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Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

Prior presentations: None INTRODUCTION The epidemic of burnout among clinicians is well documented[1]. We examined burnout among all team members using data from a project on impact of payment reform on safety net health care clinicians, staff, and patients. Burnout: 1 = not burned out, 5 = very burned out * I p i <.05 DISCUSSION Among staff and clinicians in three safety net clinics, we found a wide range of burnout, from 12.5 to 87.5%. [Extracted from the article]

Background: Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.Methods: We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.Results: Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).Conclusions: Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice. [ABSTRACT FROM AUTHOR]

Background: Concerns exist about the ability of safety net health care organizations to participate in US health care reform. Primary care practices are key to several efforts, but little is known about how capabilities of primary care practices serving a high share of disadvantaged patients compare to other practices.Objective: To assess capabilities around access to and quality of care among primary care practices serving a high share of Medicaid and uninsured patients compared to practices serving a low share of these patients.Design: We analyzed data from the National Survey of Healthcare Organizations and Systems (response rate 46.8%), conducted 2017-2018.Participants: A total of 2190 medical practices with at least three adult primary care physicians.Main Measures: Our key exposures are payer mix and federally qualified health center (FQHC) designation. We classified practices as safety net if they reported a combined total of at least 25% of annual revenue from uninsured or Medicaid patients; we then further classified safety net practices into those that identified as an FQHC and those that did not.Key Results: FQHCs were more likely than other safety net practices and non-safety net practices to offer early or late appointments (79%, 55%, 62%; p=0.001) and weekend appointments (56%, 39%, 42%; p=0.03). FQHCs more often provided medication-assisted treatment for opioid use disorders (43%, 27%, 25%; p=0.004) and behavioral health services (82%, 50%, 36%; p<0.001). FQHCs were more likely to screen patients for social and financial needs. However, FQHCs and other safety net providers had more limited electronic health record (EHR) capabilities (61%, 71%, 80%; p<0.001).Conclusion: FQHCs were more likely than other types of primary care practices (both safety net practices and other practices) to possess capabilities related to access and quality. However, safety net practices were less likely than non-safety net practices to possess health information technology capabilities. [ABSTRACT FROM AUTHOR]

Background: While health-related social needs (HRSN) are known to compromise health, work to date has not clearly demonstrated the relationship between clinically acknowledged social needs, via ICD-10 Z-codes, and readmission.Objective: Assess the rate of 30-, 60-, and 90-day readmission by the level of ICD-10-identified social need. In addition, we examined the associations between demographics, social need, hospital characteristics, and comorbidities on 30-day readmission.Design: Retrospective study using the 2017 Nationwide Readmission Database PARTICIPANTS: We identified 5 domains of HRSN from ICD-10 diagnosis codes including employment, family, housing, psychosocial, and socioeconomic status (SES) and identified how many and which an individual was coded with during the year.Main Measures: The proportion of patients with 30-, 60-, and 90-day readmission stratified by the number of HRSN domains with a multivariable logistic regression to examine the relationship between the number/type of and readmission adjusting for sex, age, payer, hospital characteristics, functional limitations, and comorbidities.Key Results: From 13,217,506 patients, only 2.4% had at least one HRSN diagnosis. Among patients without HRSN, 11.5% had a 30-day readmission, compared to 27.0% of those with 1 domain, increasing to 63.5% for patients with codes in 5 domains. Similar trends were observed for 60- and 90-day readmission; 78.7% of patients with documented HRSN in all 5 domains were hospitalized again within 90 days. The adjusted odds ratio for readmission for individuals with all 5 domains was 12.55 (95% CI: 9.04, 17.43). Housing and employment emerged as two of the most commonly documented HRSN, as well as having the largest adjusted odds ratio.Conclusions: There is a dose-response relationship between the number of HRSN diagnoses and hospital readmission. This work calls attention to the need to develop interventions to reduce readmissions for those at social risk and demonstrates the significance of ICD-10 Z-codes in health outcomes studies. [ABSTRACT FROM AUTHOR]

Accurately describing treatment effects using plain language and narrative statements is a critical step in communicating research findings to end users. However, the process of developing these narratives has not been historically guided by a specific framework. The Agency for Healthcare Research and Quality Evidence-based Practice Center Program developed guidance for narrative summaries of treatment effects that identifies five constructs. We explicitly identify these constructs to facilitate developing narrative statements: (1) direction of effect, (2) size of effect, (3) clinical importance, (4) statistical significance, and (5) strength or certainty of evidence. These constructs clearly overlap. It may not always be feasible to address all five constructs. Based on context and intended audience, investigators can determine which constructs will be most important to address in narrative statements. [ABSTRACT FROM AUTHOR]

Background: The Agency for Healthcare Research and Quality (AHRQ) could devote resources to collate and assess quality improvement studies to support learning health systems (LHS) but there is no reliable data on the consistency of data extraction for important criteria.Methods: We identified quality improvement studies and evaluated the consistency of data extraction from two experienced independent reviewers at three time points: baseline, first revision (where explicit instructions for each criterion were created), and final revision (where the instructions were revised). Six investigators looked at the data extracted by the two systematic reviewers and determined the extent of similarity on a scale of 0 to 10 (where 0 represented no similarity and 10 perfect similarity). There were 42 assessments for baseline, 42 assessments for the first revision, and 42 assessments for the final revision. We asked two LHS participants to assess the relative value of our criteria.Results: The consistency of extraction improved from 1.17 ± 1.85 at baseline to 6.07 ± 2.76 after revision 1 (P < 0.001) and to 6.81 ± 1.94 out of 10 for the final revision (P < 0.001). However, the final revision was not significantly improved over the first revision (P = 0.14). One key informant rated the difficulty in finding and using quality improvement studies a 6 (moderately difficult) while the other a 4 (moderately difficult). When asked how valuable it would be if AHRQ found and collated the demographic information about the health systems and the interventions used in published quality improvement studies, they rated it a 9 (highly valuable) and a 6 (moderately valuable).Conclusion: Creating explicit instructions for extracting data for quality improvement studies helps enhance the consistency of data extraction. This is important because it is difficult for LHS to vet these quality improvement studies on their own and they would value AHRQ's support in that regard. [ABSTRACT FROM AUTHOR]

