Background Readmission after heart failure (HF) hospitalization is an increasing focus for physicians and policy makers, but statistical models are needed to assess patient risk and to compare hospital performance. We performed a systematic review to describe models designed to compare hospital rates of readmission or to predict patients' risk of readmission, as well as to identify studies evaluating patient characteristics associated with hospital readmission, all among patients admitted for HF.
Methods We identified relevant studies published between January 1, 1950, and November 19, 2007, by searching MEDLINE, Scopus, PsycINFO, and all 4 Ovid Evidence-Based Medicine Reviews. Eligible English-language publications reported on readmission after HF hospitalization among adult patients. We excluded experimental studies and publications without original data or quantitative outcomes.
Results From 941 potentially relevant articles, 117 met inclusion criteria: none contained models to compare readmission rates among hospitals, 5 (4.3%) presented models to predict patients' risk of readmission, and 112 (95.7%) examined patient characteristics associated with readmission. Studies varied in case identification, used multiple types of data sources, found few patient characteristics consistently associated with readmission, and examined differing outcomes, often either readmission alone or a combined outcome of readmission or death, measured across varying periods (from 14 days to 4 years). Two articles reported model discriminations of patient readmission risk, both of which were modest (C statistic, 0.60 for both).
Conclusions Our systematic review identified no model designed to compare hospital rates of readmission, while models designed to predict patients' readmission risk used heterogeneous approaches and found substantial inconsistencies regarding which patient characteristics were predictive. Clinically, patient risk stratification is challenging. From a policy perspective, a validated risk-standardized statistical model to accurately profile hospitals using readmission rates is unavailable in the published English-language literature to date.
Background While there is consensus about the value of communication skills, many physicians complain that there is not enough time to use these skills. Little is known about how to combine effective relationship development and communication skills with time management to maximize efficiency. Our objective was to examine what physician-patient relationship and communication skills enhance efficiency.
Data Sources We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications.
Study Selection From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis.
Data Extraction The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus.
Results Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues.
Conclusions Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.
Background The relationship between physicians' cognitive skill and the delivery of evidence-based processes of care is not well characterized.Therefore, we set out to determine associations between general internists' performance on the American Board of Internal Medicine maintenance of certification examination and the receipt of important processes of care by Medicare patients.
Methods Physicians were grouped into quartiles based on their performance on the American Board of Internal Medicine examination. Hierarchical generalized linear models examined associations between examination scores and the receipt of processes of care by Medicare patients. The main outcome measures were the associations between diabetes care, using a composite measure of hemoglobin A1c, and lipid testing and retinal screening, mammography, and lipid testing in patients with cardiovascular disease and the physician's performance on the American Board of Internal Medicine examination, adjusted for the number of Medicare patients with diabetes and cardiovascular disease in a physician's practice panel; frequency of visits; patient comorbidity, age, and ethnicity; and physician training history and type of practice.
Results Physicians scoring in the top quartile were more likely to perform processes of care for diabetes (composite measure odds ratio [OR], 1.17; 95% confidence interval [CI], 1.07-1.27) and mammography screening (OR, 1.14; 95% CI, 1.08-1.21) than physicians in the lowest physician quartile, even after adjustment for multiple factors. There was no significant difference among the groups in lipid testing of patients with cardiovascular disease (OR, 1.00; 95% CI, 0.91-1.10).
Conclusion Our findings suggest that physician cognitive skills, as measured by a maintenance of certification examination, are associated with higher rates of processes of care for Medicare patients.
Background Although shared decision making (SDM) has been reported to facilitate quality care, few studies have explored the extent to which SDM is implemented in primary care and factors that influence its application. This study assesses the extent to which physicians enact SDM behaviors and describes factors associated with physicians' SDM behaviors within the context of depression care.
Methods In a secondary analysis of data from a randomized experiment, we coded 287 audiorecorded interactions between physicians and standardized patients (SPs) using the Observing Patient Involvement (OPTION) system to assess physician SDM behaviors. We performed a series of generalized linear mixed model analyses to examine physician and patient characteristics associated with SDM behavior.
Results The mean (SD) OPTION score was 11.4 (3.3) of 48 possible points. Older physicians (partial correlation coefficient = –0.29; β = –0.09; P < .01) and physicians who practiced in a health maintenance organization setting (β = –1.60; P < .01) performed fewer SDM behaviors. Longer visit duration was associated with more SDM behaviors (partial correlation coefficient = 0.31; β = 0.08; P < .01). In addition, physicians enacted more SDM behaviors with SPs who made general (β = 2.46; P < .01) and brand-specific (β = 2.21; P < .01) medication requests compared with those who made no request.
Conclusions In the context of new visits for depressive symptoms, primary care physicians performed few SDM behaviors. However, physician SDM behaviors are influenced by practice setting and patient-initiated requests for medication. Additional research is needed to identify interventions that encourage SDM when indicated.
Background Sicker patients are less satisfied with the quality of health care they receive than their healthier counterparts.
