Academic Appointments

Administrative Appointments

  • Co-Chief, Primary Care and Population Health (2015 - 2016)
  • Director, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System (2011 - Present)
  • Chief of Health Services Research, VA Palo Alto Health Care System (2011 - Present)
  • Professor of Medicine, Stanford University (2011 - Present)
  • Co-Director, Spectrum KL2 Program (2011 - Present)
  • Vice-Chief, Division of Primary Care and Population Health (2016 - Present)

Professional Education

  • Diplomate, ABIM, Palliative Care (2002)
  • RWJ Clinical Scholar, UCLA (1994)
  • MPH, UCLA, Epidemiology (1994)
  • Diplomate, ABIM, Internal Medicine (1991)
  • MD, UCSD (1988)

Research & Scholarship

Current Research and Scholarly Interests

Steven M. Asch MD, MPH is the Vice-Chief for Research, Stanford Division of General Medical Disciplines and the Chief of Health Services Research at the VA Palo Alto Healthcare System. He develops and evaluates quality measurement and improvement systems, often in the care of patients with communicable disease. Dr. Asch has led several national projects developing broad-based quality measurement tools for veterans, Medicare beneficiaries, and the community. He directs the Center of Innovation to Implementation (Ci2i) that focuses on how to maximize value by testing organizational innovations to make medical care more collaborative and efficient. His educational efforts are focused on training physician fellows in health services research. Dr. Asch is a tenured professor and practicing internist and palliative care physician and the author of more than 350 peer-reviewed articles.


2017-18 Courses


All Publications

  • Primary Care-Based Skin Cancer Screening in a Veterans Affairs Health Care System. JAMA dermatology Swetter, S. M., Chang, J., Shaub, A. R., Weinstock, M. A., Lewis, E. T., Asch, S. M. 2017


    Skin cancer screening may improve melanoma outcomes and keratinocyte carcinoma morbidity, but little is known about the feasibility of skin cancer training and clinical skin examination (CSE) by primary care practitioners (PCPs) in large health care systems.To assess the association of skin cancer training and screening by PCPs with dermatology referral patterns and rates of skin biopsies.In this pilot interventional study performed at the Veterans Affairs Palo Alto Health Care System, patients 35 years or older scheduled for an annual health habits screen in the PCP general medicine clinics were studied.Six PCPs underwent Internet Curriculum for Melanoma Early Detection (INFORMED) training in May 2015, and 5 screened patients during the following 14 months.Proportion of dermatology referrals, subsequent skin biopsies, and PCP diagnostic accuracy for skin cancer or precancer compared with dermatologist diagnosis were assessed in screened patients 14 months before the intervention (February 18, 2014, through April 30, 2015) and after the intervention (June 18, 2015, through August 30, 2016).Among 258 patients offered screening (median age, 70 years; age range, 35-94 years; 255 [98.8%] male), 189 (73.3%) received CSE and 69 (26.7%) declined. A total of 62 of 189 patients (32.8%) were referred to a dermatologist after intervention: 33 (53.2%) for presumptive skin cancers and 15 (24.2%) for precancers. Nine of 50 patients (18.0%) evaluated in dermatology clinic underwent biopsy to exclude skin cancer. Correct diagnoses were made by PCPs in 13 of 38 patients (34.2%; 4 of 27 patients [14.8%] diagnosed with skin cancers and 5 of 11 patients [45.5%] diagnosed with actinic keratoses). Comparison of all outpatient visits for the 5 main participating PCPs before vs after intervention revealed no significant differences in dermatology referrals overall and those for presumptive skin cancer or actinic keratoses, skin biopsies, or PCP diagnostic accuracy with the exception of significantly fewer postintervention dermatology referrals that lacked specific diagnoses (25 [1.0%] vs 10 [0.4%], P?=?.01).This pilot study suggests that PCP-based skin cancer training and screening are feasible and have the potential to improve PCP diagnostic accuracy without increasing specialty referrals or skin biopsies. Additional studies comparing screening rates, specialty referrals, and patient outcomes in trained vs untrained PCPs are needed before screening is widely implemented in large health care systems in the United States.

    View details for DOI 10.1001/jamadermatol.2017.1324

    View details for PubMedID 28593242

  • Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194


    Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

    View details for DOI 10.1111/ppe.12349

    View details for Web of Science ID 000400170000004

    View details for PubMedID 28328031

  • Using Lean Management to Reduce Emergency Department Length of Stay for Medicine Admissions QUALITY MANAGEMENT IN HEALTH CARE Allaudeen, N., Vashi, A., Breckenridge, J. S., Haji-Sheikhi, F., Wagner, S., Posley, K. A., Asch, S. M. 2017; 26 (2): 91-96


    The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored.To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions.Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016.We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work.The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach.ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites.We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.

    View details for DOI 10.1097/QMH.0000000000000132

    View details for Web of Science ID 000399390400004

    View details for PubMedID 28375955

  • The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives JOURNAL OF PALLIATIVE MEDICINE Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2017; 20 (4): 395-403
  • Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations. Journal of general internal medicine Hochman, M., Asch, S. M. 2017


    Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

    View details for DOI 10.1007/s11606-016-3945-2

    View details for PubMedID 28243870

  • Iraq and Afghanistan Veterans' Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation. Medical care Vanneman, M. E., Harris, A. H., Asch, S. M., Scott, W. J., Murrell, S. S., Wagner, T. H. 2017


    The veterans choice program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope.We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns.We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012-2014) and 1 year after VCP implementation (FY2015).Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues.In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care.There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.

    View details for DOI 10.1097/MLR.0000000000000678

    View details for PubMedID 28146036

  • Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine Zulman, D. M., Pal Chee, C., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., Kahn, J. S., Asch, S. M. 2017; 177 (2): 166-175


    Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n?=?54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P?=?.04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P?=?.03).Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost Identifier: NCT02932228.

    View details for DOI 10.1001/jamainternmed.2016.8021

    View details for PubMedID 28027338

  • Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients A Randomized Clinical Trial JAMA INTERNAL MEDICINE Zulman, D. M., Chee, C. P., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., Kahn, J. S., Asch, S. M. 2017; 177 (2): 166-175
  • Effect of a Dialysis Access Coordinator on Preemptive Access Placement among Veterans: A Quality Improvement Initiative AMERICAN JOURNAL OF NEPHROLOGY Gale, R. C., Kehoe, D., Lit, Y. Z., Asch, S. M., Tamura, M. K. 2017; 45 (1): 14-21

    View details for DOI 10.1159/000452346

    View details for Web of Science ID 000391428900003

  • Quality of Care for Work-Associated Carpal Tunnel Syndrome JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Nuckols, T., Conlon, C., Robbins, M., Dworsky, M., Lai, J., Roth, C. P., Levitan, B., Seabury, S., Seelam, R., Asch, S. M. 2017; 59 (1): 47-53


    To evaluate the quality of care provided to individuals with workers' compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care.We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects' medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality.Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality.Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.

    View details for DOI 10.1097/JOM.0000000000000916

    View details for Web of Science ID 000391123100010

    View details for PubMedID 28045797

    View details for PubMedCentralID PMC5382986

  • Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis. Digestive diseases and sciences Walling, A. M., Ahluwalia, S. C., Wenger, N. S., Booth, M., Roth, C. P., Lorenz, K., Kanwal, F., Dy, S., Asch, S. M. 2017; 62 (1): 84-92


    There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed.We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set.Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6).These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

    View details for DOI 10.1007/s10620-016-4339-3

    View details for PubMedID 27804005

  • Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open forum infectious diseases Appenheimer, A. B., Bokhour, B., McInnes, D. K., Richardson, K. K., Thurman, A. L., Beck, B. F., Vaughan-Sarrazin, M., Asch, S. M., Midboe, A. M., Taylor, T., Dvorin, K., Gifford, A. L., Ohl, M. E. 2017; 4 (1): ofx005-?


    Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care.We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ?140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics.Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68).Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.

    View details for DOI 10.1093/ofid/ofx005

    View details for PubMedID 28480278

  • Effect of a Dialysis Access Coordinator on Preemptive Access Placement among Veterans: A Quality Improvement Initiative. American journal of nephrology Gale, R. C., Kehoe, D., Lit, Y. Z., Asch, S. M., Kurella Tamura, M. 2017; 45 (1): 14-21


    Preemptive placement of permanent dialysis access is recommended in order to reduce the morbidity associated with central venous catheters. We assessed the effect of a dialysis access coordinator on preemptive access placement in veterans who are at high risk for end-stage renal disease (ESRD).Pre-post evaluation of a dialysis access coordinator in the nephrology clinics of the Veterans Affairs Palo Alto. The access coordinator streamlined access referrals, prioritized surgical waiting lists and addressed patient barriers. We compared the frequency of preemptive access referral, surgery, and use for dialysis during the intervention period, July 1, 2013 to May 31, 2016, to a pre-intervention period, January 1, 2011 to December 31, 2013, among all patients with a predicted 1-year risk for ESRD ?20%.There were 156 patients in the historical cohort and 131 in the intervention cohort. The mean age was 69.9 ± 11.6 years and the mean estimated glomerular filtration rate was 14.5 ± 5.7 ml/min/1.73 m2. The intervention was associated with an 11.8% increase in access referral (p value = 0.03), and a 9.4% increase in completed access surgery (p value = 0.05). Increases in permanent access at the start of dialysis (15.2%), and functional permanent access at the start of dialysis (12.4%) did not reach statistical significance. Among patients who received access surgery, there was no significant difference in the prevalence of unused access.Implementation of an access coordinator was associated with a modest increase in preemptive access placement among patients who are at high risk for ESRD without increasing the prevalence of unused access.

    View details for DOI 10.1159/000452346

    View details for PubMedID 27842302

  • "I had to change so much in my life to live with my new limitations": Multimorbid patients' descriptions of their most bothersome chronic conditions. Chronic illness Slightam, C. A., Brandt, K., Jenchura, E. C., Lewis, E. T., Asch, S. M., Zulman, D. M. 2017: 1742395317699448-?


    Objective To characterize diseases that are described as most bothersome by individuals with multiple chronic conditions and to identify themes that characterize their experiences with their most bothersome condition. Methods In a survey of patients at an academic center and a Veterans Affairs hospital, we asked individuals with multiple chronic conditions to identify their most bothersome chronic condition and describe why it is challenging. Standard content analysis methods were used to code responses and identify themes reflecting characteristics of most bothersome conditions. Results The most commonly cited bothersome conditions were chronic pain (52%), diabetes (43%), post-traumatic stress disorder (25%), heart failure (24%), and lung problems (20%). Conditions were described as most bothersome due to: (a) impact on function and quality of life (e.g. active symptoms, activity limitations), (b) health consequences or sequelae (e.g. risk of complications), and (c) challenges associated with treatment or self-management. Patterns of theme dominance varied for conditions with different characteristics. Discussion The conditions that patients with multiple chronic conditions identify as most bothersome vary depending on individuals' diseases and their health-related preferences and priorities. Ascertaining patients' most bothersome conditions and associated challenges, stress, and frustrations may help ensure that management decisions are aligned with patient preferences and priorities.

    View details for DOI 10.1177/1742395317699448

    View details for PubMedID 28449592

  • Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis DIGESTIVE DISEASES AND SCIENCES Walling, A. M., Ahluwalia, S. C., Wenger, N. S., Booth, M., Roth, C. P., Lorenz, K., Kanwal, F., Dy, S., Asch, S. M. 2017; 62 (1): 84-92
  • The Appropriate Provision of Primary Versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives. Journal of palliative medicine Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2016


    Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC.To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC.In-depth interviews with practicing oncologists.Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration.Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches.Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members.Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

    View details for DOI 10.1089/jpm.2016.0399

    View details for PubMedID 27997278

  • Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes BMC HEALTH SERVICES RESEARCH Maguire, E. M., Bokhour, B. G., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Elwy, A. R. 2016; 16


    Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA's national large-scale disclosure policy and identifies gaps and successes in its implementation.Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR).We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure.CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.

    View details for DOI 10.1186/s12913-016-1903-7

    View details for Web of Science ID 000387540000003

    View details for PubMedID 27835983

    View details for PubMedCentralID PMC5106838

  • Assessing the Value of High-Quality Care for Work-Associated Carpal Tunnel Syndrome in a Large Integrated Health Care System: Study Design. The Permanente journal Conlon, C., Asch, S., Hanson, M., Avins, A., Levitan, B., Roth, C., Robbins, M., Dworsky, M., Seabury, S., Nuckols, T. 2016; 20 (4)


    Little is known about quality of care for occupational health disorders, although it may affect worker health and workers' compensation costs. Carpal tunnel syndrome (CTS) is a common work-associated condition that causes substantial disability.To describe the design of a study that is assessing quality of care for work-associated CTS and associations with clinical outcomes and costs.Prospective observational study of 477 individuals with new workers' compensation claims for CTS without acute trauma who were treated at 30 occupational health clinics from 2011 to 2013 and followed for 18 months.Timing of key clinical events, adherence to 45 quality measures, changes in scores on the Boston Carpal Tunnel Questionnaire and 12-item Short Form Health Survey Version 2 (SF-12v2), and costs associated with medical care and disability.Two hundred sixty-seven subjects (56%) received a diagnosis of CTS and had claims filed around the first visit to occupational health, 104 (22%) received a diagnosis before that visit and claim, and 98 (21%) received a diagnosis or had claims filed after that visit. One hundred seventy-eight (37%) subjects had time off work, which started around the time of surgery in 147 (83%) cases and lasted a median of 41 days (interquartile range = 42 days).The timing of diagnosis varied, but time off work was generally short and related to surgery. If associations of quality of care with key medical, economic, and quality-of-life outcomes are identified for work-associated CTS, systematic efforts to evaluate and improve quality of medical care for this condition are warranted.

    View details for DOI 10.7812/TPP/15-220

    View details for PubMedID 27723446

    View details for PubMedCentralID PMC5101096

  • Palliative Care Specialist Consultation Is Associated With Supportive Care Quality in Advanced Cancer. Journal of pain and symptom management Walling, A. M., Tisnado, D., Ettner, S. L., Asch, S. M., Dy, S. M., Pantoja, P., Lee, M., Ahluwalia, S. C., Schreibeis-Baum, H., Malin, J. L., Lorenz, K. A. 2016; 52 (4): 507-514


    Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain.The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures.We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model.All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P < 0.001) and 11 percentage points higher (P < 0.001) within the information and care planning domain compared with those without a consult.Early palliative care specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence.

    View details for DOI 10.1016/j.jpainsymman.2016.04.005

    View details for PubMedID 27401515

    View details for PubMedCentralID PMC5173291

  • Risk Adjustment Tools for Learning Health Systems: A Comparison of DxCG and CMS-HCC V21. Health services research Wagner, T. H., Upadhyay, A., Cowgill, E., Stefos, T., Moran, E., Asch, S. M., Almenoff, P. 2016; 51 (5): 2002-2019


    To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21.Analysis of administrative data from the Department of Veterans Affairs (VA) for fiscal years 2010 and 2011.We regressed total annual VA costs on predicted risk scores. Model fit was judged by R-squared, root mean squared error, mean absolute error, and Hosmer-Lemeshow goodness-of-fit tests. Recalibrated models were tested using split samples with pharmacy data.We created six analytical files: a random sample (n = 2 million), high cost users (n = 261,487), users over age 75 (n = 644,524), mental health and substance use users (n = 830,832), multimorbid users (n = 817,951), and low-risk users (n = 78,032).The DxCG Medicaid with pharmacy risk score yielded substantial gains in fit over the V21 model. Recalibrating the V21 model using VA pharmacy data-generated risk scores with similar fit statistics to the DxCG risk scores.Although the CMS V21 and DxCG prospective risk scores were similar, the DxCG model with pharmacy data offered improved fit over V21. However, health care systems, such as the VA, can recalibrate the V21 model with additional variables to develop a tailored risk score that compares favorably to the DxCG models.

    View details for DOI 10.1111/1475-6773.12454

    View details for PubMedID 26839976

    View details for PubMedCentralID PMC5034200

  • Collaborative Care for Depression in Chronic Hepatitis C Clinics. Psychiatric services Kanwal, F., Pyne, J. M., Tavakoli-Tabasi, S., Nicholson, S., Dieckgraefe, B., Storay, E., Bidwell Goetz, M., Smith, D. L., Sansgiry, S., Gifford, A., Asch, S. M. 2016; 67 (10): 1076-1082


    Depression is highly prevalent yet underdiagnosed and undertreated among patients with chronic hepatitis C virus (HCV) infection. Collaborative care models have improved depression outcomes in primary care settings, and this study aimed to provide more information on testing such methods in specialty HCV care.Hepatitis C Translating Initiatives for Depression Into Effective Solutions (HEPTIDES) was a randomized controlled trial that tested a collaborative depression care model in HCV clinics at four Veterans Affairs facilities. The HEPTIDES intervention consisted of an offsite depression care team (depression care manager, pharmacist, and psychiatrist) that delivered collaborative care. Participant interview data were collected at baseline and at six months. The outcome was depression severity measured with the Hopkins Symptom Checklist (SCL-20) and reported as treatment response (?50% decrease in SCL-20 item score), remission (mean SCL-20 item score <.5), and depression-free days (DFDs).Baseline screening identified 263 HCV-infected patients with depression. In unadjusted analyses, intervention participants' reports trended toward more treatment response (19% versus 13%) and remission (12% versus 6%), but total number of DFDs (50.9) was similar to that of usual care participants (50.7). These trends did not reach statistical significance for the overall sample in the adjusted analyses: response (odds ratio [OR]=2.02, 95% confidence interval [CI]=.98-4.20), remission (OR=2.63, CI=1.00-6.94), and DFDs (?=7.6 days, CI=-.99 to 16.2). However, the intervention was effective in improving all three outcomes for patients who did not meet criteria for remission at baseline (SCL-20 score >.5, N=245).Depression collaborative care resulted in modest improvements in HCV patient depression outcomes. Future research should investigate intervention modifications to improve outcomes in specialty HCV clinics.

    View details for PubMedID 27364808

  • Collaborative Care for Depression in Chronic Hepatitis C Clinics PSYCHIATRIC SERVICES Kanwal, F., Pyne, J. M., Tavakoli-Tabasi, S., Nicholson, S., Dieckgraefe, B., Storay, E., Goetz, M. B., Smith, D. L., Sansgiry, S., Gifford, A., Asch, S. M. 2016; 67 (10): 1075-1081
  • Predicting inpatient clinical order patterns with probabilistic topic models vs conventional order sets. Journal of the American Medical Informatics Association Chen, J. H., Goldstein, M. K., Asch, S. M., Mackey, L., Altman, R. B. 2016


    Build probabilistic topic model representations of hospital admissions processes and compare the ability of such models to predict clinical order patterns as compared to preconstructed order sets.The authors evaluated the first 24 hours of structured electronic health record data for >?10?K inpatients. Drawing an analogy between structured items (e.g., clinical orders) to words in a text document, the authors performed latent Dirichlet allocation probabilistic topic modeling. These topic models use initial clinical information to predict clinical orders for a separate validation set of >?4?K patients. The authors evaluated these topic model-based predictions vs existing human-authored order sets by area under the receiver operating characteristic curve, precision, and recall for subsequent clinical orders.Existing order sets predict clinical orders used within 24 hours with area under the receiver operating characteristic curve 0.81, precision 16%, and recall 35%. This can be improved to 0.90, 24%, and 47% ( P ?

    View details for DOI 10.1093/jamia/ocw136

    View details for PubMedID 27655861

    View details for PubMedCentralID PMC5391730

  • Public Reporting of Hospital-Level Cancer Surgical Volumes in California: An Opportunity to Inform Decision Making and Improve Quality. Journal of oncology practice Clarke, C. A., Asch, S. M., Baker, L., Bilimoria, K., Dudley, R. A., Fong, N., Holliday-Hanson, M. L., Hopkins, D. S., Imholz, E. M., Malin, J., Moy, L., O'Sullivan, M., Parker, J. P., Saigal, C. S., Spurlock, B., Teleki, S., Zingmond, D., Lang, L. 2016


    Most patients, providers, and payers make decisions about cancer hospitals without any objective data regarding quality or outcomes. We developed two online resources allowing users to search and compare timely data regarding hospital cancer surgery volumes.Hospital cancer surgery volumes for all California hospitals were calculated using ICD-9 coded hospital discharge summary data. Cancer surgeries included (bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach) were selected on the basis of a rigorous literature review to confirm sufficient evidence of a positive association between volume and mortality. The literature could not identify threshold numbers of surgeries associated with better or worse outcomes. A multidisciplinary working group oversaw the project and ensured sound methodology.In California in 2014, about 60% of surgeries were performed at top-quintile-volume hospitals, but the per-hospital median numbers of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries were four or fewer. At least 670 patients received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer type; 72% of those patients lived within 50 miles of a top-quintile-volume hospital.There is clear potential for more readily available information about hospital volumes to help patient, providers, and payers choose cancer surgery hospitals. Our successful public reporting of hospital volumes in California represents an important first step toward making publicly available even more provider-specific data regarding cancer care quality, costs, and outcomes, so those data can inform decision-making and encourage quality improvement.

    View details for PubMedID 27601510

  • Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer: A Retrospective Analysis. The American journal of hospice & palliative care Patel, M. I., Bhattacharya, J., Asch, S. M., Kahn, J. 2016; 33 (8): 742-747


    To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer.We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral.Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC.We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.

    View details for DOI 10.1177/1049909115595216

    View details for PubMedID 26169523

  • Early Outpatient Follow-up and 30-Day Outcomes in Patients Hospitalized With Cirrhosis HEPATOLOGY Kanwal, F., Asch, S. M., Kramer, J. R., Cao, Y., Asrani, S., El-Serag, H. B. 2016; 64 (2): 569-581


    Preventing readmission has been the focus of numerous quality improvement efforts across many conditions. Early outpatient follow-up has been proposed as the best mechanism for reducing readmissions. The extent to which early outpatient follow-up averts readmission or improves outcomes in cirrhosis is not known. We evaluated the relationship between early outpatient follow-up and short-term readmission and mortality in patients with cirrhosis. We conducted a retrospective cohort study of patients with cirrhosis who were hospitalized with a liver-related diagnosis and discharged to home from 122 Veterans Administration hospitals between 2010 and 2013. We defined early follow-up as an outpatient visit with a clinician within 7 days after discharge. We propensity matched patients who received early visit with those who did not have any visit and examined the associations between early follow-up and all-cause readmission and mortality within 8-30 days after discharge. Of 25,217 patients hospitalized with cirrhosis, 8,123 (32.2%) had an early follow-up visit within 7 days of discharge. A total of 3,492 (13.8%) patients were readmitted and 1,185 (4.6%) died between 8 and 30 days after discharge. In the propensity-matched sample (N = 16,238), patients with early outpatient follow-up visit had a slightly higher risk of readmission (15.3% vs. 13.8%; hazard ratio [HR] =1.10; 95% confidence interval [CI] = 1.02-1.19), but significantly lower risk of mortality (3.2% vs. 5.2%; HR = 0.60; 95% CI = 0.51-0.70) than those without early visit. The findings persisted in several subgroup and sensitivity analyses.Early outpatient follow-up after discharge was associated with a small increase in readmissions but lower overall mortality in patients with cirrhosis. Transitional care may be effective in improving short-term outcomes in patients with cirrhosis, but readmission performance measures would miss this effect. (Hepatology 2016;64:569-581).

    View details for DOI 10.1002/hep.28558

    View details for Web of Science ID 000380034500026

    View details for PubMedID 26991920

  • Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus CLINICAL INFECTIOUS DISEASES Kanwal, F., Kramer, J. R., El-Serag, H. B., Frayne, S., Clark, J., Cao, Y., Taylor, T., Smith, D., White, D., Asch, S. M. 2016; 63 (3): 291-299


    Direct acting antiviral agents (DAA) are highly effective yet expensive. Disparities by race and/or gender often exist in the use of costly medical advances as they become available.We examined a cohort of hepatitis C virus (HCV) patients who received care at the Veterans Administration facilities nationwide. We evaluated the effect of race and gender on DAA receipt after adjusting for socioeconomic status, liver disease severity, comorbidity, and propensity for healthcare use. To determine if disparities had changed over time, we conducted a similar analysis of HCV patients who were seen in the previous standard of care treatment era.Of the 145 596 patients seen in the current DAA era, 17 791 (10.2%) received treatment during the first 16 months of DAA approval. Black patients had 21% lower odds of receiving DAA than whites (odds ratio [OR] = 0.79; 95% confidence interval [CI], .75, .84). Overall, women were as likely to receive treatment as men (OR = 0.99; 95% CI, .90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (OR = 0.71, 95% CI, .54-.93). Similar to the DAA cohort, black patients had significantly lower odds of receiving treatment than whites (OR = 0.74, 95% CI, .69-.79) in the previous treatment era. The racial difference between the 2 eras did not reach statistical significance.There were unexplained differences among HCV population subgroups in the receipt of new DAA treatment. Targeted interventions are needed for black patients and younger women.

    View details for DOI 10.1093/cid/ciw249

    View details for Web of Science ID 000383201900001

    View details for PubMedID 27131869

  • Effect of opioid prescribing guidelines in primary care. Medicine Chen, J. H., Hom, J., Richman, I., Asch, S. M., Podchiyska, T., Johansen, N. A. 2016; 95 (35)


    Long-term opioid use for noncancer pain is increasingly prevalent yet controversial given the risks of addiction, diversion, and overdose. Prior literature has identified the problem and proposed management guidelines, but limited evidence exists on the actual effectiveness of implementing such guidelines in a primary care setting.A multidisciplinary working group of institutional experts assembled comprehensive guidelines for chronic opioid prescribing, including monitoring and referral recommendations. The guidelines were disseminated in September 2013 to our medical center's primary care clinics via in person and electronic education.We extracted electronic medical records for patients with noncancer pain receiving opioid prescriptions (Rxs) in seasonally matched preintervention (11/1/2012-6/1/2013) and postintervention (11/1/2013-6/1/2014) periods. For patients receiving chronic (3 or more) opioid Rxs, we assessed the rates of drug screening, specialty referrals, clinic visits, emergency room visits, and quantity of opioids prescribed.After disseminating guidelines, the percentage of noncancer clinic patients receiving any opioid Rxs dropped from 3.9% to 3.4% (P?=?0.02). The percentage of noncancer patients receiving chronic opioid Rxs decreased from 2.0% to 1.6% (P?=?0.03). The rate of urine drug screening increased from 9.2% to 17.3% (P?=?0.005) amongst noncancer chronic opioid patients. No significant differences were detected for other metrics or demographics assessed.An educational intervention for primary care opioid prescribing is feasible and was temporally associated with a modest reduction in overall opioid Rx rates. Provider use of routine drug screening increased, but overall rates of screening and specialty referral remained low despite the intervention. Despite national pressures to introduce opioid prescribing guidelines for chronic pain, doing so alone does not necessarily yield substantial changes in clinical practice.

    View details for DOI 10.1097/MD.0000000000004760

    View details for PubMedID 27583928

  • Electronic Release of Pathology and Radiology Results to Patients: Opinions and Experiences of Oncologists. Journal of oncology practice / American Society of Clinical Oncology Winget, M., Haji-Sheikhi, F., Brown-Johnson, C., Rosenthal, E. L., Sharp, C., Buyyounouski, M. K., Asch, S. M. 2016; 12 (8): e792-9


    There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression.Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change.One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients.Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.

    View details for DOI 10.1200/JOP.2016.011098

    View details for PubMedID 27382001

  • Overall Survival in Patients with Localized Prostate Cancer in the US Veterans Health Administration: Is PIVOT Generalizable? EUROPEAN UROLOGY Barbosa, P. V., Thomas, I., Srinivas, S., Buyyounouski, M. K., Chung, B. I., Chertow, G. M., Asch, S. M., Wagner, T. H., Brooks, J. D., Leppert, J. T. 2016; 70 (2): 227-230


    A better understanding of overall survival among patients with clinically localized prostate cancer (PCa) in the US Veterans Health Administration (VHA) is critical to inform PCa treatment decisions, especially in light of data from the Prostate Intervention Versus Observation Trial (PIVOT). We sought to describe patterns of survival for all patients with clinically localized PCa treated by the VHA. We created an analytic cohort of 35 954 patients with clinically localized PCa diagnosed from 1995 to 2001, approximating the PIVOT inclusion criteria (age of diagnosis ?75 yr and clinical stage T2 or lower). Mean patient age was 65.9 yr, and median follow-up was 161 mo. Overall, 22.5% of patients were treated with surgery, 16.6% were treated with radiotherapy, and 23.1% were treated with androgen deprivation. Median survival of the entire cohort was 14 yr (25th, 75th percentiles, range: 7.9-20 yr). Among patients who received treatment with curative intent, median survival was 17.9 yr following surgery and 12.9 yr following radiotherapy. One-third of patients died within 10 yr of diagnosis compared with nearly half of the participants in PIVOT. This finding sounds a note of caution when generalizing the mortality data from PIVOT to VHA patients and those in the community.More than one-third of patients diagnosed with clinically localized prostate cancer treated through the US Veterans Health Administration from 1995 to 2001 died within 10 yr of their diagnosis. Caution should be used when generalizing the estimates of competing mortality data from PIVOT.

    View details for DOI 10.1016/j.eururo.2016.02.037

    View details for Web of Science ID 000378206600016

    View details for PubMedID 26948397

  • Predictive validity of a quality measure for intensive substance use disorder treatment. Substance abuse Schmidt, E. M., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Finney, J. W., Asch, S. M., Humphreys, K., Trafton, J., Vanneman, M., Harris, A. H. 2016: 1-7


    Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined.Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project (N = 5436), a national evaluation of VHA mental health services (N = 339,887), and patients receiving detoxification services (N = 23,572). Propensity score-weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility.Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol (b = 1.83, P < .001) and fewer past-month days intoxicated (b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits (b = 2.09, P < .001), more subsequent detoxification episodes (b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61-0.75; P < .001).Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHA's IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.

    View details for PubMedID 27435754

  • How Will New Guidelines Affect CD4 Testing in Veterans With HIV? CLINICAL INFECTIOUS DISEASES Barnett, P. G., Schmitt, S. K., Yu, W., Goetz, M. B., Ohl, M. E., Asch, S. M. 2016; 63 (1): 96-100


    Guidelines now recommend limited use of routine CD4 cell count testing in human immunodeficiency virus (HIV)-infected patients with successful viral control who are not immunocompromised.CD4 and viral load tests for patients receiving HIV care from the US Department of Veterans Affairs during 2009-2013 were evaluated to determine trends in CD4 testing frequency and the number, cost, and results of CD4 tests considered optional under the guidelines.There were 28 530 individuals with sufficient testing to be included. At the time of the last CD4 test, 19.8% of the cohort was eligible for optional monitoring and 15.6% for minimal monitoring. CD4 testing frequency declined by 10.8% over 4 years, reducing the direct cost of testing by US$196 000 per year. Full implementation of new treatment guidelines could reduce CD4 testing a further 28.9%, an additional annual savings of US$600 000. CD4 tests conducted during periods of potentially reduced monitoring were rarely <200 cells/µL: 1.1% of the tests conducted when minimal monitoring was recommended and just 0.3% of tests conducted when optional monitoring was recommended were less than this value.Reduced CD4 monitoring of HIV-infected patients would result in modest cost savings and likely reduce patient anxiety, with little or no impact on the quality of care. Veterans Affairs has made substantial progress in reducing the frequency of optional CD4 testing, but further reductions may still be warranted.

    View details for DOI 10.1093/cid/ciw194

    View details for Web of Science ID 000381226600019

    View details for PubMedID 27045125

  • Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses PUBLIC HEALTH Maguire, E. M., Bokhour, B. G., Asch, S. M., Wagner, T. H., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Elwy, A. R. 2016; 135: 75-82


    We examined print, broadcast and social media reports about health care systems' disclosures of large scale adverse events to develop future effective messaging.Directed content analysis.We systematically searched four communication databases, YouTube and Really Simple Syndication (RSS) feeds relating to six disclosures of lapses in infection control practices in the Department of Veterans Affairs occurring between 2009 and 2012. We assessed these with a coding frame derived from effective crisis and risk communication models.We identified 148 unique media reports. Some components of effective communication (discussion of cause, reassurance, self-efficacy) were more present than others (apology, lessons learned). Media about 'promoting secrecy' and 'slow response' appeared in reports when time from event discovery to patient notification was over 75 days. Elected officials' quotes (n = 115) were often negative (83%). Hospital officials' comments (n = 165) were predominantly neutral (92%), and focused on information sharing.Health care systems should work to ensure that they develop clear messages focused on what is not well covered by the media, including authentic apologies, remedial actions taken, and shorten the timeframe between event identification and disclosure to patients.

    View details for DOI 10.1016/j.puhe.2015.10.016

    View details for Web of Science ID 000377414200010

    View details for PubMedID 27026251

  • Surgery for Degenerative Lumbar Scoliosis The Development of Appropriateness Criteria SPINE Chen, P. G., Daubs, M. D., Berven, S., Raaen, L. B., Anderson, A. T., Asch, S. M., Nuckols, T. K. 2016; 41 (10): 910-918


    The RAND/UCLA Appropriateness Method is a well-established means of developing criteria for assessing the appropriateness of surgery in specific subpopulations. It involves a systematic review of the literature and ratings by a multidisciplinary panel of national experts.To evaluate the appropriateness of surgical interventions for degenerative lumbar scoliosis (DLS), including identifying clinical characteristics that influence when surgery is inappropriate, appropriate, or necessary, and which procedures are preferable.DLS presents with diverse clinical symptoms and radiographic findings. Variability exists in both nonoperative and operative management. The appropriateness of surgery, and of specific surgical procedures, has not been defined for this important pathology of the aging spine.We selected a panel of 11 experts, including surgical specialists from multiple disciplines. Next, we systematically reviewed relevant literature. Finally, in a three-round, modified-Delphi process, panelists rated the appropriateness and necessity of five different surgical procedures (dependent variables) on a nine-point scale for 260 different clinical scenarios that stratified patients according to age, medical comorbidities, symptoms, signs, and radiographic variables (independent variables).The 59 eligible studies identified via the systematic review were generally small or used weak designs. Panelists judged that surgery was generally appropriate for patients with at least moderate symptoms and larger or progressive deformities, moderate spinal or foraminal stenosis, or sagittal plane imbalance. Surgery was generally inappropriate for mild symptoms and smaller stable deformities, without sagittal imbalance or moderate stenosis, particularly among patients with advanced age and multiple comorbidities. For patients with larger or progressive deformities, imbalance, or severe multilevel stenosis, more extensive fusion and deformity correction procedures were generally preferred.Defining the appropriateness of surgery for patients with DLS will be useful to improve evidence-based clinical decision making as well as the consistency and quality of care for patients with DLS.3.

    View details for DOI 10.1097/BRS.0000000000001392

    View details for Web of Science ID 000375626200022

    View details for PubMedID 26679874

  • Opportunities to Enhance Value-Related Research in the US Department of Veterans Affairs JOURNAL OF GENERAL INTERNAL MEDICINE Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83
  • Opportunities to Enhance Value-Related Research in the U.S. Department of Veterans Affairs. Journal of general internal medicine Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83

    View details for DOI 10.1007/s11606-015-3538-5

    View details for PubMedID 26951279

  • Colorectal Cancer Screening in the Era of the Affordable Care Act. Journal of general internal medicine Richman, I., Asch, S. M., Bhattacharya, J., Owens, D. K. 2016; 31 (3): 315-320


    The Affordable Care Act (ACA) eliminated cost-sharing for evidence-based preventive services in an effort to encourage use.To evaluate use of colorectal cancer (CRC) screening in a national population-based sample before and after implementation of the ACA.Repeated cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) between 2009 and 2012 comparing CRC screening rates before and after implementation of the ACA.Adults 50-64 with private health insurance and adults 65-75 with Medicare.Self-reported receipt of screening colonoscopy, sigmoidoscopy, or fecal occult blood test (FOBT) within the past year among those eligible for screening.Our study included 8617 adults aged 50-64 and 3761 adults aged 65-75. MEPS response rates ranged from 58 to 63%. Among adults aged 50-64, 18.9-20.9% received a colonoscopy in the survey year, 0.59-2.1% received a sigmoidoscopy, and 7.9-10.4% received an FOBT. For adults aged 65-75, 23.6-27.7% received a colonoscopy, 1.3-3.2% a sigmoidoscopy, and 13.5-16.4% an FOBT. In adjusted analyses, among participants aged 50-64, there was no increase in yearly rates of colonoscopy (-0.28 percentage points, 95% CI -2.3 to 1.7, p?=?0.78), sigmoidoscopy (-1.1%, 95% CI -1.7 to -0.46, p?=?<0.001), or FOBT (-1.6%, 95% CI -3.2 to -0.03, p?=?0.046) post-ACA. For those aged 65-75, rates of colonoscopy (+2.3%, 95% CI -1.4 to 6.0, p?=?0.22), sigmoidoscopy (+0.34%, 95% CI 0.88 to 1.6, p?=?0.58) and FOBT (-0.65, 95% CI -4.1 to 2.8, p?=?0.72) did not increase. Among those aged 65-75 with Medicare and no additional insurance, the use of colonoscopy rose by 12.0% (95% CI 3.3 to 20.8, p?=?0.007). Among participants with Medicare living in poverty, colonoscopy use also increased (+5.7%, 95% CI 0.18 to 11.3, p?=?0.043).Eliminating cost-sharing for CRC screening has not resulted in changes in the use of CRC screening services for many Americans, although use may have increased in the post-ACA period among some Medicare beneficiaries.

    View details for DOI 10.1007/s11606-015-3504-2

    View details for PubMedID 26349953

  • Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis. Healthcare (Amsterdam, Netherlands) Breland, J. Y., Asch, S. M., Slightam, C., Wong, A., Zulman, D. M. 2016; 4 (1): 22-29


    Intensive outpatient programs aim to transform care while conserving resources for high-need, high-cost patients, but little is known about factors that influence their implementation within patient-centered medical homes (PCMHs).In this mixed-methods study, we reviewed the literature to identify factors affecting intensive outpatient program implementation, then used semi-structured interviews to determine how these factors influenced the implementation of an intensive outpatient program within the Veterans Affairs' (VA) PCMH. Interviewees included facility leadership and clinical staff who were involved in a pilot Intensive Management Patient Aligned Care Team (ImPACT) intervention for high-need, high-cost VA PCMH patents. We classified implementation factors in the literature review and qualitative analysis using the Consolidated Framework for Implementation Research (CFIR).The literature review (n=9 studies) and analyses of interviews (n=15) revealed key implementation factors in three CFIR domains. First, the Inner Setting (i.e., the organizational and PCMH environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals, including creativity, flexibility, and interpersonal skills, allowed program staff to augment existing PCMH services. Finally, certain Intervention Characteristics (e.g., adaptability) enabled implementation, while others (e.g., complexity) generated implementation barriers.Resources and structural features common to PCMHs can facilitate implementation of intensive outpatient programs, but program success is also dependent on staff creativity and flexibility, and intervention adaptations to meet patient and organizational needs.Established PCMHs likely provide resources and environments that permit accelerated implementation of intensive outpatient programs.V.

    View details for DOI 10.1016/j.hjdsi.2015.12.005

    View details for PubMedID 27001095

  • The facilitators and barriers associated with implementation of a patient-centered medical home in VHA IMPLEMENTATION SCIENCE Helfrich, C. D., Sylling, P. W., Gale, R. C., Mohr, D. C., Stockdale, S. E., Joos, S., Brown, E. J., Grembowski, D., Asch, S. M., Fihn, S. D., Nelson, K. M., Meredith, L. S. 2016; 11


    The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)).We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness.The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR?=?3.91), measurement tools (OR?=?3.47), regular team meetings (OR?=?2.88), information systems (OR?=?2.42), and disease registries (OR?=?2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR?=?2.37) and non-provider clinicians (OR?=?2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction.A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

    View details for DOI 10.1186/s13012-016-0386-6

    View details for Web of Science ID 000370924200001

    View details for PubMedID 26911135

  • Inappropriate Ordering of Lumbar Spine Magnetic Resonance Imaging: Are Providers Choosing Wisely? AMERICAN JOURNAL OF MANAGED CARE Gidwani, R., Sinnott, P., Avoundjian, T., Lo, J., Asch, S. M., Barnett, P. G. 2016; 22 (2): E68-E76


    To analyze inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain in a healthcare system with no financial incentives for overuse.We used administrative data to assess the appropriateness of lumbar spine (LS) MRI in the Veterans Health Administration.All veterans who received LS MRI in the outpatient setting in fiscal year 2012 were included. We based our assessments of appropriateness on CMS criteria, which have been endorsed by the National Quality Forum. Generalized estimating equations were used to evaluate characteristics of inappropriate scans.Of the 110,661 LS MRIs performed, 31% were classified as inappropriate. Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%). "Red flag" conditions were responsible for a much smaller percentage of scans being considered appropriate; 13% of scans were preceded by conservative therapy and were performed in patients with a red flag condition, while only 4% of scans were considered appropriate because of red flag conditions only. Scans ordered in the emergency department and in urgent care, primary care, and internal medicine clinics were most likely to be classified as inappropriate. Resident physicians were significantly less likely than other provider types to order inappropriate LS MRIs (odds ratio, 0.80; P < .0001). Approximately 24% of providers ordered 74% of inappropriate scans.We found that 31% of LS MRIs were inappropriate in a healthcare system largely absent of financial and other incentives for ordering. The problem of inappropriate ordering of LS MRI is concentrated in a small number of providers; any provider-facing interventions to reduce inappropriate order should therefore be targeted, rather than aimed at all providers who order LS MRI.

    View details for Web of Science ID 000373571700004

    View details for PubMedID 26881322

  • Quality of HIV Care and Mortality Rates in HIV-Infected Patients CLINICAL INFECTIOUS DISEASES Korthuis, P. T., McGinnis, K. A., Kraemer, K. L., Gordon, A. J., Skanderson, M., Justice, A. C., Crystal, S., Goetz, M. B., Gibert, C. L., Rimland, D., Fiellin, L. E., Gaither, J. R., Wang, K., Asch, S. M., McInnes, D. K., Ohl, M. E., Bryant, K., Tate, J. P., Duggal, M., Fiellin, D. A. 2016; 62 (2): 233-239

    View details for DOI 10.1093/cid/civ762

    View details for Web of Science ID 000368622300022

  • A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study. Frontiers in public health Trivedi, R., Slightam, C., Fan, V. S., Rosland, A., Nelson, K., Timko, C., Asch, S. M., Zeliadt, S. B., Heidenreich, P., Hebert, P. L., Piette, J. D. 2016; 4: 171-?


    Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants' feedback was used to develop a family-centered self-management program called "SUCCEED: Self-management Using Couples' Coping EnhancEment in Diseases." The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants' program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED's sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

    View details for DOI 10.3389/fpubh.2016.00171

    View details for PubMedID 27626029

    View details for PubMedCentralID PMC5004799

  • DYNAMICALLY EVOLVING CLINICAL PRACTICES AND IMPLICATIONS FOR PREDICTING MEDICAL DECISIONS. Pacific Symposium on Biocomputing. Pacific Symposium on Biocomputing Chen, J. H., Goldstein, M. K., Asch, S. M., Altman, R. B. 2016; 21: 195-206


    Automatically data-mining clinical practice patterns from electronic health records (EHR) can enable prediction of future practices as a form of clinical decision support (CDS). Our objective is to determine the stability of learned clinical practice patterns over time and what implication this has when using varying longitudinal historical data sources towards predicting future decisions. We trained an association rule engine for clinical orders (e.g., labs, imaging, medications) using structured inpatient data from a tertiary academic hospital. Comparing top order associations per admission diagnosis from training data in 2009 vs. 2012, we find practice variability from unstable diagnoses with rank biased overlap (RBO)<0.35 (e.g., pneumonia) to stable admissions for planned procedures (e.g., chemotherapy, surgery) with comparatively high RBO>0.6. Predicting admission orders for future (2013) patients with associations trained on recent (2012) vs. older (2009) data improved accuracy evaluated by area under the receiver operating characteristic curve (ROC-AUC) 0.89 to 0.92, precision at ten (positive predictive value of the top ten predictions against actual orders) 30% to 37%, and weighted recall (sensitivity) at ten 2.4% to 13%, (P<10(-10)). Training with more longitudinal data (2009-2012) was no better than only using recent (2012) data. Secular trends in practice patterns likely explain why smaller but more recent training data is more accurate at predicting future practices.

    View details for PubMedID 26776186

    View details for PubMedCentralID PMC4719775

  • Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Richardson, K. K., Bokhour, B., McInnes, K., Yakovchenko, V., Okwara, L., Midboe, A. M., Skolnik, A., Vaughan-Sarrazin, M., Asch, S. M., Gifford, A. L., Ohl, M. E. 2016; 108 (4): 201-U76


    Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States.The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data.Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

    View details for DOI 10.1016/j.jnma.2016.08.001

    View details for Web of Science ID 000397052500006

    View details for PubMedID 27979005

  • Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse. Clinical gastroenterology and hepatology Ho, S. B., Bräu, N., Cheung, R., Liu, L., Sanchez, C., Sklar, M., Phelps, T. E., Marcus, S. G., Wasil, M. M., Tisi, A., Huynh, L., Robinson, S. K., Gifford, A. L., Asch, S. M., Groessl, E. J. 2015; 13 (11): 2005-2014 e3

    View details for DOI 10.1016/j.cgh.2015.02.022

    View details for PubMedID 25724704

  • Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer JOURNAL OF PALLIATIVE MEDICINE Ahluwalia, S. C., Tisnado, D. M., Walling, A. M., Dy, S. M., Asch, S. M., Ettner, S. L., Kim, B., Pantoja, P., Schreibeis-Baum, H. C., Lorenz, K. A. 2015; 18 (10): 834-841

    View details for DOI 10.1089/jpm.2014.0431

    View details for Web of Science ID 000362268900009

    View details for PubMedID 26186553

  • Health Care Utilization Patterns Among High-Cost VA Patients With Mental Health Conditions. Psychiatric services Hunter, G., Yoon, J., Blonigen, D. M., Asch, S. M., Zulman, D. M. 2015; 66 (9): 952-958


    To inform development of intensive management programs for high-cost patients, this study investigated the relationship between psychiatric diagnoses and patterns of health care utilization among high-cost patients in the Department of Veterans Affairs (VA) health care system.The costliest 5% of patients who received care in the VA in fiscal year 2010 were assigned to five mutually exclusive hierarchical groups on the basis of diagnosis codes: no mental health condition, serious mental illness, substance use disorder, posttraumatic stress disorder (PTSD), and depression. Multivariable linear regression was used to examine associations between diagnostic groups and use of mental health and non-mental health care and costs of care, with adjustment for sociodemographic characteristics. The proportion of costs generated by mental health care was estimated for each group.Among 261,515 high-cost VA patients, rates of depression, substance use disorder, PTSD, and serious mental illness were 29%, 20%, 17%, and 13%, respectively. Individuals in the serious mental illness and substance use disorder groups were younger and had fewer chronic general medical conditions and higher adjusted rates of mental health care utilization; they also had a greater proportion of costs generated by mental health care (41% and 31%, respectively) compared with individuals in the PTSD and depression groups (18% and 11%, respectively).Optimal management of high-risk, high-cost patients may require stratification by psychiatric diagnoses, with integrated care models for patients with multiple chronic conditions and comorbid mental health conditions and intensive mental health services for patients whose primary needs stem from mental health conditions.

    View details for DOI 10.1176/

    View details for PubMedID 25930040

  • Rates and Predictors of Newly Diagnosed HIV Infection Among Veterans Receiving Routine Once-Per-Lifetime HIV Testing in the Veterans Health Administration JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Goetz, M. B., Hoang, T., Kan, V. L., Rimland, D., Rodriguez-Barradas, M. C., Asch, S. M. 2015; 69 (5): 544-550


    To determine predictors and variations in the rate of newly diagnosed HIV infection among persons who underwent routine (ie, non-risk based) rather than risk-based HIV testing in Veterans Health Administration (VHA) facilities.Retrospective observational study of the HIV infection new rates during the period when VHA policy called for routine (2009-2012) versus risk-based (2006-2009) HIV testing. Source data for testing results at 18 VHA facilities were obtained from the VHA National Corporate Data Warehouse.New HIV diagnoses were established in 0.14% (95% confidence interval (CI): 0.12 to 0.46) of the 210,957 patients tested in the routine testing period versus 0.46% (95% CI: 0.42 to 1.29) of the 89,652 patients tested in the risk-based testing period. Among persons aged 65-74 years and 75 years or older, the new diagnosis rates were 0.07% (95% CI: 0.04 to 0.09) and 0.02% (95% CI: 0.00 to 0.03), respectively, and thus less than the generally accepted cost-effective threshold of 0.10%. Among African Americans, the upper bound of the 95% CI of the crude rate of new diagnoses during the routine-testing period was greater than 0.1% across all age strata. When assessed by year of testing, the adjusted rates of new diagnoses fell from 0.20% in 2010 to 0.10% in 2012.Routine HIV testing is cost-effective among persons younger than 65 years. Among older patients, risk-based testing may be a more efficient and cost-effective approach. This will be increasingly relevant if rates of new HIV diagnoses in persons undergoing routine testing continue to decrease.

    View details for DOI 10.1097/QAI.0000000000000653

    View details for Web of Science ID 000358208800005

    View details for PubMedID 25886931

  • How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Jenchura, E. C., Cohen, D. M., Lewis, E. T., Houston, T. K., Asch, S. M. 2015; 30 (8): 1063-1070


    Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear.To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology.After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants.Fifty-three individuals with??3 chronic conditions and experience using technology for health-related purposes.Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96 %), communicate with health care providers (92 %), track medical information (83 %), track medications (77 %), and support decision-making about treatment (55 %). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

    View details for DOI 10.1007/s11606-015-3222-9

    View details for Web of Science ID 000358359400012

  • Implementing Computerized Provider Order Entry in Acute Care Hospitals in the United States Could Generate Substantial Savings to Society. Joint Commission journal on quality and patient safety / Joint Commission Resources Nuckols, T. K., Asch, S. M., Patel, V., Keeler, E., Anderson, L., Buntin, M. B., Escarce, J. J. 2015; 41 (8): 341-350


    Computerized provider order entry (CPOE) with clinical decision support is a basic criterion for hospitals' meaningful use of electronic health record systems. A study was conducted to evaluate from the societal perspective the cost-utility of implementing CPOE in acute care hospitals in the United States.A decision-analytical model compared CPOE with paper ordering among patients admitted to acute care hospitals with >25 beds. Parameters included start-up and maintenance costs, as well as costs for provider time use, medication and laboratory test ordering, and preventable adverse drug events. Probabilistic analyses produced incremental costs, effectiveness, and cost-effectiveness ratios for hospitals in four bed-size categories (25-72, 72-141, 141-267, 267-2,249).Relative to paper ordering and using typical estimates of implementation costs, CPOE had, on average, >99% probability of yielding savings to society and improving health. Per hospital in each size category, mean life-time savings -in millions-were $11.6 (standard deviation, $9.30), $34.4 ($21.2), $71.8 ($43.8), and $170 ($119) (2012 dollars), respectively, and quality-adjusted life-years (QALYs) gained were 19.9 (16.9), 53.7 (38.7), 109 (79.6), and 249 (205). Incremental effectiveness and costs were less favorable in certain circumstances, such as high implementation costs. Nationwide, anticipated increases in CPOE implementation from 2009 through 2015 could save $133 billion and 201,000 QALYs.In addition to improving health, implementing CPOE with clinical decision support could yield substantial long-term savings to society in the United States, although results for individual hospitals are likely to vary.

    View details for PubMedID 26215523

  • A Qualitative Evaluation of Web-Based Cancer Care Quality Improvement Toolkit Use in the Veterans Health Administration QUALITY MANAGEMENT IN HEALTH CARE Bowman, C., Luck, J., Gale, R. C., Smith, N., York, L. S., Asch, S. 2015; 24 (3): 147-161


    Disease severity, complexity, and patient burden highlight cancer care as a target for quality improvement (QI) interventions. The Veterans Health Administration (VHA) implemented a series of disease-specific online cancer care QI toolkits.To describe characteristics of the toolkits, target users, and VHA cancer care facilities that influenced toolkit access and use and assess whether such resources were beneficial for users.Deductive content analysis of detailed notes from 94 telephone interviews with individuals from 48 VHA facilities. We evaluated toolkit access and use across cancer types, participation in learning collaboratives, and affiliation with VHA cancer care facilities.The presence of champions was identified as a strong facilitator of toolkit use, and learning collaboratives were important for spreading information about toolkit availability. Identified barriers included lack of personnel and financial resources and complicated approval processes to support tool use.Online cancer care toolkits are well received across cancer specialties and provider types. Clinicians, administrators, and QI staff may benefit from the availability of toolkits as they become more reliant on rapid access to strategies that support comprehensive delivery of evidence-based care. Toolkits should be considered as a complement to other QI approaches.

    View details for DOI 10.1097/QMH.0000000000000063

    View details for Web of Science ID 000357941400007

    View details for PubMedID 26115063

  • Examining the Specification Validity of the HEDIS Quality Measures for Substance Use Disorders JOURNAL OF SUBSTANCE ABUSE TREATMENT Harris, A. H., Ellerbe, L., Phelps, T. E., Finney, J. W., Bowe, T., Gupta, S., Asch, S. M., Humphreys, K., Trafton, J. 2015; 53: 16-21


    Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Effectiveness Data and Information Set (HEDIS®) substance use disorder initiation and engagement measures by examining whether encounters assumed to include relevant treatment have corroborating evidence in the clinical progress notes. The positive predictive values were excellent (>90%) for residential and outpatient records selected from addiction treatment programs but more modest for records generated in non-addiction settings, and were highly variable across facilities. Stakeholders using these measures to compare care quality should be mindful of the clinical composition of the data and determine if similar validation work has been conducted on the systems being evaluated.

