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Objectives.Severity-adjusted death rates for coronary artery bypass graft (CABG) surgery by provider are published throughout the country. Whether five severity measures rated severity differently for identical patients was examined in this study.Methods.Two severity measures rate patients using cli

Individuals with disabilities experience a disproportionate rate of chronic disease and are more likely to lead sedentary lifestyles than the general population. Multiple complex factors likely contribute to these disparities, including structural, socioeconomic and attitudinal barriers that impede broad participation of individuals with disabilities in health and wellness promotion programs. Public health initiatives aimed at mitigating these health disparities emphasize improved access to physical activity and sports opportunities. Given its visibility, the Paralympic Movement provides an opportunity to transform how society conceptualizes the relationship of disability to physical fitness. The Paralympics also serve as a catalyst for public health education and program development. Already, public policies and governmental regulations are expanding grassroots sports opportunities for youth and adults with disabilities, thus promoting inclusive opportunities for participation in physical activity.

Anecdotal evidence suggests that growing numbers of American women with chronic physical disabilities (CPD) are becoming pregnant.1 Recent analyses of national survey data found that approximately 163,700 U.S. women with CPD are pregnant at some point each year, including nearly 44,200 women reporting severe physical disabilities.2 In coming decades, the population of reproductive-age women with CPD will increase,3–6 likely resulting in rising numbers of pregnancies. Therefore, learning more about the obstetrical needs of women with CPD is critical. Here we define CPD as chronic functional impairments of upper or lower extremities that limit mobility. These functional impairments may themselves affect pregnancy outcomes. In addition, the health conditions causing the impairments might contribute to obstetrical risks. For example, during pregnancy, healthy women with spinal cord injury might need specific services (e.g., intensive monitoring of skin integrity in ischial areas), which differ from those of ambulatory pregnant women with multiple sclerosis initially taking powerful disease-modifying drugs. In anticipating their specific clinical needs, understanding the nature of disabling health problems among pregnant women with CPD is essential. Few data sets contain information on current pregnancy and women’s disabling health conditions. The federal, cross-sectional National Health Interview Survey (NHIS) includes self-reported “current” pregnancy, mobility-related functional limitations, and self-reported causes of these functional limitations. Using NHIS data, we address two primary research questions: (1) What are the self-reported causes of their functional impairments for reproductive-age U.S. women with CPD? (2) and What are the associations between these underling causes and current pregnancy among women with CPD? Although these data are only descriptive, they offer an important starting point for understanding potential clinical needs of pregnant women with CPD.

The number of Americans aging with disabilities will grow substantially in coming decades. Promulgating policies and practices to improve their independent functioning within communities and participation in daily life are therefore imperative, but the most effective approaches for meeting various needs are generally unknown. Historically, research addressing approaches targeting elderly individuals have differed in important ways (e.g., underlying models of disability) from studies involving younger persons aging with disabilities. Participants in a conference addressing this discordance identified six major areas requiring study: (1) resources to support independent living; (2) improving quality of life and participation in daily activities; (3) performing activities of daily living (ADL) and instrumental ADLs; (4) role of families; (5) medical care; and (6) concerns transcending sectors. As these investigations move forward, bridging the divide between approaches addressing elderly individuals versus persons with disabilities will be critical.

Despite important progress in measuring the safety of health care delivery in a variety of health care settings, a comprehensive set of metrics for benchmarking is still lacking, especially for patient outcomes. Even in high-risk settings where similar procedures are performed daily, such as hospital intensive care units (ICUs), these measures largely do not exist. Yet we cannot compare safety or quality across institutions or regions, nor can we track whether safety is improving over time. To a large extent, ICU outcome measures deemed valid, important, and preventable by clinicians are unavailable, and abstracting clinical data from the medical record is excessively burdensome. Even if a set of outcomes garnered consensus, ensuring adequate risk adjustment to facilitate fair comparisons across institutions presents another challenge. This study reports on a consensus process to build 5 outcome measures for broad use to evaluate the quality of ICU care and inform quality improvement efforts.

In this issue, Lagu and colleagues found many physical access barriers in subspecialty practices for patients with mobility impairment. The editorialist discusses the study, as well as the findings...

Data on outcomes of medical care are becoming much more available in health care organizations and systems of care. This will create new opportunities for operations researchers to make contributions to health care policy and management. To provide some background to those new to the health care area, in this article we do the following: (1) provide a brief exposure to major administrative databases that are available and useful for analyzing outcomes data; (2) discuss the strengths and limitations of the diagnostic information contained in these databases; (3) describe several systems that use this information, or in some cases information from the medical record, to determine patient severity, thus providing a basis for severity-adjustment before considering outcomes; and (4) finally, provide an overview of some recent advances in obtaining improved parameter estimates from large databases.

