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Serotonergic dysfunction is implicated in major depressive disorder (MDD), but the mechanisms of this relationship remain elusive. Serotonin 1A (5-HT 1A ) autoreceptors regulate brain-wide serotonin neuron firing and are positioned to assert large-scale effects on negative emotion. Here we investigated the relationship between raphe 5-HT 1A binding and brain-wide network dynamics of negative emotion. 22 healthy-volunteers (HV) and 27 medication-free participants with MDD underwent positron emission tomography (PET) using [ 11 C]CUMI-101 (CUMI) to quantify 5-HT 1A binding in midbrain raphe nuclei and functional magnetic resonance imaging (fMRI) scanning during emotionally negative picture viewing. Causal connectivity across regions responsive to negative emotion was estimated in the fMRI data using a multivariate dynamical systems model. During negative picture viewing, MDD subjects demonstrated significant hippocampal inhibition of amygdala, basal-ganglia, thalamus, orbital frontal cortex, inferior frontal gyrus and dorsomedial prefrontal cortex (IFG, dmPFC). MDD-related connectivity was not associated with raphe 5-HT 1A binding. However, greater hippocampal inhibition of amygdala, thalamus, IFG and dmPFC correlated with hippocampal 5-HT 1A binding. Correlation between hippocampal 5-HT 1A binding and the hippocampal inhibition network was specific to MDD but not HV. MDD and HV groups also differed with respect to the correlation between raphe and hippocampal 5-HT 1A binding which was more pronounced in HV. These findings suggest that increased hippocampal network inhibition in MDD is linked to hippocampal serotonergic dysfunction which may in turn arise from disrupted linkage in raphe to hippocampus serotonergic circuitry., (© 2020. The Author(s), under exclusive licence to Springer Nature Limited.)

It is important to understand the risk factors and resilience factors that contribute to psychological distress or to a sense of well-being in adolescents. This study focuses on life events and social support from an external-environmental aspect. The focus from an internal-personality aspect is on self-criticism and self-disclosure. In this study, 155 adolescents, ages 12-18 years, were divided into two groups. The experimental group included 70 adolescents requesting psychotherapy for emotional disorders. The control group included 85 adolescents without emotional disorders. Participants in the experimental group were followed up to the completion of six months of psychotherapy. Adolescents in the experimental group had undergone more negative life events and a significantly smaller number of positive life events compared to the control group [F(4, 143)=9.77, p<0.001, Eta(2)=.22]. The experimental group was characterized by a diminished degree of social support compared to the control group [F(2, 144)=7.27, p<0.01, Eta(2)=.09]. Regarding self-criticism and self-disclosure, no differences were found between the control and experimental groups [F(3, 148)=2.18, p>0.05, Eta(2)=.04]. The prospective analysis following six months of psychotherapy indicated a significant improvement in distress variables reported by the parents but not by the subjects themselves, pointing to the importance of family intervention as part of adolescent psychotherapy. A decrease in the level of self-criticism after psychotherapeutic intervention was found [F(1, 18)=4.41, p<0.05, Eta(2)=.20], altering self-criticism from a factor that needs to be neutralized to a factor that can be improved during psychotherapy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Children of anxious mothers are at risk for social-emotional difficulties and disturbed, early interactions with their mother may account for some of the risk. This study evaluated the association between maternal anxiety, features of mother-infant interactions, and infants' emotion regulation during stressful situations (still-face, play with a stranger). Thirty-four anxiety-disordered mothers of 6-month-old infants and 59 typical dyads comprised the sample. Dyads were filmed during free play, teaching, care giving, and face-to-face play; and monadic (e.g., maternal sensitivity, infant affect) and dyadic measures (e.g., synchrony) were derived by global or time-event coding of the films. Results indicate that, compared to controls, more anxious mothers showed exaggerated behavior with their infant during free play and teaching, and infants of anxious mothers were less likely to show negative affect during the still-face and stranger challenges. We conclude that anxious maternal behavior reflects the hyperarousal that is characteristic of most anxiety disorders; and infants of anxious mothers and controls show differences in the manner in which they cope with social challenges., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: To assess the effect of a physician-specific pay-for-performance program on quality-of-care measures in a large group practice., Study Design: In 2007, Palo Alto Medical Clinic, a multispecialty physician group practice, changed from group-focused to physician-specific pay-for-performance incentives. Primary care physicians received incentive payments based on their quarterly assessed performance., Methods: We examined 9 reported and incentivized clinical outcome and process measures. Five reported and nonincentivized measures were used for comparison purposes. The quality score of each physician for each measure was the main dependent variable and was calculated as follows: Quality Score = (Patients Meeting Target / Eligible Patients) x 100. Differences in scores between 2006 and 2007 were compared with differences in scores between 2005 and 2006. We also compared the performance of Palo Alto Medical Clinic with that of 2 other affiliated physician groups implementing group-level incentives., Results: Eight of 9 reported and incentivized measures showed significant improvement in 2007 compared with 2006. Three measures showed an improvement trend significantly better than the previous year's trend. A similar improvement trend was observed in 1 related measure that was reported but was nonincentivized. However, the improvement trend of Palo Alto Medical Clinic was not consistently different from that of the other 2 physician groups., Conclusions: Small financial incentives (maximum, $5000/year) based on individual physicians' performance may have led to continued or enhanced improvement in well-established ambulatory care measures. Compared with other quality improvement programs having alternative foci for incentives (eg, increasing support for staff hours), the effect of physician-specific incentives was not evident.

