Addressing social determinants to improve healthcare quality and reduce cost.

Unlabelled: Most healthcare quality improvement and cost reduction efforts currently focus on care processes, or transitions-for example, the hospital discharge process. While identification and adoption of best practices to address these aspects of healthcare are essential, more is needed for systems that serve vulnerable populations: to account for social factors that often inhibit patients' ability to take full advantage of available healthcare. Our urban safety net healthcare system developed and implemented an innovative quality improvement approach.

The association of complementary and alternative medicine use and health care expenditures for back and neck problems.

Background: Health care costs associated with use of complementary and alternative medicine (CAM) by patients with spine problems have not been studied in a national sample.

Objectives: To estimate the total and spine-specific medical expenditures among CAM and non-CAM users with spine problems.

Research Design: Analysis of the 2002-2008 Medical Expenditure Panel Survey.

Effect of risk adjustment method on comparisons of health care utilization between complementary and alternative medicine users and nonusers.

Objectives: Complementary and alternative medicine (CAM) providers are becoming more integrated into the United States health care system. Because patients self-select CAM use, risk adjustment is needed to make the groups more comparable when analyzing utilization. This study examined how the choice of risk adjustment method affects assessment of CAM use on overall health care utilization.

The management of chronic diseases in rural Missouri practices.

This qualitative study describes the challenges of managing chronic diseases in small, rural, health care practices in Missouri. Four recurrent themes were identified from each of the nine focus groups: the similarity of their patient population and community characteristics, their unfamiliarity with aspects of the chronic care model, the consistent problem of poverty as a barrier to health care access for patients, and the uncertainty about what health care reform will mean for rural practice settings.

The water vapour self- and water-nitrogen continuum absorption in the 1000 and 2500 cm(-1) atmospheric windows.

The pure water vapour and water-nitrogen continuum absorption in the 1000 and 2500 cm(-1) atmospheric windows has been studied using a 2 m base-length White-type multi-pass cell coupled with a BOMEM DA3-002 Fourier transform infrared spectrometer. The measurements were carried out at the National Institute of Standards and Technology (NIST, Gaithersburg, MD) over the course of several years (2004, 2006-2007, 2009). New data on the H(2)O:N(2) continuum in the 1000 cm(-1) window are presented and summarized along with the other experimental results and the continuum model.

Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington State: a cost minimization analysis.

Objectives: The purpose of this analysis was to compare health care expenditures between insured patients with back pain, fibromyalgia syndrome, or menopause symptoms who used complementary and alternative medical (CAM) providers for some of their care to a matched group of patients who did not use any CAM care. Insurance coverage was equivalent for both conventional and CAM providers.

Design: Insurance claims data for 2000-2003 from Washington State, which mandates coverage of CAM providers, were analyzed.

Identification of ovarian cancer symptoms in health insurance claims data.

Background: Women with ovarian cancer have reported abdominal/pelvic pain, bloating, difficulty eating or feeling full quickly, and urinary frequency/urgency prior to diagnosis. We explored these findings in a general population using a dataset of insured women aged 40-64 and investigated the potential effectiveness of a routine review of claims data as a prescreen to identify women at high risk for ovarian cancer.

Methods: Data from a large Washington State health insurer were merged with the Seattle-Puget Sound Surveillance, Epidemiology and End Results (SEER) cancer registry for 2000-2004.

The Quality of Dying and Death Questionnaire (QODD): empirical domains and theoretical perspectives.

We used exploratory factor analysis within the confirmatory analysis framework, and data provided by family members and friends of 205 decedents in Missoula, Montana, to construct a model of latent-variable domains underlying the Quality of Dying and Death questionnaire (QODD). We then used data from 182 surrogate respondents, who were survivors of Seattle decedents, to verify the latent-variable structure. Results from the two samples suggested that survivors' retrospective ratings of 13 specific aspects of decedents' end-of-life experience served as indicators of four correlated, but distinct, latent-variable domains: Symptom Control, Preparation, Connectedness, and Transcendence.

Pediatric vaccination and vaccine-preventable disease acquisition: associations with care by complementary and alternative medicine providers.