Objective: To see whether severity-adjusted predictions of likelihoods of in-hospital death for stroke patients differed among severity measures. Methods: The study sam ple was 9,407 stroke patients from 94 hospitals, with 916 (9.7%) in-hospital deaths. Probability of death was calculated for each patient using logistic regression with age-sex and each of five severity measures as the independent variables: admission MedisGroups probability-of-death scores; scores based on 17 physiologic variables on admission; Disease Staging's probability-of-mortality model; the Severity Score of Pa tient Management Categones (PMCs); and the All Patient-Refined Diagnosis Groups (APR-DRGs). For each patient, the odds of death predicted by the severity measures were compared. The frequencies of seven clinical indicators of poor prognosis in stroke were examined for patients with very different odds of death predicted by different severity measures. Odds ratios were considered very different when the odds of death predicted by one severity measure was less than 0.5 or greater than 2.0 of that pre dicted by a second measure. Results: MedisGroups and the physiology scores pre dicted similar odds of death for 82.2% of the patients. MedisGroups and PMCs disa greed the most, with very different odds predicted for 61.6% of patients. Patients viewed as more severely ill by MedisGroups and the physiology score were more likely to have the clinical stroke findings than were patients seen as sicker by the other severity measures. This suggests that MedisGroups and the physiology score are more clinically credible. Conclusions: Some pairs of severity measures ranked over 60% of patients very differently by predicted probability of death. Studies of seventy-adjusted stroke outcomes may produce different results depending on which seventy measure is used for risk adjustment. Key words: seventy; risk adjustment; stroke; in-hospital deaths; mortality rates. (Med Decis Making 1996;16:348-356)

Planning for hospital discharge is an important component of nursing. Results are presented of a study to determine how well primary nurses predict the functional ability of their patients following discharge and to assess whether patients and nurses agree about their patients' understanding of the post-discharge treatment plan. Comparing nurses' predictions with patients' reports of functional status 2 months following discharge, we found that nurses consistently underestimate the functional ability of their patients. Comparing nurses' perceptions of their patients' understanding of their post-discharge treatment plan with patients' reports about their understanding, significant differences were found between nurses' perceptions and patients' reports. Nurses' perceptions were that patients were much more knowledgeable than their patients reported. These preliminary data suggest that hospital discharge planning is an area for further investigation and intervention. Nurses should explore new paradigms for patient education as lengths of hospital stay decrease and care shifts from acute care to community care.

Using data from the American Hospital Association and the Medicare program, the authors analyzed the effects of financial pressure and market competition on changes in several measures of performance of 1,435 acute care hospitals between 1987 and 1989. Over the observation period, the least profitable hospitals constrained their growth in total expenses to half that for the most profitable hospitals (13.3% versus 27.6%) by limiting the growth of their staffs and their total assets. These changes were associated with a reduction in inefficiency of 1.8% (11.2%) compared with a very slight increase in inefficiency for the highest profit group. Similarly, hospitals in highly competitive markets controlled expenses relative to those in the least competitive areas. However, they also experienced slower revenue growth than did less competitive hospitals so that, in relative terms, their profit rates fell. The authors found no evidence to suggest that financial pressures created by either low profits or market competition resulted in hospitals engaging in cost-shifting. The authors conclude that health care reforms or market forces that put financial pressures on hospitals can result in cost-containment and improved efficiency without significant cost-shifting.

To see whether predictions of patients, likelihood of dying in-hospital differed among severity methods.Retrospective cohort.18,016 persons 18 years of age and older managed medically for pneumonia; 1,732 (9.6%) in-hospital deaths.Probability of death was calculated for each patient using logistic regression with age, age squared, sex, and each of five severity measures as the independent variables: 1) admission MedisGroups probability of death scores; 2) scores based on 17 admission physiologic variables; 3) Disease Staging's probability of mortality model; the Severity Score of Patient Management Categories (PMCs); 4) and the All Patient Refined Diagnosis-Related Groups (APR-DRGs). Patients were ranked by calculated probability of death; 5) rankings were compared across severity methods. Frequencies of 14 clinical findings considered poor prognostic indicators in pneumonia were examined for patients ranked differently by different methods.MedisGroups and the physiology score predicted a similar likelihood of death for 89.2% of patients. In contrast, the three code-based severity methods rated over 25% of patients differently by predicted likelihood of death when compared with the rankings of the two clinical data-based methods [MedisGroups and the physiology score]. MedisGroups and the physiology score demonstrated better clinical credibility than the three severity methods based on discharge abstract data.Some pairs of severity measures ranked over 25% of patients very differently by predicted probability of death. Results of outcomes studies may vary depending on which severity method is used for risk adjustment.

Mortality rates are commonly used to judge hospital performance. In comparing death rates across hospitals, it is important to control for differences in patient severity. Various severity tools are now actively marketed in the United States. This study asked whether one would identify different hospitals as having higher- or lower-than-expected death rates using different severity measures. We applied 11 widely-used severity measures to the same database containing 9407 medically-treated stroke patients from 94 hospitals, with 916 (9.7%) in-hospital deaths. Unadjusted hospital mortality rates ranged from 0 to 24.4%. For 27 hospitals, observed mortality rates differed significantly from expected rates when judged by one or more, but not all 11, severity methods. The agreement between pairs of severity methods for identifying the worst 10% or best 50% of hospitals was fair to good. Efforts to evaluate hospital performance based on severity-adjusted, in-hospital death rates for stroke patients are likely to be sensitive to how severity is measured.

