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Background: Breast-conserving surgery combined with axillary lymph node dissection and radiotherapy or mastectomy are definitive treatments for women with early-stage breast cancer. Little is known about breast cancer treatment for women with disabilities. Objective: To compare initial treatment for early-stage breast cancer between women with and without disabilities and to examine the association of treatment differences and survival. Design: Retrospective cohort study. Setting: 11 Surveillance, Epidemiology, and End Results (SEER) Program tumor registries. Participants: 100 311 women who received a diagnosis of stage I to IIIA breast cancer at 21 to 64 years of age from 1988 to 1999. Women who qualified for Social Security Disability Insurance (SSDI) and Medicare at breast cancer diagnosis were considered disabled. Measurements: Receipt of breast-conserving surgery versus mastectomy. For women who had breast-conserving surgery (n = 49 166), the authors examined receipt of radiotherapy and axillary lymph node dissection. Survival was measured from diagnosis until death or until 31 December 2001. Results: Women with SSDI and Medicare coverage had lower rates of breast-conserving surgery than other women (43.2% vs. 49.2%; adjusted relative risk, 0.80 [95% CI, 0.76 to 0.84]). Among women who had breast-conserving surgery, women with SSDI and Medicare coverage were less likely than other women to receive radiotherapy (adjusted relative risk, 0.83 [CI, 0.77 to 0.90]) and axillary lymph node dissection (adjusted relative risk, 0.81 [CI, 0.74 to 0.90]). Women with SSDI and Medicare coverage had lower survival rates than those of other women in all-cause mortality (adjusted hazard ratio, 2.02 [CI, 1.88 to 2.16]) and breast cancer-specific mortality (adjusted hazard ratio, 1.31 [CI, 1.18 to 1.45]). Results were similar after adjustment for treatment differences. Limitations: Findings are limited to women who qualified for SSDI and Medicare. No data on adjuvant chemotherapy and hormonal therapy were available, and details about the underlying disability were lacking. Conclusions: Women with disabilities had higher breast cancer mortality rates and were less likely to undergo standard therapy after breast-conserving surgery than other women. Differences in treatment did not explain the differences in breast cancer mortality rates.

The purpose is to understand perceptions of health care experiences and suggestions for improving care among deaf or hard-of-hearing individuals. It concludes that physicians are not reimbursed for making some accommodations such as hiring sign language interpreters however ensuring effective communication is essential to safe, timely, efficient and patient-centered care.

Administrative data result from administering health care delivery, enrolling members into health insurance plans, and reimbursing for services. The primary producers of administrative data are the federal government, state governments, and private health care insurers. Although the clinical content of administrative data includes only the demographic characteristics and diagnoses of patients and codes for procedures, these data are often used to evaluate the quality of health care. Administrative data are readily available, are inexpensive to acquire, are computer readable, and typically encompass large populations. They have identified startling practice variations across small geographic areas and supported research about outcomes of care. Many hospital report cards (which compare patient mortality rates) and physician profiles (which compare resource consumption) are derived from administrative data. However, gaps in clinical information and the billing context compromise the ability to derive valid quality appraisals from administrative data. With some exceptions, administrative data allow limited insight into the quality of processes of care, errors of omission or commission, and the appropriateness of care. In addition, questions about the accuracy and completeness of administrative data abound. Current administrative data are probably most useful as screening tools that highlight areas in which quality should be investigated in greater depth. The growing availability of electronic clinical information will change the nature of administrative data in the future, enhancing opportunities for quality measurement., Administrative data sets collected in health care settings can provide a limited framework for studying treatment variation, cost-effectiveness, and health care quality. These data sets frequently include anonymous demographic and procedure profiles as entered by third party payers, government agencies, and health care providers. Data set analyses can point to general areas for improvement. Researchers can readily and inexpensively access volumes of data set information via computer networks.

