Center-Level Experience and Kidney Transplant Outcomes in HIV-Infected Recipients.

Excellent outcomes among HIV+ kidney transplant (KT) recipients have been reported by the NIH consortium, but it is unclear if experience with HIV+ KT is required to achieve these outcomes. We studied associations between experience measures and outcomes in 499 HIV+ recipients (SRTR data 2004-2011). Experience measures examined included: (1) center-level participation in the NIH consortium; (2) KT experiential learning curve; and (3) transplant era (2004-2007 vs. 2008-2011). There was no difference in outcomes among centers early in their experience (first 5 HIV+ KT) compared to centers having performed >6 HIV+ KT (GS adjusted hazard ratio [aHR]: 1.05, 95% CI: 0.68-1.61, p = 0.82; PS aHR: 0.93; 95% CI: 0.56-1.53, p = 0.76), and participation in the NIH-study was not associated with any better outcomes (GS aHR: 1.08, 95% CI: 0.71-1.65, p = 0.71; PS aHR: 1.13; 95% CI: 0.68-1.89, p = 0.63). Transplant era was strongly associated with outcomes; HIV+ KTs performed in 2008-2011 had 38% lower risk of graft loss (aHR: 0.62; 95% CI: 0.42-0.92, p = 0.02) and 41% lower risk of death (aHR: 0.59; 95% CI: 0.39-0.90, p = 0.01) than that in 2004-2007. Outcomes after HIV+ KT have improved over time, but center-level experience or consortium participation is not necessary to achieve excellent outcomes, supporting continued expansion of HIV+ KT in the US.

Toward a valid definition of gout flare: results of consensus exercises using Delphi methodology and cognitive mapping.

OBJECTIVE: To identify, in people known to have gout, the testable, key components of a standard definition of gout flare for use in clinical research. METHODS: Consensus methodology was used to identify key elements of a gout flare. Two Delphi exercises were conducted among different groups of rheumatologists. A cognitive mapping technique among 9 gout experts with hierarchical cluster analysis provided a framework to guide the panel discussion, which identified the final set of items that should be tested empirically. RESULTS: From the Delphi exercises, 21 items were presented to the expert panel. Cluster analysis and multidimensional scaling showed that these items clustered into 5 concepts (joint inflammation, severity of symptoms, stereotypical nature, pain, and gout archetype) distributed along 2 dimensions (objective to subjective features and general features to specific features of gout). Using this analysis, expert panel discussion generated a short list of potential features: joint swelling, joint tenderness, joint warmth, severity of pain, patient global assessment, time to maximum pain, time to complete resolution of pain, an acute-phase marker, and functional impact of the episode. CONCLUSION: A short list of features has been identified and now requires validation against a patient- and physician-defined gout flare in order to determine the best combination of features.

Survey of primary care physicians' approach to gastroesophageal reflux disease in elderly patients.

BACKGROUND: Although gastroesophageal reflux disease (GERD) is a common condition, little is known regarding physicians' approach to the diagnosis and management of GERD in elderly patients. METHODS: We surveyed by facsimile a random sample of 14,000 practicing primary care physicians throughout the United States. Physicians were questioned using a case-based format about the approach to a symptomatic patient with GERD including the use of empiric therapy, the role of diagnostic testing, and the drugs of choice to treat GERD. RESULTS: A total of 2241 surveys (16%) was returned and tabulated. Most respondents were either internists (37%) or family practice physicians (56%) in solo or group practice, and 74% had been in practice for 11 or more years. There were 1980 (90%) respondents who evaluated more than 6 patients per week with GERD. Empiric therapy was commonly recommended for the symptomatic patient, most often in a step-up approach beginning with H(2)-receptor blockers. Diagnostic testing, usually endoscopy, was recommended appropriately in patients with alarm symptoms. Proton-pump inhibitors were most often recommended for patients failing to respond to over-the-counter H(2)-receptor blockers and for those with endoscopic esophagitis; the use of cisapride in combination with H(2)-receptor blockers was also commonly recommended in these scenarios. CONCLUSIONS: The management of symptomatic GERD in elderly patients appears similar to the management of GERD in other patients. Empiric therapy was frequently recommended in a step-up approach, and diagnostic testing was appropriate. Combination therapy with cisapride and an acid-reducing agent was commonly recommended.

The role of availability as a moderator of family fruit and vegetable consumption.

