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BackgroundSystematic reviews (SRs) can become outdated as new evidence emerges over time. Organizations that produce SRs need a surveillance method to determine when reviews are likely to require updating. This report describes the development and initial results of a surveillance system to assess SRs produced by the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program.MethodsTwenty-four SRs were assessed using existing methods that incorporate limited literature searches, expert opinion, and quantitative methods for the presence of signals triggering the need for updating. The system was designed to begin surveillance six months after the release of the original review, and then ceforth every six months for any review not classified as being a high priority for updating. The outcome of each round of surveillance was a classification of the SR as being low, medium or high priority for updating.ResultsTwenty-four SRs underwent surveillance at least once, and ten underwent surveillance a second time during the 18 months of the program. Two SRs were classified as high, five as medium, and 17 as low priority for updating. The time lapse between the searches conducted for the original reports and the updated searches (search time lapse - STL) ranged from 11 months to 62 months: The STL for the high priority reports were 29 months and 54 months; those for medium priority reports ranged from 19 to 62 months; and those for low priority reports ranged from 11 to 33 months. Neither the STL nor the number of new relevant articles was perfectly associated with a signal for updating. Challenges of implementing the surveillance system included determining what constituted the actual conclusions of an SR that required assessing; and sometimes poor response rates of experts.ConclusionIn this system of regular surveillance of 24 systematic reviews on a variety of clinical interventions produced by a leading organization, about 70% of reviews

BackgroundFall prevention interventions for community-dwelling older adults have been found to reduce falls in some research studies. However, wider implementation of fall prevention activities in routine care has yielded mixed results. We implemented a theory-driven program to improve care for falls at our Veterans Affairs healthcare facility. The first project arising from this program used a nurse advice telephone line to identify patients' risk factors for falls and to triage patients to appropriate services. Here we report the formative evaluation of this project.MethodsTo evaluate the intervention we: 1) interviewed patient and employee stakeholders, 2) reviewed participating patients' electronic health record data and 3) abstracted information from meeting minutes. We describe the implementation process, including whether the project was implemented according to plan; identify barriers and facilitators to implementation; and assess the incremental benefit to the quality of health care for fall prevention received by patients in the project. We also estimate the cost of developing the pilot project.ResultsThe project underwent multiple changes over its life span, including the addition of an option to mail patients educational materials about falls. During the project's lifespan, 113 patients were considered for inclusion and 35 participated. Patient and employee interviews suggested support for the project, but revealed that transportation to medical care was a major barrier in following up on fall risks identified by nurse telephone triage. Medical record review showed that the project enhanced usual medical care with respect to home safety counseling. We discontinued the program after 18 months due to staffing limitations and competing priorities. We estimated a cost of $9194 for meeting time to develop the project.ConclusionsThe project appeared feasible at its outset but could not be sustained past the first cycle of evaluation due to insufficient resourc

Background The evidence base for quality improvement (QI) interventions is expanding rapidly. The diversity of the initiatives and the inconsistency in labeling these as QI interventions makes it challenging for researchers, policymakers, and QI practitioners to access the literature systematically and to identify relevant publications. Methods We evaluated search strategies developed for MEDLINE (Ovid) and PubMed based on free text words, Medical subject headings (MeSH), QI intervention components, continuous quality improvement (CQI) methods, and combinations of the strategies. Three sets of pertinent QI intervention publications were used for validation. Two independent expert reviewers screened publications for relevance. We compared the yield, recall rate, and precision of the search strategies for the identification of QI publications and for a subset of empirical studies on effects of QI interventions. Results The search yields ranged from 2,221 to 216,167 publications. Mean recall rates for reference publications ranged from 5% to 53% for strategies with yields of 50,000 publications or fewer. The 'best case' strategy, a simple text word search with high face validity ('quality' AND 'improv*' AND 'intervention*') identified 44%, 24%, and 62% of influential intervention articles selected by Agency for Healthcare Research and Quality (AHRQ) experts, a set of exemplar articles provided by members of the Standards for Quality Improvement Reporting Excellence (SQUIRE) group, and a sample from the Cochrane Effective Practice and Organization of Care Group (EPOC) register of studies, respectively. We applied the search strategy to a PubMed search for articles published in 10 pertinent journals in a three-year period which retrieved 183 publications. Among these, 67% were deemed relevant to QI by at least one of two independent raters. Forty percent were classified as empirical studies reporting on a QI intervention. Conclusions The presented search terms a

BackgroundImplementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.MethodsWe planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.ResultsThe leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.ConclusionA theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.

