Instrument adaptation and preliminary validation study of the Laryngeal Hypersensitivity Questionnaire used for assessment of laryngeal symptoms in patients with artificial airways.

BACKGROUND: The Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) was developed to measure abnormal laryngeal sensation and was originally validated in a patient sample from otolaryngologic and respiratory outpatient clinics. Modification is needed for patients who are mechanically ventilated via an endotracheal tube or a tracheostomy tube. OBJECTIVES: We sought to adapt and preliminarily validate a modified version of the LHQ appropriate for nurses and other clinicians to administer in acute hospital settings called the LHQ-Acute (LHQ-A). METHODS: Internal consistency and construct validity analyses using secondary data from patients at a tertiary teaching hospital who presented with symptoms of laryngeal irritability/hypersensitivity between September 2012 and October 2013 were performed. RESULTS: A total of 131 patients, most complaining of coughing and dysphonia, with a median age of 58 (interquartile range: 48, 66) years and 29 healthy participants with a median age of 62 (interquartile range: 50, 66) years were analysed. The original LHQ was reduced from 14 questions with responses on a 7-point scale to the LHQ-A containing 13 questions with responses on a 4-point scale. Correlations between items of the LHQ and LHQ-A were similar, and internal consistency was excellent and highly comparable, with Cronbach's alpha = 0.906 and 0.902, respectively. CONCLUSIONS: The LHQ-A, which has been adapted for nurses and other clinicians to administer to a critically ill patient population, demonstrated comparable reliability and validity to the original LHQ. Validation of the LHQ-A in independent patient populations from acute settings is necessary to better understand norms and changes during recovery from acute illness.

Development of the Experiences of Sex Work Stigma Scale Using Item Response Theory: Implications for Research on the Social Determinants of HIV.

While HIV stigma has received significant attention, limited work has been conducted on the measurement of intersecting stigmas. We developed the Experiences of Sex Work Stigma (ESWS) scale in the Dominican Republic (DR) and Tanzania. We conducted in-depth interviews with 20 female sex workers (FSW) per country to identify scale domains followed by cognitive debriefing interviews to assess content validity. Items were administered in a survey to FSW in DR (n = 211) and Tanzania (n = 205). Factor analysis established four sex work stigma domains including: shame (internalized), dignity (resisted), silence (anticipated) and treatment (enacted). Reliability across domains ranged from 0.81 to 0.93. Using item response theory (IRT) we created context-specific domain scores accounting for differential item functioning between countries. ESWS domains were associated with internalized HIV stigma, depression, anxiety, sexual partner violence and social cohesion across contexts. The ESWS is the first reliable and valid scale to assess multiple domains of sex work stigma and can be used to examine the effects of this form of intersectional stigma on HIV-related outcomes across settings.

Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators.

OBJECTIVE: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS: Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS: PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.

Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes.

INTRODUCTION: Minimally invasive surgery (MIS) for colorectal cancer (CRC) is increasingly common; however, uptake has differed by hospital type. It is unknown how these trends have evolved for laparoscopic or robotic approaches in different types of hospitals. This study assesses temporal trends for MIS utilization and examines differences in surgical outcomes by hospital type. METHODS: The National Cancer Database was queried for patients who underwent CRC surgery between 2010 and 2015. Time-trend analysis of MIS utilization was performed for both approaches by hospital type (community, comprehensive community, integrated network, academic). Multivariate logistic regression models were used to examine MIS utilization, differences in case severity, and surgical outcomes by hospital type, after controlling for patient characteristics. RESULTS: Across all hospital types, community hospitals had the lowest rate of laparoscopic (36.8%) and robotic (3.3%) procedures for CRC (P < 0.001). Community hospitals also exhibited a significant lag in adoption rate of robotic surgery (colon = 0.84% versus 1.41%/y; rectum = 2.14% versus 3.88 %/y). Community hospitals performing MIS had worse outcomes, including the most frequent conversions to open (colon = 15.2%; rectal = 17.1%) and highest 90-day mortality (colon = 6%; rectal = 3.2%) (P < 0.001). Finally, compared with laparoscopic colon surgery at academic centers, community centers treated lower grade tumors (OR 0.938, P < 0.05) with higher 30-day (OR 1.332, P < 0.05) and 90-day mortality (OR 1.210, P < 0.05). CONCLUSIONS: MIS for CRC lags at the community level and experiences worse postoperative outcomes. Future initiatives must focus on understanding and correcting this trend to ensure uniform access to high-quality surgical care.

