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Biomedical subjects

Lisa I Iezzoni

Publications and source records attributed to Lisa I Iezzoni.

18 recordsLinked to original sources
PubMed2004

Communicating about health care: observations from persons who are deaf or hard of hearing.

BACKGROUND: Achieving patient-centered care requires effective communication between physicians and patients. Persons who are deaf or hard of hearing face considerable barriers to communicating with physicians. OBJECTIVE: To understand perceptions of health care experiences and suggestions for improving care among deaf or hard-of-hearing individuals. DESIGN: 4 semistructured group interviews, 2 conducted in American Sign Language (for deaf individuals) and 2 using Communication Access Realtime Translation (for hard-of-hearing individuals). Men and women were interviewed separately. Tapes of interviews were transcribed verbatim for analysis. SETTING: Greater Boston, Massachusetts, and Washington, DC, in 2001. PARTICIPANTS: 14 deaf adults (23 to 51 years of age) and 12 hard-of-hearing adults (30 to 74 years of age). MEASUREMENTS: Commonly expressed themes or views organized around dimensions of communication. RESULTS: Concerns coalesced around 6 broad themes: conflicting views between physicians and patients about being deaf or hard of hearing; different perceptions about what constitutes effective communication (such as lip reading, writing notes, and sign language interpreter); medication safety and other risks posed by inadequate communication; communication problems during physical examinations and procedures; difficulties interacting with office staff, including in waiting rooms; and problems with telephone communication, such as lengthy message menus. Participants offered extensive suggestions for improvements, starting with clinicians' asking patients about their preferred communication approach. Having patients repeat critical health information (such as medication instructions) can identify potentially dangerous miscommunication. CONCLUSIONS: As the population ages, physicians will encounter many more persons with hearing limitations. Physicians are not reimbursed for making some accommodations, such as hiring sign language interpreters. However, ensuring effective communication is essential to safe, timely, efficient, and patient-centered care.

Adult↗
PubMed2004

Risk adjusting rehabilitation outcomes: an overview of methodologic issues.

The complexity and mix of rehabilitation patients varies across clinicians and institutions. Comparisons of outcomes across providers must therefore adjust for differences in risk factors across patient populations. Research on risk adjustment has generally focused on acute care hospital outcomes, although techniques for risk adjusting financial outcomes are fairly well developed in rehabilitation, primarily to support Medicare and other prospective payment systems. This article reviews important methodologic issues in risk adjusting rehabilitation outcomes in observational studies of routine clinical practice or for management, such as assessing quality or costs of care. Risk adjusting rehabilitation outcomes is more difficult than risk adjusting other clinical results, such as outcomes of many acute care services. At the outset, characterizing rehabilitation interventions is frequently difficult. Furthermore, outcomes are diverse and depend on myriad factors, including patients' physical and cognitive abilities, underlying medical diseases, sensory and emotional factors, willingness to participate in care, and supportive environments. No risk-adjustment approach can control for every factor affecting outcomes of care. Knowing which risk factors are missing helps guide interpretation of the results and determines how well risk-adjusted outcomes fairly compare providers or treatments.

Diagnosis-Related Groups↗
PubMed2004

Risk adjustment for pediatric quality indicators.

The movement to measure medical care quality has been accelerating, spurred on by evidence of poor quality of care and trials of interventions to improve care. Appropriate measurement of quality of care is an essential aspect of improving the quality of care, yet some quality measures may be influenced by patients' attributes unrelated to quality of care. Risk adjustment is the term commonly applied to those methods that account for patient-related attributes, making measurement of health care quality as comparable as possible across providers or organizations seeing different mixes of patients. The measurement of quality of care for children poses specific challenges. In addition to these measurement challenges, analysts must ensure that quality comparisons among doctors, groups of doctors, hospitals, or health plans are not adversely affected by the likelihood that different types of patients seek care in different places. Although some techniques designed to adjust performance measures for case mix were developed for both adults and children, other systems are specific to childhood circumstances. The theoretical issues involved in risk-adjusting childhood outcomes measures for newborns in the neonatal intensive care unit were reviewed recently. Here, we go beyond the neonatal intensive care unit setting to consider risk adjustment for pediatric quality measures more broadly. In particular, we 1) review the conceptual background for risk-adjusting quality measures, 2) present policy issues related to adjusting pediatric quality measures, and 3) catalog existing risk-adjustment methodologies for pediatric quality measures. We conclude with an overall assessment of the status of risk adjustment for pediatric quality measures and recommendations for additional research and application.

