Variations in definitions of mortality have little influence on neonatal intensive care unit performance ratings.

OBJECTIVE: To measure the influence of varying mortality time frames on performance rankings among regional neonatal intensive care units (NICUs) in a large state. STUDY DESIGN: We performed a cross-sectional data analysis of very low birth weight infants receiving care at 24 level 3 NICUs. We tested the effect of 4 definitions of mortality: (1) death between admission and end of birth hospitalization or up to 366 days; (2) death between 12 hours of age and the end of birth hospitalization or up to 366 days; (3) death between admission and 28 days; and (4) death between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and dividing them into 3 tiers: top 6, bottom 6, and in between. RESULTS: There was wide interinstitutional variation in risk-adjusted mortality for each definition (observed minus expected z-score range, -6.08 to 3.75). However, mortality-based NICU rankings and classification into performance tiers were very similar for all institutions in each of our time frames. Among all 4 definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier. CONCLUSION: The time frame used to ascertain mortality had little effect on comparative NICU performance.

Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial.

IMPORTANCE: Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. OBJECTIVE: To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). INTERVENTIONS: Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. MAIN OUTCOMES AND MEASURES: Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. RESULTS: Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. CONCLUSIONS AND RELEVANCE: Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00302718.

Effectiveness of an electronic health record-based intervention to improve follow-up of abnormal pathology results: a retrospective record analysis.

BACKGROUND AND OBJECTIVE: On March 11, 2009, the Veterans Health Administration (VA) implemented an electronic health record (EHR)-based intervention that required all pathology results to be transmitted to ordering providers by mandatory automated notifications. We examined the impact of this intervention on improving follow-up of abnormal outpatient pathology results. RESEARCH DESIGN AND SUBJECTS: We extracted pathology reports from the EHR of 2 VA sites. From 16,738 preintervention and 17,305 postintervention reports between 09/01/2008 and 09/30/2009, we randomly selected about 5% and evaluated follow-up outcomes using a standardized chart review instrument. Documented responses to the alerted report (eg, ordering follow-up tests or referrals, notifying patients, and prescribing/changing treatment) were recorded. MEASURES: Primary outcome measures included proportion of timely follow-up responses (within 30 d) and median time to direct response for abnormal reports. RESULTS: Of 816 preintervention and 798 postintervention reports reviewed, 666 (81.6%) and 688 (86.2%) were abnormal. Overall, there was no apparent intervention effect on timely follow-up (69% vs. 67.1%; P=0.4) or median time to direct response (8 vs. 8 d; P=0.7). However, logistic regression uncovered a significant intervention effect (preintervention odds ratio, 0.7; 95% confidence interval, 0.5-1.0) after accounting for site-specific differences in follow-up, with a lower likelihood of timely follow-up at one site (odds ratio, 0.4; 95% confidence interval, 0.2-0.7). CONCLUSIONS: An electronic intervention to improve test result follow-up at 2 VA institutions using the same EHR was found effective only after accounting for certain local contextual factors. Aggregating the effect of EHR interventions across different institutions and EHRs without controlling for contextual factors might underestimate their potential benefits.

Institutional, provider, and patient correlates of low-density lipoprotein and non-high-density lipoprotein cholesterol goal attainment according to the Adult Treatment Panel III guidelines.

BACKGROUND: The aim of this analysis was to identify the proportion of coronary heart disease (CHD) patients achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goals and to identify correlates of dual goal attainment. METHODS: We analyzed patient, provider, and facility characteristics for 21,801 CHD patients in one Veterans Affairs Hospitals Network. RESULTS: Low-density lipoprotein cholesterol goal attainment was 80%, but optional LDL-C goal attainment was 41%. Of patients with triglycerides ≥200 mg/dL, 51% attained both LDL-C and non-HDL-C goals. Correlates of higher dual goal attainment included older age (65-74 years: odds ratio [OR] 1.47, 95% CI 1.28-1.69), diabetes (OR 1.33, 95% CI 1.16-1.53), obesity (OR 1.25, 95% CI 1.04-1.50), a higher number of primary care visits (OR 1.04, 95% CI 1.04-1.05), and mild increase in illness severity of patients in provider's panel (OR 1.20, 95% CI 1.0008-1.46), whereas African American patients were less likely to achieve dual lipid goals (OR 0.63, 95% CI 0.48-0.82). Receipt of care from physician (vs nonphysician) or specialist (vs primary care) provider, number of patients in provider's panel, and percentage of patients in provider's panel with diagnosis of hyperlipidemia were not associated with dual goal attainment. CONCLUSIONS: A large proportion of CHD patients attained LDL-C goal, but optional LDL-C goal attainment was low. Patients with elevated triglycerides had poor attainment of dual LDL-C and non-HDL-C goals, suggesting a treatment gap. Factors associated with dual goal attainment may identify interventions needed to improve future guideline adherence.

Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients?

BACKGROUND: There is concern that performance measures, patient ratings of their care, and pay-for-performance programs may penalize healthcare providers of patients with multiple chronic coexisting conditions. We examined the impact of coexisting conditions on the quality of care for hypertension and patient perception of overall quality of their health care. METHODS AND RESULTS: We classified 141 609 veterans with hypertension into 4 condition groups: those with hypertension-concordant (diabetes mellitus, ischemic heart disease, dyslipidemia) and/or -discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions or neither. We measured blood pressure control at the index visit, overall good quality of care for hypertension, including a follow-up interval, and patient ratings of satisfaction with their care. Associations between condition type and number of coexisting conditions on receipt of overall good quality of care were assessed with logistic regression. The relationship between patient assessment and objective measures of quality was assessed. Of the cohort, 49.5% had concordant-only comorbidities, 8.7% had discordant-only comorbidities, 25.9% had both, and 16.0% had none. Odds of receiving overall good quality after adjustment for age were higher for those with concordant comorbidities (odds ratio, 1.78; 95% confidence interval, 1.70 to 1.87), discordant comorbidities (odds ratio, 1.32; 95% confidence interval, 1.23 to 1.41), or both (odds ratio, 2.25; 95% confidence interval, 2.13 to 2.38) compared with neither. Findings did not change after adjustment for illness severity and/or number of primary care and specialty care visits. Patient assessment of quality did not vary by the presence of coexisting conditions and was not related to objective ratings of quality of care. CONCLUSIONS: Contrary to expectations, patients with greater complexity had higher odds of receiving high-quality care for hypertension. Subjective ratings of care did not vary with the presence or absence of comorbid conditions. Our findings should be reassuring to those who care for the most medically complex patients and are concerned that they will be penalized by performance measures or patient ratings of their care.

Comparing self-reported health status and diagnosis-based risk adjustment to predict 1- and 2 to 5-year mortality.

OBJECTIVES: To compare the ability of two diagnosis-based risk adjustment systems and health self-report to predict short- and long-term mortality. DATA SOURCES/STUDY SETTING: Data were obtained from the Department of Veterans Affairs (VA) administrative databases. The study population was 78,164 VA beneficiaries at eight medical centers during fiscal year (FY) 1998, 35,337 of whom completed an 36-Item Short Form Health Survey for veterans (SF-36V) survey. STUDY DESIGN: We tested the ability of Diagnostic Cost Groups (DCGs), Adjusted Clinical Groups (ACGs), SF-36V Physical Component score (PCS) and Mental Component Score (MCS), and eight SF-36V scales to predict 1- and 2-5 year all-cause mortality. The additional predictive value of adding PCS and MCS to ACGs and DCGs was also evaluated. Logistic regression models were compared using Akaike's information criterion, the c-statistic, and the Hosmer-Lemeshow test. PRINCIPAL FINDINGS: The c-statistics for the eight scales combined with age and gender were 0.766 for 1-year mortality and 0.771 for 2-5-year mortality. For DCGs with age and gender the c-statistics for 1- and 2-5-year mortality were 0.778 and 0.771, respectively. Adding PCS and MCS to the DCG model increased the c-statistics to 0.798 for 1-year and 0.784 for 2-5-year mortality. CONCLUSIONS: The DCG model showed slightly better performance than the eight-scale model in predicting 1-year mortality, but the two models showed similar performance for 2-5-year mortality. Health self-report may add health risk information in addition to age, gender, and diagnosis for predicting longer-term mortality.

Impact of a Pay-for-Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act.

