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Poon EG, Simon SR, Jenter CA, Kaushal R, Volk LA, Cleary PD, Tumolo AZ, Bates DW. Use of features in electronic health records and health care quality: How are they related? AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2007:1079. [PMID: 18694177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 10/11/2007] [Indexed: 05/26/2023]
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Abstract
OBJECTIVE To assess how parent reports about the inpatient care of their children vary according to the health status of children with and without chronic conditions. DESIGN We analyzed parent responses to the Picker Institute Pediatric Inpatient Survey. SETTING Thirty-nine hospitals between January 1, 1997, and December 31, 1999. PARTICIPANTS Overall, 12 562 parents of children who received inpatient care at participating hospitals. Main Outcome Measure Parent rating of overall quality of care. RESULTS Fifty-one percent of parents reported that their child had a chronic condition. Quality-of-care ratings varied according to health status and the presence of chronic conditions. Parents of children in the worst (fair or poor) health without chronic conditions reported lower quality of care (P < .001) and more care problems (P < .001) than did those with chronic conditions. Parents of children in the best (excellent, very good, or good) health tended to rate care highly, whether or not their children had chronic conditions. In a multivariable model, the decrement in perceived quality of care associated with poorer health was greater for those without than for those with chronic conditions (P < .001). CONCLUSIONS Although children in poor health are at risk for experiencing a lower quality of health care, parents of such children who have chronic conditions report fewer care-related problems. This may be owing to the more frequent health care interactions and better continuity of care for children with chronic conditions.
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McInnes DK, Landon BE, Wilson IB, Hirschhorn LR, Marsden PV, Malitz F, Barini-Garcia M, Cleary PD. The impact of a quality improvement program on systems, processes, and structures in medical clinics. Med Care 2007; 45:463-71. [PMID: 17446833 DOI: 10.1097/01.mlr.0000256965.94471.c2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to assess whether participation in a quality-improvement collaborative changed care processes, systems, and organization of outpatient human immunodeficiency virus (HIV) clinics. METHODS We surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Surveys assessed clinic structures, processes, systems, and culture. During the collaborative, a clinician-administrator team from each intervention clinic attended 4 2-day sessions on quality improvement techniques. Conference calls, a website, and an e-mail list provided support and facilitated communication among collaborative participants. RESULTS Survey response rates were 85% or greater. Six of 54 organizational measures differed significantly between baseline and follow-up. Intervention clinicians reported greater computer availability (82% vs. 67%, P = 0.03) and use (3.13 vs. 2.68, P = 0.02; 4-point scale), attended more local (14.2 vs. 8.6, P < 0.01) and national (4.1 vs. 2.9, P = 0.01) conferences, and rated leaders' ability to implement quality improvement higher (3.8 vs. 3.4, P = 0.01; 5-point scale). Intervention directors were more likely to compare quality data to other clinics (79% vs. 54%, P = 0.04). For the set of 54 measures, intervention clinics were more likely to have higher post-intervention scores than controls (sign test, mean = 14.5, P < 0.0001). CONCLUSIONS A quality-improvement collaborative for HIV clinics resulted in modest organizational changes. Achieving greater change may require more focused and/or intensive interventions, greater resources for participating clinics, and better developed information technology.