Child↗
PubMed2003

Quality dimensions that most concern people with physical and sensory disabilities.

BACKGROUND: People with physical and sensory disabilities face important challenges in obtaining high-quality health care. We examined whether persons who are blind or have low vision, who are deaf or hard of hearing, or who have mobility impairments or manual dexterity problems are satisfied with the technical and interpersonal aspects of their care. METHODS: By using a 1996 nationally representative survey of 16 403 community-dwelling elderly and disabled Medicare beneficiaries, we identified persons with disabling conditions. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) controlled for demographic characteristics and managed care membership in predicting dissatisfaction with 12 dimensions of care. RESULTS: Of an estimated 33.58 million noninstitutionalized Medicare beneficiaries, 64.1% (an estimated 21.51 million) reported at least 1 potential disability and 29.5% (an estimated 9.89 million) reported more than 1 potential disability. Roughly 98% of people with and without disabilities believed their physicians were competent and well trained. But statistically significantly more people with disabilities reported dissatisfaction with care for 10 of the 12 quality dimensions. Persons reporting any major disability were more likely to be dissatisfied with physicians completely understanding their conditions (AOR, 2.4; 95% CI, 1.9-3.1), physicians completely discussing patients' health problems (AOR, 2.4; 95% CI, 1.9-2.9), physicians answering all patients' questions (AOR, 2.3; 95% CI, 1.7-3.1), and physicians often seeming hurried (AOR, 1.6; 95% CI, 1.4-1.9). CONCLUSIONS: Persons with disabilities generally reported positive views of their care, although they were significantly more likely to report poor communication and lack of thorough care. These findings held regardless of the disabling condition. Thoughtful systematic approaches are required to improve communication and to reduce time pressures that might compromise the health care experiences of people with disabilities.

Adolescent↗
PubMed2003

Comparing the importance of disease rate versus practice style variations in explaining differences in small area hospitalization rates for two respiratory conditions.

Many studies have reported large variations in age- and sex-adjusted rates of hospitalizations across small geographic areas. These variations have often been attributed to differences in medical practice style which are not reflected in differences in health care outcomes. There is, however, another potentially important source of variation that has not been examined much in the literature: geographic differences in the age-sex adjusted size of the pool of patients who present with the disease and are candidates for hospitalization. Previous studies of small area variations in hospitalization rates have only used data on hospitalizations. Thus, it has not been possible to distinguish the extent to which differences in hospitalization rates are due to (i). differences in the chance that patients diagnosed with a disease are admitted to a hospital, which we refer to as the 'practice style effect,' versus (ii). geographic differences in the total amount of diagnosed disease, which we refer to as the 'disease effect.' Elementary methods for estimating the relative strength of the two effects directly from the data can be misleading, since equal amounts of variability in each effect result in unequal impacts on hospitalization rates. In this paper we describe a model-based approach for estimating the relative importance of the practice style effect and the disease effect in explaining variations in hospitalization rates. The key to our approach is the use of data on both inpatient and outpatient visits. We use 1997 Medicare data for two respiratory medical conditions across 71 small areas in Massachusetts: chronic bronchitis and emphysema, and bacterial pneumonia. Based on a Poisson model for the process generating hospitalizations and outpatient visits, we use a Bayesian framework and Gibbs sampling to compute and compare the correlation between the number of people hospitalized and each of these two sources of variation. Our results show that for the two conditions, disease rate variation explains at least as much of the variation in hospitalization rates as does practice style variation.

Aged↗
PubMed2003

Linguistic and cultural barriers to care.