Context: Accreditation requirements mandate teaching quality improvement (QI) concepts to medical trainees, yet little is known about the effectiveness of teaching QI., Objectives: To perform a systematic review of the effectiveness of published QI curricula for clinicians and to determine whether teaching methods influence the effectiveness of such curricula., Data Sources: The electronic literature databases of MEDLINE, EMBASE, CINAHL, and ERIC were searched for English-language articles published between January 1, 1980, and April 30, 2007. Experts in the field of QI were queried about relevant studies., Study Selection: Two independent reviewers selected studies for inclusion if the curriculum taught QI principles to clinicians and the evaluation used a comparative study design., Data Extraction: Information about the features of each curriculum, its use of 9 principles of adult learning, and the type of educational and clinical outcomes were extracted. The relationship between the outcomes and the number of educational principles used was assessed., Results: Of 39 studies that met eligibility criteria, 31 described team-based projects; 37 combined didactic instruction with experiential learning. The median number of adult learning principles used was 7 (range, 2-8). Evaluations included 22 controlled trials (8 randomized and 14 nonrandomized) and 17 pre/post or time series studies. Fourteen studies described educational outcomes (attitudes, knowledge, or skills or behaviors) and 28 studies described clinical process or patient outcomes. Nine of the 10 studies that evaluated knowledge reported only positive effects but only 2 of these described a validated assessment tool. The 6 assessments of attitudes found mixed results. Four of the 6 studies on skill or behavior outcomes reported only positive effects. Eight of the 28 studies of clinical outcomes reported only beneficial effects. Controlled studies were more likely than other studies to report mixed or null effects. Only 4 studies evaluated both educational and clinical outcomes, providing limited evidence that educational outcomes influence the clinical effectiveness of the interventions., Conclusions: Most published QI curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence to perform QI. Additional studies are needed to determine whether educational methods have meaningful clinical benefits.

Patient discharges from the hospital often occur late in the day and are frequently clustered after 4 PM. When inpatients leave earlier in the day, quality is improved because new admissions awaiting beds are able to leave the emergency department sooner and emergency department waiting room backlog is reduced. Nursing staff, whose work patterns traditionally result in high activity of discharge and admission between 5 PM and 8 PM, benefit by spreading out their work across a longer part of the day. Discharging patients earlier in the day also has the potential to increase patient satisfaction. Despite multiple stakeholders in the discharge planning process, physicians play the most important role. Getting physician buy-in requires an ability to teach physicians about the concept of early-in-the-day discharges and their impact on the process. We defined a new physician-centered discharge planning process and introduced it to an internal medicine team with an identical control team as a comparison. Discharge time of day was analyzed for 1 month. Mean time of day of discharge was 13:39 for the intervention group versus 15:45 for the control group (P<.001). If reproduced successfully, this process could improve quality at an important transition point in patient care.

Objective: To determine if infants aged 6 to 15 months with frequent parent-reported nighttime awakenings require reduced parental aid during a week of diphenhydramine hydrochloride treatment and 2 and 4 weeks after its discontinuation., Design: Double-blind, randomized, controlled clinical trial., Setting: The study was conducted from May 1, 2004, through May 1, 2005; patients were recruited nationally., Participants: Forty-four participants aged 6 to 15 months., Interventions: Placebo or diphenhydramine was administered in infants 30 minutes before anticipated bedtime., Main Outcome Measures: The primary outcome was dichotomous: a parental report of improvement in the number of night awakenings requiring parental assistance during the intervention week, which ended on day 14. Secondary outcomes were improved sleep during the 2 weeks before days 29 and 43, parental overall happiness with sleep, and improved sleep latency., Results: On June 6, 2005, the data safety monitoring board voted unanimously to stop the trial early because of lack of effectiveness of diphenhydramine over placebo. Only 1 of 22 children receiving diphenhydramine showed improvement compared with 3 of 22 receiving placebo. To reach the a priori determined sample size and have a positive outcome (ie, rejecting the null hypothesis), the trial would have needed to enroll 16 more participants in each arm, with 15 of the 16 in the diphenhydramine group and 0 of 16 in the placebo group improving., Conclusion: During 1 week of therapy and at follow-up 2 and 4 weeks later, diphenhydramine was no more effective than placebo in reducing nighttime awakening or improving overall parental happiness with sleep for infants.

This study examined whether patient education by nonmedical personnel (eg, social workers, dietitians) is associated with patient outcomes in a prospective cohort study of 1,005 incident dialysis patients treated at 79 United States clinics. Logistic and Poisson regression and Cox proportional hazards models were used to assess the relationship between clinic use of nonmedical educators and patient satisfaction and self-management, hospitalization, and survival, respectively. Patients treated at clinics reporting use of nonmedical educators (84%) were more likely to be satisfied with the amount of information on dialysis modalities (odds ratio [OR]=.67, 95% confidence interval [CI] 1.08--2.58) and with the amount of information they received on dialysis (OR=1.23, 95% CI 0.90--1.67; marginally significant) than those treated at clinics without nonmedical educators (16%). These patients were also less likely to be hospitalized (incidence rate ratio [IRR]=0.91, 95% CI 0.80--1.03), but the association was of borderline statistical significance. Overall satisfaction, patient self-management, and mortality were not significantly associated with use of nonmedical educators. Use of nonmedical staff for patient education at dialysis centers has a limited but positive effect on patient satisfaction and hospitalization.

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.

Objectives: To determine whether a hierarchy of effectiveness exists with respect to complexity of published protocols of heart failure (HF) disease management (DM) incorporating specialist nurse-led HF clinics., Data Sources and Study Selection: We searched MEDLINE (1966-November 2004), the Cochrane Library, article bibliographies, and contacted experts. Inclusion criteria were random allocation of at least 100 patients, specialist HF nurses, HF clinics, and readmission as an outcome measure., Data Extraction: Paired reviewers conducted quality assessment, deconstructed and categorized protocols by complexity, and extracted results for readmission, mortality, the combined endpoint of mortality and hospitalization, HF readmission, and hospital days utilized., Data Synthesis: Six trials were selected (N=949, mean age 73 years [range 62-79], men 58%, LVEF 34% [27-41], and average follow-up of 8.5 months [3-12]). Compared with usual care, the overall relative risk [95% confidence interval] for readmission with this strategy was 0.91 [0.72, 1.16], mortality was 0.80 [0.57, 1.06], and the combined endpoint of mortality and hospitalization was 0.88 [0.74, 1.04]. We observed better outcomes for programs with versus programs without hospital discharge planning and immediate post-discharge follow-up; readmission 0.30 [0.04, 2.60] vs. 1.00 [0.86, 1.17], mortality 0.96 [0.63, 1.47] vs. 0.75 [0.55, 1.03], the combined endpoint of mortality and hospitalization 0.61 [0.18, 2.02] vs. 0.91 [0.80, 1.03], HF readmission 0.09 [0.10, 0.65] vs. 0.65 [0.43, 1.00], and hospitalized days utilized per patient -0.26 [-0.49,-0.02] vs. 0.09 [-1.17, 1.34]., Conclusions: HF DM with specialist nurse-led HF clinics is a promising strategy or effective alternative whose benefit may be optimized by programs with a homogeneous structure and components that are delivered with consistency.

