The impact of physician education regarding the importance of providing complete clinical information on the request forms of thrombophilia-screen tests at Tygerberg hospital in South Africa

BACKGROUND

Thrombophilia-screen tests are specialised haemostasis tests that are affected by numerous unique patient variables including the presence of acute thrombosis, the concomitant use of medication and patient demographics. Complete information on the request form is therefore crucial for the haematological pathologist to make patient-specific interpretation of patients' results.

OBJECTIVES

To assess the completeness of thrombophilia-screen test request forms and determine the impact of provision of incomplete information, on the interpretive comments generated by reporting haematological pathologists. To assess the impact of an educational session given to clinicians on the importance of providing all the relevant information on the request forms.

METHOD

Two retrospective audits, each covering 3 months, were performed to evaluate the completeness of demographic and clinical information on thrombophilia-screen request forms and its impact on the quality of the interpretive comments before and after an educational intervention.

RESULTS

One hundred and seventy-one request forms were included in the first audit and 146 in the second audit. The first audit revealed that all 171 thrombophilia-screen request forms had complete patient demographic information but none had clinical information. Haematological pathologists only made generic comments which could not be applied to a specific patient. The second audit, conducted after a physician educational session, did not reveal any improvement in the clinical information provision by the test-ordering physicians. This was reportedly due to the lack of space on the request form. The interpretive comments therefore remained generic and not patient-specific.

CONCLUSION

Physicians' failure to provide relevant clinical information made it impossible for pathologists to make patient-specific interpretation of the results. A single physician education session did not change the practice, reportedly due to the inappropriate design of the test request form. Further studies are required to investigate the impact of an improved request form and the planned electronic test requesting.

Chief complaints and feedback from clinic satisfaction tool: Thematic analysis of a new outpatient communication tool

OBJECTIVES

Up to half of all patients leave their outpatient clinic visit with an uncommunicated need. We designed the clinic satisfaction tool (CST) as a low-cost, highly utilised assessment of the spine clinic experience that improved communication in our multidisciplinary spine practice. The purpose of this study was to qualitatively analyse chief complaints and feedback from the CSTs to determine how spine clinic patients used the form, identify the most prevalent concerns and mark areas for improvement.

METHODS

Institutional retrospective review of CSTs. Chief complaints and feedback were inductively coded to create a framework for patient complaints.

RESULTS

832 patients presented to clinic, and 100 sets of chief complaints coded before reaching thematic saturation. Patients used the chief complaint section of CST to canvas four themes: symptoms, questions about their disease, management and treatment. Twenty-nine patients left mostly positive feedback but also wrote additional concerns about care.

CONCLUSION

Spine patients have a predictable pattern of chief complaints and with the CST were able to have all these complaints addressed. The CST efficiently collects practice-specific chief complaints that can be used to guide physician behaviour and design educational clinical tools that are useful for patients.

Audit of ethnicity data in the Waikato Hospital Patient Management System and Trauma Registry: pilot of the Hospital Ethnicity Data Audit Toolkit

BACKGROUND

Māori are disproportionately impacted by injury in New Zealand, therefore reliable ethnicity data are essential for measuring and addressing inequities in trauma incidence, care and outcomes.

AIM

To audit the quality of ethnicity data captured by the Waikato Hospital Trauma Registry and Waikato Hospital patient management system against self-identified ethnicity.

METHOD

Self-identified ethnicity using the New Zealand Census ethnicity question was gathered from 100 consecutive trauma patients and compared with ethnicity recorded in their Trauma Registry record and in the hospital's patient management database.

RESULTS

Twenty-nine (29%) participants self-identified as Māori, of whom six were classified as New Zealand European (NZE) only in the Trauma Registry and five as NZE on the hospital patient management database. Over half of Māori (n=18/29) reported more than one ethnicity compared with 4% (n=3/71) of non-Māori. Self-identified ethnicity matched Trauma Registry ethnicity for one quarter (n=7/29) of Māori versus 9% of non-Māori.

CONCLUSIONS

The degree of misclassification of Māori ethnicity data among patients in the Waikato Trauma Registry and the Waikato Hospital patient management system highlights a need for improvements to how ethnicity data is captured within these databases and potentially many other similar entities collecting ethnicity data in New Zealand. The release of revised standardised protocols for the collection of ethnicity data is timely given the recent establishment of a national trauma registry. Without quality data, the opportunity to investigate and address ethnic inequities in trauma incidence and management is greatly compromised.

Problem list completeness in electronic health records: A multi-site study and assessment of success factors

OBJECTIVE

To assess problem list completeness using an objective measure across a range of sites, and to identify success factors for problem list completeness.

METHODS

We conducted a retrospective analysis of electronic health record data and interviews at ten healthcare organizations within the United States, United Kingdom, and Argentina who use a variety of electronic health record systems: four self-developed and six commercial. At each site, we assessed the proportion of patients who have diabetes recorded on their problem list out of all patients with a hemoglobin A1c elevation>=7.0%, which is diagnostic of diabetes. We then conducted interviews with informatics leaders at the four highest performing sites to determine factors associated with success. Finally, we surveyed all the sites about common practices implemented at the top performing sites to determine whether there was an association between problem list management practices and problem list completeness.

RESULTS

Problem list completeness across the ten sites ranged from 60.2% to 99.4%, with a mean of 78.2%. Financial incentives, problem-oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture were identified as success factors at the four hospitals with problem list completeness at or near 90.0%.

DISCUSSION

Incomplete problem lists represent a global data integrity problem that could compromise quality of care and put patients at risk. There was a wide range of problem list completeness across the healthcare facilities. Nevertheless, some facilities have achieved high levels of problem list completeness, and it is important to better understand the factors that contribute to success to improve patient safety.

CONCLUSION

Problem list completeness varies substantially across healthcare facilities. In our review of EHR systems at ten healthcare facilities, we identified six success factors which may be useful for healthcare organizations seeking to improve the quality of their problem list documentation: financial incentives, problem oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture.

