Safety climate and medical errors in 62 US emergency departments.

Study Objective: We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs.

Methods: We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors.

Racial and gender disparities in implantable cardioverter-defibrillator placement: are they due to overuse or underuse?

Previous studies documented racial and gender disparities in implantable cardioverter-defibrillator (ICD) placement. The authors examined whether racial and gender disparities in ICD placement are due to underutilization or overutilization. Among 1,054 adults hospitalized from 2001 to 2004 with ventricular arrhythmias in a large academic hospital, the study found that 17% of patients had clinical indicators concordant with ICD placement criteria.

Impact of health disparities collaboratives on racial/ethnic and insurance disparities in US community health centers.

Background: The Health Resources and Services Administration Health Disparities Collaboratives (HDCs) were developed to improve care for chronic medical conditions in community health centers (CHCs).

Methods: We examined whether HDCs reduced disparities in quality by race/ethnicity or insurance status in CHCs nationally. We performed a controlled preintervention/postintervention study of 44 CHCs participating in HDCs for asthma, diabetes mellitus, or hypertension and 20 "external" control CHCs that had not participated.

The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments.

Study Objective: Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety.

Methods: This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination.

Inside the health disparities collaboratives: a detailed exploration of quality improvement at community health centers.

Background: Quality improvement collaboratives (QICs) based on the Chronic Care Model (CCM) are widely used models for improving medical care, but there has been little information to date about the specific projects undertaken by participants in these collaboratives and their outcomes.

Objectives: To describe initiatives undertaken by community health centers (CHCs) participating in QICs (the Health Disparities Collaboratives) for asthma, cardiovascular disease, or diabetes, and to determine whether particular features of these initiatives were associated with improvement in health care processes or outcomes.

Research Design: Observational cohort study.

Is spending more always wasteful? The appropriateness of care and outcomes among colorectal cancer patients.

Increased area-level medical spending is not correlated with improved patient outcomes or quality, thereby supporting the case for spending reductions in high-spending regions. However, all additional spending need not be wasteful. Examining the care of patients with colorectal cancer, we show that high-spending regions are more likely than other regions to use recommended care but are also more likely to use discretionary and nonrecommended care, the latter of which has adverse outcomes for patients.

The National Emergency Department Safety Study: study rationale and design.

The significance of medical errors is widely appreciated. Given the frequency and significance of errors in medicine, it is important to learn how to reduce their frequency; however, the identification of factors that increase the likelihood of errors poses a considerable challenge. The National Emergency Department Safety Study (NEDSS) sought to characterize organizational- and clinician-associated factors related to the likelihood of errors occurring in emergency departments (EDs).

Care in the months before death and hospice enrollment among older women with advanced breast cancer.

Background: Variations in hospice use are not well understood.

Objective: Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment.

Design/setting: Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results--Medicare database.

Access to specialty care and medical services in community health centers.

Although community health centers (CHCs) provide primary health services to the medically underserved and poor, limited access to off-site specialty services may lead to poorer outcomes among underinsured CHC patients. This study evaluates access to specialty health services for patients receiving care in CHCs, using a survey of medical directors of all federally qualified CHCs in the United States in 2004. Respondents reported that uninsured patients had greater difficulty obtaining access to off-site specialty services, including referrals and diagnostic testing, than did patients with Medicaid, Medicare, or private insurance.

The influence of cost containment strategies and physicians' financial arrangements on patients' trust and satisfaction.

Concerns have been raised about the potential for negative effects of health plans' cost containment strategies on the patient-physician relationship. We surveyed Minnesota patients with diabetes or hypertension (N = 595) and their physicians (N = 389) to assess the associations of gatekeeping, utilization profiling, and financial arrangements with patients' trust in and satisfaction with their physician. We found that patients of physicians exposed to various cost containment strategies were generally not less trusting in or less satisfied with their physicians than other patients.

Surveillance testing among survivors of early-stage breast cancer.

Purpose: Guidelines recommend against routine surveillance testing for women who have had breast cancer. We described follow-up care for breast cancer survivors, examined how surveillance testing varies by the types of physicians seen, and assessed changes in testing rates over time.

Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, we studied a population-based cohort of 44,511 women age > or = 65 years diagnosed with stage I/II breast cancer during 1992 to 1999 and observed through 2001.

Analyzing multiple informant data from an evaluation of the health disparities collaboratives.

Objective: To use multivariate regression methods to analyze simultaneously data obtained from multiple respondents or data sources (informants) at health centers.

Data Source: Surveys of executive directors, medical directors, and providers from 65 community health centers (176 informants) who participated in an evaluation of the Health Disparities Collaboratives.

Study Design: Cross-sectional survey of staff at the health centers during 2003-2004.

Improving the management of chronic disease at community health centers.

Background: The Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) were designed to improve care in community health centers, where many patients from ethnic and racial minority groups and uninsured patients receive treatment.

Methods: We performed a controlled preintervention and postintervention study of community health centers participating in quality-improvement collaboratives (the Health Disparities Collaboratives sponsored by the HRSA) for the care of patients with diabetes, asthma, or hypertension. We enrolled 9658 patients at 44 intervention centers that had participated in the collaboratives and 20 centers that had not participated (external control centers).