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Keating NL, Ayanian JZ, Cleary PD, Marsden PV. Factors affecting influential discussions among physicians: a social network analysis of a primary care practice. J Gen Intern Med 2007; 22:794-8. [PMID: 17404798 PMCID: PMC2219865 DOI: 10.1007/s11606-007-0190-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 02/26/2007] [Accepted: 03/22/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Physicians often rely on colleagues for new information and advice about the care of their patients. OBJECTIVE Evaluate the network of influential discussions among primary care physicians in a hospital-based academic practice. DESIGN Survey of physicians about influential discussions with their colleagues regarding women's health issues. We used social network analysis to describe the network of discussions and examined factors predictive of a physician's location in the network. SUBJECTS All 38 primary care physicians in a hospital-based academic practice. MEASUREMENTS Location of physician within the influential discussion network and relationship with other physicians in the network. RESULTS Of 33 responding physicians (response rate = 87%), the 5 reporting expertise in women's health were more likely than others to be cited as sources of influential information (odds ratio [OR] 6.81, 95% Bayesian confidence interval [CI] 2.25-23.81). Physicians caring for more women were also more often cited (OR 1.03, 95% CI 1.01-1.05 for a 1 percentage-point increase in the proportion of women patients). Influential discussions were more frequent among physicians practicing in the same clinic within the practice than among those in different clinics (OR 5.03, 95% CI 3.10-8.33) and with physicians having more weekly clinical sessions (OR 1.33, 95% CI 1.15 to 1.54 for each additional session). CONCLUSIONS In the primary care practice studied, physicians obtained information from colleagues with greater expertise and experience as well as colleagues who were accessible based on location and schedule. It may be possible to organize practices to promote more rapid dissemination of high-quality evidence-based medicine.
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Mack JW, Cook EF, Wolfe J, Grier HE, Cleary PD, Weeks JC. Understanding of prognosis among parents of children with cancer: parental optimism and the parent-physician interaction. J Clin Oncol 2007; 25:1357-62. [PMID: 17416854 DOI: 10.1200/jco.2006.08.3170] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients often overestimate their chances of surviving cancer. Factors that contribute to accurate understanding of prognosis are not known. We assessed understanding of likelihood of cure and functional outcome among parents of children with cancer and sought to identify factors that place parents at risk for overly optimistic beliefs about prognosis. PATIENTS AND METHODS We conducted a cross-sectional survey of 194 parents of children with cancer (response rate, 70%) who were treated at the Dana-Farber Cancer Institute and Children's Hospital in Boston, MA, and the children's physicians. Parent and physician expectations for likelihood of cure and functional outcome were compared. In 152 accurate or optimistic parents, we determined factors associated with accurate understanding of likelihood of cure compared with optimism. RESULTS The majority of parents (61%) were more optimistic than physicians about the likelihood of cure. Parents' beliefs about other outcomes of cancer treatment were similar (quality-of-life impairment, P = .70) or more pessimistic (physical impairment, P = .01; intellectual impairment, P = .01) than physicians' beliefs. Parents and physicians were more likely to agree about chances of cure when physicians had confidence in knowledge of prognosis (odds ratio [OR] = 2.55, P = .004) and allowed parents to take their preferred decision-making role (OR = 1.89, P = .019). CONCLUSION Parents of children with cancer are overly optimistic about chances of cure but not about other outcomes of cancer therapy. Parents tend to be overly optimistic about cure when physicians have little confidence and when the decision-making process does not meet parents' preferences. These findings suggest that physicians are partly responsible for parents' unrealistic expectations about cure.
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Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician-industry relationships. N Engl J Med 2007; 356:1742-50. [PMID: 17460228 DOI: 10.1056/nejmsa064508] [Citation(s) in RCA: 311] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Relationships between physicians and pharmaceutical, medical device, and other medically related industries have received considerable attention in recent years. We surveyed physicians to collect information about their financial associations with industry and the factors that predict those associations. METHODS We conducted a national survey of 3167 physicians in six specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) in late 2003 and early 2004. The raw response rate for this probability sample was 52%, and the weighted response rate was 58%. RESULTS Most physicians (94%) reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%). More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials. Cardiologists were more than twice as likely as family practitioners to receive payments. Family practitioners met more frequently with industry representatives than did physicians in other specialties, and physicians in solo, two-person, or group practices met more frequently with industry representatives than did physicians practicing in hospitals and clinics. CONCLUSIONS The results of this national survey indicate that relationships between physicians and industry are common and underscore the variation among such relationships according to specialty, practice type, and professional activities.
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Rodriguez HP, Wilson IB, Landon BE, Marsden PV, Cleary PD. Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors. Med Care 2007; 45:189-98. [PMID: 17304075 DOI: 10.1097/01.mlr.0000250252.14148.7e] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients. DESIGN We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region. RESULTS Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52). CONCLUSIONS Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.
