A replicable and customizable approach to improve ambulatory care and research

Community Physicians Describe Management Issues for Patients Expected to Live Less than Twelve Months

We examine management issues experienced by community physicians providing care to patients they expect to die within a year. In a case series, 61 physicians in northern New England enrolled 182 consecutive dying patients. Important management issues for these patients were recorded at enrollment and eight months later. The patients’ average age was 74 years; most had cancer (48%) or cardiovascular disease (38%). Almost two-thirds of the patients died within eight months of enrollment. Major management issues for the physicians in care of these patients were deficits in basic self-care, emotional support, pain control, and nutrition. Pain control and family need for support were reported most frequently. Although demand for physician time was seldom a major management issue, when it occurred it correlated with patients’ emotional needs or their desire to extend life (p<0.01). Two barriers to optimum care commonly cited by physicians were (a) the differences in treatment expectations between family members, patients, and physicians and (b) the incurable, progressive nature of the patients’ diseases. Efforts to improve care for patients who have limited life expectancy should further explore the perceptions of community physicians.

Integration of women veterans into VA quality improvement research efforts: what researchers need to know

The Department of Veterans Affairs (VA) and other federal agencies require funded researchers to include women in their studies. Historically, many researchers have indicated they will include women in proportion to their VA representation or pointed to their numerical minority as justification for exclusion. However, women's participation in the military-currently 14% of active military-is rapidly changing veteran demographics, with women among the fastest growing segments of new VA users. These changes will require researchers to meet the challenge of finding ways to adequately represent women veterans for meaningful analysis. We describe women veterans' health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans' quality improvement, and discuss VA women's health research. We then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.

Patients Report Positive Impacts of Collaborative Care

Collaborative Care refers to a partnership between healthcare professionals and patients who feel confident to manage their health conditions. Using an Internet-based assessment of health needs and healthcare quality, we surveyed 24,609 adult Americans aged 19 to 69 who had common chronic diseases or significant dysfunction. In these patients, we examined the association of Collaborative Care with specific measures for treatment effect, disease control, prevention, and economic impacts. These measures were adjusted for respondents' demographic characteristics, burden of illness, health behaviors, and overall quality of healthcare. Only 21% of respondents participated in good Collaborative Care, 36% attained fair Collaborative Care, and 43% experienced poor Collaborative Care. Regardless of overall care quality or the respondents' personal characteristics, burden of illness, or health behaviors, good Collaborative Care was associated with better control of blood pressure, blood glucose level, serum cholesterol level, and treatment effectiveness for pain and emotional problems. Some preventive actions were better, and some adverse economic impacts of illness were mitigated.

Finding common ground: patient-centeredness and evidence-based chronic illness care

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.

Quality-of-life changes following the completion of phase II cardiac rehabilitation

In this study, 302 patients who were completing Phase II cardiac rehabilitation were assessed at their entrance to cardiac rehabilitation and at 3 months. After 3 months, subjects improved on 8 of 9 dimensions. Greatest gains were in Fitness (22.5%, P < .0001) and Daily Activities (24.4%, P < .0001). Despite stratification by gender, a sedentary lifestyle, and tobacco use, quality of life was markedly improved at the completion of rehabilitation. Completion of a Phase II cardiac rehabilitation program can lead to statistically significant increases in the quality of life following consequential cardiac events.

Use of the SF-12 instrument for measuring the health of homeless persons

OBJECTIVE

To evaluate the construct validity of the Short Form 12-item Survey (SF-12) among users of a homeless day shelter. Adding brief health assessments has potential to provide information regarding the effect that programs have upon the health status and functioning of homeless persons.

STUDY SETTING

A convenience sample of 145 homeless persons at a day shelter in an urban setting.

STUDY DESIGN

Participants were verbally administered the SF-12 that provides information on mental and physical health status and the Dartmouth Improve Your Medical Care Survey (IYMC) that provides information on functional health, clinical symptoms, medical conditions, and health risk. The IYMC survey system has been widely used in clinical settings to assess health status and the outcomes of care.

DATA COLLECTION/EXTRACTION METHODS

Construct validity was assessed by the following approaches: (a) the method of extreme groups was used where multivariate analysis of variance determined if SF-12 summary scores varied for individuals who differed in self-reported clinical symptoms and medical conditions, and (b) convergent validity was assessed by correlating SF-12 summary scores with the subscales.

PRINCIPAL FINDINGS

Four to 10 point differences in physical health (PCS12) and 5-11 point differences in mental health (MCS12) were found between those who reported acute symptoms and medical conditions and those who did not. A 13-point difference in PCS12 scores and a 7-16-point difference in MCS12 scores were found for those who reported none or few to several symptoms or conditions. The summary scores and subscales yielded satisfactory convergent validity coefficients that ranged from 0.62 to 0.88 with one exception.

CONCLUSIONS

The SF-12 shows promise as a valid outcome indicator for assessing and monitoring health status among the homeless. Its strengths include brevity and availability of norms for specific medical conditions.

Merging education with measurement: a focus on the Hispanic community

There is an increasing need for community health promotion efforts directed to populations that are often disenfranchised from the health care system. The rapidly growing Hispanic population can benefit from outreach efforts that provide health education and promote community awareness of health status and health problems. This article describes a cost effective survey system that measured health status, health needs and provided individualized health feedback and education to Hispanic residents. The results underscore the importance of culturally and linguistically appropriate community-based initiatives that assess health status to aid in setting policy, eliminate health disparities, and determine priorities to meet the health needs of the growing Hispanic population.

Implementation of Web-based interaction technology to improve the quality of a city's health care

In the clinic, one method for improving the interaction is to ask patients to systematically report their health status, give them standard advice based on their responses, and ask them to discuss this advice with a health practitioner. In the school system, this approach provides aggregate information for targeting programs to meet student needs. In the workplace, this health assessment and personal feedback approach may be offered to employees to improve health care and lower health care costs. But why stop at the door of the clinic, school, or workplace when Internet technology can extend to an entire community the benefits of health assessment and feedback?

A computerized school-based health assessment with rapid feedback to improve adolescent health

Adolescent health problems are often undetected in physicians' offices. The Dartmouth Primary Care Cooperative Information Project has developed a validated and reliable approach to identify adolescent health problems and initiate education in a school setting. A self-administered, anonymous, 26-item questionnaire was given to 204 students in a rural high school. Responses were scanned into PC-based software. Within one working day students were given individualized letters identifying their problem health issues as detected by the questionnaire and recommendations for education. Ninety-nine percent of students participated. Six weeks later 49% of a sample of 41 students reported reading the information and 50% planned to change behavior. This standardized, validated strategy of adolescent health assessment, feedback, and education was feasible for use in schools. The school responded to the data by employing a psychologist to address mental health needs.