Background: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization., Methods: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART., Results: In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART., Conclusions: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Objective: To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs)., Design: Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU., Setting: The Johns Hopkins Hospital., Patients: All patients with a central venous catheter in the ICU., Intervention: To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed., Measurement: The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion., Main Results: Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU., Conclusions: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.

Context: Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF)., Objective: To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs., Data Sources: We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field., Study Selection: We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome., Data Extraction: Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner., Data Synthesis: Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials)., Conclusion: Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.

After treatment in an emergency department (ED), patients often wait several hours for hospital admission, resulting in dissatisfaction and increased wait times for both admitted and other ED patients. We implemented a new direct admission system based on telephone consultation between ED physicians and in-house hospitalists. We studied this system, measuring admission times, length of stay, and mortality. Postintervention, admission times averaged 18 minutes for transfer to the ward compared to 2.5 hours preintervention, while pre- and postintervention length of stay and mortality rates remained similar.

Context: In light of conflicting evidence of differential effects of dialysis modality on survival, patient experience becomes a more important consideration in choosing between hemodialysis and peritoneal dialysis., Objective: To compare patient satisfaction with hemodialysis and peritoneal dialysis in a cohort of patients who have recently begun dialysis., Design and Setting: Cross-sectional survey at enrollment in a prospective inception cohort study of patients who recently started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998., Patients: Of 736 enrolled incident dialysis patients, 656 (89%) returned a satisfaction questionnaire after an average of 7 weeks of dialysis., Main Outcome Measure: Data collected from a patient-administered questionnaire including 3 overall ratings and 20 items rating specific aspects of dialysis care., Results: Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85% vs 56%, respectively; relative probability, 1.46 [95% confidence interval, 1.31-1.57]) and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69% excellent] vs hemodialysis [30% excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist, response to pain, amount of fluid removed, and staff availability in an emergency. Adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis did not reduce the differences between peritoneal dialysis and hemodialysis patients., Conclusions: After several weeks of initiating dialysis, patients receiving peritoneal dialysis rated their care higher than those receiving hemodialysis. These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.

There is little evidence supporting the widespread belief that regular patient-physician contact in chronic disease management leads to better patient outcomes. The objective of this study was to examine the relationship of the frequency of patient-physician contact with several patient outcomes in a prospective cohort study begun in 1995 of incident hemodialysis patients treated at 75 US dialysis clinics. Average frequency of patient-physician contact at each clinic was determined by clinic survey (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly). The authors used logistic, Poisson, and Cox proportional hazards regression analyses to assess the relationship between contact and satisfaction, quality of life, patient adherence, hospitalizations, and mortality. Of 735 hemodialysis patients, 14.3% were treated at clinics with high frequency of contact, 65.2% intermediate, and 20.5% low. Patients treated at clinics reporting less frequent physician contact had lower odds of rating the frequency at which they saw a nephrologist excellent (low: adjusted OR = 0.39, 95% CI, 0.23-0.67; intermediate: adjusted OR = 0.57, 95% CI, 0.37-0.87; reference, high) and greater odds of nonadherence (low: adjusted OR = 2.89, 95% CI, 1.01-8.29; intermediate: adjusted OR = 1.58, 95% CI, 0.78-3.19). However, patient survival did not vary by frequency of physician contact (low: adjusted RH = 0.87, 95% CI, 0.53-1.44; intermediate: adjusted RH = 1.33, 95% CI, 0.82-2.13), nor did patients' overall ratings of care, hospitalization rates, or quality of life measures. Although less frequent patient-physician contact was associated with lower patient satisfaction with that contact and patient nonadherence, it was not associated with several other outcomes of care. Future studies are needed to assess the individual frequency and nature of physician contact over time, including total time spent with the patient and quality of the interaction, to guide the provision of patient-centered and cost-effective care.

Objective: To determine aspects of quality of life (QOL) important to people with giant cell arteritis (GCA)., Methods: We explored the domains of QOL affected by GCA in audiotaped focus groups. We then created an Importance Rating Questionnaire (IRQ) by constructing questions related to the domains most frequently mentioned. Of 214 GCA patients to whom the IRQ was sent, 145 (68%) responded. We calculated frequencies of responses and then ranked items by the proportion selecting the top category of importance and also according to a mean item rank. We compared the domains of QOL covered by the IRQ with those in the Short Form 12 (SF-12)., Results: The highest rated QOL item was "losing sight in both eyes permanently." Of the top 20 items, 12 were in domains not covered directly by the SF-12., Conclusion: We have identified aspects of QOL important to GCA patients. Assessment of QOL in GCA should include vision and other domains that are not included in standard QOL questionnaires.

Background: Despite the emphasis on patient safety in health care, few organizations have evaluated the extent to which safety is a strategic priority or their culture supports patient safety. In response to the Institute of Medicine's report and to an organizational commitment to patient safety, we conducted a systematic assessment of safety at the Johns Hopkins Hospital (JHH) and, from this, developed a strategic plan to improve safety. The specific aims of this study were to evaluate the extent to which the culture supports patient safety at JHH and the extent to which safety is a strategic priority., Methods: During July and August 2001 we implemented two surveys in disparate populations to assess patient safety. The Safety Climate Scale (SCS) was administered to a sample of physicians, nurses, pharmacists, and other ICU staff. SCS assesses perceptions of a strong and proactive organizational commitment to patient safety. The second survey instrument, called Strategies for Leadership (SLS), evaluated the extent to which safety was a strategic priority for the organization. This survey was administered to clinical and administrative leaders., Results: We received 395 completed SCS surveys from 82% of the departments and 86% of the nursing units. Staff perceived that supervisors had a greater commitment to safety than senior leaders. Nurses had higher scores than physicians for perceptions of safety. Twenty three completed SLS surveys were received from 77% of the JHH Patient Safety Committee members and 50% of the JHH Management Committee members. Management Committee responses were more positive than Patient Safety Committee, indicating that management perceived safety efforts to be further developed. Strategic planning received the lowest scores from both committees., Conclusions: We believe this is one of the first large scale efforts to measure institutional culture of safety and then design improvements in health care. The survey results suggest that strategic planning of patient safety needs enhancement. Several efforts to improve our culture of safety were initiated based on these results, which should lead to measurable improvements in patient safety.

