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Background: Treatment decision-making regarding immunosuppressive therapy is challenging for individuals with lupus. We assessed the effectiveness of a decision aid for immunosuppressive therapy in lupus nephritis.Methods and Findings: In a United States multicenter, open-label, randomized controlled trial (RCT), adult women with lupus nephritis, mostly from racial/ethnic minority backgrounds with low socioeconomic status (SES), seen in in- or outpatient settings, were randomized to an individualized, culturally tailored, computerized decision aid versus American College of Rheumatology (ACR) lupus pamphlet (1:1 ratio), using computer-generated randomization. We hypothesized that the co-primary outcomes of decisional conflict and informed choice regarding immunosuppressive medications would improve more in the decision aid group. Of 301 randomized women, 298 were analyzed; 47% were African-American, 26% Hispanic, and 15% white. Mean age (standard deviation [SD]) was 37 (12) years, 57% had annual income of <$40,000, and 36% had a high school education or less. Compared with the provision of the ACR lupus pamphlet (n = 147), participants randomized to the decision aid (n = 151) had (1) a clinically meaningful and statistically significant reduction in decisional conflict, 21.8 (standard error [SE], 2.5) versus 12.7 (SE, 2.0; p = 0.005) and (2) no difference in informed choice in the main analysis, 41% versus 31% (p = 0.08), but clinically meaningful and statistically significant difference in sensitivity analysis (net values for immunosuppressives positive [in favor] versus negative [against]), 50% versus 35% (p = 0.006). Unresolved decisional conflict was lower in the decision aid versus pamphlet groups, 22% versus 44% (p < 0.001). Significantly more patients in the decision aid versus pamphlet group rated information to be excellent for understanding lupus nephritis (49% versus 33%), risk factors (43% versus 27%), medication options (50% versus 33%; p ≤ 0.003 for all); and the ease of use of materials was higher in the decision aid versus pamphlet groups (51% versus 38%; p = 0.006). Key study limitations were the exclusion of men, short follow-up, and the lack of clinical outcomes, including medication adherence.Conclusions: An individualized decision aid was more effective than usual care in reducing decisional conflict for choice of immunosuppressive medications in women with lupus nephritis.Trial Registration: Clinicaltrials.gov, NCT02319525. [ABSTRACT FROM AUTHOR]

A critical issue for improving global health care is to better integrate basic science and clinical practice, as such integration will lead to innovative solutions. In this article, I will present models for how to prepare students to participate effectively on multidisciplinary teams that foster cooperation between scientists, medical centers, biotechnology businesses, and governmental bodies. I will provide examples of training programs in the United States (USA) designed to increase the number of and diversity of scientists and clinicians engaged in bridging basic science and clinical medicine, also called translational research. The training programs target different stages in career development, from pre-medical students through early career faculty, and have varied organisational structures. Many of the programs have existed long enough for institutions to be able to evaluate their effectiveness, and despite the different program contexts, there are key characteristics common to all of the programs that correlate with successful outcomes. Many of these characteristics can be adapted to other career stages and settings. I will summarize these and describe an example of an interdisciplinary, integrated science course for undergraduates that introduces students at the earliest stage of their careers to addressing complex problems through teamwork. Finally, I will provide suggestions for how other institutions can implement training programs that will build bridges between basic science and clinical medicine. [ABSTRACT FROM AUTHOR]

Objective: Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers.Data Sources: Veterans Health Administration's Corporate Data Warehouse.Study Design: Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE.Principal Findings: Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent.Conclusions: The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE. [ABSTRACT FROM AUTHOR]

Objective: To investigate magnitude and sources of discrepancy in quality metrics using claims versus electronic health record (EHR) data.Study Design: Assessment of proportions of HbA1c and LDL testing for people ascertained as diabetic from the respective sources. Qualitative interviews and review of EHRs of discrepant cases.Data Collection/extraction: Claims submitted to Rhode Island Medicaid by three practice sites in 2013; program-coded EHR extraction; manual review of selected EHRs.Principal Findings: Of 21,030 adult Medicaid beneficiaries attributed to a primary care patient at a site by claims or EHR data, concordance on assignment ranged from 0.30 to 0.41. Of patients with concordant assignment, the ratio of patients ascertained as diabetic by EHR versus claims ranged from 1.06 to 1.14. For patients with concordant assignment and diagnosis, the ratio based on EHR versus claims ranged from 1.08 to 18.34 for HbA1c testing, and from 1.29 to 14.18 for lipid testing. Manual record review of 264 patients discrepant on diagnosis or testing identified problems such as misuse of ICD-9 codes, failure to submit claims, and others.Conclusions: Claims data underestimate performance on these metrics compared to EHR documentation, by varying amounts. Use of claims data for these metrics is problematic. [ABSTRACT FROM AUTHOR]

The US End Stage Renal Disease (ESRD) Program, which came into existence in 1973, was initially envisioned to provide needed financial coverage for about 50 000 patients through Medicare. Over the past 45 years the evolution of the ESRD program has been quite different, and it now serves over one half million dialysis and transplant patients. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 Section 153(c) requires the Centers for Medicare and Medicaid Services (CMS) to develop and implement quality measures for dialysis patients as part of the ESRD Quality Incentive Program (QIP) beginning in payment year (PY) 2012. The annual ESRD Prospective Payment System (PPS) rulemaking process allows CMS to create ESRD QIP rules that specify the measures, scoring methods, and payment reduction ranges applicable to the respective PY. CMS assesses each facility's performance and calculates a score for each measure, according to the method detailed for that PY. Scores for each measure are combined to create the Total Performance Score (TPS) for each facility. If a facility's TPS does not meet or exceed the performance standards established during the earlier comparison period, the facility will incur a payment reduction of up to 2% for the entire PY. The QIP program has evolved over the several years since its inception. There have been deletions and additions of various measures. CMS uses additional measures in its Dialysis Facility Compare (DFC) website which is available to the public and forms the basis of the 5-star rating system for dialysis facilities. The evidence underlying inclusion many of these measures in the QIP and DFC remains an area of debate. In this review, we discuss the evolution of these measures and their appropriateness. We recommend that some of the current QIP and DFC measures should not be used for public reporting and/or payment as unintended consequences may occur. Nonetheless, all the current QIP and DFC measures and others are suitable for internal quality review. [ABSTRACT FROM AUTHOR]

