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Higher education has been touted as critical to social mobility, even greater longevity; however, these benefits accrue with degree completion, and many students who begin college never earn a degree. Using the most recent Integrated Postsecondary Education Data System (IPEDS), we sought to understand variation in college completion rates and test hypotheses related to a set of institutional factors potentially associated with higher completion rates. Our findings suggest that greater attention to low-resource institutions is paramount if higher education is to fulfill the aspiration of promoting social mobility and equity. Several policy interventions could be used to combat ongoing disparities. [ABSTRACT FROM AUTHOR]

In 2015 an estimated 2.7 million people in the United States (1 percent of the population) died. Although decedents' illness experience varies substantially, important trends in care at the end of life are evident. To identify the most pressing health care policy issues related to end-of-life care, we present a comprehensive picture of the epidemiology and care patterns of people in the last stage of life. We identify three key trends in end-of-life care: increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death. This changing epidemiology of those in the last phase of life puts new pressures on the Medicare hospice benefit to ensure the availability of high-quality end-of-life care. In addition, health care policy makers must grapple with the fact that even with increasing use of hospice care, care intensity increases at the end of life. We highlight and discuss tensions that must be managed to ensure that high-quality care is accessible for people at the end of life. [ABSTRACT FROM AUTHOR]

Although spending rates on health care and social services vary substantially across the states, little is known about the possible association between variation in state-level health outcomes and the allocation of state spending between health care and social services. To estimate that association, we used state-level repeated measures multivariable modeling for the period 2000-09, with region and time fixed effects adjusted for total spending and state demographic and economic characteristics and with one- and two-year lags. We found that states with a higher ratio of social to health spending (calculated as the sum of social service spending and public health spending divided by the sum of Medicare spending and Medicaid spending) had significantly better subsequent health outcomes for the following seven measures: adult obesity; asthma; mentally unhealthy days; days with activity limitations; and mortality rates for lung cancer, acute myocardial infarction, and type 2 diabetes. Our study suggests that broadening the debate beyond what should be spent on health care to include what should be invested in health--not only in health care but also in social services and public health--is warranted. [ABSTRACT FROM AUTHOR]

ABSTRACT Wolf ( Canis lupus) predation on livestock and management methods used to mitigate conflicts are highly controversial and scrutinized especially where wolf populations are recovering. Wolves are commonly removed from a local area in attempts to reduce further depredations, but the effectiveness of such management actions is poorly understood. We compared the effects of 3 management responses to livestock depredation by wolf packs in Montana, Idaho, and Wyoming: no removal, partial pack removal, and full pack removal. We examined the effectiveness of each management response in reducing further depredations using a conditional recurrent event model. From 1989 to 2008, we documented 967 depredations by 156 packs: 228 on sheep and 739 on cattle and other stock. Median time between recurrent depredations was 19 days following no removal ( n = 593), 64 days following partial pack removal ( n = 326), and 730 days following full pack removal ( n = 48; recurring depredations were made by the next pack to occupy the territory). Compared to no removal, full pack removal reduced the occurrence of subsequent depredations by 79% (hazard ratio [HR] = 0.21, P < 0.001) over a span of 1,850 days (5 years), whereas partial pack removal reduced the occurrence of subsequent depredations by 29% (HR = 0.71, P < 0.001) over the same period. Partial pack removal was most effective if conducted within the first 7 days following depredation, after which there was only a marginally significant difference between partial pack removal and no action (HR = 0.86, P = 0.07), and no difference after 14 days (HR = 0.99, P = 0.93). Within partial pack removal, we found no difference in depredation recurrence when a breeding female (HR = 0.64, P = 0.2) or ≥1-year-old male was removed (HR = 1.0, P = 0.99). The relative effect of all treatments was generally consistent across seasons (spring, summer grazing, and winter) and type of livestock. Ultimately, pack size was the best predictor of a recurrent depredation event; the probability of a depredation event recurring within 5 years increased by 7% for each animal left in the pack after the management response. However, the greater the number of wolves left in a pack, the higher the likelihood the pack met federal criteria to count as a breeding pair the following year toward population recovery goals. Published 2015. This article is a U.S. Government work and is in the public domain in the USA. [ABSTRACT FROM AUTHOR]

Context Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists. Objectives To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics. Methods A national cross-sectional survey of a random sample of hospices ( n = 591; 84% response rate) from September 2008 to November 2009. Results Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patient's care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region. Conclusion Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services. [ABSTRACT FROM AUTHOR]

Background: Despite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users' mechanisms of influence and examine their effects on EHR implementation outcomes. Methods: We conducted a longitudinal (October 2012 - June 2013), comparative case study of super users' behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users' behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians' information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians' IS proficiency and the clinical unit in which they worked. Results: Super users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians' IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users' role engagement, which was influenced by how the two units' managers selected super users and shaped the implementation climate. Conclusions: Super users' behaviors in implementing EHRs vary substantively and can have important influence on implementation success. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to determine the range and prevalence of practices being implemented by hospitals to reduce 30-day readmissions of patients with heart failure or acute myocardial infarction (AMI). Background: Readmissions of patients with heart failure or AMI are both common and costly; however, evidence on strategies adopted by hospitals to reduce readmission rates is limited. Methods: We used a Web-based survey to conduct a cross-sectional study of hospitals'' reported use of specific practices to reduce readmissions for patients with heart failure or AMI. We contacted all hospitals enrolled in the Hospital to Home (H2H) quality improvement initiative as of July 2010. Of 594 hospitals, 537 completed the survey (response rate of 90.4%). We used standard frequency analysis to describe the prevalence of key hospital practices in the areas of: 1) quality improvement resources and performance monitoring; 2) medication management efforts; and 3) discharge and follow-up processes. Results: Nearly 90% of hospitals agreed or strongly agreed that they had a written objective of reducing preventable readmission for patients with heart failure or AMI. More hospitals reported having quality improvement teams to reduce preventable readmissions for patients with heart failure (87%) than for patients with AMI (54%). Less than one-half (49.3%) of hospitals had partnered with community physicians and only 23.5% had partnered with local hospitals to manage patients at high risk for readmissions. Inpatient and outpatient prescription records were electronically linked usually or always in 28.9% of hospitals, and the discharge summary was always sent directly to the patient''s primary medical doctor in only 25.5% of hospitals. On average, hospitals used 4.8 of 10 key practices; <3% of hospitals utilized all 10 practices. Conclusions: Although most hospitals have a written objective of reducing preventable readmissions of patients with heart failure or AMI, the implementation of recommended practices varied widely. More evidence establishing the effectiveness of various practices is needed. [Copyright &y& Elsevier]