Diagnostic imaging requisition quality when using an electronic medical record: a before-after study

Diagnostic imaging requisition (DIR) content is legally constrained for care quality and patient safety concerns. A French national indicator, based on administrative and clinical data, has been introduced to monitor nationwide the conformity of such documents (CDIR). The purpose of this study was to assess the effect on CDIR of the deployment of the ORBIS™ electronic medical record at the Tenon hospital (Paris, France). A before-after study has been carried out. A significant increase of CDIR, from 37.0% (n=676) to 49.1% (n=800), was observed (p < 10⁻⁵). Conformity of administrative criteria improved, but there was no statistical difference of clinical criteria conformity, despite the improvement of clinical history documentation (100%). Up to five different paper-based requisition forms were used by clinical departments in the before period. In the after period, only 27.1% of requisitions were ORBIS-edited with a CDIR of 66.8% (n=217). In both periods, CDIR was correlated to the level of standardization of the forms.

Health Interoperability into Practice: Results of the Development of a Consent Form in a Pilot Project in a Health District in São Paulo, Brazil

Interoperability of health information systems is a centerpiece of the "E-Health" Brazilian Ministry of Health strategy. It aims to solve at least partially the health information technology puzzle that we face today. This paper describes a health information exchange pilot project in a health district of the city of São Paulo. It discusses the results of the development of an informed consent form for health information exchange. This consent form showed excellent results, with median application time of 3 minutes and with 97.8% of patients feeling fully clarified. The patients' perception when faced with options of consent to share their data is also described.

Acquisition of patient information from nurses by other health professionals under electronic medical record implementation

Most electronic medical record (EMR) systems in Japan are equipped with nursing documentation functions. Electronic nursing records (ENRs) are much more accessible to doctors and paramedical staff than paper-based record systems. Face-to-face communication might be used less often to acquire patient information collected by nurses if EMR systems were effectively used. We conducted a questionnaire survey to investigate the methods used by other health professionals to acquire patient information collected by nurses under EMR implementation at two university hospitals. There were 153 responses, which showed that 51% of doctors and 16% of paramedical staff still often used face-to-face communication even though more than 70% of them often accessed the ENR. Only 35% of doctors and paramedical staff recognized that the EMR system helped reduce the time needed to acquire patient information; furthermore, 32% thought that using the EMR system to acquire patient information was bothersome. These results indicate that the operability of EMR systems is still insufficient for health professionals.

Are physicians interested in the quality of life of their patients? usage of EHR-integrated patient reported outcomes data

In addition to clinical findings, patient reported outcomes (PRO) are a valuable source of information. However, the available time of a physician per patient is limited. Under these constraints, do physicians look into PRO data? By using an, electronic health record (EHR) integrated system for the documentation of PRO the data is directly available during treatment. To evaluate whether this information is used we analyzed access patterns for two types of PRO forms. 56% and 74% of these forms were accessed within routine care while 74% and 100% were analyzed for clinical research.

Automatic detection of inconsistencies between free text and coded data in Sarcoma discharge letters

Discordance between data stored in Electronic Health Records (EHR) may have a harmful effect on patient care. Automatic identification of such situations is an important yet challenging task, especially when the discordance involves information stored in free text fields. Here we present a method to automatically detect inconsistencies between data stored in free text and related coded fields. Using EHR data we train an ensemble of classifiers to predict the value of coded fields from the free text fields. Cases in which the classifiers predict with high confidence a code different from the clinicians' choice are marked as potential inconsistencies. Experimental results over discharge letters of sarcoma patients, verified by a domain expert, demonstrate the validity of our method.

HIV management by nurse prescribers compared with doctors at a paediatric centre in Gaborone, Botswana

OBJECTIVES

To compare compliance with national paediatric HIV treatment guidelines between nurse prescribers and doctors at a paediatric referral centre in Gaborone, Botswana.

METHODS

A cross-sectional study was conducted in 2009 at the Botswana-Baylor Children's Clinical Centre of Excellence (COE), Gaborone, Botswana, comparing the performance of nurse prescribers and physicians caring for HIV-infected paediatric patients. Selected by stratified random sampling, 100 physician and 97 nurse prescriber encounters were retrospectively reviewed for successful documentation of eight separate clinically relevant variables: pill count charted; chief complaint listed; social history updated; disclosure reviewed; physical exam; laboratory testing; World Health Organization (WHO) staging documented; paediatric dosing.

RESULTS

Nurse prescribers and physicians correctly documented 96.0% and 94.9% of the time, respectively. There was a trend towards a higher proportion of social history documentation by the nurses, but no significant difference in any other documentation items.

CONCLUSIONS

Our findings support the continued investment in programmes employing properly trained nurses in southern Africa to provide quality care and ART services to HIV-infected children who are stable on therapy. Task shifting remains a promising strategy to scale up and sustain adult and paediatric ART more effectively, particularly where provider shortages threaten ART rollout. Policies guiding ART services in southern Africa should avoid restricting the delivery of crucial services to doctors, especially where their numbers are limited.

Administrative data have high variation in validity for recording heart failure

BACKGROUND

Many studies have relied on administrative data to identify patients with heart failure (HF).

OBJECTIVE

To systematically review studies that assessed the validity of administrative data for recording HF.

METHODS

English peer-reviewed articles (1990 to 2008) validating International Classification of Diseases (ICD)-8, -9 and -10 codes from administrative data were included. An expert panel determined which ICD codes should be included to define HF. Frequencies of ICD codes for HF were calculated using up to the 16 diagnostic coding fields available in the Canadian hospital discharge abstract during fiscal years 2000⁄2001 and 2005⁄2006.

RESULTS

Between 1992 and 2008, more than 70 different ICD codes for defining HF were used in 25 published studies. Twenty-one studies validated hospital discharge abstract data; three studies validated physician claims and two studies validated ambulatory care data. Eighteen studies reported sensitivity (range 29% to 89%). Specificity and negative predictive value were greater than 70% across 17 studies. Nineteen studies reported positive predictive values (range 12% to 100%). Ten studies reported kappa values (range 0.39 to 0.84). For Canadian hospital discharge data, ICD-9 and -10 codes 428 and I50 identified HF in 5.50% and 4.80% of discharge records, respectively. Additional HF-related ICD-9 and -10 codes did not impact HF prevalence.

CONCLUSION

The ICD-9 and -10 codes 428 and I50 were the most commonly used to define HF in hospital discharge data. Validity of administrative data in recording HF varied across the studies and data sources that were assessed.

Completeness and consistency in recording information in the tuberculosis case register, Cambodia, China and Viet Nam

SETTING

Tuberculosis (TB) case registers in Cambodia, two provinces in China and in Viet Nam.

OBJECTIVE

To determine completeness and consistency of information for quarterly reports on case finding and treatment outcome.