Objective: To examine whether changes in resident-centered care (RCC) over time were associated with changes in quality.Data Sources/study Setting: Data sources were the Minimum Dataset quality indicators (which consist of measures of both prevalence and incidence of adverse events) and the Artifacts of Culture Change Tool (which measures RCC; FYs 2009-2012) from 130 Veterans Health Administration community living centers.Study Design: A retrospective longitudinal study.Data Collection/extraction Methods: Data were from VA secondary data sources.Principal Findings: The overall relationship between RCC and quality was not statistically significant (p = .22), although there was a weakly significant negative relationship (i.e., increased RCC was associated with poorer quality) in the seven quarters after implementation of an automated version of the Artifacts Tool (p = .08). In facility-specific analyses, there were 15 facilities with a weakly significant (p < .10) positive relationship between RCC and quality and 21 with a weakly significant negative relationship. Adjusted cost per patient day was over 50 percent higher in the 21 facilities with a negative relationship than in the 15 facilities with a positive relationship (p < .05).Conclusions: The Artifacts score is a formal performance metric in the VA, and thus, facilities were explicitly incentivized to increase RCC. Using qualitative methods to identify characteristics that distinguished those facilities able to increase both RCC and quality from those that suffered declines in quality as RCC was improved is an important follow-up to this study. [ABSTRACT FROM AUTHOR]

Objective: To examine the influence of Oregon's coordinated care organizations (CCOs) and pay-for-performance incentive model on completion of screening and brief intervention (SBI) and utilization of substance use disorder (SUD) treatment services.Data Sources/study Setting: Secondary analysis of Medicaid encounter data from 2012 to 2015 and semiannual qualitative interviews with stakeholders in CCOs.Study Design: Longitudinal mixed-methods design with simultaneous data collection with equal importance.Data Collection/extraction Methods: Qualitative interviews were recorded, transcribed, and coded in ATLAS.ti. Quantitative data included Medicaid encounters 30 months prior to CCO implementation, a 6-month transition period, and 30 months following CCO implementation. Data were aggregated by half-year with analyses restricted to Medicaid recipients 18-64 years of age enrolled in a CCO, not eligible for Medicare coverage or Medicaid expansion.Principal Findings: Quantitative analysis documented a significant increase in SBI rates coinciding with CCO implementation (0.1 to 4.6 percent). Completed SBI was not associated with increased initiation in treatment for SUD diagnoses. Qualitative analysis highlighted importance of aligning incentives, workflow redesign, and leadership to facilitate statewide SBI.Conclusions: Results provide modest support for use of a performance metric to expand SBI in primary care. Future research should examine health reform efforts that increase initiation and engagement in SUD treatment. [ABSTRACT FROM AUTHOR]

Objective: To investigate the potential spillover effects of the Hospital Readmissions Reduction Program (HRRP) on readmissions for nontargeted conditions and patient populations. We examine HRRP effects on nontargeted conditions separately and on non-Medicare populations in Florida and California.Data Sources: From 2007-2013, 100 percent Medicare inpatient claims data, 2007-2013 State Inpatient Database (SID) for Florida, and 2007-2011 SID for California.Study Design: We conducted an interrupted time series analysis to estimate the change in 30-day all-cause unplanned readmission trends after the start of HRRP using logistic regression.Principal Findings: Hospitals with the largest reductions in targeted Medicare readmissions experienced higher reductions in nontargeted Medicare readmissions. Among nontargeted conditions, reductions were higher for neurology and surgery conditions than for the cardiovascular and cardiorespiratory conditions, which are clinically similar to the targeted conditions. For non-Medicare patients, readmission trends for targeted conditions in Florida and California did not change after HRRP.Conclusions: Our findings are consistent with positive spillover benefits associated with HRRP. The extent of these benefits, however, varies across condition and patient groups. The observed patterns suggest a complex response, including a role of nonfinancial factors, in driving lower readmissions. [ABSTRACT FROM AUTHOR]

People commonly use the Internet to search for health information and tend to use the information they find without regard to source or credibility. Although regulation plays some role in minimizing false claims made by manufacturers of self-help products, effective communication with health professionals likely offers greater protection to the patient or consumer accessing self-help materials. In order to best serve patients (or healthcare consumers), providers should educate them about their healthcare needs, inquire about self-help product use, understand appropriate use, discuss the risks and benefits of use, monitor the patients' condition during use, and document these conversations. Although some people fear that patient use of brain-themed self-help will undermine the doctor-patient relationship, it is more likely to open another avenue of communication if providers are knowledgeable about self-help products. Given the rise in importance of the Internet as a source of information for people, opting out of these discussions is realistically not an option. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality.Data Sources: Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012.Study Design: We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals.Data Collection: Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association.Principal Findings: Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals.Conclusions: Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options. [ABSTRACT FROM AUTHOR]

Objective: To assess whether provider organizations exhibit distinct profiles of low-value service provision.Data Sources: 2007-2011 Medicare fee-for-service claims and enrollment data.Study Design: Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low-value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics.Principal Findings: Organizations provided 45.6 low-value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72-1.84), including substantial between-organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60-1.71). Low-value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97-0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24-0.28), with the greatest correlation between low-value imaging and low-value cardiovascular testing and procedures (r, 0.54).Conclusions: Use of low-value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians. [ABSTRACT FROM AUTHOR]