Perceived Barriers to Mobility in a Medical ICU: The Patient Mobilization Attitudes & Beliefs Survey for the ICU.

PURPOSE: Early mobilization in the intensive care unit (ICU) can improve patient outcomes but has perceived barriers to implementation. As part of an ongoing structured quality improvement project to increase mobilization of medical ICU patients by nurses and clinical technicians, we adapted the existing, validated Patient Mobilization Attitudes & Beliefs Survey (PMABS) for the ICU setting and evaluated its performance characteristics and results. MATERIALS AND METHODS: The 26-item PMABS adapted for the ICU (PMABS-ICU) was administered as an online survey to 163 nurses, clinical technicians, respiratory therapists, attending and fellow physicians, nurse practitioners, and physician assistants in one medical ICU. We evaluated the overall and subscale (knowledge, attitude, and behavior) scores and compared these scores by respondent characteristics (clinical role and years of work experience). RESULTS: The survey response rate was 96% (155/163). The survey demonstrated acceptable discriminant validity and acceptable internal consistency for the overall scale (Cronbach α: 0.82, 95% confidence interval: 0.76-0.85), with weaker internal consistency for all subscales (Cronbach α: 0.62-0.69). Across all respondent groups, the overall barrier score (range: 1-100) was relatively low, with attending physicians perceiving the lowest barriers (median [interquartile range]: 30 [28-34]) and nurses perceiving the highest (37 [31-40]). Within the first 10 years of work experience, greater experience was associated with a lower overall barrier score (-0.8 for each additional year; P = 0.02). CONCLUSIONS: In our medical ICU, across 6 different clinical roles, there were relatively low perceived barriers to patient mobility, with greater work experience over the first 10 years being associated with lower perceived barriers. As part of a structured quality improvement project, the PMABS-ICU may be valuable in assisting to identify specific perceived barriers for consideration in designing mobility interventions for the ICU setting.

Climate of Respect Evaluation in ICUs: Development of an Instrument (ICU-CORE).

OBJECTIVES: To develop a valid, reliable measure that reflected the environment of respectfulness within the ICU setting. DESIGN: We developed a preliminary survey instrument based on conceptual domains of respect identified through prior qualitative analyses of ICU patient, family member, and clinician perspectives. The initial instrument consisted of 21 items. After five cognitive interviews and 16 pilot surveys, we revised the instrument to include 23 items. We used standard psychometric methods to analyze the instrument. SETTINGS: Eight ICUs serving adult patients affiliated with a large university health system. SUBJECTS: ICU clinicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on 249 responses, we identified three factors and created subscales: General Respect, Respectful Behaviors, and Disrespectful Behaviors. The General Respect subscale had seven items (α = 0.932) and reflected how often patients in the ICU are treated with respect, in a dignified manner, as an individual, equally to all other patients, on the "same level" as the ICU team, as a person, and as you yourself would want to be treated. The Respectful Behaviors subscale had 10 items (α = 0.926) and reflected how often the ICU team responds to patient and/or family anxiety, makes an effort to get to know the patient and family as people, listens carefully, explains things thoroughly, gives the opportunity to provide input into care, protects patient modesty, greets when entering room, and talks to sedated patients. The subscale measuring disrespect has four items (α = 0.702) and reflects how often the ICU team dismisses family concerns, talks down to patients and families, speaks disrespectfully behind their backs, and gets frustrated with patients and families. CONCLUSIONS: We created a reliable set of scales to measure the climate of respectfulness in intensive care settings. These measures can be used for ongoing quality improvement that aim to enhance the experience of ICU patients and their families.

