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Background: The mortality and complication rates of many surgical procedures are inversely related to hospital procedure volume. The objective of this study was to determine whether the volumes of primary and revision total hip replacements performed at hospitals and by surgeons are associated with rates of mortality and complications.Methods: We analyzed claims data of Medicare recipients who underwent elective primary total hip replacement (58,521 procedures) or revision total hip replacement (12,956 procedures) between July 1995 and June 1996. We assessed the relationship between surgeon and hospital procedure volume and mortality, dislocation, deep infection, and pulmonary embolus in the first ninety days postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, comorbid conditions, and income. Analyses of hospital volume were adjusted for surgeon volume, and analyses of surgeon volume were adjusted for hospital volume.Results: Twelve percent of all primary total hip replacements and 49% of all revisions were performed in centers in which ten or fewer of these procedures were carried out in the Medicare population annually. In addition, 52% of the primary total hip replacements and 77% of the revisions were performed by surgeons who carried out ten or fewer of these procedures annually. Patients treated with primary total hip replacement in hospitals in which more than 100 of the procedures were performed per year had a lower risk of death than those treated with primary replacement in hospitals in which ten or fewer procedures were performed per year (mortality rate, 0.7% compared with 1.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.38, 0.89). Patients treated with primary total hip replacement by surgeons who performed more than fifty of those procedures in Medicare beneficiaries per year had a lower risk of dislocation than those who were treated by surgeons who performed five or fewer of the procedures per year (dislocation rate, 1.5% compared with 4.2%; adjusted odds ratio, 0.49; 95% confidence interval, 0.34, 0.69). Patients who had revision total hip replacement done by surgeons who performed more than ten such procedures per year had a lower rate of mortality than patients who were treated by surgeons who performed three or fewer of the procedures per year (mortality rate, 1.5% compared with 3.1%; adjusted odds ratio, 0.65; 95% confidence interval, 0.44, 0.96).Conclusions: Patients treated at hospitals and by surgeons with higher annual caseloads of primary and revision total hip replacement had lower rates of mortality and of selected complications. These analyses of Medicare claims are limited by a lack of key clinical information such as operative details and preoperative functional status. [ABSTRACT FROM AUTHOR]

Previous studies documented racial and gender disparities in implantable cardioverter-defibrillator (ICD) placement. The authors examined whether racial and gender disparities in ICD placement are due to underutilization or overutilization. Among 1,054 adults hospitalized from 2001 to 2004 with ventricular arrhythmias in a large academic hospital, the study found that 17% of patients had clinical indicators concordant with ICD placement criteria. Among those, Blacks were less likely than Whites to receive an ICD (adjusted odds ratio [OR] = 0.24; 95% CI = 0.08-0.71). Among the 83% who were discordant with ICD placement criteria, Blacks (adjusted OR = 0.30; 95% CI = 0.18-0.52) and Hispanics (adjusted OR = 0.24, 95% CI = 0.10-0.57) were less likely than Whites, and women less likely than men, to receive an ICD (adjusted OR = 0.48; 95% CI = 0.34-0.67). In this cohort, these differences appear related to overutilization among men and Whites who are discordant with ICD placement criteria in addition to underutilization among Blacks concordant with placement criteria. [ABSTRACT FROM AUTHOR]

