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Pittsburgh, PA, United States

Werner R.M.,Center for Health Equity Research and Promotion | Werner R.M.,University of Pennsylvania | Dudley A.,University of California at San Francisco
Health Affairs

Medicare's new hospital pay-for-performance program for all acute care hospitals will begin in October 2012. It will be the largest Medicare quality improvement initiative for hospitals to date. Using 2009 data on hospital performance, we calculated hospital performance scores and projected payments under the new program for all eligible hospitals. Despite differences across hospitals in terms of performance, expected changes in payments were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of 1 percent. Although the program will in effect redistribute resources among hospitals, our data suggest that the redistribution is not likely to cause major problems because the amount being redistributed is also small. These results raise questions about whether the new pay-for-performance program will substantially alter the quality of hospital care, and they highlight the challenges of designing effective quality improvement incentives. Source

Broyles L.M.,Center for Health Equity Research and Promotion
American journal of critical care : an official publication, American Association of Critical-Care Nurses

Little is known about communication between patients and their family members during critical illness and mechanical ventilation in the intensive care unit, including use of augmentative and alternative communication tools and strategies. To identify (1) which augmentative and alternative communication tools families use with nonspeaking intensive care patients and how they are used, and (2) what families and nurses say about communication of family members with nonspeaking intensive care patients. A qualitative secondary analysis was conducted of existing data from a clinical trial testing interventions to improve communication between nurses and intensive care patients. Narrative study data (field notes, intervention logs, nurses' interviews) from 127 critically ill adults were reviewed for evidence of family involvement with augmentative and alternative communication tools. Qualitative content analysis was applied for thematic description of family members' and nurses' accounts of patient-family communication. Family involvement with augmentative and alternative communication tools was evident in 44% of the 93 patients who completed the parent study protocol. Spouses or significant others communicated with patients most often. Main themes describing patient-family communication included (1) families being unprepared and unaware, (2) families' perceptions of communication effectiveness, (3) nurses deferring to or guiding patient-family communication, (4) patients' communication characteristics, and (5) families' experience with and interest in augmentative and alternative communication tools. Assessment by skilled bedside clinicians can reveal patients' communication potential and facilitate useful augmentative and alternative communication tools and strategies for patients and their families. Source

Bachhuber M.A.,Center for Health Equity Research and Promotion | Bachhuber M.A.,University of Pennsylvania | Saloner B.,University of Pennsylvania | Cunningham C.O.,Yeshiva University | Barry C.L.,University of Pennsylvania
JAMA Internal Medicine

Importance: Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them.Objective: To determine the association between the presence of state medical cannabis laws and opioid analgesic overdose mortality.Design, Setting, and Participants: A time-series analysiswas conducted of medical cannabis laws and state-level death certificate data in the United States from 1999 to 2010; all 50 states were included.Exposures: Presence of a law establishing a medical cannabis program in the state.Main Outcomes and Measures: Age-adjusted opioid analgesic overdose death rate per 100 000 population in each state. Regression models were developed including state and year fixed effects, the presence of 3 different policies regarding opioid analgesics, and the state-specific unemployment rate.Results: Three states (California, Oregon, andWashington) had medical cannabis laws effective prior to 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8%lower mean annual opioid overdose mortality rate (95%CI, ?37.5%to ?9.5%; P = .003) compared with states without medical cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time: year 1 (?19.9%; 95%CI, ?30.6%to ?7.7%; P = .002), year 2 (?25.2%; 95%CI, ?40.6%to ?5.9%; P = .01), year 3 (?23.6%; 95%CI, ?41.1% to ?1.0%; P = .04), year 4 (?20.2%; 95%CI, ?33.6%to ?4.0%; P = .02), year 5 (?33.7%; 95%CI, ?50.9%to ?10.4%; P = .008), and year 6 (?33.3%; 95%CI, ?44.7%to ?19.6%; P < .001). In secondary analyses, the findings remained similar.Conclusions and Relevance: Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws may interact with policies aimed at preventing opioid analgesic overdose. Copyright © 2014 American Medical Association. All rights reserved. Source

Dichter M.E.,Center for Health Equity Research and Promotion
Women's health issues : official publication of the Jacobs Institute of Women's Health

Cardiovascular disease (CVD) is the leading cause of death for women in the United States. CVD risk factors, including depression, smoking, heavy drinking, being overweight, and physical inactivity, are associated with stress and may be linked to women's experiences of intimate partner violence (IPV) victimization. We know little about IPV and CVD risk factors among veteran women. The purpose of this study was to identify the association between lifetime IPV victimization and CVD risk factors among women, accounting for veteran status. We used data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System for 2006 for the eight states that included the IPV module. We explored the associations between veteran status and lifetime IPV victimization and between IPV exposure and CVD risk factors, for veteran and non-veteran women. Veteran women were more likely than non-veteran women to report lifetime IPV victimization (33.0% vs. 23.8%). IPV exposure was associated with depression, smoking, and heavy drinking. We did not find evidence for an association between IPV exposure and lack of exercise or being overweight or obese, when controlling for demographic characteristics and veteran status. Women veterans have particularly high rates of lifetime IPV victimization. In addition, IPV victimization is associated with an increased risk of heart health risk factors. The findings suggest that we should attend to IPV exposure among veteran women and further investigate the link between IPV and military service, and the associated health impacts. Published by Elsevier Inc. Source

To test the effects of patient and patient-oncologist relationship factors on the time spent communicating about health-related quality of life (HRQOL) during outpatient clinic encounters between oncologists and their patients with advanced cancer. Using mixed methods, we coded for duration of HRQOL talk in a subset of audio-recorded conversations from the Study of Communication in Oncologist-Patient Encounters (SCOPE) Trial. Multivariable linear regression modeling was used to investigate the relationship between duration of HRQOL talk and gender concordance, race concordance, patient education status, patient marital status, and length of the patient-oncologist relationship (i.e. number of previous visits). Sixty-six encounters were analyzed that involved 63 patients and 34 oncologists. Patients were more likely to be female (51%), white (86%), married (78%), and possess a college or more advanced degree (33%). Most oncologists were male (82%) and white (82%). Mean ages were 58.8 years for patients and 44.9 years for oncologists. Regression results showed that the number of a patient's previous visits with their oncologist was significantly associated with a longer duration of HRQOL talk during their audio-recorded clinic visit. The remaining independent variables, gender concordance, race concordance, patient education status, and patient marital status were not significant predictors of duration of HRQOL talk. Our findings suggest that length of the patient-oncologist relationship is related to duration of HRQOL talk. Improvements in HRQOL communication may best be achieved through efforts directed at those in earlier stages of the doctor-patient relationship. Copyright © 2010 John Wiley & Sons, Ltd. Source

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