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Albert W Wu

Publications and source records attributed to Albert W Wu.

At least 19 recordsLinked to original sources
PubMed2006

Off-pump surgery is associated with reduced occurrence of stroke and other morbidity as compared with traditional coronary artery bypass grafting: a meta-analysis of systematically reviewed trials.

BACKGROUND AND PURPOSE: There is growing enthusiasm for coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB). Although deleterious effects of CPB are known, it remains to be proven that avoiding CPB will result in reduction in morbidity. We sought to determine whether off-pump surgery is associated with reduced occurrence of adverse outcomes as compared with CABG with CPB. METHODS: Studies were identified by searching the MEDLINE, EMBASE and the Cochrane Register 1980 to 2006 (February). We also searched the reference lists of randomized clinical trials (RCT) and reviews to look for additional studies. STUDY SELECTION: RCTs comparing off-pump surgery to CABG with CPB. No restriction applied on the size of the trial or end point reports. DATA EXTRACTION: 2 reviewers independently searched for studies, read abstracts and abstracted all data. DATA SYNTHESIS: combined estimates were obtained using fixed or random effect meta-analyses. Relative risks and risk differences were calculated. Heterogeneity was assessed using chi(2) and I(2) values. RESULTS: There were 3996 patients enrolled in 41 RCTs (mean age 62, 22% female). No study reported information on race. Off-pump CABG was associated with a 50% reduction in the relative risk of stroke (95% CI, 7% to 73%), 30% reduction in atrial fibrillation (AF; 95% CI, 16% to 43%) and 48% reduction in wound infection (95% CI, 26% to 63%) with no heterogeneity among RCTs. This translated into avoidance of 10 strokes, 80 cases of AF and 40 infections per 1000 CABG. Fewer distal grafts were performed and there was evidence for >10 reinterventions per 1000 with off-pump CABG. Long-term follow-up is not yet reported in the trials. CONCLUSIONS: Off-pump CABG is associated with reduced risk of stroke, AF and infections as compared with CABG with CPB. Evidence should be generalized taking into account RCT enrollment limitations, drawbacks related to training requirements, propensity to perform fewer grafts and likely reinterventions after off-pump surgery.

Aged↗
PubMed2006

Comorbid illnesses and health care utilization among Medicare beneficiaries with lung cancer.

We evaluated the association of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) with outcomes in a 5% Medicare sample of 4447 elderly beneficiaries with lung cancer. Twenty-nine percent of patients had COPD and 13% had CHF. Patients with COPD or CHF had significantly decreased survival (hazard ratios 1.14 (1.05-1.25) and 1.38 (1.18-1.62), respectively); most of this differential was within 2 months after diagnosis. Patients with COPD or CHF were significantly less likely to receive surgery or chemotherapy than patients with neither COPD nor CHF. The association with less chemotherapy was similar in patients with the highest probability of surviving more than 2 months after the cancer diagnosis. In Medicare beneficiaries with lung cancer, COPD and CHF were common and were associated with both short-term mortality and decreased use of cancer treatments. Accounting for these two comorbid illnesses is important in evaluating health care utilization in this population.

Aged↗
PubMed2006

Variations in self-rated health among patients with HIV infection.

