Multilevel Interaction Effects of Family and Community Factors on Mothers' Engagement in Evidence-Based Home Visiting.

Informed by ecological and family system frameworks, our study investigated the relationship between family- and community-level factors, and their cross-level interactions, with evidence-based home visiting program participation in a sample of 2409 mothers (mean age: 24.15 years). Using 2-level hierarchical linear modeling, we observed that mothers living in disadvantaged communities demonstrated less active engagement in evidence-based home visiting. Cross-level interaction effects revealed that mothers' unstable living conditions and psychiatric problems amplified the negative influence of disadvantaged communities on program engagement. Conversely, mothers who were first-time parents showed higher levels of participation in family support programs when they resided in disadvantaged communities.

Effect of individualized communication skills training on physicians' discussion of clinical trials in oncology: results from a randomized controlled trial.

BACKGROUND: Discussing randomized clinical trials (RCTs) with cancer patients is one of the most challenging communication tasks a physician faces. Only two prior Communication Skills Trainings (CSTs) focused on RCTs in oncology have been reported. Their results demonstrated the need for further improvement. We developed and evaluated an enhanced, individually-tailored CST focused on improving physicians' communication during discussions of RCTs. METHODS: The CST focused on personal learning goals derived from video pre-assessment that were addressed in a 1.5-day group workshop and one-on-one coaching sessions. Forty physicians were recruited and randomly assigned to intervention and control groups. Video-recorded standardized consultations with actor-patients were utilized. As a primary outcome (1), training success was evaluated by blinded raters using a previously developed checklist. Change in checklist items was evaluated between pre- and post-training assessment and compared against control group results. As a secondary outcome (2), the physicians' feeling of confidence was assessed by a questionnaire. RESULTS: (1) Significant improvements in the intervention group were observed for the score on all items (p = 0.03), for the subgroup of content-specific items (p = 0.02), and for the global rating of communication competence (p = 0.04). The improvement observed for the subgroup of general communication skill items did not achieve significance (p = 0.20). (2) The feeling of confidence improved in nine out of ten domains. CONCLUSION: While the individually-tailored CST program significantly improved the physicians' discussions of RCTs, specifically related to discussion content, what remains unknown is the influence of such programs in practice on participant recruitment rates. The study was registered retrospectively in 2010/07/22 under DRKS-ID: DRKS00000492 .

It is not always about gains: utilities and disutilities associated with treatment features in patients with moderate-to-severe psoriasis.

BACKGROUND: Patient-centered care has been proposed as a strategy for improving treatment outcomes in the management of psoriasis and other chronic diseases. A more detailed understanding of patients' utilities and disutilities associated with treatment features may facilitate shared decision-making in the clinical encounter. The purpose of this study was to examine the features of psoriasis treatment that are most and least preferred by patients and to identify correlates of these preferences. METHODS: A cross-sectional survey of 163 patients with moderate-to-severe psoriasis was conducted in a German academic medical center. We assessed patients' characteristics, elicited their preferences for a range of potential treatment features, and quantified preference scores (utilities) associated with each treatment feature using hierarchical Bayes estimation. After identifying the most and least preferred treatment features, we explored correlates of these preferences using multivariate regression models. RESULTS: Mean preference scores (MPS) for the least preferred treatment features were consistently greater than those for the most preferred treatment features. Patients generally expressed strong preferences against prolonged treatments in the inpatient setting (MPS = -13.48) and those with a lower probability of benefit (MPS = -12.28), while treatments with a high probability of benefit (MPS = 10.51) were generally preferred. Younger patients and women were more concerned with treatment benefit as compared with older patients and men. CONCLUSION: Both negative and positive preferences appear important for shared decision-making. Recognition of characteristics associated with strong negative preferences may be particularly useful in promoting patient-centered environments.

Perceived organizational problems in health care: a pilot test of the structured problem and success inventory.

Our objective was to test whether the Structured Problem and Success Inventory (SPI) instrument could capture mental representations of organizational and work-related problems as described by individuals working in health care organizations and to test whether these representations varied according to organizational position. A convenience sample (n = 56) of middle managers (n = 20), lower-level managers (n = 20), and staff (n = 16) from health care organizations in Stockholm (Sweden) attending organizational development courses during 2003-2004 was recruited. Participants used the SPI to describe the 3 most pressing organizational and work-related problems. Data were systematically reviewed to identify problem categories and themes. One hundred sixty-four problems were described, clustered into 13 problem categories. Generally, middle managers focused on organizational factors and managerial responsibilities, whereas lower-level managers and staff focused on operational issues and what others did or ought to do. Furthermore, we observed similarities and variation in perceptions and their association with respondents' position within an organization. Our results support the need for further evaluation of the SPI as a promising tool for health care organizations. Collecting structured inventories of organizational and work-related problems from multiple perspectives may assist in the development of shared understandings of organizational challenges and lead to more effective and efficient processes of solution planning and implementation.

