patients with moderate to severe disease. Methods A multicenter, randomized clinical trial was carried out in 7 hospitals from February 1998 to July 1999. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and patient health status. Results Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group ( P = .01), and admissions for other health problems were reduced by 57.1% ( P = .01). Emergency department visits were reduced by 41.0% ( P = .02) and unscheduled physician visits by 58.9% ( P = .003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months. Conclusions A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice.

Book
01 Jan 2003
TL;DR: Education as learned effectiveness the association between education and health education, personal control, lifestyle and healthEducation, socioeconomic status and healtheducation, interpersonal relationships and health age and cumulative advantage specious views of education conclusion - self-direction toward health.
Abstract: Education forms a unique dimension of social status, with qualities that make it especially important to health. It influences health in ways that are varied, present at all stages of adult life, cumulative, self-amplifying, and uniformly positive. Educational attainment marks social status at the beginning of adulthood, functioning as the main bridge between the status of one generation and the next, and also as the main avenue of upward mobility. It precedes the other acquired social statuses and substantially influences them, including occupational status, earnings, and personal and household income and wealth. Education creates desirable outcomes because it trains individuals to acquire, evaluate, and use information. It teaches individuals to tap the power of knowledge. Education develops the learned effectiveness that enables self-direction toward any and all values sought, including health.For decades American health sciences has acted as if social status had little bearing on health. The ascendance of clinical medicine within a culture of individualism probably accounts for that omission. But research on chronic diseases over the last half of the twentieth century forced science to think differently about the causes of disease. Despite the institutional and cultural forces focusing medical research on distinctive proximate causes of specific diseases, researchers were forced to look over their shoulders, back toward more distant causes of many diseases. Some fully turned their orientation toward the social status of health, looking for the origins of that cascade of disease and disability flowing daily through clinics.Why is it that people with higher socioeconomic status have better health than lower status individuals? The authors, who are well recognized for their strength in survey research on a broad national scale, draw on findings and ideas from many sciences, including demography, economics, social psychology, and the health sciences. People who are well educated feel in control of their lives, which encourages and enables a healthy lifestyle. In addition, learned effectiveness, a practical end of that education, enables them to find work that is autonomous and creative, thereby promoting good health.

Journal ArticleDOI
Jan Mainz1
TL;DR: Monitoring health care quality is impossible without the use of clinical indicators, and they create the basis for quality improvement and prioritization in the health care system.
Abstract: Objective. This paper provides a brief review of deWnitions, characteristics, and categories of clinical indicators for quality improvement in health care. Analysis. Clinical indicators assess particular health structures, processes, and outcomes. They can be rate- or mean-based, providing a quantitative basis for quality improvement, or sentinel, identifying incidents of care that trigger further investigation. They can assess aspects of the structure, process, or outcome of health care. Furthermore, indicators can be generic measures that are relevant for most patients or disease-speciWc, expressing the quality of care for patients with speciWc diagnoses. Conclusions. Monitoring health care quality is impossible without the use of clinical indicators. They create the basis for quality improvement and prioritization in the health care system. To ensure that reliable and valid clinical indicators are used, they must be designed, deWned, and implemented with scientiWc rigour.