Introduction: The past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities. Materials and methods: Retrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year of data (2014) to examine the influence of patient-, physician-, and hospital-level preoperative factors and surgical approaches on outpatient migration. Results: From 2008–2014, surgical approaches for LH and RH increased, which coincided with decreases in VH and AH. Overall, a 44.2% shift was observed from inpatient to outpatient settings (P<0.0001). Among all outpatient visits MIS increased, particularly for RH (3.6% to 41.07%). We observed increases in the proportion of non-Hispanic Black and Medicaid patients who obtained MIS in 2014 vs. 2008 (P<0.001). Surgical approach (51.8%) and physician outpatient MIS experience (19.9%) had the greatest influence on predicting outpatient BH. Compared with LH, RH was associated with statistically significantly higher likelihood of outpatient BH overall (OR 1.23; 95% CI, 1.16–1.31), as well as in sub-analyses of more complex cases and hospitals that performed ≥1 RH (P<0.05). Conclusion: From 2008–2014, rates of LH and RH significantly increased. A significant shift from inpatient to outpatient setting was observed. These findings suggest that RH may facilitate the shift to outpatient BH, particularly for patients with complexities. The adoption of MIS in outpatient settings may improve access to disadvantaged patient groups. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the reliability of longitudinally reporting age at first drink (AFD), and to test AFD and setting of first drink (SFD) as predictors of collegiate problem drinking. Participants: 338 first-year college students were interviewed multiple times during their first academic year, from May 2011 through August 2012. Methods: AFD, SFD, and problem drinking were measured using the Alcohol Use Disorders Identification Test (AUDIT) during the first year of college. Bivariate analysis and parsimonious multivariate linear regression model were conducted. Results: 62% of respondents were inconsistent in reporting AFD over time. Social SFD was the strongest independent predictor for higher AUDIT scores (b = 4.74, 95% confidence interval; 1.91, 7.57; p =.002). Conclusions: Findings suggest caution should be used in relying upon using AFD as a sole predictor of problem drinking. SFD may be a complementary measure to identify students at high risk of collegiate problem drinking. [ABSTRACT FROM AUTHOR]

Objective: In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality.Research Design and Subjects: Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality.Principal Findings: Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement.Conclusion: Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes. [ABSTRACT FROM AUTHOR]

Objective: To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health.Data Sources: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008-2010 State Inpatient Databases and State Emergency Department Databases.Study Design: Empirical analyses and structured panel reviews.Methods: Panels of 14-17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county-level poverty, uninsurance, and density of primary care physicians (PCPs).Principal Findings: ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end-user panel separately rated the indicators as having strong face validity for most uses evaluated.Conclusions: The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research. [ABSTRACT FROM AUTHOR]

With rapid consolidation of American medicine into large-scale corporations, corporate strategies are coming to the forefront in health care delivery, requiring a dramatic increase in the amount and detail of documentation, implemented through use of electronic health records (EHRs). EHRs are structured to prioritize the interests of a myriad of political and corporate stakeholders, resulting in a complex, multi-layered, and cumbersome health records system, largely not directly relevant to clinical care. Drawing on observations conducted in outpatient specialty clinics, we consider how EHRs prioritize institutional needs manifested as a long list of requisites that must be documented with each consultation. We argue that the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician's role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative. [ABSTRACT FROM AUTHOR]

Background: Spreading effective, guideline-based cardioprotective care quality improvement strategies between healthcare settings could yield great benefits, particularly in under-resourced contexts. Understanding the diverse factors facilitating or impeding such guideline implementation could improve cardiovascular care quality and outcomes for vulnerable patients.Methods: We sought to identify multi-level factors affecting uptake of cardioprotective care guidelines in community health centers (CHCs), within a successful trial of cross-setting implementation of an effective intervention. Quantitative analyses used multivariable logistic regression to examine in-person patient encounters at 10 CHCs from June 2011-May 2014. At these encounters, a point-of-care alert flagged adults with diabetes who were clinically indicated for, but not currently prescribed, cardioprotective medications. The main outcome measure was the rate of relevant prescriptions issued within two days of encounters. Qualitative analyses focused on CHC providers and staff, and, guided by the constant comparative method, were used to enhance understanding of the factors that influenced this prescribing.Results: Recommended prescribing occurred at 13-16% of encounters with patients who were indicated for such prescribing. The odds of this prescribing were higher when the patient was male, had HbA1c ≥7, was previously prescribed a similar medication, gave diabetes as the chief complaint, saw a mid-level practitioner, or saw their primary care provider. The odds were lower when the patient was insured, had ≥1 clinic visits in the past year, had kidney disease, or was prescribed certain other medications. Additional factors were associated with prescribing of each medication class. Qualitative results both supported and challenged the quantitative findings, illustrating important tensions involved in guideline-based prescribing. Clinic staff stressed the importance of the provider-patient relationship in guiding prescribing decisions in the face of competing priorities and care needs, and the impact of rapidly changing guidelines.Conclusions: Diverse factors associated with guideline-concordant prescribing illuminate the complexity of delivering evidence-based care in CHCs. We present possible strategies for addressing barriers to guideline-based prescribing.Clinical Trials Registration: This trial was registered retrospectively. Currently Controlled Trials NCT02299791 . Retrospectively registered 10 November 2014. [ABSTRACT FROM AUTHOR]