Objective: We applied constructs from the transtheoretical model (TTM) of behavior change to identify modifiable determinants of patient participation in medical decision-making.Method: We surveyed a convenience sample of 621 primary care patients at one Boston hospital (response rate 60.6%). With a random half of the sample, we examined the factor structure of a new Patient Attitudes and Beliefs Scale (PABS) that focused on issues about participation in medical decision-making, and with the other half we confirmed the factor structure and examined the association of patients' stage of readiness to participate in decision-making with subscales of the PABS (pros, cons, and decisional balance), self-efficacy, and trust in physician.Results: Patients were classified into 4 stages: precontemplation (don't participate and don't intend to, 17.2%), contemplation (don't participate but contemplating participating, 6.9%), preparation (participate to some degree, 36.1%), and action (participate fully, 39.8%). Factor analysis of the PABS items indicated 2 factors representing pros and cons of participation. Scores on the pros increased and cons decreased significantly from precontemplation to action (P < 0.001). Significant nonlinear associations of stage of readiness with self-efficacy (P < 0.01) and trust in physician (P < 0.01) were evident; self-efficacy scores were highest for those in action whereas trust scores were highest for those in precontemplation.Conclusions: To move people from precontemplation towards action in participating in medical decision-making, interventions focusing on increasing the pros and decreasing the cons of participation may be needed. The challenge is to balance advocacy for an active patient role with individual patients' preference for participation. [ABSTRACT FROM AUTHOR]

Context: Health care organizations use many strategies to influence physician behavior and the care delivered, but the effect of such strategies on quality is not known.Objective: We sought to assess the influence of practice management strategies and financial arrangements on the quality of diabetes care.Design: This was a retrospective cohort study including medical record reviews and a physician survey.Participants: Patients with diabetes mellitus (n=652) enrolled in 3 health plans located in Minnesota and 399 physicians in 135 practices who cared for them participated in this study.Main Outcome Measure: Our main outcome measures was a quality score indicating receipt of care in accordance with 6 accepted quality indicators.Results: The mean quality score was 2.4 (SD 1.2) on a 6-point scale. Only a small proportion of the variation in quality was attributed to characteristics of physicians' practices (5%). Quality scores tended to be higher for patients whose physicians received quality performance reports or utilization profiles from more than 1 source (P=0.08), routinely enrolled diabetic patients in disease-management programs (P=0.06), or received diabetes-specific reports (P=0.06). Quality scores were lower for patients whose physicians were paid according to fee-for-service compared with salary (P=0.04) and served as gatekeepers for >50% of their patients (P=0.06). However, these findings were all of borderline statistical significance, and the absolute differences in quality were small.Conclusions: Current practice management strategies and financial arrangements have a limited impact on the quality of care for patients with diabetes. These findings suggest that other strategies may be necessary for health care organizations to improve care for patients with diabetes. [ABSTRACT FROM AUTHOR]

Past assessments of comorbidity indices have sought to recommend a single index that performs better than others. The authors used a multiple informants approach as an alternative method to simultaneously assess five indices of comorbidity. This approach provides a single estimate of the overall effect of comorbidity and evaluates the relation any individual index has to the outcomes of interest. Association of comorbidity with definitive primary therapy, discussion of tamoxifen, and receipt of tamoxifen was evaluated in a cohort of 830 older breast cancer patients enrolled at four geographically distinct centers in the United States from 1996 to 1999. The estimated adjusted effect of a unit increase in comorbidity on the odds of discussing tamoxifen therapy was 0.70 (95% confidence interval: 0.56, 0.88). An increase in comorbidity was not associated with receipt of definitive primary therapy (odds ratio = 0.94, 95% confidence interval: 0.79, 1.13) or receipt of tamoxifen (odds ratio = 0.96, 95% confidence interval: 0.72, 1.27). The multiple informants regression proved superior to separate regression models that included only one index. In analyses that require comorbidity adjustment and for which no single index is expected to be ideal, the multiple informants approach is an attractive alternative to selecting a single index and to other methods of using multiple indices. [ABSTRACT FROM AUTHOR]