    View details for DOI 10.1016/j.jsat.2015.01.002

    View details for Web of Science ID 000354505900003

    View details for PubMedID 25736624

  • Uptake and utilization of directly acting antiviral medications for hepatitis C infection in US veterans JOURNAL OF VIRAL HEPATITIS Gidwani, R., Barnett, P. G., Goldhaber-Fiebert, J. D., Asch, S. M., Lo, J., Dally, S. K., Owens, D. K. 2015; 22 (5): 489-495


    New drugs therapies have revolutionized the treatment of hepatitis C virus (HCV) infection. The objectives of this study were to evaluate uptake and utilization of boceprevir and telaprevir in the Department of Veterans Affairs (VA). We evaluated whether therapies conformed to response-guided protocols, whether they replaced standard interferon plus ribavirin treatment, and whether IL-28B was used to guide treatment. We performed an administrative data-based analysis of all patients receiving pharmacologic treatment for HCV in VA from October 2009 to July 2013. There were 12 737 new HCV prescriptions in VA during this time, with 5564 boceprevir or telaprevir prescriptions (44%) and 7173 prescriptions (56%) written for standard interferon plus ribavirin treatment. Prescriptions for the new treatments heavily favoured boceprevir vs telaprevir (83% vs 17%). Sixty-two percent (62%) of boceprevir-treated patients completed their minimum-specified protocol, while 69.2% of telaprevir-treated patients completed their minimum-specified protocol. From October 2010 to July 2012, 4090 patients had an IL-28B test; less than 16% of these tests guided subsequent HCV prescriptions. Uptake of boceprevir and telaprevir was rapid; the number of patients initiating treatment approximately doubled in the period after their introduction. While new prescriptions favor boceprevir or telaprevir over standard interferon plus ribavirin therapy, there appears to still be a strong role of interferon plus ribavirin in treating HCV patients. This work can inform our understanding of how other new effective HCV therapies will be used, their diffusion, and the timing of their diffusion in actual clinical practice.

    View details for DOI 10.1111/jvh.12344

    View details for Web of Science ID 000352566200005

    View details for PubMedID 25417805

  • Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications BMJ QUALITY & SAFETY Wagner, T. H., Taylor, T., Cowgill, E., Asch, S. M., Su, P., Bokhour, B., Durfee, J., Martinello, R. A., Maguire, E., Elwy, A. R. 2015; 24 (5): 295-302


    How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE.We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45?274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns.Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure.The majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care.

    View details for DOI 10.1136/bmjqs-2014-003800

    View details for Web of Science ID 000353038100002

    View details for PubMedID 25882785

  • Implementing a user-driven online quality improvement toolkit for cancer care. Journal of oncology practice / American Society of Clinical Oncology Luck, J., York, L. S., Bowman, C., Gale, R. C., Smith, N., Asch, S. M. 2015; 11 (3): e421-7


    Peer-to-peer collaboration within integrated health systems requires a mechanism for sharing quality improvement lessons. The Veterans Health Administration (VA) developed online compendia of tools linked to specific cancer quality indicators. We evaluated awareness and use of the toolkits, variation across facilities, impact of social marketing, and factors influencing toolkit use.A diffusion of innovations conceptual framework guided the collection of user activity data from the Toolkit Series SharePoint site and an online survey of potential Lung Cancer Care Toolkit users.The VA Toolkit Series site had 5,088 unique visitors in its first 22 months; 5% of users accounted for 40% of page views. Social marketing communications were correlated with site usage. Of survey respondents (n = 355), 54% had visited the site, of whom 24% downloaded at least one tool. Respondents' awareness of the lung cancer quality performance of their facility, and facility participation in quality improvement collaboratives, were positively associated with Toolkit Series site use. Facility-level lung cancer tool implementation varied widely across tool types.The VA Toolkit Series achieved widespread use and a high degree of user engagement, although use varied widely across facilities. The most active users were aware of and active in cancer care quality improvement. Toolkit use seemed to be reinforced by other quality improvement activities. A combination of user-driven tool creation and centralized toolkit development seemed to be effective for leveraging health information technology to spread disease-specific quality improvement tools within an integrated health care system.

    View details for DOI 10.1200/JOP.2014.003012

    View details for PubMedID 25852141

  • The most used and most helpful facilitators for patient-centered medical home implementation IMPLEMENTATION SCIENCE Gale, R. C., Asch, S. M., Taylor, T., Nelson, K. M., Luck, J., Meredith, L. S., Helfrich, C. D. 2015; 10


    Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful.This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals.Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as "somewhat/very helpful" than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful.These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff's access to and the helpfulness of PCMH implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators' and policymakers' investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives.

    View details for DOI 10.1186/s13012-015-0246-9

    View details for Web of Science ID 000353657900001

    View details for PubMedID 25924611

  • Sex Differences in Mental Health and Substance Use Disorders and Treatment Entry Among Justice-involved Veterans in the Veterans Health Administration. Medical care Finlay, A. K., Binswanger, I. A., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-Howells, J., Timko, C., Blodgett, J. C., Harris, A. H., Asch, S. M., Frayne, S. 2015; 53 (4): S105-11


    Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010-2012.A total of 1535 females and 30,478 male veterans were included.Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68-2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45-0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57-0.83).Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

    View details for DOI 10.1097/MLR.0000000000000271

    View details for PubMedID 25767963

  • Proactive Case Finding To Improve Concurrently Curative and Palliative Care in Patients with End-Stage Liver Disease JOURNAL OF PALLIATIVE MEDICINE Walling, A. M., Schreibeis-Baum, H., Pimstone, N., Asch, S. M., Robinson, L., Korlekar, S., Lorenz, K., Nwajuaku, T., Rosenfeld, K. 2015; 18 (4): 378-381

    View details for DOI 10.1089/jpm.2014.0265

    View details for Web of Science ID 000351274500013

    View details for PubMedID 25493552

  • In reply. Obstetrics and gynecology Shaw, J. G., Asch, S. M., Frayne, S. M., Phibbs, C. S., Kimerling, R., Shaw, K. A. 2015; 125 (4): 989-?

    View details for DOI 10.1097/AOG.0000000000000783

    View details for PubMedID 25798980

  • Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. Journal of palliative medicine Walling, A. M., Schreibeis-Baum, H., Pimstone, N., Asch, S. M., Robinson, L., Korlekar, S., Lorenz, K., Nwajuaku, T., Rosenfeld, K. 2015; 18 (4): 378-381


    Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention.We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ?14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ?14 and palliative care consults for all veterans with a MELD ?20 or inoperable HCC.We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38).Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.

    View details for DOI 10.1089/jpm.2014.0265

    View details for PubMedID 25493552

  • The role of evidence and context for implementing a multimodal intervention to increase HIV testing IMPLEMENTATION SCIENCE Bokhour, B. G., Saifu, H., Goetz, M. B., Fix, G. M., Burgess, J., Fletcher, M. D., Knapp, H., Asch, S. M. 2015; 10
  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238


    While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)


    To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system.In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals' outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status.USA VA Health Care System.5.2 million VA patients.Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations.The 5% highest cost patients (n=261?699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ?3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (-0.6 percentage points per affected body system, p<0.01).Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

  • Using a Clinical Knowledge Base to Assess Comorbidity Interrelatedness Among Patients with Multiple Chronic Conditions. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Zulman, D. M., Martins, S. B., Liu, Y., Tu, S. W., Hoffman, B. B., Asch, S. M., Goldstein, M. K. 2015; 2015: 1381-1389


    Decision support tools increasingly integrate clinical knowledge such as medication indications and contraindications with electronic health record (EHR) data to support clinical care and patient safety. The availability of this encoded information and patient data provides an opportunity to develop measures of clinical decision complexity that may be of value for quality improvement and research efforts. We investigated the feasibility of using encoded clinical knowledge and EHR data to develop a measure of comorbidity interrelatedness (the degree to which patients' co-occurring conditions interact to generate clinical complexity). Using a common clinical scenario-decisions about blood pressure medications in patients with hypertension-we quantified comorbidity interrelatedness by calculating the number of indications and contraindications to blood pressure medications that are generated by patients' comorbidities (e.g., diabetes, gout, depression). We examined properties of comorbidity interrelatedness using data from a decision support system for hypertension in the Veterans Affairs Health Care System.

    View details for PubMedID 26958279

    View details for PubMedCentralID PMC4765555

  • Predictive validity of two process-of-care quality measures for residential substance use disorder treatment. Addiction science & clinical practice Harris, A. H., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Rubinsky, A. D., Finney, J. W., Asch, S. M., Humphreys, K., Trafton, J. 2015; 10: 22-?


    In order to monitor and ultimately improve the quality of addiction treatment, professional societies, health care systems, and addiction treatment programs must establish clinical practice standards and then operationalize these standards into reliable, valid, and feasible quality measures. Before being implemented, quality measures should undergo tests of validity, including predictive validity. Predictive validity refers to the association between process-of-care quality measures and subsequent patient outcomes. This study evaluated the predictive validity of two process quality measures of residential substance use disorder (SUD) treatment.Washington Circle (WC) Continuity of Care quality measure is the proportion of patients having an outpatient SUD treatment encounter within 14 days after discharge from residential SUD treatment. The Early Discharge measure is the proportion of patients admitted to residential SUD treatment who discharged within 1 week of admission. The predictive validity of these process measures was evaluated in US Veterans Health Administration patients for whom utilization-based outcome and 2-year mortality data were available. Propensity score-weighted, mixed effects regression adjusted for pre-index imbalances between patients who did and did not meet the measures' criteria and clustering of patients within facilities.For the WC Continuity of Care measure, 76 % of 10,064 patients had a follow-up visit within 14 days of discharge. In propensity score-weighted models, patients who had a follow-up visit had a lower 2-year mortality rate [odds ratio (OR) = 0.77, p = 0.008], but no difference in subsequent detoxification episodes relative to patients without a follow-up visit. For the Early Discharge measure, 9.6 % of 10,176 discharged early and had significantly higher 2-year mortality (OR = 1.49, p < 0.001) and more subsequent detoxification episodes.These two measures of residential SUD treatment quality have strong associations with 2-year mortality and the Early Discharge measure is also associated with more subsequent detoxification episodes. These results provide initial support for the predictive validity of residential SUD treatment quality measures and represent the first time that any SUD quality measure has been shown to predict subsequent mortality.

    View details for DOI 10.1186/s13722-015-0042-5

    View details for PubMedID 26520402

    View details for PubMedCentralID PMC4672518

  • Using lean management to reduce blood culture contamination. Joint Commission journal on quality and patient safety / Joint Commission Resources Sinnott, P. L., Breckenridge, J. S., Helgerson, P., Asch, S. 2015; 41 (1): 26-22


    Blood culture contamination (BCC) is a common and avoidable complication of patient care and incurs considerable cost. A quality improvement (QI) initiative was undertaken at a large Department of Veterans Affairs (VA) medical center to reduce the BCC rate.Lean management QI methods, including a rapid process improvement workshop (RPIW), were used to identify root causes of variation in blood culture procedures and countermeasures (potential improvement strategies) to address each problem were developed. BCC rates were collected for five and one quarter years, including the pre-RPIW (baseline) period, and changes in the contamination rates were calculated. The observed change in BCC rates was compared to a forecast of the pre-RPIW trend and estimated BCCs avoided. Results for the primary medical center were compared with those of a similarly complex VA medical center during the same time periods using difference-in-differences methodology.Qualitative assessment of the processes of care identified four root cause problems, each of which was addressed with countermeasures. The BCC rate at the primary medical center decreased significantly from the baseline period in each year of follow-up, improving from 4.2% in the 19-month baseline period to 2.8% in the last 12 months of follow-up (April 2013-March 2014), while changes from baseline in the BCC rate at the comparison site were significant in only one year of follow-up. An estimated 261 BCCs were avoided at the primary medical center in the follow-up period.The QI initiative was successful in reducing BCC rates and in producing continued improvement for nearly four years of follow-up. Further study will determine if these results are generalizable to other settings.

    View details for PubMedID 25976721

  • Prevalence of mental health disorders among justice-involved veterans. Epidemiologic reviews Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., Midboe, A. M. 2015; 37 (1): 163-176


    Justice-involved veterans are a special population with unique mental health needs compared with other veterans or justice-involved adults. Prevalence estimates of mental health concerns of justice-involved veterans across 18 samples of these veterans (1987-2013), including both incarcerated and community samples, were identified through a systematic literature search of published studies supplemented by Department of Veterans Affairs Veterans Justice Programs data. Despite heterogeneity across samples and measures used, the review highlights several prominent mental health concerns among veterans. Many justice-involved veterans have likely experienced at least one traumatic event, and many have post-traumatic stress disorder (prevalence from 4% to 39% across samples). At least half of justice-involved veterans have an alcohol and/or drug use disorder (estimates as high as 71% and 65%, respectively), and other psychiatric disorders, such as depression (14%-51%) and psychotic disorders (4%-14%), are common. Justice-involved veterans with comorbid substance use and psychiatric disorders are at increased risk of negative outcomes, including homelessness and violent behavior. Overall, comparisons of justice-involved veterans with other justice-involved adults found a slightly higher rate of mental health concerns among justice-involved veterans, with some indication that intravenous drug use is more prevalent. Compared with other veterans, justice-involved veterans have consistently higher rates of mental health concerns, particularly substance use disorders.

    View details for DOI 10.1093/epirev/mxu003

    View details for PubMedID 25600416

  • Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)

    View details for DOI 10.1136/bmjopen-2015-007771

    View details for PubMedID 25882486

  • The role of evidence and context for implementing a multimodal intervention to increase HIV testing. Implementation science Bokhour, B. G., Saifu, H., Goetz, M. B., Fix, G. M., Burgess, J., Fletcher, M. D., Knapp, H., Asch, S. M. 2015; 10: 22-?


    Increasing the use of routine preventive care such as HIV testing is important, yet implementation of such evidence-based clinical care is complex. The Promoting Action on Research Implementation in Health Services (PARiHS) model for implementation posits that implementation will be most successful when the evidence, context, and facilitation strategies are strong for the clinical practice. We evaluated the relative importance of perceived evidence, context, and facilitation of HIV testing during the implementation of a multimodal intervention in US Department of Veterans Affairs primary care clinics.A multimodal intervention including clinical reminders (CRs), academic detailing-providing education sessions for providers-and social marketing to improve HIV testing was implemented in 15 VA primary care clinics in three regions. We conducted qualitative formative and process evaluations using semi-structured interviews with HIV lead clinicians, primary care lead clinicians, nurse managers, and social workers. Interviews were analyzed thematically to identify barriers and facilitators to implementation of HIV testing and how these were addressed by the intervention. Sites were then rated high, medium, or low on the dimensions of perceived evidence and the context for testing. We then assessed the relationship of these ratings to improvements in HIV testing rates found in earlier quantitative analyses.Sites that showed greatest improvements in HIV testing rates also rated high on evidence and context. Conversely, sites that demonstrated the poorest improvements in testing rates rated low on both dimensions. Perceptions of evidence and several contextual aspects resulted in both barriers and facilitators to implementing testing. Evidence barriers included provider perceptions of evidence for routine testing as irrelevant to their population. Contextual barriers included clinical reminder overload, insufficient resources, onerous consent processes, stigma, provider discomfort, and concerns about linking individuals who test positive to HIV treatment. While most barriers were ameliorated by the intervention, HIV stigma in particular regions and concerns about linkage to care persisted.Interventions to implement evidence-based practices such as HIV testing can be successful when utilizing proven quality improvement techniques. However, it is critical to address providers' perceptions of evidence and consider aspects of the local context in order to fully implement new routine clinical practices such as HIV testing.

    View details for DOI 10.1186/s13012-015-0214-4

    View details for PubMedID 25889388

  • Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Ezeji-Okoye, S. C., Shaw, J. G., Hummel, D. L., Holloway, K. S., Smither, S. F., Breland, J. Y., Chardos, J. F., Kirsh, S., Kahn, J. S., Asch, S. M. 2014; 29: S861-S869
  • Socioeconomic Inequalities in Quality of Care and Outcomes Among Patients With Acute Coronary Syndrome in the Modern Era of Drug Eluting Stents JOURNAL OF THE AMERICAN HEART ASSOCIATION Yong, C. M., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2014; 3 (6)

    View details for DOI 10.1161/JAHA.114.001029

    View details for Web of Science ID 000345067600027

    View details for PubMedID 25398888

  • Socioeconomic inequalities in quality of care and outcomes among patients with acute coronary syndrome in the modern era of drug eluting stents. Journal of the American Heart Association Yong, C. M., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2014; 3 (6)


    The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

    View details for DOI 10.1161/JAHA.114.001029

    View details for PubMedID 25398888

  • Improving Healthcare Systems' Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership JOURNAL OF GENERAL INTERNAL MEDICINE Elwy, A. R., Bokhour, B. G., Maguire, E. M., Wagner, T. H., Asch, S. M., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., Schiffner, S., Jesse, R. L. 2014; 29: S895-S903
  • Building Strong Research Partnerships Between Public Health and Researchers: A VA Case Study JOURNAL OF GENERAL INTERNAL MEDICINE Midboe, A. M., Elwy, A. R., Durfee, J. M., Gifford, A. L., Yakovchenko, V., Martinello, R. A., Ross, D., Czarnogorski, M., Goetz, M. B., Asch, S. M. 2014; 29: S831-S834
  • Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119
  • Quality of supportive care for patients with advanced lung cancer in the Veterans Health Administration. The Journal of community and supportive oncology Oishi, S. M., Antonio, A. L., Ryoo, J., Ordin, D. L., Lorenz, K. A., He, R., Asch, S. M., Kim, B., Malin, J. 2014; 12 (10): 361-369


    Morbidity related to cancer and its treatment remains a significant source of human suffering and a challenge to the delivery of high-quality care.To develop and apply quality indicators to evaluate quality of supportive care for advanced lung cancer in the Veterans Health Administration (VHA) and examine facility-level predictors of quality.We evaluated supportive care quality using 12 quality indicators. Data were taken from VHA electronic health records for incident lung cancer cases occurring during 2007. Organizational characteristics of 111 VHA facilities were examined for association with receipt of care.Not all supportive care was evaluated. Care processes identified as present at facilities may not have been applied to cohort patients. Facility-level results may be influenced by errors in attributing a patient's care to the correct facility.Quality indicators for supportive cancer care can be developed and applied in large evaluations using electronic health record review. This study confirmed high-quality supportive care, while identifying significant facility-level variation in VHA.

    View details for DOI 10.12788/jcso.0079

    View details for PubMedID 25853258

  • Retaining Homeless Veterans in Outpatient Care: A Pilot Study of Mobile Phone Text Message Appointment Reminders AMERICAN JOURNAL OF PUBLIC HEALTH McInnes, D. K., Petrakis, B. A., Gifford, A. L., Rao, S. R., Houston, T. K., Asch, S. M., O'Toole, T. P. 2014; 104: S588-S594


    We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows.We sent 2 text message reminders to participants (n?=?20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation.Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI]??=?2.2, 17.8; P?=?.01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI?=?-0.4, 6.4; P?=?.08).Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.

    View details for DOI 10.2105/AJPH.2014.302061

    View details for Web of Science ID 000341363000018

    View details for PubMedID 25100425

  • Effect of electronic prescribing with formulary decision support on medication tier, copayments, and adherence BMC MEDICAL INFORMATICS AND DECISION MAKING Pevnick, J. M., Li, N., Asch, S. M., Jackevicius, C. A., Bell, D. S. 2014; 14


    Medication non-adherence is prevalent. We assessed the effect of electronic prescribing (e-prescribing) with formulary decision support on preferred formulary tier usage, copayment, and concomitant adherence.We retrospectively analyzed 14,682 initial pharmaceutical claims for angiotensin receptor blocker and inhaled steroid medications among 14,410 patients of 2189 primary care physicians (PCPs) who were offered e-prescribing with formulary decision support, including 297 PCPs who adopted it. Formulary decision support was initially non-interruptive, such that formulary tier symbols were displayed adjacent to medication names. Subsequently, interruptive formulary decision support alerts also interrupted e-prescribing when preferred-tier alternatives were available. A difference in differences design was used to compare the pre-post differences in medication tier for each new prescription attributed to non-adopters, low user (<30% usage rate), and high user PCPs (>30% usage rate). Second, we modeled the effect of formulary tier on prescription copayment. Last, we modeled the effect of copayment on adherence (proportion of days covered) to each new medication.Compared with non-adopters, high users of e-prescribing were more likely to prescribe preferred-tier medications (vs. non-preferred tier) when both non-interruptive and interruptive formulary decision support were in place (OR 1.9 [95% CI 1.0-3.4], p?=?0.04), but no more likely to prescribe preferred-tier when only non-interruptive formulary decision support was in place (p?=?0.90). Preferred-tier claims had only slightly lower mean monthly copayments than non-preferred tier claims (angiotensin receptor blocker: $10.60 versus $11.81, inhaled steroid: $14.86 versus $16.42, p?

    View details for DOI 10.1186/1472-6947-14-79

    View details for Web of Science ID 000344108600001

    View details for PubMedID 25167807

  • Delivering PACT-principled care: are specialty care patients being left behind? Journal of general internal medicine Fix, G. M., Asch, S. M., Saifu, H. N., Fletcher, M. D., Gifford, A. L., Bokhour, B. G. 2014; 29: S695-702


    With the reorganization of primary care into Patient Aligned Care Teams (PACT) teams, the Veteran Affairs Health System (VA) aims to ensure all patients receive care based on patient-centered medical home (PCMH) principles. However, some patients receive the preponderance of care from specialty rather than primary care clinics because of the special nature of their clinical conditions. We examined seven VA (HIV) clinics as a model to test the extent to which such patients receive PCMH-principled care.To examine the extent to which HIV specialty care in VA conforms to PCMH principles.Qualitative study.Forty-one HIV providers from seven HIV clinics and 20 patients from four of these clinics.We conducted semi-structured interviews with HIV clinic providers and patients about care practices and adherence to PCMH principles. Using an iterative approach, data was analyzed using both a content analysis and an a priori, PCMH-principled coding strategy.Patients with HIV receive varying levels of PCMH-principled care across a range of VA HIV clinic structures. The more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient's medical home, and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care.Even in a large, integrated healthcare system, there is wide variation in patients' receipt of PCMH-principled care in specialty care settings. In order to meet the goal of having all patients receiving PCMH-principled care, there needs to be careful consideration of where primary and specialty care services are delivered and coordinated. The best mechanisms for ensuring that patients with complex medical conditions receive PCMH-principled care may need to be tailored to different specialty care contexts.

    View details for DOI 10.1007/s11606-013-2677-9

    View details for PubMedID 24715390

  • Delivering PACT-Principled Care: Are Specialty Care Patients Being Left Behind? JOURNAL OF GENERAL INTERNAL MEDICINE Fix, G. M., Asch, S. M., Saifu, H. N., Fletcher, M. D., Gifford, A. L., Bokhour, B. G. 2014; 29: 695-702
  • Multimethod evaluation of the VA's peer-to-peer Toolkit for patient-centered medical home implementation. Journal of general internal medicine Luck, J., Bowman, C., York, L., Midboe, A., Taylor, T., Gale, R., Asch, S. 2014; 29: S572-8


    Effective implementation of the patient-centered medical home (PCMH) in primary care practices requires training and other resources, such as online toolkits, to share strategies and materials. The Veterans Health Administration (VA) developed an online Toolkit of user-sourced tools to support teams implementing its Patient Aligned Care Team (PACT) medical home model.To present findings from an evaluation of the PACT Toolkit, including use, variation across facilities, effect of social marketing, and factors influencing use.The Toolkit is an online repository of ready-to-use tools created by VA clinic staff that physicians, nurses, and other team members may share, download, and adopt in order to more effectively implement PCMH principles and improve local performance on VA metrics.Multimethod evaluation using: (1) website usage analytics, (2) an online survey of the PACT community of practice's use of the Toolkit, and (3) key informant interviews.Survey respondents were PACT team members and coaches (n = 544) at 136 VA facilities. Interview respondents were Toolkit users and non-users (n = 32).For survey data, multivariable logistic models were used to predict Toolkit awareness and use. Interviews and open-text survey comments were coded using a "common themes" framework. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analyses.The Toolkit was used by 6,745 staff in the first 19 months of availability. Among members of the target audience, 80 % had heard of the Toolkit, and of those, 70 % had visited the website. Tools had been implemented at 65 % of facilities. Qualitative findings revealed a range of user perspectives from enthusiastic support to lack of sufficient time to browse the Toolkit.An online Toolkit to support PCMH implementation was used at VA facilities nationwide. Other complex health care organizations may benefit from adopting similar online peer-to-peer resource libraries.

    View details for DOI 10.1007/s11606-013-2738-0

    View details for PubMedID 24715401

  • The Quality of Care Provided to Patients With Varices in the Department of Veterans Affairs AMERICAN JOURNAL OF GASTROENTEROLOGY Buchanan, P. M., Kramer, J. R., El-Serag, H. B., Asch, S. M., Assioun, Y., Bacon, B. R., Kanwal, F. 2014; 109 (7): 934-940


    Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care.We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients' medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators.Quality scores (max. 100%) varied across individual indicators, ranging from 24.3% for upper endoscopy for varices screening to 72.4% for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (<60 vs. >60 year, odds ratio (OR)=1.29, 95% confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR=1.55, 95% CI=1.09-2.21), or those who were seen in the facility with academic affiliation (OR=1.26, 95% CI=1.01-1.58) received higher quality care.Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.

    View details for DOI 10.1038/ajg.2013.487

    View details for Web of Science ID 000344459100001

    View details for PubMedID 24989087

  • Using the Precaution Adoption Process model to describe a disaster preparedness intervention among low-income Latinos HEALTH EDUCATION RESEARCH Glik, D. C., Eisenman, D. P., Zhou, Q., Tseng, C., Asch, S. M. 2014; 29 (2): 272-283


    Only 40-50% of households in the United States are currently disaster prepared. In this intervention study, respondent-driven sampling was used to select a sample (n = 187) of low income, Latino residents of Los Angeles County, randomly assigned into two treatment conditions: (i) household preparedness education received through 'promotora' (community health worker) led small group meetings, and (ii) household preparedness education received through print media. Weinstein's Precaution Adoption Process, a stage model appropriate for risk communication guided the intervention. Outcomes are conceptualized as stages of decision making linked to having disaster supplies and creating a family communication plan. Quantitative results showed a significant shift over time from awareness to action and maintenance stages for disaster communication plans and supplies in both study arms; however, the shift in stage for a communication plan for those in the 'platica' study arm was (P < 0.0001) than for those in the media arm. For changes in stage linked to disaster supplies, people in both media and 'platica' study arms improved at the same rate. Simple media-based communications may be sufficient to encourage disadvantaged households to obtain disaster supplies; however, adoption of the more complex disaster family communication requires interpersonal education.

    View details for DOI 10.1093/her/cyt109

    View details for Web of Science ID 000333266100008

    View details for PubMedID 24399266

  • Facility Characteristics and Quality of Lung Cancer Care in an Integrated Health Care System JOURNAL OF THORACIC ONCOLOGY Ryoo, J. J., Malin, J. L., Ordin, D. L., Oishi, S. M., Kim, B., Asch, S. M., He, R., Gould, M. K. 2014; 9 (4): 447-455


    In a national, integrated health care system, we sought to identify facility-level attributes associated with better quality of lung cancer care.Adherence to 23 quality indicators across four domains (Diagnosis and Staging, Treatment, Supportive Care, End-of-Life Care) was assessed through abstraction of electronic records from 4804 lung cancer patients diagnosed in 2007 at 131 Veterans Health Administration facilities. Performance was reported as proportions of eligible patients fulfilling adherence criteria. With stratification of patients by stage, generalized estimating equations identified facility-level characteristics associated with performance by domain.Overall performance was high for the older (mean age 67.7 years, SD 9.4 years), predominantly male (98%) veterans. However, no facility did well on every measure, and range of adherence across facilities was large; 9% of facilities were in the highest quartile for one or more domain of care, more than 30% for two, and 65% for three. No facility performed consistently well across all domains. Less than 1% performed in the lowest quartile for all. Few facility-level characteristics were associated with care quality. For End-of-Life Care, diagnosis and treatment within the same facility, availability of cancer psychiatry/psychology consultation services, and availability of both inpatient and outpatient palliative care consultation services were associated with better adherence.Quality of Veterans Health Administration lung cancer care is generally high, though substantial variation exists across facilities. With the exception of the salutary impact of palliative care consultation services on end-of-life quality of care, observed facility-level characteristics did not consistently predict adherence to indicators, suggesting quality may be determined by complex local factors that are difficult to measure.

    View details for DOI 10.1097/JTO.0000000000000108

    View details for Web of Science ID 000333145300008

    View details for PubMedID 24736065

  • Developing an Informatics Tool To Advance Supportive Care: The Veterans Health Care Administration Palliative Care National Clinical Template JOURNAL OF PALLIATIVE MEDICINE Goebel, J. R., Ahluwalia, S. C., Chong, K., Shreve, S. T., Goldzweig, C. L., Austin, C., Asch, S. M., Lorenz, K. A. 2014; 17 (3): 266-273


    Increasing emphasis in performance-based payment, public reporting, and quality improvement (QI) has led to widespread interest in measuring and improving the quality of care. By 2014, hospice programs will be required to report quality data to the federal government or incur financial penalties. With this increased interest in quality reporting comes an opportunity to develop informatics tools to capture data that reflect the complex practices involved in palliative care (PC). Therefore, there is a need to disseminate information on developing tools that facilitate capturing data and fostering improved performance. The Veterans Health Care Administration, a national leader in health information technology (HIT) and PC, established the Quality Improvement Resource Center (QuIRC) to develop innovative HIT tools to standardize and improve PC practices throughout the 153 Department of Veterans Affairs (VA) medical centers nationwide.The aim of the paper is to describe the development of the Palliative Care-National Clinical Template (PC-NCT) for documenting initial PC consults.Domains of quality of life provided the foundation for this template. Principles of user-centered informatics design guided development activities. A national consensus panel of PC experts prioritized quality indicators as targets for QI. An interdisciplinary team of PC providers identified desired aspects of template functionality. QuIRC balanced PC providers' desired aspects of functionality against the feasibility within the VA HIT system. Formal pilot and usability testing contributed to numerous iterations of the PC-NCT currently piloted in five geographically distributed sites.This paper presents a robust approach to developing an informatics tool for PC practice. Data collected via the PC-NCT will bring variations in current practice into view and assist in directing resources at "important targets" for QI. Although the development of HIT tools to quantify PC practice is complex, there is enormous potential to improve the quality of care for patients and families facing serious illnesses.

    View details for DOI 10.1089/jpm.2013.0288

    View details for Web of Science ID 000337027700007

    View details for PubMedID 24548178

  • Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life. Journal of graduate medical education Saft, H. L., Richman, P. S., Berman, A. R., Mularski, R. A., Kvale, P. A., Ray, D. E., Selecky, P., Ford, D. W., Asch, S. M. 2014; 6 (1): 44-49


    Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life.We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness.Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service.For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use.We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

    View details for DOI 10.4300/JGME-06-01-38

    View details for PubMedID 24701309

  • Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. Journal of general internal medicine Zulman, D. M., Asch, S. M., Martins, S. B., Kerr, E. A., Hoffman, B. B., Goldstein, M. K. 2014; 29 (3): 529-537


    Multimorbidity-the presence of multiple chronic conditions in a patient-has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.

    View details for DOI 10.1007/s11606-013-2616-9

    View details for PubMedID 24081443

  • Association Between Facility Characteristics and the Process of Care Delivered to Patients with Hepatitis C Virus Infection DIGESTIVE DISEASES AND SCIENCES Kanwal, F., Tuyen Hoang, T., Chrusciel, T., Kramer, J. R., El-Serag, H. B., Durfee, J., Dominitz, J. A., Yano, E. M., Asch, S. M. 2014; 59 (2): 273-281
  • The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic reviews Nuckols, T. K., Smith-Spangler, C., Morton, S. C., Asch, S. M., Patel, V. M., Anderson, L. J., Deichsel, E. L., Shekelle, P. G. 2014; 3: 56-?


    The Health Information Technology for Economic and Clinical Health (HITECH) Act subsidizes implementation by hospitals of electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries caused by medication errors (preventable adverse drug events, pADEs). Effects on pADEs have not been rigorously quantified, and effects on medication errors have been variable. The objectives of this analysis were to assess the effectiveness of CPOE at reducing pADEs in hospital-related settings, and examine reasons for heterogeneous effects on medication errors.Articles were identified using MEDLINE, Cochrane Library, Econlit, web-based databases, and bibliographies of previous systematic reviews (September 2013). Eligible studies compared CPOE with paper-order entry in acute care hospitals, and examined diverse pADEs or medication errors. Studies on children or with limited event-detection methods were excluded. Two investigators extracted data on events and factors potentially associated with effectiveness. We used random effects models to pool data.Sixteen studies addressing medication errors met pooling criteria; six also addressed pADEs. Thirteen studies used pre-post designs. Compared with paper-order entry, CPOE was associated with half as many pADEs (pooled risk ratio (RR)?=?0.47, 95% CI 0.31 to 0.71) and medication errors (RR?=?0.46, 95% CI 0.35 to 0.60). Regarding reasons for heterogeneous effects on medication errors, five intervention factors and two contextual factors were sufficiently reported to support subgroup analyses or meta-regression. Differences between commercial versus homegrown systems, presence and sophistication of clinical decision support, hospital-wide versus limited implementation, and US versus non-US studies were not significant, nor was timing of publication. Higher baseline rates of medication errors predicted greater reductions (P?

    View details for DOI 10.1186/2046-4053-3-56

    View details for PubMedID 24894078

  • Impact of Rural Residence and Health System Structure on Quality of Liver Care PLOS ONE Rongey, C., Shen, H., Hamilton, N., Backus, L. I., Asch, S. M., Knight, S. 2013; 8 (12)


    Specialist physician concentration in urban areas can affect access and quality of care for rural patients. As effective drug treatment for hepatitis C (HCV) becomes increasingly available, the extent to which rural patients needing HCV specialists face access or quality deficits is unknown. We sought to determine the influence of rural residency on access to HCV specialists and quality of liver care.The study used a national cohort of 151,965 Veterans Health Administration (VHA) patients with HCV starting in 2005 and followed to 2009. The VHA's constant national benefit structure reduces the impact of insurance as an explanation for observed disparities. Multivariate cox proportion regression models for each quality indicator were performed.Thirty percent of VHA patients with HCV reside in rural and highly rural areas. Compared to urban residents, highly rural (HR 0.70, CI 0.65-0.75) and rural (HR 0.96, CI 0.94-0.97) residents were significantly less likely to access HCV specialty care. The quality indicators were more mixed. While rural residents were less likely to receive HIV screening, there were no significant differences in hepatitis vaccinations, endoscopic variceal and hepatocellular carcinoma screening between the geographic subgroups. Of note, highly rural (HR 1.31, CI 1.14-1.50) and rural residents (HR 1.06, CI 1.02-1.10) were more likely to receive HCV therapy. Of those treated for HCV, a third received therapy from a non-specialist provider.Rural patients have less access to HCV specialists, but this does not necessarily translate to quality deficits. The VHA's efforts to improve specialty care access, rural patient behavior and decentralization of HCV therapy beyond specialty providers may explain this contradiction. Lessons learned within the VHA are critical for US healthcare systems restructuring into accountable care organizations that acquire features of integrated systems.

    View details for DOI 10.1371/journal.pone.0084826

    View details for Web of Science ID 000329116700119

    View details for PubMedID 24386420

  • The Quality of Supportive Cancer Care in the Veterans Affairs Health System and Targets for Improvement JAMA INTERNAL MEDICINE Walling, A. M., Tisnado, D., Asch, S. M., Malin, J. M., Pantoja, P., Dy, S. M., Ettner, S. L., Zisser, A. P., Schreibeis-Baum, H., Lee, M., Lorenz, K. A. 2013; 173 (22): 2071-2079


    Characterizing the quality of supportive cancer care can guide quality improvement.To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans.Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer.We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ? 30 days following diagnosis with ? 1 Veterans Affairs hospitalization or ? 2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains.Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option.These care gaps reflect important targets for improving the patient and family experience of cancer care.

    View details for DOI 10.1001/jamainternmed.2013.10797

    View details for Web of Science ID 000330954800015

    View details for PubMedID 24126685

  • The Hepatitis C Self-Management Program: Sustainability of Primary Outcomes at 1 Year HEALTH EDUCATION & BEHAVIOR Groessl, E. J., Ho, S. B., Asch, S. M., Stepnowsky, C. J., Laurent, D., Gifford, A. L. 2013; 40 (6): 730-740


    Objective. Chronic hepatitis C infection afflicts millions of people worldwide. Although antiviral treatments are increasingly effective, many hepatitis C virus (HCV) patients avoid treatment, do not complete or respond to treatment, or have contraindications. Self-management interventions are one option for promoting behavioral changes leading to liver wellness and improved quality of life. Our objective was to evaluate whether the effects of the HCV self-management program were sustained at the 12-month follow-up assessment. Methods. Veteran Affairs patients with hepatitis C (N = 134; mean age = 54.6 years, 95% male, 41% ethnic minority, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-hour self-management sessions were based on a cognitive-behavioral program with hepatitis C-specific modules. Outcomes including hepatitis C knowledge, depression, energy, and health-related quality of life were measured at baseline, 6 weeks, 6 months, and 12 months later. Data were analyzed using repeated measures ANOVA. Results. Compared with the information-only group, participants attending the self-management workshop improved more on HCV knowledge (p < .005), SF-36 energy/vitality (p = .016), and the Quality of Well-Being Scale (p = .036). Similar trends were found for SF-36 physical functioning and Center for Epidemiologic Studies Short Depression Scale. Conclusion. Better outcomes were sustained among self-management participants at the 12-month assessment despite the intervention only lasting 6 weeks. HCV health care providers should consider adding self-management interventions for patients with chronic HCV.

    View details for DOI 10.1177/1090198113477112

    View details for Web of Science ID 000326980400012

    View details for PubMedID 23445604

  • Online toolkits for metric-driven quality improvement: the Veterans Health Administration managed grassroots approach. Joint Commission journal on quality and patient safety / Joint Commission Resources York, L., Bruce, B., Luck, J., Bowman, C., Midboe, A. M., Smith, N., Elenes, M., Girard, J., Griffith, D., Edwards, G., Ahluwalia, S., Zisser, A., Asch, S. 2013; 39 (12): 561-569

    View details for PubMedID 24416947

  • Cost Effectiveness of Direct-Acting Antiviral Therapy for Treatment-Naive Patients With Chronic HCV Genotype 1 Infection in the Veterans Health Administration CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Chan, K., Lai, M. N., Groessl, E. J., Hanchate, A. D., Wong, J. B., Clark, J. A., Asch, S. M., Gifford, A. L., Ho, S. B. 2013; 11 (11): 1503-1510


    BACKGROUND AND AIM: The Veterans Health Administration (VHA) is the largest single provider of care for hepatitis C virus (HCV) infection in the US. We analyzed the cost-effectiveness of treatment with the HCV protease inhibitors boceprevir and telaprevir in a defined managed care population of 102,851 patients with untreated chronic genotype 1 infection. METHODS: We used a decision-analytic Markov model to examine 4 strategies: standard dual-therapy with pegylated interferon-alfa and ribavirin (PR), the combination of boceprevir and PR triple therapy, the combination of telaprevir and PR, or no antiviral treatment; sensitivity analysis was performed. Sources of data included published rates of disease progression, the census bureau, and VHA pharmacy and hospitalization cost databases. RESULTS: The estimated costs for treating each patient were $8000 for PR, $31,300 for boceprevier and PR, and $41,700 for telaprevir and PR. Assuming VHA treatment rates of 22% and optimal rates of sustained viral response, PR, boceprevir and PR, and telaprevir and PR would reduce relative liver-related deaths by 5.2%, 10.9%, and 11.5%, respectively. Increasing treatment rates to 50% would reduce liver-related deaths by 12%, 24.7%, and 26.1%, respectively. The incremental cost-effectiveness ratios were $29,184/quality of adjusted-life years (QALY) for boceprevir and PR and $44,247/QALY for telaprevir and PR vs only PR. With the current 22% treatment rate, total system-wide costs to adopt boceprevir and PR or telaprevir and PR would range from $708 million to $943 million. CONCLUSIONS: Despite substantial upfront costs of treating HCV-infected patients in the VHA with PR, or telaprevir and PR, each regimen improves quality of life and extends life expectancy, by reducing liver-related morbidity and mortality, and should be cost effective. Further efforts to expand access to direct-acting antiviral therapy are warranted.

    View details for DOI 10.1016/j.cgh.2013.05.014

    View details for Web of Science ID 000325759900026

    View details for PubMedID 23707354

  • Is Emergency Department Crowding Associated With Increased "Bounceback" Admissions? MEDICAL CARE Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Gabayan, G., Liang, L., Han, W., McCreath, H., Sun, B. C. 2013; 51 (11): 1008-1014


    Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions.We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission.We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00).Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.

    View details for DOI 10.1097/MLR.0b013e3182a98310

    View details for Web of Science ID 000326033800009

    View details for PubMedID 24036997

  • Patient-Centered Medical Home Intervention at an Internal Medicine Resident Safety-Net Clinic JAMA INTERNAL MEDICINE Hochman, M. E., Asch, S., Jibilian, A., Chaudry, B., Ben-Ari, R., Hsieh, E., Berumen, M., Mokhtari, S., Raad, M., Hicks, E., Sanford, C., Aguirre, N., Tseng, C., Vangala, S., Mangione, C. M., Goldstein, D. A. 2013; 173 (18): 1694-1701


    The patient-centered medical home (PCMH) model holds promise for improving primary care delivery, but it has not been adequately tested in teaching settings.We implemented an intervention guided by PCMH principles at a safety-net teaching clinic with resident physician providers. Two similar clinics served as controls.Using a cross-sectional design, we measured the effect on patient and resident satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey and a validated teaching clinic survey, respectively. Both surveys were conducted at baseline and 1 year after the intervention. We also measured the effect on emergency department and hospital utilization.Following implementation of our intervention, the clinic?s score on the National Committee for Quality Assurance?s PCMH certification tool improved from 35 to 53 of 100 possible points, although our clinic did not achieve all must-pass elements to qualify as a PCMH. During the 1-year study period, 4676 patients were exposed to the intervention; 39.9% of these used at least 1 program component. Compared with baseline, patient-reported access and overall satisfaction improved to a greater extent in the intervention clinic, and the composite satisfaction rating increased from 48% to 65% in the intervention clinic vs from 50% to 59% in the control sites (P?=?.04). The improvements were particularly notable for questions relating to access. For example, satisfaction with urgent appointment scheduling increased from 12% to 53% in the intervention clinic vs from 14% to 18% in the control clinics (P?

    View details for DOI 10.1001/jamainternmed.2013.9241

    View details for Web of Science ID 000328193600007

    View details for PubMedID 24006034

  • Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities JOURNAL OF GENERAL INTERNAL MEDICINE Goetz, M. B., Tuyen Hoang, T., Knapp, H., Burgess, J., Fletcher, M. D., Gifford, A. L., Asch, S. M. 2013; 28 (10): 1311-1317


    Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown.To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support.Three arm, quasi-experimental implementation research study.Veterans Health Administration (VHA) facilities.Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no interventionFrequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II).The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p?

    View details for DOI 10.1007/s11606-013-2420-6

    View details for Web of Science ID 000325015000015

    View details for PubMedID 23605307

  • How Do Providers Prioritize Prevention? A Qualitative Study AMERICAN JOURNAL OF MANAGED CARE Solomon, J. L., Gifford, A. L., Asch, S. M., Mueller, N., Thomas, C. M., Stevens, J. M., Bokhour, B. G. 2013; 19 (10): E342-?


    Preventive care is an essential element of comprehensive primary care medicine, yet many providers do not address the full range of recommended preventive care services. There is little understanding of how, during time-constrained clinical encounters, providers prioritize preventive care services.To identify and compare how Department of Veterans Affairs (VA) primary care providers (PCPs) prioritized general preventive care services, including HIV testing.A semistructured, qualitative interview design.We conducted semistructured phone interviews with 31 PCPs across 2 urban VA facilities. Interviews entailed questions about the most common preventive care services in primary care, how decisions are made to address some preventive care services but not others, and the role of clinical reminders (CRs) in prioritizing care. Interviews were audio-recorded and transcribed verbatim. We conducted an iterative thematic analysis of interview transcripts, utilizing NVivo 8, a qualitative data management and coding software.Most PCPs indicated they did not utilize CRs as a primary means of prioritizing general preventive care. Instead, PCPs prioritized general preventive care by attending to patients' individual needs and/or keeping in mind influential clinical training experiences. Prioritizing HIV testing included 1 or a combination of the following strategies: being attuned to HIV risk factors prior to the appearance of the CR, being prompted by the CR, and having a positive attitude toward CR design.Prioritizing preventive care can be accomplished using various strategies, including CRs. Healthcare systems might benefit from encouraging PCPs to use a range of strategies.

    View details for Web of Science ID 000326420300009

    View details for PubMedID 24304181

  • Factors Associated With Short-Term Bounce-Back Admissions After Emergency Department Discharge ANNALS OF EMERGENCY MEDICINE Gabayan, G. Z., Asch, S. M., Hsia, R. Y., Zingmond, D., Liang, L., Han, W., McCreath, H., Weiss, R. E., Sun, B. C. 2013; 62 (2): 136-144


    STUDY OBJECTIVE: Hospitalizations that occur shortly after emergency department (ED) discharge may reveal opportunities to improve ED or follow-up care. There currently is limited, population-level information about such events. We identify hospital- and visit-level predictors of bounce-back admissions, defined as 7-day unscheduled hospital admissions after ED discharge. METHODS: Using the California Office of Statewide Health Planning and Development files, we conducted a retrospective cohort analysis of adult (aged >18 years) ED visits resulting in discharge in 2007. Candidate predictors included index hospital structural characteristics such as ownership, teaching affiliation, trauma status, and index ED size, along with index visit patient characteristics of demographic information, day of service, against medical advice or eloped disposition, insurance, and ED primary discharge diagnosis. We fit a multivariable, hierarchic logistic regression to account for clustering of ED visits by hospitals. RESULTS: The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Bounce-back admission within 7 days occurred in 130,526 (2.6%) visits and was associated with Medicaid (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.40 to 1.45) or Medicare insurance (OR 1.53; 95% CI 1.50 to 1.55) and a disposition of leaving against medical advice or before the evaluation was complete (OR 1.90; 95% CI 1.89 to 2.0). The 3 most common age-adjusted index ED discharge diagnoses associated with a bounce-back admission were chronic renal disease, not end stage (OR 3.3; 95% CI 2.8 to 3.8), end-stage renal disease (OR 2.9; 95% CI 2.4 to 3.6), and congestive heart failure (OR 2.5; 95% CI 2.3 to 2.6). Hospital characteristics associated with a higher bounce-back admission rate were for-profit status (OR 1.2; 95% CI 1.1 to 1.3) and teaching affiliation (OR 1.2; 95% CI 1.0 to 1.3). CONCLUSION: We found 2.6% of discharged patients from California EDs to have a bounce-back admission within 7 days. We identified vulnerable populations, such as the very old and the use of Medicaid insurance, and chronic or end-stage renal disease as being especially at risk. Our findings suggest that quality improvement efforts focus on high-risk individuals and that the disposition plan of patients consider vulnerable populations.

    View details for DOI 10.1016/j.annemergmed.2013.01.017

    View details for Web of Science ID 000323014800008

    View details for PubMedID 23465554

  • Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge ACADEMIC EMERGENCY MEDICINE Gabayan, G. Z., Sun, B. C., Asch, S. M., Timmermans, S., Sarkisian, C., Yiu, S., Lancaster, E. M., Poon, K. T., Kellermann, A. L., Ryan, G., Miniel, N. J., Flansbaum, D., Hoffman, J. R., Derose, S. F. 2013; 20 (8): 778-785


    Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

    View details for DOI 10.1111/acem.12181

    View details for Web of Science ID 000323134300005

    View details for PubMedID 24033620

  • Patient Preference and Contraindications in Measuring Quality of Care: What Do Administrative Data Miss? JOURNAL OF CLINICAL ONCOLOGY Ryoo, J. J., Ordin, D. L., Antonio, A. L., Oishi, S. M., Gould, M. K., Asch, S. M., Malin, J. L. 2013; 31 (21): 2716-?


    PURPOSE Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy. PATIENTS AND METHODS Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment. Results Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments. CONCLUSION Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.

    View details for DOI 10.1200/JCO.2012.45.7473

    View details for Web of Science ID 000330538700020

    View details for PubMedID 23752110

  • The effects of quality of care on costs: a conceptual framework. Milbank quarterly Nuckols, T. K., Escarce, J. J., Asch, S. M. 2013; 91 (2): 316-353


    The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs.We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources.The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain.The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status-related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

    View details for DOI 10.1111/milq.12015

    View details for PubMedID 23758513

  • MULTIMORBIDITY AND HEALTH CARE UTILIZATION AMONG HIGH-COST PATIENTS: IMPLICATIONS FOR CARE COORDINATION 36th Annual Meeting of the Society-of-General-Internal-Medicine Zulman, D., Yoon, J., Cohen, D. M., Wagner, T. H., Ritchie, C., Asch, S. SPRINGER. 2013: S123?S124
  • Effect of emergency department crowding on outcomes of admitted patients. Annals of emergency medicine Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., Asch, S. M. 2013; 61 (6): 605-611 e6


    Emergency department (ED) crowding is a prevalent health delivery problem and may adversely affect the outcomes of patients requiring admission. We assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients.We performed a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of admission. To control for hospital-level confounders of ambulance diversion, we defined periods of high ED crowding as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. We used bootstrap sampling to estimate excess outcomes attributable to ED crowding.We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs.Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients.

    View details for DOI 10.1016/j.annemergmed.2012.10.026

    View details for PubMedID 23218508

  • Provider Approaches to Palliative Dyspnea Assessment: Implications for Informatics-Based Clinical Tools AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE Ahluwalia, S. C., Leos, R. L., Goebel, J. R., Asch, S. M., Lorenz, K. A. 2013; 30 (3): 231-238


    To understand provider practices around dyspnea assessment to inform the development of an electronic medical record (EMR)-based dyspnea assessment module in an inpatient palliative care consultation template.Qualitative analysis of palliative care provider interviews.Three themes emerged: (1) integration of patient self-report of breathlessness with a clinical observation of dyspnea; (2) identification of patients for dyspnea assessment based on perceived patient need; and (3) variability in preferences for and use of existing severity scales for dyspnea.The assessment approaches described by providers underscore the challenge of developing an informatics tool that supports the natural clinical experience and facilitates standardized care. The complexity of the dyspnea assessment process and variation in provider practices necessitate a level of flexibility and choice to be built into a computer-based tool.

    View details for DOI 10.1177/1049909112448922

    View details for Web of Science ID 000317674300002

    View details for PubMedID 22669935

  • Development and evaluation of an internet and personal health record training program for low-income patients with HIV or hepatitis C. Medical care McInnes, D. K., Solomon, J. L., Shimada, S. L., Petrakis, B. A., Bokhour, B. G., Asch, S. M., Nazi, K. M., Houston, T. K., Gifford, A. L. 2013; 51 (3): S62-6


    Vulnerable populations face difficulties accessing and using the internet and personal health record (PHR) systems for health-related purposes. Populations disconnected from the internet also tend to be disconnected from health care services.To develop and evaluate an intervention to increase skills in health-related internet and PHR use for vulnerable populations with limited computer and internet experience.Preevaluation and postevaluation using quantitative surveys, semistructured interviews, focus groups, and ethnographic observation.Fourteen low-income Veterans receiving care at Veterans Affairs medical centers for human immunodeficiency virus or hepatitis C.Internet and PHR use, self-efficacy, patient activation, disease knowledge, predictors of medication adherence.At follow-up one (FU1), mean number of internet for health features used increased from 1.57 to 4.07 (P<0.001) as did number of PHR features, from 0.36 to 2.00 (P<0.001). Mean self-efficacy increased at FU1, from 7.12 to 8.60, (P=0.009) and was maintained at follow-up two (FU2). Patient activation increased only at FU2, from 3.42 to 3.61 (P=0.03). Disease specific knowledge showed borderline increase at FU1, from 67.9% to 72.2% (P=0.05), whereas there were no changes in predictors of medication adherence. Qualitative findings underscored the interest in using internet and PHRs and their contribution to increased engagement in care. Training cost per participant was $287.Group training of vulnerable patients represents a cost-effective method to increase internet and PHR skills, and improve patient confidence in finding health-related information, making online health-related transactions, and interacting with health care providers.

    View details for DOI 10.1097/MLR.0b013e31827808bf

    View details for PubMedID 23407015

  • Impact of Consideration of Transplantation on End-of-Life Care for Patients During a Terminal Hospitalization TRANSPLANTATION Walling, A. M., Asch, S. M., Lorenz, K. A., Wenger, N. S. 2013; 95 (4): 641-646


    Many patients considered for transplantation die before receiving the organ, underlining the importance of providing high-quality symptomatic relief and communication for all transplant patients.To study how consideration of transplantation affects the end-of-life care received by patients, care was evaluated by abstracting medical records for 496 adults who died in one high-volume transplant medical center between April 2005 and April 2006. Sixteen quality indicators from the Assessing Care of Vulnerable Elders set that focused on communication and symptom management were measured to calculate an overall patient-level quality score. We evaluated the predictors of quality of end-of-life care, with the main independent variable being whether the patient was being considered for transplantation. Restricting to patients who died an "expected death," we also evaluated the end-of-life treatments received.Twenty-five percent of decedent patients were considered for transplantation. In adjusted models, patients considered for transplantation received lower-quality end-of-life care, had longer hospital stays before death, and were more likely to receive aggressive life-sustaining treatments.Care models should incorporate an emphasis on symptom relief and communication along with transplant preparation.

    View details for DOI 10.1097/TP.0b013e318277f238

    View details for Web of Science ID 000315199200021

    View details for PubMedID 23197177

  • Facilitating out-of-home caregiving through health information technology: survey of informal caregivers' current practices, interests, and perceived barriers. Journal of medical Internet research Zulman, D. M., Piette, J. D., Jenchura, E. C., Asch, S. M., Rosland, A. 2013; 15 (7)


    Many patients with chronic conditions are supported by out-of-home informal caregivers-family members, friends, and other individuals who provide care and support without pay-who, if armed with effective consumer health information technology, could inexpensively facilitate their care.We sought to understand caregivers' use of, interest in, and perceived barriers to health information technology for out-of-home caregiving.We conducted 2 sequential Web-based surveys with a national sample of individuals who provide out-of-home caregiving to an adult family member or friend with a chronic illness. We queried respondents about their use of health information technology for out-of-home caregiving and used multivariable regression to investigate caregiver and care-recipient characteristics associated with caregivers' technology use for caregiving.Among 316 out-of-home caregiver respondents, 34.5% (109/316) reported using health information technology for caregiving activities. The likelihood of a caregiver using technology increased significantly with intensity of caregiving (as measured by number of out-of-home caregiving activities). Compared with very low intensity caregivers, the adjusted odds ratio (OR) of technology use was 1.88 (95% CI 1.01-3.50) for low intensity caregivers, 2.39 (95% CI 1.11-5.15) for moderate intensity caregivers, and 3.70 (95% CI 1.62-8.45) for high intensity caregivers. Over 70% (149/207) of technology nonusers reported interest in using technology in the future to support caregiving. The most commonly cited barriers to technology use for caregiving were health system privacy rules that restrict access to care-recipients' health information and lack of familiarity with programs or websites that facilitate out-of-home caregiving.Health information technology use for out-of-home caregiving is common, especially among individuals who provide more intense caregiving. Health care systems can address the mismatch between caregivers' interest in and use of technology by modifying privacy policies that impede information exchange.