Evaluating Muscle Mass in Survivors of Acute Respiratory Distress Syndrome: A 1-Year Multicenter Longitudinal Study.

OBJECTIVES: Rapid muscle wasting occurs during acute respiratory failure, resulting in muscle weakness and functional impairments. This study examines survivors' body composition in the year after acute respiratory distress syndrome and tests associations of patient characteristics, hospital exposures, and survivors' strength and physical functioning with whole body percent lean mass. DESIGN: Prospective cohort study with 6- and 12-month follow-up. SETTING: National study enrolling patients from five study centers. PATIENTS: Acute respiratory distress syndrome survivors (n = 120). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Lean and fat mass from dual energy x-ray absorptiometry. On average, survivors gained whole body total mass (+1.4 kg; 0.1-2.7) and fat mass (+1.2 kg; 0.2-2.2) and maintained lean mass (+0.2 kg; -0.4 to 0.8) between 6 and 12 months. Proportionally, percent fat mass increased and percent lean mass decreased for the whole body, trunk, and legs (p < 0.05). Greater whole body percent lean mass was associated with younger age, male sex, and lower baseline body mass index, but not other patient characteristics or ICU/hospital exposures. Greater percent lean mass was also significantly associated with gait speed and 6-minute walk distance, but not volitional strength or self-reported functional status. CONCLUSIONS: In the first year after acute respiratory distress syndrome, patients gained fat mass and maintained lean mass. We found no association of whole body percent lean mass with commonly hypothesized hospital risk factors. Direct measurement of body composition and performance-based functional measures may be helpful for understanding functional recovery in ICU survivors.

The neighborhood environment and obesity: Understanding variation by race/ethnicity.

Neighborhood characteristics have been associated with obesity, but less is known whether relationships vary by race/ethnicity. This study examined the relationship between soda consumption - a behavior strongly associated with obesity - and weight status with neighborhood sociodemographic, social, and built environments by race/ethnicity. We merged data on adults from the 2011-2013 California Health Interview Survey, U.S. Census data, and InfoUSA (n=62,396). Dependent variables were soda consumption and weight status outcomes (body mass index and obesity status). Main independent variables were measures of three neighborhood environments: social (social cohesion and safety), sociodemographic (neighborhood socioeconomic status, educational attainment, percent Asian, percent Hispanic, and percent black), and built environments (number of grocery stores, convenience stores, fast food restaurants, and gyms in neighborhood). We fit multi-level linear and logistic regression models, stratified by individual race/ethnicity (NH (non-Hispanic) Whites, NH African Americans, Hispanics, and NH Asians) controlling for individual-level characteristics, to estimate neighborhood contextual effects on study outcomes. Lower neighborhood educational attainment was associated with higher odds of obesity and soda consumption in all racial/ethnic groups. We found fewer associations between study outcomes and the neighborhood, especially the built environment, among NH African Americans and NH Asians. While improvements to neighborhood environment may be promising to reduce obesity, null associations among minority subgroups suggest that changes, particularly to the built environment, may alone be insufficient to address obesity in these groups.

Are physical measures related to patient-centred outcomes in ARDS survivors?

