Childbirth-specific patient-reported outcomes as predictors of hospital satisfaction.

BACKGROUND: Under value-based payment programs, patient-reported experiences and outcomes can impact hospital and physician revenue. To enable obstetrical providers to improve the childbirth experience, a framework for understanding what women expect and desire during childbirth is needed. OBJECTIVE: The purpose of this study was to identify key predictors of childbirth hospital satisfaction with the use of the Childbirth Experiences Survey. STUDY DESIGN: This study builds on a larger effort that used Patient-Reported Outcomes Management Information System methods to develop a childbirth-specific preliminary patient-reported experiences and outcomes item bank. These efforts led to the development of an antepartum and postpartum survey (Childbirth Experiences Survey Parts 1 and 2). All phases of the study were conducted with the participation of a community-based research team. We conducted a prospective observational study using national survey response panels that was organized through Nielsen to identify women's antepartum values and preferences for childbirth (Childbirth Experiences Survey Part 1). Eligible participants were pregnant women in the United States (English or Spanish speaking) who were ≥18 years old and ≥20 weeks pregnant. Women were recontacted and invited to participate in a postpartum follow-up survey to collect information about their childbirth patient-reported experiences and outcomes, which included childbirth satisfaction (Childbirth Experiences Survey Part 2). In bivariate analyses, we tested whether predisposing conditions (eg, patient characteristics or previous experiences), values and preferences, patient-reported experiences and outcomes, and the "gaps" between values and preferences and patient-reported experiences and outcomes were predictors of women's satisfaction with hospital childbirth services. Multivariable logistic regression models were fitted to examine the simultaneous effect of predictors on hospital satisfaction, which were adjusted for key predisposing conditions. RESULTS: From 500 women who anticipated a vaginal delivery at the time of the antepartum survey, who labored before delivery, and who answered the postpartum survey, key findings included the following responses: (1) the strongest predictors of women's satisfaction with hospital childbirth services were items in the domains of staff communication, compassion, empathy, and respect, and (2) 23 childbirth-specific patient-reported experiences and outcomes were identified. Examples of these patient-reported experiences and outcomes (such as being told about progress in labor and being involved in decisions regarding labor pain management) appeared especially relevant to women who experienced childbirth. A final model that predicted women's satisfaction with hospital childbirth services included a total of 8 items that could be optimized by doctors, midwives, and hospitals. These included the patient's report of how well she coped with labor pain, whether the hospital provided adequate space and food for their support person, and whether she received practical support for feeding the newborn infant. CONCLUSION: This study identified 23 childbirth-specific patient-reported experiences and outcomes that were predictors of childbirth hospital satisfaction. The implementation of the Childbirth Experiences Survey Parts 1 and 2 in a multihospital setting may lead to the development of childbirth hospital performance measures and strategies for improvement of the childbirth experience.

A randomized, controlled trial of team-based competition to increase learner participation in quality-improvement education.

OBJECTIVE: Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum. DESIGN: Randomized, controlled trial. SETTING: Tertiary-care medical center residency training programs. PARTICIPANTS: Resident physicians (n = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (n = 200) or the control group (n = 222). INTERVENTION: Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants. MAIN OUTCOME MEASURES: Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework. RESULTS: Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD ± 32] versus control, 68% [SD ± 37], P= 0.03). Median response time was faster in the competition group (P= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each P< 0.001). CONCLUSIONS: Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.

Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care.

OBJECTIVE: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. STUDY DESIGN: We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). RESULTS: The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. CONCLUSION: Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.

Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals.

OBJECTIVE: The objective of the study was to describe the resources and activities associated with childbirth services. STUDY DESIGN: We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals). RESULTS: Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001). CONCLUSION: Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care.

Do laborists improve delivery outcomes for laboring women in California community hospitals?

OBJECTIVE: We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals. STUDY DESIGN: This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012. RESULTS: Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P < .0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate. CONCLUSION: We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction.

The prevalence of harmful and hazardous alcohol consumption in older U.S. adults: data from the 2005-2008 National Health and Nutrition Examination Survey (NHANES).

