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Arlene A Schmid1,2,3,4, John R Kapoor5, Edward J Miech1, Deborah Kuehn6, Mary I Dallas7, Robert D Kerns8, Albert C Lo9,10, John Concato11,12, Michael S Phipps13,14,15, Cody D Couch13, Eileen Moran13, Linda S Williams1,2,3,16, Layne A Goble17,18, Dawn M Bravata1,2,3,191Department of Veteran Affairs (VA) Health Services Research & Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice (CIEBP), 2VA HSR&D Stroke Quality Enhancement Research Initiative (QUERI) Program, Richard L Roudebush VA Medical Center, Indianapolis, IN, USA; 3Regenstrief Institute, Indianapolis, IN, USA; 4Department of Occupational Therapy, Indiana University, IN, USA; 5Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA; 6Nursing Service, 7Physical Medicine and Rehabilitation Service, 8Psychology Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; 9Departments of Neurology, Community Health, and Engineering at Brown University, Providence, RI, USA; 10Providence Veterans Administration Medical Center, Providence, RI, USA; 11Clinical Epidemiology Research Center (CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; 12Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; 13Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; 14Robert Wood Johnson Clinical Scholars Program, 15Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; 16Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA; 17Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA; 18Veterans Administration Medical Center, Charleston, SC, USA; 19Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USABackground: Managing cerebrovascular risk factors is complex and difficult. The objective of this program evaluation was to assess the effectiveness of an outpatient Multidisciplinary Stroke Clinic model for the clinical management of veterans with cerebrovascular disease or cerebrovascular risk factors.Methods: The Multidisciplinary Stroke Clinic provided care to veterans with cerebrovascular disease during a one-half day clinic visit with interdisciplinary evaluations and feedback from nursing, health psychology, rehabilitation medicine, internal medicine, and neurology. We conducted a program evaluation of the clinic by assessing clinical care outcomes, patient satisfaction, provider satisfaction, and costs.Results: We evaluated the care and outcomes of the first consecutive 162 patients who were cared for in the clinic. Patients had as many as six clinic visits. Systolic and diastolic blood pressure decreased: 137.2 ± 22.0 mm Hg versus 128.6 ± 19.8 mm Hg, P = 0.007 and 77.9 ± 14.8 mm Hg versus 72.0 ± 10.2 mm Hg, P = 0.004, respectively as did low-density lipoprotein (LDL)-cholesterol (101.9 ± 23.1 mg/dL versus 80.6 ± 25.0 mg/dL, P = 0.001). All patients had at least one major change recommended in their care management. Both patients and providers reported high satisfaction levels with the clinic. Veterans with stroke who were cared for in the clinic had similar or lower costs than veterans with stroke who were cared for elsewhere.Conclusion: A Multidisciplinary Stroke Clinic model provides incremental improvement in quality of care for complex patients with cerebrovascular disease at costs that are comparable to usual post-stroke care.Keywords: clinical management of stroke, cost, blood pressure management, clinical outcome

Background: In the hierarchy of research designs, the results of randomized, controlled trials are considered to be evidence of the highest grade, whereas observational studies are viewed as having less validity because they reportedly overestimate treatment effects. We used published meta-analyses to identify randomized clinical trials and observational studies that examined the same clinical topics. We then compared the results of the original reports according to the type of research design.Methods: A search of the Medline data base for articles published in five major medical journals from 1991 to 1995 identified meta-analyses of randomized, controlled trials and meta-analyses of either cohort or case-control studies that assessed the same intervention. For each of five topics, summary estimates and 95 percent confidence intervals were calculated on the basis of data from the individual randomized, controlled trials and the individual observational studies.Results: For the five clinical topics and 99 reports evaluated, the average results of the observational studies were remarkably similar to those of the randomized, controlled trials. For example, analysis of 13 randomized, controlled trials of the effectiveness of bacille Calmette-Guérin vaccine in preventing active tuberculosis yielded a relative risk of 0.49 (95 percent confidence interval, 0.34 to 0.70) among vaccinated patients, as compared with an odds ratio of 0.50 (95 percent confidence interval, 0.39 to 0.65) from 10 case-control studies. In addition, the range of the point estimates for the effect of vaccination was wider for the randomized, controlled trials (0.20 to 1.56) than for the observational studies (0.17 to 0.84).Conclusions: The results of well-designed observational studies (with either a cohort or a case-control design) do not systematically overestimate the magnitude of the effects of treatment as compared with those in randomized, controlled trials on the same topic. [ABSTRACT FROM AUTHOR]