Background: Hospital readmissions are associated with higher resource utilization and worse patient outcomes. Causes of unplanned readmission to the hospital are multiple with some being better targets for intervention than others. To understand risk factors for surgical readmission and their incremental contribution to current Veterans Health Administration (VA) surgical quality assessment, the study, Improving Surgical Quality: Readmission (ISQ-R), is being conducted to develop a readmission risk prediction tool, explore predisposing and enabling factors, and identify and rank reasons for readmission in terms of salience and mutability.Methods: Harnessing the rich VA enterprise data, predictive readmission models are being developed in data from patients who underwent surgical procedures within the VA 2007-2012. Prospective assessment of psychosocial determinants of readmission including patient self-efficacy, cognitive, affective and caregiver status are being obtained from a cohort having colorectal, thoracic or vascular procedures at four VA hospitals in 2015-2017. Using these two data sources, ISQ-R will develop readmission categories and validate the readmission risk prediction model. A modified Delphi process will convene surgeons, non-surgeon clinicians and quality improvement nurses to rank proposed readmission categories vis-à-vis potential preventability.Discussion: ISQ-R will identify promising avenues for interventions to facilitate improvements in surgical quality, informing specifications for surgical workflow managers seeking to improve care and reduce cost. ISQ-R will work with Veterans Affairs Surgical Quality Improvement Program (VASQIP) to recommend potential new elements VASQIP might collect to monitor surgical complications and readmissions which might be preventable and ultimately improve surgical care. [ABSTRACT FROM AUTHOR]

Copyright of Milbank Quarterly is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article offers information on a plan released by the U.S. Food and Drug Administration (FDA) for pre-dementia Alzheimer's trials. It informs about electronic clinical outcome assessments (eCOA) and clinician reported outcomes (ClinROs) which can provide life science companies an easier way to work with and tackling problems associated with clincal industries. It mentions that eCOA can provide guidance to clinician addressing problems through an assessment in a user-friendly manner.

The article offers news briefs related to American Society for Clinical Pharmacology and Therapeutics (ASCPT). Presidential trainees including Matthew Baggot, Andre Breddemann and Kelly Filipski were honored at the 2009 ASCPT annual meeting. The society is seeking abstracts of unpublished papers for the 2010 ASCPT Presidential Trainee Award. The 2009-2010 ASCPT Board of Directors was officially seated at the conclusion of the 2009 annual meeting.

The article responds to the paper "Noninvasive Imaging of Atherosclerosis Among Asymptomatic Individuals," by Paolo Raggi in this issue. The author disagrees with Raggi on the interpretation of evidence supporting the routine application of diagnostic screening for atherosclerosis in asymptomatic people. There is not enough measurement of risk factors in most of the prospective cohort studies, and most of the multivariate analyses are insufficient to evaluate the true independent prognostic value of the data.

Presents a letter to the editor in response to an editorial on computer technology and clinical trial work in the March 9, 2005 edition of the "Journal of the American Medical Association."

Third-party reproduction is a growing field, and an increasing body of literature considers the ethics of embryo donation. Due to the psychosocial complexities that generally accompany the donation and/or use of donor embryos, psychologists can play a pivotal role in these specialised fertility cases. While laws in the USA are in place to regulate the medical procedures involved in embryo donation, only unenforceable guidelines exist for psychologists specialising in fertility cases. The presentation of this case study aims to: (1) clarify the ethical concerns that fertility psychologists should consider in similar situations by assessing whether American Society of Reproductive Medicine (ASRM) and the American Psychological Association (APA) guidelines compete or complement one another within this case of embryo donation and (2) consider the interests, obligations and rights of all parties involved. Several principles, standards and guidelines that must be considered are described. Overall, the APA Ethics Code and the ASRM Guidelines appear to complement one another for most aspects of this case. Fertility psychologists should consider the clinical implications of the interests, rights and duties of all involved parties, including themselves. [ABSTRACT FROM AUTHOR]

Context Longitudinal integrated clerkships ( LICs) represent a model of the structural redesign of clinical education that is growing in the USA, Canada, Australia and South Africa. By contrast with time-limited traditional block rotations, medical students in LICs provide comprehensive care of patients and populations in continuing learning relationships over time and across disciplines and venues. The evidence base for LICs reveals transformational professional and workforce outcomes derived from a number of small institution-specific studies. Objectives This study is the first from an international collaborative formed to study the processes and outcomes of LICs across multiple institutions in different countries. It aims to establish a baseline reference typology to inform further research in this field. Methods Data on all LIC and LIC-like programmes known to the members of the international Consortium of Longitudinal Integrated Clerkships were collected using a survey tool developed through a Delphi process and subsequently analysed. Data were collected from 54 programmes, 44 medical schools, seven countries and over 15 000 student-years of LIC-like curricula. Results Wide variation in programme length, student numbers, health care settings and principal supervision was found. Three distinct typological programme clusters were identified and named according to programme length and discipline coverage: Comprehensive LICs; Blended LICs, and LIC-like Amalgamative Clerkships. Two major approaches emerged in terms of the sizes of communities and types of clinical supervision. These referred to programmes based in smaller communities with mainly family physicians or general practitioners as clinical supervisors, and those in more urban settings in which subspecialists were more prevalent. Conclusions Three distinct LIC clusters are classified. These provide a foundational reference point for future studies on the processes and outcomes of LICs. The study also exemplifies a collaborative approach to medical education research that focuses on typology rather than on individual programme or context. [ABSTRACT FROM AUTHOR]