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Simon SR, Kaushal R, Cleary PD, Jenter CA, Volk LA, Orav EJ, Burdick E, Poon EG, Bates DW. Physicians and electronic health records: a statewide survey. ACTA ACUST UNITED AC 2007; 167:507-12. [PMID: 17353500 DOI: 10.1001/archinte.167.5.507] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Electronic health records (EHRs) allow for a variety of functions, ranging from visit documentation to laboratory test ordering, but little is known about physicians' actual use of these functions. METHODS We surveyed a random sample of 1884 physicians in Massachusetts by mail and assessed availability and use of EHR functions, predictors of use, and the relationships between EHR use and physicians' perceptions of medical practice. RESULTS A total of 1345 physicians responded to the survey (71.4% response rate), and 387 (28.8%) reported that their practice had adopted EHRs. More than 80% of physicians with EHRs reported having the ability to view laboratory reports (84.8%) and document visits electronically (84.0%), but considerably fewer reported being able to order laboratory tests electronically (46.8%) or transmit prescriptions to a pharmacy electronically (44.7%). Fewer than half of the physicians who had systems with clinical decision support, transmittal of electronic prescriptions, and radiology order entry actually used these functions most or all of the time. Compared with physicians who had not adopted EHRs, EHR users reported more positive views of the effects of computers on health care; there were no significant differences in these attitudes between high and low users of EHRs. Overall, about 1 in 4 physicians reported dissatisfaction with medical practice; there was no difference in this measure by EHR adoption or use. CONCLUSIONS There is considerable variability in the functions available in EHRs and in the extent to which physicians use them. Future work should emphasize factors that affect the use of available functions.
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Simon SR, Kaushal R, Cleary PD, Jenter CA, Volk LA, Poon EG, Orav EJ, Lo HG, Williams DH, Bates DW. Correlates of electronic health record adoption in office practices: a statewide survey. J Am Med Inform Assoc 2007; 14:110-7. [PMID: 17068351 PMCID: PMC2215070 DOI: 10.1197/jamia.m2187] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2006] [Accepted: 09/21/2006] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption. DESIGN Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey. MEASUREMENTS EHR adoption rates. RESULTS The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%). CONCLUSIONS While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.
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Mack JW, Wolfe J, Grier HE, Cleary PD, Weeks JC. Communication about prognosis between parents and physicians of children with cancer: parent preferences and the impact of prognostic information. J Clin Oncol 2006; 24:5265-70. [PMID: 17114660 DOI: 10.1200/jco.2006.06.5326] [Citation(s) in RCA: 230] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Concerns about the harms of prognostic information, including distress and loss of hope, cause some physicians to avoid frank disclosure. We aimed to determine parent preferences for prognostic information about their children with cancer and the results of receiving such information. PATIENTS AND METHODS We surveyed 194 parents of children with cancer (overall response rate, 70%), treated at the Dana-Farber Cancer Institute and Children's Hospital (Boston, MA) and the children's physicians. Our main outcome measure was parent rating of prognostic information as extremely or very upsetting. RESULTS The majority of parents desired as much information about prognosis as possible (87%) and wanted it expressed numerically (85%). Although 36% of parents found information about prognosis to be extremely or very upsetting, those parents were more likely to want additional information about prognosis than those who were less upset (P = .01). Parents who found information upsetting were no less likely to say that knowing prognosis was important (P = .39), that knowing prognosis helped in decision making (P = .40), or that hope for a cure kept them going (P = .72). CONCLUSION Although many parents find prognostic information about their children with cancer upsetting, parents who are upset by prognostic information are no less likely to want it. The upsetting nature of prognostic information does not diminish parents' desire for such information, its importance to decision making, or parents' sense of hope.