Rationale: The lambda-mu-sigma (LMS) method is a novel approach that defines the lower limit of normal (LLN) for the ratio of FEV1/FVC as the fifth percentile of the distribution of Z scores. The clinical validity of this threshold as a basis for establishing chronic obstructive pulmonary disease is unknown.Objective: To evaluate the association between the LMS method of determining the LLN for the FEV1/FVC, set at successively higher thresholds, and clinically meaningful outcomes.Methods: Using data from a nationally representative sample of 3,502 white Americans aged 40-80 years, we stratified the FEV1/FVC according to the LMS-LLN, with thresholds set at the 5th, 10th, 15th, 20th, and 25th percentiles (i.e., LMS-LLN5, LMS-LLN10, etc.). We then evaluated whether these thresholds were associated with an increased risk of death or prevalence of respiratory symptoms. Spirometry was not specifically completed after a bronchodilator.Measurements and Main Results: Relative to an FEV1/FVC greater than or equal to LMS-LLN25 (reference group), the risk of death and the odds of having respiratory symptoms were elevated only in participants who had an FEV1/FVC less than LMS-LLN(5), with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.34-2.12) and an adjusted odds ratio of 2.46 (95% confidence interval, 2.01-3.02), respectively, representing 13.8% of the cohort. Results were similar for persons aged 40-64 years and those aged 65-80 years.Conclusions: In white persons aged 40-80 years, an FEV1/FVC less than LMS-LLN5 identifies persons with an increased risk of death and prevalence of respiratory symptoms. These results support the use of the LMS-LLN5 threshold for establishing chronic obstructive pulmonary disease. [ABSTRACT FROM AUTHOR]

Screening for prostate cancer with prostate-specific antigen remains controversial approximately 20 years after its introduction into routine clinical care. Although numerous research studies have generated evidence to support or refute a benefit of screening, very few reports focus on the most relevant outcome of reducing mortality, and even fewer use rigorous methods of patient-oriented research. In addition, the tendency for personal beliefs (among investigators) to influence the interpretation of data introduces further complexity. Two major randomized trials evaluating the association of screening for prostate cancer and mortality are ongoing, and the results from these trials are anticipated as if an 'emperor' was about to make a pronouncement. In reality, however, the expectation of a definitive answer from these trials may overlook methodological problems and underestimate the uncertainty inherent in scientific investigations. As of 2008, the need to counsel patients regarding the possible benefits and harms that can result from screening for (and treating) prostate cancer remains justified. [ABSTRACT FROM AUTHOR]

CONTEXT: Although many studies have documented problems in communication between physicians and patients, few have focused on discussions regarding prognosis among community dwelling patients with terminal illness. OBJECTIVE: To examine the association of patient race and financial status with patient and clinician reports of discussions about prognosis. DESIGN: Cross-sectional survey. SETTING: Participants' homes. PARTICIPANTS: Two hundred fourteen patients age 60 years or older seriously ill secondary to congestive heart failure, chronic obstructive pulmonary disease, or cancer; and their primary clinicians. MAIN OUTCOME MEASURES: Patient/clinician agreement regarding discussions of prognosis. Results: In adjusted analysis, patients and clinicians were more likely to agree that discussions about prognosis had taken place when patients had a lower financial status (odds ratio [OR] 2.26, 95% confidence interval [CI] 1.03-4.96), or were nonwhite (OR 2.56, CI 0.85-7.68), compared to patients who had a higher financial status or were white. Agreement about prognosis discussions was also more likely (adjusted OR 4.12, 95% CI 1.15-14.76) when patients were younger (i.e., age < 80). CONCLUSIONS: Among a cohort of seriously ill community-dwelling patients, patients and clinicians were more likely to agree that discussions about prognosis had occurred when patients were poorer and nonwhite. These findings contrast with the majority of studies examining the relationship between race or income and patient-physician communication about other end-of-life issues. [ABSTRACT FROM AUTHOR]

