The effectiveness of screening colonoscopy in average-risk adults is uncertain, particularly for right colon cancers.
Examine the association between screening colonoscopy and incident late-stage colorectal cancer (CRC) risk.
Nested case-control study.
Four U.S. health plans
Average-risk adults with ≥5 years of enrollment in one of the health plans (n=1,039). Cases were 55–85 years old on their diagnosis date (reference date) of stage ≥IIB (late-stage) CRC during 2006–2008. We selected 1–2 controls for each case, matched on birth year, gender, health plan, and prior enrollment duration.
Receipt of CRC screening between 3 months and up to 10 years before the reference date, ascertained through medical record audits. We compared cases and controls on receipt of screening colonoscopy or sigmoidoscopy using conditional logistic regressions that accounted for health history, socioeconomic status and other screening exposures.
In analyses restricted to 471 eligible cases and their matched controls (n=509), 13 cases (2.8%) and 46 controls (9.0%) had undergone screening colonoscopy, which corresponded to an adjusted odds ratio (AOR) of 0.30 (95% confidence interval [CI]: 0.15–0.59) for any late-stage CRC, 0.37 (CI: 0.16–0.82) for right colon cancers, and 0.26 (CI: 0.06–1.11) for left-sided colon/rectum cancers. Ninety-two cases (19.5%) and 173 controls (34.0%) underwent screening sigmoidoscopy, corresponding to an AOR of 0.51 (CI: 0.36–0.71) overall, 0.80 (CI: 0.52–1.25) for right colon late-stage cancers, and 0.26 (CI: 0.14–0.49) for left colon/rectum cancers.
The small number of screening colonoscopies affected the precision of our estimates.
Screening with colonoscopy in average-risk persons was associated with reduced risk of diagnosis with incident late-stage CRC in both the right colon and left colon/rectum. For sigmoidoscopy, this association was observed for left-sided CRC, but the association for right colon late-stage cancer was not statistically significant.
Primary Funding Source
National Cancer Institute of the National Institutes of Health.
Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped.
Using MarketScan’s claims-based data on 17.4 million commercially-insured lives, we modeled bundled payment to support expected primary care activity levels (PCAL) and 9 patient outcomes for performance assessment. We evaluated models using 457,000 people assigned to 436 primary care physician panels, and among 13,000 people in a distinct multi-payer medical home implementation with commercially-insured, Medicare and Medicaid patients.
Each outcome is separately predicted from age, sex, and diagnoses. We define the PCAL outcome as a subset of all costs that proxies the bundled payment needed for comprehensive primary care. Other expected outcomes are used to establish targets against which actual performance can be fairly judged. We evaluate model performance using R2s at patient- and practice-levels, and within policy-relevant subgroups.
The PCAL model explains 67% of variation in its outcome, performing well across diverse patient ages, payers, plan types and provider specialties; it explains 72% of practice-level variation. The outcome-specific models explain 17% to 86% of practice-level variation in 9 performance measures, often substantially outperforming a “one-size-fits-all” CMS-like HCC score, eg, with grouped R2s of 47% versus 5% for predicting “prescriptions for antibiotics of concern.”
Existing data can support the risk-adjusted bundled payment calculations and performance assessments needed to encourage desired transformations in primary care.
Primary care; risk adjustment; patient-centered medical home; hierarchical condition categories; capitation; Medicare; Medicaid; all-payer
Relative validity (RV), a ratio of ANOVA F-statistics, is often used to compare the validity of patient-reported outcome (PRO) measures. We used the bootstrap to establish the statistical significance of the RV and to identify key factors affecting its significance.
Based on responses from 453 chronic kidney disease (CKD) patients to 16 CKD-specific and generic PRO measures, RVs were computed to determine how well each measure discriminated across clinically-defined groups of patients compared to the most discriminating (reference) measure. Statistical significance of RV was quantified by the 95% bootstrap confidence interval. Simulations examined the effects of sample size, denominator F-statistic, correlation between comparator and reference measures, and number of bootstrap replicates.
The statistical significance of the RV increased as the magnitude of denominator F-statistic increased or as the correlation between comparator and reference measures increased. A denominator F-statistic of 57 conveyed sufficient power (80%) to detect an RV of 0.6 for two measures correlated at r = 0.7. Larger denominator F-statistics or higher correlations provided greater power. Larger sample size with a fixed denominator F-statistic or more bootstrap replicates (beyond 500) had minimal impact.