The quality of chronic disease care in U.S. community health centers.

Community health centers (CHCs) are responsible for providing care for more than fifteen million Americans, many of whom are members of groups who have been documented to receive low-quality care. This study examines the quality of care for patients with chronic disease in a nationally representative sample of federally funded CHCs. Fewer than half of eligible patients received appropriate care for the majority of indicators measured, and uninsured patients received poorer care than insured patients.

Reducing racial/ethnic disparities in female breast cancer: screening rates and stage at diagnosis.

Objectives: We assessed whether population rates of mammography screening, and their changes over time, were associated with improvements in breast cancer stage at diagnosis and whether the strength of this association varied by race/ethnicity.

Methods: We analyzed state cancer registry data linked to socioeconomic characteristics of patients' areas of residence for 1990-1998 time trends in the likelihood of early stage diagnosis. We appended each cancer registry record with matching subgroup estimates of self-reported mammography screening.

Understanding cancer patients' experience and outcomes: development and pilot study of the Cancer Care Outcomes Research and Surveillance patient survey.

Goals Of Work: The National Cancer Institute's Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is conducting a population-based study of newly diagnosed patients with lung and colorectal cancer to describe the experience of persons living with cancer and to understand which barriers present the most significant obstacles to their receipt of appropriate care. The keystone to this effort is the baseline patient survey administered approximately 4 months after diagnosis.

Patients And Methods: We developed a survey to obtain information from patients newly diagnosed with lung and colorectal cancer about their personal characteristics, decision making, experience of care, and outcomes.

Managed care market share and primary treatment for cancer.

Objective: Increases in the market share of managed care are associated with decreases in expenditures in the fee-for-service sector. To understand utilization patterns responsible for such savings, we assessed whether increases in managed care market share were related to increases in receipt of equally effective but less costly primary cancer therapies.

Data Sources: Cancer registry data linked to Medicare administrative data for a population-based sample of fee-for-service Medicare beneficiaries 66 years and older who were diagnosed with breast or prostate cancer during 1993-1999.

Factors related to underuse of surveillance mammography among breast cancer survivors.

Purpose: Many older breast cancer survivors do not undergo annual mammography despite guideline recommendations. We identified factors associated with underuse of surveillance mammography and examined whether variation was explained by differences in follow-up care.

Patients And Methods: We used Surveillance, Epidemiology, and End Results-Medicare data to identify a population-based sample of 44,511 women fee-for-service Medicare enrollees aged > or = 65 years who were diagnosed with stage I or II breast cancer in 1992 to 1999 who underwent primary surgical therapy.

Examining the relationship of patients' attitudes and beliefs with their self-reported level of participation in medical decision-making.

Objective: We applied constructs from the transtheoretical model (TTM) of behavior change to identify modifiable determinants of patient participation in medical decision-making.

Method: We surveyed a convenience sample of 621 primary care patients at one Boston hospital (response rate 60.6%).

Patients' perceptions of quality of care for colorectal cancer by race, ethnicity, and language.

Purpose: To identify opportunities for improving care, we evaluated patients' perceptions of the quality of their cancer care by race, ethnicity, and language.

Patients And Methods: We surveyed a population-based cohort of 1,067 patients with colorectal cancer in northern California approximately 9 months after diagnosis. Adjusting for clinical and demographic factors, mean problem scores were analyzed on a 100-point scale for six domains of care.

Do increases in the market share of managed care influence quality of cancer care in the fee-for-service sector?

Background: Increases in the market share of managed care in an area are associated with decreases in expenditures in the fee-for-service sector (i.e., a spillover effect).

The association of ambulatory care with breast cancer stage at diagnosis among Medicare beneficiaries.

Objective: Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis.

Design: Retrospective cohort study using cancer registry and Medicare claims data.

Care following acute myocardial infarction in the Veterans Administration Medical Centers: a comparison with Medicare.

Objective: To compare patients treated for acute myocardial infarction (AMI) in a Veterans Health Administration (VHA) facility to similar patients treated under Medicare.

Data Sources: Administrative data on 13,129 elderly male veterans hospitalized for AMI in a VHA facility between October 1, 1996, and September 30, 1999, and a matched set of male Medicare beneficiaries with AMI treated in a non-VHA facility during the same time period.

Study Design: We conducted a retrospective cohort study using propensity score methods to identify a matched set of male elderly AMI patients treated either in a VHA facility or in a non-VHA facility under Medicare.

The effect of managed care market share on appropriate use of coronary angiography among traditional Medicare beneficiaries.

Evidence suggests that when managed care market share increases in a geographic area, expenditures in Medicare's fee-for-service sector decrease. But it is unclear how expenditure reductions relate to the quality of medical care for traditional Medicare beneficiaries. We estimated how managed care market share varied with the proportion of fee-for-service Medicare beneficiaries who were admitted for acute myocardial infarction (AMI) and underwent angiography.

Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure.

Purpose: To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure.

Methods: The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name.