    View details for DOI 10.2196/jmir.2472

    View details for PubMedID 23841987

  • Development of a mild traumatic brain injury-specific vision screening protocol: A Delphi study JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Goodrich, G. L., Martinsen, G. L., Flyg, H. M., Kirby, J., Asch, S. M., Brahm, K. D., Brand, J. M., Cajamarca, D., Cantrell, J. L., Chong, T., Dziadul, J. A., Hetrick, B. J., Huang, M. A., Ihrig, C., Ingalla, S. P., Meltzer, B. R., Rakoczy, C. M., Rone, A., Schwartz, E., Shea, J. E. 2013; 50 (6): 757-768


    Although traumatic brain injury (TBI) can happen to anyone at any time, the wars in Iraq and Afghanistan have brought it renewed attention. Fortunately, most cases of TBI from the recent conflicts are mild TBI (mTBI). Still, many physical, psychological, and social problems are associated with mTBI. Among the difficulties encountered are oculomotor and vision problems, many of which can impede daily activities such as reading. Therefore, correct diagnosis and treatment of these mTBI-related vision problems is an important part of patient recovery. Numerous eye care providers in the Department of Veterans Affairs, in military settings, and in civilian practices specialize and are proficient in examining patients who have a history of TBI. However, many do not have this level of experience working with and treating patients with mTBI. Recognizing this, we used a modified Delphi method to derive expert opinions from a panel of 16 optometrists concerning visual examination of the patient with mTBI. This process resulted in a clinical tool containing 17 history questions and 7 examination procedures. This tool provides a set of clinical guidelines that can be used as desired by any eye care provider either as a screening tool or adjunct to a full eye examination when seeing a patient with a history of mTBI. The goal of this process was to provide optimal and uniform vision care for the patient with mTBI.

    View details for DOI 10.1682/JRRD.2012.10.0184

    View details for Web of Science ID 000324350200005

    View details for PubMedID 24203539

  • POSTTRAUMATIC STRESS DISORDER, MILITARY SEXUAL TRAUMA AND PRETERM BIRTH Western Regional Meeting of the American-Federation-for-Medical-Research Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. LIPPINCOTT WILLIAMS & WILKINS. 2013: 226?26
  • Budget Impact Analysis of HIV Testing in the VA Healthcare System International-Association-of-Physicians in AIDS Care (IAPAC) Anaya, H. D., Chan, K., Karmarkar, U., Asch, S. M., Goetz, M. B. ELSEVIER SCIENCE INC. 2012: 1022?28


    The long-term cost effectiveness of routine HIV testing is favorable relative to other medical interventions. Facility-specific costs of expanded HIV testing and care for newly identified patients, however, are less well defined. To aid in resource allocation decisions, we developed a spreadsheet-based budget-impact tool populated with estimates of facility-specific HIV testing and care costs incurred with an expanded testing program.We modeled intervention effects on quarterly costs of antiretroviral therapy (ART), outpatient resource utilization, and staff expenditures in the Department of Veterans Affairs over a 2-year period of increasing HIV testing rates. We used HIV prevalence estimates, screening rates, counseling, positive tests, Veterans Affairs treatment, and published sources as inputs. We evaluated a single-facility cohort of 20,000 patients and at baseline assumed a serodiagnostic rate of 0.45%.Expanding testing from 2% to 15% annually identified 21 additional HIV-positive patients over 2 years at a cost of approximately $290,000, more than 60% of which was due to providing ART to newly diagnosed patients. While quarterly testing costs decreased longitudinally as fewer persons required testing, quarterly ART costs increased from $10,000 to more than $60,000 over 2 years as more infected patients were identified and started on ART. In sensitivity analyses, serodiagnostic and annual HIV testing rates had the greatest cost impact.Expanded HIV testing costs are greatest during initial implementation and predominantly due to ART for new patients. Cost determinations of expanded HIV testing provide an important tool for managers charged with allocating resources within integrated systems providing both HIV testing and care.

    View details for DOI 10.1016/j.jval.2012.08.2205

    View details for Web of Science ID 000312435300005

    View details for PubMedID 23244803

  • Commentary on Vickerman et?al. (2012): Reducing hepatitis C virus among injection drug users through harm reduction programs ADDICTION Smith-Spangler, C. M., Asch, S. M. 2012; 107 (11): 1996-1997
  • Process of Care for Hepatitis C Infection Is Linked to Treatment Outcome and Virologic Response CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Kanwal, F., Hoang, T., Chrusciel, T., Kramer, J. R., El-Serag, H. B., Dominitz, J. A., Asch, S. M. 2012; 10 (11): 1270-?


    Process of care-based measures are used commonly to assess the quality of medical care provided to patients with chronic hepatitis C virus (HCV) infection. However, the links between these processes and patient outcomes are not clear.We conducted a large retrospective cohort study of 34,749 patients with HCV infection identified from the national Veterans Administration HCV Clinical Case Registry between 2003 and 2006. We examined the relationship between meeting process-based measures of HCV care (categorized into pretreatment, preventive or comorbid care, and treatment monitoring domains) and antiviral treatment-related outcomes. For each domain, we defined optimum care as receipt of all indicated care processes in that domain. Study end points were rates of antiviral treatment, treatment completion, and sustained virologic response (SVR), adjusted for patient demographics, comorbidities, use of health services, and intrafacility clustering.Patients who received optimum pretreatment care were significantly more likely to receive antiviral treatment (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.9-3.5), complete treatment (OR, 1.26; 95% CI, 1.13-1.43), and achieve an SVR (OR, 1.29; 95% CI, 1.01-1.65), than those with suboptimum pretreatment care. Optimum preventive or comorbidity care also independently was associated with receipt of antiviral treatment (OR, 1.36; 95% CI, 1.23-1.51), but not with completion of treatment or SVR. Optimum treatment monitoring was associated with a nonsignificant trend toward achieving an SVR (OR, 1.22; 95% CI, 0.95-1.56).Optimum care for HCV infection-particularly the care delivered before treatment-is associated with increased rates of treatment and SVR. These data could be used to guide clinical policy as newer, more-effective treatments become available.

    View details for DOI 10.1016/j.cgh.2012.07.015

    View details for Web of Science ID 000310780200020

    View details for PubMedID 22841970

  • Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic JOURNAL OF HOSPITAL MEDICINE Vazirani, S., Lankarani-Fard, A., Liang, L., Stelzner, M., Asch, S. M. 2012; 7 (9): 697-701


    A structured, medical preoperative evaluation may positively impact the perioperative course of medically complex patients. Hospitalists are in a unique position to assist in preoperative evaluations, given their expertise with inpatient medicine and postoperative surgical consultation.To evaluate specific outcomes after addition of a Hospitalist-run, medical Preoperative clinic to the standard Anesthesia preoperative evaluation.A pre/post retrospective, comparative review of outcomes of 5223 noncardiac surgical patients at a tertiary care Veterans Administration (VA) medical center.Length of stay was reduced for inpatients with an American Society of Anesthesia (ASA) score of 3 or higher (P < 0.0001). There was a trend towards a reduction in same-day, medically avoidable surgical cancellations (8.5% vs 4.9%, P = 0.065). More perioperative beta blockers were used (P < 0.0001) and more stress tests were ordered (P = 0.012). Inpatient mortality rates were reduced (1.27% vs 0.36%, P = 0.0158).A structured medical preoperative evaluation may benefit medically complex patients and improve perioperative processes and outcomes.

    View details for DOI 10.1002/jhm.1968

    View details for Web of Science ID 000312241600006

    View details for PubMedID 22961756

  • The Performance of Process Measures in Hepatitis C AMERICAN JOURNAL OF GASTROENTEROLOGY Kanwal, F., Tuyen Hoang, T., Kramer, J., Chrusciel, T., El-Serag, H., Dominitz, J. A., Asch, S. M. 2012; 107 (10): 1512-1521


    Previous evaluations regarding the extent to which standard chronic hepatitis C virus (HCV) care processes are delivered during routine clinical care are scant and have primarily relied on automated data--the validity of which is unknown.We examined adherence to 24 explicit modified Delphi panel-derived HCV-specific process measures in a cohort of 122,744 patients enrolled in the automated Veterans Administration HCV Clinical Case Registry between 2000 and 2006. We reviewed medical charts of 717 patients to compare the agreement between Registry and charts. We also estimated the effect of justifiable exceptions on measured performance in HCV by determining the proportion of patients who failed a measure but met a valid exception (i.e., patient refusal, outside care, or treatment contraindications).The percentage of patients who met the individual measures varied. For example, 74% of patients received HCV genotype testing, 23% received antiviral treatment, 28% received liver biopsy, and 16% received hepatitis A vaccination. We found excellent agreement between the Registry and charts in all measures (agreement coefficients >0.75). However, exceptions to indicated care documented in charts were common for genotype testing, liver biopsy, and antiviral treatment. After accounting for these exceptions, the measure rates increased from 75 to 93% for genotype testing, 31 to 50% for liver biopsy, and from 26 to 64% for antiviral treatment. Treatment contraindications were the most common reasons for not meeting indicated care.Automated data missed several exceptions to care that are documented only in providers' notes, thus underestimating process of care. These results have implications for future quality assessment initiatives-most of which will likely rely on automated data for process-based quality reporting. After accounting for automated data and medical record reviews, vaccinations and antiviral treatment rates in the Veterans Administration left room for improvement.

    View details for DOI 10.1038/ajg.2012.201

    View details for Web of Science ID 000309701000010

    View details for PubMedID 22777337

  • Unhealthy Alcohol and Illicit Drug Use Are Associated With Decreased Quality of HIV Care JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Korthuis, P. T., Fiellin, D. A., McGinnis, K. A., Skanderson, M., Justice, A. C., Gordon, A. J., Doebler, D. A., Asch, S. M., Fiellin, L. E., Bryant, K., Gibert, C. L., Crystal, S., Goetz, M. B., Rimland, D., Rodriguez-Barradas, M. C., Kraemer, K. L. 2012; 61 (2): 171-178


    HIV-infected patients with substance use experience suboptimal health outcomes, possibly because of variations in care.To assess the association between substance use and the quality of HIV care (QOC) received.Retrospective cohort study.HIV-infected patients enrolled in the Veterans Aging Cohort Study.We collected self-report substance use data and abstracted 9 HIV quality indicators (QIs) from medical records. Independent variables were unhealthy alcohol use (AUDIT-C score ?4) and illicit drug use (self-report of stimulants, opioids, or injection drug use in past year). Main outcome was the percentage of QIs received, if eligible. We estimated associations between substance use and QOC using multivariable linear regression.The majority of the 3410 patients were male (97.4%) and black (67.0%) with a mean age of 49.1 years (SD = 8.8). Overall, 25.8% reported unhealthy alcohol use, 22% illicit drug use, and participants received 81.5% (SD = 18.9) of QIs. The mean percentage of QIs received was lower for those with unhealthy alcohol use versus not (59.3% vs. 70.0%, P < 0.001) and those using illicit drugs vs. not (57.8% vs. 70.7%, P < 0.001). In multivariable models, unhealthy alcohol use (adjusted ? -2.74; 95% confidence interval: -4.23 to -1.25) and illicit drug use (adjusted ? -3.51; 95% CI: -4.99 to -2.02) remained inversely associated with the percentage of QIs received.Although the overall QOC for these HIV-infected Veteran patients was high, gaps persist for those with unhealthy alcohol and illicit drug use. Interventions that address substance use in HIV-infected patients may improve the QOC received.

    View details for DOI 10.1097/QAI.0b013e31826741aa

    View details for Web of Science ID 000309218700014

    View details for PubMedID 22820808

  • The quality of supportive care among inpatients dying with advanced cancer SUPPORTIVE CARE IN CANCER Walling, A. M., Asch, S. M., Lorenz, K. A., Malin, J., Roth, C. P., Barry, T., Wenger, N. S. 2012; 20 (9): 2189-2194


    Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. The purpose of this study is to apply novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center.Cancer quality ASSIST is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which we piloted 15 applicable to persons with advanced cancer who died in the hospital setting. We evaluated medical records of all adult terminal hospitalizations with lengths of stay ?3 days at one university medical center between April 2005 and April 2006.Of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56% of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 quality indicators of which 476 passed (QI level pass rate 80%, range 50-100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64 and 69% of cases, respectively.This set of quality indicators can evaluate the quality of supportive and end-of-life care provided to inpatients dying with advanced cancer and identify aspects of care that need improvement.

    View details for DOI 10.1007/s00520-012-1462-3

    View details for Web of Science ID 000307285800032

    View details for PubMedID 22544290

  • Implementation of Routine Rapid HIV Testing Within the US Department of Veterans Affairs Healthcare System JOURNAL FOR HEALTHCARE QUALITY Anaya, H. D., Bokhour, B., Feld, J., Golden, J. F., Asch, S. M., Knapp, H. 2012; 34 (5): 7-14
  • Implementation of routine rapid HIV testing within the U.S. Department of Veterans Affairs Healthcare System. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Anaya, H. D., Bokhour, B., Feld, J., Golden, J. F., Asch, S. M., Knapp, H. 2012; 34 (5): 7-14


    Current HIV testing methods can be ineffective; patients often do not return for results. HIV rapid testing (RT) provides accurate results in 20?min. Patients find nurse-initiated HIV rapid testing (NRT) more acceptable than current testing methods and increases receipt of test results. Translating research findings into sustainable practice poses widely recognized implementation challenges. To ascertain effectiveness of NRT implementation, formative and process evaluations were conducted within the U.S. Department of Veterans Affairs Healthcare System (VA). Nurses and physicians at 2 VA medical centers were trained to administer RT. A preimplementation formative evaluation was conducted at Site 1. Process evaluations of ongoing RT activities were conducted at Site 2. Interviews were conducted with key informants. Content and thematic analysis was conducted on the field notes. A variety of barriers and facilitators were discovered that impacted the implementation of NRT. Findings indicate concerns regarding training and incorporating NRT into workflow. Process interviews indicated that training concerns could be alleviated through various means. Finally, interviewees highlighted that other clinic settings might be a more preferred setting for NRT than primary care. Findings are currently being used for the implementation of additional NRT interventions, and can also guide NRT adoption in other facilities.

    View details for DOI 10.1111/j.1945-1474.2011.00151.x

    View details for PubMedID 22060061

  • The Effect of Automated Telephone Appointment Reminders on HIV Primary Care No-Shows by Veterans JANAC-JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE Henry, S. R., Goetz, M. B., Asch, S. M. 2012; 23 (5): 409-418


    Appointment attendance for follow-up care and laboratory monitoring are central components of HIV treatment. In general, appointment reminders are an effective method of reducing outpatient no-shows; however, no single strategy has proven superior. This study tested the effectiveness of adding an automated telephone reminder for laboratory monitoring to the standard set of three appointment reminders to reduce subsequent HIV primary care no-shows. We conducted a quasi-experimental design study in three geographically and administratively affiliated Veterans Administration HIV clinics with one clinic serving as the intervention facility and two others as control facilities. The intervention lasted 6 months. The data show that patients who were not homeless, who were not diagnosed with depression, and who had five or more appointments scheduled in 6 months had significantly fewer no-shows after intervention. The intervention was not effective in reducing no-shows among homeless patients, racial/ethnic minorities, and patients with mental health disorders.

    View details for DOI 10.1016/j.jana.2011.11.001

    View details for Web of Science ID 000321823200005

    View details for PubMedID 22424961

  • National patterns and predictors of liver biopsy use for management of hepatitis C JOURNAL OF HEPATOLOGY Groessl, E. J., Liu, L., Ho, S. B., Kanwal, F., Gifford, A. L., Asch, S. M. 2012; 57 (2): 252-259


    Liver biopsy remains the standard, recommended method for assessing liver damage associated with chronic hepatitis C (HCV) infection. However, there is considerable debate about how liver biopsy should best be used, especially with the advent of more efficacious antiviral therapies. To identify the factors that influence the use of liver biopsy for HCV patients, we describe variations in liver biopsy use at the delivery system and patient level in a national VA sample.We analyzed VA HCV registry data for 171,893 VA patients with confirmed chronic HCV. Delivery system characteristics included geographic region and specialist time. Patient characteristics included antiviral treatment indicators, contraindications, volume of healthcare visits, and demographic variables. Logistic regression was used to explore correlates of biopsy use.Liver biopsy use in the VA system increased from 1997 to 2003 but began declining in 2004. Rates of liver biopsy from 2004 to 2006 varied by VA region, ranging from 5% to 18%. Treatment contraindications and laboratory tests were significantly associated with more biopsies. Demographic variables (higher age, lower BMI, race/ethnicity, and less% service connected disability) were associated with fewer biopsies. Regional variability remained significant independent of volume of care and specialist time.Liver biopsy rates in the VA system have variability that seems unrelated to clinical need. New antiviral therapies and non-invasive assessment techniques may create additional uncertainty for the role of liver biopsy, perhaps explaining its decline in recent years. The availability of more effective antiviral therapies may also affect biopsy rates in the future.

    View details for Web of Science ID 000307685300008

    View details for PubMedID 22521358

  • California Hospitals Serving Large Minority Populations Were More Likely Than Others To Employ Ambulance Diversion HEALTH AFFAIRS Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., Sun, B. C. 2012; 31 (8): 1767-1776


    It is well documented that racial and ethnic minority populations disproportionately use hospital emergency departments for safety-net care. But what is not known is whether emergency department crowding is disproportionately affecting minority populations and potentially aggravating existing health care disparities, including poorer outcomes for minorities. We examined ambulance diversion, a proxy measure for crowding, at 202 California hospitals. We found that hospitals serving large minority populations were more likely to divert ambulances than were hospitals with a lower proportion of minorities, even when controlling for hospital ownership, emergency department capacity, and other hospital demographic and structural factors. These findings suggest that establishing more-uniform criteria to regulate diversion may help reduce disparities in access to emergency care.

    View details for DOI 10.1377/hlthaff.2011.1020

    View details for Web of Science ID 000307498200014

    View details for PubMedID 22869655

  • The Quality of Care Provided to Patients With Cirrhosis and Ascites in the Department of Veterans Affairs GASTROENTEROLOGY Kanwal, F., Kramer, J. R., Buchanan, P., Asch, S. M., Assioun, Y., Bacon, B. R., Li, J., El-Serag, H. B. 2012; 143 (1): 70-77


    Ascites are the most common complication of cirrhosis. Evidence-based guidelines define the criteria and standards of care for patients with cirrhosis and ascites. However, little is known about the extent to which patients with ascites meet these standards.We evaluated the quality of ascites care, measured by 8 explicit Delphi panel-derived quality indicators, in 774 patients with cirrhosis and ascites, seen at 3 Veterans Affairs Medical Centers between 2000 and 2007. We also conducted a structured implicit review of patients' medical charts to determine whether patient refusal, outside care, or other justifiable exceptions to care processes account for nonadherence to the quality indicators.Quality scores (maximum 100%) varied among individual indicators, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis, to 90% for assays for cell number and type in the paracentesis fluid. In general, care targeted at treatment was more likely to meet standards than preventive care. Only 33.2% (95% confidence interval [CI]: 29.9%-32.9%) of patients received all recommended care. Patients with no comorbidity (Deyo index 0 vs >3; odds ratio = 2.21; 95% CI: 1.43-3.43), who saw a gastroenterologist (odds ratio = 1.33; 95% CI, 1.01-1.74), or were seen in a facility with academic affiliation (odds ratio = 1.73; 95% CI: 1.29-2.35) received higher-quality care. Justifiable exceptions to indicated care, documented in charts, were common for patients with paracentesis after diagnosis with ascites, patients that received antibiotics for gastrointestinal bleeding, and patients that required diuretics. However, most patients did not have an explanation documented for nonadherence to recommended care.Health care quality, measured by whether patients received recommended services, was suboptimal for patients with cirrhosis-related ascites. Care that included gastroenterologists was associated with high quality. However, for some of the quality indicators, too many denominator exceptions existed to allow for accurate automated measurement.

    View details for DOI 10.1053/j.gastro.2012.03.038

    View details for Web of Science ID 000305781500030

    View details for PubMedID 22465432



    Human immunodeficiency virus (HIV) screening is cost-effective and recommended in populations with low disease prevalence. However, because screening is not cost-saving, its financial feasibility must be understood.We forecast the costs of two Emergency Department-based HIV testing programs in the Veterans Administration: 1) implementing a non-targeted screening program and providing treatment for all patients thusly identified (Rapid Testing); and 2) treating patients identified due to late-stage symptoms (Usual Care); to determine which program was the most financially feasible.Using a dynamic decision-analysis model, we estimated the financial impact of each program over a 7-year period. Costs were driven by patient disease-severity at diagnosis, measured by CD4+ category, and the proportion of patients in each disease-severity category. Cost per CD4+ category was modeled from chart review and database analysis of treatment-naļve HIV-positive patients. Distributions of CD4+ counts differed in patients across the Rapid Testing and Usual Care arms.A non-targeted Rapid Testing program was not significantly more costly than Usual Care. Although Rapid Testing had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. Assuming an HIV prevalence of 1% and 80% test acceptance, the cost of Rapid Testing was $1,418,088, vs. $1,320,338 for Usual Care (p=0.5854). Results support implementation of non-targeted rapid HIV screening in integrated systems.This analysis adds a new component of support for HIV screening by demonstrating that rapid, non-targeted testing does not cost significantly more than a diagnostic testing approach.

    View details for DOI 10.1016/j.jemermed.2010.11.038

    View details for Web of Science ID 000305591000019

    View details for PubMedID 21277144

  • Provider Stakeholders' Perceived Benefit from a Nascent Health Information Exchange: A Qualitative Analysis JOURNAL OF MEDICAL SYSTEMS Pevnick, J. M., Claver, M., Dobalian, A., Asch, S. M., Stutman, H. R., Tomines, A., Fu, P. 2012; 36 (2): 601-613


    We sought to better understand the perceived costs and benefits of joining a nascent health information exchange (HIE) from the perspective of potential provider organization participants. We therefore conducted semi-structured interviews with organizational representatives. Interview transcriptions were thematically coded, and coded text was subsequently aggregated to summarize the breadth and depth of responses. Although no respondents expected HIE to result in net financial benefit to their organization, all respondents recognized some potential benefits, and some respondents expected HIE to result in overall organizational benefit. Disproportionate benefit was expected for the poorest, sickest patients. Many respondents had concerns about HIE increasing the risk of data security breaches, and these concerns were most pronounced at larger organizations. We found little evidence of organizational concern regarding loss of patients to other organizations or publication of unfavorable quality data. If HIE's greatest benefactors are indeed the poorest, sickest patients, our current health care financing environment will make it difficult to align HIE costs with benefits. To sustain HIE, state and federal governments may need to consider ongoing subsidies. Furthermore, these governments will need to ensure that policies regulating data exchange have sufficient nationwide coordination and liability limitations that the perceived organizational risks of joining HIEs do not outweigh perceived benefits. HIE founders can address organizational concerns by attempting to coordinate HIE policies with those of their largest founding organizations, particularly for data security policies. Early HIE development and promotional efforts should not only focus on potential benefits, but should also address organizational concerns.

    View details for DOI 10.1007/s10916-010-9524-x

    View details for Web of Science ID 000303825500026

    View details for PubMedID 20703673

  • Evaluation of Human Immunodeficiency Virus and Hepatitis C Telemedicine Clinics AMERICAN JOURNAL OF MANAGED CARE Saifu, H. N., Asch, S. M., Goetz, M. B., Smith, J. P., Graber, C. J., Schaberg, D., Sun, B. C. 2012; 18 (4): 207-212


    Geographical barriers to subspecialty care may prevent optimal care of patients living in rural areas. We assess the impact of human immunodeficiency virus (HIV) and hepatitis C telemedicine consultation on patient-oriented outcomes in a rural Veterans Affairs population.This was a pre- and post-intervention study comparing telemedicine with in-person subspecialty clinic visits for HIV and hepatitis C. Eligible patients resided in 2 rural catchment areas. The primary binary outcome was clinic completion. We estimated a logistic regression model with patient-level fixed effects. This approach controls for the clustering of visits by patient, uses each patient's in-person clinic experience as an internal control group, and eliminates confounding by person-level factors. We also surveyed patients to assess satisfaction and patient-perceived reductions in health visit-related time.There were 43 patients who accounted for 94 telemedicine visits and 128 in-person visits. Clinic completion rates were higher for telemedicine (76%) than for in-person visits (61%). In regression analyses, telemedicine was strongly predictive of clinic completion (OR 2.2; 95% confidence interval [CI]: 1.0-4.7). The adjusted effect of telemedicine on clinic completion rate was 13% (95% CI: 12-13). Of the 30 patients (70%) who completed the survey, more than 95% rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person clinic visits. Patients reported a significant reduction in health visit-related time (median 340 minutes, interquartile range 250-440), mostly due to decreased travel time.HIV and hepatitis C telemedicine clinics are associated with improved access, high patient satisfaction, and reduction in health visit-related time.

    View details for Web of Science ID 000308443000003

    View details for PubMedID 22554009

  • Translation of Evidence-Based Clinical Standards into a New Prehospital Resuscitation Policy in Los Angeles County HEALTH SERVICES RESEARCH Grudzen, C. R., Richardson, L. D., Koenig, W. J., Hoffman, J. R., Lorenz, K. A., Asch, S. M. 2012; 47 (1): 363-379


    To translate a set of evidence-based clinical standards designed to allow paramedics to forego unnecessary and potentially harmful resuscitation attempts into a feasible new policy.Policy documents, meeting minutes, and personal communications between a large urban Emergency Medical Services (EMS) agency serving all of Los Angeles County (LAC) and a research group were reviewed over 12 months.LAC EMS and University of California, Los Angeles (UCLA) formed a partnership (the EMS-UCLA Collaborative) to develop and translate the standards into new EMS protocols. Clinical indicators considered appropriate and feasible by an expert panel were submitted to the agency for inclusion in the new policy.The Collaborative submitted the results to the LAC EMS Commission and a physician advisory group for review. Of the 41 indicators approved by the expert panel, 22 would have resulted in changes to the current policy. All six involved asking family members about or honoring written and verbal Do Not Attempt Resuscitate requests, but only 4 of the 16 indicators based on clinical characteristics were included in the new policy. Ultimately, 10 of the 22 indicators that would have changed policy were approved and implemented.By collaboration, a large EMS agency and a research team were able to develop and implement a revised resuscitation policy within 1 year.

    View details for DOI 10.1111/j.1475-6773.2011.01341.x

    View details for Web of Science ID 000299041600004

    View details for PubMedID 22091960

  • Methods for improving efficiency in quality measurement: the example of pain screening INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Bentley, T. G., Malin, J., Longino, S., Asch, S., Dy, S., Lorenz, K. A. 2011; 23 (6): 657-663


    Collecting unnecessary data when assessing quality of care wastes valuable resources. We evaluated three approaches for estimating quality-measure adherence and determined minimum visit data required to achieve accurate estimates.We abstracted medical records for calculating physician-level pain screening rates as: visit-specific, using single-visit data for each patient; visit-level average, using data for all patients and visits; and patient-level average, using data from a subset of patients and visits.VA Greater Los Angeles Health-care System, 2006.One hundred and six patients with Stage IV solid tumors.Pain screening at every medical encounter, measured by a 0-10 numeric rating scale and reported to the national Medicare insurance program under a 'pay-for-reporting' program.Amount of visit data needed to reach the smallest 95% confidence interval (CI) and stable pain screening estimates.Pain screening occurred at 22% (23/106; 95% CI: 14-30%) of initial visits and 50% (8/16; 95% CI: 25-75%) of single visits. Across all visits, screening adherence averaged 34% when estimated at the visit-level precision and 30% at the patient level. Maximum patient-level precision was reached at visit 4 (95% CI: ± 8%) and visit level at visit 14 (95% CI: ± 6%). Using patient-level and visit-level approaches, estimates stabilized at visits 8 and 11, respectively, and reached within 1 percentage point of the steady-state value at visits 4 and 9.To address low-pain screening among cancer patients, an oncology pain screening measure may be most efficiently evaluated with data from a sample of patients and visits. This approach may be valid for visit-level quality measures in other settings.

    View details for DOI 10.1093/intqhc/mzr054

    View details for Web of Science ID 000297067900006

    View details for PubMedID 21846733

  • Access to care for vulnerable veterans with hepatitis C: a hybrid conceptual framework and a case study to guide translation TRANSLATIONAL BEHAVIORAL MEDICINE Rongey, C., Asch, S., Knight, S. J. 2011; 1 (4): 644-651
  • Access to care for vulnerable veterans with hepatitis C: a hybrid conceptual framework and a case study to guide translation. Translational behavioral medicine Rongey, C., Asch, S., Knight, S. J. 2011; 1 (4): 644-651


    The Veterans Health Administration (VHA) is the largest single provider of medical care to people with hepatitis C (HCV) in the USA. Given the advent of promising new HCV therapies, the VHA is now faced with a large number of chronically HCV-infected veterans with concomitant psychiatric or substance use comorbid conditions who will need to either be retreated or newly treated for HCV or will require management for chronic liver disease. There is a critical need in the VHA for behavioral medicine and hepatology specialists, along with infectious disease and primary care providers with an interest in hepatitis C, to provide coordinated care for these complex patients. The VHA Health Services Research and Development Service has advocated for the application of strong implementation science theories and methods to translate new models of healthcare delivery in clinical practice. To inform the delivery and evaluation of integrated behavioral medicine and specialty care for vulnerable patient populations, we sought to develop an enriched framework which incorporates implementation science theory and strong conceptual models for access to care. In this paper, we present a hybrid conceptual framework that accomplishes this goal. To illustrate how this hybrid model could inform the translation of a novel method of healthcare delivery, we provide a case study of a VHA initiative to improve access to integrated behavioral medicine and specialty care among veterans with HCV.

    View details for DOI 10.1007/s13142-011-0098-z

    View details for PubMedID 24073089

  • Emergency Medicine Physicians' Perspectives of Providing Palliative Care in an Emergency Department JOURNAL OF PALLIATIVE MEDICINE Stone, S. C., Mohanty, S., Grudzen, C. R., Shoenberger, J., Asch, S., Kubricek, K., Lorenz, K. A. 2011; 14 (12): 1333-1338


    This study describes emergency physicians' perspectives on the challenges and benefits to providing palliative care in an academic, urban, public hospital in Los Angeles. Participants underwent a semi-structured interview on their training and experiences related to palliative care, perceptions of providing palliative care, and their recommendations for education and training in this area. Overall, respondents felt that palliative care is not prioritized appropriately, leading patients to be unaware of their options for end-of-life care. Providing educational materials and courses that have been developed from the ED perspective should be included in ongoing continuing medical education. Having a palliative care team that is responsive to the needs of the ED will further enhance collaboration with the ED. Future research should focus on understanding the range of benefits to having palliative care in the ED.

    View details for DOI 10.1089/jpm.2011.0106

    View details for Web of Science ID 000298145800012

    View details for PubMedID 22136262

  • Patterns and Predictors of Short-Term Death After Emergency Department Discharge ANNALS OF EMERGENCY MEDICINE Gabayan, G. Z., Derose, S. F., Asch, S. M., Yiu, S., Lancaster, E. M., Poon, K. T., Hoffman, J. R., Sun, B. C. 2011; 58 (6): 551-558


    The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome; understanding it can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experienced 7-day death after ED discharge.Administrative data from 12 hospitals were used to identify death after discharge in adults aged 18 year or older within 7 days of ED presentation from January 1, 2007, to December 31, 2008. Patients who were nonmembers of the health system, in hospice care, or treated at out-of-network EDs were excluded. Predictors of 7-day postdischarge death were identified with multivariable logistic regression.The study cohort contained a total of 475,829 members, with 728,312 discharges from Kaiser Permanente Southern California EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male sex, and number of preexisting comorbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge included noninfectious lung disease (odds ratio [OR] 7.1; 95% confidence interval [CI] 2.9 to 17.4), renal disease (OR 5.6; 95% CI 2.2 to 14.2), and ischemic heart disease (OR 3.8; 95% CI 1.0 to 13.6).Our study suggests that 50 in 100,000 patients in the United States die within 7 days of discharge from an ED. To our knowledge, our study is the first to identify potentially "high-risk" discharge diagnoses in patients who experience a short-term death after discharge.

    View details for DOI 10.1016/j.annemergmed.2011.07.001

    View details for Web of Science ID 000298224600012

    View details for PubMedID 21802775

  • Exportability of an intervention to increase HIV testing in the Veterans Health Administration. Joint Commission journal on quality and patient safety / Joint Commission Resources Goetz, M. B., Hoang, T., Knapp, H., Henry, S. R., Anaya, H., Chou, A. F., Gifford, A. L., Asch, S. M. 2011; 37 (12): 553-559


    Exportability, or the dissemination of successful health services interventions from one site to another, must be demonstrated before systemwide implementation.The effectiveness of a previously successful multicomponent intervention to increase rates of HIV testing in Veterans Health Administration (VHA) health care facilities among those without records of previous testing was evaluated in two other VHA facilities. Whereas the principle responsibility for the provider-activation component of the intervention was previously borne by research staff, nonresearch staff now took on these responsibilities.The annual rate of HIV testing among persons with documented risk factors for acquiring HIV infection increased by 5.8% and 16% after the end of the first year of implementation for the sites to which the project was newly exported and where nonresearch staff were responsible for implementation. In contrast, for the original implementation sites, where research staff played a major role in implementation, testing rates increased by 9.3% and 12.4%. There was no change in the rate of testing at a control site. At one site, HIV testing rates increased before implementation of the provider activation aspect of the intervention program.An intervention to increase HIV testing rates, which combines informatics, organizational support, and provider activation, can be successfully exported and implemented by nonresearch staff and may not require an extensive provider activation program. The resultant increases in HIV testing are similar to those seen in facilities where research staff play an active role. This work provides support for further efforts to refine this program to promote non-risk-based testing for HIV infection, as per current VHA policy and to more broadly implement this program.

    View details for PubMedID 22235540

  • Provider and Practice Characteristics Associated with Use of Rapid HIV Testing by General Internists JOURNAL OF GENERAL INTERNAL MEDICINE Bass, M. G., Korthuis, P. T., Cofrancesco, J., Berkenblit, G. V., Sullivan, L. E., Asch, S. M., Bashook, P. G., Edison, M., Sosman, J. M., Cook, R. L. 2011; 26 (11): 1258-1264


    Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective.To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers.Web-based cross-sectional survey conducted in 2009.A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings.Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing.Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06).Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing.

    View details for DOI 10.1007/s11606-011-1764-z

    View details for Web of Science ID 000295683500009

    View details for PubMedID 21710314

  • Hospital Determinants of Emergency Department Left Without Being Seen Rates ANNALS OF EMERGENCY MEDICINE Hsia, R. Y., Asch, S. M., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., Sun, B. C. 2011; 58 (1): 24-32


    The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates.We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits.We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status.Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care.

    View details for DOI 10.1016/j.annemergmed.2011.01.009

    View details for Web of Science ID 000292341100008

    View details for PubMedID 21334761

  • GENERAL INTERNISTS' BELIEFS, BEHAVIORS, AND PERCEIVED BARRIERS TO ROUTINE HIV SCREENING IN PRIMARY CARE AIDS EDUCATION AND PREVENTION Korthuis, P. T., Berkenblit, G. V., Sullivan, L. E., Cofrancesco, J., Cook, R. L., Bass, M., Bashook, P. G., Edison, M., Asch, S. M., Sosman, J. M. 2011; 23 (3): 70-83


    The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.

    View details for Web of Science ID 000291763900007

    View details for PubMedID 21689038

  • Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery. Hand (New York, N.Y.) Nuckols, T. K., Maggard Gibbons, M., Harness, N. G., Chang, W. T., Chung, K. C., Asch, S. M. 2011; 6 (2): 119-131


    Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.

    View details for DOI 10.1007/s11552-011-9325-9

    View details for PubMedID 21776197

  • Prescription Sharing, Alcohol Use, and Street Drug Use to Manage Pain Among Veterans JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Goebel, J. R., Compton, P., Zubkoff, L., Lanto, A., Asch, S. M., Sherbourne, C. D., Shugarman, L., Lorenz, K. A. 2011; 41 (5): 848-858


    Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain.This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors.We analyzed cross-sectional data from the Help Veterans Experience Less Pain study.Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior.Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.

    View details for DOI 10.1016/j.jpainsymman.2010.07.009

    View details for Web of Science ID 000290942200008

    View details for PubMedID 21256706

  • Quality of Supportive Care for Patients with Advanced Cancer in a VA Medical Center JOURNAL OF PALLIATIVE MEDICINE Malin, J. L., O'Neill, S. M., Asch, S. M., Dy, S. M., Walling, A. M., Tisnado, D., Antonio, A. L., Lorenz, K. A. 2011; 14 (5): 573-577


    Using the Assessing Symptoms Side Effects and Indicators of Supportive Treatment (ASSIST) quality indicators (QIs), we conducted a comprehensive evaluation of the quality of care provided in our institution to patients diagnosed with advanced cancer in 2006.Patients diagnosed with a Stage IV solid tumor were identified from the hospital's cancer registry. Using data abstracted from medical records, care was assessed using 41 explicit QIs. Mean percent adherence to QIs was calculated overall, as well as across five clinical domains: (1) Pain, (2) Depression and Psychosocial Distress, (3) Dyspnea, (4) Treatment Toxicity, (5) Other Symptoms, and (6) Information and Care Planning.The study cohort (n?=?118) was almost all male (2% female) and mean age was 65.9 years (standard deviation [SD] 9.9 years). The most common cancers were lung and head and neck cancer (23% each); 17% had prostate cancer; 13% had colorectal cancer; and the rest (24%) had breast, esophageal, stomach, genitourinary, liver/biliary, or pancreas cancer. Patients received 51% (95% confidence interval [CI] 48%-54%) of recommended care. Adherence to recommended care within domains ranged from 38% (95% CI 35%-42%) for Other Symptoms to 79% (95% CI 73%-86%) for Information and Care Planning.This study suggests that the quality of supportive care for patients with advanced cancer can be greatly improved. Future efforts should use the ASSIST indicators to evaluate the quality of supportive care in larger and more diverse cohorts of advanced cancer patients.

    View details for DOI 10.1089/jpm.2010.0464

    View details for Web of Science ID 000290756700012

    View details for PubMedID 21413885

  • A provider participatory implementation model for HIV testing in an ED AMERICAN JOURNAL OF EMERGENCY MEDICINE Chen, J. C., Goetz, M. B., Feld, J. E., Taylor, A., Anaya, H., Burgess, J., Flores, R. d., Gidwani, R. A., Knapp, H., Ocampo, E. H., Asch, S. M. 2011; 29 (4): 418-426


    The Centers for Disease Control and Prevention recommends routine HIV screening for adults.Community-based participatory research incorporates subjects in the design and conduct of research. We included nurses and physicians in the implementation of HIV rapid test use in the emergency department (ED). We explored the process, facilitators, and barriers.We identified clinical champions and trained staff. Physicians obtained consent and ordered HIV testing; nurses performed rapid testing. Testing rates were tracked by electronic medical record. We conducted regular meetings between staff and researchers. Semistructured qualitative interviews with providers were conducted at 3 months.By week 15, we administered 121 tests. After the eligibility protocol evolved to incorporate ED nursing concerns regarding staffing limitations from a random sampling model to one focused on testing during nonpeak hours, the weekly number of tests increased. Eighteen percent of providers favored nontargeted HIV screening, 27% favored the current model of testing at nonpeak hours, 32% supported diagnostic testing, and 18% favored no testing or "other." Barriers include written consent, electronic documentation, time constraints, and belief that screening is not a core ED duty. Facilitators include ease of test administration, belief that ED patients are at higher risk, and flexibility to tailor screening efforts according to patient volume.The ED-based HIV testing is feasible within a Veterans Hospital Administration setting. Involvement of nursing in a community-based participatory research implementation model may facilitate staff acceptance of nontargeted HIV screening and be a mechanism to initiate administration of clinical preventive services to ED patients with limited primary care contact.

    View details for DOI 10.1016/j.ajem.2009.11.016

    View details for Web of Science ID 000290574600010

    View details for PubMedID 20825814

  • Development of the Hepatitis C Self-Management Program PATIENT EDUCATION AND COUNSELING Groessl, E. J., Weingart, K. R., Gifford, A. L., Asch, S. M., Ho, S. B. 2011; 83 (2): 252-255


    Chronic hepatitis C infection (HCV) is a major health problem that disproportionately affects people with limited resources. Many people with HCV are ineligible or refuse antiviral treatment, but less curative treatment options exist. These options include adhering to follow-up health visits, lifestyle changes, and avoiding hepatotoxins like alcohol. Herein, we describe a recently developed self-management program designed to assist HCV-infected patients with adherence and improve their health-related quality of life (HRQOL).The development of the Hepatitis C Self-Management Program (HCV-SMP) was informed by scientific literature, qualitative interviews with HCV-infected patients, self-management training, and feedback from HCV clinical experts.The Hepatitis C Self-Management Program (HCV-SMP) is a multi-faceted program that employs cognitive-behavioral principles and is designed to provide HCV-infected people with knowledge and skills for improving their HRQOL. The program consists of six 2-h workshop sessions which are held weekly. The sessions consist of a variety of group activities, including disease-specific information dissemination, action planning, and problem-solving.The intervention teaches skills for adhering to challenging treatment recommendations using a validated theoretical model. A randomized trial will test the efficacy of this novel HCV self-management program for improving HRQOL in a difficult to reach population.

    View details for DOI 10.1016/j.pec.2010.06.006

    View details for Web of Science ID 000290929200020

    View details for PubMedID 20638216

  • The hepatitis C self-management programme: a randomized controlled trial JOURNAL OF VIRAL HEPATITIS Groessl, E. J., Weingart, K. R., Stepnowsky, C. J., Gifford, A. L., Asch, S. M., Ho, S. B. 2011; 18 (5): 358-368


    Chronic hepatitis C (HCV) infection afflicts millions of people worldwide. While antiviral treatments are effective for some patients, many either cannot or choose not to receive antiviral treatment. Education about behavioural changes like alcohol avoidance and symptom management, in contrast, is universally recommended, particularly in HCV-infected persons from disadvantaged groups where liver risk factors are most prevalent. Self-management interventions are one option for fostering improved HCV knowledge and health-related quality of life (HRQOL). One hundred and thirty-two patients with VA with HCV (mean age of 54.6, 95% men, 41% ethnic minority, 83% unmarried, 72% unemployed/disabled, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-h self-management sessions were based on cognitive-behavioural principles and were adapted from an existing self-management programme that has been efficacious with other chronic diseases. HCV-specific modules were added. Outcomes including HRQOL, HCV knowledge, self-efficacy, depression, energy and health distress were measured at baseline and 6 weeks later. Data were analysed using ANOVA. When compared to the information-only group, participants attending the self-management workshop improved more on HCV knowledge (P < 0.001), HCV self-efficacy (P = 0.011), and SF-36 energy/vitality (P = 0.040). Similar trends were found for SF-36 physical functioning (P = 0.055) and health distress (P = 0.055). Attending the self-management programme improved disease knowledge and HRQOL 6 weeks later in this disadvantaged population. The intervention can improve the health of people with hepatitis C, independent of antiviral therapy. Future research will study longer-term outcomes, effects on antiviral treatment and costs.

    View details for DOI 10.1111/j.1365-2893.2010.01328.x

    View details for Web of Science ID 000289251900007

    View details for PubMedID 20529203

  • A review of quality measures used by state and federal prisons. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care Damberg, C. L., Shaw, R., Teleki, S. S., Hiatt, L., Asch, S. M. 2011; 17 (2): 122-137


    In response to deficiencies in the delivery of health care in prisons, a number of state correctional systems and the Federal Bureau of Prisons (BOP) have established quality of care monitoring systems. In 2009, the California Department of Corrections and Rehabilitation and the federal receiver overseeing the system asked the RAND Corporation to identify existing indicators of quality performance and to recommend a set of indicators applicable to the prison population. An environmental scan of quality measures being used by other state correctional systems and the BOP found substantial variation in the number and type of measures being used and the underlying data systems used to construct measures. Explicit quality measures were being used, as were measures of disease prevalence and standards.

    View details for DOI 10.1177/1078345810397605

    View details for PubMedID 21525116

  • Quality of End-of-Life Care for Patients with Advanced Cancer in an Academic Medical Center JOURNAL OF PALLIATIVE MEDICINE Morss, S., Asch, S. M., Lorenz, K. A., Weeks, K., Sharma, R. K., Wolff, A. C., Malin, J. L. 2011; 14 (4): 451-457


    We assessed key aspects of the quality of end-of-life care using validated explicit process quality measures in an academic medical center (hospital and cancer center) before expanding to a broader palliative care initiative.We evaluated 21 indicators most relevant to end-of-life care from the Cancer Quality-ASSIST supportive oncology indicator set for 238 patients with advanced/metastatic solid tumors who died between 2-15 months after diagnosis. These included outpatient and hospital indicators for cancer symptoms and information and care planning that met criteria for feasibility, reliability, and validity. We abstracted detailed information from medical records to specify the necessary data elements.Overall adherence was 53% (95% confidence interval [CI], 50%-56%); this varied widely among indicators. Adherence was highest for pain indicators; in particular, 97% of eligible subjects' hospitalizations had documented screening for pain, and, after an outpatient pain medication was changed, 97% of patients had a pain assessment at the subsequent visit. For other symptoms, adherence ranged from 0% for documentation of life expectancy for patients starting parenteral or enteral nutrition to 87% for assessment of nausea or vomiting on hospital admission. For information and care planning, results ranged from 6% for documentation of ventilation preferences prior to intubation to 68% for documented communication of risks and benefits or prognosis prior to starting chemotherapy.In conclusion, Cancer Quality-ASSIST indicators are useful for practical quality assessment of cancer end-of-life care in an academic medical center. These results will serve as useful data for targeting areas for quality improvement and measuring progress.

    View details for DOI 10.1089/jpm.2010.0434

    View details for Web of Science ID 000289235100015

    View details for PubMedID 21391819

  • The current state of quality of care measurement in the California Department of Corrections and Rehabilitation. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care Teleki, S. S., Damberg, C. L., Shaw, R., Hiatt, L., Williams, B., Hill, T. E., Asch, S. M. 2011; 17 (2): 100-121


    The quality of health care in prisons is lacking in many states. In particular, the California Department of Corrections and Rehabilitation (CDCR) is in the midst of an extreme legal remedy to address problems related to access to and quality of care; it now operates under the direction of a federally appointed receiver for medical care. To understand the current state of access and quality measurement and to assess strengths and weaknesses of current activities, the RAND Corporation conducted a series of interviews and site visits in the CDCR and related offices as well as document reviews (December 2008 to February 2009). Findings supported RAND's larger project goals to identify measures for use in a sustainable quality measurement system.

    View details for DOI 10.1177/1078345810397498

    View details for PubMedID 21525115

  • Selecting performance indicators for prison health care. Journal of correctional health care : the official journal of the National Commission on Correctional Health Care Asch, S. M., Damberg, C. L., Hiatt, L., Teleki, S. S., Shaw, R., Hill, T. E., Benjamin-Johnson, R., Eisenman, D. P., Kulkarni, S. P., Wang, E., Williams, B., Yesus, A., Grudzen, C. R. 2011; 17 (2): 138-149


    Improving prison health care requires a robust measurement dashboard that addresses multiple domains of care. We sought to identify tested indicators of clinical quality and access that prison health managers could use to ascertain gaps in performance and guide quality improvement. We used the RAND/UCLA modified Delphi method to select the best indicators for correctional health. An expert panel rated 111 indicators on validity and feasibility. They voted to retain 79 indicators in areas such as access, cardiac conditions, geriatrics, infectious diseases, medication monitoring, metabolic diseases, obstetrics/gynecology, screening/prevention, psychiatric disorders/substance abuse, pulmonary conditions, and urgent conditions. Prison health institutions, like all other large health institutions, need robust measurement systems. The indicators presented here provide a basic library for prison health managers developing such systems.

    View details for DOI 10.1177/1078345810397712

    View details for PubMedID 21525117

  • Increasing Prevalence of HCC and Cirrhosis in Patients With Chronic Hepatitis C Virus Infection GASTROENTEROLOGY Kanwal, F., Tuyen Hoang, T., Kramer, J. R., Asch, S. M., Goetz, M. B., Zeringue, A., Richardson, P., El-Serag, H. B. 2011; 140 (4): 1182-?


    Patients with hepatitis C virus (HCV) infection are at risk for developing costly and morbid complications, although the actual prevalence of these complications is unknown. We examined time trends in the prevalence of cirrhosis and its related complications, such as hepatic decompensation and hepatocellular carcinoma (HCC).We calculated the annual prevalence of cirrhosis, decompensated cirrhosis, and HCC in a national sample of veterans diagnosed with HCV between 1996 and 2006. Patients with HCV who had at least one physician visit in a given calendar year were included in the analysis of prevalence for that year. We used direct standardization to adjust the prevalence of cirrhosis and related complications for increasing age of the cohort as well as sex and changes in clinical characteristics.In this cohort, the number of individuals with HCV increased from 17,261 in 1996 to 106,242 in 2006. The prevalence of cirrhosis increased from 9% in 1996 to 18.5% in 2006. The prevalence of patients with decompensated cirrhosis doubled, from 5% in 1996 to 11% in 2006, whereas the prevalence of HCC increased approximately 20-fold (0.07% in 1996 to 1.3% in 2006). After adjustment, the time trend in the prevalence of cirrhosis (and its complications) was lower than the crude trend, although it still increased significantly.The prevalence of cirrhosis and HCC in HCV-infected patients has increased significantly over the past 10 years. An aging cohort of patients with HCV could partly explain our findings. Clinicians and health care systems should develop strategies to provide timely and effective care to this high-risk population of patients.

    View details for DOI 10.1053/j.gastro.2010.12.032

    View details for Web of Science ID 000288789900025

    View details for PubMedID 21184757

  • Communication with Families Facing Life-Threatening Illness: A Research-Based Model for Family Conferences JOURNAL OF PALLIATIVE MEDICINE Fineberg, I. C., Kawashima, M., Asch, S. M. 2011; 14 (4): 421-427


    Communication is an ongoing challenge for clinicians working with people facing life-threatening illnesses and end of life. Family conferences offer patient-focused, family-oriented care that brings together patients, family members, and health care providers.The aim of this study was to develop a research-based model for family conferences to help physicians and other health care providers conduct such conferences effectively and improve communication with patients and families.We prospectively studied family conferences for patients facing life-threatening illness in two inpatient medical centers. We videotape and audiotape recorded real-life conferences and postconference interviews with participants.Twenty-four family conferences were included in the study. Participants consisted of 24 patients, 10 of whom took part in the family conferences, 49 family members, and 85 health care providers.A multidisciplinary team conducted a qualitative analysis of the videotaped and audiotaped materials using thematic analysis. The team used a multistage approach to independently and collectively analyze and integrate three data sources.The resulting theoretical model for family conferences has 4 main components. These include the underlying structural context of conference organization and the key process components of negotiation and personal stance. Emotional engagement by health care providers, emotion work, appears central to the impact of these components on the successful outcome of the conference. In addition to the theoretical model, the authors found that family conference participants place specific value on the "simultaneous presence" of conference attendees that leads to being on the "same page."Physicians and other health care professionals can use the model as a guide for conducting family conferences and strengthening communication with patients, families and colleagues.

    View details for DOI 10.1089/jpm.2010.0436

    View details for Web of Science ID 000289235100011

    View details for PubMedID 21385083

  • Quality Measures for the Diagnosis and Non-Operative Management of Carpal Tunnel Syndrome in Occupational Settings JOURNAL OF OCCUPATIONAL REHABILITATION Nuckols, T., Harber, P., Sandin, K., Benner, D., Weng, H., Shaw, R., Griffin, A., Asch, S. 2011; 21 (1): 100-119


    Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations.Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility.Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations.These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

    View details for DOI 10.1007/s10926-010-9260-6

    View details for Web of Science ID 000287505100012

    View details for PubMedID 20737200

  • "I Want To Be Taking My Own Last Breath": Patients' Reflections on Illness When Presenting to the Emergency Department at the End of Life JOURNAL OF PALLIATIVE MEDICINE Grudzen, C. R., Stone, S. C., Mohanty, S. A., Asch, S. M., Lorenz, K. A., Torres, J. M., Morrison, M., Ortiz, J. M., Timmermans, S. 2011; 14 (3): 293-296


    To understand perceptions regarding their illness of patients who present to the Emergency Department at the end of life.Semistructured one-on-one interviews were performed with a convenience sample of seriously ill, Emergency Department (ED) patients with advanced illness presenting to an urban, public hospital. A bilingual Latina health promoter used a predetermined discussion guide to conduct all interviews. Non-English- or Non-Spanish-speaking patients and those with uncontrolled symptoms or cognitive deficits were excluded. All interviews were recorded and transcribed, and grounded theory methodology was used to analyze the results.Thirteen patients with advanced illness participated, 8 of whom were Spanish-speaking only. Because of difficulty accessing care and financial concerns, patients with advanced illness present to EDs when their pain or other symptoms are out of control. The majority derive great comfort and strength from their faith in God, who they believe determines their fate. Most listed spending time with family, and not being a burden, as most important at the end of life, and many expressed a preference to die at home surrounded by loved ones. Almost none had spoken to physicians about their care preferences.Patients with advanced illness present to the ED of a safety net hospital when symptoms are out of control. They have many financial concerns, want to spend their remaining days with family, and do not want to be a burden. Most derive immense comfort from faith in God, but do not feel they have control over their own fate.