The bootstrap is valuable for establishing the statistical significance of RV estimates. A reasonably large denominator F-statistic (F > 57) is required for adequate power when using the RV to compare the validity of measures with small or moderate correlations (r < 0.7). Substantially greater power can be achieved when comparing measures of a very high correlation (r > 0.9).
Bootstrap; Relative validity; Analysis of variance (ANOVA); Confidence interval; Patient-reported outcome (PRO) measure; Chronic kidney disease (CKD)
Racial and ethnic minorities generally receive fewer medical interventions than Whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end.
Based on a random, stratified sample of Medicare decedents (n=158,780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (e.g., ventilators), and hospice to racial/ethnic differences in Medicare expenditures in the last 6 months of life.
In the final 6 months of life, costs for Whites average $20,166; Blacks, $26,704 (32% more); Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice account for 53% and 63% of the higher costs for Blacks and Hispanics respectively. While Whites use hospice most frequently (Whites 26%, Blacks 20%, and Hispanics 23%), this affects racial and ethnic differences in end-of-life expenditures only minimally. However, fully 85% of the observed higher costs for non-Whites are accounted for after additionally modeling their greater end-of-life use of the ICU and various intensive procedures (such as, gastrostomies, used by 10.5% of Blacks, 9.1% of Hispanics, 4.1% of Whites).
At life's end, Black and Hispanic decedents have substantially higher costs than Whites. Over half of this is related to geographic, socio-demographic and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.
To compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer.
Prospective five-year longitudinal comparison of cases and matched controls.
Newly identified breast cancer patients recruited during 1997–1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656).
Survival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening.
Five-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p < 0.01), with most differences diminishing over time. However, the number of physician visits was higher for cases (p < 0.01) in every year, driven partly by more cancer and surgical specialist visits. Cases and controls adhered similarly to recommended bone density testing, and monitoring of cardiovascular disease and diabetes; adherence to recommended colorectal cancer screening was better among cases.
Breast cancer survivors’ health care utilization and disease burden return to pre-diagnosis levels after one year, yet their greater use of outpatient care persists at least five years. Quality of care for other chronic health problems is similar for cases and controls.
survival; case-control; inpatient care; outpatient care; costs; preventive care
We sought to measure time and identify predictors of timely follow-up among a cohort of racially/ethnically diverse inner city women with breast and cervical cancer screening abnormalities.
Eligible women had an abnormality detected on a mammogram or Pap test between January 2004 and December 2005 in one of six community health centers in Boston, MA. Retrospective chart review allowed us to measure time to diagnostic resolution. We used Cox proportional hazards models to develop predictive models for timely resolution (defined as definitive diagnostic services completed within 180 days from index abnormality).
Among 523 women with mammography abnormalities and 474 women with Pap test abnormalities, >90% achieved diagnostic resolution within 12 months. Median time to resolution was longer for Pap test than for mammography abnormalities (85 versus 27 days). Site of care, rather than any sociodemographic characteristic of individuals, including race/ethnicity, was the only significant predictor of timely follow up for both mammogram and Pap test abnormalities.
Site specific community based interventions may be the most effective interventions to reduce cancer health disparities when addressing the needs of underserved populations.
Public health; Women's Health; Neoplasms; Health Services; Internal Medicine
Family studies of exceptional longevity can potentially identify genetic and other factors contributing to long life and healthy aging. Although such studies seek families that are exceptionally long lived, they also need living members who can provide DNA and phenotype information. On the basis of these considerations, the authors developed a metric to rank families for selection into a family study of longevity. Their measure, the family longevity selection score (FLoSS), is the sum of 2 components: 1) an estimated family longevity score built from birth-, gender-, and nation-specific cohort survival probabilities and 2) a bonus for older living siblings. The authors examined properties of FLoSS-based family rankings by using data from 3 ongoing studies: the New England Centenarian Study, the Framingham Heart Study, and screenees for the Long Life Family Study. FLoSS-based selection yields families with exceptional longevity, satisfactory sibship sizes and numbers of living siblings, and high ages. Parameters in the FLoSS formula can be tailored for studies of specific populations or age ranges or with different conditions. The first component of the FLoSS also provides a conceptually sound survival measure to characterize exceptional longevity in individuals or families in various types of studies and correlates well with later-observed longevity.
aged, 80 and over; family data; longevity; Shannon information
Heart failure is the leading non-cancer hospice diagnosis and the leading cause of hospitalization among Medicare beneficiaries. Racial differences in hospice use are well documented for cancer but poorly described for heart failure.