Background: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality of information, rather than evaluating information accuracy and comprehensiveness., Objective: This research sought to build a conceptual framework that could lay the groundwork for a robust performance-measurement system for evaluating the quality of Internet health information., Methods: Application of the quality-of-care measurement paradigm to developing a conceptual framework for defining and evaluating the quality of diabetes consumer-information Web sites., Results: Performance measures related to accuracy and comprehensiveness of information can be added to structural criteria to provide a more-robust approach to Web site evaluation., Conclusions: The development and implementation of a reliable and valid method for evaluating the quality of Internet health sites could provide lay people with a tool to identify useful content more easily and distinguish between beneficial and misleading information.

Background: Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality information rather than evaluating actual accuracy and comprehensiveness., Objective: This research sought to develop a new performance-measurement tool for evaluating the quality of Internet health information, test the validity and reliability of the tool, and assess the variability in diabetes Web site quality., Methods: An objective, systematic tool was developed to evaluate Internet diabetes information based on a quality-of-care measurement framework. The principal investigator developed an abstraction tool and trained an external reviewer on its use. The tool included 7 structural measures and 34 performance measures created by using evidence-based practice guidelines and experts' judgments of accuracy and comprehensiveness., Results: Substantial variation existed in all categories, with overall scores following a normal distribution and ranging from 15% to 95% (mean was 50% and median was 51%). Lin's concordance correlation coefficient to assess agreement between raters produced a rho of 0.761 (Pearson's r of 0.769), suggesting moderate to high agreement. The average agreement between raters for the performance measures was 0.80., Conclusions: Diabetes Web site quality varies widely. Alpha testing of this new tool suggests that it could become a reliable and valid method for evaluating the quality of Internet health sites. Such an instrument could help lay people distinguish between beneficial and misleading information.

Objectives: To determine whether patient age is associated with differences in flexible bronchoscopy technique and tolerance., Design: Prospective cohort study., Setting: University hospital system., Participants: One thousand three hundred fifty-eight adults, including 219 (16.1%) aged 70 and older, undergoing bronchoscopy., Measurements: Indications, sampling procedures, medication doses, patient reports of pain, willingness to return, and adverse events associated with bronchoscopy., Results: Indications for bronchoscopy varied with age, with solitary pulmonary nodule (P <.001), mass (P <.001), or lymphadenopathy (P <.001) being more common in older patients. Invasive sampling methods were used more often with increasing age, but variation in disease processes between age groups accounted for the difference in sampling method performed. Mean doses of midazolam and fentanyl given for sedation decreased with increasing age (P <.001). There was no significant difference between older and younger patients in reported very good to excellent pain control (50% of patients >/=70 vs 64% of patients <40; P =.56) or in willingness to return for repeat bronchoscopy (98% vs 92%, respectively; P =.324). Overall risk for an adverse event increased with increasing patient age (P <.01), but adverse events were uncommon and generally not severe. Hypotension and pneumothorax were rare but occurred more often in older persons (1.9% and 3.4% in patients >/=70 vs 0.5% and 0.7% in patients <40, respectively)., Conclusion: Despite more-invasive sampling methods and less sedation during bronchoscopy, elderly patients tolerate bronchoscopy as well as younger patients. There is increased risk for adverse events with increasing age, but the absolute frequency is low, suggesting that chronological age should not be a contraindication for bronchoscopy in older persons.

Background: Many hospitals use critical pathways to attempt to reduce postoperative length of stay (PLOS) for diverse conditions and procedures., Objective: To evaluate whether critical pathways were associated with reductions in postoperative PLOS after accounting for prepathway trends in PLOS., Research Design: Retrospective cohort study, from 1988 to 1998., Setting: Academic medical center department of surgery., Subjects: A total of 10,960 admissions eligible for 1 of 26 critical pathways implemented from 1990 to 1996, from 2 years before to 2 years after each pathway implementation date. Coding definitions were developed and validated to identify admissions eligible for each pathway, and data were abstracted from the hospital's discharge database., Measure: A pathway was considered effective if, after its implementation, there was a statistically significant decrease in the prepathway trend for PLOS., Results: Median number of annual eligible admissions per pathway was 59 (range, 18-706). Median PLOS for the prepathway periods was 8 days (interquartile range, 5-10 days). For 16 (62%) pathways, PLOS was already declining in the prepathway period. After adjusting for demographics, comorbidity, admission characteristics, and prepathway time trends in PLOS, 7 (27%) pathways were associated with a significant postimplementation decrease in the rate of change in PLOS (range among the 7 pathways, 5-45% decrease) and none with a significant increase from the prepathway trend for PLOS., Conclusion: Critical pathways may decrease postoperative stay for some, but not all, surgeries. Trends toward decreasing length of stay over time may reduce the impact of critical pathways on this outcome.

Study Objectives: To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy (FB) reduces pain and anxiety., Design: Randomized controlled trial., Setting: Teaching hospital in Baltimore, MD., Patients: Consecutive adult patients (n = 80) undergoing FB with conscious sedation., Intervention: Nature scene murals were placed at the bedside, and patients were provided a tape of nature sounds to listen to before, during, and after the procedure. Patients assigned to the control group were not offered either the nature scene or the sounds., Measurements and Results: The primary outcomes were patient ratings of pain control (a 5-point scale ranging from poor to excellent) and anxiety. In a multivariate ordinal logistic regression model, the odds of better pain control were greater in the intervention patients than in the control patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 1.35 to 16.7), after adjustment for age, gender, race, education, health status, and dose of narcotic medication. Older patients and patients with better health status reported significantly less pain. There was no difference in patient-reported anxiety between the two groups (OR, 0.87; 95% CI, 0.39 to 1.96)., Conclusions: Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB. Although the precise mechanism of this beneficial effect requires further investigation, clinicians should consider this nonintrusive strategy in addition to standard analgesic medications in patients undergoing painful, invasive procedures.