PURPOSE: To assess how patients with HIV who are enrolled in a clinical trials cohort rate their health and to compare their ratings with those of patients with HIV from 2 other cohorts: the HIV Cost and Services Utilization Study (HCSUS), and Adult AIDS Clinical Trials Group protocol 320 (ACTG 320). METHODS: We analyzed baseline information for the 1649 subjects enrolled in the Adult AIDS Clinical Trials Group Longitudinal Linked Randomized Trials (ALLRT) study prior to March 2002 who had self-rated health data available. We compared those results with results from 2 other groups: HCSUS, the only nationally representative sample of people in care for HIV in the U.S., which conducted baseline interviews in 1996 and 1997, and ACTG 320, a randomized, double-blinded, placebo-controlled trial comparing a 3-drug antiretroviral regimen with a 2-drug combination, which enrolled subjects in the same general time frame as HCSUS. We used t tests, Pearson correlations, and linear regression to determine factors associated with self-rated health and z scores to compare results between cohorts. RESULTS: The mean (SD) rating scale value on a 0-100 scale for ALLRT participants was 79.8 (16.8). Values were significantly lower for subjects who were older, had a history of injection drug use, had lower CD4 cell counts, or were beginning salvage antiretroviral therapy. Subjects in ALLRT reported significantly better self-rated health at baseline than those in HCSUS or ACTG 320 (11-12% higher rating scale values in ALLRT; p<0.05). When cohort differences were accounted for through regression and stratification, the differences in scores between subjects in ALLRT and HCSUS increased and the differences in scores between subjects in ALLRT and ACTG 320 diminished. CONCLUSIONS: Self-rated health varied significantly by age, CD4 count, injection drug use history, and salvage therapy status. Differences in self-rated health for clinical trials and non-clinical trials samples appear to be substantial and should be considered when applying trial results to clinical populations.

Adult↗
PubMed2006

Do the SF-36 and WHOQOL-BREF measure the same constructs? Evidence from the Taiwan population*.

BACKGROUND: The SF-36 and WHOQOL-BREF are available for international use, but it is not clear if they measure the same constructs. We compared the psychometric properties and factor structures of these two instruments. METHODS: Data were collected from a national representative sample (n=11,440) in the 2001 Taiwan National Health Interview Survey, which included Taiwan versions of the SF-36 and WHOQOL-BREF. We used Cronbach's alpha coefficient to estimate scale reliability. We conducted exploratory factor analysis to determine factor structure of the scales, and applied multi trait analysis to evaluate convergent and discriminant validity. We used standardized effect size to compare known-groups validity for health-related variables (including chronic conditions and health care utilization) and self-reported overall quality of life. Structural equation modeling was used to analyze relationships among the two SF-36 component scales (PCS and MCS) and the four WHOQOL subscales (physical, psychological, social relations, and environmental). RESULTS: Cronbach's alpha coefficients were acceptable ([Symbol: see text]0.7) for all subscales of both instruments. The factor analysis yielded two unique factors: one for the 8 SF-36 subscales and a second for the 4 WHOQOL subscales. Pearson correlations were weak (<0.3) among subscales of both instruments. Correlations for subscales hypothesized to measure similar constructs differed little from those measuring heterogeneous subscales. Effect sizes suggested greater discrimination by the SF-36 for health status and services utilization known groups, but greater discrimination by the WHOQOL for QOL-defined groups. Structural equation modeling suggested that the SF-36 PCS and MCS were weakly associated with WHOQOL. CONCLUSIONS: In this Taiwan population sample, the SF-36 and WHOQOL-BREF appear to measure different constructs: the SF-36 measures health-related QOL, while the WHOQOL-BREF measures global QOL. Clinicians and researchers should carefully define their research questions related to patient-reported outcomes before selecting which instrument to use.

Adult↗
PubMed2006

Ethical and practical aspects of disclosing adverse events in the emergency department.

Physicians and hospitals should be aware of the ethical duty to disclose a medical error that causes harm to a patient. Disclosure should be made to the affected patient or, when appropriate, to a family member of the patient. The manner in which the disclosure process is performed is also important. In emergency medicine, disclosure discussions are problematic because of the limited nature of the patient-physician relationship. The initial disclosure can be conducted in a way that maintains or even improves the relationship with the patient, or in a manner that damages trust. This article discusses the importance of disclosure in emergency medicine; the ethical basis for, and barriers to, disclosure; and the key elements of the disclosure process.

Emergency Medicine↗
PubMed2006

Toward learning from patient safety reporting systems.

PURPOSE: To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS: Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. RESULTS: Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. CONCLUSIONS: The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Adult↗
PubMed2006

A randomized trial of the impact of a programmable medication reminder device on quality of life in patients with AIDS.