Background: Narrow definitions of long-term opioid (LTO) use result in limited knowledge of the full range of LTO prescribing patterns and the rates of these patterns.Objective: To investigate a model of new LTO prescribing typologies using latent class analysis.Design: National administrative data from the VA Corporate Data Warehouse were accessed using the VA Informatics and Computing Infrastructure. Characterization of the typology of initial LTO prescribing was explored using latent class analysis.Participants: Veterans initiating LTO during 2016 through the Veteran's Administration Healthcare System (N = 42,230).Main Measures: Opioid receipt as determined by VA prescription data, using the cabinet supply methodology.Key Results: Over one-quarter (27.7%) of the sample fell into the fragmented new long-term prescribing category, 39.8% were characterized by uniform daily new LTO, and the remaining 32.7% were characterized by uniform episodic LTO. Each of these three broad sub-groups also included two additional sub-groups (6 classes total in the model), characterized by the presence or absence of prior opioid prescriptions.Conclusions: New LTO prescribing in the VA includes uniform daily prescribing, uniform episodic prescribing, and fragmented prescribing. Future work is needed to elucidate the safety and efficacy of these prescribing patterns. [ABSTRACT FROM AUTHOR]

Background: On July 1, 2018, the Veterans Health Administration (VA) National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI). Its goal is to identify, document, and honor LST decisions of seriously ill veterans. Providers document veterans' goals and decisions using a standardized LST template and order set.Objective: Evaluate the first 7 months of LSTDI implementation and identify predictors of LST template completion.Design: Retrospective observational study of clinical and administrative data. We identified all completed LST templates, defined as completion of four required template fields. Templates also include four non-required fields. Results were stratified by risk of hospitalization or death as estimated by the Care Assessment Need (CAN) score.Subjects: All veterans with VA utilization between July 1, 2018, and January 31, 2019.Main Measures: Completed LST templates, goals and LST preferences, and predictors of documentation.Results: LST templates were documented for 108,145 veterans, and 85% had one or more of the non-required fields completed in addition to the required fields. Approximately half documented a preference for cardiopulmonary resuscitation. Among those who documented specific goals, half wanted to improve or maintain function, independence, and quality of life while 28% had a goal of life prolongation irrespective of risk of hospitalization/death and 45% expressed a goal of comfort. Only 7% expressed a goal of being cured. Predictors of documentation included VA nursing home residence, older age, frailty, and comorbidity, while non-Caucasian race, rural residence, and receipt of care in a lower complexity medical center were predictive of no documentation.Conclusions: LST decisions were documented for veterans at high risk of hospitalization or death. While few expressed a preference for cure, half desire, cardiopulmonary resuscitation. Predictors of documentation were generally consistent with existing literature. Opportunities to reduce observed disparities exist by leveraging available VA resources and programs. [ABSTRACT FROM AUTHOR]

Background: Heterogeneity of existing physician burnout studies impairs analyses of longitudinal trends, geographic distribution, and organizational factors impacting physician burnout. The Department of Veterans Affairs (VA) is one of the largest integrated healthcare systems in the USA, offering a unique opportunity to study burnout across VA sites and time.Objective: To characterize longitudinal burnout trends of VA physicians and assess organizational characteristics and geographic distribution associated with physician burnout.Design: Longitudinal study of the VA All Employee Survey during 2013-2017.Participants: Self-identified physicians practicing in one of nine clinical service areas at 140 VA sites nationwide.Main Measures: We identified burnout using a validated definition adapted from the Maslach Burnout Inventory and characterized burnout trends for physicians in different clinical service areas. We used clustering analysis to categorize sites based on their burnout rates over time, and compared organizational characteristics and geographic distribution of high, medium, and low burnout categories.Key Results: We identified 40,382 physician responses from 140 VA sites. Mean burnout rates across all physicians ranged from 34.3% in 2013 to a high of 39.0% in 2014. Primary care physicians had the highest burnout. High burnout sites were more likely to be rural and non-teaching, have lower complexity (i.e., offer fewer advanced clinical services), and have fewer unique patients per site.Conclusions: VA physician burnout was lower than previously described in many non-VA studies and was relatively stable over time. These findings may be due to unique characteristics of the VA practice environment. Nonetheless, with over a third of VA physicians reporting burnout, organizational interventions are needed. Primary care physicians and those practicing at small, rural sites have higher rates of burnout and may warrant more focused attention. Our results can guide targeted interventions to promote VA physician well-being and inform efforts to address burnout in diverse clinical settings. [ABSTRACT FROM AUTHOR]

Background: Short-term health care costs following completion of health risk assessments and coaching programs in the VA have not been assessed.Objective: To compare VA health care expenditures among veterans who participated in a behavioral intervention trial that randomized patients to complete a HRA followed by health coaching (HRA + coaching) or to complete the HRA without coaching (HRA-alone).Design: Four-hundred seventeen veterans at three Veterans Affairs (VA) Medical Centers or Clinics were randomized to HRA + coaching or HRA-alone. Veterans randomized to HRA-alone (n = 209) were encouraged to discuss HRA results with their primary care team, while veterans randomized to HRA + coaching (n = 208) received two brief telephone-delivered health coaching calls.Participants: We included 411 veterans with available cost data.Main Measures: Total VA health expenditures 6 months following trial enrollment were estimated using a generalized linear model with a gamma distribution and log link function. In exploratory analysis, model-based recursive partitioning was used to determine whether the intervention effect on short-term costs differed among any patient subgroups.Key Results: Most participants were male (85%); mean age was 56, and mean body mass index was 34. From the generalized linear model, 6-month estimated mean total VA expenditures were similar ($8665 for HRA + coaching vs $9900 for HRA-alone, p = 0.25). In exploratory subgroup analysis, among unemployed veterans with good sleep and fair or poor perceived health, mean observed expenditures in the HRA + coaching group were higher than in the HRA-alone group ($12,814 vs $7971). Among unemployed veterans with good sleep and good general health, mean observed expenditures in the HRA + coaching group were lower than in the HRA-alone group ($5082 vs $11,612).Conclusions: Compared to completing and receiving HRA results, working with health coaches to set actionable health behavior change goals following HRA completion did not reduce short-term health expenditures.Trial Registration: Clinicaltrials.gov identifier: NCT01828567. [ABSTRACT FROM AUTHOR]