OBJECTIVE: Evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black patients and determine whether it produced risk selection. DATA SOURCE/STUDY SETTING: Primary data collected between 2007 and 2009 from Veterans Affairs physicians and their primary care panels. STUDY DESIGN: Nested study within a cluster randomized controlled trial of three types of financial incentives and no incentives (control). We compared the proportion of physicians' black patients meeting hypertension performance measures for baseline and final performance periods. We measured risk selection by comparing the proportion of patients who switched providers, patient visit frequency, and panel turnover. Due to limited power, we prespecified in the analysis plan combining the three incentive groups and oversampling black patients. DATA COLLECTION/EXTRACTION METHOD: Data collected electronically and by chart review. PRINCIPAL FINDINGS: The proportion of black patients who achieved blood pressure control or received an appropriate response to uncontrolled blood pressure in the final period was 6.3 percent (95 percent confidence interval, 0.8-11.7 percent) greater for physicians who received an incentive than for controls. There was no difference between intervention and controls in the proportion of patients who switched providers, visit frequency, or panel turnover. CONCLUSIONS AND RELEVANCE: A pay-for-performance intervention improved blood pressure control or appropriate response to uncontrolled blood pressure in black patients and did not produce risk selection.

Prevalence of comorbid hypertension and dyslipidemia and associated cardiovascular disease.

OBJECTIVES: To estimate the prevalence of concurrent hypertension and dyslipidemia among a general veteran population and separately among patients with diabetes mellitus, and to compare the prevalence of cardiovascular disease among groups with isolated versus concurrent hypertension and dyslipidemia. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: This study was conducted in 6 medical centers of the Department of Veterans Affairs and included 371221 patients seen for any reason from October 1, 1998, to September 30, 2001. The proportion of patients with isolated or concurrent hypertension and dyslipidemia was estimated based on diagnostic, pharmacy, laboratory, and vital sign information, and the age-adjusted proportions of individuals with cardiovascular disease were compared between groups. RESULTS: We found that 57.8% of all patients had hypertension or dyslipidemia; 30.7% had both. Sixteen percent of all patients had diabetes mellitus, and 66.3% of these patients had concomitant hypertension and dyslipidemia. The prevalence of coronary artery disease was often more than doubled among patients with concomitant conditions compared with patients with either condition alone. The prevalence of stroke and peripheral arterial disease similarly increased among patients with both conditions. The prevalence of these cardiovascular diseases was highest among patients with diabetes mellitus. CONCLUSION: The prevalence of cardiovascular disease was high among this population of older, predominately male US veterans.

Aspirin use in advanced uncontrolled glaucoma.

PURPOSE: To evaluate if aspirin use affects progression of primary open angle glaucoma (POAG). METHODS: A retrospective review of patients with uncontrolled glaucoma was performed. Incidence of aspirin use was noted by a one-time self-reporting survey. Controls were medically stable patients diagnosed with POAG. The primary outcome measure studied was a comparison of percentages of aspirin use in patients who have and have not undergone glaucoma filtering surgery (trabeculectomy). RESULTS: Forty-one percent (26/64) of the patients in the trabeculectomy group and 23% (17/74) of controls were using aspirin. Patients undergoing trabeculectomy were twice as likely to take aspirin (O.R., 2.29; 95% C.I., 1.10-4.79). Subgroup analyses demonstrated increased aspirin use in those operative patients who are current or former smokers (O.R., 3.71; 95% C.I., 1.10-12.56), have systemic hypertension (O.R., 3.30; 95% C.I., 1.02-22.58), or have joint disease (O.R., 4.60; 95% C.I., 1.34-15.82). CONCLUSION: A higher concurrence of aspirin use was observed in patients with POAG who required surgical management compared with patients having relatively medically stable glaucoma. This may be secondary to a higher rate of glaucoma surgery performed on patients with greater systemic illnesses, more of whom use aspirin.

Baby-MONITOR: a composite indicator of NICU quality.

BACKGROUND AND OBJECTIVES: NICUs vary in the quality of care delivered to very low birth weight (VLBW) infants. NICU performance on 1 measure of quality only modestly predicts performance on others. Composite measurement of quality of care delivery may provide a more comprehensive assessment of quality. The objective of our study was to develop a robust composite indicator of quality of NICU care provided to VLBW infants that accurately discriminates performance among NICUs. METHODS: We developed a composite indicator, Baby-MONITOR, based on 9 measures of quality chosen by a panel of experts. Measures were standardized, equally weighted, and averaged. We used the California Perinatal Quality Care Collaborative database to perform across-sectional analysis of care given to VLBW infants between 2004 and 2010. Performance on the Baby-MONITOR is not an absolute marker of quality but indicates overall performance relative to that of the other NICUs. We used sensitivity analyses to assess the robustness of the composite indicator, by varying assumptions and methods. RESULTS: Our sample included 9023 VLBW infants in 22 California regional NICUs. We found significant variations within and between NICUs on measured components of the Baby-MONITOR. Risk-adjusted composite scores discriminated performance among this sample of NICUs. Sensitivity analysis that included different approaches to normalization, weighting, and aggregation of individual measures showed the Baby-MONITOR to be robust (r = 0.89-0.99). CONCLUSIONS: The Baby-MONITOR may be a useful tool to comprehensively assess the quality of care delivered by NICUs.