Purpose/Objectives: To describe experiences of self-management and transitioning among women with ovarian cancer.Research Approach: Interpretive description.Setting: Participants' homes.Participants: Purposive sample of 10 women with ovarian cancer.Methodologic Approach: Individual interviews about women's self-management and transition experiences.Main Research Variables: Self-management, transitions, and ovarian cancer.Findings: Participants self-managed to increase their sense of control and to self-advocate. They managed their care one step at a time to prevent becoming overwhelmed. Common transitions were diagnosis, surgery and recovery, starting chemotherapy, managing symptoms, and recurrence. Transitions were challenging, even if previously experienced, and influenced the ability and willingness of women to self-manage. Barriers and facilitators to self-management were identified.Conclusions: The approach to self-management of one step at a time is somewhat illusory, as women face multiple transitions simultaneously. The short trajectory of ovarian cancer leaves little time between transitions and an awareness of mortality. Women are forced to confront goals of care quickly, which may affect their ability to self-manage.Interpretation: Women with ovarian cancer need clinical and social support to prioritize and manage transitions. Introducing palliative care shortly after diagnosis could facilitate women's anticipation of and adjustment to transitions. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: To describe experiences of self-management and transitioning among women with ovarian cancer.Research Approach: Interpretive description.Setting: Participants' homes.Participants: Purposive sample of 10 women with ovarian cancer.Methodologic Approach: Individual interviews about women's self-management and transition experiences.Main Research Variables: Self-management, transitions, and ovarian cancer.Findings: Participants self-managed to increase their sense of control and to self-advocate. They managed their care one step at a time to prevent becoming overwhelmed. Common transitions were diagnosis, surgery and recovery, starting chemotherapy, managing symptoms, and recurrence. Transitions were challenging, even if previously experienced, and influenced the ability and willingness of women to self-manage. Barriers and facilitators to self-management were identified.Conclusions: The approach to self-management of one step at a time is somewhat illusory, as women face multiple transitions simultaneously. The short trajectory of ovarian cancer leaves little time between transitions and an awareness of mortality. Women are forced to confront goals of care quickly, which may affect their ability to self-manage.Interpretation: Women with ovarian cancer need clinical and social support to prioritize and manage transitions. Introducing palliative care shortly after diagnosis could facilitate women's anticipation of and adjustment to transitions. [ABSTRACT FROM AUTHOR]

Background: Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30- day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs. Objective: To identify hospital strategies that were associated with lower RSMRs. Design: Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs. Setting: Acute care hospitals with an annualized AMI volume of at least 25 patients. Participants: Patients hospitalized with AMI between 1 January 2008 and 31 December 2009. Measurements: Hospital performance improvement strategies, characteristics, and 30-day RSMRs. Results: In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies. Limitation: The cross-sectional design demonstrates statistical associations but cannot establish causal relationships. Conclusion: Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30- day RSMRs for patients with AMI. Primary Funding Source: The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund. [ABSTRACT FROM AUTHOR]

Background: Multiple interventions have been launched to improve the quality, access, and utilization of primary health care in rural, low-income settings; however, the success of these interventions varies substantially, even within single studies where the measured impact of interventions differs across sites, centers, and regions. Accordingly, we sought to examine the variation in impact of a health systems strengthening intervention and understand factors that might explain the variation in impact across primary health care units. Methodology/Principal Findings: We conducted a mixed methods positive deviance study of 20 Primary Health Care Units (PHCUs) in rural Ethiopia. Using longitudinal data from the Ethiopia Millennium Rural Initiative (EMRI), we identified PHCUs with consistently higher performance (n = 2), most improved performance (n = 3), or consistently lower performance (n = 2) in the provision of antenatal care, HIV testing in antenatal care, and skilled birth attendance rates. Using data from site visits and in-depth interviews (n = 51), we applied the constant comparative method of qualitative data analysis to identify key themes that distinguished PHCUs with different performance trajectories. Key themes that distinguished PHCUs were 1) managerial problem solving capacity, 2) relationship with the woreda (district) health office, and 3) community engagement. In higher performing PHCUs and those with the greatest improvement after the EMRI intervention, health center and health post staff were more able to solve day-to-day problems, staff had better relationships with the woreda health official, and PHCU communities' leadership, particularly religious leadership, were strongly engaged with the health improvement effort. Distance from the nearest city, quality of roads and transportation, and cultural norms did not differ substantially among PHCUs. Conclusions/Significance: Effective health strengthening efforts may require intensive development of managerial problem solving skills, strong relationships with government offices that oversee front-line providers, and committed community leadership to succeed. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue on topics including the influence of hospitals' organizational culture in China to the hospital influence, the impact of system organization and regulation to the health expenditures and satisfaction, and racial disparities in childhood insurance.

