Center for Healthcare Organization and Implementation Research

Bedford, United Kingdom

Center for Healthcare Organization and Implementation Research

Bedford, United Kingdom
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Rose A.J.,Center for Healthcare Organization and Implementation Research | Rose A.J.,Boston University | Allen A.L.,VA Salt Lake City Healthcare System | Minichello T.,San Francisco Medical Center | Minichello T.,University of California at San Francisco
Circulation: Cardiovascular Quality and Outcomes | Year: 2016

Because of the recent publication of several important studies, there has been a major change in how we think about perioperative management of anticoagulation. Because of these changes, existing consensus guidelines are suddenly out of date and can no longer be used as is, particularly the 2012 American College of Chest Physicians Antithrombotic Guidelines, version 9. We estimate that well over 90% of patients receiving warfarin therapy should not receive bridging anticoagulation during periprocedural interruptions of therapy, except under unusual circumstances and with appropriate justification. Accumulating evidence also suggests that bridging is not indicated among patients receiving direct-Acting oral anticoagulant therapy. The large number of patients potentially affected represents an important safety concern and requires an immediate change in practice. © 2015 American Heart Association, Inc.


Luger T.M.,Center for Healthcare Organization and Implementation Research | Suls J.,U.S. National Cancer Institute | Vander Weg M.W.,University of Iowa | Vander Weg M.W.,Comprehensive Access and Delivery Research and Evaluation Center
Addictive Behaviors | Year: 2014

Introduction: Our objective was to use meta-analytic techniques to assess the strength of the overall relationship and role of potential moderators in the association between smoking and depression in adults. Methods: Two popular health and social science databases (PubMed and PsycINFO) were systematically searched to identify studies which examined the association between adult smoking behavior and major depressive disorder (MDD) or depressive symptoms. A total of 85 relevant studies were selected for inclusion. Studies were analyzed using a linear mixed effects modeling package ("lme4" for R) and the Comprehensive Meta-Analysis program version 2. Results: Multiple nested linear mixed-effects models were compared. The best fitting models were those that included only random study effects and smoking status. In cross-sectional studies, current smokers were more likely to be depressed than never smokers (OR= 1.50, CI= 1.39-1.60), and current smokers were more likely to be depressed than former smokers (OR= 1.76, CI= 1.48-2.09). The few available prospective studies, that used the requisite statistical adjustments, also showed smokers at baseline had greater odds of incident depression at follow-up than never smokers (OR= 1.62, CI= 1.10-2.40). Conclusions: In cross-sectional studies, smoking was associated with a nearly two-fold increased risk of depression relative to both never smokers and former smokers. In the smaller set of prospective studies, the odds of subsequent depression were also higher for current than never smokers. Attesting to its robustness, the relationship between smoking and depression was exhibited across several moderators. Findings could help health care providers to more effectively anticipate co-occurring health issues of their patients. Several methodological recommendations for future research are offered. © 2014.


Ruben M.A.,Center for Healthcare Organization and Implementation Research | van Osch M.,NIVEL Netherlands Institute for Health Services Research | Blanch-Hartigan D.,Bentley University
Patient Education and Counseling | Year: 2015

Objective: Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy. Methods: A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain. Results: 60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity. Conclusion: Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (≥10 years) and those providing care for vulnerable patient populations. Practice implications: More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients. © 2015.


McInnes D.K.,Center for Healthcare Organization and Implementation Research | Petrakis B.A.,Center for Healthcare Organization and Implementation Research | Gifford A.L.,Center for Healthcare Organization and Implementation Research | Rao S.R.,Center for Healthcare Organization and Implementation Research | And 3 more authors.
American Journal of Public Health | Year: 2014

Objectives. We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows. Methods.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. Results. Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patientcancelled 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). Conclusions. 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.