Correlation of neonatal intensive care unit performance across multiple measures of quality of care.

OBJECTIVES: To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance. DESIGN: We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations. SETTING: Twenty-two regional NICUs in California. PATIENTS: In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007. MAIN OUTCOMES MEASURES: Pneumothorax, growth velocity, health care-associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk. RESULTS: The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations, 6 were significant (ρ < .05). Correlations between pairs of measures of quality of care were strong (ρ ≥ .5) for 1 pair, moderate (range, ρ ≥ .3 to ρ < .5) for 8 pairs, weak (range, ρ ≥ .1 to ρ < .3) for 5 pairs, and negligible (ρ < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care-associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4. CONCLUSION: In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.

Correlates of repeat lipid testing in patients with coronary heart disease.

IMPORTANCE: Understanding the frequency and correlates of redundant lipid testing could identify areas for quality improvement initiatives aimed at improving the efficiency of cholesterol care in patients with coronary heart disease (CHD). OBJECTIVE: To determine the frequency and correlates of repeat lipid testing in patients with CHD who attained low-density lipoprotein cholesterol (LDL-C) goals and received no treatment intensification. DESIGN, SETTING, AND PARTICIPANTS: We assessed the proportion of patients with LDL-C levels of less than 100 mg/dL and no intensification of lipid-lowering therapy who underwent repeat lipid testing during an 11-month follow-up period. We performed logistic regression analyses to evaluate facility, provider, and patient characteristics associated with repeat testing. In total, we analyzed 35,191 patients with CHD in a Veterans Affairs network of 7 medical centers with associated community-based outpatient clinics. MAIN OUTCOMES AND MEASURES: Frequency and correlates of repeat lipid testing in patients having CHD with LDL-C levels of less than 100 mg/dL and no further treatment intensification with lipid-lowering therapies. RESULTS: Of 27,947 patients with LDL-C levels of less than 100 mg/dL, 9200 (32.9%) had additional lipid assessments without treatment intensification during the following 11 months (12 ,686 total additional panels; mean, 1.38 additional panel per patient). Adjusting for facility-level clustering, patients with a history of diabetes mellitus (odds ratio [OR], 1.16; 95% CI, 1.10-1.22), a history of hypertension (OR, 1.21; 95% CI, 1.13-1.30), higher illness burden (OR, 1.39; 95% CI, 1.23-1.57), and more frequent primary care visits (OR, 1.32; 95% CI, 1.25-1.39) were more likely to undergo repeat testing, whereas patients receiving care at a teaching facility (OR, 0.74; 95% CI, 0.69-0.80) or from a physician provider (OR, 0.93; 95% CI, 0.88-0.98) and those with a medication possession ratio of 0.8 or higher (OR, 0.75; 95% CI, 0.71-0.80) were less likely to undergo repeat testing. Among 13,114 patients who met the optional LDL-C target level of less than 70 mg/dL, repeat lipid testing was performed in 8177 (62.4% of those with LDL-C levels of <70 mg/dL) during 11 follow-up months. CONCLUSIONS AND RELEVANCE: One-third of patients having CHD with LDL-C levels at goal underwent repeat lipid panels. Our results highlight areas for quality improvement initiatives to reduce redundant lipid testing. These efforts would be more important if the forthcoming cholesterol guidelines adopt a medication dose-based approach in place of the current treat-to-target approach.

Financial incentives and physician commitment to guideline-recommended hypertension management.