Background: The quality of discharge planning is an important determinant of patient outcomes following hospital discharge. Patients often report inadequate discussion prior to discharge regarding major elements of the postdischarge treatment plan, including medication and daily activities. Objective: To determine whether this apparent lack of communication might be the result of differing perceptions on the part of patients and physicians regarding the patients, understanding of the treatment plan. Methods: We surveyed 99 patients and their attending physicians. All patients had been discharged recently from an academic medical center with the diagnosis of acute myocardial infarction or pneumonia. We asked both patients and physicians about time spent prior to discharge discussing the postdis-charge treatment plan and the patients, understanding of this plan. McNemar test was used to determine whether responses of patients and physicians differed. Results: Physicians reported spending more time discussing postdischarge care than did patients (P=.10). Physicians believed that 89% of patients understood the potential side effects of their medications, but only 57% of patients reported that they understood (P

In 1863, Florence Nightingale argued that London hospitals were dangerous, especially compared with provincial facilities. She bolstered this contention with statistics published in William Farr's Registrar-General report, which claimed that 24 London hospitals had mortality rates exceeding 90%, whereas rural hospitals had an average mortality rate of 13%. Farr had calculated mortality rates by dividing the total number of patients who died throughout the year by the number of inpatients on a single day. When calculated as the annual number of deaths divided by the total number of inpatients during the year, the mortality rate of London hospitals was 10%. A raucous debate erupted in the London medical press over how best to calculate hospital mortality rates. Critics claimed that Farr had not adjusted for differences in severity of illness between urban and rural hospitals and that his figures would mislead the public. Farr and Nightingale, in turn, criticized the poor quality of hospital data. This story reinforces the need to understand the methodologic derivation of statistics intended to compare provider quality., Examining the controversy around hospital mortality statistics generated by Florence Nightingale and William Farr in 1863 may prove instructive in examining hospital mortality rates being used as measures of hospital quality today. Nightingale and Farr calculated mortality rates based on deaths over the year divided by bed occupants on a single day. This resulted in rates exceeding 90% for some hospitals. As today, statistics served political purposes. The two wanted to prod hospitals to improve care whereas hospitals, mostly charitable institutions, wanted to persuade benefactors that they offered quality care. Also as today, the two recognized that not admitting patients with certain serious illnesses and discharging dying patients or transferring them to another hospital could skew the accuracy of mortality rates. Nightingale's and Farr's statistical technique was criticized in the medical literature of the time. Today, statistical measures of mortality by insurers and others measuring hospital quality invite similar criticism.

The type of assessment tool used to predict patient survival may influence the usefulness of hospital death rate analyses. Researchers compared the consistency and the accuracy of four patient survival assessment tools, including Medisgroups scores, physiology scores, Disease Staging, and All Patient Refined Diagnosis Related Groups (APR-DRGs), on 11,880 patients admitted for heart attack. They also evaluated the correlation between each assessment tool and symptoms thought to predict patient survival. Medisgroup and physiology scores correlated better with high death risk symptoms than Disease Staging and APR-DRGs. However, Disease Staging and APR-DRGs tended to predict death better than the Medisgroup and physiology scores. There was a strong correlation between each high-risk symptom and patient death. Two pairs of assessment tools gave similar survival predictions, Medisgroup and physiology scores, and Disease Staging and APR-DRGs.

Haiti's earthquake caused untold numbers of new disabilities across the age spectrum, from infants and children to elderly individuals. Amputations, spinal cord and brain injuries, complex multiple fractures, and other massive trauma will leave residual impairments, precipitating pressing needs at both the individual and societal levels. Short-term priorities include clinical stabilization, wound healing, and surgical revisions of suboptimal repairs. Afterward, in the near term, comprehensive rehabilitation must commence to ensure the best possible functional outcomes. Even before the earthquake struck, Haiti had few rehabilitation professionals and little capacity to manufacture essential assistive technologies, including prostheses and wheelchairs. While international organizations are assisting to fill these gaps, ultimately rehabilitation programs and assistive technologies will need to fit the specific demands of Haiti's culture and rugged natural physical environment. As Haiti rebuilds its public and private spaces, ensuring accessibility to persons with disabilities will be critical. Ultimately, one positive legacy of Haiti's earthquake could be the emergence of social attitudes, public policies, and physical environments that more fully accommodate disability across the life span.

The medical profession and general public need to determine the worth of quality of care information and whether they will pay it. Medical care costs instead of quality have increasingly driven the medical care decision making process. However, obtaining information about medical care quality can also be costly. Needed information may be available electronically but also may be technically difficult to link. There is also debate about what information is appropriate when evaluating medical quality.

Abstract Objectives To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. Design Weighted linear regression analysis of routinely collected [...]