Background: Little is known about the frequency, patterns, and determinants of readmissions among patients initially hospitalized for an ambulatory care-sensitive condition (ACSC). The degree to which hospitalizations in close temporal proximity cluster has also not been studied. Readmission patterns involving clustering likely reflect different underlying determinants than the same number of readmissions more evenly spaced.Objective: To characterize readmission rates, patterns, and predictors among patients initially hospitalized with an ACSC.Design: Retrospective analysis of the 2010-2014 Nationwide Readmissions Database.Participants: Non-pregnant patients aged 18-64 years old during initial ACSC hospitalization and who were discharged alive (N = 5,007,820).Main Measures: Frequency and pattern of 30-day all-cause readmissions, grouped as 0, 1, 2+ non-clustered, and 2+ clustered readmissions.Key Results: Approximately 14% of patients had 1 readmission, 2.4% had 2+ non-clustered readmissions, and 3.3% patients had 2+ clustered readmissions during the 270-day follow-up. A higher Elixhauser Comorbidity Index was associated with increased risk for all readmission groups, namely with adjusted odds ratios (AORs) ranging from 1.12 to 3.34. Compared to patients aged 80 years and older, those in younger age groups had increased risk of 2+ non-clustered and 2+ clustered readmissions (AOR range 1.27-2.49). Patients with chronic versus acute ACSCs had an increased odds ratio of all readmission groups compared to those with 0 readmissions (AOR range 1.37-2.69).Conclusions: Among patients with 2+ 30-day readmissions, factors were differentially distributed between clustered and non-clustered readmissions. Identifying factors that could predict future readmission patterns can inform primary care in the prevention of readmissions following ACSC-related hospitalizations. [ABSTRACT FROM AUTHOR]

Background: Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization.Objectives: To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration.Design: Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center.Subjects: Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011.Main Measures: Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life.Key Results: Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138).Conclusions: PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients.Trial Registration: NCT00234286. [ABSTRACT FROM AUTHOR]

Background: Shared decision-making (SDM) is widely recommended and required by the Centers for Medicare and Medicaid for patients considering lung cancer screening (LCS).Objective: We examined clinicians' communication practices and perceived barriers of SDM for LCS at three medical centers with established screening programs.Design: Multicenter qualitative study of clinicians participating in LCS.Approach: We performed semi-structured interviews, which were transcribed and analyzed using directed content analysis, guided by a theoretical model of patient-clinician communication.Participants: We interviewed 24 clinicians including LCS coordinators (2), pulmonologists (3), and primary care providers (17), 4 of whom worked for the LCS program, a thoracic surgeon, and a radiologist.Results: All clinicians agreed with the goal of SDM, to ensure the screening decision was congruent with the patient's values. The depth and type of information presented by each clinician role varied considerably. LCS coordinators presented detailed information including numeric estimates of benefit and harm. Most PCPs explained the process more generally, focusing on logistics and the high rate of nodule detection. No clinician explicitly elicited values or communication preferences. Many PCPs tailored the conversation based on their implicit understanding of patients' values and preferences, gained from past experiences. PCPs reported that time, lack of detailed personal knowledge of LCS, and patient preferences were barriers to SDM. Many clinicians perceived that a significant proportion of patients were not interested in specific percentages and preferred to receive a clinician recommendation.Conclusions: Our results suggest that clinicians support the goal of SDM for LCS decisions but PCPs may not perform some of its elements. The lack of completion of some elements, such as PCPs' lack of in-depth information exchange, may reflect perceived patient preferences for communication. As LCS is implemented, further research is needed to support a personalized, patient-centered approach to produce better outcomes. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services.Objective: This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making.Design: We conducted a qualitative study using in-depth semi-structured interviewing.Participants: Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016.Approach: Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach.Key Results: Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening.Conclusions: Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care. [ABSTRACT FROM AUTHOR]

Background: Transitions of care are high risk for vulnerable populations such as rural Veterans, and adequate care coordination can alleviate many risks. Single-center care coordination programs have shown promise in improving transitional care practices. However, best practices for implementing effective transitional care interventions are unknown, and a common pitfall is lack of understanding of the current process at different sites. The rural Transitions Nurse Program (TNP) is a Veterans Health Administration (VA) intervention that addresses the unique transitional care coordination needs of rural Veterans, and it is currently being implemented in five VA facilities.Objective: We sought to employ and study process mapping as a tool for assessing site context prior to implementation of TNP, a new care coordination program.Design and Participants: Observational qualitative study guided by the Lean Six Sigma approach. Data were collected in January-March 2017 through interviews, direct observations, and group sessions with front-line staff, including VA providers, nurses, and administrative staff from five VA Medical Centers and nine rural Patient-Aligned Care Teams.Key Results: We integrated key informant interviews, observational data, and group sessions to create ten process maps depicting the care coordination process prior to TNP implementation at each expansion site. These maps were used to adapt implementation through informing the unique role of the Transitions Nurse at each site and will be used in evaluating the program, which is essential to understanding the program's impact.Conclusions: Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems. The process mapping activities were useful in engaging the local staff and simultaneously guided adaptations to the TNP intervention to meet local needs. Our approach-combining multiple data sources while adapting Lean Six Sigma principles into practical use-may be generalizable to other care coordination programs. [ABSTRACT FROM AUTHOR]

Objective: Understanding how to successfully implement care coordination programs across diverse settings is critical for disseminating best practices. We describe how we operationalized the Practical Robust Implementation and Sustainability Model (PRISM) to guide the assessment of local context prior to implementation of the rural Transitions Nurse Program (TNP) at five facilities across the Veterans Health Administration (VHA).Methods: We operationalized PRISM to create qualitative data collection techniques (interview guides, semi-structured observations, and a group brainwriting premortem) to assess local context, the current state of care coordination, and perceptions of TNP prior to implementation at five facilities. We analyzed data using deductive-inductive framework analysis to identify themes related to PRISM. We adapted implementation strategies at each site using these findings.Results: We identified actionable themes within PRISM domains to address during implementation. The most commonly occurring PRISM domains were "organizational characteristics" and "implementation and sustainability infrastructure." Themes included a disconnect between primary care and hospital inpatient teams, concerns about work duplication, and concerns that one nurse could not meet the demand for the program. These themes informed TNP implementation.Conclusions: The use of PRISM for pre-implementation site assessments yielded important findings that guided adaptations to our implementation approach. Further, barriers and facilitators to TNP implementation may be common to other care coordination interventions. Generating a common language of barriers and facilitators in care coordination initiatives will enhance generalizability and establish best practices.Impact Statements: TNP is a national intensive care coordination program targeting rural Veterans. We operationalized PRISM to guide implementation efforts. We effectively elucidated facilitators, barriers, and unique contextual factors at diverse VHA facilities. The use of PRISM enhances the generalizability of findings across care settings and may optimize implementation of care coordination interventions in the VHA. [ABSTRACT FROM AUTHOR]

Background: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy.Objective: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities.Conclusions: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion. [ABSTRACT FROM AUTHOR]