BACKGROUND: Information on the epidemiology of primary total hip replacement is limited, and we are not aware of any reports on the epidemiology of revision total hip replacement. The objective of this study was to characterize the rates and immediate postoperative outcomes of primary and revision total hip replacement in persons sixty-five years of age and older residing in the United States. METHODS: We used Medicare claims submitted by hospitals, physicians, and outpatient facilities between July 1, 1995, and June 30, 1996, to identify individuals who had undergone elective primary total hip replacement for a reason other than a fracture (61,568 patients) or had had revision total hip replacement (13,483 patients). Annual incidence rates of primary and revision total hip replacement were calculated, and multivariate modeling was used to evaluate the association between patient characteristics and surgical rates. The rates of occurrence of five complications within ninety days postoperatively were also evaluated, and relationships between those outcomes and patient characteristics were assessed with use of multivariate models adjusted for hospital and surgeon volume. RESULTS: The rates of primary total hip replacement were three to six times higher than the rates of revision total hip replacement. Women had higher rates than men, and whites had higher rates than blacks. The rates of primary and revision total hip replacement increased with age until the age of seventy-five to seventy-nine years and then declined. The rates of complications occurring within ninety days after primary total hip replacement were 1.0% for mortality, 0.9% for pulmonary embolus, 0.2% for wound infection, 4.6% for hospital readmission, and 3.1% for hip dislocation. The rates after revision total hip replacement were 2.6%, 0.8%, 0.95%, 10.0%, and 8.4%, respectively. Factors associated with an increased risk of an adverse outcome included increased age, gender (men were at higher risk than women), race (blacks were at higher risk than whites), a medical comorbidity, and a low income. CONCLUSIONS: Analysis of United States Medicare population data showed that the rates of total hip replacement increased with age up to the age of seventy-five to seventy-nine years and that blacks had a significantly lower rate of total hip replacement than whites. The overall rates of adverse outcomes were relatively low, but they were significantly higher after revision than after primary total hip replacement. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective study). See p. 2 for complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The lengths of acute hospital stays following total hip replacement have diminished substantially in recent years. As a result, a greater proportion of complications occurs following discharge. Data on the incidence trends of major complications of total hip replacement would facilitate recognition and management of these adverse events.Methods: We used Medicare claims data on beneficiaries sixty-five years and older who had had elective, primary total hip replacement for a reason other than a fracture (58,521 patients) or had had revision total hip replacement (12,956 patients) between July 1, 1995, and June 30, 1996. We calculated incidence rates of dislocation, pulmonary embolism, and deep hip infection per 10,000 person-weeks for four time-periods following the admission for the surgery (during the index hospitalization, from discharge to four weeks postoperatively, from five to thirteen weeks postoperatively, and from fourteen to twenty-six weeks postoperatively). We then used life-table methods to estimate the cumulative incidence of each complication over the first six postoperative months.Results: Of the patients who had had a primary total hip replacement, 3.9% had a dislocation, 0.9% had a pulmonary embolism, and 0.2% had a deep infection in the first twenty-six postoperative weeks. In the revision total hip replacement cohort, the proportions with dislocation, pulmonary embolism, and deep infection were 14.4%, 0.8%, and 1.1%, respectively. The rates of these adverse outcomes were highest during the index hospitalization, diminished considerably in the period from discharge to four weeks postoperatively, and continued to drop in the periods from five to thirteen and fourteen to twenty-six weeks postoperatively.Conclusions: The incidence rates of dislocation, pulmonary embolism, and deep infection are highest immediately after total hip replacement, but they continue to be elevated throughout the first three postoperative months. With the lengths of hospital stays continuing to diminish, an increasing proportion of complications will occur in outpatients. These findings provide a basis for developing strategies to prevent these complications in the postdischarge management of patients who have had elective total hip replacement.Level Of Evidence: Prognostic study, Level II-1 (retrospective study). See p. 2 for complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

We review the research both for and against patient participation in decision-making and conclude that (a) patients want to be informed of treatment alternatives, (b) they, in general, want to be involved in treatment decisions when more than one treatment alternative exists, and (c) the benefits of participation have not yet been clearly demonstrated in research studies. However, studies that have addressed the latter issue suffer from methodological problems such as small sample sizes and lack of control for potential confounding variables. We conclude that patient participation in decision-making is justified on humane grounds alone and that physicians should endeavor to engage patients in decision-making, albeit at varying degrees, when more than one effective treatment option exists. We propose that methods be developed to evaluate a patient's level of 'readiness' to participate in decision-making and that interventions that match the patient's level of readiness be applied to increase participation. [ABSTRACT FROM AUTHOR]

Surveys active cancer chemotherapy outpatients receiving treatment in the community to document the prevalence and to identify the correlates of their daily living needs. Introduction; Methods; Results; Level of need and unmet need; Care providers; Correlates of need; Correlates of unmet need; Screening algorithm for unmet need; Discussion.