Abstract: Context: Self-management involves behaviors that individuals perform to handle health conditions. Self-management may be particularly challenging during transitions—shifts from one life phase or status to another, for example, from cure- to noncure-oriented care—because they can be disruptive and stressful. Little is known about individuals'' experiences with self-management, especially during transitions. Objectives: Our purpose was to describe experiences of self-management in the context of transitions among women with advanced breast cancer. Methods: We interviewed a purposive sample of 15 women with metastatic breast cancer about their self-management preferences, practices, and experiences, including how they managed transitions. Interviews were recorded and transcribed. The qualitative method of interpretive description was used to code and analyze the data. Results: Participants'' mean age was 52 years (range 37–91 years); most were White (80%), married (80%), and college educated (60%). Self-management practices related to womens'' health and to communication with loved ones and providers. Participants expressed a range of preferences for participation in self-management. Self-management included developing skills, becoming empowered, and creating supportive networks. Barriers to self-management included symptom distress, difficulty obtaining information, and lack of knowledge about the cancer trajectory. Women identified transitions as shifts in physical, emotional, and social well-being, as when their cancer progressed and there was a need to change therapy. Transitions often prompted changes in how actively women self-managed and were experienced as positive, negative, and neutral. Conclusion: Self-management preferences can vary. Providers should explore and revisit patients'' preferences and ability to self-manage over time, particularly during transitions. [Copyright &y& Elsevier]

The article discusses a study of health care quality at hospitals in U.S. states and in the U.S. territories. The hospitals involved discharged at least one Medicare fee-for-service (FFS) adult diagnosed with acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PNE) from July 2005 to June 2008. Hospitals in the U.S. territories differ from stateside ones in terms of for-profit ownership. Mortality rates are said to be higher in hospitals in the U.S. territories.

Background: The treatment of patients with advanced cancer with multiple comorbid illnesses is complex. Although an increasing number of such patients are being referred to hospice, the comorbidity burden of this patient population is largely unknown but has implications for the complexity of care provided by hospices. This study reports the comorbidity burden in a national sample of hospice users with cancer and estimates the effect of higher comorbidity on health care use and site of death. Methods: Cross-sectional study using Surveillance, Epidemiology and End Results-Medicare data for hospice users who died of cancer in 2002 ( N = 27,166). We measured comorbidity burden using the Charlson comorbidity index and used multivariable generalized estimating equations to estimate the association between comorbidity burden and the following outcomes: emergency department and intensive care unit (ICU) admission, hospitalization, hospice disenrollment, and hospital death. Results: Patients with cancer who used hospice had an average Charlson comorbidity index value of 1.24, including 18.8% who suffered from comorbid dementia. In analyses adjusted for patient demographics, site of primary cancer, and number of days with hospice, higher comorbidity burden was associated with higher likelihood of emergency department admission (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.52, 1.87), ICU admission (OR = 3.28, 95% CI 2.45, 4.38), inpatient hospitalization (OR = 2.14, 95% CI 1.90, 2.42), hospice disenrollment (OR = 1.41, 95% CI 1.29, 1.56) and hospital death (OR = 2.51, 95% CI 2.08, 3.02). Conclusion: These findings underscore the complexity of the hospice patient population and highlight a potential need to risk adjust the per diem hospice reimbursement rates to account for increased resource requirements for hospices serving patients with higher comorbidity burden. [ABSTRACT FROM AUTHOR]

To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements. In-depth interviews, hospital surveys, and Health Quality Alliance data. We conducted a qualitative study using in-depth interviews with clinical and administrative staff ( N=99) at hospitals reporting strong influence ( n=6) as well as hospitals reporting limited influence ( n=6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data. In-depth, open-ended interviews; hospital survey. Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes. The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals. [ABSTRACT FROM AUTHOR]

Background: Despite a 41% increase in the number of hospices since 2000, more than 60% of Americans die without hospice care. Given that hospice care is predominantly home based, proximity to a hospice is important in ensuring access to hospice services. We estimated the proportion of the population living in communities within 30 and 60 minutes driving time of a hospice. Methods: We conducted a cross-sectional study of geographic access to U.S. hospices using the 2008 Medicare Provider of Services data, U.S. Census data, and ArcGIS software. We used multivariate logistic regression to identify gaps in hospice availability by community characteristics. Results: As of 2008, 88% of the population lived in communities within 30 minutes and 98% lived in communities within 60 minutes of a hospice. Mean time to the nearest hospice was 15 minutes and the range was 0 to 403 minutes. Community characteristics independently associated with greater geographic access to hospice included higher population density, higher median income, higher educational attainment, higher percentage of black residents, and the state not having a Certificate of Need policy. The percentage of each state's population living in communities more than 30 minutes from a hospice ranged from 0% to 48%. Conclusions: Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice. [ABSTRACT FROM AUTHOR]

Hospitals vary by twofold in their hospital-specific 30-day risk-stratified mortality rates (RSMRs) for Medicare beneficiaries with acute myocardial infarction (AMI). However, we lack a comprehensive investigation of hospital characteristics associated with 30-day RSMRs and the degree to which the variation in 30-day RSMRs is accounted for by these characteristics, including the socioeconomic status (SES) profile of hospital patient populations. We conducted a cross-sectional national study of hospitals with ≥15 AMI discharges from July 1, 2005 to June 20, 2008. We estimated a multivariable weighted regression using Medicare claims data for hospital-specific 30-day RSMRs, American Hospital Association Survey of Hospitals for hospital characteristics, and the United States Census data reported by Neilsen Claritas, Inc., for zip-code level estimates of SES status. Analysis included 2,908 hospitals with 513,202 AMI discharges. Mean hospital 30-day RSMR was 16.5% (SD 1.7 percentage points). Our multivariable model explained 17.1% of the variation in hospital-specific 30-day RSMRs. Teaching status, number of hospital beds, AMI volume, cardiac facilities available, urban/rural location, geographic region, ownership type, and SES profile of patients were significantly (p <0.05) associated with 30-day RSMRs. In conclusion, substantial variation in hospital outcomes for patients with AMI remains unexplained by measurements of hospital characteristics including SES patient profile. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation. Background: The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation. Methods: We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008. Results: By March 2008, >75% of patients had D2B times of ≤90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27). Conclusions: The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008. [Copyright &y& Elsevier]