Methods A sample of 12 018 community-dwelling Medicare beneficiaries 65 years or older from the 2004 Medicare Current Beneficiary Survey was studied. Multivariate regression was used to describe whether beneficiaries' self-reported satisfaction with their usual-care physician was related to the presence or functions assumed by visit companions.
Results Overall, 38.6% of beneficiaries reported being typically accompanied to routine medical visits. Accompanied beneficiaries were older, less educated, and in worse health than their unaccompanied counterparts. More than 60% of companions facilitated visit communication by recording physician instructions (44.1%), providing information regarding patients' medical conditions or needs (41.6%), asking questions (41.1%), or explaining physicians' instructions (29.7%). After controlling for sociodemographic and health differences, accompanied beneficiaries were more highly satisfied with their physician's technical skills (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.02-1.30), information giving (OR, 1.19; 95% CI, 1.05-1.35), and interpersonal skills (OR, 1.18; 95% CI, 1.03-1.35) than unaccompanied beneficiaries. Accompanied beneficiaries whose visit companions were more actively engaged in communication rated physician information giving (OR, 1.42; 95% CI, 1.14-1.77) and interpersonal skills (OR, 1.29; 95% CI, 1.05-1.59) more favorably. This relationship was strongest among beneficiaries with the worst self-rated health.
Conclusions Visit companions are commonly present in older adults' routine medical encounters, actively engaged in care processes, and influential to patients' satisfaction with physician care. More systematic recognition and integration of visit companions in health care processes may benefit quality of care for a particularly vulnerable patient population.
Background Current international health policy has emphasized the importance of managing long-term conditions in the community with the aim of preventing emergency hospitalizations. Previous algorithms and rules have been developed but are limited to those older than 65 years and generally only for readmission. Our aim was to develop an algorithm to predict emergency hospital admissions in the whole population of those 40 years or older.
Methods The design was a historical cohort observational study from 1996 to 2004 with at least 1 year of follow-up and split-half validation, set in the population of Tayside, Scotland (n = 410 000). Participants were 40 years or older with a 3-year history of prescribed drugs and hospital admissions. The main outcome measure was first emergency hospital admission in the following year, analyzed using logistic regression.
Results A total of 186 523 subjects 40 years or older were identified at baseline. A derivation data set (n = 90 522) yielded 6793 participants (7.5%) who experienced an emergency hospital admission in the following year. Strong predictors of admissions were age; being male; high social deprivation; previously prescribed analgesics, antibacterials, nitrates, and diuretics; the number of respiratory medications; and the number of previous admissions and previous total bed-days. Discriminatory power was good (c statistic, 0.80) and split-half validation gave good calibration, especially for the highest decile of risk.
Conclusions A population-derived algorithm provided the first easy-to-use algorithm, to our knowledge, to predict future emergency admissions in all individuals 40 years or older. The model can be implemented at individual patient level as well as family practice level to target case management.
Background Current guidelines do not recommend routine cardiac stress testing in patients with stable coronary heart disease (CHD) unless they report symptoms of angina. Our objective was to compare the prognosis of self-reported angina symptoms, inducible ischemia, or both in patients with stable CHD.
Methods We measured self-reported angina by questionnaire and inducible ischemia using treadmill stress echocardiography in 937 outpatients with stable CHD. We used Cox proportional hazard models, adjusted for traditional cardiovascular risk factors, to evaluate the independent association of angina and inducible ischemia with CHD events (myocardial infarction or CHD death) during a mean of 3.9 years of follow-up.
Results Of the study participants, 129 (14%) had angina alone, 188 (20%) had inducible ischemia alone, and 40 (4%) had both angina and ischemia. Recurrent CHD events occurred in 7% of participants without angina or inducible ischemia, 10% of those with angina alone, 21% of those with inducible ischemia alone, and 23% of those with both angina and inducible ischemia (P < .001). The presence of angina alone was not associated with recurrent CHD events (adjusted hazard ratio, 1.4; 95% confidence interval, 0.7-2.9) (P = .31). However, the presence of inducible ischemia without self-reported angina strongly predicted recurrent CHD events (adjusted hazard ratio, 2.2; 95% CI, 1.4-3.5) (P = .005).
Conclusions We found that 24% of patients with stable CHD had inducible ischemia, and more than 80% of these patients did not report angina. The presence of inducible ischemia without self-reported angina is associated with a greater than 2-fold increased rate of recurrent CHD events.
Background Osteoarthritis (OA) of the hip and knee is a common cause of pain and disability in elderly patients. Joint replacement surgery can alleviate pain and restore function but is associated with risks and discomfort.
Methods We conducted a prospective cohort study to examine decision making and clinical outcomes for elderly patients (age ≥65 years) with severe OA of the hip or knee with symptoms inadequately controlled with conservative treatments. Osteoarthritis symptoms and functional status were assessed at baseline and at 12 months. Postoperative symptoms and function were assessed 6 weeks, 6 months, and 12 months after surgery.
