Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events.

OBJECTIVES: Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs. DESIGN: Longitudinal quasi-experimental study. SETTING: Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. INTERVENTIONS: We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal. MEASUREMENTS AND RESULTS: ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively. CONCLUSIONS: A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.

Eudaimonic well-being and tumor norepinephrine in patients with epithelial ovarian cancer.

BACKGROUND: The impact of psychological well-being on the physiologic processes involved in cancer progression remains unclear. Prior research has implicated adrenergic signaling in tumor growth and metastasis. Given that adrenergic signaling is influenced by both positive and negative factors, the authors examined how 2 different aspects of well-being (eudaimonic and positive affect) and psychological distress were associated with tumor norepinephrine (NE) in patients with ovarian cancer. METHODS: A total of 365 women with suspected ovarian cancer completed psychosocial assessments before surgery and clinical information was obtained from medical records. Study inclusion was confirmed after histological diagnosis. Tumor NE was measured in frozen tissue samples using high-performance liquid chromatography with electrochemical detection. Confirmatory factor analysis was used to model eudaimonic well-being, positive affect, and psychological distress, and structural equation modeling was used to examine associations between these factors and tumor NE. RESULTS: Eudaimonic well-being, positive affect, and psychological distress, modeled as distinct but correlated constructs, best fit the data (ie, compared with unitary or 2-factor models) (root mean square error of approximation, 0.048; comparative fit index, 0.982; and standardized root-mean-squared residual, 0.035). Structural equation modeling analysis that included physical well-being, stage of disease, histology, psychological treatment history, beta-blocker use, and caffeine use as covariates was found to have good model fit (root mean square error of approximation, 0.052; comparative fit index, 0.955; and standardized root-mean-squared residual, 0.036) and demonstrated that eudaimonic well-being was related to lower tumor NE (ß = -.24 [P = .045]). In contrast, no effects were found for positive affect or psychological distress. CONCLUSIONS: Eudaimonic well-being was found to be associated with lower tumor NE, independent of positive affect and psychological distress. Because adrenergic signaling is implicated in tumor progression, increasing eudaimonic well-being may improve both psychological and physiologic resilience in patients with ovarian cancer.

Biobehavioral and neuroendocrine correlates of antioxidant enzyme activity in ovarian carcinoma.

Increased levels of reactive oxygen species (ROS) such as superoxide anions and hydrogen peroxide have been reported in many cancer cells and they have been implicated in carcinogenesis and tumor progression. Antioxidant enzymes, such as Manganese Superoxide Dismutase (MnSOD or SOD2) and Glutathione Peroxidase-1 (GPx1), act coordinately to neutralize ROS. These enzymes are also thought to contribute to cancer cell resistance to conventional radio-chemo-therapies. Although some relationships have been reported between psychosocial factors and the regulation of antioxidant enzymes, little is known about these relationships in the context of cancer progression. The current study investigated the levels of MnSOD and GPx1in confirmed serous, high-grade tumor tissue from 60 ovarian cancer patients, and explored the relationship between the activity of these enzymes, the levels of tumor norepinephrine (NE), and patient mood as determined via pre-operative questionnaires. MnSOD activity was positively related to depressed mood (p=0.025) and tumor NE (p=0.023). In contrast, GPx1 activity was inversely related to fatigue (p=0.015) and tumor NE (p=0.009), and was positively associated with vigor (p=0.024). These findings suggest that psychological state and adrenergic signaling are linked with antioxidant enzyme activity in ovarian cancer and may have implications for patient treatments and outcomes.

Clinician advice to quit smoking among seniors.

OBJECTIVE: Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics. METHOD: In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation. RESULTS: 12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05. CONCLUSIONS: Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

Specialties differ in which aspects of doctor communication predict overall physician ratings.