This 6-month randomized controlled trial evaluated the impact on quality of life (QOL) of a medication reminder device for patients with HIV. Patients were eligible if they had taken three or fewer highly active antiretroviral therapy (HAART) regimens or were treatment naïve. The intervention group received the Disease Management Assistance System (DMAS), a prompting device that verbally reminds patients at medication times and electronically records doses, and a monthly 30 minute adherence educational session. Controls received education only. QOL was measured at baseline and 6 months using the Centers for Epidemiologic Studies Depression Scale (CES-D), Instrumental Activities of Daily Living (IADLs), and the Medical Outcomes Study HIV Health Survey (MOS-HIV). At baseline, 62 patients completed surveys (31 control, 31 DMAS); at month 6, 48 patients completed surveys (23 control, 25 DMAS). At month 6, controls had improved QOL scores for CES-D, IADLs, physical health, general health, pain, QOL, and role functioning, while participants in the DMAS arm had some deterioration in QOL scores. These differences persisted after controlling for demographics, baseline CD4, and adherence. DMAS was associated with improved adherence but decreased QOL.

Acquired Immunodeficiency Syndrome↗
PubMed2006

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

OBJECTIVE: Our institution, like many, is struggling to develop measures that answer the question, How do we know we are safer? Our objectives are to present a framework to evaluate performance in patient safety and describe how we applied this model in intensive care units. DESIGN: We focus on measures of safety rather than broader measures of quality. The measures will allow health care organizations to evaluate whether they are safer now than in the past by answering the following questions: How often do we harm patients? How often do patients receive the appropriate interventions? How do we know we learned from defects? How well have we created a culture of safety? The first two measures are rate based, whereas the latter two are qualitative. To improve care within institutions, caregivers must be engaged, must participate in the selection and development of measures, and must receive feedback regarding their performance. The following attributes should be considered when evaluating potential safety measures: Measures must be important to the organization, must be valid (represent what they intend to measure), must be reliable (produce similar results when used repeatedly), must be feasible (affordable to collect data), must be usable for the people expected to employ the data to improve safety, and must have universal applicability within the entire institution. SETTING: Health care institutions. RESULTS: Health care currently lacks a robust safety score card. We developed four aggregate measures of patient safety and present how we applied them to intensive care units in an academic medical center. The same measures are being applied to nearly 200 intensive care units as part of ongoing collaborative projects. The measures include how often do we harm patients, how often do we do what we should (i.e., use evidence-based medicine), how do we know we learned from mistakes, and how well do we improve culture. Measures collected by different departments can then be aggregated to provide a hospital level safety score card. CONCLUSION: The science of measuring patient safety is immature. This article is a starting point for developing feasible and scientifically sound approaches to measure safety within an institution. Institutions will need to find a balance between measures that are scientifically sound, affordable, usable, and easily applied across the institution.

Forecasting↗
PubMed2005

Quality of life in a clinical trial of highly active antiretroviral therapy alone or with intravenous or subcutaneous interleukin-2 administration.

OBJECTIVE: To assess the impact of subcutaneous and intravenous interleukin-2 (IL-2) on health-related quality of life (HRQOL) in adults with HIV-1 receiving highly active antiretroviral therapy (HAART). DESIGN: Randomized clinical trial. SETTING: Twenty-two institutions from the Adult AIDS Clinical Trials Group. PATIENTS: One hundred forty-eight HIV-infected adults randomized, with baseline HRQOL data. METHODS: HAART (indinavir plus 2 nucleoside analogues) for 12 weeks, followed by 72 weeks of continued HAART alone, HAART plus subcutaneous IL-2, or HAART plus intravenous IL-2. OUTCOME MEASURES: Scores for 8 dimensions of HRQOL, an unweighted summary score, and a visual analogue health rating score. RESULTS: The IL-2 subcutaneous group had the best mean change in 6 of 8 dimension subscales and in the summary scale at 28 weeks (16 weeks after baseline). At 52 weeks, the IL-2 subcutaneous group had the best mean change in all the subscales and the summary scale. The differences were statistically significant for 3 subscales and the summary scale. Midcycle changes were statistically significantly worse for the subcutaneous IL-2 group for 4 subscales and the summary scale. CONCLUSIONS: We found evidence of a short-term but not long-term adverse impact of IL-2 on HRQOL and some evidence of long-term benefit for the subcutaneous group.