Timely use of necessary follow-up services is an important dimension of ambulatory care quality. Using a hospital-based walk-in center, this study identified patients who were referred for follow-up care and examined factors related to compliance with these referrals. The participants were 696 adults seen in a hospital-based walk-in unit between June 1, 1992, and December 1, 1992. Patients completed a self-administered questionnaire including questions about sociodemographic characteristics, prior use of health services, and the Medical Outcomes Study (MOS) 36-Item Health Survey. Medical findings, follow-up recommendations, insurance status, and compliance with follow-up referrals were ascertained using chart review, the hospital's computing system, and clinic records. Fifty percent of the patients were referred for follow-up medical care; 55% of these complied with follow-up referrals. Factors associated with referral for follow-up care included older age, inability to afford a physician, longer duration of chief complaint, the patient's belief that follow-up care would be needed, and worse MOS pain score. The most important factor associated with compliance with follow-up referral was scheduling appointments while patients were still in the walk-in unit. Patients with such scheduled appointments were almost 10 times more likely than others to receive follow-up (adjusted odds ratio = 9.6, 95% confidence interval = 4.4-21.2). The most important step a provider can take to improve compliance with follow-up referral is to schedule appointments before patients are sent home. This should presumably improve quality of ambulatory care.

Objective. To examine the impact of hospital caseload on in-hospital mortality for pediatric congenital heart surgery. Design. Population-based, retrospective cohort study. Setting. Acute care hospitals in California and Massachusetts. Patients. Children undergoing surgery for congenital heart disease, identified by the presence of procedure codes indicating surgical repair of a congenital heart defect in computerized statewide hospital discharge abstract databases. Cases were grouped into four categories based on the complexity of the procedure. Main outcome measures. Adjusted odds ratios (OR) for in-hospital death were estimated using generalized estimating equations that account for the intra-institutional correlation among patients. Results. A total of 2833 cases at 37 centers were identified. Compared with centers performing >300 cases per year, after controlling for patient characteristics, centers performing Conclusions. For children with a congenital heart defect who underwent surgery in California in 1988 or Massachusetts in 1989, the risk of dying in-hospital was much lower if the surgery was performed at an institution performing >300 cases annually. This study was limited by the absence of clinical detail in discharge abstract databases. If these findings are corroborated by other studies, health care delivery strategies that direct children requiring surgical correction of congenital heart defects to high-volume centers may substantially reduce overall mortality.

We examined computerized hospital discharge abstract data from 372,680 major surgery patients admitted to 404 California acute care hospitals in 1988 to identify potential complications of care. At least one potential in-hospital complication occurred for 10.8% of patients. Patients with complications were older and more likely to die in-hospital (9.4% compared to 1.0%, P < 0.0001). On average, patients with complications had longer stays (13.5 versus 5.4 days, p < 0.0001) and higher total charges ($30,896 versus $9,239, p < 0.0001). After adjusting for demographic, clinical, and hospital factors, patients with potential complications averaged $16,023 higher total hospital charges than uncomplicated patients. Complications were associated with 96.6% (95% confidence interval = 95.2%, 98.0%) higher hospital charges after adjusting for these factors. Across all patients, complications were related to over $647 million in additional total hospital charges for these major surgery patients.

Histories of persons with disabilities only started being widely told in the last few decades, and often they are not happy. Discrimination, disenfranchisement, and even outright hostility reach back to Biblical times. The forced isolation of many persons with disabilities over the centuries has obliterated their traces. Leaping forward two millennia, enormous strides have certainly been taken, often spurred by people with disabilities themselves. Especially in developed nations, legal, economic, societal, and environmental barriers are falling, allowing persons with disabilities to participate fully in daily life throughout communities. Nonetheless, persistent hurdles do remain, even in health care. But wait. Barriers to health care for persons with disabilities? After all, as an American presidential advisory committee on health care quality wrote, ‘The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, and disability and to improve the health and functioning of the people of the United States’ [1]. However, as amply documented by Lawthers and colleagues, the US health care system falls considerably short of these goals for persons with disabilities [2]. Within the US, the genesis of these shortcomings is obvious. Our nation does not guarantee a right to health care. Without universal health insurance, over 40 million people have no coverage, and being uninsured for 1–4 years can worsen health status [3]. Even with health insurance, persons with disabilities are often unable to receive care they need [4]. Insurers, including Medicare and Medicaid, strictly limit coverage of items and services for maintaining or restoring functioning, like long-term physical and occupational therapy, assistive devices (e.g. hearing aids, mobility aids), and even modest home modifications (e.g. bathroom grab bars) [4 …