Objective: Because there is no instrument that measures how clients judge community health worker (CHW) services, we sought to develop such a questionnaire. We report how we used client information to develop a brief questionnaire evaluating CHW services., Design: We conducted and content-analyzed 18 in-depth semi-structured interviews of clients receiving CHW services to determine aspects of care salient to clients. Based on the results of these analyses, we developed and administered an in-person survey measuring the importance of 57 aspects of CHW services to 84 clients in 3 programs using CHWs to help control hypertension or diabetes., Results: Clients perceived a broad array of aspects of CHW care including CHW attributes, services, benefits or outcomes of service and service arrangements. The 15 aspects ranking highest included: 1) CHW knows job; 2) CHW keeps client alive; 3) CHW gives information on high blood pressure; 4) CHW shows respect; 5) blood pressure is lowered; 6) CHW pays attention; 7) client gets better medical care; 8) CHW speaks understandably; and 9) client gets needed care., Conclusion: We used client information to generate and determine the relative importance of a pool of aspects that we and others can use to construct brief questionnaires to measure clients' judgments of CHW services. Such questionnaires are needed for ongoing evaluation as more providers and managed care organizations increase their use of CHWs for outreach programs.

We conducted a cohort study to characterize patient satisfaction with flexible bronchoscopy (FB) and to determine patient characteristics, care factors, and patient evaluations of bronchoscopy that are associated with a patient's willingness to return for repeat FB. Physicians and patients completed surveys between February 1997 and June 1998. Data from 481 patients were analyzed. Over 80% of the patients rated physicians as very good or excellent, but they were least satisfied with the information that they were provided about FB, waiting time before and after FB, and the FB environment. Seventy-one percent of the patients would definitely return, and 22% would probably return for a repeat FB. Better health status (odds ratio [OR] 1.4; 95% confidence interval [CI], 1.1-1.7), not being bothered by scope insertion (OR 2.0; 95% CI, 1.2-3.3), better rating of information quality (OR 1.2; 95% CI, 1.0-1.3), and better rating of physician quality (OR 1.1; 95% CI, 1.0-1.2) were associated with patients reporting that they would definitely return for a repeat FB. Although patient satisfaction with providers is high, there are specific patient and process of care factors that should be improved. Sicker patients may be at a risk of dissatisfaction with FB. Process of care measures that could improve satisfaction with FB include providing better information to patients and optimizing the experience of bronchoscope insertion.

Background: Risk stratification for comparison of outcomes after coronary artery bypass grafting (CABG) typically includes only clinical measures of risk. Patient-reported health status may be an important independent predictor of short-term health outcomes., Objective: To determine whether patient-reported health status, as measured by the Physical and Mental Component Summary scores of the SF-36, predicts in-hospital mortality and prolonged length of stay after CABG, after controlling for other clinical predictors of those outcomes., Research Design: Prospective cohort study conducted from September 1993 to November 1995., Subjects: One thousand seven hundred seventy-eight adults who underwent isolated CABG for myocardial ischemia., Measures: In-hospital mortality and prolonged length of stay (> 14 days)., Results: There were 27 deaths and 223 patients with prolonged length of stay in the study sample. A 10-point decrease in the Physical Component Summary (PCS) score increased the odds of in-hospital mortality by 61% (OR, 1.61; 95% CI, 1.04-2.49), independent of established clinical risk factors. Similarly, a 10-point decrease in the PCS score increased the odds of prolonged length of stay by 33% (OR, 1.33; 95% CI, 1.13-1.57). A 10-point decrease in the Mental Component Summary score (MCS) decreased the odds of mortality by 36% (OR, 0.64; 95% CI, 0.43-0.95)., Conclusions: The PCS score is independently and significantly associated with in-hospital mortality and prolonged length of stay, after controlling for clinical risk factors. The MCS score is independently and significantly associated only with mortality, though the direction of the effect is unexpected. The result likely reflects a property of the scoring of the MCS and not a finding of clinical substance. Although caution must be taken when interpreting the summary scores, the SF-36 yields information not otherwise captured by clinical data and may be useful in risk stratification for in-hospital mortality and prolonged length of stay after CABG.

Objective: To determine if patient satisfaction with ambulatory care visits differs when medical students participate in the visit., Design: Randomized controlled trial., Setting: Academic general internal medicine practice., Participants: Outpatients randomly assigned to see an attending physician only (N = 66) or an attending physician plus medical student (N = 68)., Measurements and Main Results: Patient perceptions of the office visit were determined by telephone survey. Overall office visit satisfaction was higher for the "attending physician only" group (61% vs 48% excellent), although this was not statistically significant (P =.16). There was no difference between the study groups for patient ratings of their physician overall (80% vs 85% excellent; P =.44). In subsidiary analyses, patients who rated their attending physician as "excellent" rated the overall office visit significantly higher in the "attending physician only" group (74% vs 55%; P =.04). Among patients in the "attending physician plus medical student" group, 40% indicated that medical student involvement "probably" or "definitely" did not improve their care, and 30% responded that they "probably" or "definitely" did not want to see a student at subsequent office visits., Conclusions: Although our sample size was small, we found no significant decrement in patient ratings of office visit satisfaction from medical student involvement in a global satisfaction survey. However, a significant number of patients expressed discontent with student involvement in the visit when asked directly. Global assessment of patient satisfaction may lack sensitivity for detection of dissatisfaction. Future research in this area should employ more sensitive measures of patient satisfaction.

Background: Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels., Objective: To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal., Design: Retrospective cohort study., Subjects: Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years., Measures: Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for., Results: Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk., Conclusions: Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.

As consumers, payers, and regulatory agencies require evidence regarding health care qualities the demand for process of care measures will grow. Although outcome measures of quality represent the desired end results of health care, validated process of care measures provide an important additional element to quality improvement efforts, as they illuminate exactly which provider actions could be changed to improve patient outcomes. In this essay, we discuss the advantages and disadvantages of process measures of quality, and outline some practical strategies and issues in implementing them.