    View details for DOI 10.1089/jpm.2010.0306

    View details for Web of Science ID 000287915700011

    View details for PubMedID 21288124

  • Improving Adherence to HIV Quality of Care Indicators in Persons With Opioid Dependence: The Role of Buprenorphine JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Korthuis, P. T., Fiellin, D. A., Fu, R., Lum, P. J., Altice, F. L., Sohler, N., Tozzi, M. J., Asch, S. M., Botsko, M., Fishl, M., Flanigan, T. P., Boverman, J., McCarty, D. 2011; 56: S83-S90


    Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients.We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants.One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (? 8.55; 95% confidence interval, 2.06-15.0).In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.

    View details for Web of Science ID 000287990500013

    View details for PubMedID 21317600

  • Quality indicator set for systemic sclerosis CLINICAL AND EXPERIMENTAL RHEUMATOLOGY Khanna, D., Kowal-Bielecka, O., Khanna, P. P., Lapinska, A., Asch, S. M., Wenger, N., Brown, K. K., Clements, P., Getzug, T., Mayes, M. D., Medsger, T. A., Oudiz, R., Simms, R., Steen, V., Maranian, P., Furst, D. E. 2011; 29 (2): S33-S39


    Systemic sclerosis (SSc) is associated with a marked economic burden, high treatment costs and decreased productivity. Although treatment strategies for SSc can have a substantial effect on patients' outcomes, it is not known whether patients with SSc consistently receive such care. Evaluation of process-of-care quality requires specification of quality indicators (QIs), clinically detailed statements of the eligible patients and the care they should receive to achieve a minimal level of quality of care. Our objective was to develop QIs for patients with SSc.We performed a comprehensive literature review of diagnosis and treatment of SSc and proposed QIs that were evaluated by a national Expert Panel (n=9) who were asked to review the supporting literature and individually rank the validity of each QI. These rankings formed the basis of discussion at a face-to-face meeting following the RAND/UCLA method to integrate expert opinion with literature review to identify a set of final QIs. We then presented these QIs to members of the Scleroderma Clinical Trials Consortium (SCTC).Thirty-two QIs for SSc care were judged valid by the Expert Panel. The QI set includes 9 QIs for newly diagnosed with SSc, 12 follow-up QIs for management of SSc, and 11 treatment QIs. The SCTC experts agreed with the validity of each of the 32 QI and agreed that for all but one QI the specified tests, procedures and treatments recommended in the QI were generally available.We have developed 32 QIs for SSc using a rigorous methodology that can be employed to evaluate and improve care for patients with SSc, as well as inform policy decisions supporting appropriate care for SSc patients.

    View details for Web of Science ID 000291117200006

    View details for PubMedID 21586216

  • Systemic Treatment of Cutaneous Lichen Planus: An Update CUTIS Asch, S., Goldenberg, G. 2011; 87 (3): 129-134


    Lichen planus (LP) is a chronic and remitting dermatosis that may be idiopathic or associated with underlying systemic diseases, such as hepatitis C virus. Although numerous cases of LP resolve spontaneously, many cases require systemic treatment. Several therapeutic advances have occurred in the last 10 years: acitretin (30 mg daily for 8 weeks) remains a first-line therapy (level B, controlled clinical trial >20 participants); systemic corticosteroids are second-line therapies (level C, clinical trial <20 participants, or larger trial without appropriate controls); and new data recommend against the use of tetracycline (level C). This article reviews the current status of systemic therapies for cutaneous LP.

    View details for Web of Science ID 000288830000006

    View details for PubMedID 21488570

  • Effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics ARCHIVES OF INTERNAL MEDICINE Pyne, J. M., Fortney, J. C., Curran, G. M., Tripathi, S., Atkinson, J. H., Kilbourne, A. M., Hagedorn, H. J., Rimland, D., Rodriguez-Barradas, M. C., Monson, T., Bottonari, K. A., Asch, S. M., Gifford, A. L. 2011; 171 (1): 23-31


    Depression is common among persons with the human immunodeficiency virus (HIV) and is associated with unfavorable outcomes.A single-blind randomized controlled effectiveness trial at 3 Veterans Affairs HIV clinics (HIV Translating Initiatives for Depression Into Effective Solutions [HITIDES]). The HITIDES intervention consisted of an off-site HIV depression care team (a registered nurse depression care manager, pharmacist, and psychiatrist) that delivered up to 12 months of collaborative care backed by a Web-based decision support system. Participants who completed the baseline telephone interview were 249 HIV-infected patients with depression, of whom 123 were randomized to the intervention and 126 to usual care. Participant interview data were collected at baseline and at the 6- and 12-month follow-up visits. The primary outcome was depression severity measured using the 20-item Hopkins Symptom Checklist (SCL-20) and reported as treatment response (?50% decrease in SCL-20 item score), remission (mean SCL-20 item score, <0.5), and depression-free days. Secondary outcomes were health-related quality of life, health status, HIV symptom severity, and antidepressant or HIV medication regimen adherence.Intervention participants were more likely to report treatment response (33.3% vs 17.5%) (odds ratio, 2.50; 95% confidence interval [CI], 1.37-4.56) and remission (22.0% vs 11.9%) (2.25; 1.11-4.54) at 6 months but not 12 months. Intervention participants reported more depression-free days during the 12 months (? = 19.3; 95% CI, 10.9-27.6; P < .001). Significant intervention effects were observed for lowering HIV symptom severity at 6 months (? = -2.6; 95% CI, -3.5 to -1.8; P < .001) and 12 months (? = -0.82; -1.6 to -0.07; P = .03). Intervention effects were not significant for other secondary outcomes.The HITIDES intervention improved depression and HIV symptom outcomes and may serve as a model for collaborative care interventions in HIV and other specialty physical health care settings where patients find their "medical home." Identifier: NCT00304915.

    View details for Web of Science ID 000286018100005

    View details for PubMedID 21220657

  • Use of electronic personal health record systems to encourage HIV screening: an exploratory study of patient and provider perspectives. BMC research notes McInnes, D. K., Solomon, J. L., Bokhour, B. G., Asch, S. M., Ross, D., Nazi, K. M., Gifford, A. L. 2011; 4: 295-?


    When detected, HIV can be effectively treated with antiretroviral therapy. Nevertheless in the U.S. approximately 25% of those who are HIV-infected do not know it. Much remains unknown about how to increase HIV testing rates. New Internet outreach methods have the potential to increase disease awareness and screening among patients, especially as electronic personal health records (PHRs) become more widely available. In the US Department of Veterans' Affairs medical care system, 900,000 veterans have indicated an interest in receiving electronic health-related communications through the PHR. Therefore we sought to evaluate the optimal circumstances and conditions for outreach about HIV screening. In an exploratory, qualitative research study we examined patient and provider perceptions of Internet-based outreach to increase HIV screening among veterans who use the Veterans Health Administration (VHA) health care system.We conducted two rounds of focus groups with veterans and healthcare providers at VHA medical centers. The study's first phase elicited general perceptions of an electronic outreach program to increase screening for HIV, diabetes, and high cholesterol. Using phase 1 results, outreach message texts were drafted and then presented to participants in the second phase. Analysis followed modified grounded theory.Patients and providers indicated that electronic outreach through a PHR would provide useful information and would motivate patients to be screened for HIV. Patients believed that electronic information would be more convenient and understandable than information provided verbally. Patients saw little difference between messages about HIV versus about diabetes and cholesterol. Providers, however, felt patients would disapprove of HIV-related messages due to stigma. Providers expected increased workload from the electronic outreach, and thus suggested adding primary care resources and devising methods to smooth the flow of patients getting screened. When provided a choice between unsecured emails versus PHRs as the delivery mechanism for disease screening messages, both patients and providers preferred PHRs.There is considerable potential to use PHR systems for electronic outreach and social marketing to communicate to patients about, and increase rates of, disease screening, including for HIV. Planning for direct-to-patient communications through PHRs should include providers and address provider reservations, especially about workload increases.

    View details for DOI 10.1186/1756-0500-4-295

    View details for PubMedID 21843313

  • Systematic Review Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings MEDICAL CARE Trivedi, A. N., Matula, S., Miake-Lye, I., Glassman, P. A., Shekelle, P., Asch, S. 2011; 49 (1): 76-88


    The Veterans Health Administration, the nation's largest integrated delivery system, launched an organizational transformation in the mid 1990 s to improve the quality of its care.To synthesize the evidence comparing the quality of medical and other nonsurgical care in Veterans Affairs (VA) and non-VA settings.MEDLINE database and bibliographies of retrieved studies.Studies comparing the technical quality of nonsurgical care in VA and US non-VA settings published between 1990 and August 2009.Two physicians independently reviewed 175 unique studies identified using the search strategy and abstracted data related to 6 domains of study quality.Thirty-six studies met the inclusion criteria. All 9 general comparative studies showed greater adherence to accepted processes of care or better health outcomes in the VA compared with care delivered outside the VA. Five studies of mortality following an acute coronary event found no clear survival differences between VA and non-VA settings. Three studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA, and 1 found lower use of clinically-appropriate angiography in the VA. Three studies of diabetes care processes demonstrated a performance advantage for the VA. Studies of hospital mortality found similar risk-adjusted mortality rates in VA and non-VA hospitals.Most studies used decade-old data, assessed self-reported service use, or included only a few VA or non-VA sites.Studies that assessed recommended processes of care almost always demonstrated that the VA performed better than non-VA comparison groups. Studies that assessed risk-adjusted mortality generally found similar rates for patients in VA and non-VA settings.

    View details for DOI 10.1097/MLR.0b013e3181f53575

    View details for Web of Science ID 000285407100011

    View details for PubMedID 20966778

  • Impact of a kiosk educational module on HIV screening rates and patient knowledge JOURNAL OF TELEMEDICINE AND TELECARE Saifu, H. N., Shamouelian, A., Davis, L. G., Santana-Rios, E., Goetz, M. B., Asch, S. M., Sun, B. C. 2011; 17 (8): 446-450


    We assessed the effect of a kiosk educational module on HIV screening rates and patient knowledge about HIV testing. The evaluation was performed in a walk-in clinic offering routine HIV screening. During alternating two-week periods, patients were referred either to view a kiosk-based, educational module prior to receiving usual care, or the kiosk module was turned off and no alterations to care processes were made. The primary outcome was HIV testing rate. The secondary outcome was knowledge about HIV rapid screening, as measured with a questionnaire. There were 71 patients in the kiosk periods and 79 patients in the usual-care periods. The overall HIV testing rate was 41%. The kiosk period was not associated with greater odds of HIV testing (OR 0.7; 95% CI: 0.4-1.4). In 44 patients who completed the knowledge survey, the kiosk group was strongly associated with increased knowledge (predicted increase in knowledge score: 1.3; 95% CI: 036-2.1). The brief kiosk educational module did not improve HIV screening rates, but it increased overall patient knowledge about HIV testing.

    View details for DOI 10.1258/jtt.2011.110415

    View details for Web of Science ID 000298899400009

    View details for PubMedID 21967998

  • Development and implementation of collaborative care for depression in HIV clinics AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Curran, G. M., Pyne, J., Fortney, J. C., Gifford, A., Asch, S. M., Rimland, D., Rodriguez-Barradas, M., Monson, T. P., Kilbourne, A. M., Hagedorn, H., Atkinson, J. H. 2011; 23 (12): 1626-1636


    We sought to develop and implement collaborative depression care in human immunodeficiency virus (HIV) clinics in a project called HIV Translating Initiatives for Depression into Effective Solutions (HITIDES). Here we describe: (i) the formative evaluation (FE) conducted prior to implementation; (ii) the process used to adapt the primary care collaborative care model for depression to specialty HIV clinics; and (iii) the intervention itself. The overall design of HITIDES was a multi-site randomized trial in United States Department of Veterans Affairs (VA) HIV clinics comparing the depression collaborative care intervention to usual depression care. Qualitative methods were used for the FEs and informed the evidence-based quality improvement (EBQI) methods that were used for adapting and implementing the intervention. Baseline assessments were completed by 249 depressed HIV participants. Summaries of respective key informant interviews with eight HIV patients who were receiving depression treatment and 25 HIV or mental health (MH) providers were presented to each site. EBQI methods were used to tailor the HITIDES intervention to each site while maintaining true to the evidence base for depression collaborative care. EBQI methods provided a useful framework for intervention adaptation and implementation. The HITIDES study provides the opportunity to evaluate collaborative depression care in a specialty physical health clinic setting with a population that has a high prevalence of depression and MH comorbidity.

    View details for DOI 10.1080/09540121.2011.579943

    View details for Web of Science ID 000299481400013

    View details for PubMedID 21714689

  • Comparisons of Quality of Surgical Care between the US Department of Veterans Affairs and the Private Sector JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Matula, S. R., Trivedi, A. N., Miake-Lye, I., Glassman, P. A., Shekelle, P., Asch, S. 2010; 211 (6): 823-832
  • Nursing Staff, Patient, and Environmental Factors Associated with Accurate Pain Assessment JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Shugarman, L. R., Goebel, J. R., Lanto, A., Asch, S. M., Sherbourne, C. D., Lee, M. L., Rubenstein, L. V., Wen, L., Meredith, L., Lorenz, K. A. 2010; 40 (5): 723-733


    Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated.This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS).Pain underestimation (N-NRSS-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken.Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.

    View details for DOI 10.1016/j.jpainsymman.2010.02.024

    View details for Web of Science ID 000284671400009

    View details for PubMedID 20692807

  • Development of National and Multiagency HIV Care Quality Measures CLINICAL INFECTIOUS DISEASES Horberg, M. A., Aberg, J. A., Cheever, L. W., Renner, P., Kaleba, E. O., Asch, S. M. 2010; 51 (6): 732-738


    Human immunodeficiency virus (HIV) is now a complex, chronic disease requiring high quality care. Demonstration of quality HIV care requires uniform, aligned HIV care quality measurement.In September 2007, the National Committee for Quality Assurance, under contract with the Health Resources and Services Administration, the Physician Consortium for Performance Improvement of the American Medical Association, and HIV Medicine Association of the Infectious Disease Society of America jointly sponsored and convened an expert panel as a HIV/AIDS Work Group to draft national HIV/AIDS performance measures for individual patient-level and system-level quality improvement.A total of 17 measures were developed to assess processes and outcomes of HIV/AIDS care for patients established in care, defined as having at least 2 visits in a 12-month period; thus, measures of HIV screening, testing, linkage, and access to care were not included. As a set, the measures assess a wide range of care, including patient retention, screening and prophylaxis for opportunistic infections, immunization, and initiation and monitoring of potent antiretroviral therapy. Since development, the HIV/AIDS measures' specifications have been fully determined and are being beta tested, and a majority have been endorsed by the National Quality Forum and have been adopted and implemented by the sponsoring organizations.HIV care quality measurement should be assessed with greater uniformity. The measures presented offer opportunities for such alignment.

    View details for DOI 10.1086/655893

    View details for Web of Science ID 000281143400015

    View details for PubMedID 20715924

  • Does Screening for Pain Correspond to High Quality Care for Veterans? JOURNAL OF GENERAL INTERNAL MEDICINE Zubkoff, L., Lorenz, K. A., Lanto, A. B., Sherbourne, C. D., Goebel, J. R., Glassman, P. A., Shugarman, L. R., Meredith, L. S., Asch, S. M. 2010; 25 (9): 900-905


    Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear.To assess adherence to measures of pain management quality and identify associated patient and provider factors.A cross-sectional visit-based study.One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients.We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that "patients want me to ask about pain" and "pain can have negative consequences on patient's functioning". Charts were more likely to document character of pain if providers agreed that "patients are able to rate their pain". Patients with musculoskeletal pain were less likely to have chart documentation of character of pain.Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening.

    View details for DOI 10.1007/s11606-010-1301-5

    View details for Web of Science ID 000280728300009

    View details for PubMedID 20229139

  • Quality of Care in Patients With Chronic Hepatitis C Virus Infection A Cohort Study ANNALS OF INTERNAL MEDICINE Kanwal, F., Schnitzler, M. S., Bacon, B. R., Hoang, T., Buchanan, P. M., Asch, S. M. 2010; 153 (4): 231-U49


    Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown.To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care.Retrospective cohort study.Nationwide U.S. health insurance company research database.10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator.Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative.Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]).The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care--and not the care itself--is suboptimum.Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care.Saint Louis University Liver Center.

    View details for Web of Science ID 000280973000003

    View details for PubMedID 20713791

  • Measuring Quality of Care in Patients With Nonvariceal Upper Gastrointestinal Hemorrhage: Development of an Explicit Quality Indicator Set AMERICAN JOURNAL OF GASTROENTEROLOGY Kanwal, F., Barkun, A., Gralnek, I. M., Asch, S. M., Kuipers, E. J., Bardou, M., Sung, J., Enns, R., Agreus, L., Armstrong, D., Spiegel, B. M. 2010; 105 (8): 1710-1718


    With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH), it is critical to establish a set of explicit quality indicators (QIs) in NVUGIH.We conducted a nine-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for NVUGIH. The panel performed independent ratings of each candidate QI using a nine-point RAND appropriateness scale, then met in person and re-voted using an iterative process of discussion. The final set comprised QIs with a median RAND Appropriateness Score >or=7 and no disagreement among experts.Among 116 candidate QIs, the panel rated 26 as valid measures of quality care. The selected QIs cover pre-endoscopy, endoscopy, and post-endoscopy care, including diagnosis, early resuscitation, risk stratification, endoscopic care, Helicobacter pylori management, and proton pump inhibitor therapy.We have developed an explicit set of evidence-based QIs in NVUGIH, providing physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in all institutions providing care for NVUGIH patients.

    View details for DOI 10.1038/ajg.2010.180

    View details for Web of Science ID 000280656800001

    View details for PubMedID 20686458

  • An Explicit Quality Indicator Set for Measurement of Quality of Care in Patients With Cirrhosis CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Kanwal, F., Kramer, J., Asch, S. M., El-Serag, H., Spiegel, B. M., Edmundowicz, S., Sanyal, A. J., Dominitz, J. A., Mcquaid, K. R., Martin, P., Keeffe, E. B., Friedman, L. S., Ho, S. B., Durazo, F., Bacon, B. R. 2010; 8 (8): 709-717


    Cirrhosis is a prevalent and expensive condition. With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with cirrhosis, we established a set of explicit quality indicators (QIs) for their treatment.We organized an 11-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for cirrhosis. We provided the panel with a report that summarized the results of a comprehensive literature review of data linking candidate QIs to outcomes. The panel performed independent ratings of each candidate QI by using a standard 9-point RAND appropriateness scale (RAS) (ranging from 1 = not appropriate to 9 = most appropriate). The panel members then met, reviewed the ratings, and voted again by using an iterative process of discussion. The final set of QIs was selected; QIs had a median RAS >7, and panel members agreed on those selected.Among 169 candidate QIs, the panel rated 41 QIs as valid measures of quality care. The selected QIs cover 6 domains of care including ascites (13 QIs), variceal bleeding (18 QIs), hepatic encephalopathy (4 QIs), hepatocellular cancer (1 QI), liver transplantation (2 QIs), and general cirrhosis care (3 QIs). Content coverage included prevention, diagnosis, treatment, timeliness, and follow-up.We developed an explicit set of evidence-based QIs for treatment of cirrhosis. These provide physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in any setting where care for patients with cirrhosis is provided.

    View details for DOI 10.1016/j.cgh.2010.03.028

    View details for Web of Science ID 000280938200016

    View details for PubMedID 20385251

  • Cost of Rapid HIV Testing at 45 US Hospitals AIDS PATIENT CARE AND STDS Pinkerton, S. D., Bogart, L. M., Howerton, D., Snyder, S., Becker, K., Asch, S. M. 2010; 24 (7): 409-413


    In 2006, the United States Centers for Disease Control and Prevention (CDC) recommended expanded and routine use of single-session rapid HIV tests in all health care settings to increase the proportion of persons who learn their HIV status. Limited empiric information is available regarding the costs of rapid testing and pre- and posttest counseling in health care settings. We surveyed 45 U.S. hospitals during 2005 through 2006 to assess the costs associated with rapid testing and counseling. Cost analyses were conducted from the provider (hospital) perspective, and results were expressed in year 2006 U.S. dollars. The mean per-test cost of rapid HIV testing and counseling was $48.07 for an HIV-negative test and $64.17 for a preliminary-positive test. Pre- and posttest counseling costs accounted for 38.4% of the total cost of rapid testing for HIV-negative patients. Counseling costs were significantly correlated with overall test costs. Many hospitals contained overall test costs by limiting time spent in pre- and posttest counseling or by using lower-paid personnel for counseling activities or both. Counseling costs constituted a significant proportion of the overall costs of rapid testing and counseling activities at study hospitals. Our data provide useful baseline data before implementation of the CDC's 2006 recommendations. Costs can be reduced by limiting time spent in pre- and posttest counseling or by using lower-paid personnel for counseling activities or both.

    View details for DOI 10.1089/apc.2009.0348

    View details for Web of Science ID 000280224500002

    View details for PubMedID 20578906

  • Indications for Performing Carpal Tunnel Surgery: Clinical Quality Measures PLASTIC AND RECONSTRUCTIVE SURGERY Maggard, M. A., Harness, N. G., Chang, W. T., Parikh, J. A., Asch, S. M., Nuckols, T. K. 2010; 126 (1): 169-179


    Rates of carpal tunnel surgery vary for unclear reasons. In this study, the authors developed measures determining when surgery is necessary (benefits exceed risks), inappropriate (risks outweigh benefits), or optional.Measures were developed using a modified-Delphi panel. Clinical scenarios were defined incorporating symptom severity, symptom duration, clinical probability of carpal tunnel syndrome, electrodiagnostic testing, and nonoperative treatment response. A multidisciplinary panel of 11 carpal tunnel syndrome experts rated appropriateness of surgery for each scenario on a scale ranging from 1 to 9 scale (7 to 9, surgery is necessary; 1 to 3, surgery is inappropriate).Of 90 scenarios (36 for mild, 36 for moderate, and 18 for severe symptoms), panelists judged carpal tunnel surgery as necessary for 16, inappropriate for 37, and optional for 37 scenarios. For mild symptoms, surgery is generally necessary when clinical probability of carpal tunnel syndrome is high, there is a positive electrodiagnostic test, and there has been unsuccessful nonoperative treatment. For moderate symptoms, surgery is generally necessary with a positive electrodiagnostic test involving two or more of the following: high clinical probability, unsuccessful nonoperative treatment, and symptoms lasting longer than 12 months. Surgery is generally inappropriate for mild to moderate symptoms involving two or more of the following: low clinical probability, no electrodiagnostic confirmation, and nonoperative treatment not attempted. For severe symptoms, surgery is generally necessary with a positive electrodiagnostic test or unsuccessful nonoperative treatment.These are the first formal measures assessing appropriateness of carpal tunnel surgery. Applying these measures can identify underuse (failure to provide necessary care) and overuse (providing inappropriate care), giving insight into variations in receipt of this procedure.

    View details for DOI 10.1097/PRS.0b013e3181da8685

    View details for Web of Science ID 000279097500021

    View details for PubMedID 20595866

  • Cancer Quality-ASSIST Supportive Oncology Quality Indicator Set Feasibility, Reliability, and Validity Testing CANCER Dy, S. M., Lorenz, K. A., ONeill, S. M., Asch, S. M., Walling, A. M., Tisnado, D., Antonio, A. L., Malin, J. L. 2010; 116 (13): 3267-3275


    Although measuring the quality of symptom management and end-of-life care could help provide a basis for improving supportive care for advanced cancer, few quality indicators in this area have been rigorously developed or evaluated.The authors conducted a pilot evaluation of a comprehensive set of 92 supportive oncology quality indicators, Cancer Quality-ASSIST, including outpatient and hospital indicators for symptoms commonly related to cancer and its treatment and information and care planning. They operationalized the indicators and developed an electronic abstraction tool and extensive guidelines and training materials. Quality assurance nurses abstracted the medical records for 356 advanced cancer patients in 2 settings: a Veterans Administration hospital and an academic hospital and cancer center. The authors evaluated the indicators' feasibility, inter-rater reliability, and validity.The authors successfully evaluated 78 indicators across the domains; results were similar in the 2 settings. They could not feasibly evaluate 3 indicators because of low prevalence; 22 indicators had significant inter-rater reliability issues, 9 had significant validity issues, and 3 had both reliability and validity issues, leaving a set of 41 indicators most promising for further testing and use in this population, with an overall kappa score of 0.85 for specified care.Of 92 Cancer Quality-ASSIST quality indicators for symptoms, treatment toxicity, and information and care planning, 41 were sufficiently feasible, reliable, and valid to be used for patients with advanced cancer in these settings. This set of indicators shows promise for describing key supportive care processes in advanced cancer.

    View details for DOI 10.1002/cncr.25109

    View details for Web of Science ID 000279208900027

    View details for PubMedID 20564637

  • The Quality of Care Provided to Hospitalized Patients at the End of Life 32nd Annual National Meeting of the Society-for-General-Internal-Medicine Walling, A. M., Asch, S. M., Lorenz, K. A., Roth, C. P., Barry, T., Kahn, K. L., Wenger, N. S. AMER MEDICAL ASSOC. 2010: 1057?63


    Patients in American hospitals receive intensive medical treatments. However, when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care. Systematic measurement of the quality of care planning and symptom palliation is needed.Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators within the domains of end-of-life care and pain management designed to measure the quality of the dying experience for adult decedents (n = 496) hospitalized for at least 3 days between April 2005 and April 2006 at a university medical center recognized for providing intensive care for the seriously ill.Over half of the patients (mean age, 62 years; 47% were women) were admitted to the hospital with end-stage disease, and 28% were 75 years or older. One-third of the patients required extubation from mechanical ventilation prior to death, and 15% died while receiving cardiopulmonary resuscitation. Overall, patients received recommended care for 70% of applicable indicators (range, 25%-100%). Goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time, whereas pain assessments (94%) and treatments for pain (95%) and dyspnea (87%) were performed with fidelity. Follow-up for distressing symptoms was performed less well than initial assessment, and 29% of patients extubated in anticipation of death had documented dyspnea assessments.A practical, medical chart-based assessment identified discrete deficiencies in care planning and symptom palliation that can be targeted to improve care for patients dying in the hospital.

    View details for Web of Science ID 000279245000012

    View details for PubMedID 20585072

  • Cost-Effectiveness of Strategies to Improve HIV Testing and Receipt of Results: Economic Analysis of a Randomized Controlled Trial JOURNAL OF GENERAL INTERNAL MEDICINE Sanders, G. D., Anaya, H. D., Asch, S., Hoang, T., Golden, J. F., Bayoumi, A. M., Owens, D. K. 2010; 25 (6): 556-563


    The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results.To examine the costs and benefits of strategies to improve HIV testing and receipt of results.Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature. SETTING/TARGET POPULATION: Primary-care patients with unknown HIV status.Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling.Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness.Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by $53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of $36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses.In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.

    View details for DOI 10.1007/s11606-010-1265-5

    View details for Web of Science ID 000277712200015

    View details for PubMedID 20204538

  • The LA story: What happened after a new policy allowing paramedics to forgo resuscitation attempts in prehospital cardiac arrest RESUSCITATION Grudzen, C. R., Hoffman, J. R., Koenig, W. J., Boscardin, J., Lorenz, K. A., Asch, S. M. 2010; 81 (6): 685-690


    Despite potential harm to patients, families, and emergency personnel, a low survival rate, and high costs and intensity of care, attempting resuscitation after prehospital cardiac arrest is the norm, unless there are signs of irreversible death or the presence of a valid, state-issued DNR.To determine whether there was a change in the rate of forgoing resuscitation attempts in prehospital cardiac arrest after implementation of a new policy allowing paramedics to forgo resuscitation based on a verbal family request or the presence of certain arrest characteristics.All prehospital run sheets for cardiac arrest in Los Angeles County were reviewed for the first seven days of each month August 2006-January 2007 (pre-policy) and January-June 2008 (post-policy). Paramedics were more likely to forgo resuscitation attempts after the policy change (13.3% vs. 8.5%, p<0.01). In addition, the percentage of patients with documented signs of irreversible death decreased post-policy, from 50.4% to 35.8%, p<0.01. After adjustment for potential confounders (patient demographics, clinical characteristics and EMS factors), as well as exclusion of patients with signs of irreversible death, paramedics are significantly more likely to forgo a resuscitation, and less likely to attempt resuscitation, after the policy change (OR 1.67 [95% CI 1.07, 2.61], p=0.024).Paramedics are more likely to forgo, and less likely to attempt, resuscitation in victims of cardiac arrest after implementation of a new policy. There was also an associated decrease in the percentage of patients who had signs of irreversible death, which might reflect a change in paramedic behavior.

    View details for DOI 10.1016/j.resuscitation.2010.02.011

    View details for Web of Science ID 000279087900012

    View details for PubMedID 20236748

  • Provider-related Barriers to Rapid HIV Testing in US Urban Non-profit Community Clinics, Community-based Organizations (CBOs) and Hospitals AIDS AND BEHAVIOR Bogart, L. M., Howerton, D., Lange, J., Setodji, C. M., Becker, K., Klein, D. J., Asch, S. M. 2010; 14 (3): 697-707


    We examined provider-reported barriers to rapid HIV testing in U.S. urban non-profit community clinics, community-based organizations (CBOs), and hospitals. 12 primary metropolitan statistical areas (PMSAs; three per region) were sampled randomly, with sampling weights proportional to AIDS case reports. Across PMSAs, all 671 hospitals and a random sample of 738 clinics/CBOs were telephoned for a survey on rapid HIV test availability. Of the 671 hospitals, 172 hospitals were randomly selected for barriers questions, for which 158 laboratory and 136 department staff were eligible and interviewed in 2005. Of the 738 clinics/CBOs, 276 were randomly selected for barriers questions, 206 were reached, and 118 were eligible and interviewed in 2005-2006. In multivariate models, barriers regarding translation of administrative/quality assurance policies into practice were significantly associated with rapid HIV testing availability. For greater rapid testing diffusion, policies are needed to reduce administrative barriers and provide quality assurance training to non-laboratory staff.

    View details for DOI 10.1007/s10461-008-9456-3

    View details for Web of Science ID 000277410500023

    View details for PubMedID 18770022

  • Addressing Patients' Concerns about Pain Management and Addiction Risks PAIN MANAGEMENT NURSING Goebel, J. R., Sherbourne, C. D., Asch, S. M., Meredith, L., Cohen, A. B., Hagenmaier, E., Lanto, A. B., Simon, B., Rubenstein, L. V., Shugarman, L. R., Lorenz, K. A. 2010; 11 (2): 92-98


    Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p=.004). Nursing staff with more years' experience (OR 1.070; p=.005) and higher levels of self-efficacy/confidence (OR 1.380; p=.001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.

    View details for DOI 10.1016/j.pmn.2009.03.009

    View details for Web of Science ID 000278748700005

    View details for PubMedID 20510839

  • Feasibility of Discussing End-of-Life Care Goals with Inpatients Using a Structured, Conversational Approach: The Go Wish Card Game JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Lankarani-Fard, A., Knapp, H., Lorenz, K. A., Golden, J. F., Taylor, A., Feld, J. E., Shugarman, L. R., Malloy, D., Menkin, E. S., Asch, S. M. 2010; 39 (4): 637-643


    Establishing goals of care is important in advance care planning. However, such discussions require a significant time investment on the part of trained personnel and may be overwhelming for the patient. The Go Wish card game was designed to allow patients to consider the importance of common issues at the end of life in a nonconfrontational setting. By sorting through their values in private, patients may present to their provider ready to have a focused conversation about end-of-life care. We evaluated the feasibility of using the Go Wish card game with seriously ill patients in the hospital. Of 133 inpatients approached, 33 (25%) were able to complete the game. The "top 10" values were scored based on frequency and adjusted for rank. The value selected of highest importance by the most subjects was "to be free from pain." Other highly ranked values concerned spirituality, maintaining a sense of self, symptom management, and establishing a strong relationship with health care professionals. Average time to review the patient's rank list after the patient sorted their values in private was 21.8 minutes (range: 6-45 minutes). The rankings from the Go Wish game are similar to those from other surveys of seriously ill patients. Our results suggest that it is feasible to use the Go Wish card game even in the chaotic inpatient setting to obtain an accurate portrayal of the patient's goals of care in a time-efficient manner.

    View details for DOI 10.1016/j.jpainsymman.2009.08.011

    View details for Web of Science ID 000277372800002

    View details for PubMedID 20413053

  • CLINICAL QUALITY MEASURES FOR ELECTRODIAGNOSIS IN SUSPECTED CARPAL TUNNEL SYNDROME MUSCLE & NERVE Sandin, K. J., Asch, S. M., Jablecki, C. K., Kilmer, D. D., Nuckols, T. K. 2010; 41 (4): 444-452


    Extensive research has documented that medical care in the United States is not of optimal quality, meaning that well-established care processes are not consistently provided to the patients who would benefit from them. To assess and improve quality of care, specific measures are needed. The objective of this study was to develop quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS). We used a variation of the well-established RAND/UCLA Appropriateness Method to develop the measures. A physiatrist and quality measurement experts developed draft measures based on guidelines and literature. Subsequently, in a two-round, modified-Delphi process, a multidisciplinary panel of 11 national experts in CTS reviewed a summary of the evidence and then rated the measures for validity and feasibility. Seven draft measures were developed. The expert panel combined two, modified the others, and then judged all resulting measures to be valid and feasible. The measures cover compelling indications for testing, essential test components when CTS is suspected, skin temperature measurement and normalization, and the appropriate interpretation of test results. These measures define a minimum standard of care for the use of electrodiagnostic tests in suspected CTS and are consistent with recent guidelines developed by the American Association of Neuromuscular and Electrodiagnostic Medicine. Provider organizations, insurance companies, and professional societies can use these measures in efforts to monitor and improve quality of care for this common and disabling condition.

    View details for DOI 10.1002/mus.21617

    View details for Web of Science ID 000276585800003

    View details for PubMedID 20336661

  • A Review of Quality of Care Evaluation for the Palliation of Dyspnea AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Basch, E., Maxwell, T. L., Hoverman, J. R., Cuny, J., Clauser, S. B., Snyder, C., Seow, H., Wu, A. W., Dy, S. 2010; 181 (6): 534-538


    Assessment and management of dyspnea has emerged as a priority topic for quality evaluation and improvement. Evaluating dyspnea quality of care requires valid, reliable, and responsive measures of the care provided to patients across settings and diseases. As part of an Agency for Healthcare Research and Quality Symposium, we reviewed quality of care measures for dyspnea by compiling quality measures identified in systematic searches and reviews. Systematic reviews identified only three existing quality measurement sets that included quality measures for dyspnea care. The existing dyspnea quality measures reported by retrospective evaluations of care assess only four aspects: dyspnea assessment within 48 hours of hospital admission, use of objective scales to rate dyspnea severity, identification of management plans, and evidence of dyspnea reduction. To begin to improve care, clinicians need to assess and regularly document patient's experiences of dyspnea. There is no consensus on how dyspnea should be characterized for quality measurement, and although over 40 tools exist to assess dyspnea, no rating scale or instrument is ideal for palliative care. The panel recommended that dyspnea assessment should include a measure of intensity and some inquiry into the associated bother or distress experienced by the patient. A simple question into the presence or absence of dyspnea would be unlikely to help guide therapy, as complete relief of dyspnea in advanced disease would not be anticipated. Additional knowledge gaps include standards for clinical dyspnea care, assessment in the cognitively impaired, and evaluation of effectiveness of dyspnea care for patients with advanced disease.

    View details for DOI 10.1164/rccm.200903-0462PP

    View details for Web of Science ID 000280446500005

    View details for PubMedID 20056904

  • Adoption and Use of Stand-Alone Electronic Prescribing in a Health Plan-Sponsored Initiative AMERICAN JOURNAL OF MANAGED CARE Pevnick, J. M., Asch, S. M., Adams, J. L., Mattke, S., Patel, M. H., Ettner, S. L., Bell, D. S. 2010; 16 (3): 182-189


    To quantify rates of stand-alone e-prescribing (SEP) adoption and use among primary care physicians (PCPs) participating in a SEP initiative and to determine which physician and patient characteristics were associated with higher rates of each.Using records from an insurer-led SEP initiative, we compared the characteristics of 297 PCPs who adopted SEP through the initiative with the characteristics of 1892 eligible PCPs who did not. Among 297 adopters, we studied the extent of SEP use.Dependent variables included each physician's adoption of SEP and his or her e-prescribing use ratio (the ratio of electronic prescriptions to pharmacy claims in the same period). Independent variables included characteristics of PCPs (specialty, practice size, and prescribing volume) and their patients (patient age, sex, race/ethnicity, and household income).Solo practitioners, pediatricians, and physicians with more patients from predominantly African American zip codes were underrepresented among SEP adopters. The mean (SD) e-prescribing use ratio among adopters was 0.23 (0.28). Twenty percent of physicians maintained e-prescribing use ratios above 0.50. Available physician characteristics explained little of the variance in use, but physicians in smaller practices had greater use (P = .02).Certain categories of physicians may need more tailored incentives to adopt SEP. On average, adopters used the SEP system for only about one-quarter of their prescriptions. Some adopters achieved high levels of SEP use, and further research is needed to elucidate the factors that enabled this.

    View details for Web of Science ID 000275483400003

    View details for PubMedID 20225913

  • Effect of an education kiosk on patient knowledge about rapid HIV screening JOURNAL OF TELEMEDICINE AND TELECARE Sun, B. C., Knapp, H., Shamouelian, A., Golden, J., Goetz, M. B., Asch, S. M. 2010; 16 (3): 158-161


    Patient education is an important part of routine HIV screening. In a pilot study, we assessed the effect of a computer kiosk education module on patient knowledge about routine HIV screening. A systematic sample of walk-in clinic patients completed a questionnaire before and after using the education module. The primary outcome was a composite nine-point knowledge score. Secondary outcomes included willingness to undergo HIV screening and patient satisfaction. Of 185 patients who were eligible to participate, 100 completed the study. The median duration of kiosk interaction was 3.9 min. The median knowledge score increased from 7 to 8 (P < 0.0001) after viewing the module. There was no significant change in the proportion of patients who were interested in HIV screening. The majority of patients expressed excellent (38%) or very good (39%) satisfaction with the kiosk module. The results suggest that a computer kiosk can deliver brief and targeted education to improve knowledge about HIV screening.

    View details for DOI 10.1258/jtt.2009.090815

    View details for Web of Science ID 000277665600010

    View details for PubMedID 20386037

  • Factors Associated with Clinician Intention to Address Diverse Aspects of Pain in Seriously III Outpatients PAIN MEDICINE Shugarman, L. R., Asch, S. M., Meredith, L. S., Sherbourne, C. D., Hagenmeier, E., Wen, L., Cohen, A., Rubenstein, L. V., Goebel, J., Lanto, A., Lorenz, K. A. 2010; 11 (9): 1365-1372


    Pain is a common, often undertreated problem among patients with palliative needs.To evaluate clinician factors associated with intention to address diverse aspects of pain.Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy. Clinicians were surveyed about their intentions for treatment.All 280 primary care and specialist clinicians working in 19 hospital and community-based primary care, oncology, and cardiology clinics at eight geographically dispersed sites in two large VA hospital systems.Endpoints were clinician intention to deliver guideline-concordant care: prescribe opioids/antidepressants, assess existential wellbeing, and offer mental health referral. Demographic and behavioral measures were evaluated in association with endpoints.Of 208 (74%) responding practitioners, 189 were responsible for prescribing decisions. Of those, 86, 77, 75, and 69 were "very"/"somewhat likely" to prescribe opioids, antidepressants, refer to a mental health specialist, or assess existential wellbeing, respectively. Factors associated with greater intent to prescribe an opioid or antidepressant included female gender, being an attending physician, being a primary care clinician, and greater confidence in pain management skills. Greater trust in the validity of pain ratings was associated with intent to prescribe an antidepressant and assess existential wellbeing. Prescribing opioids was less likely if perceived as an administrative burden. Assessing existential wellbeing was less likely if time constraints were perceived a barrier to evaluating pain. Female gender was the only factor associated with intent to refer to a mental health specialist.Our findings suggest useful targets for improving pain management include bolstering clinician confidence in pain management and their trust in pain ratings.

    View details for Web of Science ID 000281638100008

    View details for PubMedID 20807347

  • Predictors of Short-Term (Seven-Day) Cardiac Outcomes After Emergency Department Visit for Syncope AMERICAN JOURNAL OF CARDIOLOGY Gabayan, G. Z., Derose, S. F., Asch, S. M., Chiu, V. Y., Glenn, S. C., Mangione, C. M., Sun, B. C. 2010; 105 (1): 82-86


    Syncope is a common reason for emergency department (ED) visits, and patients are often admitted to exclude syncope of cardiovascular origin. Population-based data on patterns and predictors of cardiac outcomes may improve decision-making. Our objective was to identify patterns and predictors of short-term cardiac outcomes in ED patients with syncope. Administrative data from an integrated health system of 11 Southern California EDs were used to identify cardiac outcomes after ED presentation for syncope from January 1, 2002, to December 31, 2005. Syncope and cause of death were identified by codes from the International Classification of Disease, Ninth Revision. Cardiac outcomes included cardiac death and hospitalization or procedure consistent with ischemic heart disease, valvular disease, or arrhythmia. Predictors of cardiac outcomes were identified through multivariate logistic regression. There were 35,330 adult subjects who accounted for 39,943 ED visits for syncope. Risk of cardiac outcome sharply decreased following the 7 days after syncope. A 7-day cardiac outcome occurred in 893 cases (3%). Positive predictors of 7-day cardiac outcomes included age > or =60 years, male gender, congestive heart failure, ischemic heart disease, cardiac arrhythmia, and valvular heart disease. Negative predictors included dementia, pacemaker, coronary revascularization, and cerebrovascular disease. There was an age-dependent relation between 7-day cardiac outcomes and arrhythmia and valvular disease, with younger patients (<60 years of age) having greater risk of an event compared to their same-age counterparts. In conclusion, ED decision-making should focus on risk of cardiac event in the first 7 days after syncope and special attention should be given to younger patients with cardiac co-morbidities.

    View details for DOI 10.1016/j.amjcard.2009.08.654

    View details for Web of Science ID 000278136200014

    View details for PubMedID 20102895

  • Program Characteristics Associated With Testing for HIV and Hepatitis C in Veterans Substance Use Disorder Clinics PSYCHIATRIC SERVICES McInnes, D. K., Hyun, J. K., Trafton, J. A., Asch, S. M., Gifford, A. L. 2010; 61 (1): 90-94


    This study examined whether organizational characteristics and quality improvement initiatives were related to HIV and hepatitis C (HCV) testing rates in veterans' substance use disorders programs.Data were collected by surveying 232 program directors at all U.S. Department of Veterans Affairs (VA) substance use disorder programs.Program directors (N=223) reported that, on average, 35% of their patients were tested for HIV (median=10%) and 57% were tested for HCV (median=80%). Of the quality improvement initiatives examined, computerized reminders to clinicians (p=.02) and a designated clinician for screening (p=.01) were positively associated with HCV testing, and computerized templates that guide clinicians through ordering of testing were positively associated with HIV testing (p=.06).Despite national emphasis on HIV testing, rates of testing were lower for HIV than for HCV in programs serving veterans with substance use disorders and at risk of both illnesses. System-level quality improvement initiatives may be effective at increasing rates of infectious disease screening.

    View details for Web of Science ID 000273234800018

    View details for PubMedID 20044426

  • A Low-Literacy Medication Education Tool for Safety-Net Hospital Patients Annual Meeting of the Robert Wood Johnson Clinical Scholars Cordasco, K. M., Asch, S. M., Bell, D. S., Guterman, J. J., Gross-Schulman, S., Ramer, L., Elkayam, U., Franco, I., Leatherwood, C. L., Mangione, C. M. ELSEVIER SCIENCE INC. 2009: S209?S216


    To improve medication adherence in cardiac patients, in partnership with a safety-net provider, this research team developed and evaluated a low-literacy medication education tool.Using principles of community-based participatory research, the team developed a prototype of a low-literacy hospital discharge medication education tool, customizable for each patient, featuring instruction-specific icons and pictures of pills. In 2007, a randomized controlled clinical trial was performed, testing the tool's effect on posthospitalization self-reported medication adherence and knowledge, 2 weeks postdischarge in English- and Spanish-speaking safety-net inpatients. To validate the self-report measure, 4 weeks postdischarge, investigators collected self-reports of the number of pills remaining for each medication in a subsample of participants. Nurses rated tool acceptability.Among the 166/210 eligible participants (79%) completing the Week-2 interview, self-reported medication adherence was 70% (95% CI=62%, 79%) in intervention participants and 78% (95% CI=72%, 84%) in controls (p=0.13). Among the 85 participants (31%) completing the Week-4 interview, self-reported pill counts indicated high adherence (greater than 90%) and did not differ between study arms. Self-reported adherence was correlated with self-reported pill count in intervention participants (R=0.5, p=0.004) but not in controls (R=0.07, p=0.65). There were no differences by study arm in medication knowledge. The nurses rated the tool as highly acceptable.Although the evaluation did not demonstrate the tool to have any effect on self-reported medication adherence, patients who received the schedule self-reported their medication adherence more accurately, perhaps indicating improved understanding of their medication regimen and awareness of non-adherence.

    View details for DOI 10.1016/j.amepre.2009.08.018

    View details for Web of Science ID 000272770000005

    View details for PubMedID 19896021

  • Improving Latino Disaster Preparedness Using Social Networks AMERICAN JOURNAL OF PREVENTIVE MEDICINE Eisenman, D. P., Glik, D., Gonzalez, L., Maranon, R., Zhou, Q., Tseng, C., Asch, S. M. 2009; 37 (6): 512-517


    Culturally targeted, informal social networking approaches to improving disaster preparedness have not been empirically tested.In partnership with community health promoters and the Los Angeles County Department of Public Health, this study tested a disaster preparedness program for Latino households.This study had a community-based, randomized, longitudinal cohort design with two groups and was conducted during February-October 2007. Assessments were made at baseline and 3 months. Analyses were carried out January-October 2008. SETTINGS/PARTICIPANTS: Community-based study of 231 Latinos living in Los Angeles County.Participants were randomly assigned to attending platicas (small-group discussions led by a health promoter/promotora de salud) or receiving "media" (a culturally tailored mailer). A total of 187 (81.0%) completed the 3-month follow-up.A self-reported disaster preparedness checklist was used.Among participants who did not have emergency water pre-intervention, 93.3% of those in the platica arm had it at follow-up, compared to 66.7% in the media arm (p=0.003). Among participants who did not have food pre-intervention, 91.7% in the platica arm reported it at follow-up, compared to 60.6% in the media arm (p=0.013). Finally, among participants who did not have a family communication plan pre-intervention, 70.4% in the platica arm reported one at follow-up, compared to 42.3% in the media arm (p=0.002).Although both arms improved in stockpiling water and food and creating a communication plan, the platica arm showed greater improvement than the media group.

    View details for DOI 10.1016/j.amepre.2009.07.022

    View details for Web of Science ID 000272769700007

    View details for PubMedID 19944917

  • Evaluation of the Sustainability of an Intervention to Increase HIV Testing JOURNAL OF GENERAL INTERNAL MEDICINE Goetz, M. B., Hoang, T., Henry, S. R., Knapp, H., Anaya, H. D., Gifford, A. L., Asch, S. M. 2009; 24 (12): 1275-1280


    Sustainability-the routinization and institutionalization of processes that improve the quality of healthcare-is difficult to achieve and not often studied.To evaluate the sustainability of increased rates of HIV testing after implementation of a multi-component intervention in two Veterans Health Administration healthcare systems.Quasi-experimental implementation study in which the effect of transferring responsibility to conduct the provider education component of the intervention from research to operational staff was assessed.Persons receiving healthcare between 2005 and 2006 (intervention year) and 2006 and 2007 (sustainability year).Monthly HIV testing rate, stratified by frequency of clinic visits.The monthly adjusted testing rate increased from 2% at baseline to 6% at the end intervention year and then declined reaching 4% at the end of the sustainability year. However, the stratified, visit-specific testing rate for persons newly exposed to the intervention (i.e., having their first through third visits during the study period) increased throughout the intervention and sustainability years. Increases in the proportion of visits by patients who remained untested despite multiple, prior exposures to the intervention accounted for the aggregate attenuation of testing during the sustainability year. Overall, the percentage of patients who received an HIV test in the sustainability year was 11.6%, in the intervention year 11.1%, and in the pre-intervention year 5.0%Provider education combined with informatics and organizational support had a sustainable effect on HIV testing rates. The effect was most pronounced during patients' early contacts with the healthcare system.

    View details for DOI 10.1007/s11606-009-1120-8

    View details for Web of Science ID 000272375400003

    View details for PubMedID 19798538

  • Heart Failure: The Hidden Problem of Pain JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Goebel, J. R., Doering, L. V., Shugarman, L. R., Asch, S. M., Sherbourne, C. D., Lanto, A. B., Evangelista, L. S., Nyamathi, A. M., Maliski, S. L., Lorenz, K. A. 2009; 38 (5): 698-707


    Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain>or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P<0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P<0.001); interference with relations (P<0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF.

    View details for DOI 10.1016/j.jpainsymman.2009.04.022

    View details for Web of Science ID 000272060600007

    View details for PubMedID 19733032

  • Emergency Department Research in Palliative Care: Challenges in Recruitment JOURNAL OF PALLIATIVE MEDICINE Stone, S. C., Mohanty, S. A., Gruzden, C., Lorenz, K. A., Asch, S. M. 2009; 12 (10): 867-868

    View details for DOI 10.1089/jpm.2009.0139

    View details for Web of Science ID 000270515000007

    View details for PubMedID 19807230

  • Exploring Alternative Approaches to Routine Outpatient Pain Screening PAIN MEDICINE Lorenz, K. A., Krebs, E. E., Bentley, T. G., Sherbourne, C. D., Goebel, J. R., Zubkoff, L., Lanto, A. B., Asch, S. M. 2009; 10 (7): 1291-1299


    To evaluate potential alternatives to the numeric rating scale (NRS) for routine pain screening.Cross-sectional.Nineteen Veterans Affairs outpatient clinics in Southern California at two hospitals and six community sites.Five hundred twenty-eight veterans from primary care, cardiology, and oncology clinics sampled in proportion to the total number of visits made to each clinic during the previous year.Veterans were approached following clinic visits to complete researcher-administered surveys about their clinic experience. Using the Brief Pain Inventory (BPI) interference scale of > or =5 as a reference standard for important unrelieved pain, we evaluated potential alternative pain screening items and item combinations by analyzing sensitivity and specificity, area under the receiver operating curve (AUC), and likelihood ratios.Of the veterans, 43.6% had unrelieved pain as measured by the reference standard. Approximately half had painful musculoskeletal diagnoses and one-third had comorbid mental health or substance use disorders. The fifth vital sign detected pain less accurately than did an NRS with a 1-week timeframe and an item assessing pain-related bother over the past week. AUCs were 0.79, 0.86, and 0.86, respectively. A sequential approach combining the pain-related bother and NRS with a 1-week timeframe items had good discriminatory ability.Alternative single or combined pain screening strategies assessing pain-related bother may improve routine pain detection.

    View details for DOI 10.1111/j.1526-4637.2009.00709.x

    View details for Web of Science ID 000270589100014

    View details for PubMedID 19818039

  • HIV screening among substance-abusing veterans in care JOURNAL OF SUBSTANCE ABUSE TREATMENT Dookeran, N. M., Burgess, J. F., Bowman, C. C., Goetz, M. B., Asch, S. M., Gifford, A. L. 2009; 37 (3): 286-291


    Calls for screening for HIV infection among individuals with substance use disorders, including alcohol use, are increasing. We investigated HIV screening and its predictors in the Veterans Health Administration (VA) system among such individuals in care. Our primary outcome was retrospective evidence of screening for HIV infection, adjusting for patient demographics and important comorbid disease. Of the 371,749 sample patients with histories of substance use disorders using VA services, 20% had evidence of HIV screening. Screening was lowest among those with alcohol use disorders alone (11%) and highest among those treated in substance use programs (28%) or receiving inpatient care (28%). The findings suggest a low recognition of substance use disorders (especially alcohol use) as risk factors for HIV. Quality improvement initiatives to increase risk factor recognition and screening among patients with substance use disorders will yield benefits in the fight against HIV.

    View details for DOI 10.1016/j.jsat.2009.03.003

    View details for Web of Science ID 000270044200008

    View details for PubMedID 19346096

  • Barriers and Facilitators to Routine HIV Testing in VA Primary Care JOURNAL OF GENERAL INTERNAL MEDICINE Bokhour, B. G., Solomon, J. L., Knapp, H., Asch, S. M., Gifford, A. L. 2009; 24 (10): 1109-1114


    Approximately 21% of the 1.1 million HIV-infected persons in the United States are unaware of their HIV status. The Centers for Disease Control (CDC) recommend routine opt-out HIV testing for all patients aged 13-64. Yet little is known about patient and provider perspectives on routine HIV testing.We sought to understand patient and provider perspectives on the adoption of routine HIV testing within the US Department of Veterans Affairs.We conducted four focus groups with patients and two focus groups with primary care providers to explore perceptions of, communication about, and barriers and facilitators to routine HIV testing in primary care.Convenience sample of patients and primary care providers at two geographically diverse Veterans' Affairs Medical Centers.We conducted grounded thematic analyses of transcribed audio-recordings of focus groups to identify major themes, identifying similarities and differences between patient and provider perspectives.Patients and providers concurred that implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling were of benefit to patients and to public health. Patients, however, wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested. Veterans also stated that routinizing testing would help destigmatize HIV. Six steps to communicating about routine testing ("the 6 R's") were identified.Patients and providers appear ready for implementation of routine HIV testing. However, providers should use patient-centered communication strategies to ease patients' concerns about confidentiality and stigma associated with HIV disease.

    View details for DOI 10.1007/s11606-009-1078-6

    View details for Web of Science ID 000270814700005

    View details for PubMedID 19690923

  • The Challenge of Measuring Quality of Care From the Electronic Health Record AMERICAN JOURNAL OF MEDICAL QUALITY Roth, C. P., Lim, Y., Pevnick, J. M., Asch, S. M., McGlynn, E. A. 2009; 24 (5): 385-394


    The electronic health record (EHR) is seen by many as an ideal vehicle for measuring quality of health care and monitoring ongoing provider performance. It is anticipated that the availability of EHR-extracted data will allow quality assessment without the expensive and time-consuming process of medical record abstraction. A review of the data requirements for the indicators in the Quality Assessment Tools system suggests that only about a third of the indicators would be readily accessible from EHR data. Other factors involving complexity of required data elements, provider documentation habits, and EHR variability make the task of quality measurement more difficult than may be appreciated. Accurately identifying eligible cases for quality assessment and validly scoring those cases with EHR-extracted data will pose significant challenges but could potentially plummet the cost and therefore expand the use of quality assessment.