Outcomes associated with matching patients' treatment preferences to physicians' recommendations: study methodology.

BACKGROUND: Patients often express strong preferences for the forms of treatment available for their disease. Incorporating these preferences into the process of treatment decision-making might improve patients' adherence to treatment, contributing to better outcomes. We describe the methodology used in a study aiming to assess treatment outcomes when patients' preferences for treatment are closely matched to recommended treatments. METHOD: Participants included patients with moderate and severe psoriasis attending outpatient dermatology clinics at the University Medical Centre Mannheim, University of Heidelberg, Germany. A self-administered online survey used conjoint analysis to measure participants' preferences for psoriasis treatment options at the initial study visit. Physicians' treatment recommendations were abstracted from each participant's medical records. The Preference Matching Index (PMI), a measure of concordance between the participant's preferences for treatment and the physician's recommended treatment, was determined for each participant at t(1) (initial study visit). A clinical outcome measure, the Psoriasis Area and Severity Index, and two participant-derived outcomes assessing treatment satisfaction and health related quality of life were employed at t(1), t(2) (twelve weeks post-t(1)) and t(3) (twelve weeks post-t(2)). Change in outcomes was assessed using repeated measures analysis of variance. The association between participants' PMI scores at t(1) and outcomes at t(2) and t(3) was evaluated using multivariate regressions analysis. DISCUSSION: We describe methods for capturing concordance between patients' treatment preferences and recommended treatment and for assessing its association with specific treatment outcomes. The methods are intended to promote the incorporation of patients' preferences in treatment decision-making, enhance treatment satisfaction, and improve treatment effectiveness through greater adherence.

Cardiovascular and metabolic risk profile in German patients with moderate and severe psoriasis: a case control study.

Patients with psoriasis have a higher risk of cardiovascular and metabolic comorbidities, attributable to lifestyle factors, but also to shared inflammatory pathways and genetic factors. To investigate the association between moderate and severe psoriasis and metabolic and cardiovascular comorbidities, 100 patients hospitalized at University Medical Centre Mannheim, Germany, for psoriasis treatment were compared to two age- and sex-matched control groups, the first comprising other hospitalized patients (HCG) and the second comprising healthy individuals from an industrial cohort study (ICG). Multivariate logistic regression analysis with stepwise inclusion of cardiovascular risk factors was performed. Patients with psoriasis had significantly increased prevalences of smoking, obesity, diabetes, insulin resistance, pro-atherogenic cholesterol profiles and myocardial infarction and significantly decreased cardioprotective adiponectin. Unexpectedly, regression models controlling for confounding factors predicted significantly decreased OR for elevated total cholesterol in psoriasis cases (vs HCG: OR=0.50, p=0.045; vs ICG: OR=0.26, p=0.006). In contrast, OR for pro-atherogenic cholesterol profiles with LDL/HDL >3 was markedly increased (OR=2.45, p=0.012 or OR=3.02, p=0.020). Moreover, participants with psoriasis had significantly increased OR for elevated CRP as compared to the ICG (5.25, p=0.001). Our findings underscore the importance of cardiovascular and metabolic risk screening for all patients with moderate and severe psoriasis, including young patients.

Comparison of in-person and digital photograph assessment of stage III and IV pressure ulcers among veterans with spinal cord injuries.

Digital photographs are often used in treatment monitoring for home care of less advanced pressure ulcers. We investigated assessment agreement when stage III and IV pressure ulcers in individuals with spinal cord injury were evaluated in person and with the use of digital photographs. Two wound-care nurses assessed 31 wounds among 15 participants. One nurse assessed all wounds in person, while the other used digital photographs. Twenty-four wound description categories were applied in the nurses' assessments. Kappa statistics were calculated to investigate agreement beyond chance (p < or = 0.05). For 10 randomly selected "double-rated wounds," both nurses applied both assessment methods. Fewer categories were evaluated for the double-rated wounds, because some categories were chosen infrequently and agreement could not be measured. Interrater agreement with the two methods was observed for 12 of the 24 categories (50.0%). However, of the 12 categories with agreement beyond chance, agreement was only "slight" (kappa = 0-0.20) or "fair" (kappa = 0.21-0.40) for 6 categories. The highest agreement was found for the presence of undermining (kappa = 0.853, p < 0.001). Interrater agreement was similar to intramethod agreement (41.2% of the categories demonstrated agreement beyond chance) for the nurses' in-person assessment of the double-rated wounds. The moderate agreement observed may be attributed to variation in subjective perception of qualitative wound characteristics.