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Elliott MN, Zaslavsky AM, Cleary PD. Are finite population corrections appropriate when profiling institutions? HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2006. [DOI: 10.1007/s10742-006-0011-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hirschhorn LR, McInnes K, Landon BE, Wilson IB, Ding L, Marsden PV, Malitz F, Cleary PD. Gender differences in quality of HIV care in Ryan White CARE Act-funded clinics. Womens Health Issues 2006; 16:104-12. [PMID: 16765286 DOI: 10.1016/j.whi.2006.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 02/07/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women with HIV infection have lagged behind men in receipt of critical health care, but it is not known if those disparities are due in part to where women receive care. We examined differences in care received by HIV-infected women and men in a national sample of Ryan White CARE Act-funded clinics and explored the influence of clinic characteristics on care quality. METHODS Record review was done on a sample of 9,015 patients who received care at 69 CARE Act-funded HIV primary care clinics that participated in a quality improvement study. Outcome measures studied were highly active antiretroviral therapy (HAART) use, HIV viral suppression, Pneumocystis jiroveci pneumonia (PCP) prophylaxis, screening, and other disease prevention efforts. RESULTS Women were less likely than men to receive HAART (78% versus 82%, p < .001), receive PCP prophylaxis (65% versus 75%, p < .0001), or have their hepatitis C virus status known (87% versus 88%, p = .02) despite being seen more regularly (69% versus 66%, p = .04). Sites serving high percentages of women delivered similar or better care for both men and women than other sites. Although sites serving a higher percent of women had more support services such as case management and onsite obstetrician-gynecologists and provided Pap smears at higher rates, women at such sites remained less likely than men to receive important HIV care including HAART and PCP prophylaxis. CONCLUSIONS The gap in the quality of care provided to HIV-infected men and women in critical areas persists, and is not explained by the types of sites where men and women receive care.
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Marsden PV, Landon BE, Wilson IB, McInnes K, Hirschhorn LR, Ding L, Cleary PD. The reliability of survey assessments of characteristics of medical clinics. Health Serv Res 2006; 41:265-83. [PMID: 16430611 PMCID: PMC1681534 DOI: 10.1111/j.1475-6773.2005.00480.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the reliability of survey measures of organizational characteristics based on reports of single and multiple informants. DATA SOURCE Survey of 330 informants in 91 medical clinics providing care to HIV-infected persons under Title III of the Ryan White CARE Act. STUDY DESIGN Cross-sectional survey. DATA COLLECTION METHODS Surveys of clinicians and medical directors measured the implementation of quality improvement initiatives, priorities assigned to aspects of HIV care, barriers to providing high-quality HIV care, and quality improvement activities. Reliability of measures was assessed using generalizability coefficients. Components of variance and clinician-director differences were estimated using hierarchical regression models with survey items and informants nested within organizations. PRINCIPAL FINDINGS There is substantial item- and informant-related variability in clinic assessments that results in modest or low clinic-level reliability for many measures. Directors occasionally gave more optimistic assessments of clinics than did clinicians. CONCLUSIONS For most measures studied, obtaining adequate reliability requires multiple informants. Using multiple-item scales or multiple informants can improve the psychometric performance of measures of organizational characteristics. Studies of such characteristics should report the organizational level reliability of the measures used.
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Davies E, Cleary PD. Hearing the patient's voice? Factors affecting the use of patient survey data in quality improvement. Qual Saf Health Care 2006; 14:428-32. [PMID: 16326789 PMCID: PMC1744097 DOI: 10.1136/qshc.2004.012955] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To develop a framework for understanding factors affecting the use of patient survey data in quality improvement. DESIGN Qualitative interviews with senior health professionals and managers and a review of the literature. SETTING A quality improvement collaborative in Minnesota, USA involving teams from eight medical groups, focusing on how to use patient survey data to improve patient centred care. PARTICIPANTS Eight team leaders (medical, clinical improvement or service quality directors) and six team members (clinical improvement coordinators and managers). RESULTS Respondents reported three types of barriers before the collaborative: organisational, professional and data related. Organisational barriers included lack of supporting values for patient centred care, competing priorities, and lack of an effective quality improvement infrastructure. Professional barriers included clinicians and staff not being used to focusing on patient interaction as a quality issue, individuals not necessarily having been selected, trained or supported to provide patient centred care, and scepticism, defensiveness or resistance to change following feedback. Data related barriers included lack of expertise with survey data, lack of timely and specific results, uncertainty over the effective interventions or time frames for improvement, and consequent risk of perceived low cost effectiveness of data collection. Factors that appeared to have promoted data use included board led strategies to change culture and create quality improvement forums, leadership from senior physicians and managers, and the persistence of quality improvement staff over several years in demonstrating change in other areas. CONCLUSION Using patient survey data may require a more concerted effort than for other clinical data. Organisations may need to develop cultures that support patient centred care, quality improvement capacity, and to align professional receptiveness and leadership with technical expertise with the data.