Background: The impact of back pain on disability in older women is well-understood, but the influence of back pain on mortality is unclear.Objective: To examine whether back pain was associated with all-cause and cause-specific mortality in older women and mediation of this association by disability.Design: Prospective cohort study.Setting: The Study of Osteoporotic Fractures.Participants: Women aged 65 or older.Measurement: Our primary outcome, time to death, was assessed using all-cause and cause-specific adjusted Cox models. We used a four-category back pain exposure (no back pain, non-persistent, infrequent persistent, or frequent persistent back pain) that combined back pain frequency and persistence across baseline (1986-1988) and first follow-up (1989-1990) interviews. Disability measures (limitations of instrumental activities of daily living [IADL], slow chair stand time, and slow walking speed) from 1991 were considered a priori potential mediators.Results: Of 8321 women (mean age 71.5, SD = 5.1), 4975 (56%) died over a median follow-up of 14.1 years. A higher proportion of women with frequent persistent back pain died (65.8%) than those with no back pain (53.5%). In the fully adjusted model, women with frequent persistent back pain had higher hazard of all-cause (hazard ratio [HR] = 1.24 [95% CI, 1.11-1.39]), cardiovascular (HR = 1.34 [CI, 1.12-1.62]), and cancer (HR = 1.33, [CI 1.03-1.71]) mortality. No association with mortality was observed for other back pain categories. In mediation analyses, IADL limitations explained 47% of the effect of persistent frequent back pain on all-cause mortality, slow chair stand time, and walking speed, explained 27% and 24% (all significant, p < 0.001), respectively.Limitations: Only white women were included.Conclusion: Frequent persistent back pain was associated with increased mortality in older women. Much of this association was mediated by disability. [ABSTRACT FROM AUTHOR]

Among the 2041 women in our cohort, 48.0% received at least one screening mammogram during the study period, with screening rate of 60.2% among women with > 10-year-predicted life expectancy and 27.0% among women with < 10-year-predicted life expectancy (Table 1). Participant Characteristics, Screening Mammogram Rates, and Clinician Specialties Associated with Screening Mammogram Referrals Among the 2041 Women Included in the Study. [Extracted from the article]

Background: Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.Objective: To explore public perceptions of health care costs and how they intersect with medical mistrust.Design and Participants: This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.Approach: We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.Key Results: Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.Conclusions: Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust. [ABSTRACT FROM AUTHOR]

Background: Research using the Veterans Health Administration (VA) electronic medical records (EMR) has been limited by a lack of reliable smoking data.Objective: To evaluate the validity of using VA EMR "Health Factors" data to determine smoking status among veterans with recent military service.Design: Sensitivity, specificity, area under the receiver-operating curve (AUC), and kappa statistics were used to evaluate concordance between VA EMR smoking status and criterion smoking status.Participants: Veterans (N = 2025) with service during the wars in Iraq/Afghanistan who participated in the VA Mid-Atlantic Post-Deployment Mental Health (PDMH) Study.Main Measures: Criterion smoking status was based on self-report during a confidential study visit. VA EMR smoking status was measured by coding health factors data entries (populated during automated clinical reminders) in three ways: based on the most common health factor, the most recent health factor, and the health factor within 12 months of the criterion smoking status data collection date.Key Results: Concordance with PDMH smoking status (current, former, never) was highest when determined by the most commonly observed VA EMR health factor (κ = 0.69) and was not significantly impacted by psychiatric status. Agreement was higher when smoking status was dichotomized: current vs. not current (κ = 0.73; sensitivity = 0.84; specificity = 0.91; AUC = 0.87); ever vs. never (κ = 0.75; sensitivity = 0.85; specificity = 0.90; AUC = 0.87). There were substantial missing Health Factors data when restricting analyses to a 12-month period from the criterion smoking status date. Current smokers had significantly more Health Factors entries compared to never or former smokers.Conclusions: The use of computerized tobacco screening data to determine smoking status is valid and feasible. Results indicating that smokers have significantly more health factors entries than non-smokers suggest that caution is warranted when using the EMR to select cases for cohort studies as the risk for selection bias appears high. [ABSTRACT FROM AUTHOR]

Background: The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.Objective: Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.Design: Toolkit development included cognitive interviewing and test-retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.Participants: A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.Interventions: The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)-a tool that allows patients to create a personalized accommodations report for their PCP-and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.Main Measures: Satisfaction with patient-provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit's usability and utility; responses to open-ended questions.Key Results: Preliminary testing of the AHAT demonstrated strong content validity and adequate test-retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p < 0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p = 0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p = 0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).Conclusions: The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient-provider communication. [ABSTRACT FROM AUTHOR]

Purpose: For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality.Methods: Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality.Results: Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67).Conclusions: Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines. [ABSTRACT FROM AUTHOR]

Background: Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.Objective: We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.Design: This was a retrospective cohort.Participants: 316,775 community-dwelling Veterans age ≥ 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009.Methods: Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression.Key Results: We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥ 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51).Conclusions: Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation. [ABSTRACT FROM AUTHOR]

Background: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. Objective: To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. Design: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3% (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). Patients: U.S. transgender population starting before transitional therapy. Interventions: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. Main Measures: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. Key Results: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000-22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints--HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85% of simulations. Conclusions: Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions. [ABSTRACT FROM AUTHOR]

Background: Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers.Objective: To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening.Design, Setting, Participants: In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %).Main Measures: We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations.Key Results: The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %).Conclusions: Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential. [ABSTRACT FROM AUTHOR]

Background: Children and adolescents with autism spectrum disorder (ASD) have many well-known health concerns, yet health conditions in adults with ASD remain poorly defined.Objective: To examine health conditions and functional status in adults with ASD and identify factors associated with health and functional status across age cohorts.Design and Subjects: We collected cross-sectional data from 255 adult subjects aged 18 to 71 years with ASD using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey instrument. We used the National Health and Nutritional Examination Survey and National Health Interview Survey to provide comparative prevalence rates in the general population.Results: Compared to the general population, young adults aged 18-29 with ASD had a substantially higher prevalence of seizure disorder (11.2 % vs. 1.4 %; p = 0.002), depression (16.4 % vs. 6.4 %; p = 0.007), hypertension (12.9 % vs. 6.3 %; p = 0.05), and allergies (39.7 % vs. 8.4 %; p < 0.001). In contrast, young adults with ASD had considerably lower rates of sexually transmitted illness (STI) (0.9 % vs. 4.3 %; p = 0.03), tobacco use (5.2 % vs. 31.9 %; p < 0.001), and alcohol misuse (0.9 % vs. 11.9 %; p < 0.001). Adults 40 and over with ASD also had higher rates of seizure disorder (29.2 % vs. 1.7 %; p < 0.001), lower tobacco use (2.8 % vs. 24.5 %; p < 0.001), and lower alcohol misuse (1.4 % vs. 18.2 %; p < 0.001) compared to the general population. Amongst the 55 % of participants with a documented IQ score, 91 % had an intellectual disability (IQ < 70). Within the cohort aged 40 years old and older, only 54.2 % were independent with eating, 43.0 % independent with dressing, and 43.1 % independent with bathing. Lower IQ and depression were associated with lower functional status.Conclusions: Adults with ASD have a high prevalence of seizure disorders and depression, but low rates of STIs, tobacco use, and alcohol misuse. Within our cohort, the majority of older adults with ASD required some assistance with activities of daily living. [ABSTRACT FROM AUTHOR]

