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1.  Quality Improvement Implementation in the Nursing Home 
Health Services Research  2003;38(1 Pt 1):65-83.
Objective
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.
Study Design
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.
Principal Findings
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.
Conclusions
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.
doi:10.1111/1475-6773.00105
PMCID: PMC1360874  PMID: 12650381
Quality improvement; quality of care; nursing homes; decubitus ulcers
2.  Professional Satisfaction Experienced When Caring for Substance-abusing Patients 
This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients' family history. Physicians were less likely (P < .05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions.
doi:10.1046/j.1525-1497.2002.10520.x
PMCID: PMC1495049  PMID: 12047735
physician satisfaction; substance abuse; resident physicians; faculty physicians; attitudes; screening
3.  Attitudes Toward Colorectal Cancer Screening Tests 
OBJECTIVE
To examine patient and physician preferences in regard to 5 colorectal cancer screening alternatives endorsed by a 1997 expert panel, determine the impact of patient and physician values regarding certain test features on screening preference, and assess physicians' perceptions of patients' values.
DESIGN
Cross-sectional survey.
SETTING
A general internal medicine practice at an academic medical center in 1998.
PARTICIPANTS
Patients (N = 217; 76% response rate) and physicians (N = 39; 87% response rate) at the study setting.
MEASUREMENTS AND MAIN RESULTS
Patients preferred fecal occult blood testing (43%) or colonoscopy (40%). In patients for whom accuracy was the most important test feature, colonoscopy (62%) was the preferred screening method. Patients for whom invasive test features were more important preferred fecal occult blood testing (76%; P < .001). Patients and physicians were similar in their values regarding the various test features. However, there was a significant difference between physicians' perceptions of which test features were important to patients compared with the patients' actual responses (P < .001). The largest discrepancy was for accuracy (patient actual 54% vs physician opinion 15%) and discomfort (patient actual 15% vs physician opinion 64%).
CONCLUSIONS
Patients have distinct preferences for colorectal cancer screening tests that are associated with the importance placed on certain test features. Physicians incorrectly perceive those factors that are important to patients. Physicians should incorporate patient values in regard to certain test features when discussing colorectal cancer screening with their patients and when eliciting their screening preferences.
doi:10.1111/j.1525-1497.2001.10337.x
PMCID: PMC1495302  PMID: 11903761
colorectal cancer screening; patient preferences; patient attitudes; physician attitudes; screening guidelines
4.  Intensive Care Unit Use and Mortality in the Elderly 
OBJECTIVE
To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States.
DESIGN
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.
MAIN RESULTS
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.
CONCLUSIONS
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.
doi:10.1046/j.1525-1497.2000.02349.x
PMCID: PMC1495347  PMID: 10672112
intensive care; hospital mortality; health services for aged
5.  The Impact of Leaving Against Medical Advice on Hospital Resource Utilization 
OBJECTIVE
To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism.
DESIGN
Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges.
SETTING
Acute care hospitals.
PATIENTS
We studied 23,198 pneumonia hospitalizations in a statewide administrative database.
MEASUREMENTS AND MAIN RESULTS
Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD ( p = .012). ARD-attributable increases of $1,659 ( p = .002) and $1,664 ( p = .002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD ( p = .188). An increase of 1 day was seen using both strategies 2 and 3 ( p = .044 and p = .027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1.
CONCLUSIONS
Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization.
doi:10.1046/j.1525-1497.2000.12068.x
PMCID: PMC1495341  PMID: 10672113
hospitalization, patient discharge; patient dropouts; alcoholism; pneumonia; fees and charges

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