Acquired Immunodeficiency Syndrome↗
PubMed2005

The impact of anemia on energy and physical functioning in individuals with AIDS.

BACKGROUND: To our knowledge, the relationship between changes in hemoglobin level and energy and physical functioning in the anemic and "normal" ranges of hemoglobin among individuals with AIDS has not been well characterized. METHODS: In a multicenter, prospective, cohort study involving 19 clinics in the United States, 1406 individuals, 13 years and older, with AIDS were administered the Medical Outcomes Study HIV [human immunodeficiency virus] Health Survey (MOS-HIV) at baseline and at 3- to 6-month follow-up visits. Energy and physical functioning scores were the main outcomes. RESULTS: At baseline, a higher hemoglobin level was associated with a higher energy score and a higher physical functioning score (P < .001 for both), after adjusting for CD4 lymphocyte count, sex, age, education, and HIV risk factor. In longitudinal analyses, increases in hemoglobin were associated with increases in energy and physical functioning scores (P < .001 for both), after adjusting for CD4 lymphocyte count, sex, age, education, and HIV risk factor. Changes in the energy scales were, on average, 1.5 and 2.3 scale points per 1-g/dL change in hemoglobin level in the normal and anemic ranges, respectively. For the physical functioning scale, average changes were 2.7 and 2.6 scale points per 1-g/dL change in hemoglobin level in the normal and anemic ranges, respectively. CONCLUSIONS: Higher levels of hemoglobin are associated with better quality of life among individuals with AIDS. Changes in hemoglobin level within the conventional normal range of hemoglobin are also significantly associated with changes in quality of life.

Acquired Immunodeficiency Syndrome↗
PubMed2005

The influence of health status, age, and race on screening mammography in elderly women.

BACKGROUND: Screening mammography is controversial for elderly women because of an absence of efficacy data. Decisions to screen are based on individualized assessment of risks and benefits. Our objective was to determine how screening mammography varies by age and race when adjusted for propensity to die. METHODS: In a retrospective cohort study, rates of screening mammogram performed in 2000-2001 based on claims, adjusted for propensity to die in 2000, were determined for a nationally representative 5% random sample of female fee-for-service Medicare beneficiaries 65 years and older in (N = 722,310). RESULTS: The overall rate of screening was 39%. When stratified into quintiles by propensity to die, 2-year rates ranged from 61% in the lowest-risk group to 5% in the highest-risk group. In analyses stratified by age and adjusted for propensity to die, 42% of women aged 65 to 69 years were screened, declining to 26% of women 85 years and older (P<.001). Adjusted screening rates for white women, black women, and women of other races were 40%, 30%, and 25%, respectively (P<.001). Thus, among women with similar health status, the youngest women were 1.61 times more likely to be screened compared with the oldest; compared with black women and women of other races, white women were 1.38 and 1.60 times, respectively, more likely to be screened. CONCLUSIONS: Decisions to screen for breast cancer are related not only to health status but also to age and race. Underuse and overuse of screening mammography likely occurs owing to age- and race-associated decision making. Assessment of life expectancy may more accurately identify women who could benefit from screening.

Age Factors↗
PubMed2005

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.

CONTEXT: Clinical practice guidelines (CPGs) have been developed to improve the quality of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations. OBJECTIVE: To evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases. DATA SOURCES: The National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population); the National Guideline Clearinghouse (for locating evidence-based CPGs for each chronic disease). STUDY SELECTION: Of the 15 most common chronic diseases, we selected hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each. DATA EXTRACTION: Two investigators independently assessed whether each CPG addressed older patients with multiple comorbid diseases, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. Differences were resolved by consensus. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs. DATA SYNTHESIS: Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her 406 dollars per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result. CONCLUSIONS: This review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. Basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.

Aged↗
PubMed2005

A programmable prompting device improves adherence to highly active antiretroviral therapy in HIV-infected subjects with memory impairment.