Background: Reducing patient cost-sharing and engaging patients in disease management activities have been shown to increase uptake of evidence-based care.Objective: To evaluate the effect of employer purchase of a disease-specific plan with reduced cost-sharing and disease management (the Diabetes Health Plan/DHP) on medication adherence among eligible employees and dependents.Design: Employer-level "intent to treat" cohort study, including data from eligible employees and their dependents with diabetes, regardless of whether they were enrolled in the DHP.Setting: Employers that contracted with a large national health plan administrator in 2009, 2010, and/or 2011.Participants: Ten employers that purchased the DHP and 191 employers that did not (controls). Inverse probability weighting (IPW) estimation was used to adjust for inter-group differences.Intervention: The DHP includes free or low-cost medications and physician visits. Enrollment strategies and specific benefit designs are determined by the employer and vary in practice. DHP participants are notified up front that they must engage in their own health care (e.g., receiving diabetes-related screening) in order to remain enrolled.Main Outcome Measure: Mean employee adherence to metformin, statins, and ACE/ARBs at the employer level at one year post-DHP implementation, as measured by the proportion of days covered (PDC).Results: Baseline adherence to the three medications was similar across DHP and control employers, ranging from 64 to 69 %. In the first year after DHP implementation, predicted employer-level adherence for metformin (+4.9 percentage points, p = 0.017), statins (+4.8, p = 0.019), and ACE/ARBs (+4.4, p = 0.02) was higher with DHP purchase.Limitations: Non-randomized, observational study.Conclusions: The Diabetes Health Plan, an innovative health plan that combines reduced cost-sharing and disease management with an up-front requirement of enrollee participation in his or her own health care, is associated with a modest improvement in medication adherence at 12 months. [ABSTRACT FROM AUTHOR]

Background: Brief self-assessment of sexual problems in a clinical context has the potential to improve care for patients through the ability to track trends in sexual problems over time and facilitate patient-provider communication about this important topic. However, instruments designed for research are typically too long to be practical in clinical practice.Objective: To develop and validate a single-item self-report clinical screener that would capture common sexual problems and concerns for men and women.Design: We created three candidate screener items, refined them through cognitive interviews, and administered them to a large sample. We compared the prevalence of responses to each item and explored the discrepancies between items. We evaluated the construct validity of the items by comparing them to scores on the Patient-Reported Outcomes Measurement Information System® Sexual Function and Satisfaction (PROMIS® SexFS) measure.Participants: Local patients participated in two rounds of cognitive interviews (n = 7 and n = 11). A probability-based random sample of U.S. adults comprised the item-testing sample (n = 3517).Main Measures: The items were as follows: 1) a yes/no item on any sexual problems or concerns ("general screener"), 2) a yes/no item on problems experienced for 3 months or more during the past 12 months, with a list of examples ("long list screener"), and 3) an item identical to the long list screener except that examples appeared individually as response options and respondents could check all that applied ("checklist screener").Key Results: All of the screeners tested showed evidence for basic validity and had minimal missing data. Percentages of women and men endorsing the screeners were 10 % and 15 % (general); 20 % and 17 % (long list); and 38 % and 30 % (checklist), respectively. Participants who endorsed the screeners had lower function compared to those who did not endorse them.Conclusions: We recommend the checklist screener for its specificity and ability to identify specific problems associated with decreased sexual function. [ABSTRACT FROM AUTHOR]

Background: Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear.Objective: To examine older adults' use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor-patient communication and use of these programs.Design: Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries.Participants: 14,322 community-dwelling Medicare beneficiaries age ≥65.Main Measures: We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor-patient communication.Key Results: 51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95-2.42).Conclusions: In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor-patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them. [ABSTRACT FROM AUTHOR]

Background: Informed consent is required in most clinical research with humans. While federal regulations state consent information should be understandable to participants, concerns have been raised that consent forms are overly long and complex.Design: Consent forms from 2006 HIV network trials sponsored by the National Institutes of Health (NIH), Division of AIDS (DAIDS), were analyzed for complexity and length. Comparisons were made between US and international sites, template and site forms, adult and pediatric trials, and trial type. How randomization and placebos were explained was examined as these are frequently misunderstood.Results: One hundred twenty-four consent forms (21 template and 103 site forms) were reviewed. Median readability was 9.2 grade level, although confidentiality sections were 12.35 median grade level. International sites' forms had lower readability than US forms (p = 0.025), template forms had lower readability than site forms (p = 0.046), and adult forms were less complex than pediatric (parent) forms (p < 0.0001). Median length of all forms was 22.4 pages; the 85 forms from adult studies had a median length of 27.4 pages. Sections describing randomization were a median length of 53 words.Conclusions: Consent forms are extremely long, exceeding recommendations for how much information readily can be processed. Networks should consider providing shorter consent templates, consistent with federal recommendations, given that sites' forms are based on these models. Further research should examine whether forms emphasizing key information (rather than providing details about all aspects of the research) improve understanding of research. [ABSTRACT FROM AUTHOR]

Objective: To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.Data Sources: We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.Study Eligibility Criteria, Participants, and Interventions: We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.Study Appraisal and Synthesis Methods: Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.Results: The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.Limitations: The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.Conclusions: This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it. [ABSTRACT FROM AUTHOR]