Background An increasing number of U.S. emergency departments ( EDs) have implemented ED-based HIV testing programs since the Centers for Disease Control and Prevention issued revised HIV testing recommendations for clinical settings in 2006. In 2010, the National HIV/ AIDS Strategy ( NHAS) set an linkage-to-care ( LTC) rate goal of 85% within 90 days of HIV diagnosis. LTC rates for newly diagnosed HIV-infected patients vary markedly by site, and many are suboptimal. The optimal approach for LTC in the ED setting remains unknown. Objective The objective was to perform a brief descriptive analysis of the LTC methods practiced in EDs across the United States to determine the overall linkage rate of ED-based HIV testing programs. Methods We conducted a systematic review of literature related to U.S. ED HIV testing in the adult population using PubMed, Embase, Web of Science, Scopus, and Cochrane. There were 333 articles were identified; 31 articles were selected after a multiphasic screening process. We analyzed data from the 31 articles to assess LTC methods and rates. LTC methods that involved physical escort of the newly diagnosed patient to an HIV/infectious disease ( ID) clinic or interaction with a specialist health care provider at the ED were operationally defined as 'intensive' LTC protocol. 'Mixed' LTC protocol was defined as a program that employed intensive linkage only part of the coverage hours. All other forms of linkage was defined as 'nonintensive' LTC protocol. An LTC rate of ≥85% was used to identify characteristics of ED-based HIV testing program associated with a higher LTC rate. Results There were 37 ED-based HIV testing programs in the 31 articles. The overall LTC rate was 74.4%. Regarding type of protocol, nine (24.3%) employed intensive LTC protocols, 25 (67.6%) nonintensive, two (5.4%) mixed, and one (2.7%) with unclear protocols. LTC rates for programs with intensive and nonintensive LTC protocols were 80.0 and 72.7%, respectively. Four (44.4%) with intensive protocols and nine (36.0%) with the nonintensive protocols had LTC rates > 85%. The linkage staff employed was different between ED programs. Among them, 25 (67.6%) programs used exogenous staff, 10 (27.0%) used the ED staff, and two had no information. All the programs in the nonintensive group utilized drop-in HIV/ ID clinic or medical appointments while seven of nine of the programs in the intensive group physically escorted the patients to the initial medical intake appointment. There were no significant differences in characteristics of ED-based HIV testing programs between those with ≥85% LTC rate versus those with <85% within the intensive or nonintensive group. Conclusion Intensive LTC protocols had a higher LTC rate and a higher proportion of programs that surpassed the >85% NHAS goal compared to nonintensive methods, suggesting that, when possible, ED-based HIV testing programs should adopt intensive LTC strategies to improve LTC outcomes. However, intensive LTC protocols most often required involvement of multidisciplinary non- ED professionals and external research funding. Our findings provide a foundation for developing best practices for ED-based HIV LTC programs. [ABSTRACT FROM AUTHOR]

Objective: Limited consumer use of health care report cards may be due to the large amount of information presented in report cards, which can be difficult to understand. These limitations may be overcome with summary measures. Our objective was to evaluate consumer response to summary measures in the setting of nursing homes.Data Sources/study Setting: 2005-2010 nursing home Minimum Data Set and Online Survey, Certification and Reporting (OSCAR) datasets.Study Design: In December 2008, Medicare converted its nursing home report card to summary or star ratings. We test whether there was a change in consumer demand for nursing homes related to the nursing home's star rating after the information was released.Principal Findings: The star rating system was associated with a significant change in consumer demand for low- and high-scoring facilities. After the star-based rating system was released, 1-star facilities typically lost 8 percent of their market share and 5-star facilities gained over 6 percent of their market share.Conclusions: The nursing home star rating system significantly affected consumer demand for high- and low-rated nursing homes. These results support the use of summary measures in report cards. [ABSTRACT FROM AUTHOR]

Objective: To analyze health care disparities in pediatric quality of care measures and determine the impact of data imputation.Data Sources: Five HEDIS measures are calculated based on 2012 administrative data for 145,652 children in two public insurance programs in Florida.Methods: The Bayesian Improved Surname and Geocoding (BISG) imputation method is used to impute missing race and ethnicity data for 42 percent of the sample (61,954 children). Models are estimated with and without the imputed race and ethnicity data.Principal Findings: Dropping individuals with missing race and ethnicity data biases quality of care measures for minorities downward relative to nonminority children for several measures.Conclusions: These results provide further support for the importance of appropriately accounting for missing race and ethnicity data through imputation methods. [ABSTRACT FROM AUTHOR]

Background: The incidence of well-differentiated thyroid cancer (WDTC) is increasing rapidly. Many authors feel that this increase is due to over-diagnosis and that one of the contributing factors is the increasing use of various imaging studies. The rate of obesity has also been increasing in the United States. It has been suggested that patients with an increased body mass index (BMI kg/m2) have a higher incidence of WDTC than patients with normal BMI. One might hypothesize that thyroid nodules are more difficult to palpate in obese patients and that as more cancers are detected by imaging the apparent rate of increase in WDTC in obese patients would appear to be greater than in non-obese patients. This study was undertaken to evaluate this hypothesis by determining if there is any difference in the way thyroid cancers are initially detected in obese and non-obese patients. Methods: The medical records of all 519 patients with a postoperative diagnosis of WDTC who underwent thyroidectomy at NYU Langone Medical Center from January 1, 2007 through August 31, 2010 by the three members of NYU Endocrine Surgery Associates were reviewed. Patients were divided into Non-obese (BMI<30 kg/m2) and Obese (BMI≥30 kg/m2) groups. Patients were also divided by the initial method of detection of their tumor into Palpation, Imaging, and Incidental groups. Results: The final study group contained 270 patients, 181(67%) of whom were in the Non-obese Group and 89(33%) were in the Obese Group. In the Non-obese group, 81(45%) of tumors were found by palpation, 72(40%) were found by imaging, and 28(16%) were found incidentally. In the Obese group, 40(45%) were found by palpation, 38(43%) were found by imaging, and 11(12%) were found incidentally. These differences were not statistically significant (p-value 0.769). Conclusion: We show that BMI does not play a role in the method of initial detection in patients with WDTC. This suggests that the prevalence of WDTC detected by imaging is not an artifact caused by an increasingly obese population and that any association of WDTC and obesity is not related to the way in which these tumors are detected. [ABSTRACT FROM AUTHOR]

