Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation.

OBJECTIVE: The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings. METHODS: Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated. RESULTS: In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care. CONCLUSIONS: Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Development of a machine learning model to predict mild cognitive impairment using natural language processing in the absence of screening.

BACKGROUND: Patients and their loved ones often report symptoms or complaints of cognitive decline that clinicians note in free clinical text, but no structured screening or diagnostic data are recorded. These symptoms/complaints may be signals that predict who will go on to be diagnosed with mild cognitive impairment (MCI) and ultimately develop Alzheimer's Disease or related dementias. Our objective was to develop a natural language processing system and prediction model for identification of MCI from clinical text in the absence of screening or other structured diagnostic information. METHODS: There were two populations of patients: 1794 participants in the Adult Changes in Thought (ACT) study and 2391 patients in the general population of Kaiser Permanente Washington. All individuals had standardized cognitive assessment scores. We excluded patients with a diagnosis of Alzheimer's Disease, Dementia or use of donepezil. We manually annotated 10,391 clinic notes to train the NLP model. Standard Python code was used to extract phrases from notes and map each phrase to a cognitive functioning concept. Concepts derived from the NLP system were used to predict future MCI. The prediction model was trained on the ACT cohort and 60% of the general population cohort with 40% withheld for validation. We used a least absolute shrinkage and selection operator logistic regression approach (LASSO) to fit a prediction model with MCI as the prediction target. Using the predicted case status from the LASSO model and known MCI from standardized scores, we constructed receiver operating curves to measure model performance. RESULTS: Chart abstraction identified 42 MCI concepts. Prediction model performance in the validation data set was modest with an area under the curve of 0.67. Setting the cutoff for correct classification at 0.60, the classifier yielded sensitivity of 1.7%, specificity of 99.7%, PPV of 70% and NPV of 70.5% in the validation cohort. DISCUSSION AND CONCLUSION: Although the sensitivity of the machine learning model was poor, negative predictive value was high, an important characteristic of models used for population-based screening. While an AUC of 0.67 is generally considered moderate performance, it is also comparable to several tests that are widely used in clinical practice.

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care.

PURPOSE: We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS: Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS: Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS: Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

If You Listen, I Will Talk: the Experience of Being Asked About Suicidality During Routine Primary Care.

BACKGROUND: Routine population-based screening for depression is an essential part of evolving health care models integrating care for mental health in primary care. Depression instruments often include questions about suicidal thoughts, but how patients experience these questions in primary care is not known and may have implications for accurate identification of patients at risk. OBJECTIVES: To explore the patient experience of routine population-based depression screening/assessment followed, for some, by suicide risk assessment and discussions with providers. DESIGN: Qualitative, interview-based study. PARTICIPANTS: Thirty-seven patients from Kaiser Permanente Washington who had recently screened positive for depression on the 2-item Patient Health Questionnaire [PHQ] and completed the full PHQ-9. APPROACH: Criterion sampling identified patients who had recently completed the PHQ-9 ninth question which asks about the frequency of thoughts about self-harm. Patients completed semi-structured interviews by phone, which were recorded and transcribed. Directive and conventional content analyses were used to apply knowledge from prior research and elucidate new information from interviews; thematic analysis was used to organize key content overall and across groups based on endorsement of suicide ideation. KEY RESULTS: Four main organizing themes emerged from analyses: (1) Participants believed being asked about suicidality was contextually appropriate and valuable, (2) some participants described a mismatch between their lived experience and the PHQ-9 ninth question, (3) suicidality disclosures involved weighing hope for help against fears of negative consequences, and (4) provider relationships and acts of listening and caring facilitated discussions about suicidality. CONCLUSIONS: All participants believed being asked questions about suicidal thoughts was appropriate, though some who disclosed suicidal thoughts described experiencing stigma and sometimes distanced themselves from suicidality. Direct communication with trusted providers, who listened and expressed empathy, bolstered comfort with disclosure. Future research should consider strategies for reducing stigma and encouraging fearless disclosure among primary care patients experiencing suicidality.