    View details for DOI 10.1177/1062860609336627

    View details for Web of Science ID 000269765900002

    View details for PubMedID 19482968

  • Body Mass Index, Neighborhood Fast Food and Restaurant Concentration, and Car Ownership JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Inagami, S., Cohen, D. A., Brown, A. F., Asch, S. M. 2009; 86 (5): 683-695


    Eating away from home and particularly fast food consumption have been shown to contribute to weight gain. Increased geographic access to fast food outlets and other restaurants may contribute to higher levels of obesity, especially in individuals who rely largely on the local environment for their food purchases. We examined whether fast food and restaurant concentrations are associated with body mass index and whether car ownership might moderate this association. We linked the 2000 US Census data and information on locations of fast food and other restaurants with the Los Angeles Family and Neighborhood Study database, which consists of 2,156 adults sampled from 63 neighborhoods in Los Angeles County. Multilevel modeling was used to estimate associations between body mass index (BMI), fast food and restaurant concentration, and car ownership after adjustment for individual-level factors and socioeconomic characteristics of residential neighborhoods. A high concentration of local restaurants is associated with BMI. Car owners have higher BMIs than non-car owners; however, individuals who do not own cars and reside in areas with a high concentration of fast food outlets have higher BMIs than non-car owners who live in areas with no fast food outlets, approximately 12 lb more (p = 0.02) for an individual with a height of 5 ft. 5 in. Higher restaurant density is associated with higher BMI among local residents. The local fast food environment has a stronger association with BMI for local residents who do not have access to cars.

    View details for DOI 10.1007/s11524-009-9379-y

    View details for Web of Science ID 000269195200004

    View details for PubMedID 19533365

  • Opportunities for improving medication use and monitoring in gout ANNALS OF THE RHEUMATIC DISEASES Singh, J. A., Hodges, J. S., Asch, S. M. 2009; 68 (8): 1265-1270


    To study patterns and predictors of medication use and laboratory monitoring in gout.In a cohort of veterans with a diagnosis of gout prescribed allopurinol, colchicine or probenecid, quality of care was assessed by examining adherence to the following evidence-based recommendations: (1) whether patients starting a new allopurinol prescription (a) received continuous allopurinol, (b) received colchicine prophylaxis, (c) achieved the target uric acid level of

    View details for DOI 10.1136/ard.2008.092619

    View details for Web of Science ID 000268010500006

    View details for PubMedID 18701554

  • Race and Sex Differences in the Receipt of Timely and Appropriate Lung Cancer Treatment MEDICAL CARE Shugarman, L. R., Mack, K., Sorbero, M. E., Tian, H., Jain, A. K., Ashwood, J. S., Asch, S. M. 2009; 47 (7): 774-781


    Previous research suggests that disparities in non-small-cell lung cancer (NSCLC) survival can be explained in part by disparities in the receipt of cancer treatment. Few studies, however, have considered race and sex disparities in the timing and appropriateness of treatment across stages of diagnosis.To evaluate the relationship of sex and race with the receipt of timely and clinically appropriate NSCLC treatment for each stage of diagnosis.Surveillance Epidemiology and End Result data linked to Medicare claims for beneficiaries diagnosed with NSCLC between 1995 and 1999 were used to evaluate the relationship between race and sex with timely and appropriate NSCLC treatment while controlling for other demographic characteristics, comorbidities, socioeconomic status, and provider supply (N = 22,145).Overall adjusted rates of timely and appropriate treatment are 37.2%, 58.1%, and 29.2% for Medicare beneficiaries diagnosed with stage I or II, III, and IV NSCLC, respectively. Among stage I or II patients, women were 25% less likely to receive timely surgical resection relative to men, and blacks were 66% less likely to receive timely and appropriate treatment than whites. Black men were least likely to receive resection (22.2% compared with 43.7% for white men). Blacks were 34% less likely to receive timely surgery, chemotherapy, or radiation for stage III disease and were 51% less likely to receive chemotherapy in a timely fashion for stage IV disease relative to whites.Significant variations in appropriate timely treatment were found within and across stages of diagnosis, confirming that sex and race differences in NSCLC treatment exist.

    View details for Web of Science ID 000267462400009

    View details for PubMedID 19536007

  • Health literacy and English language comprehension among elderly inpatients at an urban safety-net hospital. Journal of health and human services administration Cordasco, K. M., Asch, S. M., Franco, I., Mangione, C. M. 2009; 32 (1): 30-50


    To evaluate the relationship between health literacy and age in chronically-ill inpatients at a safety-net hospital.We recruited 399 English- and Spanish-speaking inpatients being evaluated or treated for Congestive Heart Failure or Coronary Artery Disease at a large, urban safety-net teaching hospital in Southern California.Participants were interviewed to ascertain education, English comprehension, and in-home language use. Health literacy was assessed using The Test of Functional Health Literacy in Adults (TOFHLA). We compared by age (aged 65 or more, 51 to 64 years of age, and less than age 50) levels of health literacy, educational attainment, English comprehension, and language use.Prevalence of inadequate health literacy significantly increased with increasing age (87.2% in > or = 65, 48.9% for 51-64, and 26.3% in < or = 50, p<0.001). The correlation between older age and lower health literacy persisted when controlling for educational achievement, race, ethnicity, gender, and immigration status. Additionally, older patients were more likely to have never learned to read (34.9% in > or = 65, 6.5% for 51-64, and 1.5% in < or = 50, p<0.001), no formal education (27.9% in > or = 65, 9.0% for 51-64, and 0.8% in < or = 50, p<0.001), have limited English comprehension (74.2% in > or = 65, 43.5% for 51-64, and 35.8% in < or = 50, p<0.001), and speak a non-English language at home (82.3% in > or = 65, 70.2% for 51-64, and 62.2% in < or = 50, p=0.015).To prepare to meet the chronic disease needs of a growing older patient population, and ameliorate the negative health effects of associated low literacy, safety-net hospital leaders and providers need to prioritize the development and implementation of low-literacy educational materials, programs, and services.

    View details for PubMedID 19558032

  • Quality Measures for Supportive Cancer Care: The Cancer Quality-ASSIST Project Conference of the Australian-New-Zealand-Health-Services-Association Lorenz, K. A., Dy, S. M., Naeim, A., Walling, A. M., Sanati, H., Smith, P., Shanman, R., Roth, C. P., Asch, S. M. ELSEVIER SCIENCE INC. 2009: 943?64


    Patients and physicians often cite symptom control as one of their most important goals in cancer care. Despite this, a previous systematic review found few tools for evaluating the quality of supportive cancer management. We developed a comprehensive set of quality indicators for evaluating pain and nonpain symptom management as well as care planning needs in cancer patients. Based on the prevalence and quality-of-life data, clinician-researchers prioritized pain, psychosocial distress, dyspnea, nausea and vomiting, fatigue and anorexia, treatment-associated toxicities, and information and care planning for quality-indicator development. Using search terms and selection criteria, we identified English-language documents from Medline (1997-2007) and Internet-based searches. Based on this evidence, clinician-reviewers proposed process quality indicators. We then used the VA Health Services Research and Development (VA HSR & D) appropriateness methods to compile the ratings of a multidisciplinary, international expert panel of the validity and feasibility of each indicator. The panel judged 92 out of 133 (69%) proposed quality indicators valid and feasible (15 out of 23 pain, 5 out of 6 depression, 8 out of 11 dyspnea, 15 out of 19 nausea and vomiting, 13 out of 26 fatigue and anorexia, 23 out of 32 other treatment-associated toxicities, and 13 out of 16 information and care planning). Of the final indicators, 67 are potentially useful for inpatient and 81 for outpatient evaluation, and 26 address screening, 12 diagnostic evaluation, 20 management, and 21 follow-up. These quality indicators provide evidence-explicit tools for measuring processes critical to ensuring high-quality supportive cancer care. Research is needed to characterize adherence to recommended practices and to evaluate the use of these measures in quality improvement efforts.

    View details for DOI 10.1016/j.jpainsymman.2008.05.018

    View details for Web of Science ID 000267183400001

    View details for PubMedID 19359135

  • Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field ACADEMIC EMERGENCY MEDICINE Grudzen, C. R., Timmermans, S., Koenig, W. J., Torres, J. M., Hoffman, J. R., Lorenz, K. A., Asch, S. M. 2009; 16 (6): 532-538


    The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest.Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances.Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role.Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.

    View details for DOI 10.1111/j.1553-2712.2009.00427.x

    View details for Web of Science ID 000266594600009

    View details for PubMedID 19438412

  • Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference JOURNAL OF GENERAL INTERNAL MEDICINE Krebs, E. E., Lorenz, K. A., Bair, M. J., Damush, T. M., Wu, J., Sutherland, J. M., Asch, S. M., Kroenke, K. 2009; 24 (6): 733-738


    Inadequate pain assessment is a barrier to appropriate pain management, but single-item "pain screening" provides limited information about chronic pain. Multidimensional pain measures such as the Brief Pain Inventory (BPI) are widely used in pain specialty and research settings, but are impractical for primary care. A brief and straightforward multidimensional pain measure could potentially improve initial assessment and follow-up of chronic pain in primary care.To develop an ultra-brief pain measure derived from the BPI.Development of a shortened three-item pain measure and initial assessment of its reliability, validity, and responsiveness.We used data from 1) a longitudinal study of 500 primary care patients with chronic pain and 2) a cross-sectional study of 646 veterans recruited from ambulatory care.Selected items assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G). Reliability of the three-item scale (PEG) was alpha = 0.73 and 0.89 in the two study samples. Overall, construct validity of the PEG was good for various pain-specific measures (r = 0.60-0.89 in Study 1 and r = 0.77-0.95 in Study 2), and comparable to that of the BPI. The PEG was sensitive to change and differentiated between patients with and without pain improvement at 6 months.We provide strong initial evidence for reliability, construct validity, and responsiveness of the PEG among primary care and other ambulatory clinic patients. The PEG may be a practical and useful tool to improve assessment and monitoring of chronic pain in primary care.

    View details for DOI 10.1007/s11606-009-0981-1

    View details for Web of Science ID 000266241300007

    View details for PubMedID 19418100

  • Developing a Disaster Preparedness Campaign Targeting Low-Income Latino Immigrants: Focus Group Results for Project PREP JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Eisenman, D. P., Glik, D., Maranon, R., Gonzales, L., Asch, S. 2009; 20 (2): 330-345


    Low-income immigrant Latinos are particularly vulnerable to disasters because they are both ill-prepared and disproportionately affected. Disaster preparedness programs that are culturally appropriate must be developed and tested. To develop such a program, we conducted 12 focus groups with low-income immigrant Latinos to understand their perceptions and understanding of disaster preparedness, and facilitators and obstacles to it. Participants were concerned about remaining calm during an earthquake. Obstacles to storage of disaster supplies in a kit and developing a family communication plan were mentioned frequently. Misunderstandings were voiced about the proper quantity of water to store and about communication plans. Several focus groups spontaneously suggested small group discussions (platicas) as a way to learn about disaster preparedness. They wanted specific help with building their family communication plans. They rated promotoras de salud highly as potential teachers. Results will guide the development of a disaster preparedness program tailored to the needs of low-income Latino immigrants.

    View details for Web of Science ID 000265887100004

    View details for PubMedID 19395833

  • Early Identification of Co-Occurring Pain, Depression and Anxiety JOURNAL OF GENERAL INTERNAL MEDICINE Sherbourne, C. D., Asch, S. M., Shugarman, L. R., Goebel, J. R., Lanto, A. B., Rubenstein, L. V., Wen, L., Zubkoff, L., Lorenz, K. A. 2009; 24 (5): 620-625


    Depression and anxiety frequently co-occur with pain and may affect treatment outcomes. Early identification of these co-occurring psychiatric conditions during routine pain screening may be critical for optimal treatment.To determine aspects of pain related to psychological distress, and, among distressed patients, to determine whether pain factors are related to provider identification of distress.Cross-sectional interview of primary care patients and their providers participating in a Veteran's Administration HELP-Vets study.A total of 528 predominately male VeteransWe measured self-reported pain, including a 0-10 numeric rating scale and interference items from the Brief Pain Inventory. To evaluate distress, brief indicators of depression, anxiety and PTSD were combined. A substantial number of patients had psychological distress (41%), which was even higher (62%) among patients with moderate-severe current pain. Only 29% of those with distress reported talking to their provider about emotional problems during their visit. In multivariate analyses, other pain factors related to distress included interference with enjoyment of life and relationships with others, pain in multiple locations and joint pains. Prior diagnoses of depression and anxiety were also related to current distress. Only prior diagnosis and patient reported headaches and sleep interference because of pain were related to provider identification of distress.VA patients with moderate-severe pain are at high risk for psychological distress, which often goes unrecognized. Providers need to be more vigilant to mental health problems in patients experiencing high pain levels. Targeted screening for co-occurring conditions is warranted.

    View details for DOI 10.1007/s11606-009-0956-2

    View details for Web of Science ID 000265306700012

    View details for PubMedID 19308333

  • Cancer screening adherence: Does physician-patient communication matter? PATIENT EDUCATION AND COUNSELING Fox, S. A., Heritage, J., Stockdale, S. E., Asch, S. M., Duan, N., Reise, S. P. 2009; 75 (2): 178-184


    The objective of this study was to examine the separate contributions of patients and physicians to their communication regarding cancer screening.Research design and subjects: The authors conducted a cross-sectional analysis of survey data collected from 63 community-based primary care physicians and 904 of their female patients in Los Angeles.Patients who perceived their physicians to be enthusiastic (at any level) in their discussions of mammography or fecal occult blood tests (FOBT) were significantly more likely to report a recent test than patients who reported no discussions.Physician discussions of cancer screening are important and effective even when, as in the case of mammography, screening rates are already high, or, as in the case of FOBT, rates have tended to remain low. The value of communication about screening should be taught and promoted to primary care physicians who serve as gatekeepers to screening.Those who train physicians in communication skills should take into account our finding that the communication style of physicians (e.g., enthusiasm for screening) was the only patient or physician variable that both influenced screening adherence and that could be taught.

    View details for DOI 10.1016/j.pec.2008.09.010

    View details for Web of Science ID 000265471500007

    View details for PubMedID 19250793

  • The Impact of Integrated HIV Care on Patient Health Outcomes MEDICAL CARE Hoang, T., Goetz, M. B., Yano, E. M., Rossman, B., Anaya, H. D., Knapp, H., Korthuis, P. T., Henry, R., Bowman, C., Gifford, A., Asch, S. M. 2009; 47 (5): 560-567


    Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have comorbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers.To evaluate effect of integrated HIV care (IHC) on suppression of HIV replication.A retrospective cohort study of HIV patients from 5 Veterans Affairs healthcare facilities 2000 to 2006.Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART.We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of IHC utilization. We evaluated effect of IHC utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis.: The 1018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had comorbidities with mean 3.2 comorbidities per patient (SD = 2.0); 52% achieved viral suppression in median 231 days (SD = 411.6). Patients visiting clinics that offered hepatitis, psychiatric, psychologic, and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (hazard ratio = 3.1, P < 0.001).Patients who visited IHC clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.

    View details for Web of Science ID 000265563500009

    View details for PubMedID 19318998

  • How Reliable is Pain as the Fifth Vital Sign? JOURNAL OF THE AMERICAN BOARD OF FAMILY MEDICINE Lorenz, K. A., Sherbourne, C. D., Shugarman, L. R., Rubenstein, L. V., Wen, L., Cohen, A., Goebel, J. R., Hagenmeier, E., Simon, B., Lanto, A., Asch, S. M. 2009; 22 (3): 291-298


    Although many health care organizations require routine pain screening (eg, "5th vital sign") with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error.We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured "5th vital sign" (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI).During 528 encounters, nurse-recorded NRS and research-recorded NRS correlated moderately (r = 0.627), as did nurse-recorded NRS and BPI severity scales (r = 0.613 for pain during the last 24 hours and r = 0.588 for pain during the past week). Correlation with BPI interference was lower (r = 0.409). However, the research-recorded NRS correlated substantially with the BPI severity during the past 24 hours (r = 0.870) and BPI severity during the last week (r = 0.840). Receiver operating characteristic analysis showed similar results. Of the 98% of cases where a numeric score was recorded, 51% of patients reported their pain was rated qualitatively, rather than with a 0 to 10 scale, a practice associated with pain underestimation (chi2 = 64.04, P < .001).Though moderately accurate, the outpatient "5th vital sign" is less accurate than under ideal circumstances. Personalizing assessment is a common clinical practice but may affect the performance of research tools such as the NRS adopted for routine use.

    View details for DOI 10.3122/jabfm.2009.03.080162

    View details for Web of Science ID 000265939400010

    View details for PubMedID 19429735

  • Variations in disaster preparedness by mental health, perceived general health, and disability status. Disaster medicine and public health preparedness Eisenman, D. P., Zhou, Q., Ong, M., Asch, S., Glik, D., Long, A. 2009; 3 (1): 33-41


    Chronic medical and mental illness and disability increase vulnerability to disasters. National efforts have focused on preparing people with disabilities, and studies find them to be increasingly prepared, but less is known about people with chronic mental and medical illnesses. We examined the relation between health status (mental health, perceived general health, and disability) and disaster preparedness (home disaster supplies and family communication plan).A random-digit-dial telephone survey of the Los Angeles County population was conducted October 2004 to January 2005 in 6 languages. Separate multivariate regressions modeled determinants of disaster preparedness, adjusting for sociodemographic covariates then sociodemographic variables and health status variables.Only 40.7% of people who rated their health as fair/poor have disaster supplies compared with 53.1% of those who rate their health as excellent (P < 0.001). Only 34.8% of people who rated their health as fair/poor have an emergency plan compared with 44.8% of those who rate their health as excellent (P < 0.01). Only 29.5% of people who have a serious mental illness have disaster supplies compared with 49.2% of those who do not have a serious mental illness (P < 0.001). People with fair/poor health remained less likely to have disaster supplies (adjusted odds ratio [AOR] 0.69, 95% confidence interval [CI] 0.50-0.96) and less likely to have an emergency plan (AOR 0.68, 95% CI 0.51-0.92) compared with those who rate their health as excellent, after adjusting for the sociodemographic covariates. People with serious mental illness remained less likely to have disaster supplies after adjusting for the sociodemographic covariates (AOR 0.67, 95% CI 0.48-0.93). Disability status was not associated with lower rates of disaster supplies or emergency communication plans in bivariate or multivariate analyses. Finally, adjusting for the sociodemographic and other health variables, people with fair/poor health remained less likely to have an emergency plan (AOR 0.66, 95% CI 0.48-0.92) and people with serious mental illness remained less likely to have disaster supplies (AOR 0.67, 95% CI 0.47-0.95).People who report fair/poor general health and probable serious mental illness are less likely to report household disaster preparedness and an emergency communication plan. Our results could add to our understanding of why people with preexisting health problems suffer disproportionately from disasters. Public health may consider collaborating with community partners and health services providers to improve preparedness among people with chronic illness and people who are mentally ill.

    View details for DOI 10.1097/DMP.0b013e318193be89

    View details for PubMedID 19293742

  • Addressing Physician Concerns About Performance Profiling: Experience With a Local Veterans Affairs Quality Evaluation Program AMERICAN JOURNAL OF MEDICAL QUALITY Ta, S., Goldzweig, C., Juzba, M., Lee, M., Wenger, N., Yano, E. M., Asch, S. 2009; 24 (2): 123-131


    The Authors investigated the addition of novel quality indicators, patient risk adjustment, and simple statistics in an ongoing clinician feedback initiative that profiles diabetes care for 13 Veterans Affairs (VA) clinics. Data were extracted from a computerized database for calendar years 2004 to 2005. Performance was assessed with 4 monitoring measures, 3 intermediate outcomes, and 3 appropriate treatment measures. Attainment rates for each indicator were calculated by clinic. The effect of risk adjustment and the significance of clinic performance variation were determined with multivariate logistic models. Analysis of the 10 quality measures revealed lower attainment and greater clinic-level variation for the less familiar indicators. Statistically significant performance variations were detected among clinics, with several being of a clinically important magnitude. Risk adjustment did not substantially change performance. The addition of clinically relevant quality measures and simple statistics appeared to enhance the characterization of performance by this profiling program.

    View details for DOI 10.1177/1062860608330828

    View details for Web of Science ID 000264494900005

    View details for PubMedID 19228893

  • Viral RNA Testing in Hepatitis C Antibody-Positive Veterans AMERICAN JOURNAL OF PREVENTIVE MEDICINE Rongey, C. A., Kanwal, F., Hoang, T., Gifford, A. L., Asch, S. M. 2009; 36 (3): 235-238


    Chronic hepatitis C virus (HCV) infection affects approximately 1.3% of the U.S. population. As up to 30% of HCV-antibody (anti-HCV)-positive patients have negative HCV ribonucleic acid (RNA), indicating resolution of infection, VA (Veterans Affairs) guidelines recommend RNA testing on all anti-HCV-positive patients. As HCV RNA testing is a prequel to treatment, perceived eligibility for treatment may influence the decision to order an RNA test. This study was designed to determine the patient and healthcare facility factors associated with patient receipt of HCV RNA testing.Two logistic regression analyses were conducted in anti-HCV-positive patients, including the entire sample and then on a subsample excluding sites with routine HCV RNA testing policies, using data stored in the VA Southern California Network data warehouse. Significant patient- and site-level predictors of patient receipt of HCV RNA testing were determined.Of the 13,257 antibody-positive patients, 76% received HCV RNA testing. Excluding sites with routine HCV RNA testing, patients aged >65 years (RR=0.79) and illicit drug users (RR=0.94) were significantly less likely to receive HCV RNA testing. Patients with abnormal transaminases (RR=1.14), presence of non-HCV hepatitis (RR=1.08), or decompensated liver disease (RR=1.22) were significantly more likely to receive HCV RNA testing.Without policies for routine RNA testing, patients with hepatitic C who either are aged >65 years or are illicit drug users are less likely to be tested. Also, patient receipt of RNA testing becomes dependent on clinical cues of hepatic decompensation or inflammation. The results support the implementation of routine RNA testing for anti-HCV-positive patients.

    View details for DOI 10.1016/j.amepre.2008.10.013

    View details for Web of Science ID 000263538300007

    View details for PubMedID 19162434

  • Adherence to Quality Indicators and Survival in Patients With Breast Cancer MEDICAL CARE Cheng, S. H., Wang, C. J., Lin, J., Horng, C., Lu, M., Asch, S. M., Hilborne, L. H., Liu, M., Chen, C., Huang, A. T. 2009; 47 (2): 217-225


    International initiatives increasingly advocate physician adherence to clinical protocols that have been shown to improve outcomes, yet the process-outcome relationship for adhering to breast cancer care protocol is unknown.This study explores whether 100% adherence to a set of quality indicators applied to individuals with breast cancer is associated with better survival.Ten quality indicators (4 diagnosis-related and 6 treatment-related indicators) were used to measure the quality of care in 1378 breast cancer patients treated from 1995 to 2001. Adherence to each indicator was based on the number of procedures performed divided by the number of patients eligible for that procedure. The main analysis of adherence was dichotomous (ie, 100% adherence vs. <100% adherence).The outcome measures studied were 5-year overall survival and progression-free survival, calculated using the Kaplan-Meier method. The Cox's proportional hazard regression model was used for univariate and multivariate analyses.Most patients received care that demonstrated good adherence to the quality indicators. Multivariate analysis revealed that 100% adherence to entire set of quality indicators was significantly associated with better overall survival [hazard ratio (HR): 0.46; 95% confidence interval (CI): 0.33-0.63] and progression-free survival (HR 0.51; 95% CI, 0.39-0.67). One hundred percent adherence to treatment indicators alone was also associated with statistically significant improvements in overall and progression-free survivals.Our study strongly supports that 100% adherence to evidence supported quality-of-care indicators is associated with better survival rates for breast cancer patients and should be a priority for practitioners.

    View details for Web of Science ID 000262913200012

    View details for PubMedID 19169123

  • A Comparative Study of Pain in Heart Failure and Non-Heart Failure Veterans JOURNAL OF CARDIAC FAILURE Goebel, J. R., Doering, L. V., Evangelista, L. S., Nyamathi, A. M., Maliski, S. L., Asch, S. M., Sherbourne, C. D., Shugarman, L. R., Lanto, A. B., Cohen, A., Lorenz, K. A. 2009; 15 (1): 24-30


    Progress has been made in addressing pain in specific diseases such as cancer, but less attention has focused on understanding pain in nonmalignant states, including heart failure (HF).From March 2006 to June 2007, 672 veterans were surveyed and scores for the Brief Pain Inventory, pain distress, clinically significant pain levels (moderate to severe pain), and pain locations were compared using univariate and multivariate models. Fifteen percent of the final sample had HF (95/634). In our study, the HF patients were older (P < .000), reported lower levels of general health (P = .018), had more co-morbidities (P < .000), were more likely to have a history of cancer (P = .035), and suffered more chest pain and fewer headaches (P = .026, P = .03, respectively) than their non-HF cohorts. When controlling for age, co-morbidity and cancer disorders, HF and non-HF patients did not differ in pain severity, interference, distress or locations. Of the patients currently experiencing pain, 67.3% of HF patients and 68.4% of non-HF patients rated their pain as moderate or severe (pain >or=4 on a 0 to 10 scale).Although HF has not been identified as a painful condition, this study suggests the burden of pain is significant for both HF and non-HF ambulatory care patients.

    View details for DOI 10.1016/j.cardfail.2008.09.002

    View details for Web of Science ID 000263441400004

    View details for PubMedID 19181290

  • Potential Impact of a Verbal Prehospital DNR Policy PREHOSPITAL EMERGENCY CARE Grudzen, C. R., Koenig, W. J., Hoffman, J. R., Boscardin, W. J., Lorenz, K. A., Asch, S. M. 2009; 13 (2): 169-172


    Forgoing resuscitation in prehospital cardiac arrest has previously required a written prehospital do-not-resuscitate (DNR) order. Some emergency medical services (EMS) agencies, including Los Angeles County (LAC), have implemented policies allowing surrogate decision makers to verbally request to forgo resuscitation. The impact of a verbal DNR policy is unclear, given the absence of information about how often cardiac arrest occurs at home, or in the presence of a family member.To determine the prevalence of written DNR forms, rate of resuscitation, location of cardiac arrest, and availability of a family member in nontraumatic cardiac arrest prior to implementation of the new policy in LAC.All prehospital run sheets for nontraumatic cardiac arrest in LAC were reviewed for the first seven days of each month (August 2006-January 2007) for DNR status, location of cardiac arrest, presence of family members, and whether resuscitation was attempted.Of the 897 cardiac arrests, 492 occurred at home, 111 in a public place, and 93 in a nursing home (location was unknown for 201). Fifty-five patients (6%) had a written DNR order, although it was not always available. Of these 55 patients, ten were resuscitated, the majority of the time because the family could not produce the paperwork. A family member was listed as present 29% of the time (261 of 897 cases). A medical history was obtained in an additional 465 cases (52%), indicating that someone familiar with the patient's medical history was present more than half the time, even when a family member was not mentioned.A written DNR order is uncommonly used in the prehospital setting as a reason to forgo resuscitation in LAC. Even when family members state that the patient has a DNR order, patients are often resuscitated. A majority of cardiac arrests occurs at the patient's home, and in many cases in the presence of family members, some of whom may be able to express a patient's preferences regarding end-of-life care.

    View details for DOI 10.1080/10903120802471923

    View details for Web of Science ID 000264224400003

    View details for PubMedID 19291552

  • Terrorism-Related Fear and Avoidance Behavior in a Multiethnic Urban Population AMERICAN JOURNAL OF PUBLIC HEALTH Eisenman, D. P., Glik, D., Ong, M., Zhou, Q., Tseng, C., Long, A., Fielding, J., Asch, S. 2009; 99 (1): 168-174


    We sought to determine whether groups traditionally most vulnerable to disasters would be more likely than would be others to perceive population-level risk as high (as measured by the estimated color-coded alert level) would worry more about terrorism, and would avoid activities because of terrorism concerns.We conducted a random digit dial survey of the Los Angeles County population October 2004 through January 2005 in 6 languages. We asked respondents what color alert level the country was under, how often they worry about terrorist attacks, and how often they avoid activities because of terrorism. Multivariate regression modeled correlates of worry and avoidance, including mental illness, disability, demographic factors, and estimated color-coded alert level.Persons who are mentally ill, those who are disabled, African Americans, Latinos, Chinese Americans, Korean Americans, and non-US citizens were more likely to perceive population-level risk as high, as measured by the estimated color-coded alert level. These groups also reported more worry and avoidance behaviors because of concerns about terrorism.Vulnerable populations experience a disproportionate burden of the psychosocial impact of terrorism threats and our national response. Further studies should investigate the specific behaviors affected and further elucidate disparities in the disaster burden associated with terrorism and terrorism policies.

    View details for DOI 10.2105/AJPH.2007.124206

    View details for Web of Science ID 000262241400027

    View details for PubMedID 19008521

  • Cost of OraQuick oral fluid rapid HIV testing at 35 community clinics and community-based organizations in the USA AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Pinkerton, S. D., Bogart, L. M., Howerton, D., Snyder, S., Becker, K., Asch, S. M. 2009; 21 (9): 1157-1162


    The US Centers for Disease Control and Prevention recommends the expanded use of rapid HIV antibody tests in community settings to increase the proportion of persons who are aware of their HIV status. The cost of providing rapid testing services in these settings is not known. We conducted a cost survey of non-profit community clinics and community-based organizations (CBOs). The final study sample for the cost analyses included 28 community clinics and seven CBOs that offered rapid HIV testing, all of which used OraSure's OraQuick oral fluid assay. Overall, the mean per-client rapid testing cost was 36.68 dollars for HIV-negative clients (2006 dollars, provider perspective) and 44.22 dollars for preliminary-positive clients. Personnel costs accounted for 55.6% of overall testing costs for negative clients and 63.2% for preliminary-positive clients. This study contributes unique empirical data about the costs of OralQuick rapid testing that can be used by clinic and CBO directors to assess the economic impact of implementing rapid testing at their sites. The findings also could be used to inform discussions regarding national and local HIV testing policies.

    View details for DOI 10.1080/09540120902729940

    View details for Web of Science ID 000271477000010

    View details for PubMedID 20024775

  • Finding order in heterogeneity: types of quality-improvement intervention publications QUALITY & SAFETY IN HEALTH CARE Rubenstein, L. V., Hempel, S., Farmer, M. M., Asch, S. M., Yano, E. M., Dougherty, D., Shekelle, P. W. 2008; 17 (6): 403-408


    Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications.A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs.By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

    View details for DOI 10.1136/qshc.2008.028423

    View details for Web of Science ID 000261501800004

    View details for PubMedID 19064654

  • 'A routine thing': clinician strategies for implementing HIV testing for at-risk patients in a busy healthcare organisation (and implications for implementation of other new practice recommendations). Anthropology & medicine Sobo, E. J., Bowman, C., Halloran, J., Asch, S. M., Goetz, M. B., Gifford, A. L. 2008; 15 (3): 213-225


    Increasing HIV testing is a necessary step toward control of the disease. Many experts suggest routinely offering HIV testing to specific population segments. We explore provider discourse regarding an HIV test implementation project with the aim of illuminating a structurally emergent clinician strategy for promoting testing and the socio-cultural factors underlying it. Twenty US Veterans Affairs Healthcare System clinical care providers were interviewed. Using standard anthropological text analysis techniques, themes, their relationships, and the significance of these for increasing appropriately targeted HIV test offers were established. Presenting the HIV test offer to their patients as if routine ('routinisation') supported providers' desire to do no harm by lessening the test's potential stigma. Offering the test helped providers maintain professional integrity: it empowered veterans to realise access to care and fit with providers' sense of honour and duty. Routinising HIV testing also helped providers to manage scarce time effectively. Findings can be leveraged to support routine screening's successful roll-out. The carefully managed introduction of routine HIV test offering policies will formalise and legitimise productive strategies of destigmatisation already being enacted by some front-line providers. The fact that routinisation strategies are in use although HIV testing is not actually routine attests to the potential power routinisation has to reduce HIV's stigma, increase HIV test uptake, and thereby improve access to care. What I've learned about tough questions is: The more routine you make them, the easier it is to get the questions answered, the less destructive it is to the relationship and that's the sort of paradigm I've come to believe in and will use now into the future. (Marvin K, MD).

    View details for DOI 10.1080/13648470802357489

    View details for PubMedID 27269425

  • Selection of Workers' Compensation Treatment Guidelines: California Experience JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Harber, P., Wynn, B. O., Lim, Y., Mattke, S., Asch, S. M., Nuckols, T. K. 2008; 50 (11): 1282-1292


    Workers' compensation systems increasingly use mandatory treatment guidelines to guide clinicians and for utilization management. This article describes the steps for selecting such guidelines.On the basis of experience with the RAND/University of California, Los Angeles project to help California select guidelines, we identified the necessary choices and processes for guideline selection and evaluation.Major steps in guideline selection include: 1) define purpose; 2) assign decision-making authority; 3) decide whether to use existing guidelines or develop new ones; 4) choose whether to use one or multiple existing guidelines; 5) specify clinical topics that guidelines should address; 6) identify and screen guidelines; 7) evaluate guidelines; 8) consider implications of results; 9) select guideline(s); 10) disseminate selection; and 11) assess long-term effectiveness.Given the many choices required, selecting mandatory workers' compensation guidelines should involve careful planning and a transparent, well-defined process.

    View details for DOI 10.1097/JOM.0b013e3181841fb4

    View details for Web of Science ID 000260880800009

    View details for PubMedID 19001954

  • Automating PowerPoint to expand healthcare education--a how-to guide. Journal for healthcare quality : official publication of the National Association for Healthcare Quality Knapp, H., Asch, S. 2008; 30 (6): 44-47


    Faced with the challenges of disseminating innovative healthcare practices to numerous clinics over a broad geographic region, we developed a cost-effective method of delivering in-service information using an automated multimedia show, in lieu of repeatedly deploying our limited staff to provide in-person presentations. This article details the hardware, software, and methods involved in producing this exportable product, which enabled us to maximize outreach education while working within the constraints of limited staffing, time, and fiscal resources.

    View details for PubMedID 19160874

  • Quality indicators for depression care in HIV patients AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV Pyne, J. M., Asch, S. M., Lincourt, K., Kilbourne, A. M., Bowman, C., Atkinson, H., Gifford, A. 2008; 20 (9): 1075-1083


    HIV patients are at increased risk for depression. However, a comprehensive set of quality of care indicators for depression in the context of HIV does not exist. We report the results of a recent expert panel convened to develop a comprehensive set of HIV depression quality indicators. We systematically reviewed the depression and HIV depression literature to provide the evidence for the quality indicators. The HIV depression quality indicators were divided into six chapters: general, bereavement, substance abuse, viral hepatitis, cognitive impairment and drug interactions. A modified Delphi expert panel method was used to evaluate the validity and feasibility of the candidate quality indicators. The expert panel included HIV physicians, psychiatrists and a pharmacist, all with experience with HIV depression. The in-person eleven-member panel rated 80 candidate HIV-depression quality indicators. Indicators were evaluated using main and sensitivity analysis criteria for validity and feasibility. Seventy-four percent (59/80) of the quality indicators met a priori main analysis criteria for validity and feasibility and 61% met sensitivity analysis criteria. Approved indicators that are more specific to HIV depression include: depression screening frequency; depression screening and treatment in the context of hepatitis C; optimizing depression and HIV treatment in the context of cognitive impairment; and starting antidepressants at lower doses but advancing to doses typical for the general population. Most adverse medication interaction indicators did not meet main analysis validity criteria. The quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV-depression care.

    View details for DOI 10.1080/09540120701796884

    View details for Web of Science ID 000260298300007

    View details for PubMedID 18825515

  • Evidence-based recommendations for cancer nausea and vomiting JOURNAL OF CLINICAL ONCOLOGY Naeim, A., Dy, S. M., Lorenz, K. A., Sanati, H., Walling, A., Asch, S. M. 2008; 26 (23): 3903-3910


    The experience of patients living with cancer and being treated with chemotherapy often includes the symptoms of nausea and vomiting. To provide a framework for high-quality management of these symptoms, we developed a set of key targeted evidence-based standards through an iterative process of targeted systematic review, development, and refinement of topic areas and standards and consensus ratings by a multidisciplinary expert panel as part of the RAND Cancer Quality-Assessing Symptoms Side Effects and Indicators of Supportive Treatment Project. For nausea and vomiting, key clinical standards included screening at the initial outpatient and inpatient visit, prophylaxis for acute and delayed emesis in patients receiving moderate to highly emetic chemotherapy, and follow-up after treatment for nausea and vomiting symptoms. In addition, patients with cancer and small bowel obstruction were examined as a special subset of patients who present with nausea and vomiting. The standards presented here for preventing and managing nausea and vomiting in cancer care should be incorporated into care pathways and should become the expectation rather than the exception.

    View details for DOI 10.1200/JCO.2007.15.9533

    View details for Web of Science ID 000258296400013

    View details for PubMedID 18688059

  • Evidence-based standards for cancer pain management JOURNAL OF CLINICAL ONCOLOGY Dy, S. M., Asch, S. M., Naeim, A., Sanati, H., Walling, A., Lorenz, K. A. 2008; 26 (23): 3879-3885


    High-quality management of cancer pain depends on evidence-based standards for screening, assessment, treatment, and follow-up for general cancer pain and specific pain syndromes. We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Providers should routinely screen for the presence or absence and intensity of pain and should perform descriptive pain assessment for patients with a positive screen, including assessment for likely etiology and functional impairment. For treatment, providers should provide pain education, offer breakthrough opioids in patients receiving long-acting formulations, offer bowel regimens in patients receiving opioids chronically, and ensure continuity of opioid doses across health care settings. Providers should also follow up on patients after treatment for pain. For metastatic bone pain, providers should offer single-fraction radiotherapy as an option when offering radiation, unless there is a contraindication. When spinal cord compression is suspected, providers should treat with corticosteroids and evaluate with whole-spine magnetic resonance imaging scan or myelography as soon as possible but within 24 hours. Providers should initiate definitive treatment (radiotherapy or surgical decompression) within 24 hours for diagnosed cord compression and should follow up on patients after treatment. These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes.

    View details for DOI 10.1200/JCO.2007.15.9517

    View details for Web of Science ID 000258296400010

    View details for PubMedID 18688056

  • Evidence-based recommendations for information and care planning in cancer care JOURNAL OF CLINICAL ONCOLOGY Walling, A., Lorenz, K. A., Dy, S. M., Naeim, A., Sanati, H., Asch, S. M., Wenger, N. S. 2008; 26 (23): 3896-3902


    The practice of oncology is characterized by challenging communication tasks that make it difficult to ensure optimal physician-patient information sharing and care planning. Discussions of diagnosis, prognosis, and patient goals are essential processes that inform decisions. However, data suggest that there are deficiencies in this area. We conducted a systematic review to identify the evidence supporting high-quality clinical practices for information and care planning in the context of cancer care as part of the RAND Cancer Quality-Assessing Symptoms, Side Effects, and Indicators of Supportive Treatment Project. Domains of information and care planning that are important for high-quality cancer care include integration of palliation into cancer care, advance care planning, sentinel events as markers for the need to readdress a patient's goals of care, and continuity of care planning. The standards presented here for information and care planning in cancer care should be incorporated into care pathways and should become the expectation rather than the exception.

    View details for DOI 10.1200/JCO.2007.15.9509

    View details for Web of Science ID 000258296400012

    View details for PubMedID 18688058

  • Evidence-based recommendations for cancer fatigue, anorexia, depression, and dyspnea JOURNAL OF CLINICAL ONCOLOGY Dy, S. M., Lorenz, K. A., Naeim, A., Sanati, H., Walling, A., Asch, S. M. 2008; 26 (23): 3886-3895


    PURPOSE The experience of patients with cancer often involves symptoms of fatigue, anorexia, depression, and dyspnea. METHODS We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Results For fatigue, providers should screen patients at the initial visit, for newly identified advanced cancer, and at chemotherapy visits; assess for depression and insomnia in newly identified fatigue; and follow up after treatment for fatigue or a secondary cause. For anorexia, providers should screen at the initial visit for cancer affecting the oropharynx or gastrointestinal tract or advanced cancer, evaluate for associated symptoms, treat underlying causes, provide nutritional counseling for patients undergoing treatment that may affect nutritional intake, and follow up patients given appetite stimulants. For depression, providers should screen newly diagnosed patients, those started on chemotherapy or radiotherapy, those with newly identified advanced disease, and those expressing a desire for hastened death; document a treatment plan in diagnosed patients; and follow up response after treatment. For general dyspnea, providers should evaluate for causes of new or worsening dyspnea, treat or symptomatically manage underlying causes, follow up to evaluate treatment effectiveness, and offer opioids in advanced cancer when other treatments are unsuccessful. For dyspnea and malignant pleural effusions, providers should offer thoracentesis, follow up after thoracentesis, and offer pleurodesis or a drainage procedure for patients with reaccumulation and dyspnea. CONCLUSION These standards provide a framework for evidence-based screening, assessment, treatment, and follow-up for cancer-associated symptoms.

    View details for DOI 10.1200/JCO.2007.15.9525

    View details for Web of Science ID 000258296400011

    View details for PubMedID 18688057

  • A system-wide intervention to improve HIV testing in the Veterans Health Administration JOURNAL OF GENERAL INTERNAL MEDICINE Goetz, M. B., Hoang, T., Bowman, C., Knapp, H., Rossman, B., Smith, R., Anaya, H., Osborn, T., Gifford, A. L., Asch, S. M. 2008; 23 (8): 1200-1207


    Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing.To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing.Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program.Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection.Pre- to post-changes in the rates of HIV testing at the intervention and control facilitiesAt the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities.Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention's goal of having every American know their HIV status as a matter of routine clinical practice.

    View details for DOI 10.1007/s11606-008-0637-6

    View details for Web of Science ID 000258454300013

    View details for PubMedID 18452045

  • Scope of in rapid HIV testing in urban US hospitals PUBLIC HEALTH REPORTS Bogart, L. M., Howerton, D., Lange, J., Becker, K., Setodji, C. M., Asch, S. M. 2008; 123 (4): 494-503


    The present study examined the scope of rapid human immunodeficiency virus (HIV) testing in urban U.S. hospitals.In a multistage national probability sample, 12 primary metropolitan statistical areas (three per region) were sampled randomly, with weights proportionate to acquired immunodeficiency syndrome (AIDS) populations. All 671 eligible hospitals within areas were selected. Laboratory staff from 584 hospitals (87%) were interviewed by telephone in 2005.About 52% reported rapid HIV test availability (50% in occupational health, 29% in labor and delivery, and 13% in emergency department/urgent care), and 86% of hospitals offering rapid tests processed them in the laboratory. In multivariate models, rapid test availability was more likely in hospitals serving more patients, and located in high-poverty, high-AIDS prevalence areas, and in the South or Midwest vs. West. It was less likely in hospitals serving areas with large percentages of people who were black/African American or Hispanic/Latino (p<0.05).Rapid HIV testing is increasing across urban U.S. hospitals, primarily for occupational exposure and in hospitals with greater resources and need. To achieve routine HIV screening, policies should encourage greater breadth of diffusion of rapid testing at the point of care, especially in smaller facilities, the West, and communities with racial/ethnic diversity.

    View details for Web of Science ID 000256570700013

    View details for PubMedID 18763412

  • A longitudinal evaluation of persons with disabilities: Does a longitudinal definition help define who receives necessary care? ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION Chan, L., Ciol, M. A., Shumway-Cook, A., Yorkston, K. M., Dudgeon, B. J., Asch, S. M., Hoffman, J. M. 2008; 89 (6): 1023-1030


    To assess, using a longitudinal definition, the impact of disability on a broad range of objective health care quality indicators.Longitudinal cohort study following up with patients over several years. The first 2 interviews, 1 year apart, were used to determine each patient's disability status in activities of daily living (ADLs). Assessment of the health care indicators commenced after the second interview and continued throughout the survey period (an additional 1-3y).National survey.Participants (N=29,074) of the Medicare Current Beneficiary Survey (1992-2001) with no, increasing, decreasing, and stable ADL disability.Not applicable.The incidence of 5 avoidable outcomes, receipt of 3 preventive care measures, and adherence to 32 diagnostically based indicators assessing the quality of treatment for acute myocardial infarction [AMI], angina, breast cancer, cerebrovascular accident, transient ischemic attack, cholelithiasis, chronic obstructive pulmonary disease [COPD], congestive heart failure, depression, gastrointestinal bleeding, diabetes, and hypertension.For most indicators, less than 75% of eligible patients received necessary care, regardless of disability status. For 5 indicators, less than 50% of patients received appropriate treatment. In a logistic regression analysis that controlled for patient age, sex, race, and income, disability status was a significant factor in 7 quality measures (AMI, breast cancer, COPD, diabetes, angina, pneumonia, annual visits).Using a longitudinal definition of disability and objective health quality indicators, we found that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories. However, the impact of disability status varies depending on the indicator measured. In this cohort of patients, the changing nature of a person's disability seems to have less impact than whether they ever have had any functional deficits.

    View details for DOI 10.1016/j.apmr.2007.10.045

    View details for Web of Science ID 000256553400003

    View details for PubMedID 18503795

  • Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing JOURNAL OF GENERAL INTERNAL MEDICINE Anaya, H. D., Hoang, T., Golden, J. F., Goetz, M. B., Gifford, A., Bowman, C., Osborn, T., Owens, D. K., Sanders, G. D., Asch, S. M. 2008; 23 (6): 800-807


    HIV testing is cost-effective in unselected general medical populations, yet testing rates among those at risk remain low, even among those with regular primary care. HIV rapid testing is effective in many healthcare settings, but scant research has been done within primary care settings or within the US Department of Veteran's Affairs Healthcare System.We evaluated three methods proven effective in other diseases/settings: nurse standing orders for testing, streamlined counseling, and HIV rapid testing.Randomized, controlled trial with three intervention models: model A (traditional counseling/testing); model B (nurse-initiated screening, traditional counseling/testing); model C (nurse-initiated screening, streamlined counseling/rapid testing).Two hundred fifty-one patients with primary/urgent care appointments in two VA clinics in the same city (one large urban hospital, one freestanding outpatient clinic in a high HIV prevalence area).Rates of HIV testing and receipt of results; sexual risk reduction; HIV knowledge improvement.Testing rates were 40.2% (model A), 84.5% (model B), and 89.3% (model C; p = <.01). Test result receipt rates were 14.6% (model A), 31.0% (model B), 79.8% (model C; all p = <.01). Sexual risk reduction and knowledge improvement did not differ significantly between counseling methods.Streamlined counseling with rapid testing significantly increased testing and receipt rates over current practice without changes in risk behavior or posttest knowledge. Increased testing and receipt of results could lead to earlier disease identification, increased treatment, and reduced morbidity/mortality. Policymakers should consider streamlined counseling/rapid testing when implementing routine HIV testing into primary/urgent care.

    View details for DOI 10.1007/s11606-008-0617-x

    View details for Web of Science ID 000256027500015

    View details for PubMedID 18421508

  • The relationship between multimorbidity and patients' ratings of communication JOURNAL OF GENERAL INTERNAL MEDICINE Fung, C. H., Setodji, C. M., Kung, F., Keesey, J., Asch, S. M., Adams, J., McGlynn, E. A. 2008; 23 (6): 788-793


    The growing interest in pay-for-performance and other quality improvement programs has generated concerns about potential performance measurement penalties for providers who care for more complex patients, such as patients with more chronic conditions. Few data are available on how multimorbidity affects common performance metrics.To examine the relationship between multimorbidity and patients' ratings of communication, a common performance metric.Cross-sectional studyNationally representative sample of U.S. residentsA total of 15,709 noninstitutionalized adults living in the United States participated in a telephone interview.We used 2 different measures of multimorbidity: 1) "individual conditions" approach disregards similarities/concordance among chronic conditions and 2) "condition-groups" approach considers similarities/concordance among conditions. We used a composite measure of patients' ratings of patient-physician communication.A higher number of individual conditions is associated with lower ratings of communication, although the magnitude of the relationship is small (adjusted average communication scores: 0 conditions, 12.20; 1-2 conditions, 12.06; 3+ conditions, 11.90; scale range 5 = worst, 15 = best). This relationship remains statistically significant when concordant relationships among conditions are considered (0 condition groups 12.19; 1-2 condition groups 12.03; 3+ condition groups 11.94).In our nationally representative sample, patients with more chronic conditions gave their doctors modestly lower patient-doctor communication scores than their healthier counterparts. Accounting for concordance among conditions does not widen the difference in communication scores. Concerns about performance measurement penalty related to patient complexity cannot be entirely addressed by adjusting for multimorbidity. Future studies should focus on other aspects of clinical complexity (e.g., severity, specific combinations of conditions).

    View details for DOI 10.1007/s11606-008-0602-4

    View details for Web of Science ID 000256027500013

    View details for PubMedID 18427902

  • Measuring persistence of implementation: QUERI Series IMPLEMENTATION SCIENCE Bowman, C. C., Sobo, E. J., Asch, S. M., Gifford, A. L. 2008; 3


    As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the "need for further research" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses. This article is one in a Series of articles documenting implementation science frameworks and approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).

    View details for DOI 10.1186/1748-5908-3-21

    View details for Web of Science ID 000265150200002

    View details for PubMedID 18430200

  • An evaluation of the veterans health administration's clinical reminders system: A national survey of generalists JOURNAL OF GENERAL INTERNAL MEDICINE Fung, C. H., Tsai, J. S., Lulejian, A., Glassman, P., Patterson, E., Doebbeling, B. N., Asch, S. M. 2008; 23 (4): 392-398


    The Veterans Health Administration (VHA) is a leader in developing computerized clinical reminders (CCRs). Primary care physicians' (PCPs) evaluation of VHA CCRs could influence their future development and use within and outside the VHA.Survey PCPs about usefulness and usability of VHA CCRs.In a national survey, VHA PCPs rated on a 7-point scale usefulness and usability of VHA CCRs, and standardized scales (0-100) were constructed. A hierarchical linear mixed (HLM) model predicted physician- and facility-level variables associated with more positive global assessment of CCRs.Four hundred sixty-one PCPs participated (response rate, 69%). Scale Cronbach's alpha ranged from 0.62 to 0.82. Perceptions of VHA CCRs were primarily in the midrange, where higher ratings indicate more favorable attitudes (weighted standardized median, IQR): global assessment (50, 28-61), clinical/situational specificity (29, 17-42), integration with workflow/workload (39, 17-50), training (50, 33-67), VHA's management of CCR use (67, 50-83), design/interface (53, 40-67), perceived role in CCR use (67, 50-83), and self-efficacy (67, 57-78). In a HLM model, design/interface (p < .001), self-efficacy (p < .001), integration with workflow/workload (p < .001), and training (p < .001) were associated with more favorable global assessments of CCRs. Facilities in the west as compared to the south (p = .033), and physicians with academic affiliation (p = .045) had less favorable global assessment of CCRs.Our systematic assessment of end-users' perceptions of VHA CCRs suggests that CCRs need to be developed and implemented with a continual focus on improvement based on end-user feedback. Potential target areas include better integration into the primary care clinic workflow/workload.

    View details for DOI 10.1007/s11606-007-0417-8

    View details for Web of Science ID 000254456400008

    View details for PubMedID 18373135

  • Scope of rapid HIV testing in private nonprofit urban community health settings in the United States AMERICAN JOURNAL OF PUBLIC HEALTH Bogart, L. M., Howerton, D., Lange, J., Becker, K., Setodji, C. M., Asch, S. M. 2008; 98 (4): 736-742


    We examined patterns of rapid HIV testing in a multistage national random sample of private, nonprofit, urban community clinics and community-based organizations to determine the extent of rapid HIV test availability outside the public health system.We randomly sampled 12 primary metropolitan statistical areas in 4 regions; 746 sites were randomly sampled across areas and telephoned. Staff at 575 of the sites (78%) were reached, of which 375 were eligible and subsequently interviewed from 2005 to 2006.Seventeen percent of the sites offered rapid HIV tests (22% of clinics, 10% of community-based organizations). In multivariate models, rapid test availability was more likely among community clinics in the South (vs West), clinics in high HIV/AIDS prevalence areas, clinics with on-site laboratories and multiple locations, and clinics that performed other diagnostic tests.Rapid HIV tests were provided infrequently in private, nonprofit, urban community settings. Policies that encourage greater diffusion of rapid testing are needed, especially in community-based organizations and venues with fewer resources and less access to laboratories.

    View details for DOI 10.2105/AJPH.2007.111567

    View details for Web of Science ID 000254595500033

    View details for PubMedID 18309135

  • Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI Series IMPLEMENTATION SCIENCE Goetz, M. B., Bowman, C., Hoang, T., Anaya, H., Osborn, T., Gifford, A. L., Asch, S. M. 2008; 3


    We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis - a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA.Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide decision support; audit/feedback as a clinical information system, and appropriate changes in delivery system design. These activities are complemented by academic detailing and social marketing interventions to achieve provider activation.Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3-5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).

    View details for DOI 10.1186/1748-5908-3-16

    View details for Web of Science ID 000265149900001

    View details for PubMedID 18353185

  • Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers JOURNAL OF GENERAL INTERNAL MEDICINE Nuckols, T. K., Lim, Y., Wynn, B. O., Mattke, S., MacLean, C. H., Harber, P., Brook, R. H., Wallace, P., Garland, R. H., Asch, S. 2008; 23 (1): 37-44


    Rigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines' acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability.To examine the clinical acceptability of guidelines having excellent technical quality.We selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including "perceived comprehensiveness" (perceived relevance to common clinical situations) and "perceived validity" (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders.Five guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as "comprehensive" and 6% to 50% as "valid".Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.