The public health objective to improve the diet of Americans includes increasing the consumption of fruits and vegetables (F&V). The availability of F&V in the home has been suggested but not confirmed as one environmental factor that influences the types and quantities of F&V eaten by family members. Using a model of parental and child influences on a child's intake of F&V, the authors investigated F&V availability as a moderating variable for the relationships between the model constructs and how the relationships might change with varying levels of F&V availability. Path analysis and multigroup structural equation modeling were the analytic tools. Results indicated that homes with more F&V available had a richer and generally stronger set of motivating factors for parent and child F&V consumption than homes with low F&V availability. Findings have implications for parental involvement in interventions to enhance the diet of fourth-grade children.

Self-appraised social problem solving abilities, emotional reactions and actual problem solving performance.

Self-report measures of social problem solving abilities have yet to be associated with objective problem solving performance in any consistent manner. In the present study, we investigated the relation of social problem solving abilities--as measured by the Social Problem Solving Skills Inventory--Revised (SPSI-R [Maydeu-Olivares, A. & D'Zurilla, T. J. (1996). A factor analytic study of the Social Problem Solving Inventory: an integration of theory and data. Cognitive Therapy and Research, 20, 115-133])--to performance on a structured problem solving task. Unlike previous studies, we examined the relation of problem solving skills to performance curves observed in repeated trials, while controlling for affective reactions to each trial. Using hierarchical modeling techniques, a negative problem orientation was significantly predictive of performance and this effect was not mediated by negative affectivity. Results are discussed as they pertain to contemporary models of social problem solving.

Perceptual gaps in understanding patient expectations for health care service quality.

This article assesses how well physicians, health administrators, patient-contact employees, and especially medical and nursing students understand patient expectations for service quality as measured by the SERVQUAL scale. Using a cross-sectional research design and discriminant analysis, it was found that health administrators were most likely to accurately estimate the service expectations of patients, while medical and nursing students were most likely to underestimate them.

Access to the environment and life satisfaction after spinal cord injury.

OBJECTIVE: To determine the potential relation between satisfaction with life after spinal cord injury and access to the environment as measured by selected items from the Craig Handicap Assessment and Reporting Technique (CHART). DESIGN: Prospective, correlational/predictive study using cross-sectional and longitudinal data from 18 Model Spinal Cord Injury Systems of Care. SUBJECTS: Adult persons with traumatic-onset spinal cord injury (n = 650) evaluated at 1 or 2 years postinjury. OUTCOME MEASURE: Satisfaction With Life Scale (SWLS). PREDICTOR VARIABLES: Demographic characteristics, impairment and disability classifications. medical complications, rehabilitation insurance status, occupational status as measured by the CHART Occupation Scale, self-perceived health (from SF-36), and access to the environment as measured by items from the CHART Mobility Scale. RESULTS: Access to the environment was positively and linearly associated with satisfaction with life, demonstrated both positive and negative change over time, and was positively associated with subject's neurologic status. Access to the environment added to the explanatory model to predict life satisfaction even after all other independent measures were accounted for. CONCLUSION: Access to the environment (an "outside the person" factor) is important in predicting satisfaction with life for persons with spinal cord injury. The measure of access to the environment developed here is promising and worthy of further exploration and expansion.

Dynamic processes in health outcomes among caregivers of patients with spinal cord injuries.

The developmental trajectories of health outcomes in caregivers of patients with spinal cord injuries (SCIs) were studied as a function of caregiver and patient characteristics. Hierarchical linear modeling analysis examined (a) intraindividual developmental patterns of depressive behavior, anxiety, and physical symptoms over the 1st year of the caregiving career and (b) correlates of heterogeneity in the developmental patterns among 62 caregivers of persons with SCIs. Physical symptoms and anxiety were highly interdependent. Anxiety was a salient predictor of initial levels of and the rate of change in physical symptoms of caregivers. Physical symptoms and younger patient age were significantly predictive of initial levels of anxiety. Physical symptoms and positive affect predicted initial levels of depressive behavior among caregivers. Expressive support predicted the rate of change in anxiety and depressive behavior over time. These findings illustrate the value of studying caregiving as a developmental process.

Longitudinal changes in fatness in white children: no effect of childhood energy expenditure.