Background: Patient-reported experience measures (PREMs) are useful for assessing health care quality and safety and patients' perceptions of health care.Objective: We aimed to assess the relationship between PREMS [e.g., measures of patient-centered care (PCC)] and health care quality metrics.Design: We conducted a national survey via mail. Survey data were supplemented with US Department of Veteran Affairs (VA) administrative data.Participants: Veteran (n = 5512) VA health care users participated in the study.Main Measures: PCC measures included: patient activation; shared decision-making (SDM); empathy and holistic care; chronic illness care; perceptions of participation, respect for choices, and support; and overall health care experience. Health care quality measures included: preventive care screening receipt; chronic condition management (diabetes, hypertension); and health care utilization (hospitalizations, emergency room (ER) visits). Analyses included: bivariate comparisons of PCC measures by health care quality measures; and multivariate linear regression to identify variables associated with attaining multiple positive health care quality indicators (when controlling for potential confounders).Key Results: PREMs assessing factors relating to patient-provider communication (e.g., empathic provider care, shared decision-making) are mainly related to clinical indicators representing good chronic condition management, while those relating more broadly to health care in general (e.g., patient activation, chronic illness care) are mainly related to measures of appropriate health care use (e.g., preventive care screening receipt; potentially avoidable hospitalizations; unscheduled care, such as ER visits). When controlling for potential confounders, higher perceptions of the decision-making effectiveness component of SDM (β = 0.004, p = 0.03) and empathy and holistic care (β = 0.01, p = 0.02) showed a weak but positive relationship with attaining a greater number of positive health care quality indicators, while a weak but negative relationship emerged for perceptions of participation, respect for choices, and support (β = -0.003, p = 0.03) and overall VA experiences (β = -0.10, p = 0.04).Conclusions: PREMs that measure PCC offer rich data about health care quality while engaging patients, and considering patient experiences and preferences, in performance assessment. PREMs may be used to supplement existing performance metrics. [ABSTRACT FROM AUTHOR]

Background: Clinical-performance measurement has helped improve the quality of health-care; yet success in attaining high levels of quality across multiple domains simultaneously still varies considerably. Although many sources of variability in care quality have been studied, the difficulty required to complete the clinical work itself has received little attention.Objective: We present a task-based methodology for evaluating the difficulty of clinical-performance measures (CPMs) by assessing the complexity of their component requisite tasks.Design: Using Functional Job Analysis (FJA), subject-matter experts (SMEs) generated task lists for 17 CPMs; task lists were rated on ten dimensions of complexity, and then aggregated into difficulty composites.Participants: Eleven outpatient work SMEs; 133 VA Medical Centers nationwide.Main Measures: Clinical Performance: 17 outpatient CPMs (2000-2008) at 133 VA Medical Centers nationwide. Measure Difficulty: for each CPM, the number of component requisite tasks and the average rating across ten FJA complexity scales for the set of tasks comprising the measure.Key Results: Measures varied considerably in the number of component tasks (M = 10.56, SD = 6.25, min = 5, max = 25). Measures of chronic care following acute myocardial infarction exhibited significantly higher measure difficulty ratings compared to diabetes or screening measures, but not to immunization measures ([Formula: see text] = 0.45, -0.04, -0.05, and -0.06 respectively; F (3, 186) = 3.57, p = 0.015). Measure difficulty ratings were not significantly correlated with the number of component tasks (r = -0.30, p = 0.23).Conclusions: Evaluating the difficulty of achieving recommended CPM performance levels requires more than simply counting the tasks involved; using FJA to assess the complexity of CPMs' component tasks presents an alternate means of assessing the difficulty of primary-care CPMs and accounting for performance variation among measures and performers. This in turn could be used in designing performance reward programs, or to match workflow to clinician time and effort. [ABSTRACT FROM AUTHOR]

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions. [ABSTRACT FROM AUTHOR]

Objectives The patient centered medical home is now widely supported as a strategy for delivering high quality primary care. The objective of this study was to examine whether children's primary care experiences nationally have become more aligned with the medical home model over time, and how this may have varied for vulnerable children. Methods This study analyzed data on 289,672 children, aged 0-17 years, of families responding to one of three iterations of National Survey of Children's Health from 2003, 2007 and 2011-2012. Each year, we assessed indicators of four medical home features (access, continuity, comprehensiveness, and family-centeredness) and a total medical home score for children nationally and for those with a set of social and demographic risk factors. Results Indicators of access and continuity, and total medical home scores fluctuated but improved overall from 2003 to 2012 (7.1, 6.7 and 1.4 % point increases, respectively), while indicators of comprehensiveness and family-centered care measures declined (2.4 and 1.8 % point decreases, respectively). Children with the highest levels of social and demographic risk experienced larger fluctuations in these measures over time. Conclusions for Practice There were improvements in the extent to which children's primary care experiences aligned with a medical home model, though not linearly or for all component features. Children with more risk factors experienced more volatile changes, suggesting a particular need to attend to the primary care experiences of the most vulnerable children. [ABSTRACT FROM AUTHOR]

Objective: The concurrent use of multiple health care systems may duplicate or fragment care. We assessed the characteristics of veterans who were dually enrolled in both the Veterans Affairs (VA) health care system and a Medicare Advantage (MA) plan, and compared intermediate quality outcomes among those exclusively receiving care in the VA with those receiving care in both systems.Data Sources/study Setting: VA and MA quality and administrative data from 2008 to 2009.Study Design: We used propensity score methods to test the association between dual use and five intermediate outcome quality measures. Outcomes included control of cholesterol, blood pressure, and glycosylated hemoglobin among persons with coronary heart disease (CHD), hypertension, and diabetes.Data Collection/extraction Methods: VA and MA data were merged to identify VA-only users (n = 1,637) and dual-system users (n = 5,006).Principal Findings: We found no significant differences in intermediate outcomes between VA-only and dual-user populations. Differences ranged from a 3.2 percentage point (95 percent CI: -1.8 to 8.2) greater rate of controlled cholesterol among VA-only users with CHD to a 2.2 percentage point (95 percent CI: -2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.Conclusions: For the five measures studied, we did not find evidence that veterans with dual use of VA and MA care experienced improved or worsened outcomes as compared with veterans who exclusively used VA care. [ABSTRACT FROM AUTHOR]

