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1.  Do Not Hospitalize Orders for Patients with Advanced Dementia: Health Care Proxies’ Perspectives 
Objectives
Approximately 5 million patients with advanced dementia reside in nursing homes in the United States. “Do not hospitalize” (DNH) orders can reduce unnecessary hospitalizations for patients at the end of life, but are rarely used. Health care proxies (HCPs) often decide about DNH orders, yet little is known about how well these orders are understood by HCPs or why HCPs may or may not initiate DNH orders
Methods
Semi-structured qualitative interviews were held with HCPs of nursing home residents with advanced dementia at two nursing homes in Western Massachusetts. Interviews were audio-taped and transcribed verbatim. Data were qualitatively analyzed in an iterative process; emergent concepts were conceptually ordered into explanatory categories. Pertinent demographic and clinical information were collected from the Minimum Data Set (MDS) and patient charts.
Results
Sixteen of 31 eligible HCPs were interviewed. Major findings included barriers and facilitators to initiating DNH orders. Barriers included a perceived lack of physician involvement in decision-making and limited understanding of both DNH orders and the resident's prognosis. Facilitators included a HCPs’ personal experience in health care, understanding the prognosis of advanced dementia, and a desire to limit resident distress.
Conclusion
The potential barriers and facilitators to HCPs’ initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with health care providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect patients’ values and wishes.
doi:10.1111/jgs.12406
PMCID: PMC3773256  PMID: 23888937
Advanced dementia; do not hospitalize orders; qualitative
2.  Patterns of Obstetric Infection Rates in a Large Sample of U.S. Hospitals 
American journal of obstetrics and gynecology  2013;208(6):456.e1-456.e13.
Objective
Maternal infection is a common complication of childbirth, yet little is known about the extent to which infection rates vary among hospitals. We estimated hospital level risk-adjusted maternal infection rates (RAIR) in a large sample of U.S. hospitals and explored associations between RAIR and select hospital features.
Study Design
This retrospective cohort study included hospitals in the Perspective database with more than 100 deliveries over two years. Using a composite measure of infection, we estimated and compared RAIR across hospitals using hierarchical generalized linear models. We then estimated the amount of variation in RAIR attributable to hospital features.
Results
Of the 1,001,189 deliveries at 355 hospitals, 4.1% were complicated by infection. Women ages 15-19 were 50% more likely to experience infection than those ages 25-29. Rupture of membranes >24 hours (OR 3.0, 95% CI 3.24, 3.5), unengaged fetal head (OR 3.11. 95% CI 2.97, 3.27), and blood loss anemia (OR 2.42, 95% CI 2.34, 2.49) had the highest odds ratios among comorbidities commonly found in patients with infection. RAIR ranged from 1.0% to 14.4% (median 4.0%, IQR 2.8%-5.7%). Hospital features such as geographic region, teaching status, urban setting and higher number of obstetric beds were associated with higher infection rates, accounting for 14.8% of the variation observed.
Conclusions
Obstetric RAIR vary among hospitals, suggesting an opportunity to improve obstetric quality of care. Hospital features such as region, number of OB beds and teaching status account for only a small portion of the observed variation in infection rates.
doi:10.1016/j.ajog.2013.02.001
PMCID: PMC3670964  PMID: 23395644
Maternal infection rates; variation; hospital characteristics
3.  IDEAS for a healthy baby - reducing disparities in use of publicly reported quality data: study protocol for a randomized controlled trial 
Trials  2013;14:244.
Background
Publicly reported performance on quality measures is intended to enable patients to make more informed choices. Despite the growing availability of these reports, patients’ use remains limited and disparities exist. Low health literacy and numeracy are two barriers that may contribute to these disparities. Patient navigators have helped patients overcome barriers such as these in other areas, such as cancer care and may prove useful for overcoming barriers to using publicly reported quality data.
