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Background: Many newly diagnosed patients present to outpatient care with advanced HIV infection. More timely HIV diagnosis and initiation of care has the potential to improve individual health outcomes and has public health implications.Objective: To assess temporal trends in late presentation for outpatient HIV medial care as measured by CD4 count <200 cells/mm(3) and the implications on short-term (1-year) mortality.Design: We conducted a cohort study nested in a prospective HIV clinical cohort including patients establishing initial outpatient HIV treatment between 2000-2010. Time series regression analysis evaluated temporal trends in late presentation for care measured by the proportion of patients with a CD4 count <200 cells/mm(3) or an opportunistic infection at enrollment, and also evaluated trends in short-term mortality.Participants: Patients establishing initial outpatient HIV treatment between 2000-2010 at an academic HIV clinic.Main Measures: The proportion of patients with a CD4 count <200 cells/mm(3) or an opportunistic infection at initial presentation and short-term (1-year) mortality following clinic enrollment.Key Results: Among 1121 patients, 41% had an initial CD4 count <200 cells/mm(3), 25% had an opportunistic infection and 2.4% died within 1-year of their initial visit. Time series regression analysis demonstrated significant reductions in late presentation for HIV care and decreases in short-term mortality with temporal improvement preceding updated CDC HIV testing recommendations.Conclusion: We observed a significant decline in the number of patients presenting for outpatient HIV care with advanced disease, particularly in 2006-2010. A significant trend in improved short-term survival among patients establishing HIV care was also observed, likely related to more timely presentation for outpatient care in more recent years. [ABSTRACT FROM AUTHOR]

Background: Low-income, African-American smokers are less likely to have resources to aid in quitting smoking. Narrative communication may provide an enhancement to traditional smoking cessation interventions like NRT, medications, or behavioral treatments for this audience. After extensive pilot testing of stories and personal experiences with smoking cessation from African-Americans from a low-income community, we conducted a randomized control trial using stories to augment routine inpatient treatment among African-Americans at an urban Southern hospital (N = 300). Results: Differences in smoking cessation outcomes between the intervention (stories DVD + routine clinical treatment) and control (routine clinical treatment) arms were compared using self-report and carbon monoxide measurement at 6-months. Compared to control, individuals who viewed the intervention stories DVD reported greater intentions to quit. Although continuous quitting marginally favored the intervention, our main result did not reach statistical significance (p = 0.16). Conclusion: Narrative communication via storytelling to promote smoking cessation among African-Americans in the South is one method to communicate smoking cessation. Results suggest this may not be sufficient as a standalone augmentation of routine clinical treatment for continuous smoking cessation. Smoking cessation efforts need to continually assess different means of communicating to smokers about quitting. [ABSTRACT FROM AUTHOR]

Purpose: To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes. Methods: Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction). Findings: Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P= .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P= .16). We observed no differences between degree of rural and reasonable BP or LDL control ( P= .42, P= .23 , respectively) or optimal A1c or BP control ( P= .52, P= .65 , respectively). Optimal and mean LDL values worsened as rurality increased ( P= .08, P= .029 , respectively). Conclusions: In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients' residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted. [ABSTRACT FROM AUTHOR]

Objectives. We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs. Methods. Data from the 2003-2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women. Results. No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P=.59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR]=0.57; 95% confidence interval [CI] = 0.42,0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24,2.31) and 2.18 (95% CI = 1.25,3.82) among African American women with 13to 15years of education and 16years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women. Conclusions. Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be an important driver of health disparities, representing a fruitful area for future interventions. (Am J Public Health. 2009;99:1659-1665. doi:10.2105/AJPH.2008.154088) [ABSTRACT FROM AUTHOR]

Background: The conceptualization of patient complexity is just beginning in clinical medicine.Objectives: This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.Methods/results: The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare.Conclusions/recommendations: We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health. [ABSTRACT FROM AUTHOR]