BACKGROUND: Alcohol consumption and its interaction with disease, medication use, and functional status may result in serious health problems, but little information exists about the national prevalence of alcohol-related health risk in older adults. OBJECTIVE: To estimate the prevalence of harmful and hazardous alcohol use and the prevalence of consumption in excess of National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommendations, in people aged 65 and older, and by sex and race/ethnicity sub-group. DESIGN: Cross-sectional, using data from the 2005-2008 National Health and Nutrition Examination Survey of the non-institutionalized U.S. population. PARTICIPANTS: One thousand and eighty-three respondents aged 65 and older who consume alcohol. MAIN MEASURES: Participants' alcohol consumption was classified as Harmful, Hazardous, or Healthwise, in the context of their specific health status, using the Alcohol-Related Problems Survey classification algorithm. KEY RESULTS: Overall, 14.5 % of older drinkers (95 % CI: 12.1 %, 16.8 %) consumed alcohol above the NIAAA's recommended limits. However, when health status was taken into account, 37.4 % of older drinkers (95 % CI: 34.9 %, 40.0 %) had Harmful consumption and 53.3 % (95 % CI: 50.1 %, 56.6 %) had either Hazardous or Harmful consumption. Among light/moderate drinkers, the proportions were 17.7 % (95 % CI: 14.7 %, 20.7 %) and 28.0 % (95 % CI: 24.8 %, 31.1 %), respectively. Male drinkers had significantly greater odds of Hazardous/Harmful consumption than female drinkers (OR = 2.14 [95 % CI: 1.77, 2.6]). Black drinkers had worse health status and significantly greater odds of Hazardous/Harmful consumption than white drinkers (OR = 1.49; 95 % CI: 1.02, 2.17), despite having no greater prevalence of drinking in excess of NIAAA-recommended limits. CONCLUSION: Most older Americans who drink are light/moderate drinkers, yet substantial proportions of such drinkers drink in a manner that is either harmful or hazardous to their health. Older adults with risky alcohol consumption are unlikely to be identified by health care providers if clinicians rely solely on whether patient consumption exceeds the NIAAA-recommended limits.

Impact of Comprehensive Health Insurance on Quality of Life in Low-Income Hispanic Men with Prostate Cancer.

OBJECTIVE: To evaluate the effect of the transition from IMPACT, a disease-focused treatment program, to comprehensive health insurance under Medicaid through the Affordable Care Act (ACA) on general and prostate cancer-specific quality of life (QoL) on a cohort of previously uninsured low-income men. We hypothesize that general QoL would improve and prostate cancer-specific QoL would remain the same after the transition to comprehensive health insurance. METHODS: We assessed and compared general QoL using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and prostate cancer-specific QoL using the UCLA PCI (Prostate Cancer Index) one year before, at, and one year after the transition between 30 men who transitioned to comprehensive insurance (newly insured/Medicaid group) and 54 men who remained in the prostate cancer program (uninsured/IMPACT group). We assessed the independent effects of Medicaid coverage on QoL outcomes using repeated-measures regression. RESULTS: Our cohort was composed primarily of Hispanic men (82%). At transition, patient demographics and clinical characteristics were similar between the groups. General and prostate cancer-specific QoL did not differ between the groups and remained stable over time, Radical prostatectomy as primary treatment and shorter time since treatment were associated with worse urinary and sexual function across both groups and over all three time points. CONCLUSION: Those who transitioned to full-scope insurance and those who remained in the free prostate cancer-focused treatment program had stable general and prostate cancer-specific QoL. High-touch navigation aspects of a disease-focused program may have contributed to stability in outcomes.

The role of self-efficacy in quality of life for disadvantaged men with prostate cancer.

