RESUMO
OBJECTIVES: Considerable differences in prevalence of diabetes and management of the disease exist among racial/ethnic groups. We examined the relationship between race/ethnicity and hospital readmissions for diabetes-related conditions. METHODS: Nonmaternal adult patients with Medicare, Medicaid, or private insurance coverage hospitalized for diabetes-related conditions in 5 states were identified from the 1999 State Inpatient Databases of the Healthcare Cost and Utilization Project. Racial/ethnic differences in the likelihood of readmission were estimated by logistic regression with adjustment for patient demographic, clinical, and socioeconomic characteristics and hospital attributes. RESULTS: The risk-adjusted likelihood of 180-day readmission was significantly lower for non-Hispanic Whites than for Hispanics across all 3 payers or for non-Hispanic Blacks among Medicare enrollees. Within each payer, Hispanics from low-income communities had the highest risk of readmission. Among Medicare beneficiaries, Blacks and Hispanics had higher percentages of readmission for acute complications and microvascular disease, while Whites had higher percentages of readmission for macrovascular conditions. CONCLUSIONS: Racial/ethnic disparities are more evident in 180-day than in 30-day readmission rates, and greatest among the Medicare population. Readmission diagnoses vary by race/ethnicity, with Blacks and Hispanics at higher risk for those complications more likely preventable with effective postdischarge care.
Assuntos
Diabetes Mellitus/etnologia , Diabetes Mellitus/terapia , Hospitais/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Justiça Social , Adolescente , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Bases de Dados como Assunto , Diabetes Mellitus/epidemiologia , Feminino , Pesquisas sobre Atenção à Saúde , Hispânico ou Latino/estatística & dados numéricos , Hospitais/classificação , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , População Branca/estatística & dados numéricosRESUMO
BACKGROUND: Congress directed the Agency for Healthcare Research and Quality (AHRQ) to lead an effort for the US Department of Health and Human Services (DHHS) to develop 2 annual reports: a National Healthcare Quality Report (NHQR) and a National Healthcare Disparities Report (NHDR). OBJECTIVES: This article lays out key concepts, definitions, statistical methods, and findings from these first ever national reports on quality and disparities. We also summarize some possible future directions for the reports. RESEARCH DESIGN: The NHQR and NHDR rely on secondary analysis of available data from over 40 established, national databases. The NHQR presents data at the national level, by sociodemographic characteristics, and at the state level. The NHDR presents data broken out by race/ethnicity and by socioeconomic status. MEASURES: The 2003 NHQR presented data on approximately 140 quality measures and the NHDR presented data on these same measures plus approximately 100 measures of access to care. RESULTS: The reports found that high healthcare quality is not a given and that disparities are pervasive throughout the US healthcare system. In addition, they found the quality and disparities issues are particularly apparent in preventive care, but that greater improvement is possible. CONCLUSIONS: As these reports evolve for the 2004 version and beyond, they will be a vital step in the effort to improve healthcare quality for all populations in the United States.
Assuntos
Atenção à Saúde/tendências , Acessibilidade aos Serviços de Saúde , Qualidade da Assistência à Saúde , United States Agency for Healthcare Research and Quality , Adulto , Relatórios Anuais como Assunto , População Negra , Interpretação Estatística de Dados , Bases de Dados como Assunto , Atenção à Saúde/normas , Demografia , Etnicidade , Feminino , Previsões , Hispânico ou Latino , Humanos , Masculino , Programas de Rastreamento , Garantia da Qualidade dos Cuidados de Saúde , Segurança , Fatores Socioeconômicos , Estados Unidos , População BrancaRESUMO
BACKGROUND: In 1999, the US Congress mandated the Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (DHHS), to report annually to the nation about healthcare quality. One chapter in the National Healthcare Quality Report (NHQR) is focused on patient safety. OBJECTIVES: The objectives of this study were to describe the challenges in reporting the national status on patient safety for the first NHQR and discuss emerging opportunities to improve the comprehensiveness and reliability of future reporting. RESEARCH DESIGN: This study is a selective review of definitions, frameworks, data sources, measures, and emerging developments for assessing patient safety in the United States. RESULTS: Available data and measures for patient safety assessment in the nation are inadequate, especially for comparing regions and subpopulations and for trend analysis. However, many opportunities are emerging from the recently increased investments in patient safety research and many ongoing safety improvement efforts in the private sector and at the federal, state, and local government levels. CONCLUSION: There are many challenges in assessing national performance on patient safety today. Ongoing developments on multiple fronts will provide data and measures for more accurate and more comprehensive assessments of patient safety for future NHQRs.
