New Bedford, MA, United States
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Brashers D.E.,University of Illinois at Urbana - Champaign | Hogan T.P.,Center for Health Quality | Hogan T.P.,University of Massachusetts Medical School
Information Processing and Management | Year: 2013

Uncertainty is an important idea in information-retrieval (IR) research, but the concept has yet to be fully elaborated and explored. Common assumptions about uncertainty are (a) that it is a negative (anxiety-producing) state and (b) that it will be reduced through information search and retrieval. Research in the domain of uncertainty in illness, however, has demonstrated that uncertainty is a complex phenomenon that shares a complicated relationship with information. Past research on people living with HIV and individuals who have tested positive for genetic risk for different illnesses has revealed that information and the reduction of uncertainty can, in fact, produce anxiety, and that maintaining uncertainty can be associated with optimism and hope. We review the theory of communication and uncertainty management and offer nine principles based on that theoretical work that can be used to influence IR system design. The principles reflect a view of uncertainty as a multi-faceted and dynamic experience, one subject to ongoing appraisal and management efforts that include interaction with and use of information in a variety of forms.


Nazi K.M.,C o Stratton Medical Center | Hogan T.P.,Center for Health Quality | Hogan T.P.,University of Massachusetts Medical School | McInnes D.K.,Center for Health Quality | And 3 more authors.
Medical Care | Year: 2013

Objective: Personal Health Records (PHRs) tethered to an Electronic Health Record (EHR) offer patients unprecedented access to their personal health information. At the Department of Veteran Affairs (VA), the My HealtheVet Pilot Program was an early PHR prototype enabling patients to import 18 types of information, including clinical notes and laboratory test results, from the VA EHR into a secure PHR portal. The goal of this study was to explore Veteran perceptions about this access to their medical records, including perceived value and effect on satisfaction, self-care, and communication. Methods: Patients enrolled in the pilot program were invited to participate in a web-based survey. Results: Among 688 Veteran respondents, there was a high degree of satisfaction with the pilot program, with 84% agreeing that the information and services were helpful. The most highly ranked feature was access to personal health information from the VA EHR. The majority of respondents (72%) indicated that the pilot Web site made it easy for them to locate relevant information. Most participants (66%) agreed that the pilot program helped improve their care, with 90% indicating that they would recommend it to another Veteran. Conclusions: Veterans' primary motivation for use of the pilot Web site was the ability to access their own personal health information from the EHR. With patients viewing such access as beneficial to their health and care, PHRs with access to EHR data are positioned to improve health care quality. Making additional information accessible to patients is crucial to meet their needs and preferences. © 2013 by Lippincott Williams & Wilkins.


Hawn M.T.,The Surgical Center | Hawn M.T.,University of Alabama at Birmingham | Houston T.K.,Center for Health Quality | Houston T.K.,University of Massachusetts Medical School | And 6 more authors.
Annals of Surgery | Year: 2011

OBJECTIVE:: This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes. SUMMARY BACKGROUND DATA:: Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention. METHODS:: A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression. RESULTS:: Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications. CONCLUSIONS:: This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events. Copyright C © 2011 by Lippincott Williams & Wilkins.


Rose A.J.,Center for Health Quality | Hylek E.M.,Section of General Internal Medicine | Ozonof A.,Center for Health Quality | Ozonof A.,Boston University | And 5 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2011

Background-Oral anticoagulation is safer and more effective when patients receive high-quality care. However, there have been no prior efforts to measure quality of oral anticoagulation care or to risk adjust it to ensure credible comparisons. Our objective was to profile site performance in the Veterans Health Administration (VA) using risk-adjusted percent time in therapeutic range (TTR). Methods and Results-We included 124 551 patients who received outpatient oral anticoagulation from 100 VA sites of care for indications other than valvular heart disease from October 1, 2006, to September 30, 2008. We calculated TTR for each patient and mean TTR for each site of care. Expected TTR was calculated for each patient and each site based on the variables in the risk adjustment model, which included demographics, comorbid conditions, medications, and hospitalizations. Mean TTR for the entire sample was 58%. Site-observed TTR varied from 38% to 69% or from poor to excellent. Site-expected TTR varied from 54% to 62%. Site risk-adjusted performance ranged from 18% below expected to 12% above expected. Risk adjustment did not alter performance rankings for many sites, but for other sites, it made an important difference. For example, the site ranked 27th of 100 before risk adjustment was one of the best (risk-adjusted rank, 7). Risk-adjusted site rankings were consistent from year to year (correlation between years, 0.89). Conclusions-Risk-adjusted TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated health system. This measure can serve as the basis for quality measurement and quality improvement efforts. © 2011 American Heart Association, Inc.