METHODS

A representative sample of TB case registers was selected in Cambodia, in two provinces in China and in Viet Nam. Quarterly reports were reproduced from double-entered, validated data to determine completeness and consistency.

RESULTS

The dataset comprised 37,635 patient records in 2 calendar years. Only 0.2%, 3.6% and 1.1% of cases, respectively, in Cambodia, the two China provinces, and Viet Nam did not allow classification for the quarterly report on case finding. If the treatment outcome was reported as cured, it was correct in 99.9%, 85.7%, and 98.5% of the respective three jurisdictions: errors were mostly due to misclassification of completion as cure. Under-reporting of failures was more frequent than over-reporting in Cambodia and Viet Nam, while in the two provinces in China 84% of reported failures did not actually meet the bacteriological criterion.

CONCLUSIONS

This evaluation demonstrates that recording essential information is exemplary in all three countries. It will be essential to carefully supervise the ability of staff to correctly define TB treatment outcome results in all three countries.

An evaluation of the completeness and accuracy of active tuberculosis reporting in the United States military

SETTING

Despite the low incidence of tuberculosis (TB) in the United States military, there is uncertainty in the overall reporting and estimates of incidence.

OBJECTIVE

To assess TB reporting in the active component US military.

DESIGN

TB notification in the US military was compared with three other data sources: laboratory, hospitalization and pharmacy records. Sensitivity and positive predictive value were estimated for all data sources using a gold standard of either a reportable medical event (RME) reported as confirmed or a positive laboratory result for Mycobacterium tuberculosis. Uncorrected and capture-recapture (CR) methods were used to estimate underreporting and completeness of data sources.

RESULTS

Completeness of reporting of pulmonary TB cases was estimated as 72.4% uncorrected or 58.3% with CR. Even after correction for possible underreporting, the incidence of active pulmonary TB was only 0.87 per 100,000 person-years between 2004 and 2006.

CONCLUSION

The rate of active TB in the US military is low. Like civilian surveillance, US military RME surveillance may substantially underreport TB incidence rates. Expanding surveillance to include data sources such as hospitalizations and pharmacy records will increase the number of TB diagnoses at the cost of including many false-positives.

Mortality from ischaemic heart disease in Poland in 1991-1996 estimated by the coding system used since 1997

BACKGROUND

Official statistical data on deaths due to heart disease and cerebrovascular disease in Poland in 1991-2005 are not consistent because of the changes in the coding system introduced after 1996. Between 1996 and 1999, the number of deaths due to ischaemic heart disease (IHD) increased considerably, while the number of deaths due to atherosclerosis decreased. Considering the magnitude of these changes, any analyses of mortality trends in these periods treating these data as consistent are practically impossible. This also applies to international comparisons of IHD mortality data.

AIM

To develop a method of estimating the number of deaths that would approximate the real numbers of deaths due to IHD in Poland in 1991-2005.

METHODS

Sets of individual death records from the Central Statistical Office (CSO) and data from the WHO Mortality Database were used. The IHD mortality data documented officially in Poland were obtained using two different coding systems used consistently before and since 1997. IHD mortality was highly consistent in each of these periods. The applied version of the regression model makes use of both these properties.

RESULTS

The system of certifying death causes which was used in Poland before 1997 resulted in underestimating the real number of IHD deaths in Poland in 1991 by around 35% compared to the numbers estimated using a more correct system of certifying death causes used after 1997. Approximate relative error of the official number of deaths due to IHD in 1991 in age groups of 45-54, 65-74, 75-84, and > or = 85 years was 30%, 24%, 49% and 67%, respectively, in men, and 27%, 25%, 52% and 72%, respectively, in women.

CONCLUSIONS

An increase in the IHD mortality rate in Poland in 1996-1999 noted by CSO was an apparent phenomenon resulting from inaccuracies in coding death causes before 1997. These inaccuracies were mainly related to IHD, atherosclerosis and cerebrovascular disease. Our method enabled correction of the number of deaths between 1991 and 1996, yielding figures much closer to the real ones. Using this method, it is also possible to assess long-term mortality trends, including evaluation of the effectiveness of different methods of treatment and prevention. In particular, it also refers to the use of the IMPACT model to analyse reasons of changes in IHD mortality in Poland.

Four minutes for a patient, twenty seconds for a relative - an observational study at a university hospital

BACKGROUND

In the modern hospital environment, increasing possibilities in medical examination techniques and increasing documentation tasks claim the physicians' energy and encroach on their time spent with patients. This study aimed to investigate how much time physicians at hospital wards spend on communication with patients and their families and how much time they spend on other specific work tasks.

METHODS

A non-participatory, observational study was conducted in thirty-six wards at the University Medical Center Freiburg, a 1700-bed academic hospital in Germany. All wards belonging to the clinics of internal medicine, surgery, radiology, neurology, and to the clinic for gynaecology took part in the study. Thirty-four ward doctors from fifteen different medical departments were observed during a randomly chosen complete work day. The Physicians' time for communication with patients and relatives and time spent on different working tasks during one day of work were assessed.

RESULTS

374 working hours were analysed. On average, a physician's workday on a university hospital ward added up to 658.91 minutes (10 hrs 58 min; range 490 - 848 min). Looking at single items of time consumption on the evaluation sheet, discussions with colleagues ranked first with 150 minutes on average. Documentation and administrative requirements took an average time of 148 minutes per day and ranked second. Total time for communication with patients and their relatives was 85 minutes per physician and day. Consequently, the available time for communication was 4 minutes and 17 seconds for each patient on the ward and 20 seconds for his or her relatives. Physicians assessed themselves to communicate twice as long with patients and sevenfold with relatives than they did according to this study.

CONCLUSIONS

Workload and time pressure for physicians working on hospital wards are high. To offer excellent medical treatment combined with patient centred care and to meet the needs of patients and relatives on hospital wards, physicians should be given more time to focus on core clinical tasks. Time and health care management solutions to minimize time pressure are required. Further research is needed to assess quality of communication in hospital settings.

Lessons learned from implementation of voice recognition for documentation in the military electronic health record system

This study evaluated the implementation of voice recognition (VR) for documenting outpatient encounters in the electronic health record (EHR) system at a military hospital and its 12 outlying clinics. Seventy-five clinicians volunteered to use VR, and 64 (85 percent) responded to an online questionnaire post implementation to identify variables related to VR continuance or discontinuance. The variables investigated were user characteristics, training experience, logistics, and VR utility. Forty-four respondents (69 percent) continued to use VR and overall felt that the software was accurate, was faster than typing, improved note quality, and permitted closing a patient encounter the same day. The discontinuation rate of 31 percent was related to location at an outlying clinic and perceptions of inadequacy of training, decreased productivity due to VR inaccuracies, and no improvement in note quality. Lessons learned can impact future deployment of VR in other military and civilian healthcare facilities.