Objective: We sought to evaluate the validity of retrieving data from a commercial, outpatient electronic medical record (EMR) to assess the management of pharyngitis, an important measure of quality of healthcare in pediatrics and a new measure for the Health Plan Employer Data and Information Set (HEDIS).Methods: For children ages 3-18 years, we electronically identified clinical encounters with diagnoses of pharyngitis using 3 different strategies (an EMR-based strategy, an administrative data-based strategy, and a reference strategy which used medical record review). By each strategy, we calculated the proportion of episodes of pharyngitis during 1 year for which management of pharyngitis adhered to published guidelines.Results: Among 479 total episodes of pharyngitis, 434 (91%) were from the EMR-based strategy and 281 (59%) from the administrative data-based strategy. Review of the records (the reference strategy) found that 391 of 479 (82%) were confirmed episodes of pharyngitis. A diagnostic test for group A streptococcus (GAS) was performed at 310 of 434 (71%) of episodes identified by the EMR-based strategy and at 214 of 281 (76%) of episodes by the administrative data-based strategy (P = 0.045). By the reference strategy, a diagnostic test was done in 301 of 391 (77%); more than at episodes found by the EMR-based strategy (71%, P < 0.001).Conclusions: The EMR-based strategy resulted in a statistically different proportion of episodes having diagnostic testing for GAS compared with a reference strategy. Complete evaluations to validate strategies for extracting data from electronic databases are necessary before assuming that measures of quality of care will be the same regardless of the source of data. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify the specific bathing subtasks that are affected in community-living-older persons with bathing disability and to determine the self-reported reasons for bathing disability. DESIGN: Cross-sectional study. SETTING: General community of greater New Haven, Connecticut. PARTICIPANTS: A total of 626 community-living persons, aged 73 and older, who completed a comprehensive assessment, including a detailed evaluation of bathing disability. MEASUREMENTS: Trained research nurses assessed bathing disability (defined as requiring personal assistance or having difficulty washing and drying the whole body), the specific bathing subtasks that were affected, and the main reasons (up to three) for bathing disability. RESULTS: Disability in bathing was present in 195 (31%) participants; of these, 97 required personal assistance (i.e., dependence), and 98 had difficulty bathing. Participants with bathing disability reported a mean+/-standard deviation of 4.0+/-2.4 affected subtasks. The prevalence rate of disability for the eight prespecified bathing subtasks ranged from 25% for taking off clothes to 75% for leaving the bathing position. The majority of participants (59%) provided more than one reason for bathing disability. The most common reasons cited by participants for their bathing disability were balance problems (28%), arthritic complaints (26%), and fall or fear of falling (23%). CONCLUSION: For community-living older persons, disability in bathing is common, involves multiple subtasks, and is attributable to an array of physical and psychological problems. Preventive and restorative interventions for bathing disability will need to account for the inherent complexity of this essential activity of daily living. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study was undertaken to determine pertinent attributes of women's hospital experience related to the delivery of their children and to use open-ended responses from women to develop a taxonomy for classifying patient satisfaction in obstetrics. STUDY DESIGN: By using clinimetric methods, we interviewed 67 obstetric patients during their postpartum hospital stays, asking open-ended questions about their satisfaction with care. Responses were transcribed, arranged into distinct groups, and organized as a taxonomy of patient satisfaction. RESULTS: The final taxonomy derived from patient responses was divided into six main axes related to physicians, nurses, other staff, special services, hospital attributes, and personal focus; a total of 51 individual items were identified related to patient satisfaction. These items have face validity, and many are not routinely included in assessments of patient satisfaction. CONCLUSION: A simple strategy of using open-ended questions leads to a clinically relevant and easily understood classification scheme for patient satisfaction with in-hospital obstetric services. [ABSTRACT FROM AUTHOR]