Context: The effectiveness of recruiting local medical opinion leaders to improve quality of care is poorly understood.Objective: To evaluate a guideline-implementation intervention of clinician education by local opinion leaders and performance feedback to (1) increase use of lifesaving drugs (aspirin and thrombolytics in eligible elderly patients, beta-blockers in all eligible patients) for acute myocardial infarction (AMI), and (2) decrease use of a potentially harmful therapy (prophylactic lidocaine).Design: Randomized controlled trial with hospital as the unit of randomization, intervention, and analysis.Setting: Thirty-seven community hospitals in Minnesota.Patients: All patients with AMI admitted to study hospitals over 10 months before (1992-1993, N=2409) or after (1995-1996, N=2938) the intervention.Intervention: Using a validated survey, we identified opinion leaders at 20 experimental hospitals who influenced peers through small and large group discussions, informal consultations, and revisions of protocols and clinical pathways. They focused on (1) evidence (drug efficacy), (2) comparative performance, and (3) barriers to change. Control hospitals received mailed performance feedback.Main Outcome Measures: Hospital-specific changes before and after the intervention in the proportion of eligible patients receiving each study drug.Results: Among experimental hospitals, the median change in the proportion of eligible elderly patients receiving aspirin was +0.13 (17% increase from 0.77 at baseline), compared with a change of -0.03 at control hospitals (P=.04). For beta-blockers, the respective changes were +0.31 (63% increase from 0.49 at baseline) vs +0.18 (30% increase from baseline) for controls (P=.02). Lidocaine use declined by about 50% in both groups. The intervention did not increase thrombolysis in the elderly (from 0.73 at baseline), but nearly two thirds of eligible nonrecipients were older than 85 years, had severe comorbidities, or presented after at least 6 hours.Conclusions: Working with opinion leaders and providing performance feedback can accelerate adoption of some beneficial AMI therapies (eg, aspirin, beta-blockers). Secular changes in knowledge and hospital protocols may extinguish outdated practices (eg, prophylactic lidocaine). However, it is more difficult to increase use of effective but riskier treatments (eg, thrombolysis) for frail elderly patients. [ABSTRACT FROM AUTHOR]

Objective: To determine whether physicians' risk attitudes correlate with their triage decisions for emergency department patients with acute chest pain.Design: Cohort.Setting: The emergency department of a university teaching hospital.Patients: Patients presenting to the emergency department with a chief complaint of acute chest pain. PHYSICIANS: All physicians who were primarily responsible for the emergency department triage of at least one patient with acute chest pain from July 1990 to July 1991.Methods: The physicians' risk attitudes were assessed by two methods: 1) a new, six-question risk-taking scale adapted from the Jackson Personality Index (JPI), and 2) the Stress from Uncertainty Scale (SUS).Results: The physicians who had high risk-taking scores ("risk seekers") admitted only 31% of the patients they evaluated, compared with admission rates of 44% for the medium scores and 53% for the physicians who had low risk-taking scores ("risk avoiders"), p < 0.001. After adjustment for clinical factors, the patients triaged by the risk-seeking physicians had half the odds of admission [odds ratio (OR) 0.51, 95% confidence interval (95% CI) 0.27 to 0.97], and the patients triaged by the risk-avoiding physicians had nearly twice the odds of admission (OR 1.83, 95% CI 1.10 to 3.03) of the patients triaged by the medium-risk scoring physicians. The SUS did not correlate significantly with admission rates. Of the 92 patients released home by the risk-seeking physicians, 91 (99%) were known to be alive four to six weeks afterwards and one was lost to follow-up; among the 66 patients released by the risk-avoiding physicians, 64 (97%) were known to be alive at four to six weeks, one was lost to follow-up, and one died of ischemic heart disease during a subsequent hospitalization (p = NS).Conclusions: The physicians' risk attitudes as measured by a brief risk-taking scale correlated significantly with their rates of admission for emergency department patients with acute chest pain. These data do not suggest that the risk-seeking physicians achieved lower admission rates by releasing more patients who needed to be in the hospital, but an adequate evaluation of the appropriateness of triage decisions of risk-seeking and risk-avoiding physicians will require further study. [ABSTRACT FROM AUTHOR]