Background: African Americans (AA) and rural communities often suffer disproportionately from poorer health. Theory-guided research examining how individual- and community-level factors influence health behaviors and contribute to disparities is needed.Objective: To understand how a social network model that captures the interplay between individual and community factors might inform community-based interventions to reduce HIV risk in rural AA communities.Design: Qualitative study.Setting and Participants: Eleven focus groups with 38 AA 16-24 year olds, 42 adults over age 25, and 13 formerly incarcerated individuals held in community settings in two rural, predominantly AA counties in North Carolina. Thirty-seven semi-structured interviews with multiethnic key informants.Approach: Semi-structured interviews and focus groups with open-ended questions assessed a) perceptions of multi-level HIV risk determinants from a social network model (individual, interpersonal, social, economic, political and structural) identified through literature review and b) community needs and assets affecting local HIV rates. Qualitative data was analyzed using directive content analysis guided by a social network model.Results: We identified four themes regarding the interaction between individuals and their communities that mediate HIV risk: interpersonal processes, community structural environment, social disorder, and civic engagement. Communities were characterized as having a high degree of cohesiveness, tension, and HIV-related stigma. The community structural environment-characterized by neighborhood poverty, lack of skilled jobs, segregation, political disenfranchisement and institutional racism-was felt to reduce the availability and accessibility of resources to combat HIV. Adults noted an inability to combat social problems due to social disorder, which fuels HIV risk behaviors. Civic engagement as a means of identifying community concerns and developing solutions is limited by churches' reluctance to address HIV-related issues.Conclusion: To combat HIV-related stigma, physicians should follow recommendations for universal HIV testing. Besides asking about individual health behaviors, physicians should ask about the availability of support and local community resources. Physicians might consider tailoring their treatment recommendations based on available community resources. This strategy may potentially improve patient adherence and clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Homeless people have high rates of hospitalization and emergency department (ED) use. Obtaining adequate food is a common concern among homeless people and may influence health care utilization.Objective: We tested the hypothesis that food insufficiency is related to higher rates of hospitalization and ED use in a national sample of homeless adults.Design: We analyzed data from the 2003 Health Care for the Homeless (HCH) User Survey.Participants: Participants were 966 adults surveyed at 79 HCH clinic sites throughout the US. The study sample was representative of over 436,000 HCH clinic users nationally.Measures: We determined the prevalence and characteristics of food insufficiency among respondents. Using multivariable logistic regression, we examined the association between food insufficiency and four past-year acute health services utilization outcomes: (1) hospitalization for any reason, (2) psychiatric hospitalization, (3) any ED use, and (4) high ED use (≥ 4 visits).Results: Overall, 25% of respondents reported food insufficiency. Among them, 68% went a whole day without eating in the past month. Chronically homeless (p = 0.01) and traumatically victimized (p = 0.001) respondents were more likely to be food insufficient. In multivariable analyses, food insufficiency was associated with significantly greater odds of hospitalization for any reason (AOR 1.59, 95% CI 1.07, 2.36), psychiatric hospitalization (AOR 3.12, 95% CI 1.73, 5.62), and high ED utilization (AOR 2.83, 95% CI 1.32, 6.08).Conclusions: One-fourth of homeless adults in this national survey were food insufficient, and this was associated with increased odds of acute health services utilization. Addressing the adverse health services utilization patterns of homeless adults will require attention to the social circumstances that may contribute to this issue. [ABSTRACT FROM AUTHOR]

Background: Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population.Objective: To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS).Design: Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007.Participants: Adult patients cared for within the IHS and 740 federally employed physicians within the IHS.Main Measures: Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening.Key Results: Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care.Conclusions: Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources. [ABSTRACT FROM AUTHOR]

Background: There are growing reports of United States (US) residents traveling overseas for medical care, but empirical data about medical tourism are limited.Objective: To characterize the businesses and business practices of entities promoting medical tourism and the types and costs of procedures being offered. DESIGN, PARTICIPANTS, AND OUTCOMES: Between June and August 2008, we conducted a telephone survey of all businesses engaged in facilitating overseas medical travel for US residents. We collected information from each company including: the number of employees; number of patients referred overseas; medical records security processes; destinations to which patients were referred; treatments offered; treatment costs; and whether patient outcomes were collected.Results: We identified 63 medical tourism companies and 45 completed our survey (71%). Companies had a mean of 9.8 employees and had referred an average of 285 patients overseas (a total of approximately 13,500 patients). 35 (79%) companies reported requiring accreditation of foreign providers, 22 (50%) collected patient outcome data, but only 17 (39%) described formal medical records security policies. The most common destinations were India (23 companies, 55%), Costa Rica (14, 33%), and Thailand (12, 29%). The most common types of care included orthopedics (32 companies, 73%), cardiac care (23, 52%), and cosmetic surgery (29, 66%). 20 companies (44%) offered treatments not approved for use in the US--most commonly stem cell therapy. Average costs for common procedures, CABG ($18,600) and knee arthroplasty ($10,800), were similar to previous reports.Conclusions: The number of Americans traveling overseas for medical care with assistance from medical tourism companies is relatively small. Attention to medical records security and patient outcomes is variable and cost-savings are dependent on US prices. That said, overseas medical care can be a reasonable alternative for price sensitive patients in need of relatively common, elective medical procedures. [ABSTRACT FROM AUTHOR]

Background: Previous studies have noted a high (41%) prevalence and poor discharge summary communication of pending laboratory (lab) tests at the time of hospital discharge for general medical patients. However, the prevalence and communication of pending labs within a high-risk population, specifically those patients discharged to sub-acute care (i.e., skilled nursing, rehabilitation, long-term care), remains unknown.Objective: To determine the prevalence and nature of lab tests pending at hospital discharge and their inclusion within hospital discharge summaries, for common sub-acute care populations.Design: Retrospective cohort study.Participants: Stroke, hip fracture, and cancer patients discharged from a single large academic medical center to sub-acute care, 2003-2005 (N = 564)Main Measures: Pending lab tests were abstracted from the laboratory information system (LIS) and from each patient's discharge summary, then grouped into 14 categories and compared. Microbiology tests were sub-divided by culture type and number of days pending prior to discharge.Key Results: Of sub-acute care patients, 32% (181/564) were discharged with pending lab tests per the LIS; however, only 11% (20/181) of discharge summaries documented these. Patients most often left the hospital with pending microbiology tests (83% [150/181]), particularly blood and urine cultures, and reference lab tests (17% [30/181]). However, 82% (61/74) of patients' pending urine cultures did not have 24-hour preliminary results, and 19% (13/70) of patients' pending blood cultures did not have 48-hour preliminary results available at the time of hospital discharge.Conclusions: Approximately one-third of the sub-acute care patients in this study had labs pending at discharge, but few were documented within hospital discharge summaries. Even after considering the availability of preliminary microbiology results, these omissions remain common. Future studies should focus on improving the communication of pending lab tests at discharge and evaluating the impact that this improved communication has on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Despite compelling reasons to draw on the contributions of under-represented minority (URM) faculty members, US medical schools lack these faculty, particularly in leadership and senior roles.Objective: The study's purpose was to document URM faculty perceptions and experience of the culture of academic medicine in the US and to raise awareness of obstacles to achieving the goal of having people of color in positions of leadership in academic medicine.Design: The authors conducted a qualitative interview study in 2006-2007 of faculty in five US medical schools chosen for their diverse regional and organizational attributes.Participants: Using purposeful sampling of medical faculty, 96 faculty were interviewed from four different career stages (early, plateaued, leaders and left academic medicine) and diverse specialties with an oversampling of URM faculty.Approach: We identified patterns and themes emergent in the coded data. Analysis was inductive and data driven.Results: Predominant themes underscored during analyses regarding the experience of URM faculty were: difficulty of cross-cultural relationships; isolation and feeling invisible; lack of mentoring, role models and social capital; disrespect, overt and covert bias/discrimination; different performance expectations related to race/ethnicity; devaluing of research on community health care and health disparities; the unfair burden of being identified with affirmative action and responsibility for diversity efforts; leadership's role in diversity goals; and financial hardship.Conclusions: Achieving an inclusive culture for diverse medical school faculty would help meet the mission of academic medicine to train a physician and research workforce that meets the disparate needs of our multicultural society. Medical school leaders need to value the inclusion of URM faculty. Failure to fully engage the skills and insights of URM faculty impairs our ability to provide the best science, education or medical care. [ABSTRACT FROM AUTHOR]