Taking action on overuse: Creating the culture for change.

BACKGROUND: Unnecessary care contributes to high costs and places patients at risk of harm. While most providers support reducing low-value care, changing established practice patterns is difficult and requires active engagement in sustained behavioral, organizational, and cultural change. Here we describe an action-planning framework to engage providers in reducing overused services. METHODS: The framework is informed by a comprehensive review of social science theory and literature, published reports of successful and unsuccessful efforts to reduce low-value care, and interviews with innovators of value-based care initiatives in twenty-three health care organizations across the United States. A multi-stakeholder advisory committee provided feedback on the framework and guidance on optimizing it for use in practice. RESULTS: The framework describes four conditions necessary for change: prioritize addressing low-value care; build a culture of trust, innovation and improvement; establish shared language and purpose; and commit resources to measurements. These conditions foster productive sense-making conversations between providers, between providers and patients, and among members of the health care team about the potential for harm from overuse and reflection on current frequency of use. Through these conversations providers, patients and team members think together as a group, learn how to coordinate individual behaviors, and jointly develop possibilities for coordinated action around specific areas of overuse. CONCLUSIONS: Organizational efforts to engage providers in value-based care focused on creating conditions for productive sense-making conversations that lead to change. IMPLICATIONS: Organizations can use this framework to enhance and strengthen provider engagement efforts to do less of what potentially harms and more of what truly helps patients.

The Impact of the Massachusetts Behavioral Health Child Screening Policy on Service Utilization.

OBJECTIVE: In 2008, Massachusetts Medicaid implemented a pediatric behavioral health (BH) screening mandate. This study conducted a population-level, longitudinal policy analysis to determine the impact of the policy on ambulatory, emergency, and inpatient BH care in comparison with use of these services in California, where no similar policy exists. METHODS: With Medicaid Analytic Extract (MAX) data, an interrupted time-series analysis with control series design was performed to assess changes in service utilization in the 18 months (January 2008-June 2009) after a BH screening policy was implemented in Massachusetts and to compare service utilization with California's. Outcomes included population rates of BH screening, BH-related outpatient visits, BH-related emergency department visits, BH-related hospitalizations, and psychotropic drug use. Medicaid-eligible children from January 1, 2006, to December 31, 2009, with at least ten months of Medicaid eligibility who were older than 4.5 years and younger than 18 years were included. RESULTS: Compared with rates in California, Massachusetts rates of BH screening and BH-related outpatient visits rose significantly after Massachusetts implemented its screening policy. BH screening rose about 13 per 1,000 youths per month during the first nine months, and BH-related outpatient visits rose to about 4.5 per 1,000 youths per month (p<.001). Although BH-related emergency department visits, hospitalization and psychotropic drug use increased, there was no difference between the states in rate of increase. CONCLUSIONS: The goal of BH screening is to identify previously unidentified children with BH issues and provide earlier treatment options. The short-term outcomes of the Massachusetts policy suggest that screening at preventive care visits led to more BH-related outpatient visits among vulnerable children.

Study protocol for "Healthy Hearts Northwest": a 2 × 2 randomized factorial trial to build quality improvement capacity in primary care.

BACKGROUND: Little attention has been paid to quality improvement (QI) capacity within smaller primary care practices which comprise nearly half of all primary care settings. Strategies for external support to build such capacity include practice facilitation (PF), shared learning opportunities, and educational outreach. Although PF has proven effectiveness, little is known about the comparative effectiveness of combining these strategies. Here, we describe the protocol of the "Healthy Hearts Northwest" (H2N) study, a randomized trial designed to address these questions while improving risk factors for cardiovascular disease. METHODS/DESIGN: The targeted enrollment is 250 smaller primary care practices across Washington, Oregon, and Idaho. The study is utilizing a two-by-two factorial design to assess four different combinations of practice support: PF alone, PF with educational outreach, PF with shared learning opportunities, or PF with both. A mixed methods approach is being used for evaluation and will include data from (1) baseline and follow-up practice and staff surveys; (2) baseline and quarterly clinical performance measurement from each practice on four cardiovascular risk factors: appropriate aspirin use, blood pressure control, lipid management and smoking cessation support; and (3) a quality improvement capacity assessment (QICA) survey used by external practice facilitators to guide improvement efforts. DISCUSSION: Results from this study will inform future large-scale practice improvement initiatives by providing comparisons of promising external practice support strategies and advance our understanding of how to build QI capacity in primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02839382.