OBJECTIVE: To inform selection of physical measures for studies of acute respiratory distress syndrome (ARDS) survivors within 12 months of ARDS. METHODS: Secondary analysis of data from 6-month survivors participating in a US multicentre prospective study (ARDSNet Long-Term Outcome Study, N=134) or a multisite prospective study in Baltimore, Maryland, USA (Improving Care of Acute Lung Injury Patients, N=99). Physical measures, assessed at 6-month follow-up, were categorised according to the WHO's International Classification of Disability and Health: body functions and structures, activity and participation. Patient-centred outcomes were evaluated at 6 and 12 months: survival, hospitalisation, alive at home status and health-related quality of life. Pearson correlation, linear and logistic regression models were used to quantify associations of physical measures with patient-centred outcomes. MAIN RESULTS: No 6-month body functions and structures measure demonstrated consistent association with 6-month or 12-month outcomes in multivariable regression. The 6 min walk test, an activity measure, was associated with 6-month Short-Form 36 (SF-36) physical component scores (PCS, ß range: 0.99 to 1.52, p<0.05). Participation measures (Functional Performance Inventory, FPI; Instrumental Activities of Daily Living, IADLs) were associated with SF-36 PCS (ß range: FPI, 1.51-1.52; IADL, -1.88 to -1.32; all p<0.05) and Euro-QOL-5D utility score (ß range: FPI, 2.00-3.67; IADL, -2.89 to -2.50; all p<0.01) at 6 and 12 months. CONCLUSIONS: Participation measures better reflect patient's quality of life than measures of body functions and structures within 12 months of ARDS among 6-month survivors, and are recommended for inclusion as a core measure in future studies.

Development and validation of the Medical Student Scholar-Ideal Mentor Scale (MSS-IMS).

BACKGROUND: Programs encouraging medical student research such as Scholarly Concentrations (SC) are increasing nationally. However, there are few validated measures of mentoring quality tailored to medical students. We sought to modify and validate a mentoring scale for use in medical student research experiences. METHODS: SC faculty created a scale evaluating how medical students assess mentors in the research setting. A validated graduate student scale of mentorship, the Ideal Mentor Scale, was modified by selecting 10 of the 34 original items most relevant for medical students and adding an item on project ownership. We administered this 11-item assessment to second year medical students in the Johns Hopkins University SC Program from 2011 to 2016, and performed exploratory factor analysis with oblique rotation to determine included items and subscales. We correlate overall mentoring quality scale and subscales with four student outcomes: 'very satisfied' with mentor, 'more likely' to do future research, project accepted at a national meeting, and highest SC faculty rating of student project. RESULTS: Five hundred ninety-eight students responded (87% response rate). After factor analysis, we eliminated three items producing a final scale of overall mentoring quality (8 items, Cronbach's alpha = 0.92) with three subscales: advocacy, responsiveness, and assistance. The overall mentoring quality scale was significantly associated with all four student outcomes, including mentor satisfaction: OR [(95% CI), p-value] 1.66 [(1.53-1.79), p < 0.001]; likelihood of future research: OR 1.06 [(1.03-1.09), p < 0.001]; abstract submission to national meetings: OR 1.05 [(1.02-1.08), p = 0.002]; and SC faculty rating of student projects: OR 1.08 [(1.03-1.14), p = 0.004]. Each subscale also correlated with overall mentor satisfaction, and the strongest relationship of each subscale was seen with 'mentor advocacy.' CONCLUSIONS: Mentor quality can be reliably measured and associates with important medical student scholarly outcomes. Given the lack of tools, this scale can be used by other SC Programs to advance medical students' scholarship.

Evaluating Physical Outcomes in Acute Respiratory Distress Syndrome Survivors: Validity, Responsiveness, and Minimal Important Difference of 4-Meter Gait Speed Test.