CONTEXT: Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality. OBJECTIVE: To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills. DESIGN: Qualitative study using focus groups and content analysis to determine domains of quality of care. SETTING: Four community health centers in Massachusetts. PARTICIPANTS: A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide. MAIN OUTCOME MEASURES: Domains of quality of care mentioned by patients in verbatim transcripts. RESULTS: In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services. CONCLUSIONS: Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services.

Asian↗
PubMed2003

Capturing and classifying functional status information in administrative databases.

The health care delivery system aims to improve the functioning of Americans, but little information exists to judge progress toward meeting this goal. Administrative data generated through running and overseeing health care delivery offer considerable information about diagnoses and procedures in coded formats comparable across settings of care. This article explores the issues raised when considering adding coded information about functional status to administrative databases throughout the health care system. The National Committee on Vital and Health Statistics (NCVHS) identified the International Classification of Functioning, Disability and Health (ICF) as the only viable code set for consistently reporting functional status.

Activities of Daily Living↗
PubMed2002

Reasonable accommodations for medical faculty with disabilities.

An unknown number of medical school faculty have disabilities, and their experiences have generally escaped notice and scrutiny. Although most medical schools offer long-term insurance and extended leaves of absence for disability, relatively few have policies explicitly addressing accommodations for faculty with disabilities as they perform teaching, research, and clinical duties. We discuss accommodating active medical school faculty with disabilities, drawing on University of Pennsylvania School of Medicine initiatives exploring the concerns of faculty with sensory and physical disabilities. Anecdotal reports suggest that many faculty, fearing reprisals, resist seeking job accommodations such as those mandated in the 1990 Americans with Disabilities Act (ADA). Although some faculty with disabilities have found supportive academic mentors, others report that lax institutional enforcement of ADA requirements, including physical access problems, demonstrates a tepid commitment to disabled staff. Potentially useful job accommodations include adjusting timelines for promotion decisions; reassessing promotions requirements that inherently require extensive travel; improving physical access to teaching, research, and clinical sites; and modifying clinical and teaching schedules. Faculty with disabilities bring identical intellectual and collegial benefits to medical schools as their nondisabled counterparts. In addition, they may offer special insights into how chronic illness and impairments affect daily life.

Architectural Accessibility↗
PubMed2002

Obesity among adults with disabling conditions.

CONTEXT: Obesity, a leading cause of preventable death and chronic disease, is associated with disability. Little is known about obesity among adults with specific disabilities. OBJECTIVES: To determine the prevalence of obesity in adults with physical and sensory limitations and serious mental illness. DESIGN, SETTING, AND PARTICIPANTS: The 1994-1995 National Health Interview Survey of 145 007 US community-dwelling respondents, 25 626 of whom had 1 or more disabilities. MAIN OUTCOME MEASURES: Likelihood of being obese, attempting weight loss, and receiving exercise counseling among adults with and without disabilities. RESULTS: Among adults with disabilities, 24.9% were obese vs 15.1% of those without disabilities. After adjusting for sociodemographic factors, adults with a disability were more likely to be obese, with an adjusted odds ratio (AOR) of 1.9 (95% confidence interval [CI], 1.8-2.0). The highest risk occurred among adults with some (AOR, 2.4; 95% CI, 2.3-2.5) or severe (AOR, 2.5; 95% CI, 2.3-2.7) lower extremity mobility difficulties. After further adjustment for comorbid conditions, adults with disabilities were as likely to attempt weight loss as those without disabilities, except for adults with severe lower extremity mobility difficulties, who were less likely (AOR, 0.7; 95% CI, 0.5-0.9]), and adults with mental illness, who were more likely (AOR, 1.4; 95% CI, 1.2-1.8). Physician exercise counseling was reported less often among adults with severe lower extremity (AOR, 0.5; 95% CI, 0.4-0.7) and upper extremity (AOR, 0.7; 95% CI, 0.5-1.0) mobility difficulties. CONCLUSION: Obesity appears to be more prevalent in adults with sensory, physical, and mental health conditions. Health care practitioners should address weight control and exercise among adults with disabilities.