Evaluation of factors influencing accuracy of principal procedure coding based on ICD-9-CM: an Iranian study

To evaluate the accuracy of procedural coding and the factors that influence it, 246 records were randomly selected from four teaching hospitals in Kashan, Iran. "Recodes" were assigned blindly and then compared to the original codes. Furthermore, the coders' professional behaviors were carefully observed during the coding process. Coding errors were classified as major or minor. The relations between coding accuracy and possible effective factors were analyzed by chi(2) or Fisher exact tests as well as the odds ratio (OR) and the 95 percent confidence interval for the OR. The results showed that using a tabular index for rechecking codes reduces errors (83 percent vs. 72 percent accuracy). Further, more thorough documentation by the clinician positively affected coding accuracy, though this relation was not significant. Readability of records decreased errors overall (p = .003), including major ones (p = .012). Moreover, records with no abbreviations had fewer major errors (p = .021). In conclusion, not using abbreviations, ensuring more readable documentation, and paying more attention to available information increased coding accuracy and the quality of procedure databases.

The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians' activities

OBJECTIVES

Health care professionals seem to be confronted with an increasing need for high-quality, timely, patient-oriented documentation. However, a steady increase in documentation tasks has been shown to be associated with increased time pressure and low physician job satisfaction. Our objective was to examine the time physicians spend on clinical and administrative documentation tasks. We analyzed the time needed for clinical and administrative documentation, and compared it to other tasks, such as direct patient care.

METHODS

During a 2-month period (December 2006 to January 2007) a trained investigator completed 40 hours of 2-minute work-sampling analysis from eight participating physicians on two internal medicine wards of a 200-bed hospital in Austria. A 37-item classification system was applied to categorize tasks into five categories (direct patient care, communication, clinical documentation, administrative documentation, other).

RESULTS

From the 5555 observation points, physicians spent 26.6% of their daily working time for documentation tasks, 27.5% for direct patient care, 36.2% for communication tasks, and 9.7% for other tasks. The documentation that is typically seen as administrative takes only approx. 16% of the total documentation time.

CONCLUSIONS

Nearly as much time is being spent for documentation as is spent on direct patient care. Computer-based tools and, in some areas, documentation assistants may help to reduce the clinical and administrative documentation efforts.

Ability to perform registry functions among practices with and without electronic health records

Patient care registries allow physicians to identify patients based on a subset of conditions, including medicine prescribed, laboratory results and diagnosis. The presence of EHRs and a physician's ability to query across patient medical records is unknown in Massachusetts. A survey was conducted to examine the presence of EHRs in medical practices, and the degree to which EHRs enable physicians to carry out registry functions. EHR adoption was correlated with the use of registry functions.

An audit of basic record keeping standards: lessons learnt from the Royal College of Physicians

This paper describes an audit of the basic standard of record keeping for inpatient clinical records. Following an initial audit, the Royal College of Physicians' inpatient record keeping standards 6 and 7 were adopted. The standard was then reassessed in a second audit. During the first audit, 189 medical entries were assessed and 274 were assessed on repeat audit. A significant improvement was achieved in many areas including recording of time (19-82%), name of author (60-89%), location of patient (58-94%) and identity of the most senior doctor present (68-89%), (p<0.001). The Royal College of Physicians' record keeping standards through the use of audit can lead to considerable improvement in the standard of record keeping within psychiatric practice.

Maintenance of a computerized medical record form

Structured entry forms for clinical records should be updated to take into account the physicians' needs during consultation and advances in medical knowledge and practice. We updated the computerized medical record form of a hypertension clinic, based on its previous use and clinical guidelines. A statistical analysis of previously completed forms identified several unnecessary items rarely used by clinicians. A terminological analysis of guidelines and of free-text answers on completed forms identified several new topics relevant to current clinical practice. We therefore added new items to the form and some topics previously recorded as free text were itemized. We collaborated with clinicians in interpretation of the results of the statistical and terminological analyses used as the starting point and guide for this updating process.

Systemic sclerosis mortality in the United States: 1999-2002 implications for patient care

OBJECTIVE

To describe the systemic sclerosis mortality rates in the United States between 1999 and 2002, a time period in which a new coding system was used to record deaths, and to describe its implications in patient care.

METHODS

We used the mortality database from the National Center of Health Statistics and with the use of ICD-10 codes for systemic sclerosis calculated death rates by gender, race, age, state, and region for the United States. Death rates are expressed as per million population.

RESULTS

Age-adjusted death rates for systemic sclerosis were 6.8 cases per million in women, 2.1 cases per million in men, and 4.7 cases per million for the whole population. Death rates peaked a decade earlier in the African American population when compared with those in the white population (65-74 vs. 75-84 years of age). Age-adjusted mortality was highest in African American women at 9.5 cases per million.

CONCLUSION

Mortality rates for systemic sclerosis are slightly higher since the implementation of the new disease-specific ICD-10 coding system for recording deaths. Death rates related to systemic sclerosis among the African American population are remarkably higher than those among the white population; this is believed to be related to the more aggressive disease seen in the African American patients and to the disparity of healthcare resources. These findings suggest that earlier and more aggressive treatment is warranted in the African American population, with more frequent follow-up and preventive care.

Prevalence of systemic lupus erythematosus and associated comorbidities in Puerto Rico

OBJECTIVE

To examine the prevalence of systemic lupus erythematosus (SLE) and its associated comorbidities in patients from Puerto Rico using a database from a health insurance company.

METHODS

The insurance claims submitted by physicians in 2003 to a health insurance company of Puerto Rico were examined. Of 552,733 insured people, 877 had a diagnosis of SLE (code 710.0) per the International Classification of Diseases, Ninth Revision (ICD-9). Demographic parameters and selected comorbidities were determined. The diagnosis of comorbities was ascertained using the ICD-9 code, the Current Procedural Terminology-4 code (for disease-specific procedures) and/or the Medi-Span Therapeutic Classification System (for disease-specific pharmacologic treatment). Fisher exact test and chi were used to evaluate differences between SLE patients groups.