Background To mitigate shortages of primary care physicians and ensure access to health care services for a growing number of Medicare beneficiaries, some policy makers have recommended expanding the supply and roles of nurse practitioners (NPs). Little is known about the number of NPs billing Medicare or their practice patterns. Purpose This study examines the geographic distribution and county characteristics of NPs billing Medicare, compares the types and quantities of primary care services provided to Medicare beneficiaries by NPs and primary care physicians, and analyzes the characteristics of beneficiaries receiving primary care from each type of clinician. Methods We performed a cross-sectional analysis of 2008 Medicare administrative data from 959,848 aged and/or disabled beneficiaries continuously enrolled in fee-for-service Medicare during the study period. Outcome measures included geographic distribution of NPs measured by the rate of NPs per 1,000 Medicare beneficiaries by state, average utilization, and patient characteristics. Discussion States with the highest rate of NPs billing were rural. Over 80% of the payments received by both NPs and primary care physicians were for evaluation and management services. Beneficiaries assigned to an NP were more likely to be female, to be dually eligible for Medicare and Medicaid, and to have qualified for Medicare because of a disability. NPs with assigned beneficiaries were significantly more likely than similar primary care physicians to practice in federally designated primary care shortage areas. Conclusions Approximately 45,000 NPs were providing services to beneficiaries and billing under their own provider numbers in 2008. Aspects of NP practice patterns were different from primary care physicians, and NPs appeared more likely to provide services to disadvantaged Medicare beneficiaries.

According to the World Report on Disability, physicians worldwide generally lack training about caring for persons with disabilities, thus frequently compromising their health care experiences and health outcomes. Many U.S. physicians are similarly untrained about critical aspects of providing care to persons with disabilities, perhaps contributing to disparities in their care. Recognizing these inadequacies, U.S. medical educators are beginning to develop core competencies for trainees relating to the care of patients with disabilities, including understanding patients' perceptions of their quality of life and skills in providing patient-centered care. Having today's physicians, even when genuinely well-intentioned, retain control over designing disability-related training programs for future doctors may miss critical issues in caring empathically and effectively for persons with disabilities. Involving persons with disabilities in identifying training needs and implementing curricula for future physicians may offer important opportunities for ensuring their competency to provide patient-centered care to persons with disabilities.

The Charter on Medical Professionalism, endorsed by more than 100 professional groups worldwide and the US Accreditation Council for Graduate Medical Education, requires openness and honesty in physicians' communication with patients. We present data from a 2009 survey of 1,891 practicing physicians nationwide assessing how widely physicians endorse and follow these principles in communicating with patients. The vast majority of physicians completely agreed that physicians should fully inform patients about the risks and benefits of interventions and should never disclose confidential information to unauthorized persons. Overall, approximately one-third of physicians did not completely agree with disclosing serious medical errors to patients, almost one-fifth did not completely agree that physicians should never tell a patient something untrue, and nearly two-fifths did not completely agree that they should disclose their financial relationships with drug and device companies to patients. Just over one-tenth said they had told patients something untrue in the previous year. Our findings raise concerns that some patients might not receive complete and accurate information from their physicians, and doubts about whether patient-centered care is broadly possible without more widespread physician endorsement of the core communication principles of openness and honesty with patients.

Increasingly, health care providers are being evaluated and held accountable for their patients' outcomes, ranging from the costs to service consumption to death. To be meaningful, the outcomes under scrutiny must be important to patients or to the health care system as a whole, relatively common, and linked temporally and causally to the care provided. In addition, outcomes findings should be adjusted for patient risk factors, with the goal of accounting for pertinent clinical characteristics before drawing inferences about the effectiveness or quality of care. Risk adjustment "levels the playing field" in comparing outcomes across providers. Although this concept is straightforward, performing clinically credible risk adjustment is difficult, especially given the widespread data constraints. In this article, I review the major issues involved in performing risk adjustment for health care outcomes studies.

This paper uses a stochastic frontier multiproduct cost function to derive hospital-specific measures of inefficiency. The cost function includes direct measures of illness severity, output quality, and patient outcomes to reduce the likelihood that the inefficiency estimates are capturing unmeasured differences in hospital outputs. Models are estimated using data from the AHA Annual Survey, Medicare Hospital Cost Reports, and MEDPAR. We explicitly test the assumption of output endogeneity and reject it in this application. We conclude that inefficiency accounts for 13.6 percent of total hospital costs. This estimate is robust with respect to model specification and approaches to pooling data across distinct groups of hospitals.

When comparing outcomes of medical care, it is essential to adjust for patient risk, including severity of illness. A variety of severity measures exist, but perceptions of outcomes may differ depending on how severity is defined. We used two severity-adjustment approaches to demonstrate that comparisons of outcomes across subgroups of patients can vary dramatically depending on how severity is assessed. We studied two approaches: model 1 was the admission MedisGroups score; model 2 was computed from age and 12 chronic conditions defined by diagnosis codes. Although common summary measures of model performance (R-squared and C) both suggested that model 1 is a better predictor of in-hospital death than model 2, the weaker model consistently produced more accurate expectations by payer class and age group. Using model 1 for severity adjustment suggested that Medicare patients did substantially worse than expected and Medicaid patients substantially better. In contrast, use of model 2 found Medicare patients doing as expected, but Medicaid patients faring poorly.