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Simon SR, Kaushal R, Cleary PD, Jenter CA, Volk LA, Poon EG, Williams DH, Orav EJ, Bates DW. Correlates of electronic health record adoption in office practices: a statewide survey. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2006; 2006:1098. [PMID: 17238717 PMCID: PMC1839711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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Keller S, O'Malley AJ, Hays RD, Matthew RA, Zaslavsky AM, Hepner KA, Cleary PD. Methods used to streamline the CAHPS Hospital Survey. Health Serv Res 2005; 40:2057-77. [PMID: 16316438 PMCID: PMC1361248 DOI: 10.1111/j.1475-6773.2005.00478.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To identify a parsimonious subset of reliable, valid, and consumer-salient items from 33 questions asking for patient reports about hospital care quality. DATA SOURCE CAHPS Hospital Survey pilot data were collected during the summer of 2003 using mail and telephone from 19,720 patients who had been treated in 132 hospitals in three states and discharged from November 2002 to January 2003. METHODS Standard psychometric methods were used to assess the reliability (internal consistency reliability and hospital-level reliability) and construct validity (exploratory and confirmatory factor analyses, strength of relationship to overall rating of hospital) of the 33 report items. The best subset of items from among the 33 was selected based on their statistical properties in conjunction with the importance assigned to each item by participants in 14 focus groups. PRINCIPAL FINDINGS Confirmatory factor analysis (CFA) indicated that a subset of 16 questions proposed to measure seven aspects of hospital care (communication with nurses, communication with doctors, responsiveness to patient needs, physical environment, pain control, communication about medication, and discharge information) demonstrated excellent fit to the data. Scales in each of these areas had acceptable levels of reliability to discriminate among hospitals and internal consistency reliability estimates comparable with previously developed CAHPS instruments. CONCLUSION Although half the length of the original, the shorter CAHPS hospital survey demonstrates promising measurement properties, identifies variations in care among hospitals, and deals with aspects of the hospital stay that are important to patients' evaluations of care quality.
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O'Malley AJ, Zaslavsky AM, Hays RD, Hepner KA, Keller S, Cleary PD. Exploratory factor analyses of the CAHPS Hospital Pilot Survey responses across and within medical, surgical, and obstetric services. Health Serv Res 2005; 40:2078-95. [PMID: 16316439 PMCID: PMC1361242 DOI: 10.1111/j.1475-6773.2005.00471.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the associations among hospital-level scores from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital pilot survey within and across different services (surgery, obstetrics, medical), and to evaluate differences between hospital- and patient-level analyses. DATA SOURCE CAHPS Hospital pilot survey data provided by the Centers for Medicare and Medicaid Services. STUDY DESIGN Responses to 33 questionnaire items were analyzed using patient- and hospital-level exploratory factor analytic (EFA) methods to identify both a patient-level and hospital-level composite structures for the CAHPS Hospital survey. The latter EFA was corrected for patient-level sampling variability using a hierarchical model. We compared results of these analyses with each other and to separate EFAs conducted at the service level. To quantify the similarity of assessments across services, we compared correlations of different composites within the same service with those of the same composite across different services. DATA COLLECTION Cross-sectional data were collected during the summer of 2003 via mail and telephone from 19,720 patients discharged from November 2002 through January 2003 from 132 hospitals in three states. PRINCIPAL FINDINGS Six factors provided the best description of inter-item covariation at the patient level. Analyses that assessed variability across both services and hospitals suggested that three dimensions provide a parsimonious summary of inter-item covariation at the hospital level. Hospital-level factor structures also differed across services; as much variation in quality reports was explained by service as by composite. CONCLUSIONS Variability of CAHPS scores across hospitals can be reported parsimoniously using a limited number of composites. There is at least as much distinct information in composite scores from different services as in different composite scores within each service. Because items cluster slightly differently in the different services, service-specific composites may be more informative when comparing patients in a given service across hospitals. When studying individual-level variability, a more differentiated structure is probably more appropriate.