Based on a national sample of 98,258 Medicare beneficiaries aged 66 and older on January 1, 2001 with a diagnosis of heart failure, who were not enrolled in hospice in 2000, we determined the effect of race/ethnicity on hospice entry for heart failure in 2001 after adjusting for sociodemographic, clinical, and geographic factors.
In unadjusted analysis, Blacks (odds ratio [OR] = 0.52) and Hispanics (OR = 0.43) used hospice for heart failure less than Whites. Racial/ethic differences in hospice use for heart failure persisted after adjusting for markers of income, urbanicity, severity of illness, local density of hospice use, and medical comorbidity (adjusted odds ratio (AOR) for Blacks [AOR = 0.59 (95% confidence interval (CI), 0.47-0.73)], and for Hispanics [AOR = 0.49 (95% CI 0.37-0.66)], compared to Whites). Advanced age, greater comorbidity, emergency department visits, hospitalizations, and greater local density of hospice use were also associated with hospice utilization.
In a national sample of Medicare beneficiaries with heart failure, Blacks and Hispanics used hospice for heart failure less than Whites after adjustment for individual and market factors. This work extends the findings of racial and ethnic differences in hospice utilization to the leading non-cancer diagnosis. To understand the mechanisms underlying these findings, further examination of patient preferences and physician referral behavior are needed.
This study compared glycemic control in finger tip versus forearm sampling methods of self-monitoring of blood glucose (SMBG).
Research Design and Methods
One hundred seventy-four insulin-using patients with type 2 diabetes were randomized to SMBG using either finger-tip testing (FT) or forearm alternative site testing (AST) and followed up for 7 months. Hemoglobin A1C (HbA1C) was measured at baseline, month 4, and month 7. The study was designed to test the noninferiority of the AST method for the primary end point of change in HbA1C from baseline to month 7. Adherence with the testing schedule and frequency of hypoglycemic episodes were also measured.
The FT (n = 85) and AST (n = 89) groups each had significant decreases in mean HbA1C from baseline to month 7 (FT, −0.4 ± 1.4%, P = 0.008; AST, −0.3 ± 1.2%, P = 0.045), and noninferiority between groups was demonstrated with a margin of equivalence of 0.5 (P = 0.043). There was no observable difference in HbA1C change between the groups (P = 0.442). Adherence was better in the FT (87%) than the AST (78%) group (P = 0.003), which may have been because of the difficulty some subjects had in obtaining blood samples for AST. The number of hypoglycemic episodes was too small to assess for a difference between groups.
SMBG by the AST, rather than FT, method did not have a detrimental effect on long-term glycemic control in insulin-using patients with type 2 diabetes. Although adherence with testing was expected to be better in the AST group, it was actually better in the FT group.
Medical respite programs offer medical, nursing, and other care as well as accommodation for homeless persons discharged from acute hospital stays. They represent a community-based adaptation of urban health systems to the specific needs of homeless persons. This paper examines whether post-hospital discharge to a homeless medical respite program was associated with a reduced chance of 90-day readmission compared to other disposition options. Adjusting for imbalances in patient characteristics using propensity scores, Respite patients were the only group that was significantly less likely to be readmitted within 90 days compared to those released to Own Care. Respite programs merit attention as a potentially efficacious service for homeless persons leaving the hospital.
homeless; readmission; retrospective studies; discharge planning; health services
To estimate national total knee arthroplasty (TKA) rates by economic factors, and the extent to which differences in insurance coverage, income, and assets contribute to racial and ethnic disparities in TKA use.
US longitudinal Health and Retirement Study survey data for the elderly and near-elderly (biennial rounds 1994–2004) from the Institute of Social Research, University of Michigan.
The outcome is dichotomous, whether the respondent received first TKA in the previous 2 years. Longitudinal, random-effects logistic regression models are used to assess associations with lagged economic indicators.
Sample was 55,469 person-year observations from 18,439 persons; 663, with first TKA.