Article-at-a-Glance Background Controlling costs while maintaining quality is a crucial element of national health care reform. Prompted generally by concerns of local businesses, states and regions around the country have already initiated such dual efforts. The central component of these activities is the examination of risk-adjusted outcomes. Issues Publicizing comparisons across providers and using these data for payer contracting have prompted several concerns among many providers, primarily involving reservations about the validity of the risk-adjustment methodologies and the fairness of the outcomes data reports. In contrast, business leaders recognize potential limitations in the data but argue that some information is better than none. They believe that these efforts have already saved money by forcing providers to compete and to justify unusually high costs. Troubling questions arise about whether publicizing their outcomes may prompt providers to avoid especially sick and high-risk patients. Although common themes emerge, each of these initiatives to monitor risk-adjusted outcomes has had to address specific local concerns. The form that these local initiatives take is influenced particularly by relationships between the business and provider communities and their respective visions of how to motivate change in the health care sector. Summary In some regions, businesses and providers have worked collaboratively, whereas in others relationships have been strained. One major problem in making objective decisions about risk-adjusted outcomes methods is the lack of clear evidence about whether such information truly measures quality of care. Whether a standard national quality monitoring program will satisfy local demands remains unclear.

This research investigates the degree that estimates of the magnitude of small area variations in hospitalization rates depend on both the estimation method and the number of years of data used. Hospital discharge abstracts for patients 65 and older from acute care hospitals in Massachusetts from 1982 to 1987 were analyzed. The SCV statistic, the approach used in many current small area variation studies, and empirical Bayes (EB), an approach that adjusts more fully for the effect of random variation, were compared. EB estimates based on 3 years of data were best able to predict future area-specific hospitalization rates. Compared to EB estimates using 3 years of data, the SCV statistic with 1 year of data overestimated the median amount of systematic variation by over 70% for the 68 conditions studied; with 3 years of data, the SCV overestimated the median by 55%. Regardless of method, the same conditions were identified as relatively more variable and the same geographic areas were found to have higher than expected hospitalization rates. The magnitude of differences in hospitalization rates depends on how the data are analyzed and how many years of data are used. Hospitalization rates across small geographic areas may vary substantially less than reported previously.

Purpose The authors sought to generate insights and hypotheses about the professional experiences of registered nurses and physicians with self-identified disabilities to inform local and national policy conversations on supporting a diverse health care workforce. Method In 2009-2010, the authors conducted in-depth interviews in person and over the telephone with a sample of licensed registered nurses and physicians across the country who self-identified as having a permanent disability. They coded the interview transcripts to identify key themes across the participants' responses. Results The authors interviewed 10 registered nurses and 10 physicians. Five novel and consistent themes emerged from the data analysis: (1) Living and working with a physical/sensory disability narrows the career choices and trajectories of nurses and physicians, (2) nurses and physicians struggle with decisions regarding whether to disclose and discuss their disabilities at work, (3) nurses and physicians rarely seek legally guaranteed workplace accommodations, instead viewing patient safety as a personal responsibility, (4) interpersonal interactions often reflect the institutional climate and set the tone for how welcome nurses and physicians feel at work, and (5) reactions to workplace disability-related challenges run an emotional spectrum from anger and grief to resilience and optimism. Conclusions The responses revealed several missed opportunities for supporting health care professionals with disabilities in the workplace. These findings should inform the continuing debate regarding what defines "reasonable accommodation" and how to create a workplace that is welcoming for nurses and physicians with disabilities.

We use established methods and recent data to estimate the effects of changes in premium taxes and Medicaid eligibility on the likelihood of being covered by public or private insurance. We find Medicaid expansion for working adults will crowd-out private insurance at a high rate and that premium taxes will make private coverage less attractive and public coverage more attractive to lower-income workers. We illustrate the implications of these findings by simulating the consequences of the Patient Protection and Affordable Care Act of 2010. As the high-premium excise tax affects increasing numbers of workers between 2018 and 2030, we predict that some will shift from private to public coverage, amplifying the effect of Medicaid expansion. The proportion of workers and their families covered by public insurance will grow from 6% in 2006 to about 14% in 2030 while about 5% will obtain subsidized coverage through exchanges. The fraction covered by private insurance will grow initially in response to the mandate and then decline in response to the tax.