Objectives: To examine whether differences in intensities of care by socioeconomic status and race result in worse health among adults with asthma post-hospital discharge.Design: Patients were enrolled during hospitalization and recontacted three months after discharge.Patients: Those aged 18-55 years, with a primary diagnosis of asthma (n = 97).Main Outcome Measures: Regular source of care, "intensive" therapy (use of an anti-inflammatory agent, pulmonary function testing, or an asthma specialist), and patient-reported (Intermediate Activities of Daily Living Scale [IADL] score, dyspnea) and performance-based (peak flow rate) measures of health status post-discharge.Results: 28% of patients with a yearly income less than $16,000 had no regular source of care, compared with 11% of those with an income from $16,000 to $29,999 and no patient with an income of at least $30,000 (p = 0.003). Similarly, intensive therapy was received by 40%, 67%, and 81% of these groups (p = 0.005). Education had similar associations. Patients with no regular source of care or who did not receive intensive therapy had significantly worse health. Patients of lower socioeconomic status had health outcomes that were up to 25% lower than those of patients of higher socioeconomic status (p < 0.05 for differences in LADL score, dyspnea, and peak flow by educational levels and for differences in dyspnea by income levels), after adjustment for age, gender, race, insurance status, and baseline health. After further adjustment for source of care and intensity of therapy, differences in health outcomes by socioeconomic status uniformly decreased in magnitude and only the differences in LADL scores and dyspnea by educational levels remained statistically significant. Although nonwhite patients were less likely to have a regular source of care or to receive intensive therapy, there was no difference in health outcomes by race.Conclusions: Patients of lower socioeconomic status who have asthma have worse health outcomes post-hospital discharge, which appear to be due in part to less continuous and less intensive treatment. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between the age of cholecystectomy patients and surgical complications, length of stay, symptom relief, and postdischarge functional status.Design: Patients' medical records were reviewed and patients were sent a questionnaire three months after hospital discharge.Setting: Four university-affiliated teaching hospitals.Patients: 372 patients who had a primary operation of total cholecystectomy.Outcome Measures: In-hospital complications, length of stay, patient satisfaction, symptom relief, and functional status after discharge.Results: Patients over the age of 60 years experienced a higher major postoperative complication rate than did younger patients (p < 0.01), although the overall major complication rate was too low to determine whether factors other than age were important predictors. There was no age-related difference in minor postoperative complication rates. The older patients had a longer mean length of stay, even after statistical adjustment for covariates (p < 0.05). The older patients reported similar levels of patient satisfaction, but reported recurrence of preoperative abdominal pain less often than did the younger patients (OR = 0.4, 95% CI = 0.2, 0.7). There was no statistically significant difference between the older and younger patients in postoperative functioning, except for work performance. The younger patients reported improvement in postoperative work performance, while the older patients reported a decline (p < 0.01).Conclusions: Older cholecystectomy patients may experience more postoperative complications but report less recurrence of preoperative abdominal pain than do younger patients. The decline in work performance in older patients may indicate the need for a longer recuperation period. [ABSTRACT FROM AUTHOR]