RESULTS

The mean age was 42.0 +/- 13.5, and the female-to-male ratio was 12.5:1. The overall prevalence of SLE was 159 per 100,000 individuals. The prevalence for females was 277 per 100,000 women and for males it was 25 per 100,000 men. The most common comorbidities were high blood pressure (33.7%), osteopenia/osteoporosis (22.2%), hypothyroidism (19.0%), diabetes mellitus (11.6%), and hypercholesterolemia (11.6%). Overall, high blood pressure, diabetes mellitus, hypercholesterolemia, and coronary artery disease were more prevalent in SLE patients older than 54 years. Osteopenia/osteoporosis was more prevalent in women than in men.

CONCLUSIONS

The prevalence of SLE in Puerto Rico is very high. High blood pressure, diabetes mellitus and hypercholesterolemia, hypothyroidism, and osteopenia/osteoporosis are common comorbidities in these patients. Identification and management of these comorbidities are critical for optimal medical care to this population.

A national survey of medical morning handover report in Australian hospitals

OBJECTIVE

To investigate the prevalence and format of medical morning handover report (MMHR) in Australian hospitals.

DESIGN, SETTING AND PARTICIPANTS

Questionnaire survey faxed to 76 Australian hospitals accredited for basic physician training by the Royal Australasian College of Physicians (RACP). The survey was conducted in 2005.

MAIN OUTCOME MEASURES

Use of MMHR; structure and format of meetings.

RESULTS

53 of 76 (70%) hospitals responded. However, some data (1.7% of possible responses) were missing or illegible. Prevalence of the use of MMHR in respondent hospitals was 58% (31/53). Analysing the data by RACP accreditation level, 18/24 Level 3 hospitals (75%) conducted MMHR compared with 5/9 Level 2 hospitals (56%) and 7/18 Level 1 hospitals (39%) (odds ratio [OR] for trend, 2.17; 95% CI, 1.12-4.23; P = 0.023). 44 of 53 respondents reported their Rural, Remote and Metropolitan Areas (RRMA) classification. MMHR is less likely to be held in hospitals in regions classified as RRMA 2-4 (8/21 [38%]) than those in capital cities (RRMA 1) (16/23 [70%]) (OR, 0.27; 95% CI, 0.08-0.95; P = 0.042). In 62% of hospitals, MMHR was chaired by a consultant, and at most hospitals (23/31 [74%]), meetings were 15-30 minutes long.

CONCLUSIONS

In spite of RACP accreditation requirements, the use of MMHR in Australian hospitals accredited for basic physician training is low.

Proportion of injury deaths with unspecified external cause codes: a comparison of Australia, Sweden, Taiwan and the US

BACKGROUND

The proportion of injury deaths with unspecified external cause codes has been used as an indicator of the level of comprehensiveness and specificity of information on death certificates provided by certifiers.

OBJECTIVE

To compare the proportion of unspecified external cause codes across countries.

METHODS

Multiple-cause-of-death mortality data for people who died in 2001 due to external causes in Australia, Sweden, Taiwan and the USA were used for this international comparison study. The proportion of injury deaths coded as due to an unspecified external cause (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, ICD-10, chapter XX) to all injury deaths in each block was calculated.

RESULTS

Sweden (33%) had the highest proportion of use of the least specific code (ICD-10 code X59 exposure to unspecified factor), followed by Australia (17%), Taiwan (13%) and the USA (7%). More than two-thirds of the deceased for whom an ICD-10 code X59 was assigned in Sweden and Australia were those aged > or =65 years, and more than half of them had femoral fractures. The percentage of use of the unspecified codes within specific groups of external causes was relatively high for falls and unintentional drowning.

CONCLUSIONS

Caution should be used in examining the compensatory effects of the unspecified external event code (ICD-10 code X59) on specific external causes (especially falls) when making international comparisons. Efforts are needed to educate certifiers to report sufficient information for specific coding so as to provide more useful information for injury prevention.

Outcomes from homeopathic prescribing in dental practice: a prospective, research-targeted, pilot study

BACKGROUND AND AIMS

A base for targeted research development in dental homeopathy can be founded on systematic collection and analysis of relevant data obtained by dentists in clinical practice. With these longer-term aims in mind, we conducted a pilot data collection study, in which 14 homeopathic dentists collected clinical and outcome data over a 6-month period in their practice setting.

METHODS

A specifically designed Excel spreadsheet enabled recording of consecutive dental appointments under the following main headings: date; patient identity (anonymised), age and gender; dental condition/complaint treated; whether chronic or acute, new or follow-up case; patient-assessed outcome (7-point Likert scale: -3 to +3) compared with first appointment; homeopathic medicine/s prescribed; whether any other medication/s being taken for the condition. Spreadsheets were submitted monthly via e-mail to the project co-ordinator for data synthesis and analysis.

RESULTS

Practitioners typically submitted data regularly and punctually, and most data cells were completed as required, enabling substantial data analysis. The mean age of patients was 46.2 years. A total of 726 individual patient conditions were treated overall. There was opportunity to follow-up 496 individual cases (positive outcome in 90.1%; negative in 1.8%; no change in 7.9%; outcome not recorded in 0.2%). Sixty-four of these 496 patients reported their outcome assessment before the end of the homeopathic appointment. Strongly positive outcomes (scores of +2 or +3) were achieved most notably in the frequently treated conditions of pericoronitis, periodontal abscess, periodontal infection, reversible pulpitis, sensitive cementum, and toothache with decay.

CONCLUSIONS

This multi-practitioner pilot study has indicated that systematic recording of practice data in dental homeopathy is both feasible and capable of informing future research. A refined version of the spreadsheet can be employed in larger-scale research-targeted data collection in the dental practice setting.

Finding midwifery in administrative data systems

Nurse-midwifery has accomplished remarkable clinical, policy, and political achievements using specially-collected data. Today, midwifery practice data can be found in existing administrative data systems: birth registration, hospital data depositories, and claims files. Issues in finding midwifery as practice and profession in these data systems are discussed. Improving the integrity of data that reveal midwives as caregivers should be a priority.

[Chemotherapy registry quality in Andalusian hospital pharmacy departments]

OBJECTIVE

To analyze registry quality in centralized cytostatic therapy units in Andalusian hospitals, and the availability of data to analyze the use of these drugs.