BACKGROUND Several countries use hospital-wide mortality rates to evaluate the quality of hospital care, although the usefulness of this metric has been questioned. Massachusetts policymakers recently requested an assessment of methods to calculate this aggregate mortality metric for use as a measure of hospital quality. METHODS The Massachusetts Division of Health Care Finance and Policy provided four vendors with identical information on 2,528,624 discharges from Massachusetts acute care hospitals from October 1, 2004, through September 30, 2007. Vendors applied their risk-adjustment algorithms and provided predicted probabilities of in-hospital death for each discharge and for hospital-level observed and expected mortality rates. We compared the numbers and characteristics of discharges and hospitals included by each of the four methods. We also compared hospitals' standardized mortality ratios and classification of hospitals with mortality rates that were higher or lower than expected, according to each method. RESULTS The proportions of discharges that were included by each method ranged from 28% to 95%, and the severity of patients' diagnoses varied widely. Because of their discharge-selection criteria, two methods calculated in-hospital mortality rates (4.0% and 5.9%) that were twice the state average (2.1%). Pairwise associations (Pearson correlation coefficients) of discharge-level predicted mortality probabilities ranged from 0.46 to 0.70. Hospital-performance categorizations varied substantially and were sometimes completely discordant. In 2006, a total of 12 of 28 hospitals that had higher-than-expected hospital-wide mortality when classified by one method had lower-than-expected mortality when classified by one or more of the other methods. CONCLUSIONS Four common methods for calculating hospital-wide mortality produced substantially different results. This may have resulted from a lack of standardized national eligibility and exclusion criteria, different statistical methods, or fundamental flaws in the hypothesized association between hospital-wide mortality and quality of care. (Funded by the Massachusetts Division of Health Care Finance and Policy.).

Background One tenet of medical professionalism is managing conflicts of interest related to physician-industry relationships (PIRs). Since 2004 much has been done at the institutional, state, and national levels to limit PIRs. This study estimates the nature, extent, consequences, and changes in PIRs nationally. Methods We performed a national survey of a stratified random sample of 2938 primary care physicians (internal medicine, family practice, and pediatrics) and specialists (cardiology, general surgery, psychiatry, and anesthesiology). A total of 1891 physicians completed the survey, yielding an overall response rate of 64.4%. The main outcome measure was prevalence of several types of PIRs and comparison with PIRs in 2004. Results Overall, 83.8% of all respondents reported some type of relationship with industry during the previous year. Approximately two-thirds (63.8%) received drug samples, 70.6% food and beverages, 18.3% reimbursements, and 14.1% payments for professional services. Since 2004 the percentage of each of these benefits has decreased significantly. Higher rates of PIRs are significantly and inversely associated with low levels of Medicare spending. Conclusion Among a random sample of physicians, the prevalence of self-reported PIRs in 2009 was 83.8%, which was lower than in 2004.

Objective To examine patterns of mobility aid ownership and use among working-age United States residents with multiple sclerosis. Design A 30-min telephone survey in mid-2007 with 703 community-dwelling, working-age adults who self-reported having multiple sclerosis; response rate was 73.4%. We identified potential survey respondents using membership lists of the National Multiple Sclerosis Society. All analyses and calculations used sampling weights to produce population estimates. Results Among working-age persons with multiple sclerosis living in communities nationwide, 60.5% own at least one mobility aid, most commonly manual wheelchairs (38.4%), followed by canes or crutches (35.7%). Despite owning mobility aids, many had not used this equipment in the previous 12 mos, including 4.5% of power wheelchair owners, 13.8% of those with manual wheelchairs, and 9.3% of scooter owners. Among manual wheelchair and scooter users, 25%-30% used this equipment only outside their homes. Many reported needing wheeled mobility aids inside their homes but being unable to move their equipment easily within their homes. Conclusions Persons with multiple sclerosis own many mobility aids but can confront substantial barriers to their use, especially within homes. Consultations with physiatrists and home evaluations by physical or occupational therapists before purchasing equipment could provide practical suggestions for addressing barriers.

Multiple sclerosis (MS) causes a wide variety of neurological deficits, with ambulatory impairment the most obvious cause of disability. Within 10 to 15 years of disease onset, 80% of persons with MS experience gait problems due to muscle weakness or spasticity, fatigue, and loss of balance. To facilitate mobility, persons with MS frequently use mobility assistive technology (MAT), such as canes, crutches, walkers, wheelchairs, and scooters. We systematically reviewed the published literature on MAT use among persons with MS. We used electronic reference lists such as Ovid MEDLINE and PubMed to search the literature. We located 50 articles that met the initial criteria of providing good evidence of the types of MAT devices and their benefits for individuals with MS. A limited number of articles with higher levels of evidence was found regarding benefits of MAT use specifically for persons with MS. Evidence-based literature provides the basis for the strongest method of measurable clinical performance; therefore, having a strong research study design is vital to the justification of MAT prescription and reimbursement decisions. However, a paucity of studies with higher levels of evidence-based practice exists.

Context Peer monitoring and reporting are the primary mechanisms for identifying physicians who are impaired or otherwise incompetent to practice, but data suggest that the rate of such reporting is lower than it should be. Objective To understand physicians' beliefs, preparedness, and actual experiences related to colleagues who are impaired or incompetent to practice medicine. Design, Setting, and Participants Nationally representative survey of 2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded. Main Outcome Measures Beliefs about and preparedness for reporting and experiences with colleagues who practice medicine while impaired or who are incompetent in their medical practice. Results Sixty-four percent (n = 1120) of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice. Nonetheless, only 69% (n = 1208) of physicians reported being prepared to effectively deal with impaired colleagues in their medical practice, and 64% (n = 1126) reported being so prepared to deal with incompetent colleagues. Seventeen percent (n = 309) of physicians had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, 67% (n = 204) reported this colleague to the relevant authority. Underrepresented minorities and graduates of non-US medical schools were less likely than their counterparts to report, and physicians working in hospitals or medical schools were most likely to report. The most frequently cited reason for taking no action was the belief that someone else was taking care of the problem (19% [n = 58]), followed by the belief that nothing would happen as a result of the report (15% [n = 46]) and fear of retribution (12% [n = 36]). Conclusion Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.