McInnes D.K.,Center for Health Quality | McInnes D.K.,Boston University | Li A.E.,Amherst College | Hogan T.P.,Center for Health Quality | And 2 more authors.
American Journal of Public Health | Year: 2013

We systematically reviewed the health and social science literature on access to and use of information technologies by homeless persons by searching 5 bibliographic databases. Articles were included if they were in English, represented original research, appeared in peer-reviewed publications, and addressed our research questions. Sixteen articles met our inclusion criteria. We found that mobile phone ownership ranged from 44% to 62%; computer ownership, from 24% to 40%; computer access and use, from47%to 55%; and Internet use, from 19% to 84%. Homeless persons used technologies for a range of purposes, some of whichwere health related. Many homeless persons had access to information technologies, suggesting possible health benefits to developing programs that link homeless persons to health care through mobile phones and the Internet.


Carey K.,Center for Health Quality | Carey K.,Boston University | Stefos T.,VA Office of Productivity | Stefos T.,Boston University
Health Economics | Year: 2011

This paper estimates the excess cost of hospital inpatient care due to adverse safety events in the US Department of Veterans Affairs (VA) hospitals during fiscal year 2007. We measured adverse events according to the Patient Safety Indicator (PSI) algorithms of the Agency for Healthcare Research and Quality. Patient level cost regression analyses were performed using generalized linear modeling techniques. Accounting for the heavily skewed distribution of costs among patients having adverse safety events, results suggested that the excess cost of nine different PSIs for VA patients are much higher than previously estimated. We tested sensitivity of results to whether costs were measured by VA's Decision Support System (DSS) that uses local costs of specific inputs, or by the average costing system developed by VA's Health Economics Resource Center. DSS costing appeared to better characterize the high cost patients.


Bokhour B.G.,Center for Health Quality
Journal of general internal medicine | Year: 2012

Uncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients' hypertension self-management have had lasting effects. Previous work has focused largely on patients' beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients' social contexts. This study aims to explore how patients' "explanatory models" of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors. Semi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers. PARTICIPANTS (OR PATIENTS OR SUBJECTS): African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure. We conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients' explanatory models, social context and hypertension management behaviors. Patients' perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients' daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management. Designing interventions to improve patients' hypertension self-management requires consideration of patients' explanatory models and their daily-lived experience. We propose a new conceptual model - the dynamic model of hypertension self-management behavior - which incorporates these key elements of patients' experiences.


Wilkinson J.E.,Boston University | Deis C.E.,Boston University | Bowen D.J.,Boston University | Bokhour B.G.,Boston University | Bokhour B.G.,Center for Health Quality
Annals of Family Medicine | Year: 2011

PURPOSE Women with intellectual disabilities (or mental retardation) are living longer, receiving primary care in the community, and have equal rates of breast cancer compared with women in the general population, but they have lower rates of mammography. Although several public campaigns have successfully raised the mammography rate for racial and ethnic minority women, they have not penetrated the community of women with intellectual disabilities. No research to date has explored potential barriers to mammography for these women by involving the women themselves as participants. METHODS We undertook a qualitative study to explore the perceptions and understanding of mammography for women with intellectual disabilities and some of the potential reasons they would or would not have the test. Twenty-seven intellectually disabled women were recruited through a variety of community groups and interviewed using a semistructured interview guide. Data were analyzed using qualitative techniques from grounded theory. RESULTS Participants in this study described being poorly prepared for mam-mography: they did not understand its purpose and were not prepared for the logistics of the experience. The latter was more upsetting to participants and contributed to their negative perceptions of mammography. Participants reported feeling unprepared and singled out for being unprepared, despite their desire to have at least 1 mammogram, as do other women their age. CONCLUSIONS Women with intellectual disabilities perceive mammography differently than do women who do not have intellectual disabilities, and their perception is informed by inadequate knowledge, anxiety, and inadequate preparation. These themes should be considered when planning cancer prevention interventions with this population and when counseling individual women in the clinical setting.