Background: US cholesterol guidelines use original and simplified versions of the Framingham model to estimate future coronary risk and thereby classify patients into risk groups with different treatment strategies. We sought to compare risk estimates and risk group classification generated by the original, complex Framingham model and the simplified, point-based version.Methods: We assessed 2,543 subjects age 20-79 from the 2001-2006 National Health and Nutrition Examination Surveys (NHANES) for whom Adult Treatment Panel III (ATP-III) guidelines recommend formal risk stratification. For each subject, we calculated the 10-year risk of major coronary events using the original and point-based Framingham models, and then compared differences in these risk estimates and whether these differences would place subjects into different ATP-III risk groups (<10% risk, 10-20% risk, or >20% risk). Using standard procedures, all analyses were adjusted for survey weights, clustering, and stratification to make our results nationally representative.Results: Among 39 million eligible adults, the original Framingham model categorized 71% of subjects as having "moderate" risk (<10% risk of a major coronary event in the next 10 years), 22% as having "moderately high" (10-20%) risk, and 7% as having "high" (>20%) risk. Estimates of coronary risk by the original and point-based models often differed substantially. The point-based system classified 15% of adults (5.7 million) into different risk groups than the original model, with 10% (3.9 million) misclassified into higher risk groups and 5% (1.8 million) into lower risk groups, for a net impact of classifying 2.1 million adults into higher risk groups. These risk group misclassifications would impact guideline-recommended drug treatment strategies for 25-46% of affected subjects. Patterns of misclassifications varied significantly by gender, age, and underlying CHD risk.Conclusions: Compared to the original Framingham model, the point-based version misclassifies millions of Americans into risk groups for which guidelines recommend different treatment strategies. [ABSTRACT FROM AUTHOR]

Background: Fecal occult blood testing (FOBT) is an important option for colorectal cancer screening that should be available in order to achieve high population screening coverage. However, results from a national survey of clinical practice in 1999-2000 indicated that many primary care physicians used inadequate methods to implement FOBT screening and follow-up.Objective: To determine whether methods to screen for fecal occult blood have improved, including the use of newer more sensitive stool tests.Design: Cross-sectional national survey of primary care physicians.Participants: Participants consisted of 1,134 primary care physicians who reported ordering or performing FOBT in the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Cancer Screening.Main Measures: Self-reported data on details of FOBT implementation and follow-up of positive results.Results: Most physicians report using standard guaiac tests; higher sensitivity guaiac tests and immunochemical tests were reported by only 22.0% and 8.9%, respectively. In-office testing, that is, testing of a single specimen collected during a digital rectal examination in the office, is still widely used although inappropriate for screening: 24.9% of physicians report using only in-office tests and another 52.9% report using both in-office and home tests. Recommendations improved for follow-up after a positive test: fewer physicians recommend repeating the FOBT (17.8%) or using tests other than colonoscopy for the diagnostic work-up (6.6%). Only 44.3% of physicians who use home tests have reminder systems to ensure test completion and return.Conclusions: Many physicians continue to use inappropriate methods to screen for fecal occult blood. Intensified efforts to inform physicians of recommended technique and promote the use of tracking systems are needed. [ABSTRACT FROM AUTHOR]

Background: Chronic hepatitis B and hepatitis B-associated liver cancer is a major health disparity among Vietnamese Americans, who have a chronic hepatitis B prevalence rate of 7-14% and an incidence rate for liver cancer six times that of non-Latino whites.Objective: Describe factors associated with hepatitis B testing among Vietnamese Americans.Design: A population-based telephone survey conducted in 2007-2008.Participants: Vietnamese Americans age 18-64 and living in the Northern California and Washington, DC areas (N = 1,704).Main Measures: Variables included self-reports of sociodemographics, health care factors, and hepatitis B-related behaviors, knowledge, beliefs, and communication with others. The main outcome variable was self-reported receipt of hepatitis B testing.Key Results: The cooperation rate was 63.1% and the response rate was 27.4%. Only 62% of respondents reported having received a hepatitis B test and 26%, hepatitis B vaccination. Only 54% knew that hepatitis B could be transmitted by sexual intercourse. In multivariable analyses, factors negatively associated with testing included: age 30-49 years, US residence for >10 years, less Vietnamese fluency, lower income, and believing that hepatitis B can be deadly. Factors positively associated with testing included: Northern California residence, having had hepatitis B vaccination, having discussed hepatitis B with family/friends, and employer requested testing. Physician recommendation of hepatitis B testing (OR 4.46, 95% CI 3.36, 5.93) and respondent's request for hepatitis B testing (OR 8.37, 95% CI 5.95, 11.78) were strongly associated with test receipt.Conclusion: Self-reports of hepatitis B testing among Vietnamese Americans remain unacceptably low. Physician recommendation and patient request were the factors most strongly associated with test receipt. A comprehensive effort is needed to promote hepatitis B testing in this population, including culturally-targeted community outreach, increased access to testing, and physician education. [ABSTRACT FROM AUTHOR]