The article presents a result of the study regarding the percentage of emergency department (ED) patients seen within the recommended triage time in the U.S. It notes the increasing problem of ED crowding in the country which differentially affect patients with varied insurance status and racial or ethnic backgrounds. The study has determined that the percentage of patients seen within the triage target time has reduced a mean of 0.8 percent per year

Background: Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality. Methods: We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction. Results: The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices. Conclusion: The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality. [ABSTRACT FROM AUTHOR]

The article discusses about factors related with longer time from symptom onset to patients with ST-elevation myocardial infraction's hospital presentation. According to the article, a researched was conducted about risk factors to determine the cumulative effect of delay times in patients with ST-elevation myocardial infraction currently listed in the National Registry of Myocardial Infraction. Research concludes that subgroups of patients which is composed of people with different age and race have long delay times than subgroups that does not have such characteristics.

Abstract: Background: We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time. Methods: Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as ≤1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time. Results: In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting ≤1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively. Conclusions: Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times. [Copyright &y& Elsevier]

This article evaluates the rate of people with disabilities who have been tested for HIV as opposed to those without disabilities within the United States. The data used for the evaluation was collected from the 2002 National Health Interview Survey. The data evaluated in the article implies that adults with disabilities are more likely than nondisabled people to report being tested for HIV. The article suggests improved outreach and educational programs to ensure the people with disabilities who should be tested are being tested for the disease.

This article focuses on reperfusion therapy in patients with ST-elevation myocardial infarction. The authors discuss door-to-balloon time as a primary indicator of quality of care for patients with ST-elevation myocardial infarction who are treated with primary percutaneous coronary intervention (PCI). The pathophysiology of myocardial necrosis is mentioned. The efficacy of fibrinolytic therapy and primary PCI are compared. Clinical guidelines for door-to-balloon time are mediations. Combination therapies and future challenges are discussed.

Objective. To provide practical strategies for conducting and evaluating analyses of qualitative data applicable for health services researchers. Data Sources and Design. We draw on extant qualitative methodological literature to describe practical approaches to qualitative data analysis. Approaches to data analysis vary by discipline and analytic tradition; however, we focus on qualitative data analysis that has as a goal the generation of taxonomy, themes, and theory germane to health services research. Principle Findings. We describe an approach to qualitative data analysis that applies the principles of inductive reasoning while also employing predetermined code types to guide data analysis and interpretation. These code types (conceptual, relationship, perspective, participant characteristics, and setting codes) define a structure that is appropriate for generation of taxonomy, themes, and theory. Conceptual codes and subcodes facilitate the development of taxonomies. Relationship and perspective codes facilitate the development of themes and theory. Intersectional analyses with data coded for participant characteristics and setting codes can facilitate comparative analyses. Conclusions. Qualitative inquiry can improve the description and explanation of complex, real-world phenomena pertinent to health services research. Greater understanding of the processes of qualitative data analysis can be helpful for health services researchers as they use these methods themselves or collaborate with qualitative researchers from a wide range of disciplines. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to assess whether recurrent involuntary job loss among US workers nearing retirement resulted in increasingly less severe changes in depressive symptoms with successive job losses. Methods: With data drawn from the US Health and Retirement Survey (HRS), we used repeated measures longitudinal analysis to investigate the effect of recurrent job loss on follow-up depressive symptoms, measured up to 2 years following job loss. Study participants include 617 individuals, aged 51–61 years at the 1992 study baseline, who had at least one job loss between 1990 and 2000. Our primary outcome variable was a continuous measure of depressive symptoms, constructed from the 8-item Center for Epidemiologic Studies-Depression (CES-D) battery administered at every HRS wave. A second, dichotomous outcome, derived from the continuous measure, measured clinically relevant depressive symptoms. The exposure (recurrent job loss) was defined by binary dummy variables representing two and three/four job losses. All job losses were the result of either plant closing or layoff. Results: Our main finding indicates that, after relevant covariates are controlled, compared to one job loss, two job losses result in a modest increase in the level depressive symptoms (not significant) at two-year follow-up. Three or more job losses result, on average, in a decline in depressive symptoms to a level near pre-displacement assessment (not significant). Somewhat in contrast, two job losses were found to be associated with increased risk of clinically relevant depressive symptoms. Conclusions: The principal finding confirms our hypothesis that, among US workers nearing retirement, repeated exposure to job separation results in diminished effects on mental health. Adaptation to the job loss stressor may underlie the observed response, although other explanations, including macroeconomic developments, are possible. [ABSTRACT FROM AUTHOR]

The article presents a study examining quality process measures for acute myocardial infarction and the measures' association with 30-day mortality rates. The study concludes that multiple measures are needed to better evaluate hospital performance. The article discusses variations in risk-standardized short-term mortality rates, the Centers for Medicare & Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations, the use of β-blocker, aspirin, and angiotensin-converting enzyme inhibitors, reperfusion therapy, and smoking cessation counseling.

Objectives. The purpose of this study was to investigate the association between involuntary job loss among workers nearing retirement and long-feral changes in depressive symptoms. Methods. Analyzing data from the first four waves (1992–1998) of the Health and Retirement Survey, we used longitudinal multiple regression in order to assess whether involuntary job loss between Wave 1 and Wave 2 was associated with depressive symptoms at Wave 3 and Wave 4. The study sample included 231 workers who had experienced job loss in the Wave 1-Wave 2 interval and a comparison group of 3,324 nondisplaced individuals. We analyzed the effect of job loss on depressive symptoms both in the full study sample and in subsamples determined by wealth. Results. Among individuals with below median net worth, Wave l-Wave 2 involuntary job loss was associated with increased depressive symptoms at Wave 3 and Wave 4. We found no effect of involuntary job loss for high net worth individuals at the later survey waves. Discussion. Our findings identify older workers with limited wealth as an important group for which the potential effect of involuntary job separation in the years preceding retirement is ongoing (enduring) adverse mental health. [ABSTRACT FROM AUTHOR]

This article examines the use of health care services by lower-income and higher-income uninsured adults. The objective of this article is to determine whether having higher income attenuates the association between being uninsured and using fewer recommended health care services. Over 45 million individuals in the United States are without health insurance, which potentially limits their access to and use of appropriate health care services. Although the uninsured comprise a range of income levels, little attention has been directed at higher-income uninsured adults and their patterns of care.

