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The number of uninsured Americans increased by more than 6 million adults, primarily due to a decline in employer-sponsored coverage without a compensatory increase in federal- and state-sponsored coverage such as the authorization of health savings accounts through 2003 Medicare Modernization Act. Efforts to improve the use of recommended health care services among the uninsured should focus on patient education and expanding insurance eligibility for both lower-income and higher-income adults.

An attempt is made to determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. The findings reveal that door-to-balloon times were longer during off-hours than regular hours while door-to-drug times did not differ appreciably by time of day or day of week.

* BACKGROUND Although nurses are ideally situated to facilitate communication about prognosis and hospice referral among patients, patients family members, and hospital staff, nurses do not always assume this task. [...]

Race and ethnicity differences in door-to-drug and door-to-balloon times for patients receiving primary reperfusion for ST-segment elevation myocardial infarction are estimated. The results revealed that a substantial portion of the racial and ethnic disparity in time to treatment was accounted for by the specific hospital to which patients were admitted, in contrast to differential treatment by race and ethnicity inside the hospital.

Objectives. This study estimates the consequences of older husbands' involuntary job loss for their wives' mental health. Methods. Using longitudinal data from the 1992, 1994, and 1996 waves of the Health and Retirement Study, multivariate regression models were estimated to measure the impact of older husbands' involuntary job loss on wives' mental health. We created two longitudinal data sets of two waves each to use in our analysis. The first data set, or period, combined Waves 1 and 2 of the Health and Retirement Study and described the 1992-1994 experience of spouse pairs in our sample. It included the wives of 55 husbands who experienced involuntary job loss between these survey dates and a comparison group of wives of 730 continuously employed husbands. The second data set described the 1994-1996 experience of couples. In particular, it included the wives of an additional 38 husbands who were displaced from their jobs between Waves 2 and 3, and a comparison group of wives of 425 husbands who were continuously employed from 1994 to 1996. Results. Husbands' involuntary job loss did not have a statistically significant effect on wives' mental health. We found no evidence that changes in husbands' depressive symptoms modified the effect of his job loss on wives' mental health. In the first period only, the effect of husbands' job loss on wives' mental health was more pronounced for wives who were more financially satisfied at baseline. Discussion. There is limited evidence among this cohort that husbands' job loss increases wives' subsequent depressive symptoms. However, the effect of husbands' job loss on wives' mental health appears to be magnified when wives report being financially satisfied pre-job loss. This suggests that, for subgroups of older couples, mental health services specifically targeted at displaced men should also be made available to wives.

Objectives. The purpose of this study was to develop a patient-centered measure of treatment preference applicable across a range of diseases and treatment decisions. Methods. Instrument development was based on previous research supplemented by open-ended interviews and focus groups. Psychometric properties of the instrument were determined by administration to 125 persons aged 60 or older with a limited life expectancy secondary to congestive heart failure, chronic obstructive pulmonary disease, or cancer. Test-retest and inter-rater reliability were established using intraclass correlation coefficients. Construct validity was established by examining associations of the measure with a single-item question regarding treatment goals and with age, ethnicity, and functional impairment, characteristics known to be associated with preferences. The Willingness to Accept Life-Sustaining Treatment instrument (WALT) consists of 6 scenarios in which respondents weigh treatment burden against treatment outcomes expressed in terms of the likelihood of different health states and length of life following treatment. Results. Inter-rater reliability ranged from .73 to .95 and test-retest reliability from .49 to .93. WALT scores were significantly associated with a simpler measure of preference and with age, ethnicity, and functional impairment. Conclusions. The WALT measures patients' treatment preferences, assessed in the context of treatment burden and multiple aspects of treatment outcome with sound psychometric properties.

Many terminally ill patients will not accept treatments that might leave them with severe functional or intellectual impairment even if the treatment might lengthen their survival. In other words, the patient may or may not accept a particular treatment depending on its outcome. Consequently, doctors must be prepared to discuss any potential outcomes with their patients.

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.