Background: The National Consortium for Multicultural Education for Health Professionals (Consortium) comprises educators representing 18 US medical schools, funded by the National Institutes of Health. Collective lessons learned from curriculum implementation by principal investigators (PIs) have the potential to guide similar educational endeavors.Objective: Describe Consortium PI's self-reported challenges with curricular development, solutions and their new curricular products.Methods: Information was collected from PIs over 2 months using a 53-question structured three-part questionnaire. The questionnaire addressed PI demographics, curriculum implementation challenges and solutions, and newly created curricular products. Study participants were 18 Consortium PIs. Descriptive analysis was used for quantitative data. Narrative responses were analyzed and interpreted using qualitative thematic coding.Results: Response rate was 100%. Common barriers and challenges identified by PIs were: finding administrative and leadership support, sustaining the momentum, continued funding, finding curricular space, accessing and engaging communities, and lack of education research methodology skills. Solutions identified included engaging stakeholders, project-sharing across schools, advocacy and active participation in committees and community, and seeking sustainable funding. All Consortium PIs reported new curricular products and extensive dissemination efforts outside their own institutions.Conclusion: The Consortium model has added benefits for curricular innovation and dissemination for cultural competence education to address health disparities. Lessons learned may be applicable to other educational innovation efforts. [ABSTRACT FROM AUTHOR]

Background: General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has "crowded out" generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care.Objective: To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends.Design: Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists.Results: Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists.Conclusions: Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization. [ABSTRACT FROM AUTHOR]

Background: The majority of states have enacted price transparency laws to allow patients to shop for care and to prevent price discrimination of the uninsured. In California, hospitals must provide a price estimate to a requesting uninsured patient and cannot bill for an amount greater than the reimbursement the hospital would receive from a government payer.Objective: To assess the response rate of California hospitals to a patient price request and to compare the price estimates received to Medicare reimbursement.Design: We sent letters to California acute-care hospitals from a fictional uninsured patient requesting an estimate for one of three common elective procedures: a laparoscopic cholecystectomy, a hysterectomy, or routine screening colonoscopy.Participants: Three hundred and fifty-three hospitals in California.Measurements: Hospital response rates, difference between price estimates received, and Medicare reimbursement for equivalent procedures.Results: Only 28% (98/353) of hospitals responded and their response varied in content. Of the 98 responses, 15 (15%) did not provide a quote and instead asked for more information such as the billing code, 55 (56%) provided a price estimate for hospital services only, 10 (10%) included both physician and hospital services, and 18 (18%) did not specify what was covered. The median discounted price estimate was higher than Medicare reimbursement rates for all procedures: hysterectomy ($17,403 vs. $5,569; p<0.001), cholecystectomy ($14,014 vs. $7,196; p<0.001) and colonoscopy ($2,017 vs. $216; p<0.001).Conclusions: Current California legislation fails to meet its objective of enabling uninsured patients to compare prices for hospital-based health care services. [ABSTRACT FROM AUTHOR]

Background: There is accelerating interest in measuring and reporting the quality of care delivered by health care providers and organizations, but methods for defining the patient panels for which they are held accountable are not well defined.Objectives: To examine the potential impact of using alternative algorithms to define accountable patient populations for performance assessment.Research Design: We used administrative data regarding Community Health Center (CHC) visits in simulations of performance assessment for breast, cervical, and colorectal cancer screening.Participants: Fifteen CHC sites in the northeastern US.Measures: We used three different algorithms to define patient populations eligible for measurement of cancer screening rates and simulated center-level performance rates based on these alternative population definitions.Results: Focusing on breast cancer screening, the percentage of women aged 51-75 eligible for this measure across CHCs, if using the most stringent algorithm (requiring a visit in the assessment year plus at least one visit in the 2 years prior), ranged from 28% to 60%. Analogous ranges for cervical and colorectal cancer screening were 18-59% and 26-62%, respectively. Simulated performance data from the centers demonstrate that variations in eligible patient populations across health centers could lead to the appearance of large differences in health center performance or differences in expected rankings of CHCs when no such differences exist. For instance, when holding performance among similar populations constant, but varying the proportion of populations seen across different health centers, simulated health center adherence to screening guidelines varied by over 15% even though actual adherence for similar populations did not differ.Conclusions: Quality measurement systems, such as those being used in pay-for-performance and public reporting programs, must consider the definitions used to identify sample populations and how such populations might differ across providers, clinical practice groups, and provider systems. [ABSTRACT FROM AUTHOR]

Background: Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients' use of non-mental health medical services and the impact of mental disorders on utilization.Objective: To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD.Design and Participants: National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008.Measurements: We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans' first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics.Main Results: Veterans with mental disorders had 42-146% greater utilization than those without mental disorders, depending on the service category (all P < 0.001). Those with PTSD had the highest utilization in all categories: 71-170% greater utilization than those without mental disorders (all P < 0.001). In adjusted analyses, compared with veterans without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. Female sex and lower rank were also independently associated with greater utilization.Conclusions: Veterans with mental health diagnoses, particularly PTSD, utilize significantly more VA non-mental health medical services. As more veterans return home, we must ensure resources are allocated to meet their outpatient, inpatient, and emergency needs. [ABSTRACT FROM AUTHOR]

Background: Prognostic information is becoming increasingly important for clinical decision-making.Objective: To develop and validate an index to predict 5-year mortality among community-dwelling older adults.Design and Participants: A total of 24,115 individuals aged >65 who responded to the 1997-2000 National Health Interview Survey (NHIS) with follow-up through 31 December 2002 from the National Death Index; 16,077 were randomly selected for the development cohort and 8,038 for the validation cohort.Measurements: 39 risk factors (functional measures, illnesses, behaviors, demographics) were included in a multivariable Cox proportional hazards model to determine factors independently associated with mortality. Risk scores were calculated for participants using points derived from the final model's beta coefficients. To evaluate external validity, we compared survival by quintile of risk between the development and validation cohorts.Results: Seventeen percent of participants had died by the end of the study. The final model included 11 variables: age (1 point for 70-74 up to 7 points for >85); male: 3 points; BMI <25: 2 points; perceived health (good: 1 point, fair/poor: 2 points); emphysema: 2 points; cancer: 2 points; diabetes: 2 points; dependent in instrumental activities of daily living: 2 points; difficulty walking: 3 points; smoker-former: 1 point, smoker-current: 3 points; past year hospitalizations-one: 1 point, >2: 3 points. We observed close agreement between 5-year mortality in the two cohorts; which ranged from 5% in the lowest risk quintile to 50% in the highest risk quintile in the validation cohort.Conclusions: This validated mortality index can be used to account for participant life expectancy in analyses using NHIS data. [ABSTRACT FROM AUTHOR]