Purpose: To examine changes in patients' and caregivers' understanding of prognosis with progression of the patient's illness. Subjects and methods: Community-dwelling persons 60 years of age and older who were seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers were interviewed every 4 months and more frequently with a decline in the patient's status for up to one year. We examined responses to, "If you had to take a guess, how long do you think that (you/the patient) might have to live?" at baseline and at the interview closest to death. Results: Among 218 patients, 87 died within 1 year. At their initial interview 46% were uncertain about their life expectancy (LE) and 9% believed LE was 1 year or less; at their final interview, 55% were uncertain and 17% believed LE was 1 year or less. At the caregiver's initial interview, 29% were uncertain about the patient's LE and 20% believed LE was 1 or less; at their final interview, 30% were uncertain and 34% believed LE was 1 year or less. Among those interviewed within 30 days of the patient's death, 31% of patients and 52% of caregivers believed LE was 1 year or less. Patients' estimates of the LE did not differ according to their diagnosis. Conclusions: There was little change in prognostic awareness over time. Even close to death, a large proportion of patients and caregivers were uncertain about prognosis, and few believed the patient had a limited life expectancy. Whether or not patients should know their prognosis is the subject of active debate; the persistence of prognostic misperception suggests that prognostic awareness may be difficult to change. [ABSTRACT FROM AUTHOR]

Managing wolf (Canis lupus) depredation on livestock is expensive and controversial; therefore, managers seek to improve and develop new methods to mitigate conflicts. Determining which factors put ranches at higher risk to wolf depredation may provide ideas for ways to reduce livestock and wolf losses. We sampled cattle pastures in Montana and Idaho that experienced confirmed wolf depredations (n = 34) from 1994-2002 and compared landscape and selected animal husbandry factors with cattle pastures on nearby ranches where depredations did not occur (n = 62). Pastures where depredations occurred were more likely to have elk (Cervus elaphus) present, were larger in size, had more cattle, and grazed cattle farther from residences than pastures without depredations. Using classification tree analysis, we found that a higher percentage of vegetation cover also was associated with depredated pastures in combination with the variables above. We found no relationship between depredations and carcass disposal methods, calving locations, calving times, breed of cattle, or the distance cattle were grazed from the forest edge. Most pastures where depredations occurred during the wolf denning season (April 15-June 15) were located closer to wolf dens than nearby cattle pastures without depredations. Physical vulnerability, especially of calves, also may increase risk of depredation. [ABSTRACT FROM AUTHOR]

Successful nonlethal management of livestock predation is important for conserving rare or endangered carnivores. In the northwestern United States, wolves (Canis lupus ) have been translocated away from livestock to mitigate conflicts while promoting wolf restoration. We assessed predation on livestock, pack establishment, survival, and homing behavior of 88 translocated wolves with radiotelemetry to determine the effectiveness of translocation in our region and consider how it may be improved. More than one-quarter of translocated wolves preyed on livestock after release. Most translocated wolves (67%) never established or joined a pack, although eight new packs resulted from translocations. Translocated wolves had lower annual survival (0.60) than other radio-collared wolves (0.73), with government removal the primary source of mortality. In northwestern Montana, where most wolves have settled in human-populated areas with livestock, survival of translocated wolves was lowest (0.41) and more wolves proportionally failed to establish packs (83%) after release. Annual survival of translocated wolves was highest in central Idaho (0.71) and more wolves proportionally established packs (44%) there than in the other two recovery areas. Translocated wolves showed a strong homing tendency; most of those that failed to home still showed directional movement toward capture sites. Wolves that successfully returned to capture sites were more likely to be adults, hard (immediately) rather than soft (temporarily held in enclosure) released, and translocated shorter distances than other wolves that did not return home. Success of translocations varied and was most affected by the area in which wolves were released. We suggest managers translocating wolves or other large carnivores consider soft releasing individuals (in family groups, if social) when feasible because this may decrease homing behavior and increase release-site fidelity. [ABSTRACT FROM AUTHOR]

To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program (HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults. Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation. Thirteen hospitals implementing HELP. Forty-two hospital staff members (physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews. Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges. Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP. Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice. [ABSTRACT FROM AUTHOR]

To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement.Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002.We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness.More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators.Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians. [ABSTRACT FROM AUTHOR]

To examine the adequacy of caregiver-patient communication in serious illness and its relationship to caregiver burden.Cross-sectional cohort study.Participants' homes.One hundred ninety-three persons aged 60 and older seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers.Communication concerns, measured in terms of agreement with statements regarding desire for and difficulty with communication about the patient's illness. Caregiver burden, measured using a 10-item subset of the Zarit Burden Inventory, with scores ranging from 0 to 40 and higher scores indicating greater burden.Of caregivers, 39.9% desired more communication, and 37.3% reported that communication was difficult. Of patients, 20.2% desired more communication, and 22.3% reported that communication was difficult. Disagreement regarding communication concerns was frequent in caregiver-patient pairs; of caregivers who desired more communication, 83.1% of patients did not, and of patients who desired more communication, 66.7% of caregivers did not. Caregivers who desired more communication had significantly higher caregiver burden scores than did caregivers who did not (9.2 vs 4.7,P<.001), even after adjusting for patient's diagnosis, income, and functional status and caregivers' age, sex, and relationship to the patient.A large proportion of caregivers and seriously ill older persons had an unmet desire for increased communication, although they frequently disagreed with each other about this desire. Caregivers' desire for increased communication may be a modifiable determinant of caregiver burden. [ABSTRACT FROM AUTHOR]