Reduced energy expenditure may predispose children to the development of obesity, but there are limited longitudinal studies to support this theory. We studied 75 white, preadolescent children over 4 y by taking annual measures of body composition and resting energy expenditure (by indirect calorimetry) and two annual measures of total energy expenditure and physical-activity-related energy expenditure (by doubly labeled water). Body composition of parents was assessed at the onset of the study with use of underwater weighing. The major outcome variable was the individual rate of change in fat mass (FM) adjusted for fat-free mass (FFM). The influence of sex, energy expenditure components, initial FM, and parental FM on the rate of change in FM was analyzed by hierarchical linear modeling and analysis of variance. The rate of change in absolute FM was 0.89 +/- 1.08 kg/y (range: -0.44 to 5.6 kg/y). The rate of change in FM adjusted for FFM was 0.08 +/- 0.64 kg/y (range: -1.45 to 2.22 kg/y) and was similar among children of two nonobese parents and children with one nonobese or one obese parent, but was significantly higher in children with two obese parents (0.61 +/- 0.87 kg/y). The major determinants of change in FM adjusted for FFM were sex (greater fat gain in girls), initial fatness, and parental fatness. None of the components of energy expenditure were inversely related to change in FM. The main predictors of change in FM relative to FFM during preadolescent growth are sex, initial fatness, and parental fatness, but not reduced energy expenditure.

Serum leptin and energy expenditure in children.

Leptin has been hypothesized to play an important role in energy balance by affecting both energy intake and energy expenditure. The purpose of our study was to determine the relationship between fasting serum leptin concentrations and measures of energy expenditure in prepubertal children. We measured total energy expenditure (TEE; by the doubly labeled water technique), resting energy expenditure (REE; after an overnight fast), activity energy expenditure (AEE; TEE-REE), body composition (by dual energy x-ray absorptiometry), and fasting serum leptin concentration (by RIA) in 76 children. Simple correlations showed that all measures of energy expenditure (TEE, REE, and AEE) were positively related to the serum leptin concentration (r = 0.50, P < 0.001; r = 0.45, P < 0.001; and r = 0.30, P < 0.01, respectively). However, after adjusting for body composition (fat-free mass and fat mass), gender, and ethnicity, serum leptin concentrations were not related to any measure of energy expenditure (TEE, P = 0.61; REE, P = 0.97; AEE, P = 0.65). These latter findings were further confirmed using structural equation models with leptin and energy expenditure as dependent variables, and fat-free mass and fat mass as independent variables. Results from these models showed no direct effect of leptin and no indirect effect of fat mass (through leptin) on any measure of energy expenditure, when a path between fat mass and energy expenditure was present in the model. Thus, our data do not support the hypothesis that the serum leptin concentration (independent of fat mass) is related to measures of energy expenditure in children.

Effects of gender, ethnicity, body composition, and fat distribution on serum leptin concentrations in children.

The Ob protein leptin has been shown to be closely correlated with measures of body fat in humans and animals. Studies have suggested that there are both gender and ethnic differences in serum leptin concentrations, even after controlling for total and relative body fat and body mass index. We hypothesized that gender and ethnic differences in serum leptin concentrations are due to differences in both body composition and body fat distribution. We measured fasting serum leptin concentration, body composition (fat mass and fat-free mass by dual energy x-ray absorptiometry), and body fat distribution (intraabdominal and sc abdominal adipose tissue by computed tomography) in 74 prepubertal boys and girls (43 African-Americans and 31 Caucasians). Our results showed that gender differences in serum leptin concentrations could not be fully explained by differences in body mass index, total fat mass, or relative body composition. However, when serum leptin concentrations were adjusted for differences in relative body composition (fat mass and fat-free mass) and body fat distribution (sc and intraabdominal adipose tissue), gender no longer had an independent effect on the serum leptin concentration. Serum leptin concentrations were not influenced by ethnicity. Thus, when comparing group differences in serum leptin concentrations, it is necessary to adequately control for group differences in body composition and fat distribution.

Organizational tenure and the perceived importance of retention factors in nursing homes.

Health care organizations can avoid substantial turnover costs through retention strategies geared to the varying needs of employees. The study on which this article is based examined retention needs of registered nurses in nursing homes and found that they varied by tenure. Low tenure nurses preferred learning opportunities and advancement potential while high tenure nurses favored work flexibility. Implications for retention policy in nursing homes are discussed.

Attracting RNs to nursing homes: nurses' work experience and perceived importance of organization and job attributes.