OBJECTIVE: To examine the reliability, validity, responsiveness, and minimal important difference of the 4-m gait speed test in acute respiratory distress syndrome survivors. DESIGN: Secondary analyses of data from two longitudinal follow-up studies of acute respiratory distress syndrome survivors. Test-retest and inter-rater reliability, construct validity (convergent, discriminant, and known group), predictive validity, and responsiveness were examined. The minimal important difference was estimated using anchor- and distribution-based approaches. SETTING: A national multicenter prospective study (ARDSNet Long-Term Outcome Study) and a multisite prospective study in Baltimore, MD (Improving Care of Acute Lung Injury Patients). PATIENTS: Acute respiratory distress syndrome survivors with 4-m gait speed assessment up to 60 months after acute respiratory distress syndrome (ARDSNet Long-Term Outcome Study, n = 184; Improving Care of Acute Lung Injury Patients, n = 122). INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Four-meter gait speed was assessed at 6- and 12-month follow-up (ARDSNet Long-Term Outcome Study) and 36-, 48-, and 60-month follow-up (Improving Care of Acute Lung Injury Patients). Excellent test-retest (intraclass correlation, 0.89-0.99 across studies and follow-up) and inter-rater (intraclass correlation, 0.97) reliability were found. Convergent validity was supported by moderate-to-strong correlations (69% of 32 > 0.40) with other physical function measures. Discriminant validity was supported by weak correlations (86% of 28 < 0.30) with mental health measures. Survivors with impaired versus nonimpaired measures of muscle strength and pulmonary function had significantly slower 4-m gait speed (all but one p < 0.05). Furthermore, 4-m gait speed significantly predicted future hospitalization and health-related quality of life. Gait speed changes were consistent with reported changes in function, supporting responsiveness. The estimated 4-m gait speed minimal important difference was 0.03-0.06 m/s. CONCLUSIONS: The 4-m gait speed is a reliable, valid, and responsive measure of physical function in acute respiratory distress syndrome survivors. The estimated minimal important difference will facilitate sample size calculations for clinical studies evaluating the 4-m gait speed test in acute respiratory distress syndrome survivors.

Functional Status Score for the ICU: An International Clinimetric Analysis of Validity, Responsiveness, and Minimal Important Difference.

OBJECTIVES: To evaluate the internal consistency, validity, responsiveness, and minimal important difference of the Functional Status Score for the ICU, a physical function measure designed for the ICU. DESIGN: Clinimetric analysis. SETTINGS: Five international datasets from the United States, Australia, and Brazil. PATIENTS: Eight hundred nineteen ICU patients. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Clinimetric analyses were initially conducted separately for each data source and time point to examine generalizability of findings, with pooled analyses performed thereafter to increase power of analyses. The Functional Status Score for the ICU demonstrated good to excellent internal consistency. There was good convergent and discriminant validity, with significant and positive correlations (r = 0.30-0.95) between Functional Status Score for the ICU and other physical function measures, and generally weaker correlations with nonphysical measures (|r| = 0.01-0.70). Known group validity was demonstrated by significantly higher Functional Status Score for the ICU scores among patients without ICU-acquired weakness (Medical Research Council sum score, ≥ 48 vs < 48) and with hospital discharge to home (vs healthcare facility). Functional Status Score for the ICU at ICU discharge predicted post-ICU hospital length of stay and discharge location. Responsiveness was supported via increased Functional Status Score for the ICU scores with improvements in muscle strength. Distribution-based methods indicated a minimal important difference of 2.0-5.0. CONCLUSIONS: The Functional Status Score for the ICU has good internal consistency and is a valid and responsive measure of physical function for ICU patients. The estimated minimal important difference can be used in sample size calculations and in interpreting studies comparing the physical function of groups of ICU patients.

What is the role of community capabilities for maternal health? An exploration of community capabilities as determinants to institutional deliveries in Bangladesh, India, and Uganda.

BACKGROUND: While community capabilities are recognized as important factors in developing resilient health systems and communities, appropriate metrics for these have not yet been developed. Furthermore, the role of community capabilities on access to maternal health services has been underexplored. In this paper, we summarize the development of a community capability score based on the Future Health System (FHS) project's experience in Bangladesh, India, and Uganda, and, examine the role of community capabilities as determinants of institutional delivery in these three contexts. METHODS: We developed a community capability score using a pooled dataset containing cross-sectional household survey data from Bangladesh, India, and Uganda. Our main outcome of interest was whether the woman delivered in an institution. Our predictor variables included the community capability score, as well as a series of previously identified determinants of maternal health. We calculate both population-averaged effects (using GEE logistic regression), as well as sub-national level effects (using a mixed effects model). RESULTS: Our final sample for analysis included 2775 women, of which 1238 were from Bangladesh, 1199 from India, and 338 from Uganda. We found that individual-level determinants of institutional deliveries, such as maternal education, parity, and ante-natal care access were significant in our analysis and had a strong impact on a woman's odds of delivering in an institution. We also found that, in addition to individual-level determinants, greater community capability was significantly associated with higher odds of institutional delivery. For every additional capability, the odds of institutional delivery would increase by up to almost 6 %. CONCLUSION: Individual-level characteristics are strong determinants of whether a woman delivered in an institution. However, we found that community capability also plays an important role, and should be taken into account when designing programs and interventions to support institutional deliveries. Consideration of individual factors and the capabilities of the communities in which people live would contribute to the vision of supporting people-centered approaches to health.