Assuntos
Pacientes , Garantia da Qualidade dos Cuidados de Saúde , Segurança , United States Agency for Healthcare Research and Quality , Relatórios Anuais como Assunto , Infecção Hospitalar/prevenção & controle , Coleta de Dados , Humanos , Medicaid , Erros Médicos/prevenção & controle , Sistemas Computadorizados de Registros Médicos , Medicare , Pacientes/legislação & jurisprudência , Gestão da Segurança , Estados UnidosAssuntos
Atenção à Saúde/normas , Casas de Saúde/normas , Avaliação de Resultados em Cuidados de Saúde , Qualidade da Assistência à Saúde , Adulto , Idoso , Criança , Atenção à Saúde/economia , Atenção à Saúde/tendências , Custos de Medicamentos/tendências , Previsões , Humanos , Medicaid , Medicare , Casas de Saúde/economia , Pesquisa , Estados UnidosRESUMO
Decision makers in health care are increasingly interested in using high-quality scientific evidence to support clinical and health policy choices; however, the quality of available scientific evidence is often found to be inadequate. Reliable evidence is essential to improve health care quality and to support efficient use of limited resources. The widespread gaps in evidence-based knowledge suggest that systematic flaws exist in the production of scientific evidence, in part because there is no consistent effort to conduct clinical trials designed to meet the needs of decision makers. Clinical trials for which the hypothesis and study design are developed specifically to answer the questions faced by decision makers are called pragmatic or practical clinical trials (PCTs). The characteristic features of PCTs are that they (1) select clinically relevant alternative interventions to compare, (2) include a diverse population of study participants, (3) recruit participants from heterogeneous practice settings, and (4) collect data on a broad range of health outcomes. The supply of PCTs is limited primarily because the major funders of clinical research, the National Institutes of Health and the medical products industry, do not focus on supporting such trials. Increasing the supply of PCTs will depend on the development of a mechanism to establish priorities for these studies, significant expansion of an infrastructure to conduct clinical research within the health care delivery system, more reliance on high-quality evidence by health care decision makers, and a substantial increase in public and private funding for these studies. For these changes to occur, clinical and health policy decision makers will need to become more involved in all aspects of clinical research, including priority setting, infrastructure development, and funding.
Assuntos
Ensaios Clínicos como Assunto , Política de Saúde , Formulação de Políticas , Qualidade da Assistência à Saúde , Ensaios Clínicos como Assunto/economia , Ensaios Clínicos como Assunto/ética , Ensaios Clínicos como Assunto/normas , Ensaios Clínicos como Assunto/estatística & dados numéricos , Análise Custo-Benefício , Tomada de Decisões , Medicina Baseada em Evidências , Humanos , Avaliação das Necessidades , Avaliação de Resultados em Cuidados de Saúde , Seleção de Pacientes , Projetos de Pesquisa , Apoio à Pesquisa como Assunto , Estados UnidosRESUMO
OBJECTIVE: To describe the extent to which hospitalizations for patients with diabetes reflect multiple stays by the same individuals and to examine how multiple hospitalizations vary by patient demographic and socioeconomic characteristics. RESEARCH DESIGN AND METHODS: Using the Healthcare Cost and Utilization Project complete discharge data for five states (California, Missouri, New York, Tennessee, and Virginia) in 1999, we identified 648,748 nonneonatal, nonmaternal patients who had one or more hospitalizations listing diabetes. Multiple hospitalizations were measured as percent of patients with multiple stays, percent of total stays represented by multiple stays, and average number of stays per patient. Total hospital costs were also examined. Stratified analysis and regression were performed to assess differences by age, sex, race/ethnicity, payer, location, and income. RESULTS: Among patients with diabetes who had been hospitalized, 30% had two or more stays accounting for >50% of total hospitalizations and hospital costs. Controlled for patient age, sex, and clinical characteristics, the likelihood of having multiple hospitalizations was higher for Hispanics and non-Hispanic blacks compared with non-Hispanic whites, as well as for patients covered by Medicare or Medicaid and those living in low-income areas. The prevalence of diabetes complications and multiple conditions differed by age, race/ethnicity, and payer among patients with multiple stays. CONCLUSIONS: Multiple hospitalizations are common among patients with diabetes but vary by age, race/ethnicity, payer, and income, with those populations traditionally considered to be more vulnerable experiencing higher likelihoods of multiple stays. Significant opportunities exist to reduce the proportion of multiple hospitalizations for patients with diabetes. Clinical and policy interventions to improve the quality of care and outcomes for these patients should be designed accordingly and have the potential to pay major dividends.