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O'Malley AJ, Zaslavsky AM, Elliott MN, Zaborski L, Cleary PD. Case-mix adjustment of the CAHPS Hospital Survey. Health Serv Res 2005; 40:2162-81. [PMID: 16316443 PMCID: PMC1361241 DOI: 10.1111/j.1475-6773.2005.00470.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To develop a model for case-mix adjustment of Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital survey responses, and to assess the impact of adjustment on comparisons of hospital quality. DATA SOURCES Survey of 19,720 patients discharged from 132 hospitals. METHODS We analyzed CAHPS Hospital survey data to assess the extent to which patient characteristics predict patient ratings ("predictive power") and the heterogeneity of the characteristics across hospitals. We combined the measures to estimate the impact of each predictor ("impact factor") and selected high impact variables for adjusting ratings from the CAHPS Hospital survey. PRINCIPLE FINDINGS The most important case-mix variables are: hospital service (surgery, obstetric, medical), age, race (non-Hispanic black), education, general health status (GHS), speaking Spanish at home, having a circulatory disorder, and interactions of each of these variables with service. Adjustment for GHS and education affected scores in each of the three services, while age and being non-Hispanic black had important impacts for those receiving surgery or medical services. Circulatory disorder, Spanish language, and Hispanic affected scores for those treated on surgery, obstetrics, and medical services, respectively. Of the 20 medical conditions we tested, only circulatory problems had an important impact within any of the services. Results were consistent for the overall ratings of nurse, doctor, and hospital. Although the overall impact of case-mix adjustment is modest, the rankings of some hospitals may be substantially affected. CONCLUSIONS Case-mix adjustment has a small impact on hospital ratings, but can lead to important reductions in the bias in comparisons between hospitals.
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Wilson IB, Landon BE, Hirschhorn LR, McInnes K, Ding L, Marsden PV, Cleary PD. Quality of HIV care provided by nurse practitioners, physician assistants, and physicians. Ann Intern Med 2005; 143:729-36. [PMID: 16287794 DOI: 10.7326/0003-4819-143-10-200511150-00010] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide. OBJECTIVE To compare the quality of care provided by NPs and PAs with that provided by physicians. DESIGN Cross-sectional analysis. SETTING 68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states. PARTICIPANTS The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS. MEASUREMENTS 8 quality-of-care measures assessed by medical record review. RESULTS After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P < 0.001] and 0.62 [P = 0.025], respectively). Nurse practitioners and PAs had statistically significantly higher performance scores than generalist non-HIV experts on 6 of the 8 quality measures. LIMITATIONS These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes. CONCLUSIONS For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non-HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.
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Andersen KS, Ball JR, Cleary PD, Fox DM, Gottsegen PM, Gray BH, Stevens RA, Stoeckle JD. In This Issue. Milbank Q 2005. [DOI: 10.1111/j.1468-0009.2005.00412.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Oster G, Harding G, Dukes E, Edelsberg J, Cleary PD. Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey. THE JOURNAL OF PAIN 2005; 6:356-63. [PMID: 15943957 DOI: 10.1016/j.jpain.2005.01.359] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Revised: 12/20/2004] [Accepted: 01/24/2005] [Indexed: 11/16/2022]
Abstract
UNLABELLED Persons aged >65 years with pain caused by postherpetic neuralgia (PHN) were recruited via advertisements in 24 US newspapers and were mailed a questionnaire that addressed pain intensity (average, worst, least, current), pain interference (with general activity, mood, relations with other people, sleep, enjoyment of life), and health-related quality of life (using the EuroQoL health measure [EQ-5D] and a global rating scale). Respondents also were asked about their use of medication for shingles pain. A total of 385 persons completed the survey; 61% were >75 years of age. Mean (+/-standard deviation) duration of PHN was 3.3 (+/-4.0) years. Only about one half had taken prescription medication for shingles pain during the prior week; dosages were typically low. Mean average, worst, least, and current pain caused by shingles (0- to 10-point scale) was 4.6 (+/-2.1), 6.0 (+/-2.4), 2.9 (+/-2.3), and 4.0 (+/-2.7), respectively. Mean pain interference with general activity, mood, relations with other people, sleep, and enjoyment of life (0- to 10-point scale) was 3.7 (+/-3.1), 4.3 (+/-2.9), 3.0 (+/-2.8), 3.8 (+/-2.9), and 4.5 (+/-3.1), respectively. The mean EQ-5D health index score was 0.61; respondents rated their overall health as 65.7 (+/-21.1) on a 100-point scale. PHN causes substantial pain, dysfunction, and poor health-related quality of life in older persons, many of whom might be suboptimally treated. PERSPECTIVE Many older persons (age >65 years) with PHN experience longstanding, severe, and debilitating pain and poor health-related quality of life; levels of dissatisfaction with treatment are high. Our study highlights the need for improved management of this disease.
