Insight into patient dissatisfaction with asthma treatment.

BACKGROUND: Measures of patient satisfaction or dissatisfaction with treatment are increasingly being used as indicators of quality of care. As these measures become more widely used, it is important to know if patient dissatisfaction is associated with important processes or outcomes of medical care. METHODS: Survey of patient-reported asthma management issues using the Asthma Therapy Assessment Questionnaire in a large health maintenance organization in the Pacific Northwest. Associations between patient dissatisfaction with asthma treatment and patient-reported measures of asthma control, patient-provider communication, and belief in asthma medications (self-efficacy) were examined. RESULTS: Of the 5181 adult members with asthma enrolled in the health maintenance organization, 30% indicated dissatisfaction with current treatment. Dissatisfaction was higher among patients with a higher number of asthma control problems, patient-provider communication problems, or belief in medication problems (eg, failure to believe their medications are useful and inability to take asthma medications as directed). The odds of dissatisfaction with treatment were 2.8 (95% confidence interval [CI], 2.4-3.3; P<.001) for asthma control problems, 2.0 (95% CI, 1.6-2.6; P<.001) for communication problems, and 8.0 (95% CI, 6.7-9.5; P<.001) for belief in medication problems compared with patients without these perceived problems. CONCLUSION: Patient dissatisfaction with treatment may be related to important asthma disease management issues.

Incidence and characteristics of antibiotic use in aged nursing home patients.

OBJECTIVE: To measure the prevalence, incidence, types, and certain characteristics of antibiotics prescribed in nursing homes. DESIGN AND SETTING: Periodic survey over 1 year of patient charts in 53 stratified, randomly selected nursing homes in the state of Maryland. PATIENTS: All patients 65 years of age or more residing in these nursing homes on the first day of study. RESULTS: Of 4,165 patients in 53 nursing homes, records over the year were satisfactory in 3,899 patients in 52 nursing homes. The prevalence of antibiotic use on the first day of the study was 8%. Over the next 12 months, observations of more than one million patient-days revealed an incidence of 0.46 antibiotic courses/100 patient-days; 54% of the 3,899 patients received at least one antibiotic course. For presumed active infections, beta lactam antibiotics were the most commonly used, 54% of antibiotic orders. For all antibiotics, urinary tract infection was the most common indication, eliciting 36% of orders including 9% for asymptomatic bacteriuria. Skin, lower respiratory, and upper respiratory infections comprised 14%-17% each. Physicians prescribed 94% of courses but documented examinations of only 44% of patients at the outset of these courses. Consensus criteria for minimal diagnostic evaluation of four selected infections were met in only 11% of episodes of infection. Although the most serious infections tended to be better evaluated than others, 31% of the former were not noted to have been examined by a physician. Three percent of orders were for prophylaxis and two-thirds of these antibiotics were administered for more than 2 days. CONCLUSIONS: Antibiotics are frequently prescribed for aged nursing home patients, often in the absence of a physician's examination and other features commonly performed in evaluation of specific infectious diseases. More than one-fifth of antibiotics prescribed by presumed active infections were for two infections usually thought not to require antibiotic therapy, "viral" upper respiratory infection (13%) and asymptomatic bacteriuria (9%). To optimize antibiotic use in nursing homes, greater attention should be directed to appropriate durations of prophylaxis for urologic, dental, and minor surgical procedures; to standards for diagnostic evaluations of common infections; and to the roles of antibiotics in upper respiratory infections and in asymptomatic bacteriuria.

Epidemiology of drug-drug interactions as a cause of hospital admissions.

The purpose of this review was to focus on hospital admissions caused by a specific type of adverse drug reaction (ADR) that can be assumed to be avoidable in almost all cases: the drug-drug interaction (D-DI). To determine the epidemiology of D-DIs in hospital admissions, a review of the adverse drug reaction literature was undertaken to answer several questions: (a) what is the incidence of hospital admissions attributable to D-DIs?; (b) what percentage of drug-related hospital admissions are attributable to D-DIs?; (c) are there any patterns to the above findings, i.e. are some D-DIs or specific drugs more likely to have been associated with hospital admissions?; and (d) are there certain patient risk factors (e.g. age) that are associated with D-DIs that led to a hospital admission? Nine ADR studies were found that either included a D-DI category as a cause for hospital admissions, or provided sufficient information so that a causal relationship could be inferred. The incidence of hospital admissions due to D-DIs ranged from 0 to 2.8%. The data found in the studies we reviewed, however, were insufficient to allow meaningful quantification of specific drugs as usual causes for D-DI-related admissions, and because of the very small numbers of patients for which a D-DI was believed to be the cause it is not possible to provide a meaningful summary of risk factors specific for D-DI admissions. We cannot conclude that D-DIs are a significant problem. There is a need to view the quantification of D-DIs in relation to the number of medications prescribed by physicians, dispensed by pharmacists and taken by patients.

The quality of health data obtained in a new survey of elderly Americans: a validation study of the proposed Medicare Beneficiary Health Status Registry (MBHSR).