Do depressed newly diagnosed cancer patients differentially benefit from nurse navigation?

OBJECTIVE: To examine whether the effects of a nurse navigator intervention for cancer vary with baseline depressive symptoms. METHOD: Participants were enrolled in a randomized controlled trial of a nurse navigation intervention for patients newly diagnosed with lung, breast or colorectal cancer (N=251). This exploratory analysis used linear regression models to estimate the effect of a nurse navigator intervention on patient experience of care. Models estimated differential effects by including interactions between randomization group and baseline depressive symptoms. Baseline scores on the 9-item Patient Health Questionnaire (PHQ) were categorized into 3 groups: no depression (PHQ=0-4, N=138), mild symptoms of depression (PHQ=5-9, N=76) and moderate to severe symptoms (PHQ=10 or greater, N=34). Patient experience outcomes were measured by subscales of the Patient Assessment of Chronic Illness Care (PACIC) and subscales from an adaptation of the Picker Institute's patient experience survey at 4-month follow-up. RESULTS: With the exception of the PACIC subscale of delivery system/practice design, interaction terms between randomization group and PHQ-9 scores were not statistically significant. CONCLUSIONS: The intervention was broadly useful; we found that it was equally beneficial for both depressed patients and patients who were not significantly depressed in the first 4 months postdiagnosis. However, because of the small sample size, we cannot conclude with certainty that patients with depressive symptoms did not differentially benefit from the intervention.

A differential item function analysis of somatic symptoms of depression in people with cancer.

BACKGROUND: The overlap of somatic symptoms of depression with symptoms of cancer treatment is widely acknowledged and studied. However, this literature provides little guidance for clinicians as to whether these items should be used in assessing depression. The current study examined the appropriateness of using somatic items for assessment of depression in people with cancer. METHODS: People with newly diagnosed breast, lung or colorectal cancer (n=251) completed the Patient Health Questionnaire-9 (PHQ9) shortly after cancer diagnosis but before cancer treatment (baseline), 4 months later, typically during or shortly after treatment, and 12 months later. Pharmacy data was used to classify participants as having low somatic symptoms or high somatic symptoms. Differential item function (DIF) compared the functioning of the somatic items of the PHQ9 in the low vs. high symptom groups and the chemotherapy vs. no chemotherapy groups at the 4-month assessment. RESULTS: Significant DIF was not found on any of the four somatic items of the PHQ9 and differences in the item parameters of the somatic items were not consistent across the groups. However, fatigue and sleep indicated only mild depression. Only removing the fatigue item greatly affected the number screening positive for depression at 4 months (8.3%) but removing the other somatic items did not have as large an effect. Only one participant at baseline screened positive for depression by somatic symptoms alone (no psychological symptoms) and no participants screened positive by somatic symptoms alone at 4 months and 12 months. LIMITATIONS: The sample size was small for DIF and consisted of mostly women with breast cancer. CONCLUSIONS: Somatic symptoms of depression can continue to be administered to people with cancer, however the fatigue and sleep items should be used with caution.

Behavioral health services following implementation of screening in Massachusetts Medicaid children.

OBJECTIVES: To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children. METHODS: After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services. RESULTS: Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06). CONCLUSIONS: Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

Dimensions of impulsive behavior and treatment outcomes for adolescent smokers.