Racial/ethnic disparities in TKA were more prominent among men than women. For example, relative to white women, odds ratios (ORs) were 0.94, 0.46, and 0.79, for white, black, and Hispanic men, respectively (P < 0.05 for black men). After adjusting for economic factors, racial/ethnic differences in TKA rates for women essentially disappeared, while the deficit for black men remained large. Among Medicare-enrolled elderly, those with supplemental insurance may be more likely to have first TKA compared with those without it, whether the supplemental coverage was private [OR: 1.27; 95% confidence interval (CI): 0.82–1.96] or Medicaid (OR: 1.18; 95% CI: 0.93–1.49). Among the near-elderly (age 47–64), compared with the privately insured, the uninsured were less likely (OR: 0.61; 95% CI: 0.40–0.92) and those with Medicaid more likely (OR: 1.53; 95% CI: 1.03–2.26) to have first TKA.
Limited insurance coverage and financial constraints explain some of the racial/ethnic disparities in TKA rates.
To impute limited health literacy from commonly measured socio-demographic data and to compare it to the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) for estimating the influence of limited health literacy on health status in the elderly.
The Prudential Medicare Study assesses the S-TOFHLA score, leading to a “reference standard” classification of 25% of people with inadequate literacy; the National Health Interview Survey has no such assessment. We estimated a regression of S-TOFHLA on sex, age, years of schooling, and race/ethnicity in The Prudential Medicare Study data to derive a Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. Using regression, we then examined associations between several health status measures (including hypertension, diabetes, physical and mental SF-12) and inadequate literacy (imputed or test-based).
Estimates of association using imputed inadequate literacy closely approximate those obtained using S-TOFHLA-based inadequate literacy for most outcomes examined.
As few population surveys measure health literacy, the DAHL, a readily calculated health literacy proxy score, may be useful for expanding the scope of health literacy research in national survey data.
inadequate health literacy; health status; functional status; national surveys
Medical care at the end of life is often expensive and ineffective.
To explore associations between primary care and hospital utilization at the end of life.
Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.
National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.
Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.
Sample characteristics: 38% had 0 primary care visits; 22%, 1–2; 19%, 3–5; 10%, 6–8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with ≥9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).
Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.
end-of-life care; health services research; primary care
Alzheimer's disease (AD) is a neurodegenerative disorder incurring significant social and economic costs. This study uses a US administrative claims database to evaluate the effect of AD on direct healthcare costs and utilization, and to identify the most common reasons for AD patients' emergency room (ER) visits and inpatient admissions.
Demographically matched cohorts age 65 and over with comprehensive medical and pharmacy claims from the 2003–2004 MEDSTAT MarketScan® Medicare Supplemental and Coordination of Benefits (COB) Database were examined: 1) 25,109 individuals with an AD diagnosis or a filled prescription for an exclusively AD treatment; and 2) 75,327 matched controls. Illness burden for each person was measured using Diagnostic Cost Groups (DCGs), a comprehensive morbidity assessment system. Cost distributions and reasons for ER visits and inpatient admissions in 2004 were compared for both cohorts. Regression was used to quantify the marginal contribution of AD to health care costs and utilization, and the most common reasons for ER and inpatient admissions, using DCGs to control for overall illness burden.
Compared with controls, the AD cohort had more co-morbid medical conditions, higher overall illness burden, and higher but less variable costs ($13,936 s. $10,369; Coefficient of variation = 181 vs. 324). Significant excess utilization was attributed to AD for inpatient services, pharmacy, ER visits, and home health care (all p < 0.05). In particular, AD patients were far more likely to be hospitalized for infections, pneumonia and falls (hip fracture, syncope, collapse).
Patients with AD have significantly more co-morbid medical conditions and higher healthcare costs and utilization than demographically-matched Medicare beneficiaries. Even after adjusting for differences in co-morbidity, AD patients incur excess ER visits and inpatient admissions.
To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.
Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.
Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.
Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p<.001).
Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.
Diabetes mellitus; outcomes assessment; quality of health care
To see if changes in the demographics and illness burden of Medicare patients hospitalized for acute myocardial infarction (AMI) from 1995 through 1999 can explain an observed rise (from 32 percent to 34 percent) in one-year mortality over that period.
Utilization data from the Centers for Medicare and Medicaid Services (CMS) fee-for-service claims (MedPAR, Outpatient, and Carrier Standard Analytic Files); patient demographics and date of death from CMS Denominator and Vital Status files. For over 1.5 million AMI discharges in 1995–1999 we retain diagnoses from one year prior, and during, the case-defining admission.