METHOD

An ad hoc questionnaire was designed using variables related to information coverage on patients and their treatments, data processing extent, and organization. Questionnaires were completed in September 2005 by surveying people responsible for chemotherapy in all 19 pharmacy departments in Andalusian hospitals that treat oncologic patients.

RESULTS

Response rate was 100%, but one department had no centralized cytostatic therapy unit. Centralized preparation coverage was 89% for the day hospital, 84% for inpatients, 79% for hematologic patients, and 69% for pediatric patients. Registries are computerized in only 13 hospitals (68%) with a variety of software programs. Temozolamide and capecitabine dispensation has a separate registry in 68% and 42% of cases, respectively. Patient name, and cytostatic name and dosage are the only data recorded in all instances, while protocol name is only recorded in 47%, and diagnosis, staging, and TNM categorization in 58%, 31%, and 16% of cases, respectively.

CONCLUSIONS

There is great variability regarding information systems for cytostatic use management, and a relevant shortage of patient data available for prescription use and adaptation studies.

Outcomes from homeopathic prescribing in medical practice: a prospective, research-targeted, pilot study

BACKGROUND AND AIMS

A base for targeted research and development in homeopathy can be founded on systematic collection and analysis of relevant clinical data obtained by doctors in routine practice. With these longer-term aims in mind, we conducted a pilot data collection study, in which 14 homeopathic physicians collected clinical and outcomes data over a 6-month period in their practice setting.

METHODS

A specifically designed Excel spreadsheet enabled recording of consecutive clinical appointments under the following main headings: date, patient identity (anonymised), age and gender, medical condition/complaint treated, whether chronic or acute, new or follow-up case, patient-assessed outcome (7-point Likert scale: -3 to +3) compared with first appointment, homeopathic medicine/s prescribed, whether any other medication/s being taken for the condition. Spreadsheets were submitted monthly via email to the project co-ordinator for data synthesis and analysis.

RESULTS

Practitioners typically submitted data regularly and punctually, and most data cells were completed as required, enabling substantial data analysis. The mean age of patients was 41.5 years. A total of 1,783 individual patient conditions were treated overall. Outcome from two or more homeopathic appointments per patient condition was obtained in 961 cases (75.9% positive, 4.6% negative, 14.7% no change; 4.8% outcome not recorded). Strongly positive outcomes (scores of +2 or +3) were achieved most notably in the frequently treated conditions of anxiety, depression, and irritable bowel syndrome.

CONCLUSIONS

This multi-practitioner pilot study has indicated that systematic recording of clinical data in homeopathy is both feasible and capable of informing future research. A refined version of the spreadsheet can be employed in larger-scale research-targeted clinical data collection in the medical practice setting--particularly in primary care.

Outcomes from homeopathic prescribing in veterinary practice: a prospective, research-targeted, pilot study

BACKGROUND AND AIMS

Targeted research development in veterinary homeopathy is properly informed by the systematic collection and analysis of relevant clinical data obtained by its practitioners. We organised a pilot data collection study, in which 8 Faculty of Homeopathy veterinarians collected practice-based clinical and outcomes data over a 6-month period.

METHODS

A specifically designed Excel spreadsheet enabled recording of consecutive clinical appointments under the following headings: date; identity of patient and owner (anonymised); age, sex and species of patient; medical condition/complaint treated; whether confirmed diagnosis, chronic or acute, new or follow-up case; owner-assessed outcome (7-point Likert scale: -3 to +3) compared with first appointment; homeopathic medicine/s prescribed; other medication/s for the condition/complaint. Spreadsheets were submitted monthly by e-mail to the project organisers for data checking, synthesis and analysis.

RESULTS

Practitioners submitted data regularly and punctually, and most data cells were completed. 767 individual patients were treated (547 dogs, 155 cats, 50 horses, 5 rabbits, 4 guinea-pigs, 2 birds, 2 goats, 1 cow, and 1 tortoise). Outcome from two or more homeopathic appointments per patient condition was obtained in 539 cases (79.8% showing improvement, 6.1% deterioration, 11.7% no change; outcome not recorded in 2.4% of follow-ups). Strongly positive outcomes (scores of +2 or +3) were achieved in: arthritis and epilepsy in dogs and, in smaller numbers, in atopic dermatitis, gingivitis and hyperthyroidism in cats.

CONCLUSIONS

Systematic recording of data by veterinarians in clinical practice is feasible and capable of informing future research in veterinary homeopathy. A refined version of the spreadsheet can be used in larger-scale research-targeted veterinary data collection.

Research records and the resolution of misconduct allegations at research universities

Accurate record keeping is an important part of the responsible conduct of research. However, there is very little empirical research on scientific record keeping. No one knows the incidence of serious problems with research records, the types of problems that occur, nor their consequences. In this study, we examined the role of research records in the resolution of misconduct allegations as a useful barometer for the incidence and types of problems that occur with records. We interviewed Research Integrity Officers (RIOs) at 90 major research universities and conducted focus groups with active research faculty. RIOs reported problems with research records in 38% of the 553 investigations they conducted. Severe problems with research records often prevented completion of investigations while problems that are more typical lengthened them by 2 to 3 weeks. Five types of poor record keeping practices accounted for 75 % of the problems with incomplete/inadequate records being the most common (30%). The focus groups concurred with the findings from the interviews with RIOs, stressed the importance of the research group leader in setting and maintaining record practices, and offered additional insights. While university officials and faculty members have suspected for many years that there are serious problems with research record keeping, our study provides empirical evidence for this belief. By documenting some of the problems with record keeping in university-based research, the results of our study provide information that will be useful for policy development at academic institutions.

Ascertainment of Hispanic ethnicity on California death certificates: implications for the explanation of the Hispanic mortality advantage

OBJECTIVES

We determined the size and correlates of underascertainment of Hispanic ethnicity on California death certificates.

METHODS

We used 1999 to 2000 vital registration data. We compared Hispanic ethnicity reported on the death certificate to Hispanic ethnicity derived from birthplace for the foreign-born and an algorithm that used first and last name and percentage of Hispanics in the county of residence for the US-born. We validated death certificate nativity by comparing data with that in linked Social Security Administration records.

RESULTS

Ethnicity and birthplace information was concordant for foreign-born Hispanics, who have mortality rates that are 25% to 30% lower than those of non-Hispanic Whites. Death certificates likely underascertain deaths of US-born Hispanics, particularly at older ages, for persons with more education, and in census tracts with lower percentages of Hispanics. Conservative correction for under-ascertainment eliminates the Hispanic mortality advantage for US-born men.