Adolescent cigarette smoking rates remain a significant public health concern, and as a result there is a continued need to understand factors that contribute to an adolescent's ability to reduce or quit smoking. Previous research suggests that impulsive behavior may be associated with treatment outcomes for smoking. The current research (N = 81) explored 3 dimensions of impulsive behavior as predictors of treatment response from a social-cognitive type program for adolescent smokers (i.e., Not On Tobacco; N-O-T). Measures included laboratory assessments of delay discounting, sustained attention, and behavioral disinhibition. A self-report measure of impulsivity was also included. Adolescent smokers who had better sustained attention were more likely to reduce or quit smoking by the end of treatment. No other measures of impulsivity were significantly associated with treatment response. From these findings, an adolescent smoker's ability to sustain attention appears to be an important behavioral attribute to consider when implementing smoking cessation programs such as N-O-T.

Nurse navigators in early cancer care: a randomized, controlled trial.

PURPOSE: To determine whether a nurse navigator intervention improves quality of life and patient experience with care for people recently given a diagnosis of breast, colorectal, or lung cancer. PATIENTS AND METHODS: Adults with recently diagnosed primary breast, colorectal, or lung cancer (n = 251) received either enhanced usual care (n = 118) or nurse navigator support for 4 months (n = 133) in a two-group cluster randomized, controlled trial with primary care physicians as the units of randomization. Patient-reported measures included the Functional Assessment of Cancer Therapy-General (FACT-G) Quality of Life scale, three subscales of the Patient Assessment of Chronic Illness Care (PACIC), and selected subscales from a cancer adaptation of the Picker Institute's patient experience survey. Self-report measures were collected at baseline, 4 months, and 12 months. Automated administrative data were used to assess time to treatment and total health care costs. RESULTS: There were no significant differences between groups in FACT-G scores. Nurse navigator patients reported significantly higher scores on the PACIC and reported significantly fewer problems with care, especially psychosocial care, care coordination, and information, as measured by the Picker instrument. Cumulative costs after diagnosis did not differ significantly between groups, but lung cancer costs were $6,852 less among nurse navigator patients. CONCLUSION: Compared with enhanced usual care, nurse navigator support for patients with cancer early in their course improves patient experience and reduces problems in care, but did not differentially affect quality of life.

Screening for behavioral health issues in children enrolled in Massachusetts Medicaid.

OBJECTIVES: To understand mandated behavioral health (BH) screening in Massachusetts Medicaid including characteristics of screened children, predictors of positive screens, and whether screening identifies children without a previous BH history. METHODS: Massachusetts mandated BH screening in particularly among underidentified groups. 2008. Providers used a billing code and modifier to indicate a completed screen and whether a BH need was identified. Using MassHealth claims data, children with ≥ 300 days of eligibility in fiscal year (FY) 2009 were identified and categorized into groups based on first use of the modifier, screening code, or claim. Bivariate analyses were conducted to determine differences among groups. BH history was examined by limiting the sample to those continuously enrolled in FY 2008 and 2009. Multivariate logistic regression was used to determine predictors of positive screens. RESULTS: Of 355,490 eligible children, 46% had evidence of screening. Of those with modifiers, 12% were positive. Among continuously enrolled children (FY 2008 and FY 2009) with evidence of screening, 43% with positive modifiers had no BH history. This "newly identified" group were more likely to be female, younger, minority, and from rural residences (P < .0001). Among children with modifiers; gender (male), age (5-7), being in foster care, recent BH history, and Hispanic ethnicity predicted having a positive modifier. CONCLUSIONS: The high rate of newly identified Medicaid children with a BH need suggests that screening is performing well, particularly among underidentified groups. To better assess screening value, future work on cost-effectiveness and the impact on subsequent mental health treatment is needed.

Impact of electronic health record transition on behavioral health screening in a large pediatric practice.