This paper outlines the steps in developing and implementing process measures of quality. Developing a process measure includes defining the purpose of and audiences for the measures, choosing the clinical area to evaluate, organizing the assessment team, choosing the component of the process to measure, writing the indicator specifications, performing preliminary tests of feasibility, reliability and validity, and determining scoring and analytical specifications. Given the growing evidence in the literature regarding the impact of care, and an evolving understanding of how to develop and implement process of care measures as outlined here, the future should bring the development and implementation of quality indicators that are rigorously developed and that will provide insights into opportunities to improve the quality of care.

Background: The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines include recommendations on how to improve the quality of care for asthma., Objective: To identify barriers to physician adherence to the NHLBI guidelines., Design: Cross-sectional survey., Participants: A national random sample of 829 primary care pediatricians., Main Outcome Measures: Self-reported adherence to 4 components of the NHLBI guidelines (steroid prescription, instructing peak flow meter use, screening and counseling patients with asthma for smoking, and screening and counseling parents for smoking). We also collected information on physician demographics, practice characteristics, and possible barriers to adherence. We defined adherence as following a guideline component more than 90% of the time., Results: The response rate was 55% (456/829). Most of the responding pediatricians were aware of the guidelines (88%) and reported having access to a copy of the guidelines (81%). Self-reported rates of adherence were between 39% and 53% for the guideline components. After controlling for demographics and other barriers, we found that nonadherence was associated with specific barriers for each guideline component: for corticosteroid prescription, lack of agreement (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.2-14.4); for peak flow meter use, lack of self-efficacy (OR, 3.4; 95% CI, 1.9-6.1) and lack of outcome expectancy (OR, 4.7; 95% CI, 2.5-8.9); and for screening and counseling of patients and parents for smoking, lack of self-efficacy (OR, 3.8; 95% CI, 1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectively)., Conclusions: Although pediatricians in this sample were aware of the NHLBI guidelines, a variety of barriers precluded their successful use. To improve NHLBI guideline adherence, tailored interventions that address the barriers characteristic of a given guideline component need to be implemented.

This article demonstrates the value of using benchmark patient satisfaction data for Medicaid program quality improvement. The authors compare surveys of Maryland Medicaid and federal employees in Maryland, utilizing the latter as an external benchmark. Unadjusted and adjusted analyses found a significantly lower percentage of Medicaid than federal respondents rated telephone access excellent, very good, or good, whereas more Medicaid respondents rated advice on prevention and choice of primary care doctor highly. Patient satisfaction external benchmark data provide managed care organizations (MCOs) and state policy makers with goals to improve quality and standards to measure care objectively in vulnerable populations.

The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease ([ESRD] CHOICE) Study was designed to evaluate the effectiveness of alternative dialysis prescriptions. As part of CHOICE, we developed an instrument for measuring health-related quality of life (HRQOL) for patients with ESRD that would complement the Medical Outcomes Study 36-Item Short-Form Survey (SF-36) and be sensitive to differences in dialysis modality (hemodialysis [HD] and peritoneal dialysis [PD]) and dialysis dose. The selection of HRQOL domains to be included was based on: (1) a structured literature review of 47 articles describing 53 different instruments; (2) content analysis of five focus groups with HD and PD patients, nephrologists, and other providers; (3) a survey of 110 dialysis providers about features of different modalities that affect patient HRQOL; and (4) a semistructured survey of 25 patients with ESRD on the effects of dialysis on functioning and HRQOL. To help prioritize domains and items identified by these methods, a representative sample of 136 dialysis patients rated each item for frequency and bother. A panel of nephrologists provided advice about the salience of items to modality or dose. Items and scales were selected with a preference for existing measures tested in patients with ESRD and were tested for reliability and validity. The first four steps yielded 22 HRQOL domains that included 96 items: 8 generic domains in the SF-36 (health perceptions, physical, social, physical and emotional role function, pain, mental health, and energy); 8 additional generic domains (cognitive functioning, sexual functioning, sleep, work, recreation, travel, finances, and general quality of life); and 6 ESRD-specific domains (diet, freedom, time, body image, dialysis access [catheters and/or vascular], and symptoms). New items were developed or adapted to assess ESRD-specific domains. Scales for these items showed adequate internal consistency (Cronbach's alpha > 0.70, except for time [alpha = 0.57] and quality of life [alpha = 0.68]), as well as convergent and discriminant construct validity in a sample of 928 patients. The final questionnaire included 21 domains (time was deleted) and 83 items. We have designed a patient-centered instrument, the CHOICE Health Experience Questionnaire, that addresses domains that may be sensitive to differences in dialysis modality and dose and shows evidence for reliability and validity as a measure of HRQOL in ESRD.

Context: Barriers to the use of cochlear implants in children with profound deafness include device costs, difficulty assessing benefit, and lack of data to compare the implant with other medical interventions., Objective: To determine the quality of life and cost consequences for deaf children who receive a cochlear implant., Design: Cost-utility analysis using preintervention, postintervention, and cross-sectional surveys conducted from July 1998 to May 2000., Setting: Hearing clinic at a US academic medical center., Participants: Parents of 78 profoundly deaf children (average age, 7.5 years) who received cochlear implants., Main Outcome Measures: Direct and total cost to society per quality-adjusted life-year (QALY) using the time-trade-off (TTO), visual analog scale (VAS), and Health Utilities Index-Mark III (HUI), discounting costs and benefits 3% annually. Parents rated their child's health state at the time of the survey and immediately before and 1 year before implantation., Results: Recipients had an average of 1.9 years of implant use. Mean VAS scores increased by 0. 27, from 0.59 before implantation to 0.86 at survey. In a subset of participants, TTO scores increased by 0.22, from 0.75 to 0.97 (n = 40) and HUI scores increased by 0.39, from 0.25 to 0.64 (n = 22). Quality-of-life scores were no different 1 year before and immediately before implantation. Discounted direct costs were $60,228, yielding $9,029 per QALY using the TTO, $7,500 per QALY using the VAS, and $5,197 per QALY using the HUI. Including indirect costs such as reduced educational expenses, the cochlear implant provided a savings of $53,198 per child., Conclusions: Cochlear implants in profoundly deaf children have a positive effect on quality of life at reasonable direct costs and appear to result in a net savings to society. JAMA. 2000;284:850-856