This study investigated provider-based complementary/alternative medicine use and its association with receipt of recommended vaccinations by children aged 1-2 years and with acquisition of vaccine-preventable disease by children aged 1-17 years. Results were based on logistic regression analysis of insurance claims for pediatric enrollees covered by two insurance companies in Washington State during 2000-2003. Primary exposures were use of chiropractic, naturopathy, acupuncture, or massage practitioner services by pediatric enrollees or members of their immediate families.

Might massage or guided meditation provide "means to a better end"? Primary outcomes from an efficacy trial with patients at the end of life.

This article reports findings from a randomized controlled trial of massage and guided meditation with patients at the end of life. Using data from 167 randomized patients, the authors considered patient outcomes through 10 weeks post-enrollment, as well as next-of-kin ratings of the quality of the final week of life for 106 patients who died during study participation. Multiple regression models demonstrated no significant treatment effects of either massage or guided meditation, delivered up to twice a week, when compared with outcomes of an active control group that received visits from hospice-trained volunteers on a schedule similar to that of the active treatment arms.

Preventive screening of women who use complementary and alternative medicine providers.

Background: Many women use complementary and alternative medicine (CAM). Although CAM use has been associated with reductions in conventionally recommended pediatric preventive care (e.g.

Chiropractic use by urban and rural residents with insurance coverage.

Purpose: To describe the use of chiropractic care by urban and rural residents in Washington state with musculoskeletal diagnoses, all of whom have insurance coverage for this care. The analyses investigate whether restricting the analyses to insured individuals attenuates previously reported differences in the prevalence of chiropractic use between urban and rural residents as well as whether differences in provider availability or patient cost-sharing explain the difference in utilization.

Methods: Claims data from 237,500 claimants in 2 large insurance companies in Washington state for calendar year 2002 were analyzed, using adjusted clinical group risk adjustment for differences in disease burden and rural urban commuting area codes for rurality definition.

Three lessons from a randomized trial of massage and meditation at end of life: patient benefit, outcome measure selection, and design of trials with terminally ill patients.

Improving end-of-life care is a priority in the United States, but assigning priorities for standard care services requires evaluations using appropriate study design and appropriate outcome indicators. A recent randomized controlled trial with terminally ill patients produced no evidence of benefit from massage or guided meditation, when evaluated with measures of global quality of life or pain distress over the course of patient participation. However, reanalysis using a more targeted outcome, surrogates' assessment of patients' benefit from the study intervention, suggested significant gains from massage-the treatment patients gave their highest preassignment preference ratings.

Secondary prevention of myocardial infarction with nonpharmacologic strategies in a Medicaid cohort.

Background: The quality of health care after myocardial infarction (MI) may be lacking; in particular, guidelines for nonpharmacologic interventions (cardiac rehabilitation, smoking cessation) may receive insufficient priority. We identified gaps between secondary prevention guidelines and ambulatory care received by Medicaid enrollees after an MI.

Methods: MI survivors were selected by using 2004 Washington State Medicaid administrative claims.

Medication Management Among Medicaid Myocardial Infarction Survivors.

Despite guidelines to direct appropriate medical management, the quality of care following acute myocardial infarction (AMI) may be lacking. This study characterizes medication utilization by Medicaid enrollees in the year following AMI, compares it to guidelines for secondary prevention and investigates associations with rehospitalization and survival. Using DSHS administrative claims data from Washington State, Medicaid enrollees who had an AMI in 2004 were selected.

Shared priorities for the end-of-life period.

This study investigated end-of-life priorities of terminally ill patients and their intimate associates. A primary goal was to reduce the number of items in an existing instrument measuring survivors' evaluations of the quality of dying and death. Three Seattle-area patient samples (chronic obstructive pulmonary disease patients, hospice patients, and participants in an efficacy trial of complementary comfort care) and their significant others provided priority rankings of 26 experiences at end of life.

Complementary and alternative medicine provider use and expenditures by cancer treatment phase.

Objective: To assess the use of complementary and alternative medicine (CAM) providers and the associated expenditures by specific treatment phases among patients with cancer.