OBJECTIVE: The objective was to determine whether transitioning from paper to electronic health records affected behavioral health screening rates in a large Northeastern pediatric practice. METHODS: The study setting was a pediatric practice with seven pediatricians, serving about 6,000 patients. The patient population was diverse (54% nonwhite, 40% publicly insured or self-paying, and 31% non-English speakers). An interrupted times series design was used to evaluate the impact of electronic record implementation on behavioral health screening rates. The main outcome measure was the rate of such screening 18 months before and 36 months after implementation. RESULTS: The rate of behavioral health screening increased from 70% to 91% during the baseline period. The training period-six months before electronic record implementation-was associated with a 28% decline in adjusted screening rates (from 83.3% to 55.5%). Only 50% of eligible youths were screened in the first month after implementation. The screening rate took more than three years to recover to baseline levels, climbing to 82% by April 2008. CONCLUSIONS: Practice changes resulting from electronic record adoption were highly disruptive of care, and disruptions took several years to resolve completely. When medical assistants rather than physicians were tasked with transferring data from paper screening forms to the electronic record, reporting compliance improved. Compliance with Healthcare Effectiveness Data and Information Set standards and Medicaid performance measures will likely be similarly affected as electronic records are implemented nationwide. Although implementing a fully automated medical record has some benefits, the unintended effects on care after implementation must be acknowledged.

Health care use and decision making among lower-income families in high-deductible health plans.

BACKGROUND: Lower-income families may face unique challenges in high-deductible health plans (HDHPs). METHODS: We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's HDHP with at least $500 in annualized out-of-pocket expenditures. Lower-income families were defined as having incomes that were less than 300% of the federal poverty level. Primary outcomes were cost-related delayed or foregone care, difficulty understanding plans, unexpected costs, information-seeking, and likelihood of families asking their physician about hypothetical recommended services subject to the plan deductible. Multivariate logistic regression was used to control for potential confounders of associations between income group and primary outcomes. RESULTS: Lower-income families (n = 141) were more likely than higher-income families (n = 273) to report cost-related delayed or foregone care (57% vs 42%; adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.15-2.83]). There were no differences in plan understanding, unexpected costs, or information-seeking by income. Lower-income families were more likely than others to say they would ask their physician about a $100 blood test (79% vs 63%; AOR, 1.97; 95% CI, 1.18-3.28) or a $1000 screening colonoscopy (89% vs 80%; AOR, 2.04; 95% CI, 1.06-3.93) subject to the plan deductible. CONCLUSIONS: Lower-income families with out-of-pocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone care but did not report more difficulty understanding or using their plans, and might be more likely to question services requiring out-of-pocket expenditures. Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.

Predictors of serious complications associated with lower gastrointestinal endoscopy in a major city-wide health region.

BACKGROUND: There are limited data regarding complications associated with colonoscopy and flexible sigmoidoscopy in usual clinical practice in Canada. OBJECTIVE: To determine the risk factors for lower gastrointestinal (GI) endoscopy-associated complications in usual clinical practice. METHODS: All outpatient lower GI endoscopies performed in Winnipeg (Manitoba) between April 1, 2004 and March 31, 2006, were identified from the provincial physicians' claims database. All subsequent hospital admissions within 30 days that documented potential complications associated with lower GI endoscopies were identified from the electronic hospital discharges database and reviewed. Multivariate generalized estimating equation regression analysis was performed to determine independent factors (patient, endoscopist and procedure) associated with the risk of developing complications. RESULTS: There were 29,990 outpatient lower GI endoscopies performed in Winnipeg during the years studied. Seventy-seven (0.26%) procedures were associated with complications requiring hospitalization within 30 days of the index procedure. Stricture dilation (rate ratio [RR] 23.14; 95% CI 6.70 to 76.51), polypectomy (RR 5.93; 95% CI 3.66 to 9.62), increasing patient age (for each year increase in age, RR 1.03; 95% CI 1.01 to 1.05) and performance of endoscopy by low-volume endoscopists (fewer than 200 procedures per year, RR 2.28; 95% CI 1.18 to 4.42) and family physicians (RR 2.23; 95% CI 1.39 to 3.58) were independently associated with complications. CONCLUSIONS: The results of the present study suggest that increasing patient age, complex procedures and performance of the index procedure by low-volume endoscopists are independent risk factors for lower GI endoscopy-associated complications in usual clinical practice. This suggests that it may be time to consider implementing minimum volume requirements for endoscopists performing non-screening lower GI endoscopies.