OBJECTIVE--With performance-based reimbursement pressures, it is concerning that most performance measurements treat each condition in isolation, ignoring the complexities of patients with multiple comorbidities. We sought to examine the relationship between comorbidity and commonly assessed services for diabetic patients in a managed care organization. RESEARCH DESIGN AND METHODS--In 6,032 diabetic patients, we determined the association between the independent variable medical comorbidity, measured by the Charlson Comorbidity Index (CCI), and the dependent variables A1C testing, lipid testing, dilated eye exam, and urinary microalbumin testing. We calculated predicted probabilities of receiving tests for patients with increasing comorbid illnesses, adjusting for patient demographics. RESULTS--A1C and lipid testing decreased slightly at higher CCI: predicted probabilities for CCI quartiles 1,2, 3, and 4 were 0.83 (95% CI 0.70-0.91), 0.83 (0.69-0.92), 0.82 (0.68-0.91), and 0.78 (0.61-0.88) for A1C, respectively, and 0.82 (0.69-0.91), 0.81(0.67-0.90), 0.79 (0.64-0.89), and 0.77 (0.61-0.88) for lipids. Dilated eye exam and urinary microalbumin testing did not differ across CCI quartiles: for quartiles 1,2, 3, and 4, predicted probabilities were 0.48 (0.33-0.63), 0.54 (0.38-0.69), 0.50 (0.34-0.65), and 0.50 (0.34-0.65) for eye exam, respectively, and 0.23 (0.12-0.40), 0.24 (0.12-0.42), 0.24 (0.12-0.41), and 23 (0.11-0.40) for urinary microalbumin. CONCLUSIONS--Services received did not differ based on comorbid illness burden. Because it is not clear whether equally aggressive care confers equal benefits to patients with varying comorbid illness burden, more evidence confirming such benefits may be warranted before widespread implementation of pay-for-performance programs using currently available "one size fits all" performance measures. [ABSTRACT FROM AUTHOR]

It is estimated that up to one-third of persons with known human immunodeficiency virus (HIV) infection in the United States are not engaged in care. We evaluated factors associated with patients' failure to establish outpatient HIV care at our clinic and found that females, racial minorities, and patients lacking private health insurance were more likely to be ‘no shows.’ At the clinic level, longer waiting time from the call to schedule a new patient visit to the appointment date was associated with failure to establish care. Because increased numbers of patients will be in need of outpatient HIV care as a result of recent Centers for Disease Control and Prevention guidelines advocating routine HIV testing, it is imperative that strategies to improve access are developed to overcome the ‘no show’ phenomenon. [ABSTRACT FROM AUTHOR]

It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively. To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training. Cross-sectional study. One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003. We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents. Postgraduaute year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P=.03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year. Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training. [ABSTRACT FROM AUTHOR]

Reports on a study done on quality improvement using achievable benchmarks for physician feedback. Performance feedback and benchmarking as common tools for health care improvement; Multimodal improvement intervention; Preintervention and postintervention changes; results; conclusion.

Discusses the appropriate application of inferential statistics to practice profiles and other measures of medical care. Domains of medical quality; Circumstances that arise in the measurement of medical care; Statistical techniques commonly used in the measurement of quality; Challenges that arise in using the techniques.

Objectives. Expert panels determined the public health goals of Healthy People 2000 subjectively. The present study examined whether data-driven benchmarks provide a better alternative. Methods. We developed the "pared-mean" method to define from data the best achievable health care practices. We calculated the pared-mean benchmark for screening mammography from the 1994 National Health Interview Survey, using the metropolitan statistical area as the "provider" unit. Beginning with the best-performing provider and adding providers in descending sequences, we established the minimum provider subset that included at least 10% of all women surveyed on this question. The pared-mean benchmark is then the proportion of women in this subset who received mammography. Results. The pared-mean benchmark for screening mammography was 71%, compared with the Healthy People 2000 goal of 60%. Conclusions. For Healthy People 2010, benchmarks derived from data reflecting the best available care provide viable alternatives to consensus-derived targets. We are currently pursuing additional refinements to the data-driven pared-mean benchmark approach. [ABSTRACT FROM AUTHOR]