Purpose: In May 2012, the Association of Maternal and Child Health (MCH) Programs initiated a project to develop indicators for use at a state or community level to assess, monitor, and evaluate the application of life course principles to public health. Description: Using a developmental framework established by a national expert panel, teams of program leaders, epidemiologists, and academicians from seven states proposed indicators for initial consideration. More than 400 indicators were initially proposed, 102 were selected for full assessment and review, and 59 were selected for final recommendation as Maternal and Child Health (MCH) life course indicators. Assessment: Each indicator was assessed on five core features of a life course approach: equity, resource realignment, impact, intergenerational wellness, and life course evidence. Indicators were also assessed on three data criteria: quality, availability, and simplicity. Conclusion: These indicators represent a major step toward the translation of the life course perspective from theory to application. MCH programs implementing program and policy changes guided by the life course framework can use these initial measures to assess and influence their approaches. [ABSTRACT FROM AUTHOR]

Objective: This description of the College Health Surveillance Network (CHSN) includes methodology, demography, epidemiology, and health care utilization. Participants: Twenty-three universities representing approximately 730,000 enrolled students contributed data from January 1, 2011, through May 31, 2014. Methods: Participating schools uploaded de-identified electronic health records from student health services monthly. Results: During this study, just over 800,000 individuals used the health centers, comprising 4.17 million patient encounters. Sixty percent of visits included primary care, 13% mental health, 9% vaccination, and 31% other miscellaneous services. The 5 most common specific diagnostic categories (with annual rates per 100 enrolled students) were preventive (16); respiratory (12); skin, hair, and nails; infectious non–sexually transmitted infection (5 each); and mental health (4). Utilization and epidemiologic trends are identified among subpopulations of students. Conclusions: CHSN data establish trends in utilization and epidemiologic patterns by college students and the importance of primary and behavioral health care services on campuses. [ABSTRACT FROM AUTHOR]

Barcode medication administration (BCMA) systems can reduce medication errors, but sociotechnical issues are quite common. Although crucial to nurses’ work, few usability evaluations are available for electronic medication administration record (eMARs) screens. The purpose of this research was to identify current usability problems in the Veterans Administration’s (VA) eMAR/BCMA system and explore how these might affect nurses’ situation awareness (SA). Three expert evaluators used 10 tasks/elements, heuristic evaluation techniques, and explored potential impacts using a SA perspective. The results yielded 99 usability problems categorized into 440 heuristic violations with the largest volume in the category of Match With the Real World. Fifteen usability issues were rated as catastrophic with the Administer/Chart medications task having the most. Situational awareness was affected at all levels, especially at Level 2, Comprehension. Usability problems point to important areas for improvement, because these issues have the potential to affect nurses’ SA, “at a glance” information, nurse productivity, and patient safety. [ABSTRACT FROM PUBLISHER]

Health care in the United States is fragmented, inefficient, and rife with quality concerns. These shortcomings have particularly serious implications for adults with disabilities and functionally impaired older adults in need of long-term services and supports (LTSS). Three strategies have been commonly pursued by state governments to improve LTSS: expanding noninstitutional care, integrating payment and care delivery, and realigning incentives through market-based reforms. These strategies were analyzed using an evaluation framework consisting of the following dimensions: ease of access; choice of setting/provider; quality of care/life; support for family caregivers; effective transitions among multiple providers and across settings; reductions in racial/ethnic disparities; cost-effectiveness; political feasibility; and implementability. Although the analysis highlights potential benefits and drawbacks associated with each strategy, the limited breadth of the evidentiary base precludes an assessment of impact across all nine dimensions. More importantly, the analysis exposes the interdependent, complex system of care within which LTSS is situated, suggesting that policy makers will require a holistic and long-term perspective to achieve needed changes. Addressing the nation's LTSS needs will require a multipronged strategy incorporating a range of health and social services to meet the complex care needs of a diverse population in a variety of settings. [ABSTRACT FROM AUTHOR]

United States (U.S.) pregnant and postpartum (P/PP) women and their infants may be particularly vulnerable to effects from disasters. In an effort to guide post-disaster assessment and surveillance, we initiated a collaborative process with nationwide expert partners to identify post-disaster epidemiologic indicators for these at-risk groups. This 12 month process began with conversations with partners at two national conferences to identify critical topics for P/PP women and infants affected by disaster. Next we hosted teleconferences with a 23 member Indicator Development Working Group (IDWG) to review and prioritize the topics. We then divided the IDWG into three population subgroups (pregnant women, postpartum women, and infants) that conducted at least three teleconferences to discuss the proposed topics and identify/develop critical indicators, measures for each indicator, and relevant questions for each measure for their respective population subgroup. Lastly, we hosted a full IDWG teleconference to review and approve the indicators, measures, and questions. The final 25 indicators and measures with questions (available online) are organized by population subgroup: pregnant women (indicators = 9; measures = 24); postpartum women (indicators = 10; measures = 36); and infants (indicators = 6; measures = 30). We encourage our partners in disaster-affected areas to test these indicators and measures for relevancy and completeness. In post-disaster surveillance, we envision that users will not use all indicators and measures but will select ones appropriate for their setting. These proposed indicators and measures promote uniformity of measurement of disaster effects among U.S. P/PP women and their infants and assist public health practitioners to identify their post-disaster needs. [ABSTRACT FROM AUTHOR]