BACKGROUND: Effective doctor communication is critical to positive doctor-patient relationships and predicts better health outcomes. Doctor communication is the strongest predictor of patient ratings of doctors, but the most important aspects of communication may vary by specialty. OBJECTIVE: To determine the importance of five aspects of doctor communication to overall physician ratings by specialty. DESIGN: For each of 28 specialties, we calculated partial correlations of five communication items with a 0-10 overall physician rating, controlling for patient demographics. PATIENTS: Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS®) 12-month Survey data collected 2005-2009 from 58,251 adults at a 534-physician medical group. MAIN MEASURES: CG-CAHPS includes a 0 ("Worst physician possible") to 10 ("Best physician possible") overall physician rating. Five doctor communication items assess how often the physician: explains things; listens carefully; gives easy-to-understand instructions; shows respect; and spends enough time. KEY RESULTS: Physician showing respect was the most important aspect of communication for 23/28 specialties, with a mean partial correlation (0.27, ranging from 0.07 to 0.44 across specialties) that accounted for more than four times as much variance in the overall physician rating as any other communication item. Three of five communication items varied significantly across specialties in their associations with the overall rating (p < 0.05). CONCLUSIONS: All patients valued respectful treatment; the importance of other aspects of communication varied significantly by specialty. Quality improvement efforts by all specialties should emphasize physicians showing respect to patients, and each specialty should also target other aspects of communication that matter most to their patients. The results have implications for improving provider quality improvement and incentive programs and the reporting of CAHPS data to patients. Specialists make important contributions to coordinated patient care, and thus customized approaches to measurement, reporting, and quality improvement efforts are important.

Experiences of care among Medicare beneficiaries with ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results.

BACKGROUND: Patients with end-stage renal disease (ESRD) have special health needs; little is known about their care experiences. STUDY DESIGN: Secondary analysis of 2009-2010 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, using representative random samples of Medicare beneficiaries. Description of Medicare beneficiaries with ESRD and investigation of differences in patient experiences by sociodemographic characteristics and coverage type. SETTING & PARTICIPANTS: Data were collected from 823,564 Medicare beneficiaries (3,794 with ESRD) as part of the Medicare CAHPS survey, administered by mail with telephone follow-up of nonrespondents. PREDICTOR: ESRD status, age, education, self-reported general and mental health status, race/ethnicity, sex, Medicare coverage type, state of residence, and other demographic measures. OUTCOMES: 6 composite measures of patient experience in 4 care domains (access to care, physician communication, customer service, and access to prescription drugs and drug information) and 4 ratings (overall care, personal physician, specialist physician, and prescription drug plan). RESULTS: Patients with ESRD reported better care experiences than non-ESRD beneficiaries for 7 of 10 measures (P < 0.05) after adjustment for patient characteristics, geography, and coverage type, although to only a small extent (adjusted mean difference, <3 points [scale, 0-100]). Black patients with ESRD and less educated patients were more likely than other patients with ESRD to report poor experiences. LIMITATIONS: Inability to distinguish patient experiences of care for different treatment modalities. CONCLUSIONS: On average, beneficiaries with ESRD report patient experiences that are at least as positive as non-ESRD beneficiaries. However, black and less educated patients with ESRD reported worse experiences than other ESRD patients. Stratified reporting of patient experience by race/ethnicity or education in patients with ESRD can be used to monitor this disparity. Physician choice and confidence and trust in physicians may be particularly important for patients with ESRD.

Measuring success for health care quality improvement interventions.

BACKGROUND: The lack of a standard measure of quality improvement (QI) success and the use of subjective or self-reported measures of QI success has constrained efforts to formally evaluate QI programs and to understand how the various contextual factors impact QI success. OBJECTIVES: The objective of this study was to assess how best to measure "QI success" by comparing self-reported and externally rated measures of QI success. RESEARCH DESIGN: We performed a retrospective evaluation that analyzed data on different measures of QI success for organizations after their staff completed the QI training. SUBJECTS: The sample included 30 organizations whose staff had received QI training during 2006-2008, and who had used this training to carry out at least some subsequent QI initiative in their organizations. MEASURES: We developed 2 measures of self-reported QI success based on survey responses and 4 externally rated measures of QI success based on outcome data provided by the participating organizations in addition to qualitative data generated from the interviews. RESULTS: We found some variation in the mean scores of the different QI success measures and only moderate to small correlations between the self-report and externally rated QI measures. CONCLUSIONS: This study confirms that there are important differences between self-reported and externally rated measures of QI success and provides researchers with a methodology and criteria to externally rate measures of QI success.

