The nature of life-transforming changes among cancer survivors.

Some cancer survivors report positive subjective changes they describe as "life transforming." We used a grounded theory approach to identify the content, underlying process, and identifying characteristics of self-defined "life-transforming" changes (LTCs) reported by 9 cancer survivors. To actualize their hopes for improvement, participants used a self-guided process centered on pragmatic action: researching options, gaining experience, and frankly evaluating results. Many participants discovered unanticipated personal abilities and resources, and those became highly useful in coping with other challenges apart from cancer. This made the increased personal abilities and resources "life transforming" rather than being substantially limited to reducing cancer-related problems. The action-oriented features and processes of LTCs seemed to be more fully described by experiential learning theory than by posttraumatic growth and coping. Supportive intervention to facilitate positive change processes could decrease suffering and enhance positive psychosocial and spiritual outcomes for cancer survivors.

BRIEF REPORT: Factors affecting outpatient follow-up compliance of emergency department patients.

BACKGROUND: Emergency department (ED) patients often fail to follow-up with referrals to outpatient clinics and physicians. OBJECTIVE: To compare the effects of 2 ED discharge instructional methods on outpatient follow-up compliance and to evaluate sociodemographic characteristics as possible factors affecting outpatient follow-up compliance. DESIGN AND PARTICIPANTS: Randomized trial of ED patients. At discharge, the intervention group had their follow-up appointment made and the standard group was given our hospital's referral service phone number to make their own follow-up appointment. MEASUREMENTS: Outpatient clinics were called 1 month after each subject's ED discharge to ascertain if they followed-up. Poisson regression was used to examine the effects of sociodemographic factors on follow-up compliance. RESULTS: Of 287 eligible subjects, 250 (87%) agreed to participate. Follow-up rates were 59% for the intervention group and 37% for the standard group (P<.001). Having a primary care physicians appeared to increase ED patients' outpatient follow-up compliance and having Medicaid insurance appeared to decrease outpatient follow-up compliance, but neither of these findings was statistically significant. CONCLUSIONS: In our ED, patients who have their outpatient follow-up appointment made at discharge have a significantly greater probability of follow-up compliance compared with patients given standard discharge instructions. Most sociodemographic characteristics do not affect our ED patients' follow-up compliance.

The effect of emergency department crowding on clinically oriented outcomes.

BACKGROUND: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated. OBJECTIVES: The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs). METHODS: We reviewed the English-language literature for the years 1989-2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,""ED overcrowding,""mortality,""time to treatment,""patient satisfaction,""quality of care," and others. RESULTS: A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints. CONCLUSIONS: A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.