Assuntos
Diabetes Mellitus/terapia , Hospitalização/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Custos e Análise de Custo , Demografia , Diabetes Mellitus/economia , Etnicidade , Feminino , Hospitalização/economia , Humanos , Lactente , Masculino , Maryland , Pessoa de Meia-Idade , Grupos Raciais , População Rural , Fatores Socioeconômicos , População UrbanaAssuntos
Atenção à Saúde/normas , Etnicidade , Acessibilidade aos Serviços de Saúde , Grupos Raciais , Justiça Social , United States Agency for Healthcare Research and Quality , Atenção à Saúde/organização & administração , Feminino , Humanos , Masculino , Área Carente de Assistência Médica , Fatores Socioeconômicos , Estados UnidosRESUMO
Several of AHRQ's priority areas including disease prevention, health promotion, primary care, quality of care, service delivery, and patient safety are particularly relevant to nurse researchers. With much national attention focused on nursing-related issues such as staff shortages, training, mandatory overtime, working conditions, and autonomy, it is mandatory that nursing research be conducted to inform healthcare delivery and policy. Nurses also need to contribute to the health services literature so that an even balance of discipline perspective is represented. AHRQ's mandate is represented by the slogan "quality research for quality health care." Although our understanding has expanded of contributors to and determinants of evidence-based practice and the relationship between clinical care and improved outcomes, we have much to learn. Appreciating how and which components of nursing care influence patient outcomes represents an essential area of research in need of development. While clarifying nursing contributions to improved outcomes is not the sole purview of nurse researchers, it is plausible to assume that a clinical background in nursing combined with strong methodological skills can help policy makers and health system leaders understand how nurses can most effectively contribute to outcomes and quality improvement. AHRQ is clearly interested in capacity building of researchers from all relevant disciplines. Nurses, the largest provider of healthcare, need to build capacity and develop a much stronger presence in the health services research community of scholars.
Assuntos
Pesquisa em Avaliação de Enfermagem/organização & administração , Avaliação de Resultados em Cuidados de Saúde/organização & administração , United States Agency for Healthcare Research and Quality , Prioridades em Saúde , Pesquisa sobre Serviços de Saúde/organização & administração , Humanos , Auditoria de Enfermagem , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Projetos de Pesquisa , Apoio à Pesquisa como Assunto , Estados UnidosRESUMO
OBJECTIVE: To summarize and analyze the focus and methodologies of the Translating Research into Practice (TRIP) projects funded in 1999-2000 by the US Agency for Healthcare Research and Quality (AHRQ). DATA SOURCES AND STUDY DESIGN: An analysis of the successful applications for the TRIP I and II requests for applications in 1999 and 2000 was produced from the data collected. DATA COLLECTION: The following items were abstracted from each of the successful applications: provider focus, patient population, vulnerable populations, methodologies, interventions for change, outcomes measured, and conceptual framework used. PRINCIPAL FINDINGS: AHRQ funded 27 TRIP grants in 1999 and 2000. A wide variety of health care providers, settings, and patients were the target of the grants. The most common study design was a randomized controlled trial. The most common TRIP interventions were educational and the most common frameworks were either adult learning theory or organizational theory. More than half of the projects planned to use information technology and half the projects had a focus on reducing errors. CONCLUSIONS: The TRIP projects encompass a broad range of providers, environments, patients, and interventions. The field of applied research and quality improvements should be considerably enhanced by these research projects.