OBJECTIVES: To examine the impact of financial incentives on physician goal commitment to guideline-recommended hypertension care. STUDY DESIGN: Clinic-level cluster-randomized trial with 4 arms: individual, group, or combined incentives, and control. METHODS: A total of 83 full-time primary care physicians at 12 Veterans Affairs medical centers completed web-based surveys measuring their goal commitment to guideline-recommended hypertension care every 4 months and telephone interviews at months 8 and 16. Intervention arm participants received performance-based incentives every 4 months for 5 periods. All participants received guideline education at baseline and audit and feedback every 4 months. RESULTS: Physician goal commitment did not vary over time or across arms. Participants reported patient nonadherence was a perceived barrier and consistent follow-up was a perceived facilitator to successful hypertension care, suggesting that providers may perceive hypertension management as more of a patient responsibility (external locus of control). CONCLUSIONS: Financial incentives may constitute an insufficiently strong intervention to influence goal commitment when providers attribute performance to external forces beyond their control.

Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol.

BACKGROUND: Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens. METHODS/DESIGN: This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period. DISCUSSION: We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements. TRIAL REGISTRATION: http://www.clinicaltrials.govNCT00302718.

A randomized controlled trial of acupuncture for osteoarthritis of the knee: effects of patient-provider communication.

OBJECTIVE: There is conflicting evidence on the efficacy of traditional Chinese acupuncture (TCA), and the role of placebo effects elicited by acupuncturists' behavior has not been elucidated. We conducted a 3-month randomized clinical trial in patients with knee osteoarthritis to compare the efficacy of TCA with sham acupuncture and to examine the effects of acupuncturists' communication styles. METHODS: Acupuncturists were trained to interact in 1 of 2 communication styles: high or neutral expectations. Patients were randomized to 1 of 3 style groups, waiting list, high, or neutral, and nested within style, TCA or sham acupuncture twice a week over 6 weeks. Sham acupuncture was performed in nonmeridian points with shallow needles and minimal stimulation. Primary outcome measures were Joint-Specific Multidimensional Assessment of Pain (J-MAP), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and satisfaction scores. RESULTS: Patients (n = 455) received treatment (TCA or sham) and 72 controls were included. No statistically significant differences were observed between TCA or sham acupuncture, but both groups had significant reductions in J-MAP (-1.1, -1.0, and -0.1, respectively; P < 0.001) and WOMAC pain (-13.7, -14, and -1.7, respectively; P < 0.001) compared with the waiting group. Statistically significant differences were observed in J-MAP pain reduction and satisfaction, favoring the high expectations group. In the TCA and sham groups, 52% and 43%, respectively, thought they had received TCA (κ = 0.05), suggesting successful blinding. CONCLUSION: TCA was not superior to sham acupuncture. However, acupuncturists' styles had significant effects on pain reduction and satisfaction, suggesting that the analgesic benefits of acupuncture can be partially mediated through placebo effects related to the acupuncturist's behavior.

Errors of diagnosis in pediatric practice: a multisite survey.

OBJECTIVE: We surveyed pediatricians to elicit their perceptions regarding frequency, contributing factors, and potential system- and provider-based solutions to address diagnostic errors. METHODS: Academic, community, and trainee pediatricians (N = 1362) at 3 tertiary care institutions and 109 affiliated clinics were invited to complete the survey anonymously through an Internet survey administration service between November 2008 and May 2009. RESULTS: The overall response rate was 53% (N = 726). More than one-half (54%) of respondents reported that they made a diagnostic error at least once or twice per month; this frequency was markedly higher (77%) among trainees. Almost one-half (45%) of respondents reported diagnostic errors that harmed patients at least once or twice per year. Failure to gather information through history, physical examination, or chart review was the most-commonly reported process breakdown, whereas inadequate care coordination and teamwork was the most-commonly reported system factor. Viral illnesses being diagnosed as bacterial illnesses was the most-commonly reported diagnostic error, followed by misdiagnosis of medication side effects, psychiatric disorders, and appendicitis. Physicians ranked access to electronic health records and close follow-up of patients as strategies most likely to be effective in preventing diagnostic errors. CONCLUSION: Pediatricians reported making diagnostic errors relatively frequently, and patient harm from these errors was not uncommon.

Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans.