PURPOSE: Self-efficacy is associated with increased participation in treatment decision making and improved health related quality of life. We examined the influence of perceived efficacy in patient-physician interactions on health related quality of life among low income, uninsured men with prostate cancer during a 2-year period. MATERIALS AND METHODS: We analyzed data derived on participants enrolled in a state funded program providing free prostate cancer treatment and care to indigent men. We used validated instruments to measure patient self-efficacy (confidence in interacting with physicians), and the general and prostate specific health related quality of life outcomes of urinary, sexual and bowel bother, symptom distress, psychological well-being and vitality. We performed repeated measures analysis with general linear mixed modeling to estimate the association of sociodemographic and clinical covariates with health related quality of life. RESULTS: Our cohort included a total of 472 observations in 99 men. Self-efficacy had a measurable effect on subjective measurements of general and disease specific health related quality of life. Men with the lowest self-efficacy had inferior mean health related quality of life scores across all outcomes. Low self-efficacy was significantly associated with worse bowel bother and general symptom distress during the 2-year study period. Similar health related quality of life outcomes trajectories were observed across self-efficacy categories. CONCLUSIONS: Of disadvantaged men with clinically localized prostate cancer those with the lowest self-efficacy in physician interactions fared worst across all measured domains of health related quality of life. Interventions to improve patient-physician communication in this population may provide physicians with a supplemental method by which to address health perceptions, mitigate symptom experience and improve health outcomes.

Blood center practice and education for blood donors with anemia.

BACKGROUND: Anemia is an early indicator of many diseases, yet blood donors with low hematocrit (Hct) often receive inadequate information about its medical importance. We sought to understand the types of information that are and should be provided to these donors. STUDY DESIGN AND METHODS: Two companion studies were performed. The first investigated blood center practices for care of donors with low Hct including deferral length, information provided, and cutoff values used when referring donors for medical attention. The second was a randomized prospective pilot study comparing behavior of deferred donors receiving an "older" pamphlet providing a list of iron-rich foods or a "newer" pamphlet providing descriptions of common causes of anemia and advice for seeking medical attention. RESULTS: More than 70% of centers defer donors for 1 day. Only 6% defer donors for more than 2 weeks. Most centers provide written and/or verbal information about low Hct. Only 35% have a cutoff value defining significant anemia that requires additional medical attention. In the study of donors with low Hct, significant disease was identified within 3 months after deferral in 2 of 104 subjects: metastatic lung cancer and acute lymphocytic leukemia. Only donors receiving the newer pamphlet reported that it "definitely improved" their ability to speak with their doctor about anemia. CONCLUSIONS: The diagnosis of anemia in blood donors may be an indicator of significant undiagnosed disease. There are wide variations in how centers care for and educate donors with anemia. Donors with anemia should be provided improved and consistent educational information.

Spirituality and end-of-life care in disadvantaged men dying of prostate cancer.

PURPOSE: Despite the positive influence of spiritual coping on the acceptance of a cancer diagnosis, higher spirituality is associated with receipt of more high intensity care at the end of life. The purpose of our study was to assess the association between spirituality and type of end-of-life care received by disadvantaged men with prostate cancer. METHODS: We studied low-income, uninsured men in IMPACT, a state-funded public assistance program, who had died since its inception in 2001. Of the 60 men who died, we included the 35 who completed a spirituality questionnaire at program enrollment. We abstracted sociodemographic and clinical information as well as treatment within IMPACT, including zolendroic acid, chemotherapy, hospice use, and palliative radiation therapy. We measured spirituality with the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being questionnaire (FACIT-Sp) and compared end-of-life care received between subjects with low and high FACIT-Sp scores using chi-squared analyses. RESULTS: A higher proportion of men with high (33%) versus low (13%) spirituality scores enrolled in hospice, although our analysis was not adequately powered to demonstrate statistical significance. Likewise, we saw a trend toward increased receipt of palliative radiation among those with higher spirituality (37% vs. 25%, P=0.69). The differences in end-of-life care received among those with low and high spirituality varied little by the FACIT-Sp peace and faith subscales. CONCLUSIONS: End-of-life care was similar between men with lower and higher spirituality. Men with higher spirituality trended toward greater hospice use, suggesting that they redirected the focus of their care from curative to palliative goals.

Community blood donors' knowledge of anemia and design of a literacy-appropriate educational intervention.