Toward more sustainable health care quality improvement in developing countries: the "little steps" approach.

BACKGROUND: Resource constraints are often identified as a hurdle to the sustainability of large-scale (national and regional) health care quality improvement (QI) programs in developing countries. However, poor fit of a QI model with a given country's context may present the greater challenge. METHODS: To explore contextual factors influencing the sustainability of large-scale QI initiatives in developing countries, we performed a systematic literature review. RESULTS: Large-scale initiatives appear to have received significant attention only recently in these settings, as priority was traditionally given to extending service coverage. Further, these initiatives often relied on QI models originating from developed country settings, which differed significantly from the systems, resource structures, culture, and values found in the target country. The QI programs frequently focused on high-impact/immediate change rather than on program sustainability. Barriers to sustainability were identified during the planning, start-up, and continuation phases. On the basis of our review, greater attention to sustainable methods for large-scale QI in developing countries is needed. CONCLUSION: We suggest a "Little Steps" approach that begins by defining QI concepts, goals, and processes in a manner congruent with the target setting and that builds upon existing systems, structures, and values. Despite immediate short-term needs, an approach emphasizing incremental QI achievements may be more effective in yielding sustainable improvements in health care quality at the national or regional level.

High-throughput ambulatory assessment of digital reactive hyperemia: concurrent validity with known cardiovascular risk factors and potential confounding.

OBJECTIVES: Reactive hyperemia index (RHI) measurement through digital peripheral arterial tonometry (PAT) is proposed for cardiovascular disease (CVD) risk screening. We evaluated the concurrent validity of RHI, measured in a high-throughput ambulatory setting, with known CVD risk factors and biomarkers. METHODS: PAT was included in the 2007 EADS/Augsburg (Germany) cohort follow-up. CVD risk factors (age, sex, hypertension, hyperlipidemia, diabetes, smoking, physical activity, prevalent coronary heart disease, family history, cholesterol, triglycerides, blood pressure (BP), waist-to-hip ratio (WHR)) and biomarkers (d-dimers, fibrinogen, log(c-reactive protein)) were assessed. The relationship between RHI and CVD risk factors and biomarkers was evaluated using multivariate linear regression, controlling for potential confounders (time of day, time since subject's last meal, baseline heart rate, examiner). RESULTS: Of 926 subjects approached, 710 underwent PAT and 603 (mean age 44.9+/-10 years, 88.7% men) with complete data were included for analysis. RHI was significantly related to being female (beta=0.128, p=0.02), low-density lipoprotein cholesterol (beta=-0.001, p=0.02), systolic BP (beta=0.007, p<0.001), WHR (beta=-1.04, p<0.01), time of day (beta=-0.011, p=0.04) and time since last meal (beta=0.013, p<0.01). CONCLUSIONS: Concurrent validity was partially demonstrated, while the need to control for potential confounding was reinforced. Participation was high and may be higher in less time-constrained settings.

Music programs designed to remedy burnout symptoms show significant effects after five weeks.

Earlier studies have demonstrated that music interventions can lessen symptoms of depression. Depression and burnout are closely related. We hypothesized that specially designed receptive music therapy programs and protocols might reduce the symptoms of burnout. In a four-arm randomized, placebo- and waiting-list-controlled double-blind study, including 150 participants, two specific music programs significantly reduced burnout symptoms after 5 weeks. The effects were maintained over a long time period. This newly developed method of receptive music therapy was also evaluated for the treatment of depression and dysthymia, with significant outcomes.

A one-item subjective work stress assessment tool is associated with cortisol secretion levels in critical care nurses.

BACKGROUND: Stress-related diseases are increasing in prevalence, with workplace interventions targeting stress receiving greater attention. Cortisol levels, a marker of physiological stress reaction, can be used to evaluate intervention effects, but measurement can be challenging to implement. Objective workload and subjective stress measures are alternatives previously related to cortisol secretion. We evaluated the validity of a one-item subjective stress measure based on its association with cortisol levels. METHODS: Eighty-two pediatric critical care nurses participated in a prospective cohort study in Switzerland between September 2004 and March 2005. Salivary cortisol samples were collected during three, nine-day periods. Sampling occurred at shift start, repeating every two hours. Subjective stress was recorded with each sample and at shift end. Objective workload for each shift and nursing unit was derived from the hospital's LEP Nursing Workload Management System. Multilevel regression models were employed in the analysis. RESULTS: Subjective stress, measured contemporaneously (beta=0.098, p=0.044), but not retrospectively (beta=0.012, p=0.556), was significantly related to increased cortisol secretion. Objective workload was not significantly associated with cortisol levels. CONCLUSIONS: The one-item summary measure of subjective work stress, administered contemporaneously,may be a valid tool for evaluation of workplace interventions. Future study is needed to establish reliability and generalizability

Measuring the effect of workplace health promotion interventions on "presenteeism": a potential role for biomarkers.