Razouki Z.,Center for Healthcare Organization and Implementation Research | Razouki Z.,Boston University | Ozonoff A.,Center for Healthcare Organization and Implementation Research | Ozonoff A.,Boston Childrens Hospital | And 4 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2014

Background-Among patients receiving warfarin, percent time in therapeutic range (TTR) and international normalized ratio (INR) variability predict adverse events individually. Here, we examined what is added to the prediction of adverse events by using both measures together. Methods and Results-We included 40 404 patients anticoagulated for atrial fibrillation, aged 65+, within the Veterans Health Administration. TTR and log-transformed INR variability were calculated for each patient. Our study outcomes were ischemic stroke and major bleeding, defined using International Classification of Diseases-9 codes. We estimated the hazard ratios (HRs) for the study outcomes using 3 nested Cox regression models, including (1) TTR or log INR variability separately; (2) TTR and log INR variability together; and (3) both predictors together plus an interaction term. We divided TTR into 3 categories (high, >70%; moderate, 50% to 70%; low, <50%) and log INR variability into 2 categories (stable and unstable). The reference groups high TTR and stable anticoagulation each denote good control. Higher log INR variability (ie, unstable control) predicted ischemic stroke (HR=1.45, P<0.001) and major bleeding (HR=1.57, P<0.001) independently, regardless of TTR levels. Our model with interaction terms showed that High log INR variability predicted a significantly higher risk for ischemic stroke and major bleeding compared with low log INR variability, at moderate TTR levels (HR= 1.27 and HR=1.29, respectively) and at high TTR levels (HR=1.55 and HR=1.56, respectively), but not at low TTR levels. Conclusions-Unstable anticoagulation predicts warfarin adverse effects independent of TTR. Moreover, knowledge about anticoagulation stability further stratifies the risk for adverse events at given levels of TTR. © 2014 American Heart Association, Inc.


Rao S.R.,University of Massachusetts Medical School | Rao S.R.,Center for Healthcare Organization and Implementation Research
Annals of Family Medicine | Year: 2014

When my mother fell ill while visiting me in the United States, I had the opportunity to compare costs of surgical cardiac care in the United States and India. I faced challenges in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in choice of care, whereas in India costs are readily available and allow most people to freely choose their preferred type of care. © 2014 by the Annals of Family Medicine, Inc.


Amante D.J.,University of Massachusetts Medical School | Hogan T.P.,University of Massachusetts Medical School | Hogan T.P.,Center for Healthcare Organization and Implementation Research | Pagoto S.L.,University of Massachusetts Medical School | And 2 more authors.
Journal of Medical Internet Research | Year: 2015

Background: The insurance mandate of the Affordable Care Act has increased the number of people with health coverage in the United States. There is speculation that this increase in the number of insured could make accessing health care services more difficult. Those who are unable to access care in a timely manner may use the Internet to search for information needed to answer their health questions. Objective: The aim was to determine whether difficulty accessing health care services for reasons unrelated to insurance coverage is associated with increased use of the Internet to obtain health information. Methods: Survey data from 32,139 adults in the 2011 National Health Interview Study (NHIS) were used in this study. The exposure for this analysis was reporting difficulty accessing health care services or delaying getting care for a reason unrelated to insurance status. To define this exposure, we examined 8 questions that asked whether different access problems occurred during the previous 12 months. The outcome for this analysis, health information technology (HIT) use, was captured by examining 2 questions that asked survey respondents if they used an online health chat room or searched the Internet to obtain health information in the previous 12 months. Several multinomial logistic regressions estimating the odds of using HIT for each reported access difficulty were conducted to accomplish the study objective. Results: Of a survey population of 32,139 adults, more than 15.90% (n=5109) reported experiencing at least one access to care barrier, whereas 3.63% (1168/32,139) reported using online health chat rooms and 43.55% (13,997/32,139) reported searching the Internet for health information. Adults who reported difficulty accessing health care services for reasons unrelated to their health insurance coverage had greater odds of using the Internet to obtain health information. Those who reported delaying getting care because they could not get an appointment soon enough (OR 2.2, 95% CI 1.9-2.5), were told the doctor would not accept them as a new patient or accept their insurance (OR 2.1, 95% CI 1.7-2.5 and OR 2.1, 95% CI 1.7-2.5, respectively), or because the doctor's office was not open when they could go (OR 2.2, 95% CI 1.9-2.7) had more than twice the odds of using the Internet to obtain health information compared to those who did not report such access difficulties. Conclusions: People experiencing trouble accessing health care services for reasons unrelated to their insurance status are more likely to report using the Internet to obtain health information. Improving the accuracy and reliability of health information resources that are publicly available online could help those who are searching for information due to trouble accessing health care services. ©Daniel J Amante, Timothy P Hogan, Sherry L Pagoto, Thomas M English, Kate L Lapane.