BACKGROUND: The purpose of this project is to improve the health of blood donors by educating and motivating them to seek medical attention for anemia. The National Anemia Action Council, BloodCenter of Wisconsin, and the Medical College of Wisconsin formed a partnership to engage volunteer blood donors and develop an educational intervention to motivate donors with anemia to seek appropriate medical care. STUDY DESIGN AND METHODS: Partners developed an educational pamphlet and conducted two focus groups with volunteer blood donors for feedback. Participants were recruited from volunteer donors at BloodCenter of Wisconsin found to have anemia (men age, 18 years and older with a hematocrit [Hct] level of <38%; women age 50 years and older with a Hct level of <36%) at blood screening before donation. RESULTS: Participants (n = 25) addressed their understanding of anemia, information they received after being deferred, their reactions about the deferral, and comments on the educational material. The educational pamphlet was revised based on focus group comments. CONCLUSION: Volunteer donors are extremely dedicated and interested in increasing their understanding of anemia and the ability to continue donation. Community members' feedback on educational material is a valuable resource to improve the literacy level of information.

Caring for the Uninsured with Prostate Cancer: A Comparison of Four Policy Alternatives in California.

The IMPACT Program seeks to improve access to prostate cancer care for low-income, uninsured men. The objective of the current study was to compare the cost-effectiveness of four policy alternatives in treating this population. We analyzed the cost-effectiveness of four policy alternatives for providing care to low-income, uninsured men with prostate cancer: (1) IMPACT as originally envisioned, (2) a version of IMPACT with reduced physician fees, (3) a hypothetical Medicaid prostate cancer treatment program, and (4) the existing county safety net. We calculated cost-effectiveness based on incremental cost-effectiveness ratios (ICERs) with the formula ICER = (Cost(alternative strategy) - Cost(baseline strategy)) / (QALY(alternative strategy) - QALY(baseline strategy)). We measured outcomes as quality-adjusted life years (QALYs). "Best-case" scenarios assumed timely access to care in 50% of cases in the county system and 70% of cases in any system that reimbursed providers at Medicaid fee-for-service rates. "Worst-case" scenarios assumed timely access in 35 and 50% of corresponding cases. In fiscal year 2004-2005, IMPACT allocated 11% of total expenditures to administrative functions and 23% to fixed clinical costs, with an overall budget of $5.9 million. The ICERs ($/QALY) assuming "best-case" scenarios for original IMPACT, modified IMPACT, and a hypothetical Medicaid program were $32,091; $64,663; and $10,376; respectively. ICERs assuming "worst-case" scenarios were $27,189; $84,236; and $10,714; respectively. County safety net was used as a baseline. In conclusion, IMPACT provides underserved Californians with prostate cancer care and value-added services with only 11% of funds allocated to administrative fixed costs. Both the original IMPACT program and the hypothetical Medicaid prostate cancer program were cost-effective compared to the county safety net, while the reduced-fees version of IMPACT was not.

Developing quality indicators for elderly surgical patients.

OBJECTIVE: To develop process-based quality indicators to improve perioperative care for elderly surgical patients. BACKGROUND: The population is aging and expanding, and physicians must continue to optimize elderly surgical care to meet the anticipated increase in surgical services. We sought to develop process-based quality indicators applicable to virtually all disciplines of surgery to identify necessary and meaningful ways to improve surgical care and outcomes in the elderly. METHODS: We identified candidate perioperative quality indicators for elderly patients undergoing ambulatory, or major elective or nonelective inpatient surgery through structured interviews with thought leaders and systematic reviews of the literature. An expert panel of physicians in surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology. RESULTS: Ninety-one of 96 candidate indicators were rated as valid. They were categorized into 8 domains: comorbidity assessment, elderly issues, medication use, patient-provider discussions, intraoperative care, postoperative management, discharge planning, and ambulatory surgery. Of note, 71 (78%) of the indicators rated as valid address processes of care not routinely performed in younger surgical populations. CONCLUSIONS: Attention to the quality of care in elderly patients is of great importance due to the increasing numbers of elderly undergoing surgery. This project used a validated methodology to identify and rate process measures to achieve high quality perioperative care for elderly surgical patients.