Results For the 174 patients studied (mean age, 75 years; 76% were female, 17% were nonwhite, 69% had knee OA, and 31% had hip OA), the mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 56 on a 100-point scale. During a 12-month follow-up, 29% had joint replacement surgery. Of patients who had surgery, no patients died, 17% had postoperative complications, and 38% had postoperative pain lasting more than 4 weeks. The median time to recovery of independence in walking was 12 days and to ability to perform household chores was 49 days, with similar times for patients 65 to 74 years old and those 75 years or older. At 12 months, WOMAC scores improved by 24 points in the patients who had surgery and 0.5 point in the patients who did not have surgery (P < .001); improvements were 19 and 0.3 points in patients 75 or older (P < .001). Among patients who did not have surgery, 45% reported that surgery was not offered as a potential treatment option.
Conclusions Elderly patients who had hip or knee replacements for severe OA took several weeks to recover but experienced excellent long-term outcomes. Physicians often do not discuss joint replacement surgery with elderly patients who might benefit.
Background We sought to estimate the prevalence of low sexual desire and hypoactive sexual desire disorder (HSDD) in US women, focusing on their menopausal status.
Methods We performed a cross-sectional study. From a probability sample of households, 2207 US women aged 30 to 70 years and in stable relationships (≥3 months) were interviewed by telephone. The analysis focused on 755 premenopausal women and 552 naturally and 637 surgically menopausal women. Low sexual desire was defined using the Profile of Female Sexual Function desire domain, and HSDD was defined using the Profile of Female Sexual Function and the Personal Distress Scale.
Results Prevalence of low sexual desire ranged from 26.7% among premenopausal women to 52.4% among naturally menopausal women. The prevalence of HSDD was highest among surgically menopausal women (12.5%). Compared with premenopausal women and adjusting for age, race/ethnicity, educational level, and smoking status, the prevalence ratios for HSDD were 2.3 (95% confidence interval, 1.2-4.5) for surgically menopausal women and 1.2 (0.5-2.8) for naturally menopausal women; the prevalence ratios for low sexual desire were 1.3 (0.9-1.9) and 1.5 (1.0-2.2) for surgically and naturally menopausal women, respectively.
Conclusions Prevalence of low sexual desire is elevated among surgically and naturally menopausal women vs premenopausal women. Distress about low desire (HSDD) appears to be more than twice as prevalent among surgically menopausal women vs premenopausal women, although the estimate is fairly imprecise.
Background Long-term blood pressure (BP) progression and its importance as a predictor of clinical outcome have not been well characterized across different periods.
Methods We evaluated period trends for 3 BP variables (long-term slope and mean BP during a baseline period of 16 years, and last baseline value) in an earlier period (1953-1971; n = 1644, mean participant age, 61 years) and in a later period (1971-1990; n = 1040, mean participant age, 58 years) in participants in the Framingham Heart Study who initially did not have hypertension. In addition, we explored the relation of BP to cardiovascular disease incidence and all-cause mortality in the 2 periods, each with up to 16 years of follow-up.
Results Long-term slope, mean, and last baseline BP measurements were significantly lower in the later period (P < .001). Rates of hypertension control (BP <140/90 mm Hg) were higher in the later vs the earlier period (32% vs 23%; P < .001). Multivariate hazard ratios for the relation of BP to outcomes were generally lower in the later period; this was statistically significant for the relation of last baseline BP to all-cause mortality (hazard ratio for 1-SD increase in systolic BP, 1.02 vs 1.25, P = .03; hazard ratio for diastolic BP, 1.00 vs 1.23, P = .04).
Conclusions We found evidence that BP levels in the community have changed over time, coinciding with improved rates of hypertension control and attenuation of BP-mortality relations. These findings are consistent with the hypothesis that hypertension treatment in the community has altered the natural history of BP progression and its relation to clinical outcome.
Background While the Centers for Disease Control and Prevention recommends at least annual human immunodeficiency virus (HIV) screening for men who have sex with men (MSM), a large number of HIV infections among this population go unrecognized. We examined the association between disclosing to their medical providers (eg, physicians, nurses, physician assistants) same-sex attraction and self-reported HIV testing among MSM in New York City, New York.
Methods All men recruited from the New York City National HIV Behavioral Surveillance (NHBS) project who reported at least 1 male sex partner in the past year and self-reported as HIV seronegative were included in the analysis. The primary outcome of interest was a participant having told his health care provider that he is attracted to or has sex with other men. Sociodemographic and behavioral factors were examined in relation to disclosure of same-sex attraction.
Results Among the 452 MSM respondents, 175 (39%) did not disclose to their health care providers. Black and Hispanic MSM (adjusted odds ratios, 0.28 [95% confidence interval, 0.14-0.53] and 0.46 [95% confidence interval, 0.24-0.85], respectively) were less likely than white MSM to have disclosed to their health care providers. No MSM who identified themselves as bisexual had disclosed to their health care providers. Those who had ever been tested for HIV were more likely to have disclosed to their health care providers (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.38).
Conclusions These data suggest that risk-based HIV testing, which is contingent on health care providers being aware of their patients' risks, could miss these high-risk persons.