Health promotion activities to improve employee health to reduce health care costs and increase productivity are of particular importance for organizations and society. The evaluation of employee health and health promotion programs has typically focused on absenteeism, disability and increasingly, "presenteeism", which refers to an employee's presence at work with reduced performance due to illness. Existing psychometric measures of presenteeism may be subject to the effects of recall bias as they typically rely on questionnaires. Biomarkers such as heart rate variability and salivary cortisol can provide additional objective measures of illness and stress. Combining such physiologic measures of stress with assessments of presenteeism may offer a more comprehensive way to assess workplace productivity when developing health promotion programs.

Employees' sleep duration and body mass index: potential confounders.

OBJECTIVE: Productivity losses are associated with both employees' sleep and weight problems. Addressing these issues independently may be complicated by a potential link between sleep duration and weight. The mixed results of prior studies, both supporting and refuting an association between sleep duration and weight, may have been subject to missing variable bias. To clarify future strategies for workplace health promotion, possible confounders to the sleep duration/weight relationship were investigated. METHOD: Multivariate models were used to explore the relationship between self-reported average sleep duration and body mass index (BMI) by sequentially adding blocks of demographic, health behavior, work status, physical health, and emotional status variables. Cross-sectional data from the 2007 EADS/Augsburg (Germany) cohort follow-up study (n=1163) were used in the analysis. RESULTS: The relationship between average sleep duration and BMI was significant (beta(St)=-0.06, p=0.04) when demographic, health behavior, and work status variables were included. When physical health and emotional status variables were added, the relationship between sleep duration and BMI did not persist. CONCLUSION: The relationship between employees' sleep duration and weight, if present, involves several pathways and potential confounders that should be taken into account when designing workplace health promotion programs.

Data quality bias: an underrecognized source of misclassification in pay-for-performance reporting?

Pay-for-performance (P4P) initiatives, in which provider reimbursement is linked to quality assessment, are receiving increasing attention as a possible approach to encouraging and accelerating quality improvement in America's health care systems. The potential of P4P programs, however, is constrained by the quality of data and information resources available for performance reporting. Accurate and reliable appraisal of health care quality is a challenging issue, as achieving recommended processes of care and desired health outcomes is influenced by a diverse range of interrelated factors occurring at multiple levels and arising from multiple sources within the patient encounter, health care system, and larger environment. The challenge of quality assessment is further complicated by the variable quality of data available for reporting by each provider. When data quality varies systematically among providers, a significant risk of inequity in assessment, and therefore reimbursement under P4P programs, may occur. The issue of data quality should be investigated and addressed before widespread implementation of P4P programs is pursued. Significant investment in data collection and reporting mechanisms may be required, especially in resource-limited settings, to achieve the intended effects and avoid increasing disparities in health care quality.

Health state information derived from secondary databases is affected by multiple sources of bias.

OBJECTIVE: Secondary databases are used in descriptive studies of patient subgroups; evaluation of associations between individual characteristics and diagnosis, prognosis, and/or service utilization rates; and studies of the quality of health care delivered. This article identifies sources of bias for health state characteristics stored in secondary databases that arise from patients' encounters with health systems, highlighting sources of bias that arise from organizational and environmental factors. STUDY DESIGN AND SETTING: Potential sources of bias, from patient access of services and diagnosis, through encoding and filing of patient information in secondary databases, are discussed. A patient presenting with acute myocardial infarction is used as an illustrative example. RESULTS: The accuracy of health state characteristics derived from secondary databases is a function of both the quality and quantity of information collected before data entry and is dependent on complex interactions between patients, clinicians, and the structures and systems surrounding them. CONCLUSION: The use of health state information included in secondary databases requires that estimates of potential bias from all sources be included in the analysis and presentation of results. By making this common practice in the field, greater value can be achieved from secondary database analyses.

Portfolio evaluation of health programs: a reply to Sendi et al.

Sendi et al. (Soc. Sci. Med. 57 (2003) 2207) extend previous research on cost-effectiveness analysis to the evaluation of a portfolio of interventions with risky outcomes using a "second best" approach that can identify improvements in efficiency in the allocation of resources. This method, however, cannot be used to directly identify the optimal solution to the resource allocation problem. Theoretically, a stricter adherence to the foundations of portfolio theory would permit direct optimization in portfolio selection, however, when we include uncertainty in our analysis in addition to the traditional concept of risk (which is often mislabelled uncertainty) complexities are introduced that create significant hurdles in the development of practical applications of portfolio theory for health care policy decision making.