    View details for DOI 10.1007/s11606-007-0440-9

    View details for Web of Science ID 000252715700006

    View details for PubMedID 18030541

  • Enhancing Organizational Change and Improvement Prospects: Lessons from an HIV Testing Intervention for Veterans HUMAN ORGANIZATION Sobo, E. J., Bowman, C., Aarons, G. A., Asch, S., Gifford, A. L. 2008; 67 (4): 443-453
  • Predictors of treatment in patients with chronic hepatitis C infection - Role of patient versus nonpatient factors HEPATOLOGY Kanwal, F., Hoang, T., Spiegel, B. M., Eisen, S., Dominitz, J. A., Gifford, A., Goetz, M., Asch, S. M. 2007; 46 (6): 1741-1749


    Treatment with interferon and ribavirin is effective in patients with chronic infection with hepatitis C virus (HCV). Previous data indicate that treatment rates are suboptimal. We sought to identify patient and provider-level predictors of treatment receipt in HCV by conducting a retrospective cohort study of 5701 HCV patients in a large regional Veteran's Administration (VA) healthcare network. We also determined the degree of variation in treatment rates attributable to patient, provider, and facility factors. Three thousand seven hundred forty-three patients (65%) were seen by a specialist and 894 (15.7%) received treatment. Treatment rates varied from 6% to 29% across the 5 facilities included in the analysis. Patients were less likely to receive treatment if they were older [RR, 0.55; 95% CI, 0.45, 0.67), single (RR, 0.77; 95%CI, 0.67, 0.88), had hepatic dysfunction (RR, 0.73; 95%CI, 0.66, 0.89), had normal alanine aminotransferase (ALT) (RR, 0.73; 95%CI, 0.59, 0.89), had HCV genotype 1 (RR, 0.78; 95%CI, 0.71, 0.86), were African American with genotype 1 (RR, 0.78; 95% CI, 0.71, 0.86), or were anemic (RR, 0.70; CI, 0.60, 0.89). In addition, patients evaluated by less experienced providers were 77% less likely to receive treatment than those evaluated by more experienced providers. The patient, provider, and facility factors explained 23%, 25%, and 7% of variation in treatment rates, respectively. Conclusion: These data suggest that although patient characteristics are important predictors of treatment in HCV, a significant proportion of variation in treatment rates is explained by provider factors. These potentially modifiable provider-level factors may serve as high-yield targets for future quality improvement initiatives in HCV.

    View details for DOI 10.1002/hep.21927

    View details for Web of Science ID 000251471700012

    View details for PubMedID 18046707

  • Quality by Any Other Name?: A Comparison of Three Profiling Systems for Assessing Health Care Quality HEALTH SERVICES RESEARCH Kerr, E. A., Hofer, T. P., Hayward, R. A., Adams, J. L., Hogan, M. M., McGlynn, E. A., Asch, S. M. 2007; 42 (5): 2070-2087


    Many performance measurement systems are designed to identify differences in the quality provided by health plans or facilities. However, we know little about whether different methods of performance measurement provide similar answers about the quality of care of health care organizations. To examine this question, we used three different measurement approaches to assess quality of care delivered in veteran affairs (VA) facilities.Medical records for 621 patients at 26 facilities in two VA regions.We examined agreements in quality conclusions using: focused explicit (38 measures for six conditions/prevention), global explicit (372 measures for 26 conditions/prevention), and structured implicit review physician-rated care (a single global rating of care for three chronic conditions and overall acute, chronic and preventive care). Trained nurse abstractors and physicians reviewed all medical records. Correlations between scores from the three systems were adjusted for measurement error in each using multilevel regression models.Intercorrelations of scores were generally moderate to high across all three systems, and rose with adjustment for measurement error. Site-level correlations for prevention and diabetes care were particularly high. For example, adjusted for measurement error at the site level, prevention quality was correlated at 0.89 between the implicit and global systems, 0.67 between implicit and focused, and 0.73 between global and focused systems.We found moderate to high agreement in quality scores across the three profiling systems for most clinical areas, indicating that all three were measuring a similar construct called "quality." Adjusting for measurement error substantially enhanced our ability to identify this underlying construct.

    View details for Web of Science ID 000249429000017

    View details for PubMedID 17850534

  • Patient, physician, pharmacy, and pharmacy benefit design factors related to generic medication use 29th Annual Meeting of the Society-of-General-Internal-Medicine Shrank, W. H., Stedman, M., Ettner, S. L., Delapp, D., Dirstine, J., Brookhart, M. A., Fischer, M. A., Avorn, J., Asch, S. M. SPRINGER. 2007: 1298?1304


    Increased use of generic medications conserves insurer and patient financial resources and may increase patient adherence.The objective of the study is to evaluate whether physician, patient, pharmacy benefit design, or pharmacy characteristics influence the likelihood that patients will use generic drugsObservational analysis of 2001-2003 pharmacy claims from a large health plan in the Western United States. We evaluated claims for 5,399 patients who filled a new prescription in at least 1 of 5 classes of chronic medications with generic alternatives. We identified patients initiated on generic drugs and those started on branded medications who switched to generic drugs in the subsequent year. We used generalized estimating equations to perform separate analyses assessing the relationship between independent variables and the probability that patients were initiated on or switched to generic drugs.Of the 5,399 new prescriptions filled, 1,262 (23.4%) were generics. Of those initiated on branded medications, 606 (14.9%) switched to a generic drug in the same class in the subsequent year. After regression adjustment, patients residing in high-income zip codes were more likely to initiate treatment with a generic than patients in low-income regions (RR = 1.29; 95% C.I. 1.04-1.60); medical subspecialists (RR = 0.82; 0.69-0.95) and obstetrician/gynecologists (RR = 0.81; 0.69-0.98) were less likely than generalist physicians to initiate generics. Pharmacy benefit design and pharmacy type were not associated with initiation of generic medications. However, patients were over 2.5 times more likely to switch from branded to generic medications if they were enrolled in 3-tier pharmacy plans (95% C.I. 1.12-6.09), and patients who used mail-order pharmacies were 60% more likely to switch to a generic (95% C.I. 1.18-2.30) after initiating treatment with a branded drug.Physician and patient factors have an important influence on generic drug initiation, with the patients who live in the poorest zip codes paradoxically receiving generic drugs least often. While tiered pharmacy benefit designs and mail-order pharmacies helped steer patients towards generic medications once the first prescription has been filled, they had little effect on initial prescriptions. Providing patients and physicians with information about generic alternatives may reduce costs and lead to more equitable care.

    View details for DOI 10.1007/s11606-007-0284-3

    View details for Web of Science ID 000248814700012

    View details for PubMedID 17647066

  • Impact of clinical reminder redesign on learnability, efficiency, usability, and workload for ambulatory clinic nurses JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Saleem, J. J., Patterson, E. S., Militello, L., Anders, S., Falciglia, M., Wissman, J. A., Roth, E. M., Asch, S. M. 2007; 14 (5): 632-640


    Computerized clinical reminders (CRs) were designed to reduce clinicians' reliance on their memory and to present evidence-based guidelines at point of care. However, the literature indicates that CR adoption and effectiveness has been variable. We examined the impact of four design modifications to CR software on learnability, efficiency, usability, and workload for intake nursing personnel in an outpatient clinic setting. These modifications were included in a redesign primarily to address barriers to effective CR use identified during a previous field study.In a simulation experiment, 16 nurses used prototypes of the current and redesigned system in a within-subject comparison for five simulated patient encounters. Prior to the experimental session, participants completed an exploration session, where "learnability" of the current and redesigned systems was assessed.Time, performance, and survey data were analyzed in conjunction with semi-structured debrief interview data.The redesign was found to significantly increase learnability for first-time users as measured by time to complete the first CR, efficiency as measured by task completion time for two of five patient scenarios, usability as determined by all three groupings of questions taken from a commonly used survey instrument, and two of six workload subscales of the NASA Task Load Index (TLX) survey: mental workload and frustration.Modest design modifications to existing CR software positively impacted variables that likely would increase the willingness for first-time nursing personnel to adopt and consistently use CRs.

    View details for DOI 10.1197/jamia.M2163

    View details for Web of Science ID 000249769700012

    View details for PubMedID 17600106

  • Quality of care for gout in the US needs improvement ARTHRITIS & RHEUMATISM-ARTHRITIS CARE & RESEARCH Singh, J. A., Hodges, J. S., Toscano, J. P., Asch, S. M. 2007; 57 (5): 822-829


    To examine evidence-based quality indicators (QIs) in US veterans with gout diagnosis, and to examine the effect of demographics, heath care utilization/access, comorbid conditions, or physican characteristics as predictors of quality of gout care.Using the Minneapolis Veterans Affairs electronic medical record system, we identified a cohort of veterans receiving medication to treat gout between January 1, 1999 and December 31, 2003, and evaluated 3 recently published evidence-based QIs for gout management: QI 1 = allopurinol dose <300 mg in gout patients with renal insufficiency, QI 2 = uric acid check within 6 months of starting a new allopurinol prescription, and QI 3 = complete blood count and creatine kinase check every 6 months for gout patients receiving prolonged colchicine therapy. We calculated the proportion of patients whose therapy adhered to each QI and to all applicable indicators (overall physician adherence). Logistic regression analysis examined association of overall physician adherence with sociodemographics, health care utilization, comorbidity, and provider characteristics.Of 3,658 patients with a diagnosis of gout, 663 patients qualified for examination of >/=1 QI. Of these 663 patients, therapy in only 144 (22%) adhered to all applicable QIs; 59 (78%) of 76 adhered to QI 1, 155 (24%) of 643 adhered to QI 2, and 18 (35%) of 52 adhered to QI 3. Overall physician adherence to QIs was significantly lower in older veterans and in those with more inpatient visits per year, but was higher in those with more primary care visits or more health care providers.Suboptimal physician adherence to QIs was seen for all 3 QIs tested in this cohort of veterans with gout. These findings can guide quality improvement efforts.

    View details for DOI 10.1002/art.22767

    View details for Web of Science ID 000247129900018

    View details for PubMedID 17530682

  • Relationship between number of medical conditions and quality of care NEW ENGLAND JOURNAL OF MEDICINE Higashi, T., Wenger, N. S., Adams, J. L., Fung, C., Roland, M., McGlynn, E. A., Reeves, D., Asch, S. M., Kerr, E. A., Shekelle, P. G. 2007; 356 (24): 2496-2504


    There is emerging concern that the methods used to measure the quality of care unfairly penalize providers caring for patients with multiple chronic conditions. We therefore sought to study the relationship between the quality of care and the number of medical conditions a patient has.We assessed measurements of the quality of medical care received in three cohorts of community-dwelling adult patients in the Community Quality Index study, the Assessing Care of Vulnerable Elders study, and the Veterans Health Administration project (7680 patients in total). We analyzed the relationship between the quality of care that patients received, defined as the percentage of quality indicators satisfied among those for which patients were eligible, and the number of chronic medical conditions each patient had. We further explored the roles of characteristics of patients, use of health care (number of office visits and hospitalizations), and care provided by specialists as explanations for the observed relationship.The quality of care increased as the number of medical conditions increased. Each additional condition was associated with an increase in the quality score of 2.2% (95% confidence interval [CI], 1.7 to 2.7) in the Community Quality Index cohort, of 1.7% (95% CI, 1.1 to 2.4) in the Assessing Care of Vulnerable Elders cohort, and of 1.7% (95% CI, 0.7 to 2.8) in the Veterans Health Administration cohort. The relationship between the quality of care and the number of conditions was little affected by adjustment for the difficulty of delivering the care recommended in a quality indicator and for the fact that, because of multiple conditions requiring the same care, a patient could be eligible to receive the same care process more than once. Adjustment for characteristics of patients, use of health care, and care provided by specialists diminished the relationship, but it remained positive.The quality of care, measured according to whether patients were offered recommended services, increases as a patient's number of chronic conditions increases.

    View details for Web of Science ID 000247201900009

    View details for PubMedID 17568030

  • Human immunodeficiency virus and hepatitis C virus testing services at syringe exchange programs: Availability and outcomes JOURNAL OF SUBSTANCE ABUSE TREATMENT Heinzerling, K. G., Kral, A. H., Flynn, N. M., Anderson, R. L., Scott, A., Gilbert, M. L., Asch, S. M., Bluthenthal, R. N. 2007; 32 (4): 423-429


    We described the availability and outcomes of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) testing services at syringe exchange programs throughout California, using interviews with 24 syringe exchange program directors and 560 syringe exchange clients. Both HIV and HCV testing services were available in 62% of programs, 21% had HIV testing only, and 17% had neither. Programs administered by health care/social service providers were more likely than independent syringe exchange programs to have HIV and HCV testing services available. Among clients of programs with testing available, clients of illegal programs were significantly less likely than clients of legal programs to have used syringe exchange HIV and HCV testing services. The availability of HIV and HCV testing services at syringe exchange programs varies, and the use of existing testing services by clients is not universal. Efforts to increase both the availability of HIV and HCV testing services at syringe exchange programs and the use of existing testing services are needed.

    View details for DOI 10.1016/j.jsat.2006.11.002

    View details for Web of Science ID 000246575800012

    View details for PubMedID 17481466

  • "They blew the levee": Distrust of authorities among hurricane Katrina evacuees JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Cordasco, K. M., Eisenman, D. P., Glik, D. C., Golden, J. F., Asch, S. M. 2007; 18 (2): 277-282

    View details for Web of Science ID 000246162500009

    View details for PubMedID 17483557

  • Disaster planning and risk communication with vulnerable communities: lessons from Hurricane Katrina. American journal of public health Eisenman, D. P., Cordasco, K. M., Asch, S., Golden, J. F., Glik, D. 2007; 97: S109-15


    We studied the experience of Hurricane Katrina evacuees to better understand factors influencing evacuation decisions in impoverished, mainly minority communities that were most severely affected by the disaster.We performed qualitative interviews with 58 randomly selected evacuees living in Houston's major evacuation centers from September 9 to 12, 2005. Transcripts were content analyzed using grounded theory methodology.Participants were mainly African American, had low incomes, and were from New Orleans. Participants' strong ties to extended family, friends, and community groups influenced other factors affecting evacuation, including transportation, access to shelter, and perception of evacuation messages. These social connections cut both ways, which facilitated and hindered evacuation decisions.Effective disaster plans must account for the specific obstacles encountered by vulnerable and minority communities. Removing the more apparent obstacles of shelter and transportation will likely be insufficient for improving disaster plans for impoverished, minority communities. The important influence of extended families and social networks demand better community-based communication and preparation strategies.

    View details for PubMedID 17413069

  • Suboptimal control of atherosclerotic disease risk factors after cardiac and cerebrovascular procedures STROKE Cheng, E. M., Asch, S. M., Brook, R. H., Vassar, S. D., Jacob, E. L., Lee, M. L., Chang, D. S., Sacco, R. L., Hsiao, A., Vickrey, B. G. 2007; 38 (3): 929-934


    Undergoing a carotid endarterectomy, a coronary artery bypass graft, or a percutaneous coronary intervention provides an opportunity to optimize control of blood pressure and low-density lipoprotein.Using Veterans Administration databases, we determined whether patients who underwent a carotid endarterectomy (n=252), coronary artery bypass graft (n=486), or percutaneous coronary intervention (n=720) in 2002 to 2003 at 5 Veterans Administration Healthcare Systems had guideline-recommended control of blood pressure and low-density lipoprotein in 12-month periods before and after a vascular procedure. Postprocedure control of risk factors across procedure groups was compared using chi(2) tests and multivariate logistic regression.The proportion of patients undergoing carotid endarterectomy who had optimal control of both blood pressure and low-density lipoprotein increased from 23% before the procedure to 33% after the procedure (P=0.05) compared with increases from 32% to 43% for coronary artery bypass graft (P=0.001) and from 29% to 45% for percutaneous coronary intervention (P=0.002). Compared with the carotid endarterectomy group, the percutaneous coronary intervention group was more likely to achieve optimal control of blood pressure (OR: 1.92, 95% CI: 1.42 to 2.59) or low-density lipoprotein (OR: 1.51, 95% CI: 1.01 to 2.26) and the coronary artery bypass graft group was more likely to achieve optimal control of blood pressure (OR: 1.53, 95% CI: 1.42 to 2.59). Postprocedure cardiology visits, increase in medication intensity, and greater frequency of outpatient visits were also associated with optimal postprocedure risk factor control.Although modest improvements in risk factor control were detected, a majority of patients in each vascular procedure group did not achieve optimal risk factor control. More effective risk factor control programs are needed among most vascular procedure patients.

    View details for DOI 10.1161/01.STR.0000257310.08310.0f

    View details for Web of Science ID 000244482500026

    View details for PubMedID 17255549

  • Can a chronic care model collaborative reduce heart disease risk in patients with diabetes? 27th Annual Meeting of the Society-of-General-Internal-Medicine Vargas, R. B., Mangione, C. M., Asch, S., Keesey, J., Rosen, M., Schonlau, M., Keeler, E. B. SPRINGER. 2007: 215?22


    There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes.We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes.Controlled pre- and postintervention study.Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites.Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI -3.7%, -0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention.Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization's settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.

    View details for DOI 10.1007/s11606-006-0072-5

    View details for Web of Science ID 000244521900009

    View details for PubMedID 17356989

  • Developing quality indicators for the appropriateness of resuscitation in prehospital atraumatic cardiac arrest PREHOSPITAL EMERGENCY CARE Grudzen, C. R., Liddicoat, R., Hoffman, J. R., Koenig, W., Lorenz, K. A., Asch, S. M. 2007; 11 (4): 434-442


    The vast majority of out-of-hospital cardiac arrest victims do not survive or suffer severe neurological impairment. We sought to develop a set of straightforward clinical indicators that paramedics could use to better match resuscitation attempts to those most likely to benefit.In partnership with the Los Angeles County Emergency Medical Services, we used the RAND/UCLA appropriateness method of quantifying expert opinion regarding the risks and benefits of medical procedures. We presented available scientific evidence related to potential indicators of the quality of resuscitative care to stakeholder-nominated experts. Forty-one candidate indicators incorporated key variables, including initial rhythm, patient preferences, presence of witnesses, and place of arrest. Nine panelists, including palliative care and emergency medical specialists, rated the appropriateness of paramedic use of each indicator by using a 1-9 scale. An indicator was considered appropriate if the potential benefits outweighed the potential harm to the patient or their family. Indicators were retained if median score was >/=7.The expert panel voted to retain 28 quality indicators. Three addressed signs of irreversible death (e.g., dependent lividity), 8 addressed patient preferences (e.g., inquiring about DNR status), and the remainder addressed combinations of initial rhythm and other prognostic signs (e.g., "If initial rhythm is asystole and patient is known by apparent surrogate decision maker to have a terminal illness, then forgo resuscitation."). Our experts recommended a series of much more liberal criteria for forgoing resuscitation than is currently practiced. This includes ascertaining and honoring patient preferences, either through written documents or family members, and combinations of clinical criteria that predict poor neurological outcome, such as asystole, terminal illness, age greater than 70, and response time greater than 15 minutes.These quality indicators expand on the previously limited circumstances in which paramedics might forgo field resuscitation and implementation could reduce future harm from such procedures among seriously ill patients. Our current efforts focus on using these indicators to aid implementation of a new resuscitation policy for seriously ill patients in our county.

    View details for DOI 10.1080/10903120701536925

    View details for Web of Science ID 000249958600012

    View details for PubMedID 17907029

  • Using human factors methods to design a new interface for an electronic medical record. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Saleem, J. J., Patterson, E. S., Militello, L., Asch, S. M., Doebbeling, B. N., Render, M. L. 2007: 640-644


    The Veterans Health Administration (VHA) is a leader in development and use of electronic patient records and clinical decision support. The VHA is currently reengineering a somewhat dated platform for its Computerized Patient Record System (CPRS). This process affords a unique opportunity to implement major changes to the current design and function of the system. We report on two human factors studies designed to provide input and guidance during this reengineering process. One study involved a card sort to better understand how providers tend to cognitively organize clinical data, and how that understanding can help guide interface design. The other involved a simulation to assess the impact of redesign modifications on computerized clinical reminders, a form of clinical decision support in the CPRS, on the learnability of the system for first-time users.

    View details for PubMedID 18693914

  • The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes CHEST Mularski, R. A., Asch, S. M., Shrank, W. H., Kerr, E. A., Setodji, C. M., Adams, J. L., Keesey, J., McGlynn, E. A. 2006; 130 (6): 1844-1850


    The extent to which patients with obstructive lung disease receive recommended processes of care is largely unknown. We assessed the quality of care delivered to a national sample of the US population.We extracted medical records for 2 prior years from consenting participants in a random telephone survey in 12 communities and measured the quality of care provided with 45 explicit, process-based quality indicators for asthma and COPD developed using the modified Delphi expert panel methodology. Multivariate logistic regression evaluated effects of patient demographics, insurance, and other characteristics on the quality of health care.We identified 2,394 care events among 260 asthma participants and 1,664 events among 169 COPD participants. Overall, participants received 55.2% of recommended care for obstructive lung disease. Asthma patients received 53.5% of recommended care; routine management was better (66.9%) than exacerbation care (47.8%). COPD patients received 58.0% of recommended care but received better exacerbation care (60.4%) than routine care (46.1%). Variation was seen in mode of care with considerable deficits in documenting recommended aspects of medical history (41.4%) and use of diagnostic studies (40.1%). Modeling demonstrated modest variation between racial groups, geographic areas, insurance types, and other characteristics.Americans with obstructive lung disease received only 55% of recommended care. The deficits and variability in the quality of care for obstructive lung disease present ample opportunity for quality improvement. Future endeavors should assess reasons for low adherence to recommended processes of care and assess barriers in delivery of care.

    View details for DOI 10.1378/chest.130.6.1844

    View details for Web of Science ID 000242876200037

    View details for PubMedID 17167007

  • Quality measures for symptoms and advance care planning in cancer: A systematic review Annual Meeting of the American-Academy-of-Hospice-and-Palliative-Medicine Lorenz, K. A., Lynn, J., Dy, S., Wilkinson, A., Mularski, R. A., Shugarman, L. R., Hughes, R., Asch, S. M., Rolon, C., Rastegar, A., Shekelle, P. G. AMER SOC CLINICAL ONCOLOGY. 2006: 4933?38


    Measuring quality of care for symptom management and ascertaining patient goals offers an important step toward improving palliative cancer management. This study was designed to identify systematically the quality measures and the evidence to support their use in pain, dyspnea, depression, and advance care planning (ACP), and to identify research gaps.English-language documents were selected from MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO (1995 to 2005); Internet-based searches; and contact with measure developers. We used terms for each domain to select studies throughout the cancer care continuum. We included measures that expressed a normative relationship to quality, specified the target population, and specified the indicated care. Dual data review and abstraction was performed by palliative care researchers describing populations, testing, and attributes for each measure.A total of 4,599 of 5,182 titles were excluded at abstract review. Of 537 remaining articles, 19 contained measures for ACP, six contained measures for depression, five contained measures for dyspnea, and 20 contained measures for pain. We identified 10 relevant measure sets that included 36 fully specified or fielded measures and 14 additional measures (16 for pain, five for dyspnea, four for depression, and 25 for ACP). Most measures were unpublished, and few had been tested in a cancer population. We were unable to describe the specifications of all measures fully and did not search for measures for pain and depression that were not cancer specific.Measures are available for assessing quality and guiding improvement in palliative cancer care. Existing measures are weighted toward ACP, and more nonpain symptom measures are needed. Additional testing is needed before the measures are used for accountability, and basic research is required to address measurement when self-report is impaired.

    View details for DOI 10.1200/JCO.2006.06.8650

    View details for Web of Science ID 000241497900023

    View details for PubMedID 17050878

  • The quality of pharmacologic care for adults in the United States MEDICAL CARE Shrank, W. H., Asch, S. M., Adams, J., Setodji, C., Kerr, E. A., Keesey, J., Malik, S., McGlynn, E. A. 2006; 44 (10): 936-945


    Despite rising annual expenditures for prescription drugs, little systematic information is available concerning the quality of pharmacologic care for adults in the United States. We evaluated how frequently appropriate pharmacologic care is ordered in a national sample of U.S. residents.The RAND/UCLA Modified Delphi process was used to select quality-of-care indicators for adults across 30 chronic and acute conditions and preventive care. One hundred thirty-three pharmacologic quality-of-care indicators were identified. We interviewed a random sample of adults living in 12 metropolitan areas in the United States by telephone and received consent to obtain copies of their medical records for the most recent 2-year period. We abstracted patient medical records and evaluated 4 domains of the prescribing process that encompassed the entire pharmacologic care experience: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. A total of 3,457 participants were eligible for at least 1 quality indicator, and 10,739 eligible events were evaluated. We constructed aggregate scores and studied whether patient, insurance, and community factors impact quality.Participants received 61.9% of recommended pharmacologic care overall (95% confidence interval 60.3-63.5%). Performance was lowest in education and documentation (46.2%); medication monitoring (54.7%) and underuse of appropriate medications (62.6%) performance were higher. Performance was best for avoiding inappropriate medications (83.5%). Patient race and health services utilization were associated with modest quality differences, while insurance status was not.Significant deficits in the quality of pharmacologic care were seen for adults in the United States, with large shortfalls associated with underuse of appropriate medications. Strategies to measure and improve pharmacologic care quality ought to be considered, especially as we initiate a prescription drug benefit for seniors.

    View details for Web of Science ID 000241115500008

    View details for PubMedID 17001265

  • Physicians' perceived knowledge of and responsibility for managing patients' out-of-pocket costs for prescription drugs ANNALS OF PHARMACOTHERAPY Shrank, W. H., Asch, S. M., Joseph, G. J., Young, H. N., Ettner, S. L., Kholodenko, Y., Glassman, P., Kravitz, R. L. 2006; 40 (9): 1534-1540


    Most insurers in the US have implemented incentive-based formularies that rely on out-of-pocket costs to influence prescription drug utilization. Medicare Part D plans have broadly adopted such benefit designs.To evaluate physicians' perceptions of their knowledge of formularies and out-of-pocket costs, factors that influence knowledge of costs, physicians' perceived responsibility for helping patients manage their out-of-pocket costs for prescription drugs, and physicians' perceptions of the role of pharmacists in managing these costs.A multiple-choice survey was mailed to a random sample of 1200 physician members of the California Medical Association; a phone survey of nonresponders was then conducted.Of 1027 surveys delivered to correct addresses, 509 (49.6%) responses were received. Thirty-three percent of physicians reported that they were usually or always aware of patients' formularies and 20% were usually or always aware of patients' out-of-pocket costs for medications. Surgeons, emergency department physicians, and physicians that prescribe from more formularies than other physicians are less likely to be aware of patients' out-of-pocket costs, while physicians in large practices and those who use computers to prescribe are more aware. While 91% of physicians agreed that it is important that patients' out-of-pocket costs be managed, 40% somewhat or strongly agreed that it is their responsibility to help. Sixty-five percent of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs.Physicians often lack the knowledge to assist patients in the management of their out-of-pocket costs for prescription drugs and they depend on pharmacists to help patients manage those costs. Computer order entry and resources available in large physician organizations improve physicians' awareness of out-of-pocket costs when prescribing.

    View details for DOI 10.1345/aph.1H158

    View details for Web of Science ID 000240112500005

    View details for PubMedID 16912246

  • Physicians' perceptions of relevant prescription drug costs: Do costs to the individual patient or to the population matter most? AMERICAN JOURNAL OF MANAGED CARE Shrank, W. H., Joseph, G. J., Choudhry, N. K., Young, H. N., Ettner, S. L., Glassman, P., Asch, S. M., Kravitz, R. L. 2006; 12 (9): 545-551


    Physicians may be aware of at least 2 types of costs when prescribing: patient's out-of-pocket costs and the actual costs of the medication. We evaluated physicians' perceptions about relevant costs for prescription drugs and the importance of communication about these costs.Mailed survey to a random sample of 1200 physician members of the California Medical Association, and a phone survey of a sample of nonresponders.Descriptive statistics of survey items, McNemar's test to compare survey item responses, and logistic regression to evaluate the relationship between physician, practice, and system variables and physicians' perceptions of relevant medication costs.Of respondents with correct addresses, 49.6% responded to the survey; 13% of nonresponders were contacted by phone. Approximately 91% and 80% of physicians reported that it is important to manage patients' out-of-pocket costs and total medication costs, respectively. When comparing the relative importance of managing the 2 types of costs, 59% of physicians agreed that managing patients' out-of-pocket costs was more important than managing the total medication costs and only 16% disagreed. Physicians believed it was more important to discuss out-of-pocket costs than total costs with patients (P < .0001), but only 15% of physicians reported discussing out-of-pocket costs frequently and 5% reported talking about total medication costs frequently. Physicians who managed more Medicare patients had a greater likelihood than physicians managing fewer Medicare patients of prioritizing out-of-pocket cost rather than total cost management (P = .038), and generalists had a greater likelihood than medical subspecialists (P = .046).Physicians prioritize managing out-of-pocket costs over total medication costs. Pharmacy benefit designs that use patient out-of-pocket cost incentives to influence utilization are addressing the costs to which physicians may be most responsive. When physicians face conflicts between managing patients' out-of-pocket costs and total costs, they will likely try to protect the patients' resources at the expense of the insurer or society. Efforts to align patients', insurers', and societies' incentives will simplify prescribing decisions and result in better value in prescribing.

    View details for Web of Science ID 000240572800005

    View details for PubMedID 16961443

  • Measuring the quality of colorectal cancer screening: The importance of follow-up DISEASES OF THE COLON & RECTUM Etzioni, D. A., Yano, E. M., Rubenstein, L. V., Lee, M. L., Ko, G. Y., Brook, R. H., Parkerton, P. H., Asch, S. M. 2006; 49 (7): 1002-1010


    As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration.We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test.A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9-0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89-0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test.The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process.

    View details for DOI 10.1007/s10350-006-0533-2

    View details for Web of Science ID 000238818600008

    View details for PubMedID 16673056

  • You are where you shop - Grocery store locations, weight, and neighborhoods AMERICAN JOURNAL OF PREVENTIVE MEDICINE Inagami, S., Cohen, D. A., Finch, B. K., Asch, S. M. 2006; 31 (1): 10-17


    Residents in poor neighborhoods have higher body mass index (BMI) and eat less healthfully. One possible reason might be the quality of available foods in their area. Location of grocery stores where individuals shop and its association with BMI were examined.The 2000 U.S. Census data were linked with the Los Angeles Family and Neighborhood Study (L.A.FANS) database, which consists of 2620 adults sampled from 65 neighborhoods in Los Angeles County between 2000 and 2002. In 2005, multilevel linear regressions were used to estimate the associations between BMI and socioeconomic characteristics of grocery store locations after adjustment for individual-level factors and socioeconomic characteristics of residential neighborhoods.Individuals have higher BMI if they reside in disadvantaged areas and in areas where the average person frequents grocery stores located in more disadvantaged neighborhoods. Those who own cars and travel farther to their grocery stores also have higher BMI. When controlling for grocery store census tract socioeconomic status (SES), the association between residential census tract SES and BMI becomes stronger.Where people shop for groceries and distance traveled to grocery stores are independently associated with BMI. Exposure to grocery store mediates and suppresses the association of residential neighborhoods with BMI and could explain why previous studies may not have found robust associations between residential neighborhood predictors and BMI.

    View details for DOI 10.1016/j.amepre.2006.03.019

    View details for Web of Science ID 000238721300002

    View details for PubMedID 16777537

  • Measuring pain as the 5th vital sign does not improve quality of pain management JOURNAL OF GENERAL INTERNAL MEDICINE Mularski, R. A., White-Chu, F., Overbay, D., Miller, L., Asch, S. M., Ganzini, L. 2006; 21 (6): 607-612


    To improve pain management, the Veterans Health Administration launched the "Pain as the 5th Vital Sign" initiative in 1999, requiring a pain intensity rating (0 to 10) at all clinical encounters.To measure the initiative's impact on the quality of pain management.We retrospectively reviewed medical records at a single medical center to compare providers' pain management before and after implementing the initiative and performed a subgroup analysis of patients reporting substantial pain (> or =4) during a postimplementation visit.Unique patient visits selected from all 15 primary care providers of a general medicine outpatient clinic.We used 7 process indicators of quality pain management, based on appropriately evaluating and treating pain, to assess 300 randomly selected visits before and 300 visits after implementing the pain initiative.The quality of pain care was unchanged between visits before and after the pain initiative (P>.05 for all comparisons): subjective provider assessment (49.3% before, 48.7% after), pain exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing analgesics (6.7%, 4.3%), other pain treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%). Patients (n=79) who reported substantial pain often did not receive recommended care: 22% had no attention to pain documented in the medical record, 27% had no further assessment documented, and 52% received no new therapy for pain at that visit.Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.

    View details for DOI 10.1111/j.1525-1497.2006.00415.x

    View details for Web of Science ID 000238147800011

    View details for PubMedID 16808744

  • An HIV collaborative in the VHA: do advanced HIT and one-day sessions change the collaborative experience? Joint Commission journal on quality and patient safety / Joint Commission Resources Fremont, A. M., Joyce, G., Anaya, H. D., Bowman, C. C., Halloran, J. P., Chang, S. W., Bozzette, S. A., Asch, S. M. 2006; 32 (6): 324-336


    Many organizations participate in quality collaboratives, yet the return on investment of the associated time and costs is unclear.Semistructured interviews, surveys, and direct observation were used to assess experiences, improvement activities, and costs associated with participation in a year-long modified Institute for Healthcare Improvement-style collaborative designed to improve HIV care within the Veterans Health Administration. All nine sites had access to automated patient registries and semi-automated clinical measure reports; five sites also received computerized clinical reminders. Three one-day learning sessions were conducted.Participants reported that burden was small and value high, although many suggested that more time for peer-to peer learning would have been helpful. Teams averaged five quality improvement activities per site and most reported improvements in HIV care processes. The average annual cost per site was dollars 28,000 but costs varied considerably by site.Shortened learning sessions and the incorporation of health information technology can reduce some of the costs and burdens associated with collaboratives, yet peer-to-peer interaction and local organizational factors remain important to ensuring perceived effectiveness of collaboratives.

    View details for PubMedID 16776387

  • Predictors of on-call specialist response times in California emergency departments 28th Annual Meeting of the Society-of-General-Internal-Medicine Mohanty, S. A., Washington, D. L., Lambe, S., Fink, A., Asch, S. M. WILEY-BLACKWELL PUBLISHING, INC. 2006: 505?12


    To assess waiting times in emergency departments (EDs) for on-call specialist response and how these might vary by facility or neighborhood characteristics. Limited availability of on-call specialists is thought to contribute to ED overcrowding.Direct observational data from a random sample of 1,798 patients visiting 30 California EDs during a six-month period provided specialist waiting times. The authors used multivariate logistic regression and survival analysis to analyze predictors of time to on-call specialists' telephone response.Eighty-six percent of on-call specialists who were paged responded by telephone within 30 minutes. Ten percent of specialists did not respond at all. After controlling for the annual percentage of nonurgent ED patients at each facility, near closure status, and hospital ownership status, for every 10,000 dollars increase in hospital zip code income, the odds of on-call specialist response within 30 minutes increased by 123% (adjusted odds ratio = 2.23; 95% confidence interval = 1.24 to 4.02; p = 0.01).Although the majority of on-call specialists met the federal recommendation of a 30-minute response, those in poor neighborhoods were less likely to do so. One in ten on-call specialists did not respond at all. State and federal policies should focus on making more funding available for on-call specialist panels in poor areas.

    View details for DOI 10.1197/j.aem.2005.12.018

    View details for Web of Science ID 000237484500005

    View details for PubMedID 16609102

  • Residential segregation and Latino, black and white mortality in New York City JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Inagami, S., Borrell, L. N., Wong, M. D., Fang, J., Shapiro, M. F., Asch, S. M. 2006; 83 (3): 406-420


    Although racial segregation is associated with health status, few studies have examined this relationship among Latinos. We examined the effect of race/ethnic group concentration of Latinos, blacks and whites on all-cause mortality rates within a highly segregated metropolitan area, New York City (NYC). We linked NYC mortality records from 1999 and 2000 with the 2000 U.S. Census data by zip code area. Age-adjusted mortality rates by race/ethnic concentration were calculated. Linear regression was used to determine the association between population characteristics and mortality. Blacks living in predominantly black areas had lower all-cause mortality rates than blacks living in other areas regardless of gender (1616/100,000 vs. 2014/100,000 for men; 1032/100,000 vs. 1362/100,000 for women). Amongst whites, those living in predominantly white areas had the lowest mortality rates. Latinos living in predominantly Latino areas had lower mortality rates than those in predominantly black areas (1187/100,000 vs.1950/100,000 for men; 760/100,000 vs. 779/100,000 for women). After adjustment for socioeconomic conditions, whites, older blacks, and young Latino men experienced decreasing mortality rates when living in areas with increasing similar race/ethnic concentrations. Increasing residential concentration of blacks is independently associated with lower mortality in older blacks; similarly, increasing residential concentration of Latinos and whites is associated with lower mortality in young Latino men and whites, respectively.

    View details for DOI 10.1007/s11524-006-9035-8

    View details for Web of Science ID 000238355600008

    View details for PubMedID 16739044

  • The effect of pharmacy benefit design on patient-physician communication about costs JOURNAL OF GENERAL INTERNAL MEDICINE Shrank, W. H., Fox, S. A., Kirk, A., Ettner, S. L., Cantrell, C. H., Glassman, P., Asch, S. M. 2006; 21 (4): 334-339


    Incentive-based formularies have been widely instituted to control the rising costs of prescription drugs. To work properly, such formularies depend on patients to be aware of financial incentives and communicate their cost preferences with prescribing physicians. The impact of financial incentives on patient awareness of and communication about those costs is unknown.To evaluate the relationship between enrollment in incentive-based pharmacy benefit plans and awareness of out-of-pocket costs and rates of communication about out-of-pocket costs.A matched telephone survey of patients and their primary care physicians.Los Angeles County.One thousand nine hundred and seventeen patients aged 53 to 82 (73% response rate).Patient-reported pharmacy benefit design, knowledge of out-of-pocket costs, and discussion of out-of-pocket costs with physicians.Sixty-two percent of patients who had prescription drug coverage and were aware of their pharmacy benefit design reported being enrolled in incentive-based plans. The majority of these (54%) were "never" or only "sometimes" aware of their out-of-pocket cost requirements at the time of the physician visit. After controlling for numerous physician and patient level variables, we found that patients enrolled in pharmacy benefit designs requiring no copayments were more likely to report they "never" discuss out-of-pocket costs with physicians compared with patients enrolled in incentive-based pharmacy benefit designs (81% vs 67%, P=.001) and patients with no prescription drug insurance (57%, P<.001).Incentive-based pharmacy benefit plans and lack of insurance are associated with increased rates of discussions about out-of-pocket costs. Nonetheless, most incentive-based enrollees are unaware of out-of-pocket costs when prescriptions are written and never discuss out-of-pocket costs with their physicians, likely mitigating the effectiveness of financial incentives to guide decision making. Considering that out-of-pocket costs are associated with adherence to medical therapy, interventions to improve patient access to out-of-pocket cost information and the frequency of patient-physician discussions about costs are needed.

    View details for DOI 10.1111/j.1525-1497.2006.00402.x

    View details for Web of Science ID 000237117200009

    View details for PubMedID 16686808

  • Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004 National Meeting of the Robert Wood Johnson Clinical Scholars Program Sun, B. C., Mohanty, S. A., Weiss, R., Tadeo, R., Hasbrouck, M., Koenig, W., Meyer, C., Asch, S. MOSBY-ELSEVIER. 2006: 309?16


    We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion.The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation.Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility's diversion hours increased during the study period.Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility's diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

    View details for DOI 10.1016/j.annemergmed.2005.12.003

    View details for Web of Science ID 000236555300001

    View details for PubMedID 16546614

  • Who is at greatest risk for receiving poor-quality health care? NEW ENGLAND JOURNAL OF MEDICINE Asch, S. M., Kerr, E. A., Keesey, J., Adams, J. L., Setodji, C. M., Malik, S., McGlynn, E. A. 2006; 354 (11): 1147-1156


    American adults frequently do not receive recommended health care. The extent to which the quality of health care varies among sociodemographic groups is unknown.We used data from medical records and telephone interviews of a random sample of people living in 12 communities to assess the quality of care received by those who had made at least one visit to a health care provider during the previous two years. We constructed aggregate scores from 439 indicators of the quality of care for 30 chronic and acute conditions and for disease prevention. We estimated the rates at which members of different sociodemographic subgroups received recommended care, with adjustment for the number of chronic and acute conditions, use of health care services, and other sociodemographic characteristics.Overall, participants received 54.9 percent of recommended care. Even after adjustment, there was only moderate variation in quality-of-care scores among sociodemographic subgroups. Women had higher overall scores than men (56.6 percent vs. 52.3 percent, P<0.001), and participants below the age of 31 years had higher scores than those over the age of 64 years (57.5 percent vs. 52.1 percent, P<0.001). Blacks (57.6 percent) and Hispanics (57.5 percent) had slightly higher scores than whites (54.1 percent, P<0.001 for both comparisons). Those with annual household incomes over 50,000 dollars had higher scores than those with incomes of less than 15,000 dollars (56.6 percent vs. 53.1 percent, P<0.001).The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care.

    View details for Web of Science ID 000235981700008

    View details for PubMedID 16540615

  • Hospital utilization for injection drug use-related soft tissue infections in urban versus rural counties in California JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Heinzerling, K. G., Etzioni, D. A., Hurley, B., Holtom, P., Bluthenthal, R. N., Asch, S. M. 2006; 83 (2): 176-181


    Drug related-soft tissue infections (DR-STIs) are a significant source of hospital utilization in inner-city urban areas where injection drug use is common but the magnitude of hospital utilization for DR-STIs outside of inner-city urban areas is not known. We described the magnitude and characteristics of hospital utilization for DR-STIs in urban versus rural counties in California. All discharges from all nonfederal hospitals in California in 2000 with ICD-9 codes for a soft tissue infection and for drug dependence/abuse were abstracted from the California Office of Statewide Health Planning and Development discharge database. There were 4,152 DR-STI discharges in 2000 from hospitals in 49 of California's 58 counties. Residents of 12 large metropolitan counties accounted for 3,598 discharges (87% of total). The majority of DR-STI discharges were from urban safety net hospitals with county indigent programs and Medicaid as the expected payment source and opiate related discharge diagnoses. Hospital utilization for DR-STIs in California is highest in large urban metropolitan counties, although DR-STI discharges are widespread. Increased access to harm reduction services and drug treatment may reduce government health care expenditures by preventing unnecessary hospital utilization for DR-STIs.

    View details for DOI 10.1007/s11524-005-9021-6

    View details for Web of Science ID 000237316300006

    View details for PubMedID 16736367

  • The implications of choice - Prescribing generic or preferred pharmaceuticals improves medication adherence for chronic conditions ARCHIVES OF INTERNAL MEDICINE Shrank, W. H., Hoang, T. Y., Ettner, S. L., Glassman, P. A., Nair, K., Delapp, D., Dirstine, J., Avorn, J., Asch, S. M. 2006; 166 (3): 332-337


    A large proportion of Americans are enrolled in 3-tier pharmacy benefit plans. We studied whether patients enrolled in such plans who receive generic or preferred brand-name agents when initiating chronic therapy were more adherent to treatment than those who received nonpreferred brand-name medications.We analyzed pharmacy claims filled between October 1, 2001, and October 1, 2003, from a large health plan for 6 classes of chronic medications: 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, calcium channel blockers, oral contraceptives, orally inhaled corticosteroids, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors. We measured adherence as the proportion of days covered (PDC) in each drug class during the first year of therapy. We evaluated how the formulary status of the initial prescription (generic, preferred, or nonpreferred) influenced PDC and adequate adherence, defined as PDC greater than 80%, over the subsequent year.A total of 7532 new prescriptions were filled in 1 of the classes evaluated: 1747 (23.2%) for nonpreferred medications, 4376 (58.1%) for preferred drugs, and 1409 (18.7%) for generic drugs. After controlling for patient sociodemographic characteristics and drug class, PDC was 12.6% greater for patients initiated on generic medications vs nonpreferred medications (58.8% vs 52.2%; P<.001). The PDC was 8.8% greater for patients initiated on preferred vs nonpreferred medications (56.8% vs 52.2%; P<.001). Patients initiated on generic and preferred medications had 62% and 30% greater odds, respectively, of achieving adequate adherence compared with those who received nonpreferred medications.In 3-tier pharmacy benefit plans, prescribing generic or preferred medications within a therapeutic class is associated with improvements in adherence to therapy.

    View details for Web of Science ID 000235288700010

    View details for PubMedID 16476874

  • Unmet need for recommended preventive health services among clients of California syringe exchange programs: Implications for quality improvement DRUG AND ALCOHOL DEPENDENCE Heinzerling, K. G., Kral, A. H., Flynn, N. M., Anderson, R. L., Scott, A., Gilbert, M. L., Asch, S. M., Bluthenthal, R. N. 2006; 81 (2): 167-178


    Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California.Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews.On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients.SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

    View details for DOI 10.1016/j.drugalcdep.2005.06.008

    View details for Web of Science ID 000234783000008

    View details for PubMedID 16043308

  • Organization and management of care for military veterans with human immunodeficiency virus/acquired immunodeficiency syndrome in Department of Veterans Affairs Medical Centers MILITARY MEDICINE Yano, E. M., Asch, S. M., Phillips, B., Anaya, H., Bowman, C., Chang, S., Bozzette, S. 2005; 170 (11): 952-959


    As the largest provider of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome health care services, the Department of Veterans Affairs (VA) has launched a national quality improvement program. As a first step, an assessment of how care for veterans with HIV/acquired immunodeficiency syndrome was organized was conducted.Structured surveys were administered to senior HIV clinicians in 118 VA facilities, about local approaches to structuring, staffing, and delivering HIV health services.HIV care was chiefly delivered in special VA-based HIV clinics. HIV-related services were widely available on site, with non-VA referrals being more commonly needed to meet long-term care needs. Urban VA facilities had greater HIV caseloads, were more likely to have separate HIV clinics, and had greater access to HIV expertise, whereas rural practices focused on primary care-based models and tended to rely on off-site VA HIV experts.Understanding the organization and management of VA-based HIV services will help design systematic quality improvement efforts and meet the treatment needs of HIV-infected veterans.

    View details for Web of Science ID 000235832000009

    View details for PubMedID 16450823

  • A review of instruments assessing public health preparedness PUBLIC HEALTH REPORTS Asch, S. M., Stoto, M., Mendes, M., Valdez, R. B., Gallagher, M. E., Halverson, P., Lurie, N. 2005; 120 (5): 532-542


    The purpose of this study was to review instruments that assess the level of preparedness of state and local public health departments to respond to health threats such as bioterrorism.The authors examined 27 published population-based instruments for planning or evaluating preparedness that were mostly unavailable in the peer-reviewed literature. Using the Essential Public Health Services framework, the instruments were evaluated for (1) clarity of measurement parameters, (2) balance between structural and process measures, (3) evidence of effectiveness, and (4) specification of an accountable entity.There was a great deal of overlap but little consistency in what constitutes "preparedness" or how it should be measured. Most instruments relied excessively on subjective or structural measures, lacked scientific evidence for measures assessed, and failed to clearly define what entity was accountable for accomplishing the task or function.Strategies for improvement include measure standardization, better interagency communication, and investment in public health practice research to develop the underlying evidence base required for developing quality measures and assessments.

    View details for Web of Science ID 000231513600009

    View details for PubMedID 16224986

  • Impact of chronic viral hepatitis on health-related quality of life in HIV: Results from a nationally representative sample AMERICAN JOURNAL OF GASTROENTEROLOGY Kanwal, F., Gralnek, I. M., Hays, R. D., Dulai, G. S., Spiegel, B. M., Bozzette, S., Asch, S. 2005; 100 (9): 1984-1994


    Little is known about the health burden of chronic viral hepatitis in HIV-infected patients. We compared health-related quality of life (HRQOL) of patients with HIV and hepatitis C virus (HCV) or HIV and hepatitis B virus (HBV) coinfection to those with HIV monoinfection.Using a nationally representative sample of 1,874 adults with HIV who completed a baseline and two follow-up interviews, we identified those with HIV monoinfection (n = 1,493), HIV-HCV coinfection (n = 279), and HIV-HBV coinfection (n = 122). We measured baseline and change over time scores for physical and mental health (PHS, MHS), overall quality of life (QOL), overall health, and disability days. To identify the independent effect of coinfection, we adjusted for demographic and clinical predictors of HRQOL using multivariable regression.Despite significant differences in socio-demographic characteristics between groups, there were no differences in the baseline scores for PHS, MHS, overall QOL, overall health, or disability days between groups. The HRQOL did not decline significantly over time for the HIV patients with or without HCV or HBV coinfection. All groups reported similar longitudinal changes in the HRQOL scores for all measures.We found no significant differences in disease burden as assessed by a generic HRQOL instrument between patients with HIV monoinfection and HIV-HCV or HIV-HBV coinfection. These data are relevant in counseling coinfected patients regarding the impact of coinfection on HRQOL, and are important in designing clinical trials and conducting cost-effectiveness analyses including this vulnerable cohort.

    View details for DOI 10.1111/j.1572-0241.2005.41962.x

    View details for Web of Science ID 000231853600016

    View details for PubMedID 16128943

  • Religiousness and spirituality among HIV-infected Americans. Journal of palliative medicine Lorenz, K. A., Hays, R. D., Shapiro, M. F., Cleary, P. D., Asch, S. M., Wenger, N. S. 2005; 8 (4): 774-781


    To describe the demographic and clinical factors associated with the importance of religiousness and spirituality among patients with human immunodeficiency virus (HIV) infection in the United States.Longitudinal study of a nationally representative cohort of 2266 patients receiving care for HIV infection surveyed in 1996 and again in 1998. Measures included 12 items assessing religious affiliation and attendance, the importance of religion and spirituality in life, and religious and spiritual practices. Multi-item religiousness and spirituality scales were constructed.Eighty percent of respondents reported a religious affiliation. Sixty-five percent affirmed that religion and 85% that spirituality was "somewhat" or "very" important in their lives. A majority indicated that they "sometimes" or "often" rely on religious or spiritual means when making decisions (72%) or confronting problems (65%). Women, nonwhites, and older patients were more religious and spiritual. Residents of regions other than the western United States reported higher religiousness. High school graduates were more religious and spiritual than those with less education. Patients who did not report one of the risk factors assessed for HIV infection had higher religiousness scores than injection drug users (IDUs). Women, nonwhites other than Hispanics, patients older than 45 years of age compared to those between 18 and 34 years of age, and more educated patients reported higher spirituality. Clinical stage was not associated with religiousness or spirituality.A large majority of HIV-infected patients in the United States affirm the importance of religiousness and spirituality. These findings support a comprehensive, humanistic approach to the care of HIV-infected patients.

    View details for PubMedID 16128651

  • Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: The improving chronic illness care evaluation JOURNAL OF CARDIAC FAILURE Baker, D. W., Asch, S. M., Keesey, J. W., BROWN, J. A., Chan, K. S., Joyce, G., Keeler, E. B. 2005; 11 (6): 405-413


    The objective of this study was to determine whether participation in a quality improvement (QI) collaborative for heart failure (HF) was associated with better interpersonal aspects of care and health outcomes.We conducted a cross-sectional telephone survey of patients in 6 organizations who participated in a QI collaborative for HF (participants, n = 387) and 6 comparable control organizations (controls, n = 414) and measured provider-patient communication, education received, knowledge of HF, self-management behaviors, satisfaction, and quality of life. The participant group patients were more likely to report their doctor and nurse discussed treatment options and reviewed self-management (P < .01 for both). A total of 88% of participants were told to weigh themselves daily and record their weight compared with 34% of controls (P < .01). Participants were more likely to know how often to check their weight (P < .01), recognize symptoms of worsening HF (P < or = .01 for all), have a scale (P = .002), and monitor their weight daily (P < .001). Participants had similar quality of life but fewer emergency department visits and hospitalizations.Participation in a QI collaborative for HF was associated with better communication, education, and knowledge, and lower health care use. Collaboratives may be a useful method for disseminating quality improvement strategies.

    View details for DOI 10.1016/j.cardfail.2005.03.010

    View details for Web of Science ID 000231643400001

    View details for PubMedID 16105630

  • Sins of omission - Getting too little medical care may be the greatest threat to patient safety JOURNAL OF GENERAL INTERNAL MEDICINE Hayward, R. A., Asch, S. M., Hogan, M. M., Hofer, T. P., Kerr, E. A. 2005; 20 (8): 686-691


    Little is known about the relative incidence of serious errors of omission versus errors of commission.To identify the most common substantive medical errors identified by medical record review.Retrospective cohort study.Twelve Veterans Affairs health care systems in 2 regions.Stratified random sample of 621 patients receiving care over a 2-year period.Classification of reported quality problems.Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission.Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with underuse. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission.While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.

    View details for DOI 10.1111/j.1525-1497.2005.0152.x

    View details for Web of Science ID 000230601900003

    View details for PubMedID 16050875

  • Exploring barriers and facilitators to the use of computerized clinical reminders JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Saleem, J. J., Patterson, E. S., Militello, L., Render, M. L., Orshansky, G., Asch, S. M. 2005; 12 (4): 438-447


    Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs.We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers.Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use.Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback.We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs.

    View details for DOI 10.1197/jamia.M1777

    View details for Web of Science ID 000230859200010

    View details for PubMedID 15802482

  • Does the collaborative model improve care for chronic heart failure? MEDICAL CARE Asch, S. M., Baker, D. W., Keesey, J. W., Broder, M., Schonlau, M., Rosen, M., Wallace, P. L., Keeler, E. B. 2005; 43 (7): 667-675


    Organizationally based, disease-targeted collaborative quality improvement efforts are widely applied but have not been subject to rigorous evaluation. We evaluated the effects of the Institute of Healthcare Improvement's Breakthrough Series (IHI BTS) on quality of care for chronic heart failure (CHF).We conducted a quasi-experiment in 4 organizations participating in the IHI BTS for CHF in 1999-2000 and 4 comparable control organizations. We reviewed a total of 489 medical records obtained from the sites and used a computerized data collection tool to measure performance on 23 predefined quality indicators. We then compared differences in indicator performance between the baseline and post-intervention periods for participating and non-participating organizations.Participating and control patients did not differ significantly with regard to measured clinical factors at baseline. After adjusting for age, gender, number of chronic conditions, and clustering by site, participating sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid-lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P < 0.0001). The improvement was greatest for measures of education and counseling (24% versus -1%, P < 0.0001).Organizational participation in a common disease-targeted collaborative provider interaction improved a wide range of processes of care for CHF, including both medical therapeutics and education and counseling. Our data support the use of programs like the IHI BTS in improving the processes of care for patients with chronic diseases.