Background. Patients cite "forgetting" as a reason for nonadherence to highly active antiretroviral therapy (HAART). We measured the effect of a memory-prompting device on adherence to HAART in memory-intact and memory-impaired human immunodeficiency virus (HIV)-infected subjects.Methods. The study was a prospective, randomized, controlled trial involving 64 HIV-infected adults. The intervention was the Disease Management Assistance System (DMAS) device, combined with monthly adherence counseling. Control subjects received only adherence counseling. The DMAS was programmed with HAART regimen data to provide verbal reminders at dosing times. Adherence was measured for 24 weeks using electronic drug exposure monitor (eDEM) caps.Results. A total of 58 subjects completed the 24-week study period; 28 were HAART naive (12 DMAS users and 16 control subjects). Mean adherence scores did not differ significantly between DMAS users (80%) and control subjects (65%). Post hoc analysis of 31 memory-impaired subjects (14 DMAS users and 17 control subjects) revealed significantly higher adherence rates among DMAS users (77%), compared with control subjects (57%) (P=.001). However, analysis of memory-intact subjects showed that adherence was not significantly improved for DMAS users (83%), compared with control subjects (77%) (P=.25). At week twelve, 38% of the DMAS users and 14% of the control subjects had an undetectable plasma HIV RNA load (P=.014), and at week 24, the plasma HIV RNA load was undetectable for 34% of the DMAS users and 38% of the control subjects (P=.49). CD4(+) cell counts did not differ between the study arms. Virological and immunological responses were not related to DMAS use in memory-impaired subjects.Conclusion. The DMAS prompting device improved adherence for memory-impaired subjects but not for memory-intact subjects.

Anti-HIV Agents↗
PubMed2005

Gender differences in health-related quality of life in patients with HIV/AIDS.

BACKGROUND: In studies evaluating the general US population, patients in primary care, and patients with chronic conditions, women consistently report poorer health-related quality of life (HRQoL) than men; however, studies evaluating HRQoL in patients with HIV/AIDS have not completely corroborated those findings. The objective of this study was to evaluate gender differences in HRQoL for participants in a large randomized trial comparing antiretroviral regimens. METHODS: AIDS Clinical Trials Group (ACTG) 320 was a randomized, blinded, placebo-controlled trial comparing the 3-drug regimen of indinavir + zidovudine (or stavudine) + lamivudine with the 2-drug combination of zidovudine (or stavudine) + lamivudine in subjects with CD4 cell counts less than 200 cells/microl and no prior treatment with protease inhibitors. Nine quality of life domains scored on 0-100 scales were assessed using the ACTG QOL 601-602 Health Survey at 3 points in the trial: baseline, 24 weeks and 40 weeks. Differences between men and women in HRQoL scores were assessed using the Wilcoxon rank-sum test and generalized estimating equation (GEE) models. RESULTS: Overall, 202 females and 976 males were randomized to one of two treatment arms. Female participants were more likely to be black or Hispanic and tended to be younger. At baseline, females reported lower HRQoL scores than males in all of the domains except social functioning, and at week 40, women scored lower in all of the domains except overall health. In repeated measures models, women were found to score lower in all HRQoL domains except overall health, with significant differences of 3.5-6.7 points in 3 of the 9 quality of life domains: physical functioning, pain, and energy/fatigue. HRQoL scores improved for participants in the study over time and in response to potent treatment, and the improvements were similar for men and women. CONCLUSIONS: Women with HIV/AIDS report substantially poorer HRQoL than men with HIV/AIDS in several HRQoL domains. However, changes in domain scores over time and in response to treatment do not differ significantly by gender, implying that changes in domain scores may be better HRQoL outcomes to compare between HIV-infected men and women in clinical trials than mean domain scores.

Adult↗
PubMed2005

Why is it that internists do not follow guidelines for preventing intravascular catheter infections?