Study Design: Cross-sectional analysis of medical services utilization and expenditures during the 3 therapeutic phases of initial, continuing, and end-of-life life treatment.

Methods: Analysis of an insurance claims database that had been matched to the Washington State Surveillance, Epidemiology, and End Results cancer registry.

Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy.

Purpose: The role that sex education plays in the initiation of sexual activity and risk of teen pregnancy and sexually transmitted disease (STD) is controversial in the United States. Despite several systematic reviews, few epidemiologic evaluations of the effectiveness of these programs on a population level have been conducted.

Methods: Among never-married heterosexual adolescents, aged 15-19 years, who participated in Cycle 6 (2002) of the National Survey of Family Growth and reported on formal sex education received before their first sexual intercourse (n = 1719), we compared the sexual health risks of adolescents who received abstinence-only and comprehensive sex education to those of adolescents who received no formal sex education.

Rotational Line Strengths and Self-Pressure-Broadening Coefficients for the 1.27-microm, a (1)D(g)-X (3)?(g)(-), v = 0-0 Band of O(2).

We measured at 296 K the rotational line strengths and pressure-broadening coefficients for the 1.27-mum, a (1)D(g)-X (3)?(g)(-), v = 0-0 band of O(2) with a Fourier transform infrared spectrometer using an optical path length of 84 m, a spectral resolution of 0.01 cm(-1), and sample pressures between 13 and 104 kPa.

Potential interactions between complementary/alternative products and conventional medicines in a Medicare population.

Background: Despite the high prevalence of complementary and alternative medicine (CAM) product use among the elderly, little is known about the extent of concurrent CAM-conventional medicine use and the potential for adverse reactions.

Objective: To determine the prevalence of CAM product use concurrent with conventional medications, prescription and nonprescription, in a Medicare population and assess the risk for adverse interactions.

Methods: Retrospective analysis was performed on Cardiovascular Health Study interview data from 1994, 1995, 1997, and 1999.

Quality of life at the end of life.

Background: Little is known about self-perceived quality of life (QOL) near the end of life, because such information is difficult to collect and to interpret. Here, we describe QOL in the weeks near death and determine correlates of QOL over time, with emphasis on accounting for death and missing data.

Methods: Data on QOL were collected approximately every week in an ongoing randomized trial involving persons at the end of life.

HSV-2 serologic testing in an HMO population: uptake and psychosocial sequelae.

Objectives: To prospectively measure the uptake of Herpes simplex virus Type 2 (HSV-2) testing and psychosocial response to a new serologic diagnosis of HSV-2 in a health maintenance organization (HMO) population.

Study Design: Randomly selected urban HMO enrollees were invited to be tested for HSV-2 antibody at a research clinic. Participants had blood drawn and completed demographic and psychosocial questionnaires.

Use of complementary and alternative medicine providers by fibromyalgia patients under insurance coverage.

Objective: To quantify how visits and expenditures differ between insured patients with fibromyalgia syndrome (FMS) who visit complementary and alternative medicine (CAM) providers compared with patients with FMS who do not. Patients with FMS were also compared with an age- and sex-matched comparison group without FMS.

Methods: Calendar year 2002 claims data from 2 large insurers in Washington state were analyzed for provider type (CAM versus conventional), patient comorbid medical conditions, number of visits, and expenditures.

The effect of complementary and alternative medicine claims on risk adjustment.

Objective: We sought to assess how the inclusion of claims from complementary and alternative medicine (CAM) providers affects measures of morbidity burden and expectations of health care resource use for insured patients.

Methods: Claims data from Washington State were used to create 2 versions of a case-mix index. One version included claims from all provider types; the second version omitted claims from CAM providers who are covered under commercial insurance.

The fish in secondary prevention of heart disease (FISH) survey--primary care physicians and omega3 fatty acid prescribing behaviors.

Purpose: Consumption of fish oil has been shown to reduce mortality in patients with cardiovascular disease (CVD). This study aims to determine the frequency and associations of dietary fish prescribing by family physicians.

Methods: A 22-item survey mailed to randomly selected Washington State family physicians.