The Medicare Beneficiary Health Status Registry (MBHSR) is a proposed new survey program that would collect health status indicators annually from large probability samples of Medicine beneficiaries. For reasons of economy, the MBHSR would use mail survey procedures with telephone follow-up of nonrespondents. Because of concerns about response rates and the validity and reliability of the data obtained by such methods, a large-scale (N = 1,922) field test was conducted. The field test assessed the validity of MBHSR survey reports of past medical treatment and conditions by comparing those reports with Medicare claims data. It assessed the (internal) reliability of MBHSR survey responses by comparing responses with logically related survey questions from the MBHSR. Analyses indicate that the MBHSR survey procedures using a combination of mail data collection with telephone follow-up of nonrespondents produced relatively high levels of sensitivity and specificity in identifying medical treatments and procedures previously recorded in Medicare claims data. In addition, the MBHSR Field Test obtained, in general, relatively high levels of internal consistency in survey reports.

Effects of race and income on mortality and use of services among Medicare beneficiaries.

BACKGROUND: There are wide disparities between blacks and whites in the use of many Medicare services. We studied the effects of race and income on mortality and use of services. METHODS: We linked 1990 census data on median income according to ZIP Code with 1993 Medicare administrative data for 26.3 million beneficiaries 65 years of age or older (24.2 million whites and 2.1 million blacks). We calculated age-adjusted mortality rates and age- and sex-adjusted rates of various diagnoses and procedures according to race and income and computed black:white ratios. The 1993 Medicare Current Beneficiary Survey was used to validate the results and determine rates of immunization against influenza. RESULTS: For mortality, the black:white ratios were 1.19 for men and 1.16 for women (P<0.001 for both). For hospital discharges, the ratio was 1.14 (P<0.001), and for visits to physicians for ambulatory care it was 0.89 (P<0.001). For every 100 women, there were 26.0 mammograms among whites and 17.1 mammograms among blacks. As compared with mammography rates in the respective most affluent group, rates in the least affluent group were 33 percent lower among whites and 22 percent lower among blacks. The black:white rate ratio was 2.45 for bilateral orchiectomy and 3.64 for amputations of all or part of the lower limb (P<0.001 for both). For every 1000 beneficiaries, there were 515 influenza immunizations among whites and 313 among blacks. As compared with immunization rates in the respective most affluent group, rates in the least affluent group were 26 percent lower among whites and 39 percent lower among blacks. Adjusting the mortality and utilization rates for differences in income generally reduced the racial differences, but the effect was relatively small. CONCLUSIONS: Race and income have substantial effects on mortality and use of services among Medicare beneficiaries. Providing health insurance is not enough to ensure that the program is used effectively and equitably by all beneficiaries.

Association of asthma control with health care utilization and quality of life.

Asthma severity and level of asthma control are two related, but conceptually distinct, concepts that are often confused in the literature. We report on an index of asthma control developed for use in population-based disease management. This index was measured on 5,181 adult members of a large health maintenance organization (HMO), as were various self-reported measures of health care utilization (HCU) and quality of life (QOL). A simple index of number of control problems, ranging from none through four, exhibited marked and highly significant cross-sectional associations with self- reported HCU and with both generic and disease-specific QOL instruments, suggesting that each of the four dimensions of asthma control represented by these problems correlates with clinically significant impairment. Qualitatively similar results were found for control problems assessed relative to the past month and relative to the past year. Asthma control is an important "vital sign" that may be useful both for population-based disease management as well as for the management of individual patients.

Monitoring the health status and impact of treatment on Americans: the Medicare Beneficiary Health Status Registry.

OBJECTIVE: A major new survey program, the Medicare Beneficiary Health Status Registry (MBHSR), has been proposed to improve the monitoring of the health status of Medicare beneficiaries. The MBHSR would collect data by mail with telephone follow up of nonrespondents to permit economical assessment of a total Registry of approximately 200,000 Medicare beneficiaries, approximately 54,000 of whom would be surveyed in any given year. (Surveys would be conducted of samples of new enrollees who would be reinterviewed every five years.) METHOD: To assess the feasibility of that approach, a field test was conducted with a probability sample (n = 1,922) that comprised approximately equal numbers of new Medicare enrollees (aged, 65) and current beneficiaries (age range, 76-80). The field test was designed to assess the quality of the data that this design would produce. FINDINGS: Results indicate that the proposed design of the MBHSR could achieve response rates of approximately 80% among both age cohorts using a survey instrument that took 30 minutes to complete. Internal reliability of Activities of Daily Living, Instrumental Activities of Daily Living, Mobility, Mental Health Index, General Health, and Prostate Symptomatology scales ranged from 0.77 to 0.93. When measurements were repeated approximately 30 days after the initial survey, moderate to high levels of cross temporal correlation (range, 0.64-0.96) were found for most indexes, with the exception of prostate symptomatology. In addition, an earlier comparison of survey responses in the MBHSR field test to Medicare payment records indicated that the MBHSR field test obtained highly accurate reports of most of the major surgeries that were recorded in Medicare claims files. CONCLUSION: The design proposed for the MBHSR is feasible. If implemented, it should produce acceptably high rates of response and data quality.