Patient perspectives of care and process and outcome quality measures for heart failure admissions in US hospitals: how are they related in the era of public reporting?

IMPORTANCE: Process quality measure performance has improved significantly with public reporting, requiring reevaluation of process-outcome relationships and the emerging role of patient perspectives on care. OBJECTIVE: To evaluate associations between heart failure patient perspectives of care and publicly reported processes and outcomes. DESIGN: Cross-sectional study, July 2008-June 2011. SETTING: US hospitals in the Press Ganey database. PARTICIPANTS: Heart failure inpatients. MEASURES: Outcomes were Hospital Compare hospital-level risk-adjusted 30-day heart failure mortality and readmissions. Predictors included Hospital Compare heart failure processes of care, a weighted process composite and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains for heart failure. Hospital characteristics included volume of heart failure patients and race, health status and education. RESULTS: Among 895 included hospitals, performance on process measures was high (median by hospital for composite, 95.6%); the median HCAHPS overall rating was 86.9. Median mortality was 11.3% and readmissions was 24.8%. No process measures were statistically significantly associated with lower mortality or readmissions in adjusted analyses. Higher ratings on HCAHPS patient perspectives of care were significantly correlated with lower readmissions in adjusted analyses, particularly those publicly reported domains conceptually related to readmissions. The magnitude was small (1.8 points higher on a 100-point scale between the highest and lowest quartiles of hospital readmissions). CONCLUSIONS: Publicly reported process quality measures were no longer associated with outcomes, but higher patient perspectives of care were associated with lower heart failure readmissions. These associations support continued reevaluation of these measures and increased emphasis on patient experience and outcomes, as planned for Value-Based Purchasing.

Variations in Asian Americans: How Neighborhood Concordance Is Associated With Health Care Access and Utilization.

We examined associations of different levels of same-ethnicity neighborhood concordance with health care access and utilization among all Asian American, Chinese, Filipino, and Vietnamese adults (aged 18-64 years) using the 2005, 2007, and 2009 California Health Interview Survey and the 2010 US Census. Although associations varied by subgroup, Asian Americans in highly concordant neighborhoods were more likely to lack a usual source of care but did not lack doctor visits or experience delays in medical care and prescriptions.

Effect of acculturation on variations in having a usual source of care among Asian Americans and non-Hispanic whites in California.

OBJECTIVES: We examined variations in having a usual source of care (USC) among non-Hispanic White and Asian American adults in California. METHODS: Data were from the 2005 and 2009 California Health Interview Survey. Using a modified Anderson model, we used multiple logistic regression to compare odds of having a USC between non-Hispanic White (n=38554) and Asian American adults (n=7566) and to examine associations with acculturation factors (English proficiency, length of residence, residence in a racially concordant neighborhood) and key enabling (employment, income, insurance) and predisposing (education) factors. RESULTS: Race-related disparities between Asian Americans and non-Hispanic Whites in having a USC were no longer significant after accounting for acculturation factors. Limited English proficiency and short time in the United States (<5 years) were significantly associated with not having a USC for both races. Increasing levels of education and insurance were not associated with better access among Asian Americans. CONCLUSIONS: Key differences exist in how Asian American and non-Hispanic White adults access care. Acculturation factors are key drivers of disparities and should be included in access-to-care models with Asians. Insurance and education are differentially significant for Asian Americans and non-Hispanic Whites.