Objective: Many terminally ill patients enroll in a hospice late in their illness, and recent data indicate decreasing lengths of hospice enrollment, yet we know little about the impact of hospice enrollment length on surviving caregivers. This is the first study the authors know of that examines the association between hospice enrollment length and subsequent major depressive disorder among surviving caregivers. Method: The authors conducted a prospective cohort study with 174 primary family caregivers of consecutively enrolled hospice patients with cancer between October 1999 and September 2001. Using data from in-person interviews at the time of enrollment and 6-8 months after the patient's death, they estimated with logistic regression the adjusted risk of major depressive disorder with the Structured Clinical Interview for the DSM-IV axis I modules based on the number of days of hospice care before death. Results: Caregivers of patients enrolled with hospice for 3 or fewer days were significantly more likely to have major depressive disorder at the follow-up inter- view than caregivers of those with longer hospice enrollment (24.1% versus 9.0%, respectively), adjusted for baseline major depressive disorder and other potential confounders. Conclusions: The findings identify a tar- get group for whom bereavement services might be most needed. The authors also suggest that earlier hospice enrollment may help reduce the risk of major depressive disorder during the first 6-8 months of bereavement, which raises concerns about recent trends toward decreasing lengths of hospice enrollment before death. [ABSTRACT FROM AUTHOR]

To describe the process of adoption of an evidence-based, multifaceted, innovative program into the hospital setting, with particular attention to issues that promoted or impeded its implementation. This study examined common challenges faced by hospitals implementing the Hospital Elder Life Program (HELP) and strategies used to address these challenges.Qualitative study design based on in-depth, open-ended telephone interviews.Nine hospitals implementing HELP throughout the United States.Thirty-two key staff members (physician, nursing, volunteer, and administrative staff) who were directly involved with the HELP implementation.Staff experiences implementing the program, including challenges and strategies they viewed as successful in overcoming challenges of implementation.Six common challenges faced hospital staff: (1) gaining internal support for the program despite differing requirements and goals of administration and clinical staff, (2) ensuring effective clinician leadership, (3) integrating with existing geriatric programs, (4) balancing program fidelity with hospital-specific circumstances, (5) documenting positive outcomes of the program despite limited resources for data collection and analysis, and (6) maintaining the momentum of implementation in the face of unrealistic time frames and limited resources. Strategies perceived to be successful in addressing each challenge are described.Translating research into clinical practice is challenging for staff across disciplines. Developing strategies to address common challenges identified in this study may facilitate the adoption of innovative programs within healthcare organizations. [ABSTRACT FROM AUTHOR]

Context Nonwhite patients experience significantly longer times to fibrinolytic therapy (door-to-drug times) and percutaneous coronary intervention (door-to-balloon times) than white patients, raising concerns of health care disparities, but the reasons for these patterns are poorly understood. Objectives To estimate race/ethnicity differences in door-to-drug and door-to-balloon times for patients receiving primary reperfusion for ST-segment elevation myocardial infarction; to examine how sociodemographic factors, insurance status, clinical characteristics, and hospital features mediate racial/ethnic differences. Design, Setting, and Patients Retrospective, observational study using admission and treatment data from the National Registry of Myocardial Infarction (NRMI) for a US cohort of patients with ST-segment elevation myocardial infarction or left bundle-branch block and receiving reperfusion therapy. Patients (73,032 receiving fibrinolytic therapy; 37,143 receiving primary percutaneous coronary intervention) were admitted from January 1, 1999, through December 31, 2002, to hospitals participating in NRMI 3 and 4. Main Outcome Measure Minutes between hospital arrival and acute reperfusion therapy. Results Door-to-drug times were significantly longer for patients identified as African American/black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific Islander (37.4 minutes), compared with patients identified as white (33.8 minutes) (P<.01 for all). Door-to-balloon times for patients identified as African American/black (122.3 minutes) or Hispanic (114.8 minutes) were significantly longer than for patients identified as white (103.4 minutes) (P<.001 for both). Racial/ethnic differences were still significant but were substantially reduced after accounting for differences in mean times to treatment for the hospitals in which patients were treated; significant racial/ethnic differences persisted after further adjustment for sociodemographic characte... [ABSTRACT FROM AUTHOR]

The study objective was to develop a taxonomy of psychosocial factors that may influence individual decisions for financing nursing home care. Focus groups (18 groups with a total of 155 participants) were conducted to explore personal constructs regarding nursing home financing. Data were collected through a standardized discussion guide. Qualitative analysis was accomplished with NUD*IST 4.0 for coding, sorting, and development of recurrent themes at multiple levels using a node structure, which was reviewed and modified through an iterative process by the investigators. Participants'' expectations of, and planning for, future long term care needs varied. Findings illustrate the multifaceted nature of planning behaviors in financing nursing home care, suggesting that in addition to economic variables, psychosocial factors are important determinants of such behaviors. Identified factors may inform the development of more comprehensive psychosocial measures in future investigations. [Copyright &y& Elsevier]

: PurposeDespite increased emphasis on medical ethics and professionalism in medical education, concern about unethical and unprofessional behavior by physicians is widespread. This study sought to identify and classify the range of work-related ethical conflicts experienced by medical house officers.: MethodsWe performed a qualitative study using data from in-depth interviews conducted in 2001 with 31 internal medicine residents in one traditional and one primary care residency. Using the constant comparative method, we explored work-related experiences during housestaff training that involved ethical conflict with patients or colleagues.: ResultsThe interviews revealed five categories of ethical conflict: concern over telling the truth, respecting patients'' wishes, preventing harm, managing the limits of one''s competence, and addressing performance of others that is perceived to be inappropriate. Conflicts occurred between residents and attending physicians, patients or families, and other residents. Many of the conflicts were exacerbated by the function of the hierarchical structure in residency training.: ConclusionsThis study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development. By attending to the challenges that residents face, particularly previously underemphasized conflicts concerning competence and performance, this framework can be used to enhance education in ethics and professionalism. [Copyright &y& Elsevier]