Miller C.,Center for Healthcare Organization and Implementation Research | Miller C.,Harvard University | Bauer M.S.,Center for Healthcare Organization and Implementation Research | Bauer M.S.,Harvard University
Current Psychiatry Reports | Year: 2014

Bipolar disorder is associated with high mortality, and people with this disorder on average may die 10–20 years earlier than the general population. This excess and premature mortality continues to occur despite a large and expanding selection of treatment options dating back to lithium and now including anticonvulsants, antipsychotics, and evidence-based psychotherapies. This review summarizes recent findings on mortality in bipolar disorder, with an emphasis on the role of suicide (accounting for about 15 % of deaths in this population) and cardiovascular disease (accounting for about 35–40 % of deaths). Recent care models and treatments incorporating active outreach, integrated mental and physical health care, and an emphasis on patient self-management have shown promise in reducing excess mortality in this population. © 2014, Springer Science+Business Media New York (outside the USA).


Cancino R.S.,Boston University | Hylek E.M.,Center for Healthcare Organization and Implementation Research | Hylek E.M.,Boston University | Reisman J.I.,Center for Healthcare Organization and Implementation Research | And 2 more authors.
Thrombosis Research | Year: 2014

Introduction Percent time in therapeutic range (TTR) is increasingly used to summarize anticoagulation control over time among patients receiving warfarin. Higher TTR improves outcomes of care, but studies have varied regarding whether TTR is best summarized as center-based percent time in therapeutic range (cTTR) or as individual percent time in therapeutic range (iTTR). Our aim was to compare cTTR to iTTR in predicting ischemic stroke, major hemorrhage, and all-cause mortality. Materials and methods Veterans Health Administration data of 57,281 patients receiving warfarin therapy were included. iTTR was calculated using linear interpolation. Each site's mean TTR was calculated, and the cTTR was assigned to all patients at that site. We used Cox proportional hazards to examine cTTR and iTTR as predictors of major hemorrhage, ischemic stroke, and all-cause mortality. Results Comparing worst to best quartiles of INR control, cTTR was not a statistically significant predictor of major hemorrhage or ischemic stroke, hazard ratios (HR) were 1.02 (95% confidence interval [CI] 0.93-1.11) and 1.00 (95% CI: 0.88-1.13), respectively. cTTR was a weak predictor of all-cause mortality (HR: 1.14, 95% CI: 1.07-1.22). iTTR predicted major hemorrhage (HR: 1.79, 95% CI: 1.63-1.96), ischemic stroke (HR: 1.91, 95% CI: 1.67-2.19), and all-cause mortality (HR: 2.20, 95% CI: 2.05-2.35). Conclusion iTTR significantly predicted risk of major hemorrhage, ischemic stroke, and all-cause mortality. cTTR was a weak predictor of all-cause mortality. Though cTTR may be a better target for site-level quality improvement efforts, iTTR may be a more suitable measure for use in comparative effectiveness research. © 2014 Elsevier Ltd.


Gillespie C.,Center for Healthcare Organization and Implementation Research
Sociology of Health and Illness | Year: 2015

Those who undergo health screening often experience physical and emotional effects as a result of the screening process. However, the effects of health screening go beyond these physical and mental complications, often having profound social effects for those who are screened. This study explores the social implications of health screening for people who undergo it and are designated as being at risk for potential disease. Through a qualitative analysis of the experiences of individuals with elevated cholesterol levels and men with elevated prostate-specific antigen (PSA) levels, this research offers a description of the experience of being at risk, identifying three primary components: increased medical contact, a restructuring of everyday routines and altered social relationships. Whereas the at-risk health status engendered by current clinical approaches to screening and surveillance has been characterised as proto-disease, this study develops a companion definition of proto-illness to characterise the social experience of life with an identified health risk. Those who are at risk act in ways that are similar to those who are ill. The concept of proto-illness implies that the experience of risk is parallel to the experience of illness and contributes to the sociology of medical screening by establishing a much needed bridge between the two experiences. © 2015 John Wiley & Sons Ltd.

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