Comprehensive measures to benchmark or track safety performance do not yet exist. The authors aimed to develop and validate a process to identify comprehensive, clinically meaningful sets of safety measures that would draw on the clinical experiences and perceptions of active practitioners. They pilot tested this process for safety measure development for 2 hospital departments (ie, intensive care units and general surgery services) by holding 7 brainstorming sessions with physicians and nurses in major academic and community teaching hospitals in Boston, Massachusetts, and Baltimore, Maryland. Participants identified lists of patient harms that they considered to be among the 20 most frequent and the 20 most severe in their respective units. The authors generated a master list of patient harms, which participants then ranked by both frequency and severity via E-mail voting. This process produced safety measures with inherent credibility with clinicians on the front lines of care.

PURPOSE: To determine whether professional activities, professional productivity, and salaries of life sciences faculty differ by gender. The authors undertook this study because previous studies found differences in the academic experiences of women and men. METHOD: In 2007, the authors conducted a mailed survey of 3,080 life sciences faculty at the 50 universities whose medical schools received the greatest amount of National Institutes of Health funding in 2004. The response rate was 74% (n = 2,168). The main outcome measures were a faculty member’s total number of publications; number of publications in the past three years; average impact score of the journals in which he or she had published; professional activities; work hours per week; the numbers of hours spent specifically in teaching, patient care, research, professional activities, and administrative activities; and annual income. RESULTS: Among professors, the women reported greater numbers of hours worked per week and greater numbers of administrative and professional activities than did the men. Female faculty members reported fewer publications across all ranks. After control for professional characteristics and productivity, female researchers in the life sciences earned, on average, approximately $13,226 less annually than did their male counterparts. CONCLUSIONS: Men and women in the academic life sciences take on different roles as they advance through their careers. A substantial salary gap still exists between men and women that cannot be explained by productivity or other professional factors. Compensation and advancement policies should recognize the full scope of the roles that female researchers play.

Many older adults who might benefit from using mobility aids do not or will not use them. Studies show that attitudes and beliefs strongly affect the decision to use mobility aids. Despite the growing diversity of the population, no prior studies have compared attitudes towards and beliefs about mobility aids by race and ethnicity.This study aimed to explore whether and how attitudes towards and beliefs about mobility aid use vary by race and ethnicity.We conducted 12 focus groups with 61 community dwelling persons age 65+ years from three groups: White, non-Hispanic Black, and Hispanic. Data were coded and compared across groups.For all groups, perceived benefits of mobility devices in maintaining independence and control produced positive attitudes. However, the association of mobility aid use with aging and physical decline contributed to stigmatizing attitudes. Black and Hispanic participants expressed apprehension about using unsafe or inappropriate secondhand equipment, heightened concerns about mobility aid users becoming subjects of negative biases, and a preference for fashionable aids. Hispanic participants expressed a preference for human assistance. Participants of all groups perceived physicians as influencing their decisions to use aids.Social pressures and perceived stigma deter mobility aid use, particularly in minority populations. Greater physician involvement, positive peer models and affordable, safe, visually appealing devices would promote greater acceptance of mobility aids.

Recent initiatives expanding health care data networks have increasingly emphasized severity of illness information, both to improve fairness of hospital payment and to assist in widespread assessment of hospital and physician quality. The Computerized Severity Index (CSI), one of the newest severity tools to generate interest, is disease specific and produces scores from 1 to 4 at both the disease and overall patient levels. Severity is defined as "the treatment difficulty presented to physicians due to the extent and interactions of patient's diseases." The clinical logic of the severity rating system is readily available through the "severity matrices" associated with over 820 disease groups. Questions exist about the CSI's dependence on diagnostic coding and the qualitative nature of some of the clinical criteria. More study is required to assess the utility of the CSI for various health policy purposes.

Much of this article first appeared as testimony of Dr. Iezzoni before the U.S. Senate Health, Education, Labor, and Pensions Committee, Washington, DC, January 27, 2009. Dr. Iezzoni serves on the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. This article represents her personal views and not the views of the committee.

Sometime in 1998, as ably chronicled by Brett,1 a long-simmering disagreement over an arcane administrative construct — documentation guidelines for physicians to use in coding evaluation and manag...