Objective.To examine the role of race/ethnicity in the use of informal long‐term care among African American and white elders, using an expanded Andersen model of health services use (Bradley et al., Health Services Research, vol. 37, pp. 1221–1242, 2002). Design.Four hundred respondents (n = 200 African American; n=200 white) aged 65 and older, who had been hospitalized within the last year. Data were collected using a cross‐sectional survey analyzed with ordered logistic regression. Independent variables included individuals' predisposing factors, enabling factors, need, and psychosocial factors. Intended use of informal long‐term care was defined based on responses to a hypothetical scenario of future use of unpaid services by family members, relatives, friends, or neighbors for help with daily needs. Results.African American respondents were more likely than white respondents to intend to use informal long‐term care. This effect persisted (p < 0.05) after controlling for predisposing, enabling, and need factors. However, race/ethnicity‐related differences in intended use were attenuated substantially (14–18%) after controlling for psychosocial differences. Further, in the fully adjusted models, race/ethnicity was no longer significantly associated with intended long‐term care use. Conclusions.Psychosocial factors, particularly social norms concerning family caregiving, mediated the relationship between race/ethnicity and intended use of informal long‐term care. A fuller appreciation of the multiple influences on healthcare decision making of older adults has the potential to inform policy efforts to appropriately meet the respective long‐term care needs of an ethnically diverse frail older population. [ABSTRACT FROM AUTHOR]

To determine predictors of recommendation adherence and goal attainment of family caregivers of patients at a geriatric assessment center. One-year prospective cohort study. Outpatient geriatric assessment center in Connecticut. Two hundred consecutive new patients and their family caregivers. Family caregivers were interviewed after geriatric assessment to ascertain their treatment goals for the patient. Medical records were reviewed to identify treatment recommendations. Family caregivers were interviewed 1 year later to assess adherence to recommendations and attainment of goals. Follow-up interviews were completed with 176 (88%) family caregivers. Common recommendations pertained to physician referral (71%), medications (46%), counseling/education (31%), diagnostic tests (30%), residential planning (26%), healthcare planning (21%), and community services (21%). Goal attainment was reported in 44% to 67% of the patient cases, depending on goal category. Caregiver agreement with recommendations predicted adherence to recommendations (adjusted relative risk (ARR)=1.99, 95% confidence interval (CI)=1.04–5.92) after adjusting for available clinical and demographic factors. In addition, adherence to recommendations predicted goal attainment in adjusted analyses (ARR=1.70, 95% CI=1.09–2.64). This study revealed a broad range of treatment recommendations in geriatric assessment and suggests that agreeing with recommendations can promote adherence and that adherence can promote goal attainment. Taken together, the results imply that articulating shared treatment recommendations may improve the quality of health care. [ABSTRACT FROM AUTHOR]

Objectives: To examine agreement between patients, caregivers, and clinicians regarding prognosis communication and to examine patients' and caregivers' desire for prognostic information. Design: Cross-sectional survey. Setting: Participants' homes. Participants: Two hundred fourteen persons aged 60 and older with a limited life expectancy secondary to cancer, congestive heart failure, or chronic obstructive pulmonary disease; caregivers; and clinicians. Measurements: Patient–clinician and caregiver–clinician agreement about the occurrence of prognosis discussions and patient and caregiver desire for prognostic information. Results: In 46% of patient/clinician and 34% of caregiver/clinician pairs, the clinician reported saying that the patient could die of the underlying disease, whereas the patient or caregiver reported no discussion. In 23% of patient/clinician and 30% of patient/caregiver pairs, the clinician reported discussing an approximate life expectancy, whereas the patient or caregiver reported no discussion. Of 205 patients who reported no life expectancy discussion, 40% did not want this discussion. Whereas 83% of those believing they had 1 year or less to live wanted to discuss prognosis, 79% of those believing they had 1 to 2 years, 53% of those believing they had 2 to 5 years, and 50% of those believing they had more than 5 years or who were unwilling to answer wanted this discussion (P =.007). Conclusion: Although clinicians report that they are discussing prognosis, patients and caregivers frequently do not corroborate these reports. Furthermore, many patients do not want prognostic information. Despite previous reports concluding that patients want full disclosure about their illness, many seriously ill older persons and caregivers may not be ready or able to receive prognostic information. [ABSTRACT FROM AUTHOR]

Background: Treatment outcomes are an important determinant of patients' treatment preferences. Although studies have examined how well surrogates agree with patients' preferences for specific treatment interventions, agreement regarding the valuation of health states as treatment outcomes is unknown. Methods: Cross-sectional cohort study consisting of in-home interviews with 193 persons 60 years or older and seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers. Patients were asked whether, facing an exacerbation of illness, they would find a series of health states acceptable as a result of treatment (a rating of "unacceptable" meant they would prefer to die than to receive treatment). Caregivers were asked whether they would find these states acceptable for the patient. Results: There was 80% or greater agreement for health states that were overall rated either acceptable (current health, mild memory impairment, mild pain, or other symptoms) or unacceptable (coma). There was 58% to 62% agreement (κ = 0.10-0.25) about states with more severe physical or cognitive impairment. When disagreement occurred, caregivers were more likely to rate the state as acceptable. There was 61% to 65% agreement (κ = 0.20-0.28) about states with severe pain or other symptoms. When disagreement occurred, caregivers and patients were equally likely to rate the state as acceptable. Conclusions: Patient-caregiver agreement about the acceptability of health states with functional or cognitive impairment, severe pain, or other symptoms was poor. Caregivers making surrogate decisions based on considerations of treatment outcomes may not effectively represent patients' preferences. [ABSTRACT FROM AUTHOR]