Advancing the science of patient safety.

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Angiotensin II acts through the angiotensin 1a receptor to upregulate pendrin.

Pendrin is an anion exchanger expressed in the apical regions of B and non-A, non-B intercalated cells. Since angiotensin II increases pendrin-mediated Cl(-) absorption in vitro, we asked whether angiotensin II increases pendrin expression in vivo and whether angiotensin-induced hypertension is pendrin dependent. While blood pressure was similar in pendrin null and wild-type mice under basal conditions, following 2 wk of angiotensin II administration blood pressure was 31 mmHg lower in pendrin null than in wild-type mice. Thus pendrin null mice have a blunted pressor response to angiotensin II. Further experiments explored the effect of angiotensin on pendrin expression. Angiotensin II administration shifted pendrin label from the subapical space to the apical plasma membrane, independent of aldosterone. To explore the role of the angiotensin receptors in this response, pendrin abundance and subcellular distribution were examined in wild-type, angiotensin type 1a (Agtr1a) and type 2 receptor (Agtr2) null mice given 7 days of a NaCl-restricted diet (< 0.02% NaCl). Some mice received an Agtr1 inhibitor (candesartan) or vehicle. Both Agtr1a gene ablation and Agtr1 inhibitors shifted pendrin label from the apical plasma membrane to the subapical space, independent of the Agtr2 or nitric oxide (NO). However, Agtr1 ablation reduced pendrin protein abundance through the Agtr2 and NO. Thus angiotensin II-induced hypertension is pendrin dependent. Angiotensin II acts through the Agtr1a to shift pendrin from the subapical space to the apical plasma membrane. This Agtr1 action may be blunted by the Agtr2, which acts through NO to reduce pendrin protein abundance.

Social isolation is associated with elevated tumor norepinephrine in ovarian carcinoma patients.

Noradrenergic pathways have been implicated in growth and progression of ovarian cancer. Intratumoral norepinephrine (NE) has been shown to increase with stress in an animal cancer model, but little is known regarding how tumor NE varies with disease stage and with biobehavioral factors in ovarian cancer patients. This study examined relationships between pre-surgical measures of social support, depressed mood, perceived stress, anxiety, tumor histology and tumor catecholamine (NE and epinephrine [E]) levels among 68 ovarian cancer patients. We also examined whether associations observed between biobehavioral measures and tumor catecholamines extended to other compartments. Higher NE levels were found in advanced stage (p=0.006) and higher grade (p=0.001) tumors. Adjusting for stage, grade, and peri-surgical beta blockers, patients with a perceived lack of social support had significantly higher tumor NE (ß=-0.29, p=0.012). A similar trend was seen for social support and ascites NE (adjusting for stage, peri-surgical beta blockers and caffeine: ß=-0.50, p=0.075), but not for plasma NE. Other biobehavioral factors were not related to tumor, ascites, or plasma NE (p values >0.21). Tumor E was undetectable in the majority of tumors and thus E was not further analyzed. In summary, these results suggest that tumor NE provides distinct information from circulating plasma concentrations. Tumor NE levels were elevated in relationship to tumor grade and stage. Low subjective social support was associated with elevated intratumoral NE. As beta-adrenergic signaling is related to key biological pathways involved in tumor growth, these findings may have implications for patient outcomes in ovarian cancer.

Role of pendrin in iodide balance: going with the flow.