Hospice and emergency room use by disadvantaged men dying of prostate cancer.

PURPOSE: Hospice care has been found to improve symptom management, quality of death and quality of life at the end of life. We describe hospice use by a cohort of low income, uninsured men with prostate cancer enrolled in a public assistance program. We ascertained whether hospice enrollment was associated with a decrease in the number of prostate cancer related emergency room visits made before death. MATERIALS AND METHODS: We studied all 57 low income, uninsured men in a public assistance program who had died since its inception in 2001. The association between sociodemographic and clinical data, and hospice enrollment data were evaluated. RESULTS: The overall rate of hospice use was 28% (16 of 57 patients). The mean +/- SD duration of hospice enrollment before death was 44 +/- 43 days (median 34, range 2 to 143). Two patients (12%) were enrolled fewer than 7 days and none were enrolled more than 180 days. Prostate cancer related emergency room visits, adjuvant chemotherapy treatment, evidence of metastasis at initial presentation and death from prostate cancer were significantly associated with hospice use (p <0.05). We noted a trend toward fewer mean emergency room visits made by men enrolled in hospice care than by those not enrolled (0.7 +/- 1.3 vs 1.1 +/- 0.9, p = 0.15). CONCLUSIONS: Hospice use and the duration of enrollment by low income, uninsured men dying of prostate cancer was comparable to previously reported hospice use by insured individuals. Hospice enrollment was associated with fewer prostate cancer related emergency room visits.

Spirituality and quality of life in low-income men with metastatic prostate cancer.

OBJECTIVE: To determine how spirituality is associated with health-related quality of life (HRQOL) in an ethnically diverse cohort of low-income men with metastatic prostate cancer. METHODS: Eighty-six participants in a state-funded program that provides free prostate cancer treatment to uninsured, low-income men completed written surveys and telephone interviews containing validated measures of spirituality, and general and disease-specific HRQOL. Assessments were made following diagnosis of metastatic disease. We used multivariate analyses to assess the effect of spirituality and its two subscales, faith and meaning/peace, on HRQOL. RESULTS: African American and Latino men, and men with less than a high-school education had the highest spirituality scores. Spirituality was significantly associated with general and disease-specific HRQOL. We also found a significant interaction between faith and meaning/peace in the physical and pain domains. CONCLUSION: Greater spirituality was associated with better HRQOL and psychosocial function. Meaning/peace closely tracks with HRQOL. Higher faith scores, in the absence of high meaning/peace scores, are negatively associated with HRQOL.

Identifying organizational capacities and incentives for clinical data-sharing: the case of a regional perinatal information system.

The development of regional data-sharing among healthcare organizations is viewed as an important step in the development of health information technology (HIT), but little is known about this complex task. This is a case study of a regional perinatal data system that involved four hospitals, together responsible for over 10,000 births annually. Using standard qualitative methods, we chronicled project milestones, and identified 31 "critical incidents" that delayed or prevented their achievement. We then used these critical incidents to articulate six organizational capacity domains associated with the achievement of project milestones, and a seventh domain consisting of organizational incentives. Finally, we analyzed the relationship of milestone achievement to the presence of these capacities and incentives. This data center case suggests four requirements for sharing data across organizations: 1) a readiness assessment; 2) a perceived mandate; 3) a formal governance structure; and 4) a third party IT component.

Vaginal birth after cesarean: clinical risk factors associated with adverse outcome.

OBJECTIVE: The objective of the study was to identify vaginal birth after cesarean (VBAC) success rates and maternal and neonatal complication rates for selected antenatal conditions. STUDY DESIGN: This was a population-based cohort study using administrative discharge data for women delivering in California hospitals during 2002. RESULTS: Among 41,450 women, 29.72% (12,320 of 41,450) had maternal, fetal, or placental conditions complicating pregnancy. Attempted VBAC rates and VBAC success rates varied widely by these clinical condition, ranging from 10% to 73%. The VBAC success rate for low-risk women (no conditions) was 73.76% vs 50.31% for high-risk women (at least 1 condition), P < .0001. Absolute rates of maternal and neonatal complications were low (less than 1-2%), and the rate of adverse events was higher in the high-risk clinical group as compared with the low-risk clinical group. CONCLUSION: Variation in rates of VBAC success and childbirth morbidities can be partially attributed to clinical factors complicating pregnancy. Women without such conditions show improved VBAC success and fewer maternal and neonatal complications.