Background: An extensive literature has demonstrated that self-ratings of health predict mortality, even after controlling for more objective measures of health, health habits and sociodemographic characteristics. We examine the role of a related concept, self-rated life expectancy, in predicting mortality.Objective: To assess whether self-rated life expectancy predicts mortality after controlling for measures of health, self-rated health, and sociodemographic characteristics.Methods: Using data from the 1992 Health and Retirement Survey (HRS), the 1993 Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, and the second Tracker file (2.0), Cox proportional hazard models were estimated to assess whether self-rated life expectancy predicts mortality, after adjusting for self-rated health and several potential confounders that might otherwise explain this relationship. The AHEAD sample included 2,102 men and 3,160 women. During the 2 years of follow-up, 9% (n = 185) of the men died and 5% (n = 166) of the women died. The HRS sample was comprised of 4,090 men and 4,885 women. Four percent (n = 164) of the men died and 2% (n = 99) of the women died in the 3 years of follow-up.Results: In the older, AHEAD sample, both self-rated life expectancy (p < 0.01) and self-rated health (p < 0.05) predicted mortality for both men and women, even when the two measures were included in the model together. In the younger, HRS sample, self-rated life expectancy was not significantly associated with mortality when self-rated health was included in the model.Conclusion: Our findings suggest that, although self-rated life expectancy and self-rated health may be conceptually related, they have independent empirical effects on mortality. [ABSTRACT FROM AUTHOR]

Background: Several methods exist to elicit end-of-life treatment preferences. However, little work has been done to elicit from patients themselves the aspects of treatment decision-making most important to them when making end-of-life treatment decisions. Methods: Participants consisted of 23 patients, 60 years of age and older with a primary diagnosis of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or cancer identified by their physicians as having a limited life expectancy. They took part in in-depth semistructured interviews and focus groups in which they were asked to discuss how they had made previous decisions about the treatment of their illness and/or would think about making future decisions. Transcripts were analyzed qualitatively using the constant comparative method. Results: There were three major influences on treatment preferences: treatment burden, treatment outcome, and the likelihood of the outcome. Treatment burden was bearable if the outcome of treatment was desirable, but participants were less willing to endure the burden for more marginal outcomes. Certain outcomes were so unacceptable that they determined preference regardless of burden. However, some participants revealed that their willingness to tolerate these adverse outcomes may increase as their illness progresses. Although participants generally believed that physicians know with certainty the outcomes of treatment, most understood the concept of uncertainty, and the likelihood of a given outcome influenced their preferences. Conclusions: A patient-centered approach to advance care planning needs to incorporate a consideration of both treatment burdens and treatment outcomes, including the likelihood of these outcomes. Patients' valuations of these outcomes may change over time. [ABSTRACT FROM AUTHOR]

Explores the roles of senior management in quality improvement efforts in providing health services. Occurrence of quality problems and medical errors in healthcare organizations; Organization of the roles and activities of managers in quality improvement efforts. INSET: PRACTITIONER APPLICATION.

Objectives. This study estimates the consequences of older husbands' involuntary job loss for their wives' mental health. Methods. Using longitudinal data from the 1992, 1994, and 1996 waves of the Health and Retirement Study, multivariate regression models were estimated to measure the impact of older husbands' involuntary job loss on wives' mental health. We created two longitudinal data sets of two waves each to use in our analysis. The first data set, or period, combined Waves 1 and 2 of the Health and Retirement Study and described the 1992-1994 experience of spouse pairs in our sample. It included the wives of 55 husbands who experienced involuntary job loss between these survey dates and a comparison group of wives of 730 continuously employed husbands. The second data set described the 1994-1996 experience of couples. In particular, it included the wives of an additional 38 husbands who were displaced from their jobs between Waves 2 and 3, and a comparison group of wives of 425 husbands who were continuously employed from 1994 to 1996. Results. Husbands' involuntary job loss did not have a statistically significant effect on wives' mental health. We found no evidence that changes in husbands' depressive symptoms modified the effect of his job loss on wives' mental health. In the first period only, the effect of husbands' job loss on wives' mental health was more pronounced for wives who were more financially satisfied at baseline. Discussion. There is limited evidence among this cohort that husbands' job loss increases wives' subsequent depressive symptoms. However, the effect of husbands' job loss on wives' mental health appears to be magnified when wives report being financially satisfied pre-job loss. This suggests that, for subgroups of older couples, mental health services specifically targeted at displaced men should also be made available to wives. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this study was to develop a patient centered measure of treatment preference applicable across a range of diseases and treatment decisions. Methods. instrument development was based on previous research supplemented by open ended interviews and focus groups. Psychometric properties of the instrument were determined by administration to 125 persons aged 60 or older with a limited life expectancy secondary to congestive heart failure, chronic obstructive pulmonary disease, or cancer. Test retest and inter-rater reliability were established using intraclass correlation coefficients. Construct validity was established by examining associations of the measure with a single item question regarding treatment goals and with age. ethnicity, and functional impairment, characteristics known to be associated with preferences. The Willingness to Accept Life Sustaining Treatment instrument (WALT) consists of 6 scenarios in which respondents weigh treatment bur den against treatment outcomes expressed in terms of the likelihood of different health states and length of life following treatment. Results. Inter rater reliability ranged from .73 to .95 and test retest reliability from .49 to .93. WALT scores were significantly associated with a simpler measure of preference and with age, ethnicity, and functional impairment. Conclusions. The WALT measures patients' treatment preferences, assessed in the context of treatment burden and multiple aspects of treatment outcome with sound psychometric properties. [ABSTRACT FROM AUTHOR]