We fit logistic regression models to predict one-year mortality for the 1995 cases and apply them to 1996–1999 files. The CORE model uses age, sex, and original reason for Medicare entitlement to predict mortality. Three other models use the CORE variables plus morbidity indicators from well-known morbidity classification methods (Charlson, DCG, and AHRQ's CCS). Regressions were used as is—without pruning to eliminate clinical or statistical anomalies. Each model references the same diagnoses—those recorded during the pre- and index admission periods. We compare each model's ability to predict mortality and use each to calculate risk-adjusted mortality in 1996–1999.
The comprehensive morbidity classifications (DCG and CCS) led to more accurate predictions than the Charlson, which dominated the CORE model (validated C-statistics: 0.81, 0.82, 0.74, and 0.66, respectively). Using the CORE model for risk adjustment reduced, but did not eliminate, the mortality increase. In contrast, adjustment using any of the morbidity models produced essentially flat graphs.
Prediction models based on claims-derived demographics and morbidity profiles can be extremely accurate. While one-year post-AMI mortality in Medicare may not be worsening, outcomes appear not to have continued to improve as they had in the prior decade. Rich morbidity information is available in claims data, especially when longitudinally tracked across multiple settings of care, and is important in setting performance targets and evaluating trends.
Risk adjustment; Charlson; DCG; CCS; AMI; event-centered database
Despite the need to recruit and retain minority faculty in academic medicine, little is known about the experiences of minority faculty, in particular their self-reported experience of racial and ethnic discrimination at their institutions.
To determine the frequency of self-reported experience of racial/ethnic discrimination among faculty of U.S. medical schools, as well as associations with outcomes, such as career satisfaction, academic rank, and number of peer-reviewed publications.
A 177-item self-administered mailed survey of U.S. medical school faculty.
Twenty-four randomly selected medical schools in the contiguous United States.
A random sample of 1,979 full-time faculty, stratified by medical school, specialty, graduation cohort, and gender.
Frequency of self-reported experiences of racial/ethnic bias and discrimination.
The response rate was 60%. Of 1,833 faculty eligible, 82% were non-Hispanic white, 10% underrepresented minority (URM), and 8% nonunderrepresented minority (NURM). URM and NURM faculty were substantially more likely than majority faculty to perceive racial/ethnic bias in their academic environment (odds ratio [OR], 5.4; P < .01 and OR, 2.6; P < .01, respectively). Nearly half (48%) of URM and 26% of NURM reported experiencing racial/ethnic discrimination by a superior or colleague. Faculty with such reported experiences had lower career satisfaction scores than other faculty (P < .01). However, they received comparable salaries, published comparable numbers of papers, and were similarly likely to have attained senior rank (full or associate professor).
Many minority faculty report experiencing racial/ethnic bias in academic medicine and have lower career satisfaction than other faculty. Despite this, minority faculty who reported experiencing racial/ethnic discrimination achieved academic productivity similar to that of other faculty.
schools, medical; minority groups; faculty, medical; prejudice; job satisfaction
To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care.
Data Sources/Study Settings
Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database.
A cross-sectional analysis of the association among the different measures was performed.
Data Collection/Extraction Methods
Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database.
Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development.
Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.
Quality improvement; quality of care; nursing homes; decubitus ulcers
To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States.
We used 1992 data from the Health Care Financing Administration to examine ICU utilization and mortality by age and admission reason for hospitalizations of elderly Medicare beneficiaries.
Use of the ICU was least likely for the oldest elderly overall (85+ years, 21.1% of admissions involved ICU; 75–84 years, 27.9%; 65–74 years, 29.7%), but more likely during surgical admissions. Eighty-three percent of the Medicare patients who received intensive care survived at least 90 days. Of the oldest elderly, 74% survived. Even among the 10% most expensive ICU hospitalizations, 77% of all patients and 62% of those 85 years and older survived at least 90 days.
The likelihood of ICU use among these elderly decreased with age, especially among those 85 years or older. Diagnostic mix importantly influenced ICU use by age. The great majority of the elderly, including those 85 years and older and those receiving the most expensive ICU care, survived at least 90 days.
intensive care; hospital mortality; health services for aged