Longitudinal quality of life in low-income men in a state-funded prostate cancer treatment program.

OBJECTIVES: To evaluate longitudinal changes in disease-specific health-related quality of life (HRQOL) among a cohort of low-income men treated for prostate cancer. METHODS: Three hundred fifty-seven participants in a state-funded program that provides free prostate cancer treatment to uninsured, low-income men completed written surveys and telephone interviews containing validated measures of general and disease-specific HRQOL. Assessments were made at study enrollment and at subsequent times. Determinants of change were identified with repeated-measures analyses. RESULTS: We found a significant interaction between the acute surgical treatment effects and time of assessment. Men exposed longer to the program's supportive and educational interventions reported less severe declines in post-operative urinary and bowel HRQOL than others. CONCLUSIONS: Demographic covariates predicted general and disease-specific domains of HRQOL. Among patients treated with surgery, longer duration of pre-treatment program enrollment was associated with better outcomes.

Practical Considerations for Using Online Methods to Engage Patients in Guideline Development.

Clinical practice guidelines (CPGs) have been widely used in healthcare policy, practice, and for suggesting future research. As patients increasingly become involved in CPG development to produce patient-centered recommendations, more research is needed on methods to engage patients, particularly methods allowing for scalable engagement of large, diverse, and geographically distributed groups of patients. In this article, we discuss practical considerations for using online methods to engage patients in CPG development. To inform this discussion, we conducted a rapid, systematic review of literature on patient involvement in CPG development and used qualitative evidence synthesis techniques to make inferences about potential advantages and challenges of using online methods to engage patients in this context. We identified 79 articles containing information about involving patients in CPG development. Potential advantages include the ability of online methods to facilitate greater openness and honesty by patients, as well as to reflect the diversity of patient views, which in turn further improve the utility of CPGs. Potential challenges of using online methods may include the extra skill, time, and certain types of resources that may be needed for patient engagement, as well as the difficulty engaging specific patient populations. However, these challenges are mitigated by growing calls for patient engagement as normative for CPG development in addition to patients' increasing familiarity with online technologies. These practical considerations should be examined empirically as guideline development groups further explore the appropriateness of using online methods to engage patients across different stages of CPG development.

The Development of a Conceptual Framework and Preliminary Item Bank for Childbirth-Specific Patient-Reported Outcome Measures.

OBJECTIVE: To develop a conceptual framework and preliminary item bank for childbirth-specific patient-reported outcome (PRO) domains. DATA SOURCES: Women, who were U.S. residents, ≥18 years old, and ≥20 weeks pregnant, were surveyed regarding their childbirth values and preferences (V&P) using online panels. STUDY DESIGN: Using community-based research techniques and Patient-Reported Outcomes Management Information System (PROMIS® ) methodology, we conducted a comprehensive literature review to identify self-reported survey items regarding patient-reported V&P and childbirth experiences and outcomes (PROs). The V&P/PRO domains were validated by focus groups. We conducted a cross-sectional observational study and fitted a multivariable logistic regression model to each V&P item to describe "who" wanted each item. PRINCIPAL FINDINGS: We identified 5,880 V&P/PRO items that mapped to 19 domains and 58 subdomains. We present results for the 2,250 survey respondents who anticipated a vaginal delivery in a hospital. Wide variation existed regarding each V&P item, and personal characteristics, such as maternal confidence and ability to cope well with pain, were frequent predictors in the models. The resulting preliminary item bank consisted of 60 key personal characteristics and 63 V&P/PROs. CONCLUSIONS: The conceptual framework and preliminary (PROMIS® ) item bank presented here provide a foundation for the development of childbirth-specific V&P/PROs.