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Background The Seattle Asthma Severity and Control Questionnaire (SASCQ) was designed as a short, sensitive, and quantitative measure of asthma severity, impairment, and risk. Objectives To evaluate the distribution of responses to the SASCQ in a diverse asthma population and to determine whether the questionnaire is associated with other measures of asthma severity and control. Methods A cross-sectional study of 188 asthmatic patients was conducted in a large academic primary care network. Asthma severity was confirmed in a subgroup of 44 patients by means of an in-person interview and lung function measurement. Results The SASCQ score had a nearly normal distribution across the heterogeneous population and less of a floor effect than the number of asthma-free days. The SASCQ score showed a higher symptom burden in the mildest asthmatic patients compared with nonasthmatic controls. Asthma severity evaluated using the questionnaire was correlated with asthma severity evaluated by means of in-person interview and with controller medication class. The SASCQ score was associated with primary care visits for asthma, emergency department treatment for asthma, days missed from work, and confidence to control asthma symptoms; the associations between these measures of impairment and risk were all stronger for the SASCQ score than for asthma-free days. Conclusions The SASCQ is a quantitative measure of asthma that accurately discriminates between established levels of asthma severity and that is associated with other measures of asthma control and risk.

The purpose of this study was to determine the associations between depression and the likelihood of enrollment in a health plan-sponsored physical activity program and pattern of program participation over 2 years; a secondary aim was to examine the association between participation dose and depression risk. There are no published studies on how depression influences participation in health plan-sponsored physical activity programs and how participation affects depression risk in older adults in nonresearch settings.This study used administrative data from a Medicare Advantage plan. Participants (n=4766) were enrolled in the plan for at least 1 year prior to participating in the plan-sponsored health club benefit (Silver Sneakers). Controls were age- and gender-matched to participants (n=9035). Members were identified as having depression based on ICD-9-CM codes. Multivariate regression and generalized estimating equations models were used. Data were collected between 1998 and 2003 and analyzed in 2008.Members who had a history of depression were as likely to participate in Silver Sneakers as nondepressed members (OR: 1.03; 95% CI=0.89, 1.20; p=0.67). The risk of lapse in Silver Sneakers attendance was 28%-55% (p0.05) higher for depressed participants during months 15-24. For nondepressed Silver Sneakers participants, attendance of at least 2 visits/week during Year 1 was significantly associated with lower risk of depression in Year 2 (OR=0.54; 95% CI=0.37, 0.79; p=0.002); a similar but statistically nonsignificant association was observed for previously depressed participants (OR=0.51; 95% CI=0.26, 1.02; p=0.06).While depressed older adults are as likely to enroll in a health plan-sponsored physical activity as nondepressed members, they were at higher risk of attendance lapses. Greater participation in the physical activity program was associated with lower depression risk.

Background. In 1993, the cardiac surgery community in Washington State opposed an effort by the state Health Care Authority (HCA) to identify "centers of excellence" for selective contracting of coronary artery bypass grafting (CABG) procedures, and proposed an alternate model that would create a statewide cardiac outcomes registry under physician governance to be used by all institutions for internal quality improvement activities. Methods. A prospective pilot data collection effort, which examined preoperative and postoperative patient-reported health status, served as the basis for evaluating the capacity of a physician-led organization to develop a collaborative atmosphere and facilitate universal hospital participation. Results. A surgical steering group met on a regular basis and reached consensus on governance issues, protocols for standardized data collection, and policies regarding data dissemination. All 14 centers that performed bypass surgery in the state participated. Patients who were surveyed reported statistically significant improvements in physical, emotional, and anginal-specific health status after bypass surgery. Baseline patient characteristics and longitudinal outcomes were compared across institutions. Conclusions. Based on the feasibility of this collaborative outcomes reporting program, the HCA revised its policy regarding selective contracting and has helped to support an ongoing physician-led and -governed cardiac outcomes reporting system that is particularly notable for the subsequent integration of both CABG surgery and catheterization-based procedures into one standardized registry.

This study investigated the differences between unprompted respondents, prompted respondents, and non-respondents to a postpartum postal survey, and determined the likely impact of non-response on the accuracy of calculations of patient assessments of obstetrical care quality. Birth certificate and hospital discharge data were obtained for 1664 live births at three hospitals in Washington State between 8/91–10/91 and linked with 1268 completed postpartum maternal postal surveys. Non-white race, public insurance payer, unmarried status, and smoking in pregnancy were independent risk factors for non-participation. Among participants, nonwhite race, unmarried status, and having an infant who was low birthweight, preterm, or discharged late were independent risk factors for prompted response. The inclusion of prompted respondents did not substantially alter the calculated proportion of women rating obstetrical care quality as low, and these figures were similar to proportions estimated for the entire intended cohort using a modification of Drane's method. A one-time mailing of an obstetrical care quality survey can provide information similar to that obtained with more extensive follow-up even though substantial differences may exist between unprompted and prompted respondents, and with adjustment for factors related to non-participation and timing of response, it may be possible to obtain accurate estimation of outcome prevalences for the entire intended cohort.

The Foundation for Health Care Quality (Washington) used three administrative public databases and indicators recommended by the Joint Commission and the American College of Obstetrics and Gynecology to build algorithms to measure quality of obstetric care in the state of Washington. Analyses demonstrated a high degree of variability across hospitals for major processes of care such as cesarean section, vaginal birth after cesarean section, and forceps deliveries. Eighty-five percent of the participating hospitals concluded that important aspects of care were being measured. Ninety-four percent found the information useful in describing their performance compared with other hospitals. Sixty-two percent believed the information was useful for initiating quality improvement projects. Of the 25 indicators tested in the project, indicators rated as most useful were the same 10 obstetric indicators chosen by the Joint Commission after alpha testing.

The rationale for routine repeat cesarean section (RCS) is avoidance of uterine rupture during labor. However, the incidence of uterine rupture following modern cesarean section is low, and the charge for cesarean section is greater than that for a trial of labor (TOL). The technique of decision analysis was used to investigate strategies of elective RCS and TOL with precautionary monitoring. Hypothetical cohorts of 10,000 pregnant women with previous low-transverse cesarean incisions were assumed. Probability data were obtained from the literature. In the TOL cohort, 6,623 patients were delivered vaginally. Uterine rupture occurred in 73 patients. In spite of this, TOL resulted in 37 fewer perinatal deaths and 0.7 fewer maternal deaths than elective RCS. The excessive perinatal mortality in the RCS cohort was related to iatrogenic prematurity that is now avoidable with the lecithin/sphingomyelin test. Direct costs were $5 million geater in the RCS cohort. We concluded that in contemporary practice mortality rates are essentially equal for both delivery practices. However, substantial cost savings are available with TOL.

Rates of surgery for similar patient groups are lower in well-established prepaid group plan forms of HMO than in either independent practice association forms of HMO or in traditional fee-for-service care arrangements. The biologic outcomes of care are at least as good in prepaid group plan settings as in other settings. The implications of these conclusions for the future are discussed.