BackgroundWhile falls and urinary incontinence are prevalent among older patients, who sometimes rely on proxies to provide their health information, the validity of proxy reports of concern about falls and urinary incontinence remains unknown.MethodsTelephone interviews with 43 consecutive patients with falls or fear of falling and/or bothersome urinary incontinence and their proxies chosen by patients as most knowledgeable about their health. The questionnaire included items derived from the Medical Outcomes Study Short Form 12 (SF-12), a scale assessing concerns about urinary incontinence (UI), and a measure of fear of falling, the Falls Efficacy Scale (FES). Scores were estimated using items asking the proxy perspective (6 items from the SF-12, 10 items from a UI scale, and all 10 FES items). Proxy and patient scores were compared using intraclass correlation coefficients (ICC, one-way model). Variables associated with absolute agreement between patients and proxies were explored.ResultsPatients had a mean age of 81 years (range 75-93) and 67% were female while proxies had a mean age of 70 (range 42-87) and 49% were female. ICCs were 0.63 for the SF-12, 0.52 for the UI scale, and 0.29 for the FES. Proxies tended to understate patients' general health and incontinence concern, but overstate patients' concern about falling. Proxies who lived with patients and those who more often see patients more closely reflected patient FES scores compared to those who lived apart or those who saw patients less often. Internal consistency reliability of proxy responses was 0.62 for the SF-12, 0.86 for the I-QOL, and 0.93 for the FES. In addition, construct validity of the proxy FES scale was supported by greater proxy-perceived fear of falling for patients who received medical care after a fall during the past 12 months (p < .05).ConclusionCaution should be exercised when using proxies as a source of information about older patients' health perceptions. Questions asking abou

The Centers for Medicare & Medicaid Services (CMS) must generate accurate predictions of future spending for planning purposes. To investigate a better method for understanding how medical breakthroughs and demographic trends will affect future Medicare costs, CMS contracted with RAND to develop models to project how changes in health status, disease, and disability among the next generation of elderly will affect future spending.

Diabetes mellitus is one of the most important causes of morbidity and mortality in the United States. It has been among the top ten causes of death for several decades, and it is the leading cause of end stage renal disease and visual loss among individuals under age 65. In 1997, diabetes was responsible for approximately 2.3 million hospital admissions, 14 million hospital days, and 70 million nursing home days. Direct medical expenditures on diabetic care were estimated at $44 million. At Northern California Kaiser, a matched cohort analysis indicated that the annual excess expenditures for diabetic patients totaled $3,500 per person. The prevalence of diabetes rises dramatically with age: More than 10% of persons over age 65 have clinical diabetes. Almost all of these older patients have type II diabetes. Elderly patients are still at risk for the long term complications of diabetes, having an approximately two-fold increased risk for myocardial infarction, stroke, and renal insufficiency, when compared with persons of the same age without diabetes. To date, there has been considerable high quality research on the prevention and management of complications of diabetes. However, most of these data are not specific to elderly patients, and none are specific to individuals age 80 or older. Thus, extrapolation of published data to the vulnerable elderly population is a major challenge for developing quality indicators for this group. A related challenge pertains to the time frame required in order to benefit from the proposed indicators. Many testing and management strategies require a minimum of two to three years (and in some cases, much longer) in order to accrue significant benefits. Therefore, except where noted, all of the quality indicators in this paper are intended for persons who have a life expectancy of at least two to three years., The original document contains color images.

Mr. Chairman, we welcome the opportunity to submit testimony for the New York State Senate Committee on Consumer Protection on the dietary supplement ephedra. Key findings from our research: * Ephedra and ephedrine promote modest short-term weight loss; their long-term effect is unknown. * Ephedrine plus caffeine moderately boosts performance for fit young men; there is no evidence that ephedra or ephedrine improves long-term physical performance of athletes or would work for the general public. * Ephedra and ephedrine increase the risk of nausea, vomiting, jitteriness, and palpitations. * These products may be linked to catastrophic events such as sudden death, heart attack, or stroke., Testimony submitted for the record by the authors for the New York State Senate Committee on Consumer Protection on May 30, 2003.