    View details for Web of Science ID 000230158700005

    View details for PubMedID 15970781

  • Negotiating end-of-life decision making: A comparison of Japanese and US residents' approaches ACADEMIC MEDICINE Gabbay, B. B., Matsumura, S., Etzioni, S., Asch, S. M., Rosenfeld, K. E., Shiojiri, T., Balingit, P. P., Lorenz, K. A. 2005; 80 (7): 617-621


    To compare Japanese and U.S. resident physicians' attitudes, clinical experiences, and emotional responses regarding making disclosures to patients facing incurable illnesses.From September 2003 to June 2004, the authors used a ten-item self-administered anonymous questionnaire in a cross-sectional survey of 103 internal medicine residents at two U.S. sites in Los Angeles, California, and 244 general medical practice residents at five Japanese sites in Central Honshu, Kyushu, Okinawa, Japan.The Japanese residents were more likely to favor including the family in disclosing diagnosis (95% versus 45%, p<.001) and prognosis (95% versus 51%, p<.001) of metastatic gastric cancer. Of residents who favored diagnostic or prognostic disclosure to both the patient and family, Japanese residents were more likely to prefer discussion with the family first. Trainees in Japan expressed greater uncertainty about ethical practices related to disclosure of diagnosis or prognosis. Many Japanese and U.S. residents indicated that they had deceived a patient at the request of a family (76% versus 18 %, p<.001), or provided nonbeneficial care (56% versus 72%, p<.05), and many expressed guilt about these behaviors.The residents' approaches to end-of-life decision making reflect known cultural preferences related to the role of patients and their families. Although Japanese trainees were more likely to endorse the role of the family, they expressed greater uncertainty about their approach. Difficulty and uncertainty in end-of-life decision making were common among both the Japanese and U.S. residents. Both groups would benefit from ethical training to negotiate diverse, changing norms regarding end-of-life decision making.

    View details for Web of Science ID 000230058600002

    View details for PubMedID 15980077

  • Identifying barriers to the effective use of clinical reminders: Bootstrapping multiple methods JOURNAL OF BIOMEDICAL INFORMATICS Patterson, E. S., Doebbeling, B. N., Fung, C. H., Militello, L., Anders, S., Asch, S. M. 2005; 38 (3): 189-199


    Advances in electronic medical record capabilities enable clinical reminders to inform providers when recommended actions are "due" for a patient. Despite evidence that they improve adherence to guidelines, the Veteran's Health Administration (VHA) has experienced challenges in having providers consistently use clinical reminders as intended. In this paper, we describe how multiple methods were used to opportunistically triangulate, or "bootstrap," an understanding of barriers to the effective use of clinical reminders in the VHA. In an initial study using ethnographic observations and semi-structured interviews of HIV clinical reminders, we identified six barriers to effective use: workload, time to remove inapplicable reminders, false alarms, training, reduced eye contact, and the use of paper forms rather than software. In a second study, we collected open-ended and closed-ended data regarding barriers and facilitators to the use of clinical reminders in general in the VHA through a survey of 261 participants at a national informatics meeting, where 104 of 142 VHA health care facilities were represented. The findings from the second study extended our understanding of the previously identified barriers. In addition, four new barriers were identified: ease of use issues, accessibility of workstations, resident physicians and trainees, and administration benefiting more than providers from clinical reminder use. We discuss potential implications regarding the similarities and differences in study findings for factors to consider in planning interventions to improve clinical reminder use.

    View details for DOI 10.1016/j.jbi.2004.11.015

    View details for Web of Science ID 000229494300003

    View details for PubMedID 15896692

  • Comparing strategies for United States veterans' mortality ascertainment. Population health metrics Lorenz, K. A., Asch, S. M., Yano, E. M., Wang, M., Rubenstein, L. V. 2005; 3 (1): 2-?


    BACKGROUND: We aimed to determine optimal strategies for complete mortality ascertainment comparing death certificates and United States (US) Veterans Administration (VA) records. METHODS: We constructed a cohort of California veterans who died in fiscal year (FY) 2000 and used VA services the year before death. We determined decedent status using California death certificates linked to VA utilization data and the VA Beneficiary Identification and Records Locator System (BIRLS) death file. We compared the characteristics of decedents who would not have been identified by either single source (e.g., VA BIRLS alone or California death certificates alone) with the rest of the cohort. RESULTS: A total of 8,813 veteran decedents were identified from both VA decedent files and death certificates. Of all decedents, 5,698 / 8,813 (65%) veterans were identified in both source files, but 2,426 / 8,813 (28%) decedents were not identified in VA BIRLS, and 689 / 8,813 (8%) were not identified in death certificates. Compared to the rest of the cohort, decedents whose mortality status was ascertained through either single source differed by race / ethnicity, marital status, and California residence. Clinically, veterans identified from either single source had less comorbidity and were less likely to have been users of VA inpatient or long term care, but equally or more likely to have been users of VA outpatient services. CONCLUSION: As single sources, VA decedent files and death certificates each provided an incomplete record, and death ascertainment was improved by using both source files. Potential bias may vary depending on analytic interest.

    View details for PubMedID 15730553

  • Do the incentives in 3-tier pharmaceutical benefit plans operate as intended? Results from a physician leadership survey AMERICAN JOURNAL OF MANAGED CARE Shrank, W. H., Young, H. N., Ettner, S. L., Glassman, P., Asch, S. M., Kravitz, R. L. 2005; 11 (1): 16-22


    Three-tier pharmaceutical benefit systems use graded co-payments to steer patients toward "preferred" formulary medications.To evaluate physicians' knowledge of formularies and out-of-pocket costs in such systems, as well as their perceived responsibility for helping patients manage out-of-pocket costs.Self-administered written survey.Physician leaders participating in the California Medical Association Leadership Conference were surveyed.A total of 133 responses were received from 205 participants (65% response rate). Physicians reported that they were often unaware of patients' out-of-pocket costs at the time of prescribing. Fifty-nine percent of physicians reported that they never or seldom were aware of patients' "preferred" (lower cost) formulary options when prescribing, and 70% never or seldom were aware of patients' out-of-pocket costs when prescribing. Although 88% of physicians agreed that it is important that patients' out-of-pocket costs for prescription drugs are managed, only 25% strongly or somewhat agreed that it is their "responsibility" to help. Instead, 69% of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. Physicians reported that they receive phone calls from pharmacists concerning formulary issues after 18.6% of the prescriptions they write.Physician leaders reported that they often do not possess the knowledge to assist patients in managing out-of-pocket costs for prescription drugs and they depend on pharmacists to communicate patient preferences in making prescribing decisions. As a result, price preferences are communicated indirectly, likely less efficiently, rather than intentionally when prescribing decisions are made.

    View details for Web of Science ID 000226245300002

    View details for PubMedID 15697096

  • Comparing Strategies for Mortality Ascertainment among Veterans, Population Health Metrics Population Health Metrics Lorenz , K., Asch , S., Yano E, E., Rubenstein , L. 2005; Feb 3:2
  • Quality of care for hypertension in the United States. BMC cardiovascular disorders Asch, S. M., McGlynn, E. A., Hiatt, L., Adams, J., Hicks, J., DeCristofaro, A., Chen, R., Lapuerta, P., Kerr, E. A. 2005; 5 (1): 1-?


    Despite heavy recent emphasis on blood pressure (BP) control, many patients fail to meet widely accepted goals. While access and adherence to therapy certainly play a role, another potential explanation is poor quality of essential care processes (QC). Yet little is known about the relationship between QC and BP control.We assessed QC in 12 U.S. communities by reviewing the medical records of a randomly selected group of patients for the two years preceding our study. We included patients with either a diagnosis of hypertension or two visits with BPs of >or=140/90 in their medical records. We used 28 process indicators based on explicit evidence to assess QC. The indicators covered a broad spectrum of care and were developed through a modified Delphi method. We considered patients who received all indicated care to have optimal QC. We defined control of hypertension as BP < 140/90 in the most recent reading.Of 1,953 hypertensive patients, only 57% received optimal care and 42% had controlled hypertension. Patients who had received optimal care were more likely to have their BP under control at the end of the study (45% vs. 35%, p = .0006). Patients were more likely to receive optimal care if they were over age 50 (76% vs. 63%, p < .0001), had diabetes (77% vs. 71%, p = .0038), coronary artery disease (87% vs. 69%, p < .0001), or hyperlipidemia (80% vs. 68%, p < .0001), and did not smoke (73% vs. 66%, p = .0005).Higher QC for hypertensive patients is associated with better BP control. Younger patients without cardiac risk factors are at greatest risk for poor care. Quality measurement systems like the one presented in this study can guide future quality improvement efforts.

    View details for PubMedID 15638933

  • Clinical relevance of automated drug alerts from the perspective of medical providers AMERICAN JOURNAL OF MEDICAL QUALITY Spina, J. R., Glassman, P. A., Belperio, P., Cader, R., Asch, S. 2005; 20 (1): 7-14


    The authors used a real-time survey instrument and subsequent focus group among primary care clinicians at a large healthcare system to assess usefulness of automated drug alerts. Of 108 alerts encountered, 0.9% (n = 1) represented critical alerts, and 16% (n = 17) were significant drug interaction alerts. Sixty-one percent (n = 66) involved duplication of a medication or medication class. The rest (n = 24) involved topical medications, inhalers, or vaccines. Of the 84 potentially relevant alerts, providers classified 11% (9/84), or about 1 in 9, as useful. Drug interaction alerts were more often deemed useful than drug duplication alerts (44.4% versus 1.5%, P < .001). Focus group participants generally echoed these results when ranking the relevance of 15 selected alerts, although there was wide variance in ratings for individual alerts. Hence, a "smarter" system that utilizes a set of mandatory alerts while allowing providers to tailor use of other automated warnings may improve clinical relevance of drug alert systems.

    View details for DOI 10.1177/1062860604273777

    View details for Web of Science ID 000226781900002

    View details for PubMedID 15782750

  • Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample ANNALS OF INTERNAL MEDICINE Asch, S. M., McGlynn, E. A., Hogan, M. M., Hayward, R. A., Shekelle, P., Rubenstein, L., Keesey, J., Adams, J., Kerr, E. A. 2004; 141 (12): 938-945


    The Veterans Health Administration (VHA) has introduced an integrated electronic medical record, performance measurement, and other system changes directed at improving care. Recent comparisons with other delivery systems have been limited to a small set of indicators.To compare the quality of VHA care with that of care in a national sample by using a comprehensive quality-of-care measure.Cross-sectional comparison.12 VHA health care systems and 12 communities.596 VHA patients and 992 patients identified through random-digit dialing. All were men older than 35 years of age.Between 1997 and 2000, quality was measured by using a chart-based quality instrument consisting of 348 indicators targeting 26 conditions. Results were adjusted for clustering, age, number of visits, and medical conditions.Patients from the VHA scored significantly higher for adjusted overall quality (67% vs. 51%; difference, 16 percentage points [95% CI, 14 to 18 percentage points]), chronic disease care (72% vs. 59%; difference, 13 percentage points [CI, 10 to 17 percentage points]), and preventive care (64% vs. 44%; difference, 20 percentage points [CI, 12 to 28 percentage points]), but not for acute care. The VHA advantage was most prominent in processes targeted by VHA performance measurement (66% vs. 43%; difference, 23 percentage points [CI, 21 to 26 percentage points]) and least prominent in areas unrelated to VHA performance measurement (55% vs. 50%; difference, 5 percentage points [CI, 0 to 10 percentage points]).Unmeasured residual differences in patient characteristics, a lower response rate in the national sample, and differences in documentation practices could have contributed to some of the observed differences.Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.

    View details for Web of Science ID 000225923000005

    View details for PubMedID 15611491

  • A bitter pill: Formulary variability and the challenge to prescribing physicians JOURNAL OF THE AMERICAN BOARD OF FAMILY PRACTICE Shrank, W. H., Ettner, S. L., Glassman, P., Asch, S. M. 2004; 17 (6): 401-407


    Multitiered, incentive-based formularies have been increasingly used as a mechanism to control prescription drug expenditures. Prescribing physicians who manage patients from multiple insurers must be familiar with the variability in their patients' formulary incentives to help patients choose therapy wisely. However, the degree of formulary variability among and within health plans over time is unclear.In 6 major health plans in California, we evaluated formulary incentive variability in 4 of the 5 drug classes with the highest expenditures in California: proton pump inhibitors, hydroxymethylglutaryl coenzyme A reductase inhibitors ("statins"), calcium channel blockers, and angiotensin-converting enzyme inhibitors. We categorized 20 branded members of these classes into either "preferred" or nonpreferred/uncovered categories. We calculated the consistency that brands were preferred across health plans and the frequency of changes in formulary status for each drug within plans between 2000 and 2002.None of the branded drugs evaluated were preferred on all formularies in 2002, and 10% were not available on any of the formularies. Formulary status varied greatly across plans, and more than 60% of drugs were preferred on 2 to 4 of the 6 formularies studied. Formulary status within health plans varied between 2000 and 2002 in more than half of the plans in the drug classes evaluated.In the drug classes evaluated, over a 2-year period, considerable variability was seen among and within formularies over time. This variability poses a challenge to physicians who wish to reduce patients' expenditures by prescribing the least expensive among similarly effective drugs within a drug class. This variability is especially relevant because recent legislation increases the likelihood that more Medicare beneficiaries will receive their medications from private health plans.

    View details for Web of Science ID 000225458200001

    View details for PubMedID 15575031

  • Quality care for people with HIV/AIDS: Patients perspectives HIV CLINICAL TRIALS Davis-Michaud, M., Yurk, R., Lansky, D., Asch, S., Wu, A. W. 2004; 5 (6): 406-415


    To explore patient preferences to aid in the development of quality measures to assess quality of health care for people living with human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS).This study involved three 2-hour focus groups with 29 people living with HIV/AIDS in Portland, Oregon, and San Francisco, California. Eighteen quality of care indicators for HIV/AIDS health care were presented to each group and quantitative rankings were obtained. Aggregated weightings were used to rank and prioritize the quality measures for further exploration.Participants identified 38 themes relevant to high-quality care for HIV/AIDS. Patients ranked the following candidate measures most important: effective relationship with provider, prevention of opportunistic infections, involvement in care and treatment decisions, being offered antiretroviral treatment, and access to health care services. We observed attitudinal differences among focus group participants that corresponded to gender and race/ethnicity.Participants favored quality information that rated the experience of care and outcome measures including indicators of access to services, standard treatments, and competence of the providers. Patient perspectives can inform the development of quality measures that are meaningful to consumers and can assist in the design of services that meet patients' demographic and socioeconomic needs.

    View details for Web of Science ID 000226800000006

    View details for PubMedID 15682354

  • Variation in implementation and use of computerized clinical reminders in an integrated healthcare system AMERICAN JOURNAL OF MANAGED CARE Fung, C. H., Woods, J. N., Asch, S. M., Glassman, P., Doebbeling, B. N. 2004; 10 (11): 878-885


    To identify patterns of use of computerized clinical reminders (CCRs) across an integrated healthcare system and describe institutional factors associated with their implementation.Cross-sectional study.At a national electronic health record (EHR) meeting, we surveyed 261 participants from 104 Veterans Health Administration (VHA) healthcare facilities regarding the number and types of CCRs available at each facility. Potential explanatory measures included perceived utility and ease of use of CCRs, training and personnel support for computer use, EHR functionalities, and performance data feedback to providers at each facility.The number of conditions with CCRs in use at a facility ranged from 1 to 15; most reported implementation of reminders for 10 of the 15 conditions surveyed. The most commonly implemented CCRs, used in more than 85% of facilities, were for conditions with VHA national performance measures (eg, tobacco cessation, immunizations, diabetes mellitus). The least commonly implemented CCRs were for post-deployment health evaluation and management, medically unexplained symptoms, and erectile dysfunction. Facilities that had implemented greater numbers of clinical reminders had providers who reported greater ease of use and utility of the reminders (P= .01).VHA facilities vary markedly in their implementation of CCRs. This effect may be partly explained by greater incorporation of clinical reminders for conditions with performance measures. Further study is needed to determine how to best implement clinical reminders and the institutional factors important in their use.

    View details for Web of Science ID 000225325100008

    View details for PubMedID 15609742

  • Accommodating ethnic diversity - A study of California hospice programs MEDICAL CARE Lorenz, K. A., Ettner, S. L., Rosenfeld, K. E., Carlisle, D., Liu, H., Asch, S. M. 2004; 42 (9): 871-874


    Studies have confirmed ethnic disparities in the use of hospice services and identified barriers that minorities face in accessing care.We sought to determine whether hospices provide services that might affect minority participation.We surveyed California hospices to determine whether programs use diverse health care providers and volunteers, offer translation, diverse spiritual care, or outreach materials and whether they plan to expand such services. Linking the data to the California Office of Statewide Health Planning and Development annual home care and hospice survey and 2000 US Census, we used multivariate linear regression to evaluate the relationship of program characteristics (profit status, size, chain/freestanding status, urban/rural location, and proportion of nonwhite residents) to services that might affect minority participation.One hundred of 149 programs that we surveyed responded.Many programs offer translation (81%), diverse providers (63%) and volunteers (64%), and culturally diverse spiritual services (52%). Few (21%) were conducting outreach, but 23/25 programs expanding services reported plans to improve outreach. In multivariate models adjusted for program size, chain status, profit status, urban/rural location, proportion of nonwhite residents, we found that larger hospices and those in ethnically diverse zip codes were more likely to offer such services. Larger hospices are more likely to report expanding such services.Many hospices are making efforts to accommodate ethnically diverse patients, but a substantial number are not. Culturally appropriate care and outreach should be addressed in efforts to improve the acceptability and experience of hospice care among minorities.

    View details for Web of Science ID 000223677800006

    View details for PubMedID 15319612

  • Early adoption of human immunodeficiency virus quality improvement in veterans affairs medical centers: Use of organizational surveys to measure readiness to change and adapt interventions to local priorities AMERICAN JOURNAL OF MEDICAL QUALITY Anaya, H. D., Yano, E. M., Asch, S. M. 2004; 19 (4): 137-144


    Potential delivery system responsiveness to quality improvement (QI) interventions is rarely assessed before implementation, although it might aid in interventional design. Preparing for a national initiative, we assessed Veterans Affairs (VA) human immunodeficiency virus (HIV) clinic organizational characteristics and attitudes toward QI interventions. Current QI activities and attitudes toward potential effectiveness of several techniques to improve antiretroviral and opportunistic infection prophylaxis therapy were assessed. These included computerized clinical reminders (CRs), group-based QI, expert advice, and facility and provider-level audit/feedback. Organizational characteristics were also examined. Respondents rated CRs and group-based QI (GBQI) interventions most highly. Western and complex facilities viewed CR and GBQI interventions more positively than less complex facilities or those in other regions, even controlling for organizational characteristics and perceived barriers to change. VA clinicians favored CR and GBQI over facility/ provider feedback. The persistence of regional variation should be further explored. Organizational surveys of attitudes toward potential QI interventions can assist in choosing interventions and targeting specific facilities.

    View details for Web of Science ID 000223141100002

    View details for PubMedID 15368778

  • Profiling quality of care: Is there a role for peer review? BMC HEALTH SERVICES RESEARCH Hofer, T. P., Asch, S. M., Hayward, R. A., Rubenstein, L. V., Hogan, M. M., Adams, J., Kerr, E. A. 2004; 4


    We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed.We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review.For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16-0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients.For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.

    View details for Web of Science ID 000222228200001

    View details for PubMedID 15151701

  • Hospice admission practices: Where does hospice fit in the continuum of care? 26th Annual Meeting of the Society-of-General-Internal-Medicine Lorenz, K. A., Asch, S. M., Rosenfeld, K. E., Liu, H., Ettner, S. L. WILEY-BLACKWELL PUBLISHING, INC. 2004: 725?30


    To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics.From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices.California statewide.One hundred of 149 (67%) operational licensed hospices.Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions.Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs.Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

    View details for Web of Science ID 000220855300010

    View details for PubMedID 15086652

  • Profiling the quality of care in twelve communities: Results from the CQI study HEALTH AFFAIRS Kerr, E. A., McGlynn, E. A., Adams, J., Keesey, J., Asch, S. M. 2004; 23 (3): 247-256


    Health care quality falls far short of its potential nationally. Because care is delivered locally, improvement strategies should be tailored to community needs. This analysis from the Community Quality Index (CQI) study reports on a comprehensive examination of how effectively care is delivered in twelve metropolitan areas. We find room for improvement in quality overall and in dimensions of preventive, acute, and chronic care in all of these communities; no community was consistently best or worst on the various dimensions. Having concrete estimates of the extent of the gap in performance should stimulate community-based quality improvement efforts.

    View details for DOI 10.1377/hlthaff.23.3.247

    View details for Web of Science ID 000221237300030

    View details for PubMedID 15160823

  • Racial and ethnic differences in patients' preferences for initial care by specialists AMERICAN JOURNAL OF MEDICINE Wong, M. D., Asch, S. M., Andersen, R. M., Hays, R. D., Shapiro, M. F. 2004; 116 (9): 613-620


    To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences.We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes.Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites.Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.

    View details for DOI 10.1016/j.amjmed.2003.09.051

    View details for Web of Science ID 000221143500006

    View details for PubMedID 15093758

  • Consumer knowledge of over-the-counter phenazopyridine ANNALS OF FAMILY MEDICINE Shi, C. W., Asch, S. M., Fielder, E., Gelberg, L., Nichol, M. B. 2004; 2 (3): 240-244


    Effective use of over-the-counter (OTC) medications depends on purchasers' knowledge of their indications. This study examines consumer knowledge regarding the urinary tract analgesic phenazopyridine, which recently became available without prescription.We conducted a cross-sectional survey of a stratified cluster random sample of purchasers of OTC phenazopyridine (N = 434) in 31 Los Angeles retail pharmacies.The response rate was 58%. Only 42% correctly characterized the likely cause of their symptoms, and only 57% correctly characterized the action of the drug. Worse consumer knowledge was associated with nonwhite race, first-time use, and less contact with health providers.Many consumers possess poor knowledge about phenazopyridine, potentially leading to undertreatment, especially in groups with worse access to care.

    View details for DOI 10.1370/afm.61

    View details for Web of Science ID 000225714800011

    View details for PubMedID 15209201

  • Delays and unmet need for health care among adult primary care patients in a restructured urban public health system AMERICAN JOURNAL OF PUBLIC HEALTH Diamant, A. L., Hays, R. D., Morales, L. S., Ford, W., Calmes, D., Asch, S., Duan, N. H., Fielder, E., Kim, S., Fielding, J., Sumner, G., Shapiro, M. F., Hayes-Bautista, D., Gelberg, L. 2004; 94 (5): 783-789


    We estimated the prevalence and determinants of delayed and unmet needs for medical care among patients in a restructured public health system.We conducted a stratified cross-sectional probability sample of primary care patients in the Los Angeles County Department of Health Services. Face-to-face interviews were conducted with 1819 adult patients in 6 languages. The response rate was 80%. The study sample was racially/ethnically diverse.Thirty-three percent reported delaying needed medical care during the preceding 12 months; 25% reported an unmet need for care because of competing priorities; and 46% had either delayed or gone without care.Barriers to needed health care continue to exist among patients receiving care through a large safety net system. Competing priorities for basic necessities and lack of insurance contribute importantly to unmet health care needs.

    View details for Web of Science ID 000221111400022

    View details for PubMedID 15117701

  • Consumer usage patterns of nonprescription histamine2-receptor antagonists AMERICAN JOURNAL OF GASTROENTEROLOGY Shi, C. W., Gralnek, I. M., Dulai, G. S., Towfigh, A., Asch, S. 2004; 99 (4): 606-610


    Prescription to over-the-counter (OTC) drug switches are increasingly common. Yet little is known about how the public uses these reclassified products. Histamine2-receptor antagonists (H2RAs) are popular examples, although they may be supplanted by OTC proton pump inhibitors (PPIs). We examined the extent to which consumers substitute OTC H2RAs for physician care and/or engage in off-label use of these medications.Self-administered anonymous survey of 1,116 adult OTC H2RA consumers in a random sample of 20 Los Angeles pharmacies from a major retail chain. Off-label use was defined by FDA warning label (e.g., bloody stools, dysphagia). Substitution was defined by intent to use H2RA instead of going to a physician.Forty-six percent engaged in off-label use of OTC H2RAs. Off-label use was independently associated with lower income, substitution for physician care, prior gastrointestinal disease, and past prescription H2RA use. Thirty-four percent substituted OTC H2RA use for physician care, and 54% of these met the criteria for off-label use. Substitution was associated with lack of health insurance, lack of time to see a physician, the belief that OTC H2RA was cheaper than clinic visits, and nonwhite race.Almost one-half of adult consumers reported using OTC H2RAs in a manner inconsistent with FDA labeling, and this off-label use was associated with substitution for physician care. Traditionally vulnerable populations were more prone to off-label use and to substituting H2RAs for physician care. Further studies are needed to assess patient outcomes, identify remedies, and explore implications for the reclassification of PPIs.

    View details for DOI 10.1111/j.1572-0241.2004.04130.x

    View details for Web of Science ID 000221108100007

    View details for PubMedID 15089889

  • Surgery for hepatocellular carcinoma: Does it improve survival? ANNALS OF SURGICAL ONCOLOGY Liu, J. H., Chen, P. W., Asch, S. M., Busuttil, R. W., Ko, C. Y. 2004; 11 (3): 298-303


    The incidence and mortality of hepatocellular carcinoma (HCC) are increasing in the United States. Whether surgery is associated with improved survival at the population level is relatively unknown. To address this question, we used a population-based cancer registry to compare survival outcomes between patients receiving and not receiving surgery with similar tumor sizes and health status.By using the Surveillance, Epidemiology, and End Results database, we identified HCC patients who had surgically resectable disease as defined by published expert guidelines. After excluding patients with contraindications to surgery, we performed both survival analysis and Cox regression to identify predictors of improved survival.Of the 4008 patients diagnosed with HCC between 1988 and 1998, 417 were candidates for surgical resection. The mean age was 63.6 years; mean tumor size was 3.3 cm. The 5-year overall survival with surgery was 33% with a mean of 47.1 months; without surgery, the 5-year overall survival was 7% with a mean of 17.9 months (P <.001). In the multivariate Cox regression, surgery was significantly associated with improved survival (P <.001). Specifically, patients who received surgery had a 55% decreased rate of death compared with patients who did not have surgery, even after controlling for tumor size, age, sex, and race.This study shows that surgical therapy is associated with improved survival in patients with unifocal, nonmetastatic HCC tumors <5 cm. If this is confirmed in future studies, efforts should be made to ensure that appropriate patients with resectable HCC receive high-quality care, as well as the opportunity for potentially curative surgery.

    View details for DOI 10.1245/ASO.2004.03.042

    View details for Web of Science ID 000189380800013

    View details for PubMedID 14993025

  • Lipid screening in HIV-infected veterans JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Korthuis, P. T., Asch, S. M., Anaya, H. D., Morgenstern, H., Goetz, M. B., Yano, E. M., Rubenstein, L. V., Lee, M. L., Bozzette, S. A. 2004; 35 (3): 253-260


    Lipid screening is recommended for patients taking protease inhibitors (PIs).We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs).Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95).Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.

    View details for Web of Science ID 000220327600005

    View details for PubMedID 15076239

  • Controversies and legal issues of prescribing and dispensing medications using the Internet MAYO CLINIC PROCEEDINGS Fung, C. H., Woo, H. E., Asch, S. M. 2004; 79 (2): 188-194


    Online pharmacies fall into 3 major categories: independent Internet-only sites, online branches of "brick-and-mortar" pharmacies, and sites representing partnership among neighborhood pharmacies. Potential benefits of online pharmacies include increased access, lower transaction and product costs, and greater anonymity. However, online pharmacies have generated controversies, including the use of "cyberdoctors" on some sites, the dispensing of drugs without prescriptions from other sites, and the importation of prescription medications. Although some online pharmacies are legitimate and likely provide benefits to patients, other online pharmacies engage in questionable practices. Numerous state and federal regulations and laws have tried to address controversies surrounding rogue Internet pharmacies. Because online pharmacies are increasingly common, clinicians may encounter patients asking for advice and information about online pharmacies. We review the regulatory framework governing online pharmacies and the potential risks and benefits of using online pharmacies.

    View details for Web of Science ID 000188718100008

    View details for PubMedID 14959914

  • Symptom-based framework for assessing quality of HIV care INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Asch, S. M., Fremont, A. M., Turner, B. J., Gifford, A., McCutchan, J. A., Mathews, W. M., Bozzette, S. A., Shapiro, M. F. 2004; 16 (1): 41-50


    To evaluate HIV quality of care using a symptom-based, patient-centered framework.An expert panel developed 13 quality indicators for three common symptoms: cough with fever and/or shortness of breath; severe or persistent diarrhea; and significant weight loss. A nationally representative probability sample of HIV-infected adults was interviewed between 1996 and 1997.were asked about the presence and severity of HIV symptoms during the preceding 6 months, and care received. Variation in adherence to the indicators was assessed by symptom type and patient characteristics.In all, 2864 (71%) patients completed interviews and 920 reported being at least moderately bothered with one of the three symptoms. Of these, 41, 74, and 65% of patients with a symptom of cough, weight loss, or diarrhea, respectively, reported receiving all indicated care. Performance was better for patients with more severe HIV, measured as a CD4 cell count <50 cells/microliter, compared with those with less severe HIV, measured as CD4 cell count >500 cells/microliter (43% versus 60%; P = 0.02). Uninsured patients had worse performance than Medicare patients (45% versus 62%; P = 0.04), but care did not differ by patient's age, gender, ethnicity, HIV risk factor, providers' HIV patient load, or region. Only CD4 count remained significantly associated with performance in the multivariate analyses.Symptom-based quality indicators may provide a useful supplement to conventional measures. Patients with HIV reported substantial underuse of services for common, burdensome symptoms. Although adherence to quality indicators was better for patients with more advanced HIV disease, many still received suboptimal care. Vulnerable patient groups generally did not receive worse quality of care, suggesting that symptom-based measures of quality may measure domains that are distinct from those captured by conventional indicators.

    View details for DOI 10.1093/intqhc/mzh004

    View details for Web of Science ID 000188796200006

    View details for PubMedID 15020559

  • Human factors barriers to the effective use of ten HIV clinical reminders JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Patterson, E. S., Nguyen, A. D., Halloran, J. P., Asch, S. M. 2004; 11 (1): 50-59


    Substantial variations in adherence to guidelines for human immunodeficiency virus (HIV) care have been documented. To evaluate their effectiveness in improving quality of care, ten computerized clinical reminders (CRs) were implemented at two pilot and eight study sites. The aim of this study was to identify human factors barriers to the use of these CRs.Observational study was conducted of CRs in use at eight outpatient clinics for one day each and semistructured interviews were conducted with physicians, pharmacists, nurses, and case managers.Detailed handwritten field notes of interpretations and actions using the CRs and responses to interview questions were used for measurement.Barriers present at more than one site were (1) workload during patient visits (8 of 8 sites), (2) time to document when a CR was not clinically relevant (8 of 8 sites), (3) inapplicability of the CR due to context-specific reasons (9 of 26 patients), (4) limited training on how to use the CR software for rotating staff (5 of 8 sites) and permanent staff (3 of 8 sites), (5) perceived reduction of quality of provider-patient interaction (3 of 23 permanent staff), and (6) the decision to use paper forms to enable review of resident physician orders prior to order entry (2 of 8 sites).Six human factors barriers to the use of HIV CRs were identified. Reducing these barriers has the potential to increase use of the CRs and thereby improve the quality of HIV care.

    View details for DOI 10.1197/jamia.M1364

    View details for Web of Science ID 000188206500007

    View details for PubMedID 14527974

  • Variation in Implementation and Use of Computerized Clinical Reminders in an Integrated Health System The American Journal of Managed Care Fung , C., Woods , J., Asch , S., Glassman , P., Doebbeling , B. 2004; 19 Suppl 1: 235
  • Quality of HIV Care within the Veterans Affairs Health System: a comparison using Outcomes from the HIV Cost and Services Utilization Study (HCSUS) Journal of Clinical Outcomes Management Korthuis , P., Anaya , H., Bozzette , S., Brinkerhoff , C., Mancewicz, M., Wang, M., Asch , S. 2004; 11(12): 765-774
  • Early Adoption of HIV Quality Improvement in VA Medical Centers: Use of Organizational Surveys to Measure Readiness to Change and Adapt Interventions to Local Priorities Amer J of Med Qual. Anaya HD, H., Yano EM, E., Asch SM, S. 2004; 19(4): 137-144
  • Racial and Ethnic Differences in Preferences For Specialist Care Am J Med Wong , M., Asch, S., Andersen , R., Hays , R., Shapiro , M. 2004; May; 116 (9): 613-20
  • Delays and Unmet Need for Health Care among Adult Primary Care Patients in Restructured Urban Public Health System American Journal of Public Health Diamant , A., Hays , R., Morales , L., Ford , W., Calmes , D., Asch , S., Duan , N., Fielder , E., Kim , S., Fielding , J., Sumner , G., Shapiro , M., Hayes-Bautista , D., Gelberg , L. 2004; May; 94(5): 783-9
  • Profiling the Quality of Care in Communities: Results from the Community Quality Index Study Health Affairs Kerr, E., McGlynn, E., Adams, J., Keesey, J., Asch, S. 2004; May/June; 23(3) : 247-256
  • Developing quality indicators for local health departments - Experience in Los Angeles County AMERICAN JOURNAL OF PREVENTIVE MEDICINE Derose, S. F., Asch, S. M., Fielding, J. E., Schuster, M. A. 2003; 25 (4): 347-357


    To develop public health quality indicators for local health department (LHD) use.An indicator development team utilized public health quality measurement concepts, reviewed existing quality measurement-related initiatives, and conducted interviews with LHD staff in order to identify and develop quality indicators for the Los Angeles County Health Department.Sixty-one recommended and 50 acceptable (i.e., scientifically sound but less useful) indicators were developed, with an emphasis on measuring process quality in services delivery. Pre-existing indicators from external sources, when available, were often not well suited to the Health Department's needs. The indicator development process clarified conceptual issues, highlighted strengths and limitations of potential indicators, and revealed implementation barriers.A limited number of generally available, quantitative indicators of local public health quality exist. Indicators addressing the delivery of LHD services can be locally developed to fill an important gap in public health quality-improvement efforts. However, implementation of quality measurement is difficult due to limited evidence on public health practices, sparse data resources, unclear accountability, and inconsistent organizational motivation.

    View details for DOI 10.1016/S0749-3797(03)00208-3

    View details for Web of Science ID 000186048300014

    View details for PubMedID 14580639

  • Charity for the dying: who receives unreimbursed hospice care? Journal of palliative medicine Lorenz, K. A., Rosenfeld, K. E., Asch, S. M., Ettner, S. L. 2003; 6 (4): 585-591


    Many deaths occur among persons without insurance coverage for hospice care. We examined the patient and agency characteristics associated with receiving unreimbursed hospice care in a national survey.We examined the receipt of unreimbursed care using the 1998 National Home and Hospice Care Survey (NHHCS) discharge dataset. Overall, only 3% of hospice patients received unreimbursed care. Because 98% of older adults are eligible for Medicare, we stratified multivariate analysis on age greater or less than 65 years. Among persons less than 65 years of age, younger, nonwhite persons were more likely to receive unreimbursed care, as were persons with cancer. Agencies providing unreimbursed care to persons over the age of 65 years were more likely to be not-for-profit and freestanding.Recipients of unreimbursed hospice care are demographically similar to the uninsured, and whether uninsured persons receive unreimbursed hospice care depends on clinical and agency organizational factors related to the motivation to provide unreimbursed care.

    View details for PubMedID 14516500

  • The quality of health care delivered to adults in the United States NEW ENGLAND JOURNAL OF MEDICINE McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., Kerr, E. A. 2003; 348 (26): 2635-2645


    We have little systematic information about the extent to which standard processes involved in health care--a key element of quality--are delivered in the United States.We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores.Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence.The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.

    View details for Web of Science ID 000183726400008

    View details for PubMedID 12826639

  • Underdiagnosis of depression in HIV - Who are we missing? JOURNAL OF GENERAL INTERNAL MEDICINE Asch, S. M., Kilbourne, A. M., Gifford, A. L., Burnam, M. A., Turner, B., Shapiro, M. F., Bozzette, S. A. 2003; 18 (6): 450-460


    To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV.Cross-sectional survey.National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data.We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P <.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P <.01) and those with >or=3 outpatient visits (P <.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers.Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.

    View details for Web of Science ID 000183796100006

    View details for PubMedID 12823652

  • Quality of health care for women - A demonstration of the quality assessment tools system MEDICAL CARE McGlynn, E. A., Kerr, E. A., Adams, J., Keesey, J., Asch, S. M. 2003; 41 (5): 616-625


    Consumers, purchasers, and regulators are seeking information on quality for a variety of purposes. To address these demands, methods are required that are flexible in meeting the information needs of different audiences.To test a new clinically detailed, comprehensive approach to quality measurement called Quality Assessment (QA) Tools.Quality measures were developed for women ages 18 to 50 years for preventive care and 17 clinical areas that included chronic and acute health problems. A stratified random sample of women enrolled in 1 of 2 health plans in 1996 to 1997 was drawn and data abstracted from the medical records of all their providers for a 2-year period.We evaluated quality for 758 women in 2 managed care plans. Quality of care varied substantially depending on the dimension being examined. For example, acute care was significantly better than chronic or preventive care. Quality was highest for follow-up care and lowest for treatment in both plans. Quality by modality ranged from approximately 90% for referral or admission to 16% for education and counseling. We found significant differences between the plans in the quality of care for 7 of the 17 conditions studied.The QA Tools system offers an alternative approach to evaluating health system performance. Potential advantages include the richness of the information produced by the system, the ability to create summary scores for consumers and purchasers, and the system-level performance information for use in quality improvement activities.

    View details for Web of Science ID 000182695900010

    View details for PubMedID 12719686

  • Prevalence and predictors of HIV testing among a probability sample of homeless women in Los Angeles county PUBLIC HEALTH REPORTS Herndon, B., Asch, S. M., Kilbourne, A. M., Wang, M. M., Lee, M., Wenzel, S. L., Andersen, R., Gelberg, L. 2003; 118 (3): 261-269


    To describe the prevalence and predictors of HIV testing in a probability cluster sample of urban homeless women.Analysis of data from the University of California Los Angeles-RAND Access to Health Care for Homeless Women of Reproductive Age Study, a survey conducted in six waves from January 1997 through November 1997 at shelters and soup kitchens in Los Angeles (LA) County, California. The sampling unit consists of homeless woman-visits, and data were collected using structured face-to-face interviews for which respondents were paid US dollars 10. Each sampling unit was weighted to take into account the frequency with which the respondent used shelters or meal programs. The main outcome measure was receipt of HIV test in the past year.The response rate was 83%, and the final sample size was N=970. Sixty-eight percent of our sample reported receiving an HIV test in the past year, and 1.6% reported ever being diagnosed with HIV. HIV testing in the past year was most strongly associated with pregnancy in the past year (OR 2.99; p<.001) and having a regular source of care (OR 2.13; p<.001). Approximately 25% of homeless women with indications for HIV testing had not been tested in the past year.The reported HIV seroprevalence of greater than 1% suggests that providers should offer and encourage HIV testing for all homeless women in LA County. Our data, which show a high rate of testing and few statistically significant independent predictors, indicate that this may be what is happening in practice.

    View details for Web of Science ID 000187280300012

    View details for PubMedID 12766220

  • Usage patterns of over-the-counter phenazopyridine (pyridium) JOURNAL OF GENERAL INTERNAL MEDICINE Shi, C. W., Asch, S. M., Fielder, E., Gelberg, L., Brook, R. H., Leake, B., Shapiro, M. F., Dowling, P., Nichol, M. 2003; 18 (4): 281-287


    Little is known about how the public uses formerly prescription medications that are available over-the-counter (OTC). This study examines whether consumers inappropriately use and substitute a recently widely distributed OTC urinary analgesic, phenazopyridine, for provider care.We conducted a cross-sectional survey of a stratified cluster random sample of OTC phenazopyridine purchasers (N = 434) in 31 Los Angeles retail pharmacies over 5 months. Recruited by shelf advertisements, participants were 18 years or older who purchased a phenazopyridine product. Each completed a 25-item self-administered anonymous questionnaire. Inappropriate use was defined as 1) having medical contraindications to phenazopyridine, or 2) not having concurrent antibiotic and/or provider evaluation for the urinary symptoms.The survey response rate was 58%. Fifty-one percent of the respondents used OTC phenazopyridine inappropriately, and 38% substituted it for medical care. Multiple logistic regression analyses revealed that inappropriate use was correlated with having little time to see a provider (odds ratio [OR], 1.57; 95% confidence interval [95% CI], 1.26 to 1.96), receiving friend's or family's advice (OR, 1.25; 95% CI, 1.05 to 1.47), having prior urinary tract infections (OR, 0.49; 95% CI, 0.30 to 0.80), having used prescription phenazopyridine, (OR, 0.40; 95% CI, 0.25 to 0.63), and having back pain (OR, 0.34; 95% CI, 0.16 to 0.74). Similar correlates were found in those who substituted OTC phenazopyridine for provider care. Respondents with incorrect knowledge about phenazopyridine's mode of action had 1.9 times greater odds of inappropriate use and 2.2 times greater odds of substitution than those who had correct knowledge about this drug.Inappropriate use of OTC phenazopyridine appears common. Increasing the public's knowledge about reclassified drugs may help to mitigate this problem.

    View details for Web of Science ID 000182323400007

    View details for PubMedID 12709095

  • Waiting times in California's emergency departments Annual Meeting of the Robert-Wood-Johnson-Foundation-Clinical-Scholars Lambe, S., Washington, D. L., Fink, A., Laouri, M., Liu, H. H., Fosse, J. S., Brook, R. H., Asch, S. M. MOSBY-ELSEVIER. 2003: 35?44


    Many perceive emergency department crowding as a significant problem that is getting worse. A national survey of ED directors defined crowding, in part, as waiting more than 1 hour to see a physician, a wait considered likely to result in adverse outcomes. Yet few data are available on ED waiting times among a heterogeneous group of hospitals serving a distinct geographic region.We observed a random sample of 1,798 patients visiting 30 California EDs between December 15, 2000, and May 15, 2001. We defined waiting time as the interval from ED arrival to first contact with a physician or midlevel provider.Patients waited an average of 56 minutes (95% confidence interval [CI] 52 to 61 minutes; median 38 minutes); 42% waited longer than 60 minutes. Ordinary least squares regression analysis revealed that waiting times were significantly longer at hospitals in poorer neighborhoods: For every 10,000 dollars decline in per capita income, patients waited 10.1 minutes longer (95% CI 1.8 to 18.4 minutes; P=.02) after adjusting for hospital ownership, teaching status, trauma status, proximity to a recently closed ED, ED volume, patient severity, and age. Lower ratios of physicians and triage nurses to waiting room patient were also associated with longer waits.Waiting times often exceeded the threshold set by a survey of ED directors. Further study is required to examine factors that lead to longer waiting times at hospitals in low-income areas. Physician and nurse staffing should be investigated as a means of reducing waiting times.

    View details for DOI 10.1067/mem.2003.2

    View details for Web of Science ID 000180369200006

    View details for PubMedID 12514681

  • Measuring medication - Do interviews agree with medical record and pharmacy data? MEDICAL CARE Korthuis, P. T., Asch, S., Mancewicz, M., Shapiro, M. F., Mathews, W. C., Cunningham, W. E., McCutchan, J. A., Gifford, A., Lee, M. L., Bozzette, S. A. 2002; 40 (12): 1270-1282


    Medication measurement is crucial in assessing quality for chronic conditions yet agreement of alternate data sources remains uncertain.To evaluate medication agreement between interviews, medical records, and pharmacy data; to assess data source contribution to attributing medication exposure; and to describe the impact of combining data sources on models that predict medication use.Prospective cohort study.Probability sample of HIV-infected participants in the HIV Cost and Services Utilization Study.Medications reported in 2267 interviews, 1936 medical records, and 457 pharmacy records were compared using crude agreement, kappa, and the proportion of average positive and negative agreement. The percent of medications reported in each source alone was used to assess their relative contribution to attributing exposure status. We performed weighted logistic regression in alternate data sources.Kappa varied from 0.38 for nucleoside reverse transcriptase inhibitors to 0.70 for protease inhibitors, when comparing drug classes in interview versus medical record, interview versus pharmacy data, and medical record versus pharmacy data. The percentage of medications reported in medical records was greater than that reported in interviews or pharmacy data. Pharmacy data contributed little to the attribution of medication exposure. Adding medication data to interview data did not appreciably change analytic models predicting medication use.For specific medications, agreement between alternative data sources is fair to substantial, but is lower for key drug classes. Relying on one data source may lead to misclassification of drug exposure status, but combining data sources does not change the results of analytic models predicting appropriate medication use.

    View details for DOI 10.1097/01.MLR.0000036406.61316.B5

    View details for Web of Science ID 000179621500013

    View details for PubMedID 12458308

  • Cash and compassion: profit status and the delivery of hospice services. Journal of palliative medicine Lorenz, K. A., Ettner, S. L., Rosenfeld, K. E., Carlisle, D. M., Leake, B., Asch, S. M. 2002; 5 (4): 507-514


    To evaluate the relationship of hospice profit status to patient selection and service delivery.We analyzed responses to the 1997 California Office of Statewide Health Planning and Development (OSHPD) annual home care and hospice survey. Outcomes included the percentages of patients with noncancer diagnoses, referred from long-term care, and with government payers; average length of stay (LOS); the intensity and skill mix of nursing services; and potential availability of chemotherapy and radiotherapy. Reduced models controlled for facility type, profit status, urbanicity, and patient-days. Complete models additionally controlled for patient gender, age, race/ethnicity, diagnosis, referral source, and primary reimbursement source.All 176 licensed California hospices in 1997.We report comparisons of for-profit and not-for-profit hospices as the absolute difference in percentage points between outcomes (e.g., a difference of 40% vs. 50% is reported as a 10 percentage point difference). In reduced models, for-profit hospices reported 17 percentage points more discharges with noncancer diagnoses, 15 percentage points more long-term care referrals, and 8 percentage points more patients with government payers. Average LOS did not differ by profit status. In reduced models, for-profit hospices delivered 0.20 more daily nursing visits on average; this difference was attributable to patient characteristics. The ratio of skilled to total nursing visits was 11 percentage points lower for for-profit hospices compared to not-for-profit hospices in reduced models (7 in complete models). Profit status was unrelated to the potential availability of chemotherapy and radiotherapy.For-profit hospices compared to not-for profit hospices serve a higher percentage of persons with noncancer diagnoses, residents of long-term care, and persons with government insurance. Differences in patterns of nursing services among hospices were related to patient characteristics. The potential availability of complex palliative services did not differ by profit status.

    View details for PubMedID 12243675

  • The association of access to medical care with regular source of care and sociodemographic characteristics in patients with HIV and tuberculosis JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Soloria, M. R., Asch, S. M., Globe, D., Cunningham, W. E. 2002; 94 (7): 581-589


    To examine satisfaction with access to health care in two populations, one with HIV and one with TB, and examine the effect of having a regular doctor and sociodemographic characteristics.Cross-Sectional survey.A sample of HIV inpatients hospitalized at seven Los Angeles sites (N = 217) and TB outpatients chosen randomly from the Los Angeles County TB Registry Census (N = 313).We performed bivariate and multivariate regression analyses of satisfaction with access to care on gender, race/ethnicity, age, education, income, insurance, and having a regular doctor.A six-item scale of satisfaction with access to care (range 0-100; Cronbach's alpha 0.87).The mean satisfaction with access score for the HIV sample was significantly lower than the TB sample (53.5 vs. 61.2, p<0.001). The HIV sample multivariate analysis (including all the variables) showed that increasing age (p<0.021 and having a regular doctor (p<0.002) were associated with better access, and that low income (p<0.005) was associated with poor access. In the TB sample analysis, only increasing age was associated with better satisfaction with access to care (p< 0.01).HIV patients receiving care in the private sector reported less satisfaction with access to care compared to TB patients receiving care in the public health sector. The traditional factors of socio-economic status and having a regular doctor were associated with satisfaction with access-to-care in the HIV sample but not the TB sample. Our findings suggest that certain characteristics of the TB public health programs may explain these differences and suggests that, perhaps, the existence of a similar public health program for vulnerable low-income populations with HIV would improve their satisfaction with access, as well.

    View details for Web of Science ID 000176814900020

    View details for PubMedID 12126284

  • Developing indicators of nursing quality to evaluate nurse staffing ratios JOURNAL OF NURSING ADMINISTRATION Hodge, M. B., Asch, S. M., Olson, V. A., Kravitz, R. L., Sauve, M. J. 2002; 32 (6): 338-345


    Concerns about the adequacy of patient care and safety in the state of California led to legislation that required the implementation of mandatory nurse staffing ratios. The authors describe a novel approach for identifying indicators that could be used to evaluate the impact of these regulations on quality of care and patient outcomes. The results of this project demonstrate that this is a useful method for identifying indicators appropriate for use in outcomes research with a focus on structural predictors of quality in healthcare.

    View details for Web of Science ID 000177142400009

    View details for PubMedID 12055490

  • Trends in the use and capacity of California's emergency departments, 1990-1999 CAL/ACEP Scientific Assembly Lambe, S., Washington, D. L., Fink, A., Herbst, K., Liu, H. H., Fosse, J. S., Asch, S. M. MOSBY-ELSEVIER. 2002: 389?96


    Concerns over the ability of the nation's emergency departments to meet current demands are growing among the public and health care professionals. Data supporting perceptions of inadequate capacity are sparse and conflicting. We describe changes in the use and capacity of California's EDs between 1990 and 1999, as well as trends in severity of patient illness or injury.Data from California's Office of Statewide Health Planning and Development (OSHPD), which describe all hospital and health service use in the state, were analyzed and later verified using a telephone survey of all 320 open EDs in California. Six variables were analyzed: hospital's ownership type (public or private), total number of annual ED visits, severity of patient illness or injury (percentage of visits categorized as critical, urgent, or nonurgent), number of ED beds, proximity to a closed ED, and teaching status. We tested 2 main hypotheses: (1) Have statewide ED visits, ED beds, visits per ED, and visits per bed increased or decreased between 1990 and 1999? and (2) Has severity of patient illness or injury, as reported to OSHPD, changed over the past decade? State level data were analyzed using ordinary least-squares regression. Hospital level data were analyzed using repeated measures analyses.The number of EDs in California decreased by 12% (P <.0001). The number of ED treatment stations (ie, physical spaces for the treatment of patients) increased by 687 (16%) statewide (P =.0001), or an average of 79 beds per year. The average annual change in ED visits was not statistically significant (P =.5), whereas visits per ED increased by 27% for all EDs (P <.0001), although with differing trends noted at public and private hospitals. At private hospitals, the average increase was 512 visits/ED each year, whereas at public hospitals, visits decreased by an average of 1,085 visits/ED each year (P <.0001). Overall, critical visits per ED increased by 59% (P <.0001), and nonurgent visits per ED decreased by 8% (P <.0001).The number of EDs in California decreased significantly during the 1990s, whereas the number of ED beds increased. Increases in visits per ED, beds per ED, and in the proportion of patients categorized as critical may help explain the perception that ED capacity is inadequate to meet growing demand.

    View details for DOI 10.1067/mem.2002.122433

    View details for Web of Science ID 000174696600005

    View details for PubMedID 11919525

  • Compliance among pharmacies in California with a prescription-drug discount program for Medicare beneficiaries NEW ENGLAND JOURNAL OF MEDICINE Lewis, J. H., Schonlau, M., Munoz, J. A., Asch, S. M., Rosen, M. R., Yang, H., Escarce, J. J. 2002; 346 (11): 830-835


    Several states have developed prescription-drug discount programs for Medicare beneficiaries. In California, Senate Bill 393, enacted in 1999, requires pharmacies participating in the state Medicaid program (Medi-Cal) to charge customers who present a Medicare card amounts based on Medi-Cal rates. Because Medicare beneficiaries may not be accustomed to presenting their Medicare cards at pharmacies, we assessed the compliance of pharmacies with Senate Bill 393.Fifteen Medicare beneficiaries who received special training and acted as "standardized patients" visited a random sample of pharmacies in the San Francisco Bay area and Los Angeles County in April and May 2001. According to a script, they asked for the prices of three commonly prescribed drugs: rofecoxib, sertraline, and atorvastatin. The script enabled us to determine whether and when, during their interactions with pharmacists or salespeople, the discounts specified in Senate Bill 393 were offered. Pharmacies at which the appropriate discounts were offered were considered compliant.The patients completed visits to 494 pharmacies. Seventy-five percent of the pharmacies complied with the prescription-drug discount program; at only 45 percent, however, was the discount offered before it was specifically requested. The discount was offered at 91 percent of pharmacies that were part of a chain, as compared with 58 percent of independent pharmacies (P<0.001). Compliance was higher in the San Francisco Bay area than in Los Angeles County (84 percent vs. 72 percent, P=0.004) and was higher in high-income than low-income neighborhoods (81 percent vs. 69 percent, P=0.002). A Medicare beneficiary taking all three drugs would have saved an average of $55.70 per month as compared with retail prices (a savings of 20 percent).Discounts required under California's prescription-drug discount program for Medicare beneficiaries offer substantial savings. Many patients, however, especially those who use independent pharmacies or who live in low-income neighborhoods, may not receive the discounts.

    View details for Web of Science ID 000174328900007

    View details for PubMedID 11893795

  • Response to symptoms among a US national probability sample of adults infected with human immunodeficiency virus MEDICAL CARE RESEARCH AND REVIEW Kilbourne, A. M., Andersen, R. M., Asch, S., Nakazono, T., Crystal, S., Stein, M., Gifford, A. L., Bing, E. G., Bozzette, S. A., Shapiro, M. F., Cunningham, W. E. 2002; 59 (1): 36-58


    Previous studies concerning disparities in Human Immunodeficiency Virus (HIV) services use among vulnerable groups did not control for specific clinical need for care such as symptom events. Using the Andersen Behavioral Model of Health Services Use, the authors determined whether minorities, women, and the less educated (vulnerable groups) were less likely to receive care for HIV symptoms. Persons enrolled in the HIV Cost and Services Utilization Study were asked whether they received care for their most bothersome symptom. Surprisingly, minorities and women were no more likely to go without care than other groups. Those with Medicaid, Medicare, private health maintenance organization (HMO) insurance, or no insurance were less likely to receive care for symptoms than those with private-non-HMO insurance. Vulnerable groups were no less likely to use services for HIV-related symptoms when need for care was considered. However, disparities may exist for symptom-specific care among HIV infected persons covered by public or HMO insurance.