BACKGROUND AND OBJECTIVE: High morbidity of CVC-related infections has led to national guidelines for their prevention. Despite recommendations for the use of maximal barrier precautions (mask, sterile gloves, gown, and large drape) and skin antisepsis with 2% chlorhexidine gluconate during CVC insertion, internists in the United States are not implementing these practices frequently. This study sought to identify and characterize the obstacles to and potential opportunities for improving adherence. DESIGN: Cross-sectional survey. PARTICIPANTS: One thousand randomly selected physician-members of the American College of Physicians-American Society of Internal Medicine. METHODS: Several potential determinants of adherence to maximal barrier precautions were assessed, including awareness of, agreement with, and ability to implement the recommendation, as well as the practice and training characteristics of the respondents. Factors influencing antiseptic selection were also recorded. RESULTS: Of 526 respondents, 178 (34%) had recently inserted CVCs. Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only independent predictor of adherence was high outcome expectancy for the use of large sterile drapes (OR, 5.3; CI95, 2.2-12.6). Availability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant. CONCLUSIONS: Despite established efficacy, use of maximal barrier precautions and chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

Anti-Infective Agents, Local↗
PubMed2005

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

OBJECTIVE: To analyze the system factors related to "line, tube, and drain" (LTD) incidents in the intensive care unit (ICU). DESIGN: Voluntary, anonymous Web-based patient safety reporting system. SETTING: Eighteen ICUs in the United States. PATIENTS: Incidents reported by ICU staff members during a 12-month period ending June 2003. INTERVENTIONS: None. MEASUREMENTS: Characteristics of the incidents (defined as events that could/did cause harm), patients, and patient harm were described. Separate multivariable logistic regression analyses of contributing, limiting, and preventive system factors for LTD vs. non-LTD incidents were reported. MAIN RESULTS: Of the 114 reported LTD incidents, >60% were considered preventable. One patient death was attributed to an LTD incident. Of patients experiencing LTD incidents, 56% sustained physical injury, and 23% had an anticipated increased hospital stay. Factors contributing to LTD incidents included occurrence in the operating room (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.25-9.83), occurrence on a holiday (OR, 3.65; 95% CI, 1.12-11.9), patient medical complexity (OR, 3.68; 95% CI, 2.28-5.92), and age of 1-9 yrs (OR, 7.95; 95% CI, 3.29-19.2). Factors related to team communication were less likely to limit LTD incidents (OR, 0.28; 95% CI, 0.11-0.68), while clinician knowledge and skills helped prevent LTD incidents (OR, 1.80; 95% CI, 1.09-2.97). CONCLUSIONS: Patients are harmed by preventable LTD incidents. Relative to non-LTD events, these incidents occur more frequently during holidays and in medically complex patients and children. Focusing on these contributing factors and clinician knowledge and skills is important for reducing and preventing these hazardous events.

Adolescent↗
PubMed2005

Application of a propensity score approach for risk adjustment in profiling multiple physician groups on asthma care.

OBJECTIVES: To develop a propensity score-based risk adjustment method to estimate the performance of 20 physician groups and to compare performance rankings using our method to a standard hierarchical regression-based risk adjustment method. DATA SOURCES/STUDY SETTING: Mailed survey of patients from 20 California physician groups between July 1998 and February 1999. STUDY DESIGN: A cross-sectional analysis of physician group performance using patient satisfaction with asthma care. We compared the performance of the 20 physician groups using a novel propensity score-based risk adjustment method. More specifically, by using a multinomial logistic regression model we estimated for each patient the propensity scores, or probabilities, of having been treated by each of the 20 physician groups. To adjust for different distributions of characteristics across groups, patients cared for by a given group were first stratified into five strata based on their propensity of being in that group. Then, strata-specific performance was combined across the five strata. We compared our propensity score method to hierarchical model-based risk adjustment without using propensity scores. The impact of different risk-adjustment methods on performance was measured in terms of percentage changes in absolute and quintile ranking (AR, QR), and weighted kappa of agreement on QR. RESULTS: The propensity score-based risk adjustment method balanced the distributions of all covariates among the 20 physician groups, providing evidence for validity. The propensity score-based method and the hierarchical model-based method without propensity scores provided substantially different rankings (75 percent of groups differed in AR, 50 percent differed in QR, weighted kappa=0.69). CONCLUSIONS: We developed and tested a propensity score method for profiling multiple physician groups. We found that our method could balance the distributions of covariates across groups and yielded substantially different profiles compared with conventional methods. Propensity score-based risk adjustment should be considered in studies examining quality comparisons.

Adult↗