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Lorenz KA, Hays RD, Shapiro MF, Cleary PD, Asch SM, Wenger NS. Religiousness and Spirituality Among HIV-Infected Americans. J Palliat Med 2005; 8:774-81. [PMID: 16128651 DOI: 10.1089/jpm.2005.8.774] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To describe the demographic and clinical factors associated with the importance of religiousness and spirituality among patients with human immunodeficiency virus (HIV) infection in the United States. METHODS Longitudinal study of a nationally representative cohort of 2266 patients receiving care for HIV infection surveyed in 1996 and again in 1998. Measures included 12 items assessing religious affiliation and attendance, the importance of religion and spirituality in life, and religious and spiritual practices. Multi-item religiousness and spirituality scales were constructed. RESULTS Eighty percent of respondents reported a religious affiliation. Sixty-five percent affirmed that religion and 85% that spirituality was "somewhat" or "very" important in their lives. A majority indicated that they "sometimes" or "often" rely on religious or spiritual means when making decisions (72%) or confronting problems (65%). Women, nonwhites, and older patients were more religious and spiritual. Residents of regions other than the western United States reported higher religiousness. High school graduates were more religious and spiritual than those with less education. Patients who did not report one of the risk factors assessed for HIV infection had higher religiousness scores than injection drug users (IDUs). Women, nonwhites other than Hispanics, patients older than 45 years of age compared to those between 18 and 34 years of age, and more educated patients reported higher spirituality. Clinical stage was not associated with religiousness or spirituality. CONCLUSIONS A large majority of HIV-infected patients in the United States affirm the importance of religiousness and spirituality. These findings support a comprehensive, humanistic approach to the care of HIV-infected patients.
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Landon BE, Wilson IB, McInnes K, Landrum MB, Hirschhorn LR, Marsden PV, Cleary PD. Physician specialization and the quality of care for human immunodeficiency virus infection. ARCHIVES OF INTERNAL MEDICINE 2005; 165:1133-9. [PMID: 15911726 DOI: 10.1001/archinte.165.10.1133] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND There is debate over the types of physicians who should treat patients with complex chronic medical conditions such as human immunodeficiency virus (HIV) infection. We sought to assess the relationship between specialty training and expertise and the quality of care delivered to patients with HIV infection. METHODS We selected random samples of HIV-infected patients receiving care at 64 Ryan White CARE (Comprehensive AIDS Resources Emergency) Act-funded clinics throughout the country and their primary HIV physicians for an observational cohort study in which quality-of-care measures were assessed by medical record review. RESULTS We studied 5247 patients linked to 177 physicians who responded to a survey. Fifty-eight percent of the physicians were general medicine physicians ("generalists") and 42% were infectious diseases specialists. Sixty-three percent of the generalists (37% overall) considered themselves expert in HIV care. In hierarchical logistic regression models that controlled for patient characteristics, infectious diseases physicians and expert generalists had similar performance. In contrast, nonexpert generalists delivered lower quality care. More than 80% of the appropriate patients being cared for by infectious diseases physicians and expert generalists were receiving highly active antiretroviral therapy, compared with 73% of appropriate patients of nonexpert generalists (P<.001). Physicians with fewer than 20 patients with active HIV had fewer appropriate patients on highly active antiretroviral therapy (73% vs 82% of physicians with >/=20 such patients, P = .04) and saw patients less frequently. CONCLUSION These findings extend previous work by examining a range of quality-of-care measures and suggest that generalists with appropriate experience and expertise in HIV care can provide high-quality care to patients with this complex chronic illness.