CONCLUSIONS

Hispanic ethnicity is accurately ascertained on the California death certificate for immigrants. Immigrant Hispanics have lower age-adjusted mortality rates than do non-Hispanic Whites. For US-born Hispanics, the mortality advantage compared with non-Hispanic Whites is smaller and may be explained by underreporting of Hispanic ethnicity on the death certificate.

Are statewide trauma registries comparable? Reaching for a national trauma dataset

BACKGROUND

Statewide trauma registries have proliferated in the last decade, suggesting that information could be aggregated to provide an accurate depiction of serious injury in the United States.

OBJECTIVES

To determine whether variability exists in the composition and content of statewide trauma registries, specifically addressing case-acquisition, case-definition (inclusion criteria), and registry-coding conventions.

METHODS

A cross-sectional, two-part survey was administered to managers of all statewide trauma registries. State trauma registrars also provided inclusion and exclusion criteria from their state registry and abstracted a clinical vignette designed to identify coding inconsistencies.

RESULTS

Thirty-two states maintain a centralized registry, but requirements for data submission vary significantly. Inclusion and exclusion criteria also vary, particularly for nontraumatic injuries. Coding conventions adopted by states for vague or missing information are dissimilar. When abstractions of the clinical vignette are compared, only 19% and 47% of states provided similar quantity or content for injury e-coding and diagnostic coding, respectively. Injury severity scores (based on diagnostic coding) demonstrated a range from 2 to 18.

CONCLUSIONS

Statewide trauma registries are prevalent but vary significantly in composition and content. Standardizing inclusion criteria, variable definitions, and coding conventions would greatly enhance the usability of an aggregated, national trauma registry.

Investigating the accuracy of ethnicity data in New Zealand hospital records: still room for improvement

BACKGROUND

The accuracy of ethnicity information in the New Zealand hospital data was reported on in 1994. Data collected in the Barriers to Diabetes Care in the Waikato Study enables further evaluation of the accuracy of ethnicity information in hospital records.

AIMS

One aim of public health policy is addressing health disparities between ethnic groups. Monitoring disparities depends on accurate outcome data, such as that from hospitals. It would be expected that this data would improve over time. This paper reports on the contemporary accuracy of ethnicity data in hospital records in the Waikato district.

METHODS

Self-identified ethnicity data were gathered as part of the Barriers to Diabetes Care in the Waikato mail survey. Hospital record data were collected for those participants who had consented for access to their hospital records.

RESULTS

Complete data was available for 3500 people with diabetes. Ethnicity in the hospital record was correct for one of the sometimes multiple, self-identified ethnicities for 97.7 (95CI 96.8-98.3)% of respondents. Ethnicity data were concordant for 71 (67-75)% of Maori and 99 (99-100)% of non-Maori. The non-Maori ethnic group was disaggregated into component groups: the hospital record agreed with self identified ethnicity for 89 (87-91)% of Europeans, 67 (55-78)% of Pacific groups, 70 (57-81)% of South Asian groups, 64 (48-77)% of Asian groups, and 41 (27-57)% of 'Other' ethnic groups.

CONCLUSIONS

Hospital records continue to mis-record ethnicity when compared to a self-identified ethnicity. Mis-recording occurs for all ethnic groups, and is more pronounced at more specific levels of ethnic group. Researchers, clinicians, and policy makers must be cognisant of these continuing discrepancies when using hospital record data to describe ethnic variations in health status, service utilisation, or for policy planning activities.

Dentist communication with the dental laboratory for prosthodontic treatment using implants

PURPOSE

A questionnaire was sent to U.S. dental laboratories to evaluate the level of communication between dentists and laboratory technicians and to determine trends in procedures and materials used in fixed and removable implant restorations.

METHODS AND MATERIALS

Dental laboratories were randomly chosen from the National Association of Dental Laboratories for each of the 50 states. The questionnaire was mailed to the laboratory directors for 199 dental laboratories. One hundred fourteen dental laboratories returned the survey, yielding a response rate of 57%. Of those laboratories, 37 indicated that they did not participate in the fabrication of fixed implant restorations, yielding a response rate of 39%. Forty-two dental laboratories indicated that they did not participate in the fabrication of implant-retained overdenture prostheses, yielding a response rate of 36%.

RESULTS

Results from this survey show inadequate communication by dentists in completing work authorization forms. Custom trays are used more frequently for implant-retained overdenture impressions and stock trays for impressions of fixed implant prostheses. Poly(vinyl siloxane) is the material most commonly used for both fixed and removable implant-supported prostheses. Two implants with stud attachments are used more widely than those with bar attachments for implant-retained overdentures.

CONCLUSIONS

Most laboratories working on implant prosthodontic cases report inadequate communication between the laboratory and dentists related to materials and techniques used in fabrication of implant restorations.

Dental records: a Belgium study

The aim of this study was to deduce the quality of the average dental record kept by Belgian dentists and to evaluate its potential use for forensic dental casework. The evaluated material originated from 598 Dutch speaking and 124 French speaking Belgian dentists who completed a questionnaire and returned it by mail or through the internet. The age of the participating dentists ranged from 22 to 72 years of age. The results of the inquiry were statistically analysed taking parameters such as language, gender, age, university and ZIP code into account. In general there was a tendency for the young dentists from the age category 22 to 34 years of age, especially those living in larger cities, to perform better on several of the questions asked such as completion of the dental record, storage of x-rays, working with digital x-rays and a digital dental record.

Low Back Pain in Older Adults: Are We Utilizing Healthcare Resources Wisely?

OBJECTIVES

1) To examine recent change in prevalence and Medicare-associated charges for non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain (LBP); and 2) to examine magnetic resonance imaging (MRI) utilization appropriateness in older adults with chronic low back pain (CLBP).

DESIGN

Two cross-sectional surveys of 1) national (1991-2002) and Pennsylvania (2000-2002) Medicare data; and 2) patients aged >or= 65 years with CLBP.

SETTING

Outpatient data.

PARTICIPANTS

Patients aged >or= 65 years with LBP.

MEASUREMENTS

Study 1: Outpatient national and Pennsylvania Part A Medicare data were examined for number of patients and charges for all patients, and for those with nonspecific LBP. Total number of visits and charges for imaging studies, physical therapy (PT), and spinal injections was also examined for Pennsylvania. Study 2: 111 older adults with CLBP were interviewed regarding presence of red flags necessitating imaging and history of having a lumbar MRI, neurogenic claudication (NC), and back surgery.