Colonoscopy and its complications across a Canadian regional health authority.

BACKGROUND: Defining the complication rate of endoscopy performed across an entire city will capture usual as opposed to referral center data. OBJECTIVE: Our purpose was to evaluate the current practice of colonoscopy and complications associated with lower GI endoscopy in usual clinical practice. DESIGN: All admissions within 30 days of an outpatient lower GI endoscopy at any of the 6 adult-care Winnipeg hospitals were identified. This includes endoscopy for both complex and routine patients. A chart audit of all cases with potential complications was performed. RESULTS: A total of 24,509 outpatient lower GI endoscopies for adults were performed at the 6 hospitals over the 2 study years (April 1, 2004, to March 31, 2006). There were 303 admissions with potential complications. The colonoscopy completion rate was 65% (72% for gastroenterologists vs 59% for general surgeons, P < .005). Quality of bowel preparation and nature of polyps were often not documented. The overall rate of complications was 2.9/1000 procedures; the perforation rate after polypectomy was 1.8/1000; and the postpolypectomy bleeding rate was 6.4/1000. Most (67%) complications were recognized after discharge for the index procedure. The complication rate was highest for the endoscopists performing fewer than 200 procedures per year (5.4/1000 vs 2.7/1000 for the rest, P = .02, relative risk 2 [95% CI, 1.1-3.7]). LIMITATIONS: Chart audit was limited to cases requiring admission within 30 days of the index procedure. CONCLUSIONS: The overall complication rate after lower GI endoscopy in usual clinical practice in Winnipeg is comparable to that previously reported. A higher complication rate after endoscopy by low-volume endoscopists needs to be further evaluated. The reporting of endoscopy must be standardized to enhance outcomes interpretation.

Do hospital standardized mortality ratios measure patient safety? HSMRs in the Winnipeg Regional Health Authority.

The Canadian Institute for Health Information began publishing hospital standardized mortality ratio (HSMR) data for select Canadian hospitals in November 2007. This paper describes the experience of the Winnipeg Regional Health Authority in assessing the validity of the HSMR through statistical analysis, coding definitions and chart audits. We found a lack of empirical evidence supporting the use of the HSMR in measuring reductions in preventable deaths. We also found that limitations in standardization as well as differences in palliative care coding and place of death make inter-facility comparisons of HSMRs invalid. The results of our chart audit show that the HSMR is not a sensitive measure of adverse events as defined by "unexpected death" in the Canadian Adverse Events Study. It should not be viewed as an important indicator of patient safety or quality of care. We discuss the cumulative sum statistic as an alternative to the HSMR in monitoring in-hospital mortality.

Laboratory and self-report assessments of impulsive behavior in adolescent daily smokers and nonsmokers.

This research compared adolescent daily smokers (n=25) and nonsmokers (n=26) on different measures of impulsivity. Assessments included question-based measures of delay (DDQ) and probability (PDQ) discounting, a measure of behavioral disinhibition (go-stop task), and a self-report measure of impulsivity (Barratt Impulsiveness Scale-Adolescent). Adolescent smokers were more impulsive on the DDQ and Barratt Impulsiveness Scale--Adolescent but not on the PDQ or the go-stop task. However, there was a significant interaction between smoking status and gender on the go-stop task, with male smokers performing less impulsively on this measure than male nonsmokers--an effect not observed with the female adolescents. These findings indicate that adolescents who smoke cigarettes are more impulsive with respect to some, but not all, types of impulsivity than are adolescents who do not smoke.