Adult↗
PubMed2002

The canary in the mine.

Many Americans are concerned about their access to health care in the future, especially their ability to pay for needed services. However, a person with a disabling condition requiring ongoing clinical vigilance, supportive care, and other assistive services or technologies faces special difficulties: that person is the "canary in the mine," warning others about fundamental problems within our health care system. Persons with disabilities who have health insurance are often unable to get items and services not covered by their plans. They experience more problems than others with follow-up care, availability of specialists, getting to doctors, and obtaining help during off hours. These problems suggest that people with disabilities fall into the "quality chasm," the metaphor used by the Institute of Medicine to describe the gap between ideal care and current reality. The Crossing the Quality Chasm report suggests 6 aims for fundamental reform, exhorting the health care system to become safe, effective, patient-centered, timely, efficient, and equitable. Each of these aims holds special resonance for persons with disabilities. Despite the compelling need to overhaul the health care system, the American public as yet seems little inclined to fundamental change. Perhaps the impetus must come from subgroups within the population who are particularly at risk from the current system, such as persons with disabilities. As solutions are crafted, people with disabilities, their families, and communities should help design and direct fundamental changes to the health care system.

Persons with Disabilities↗
PubMed2002

Consensus-based method for risk adjustment for surgery for congenital heart disease.

OBJECTIVE: The aim was to develop a consensus-based method of risk adjustment for in-hospital mortality among children younger than 18 years after surgery for congenital heart disease (designated RACHS-1). METHODS: An 11-member national panel of pediatric cardiologists and cardiac surgeons used clinical judgment to place surgical procedures into six risk categories. Categories were refined after review of information from the Pediatric Cardiac Care Consortium and three statewide hospital discharge data sets. The effects of including additional clinical variables were explored by comparing areas under receiver-operator characteristic curves. RESULTS: Among 4602 surgical patients in the Pediatric Cardiac Care Consortium data set and 4493 in the hospital discharge data, 3767 (81.9%) and 3832 (85.3%), respectively, had a single cardiac procedure, and 98.5% and 89.2%, respectively, were able to be assigned to one of six risk categories defined by the panel. Mortality rates showed expected trends (P <.001). For the Pediatric Cardiac Care Consortium data, mortality rates were 0.4% in category 1, 3.8% in 2, 8.5% in 3, 19.4% in 4, and 47.7% in 6; rates were similar in the hospital discharge data. There were too few cases in category 5 to estimate mortality rates. In multivariable models, younger age, prematurity, and the presence of a major noncardiac structural anomaly added to the risk of in-hospital death predicted by risk category alone. Best performance was obtained when cases with multiple procedures were placed in the risk category of the most complex procedure. CONCLUSION: The RACHS-1 method should adjust for baseline risk differences and allow meaningful comparisons of in-hospital mortality for groups of children undergoing surgery for congenital heart disease.

Cardiac Surgical Procedures↗
PubMed2002

Satisfaction with quality and access to health care among people with disabling conditions.

OBJECTIVE: To compare satisfaction with health care between persons with and without disabling conditions. DESIGN: Responses to 1996 Medicare Current Beneficiary Survey. SETTING: Nationally representative of the United States population. STUDY PARTICIPANTS: Community-dwelling Medicare beneficiaries, older and younger than 65 years (n = 16 403). MAIN OUTCOME MEASURE: Adjusted odds of being dissatisfied or very dissatisfied with five general quality measures and five access-to-care measures by five disabling conditions (blind or low vision, deaf or hard of hearing, difficulty walking, difficulty reaching, manual dexterity difficulties). Multivariable logistic regressions on dissatisfaction adjusted for age group, sex, disabling condition, race, ethnicity, urban versus rural residence, education, household income < $25 000 versus > or = $25 000, having a usual source of care, proxy respondent, and managed care. RESULTS: Of an estimated 33.58 million non-institutionalized Medicare beneficiaries, 64.1% (estimated 21.51 million) reported at least one disabling condition. Among younger beneficiaries, 10.4% with any major disability were dissatisfied with their care overall, as were 4.6% without disabilities. Nevertheless, persons with disabilities generally had significantly higher adjusted odds of dissatisfaction. For elderly persons with any major disability, the adjusted odds ratios (95% confidence interval) of dissatisfaction were: 3.2 (2.4-4.3) for overall quality; 3.2 (2.2-4.6) for access to specialists; 4.4 (3.1-6.4) for follow-up; and 4.2 (3.1-5.7) for ease of getting to doctors. Elderly managed care enrollees were less satisfied with access to specialists, but more satisfied with costs. CONCLUSION: The quality domains generating the greatest dissatisfaction were anticipated, given the nature of disabling conditions. Improving these areas requires attention inside and outside the health care system. Redesigning practice settings and procedures, and changing payment policies offer the only solutions to some problems.