Pendrin is expressed in the apical regions of type B and non-A, non-B intercalated cells, where it mediates Cl(-) absorption and HCO3(-) secretion through apical Cl(-)/HCO3(-) exchange. Since pendrin is a robust I(-) transporter, we asked whether pendrin is upregulated with dietary I(-) restriction and whether it modulates I(-) balance. Thus I(-) balance was determined in pendrin null and in wild-type mice. Pendrin abundance was evaluated with immunoblots, immunohistochemistry, and immunogold cytochemistry with morphometric analysis. While pendrin abundance was unchanged when dietary I(-) intake was varied over the physiological range, I(-) balance differed in pendrin null and in wild-type mice. Serum I(-) was lower, while I(-) excretion was higher in pendrin null relative to wild-type mice, consistent with a role of pendrin in renal I(-) absorption. Increased H2O intake enhanced differences between wild-type and pendrin null mice in I(-) balance, suggesting that H2O intake modulates pendrin abundance. Raising water intake from approximately 4 to approximately 11 ml/day increased the ratio of B cell apical plasma membrane to cytoplasm pendrin label by 75%, although circulating renin, aldosterone, and serum osmolality were unchanged. Further studies asked whether H2O intake modulates pendrin through the action of AVP. We observed that H2O intake modulated pendrin abundance even when circulating vasopressin levels were clamped. We conclude that H2O intake modulates pendrin abundance, although not likely through a direct, type 2 vasopressin receptor-dependent mechanism. As water intake rises, pendrin becomes increasingly critical in the maintenance of Cl(-) and I(-) balance.

Depression, social support, and beta-adrenergic transcription control in human ovarian cancer.

Motivated by previous indications that beta-adrenergic signaling can regulate tumor cell gene expression in model systems, we sought to determine whether similar dynamics occur in primary human ovarian cancer. DNA microarray analyses of 10 ovarian carcinomas identified 266 human transcripts that were differentially expressed in tumors from patients with elevated biobehavioral risk factors (high depressive symptoms and low social support) relative to grade- and stage-matched tumors from low-risk patients. Promoter-based bioinformatic analyses indicated increased activity of several beta-adrenergically-linked transcription control pathways, including CREB/ATF, NF-kappaB/Rel, STAT, and Ets family transcription factors. Consistent with increased beta-adrenergic signaling, high biobehavioral risk patients also showed increased intra-tumor concentrations of norepinephrine (but no difference in plasma norepinephrine). These data show that genome-wide transcriptional profiles are significantly altered in tumors from patients with high behavioral risk profiles, and they identify beta-adrenergic signal transduction as a likely mediator of those effects.

Using health information technology-related performance measures and tools to improve chronic care.

BACKGROUND: The American Medical Association led a collaborative initiative to explore opportunities for improving the quality of outpatient chronic care through the use of nationally endorsed clinical performance measures and tools. The measures and tools focused on adult diabetes, major depressive disorder, chronic stable coronary artery disease, heart failure, hypertension, and asthma. METHODS: The RAND Corporation conducted an independent, formative assessment of the initiative's four pilot activities using the Context-Input-Process-Product evaluation model. RESULTS: Pilots 1 and 2 demonstrated the feasibility and value of implementing performance measures and tools in practices with electronic health information systems, while highlighting the difficulty of using them in practices with paper-based systems and in community-based models, where multiple stakeholders are expected to share patient data. Pilot 3 illustrated the usefulness of validating performance measures before their use for internal quality improvement or external reporting. Pilot 4 documented the challenges involved in exporting clinical performance data from a physician practice to external entities for multiple potential uses. DISCUSSION: Improving the quality of chronic care through clinical performance measurement, data aggregation, and reporting will require expanded use of clinical performance measures for both internal quality improvement and pay-for-performance; integrating electronic health records (EHRs) or electronic-based registries into more physician offices; more accurate measurement and documentation of diagnoses and care procedures; EHR products that make it easier to capture certain types of information; and simplified, standardized processes for performance data extraction and exporting.