Objective: The Title V Maternal and Child Health (MCH) Block Grant is the linchpin for US MCH services. The first national performance measures (NPMs) for MCH were instituted in 1997. Changing trends in MCH risk factors, outcomes, health services, data sources, and advances in scientific knowledge, in conjunction with budgetary constraints led the Maternal and Child Health Bureau (MCHB) to design a new performance measurement system. Methods: A workgroup was formed to develop a new system. The following guiding principles were used: (1) Afford States more flexibility and reduce the overall reporting burden; (2) Improve accountability to better document Title V's impact; (3) Develop NPMs that encompass measures in: maternal and women's health, perinatal health, child health, children with special health care needs, adolescent health, and cross-cutting areas. Results: A three-tiered performance measurement system was proposed with national outcome measures (NOMs), NPMs and evidence-based/informed strategy measures (ESMs). NOMs are the ultimate goals that MCHB and States are attempting to achieve. NPMs are measures, generally associated with processes or programs, shown to affect NOMs. ESMs are evidence-based or informed measures that each State Title V program develops to affect the NPMs. There are 15 NPMs from which States select eight, with at least one from each population area. MCHB will provide the data for the NOMs and NPMs, when possible. Conclusions: The new performance measurement system increases the flexibility and reduces the reporting burden for States by allowing them to choose 8 NPMs to target, and increases accountability by having States develop actionable ESMs. Significance: The new national performance measure framework for maternal and child health will allow States more flexibility to address their areas of greatest need, reduce their data reporting burden by having the Maternal and Child Health Bureau provide data for the National Outcome and Performance Measures, yet afford States the opportunity to develop measurable strategies to address their selected performance measures. [ABSTRACT FROM AUTHOR]

Objective: Mild traumatic brain injury (mTBI) accounts for more than 75% of traumatic brain injuries every year. This study examines the temporal association between non-blast mTBI and the onset of neurologic sequelae to illuminate risks of post-concussive syndrome, epilepsy and chronic pain. Methods: A large historical prospective study was conducted utilizing electronically-recorded demographic, medical and military-specific data for over half a million active duty US Air Force Airmen. This study utilized diagnostic codes to identify mTBI exposures, two control groups and three post-mTBI time periods. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards modelling. Results: HRs were higher when mTBI exposed Airmen were compared with the full cohort and lower when compared with the other injured group. When compared to the other injured group, mTBI was positively associated with epilepsy/recurrent seizure outcomes, post-concussive syndrome and pain disorders. HRs tended to be highest within the first 30 days and decreased over time. Conclusions: Findings support that mTBI may have a prolonged neurological impact. Findings are also likely generalizable to young adult populations with exposure to non-blast related mTBI, including civilians, as those included in this study were young adults with a high prevalence of recreational/sports and motor vehicle injuries. [ABSTRACT FROM AUTHOR]

Context. The role of a dynamic legal, medical, and social setting in affecting the perceived risk associated with smoking marijuana has not been well studied. We sought to determine whether there has been a change in the perceived risk associated with marijuana use over time. Methods. A cross-sectional study was conducted using the 2002-2012 National Survey on Drug Use and Health. Respondents were asked to classify the risk of smoking marijuana. Regression analysis and the Mann-Whitney U test were used to analyze the data. Results. A total of 614579 respondents were identified. Between 2002 and 2012, the percent of respondents who characterized regular marijuana use as being associated with 'great risk' decreased from 51.3% to 40.3%, while the percent of respondents who characterized it as being associated with 'no risk' increased from 5.7% to 11.7%. The percent of respondents who characterized occasional use as 'great risk' decreased from 38.2% to 30.7%, while the percent of respondents who characterized it as 'no risk' increased from 10% to 16.3%. There was a significant negative temporal trend in the perceived risk for both occasional and regular use of marijuana from 2002 to 2012 after controlling for age and gender ( p < 0.001 for both). Increasing age was significantly associated with increased perceived risk for both occasional and regular marijuana use ( p < 0.001). Males have a significantly lower perceived risk for regular marijuana use as compared with females ( p < 0.001). Individuals who used marijuana during the preceding month reported a lower risk perception in both regular and occasional use. Conclusion. Between 2002 and 2012, there was a significant decrease in the perceived risk associated with occasional and regular marijuana use. Younger age, male gender, and past month use were also associated with decreased perceived risk. [ABSTRACT FROM AUTHOR]

Objectives There is increasing importance placed on quality of health care for musculoskeletal injuries in emergency departments ( EDs). This systematic review aimed to identify existing musculoskeletal quality indicators ( QIs) developed for ED use and to critically evaluate their methodological quality. Methods MEDLINE, EMBASE, CINAHL, and the gray literature, including relevant organizational websites, were searched in 2013. English-language articles were included that described the development of at least one QI related to the ED care of musculoskeletal injuries. Data extraction of each included article was conducted. A quality assessment was then performed by rating each relevant QI against the Appraisal of Indicators through Research and Evaluation ( AIRE) Instrument. QIs with similar definitions were grouped together and categorized according to the health care quality frameworks of Donabedian and the Institute of Medicine. Results The search revealed 1,805 potentially relevant articles, of which 15 were finally included in the review. The number of relevant QIs per article ranged from one to 11, resulting in a total of 71 QIs overall. Pain ( n = 17) and fracture management ( n = 13) QIs were predominant. Ten QIs scored at least 50% across all AIRE Instrument domains, and these related to pain management and appropriate imaging of the spine. Conclusions Methodological quality of the development of most QIs is poor. Recommendations for a core set of QIs that address the complete spectrum of musculoskeletal injury management in emergency medicine is not possible, and more work is needed. Currently, QIs with highest methodological quality are in the areas of pain management and medical imaging. [ABSTRACT FROM AUTHOR]