Adolescent↗
PubMed2002

Does more "appropriateness" explain higher rates of cardiac procedures among patients hospitalized with coronary heart disease?

BACKGROUND: There have been few studies of the extent to which differences in the pool of patients being managed might account for geographic variations in treatment rates. OBJECTIVE: For two cardiac procedures, cardiac catheterization and revascularization, we evaluate the hypothesis that differences in "the percentage of patients for whom the procedure is appropriate" is a factor explaining variations in use rates among those hospitalized with coronary heart disease (CHD). RESEARCH DESIGN: Based on hospital utilization patterns in Massachusetts in 1990, we created 70 small geographic areas. Using 1992 Massachusetts Peer Review Organization data, areas were ranked from highest to lowest based on (empirical-Bayes-adjusted) hospitalization rates for each procedure. One thousand seven hundred four cases from 43 hospitals were sampled, roughly half each from high and low use areas. Half had a procedure and half were candidates for the same procedure but did not have it. For each procedure, medical records were reviewed to determine whether the procedure was (or, for those not having it, would have been) appropriate, based on criteria developed using a modified Delphi approach. RESULTS: Among those having either procedure, appropriateness rates were similar in high and low rate areas (P = 0.59 for catheterization and P = 0.30 for revascularization). However, among candidates for either procedure who did not have it, appropriateness for performing the procedure was greater in high-rate areas (41.4% vs. 32.1%, P = 0.05 for catheterization; 71.2% vs. 57.2%, P = 0.003, for revascularization). CONCLUSION: Among those hospitalized with CHD, appropriateness rates for two cardiac procedures are higher in areas with higher use rates.

Aged↗
PubMed2002

Using administrative data to study persons with disabilities.

Administrative data result from administering health plans--tracking service utilization, paying claims, monitoring costs and quality--and have been used extensively for health services research. This article examines the strengths and limitations of administrative data for health services research studies of people with disabilities. Administrative data offer important advantages: encompassing large populations over time, ready availability, low cost, and computer readability. Questions arise about how to identify people with disabilities, capture disability-related services, and determine meaningful health care outcomes. Potentially useful administrative data elements include eligibility for Medicare or Medicaid through Social Security disability determinations, diagnosis and procedure codes, pharmacy claims, and durable medical equipment claims. Linking administrative data to survey or other data sources enhances the utility of administrative data for disability studies.

Data Collection↗
PubMed2002

Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality.

OBJECTIVE: To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care. SETTING: Forty-two acute-care hospitals in California and Connecticut in 1994. STUDY DESIGN: In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments. DATA COLLECTION: With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews. PRINCIPAL FINDINGS: Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome. CONCLUSIONS: We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality.

Aged↗
PubMedDate not supplied

Accommodating medical school faculty with disabilities.

More than ten years have passed since the Americans with Disabilities Act (ADA) mandated that all employers provide "reasonable accommodations" for employees with disabilities. This mandate applies to medical schools, but no systematic information is available to assess the accommodations provided to medical school faculty with disabilities. This Issue Brief summarizes anecdotal evidence from several medical schools about the experiences of faculty with disabilities, and the barriers they face in establishing and maintaining their careers. It also recommends practical steps medical schools can take to provide a welcoming and accessible academic medical environment.

Architectural Accessibility↗