A systematic approach for developing a ventilator-associated pneumonia prevention bundle.

BACKGROUND: Ventilator-associated pneumonia (VAP) is among the most common type of health care-associated infection in the intensive care unit and is associated with significant morbidity and mortality. Existing VAP prevention intervention bundles vary widely on the interventions included and in the approaches used to develop these bundles. The objective of this study was to develop a new VAP prevention bundle using a systematic approach that elicits clinician perceptions on which interventions are most important and feasible to implement. METHODS: We identified potential interventions to include through a review of current guidelines and literature. We implemented a 2-step modified Delphi method to gain consensus on the final list of interventions. An interdisciplinary group of clinical experts participated in the Delphi process, which was guided by a technical expert panel. RESULTS: We identified 65 possible interventions. Through the Delphi method, we narrowed that list to 19 interventions that included 5 process and 14 structural measures. CONCLUSIONS: We described a structured approach for developing a new VAP prevention bundle. Obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle.

Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide.

INTRODUCTION: Although the importance of training in patient safety has been acknowledged for over a decade, it remains under-utilized and under-valued in most countries. WHO developed the Multi-professional Patient Safety Curriculum Guide to provide schools with the requirements and tools for incorporating patient safety in education. It was field tested with 12 participating schools across the six WHO regions, to assess its effectiveness for teaching patient safety to undergraduate and graduate students in a global variety of settings. METHODS: The evaluation used a combined prospective/retrospective design to generate formative information on the experiences of working with the Guide and summative information on the impacts of the Guide. Using stakeholder interviews and student surveys, data were gathered from each participating school at three times: the start of the field test (baseline), soon after each school started teaching, and soon after each school finished teaching. RESULTS: Stakeholders interviewed were strongly positive about the Guide, noting that it emphasized universally important patient safety topics, was culturally appropriate for their countries, and gave credibility and created a focus on patient safety at their schools. Student perceptions and attitudes regarding patient safety improved substantially during the field test, and their knowledge of the topics they were taught doubled, from 10.7% to 20.8% of correct answers on the student survey. DISCUSSION: This evaluation documented the effectiveness of the Curriculum Guide, for both ease of use by schools and its impacts on improving the patient safety knowledge of healthcare students. WHO should be well positioned to refine the contents of the Guide and move forward in encouraging broader use of the Guide globally for teaching patient safety.

Shortcomings in Medicare bonus payments for physicians in underserved areas.

This study examines trends in Medicare spending for basic payments and bonus payments for physician services provided to beneficiaries residing in nonmetropolitan counties. For our analysis, we used Medicare Part B physician/supplier claims data for 1992, 1994, 1996, and 1998. Payments under the congressionally mandated bonus payment program acccounted for less than 1 percent of expenditures for physician services in nonmetropolitan, underserved counties. Physician payments increased from 1992 to 1998, while bonus payments increased through 1996 but then declined by 13 percent by 1998. The share of bonus payments to primary care physicians declined throughout the decade, but the share for primary care services increased.

Effect of CAHPS performance information on health plan choices by Iowa Medicaid beneficiaries.

This evaluation tested if Consumer Assessment of Health Plans Study (CAHPS) information on plan performance affected health plan choices by new beneficiaries in Iowa Medicaid. New cases entering Medicaid in selected counties during February through May 2000 were assigned randomly to experimental or control groups. The control group received standard Medicaid enrollment materials, and the experimental group received these materials plus a CAHPS report. We found that CAHPS information did not affect health plan choices by Iowa Medicaid beneficiaries, similar to previously reported findings for New Jersey Medicaid. However, it did affect plan choice in an earlier laboratory experiment. The value of this information may be limited to a subset of receptive consumers who actively study information received, even then only when (1) ratings of available plans differ greatly, (2) ratings differ from prior beliefs about plan quality, and (3) reports are easy to understand.