To determine if the type of insurance arrangement, specifically health maintenance organization (HMO) vs fee-for-service (FFS), affects cancer outcomes for Medicare beneficiaries with disabilities.Retrospective cohort.We used the Surveillance, Epidemiology, and End Results-Medicare linked dataset to identify beneficiaries older and younger than 65 years entitled to Medicare benefits because of disability (Social Security Disability Insurance) who subsequently were diagnosed as having breast cancer (n = 6839) or non-small cell lung cancer (n = 10,229) from 1988 through 1999. We categorized persons according to Medicare insurance arrangement (continuous FFS, continuous HMO, or mixed FFS/HMO) during the periods 12 months before diagnosis and 6 months after diagnosis. Using a retrospective cohort design, we examined stage at diagnosis, cancer-directed treatments, and survival.Women with continuous HMO insurance had earlier-stage breast cancer diagnosis (adjusted relative risk, 0.77; 95% confidence interval, 0.65-0.91) and were more likely to receive radiation therapy following breast-conserving surgery (adjusted relative risk, 1.11; 95% confidence interval, 1.03-1.19). Women having continuous HMO insurance had better breast cancer survival, primarily resulting from earlier-stage diagnosis. Among persons with non-small cell lung cancer, those having mixed FFS/HMO insurance were more likely to receive definitive surgery for early-stage disease (adjusted odds ratio, 1.23; 95% confidence interval, 1.02-1.49) and to have better overall survival but not significantly better lung cancer survival.When diagnosed as having breast cancer or non-small cell lung cancer, some Medicare beneficiaries with disabilities fare better with managed care compared with FFS insurance plans.

Anecdotal evidence suggests that hearing loss, even when sufficient to prevent full access to spoken communication, often is underreported by patients and not documented by physicians. No published studies have investigated this issue quantitatively.To assess the documentation of hearing loss in comprehensive physician notes in cases where the patients are known to have substantial binaural loss.Electronic medical record (EMR) notes for 100 consecutive patients with substantial binaural hearing loss were reviewed retrospectively at a large academic medical center. All records reviewed were created within 2 years before the patient's audiometry. Comprehensive physician notes containing the headings "History" and "Physical Exam" were examined for documentation of hearing loss and scored as: no mention of loss; finding of loss; or hearing reported as normal.Consecutive adult patients with substantial binaural hearing loss by audiometry who also had a comprehensive medical assessment in their electronic medical record created within 2 years before audiometry.Thirty-six percent of EMRs had no mention of hearing loss, 28% reported some loss, and 36% percent indicated that hearing was normal.Substantial hearing loss, sufficient to prevent effective communication in the medical setting, often is underdocumented in medical records.

Background: Studies show that patients who have higher self-efficacy and participate actively in their care have better disease management. Patient provider Internet portals offer an exciting new venue for empowering and engaging patients in better management of chronic conditions. Objectives: To describe development of an Internet-based health coaching intervention. Approach: An internet-based health coaching intervention to enhance patient- provider communication regarding three common conditions chronic pain, depression and impaired mobility, was developed. Using principles of self-management, the intervention aimed to engage and empower patients to collaborate with their primary care physician in managing their health conditions. Deliverer online by nurse electronic coaches (e-coaches), the intervention involved a standardized set of e-mails and worksheets targeting self-efficacy. patient education, and motivation to improve nealth. " Results: Participants in the intervention (N = 121) primarily used the automated elements of the program, although 35% exchanged e-mails witn the nurse e-coach. Most patients (88%) who contacted the e-coach we'e interested in further coaching. Patients who viewed the online worksheets did so repeatedly 42 patients opened the worksheets 107 times prior to the visit. Discussion: The Internet-based coaching intervention departs substantially from usual nursing care but warrants further study given its potential to offer considerable benefits to large numbers of patients. Several challenges were identified to providing patient coaching and self-management support via the internet, but this efficient and low-cost approach offers an innovative opportunity to improve patient clinician partnerships in managing chronic conditions. As patients become more accustomed to electronic communication, nurses can pray an important role, joining efforts to develop this new realm to promote patients as partners in managing their health conditions.

Working-age Americans with multiple sclerosis (MS) may face considerable financial insecurities when they become unable to work and lack the health, disability, and life insurance typically offered through employers. In order to estimate the rates of having these insurance policies, as well as how insurance status affects reports of financial stress, we conducted half-hour telephone interviews with 983 working-age persons across the US, who reported being diagnosed with MS. The interviews occurred from May through November 2005, and among the sampled individuals contacted and confirmed eligible, 93.2% completed the interview. The study population was largely female (78.9%), Caucasian (86.4%), married (68.6%), with at least some college education (71.5%), and unemployed (60.2%). Overall, 96.3% had some health insurance (40.3% with public health insurance, primarily Medicare), 56.7% had long-term disability insurance (36.4% with public programs), and 68.3% had life insurance. Notably, 27.4% indicated that, since being diagnosed with MS, health insurance concerns had significantly affected employment decisions. In addition, 16.4% reported considerable difficulty paying for health care, 27.4% put off or postponed seeking needed health care because of costs, and 22.3% delayed filling prescriptions, skipped medication doses, or split pills because of costs. Overall, 26.6% reported considerable worries about affording even basic necessities, such as food, utilities, and housing. Multiple Sclerosis 2007; 13: 534-546. http://msj.sagepub.com