Fasoli D.R.,Center for Health Quality | Glickman M.E.,Center for Health Quality | Glickman M.E.,Boston University | Eisen S.V.,Center for Health Quality | Eisen S.V.,Boston University
Medical Care | Year: 2010

Background: Though demand for mental health services (MHS) among US veterans is increasing, MHS utilization per veteran is decreasing. With health and social service needs competing for limited resources, it is important to understand the association between patient factors, MHS utilization, and clinical outcomes. Objectives: We use a framework based on Andersen's behavioral model of health service utilization to examine predisposing characteristics, enabling resources, and clinical need as predictors of MHS utilization and clinical outcomes. Methods: This was a prospective observational study of veterans receiving inpatient or outpatient MHS through Veterans Administration programs. Clinician ratings (Global Assessment of Functioning [GAF]) and self-report assessments (Behavior and Symptom Identification Scale-24) were completed for 421 veterans at enrollment and 3 months later. Linear and logistic regression analyses were conducted to examine: (1) predisposing characteristics, enabling resources, and need as predictors of MHS inpatient, residential, and outpatient utilization and (2) the association between individual characteristics, utilization, and clinical outcomes. Results: Being older, female, having greater clinical need, lack of enabling resources (employment, stable housing, and social support), and easy access to treatment significantly predicted greater MHS utilization at 3-month follow-up. Less clinical need and no inpatient psychiatric hospitalization predicted better GAF and Behavior and Symptom Identification Scale-24 scores. White race and residential treatment also predicted better GAF scores. Neither enabling resources, nor number of outpatient mental health visits predicted clinical outcomes. Conclusions: This application of Andersen's behavioral model of health service utilization confirmed associations between some predisposing characteristics, need, and enabling resources on MHS utilization but only predisposing characteristics, need, and utilization were associated with clinical outcomes. Copyright © 2010 by Lippincott Williams & Wilkins.


Vimalananda V.G.,Center for Health Quality
Women's health issues : official publication of the Jacobs Institute of Women's Health | Year: 2011

We sought to compare lipid-lowering therapy among female and male veterans with diabetes and hyperlipidemia. We conducted a cross-sectional study of veterans serviced by the Veterans Health Administration in 2006 who had both diabetes and hyperlipidemia and compared all female patients to age- and facility-matched males. We compared proportions of patients with any prescription for lipid-lowering therapy in the year and, among those with elevated low-density lipoprotein cholesterol (LDL >100 mg/dL) and no prior treatment, we compared initiation of lipid-lowering therapy. We used multiple logistic regression to estimate odds ratios (AOR) and 95% confidence intervals (CI), adjusting for race, VA eligibility, health care utilization, cardiovascular diseases, mental health conditions, and a comprehensive list of other comorbidities. We also performed the analysis stratified by age. Women had higher LDL levels than men (110 ± 38 vs. 101 ± 36 mg/dL) and were less likely to be receiving lipid-lowering therapy (80% vs. 84%; AOR, 0.79; 95% CI, 0.76-0.82) or to be initiated on such therapy (37% vs. 42%; AOR, 0.82; 95% CI, 0.74-0.90). Differences were greatest in the youngest women (<45 years old) for both any lipid-lowering therapy (61% vs. 75%; AOR, 0.50; 95% CI, 0.45-0.56) and initiation of therapy (26% vs. 38%; AOR, 0.55; 95% CI, 0.42-0.73). Adjustment for potential confounders did not change the risk estimates. Women veterans with diabetes and hyperlipidemia receive less aggressive lipid-lowering therapy than men, especially among younger age groups. This disparity is of concern, because early intervention to control hyperlipidemia can reduce the later burden of cardiovascular disease among diabetic women. Copyright © 2011 Jacobs Institute of Women's Health. All rights reserved.

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