Cognitive screening among acute respiratory failure survivors: a cross-sectional evaluation of the Mini-Mental State Examination.

INTRODUCTION: The Mini-Mental State Examination (MMSE) is a common cognitive screening test, but its utility in identifying impairments in survivors of acute respiratory failure is unclear. The purpose of this study was to evaluate MMSE performance versus a concurrently administered detailed neuropsychological test battery in survivors of acute respiratory failure. METHODS: This cross-sectional analysis used data from the ARDSNet Long Term Outcomes Study (ALTOS) and Awakening and Breathing Controlled Trial (ABC). Participants were 242 survivors of acute respiratory failure. The MMSE and detailed neuropsychological tests were administered at 6 and 12 months post-hospital discharge for the ALTOS study, and at hospital discharge, 3 and 12 months for the ABC study. Overall cognitive impairment identified by the MMSE (score <24) was compared to impairments identified by the neuropsychological tests. We also matched orientation, registration, attention, memory and language domains on the MMSE to the corresponding neuropsychological test. Pairwise correlations, sensitivity, specificity, positive and negative predictive values, and agreement were assessed. RESULTS: Agreement between MMSE and neuropsychological tests for overall cognitive impairment was fair (42 to 80%). Specificity was excellent (≥93%), but sensitivity was poor (19 to 37%). Correlations between MMSE domains and corresponding neuropsychological tests were weak to moderate (6 months: r = 0.11 to 0.28; 12 months: r = 0.09 to 0.34). The highest correlation between the MMSE and neuropsychological domains was for attention at 6 months (r = 0.28) and language at 12 months (r = 0.34). CONCLUSIONS: In acute respiratory failure survivors, the MMSE has poor sensitivity in detecting cognitive impairment compared with concurrently administered detailed neuropsychological tests. MMSE results in this population should be interpreted with caution.

Modern Measurement Approaches to Health Literacy Scale Development and Refinement: Overview, Current Uses, and Next Steps.

There are currently more than 100 health literacy instruments. The procedures used to develop and test the measures are primarily guided by classical test theory. However, a small and growing number (n = 13) of health literacy measures are guided by modern measurement theories such as item response theory. This article briefly describes (a) the benefits of using modern measurement approaches for the development of health literacy measures, (b) how these approaches have been used with existing health literacy measures, and (c) some considerations for how modern measurement theory can help strengthen future work in health literacy measurement. Ultimately, this article provides evidence to support an assertive shift toward the use of modern measurement approaches in health literacy instrument development.

Factors associated with having a usual source of care in an ethnically diverse sample of Asian American adults.

BACKGROUND: Despite significant population increases, how Asian Americans ethnic subgroups vary in having a usual source of care (USC) is poorly understood. OBJECTIVES: To examine how having a USC varies among Asian American ethnic subgroups (Chinese, Filipinos, Japanese, Koreans, Vietnamese, and South Asians), and the potential factors influencing variation in having a USC. RESEARCH DESIGN: Data were from 2005 and 2009 California Health Interview Survey. Logistic regressions and pair-wise comparisons were used to compare odds of having a USC among Asian ethnic adults (18-64 y) and to examine ethnicity-specific associations with immigration-related factors (English proficiency, length of residence, and living in an ethnically concordant neighborhood) and key enabling (employment, income, insurance), predisposing (education), and need (health status) factors. Models also adjusted for other sociodemographic factors. RESULTS: Significant differences in the magnitude of the variation and factors influencing having a USC were found across Asian subgroups. Korean and Japanese adults had 52%-69% lower adjusted odds of having a USC compared with Chinese. Among all Asian subgroups, uninsured adults had 85%-94% lower adjusted odds of having a USC. Patterns of associations with USC and key factors varied by specific Asian subgroup. CONCLUSIONS: Patterns of associations for USC varied by Asian subgroup, although uninsurance persisted significantly across all subgroups. Persistent variation and heterogenous associations suggest that targeted, ethnicity-specific policies and outreach are needed to improve having a USC for Asian American ethnic adults.