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Ding L, Landon BE, Wilson IB, Wong MD, Shapiro MF, Cleary PD. Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users. ACTA ACUST UNITED AC 2005; 165:618-23. [PMID: 15795336 DOI: 10.1001/archinte.165.6.618] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND We evaluated physicians' training, experience, and practice characteristics and examined associations between their attitudes toward human immunodeficiency virus (HIV)-infected persons who are injection drug users (IDUs) and quality of care. METHODS Cross-sectional surveys were conducted among a probability sample of noninstitutionalized HIV-infected individuals in the United States and their main HIV care physicians. Physician and practice characteristics, training, HIV knowledge, experience, attitudes toward HIV-infected IDUs, stress levels, and satisfaction with practice were assessed. The main quality-of-care measures were patient exposure to highly active antiretroviral therapy, reported problems, satisfaction with care, unmet needs, and perceived access to care. RESULTS Nationally, 23.2% of HIV-infected patients had physicians with negative attitudes toward IDUs. Seeing more IDUs, having higher HIV treatment knowledge scores, and treating fewer patients per week were independently associated with more positive attitudes toward IDUs. Injection drug users who were cared for by physicians with negative attitudes had a significantly lower adjusted rate of exposure to highly active antiretroviral therapy by December 1996 (13.5%) than non-IDUs who were cared for by such physicians (36.1%) or IDUs who were cared for by physicians with positive attitudes (32.3%). Physician attitudes were not associated with other problems with care, satisfaction with care, unmet needs, or perceived access to care. CONCLUSIONS Negative attitudes may lead to less than optimal care for IDUs and other marginalized populations. Providing education or experience-based exercises or ensuring that clinicians have adequate time to deal with complex problems might result in better attitudes and higher quality of care.
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Wilson IB, Landon BE, Ding L, Zaslavsky AM, Shapiro MF, Bozzette SA, Cleary PD. A national study of the relationship of care site HIV specialization to early adoption of highly active antiretroviral therapy. Med Care 2005; 43:12-20. [PMID: 15626929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Little is known about characteristics of organizations that predict early adoption of highly active antiretroviral therapy (HAART) for persons with HIV infection. OBJECTIVES To describe characteristics of sites where HIV care is provided and to assess site characteristics that predict early adoption of HAART. DESIGN Cross-sectional analysis of survey data from patients, HIV physicians, and medical directors. PATIENTS AND SETTING Participants in the HIV Cost and Services Utilization Study, a national probability sample of persons with HIV who received outpatient care in the continental United States during 1996. MAIN OUTCOME MEASURE Rates of exposure to HAART by December 1996. RESULTS Nationally, 79% of patients were treated at sites specializing in HIV care (HIV sites). Over 90% of patients were cared for by physicians who were experts in HIV care, either infectious disease specialists (46%) or general medicine experts (45%). Adjusted rates of exposure to HAART by December 1996 varied from 0.02 to 0.79 across sites (mean rate, 0.33). In multivariable models, HIV specialization (odds ratio [OR], 3.6; P < 0.001), total patient volume of more than 20,000 visits a year (OR, 2.1; P < 0.01), and educational level of the zip code in which the site was located (OR, 1.2 for each 10% increase in college education) were associated with higher rates of exposure to HAART. These effects persisted after adjustment for physician HIV expertise. Site effects were more important than physician effects in explaining rates of exposure to HAART. CONCLUSION In 1996 there were wide variations in rates of HAART use by site of care. Low-volume sites that do not specialize in HIV care should take measures to ensure that HIV expertise is available to their patients.
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