The purpose of this study was to assess the extent to which patients undergoing flexible bronchoscopy (FOB) experience pain and to identify patient factors and process of care factors that are associated with pain. We conducted a prospective cohort study on 481 patients undergoing FOB. Overall control of pain during FOB was the primary outcome. The mean age of the patients was 48 yr, 50% were male, and 32% required supplemental oxygen prior to FOB. Pain control was excellent in 36% of patients, but 10% considered it to be fair or poor. Patient factors associated with excellent pain control were excellent health (versus poor health, OR = 6.25 [95% CI, 2.28-16.67]), more education (college education versus high school education, OR = 1.72 [95% CI, 1.05-2.86]), and not having asthma (OR = 2.86 [95% CI, 1.09-7.14]). Process of care factors associated with excellent pain control were not being bothered by scope insertion (versus bothered, OR = 3.65 [95% CI, 1.99-6.98]), no memory of FOB (versus some memory, OR = 2.33 [95% CI, 1.24-4.44]), and higher ratings of information about the procedure (per 1-point increase on a 12-point scale, OR = 1.57 [95% CI, 1.41-1.78]). This is the first large-scale, prospective study to evaluate patient and process of care factors that influence pain control during FOB. It demonstrated that there are patient characteristics and process of care factors that need to be considered when evaluating pain during bronchoscopy. Improved preparation of patients with lower education, inferior health status, and asthma may lead to decreased pain during FOB. Bronchoscopists may be able to reduce pain during FOB by identifying methods to decrease pain on scope insertion, by improving the information provided to patients, and by achieving greater levels of amnesia during FOB.

Objective: To describe barriers to the successful use of the 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines., Methods: We conducted 3 focus groups to understand barriers to the use of 4 recommendations within the NHLBI guidelines (prescription of inhaled corticosteroids, recommendation of daily peak flowmeter use, smoking cessation screening and counseling, and allergen exposure counseling)., Participants: Twenty-one pediatricians and 1 nurse practitioner, who each followed an average of 47 patients with asthma, participated. Six participants (27%) had a faculty or adjunct appointment at a medical school. Nineteen (90%) of the 21 pediatricians were board certified., Results: We identified 171 comments about barriers to adherence. Type of recommendation and physician year of graduation from medical school were related to which barrier was prominent. For corticosteroid prescription, senior physicians mentioned lack of agreement, whereas younger physicians described lack of confidence in dosing or recognizing contraindications. For peak flow-meter use, senior physicians emphasized lack of training. Only senior physicians described the inertia of previous practice as a barrier. All groups mentioned time limitations., Conclusions: Efforts to improve adherence to asthma guidelines should consider the range of barriers that pediatricians face, such as lack of awareness, familiarity, or agreement, and external barriers owing to environmental, guideline, or patient factors. In addition, this study documents barriers not previously considered, such as lack of self-efficacy, lack of outcome expectancy, and inertia of previous practice, that prevent adherence. Because type of recommendation and physician demographics are related to which barriers are prominent, interventions to improve NHLBI guideline adherence should be tailored to these factors.

Objective: To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)., Design: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making., Setting: Five teaching hospitals in the United States., Participants: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died., Measurements: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making., Results: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8)., Conclusions: Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.

Study Objectives: To determine the extent to which on-site cytopathology assessment improves diagnostic yield when sampling lung nodules or masses and/or hilar or mediastinal lymphadenopathy by fiberoptic bronchoscopy (FOB)., Design: Prospective cohort study., Setting: Two teaching hospitals in Baltimore, MD., Patients: Consecutive adult patients (>/= 18 years) undergoing FOB for evaluation of lung nodules or masses and/or hilar or mediastinal lymphadenopathy., Intervention: Prospective collection of data on patient factors and details of the procedure on standardized report forms., Measurements and Results: The primary outcome measure was a new diagnosis obtained by FOB. On-site assessment was used in 81 of 204 cases (40%), and overall diagnostic yield was 62%. Yield was greater when on-site cytopathology assessment was used, in unadjusted analysis (81% vs 50%, p < 0.001) and in a multivariate model (odds ratio, 4.5; 95% confidence interval, 2.1 to 10.0). Other significant predictors of a new diagnosis included older patient age, higher dose of narcotic used during FOB, and shorter procedure time., Conclusions: We conclude that diagnostic yield was greater when on-site cytopathology was used to assist FOB evaluation of intrathoracic adenopathy and/or lung nodules or masses. Increasing the use of on-site cytopathology assessment may improve the quality of FOB services.

The effects of advance care planning are poorly understood. The purpose of this study was to evaluate the effect of an advance care planning intervention on the completion of advance directives (ADs) and patient satisfaction. A volunteer sample of persons with HIV/AIDS received advance directive documents, watched an educational video and received individual counselling on completing an advance directive during three face-to-face interviews over approximately six months. The advance care planning intervention was associated with an increase in advance directive completion rates from 16.4% to 40.7% (p = 0.001), but 23.1% of advance directives reported as completed were legally invalid. There was a trend towards decreased overall patient satisfaction with health care (p = 0.07). Advance are planning increases the rate of AD completion but many 'completed' advance directives are legally invalid. Advance care planning did not improve patient satisfaction with health care.

In the past two decades, relationships among health plans, medical groups, and providers have grown more complex and the number of clinical management strategies has increased. In this context, determining the independent effect of a particular organizational strategy on quality of care has become more difficult. The authors review some of the issues a researcher must address when studying the relationship between organizational characteristics and quality of care. They offer criteria for selecting a research question, list organizational characteristics that may influence quality, and suggest sampling and study design techniques to reduce confounding. Since this type of research often requires a health care organization as collaborator, the authors discuss strategies for developing research partnerships and collecting data from the partner organization. Finally, they offer suggestions for translating research into policy.