Applicant attraction theories stipulate that employment inducements be customized to meet the desires and specific characteristics of potential applicants. This study examined the relationship between nurses' level of work experience and perceived importance of organization and job attributes in attracting them to nursing home jobs. Importance ratings of recruitment factors varied significantly by nurses' level of work experience. Unique variation was attributed to education opportunities, potential for career advancement, compensation issues, benefits, and work flexibility.

Service quality revisited: striving for a new orientation.

This article examines the concept of service orientation. A brief overview of what is known about the concept in general service and health care organizations is provided, as is consideration of measurement issues and directions for future research in this area. Unfortunately, despite the great need for information, very little is known about service orientation in health care. This state of affairs, however, affords abundant opportunities for relevant research.

Psychological types of health administration students: suggestions for teaching, learning, and the future of the profession.

In this article, the configurations of psychological types that exist among a sample of 393 American graduate health administration students are analyzed. These data are compared to the psychological type characteristics of both university-level faculty and practicing health care administrators. Important insights can be derived from these comparisons in terms of teaching and learning in health administration programs, and they serve as a foundation for a coming transformation within the profession of health services administration.

The great gap. Physicians' perceptions of patient service quality expectations fall short of reality.

The various players in a health care encounter all hold different perspectives on what constitutes service quality. Findings from this preliminary investigation show that doctors in a multispecialty clinic rated patient expectations of reliability, responsiveness, assurance, and empathy lower than did administrators, patient-contact personnel, and, most significantly, the patients themselves. Health care marketers need to educate doctors on the importance patients place on certain issues and how to address them.

Enhancing administrator-clinician relationships: the role of psychological type.

The psychological dispositions of a sample of health administrators are contrasted with those of normative samples of physicians and nurses. Comparisons show that both physicians and nurses are more introverted, feeling, and perceiving than administrators, who tend to be more extraverted, thinking, and judging. Strategies for a common language and better communication for improved relationships between administrators and clinicians are outlined.

A cross-sectional study of the relationship between age and current health status for persons with spinal cord injuries.

As life expectancies of persons with spinal cord injuries increase, this population is aging rapidly. This trend requires that increasing attention be given to the healthcare needs of older persons with spinal cord injury. Follow up data on 11,117 persons injured since 1973 were analyzed by current age at 15-year intervals. Mean time postinjury was 4.7 years. Several trends were observed when comparing persons currently in the 16-30 year age group with persons in the oldest age group (age 76+). The percentage of persons independent in selfcare decreased from 61.9% to 29.1%. Ventilator use increased from 1.7% to 4.3%. Nursing home residence increased from 1.4% to 22.2%. The percentage of persons rehospitalized during the most recent year increased from 26.5% to 33.7%. Age was an important predictor of health status, but time postinjury was less important, perhaps due to the study's short postinjury time frame. While few differences in health status were observed in individuals between 16 and 60 years of age, persons in the oldest two age groups demonstrated lower levels of health status than younger individuals.

Somatic complaints and the CES-D.

OBJECTIVE: To evaluate the Center for Epidemiology Surveys-Depression (CES-D) scale for inordinate false positives, due to measurement of non-depression-related somatic complaints. DESIGN: Cross-sectional correlation of analysis of random multi-cluster samples. SETTING: Thirteen counties considered representative of the community-dwelling elderly population of Alabama. PARTICIPANTS: One-thousand-sixty persons aged 55 and older. INTERVENTION: None. MAIN OUTCOME MEASURES: Study evaluated the relationship of somatic symptomatology, as measured by the Multi-Level Assessment Instrument's Physical Health Domain Index (PHDI) composite score and its three component indices, with the CES-D and its four component scales, particularly the Somatic scale. RESULTS: The CES-D total score and the Somatic scale were not related to: age increases in the sample; PHDI composite score or the three index scores; or to subgroups of high and low PHDI composite scores. Among those screened as depressed, the PHDI and the three indices were not related to the CES-D total score or three of the four subscales. The CES-D Somatic scale was positively related to those depressed persons with the highest number of total PHDI somatic complaints. However, among the depressed group there were more persons scoring greater than 1.5 standard deviations above the mean on the CES-D Depressive Affect scale (n = 81) than on the Somatic scale (n = 65). CONCLUSIONS: The CES-D and its Somatic scale were relatively unbiased by the respondent's somatic complaints. The CES-D can continue to be considered valid under these circumstances.