OBJECTIVE: To determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics. DATA SOURCES/STUDY SETTING: Department of Veterans Affairs. STUDY DESIGN: We examined reliance on the VA for inpatient, outpatient, and overall medical care among all VA users in fiscal years 2003 and 2004 who were also enrolled in Medicare. We calculated the marginal effects of patient factors on VA reliance using fractional logistic regression; we also analyzed overall VA reliance separately for under-65 and age-65+ groups. The primary focus of this analysis was the relationship between aggregated condition categories (ACCs), which represent medical conditions, and reliance on the VA. PRINCIPAL FINDINGS: Mean VA reliance was significantly higher in the under-65 population than in the age-65+ group (0.800 versus 0.531). Lower differential distance to the VA, and higher VA-determined priority for health care, predicted higher VA reliance. Most individual ACCs were negatively associated with VA reliance, though substance abuse and mental health disorders were significantly associated with increased reliance on VA care. Conditions of the eyes and ears/nose/throat had positive marginal effect on VA reliance for the under 65, while diabetes was positive for age 65+. Among inpatients, veterans with ACCs for mental health conditions, eye conditions, amputations, or infectious and parasitic conditions had higher likelihood of a VA hospitalization than inpatients without these conditions. CONCLUSIONS: Many dually enrolled Veterans use both Medicare and VA health care. Age, accessibility, and priority level for VA services have a clear relationship with VA reliance. Because dual use is common, coordination of care among health care settings for such patients should be a policy priority.

Patient-to-nurse ratios and outcomes of moderately preterm infants.

OBJECTIVE: Moderately preterm infants (30-34(6/7) weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants. PATIENTS AND METHODS: Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of <20 or > or =20 infants. RESULTS: Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR. CONCLUSIONS: In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals' quality of care delivery to moderately preterm infants.

Risk of immune thrombocytopenic purpura and autoimmune hemolytic anemia among 120 908 US veterans with hepatitis C virus infection.

BACKGROUND: There is emerging evidence that hepatitis C virus (HCV) infection play a role in the etiology of immune thrombocytopenia purpura (ITP) and autoimmune hemolytic anemia (AIHA), both of which are severe autoimmune cytopenias. METHODS: To determine if HCV infection increases the risk for ITP and AIHA, we calculated the incidence rates of ITP and AIHA among 120 691 HCV-infected and 454 905 matched HCV-uninfected US veterans who received diagnoses during the period 1997 to 2004. After excluding individuals with a prior diagnosis of a lymphoproliferative disease, human immunodeficiency virus, or cirrhosis, we fitted Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) as measures of risks. RESULTS: We found 296 ITP and 90 AIHA cases. Among HCV-infected vs HCV-uninfected persons, the overall incidence rates of ITP were 30.2 and 18.5 per 100 000 person-years, and for AIHA they were 11.4 and 5.0 per 100 000 person-years, respectively. Hepatitis C virus was associated with elevated risks for ITP (HR, 1.8; 95% CI, 1.4-2.3) and AIHA (HR, 2.8; 95% CI, 1.8-4.2). The ITP incidence was increased among both untreated and treated HCV-infected persons (HR, 1.7; 95%, CI, 1.3-2.2 and HR, 2.4; 95% CI, 1.5-3.7, respectively), whereas AIHA incidence was elevated only among treated HCV-infected persons (HR, 11.6; 95% CI, 7.0-19.3). CONCLUSIONS: Individuals infected with HCV are at an increased risk for ITP, whereas the development of AIHA seems to be associated with HCV treatment. It may be beneficial to test individuals newly diagnosed as having ITP for HCV infection.

Method to develop health care peer groups for quality and financial comparisons across hospitals.

OBJECTIVE: To develop and explore the characteristics of a novel "nearest neighbor" methodology for creating peer groups for health care facilities. DATA SOURCES: Data were obtained from the Department of Veterans Affairs (VA) databases. STATISTICAL METHODS AND FINDINGS: Peer groups are developed by first calculating the multidimensional Euclidean distance between each of 133 VA medical centers based on 16 facility characteristics. Each medical center then serves as the center for its own peer group, and the nearest neighbor facilities in terms of Euclidean distance comprise the peer facilities. We explore the attributes and characteristics of the nearest neighbor peer groupings. In addition, we construct standard cluster analysis-derived peer groups and compare the characteristics of groupings from the two methodologies. CONCLUSIONS: The novel peer group methodology presented here results in groups where each medical center is at the center of its own peer group. Possible advantages over other peer group methodologies are that facilities are never on the "edge" of a group and group size-and thus group dispersion-is determined by the researcher. Peer groups with these characteristics may be more appealing to some researchers and administrators than standard cluster analysis and may thus strengthen organizational buy-in for financial and quality comparisons.