    View details for Web of Science ID 000173913900002

    View details for PubMedID 11877878

  • Comparing quality of care for sexually transmitted diseases in specialized and general clinics PUBLIC HEALTH REPORTS Asch, S. M., Sa'adah, M. G., Lopez, R., Kokkinis, A., Richwald, G. A., Rhew, D. C. 2002; 117 (2): 157-163


    The objective of this study was to compare quality of care for patients with sexually transmitted diseases (STDs) in specialized vs. general clinics.The authors conducted a retrospective chart review evaluating compliance with a set of STD-related process of care quality indicators for adult patients seen in six Los Angeles County clinics (two STD specialized clinics and four general medical clinics).Thirty-two quality indicators were selected using a modified Delphi process. From March 1, 1996, to June 31, 1996, there were 205 STD-related visits to the two specialized STD clinics and 373 STD-related visits to the four general medical clinics. For patients with "classic" STDs (those for which sexual contact is the primary means of transmission), STD clinics achieved greater compliance than general medical clinics on 14 quality indicators, while general medical clinics achieved greater compliance on 4 indicators.STD clinics provide better overall STD care than general medical clinics. Possible explanations include differences in clinician experience with STD patients and greater use of standardized protocol sheets.

    View details for Web of Science ID 000178680800008

    View details for PubMedID 12357000

  • Physician-related barriers to the effective management of uncontrolled hypertension ARCHIVES OF INTERNAL MEDICINE Oliveria, S. A., LaPuerta, P., McCarthy, B. D., L'Italien, G. J., Berlowitz, D. R., Asch, S. M. 2002; 162 (4): 413-420


    Primary care physicians may not be aggressive enough with the management of hypertension. The purpose of this study was to identify barriers to primary care physicians' willingness to increase the intensity of treatment among patients with uncontrolled hypertension.Descriptive survey study. We sampled patient visits in a large midwestern health system to identify patients with uncontrolled hypertension. The treating primary care physicians were asked to complete a survey about the patient visit with a copy of the office notes attached to the survey (patient visits, n = 270; response rate, 86%).Pharmacologic therapy was initiated or changed at only 38% of visits, despite documented hypertension for at least 6 months before the patients' most recent visit. The most frequently cited reason for no initiation or change in therapy was related to the primary care physicians being satisfied with the blood pressure (BP) value (satisfactory BP response, 30%; satisfactory diastolic BP response, 16%; only borderline hypertension, 10%). At 93% of these visits, systolic BP values were 140 mm Hg or higher, which is above the cut point recommended by Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, and 35% were 150 mm Hg or higher. On average, physicians reported that 150 mm Hg was the lowest systolic BP at which they would recommend pharmacologic treatment to patients, compared with 91 mm Hg for diastolic BP.Our findings suggest that an important reason why physicians do not treat hypertension more aggressively is that they are willing to accept an elevated systolic BP in their patients. This has an important impact on public health because of the positive association between systolic BP and cardiovascular disease.

    View details for Web of Science ID 000173854800006

    View details for PubMedID 11863473

  • Predictors of seat-belt use among school-aged children in two low-income Hispanic communities AMERICAN JOURNAL OF PREVENTIVE MEDICINE Edgerton, E. A., Duan, N. H., Seidel, J. S., Asch, S. 2002; 22 (2): 113-116


    To examine the prevalence of seat belt use among school-aged children in low-income Hispanic communities.We conducted unobtrusive observations of school-aged children (aged 5 to 12 years) traveling to and from nine elementary schools in two communities. We documented vehicle type, and belted status and seating position of children, driver, and other passengers. Results are presented as percentages with 95% confidence intervals (CIs).We observed 3651 children, of which restraint use could be determined for 2741. Overall, 29% of children were using seat belts. By seating location, 58% were in the front seat with 40% belted, and 42% were in the back seat with 14% belted. Children were most likely to be restrained when traveling in the front seat (40.0%, CI=37.6-42.5); traveling with a belted driver (42.4%, CI=40.0-44.8); or traveling without additional passengers (40.3%, CI=37.0-43.7)Seat belt use among children from this study population was below the national average and was alarmingly low among children in the back seat. While traveling, being belted in the back seat provides the most protection in a collision. Prevention efforts need to be based on an understanding of the barriers to restraint use for children traveling in the back seat.

    View details for Web of Science ID 000174322100007

    View details for PubMedID 11818181

  • Physician Barriers to the Effective Management of Uncontrolled Hypertension Arch Intern Med. Oliveria , S., Lapuerta, P., McCarthy , B., L?Italien , G., Berlowitz , D., Asch , S. 2002; 162: 413-20
  • Public health quality measurement: Concepts and challenges ANNUAL REVIEW OF PUBLIC HEALTH Derose, S. F., Schuster, M. A., Fielding, J. E., Asch, S. M. 2002; 23: 1-21


    Public health agencies increasingly are recognizing the need to formally and quantitatively assess and improve the quality of their programs, information, and policies. Measuring quality can help organizations monitor their progress toward public health goals and become more accountable to both the populations they serve and policy makers. Yet quality assessment is a complex task that involves precise determination and specification of useful measures. We discuss a well-established conceptual framework for organizing quality assessment in the context of planning and delivery of programs and services by local health departments, and consider the strengths and limitations of this approach for guiding quality improvement. We review several past and present quality measurement-related initiatives designed for public health department use, and discuss current and future challenges in this evolving area of public health practice.

    View details for Web of Science ID 000175686800002

    View details for PubMedID 11910052

  • Association of Access to Medical Care with Regular Source of Care and Sociodemographic Characteristics in Low Income Patients with HIV Infection and Patients with Tuberculosis J National Medical Association Solorio , M., Asch , S., Globe , D., Cunningham , W. 2002; 94 (7): 581-9
  • Comparing Quality of Care for Sexually Transmitted Disease in Specialized and General Clinics Public Health Reports Asch, S., Sa?adah, M., Lopez, R., Kokkinis, A., Richwald, G., Rhew, D. 2002; 117(2): 157-163
  • How well do clinicians estimate patients' adherence to combination antiretroviral therapy? 6th Conference on Retroviruses and Opportunistic Infections Miller, L. G., Liu, H. H., Hays, R. D., Golin, C. E., Beck, C. K., Asch, S. M., Ma, Y. Y., Kaplan, A. H., Wenger, N. S. SPRINGER. 2002: 1?11


    Adherence to combination antiretroviral therapy is critical for clinical and virologic success in HIV-infected patients. To combat poor adherence, clinicians must identify nonadherent patients so they can implement interventions. However, little is known about the accuracy of these assessments. We sought to describe the accuracy of clinicians' estimates of patients' adherence to combination antiretroviral therapy.Public HIV clinic.Prospective cohort study. During visits, we asked clinicians (nurse practitioners, residents and fellows, and their supervising attending physicians) to estimate the percentage of antiretroviral medication taken by patients over the last 4 weeks and predicted adherence over the next 4 weeks. Adherence was measured using electronic monitoring devices, pill counts, and self-reports, which were combined into a composite adherence measure.Clinicians estimated 464 episodes of adherence in 82 patients.Among the 464 adherence estimates, 264 (57%) were made by principal care providers (31% by nurse practitioners, 15% by fellows, 6% by residents, and 5% by staff physicians) and 200 (43%) by supervising attending physicians. Clinicians' overestimated measured adherence by 8.9% on average (86.2% vs 77.3%). Greater clinician inaccuracy in adherence prediction was independently associated with higher CD4 count nadir (1.8% greater inaccuracy for every 100 CD4 cells, P=.005), younger patient age (3.7% greater inaccuracy for each decade of age, P=.02), and visit number (P=.02). Sensitivity of detecting nonadherent patients was poor (24% to 62%, depending on nonadherence cutoff). The positive predictive value of identifying a patient as nonadherent was 76% to 83%.Clinicians tend to overestimate medication adherence, inadequately detect poor adherence, and may therefore miss important opportunities to intervene to improve antiretroviral adherence.

    View details for Web of Science ID 000175032900001

    View details for PubMedID 11903770

  • Development of Indicators of Nursing Quality to Evaluate Nurse Staffing Ratios J Nursing Administration Hodge , M., Asch , S., Olson, V., Kravitz , R., Sauvé , M. 2002; 32(6): 338-345
  • Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States 12th World AIDS Conference Asch, S. M., Gifford, A. L., Bozzette, S. A., Turner, B., Mathews, W. C., Kuromiya, K., Cunningham, W., Andersen, R., Shapiro, M., Rastegar, A., McCutchan, J. A. LIPPINCOTT WILLIAMS & WILKINS. 2001: 340?44


    Little is known about the rates of Mycobacterium avium complex (MAC) and Pneumocystis carinii (PCP) prophylaxis adherence to guidelines and how they have changed after introduction of effective antiretroviral therapy.To determine rates of primary prophylaxis for MAC and PCP and to evaluate the influence of sociodemographic characteristics, region, and provider experience.National probability sample cohort of HIV patients in care.One hundred sixty HIV health care providers.A total of 2864 patients interviewed in 1996 to 1997 (68% response) and 2267 follow-up interviews, representing 65% of surviving sampled patients (median follow-up, 15.1 months).Use of prophylactic drugs, most recent CD4 count, sociodemographics, and regional and total HIV patients/providers.Of patients eligible for primary MAC prophylaxis (most recent CD4 count <50/mm(3) ), 41% at baseline and 40% at follow-up patients were treated. Of patients eligible for primary PCP prophylaxis (i.e., those with CD4 counts <200/mm(3) ), 64% and 72% were treated, respectively. MAC prophylaxis at baseline was less likely in African American (adjusted odds ratio [OR], 35; 95% confidence interval [CI], 0.20-0.59), Hispanic (OR, 27; 95% CI, 0.08-0.94) and less-educated (OR, 0.61; 95% CI, 0.36-1.0) patients and more likely in U. S. geographic regions in the Pacific West (OR, 4.9; 95% CI, 1.0-23) and Midwest (OR, 6.4; 95% CI, 1.2-33) and in practices with more HIV patients.Most eligible patients did not receive MAC prophylaxis; PCP prophylaxis rates were better but still suboptimal. Our results support outreach efforts to African Americans, Hispanics, the less educated, and those in the northeastern United States and in practices with fewer HIV patients.

    View details for Web of Science ID 000172313100006

    View details for PubMedID 11707670

  • Justification for a new cohort study of people aging with and without HIV infection JOURNAL OF CLINICAL EPIDEMIOLOGY Justice, A. C., Landefeld, C. S., Asch, S. M., Gifford, A. L., Whalen, C. C., Covinsky, K. E. 2001; 54: S3-S8


    This supplement contains a series of papers supporting the justification, design, and implementation of a longitudinal cohort study of an aging HIV-positive and HIV-negative veteran population called the Veterans Aging Cohort Study (VACS). Although the papers cover a wide range of topics and several papers address methodologic issues not unique to a study of aging veterans, all are motivated by a unifying set of assumptions. Specifically: (a) HIV/AIDS is a chronic disease in an aging population; (b) conditions among HIV-positive and -negative patients in care have overlapping etiologies; (c) individuals with pre-existing organ injury are at increased risk for iatrogenic injury; (d) cohort studies are uniquely suited to the study of chronic disease complicated by aging, comorbid conditions, drug toxicities, and substance use/abuse; (e) VACS is well positioned to study HIV as a chronic disease in an aging population.

    View details for Web of Science ID 000172811300002

    View details for PubMedID 11750202

  • A new approach for measuring quality of care for women with hypertension PSGRG Conference on the End of Socialism - Ten Years On Asch, S. M., Kerr, E. A., LaPuerta, P., Law, A., McGlynn, E. A. AMER MEDICAL ASSOC. 2001: 1329?35


    Guidelines for care of hypertensive patients have proliferated recently, yet quality assessment remains difficult in the absence of well-defined measurement systems. Existing systems have not always linked process measures to blood pressure outcomes.A quality measurement system was developed and tested on hypertensive women in a West Coast health plan. An expert panel selected clinically detailed, evidence-explicit indicators using a modified Delphi method. Thirteen indicators (1 screening, 5 diagnostic, 5 treatment, and 2 follow-up indicators) were selected by this process. Trained nurses used a laptop-based tool to abstract data from medical records for the most recent 2 years of care.Of 15 004 eligible patients with hypertensive and other chronic disease codes, 613 patients were sampled, all eligible for the screening indicator. Of these, 234 women with an average blood pressure of 140/90 mm Hg or more, or a documented diagnosis of hypertension, were studied for the remaining indicators. The average woman received 64% of the recommended care. Most patients did not receive adequate initial history, physical examination, or laboratory tests. Only 37% of hypertensive women with persistent elevations to more than 160/90 mm Hg had changes in therapy or lifestyle recommended. The average adherence proportion to all indicators was lower in patients with uncontrolled blood pressure (>140/90 mm Hg) than in those with controlled blood pressure (54% vs 73%; P<.001).Quality of hypertensive care falls short of indicators based on randomized controlled trials and national guidelines. Poor performance in essential care processes is associated with poor blood pressure control.

    View details for Web of Science ID 000168811500010

    View details for PubMedID 11371262

  • Associations of symptoms and health-related quality of life: Findings from a national study of persons with HIV infection ANNALS OF INTERNAL MEDICINE Lorenz, K. A., Shapiro, M. F., Asch, S. M., Bozzette, S. A., Hays, R. D. 2001; 134 (9): 854-860


    Health-related quality of life refers to how well people are able to perform daily activities (functioning) and how they feel about their lives (well-being). The relationship between symptoms and health-related quality of life has not been fully explored.To estimate the association of HIV symptoms with health-related quality of life and with disability days.Prospective cohort study.HIV providers in 28 urban and 24 rural randomly selected sites throughout the United States.Nationally representative sample of 2267 adults with known HIV infection who were interviewed in 1996 and again between 1997 and 1998.Symptoms, two single-item global measures of health-related quality of life (perceived health and perceived quality of life), and disability days.White patches in the mouth; nausea or loss of appetite; persistent cough, difficulty breathing, or difficulty catching one's breath; and weight loss were associated with more disability days and worse scores on both health-related quality-of-life measures. Headache; pain in the mouth, lips, or gums; dry mouth; and sinus infection, pain, or discharge were associated with worse perceived health. Pain in the mouth, lips, or gums; trouble with eyes; pain, numbness, or tingling of hands or feet; and diarrhea or loose or watery stools were associated with worse perceived quality of life. Headache and fever, sweats, or chills were associated with more disability days.Several symptoms are associated with worse health-related quality of life and more disability days in persons with HIV infection. In such patients, targeting specific symptoms may improve health-related quality of life and reduce disability.

    View details for Web of Science ID 000168543100009

    View details for PubMedID 11346321

  • Cost-sharing for prescriptions of sildenafil and finasteride: A case study in veteran patients AMERICAN JOURNAL OF MANAGED CARE Yu, E. I., Glassman, P. A., Asch, S. M., Paige, N. M., Passman, L. J., Shekelle, P. G. 2001; 7 (4): 345-353


    To evaluate patients willingness to share the costs of 2 medications (often described as "lifestyle medications"): sildenafil for erectile dysfunction and finasteride for hair loss, which are not routinely covered by the Department of Veterans Affairs (VA) healthcare system.Self-administered, anonymous survey.Adult men (n = 339) were recruited from waiting rooms for primary care or erectile dysfunction clinic appointments at 2 Los Angeles VA facilities.Participants with self-reported need were analyzed separately for finasteride (primary care patients only) and sildenafil (both primary care and erectile dysfunction clinic patients). The mean age of the participants was 56 and 60 years for the finasteride and sildenafil groups, respectively. Mean annual household income for both groups was under $10,000. Respondents reported a mean willingness to cost-share $4.20 for a 30-day prescription of daily finasteride (VA wholesale cost = $27) and $5.40 for 4 sildenafil pills (VA wholesale cost = $20). In the multivariate analysis, higher income (P = .002) and increasing self-reported need for medication (P = .04) were associated with increased willingness to cost-share for finasteride after controlling for age, race/ethnicity, insured status, comorbid conditions, and type of clinic. In addition, younger age (P = .01) was associated with greater willingness to cost-share for sildenafil.In this low-income veteran population, patients with a self-reported need for sildenafil and finasteride would be willing to make a higher copayment than the current VA maximum copayment of $2.00 per 30-day prescription, if these medicines were made available.

    View details for Web of Science ID 000168013200003

    View details for PubMedID 11310190

  • The Development and Application of a Method to Assess the Timeliness of Medical Care for HIV-Related Symptoms Health Services and Outcomes Research Methodology Kilbourne AM, A., Asch SM, S., Andersen RM, R., Gifford A, A., Nakazono T, T., Stein M, M., Crystal S, S., Shapiro M, M., Bozzette S, S., Cunningham W, W., Consortium, H. 2001; 2(2)
  • Introduction to Supplement Journal of Clinical Epidemiology Landefeld, S., Justice, A., Covinsky, K., Gifford, A., Whalen, C., Asch, S. 2001; 54(12): S1-S2
  • Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Asch, S. M., Sloss, E. E., Hogan, C., Brook, R. H., Kravitz, R. L. 2000; 284 (18): 2325-2333


    Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333.

    View details for Web of Science ID 000165074500026

    View details for PubMedID 11066182

  • Care of vaginal symptoms among HIV-infected women JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Stein, M. D., Cunningham, W. E., Nakazono, T., Asch, S., Turner, B. J., Crystal, S., Andersen, R. M., Zierler, S., Bozzette, S. A., Shapiro, T. F. 2000; 25 (1): 51-55


    Gynecologic disease is common in HIV-infected women. We examine the sociodemographic, clinical, and provider factors associated with the care of women with vaginal symptoms.Women enrolled in the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults, were interviewed between January 1996 and April 1997. Women with vaginal symptoms who sought medical attention were asked, "Did your health care provider examine your vaginal area?" Women were also asked if they received medication for their symptoms.Among 154 women with vaginal symptoms, 127 sought care for their symptoms. Of those who sought care, 48% saw a gynecologist and 52% sought care from nongynecologists, most often their usual HIV care provider. Women who saw a gynecologist for their symptoms were more likely to have received a pelvic examination (92% versus 76%; p =.06) and vaginal fluid collection (98% versus 88%; p =.06) than those who saw their regular HIV provider. Fifteen percent of women received medication for their symptoms without having a pelvic examination; gynecologists were less likely to prescribe without an examination (8% versus 21%; p =.12).Gynecologists are more likely to provide adequate care of vaginal symptoms among HIV-infected women than nongynecologists who were HIV care providers. This specialty difference is consistent with quality of care studies for other medical conditions, but the potential gynecologic complications of inadequate evaluation and treatment warrants further investigation.

    View details for Web of Science ID 000165276800007

    View details for PubMedID 11064504

  • Problems in recruiting community-based physicians for health services research JOURNAL OF GENERAL INTERNAL MEDICINE Asch, S., Connor, S. E., Hamilton, E. G., Fox, S. A. 2000; 15 (8): 591-599


    To qualitatively determine factors that are associated with higher participation rates in community-based health services research requiring significant physician participation burden.A review of the literature was undertaken using MEDLINE and the Social Science Research Index to identify health services research studies that recruited large community-based samples of individual physicians and in which the participation burden exceeded that of merely completing a survey. Two reviewers abstracted data on the recruitment methods, and first authors were contacted to supplement published information.Sixteen studies were identified with participation rates from 2.5% to 91%. Almost all studies used physician recruiters to personally contact potential participants. Recruiters often knew some of the physicians to be recruited, and personal contact with these "known" physicians resulted in greater participation rates. Incentives were generally absent or modest, and at modest levels, did not appear to affect participation rates. Investigators were almost always affiliated with academic institutions, but were divided as to whether this helped or hindered recruitment. HMO-based and minority physicians were more difficult to recruit. Potential participants most often cited time pressures on staff and themselves as the study burden that caused them to decline.Physician personal contact and friendship networks are powerful tools for recruitment. Participation rates might improve by including HMO and minority physicians in the recruitment process. Investigators should transfer as much of the study burden from participating physicians to project staff as possible.

    View details for Web of Science ID 000089054300010

    View details for PubMedID 10940152

  • National estimates of HIV-related symptom prevalence from the HIV cost and services utilization study 22nd Annual Meeting of the Society-of-General-Internal-Medicine Mathews, W. C., McCutchan, J. A., Asch, S., Turner, B. J., Gifford, A. L., Kuromiya, K., Brown, J., Shapiro, M. F., Bozzette, S. A. LIPPINCOTT WILLIAMS & WILKINS. 2000: 750?62


    The objectives of this study were (1) to estimate the prevalence, bothersomeness, and variation of HIV-related symptoms in a nationally representative sample of HIV-infected adults receiving medical care and (2) to evaluate new aggregate measures of symptom frequency and bothersomeness.Beginning in January 1996, 76% of a multistage national probability sample of 4,042 HIV-infected adults receiving medical care were interviewed. Participants endorsed the presence and degree of bothersomeness of 14 HIV-related symptoms during the preceding 6 months. Sex-standardized symptom number and bothersomeness indices were constructed. After sampling weights were incorporated, symptom distributions were compared according to selected characteristics by analysis of variance and multiple linear regression modeling.Prevalence of specific symptoms in the reference population was as follows: fever/night sweats, 51.1%; diarrhea, 51%; nausea/anorexia, 49.8%; dysesthesias, 48.9%; severe headache, 39.3%; weight loss, 37.1%; vaginal symptoms, 35.6% of women; sinus symptoms, 34.8%; eye trouble, 32.4%; cough/dyspnea, 30.4%; thrush, 27.3%; rash, 24.3%; oral pain, 24.1%; and Kaposi's sarcoma, 4%. Aggregate measures were reliable (Cronbach's alpha > or =0.75) and demonstrated construct validity when compared with other measures of disease severity. After adjustment for CD4 count, both symptom number and bothersomeness varied significantly (P <0.05) by teaching status of care setting, exposure/risk group, educational achievement, sex, annual income, employment, and insurance category. However, the magnitude of variation was small. Symptoms were greatest in women and injection drug users, as well as in persons with lower educational levels, lower income, and Medicare enrollment or those who were followed up at teaching hospitals.The prevalence and bothersomeness of HIV-related symptoms are substantial and vary by setting of care and patient characteristics.

    View details for Web of Science ID 000087947100007

    View details for PubMedID 10901358

  • Quality enhancement research initiative for human immunodeficiency virus/acquired immunodeficiency syndrome - Framework and plan MEDICAL CARE Bozzette, S. A., Phillips, B., Asch, S., Gifford, A. L., Lenert, L., Menke, T., ORTIZ, E., Owens, D., Deyton, L. 2000; 38 (6): S60-S69
  • Quality-of-care indicators for HIV/AIDS DISEASE MANAGEMENT & HEALTH OUTCOMES Wu, A. W., Gifford, A., Asch, S., Cohn, S. E., Bozzette, S. A., Yurk, R. 2000; 7 (6): 315-330
  • Quality Enhancement Research Initiative for human immunodeficiency virus/acquired immunodeficiency syndrome: framework and plan. HIV-QUERI Executive Committee. Medical care Bozzette, S. A., Phillips, B., Asch, S., Gifford, A. L., Lenert, L., Menke, T., ORTIZ, E., Owens, D., Deyton, L. 2000; 38 (6): I60-9


    The Veterans Health Administration (VHA) sees approximately equal to 17,000 human immunodeficiency virus (HIV)-infected patients each year, which makes it the largest provider of HIV care in the United States. HIV causes chronic progressive disease that leads to early death. Newer combination antiretro viral treatments are effective but expensive and difficult to use. The HIV Quality Enhancement Research Initiative (HIV-QUERI) uses the QUERI process to identify high-risk and high-volume populations (step 1), which includes those already under VHA care for HIV, those who do not know of their infection, and those at risk for HIV. In identifying best practices (step 2), the HIV-QUERI will benefit greatly from existing guidelines for the care of established HIV infection, but gaps in knowledge regarding adherence to medication regimens and cost-effective screening are large. To identify existing practice patterns (step 3), the HIV-QUERI will develop a clean analytic data set based on Immunology Case Registry files and expand it through a survey of veterans. Interventions to improve care (step 4) will include national, regional, and site-specific feedback on performance relative to quality standards, as well as patient-level and provider-level interventions to improve adherence and support medical decision-making. To document that best practices improve outcomes and quality of life (steps 5 and 6), HIV-QUERI will track indicators on an ongoing basis by use of the Immunology Case Registry database and possible future waves of the survey. In addition, we will require that these issues be addressed in evaluations of HIV-QUERI interventions. In the present article, we present these steps within a framework and plan.

    View details for PubMedID 10843271

  • Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States HEALTH SERVICES RESEARCH Andersen, R., Bozzette, S., Shapiro, M., St Clair, P., Morton, S., Crystal, S., Goldman, D., Wenger, N., Gifford, A., Leibowitz, A., Asch, S., Berry, S., Nakazono, T., Heslin, K., Cunningham, W. 2000; 35 (2): 389-416


    To employ the behavioral model of health services use in examining the extent to which predisposing, enabling, and need factors explain the treatment of the HIV-positive population in the United States with highly active antiretroviral therapy (HAART).A national probability sample of 2,776 adults under treatment for human immunodeficiency virus (HIV) infection.The article uses data from the baseline and six-month follow-up surveys. The key independent variables describe vulnerable population groups including women, drug users, ethnic minorities, and the less educated. The dependent variable is whether or not a respondent received HAART by December 1996.All interviews were conducted using computer-assisted personal interview instruments designed for this study. Ninety-two percent of the baseline interviews were conducted in person and the remainder over the telephone.A multistage logit regression shows that the predisposing factors that have previously described vulnerable groups in the general population with limited access to medical care also define HIV-positive groups who are less likely to gain early access to HAART including women, injection drug users, African Americans, and the least educated (odds ratios, controlling for need, ranged from 0.35 to 0.59).Those HIV-positive persons with the greatest need (defined by a low CD4 count) are most likely to have early access to HAART, which suggests equitable access. However, some predisposing and enabling variables continue to be important as well, suggesting inequitable access, especially for African Americans and lower-income groups. Policymakers and clinicians need to be sensitized to the continued problems of African Americans and other vulnerable populations in gaining access to such potentially beneficial therapies. Higher income, anonymous test sites, and same-day appointments are important enabling resources.

    View details for Web of Science ID 000087570400003

    View details for PubMedID 10857469

  • What students bring to medical school - Attitudes toward health promotion and prevention AMERICAN JOURNAL OF PREVENTIVE MEDICINE Bellas, P. A., Asch, S. M., Wilkes, M. 2000; 18 (3): 242-248


    Health care providers' positive attitudes toward prevention and health promotion are important in achieving national health care goals. Limited studies of incoming medical students have been conducted that measure predictors of positive attitudes toward health promotion and prevention.Data were obtained from a 1993 curriculum evaluation survey of first-year students at five different medical schools in California. Attitudes toward health promotion and prevention were measured using a nine-question Prevention Attitude Scale (PAS). We developed 2 multivariate linear regression models using demographics, education choices, and personal social values and beliefs to predict PAS scores. We also performed bivariate analysis.Five hundred ninety-nine completed surveys were analyzed, with a response rate of 95%. Mean PAS score was 36.47 +/- 3.7 on a 0 to 44 scale. Female gender, Democratic party preference, and a planned specialty choice in preventive medicine or primary care predicted the highest PAS scores on bivariate analysis (p < 0.002). Significant correlation ( p < 0. 001) was shown between PAS scores and 2 additional scales regarding beliefs in associations of social factors and illness and in the importance of caring for the poor. Linear regression model using personal social values and beliefs explained 34% of the variance, as opposed to the demographic model that explained only 9% of the variance.In the schools studied, participating first-year medical students had moderately positive attitudes toward health promotion and prevention, as measured by PAS scores. In designing curriculum to improve medical students' attitudes toward health promotion and prevention, medical educators may need to consider other personal and social values held by medical students and to address the "political" aspects of health promotion and prevention. Future studies are needed to longitudinally follow medical student attitudes.

    View details for Web of Science ID 000086044700008

    View details for PubMedID 10722991

  • Performance measures for guidelines on preventing opportunistic infections in patients infected with human immunodeficiency virus CLINICAL INFECTIOUS DISEASES Gross, P. A., Asch, S., Kitahata, M. M., Freedberg, K. A., Barr, D., Melnick, D. A., Bozette, S. A. 2000; 30: S85-S93


    This article serves as a complement to the 1999 US Public Health Service/Infectious Diseases Society of America guidelines on the prevention of opportunistic infections in persons infected with HIV, published in this issue of Clinical Infectious Diseases [1]. A number of performance measures to assess compliance with the guidelines and to aid in their implementation are proposed.

    View details for Web of Science ID 000087067600008

    View details for PubMedID 10770917

  • Evaluating the quality of cancer care - Development of cancer quality indicators for a global quality assessment tool CANCER Malin, J. L., Asch, S. M., Kerr, E. A., McGlynn, E. A. 2000; 88 (3): 701-707


    The rise of managed care has increased interest in measuring, reporting, and improving quality of care. To date, quality assessment has relied on a leading indicator approach, which may miss important variations in care. The authors developed cancer specific indicators using a novel case-based approach for a quality measurement tool designed to compare different managed care organizations.Based on a review of the literature, quality indicators were developed for 6 types of cancer and the human immunodeficiency virus (HIV) as well as 39 general adult conditions (GAC). The validity and feasibility of these candidate indicators were evaluated using three modified Delphi expert panels. The strength of evidence, type of care (preventive, acute, or chronic), function (screening, diagnosis, treatment, and follow-up), and modality (history, physical examination, laboratory, medication, or other intervention) of the cancer/HIV quality indicators were compared with indicators developed for GAC.The final system included 117 of the 145 proposed cancer/HIV quality indicators (81%) and 569 of the 705 proposed GAC indicators (81%). A greater percentage of the cancer/HIV indicators were based on evidence from clinical trials compared with the GAC indicators (59% vs. 31%; P = 0.001). Cancer/HIV had significantly more indicators pertaining to chronic care than did GAC (74% vs. 56%; P = 0.001) as well as more indicators for treatment (53% vs. 39%; P = 0.004).Using the case-based approach, it is feasible to develop quality indicators for cancer that cover the continuum of care. Future studies will evaluate the reliability and validity of measurements made using these indicators in three managed care plans.

    View details for Web of Science ID 000084874900029

    View details for PubMedID 10649266

  • A population-based survey of tuberculosis symptoms: How atypical are atypical presentations? CLINICAL INFECTIOUS DISEASES Miller, L. G., Asch, S. M., Yu, E. I., Knowles, L., Gelberg, L., Davidson, P. 2000; 30 (2): 293-299


    There is scant information on tuberculosis symptoms from a population-based perspective. We prospectively identified 526 tuberculosis cases reported in Los Angeles County over a 6-month period. Of 313 persons who completed our questionnaire, 72.7% had cough, 48.2% for >2 weeks, and 52.3% had fever, 29.4% for >2 weeks. Among those with pulmonary disease, only 52.4% had cough for >2 weeks. In a multivariate model, persons with significant symptoms typical of tuberculosis disease (defined as cough or fever for >2 weeks, weight loss, or hemoptysis) were associated with lack of medical insurance, negative tuberculin skin test, diagnosis during a process other than screening, and non-Asian race. In summary, classic symptoms of prolonged cough and fever are insensitive predictors of tuberculosis. Our data suggest that Asians may need to be added to the list of persons who present with tuberculosis atypically. We believe that the Infectious Diseases Society of America guidelines for community-acquired pneumonia should emphasize demographic features in addition to clinical symptoms when suggesting which patients require evaluation for Mycobacterium tuberculosis.

    View details for Web of Science ID 000085849400013

    View details for PubMedID 10671331

  • High-risk sexual behavior in Los Angeles: Who receives testing for HIV? JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES Miller, L. G., Simon, P. A., Miller, M. E., Long, A., Yu, E. I., Asch, S. M. 1999; 22 (5): 490-497


    No recent population-based data on HIV testing in people with high-risk sexual behavior are available. We sought predictors of testing using data from the 1997 Los Angeles County Health Survey, a random-digit telephone survey of 8004 county households. An estimated 2.3 million (35.5%) adults were tested for HIV in the past 2 years and approximately 370,000 (5.6%) engaged in high-risk sexual behavior (defined as having > or =2 partners in the past 12 months and not always using condoms). Among high-risk persons, an estimated 46% of heterosexual men, 56% of heterosexual women, and 72% of men who had sex with men (MSM) were tested for HIV. In a multivariable model of high-risk people, both heterosexual men (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.61) and women (OR, 0.41; 95% CI, 0.19-0.87) had significantly lower proportions of testing than MSM. Although African Americans and Hispanics had significantly higher testing proportions than whites overall among all county residents, those reporting high-risk sexual behavior did not test at higher proportions. We conclude that the proportion of adults with high-risk sexual behavior tested for HIV is higher than almost a decade ago. However, testing among this group remains suboptimal. Future public health campaigns should intensify efforts to encourage HIV testing among this population.

    View details for Web of Science ID 000085336600010

    View details for PubMedID 10961611

  • New approach to assessing clinical quality of care for women: The QA tool system WOMENS HEALTH ISSUES McGlynn, E. A., Kerr, E. A., Asch, S. M. 1999; 9 (4): 184-192

    View details for Web of Science ID 000081452400002

    View details for PubMedID 10405590

  • Variations in the care of HIV-infected adults in the United States - Results from the HIV Cost and Services Utilization Study JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Shapiro, M. F., Morton, S. C., McCaffrey, D. F., Senterfitt, J. W., Fleishman, J. A., Perlman, J. F., Athey, L. A., Keesey, J. W., Goldman, D. P., Berry, S. H., Bozzette, S. A. 1999; 281 (24): 2305-2315


    Studies of selected populations suggest that not all persons infected with human immunodeficiency virus (HIV) receive adequate care.To examine variations in the care received by a national sample representative of the adult US population infected with HIV.Cohort study that consisted of 3 interviews from January 1996 to January 1998 conducted by the HIV Cost and Services Utilization Consortium.Multistage probability sample of 2864 respondents (68% of those targeted for sampling), who represent the 231400 persons at least 18 years old, with known HIV infection receiving medical care in the 48 contiguous United States in early 1996 in facilities other than emergency departments, the military, or prisons. The first follow-up consisted of 2466 respondents and the second had 2267 (65% of all surviving sampled subjects).Service utilization (<2 ambulatory visits, at least 1 emergency department visit that did not lead to hospitalization, at least 1 hospitalization) and medication utilization (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia).Inadequate HIV care was commonly reported at the time of interviews conducted from early 1996 to early 1997 but declined to varying degrees by late 1997. Twenty-three percent of patients initially and 15% of patients subsequently had emergency department visits that did not lead to hospitalization, 30% initially and 26% subsequently of those who had CD4 cell counts below 0.20 x 10(9)/L did not receive P carinii pneumonia prophylaxis, and 41% initially and 15% subsequently of those who had CD4 cell counts below 0.50 x 10(9)/L did not receive antiretroviral therapy (protease inhibitor or nonnucleoside reverse transcriptase inhibitor). Inferior patterns of care were seen for many of these measures in blacks and Latinos compared with whites, the uninsured and Medicaid-insured compared with the privately insured, women compared with men, and other risk and/or exposure groups compared with men who had sex with men even after CD4 cell count adjustment. With multivariate adjustment, many differences remained statistically significant. Even by early 1998, fewer blacks, women, and uninsured and Medicaid-insured persons had started taking antiretroviral medication (CD4 cell count adjusted P values <.001 to <.005).Access to care improved from 1996 to 1998 but remained suboptimal. Blacks, Latinos, women, the uninsured, and Medicaid-insured all had less desirable patterns of care. Strategies to ensure optimal care for patients with HIV requires identifying the causes of deficiency and addressing these important shortcomings in care.

    View details for Web of Science ID 000080925600030

    View details for PubMedID 10386555

  • The communicable disease impact of eliminating publicly funded prenatal care for undocumented immigrants. Maternal and child health journal Kuiper, H., Richwald, G. A., Rotblatt, H., Asch, S. 1999; 3 (1): 39-52


    In 1996, California proposed regulations to eliminate publicly funded prenatal care for undocumented immigrants. Prenatal treatment of sexually transmitted infections (STIs) can prevent STI-related adverse outcomes of pregnancy (AOP). The study assessed the STI-related health and economic impact of the proposed regulations in Los Angeles County (LAC).We modeled excess STI-related AOPs and associated costs that would occur in LAC as if the regulations were implemented in 1995. Using attributable fractions in the exposed for five STIs and their associated AOPs, we calculated excess STI-related AOPs and their costs that would result from the regulations and the degree to which excess morbidity would offset gross savings.The model indicates that, depending on regulatory level, 74, 110, or 132 excess AOPs would occur subsequent to the regulations, representing lost prevented morbidity. These excess AOPs would cost $5.1, $7.6, or $9.2 million dollars in direct medical expenses, offsetting anticipated savings by 19.2%, 29.0%, or 34.9%. This analysis does not include other costs of these STIs or costs associated with non-STI-related sequelae of diminished prenatal care, all of which could further offset anticipated savings.The proposed regulations would likely lead to increased STI-related morbidity and costs, thereby offsetting anticipated savings. Health departments are in a special position to promptly respond to policy issues affecting vulnerable populations. The development of a practical and rational framework for local-level policy assessment can be important for encouraging good scientific approaches that respond to calls for reductions in basic preventive health services.

    View details for PubMedID 10728288

  • Tuberculosis in homeless patients: Potential for case finding in public emergency departments ANNALS OF EMERGENCY MEDICINE Asch, S., Leake, B., Knowles, L., Gelberg, L. 1998; 32 (2): 144-147


    Previous studies have had difficulty evaluating the optimal clinical site for screening homeless patients for active tuberculosis (TB). We hypothesized that homeless patients with TB would not frequently reside in shelters at the time of their diagnosis and would be more likely than other patients with TB to seek care in public hospitals, thus presenting an opportunity for screening radiography.This registry-based survey included 743 consecutive patients with confirmed active TB in Los Angeles County. No therapeutic intervention was involved.When compared with patients with TB who were not homeless, homeless patients with TB were more likely to be male (93% versus 63%, P<.001), black (44% versus 15%, P<.001), living in the inner city (55% versus 7%, P<.001), and born in the United States (67% versus 32%, P<.001). They were more infectious than other patients with TB as evidenced by a trend toward more cavitary radiographic lesions (24% versus 16%, P=.11) and significantly more positive sputum smears (56% versus 41%, P=.009). Less than a third lived in congregate facilities such as shelters at the time of their diagnosis. Instead, their disease was diagnosed more often at county hospitals (54% versus 23%, P<.001) than patients with TB who were not homeless.Widespread screening for TB in shelters may miss most homeless patients with TB. Because most county-hospital homeless patients with TB initially present to emergency departments and many do not live in shelters, future cost-effectiveness studies should evaluate chest radiograph screening for all homeless ED patients.

    View details for Web of Science ID 000075126100003

    View details for PubMedID 9701295

  • Why do symptomatic patients delay obtaining care for tuberculosis? AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Asch, S., Leake, B., Anderson, R., Gelberg, L. 1998; 157 (4): 1244-1248


    The resurgence of tuberculosis (TB) has coincided with deteriorating access to care for high-risk populations. We sought to determine what perceived access barriers delayed symptomatic TB patients from obtaining care. In order to do this, we conducted a survey in Los Angeles County, California, using a consecutive sample of patients with active TB as confirmed by the county TB control authority. The measures used in the study were a self-reported delay in seeking care of more than 60 d from symptom onset, a period sufficient to cause skin-test conversion in exposed contacts, and self-reported access barriers. The county TB registry provided supplementary clinical data. We found that one in five of the 248 symptomatic respondents (response rate: 60%) delayed obtaining care for > 60 d (mean = 74 d, SD = 216 d). During the delay, patients exposed an average of eight contacts. As compared with the rest of the sample, delay was more common in those who were unemployed (25% versus 14%), concerned about cost (27% versus 14%), anticipated prolonged waiting-room time (26% versus 14%), believed they could treat themselves (31% versus 14%), anticipated difficulty in getting an appointment (28% versus 16%), were uncertain about where to get care (33% versus 16%), and feared immigration authorities (47% versus 18%) (p < 0.05). Logistic regression revealed that uncertainty about where to get care, unemployment, and belief in the efficacy of self-treatment independently predicted delay > 60 d. Illness severity as measured by chest radiography, sputum smears, and symptoms had little impact on delay. We conclude that because access variables such as lack of employment and knowledge about where to obtain care were more closely associated with clinically significant delay than was severity of illness, these results raise concerns about the equity of access to care among TB patients. The results suggest that improving the availability of services for high-risk groups may substantially reduce TB patients' delay in obtaining care, and thus may limit the spread of the disease.

    View details for Web of Science ID 000073024500036

    View details for PubMedID 9563746

  • Developing a clinical performance measure Conference on Prevention in Managed Care - Joining Forces for Value and Quality McGlynn, E. A., Asch, S. M. ELSEVIER SCIENCE INC. 1998: 14?21


    Clinical performance measurement is an increasingly important way for public and private purchasers alike to compare the value of health services provided by competing health delivery systems. The widespread use of performance measures has increased the demand for development of new measures that cover previously unevaluated aspects of care.Four steps required to develop a clinical performance measure that is suitable for making comparisons among health delivery systems are discussed: (1) choosing clinical areas to measure, (2) selecting performance indicators within each area, (3) designing specifications for consistent implementation of a measure, and (4) evaluating the scientific strength of a measure.The application of these steps to developing measures of quality for hypertension is provided, with an emphasis on a measure of adequacy of control of blood pressure.Developing useful clinical performance measures requires careful attention to methodologic issues. Following the steps outlined in this paper should enhance the quality of future measurement development.

    View details for Web of Science ID 000073004700005

    View details for PubMedID 9566932

  • Development of a quality of care measurement system for children and adolescents - Methodological considerations and comparisons with a system for adult women ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Schuster, M. A., Asch, S. M., McGlynn, E. A., Kerr, E. A., Hardy, A. M., Gifford, D. S. 1997; 151 (11): 1085-1092


    To describe the development of a pediatric quality of care measurement system designed to cover multiple clinical topics that could be applied to enrollees in managed care organizations and to compare the development of this system with the concurrent development of a similar system for adult women.Indicators were developed for 21 pediatric (ages 0-18 years) clinical topics and 20 adult (ages 17-50 years) women's clinical topics. Indicators were classified by the strength of evidence supporting them. A modified Delphi method was used to obtain validity and feasibility ratings from a pediatric expert panel and an adult women's expert panel. Indicators were categorized by type of care (preventive, acute, or chronic), function (screening, diagnosis, treatment, or follow up), and modality (history, physical examination, laboratory/radiology study, medication, other intervention, or other contact).Of 557 pediatric and 391 adult women's proposed indicators, 453 (81%) and 340 (87%), respectively, were retained by the 2 expert panels. A lower percentage of final pediatric indicators than adult indicators were based on randomized, controlled trials and other rigorous studies (18% vs 40%, P < .001). The expert panels were more likely to retain indicators based on rigorous studies (93% retained) than on descriptive studies and expert opinion (81% retained, P < .001). A higher percentage of pediatric indicators than women's indicators were for preventive care (30% vs 11%, P < .001) and a lower percentage were for acute care (36% vs 49%, P < .001) or chronic care (34% vs 41%, P = .06).This study contributes to the field of pediatric quality of care assessment by providing many more indicators than have been available previously and by documenting the strength of evidence supporting these indicators. Formal consensus methods are essential for the development of pediatric quality measures because the evidence base for pediatric care is more limited than for adult care.

    View details for Web of Science ID A1997YF12200003

    View details for PubMedID 9369869

  • Defining and implementing medical necessity in Washington state and Oregon INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING Jacobson, P. D., Asch, S., Glassman, P. A., Model, D. E., Hernandez, J. B. 1997; 34 (2): 143-154


    This paper reports on a qualitative study of how health care providers in the states of Washington and Oregon define and implement medical necessity. Based on a series of semi-structured interviews, we found that few insurers or health care plans in our sample attempted to resolve the ambiguities inherent in defining medical necessity. More importantly, our results suggest that physicians in managed care plans were not using general definitions of medical necessity to make clinical decisions, but instead relied on utilization management techniques to guide the use of medical resources. We conclude that medical necessity as an organizing principle for clinical practice decision making is likely to continue to erode in a managed care environment.

    View details for Web of Science ID A1997XP18200006

    View details for PubMedID 9256819

  • Medical necessity and defined coverage benefits in the Oregon Health Plan AMERICAN JOURNAL OF PUBLIC HEALTH Glassman, P. A., Jacobson, P. D., Asch, S. 1997; 87 (6): 1053-1058


    The policy debate in Oregon has primarily focused on the Prioritized List of Services. However, little information is available on how defined coverage benefits and managed care affect the role of medical necessity in determining care for Medicaid patients. This issue is important because medical necessity determinations are currently used by many states to limit extraneous health care costs but require resource-intensive oversight, are open to wide variance, and frequently prompt litigation challenging interpretations of what is necessary and what is not. The qualitative study described here addressed whether medical necessity remains a salient and useful concept in the Oregon Health Plan. Our results indicate that defined coverage benefits, as described by the funded portion of the Prioritized List of Services, supplant medical necessity determinations for coverage, while managed care incentives limit the need for medical necessity determinations at the provider level. Clinical choices are, for the most part, guided by providers' judgment within the financial constraints of capitation and by targeted use management techniques. The combination of capitated care and Oregon's defined coverage benefits package has marginalized the use of medical necessity, albeit with consequences for state oversight of Medicaid services.

    View details for Web of Science ID A1997XJ85900039

    View details for PubMedID 9224198

  • Do we understand the effects of 'managed care' in ophthalmology? A review and analysis ARCHIVES OF OPHTHALMOLOGY Asch, S., Goldzweig, C. L., Lee, P. 1997; 115 (4): 531-536


    Little has been published that directly assesses the effect of structures for providing managed care or the effects of capitated, prepaid financing on the cost and quality of eye care services. Managed care organizations use fewer ophthalmologists and may provide more screening for diabetic retinopathy. Studies of nonophthalmologic care show lower patient satisfaction with care, and mixed effects on cost, quality of care, and access to care, but are difficult to generalize to eye care. We reviewed the published peer-reviewed literature about this topic. Notable gaps exist in the knowledge of critical elements of the influence of managed care on providing eye care and on patient outcomes. Existing measures of quality, cost, satisfaction, and access could easily be adapted for use in evaluating the influence of managed care and guiding health care policy.

    View details for Web of Science ID A1997WT59600015

    View details for PubMedID 9109765

  • Effect of California's proposition 187 on the use of primary care clinics WESTERN JOURNAL OF MEDICINE Fenton, J. J., Moss, N., Khalil, H. G., Asch, S. 1997; 166 (1): 16-20


    California's ballot proposition 187, passed by the voters in November 1994, threatened to discontinue undocumented immigrants' eligibility for most health services while mandating that health care professionals report suspected undocumented patients to authorities. Although the proposition has not been put into practice, reports suggest that its passage was associated with a decline in the use of health services by some groups. To assess the effects of the passage of Proposition 187 on the use of primary care services, we surveyed a representative sample of California clinics serving low-income groups (n = 129). Using a mailed questionnaire and phone interviews with clinic directors, we obtained qualitative and quantitative data regarding the effects of the passage of the proposition on clinic use. Among primary care clinics statewide and clinics serving predominantly Latino patients, we detected no significant decline in total monthly visits following the election. Nevertheless, half of clinic directors (51%) thought that the number of clinic visits declined after the passage of Proposition 187, and many directors thought that the deterrent effects of the election persisted for weeks to months after the election. Whereas the number of visits probably declined at some clinics, only a small minority of patients at most primary care clinics could have been deterred from seeking care after the passage of Proposition 187.

    View details for Web of Science ID A1997WM11900001

    View details for PubMedID 9074334

  • Testing for human immunodeficiency virus infection among tuberculosis patients in Los Angeles AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Asch, S. M., London, A. S., Barnes, P. F., Gelberg, L. 1997; 155 (1): 378-381


    To investigate patterns of testing for human immunodeficiency virus (HIV) infection in tuberculosis patients, we obtained data from the tuberculosis registry and from medical records of 500 tuberculosis patients in Los Angeles County. Sixty-three percent of tuberculosis patients were tested for HIV infection, and multivariate logistic regression analysis revealed that the likelihood of testing was significantly higher among males, persons between 20 and 49 yr old, individuals with HIV risk factors, and patients treated by public health care providers. A minimum of 12% of the total sample, 2% of females, 2% of those outside the ages of 20 to 49, 7% of patients without recorded HIV risk factors, and 17% of patients treated by private practitioners were infected with HIV. These results suggest that health care providers, particularly private practitioners, do not follow national recommendations for universal HIV testing of tuberculosis patients. Instead, HIV testing is preferentially performed on patients perceived to be at high risk for HIV infection. Because HIV seroprevalence is at least 2 to 7% in "low-risk" groups, failure to test these patients may result in significant missed opportunities for diagnosis and treatment of HIV coinfection.

    View details for Web of Science ID A1997WC67000062

    View details for PubMedID 9001340

  • Potential impact of restricting STD/HIV care for immigrants in Los Angeles County INTERNATIONAL JOURNAL OF STD & AIDS Asch, S., Rulnick, S., Todoroff, C., RICHWALD, G. 1996; 7 (7): 532-535


    Legislative restrictions in immigrants' access to health care and local governmental funding shortfalls in the US and Western Europe have raised fears that public clinic patients might delay care for communicable diseases. To help quantify the potential impact of both policies on public clinics providing sexually transmitted disease (STD) services, we surveyed 234 patients from five LA clinics regarding their alternative sources of health care. Of the 215 providing complete information (response rate = 91%), 52 (24%) reported they had no legal rights to reside in the US. Compared to the legal resident control group, illegal immigrants were more likely to indicate that they had no alternative access to medical care (27% vs 44%; P = 0.03). We conclude that for a substantial proportion of patients, particularly illegal immigrants, the STD clinics are indeed essential. Restricting access to these clinics may have unpredictable public health consequences.

    View details for Web of Science ID A1996WC99900015

    View details for PubMedID 9116074

  • Relationship of isoniazid resistance to human immunodeficiency virus infection in patients with tuberculosis AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Asch, S., Knowles, L., Rai, A., Jones, B. E., Pogoda, J. 1996; 153 (5): 1708-1710


    To investigate the relationship between isoniazid resistance and HIV infection in patients with tuberculosis, we evaluated data in the Los Angeles County tuberculosis registry on 1,506 patients for whom drug susceptibility results were available. Among 235 HIV-infected patients, isoniazid resistance was less common than in 1,271 patients who were HIV-seronegative or who had not been tested for HIV, with an unadjusted odds ratio of 0.3. After adjustment for other factors that affect drug resistance (ethnicity, country of birth, prior diagnosis of tuberculosis, and cavitation), the frequency if isoniazid resistance remained lower than that in patients without HIV infection, with an odds ratio of 0.4 (95% confidence interval, 0.2 to 0.8; p = 0.02). We conclude that in Los Angeles, a setting where there is no ongoing outbreak of drug-resistant tuberculosis, isoniazid-resistant tuberculosis is not more common in HIV-infected patients.

    View details for Web of Science ID A1996UJ46100039

    View details for PubMedID 8630625


    View details for Web of Science ID A1995QE65800007

    View details for PubMedID 7834415


    View details for Web of Science ID A1995RJ91900001

    View details for PubMedID 7734634



    Physician groups are concerned that legislation requiring physicians to report illegal immigrants to immigration authorities will delay curative care. In particular, patients with tuberculosis may delay seeking care for infectious symptoms and spread the disease. We surveyed 313 consecutive patients with active tuberculosis from 95 different facilities to examine the relationship of immigration-related variables, symptoms, and delay in seeking care. Most patients (71%) sought care for symptoms rather than as a result of the efforts of public health personnel to screen high-risk groups or to trace contacts of infectious persons. At least 20% of respondents lacked legal documents allowing them to reside in the United States. Few (6%) feared that going to a physician might lead to trouble with immigration authorities. Those who did were almost 4 times as likely to delay seeking care for more than 2 months, a period of time likely to result in disease transmission. Patients potentially exposed an average of 10 domestic and workplace contacts during the course of the delay. Any legislation that increases undocumented immigrants' fear that health care professionals will report them to immigration authorities may exacerbate the current tuberculosis epidemic.

    View details for Web of Science ID A1994PN93400001

    View details for PubMedID 7817547

  • Are insulin and hypertension independently related? Annals of epidemiology Asch, S., Wingard, D. L., Barrett-Connor, E. L. 1991; 1 (3): 231-244


    Hyperinsulinemia has been proposed as the common pathogenetic mechanism of obesity, non-insulin-dependent diabetes mellitus, and hypertension. We examined the cross-sectional relationship between fasting and postchallenge insulin levels and hypertensive status in a population-based study of 653 men and 784 women, aged 50 to 93 years, in Rancho Bernardo, California. Hypertensive subjects had slightly but not significantly higher fasting plasma insulin levels than did normotensive subjects, but significantly higher postchallenge insulin levels. After stratification for obesity and glucose intolerance, there was no significant difference between the mean age-adjusted fasting or postchallenge insulin levels of those with and those without hypertension in 12 possible subgroups. Analysis of variance of both fasting and postchallenge insulin levels also failed to reveal a significant relationship between insulin and hypertensive status after adjusting for age, sex, body mass index, and diabetes. The current study does not support the hypothesis that insulin is independently associated with hypertension.

    View details for PubMedID 1669504



    Human parvovirus B19, the cause of erythema infectiosum, has recently been associated with adverse fetal outcomes. During a large outbreak of erythema infectiosum in Connecticut, a survey was conducted on 571 (90%) of 634 school and day-care personnel to determine the risk of acquiring B19 infection. Serologic evidence of B19 infection was determined by using an enzyme-linked immunosorbent assay. Of the school and day-care personnel, 58% had evidence of previous B19 infection. The minimal rate of B19 infection in susceptible personnel during the outbreak was 19%. The risk was increased for teachers and day-care providers who had contact with younger children and with greater numbers of ill children. These results suggest that B19 infection is an occupational risk for school and day-care personnel.

    View details for Web of Science ID A1990CY68900021

    View details for PubMedID 2157074

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