Predictive models have been used to identify factors that may prolong hospital length of stay (LOS). However, because predictors of LOS are collinear, the proportion of variance associated with each factor in a multivariate stepwise regression model may not reflect its mathematical contribution in explaining LOS. In an attempt to model factor contribution to LOS more realistically, we evaluated a clinically based clustered model. This model uses classes of candidate predictors, that is, patient attributes, adverse events, treatment modality, and health provider identity. Clusters of variables are permitted to enter into the model in a theoretically based predetermined sequence, so that the additional contribution of each cluster of factors can be assessed while the contribution of preceding factors is preserved. The clustered model was tested and compared with a free stepwise multivariate analysis in a cohort of patients undergoing prostatectomy for benign prostatic hypertrophy. We found that both models explained a similar proportion of the variance in LOS (56%-57%). However, some important differences were evident. Prostate size, associated with 12% of the variance in the clustered model, was not an independent predictor in the free model. A higher proportion of variance was associated with process variables, such as treatment modality in the free model. We conclude that use of a clustered model may facilitate more realistic assessment of the relative contribution of factors to LOS.

Context: Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines., Objective: To review barriers to physician adherence to clinical practice guidelines., Data Sources: We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence., Study Selection: Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator., Data Extraction: Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators., Data Synthesis: The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier., Conclusions: Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.

Objectives: The authors compared the quality of cardiovascular care in health maintenance organizations (HMOs) versus traditional insurance arrangements through an analysis of existing literature., Methods: Data were derived from all peer-reviewed studies published through November 1995 that used process or outcome measures to evaluate the quality of cardiovascular care in HMO versus non-HMO settings. A standardized form was used to extract information from each study on: condition studied, study time frame, type of study design, type of comparison groups, characteristics of patients and physicians, process and outcome measures used, data collection methods, reliability and validity of quality measurements, risk adjustment techniques, findings about quality of care, summary of other findings, study limitations, and other comments that explained the context of the research., Results: Seven of the 11 studies that examined process measures for cardiovascular care in HMO versus non-HMO patients found more differences in one or more process measures that favored HMOs than non-HMOs. Seven of the 10 studies that examined outcome measures found no statistically significant differences in patient care between HMO and non-HMO settings. The other three studies presented contradictory results., Conclusions: The existing literature suggests that the outcomes of care for cardiovascular conditions do not differ between HMO and non-HMO settings, although selected measures of the process of cardiovascular care are actually better in HMO than in non-HMO settings.

Study Objective: To apply the principles of quality improvement to measure the frequency and severity of symptoms that result from fiberoptic bronchoscopy (FOB), and to identify opportunities to improve FOB practice by identifying factors about patients and the process of care that predict these symptoms., Design: Concurrent longitudinal cohort study., Patients: Four hundred ninety-three adult patients who underwent FOB., Measurements and Results: Patients completed questionnaires just prior to FOB and again at 48 h postprocedure. Patients were asked to rate the severity of nose pain, throat pain, swallowing pain, and chest pain, and the frequency of coughing, hemoptysis, phlegm, shortness of breath, wheezing, difficulty swallowing, fever, and chills. Symptom severity was reported on a four-point ordinal scale., Findings: Significant worsening was found for nose pain, throat pain, swallowing pain, and hemoptysis. Shorter patients experienced more throat pain and hemoptysis, and longer procedure time predicted nose pain and hemoptysis., Conclusions: Bronchoscopy causes nose pain, throat pain, swallowing pain, and hemoptysis to a larger extent than previously has been recognized. There are opportunities to improve the patient experience with bronchoscopy by using smaller bronchoscopes in shorter patients, shortening the procedure length, and reanesthetizing the nares in longer procedures.

Objectives: The authors compared the validity and reliability of three methods of medical record screening for detecting problems with quality of care of patients undergoing cardiovascular procedures: (1) the Uniform Clinical Data Set System (UCDSS), a software-based system developed by the Health Care Financing Administration (HCFA), (2) the HCFA generic screens, and (3) the Harvard Medical Practice Study (HMPS) screening criteria., Methods: A random sample of 451 medical records of inpatients who underwent cardiovascular procedures were screened by trained nurses and were also examined by physicians masked to screening results. Physicians' judgment provided a reference standard for validity assessment of screening applied by nurses., Results: Agreement between pairs of physician reviews about the quality of care was fair or slight (Kappa < 0.40). Agreement between nurses about presence of any screening flags was excellent for UCDSS (0.93), slight for HCFA (0.11), and fair for HMPS (0.41). The UCDSS was more sensitive to quality problems agreed on by two physicians than HCFA or HMPS (85%, 74%, and 69%, respectively), but was also less specific (48%, 57%, and 56%, respectively). The UCDSS was much more labor-intensive with an average of 6.7 hours of nurse review per quality problem disclosed versus 2 hours required by HCFA and HMPS., Conclusions: The UCDSS computerized screens brought about substantial improvements in reliability of medical record screening, but needed to reduce its false-positive rate and to increase efficiency before it is used. From the perspective of continuous quality improvement, the UCDSS computerized algorithms provided a starting point to developing disease-specific patterns of practice to guide interventions.

Objectives: To evaluate whether routine laboratory data can improve the ability to compare risk-adjusted outcomes of different medical wards, and to detect 'outlier' wards with significantly better or worse outcome., Methods: Patient data were taken from the Combined Patient Database Systematic Management and Research Tool, a database created by merging different computerized sources at a tertiary care hospital. All patients admitted to internal wards with the diagnosis of pneumonia during the years 1991-1995 were included (n = 2734). The outcome variable was mortality 30 days post-admission. We used three comorbidity measures based on ICD-9-CM codes as possible predictors of mortality: secondary diagnoses; the Health Care Financing Administration severity index; and the Charlson comorbidity index. Models were created using logistic regression. To each model, laboratory data gathered in the first 48 hours after admission were added. To identify 'outlier' services we determined whether the patients' ward was an independent predictor of mortality. The area under the receiver operator curve (ROC) of the models was used for comparisons., Results: The area under the ROC was 0.65-0.72 for the models based on age and comorbid diagnoses. The addition of laboratory data improved markedly the discriminatory ability of each of the models, as reflected by an increase in the area under the ROC to 0.83-0.84. An 'outlier' ward with a higher risk-adjusted mortality rate was identified only by the models that included laboratory data., Conclusion: Basic, automated, routinely gathered laboratory data added significantly to the discriminatory power of risk models based on administrative data with abstracted diagnoses. Addition of laboratory data improved the ability to identify providers with possible exceptional quality of care.