RESULTS

Study 1: Between 1991 and 2002, there was a 42.5% increase in total Medicare patients, 131.7% increase in LBP patients, 310% increase in total charges, and 387.2% increase in LBP charges. In Pennsylvania (2000-2002), there was a 5.5% increase in LBP patients and 33.2% increase in charges (0.2% for PT, 59.4% for injections, 41.9% for MRI/CT, and 19.3% for X rays). Study 2: None of the 111 participants had red flags and 61% had undergone MRIs (29% with NC, 24% with failed back surgery syndrome).

CONCLUSION

LBP documentation and diagnostic studies are increasing in Medicare beneficiaries, and evidence suggests that MRIs may often be ordered unnecessarily. Injection procedures appear to account for a significant proportion of LBP-associated costs. More studies are needed to examine the appropriateness with which imaging procedures and non-invasive/minimally invasive treatments are utilized, and their effect on patient outcomes.

Effects coding in discrete choice experiments

This paper discusses the inherent problems associated with applying dummy coding when including a fixed comparator in a discrete choice experiment, and seeks to illustrate the misinterpretations that may arise if the analyst is not aware of the problem. This note provides two examples of possible misinterpretations with dummy coding and how it is solved with the use of effects coding.

Study of codes of disposal at different parities of Large White sows using a linear censored model

To study the genetic relationship between three grouped reasons for sow removal (SR) in consecutive parities, accounting for censoring, 13,838 records from Large White sows were analyzed. Data were from seven pure-line farms having, on average, 5.9% unknown SR. Three traits were subjectively defined, each corresponding to a classification of SR (reproductive [RR], nonreproductive [RN], and others [RO]). Records for each trait could take one of five categories, according to parity at removal (0 to 4 or later). A multivariate linear censored model was implemented. The model to estimate (co)variance components and parameters included the effects of year-season, region, contemporary group, and additive genetic effects. The most common SR was related to reproduction (48.5%). Diseases of different origin and cause, old age/parity, and sow death or loss accounted for about 18, 7, and 4% of total culls, respectively. Estimates of variance components showed heterogeneity of additive genetic and residual variances for the three traits. Estimates of heritability were 0.18, 0.13, and 0.15 for RR, RN, and RO, respectively. Genetic correlations between removal codes were high (> or =0.90). Results suggest sizeable additive genetic variances exist for parity at removal and different codes of removal. Different SR reasons seem to operate similarly or as a closely related genetic trait associated with fitness. In particular, RN and RO seem to be genetically indistinguishable. Data structure, definition, and volume are major limitations in studies of sow survival. A multiple-trait censored model is preferred to evaluate reasons of sow disposal. Grouped removal causes seem to be strongly genetically correlated but with heterogeneous variances, suggesting that combining all removal causes and treating the trait as parity at disposal is an alternative approach.

Quality of Data Reported on Abdominal Aortic Aneurysm Repair—A Comparison between a National Vascular and a National Administrative Registry

OBJECTIVE

To study consistency of data and completeness of reporting in a national vascular registry, NorKar, and a national administrative registry, The Norwegian patient register (NPR).

DESIGN

Comparative registry-based national study supplemented with a comprehensive control of patients registered in one major hospital.

MATERIAL

All patients registered with a procedure-code for treatment of AAA in NorKar or NPR during 2001 or 2002, were included.

METHOD

We compared the reporting of procedure-codes, diagnosis-codes and in-hospital deaths after treatment for abdominal aortic aneurysm (AAA) in the two registries to evaluate completeness. Consistency between procedure-codes and diagnoses were evaluated within both registries. Completeness of reporting to one NorKar Local Registry was investigated in more detail in one of the hospitals.

RESULTS

Compared with the NPR numbers, NorKar contained 69% of the patients treated for AAA in Norway, while completeness for NorKar member hospitals was 84%. The detailed investigation in one of the hospitals showed a completeness of 91% and a false inclusion of 5.3% of all cases treated for AAA. The consistency between procedure-codes and diagnosis-codes was 93% in both registries. We found evidence of substantial underreporting of in-hospital deaths to NorKar in several hospitals. Overall reporting of early deaths to NorKar relative to completeness of reported cases was estimated to 72%.

CONCLUSION

There is an underreporting of patients with AAA to NorKar according to the NPR numbers and a need for better control of procedure-diagnosis consistency in both registries. There seems to be a substantial underreporting of early deaths to NorKar. Introduction of unique patient-identifiable data could improve the quality of both registries by making matching of data possible.

Can hospital discharge diagnoses be used for surveillance of surgical-site infections?

The aim of this study was to assess the data quality of postoperative infections in a hospital discharge registry in the Emilia-Romagna region of Italy. Data from a prospective regional study of postoperative infections in 6158 patients from 31 of the 36 public hospitals of the region were compared with data from the regional hospital discharge registry, using different classes of ICD-9-CM codes. The sensitivity of the hospital discharge database for postoperative surgical infections was 10% when ICD-9-CM codes directly indicative of postoperative infectious complications were used. When non-specific codes of postoperative complications, not necessarily of infectious origin, were added, the sensitivity reached 21%. At present, the hospital discharge registry is not suited for surveillance of hospital-acquired infection.

Documenting natural recovery in American-Indian drinking behavior: a coding scheme

OBJECTIVE

This report describes a coding scheme developed to analyze how some American Indians changed their drinking behavior and explores the contributions of this approach to our understanding of natural recovery in American-Indian communities.

METHOD

We analyzed the responses to two open-ended questions about drinking in an epidemiological survey. The first question asked what helped respondents to quit or cut down on their drinking; the second asked respondents what they did instead of drinking when they wanted to drink. Codes were developed using anthropological analyses of content and then refined through analyses of frequencies and attempts to establish reliability. The frequencies of these codes were then examined by gender, age and current drinking status.

RESULTS

Reliability was attained for the coding of responses to both questions. Their content reflects salient themes in the literature on natural recovery. The distribution of these codes across gender, age and current drinking status reveals interesting insights into what prompts and supports quitting and change for different members of these American-Indian communities, especially for women, older respondents and those who abstain from alcohol.

CONCLUSIONS

This approach points the way to a consideration of a broad set of factors related to changes in drinking behavior in American-Indian populations that can be applied in future studies, both in American-Indian communities and, potentially, in other populations as well.