The author focuses on a supplement that provides a systematic summary of intervention strategies to promote equitable health outcomes through evidence-based care for communities of color. The supplement is supported by the Robert Wood Johnson Foundation through Finding Answers: Disparities Research for Change. The author is tasked to read the initial manuscripts solicit peer reviewers and assist authors in responding to critiques.

The article focuses on the important role of pharmacists in providing quality health care in the U.S. Providing quality health care can be achieved by understanding the principles in comparative effectiveness studies. Comparative effectiveness studies are important in the health care industry because this involves the discussion of health care policies which can affect direct patient care.

A response by Monika M. Safford, Catarina I. Kiefe and Jeroan J. Allison to a letter to the editor on their article about patient complexity vector model is presented.

A letter to the editor is presented in response to an article related to adoption of computerized physician order entry by David Culter in the November/December 2005 issue.

Objectives: This study examined how physicians perceive pharmaceutical companies' medication assistance programs (MAPs).Methods: The study was conducted using a survey of 373 primary care physicians from four southern states; they were surveyed within the formative evaluation phase of a larger study (MI-Plus). Respondents were queried about use and usefulness of MAPs for patients who cannot afford drugs, and barriers to using them. Bivariate associations between physician-level variables (patients without drug coverage) and usefulness and barriers to using MAPs were assessed using Chi square tests. Independence of associations was assessed using multiple logistic regressions.Results: Of the 364 (97.6%) respondents who used MAPs, 70% used them regularly, the rest occasionally; 63% found MAPs very useful in caring for patients who could not afford drugs. About 89% reported one or more barriers to using MAPs; 47% saw "inability of patients to apply directly;" and 57% saw "enrollment process being time-consuming for staff" as barriers. Compared to physicians with fewer elderly patients without drug coverage, those with more of these patients were less likely to find MAPs very useful; less likely to report no barriers to using MAPs; and more likely to see "low income thresholds" and "inability of patients to apply directly" as barriers.Conclusion: While MAPs are considered useful in caring for patients in need of assistance, there are many barriers to their use. Pharmaceutical companies should address these barriers. Limitations include a low response rate (about 10%). [ABSTRACT FROM AUTHOR]

Efforts to identify the underlying structure of 40 survey items dealing with perceptions of medical errors are reported on the basis of responses from 195 medical residents. Factor analysis revealed that the medical errors perceptions were represented by a 10-factor solution. The external validity of these factors was examined relative to perceptions about the cost of medical errors, the cost of errors to health care, and the need for education and interventions to address errors. Results indicated that 13.9% of the variation in the perceived cost of medical errors and 17.1% of the variation in the perceived need for additional physician education was explained by the factor structure. [ABSTRACT FROM AUTHOR]

Objectives: Despite effective approaches for managing chlamydial infection, asymptomatic disease remains highly prevalent. We linked administrative data with physician data from the American Medical Association physician survey to identify characteristics of primary care offices associated with best chlamydia screening practices.Study: Criteria from the National Committee for Quality Assurance provided chlamydia screening rates. We defined top-performing offices as those with rates in the top decile among 978 primary care offices from 26 states.Results: Offices screened an average of 16.2% of at-risk, young women, but top-performing offices screened 42.2%. Top-performing offices on average had more black physicians (12.5%, 5.1%, P = 0.001) and were more often located in zip code areas with median income less than $30,000 (22.6%, 5.5%, P = 0.001).Conclusions: Although chlamydia screening rates are alarmingly low overall, there is substantial variation across offices. Understanding predictors of better office performance may lead to effective interventions to promote screening. [ABSTRACT FROM AUTHOR]