Methods/Design
The goals of this study are: to determine the efficacy of a patient navigator intervention to assist low-income pregnant women in the use of publicly available information about quality of care when choosing a pediatrician; to evaluate the relative importance of factors influencing women’s choice of pediatric practices; to evaluate the effect of the intervention on patient engagement in management of their own and their child’s health care; and to assess variation in efficacy of the intervention for sub-groups based on parity, age, and race/ethnicity. English speaking women ages 16 to 50 attending a prenatal clinic at a large urban medical center will be randomized to receive an in-person navigator intervention or an informational pamphlet control between 20 to 34 weeks of gestation. The intervention will include in-person guided use of the Massachusetts Health Quality Partners website, which reports pediatric practices’ performance on quality measures and patient experience. The primary study outcomes will be the mean scores on a) clinical quality and b) patient experience measures.
Discussion
Successful completion of the study aims will yield important new knowledge about the value of guided website navigation as a strategy to increase the impact of publicly reported quality data and to reduce disparities in use of these data.
Trial registration
ClinicalTrials.gov #NCT01784575
doi:10.1186/1745-6215-14-244
PMCID: PMC3751013  PMID: 23919671
Publicly reported quality data; Pediatric; Patient navigator; Pregnancy; Intervention studies; Randomized trials
4.  Patients’ Beliefs and Preferences Regarding Doctors’ Medication Recommendations 
Background
An estimated 20–50% of patients do not take medications as recommended. Accepting a doctor’s recommendation is the first step in medication adherence, yet little is known about patients’ beliefs and preferences about how medications are prescribed.
Objective
To explore patients’ beliefs and preferences about medication prescribing to understand factors that might affect medication adherence.
Methods
Fifty members from 2 health plans in Massachusetts participated in in-depth telephone interviews. Participants listened to an audio-vignette of a doctor prescribing a medication to a patient and were asked a series of questions related to the vignette. Responses were reviewed in an iterative process to identify themes related to participants’ beliefs and preferences about medication prescribing.
Results
Participants’ beliefs and preferences about medication prescribing encompassed 3 major areas: patient–doctor relationships, outside influences, and professional expertise. Important findings included participants’ concerns about the pharmaceutical industry’s influence on doctors’ prescribing practices and beliefs that there is a clear “best” medication for most health problems.
Conclusions
Patients’ beliefs and preferences about medication prescribing may affect medication adherence. Additional empiric studies that explore whether doctors’ relationships with pharmaceutical representatives impact medication adherence by affecting trust are indicated. In addition, it would be worthwhile to explore whether discussions between patients and doctors regarding equipoise (no clear scientific evidence for 1 treatment choice over another) affect medication adherence.
doi:10.1007/s11606-007-0470-3
PMCID: PMC2359465  PMID: 18204991
medication adherence; qualitative; patient preferences; communication; medication prescribing; pharmaceutical detailing; shared decision making
5.  BRIEF REPORT: Nutrition and Weight Loss Information in a Popular Diet Book: Is It Fact, Fiction, or Something in Between? 
BACKGROUND/OBJECTIVE
Diet books dominate the New York Times Advice Best Seller list and consumers cite such books as an important source of nutrition information. However, the scientific support for nutrition claims presented as fact (nutrition facts) in diet books is not known.
DESIGN/MEASUREMENTS
We assessed the quality of nutrition facts in the best-selling South Beach Diet using support in peer-reviewed literature as a measure of quality. We performed structured literature searches on nutrition facts located in the books' text, and then assigned each fact to 1 of 4 categories (1) fact supported, (2) fact not supported, (3) fact both supported and not supported, and (4) no related papers. A panel of expert reviewers adjudicated the findings.
RESULTS
Forty-two nutrition facts were included. Fourteen (33%) facts were supported, 7 (17%) were not supported, 18 (43%) were both supported and not supported, and 3 (7%) had no related papers, including the fact that the diet had been “scientifically studied and proven effective.”
CONCLUSIONS
Consumers obtain nutrition information from diet books. We found that over 67% of nutrition facts in a best-seller diet book may not be supported in the peer-reviewed literature. These findings have important implications for educating consumers about nutrition information sources.
doi:10.1111/j.1525-1497.2006.00501.x
PMCID: PMC1924692  PMID: 16808780
health information; nutrition; weight loss

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