Biomedical subjects

Paul D Cleary

Publications and source records attributed to Paul D Cleary.

At least 19 recordsLinked to original sources

PubMed2006

Communication about prognosis between parents and physicians of children with cancer: parent preferences and the impact of prognostic information.

PURPOSE: Concerns about the harms of prognostic information, including distress and loss of hope, cause some physicians to avoid frank disclosure. We aimed to determine parent preferences for prognostic information about their children with cancer and the results of receiving such information. PATIENTS AND METHODS: We surveyed 194 parents of children with cancer (overall response rate, 70%), treated at the Dana-Farber Cancer Institute and Children's Hospital (Boston, MA) and the children's physicians. Our main outcome measure was parent rating of prognostic information as extremely or very upsetting. RESULTS: The majority of parents desired as much information about prognosis as possible (87%) and wanted it expressed numerically (85%). Although 36% of parents found information about prognosis to be extremely or very upsetting, those parents were more likely to want additional information about prognosis than those who were less upset (P = .01). Parents who found information upsetting were no less likely to say that knowing prognosis was important (P = .39), that knowing prognosis helped in decision making (P = .40), or that hope for a cure kept them going (P = .72). CONCLUSION: Although many parents find prognostic information about their children with cancer upsetting, parents who are upset by prognostic information are no less likely to want it. The upsetting nature of prognostic information does not diminish parents' desire for such information, its importance to decision making, or parents' sense of hope.

Adolescent↗

PubMed2006

Correlates of electronic health record adoption in office practices: a statewide survey.

OBJECTIVE: Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption. DESIGN: Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey. MEASUREMENTS: EHR adoption rates. RESULTS: The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%). CONCLUSIONS: While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

Attitude to Computers↗

PubMed2006

The reliability of survey assessments of characteristics of medical clinics.

OBJECTIVE: To assess the reliability of survey measures of organizational characteristics based on reports of single and multiple informants. DATA SOURCE: Survey of 330 informants in 91 medical clinics providing care to HIV-infected persons under Title III of the Ryan White CARE Act. STUDY DESIGN: Cross-sectional survey. DATA COLLECTION METHODS: Surveys of clinicians and medical directors measured the implementation of quality improvement initiatives, priorities assigned to aspects of HIV care, barriers to providing high-quality HIV care, and quality improvement activities. Reliability of measures was assessed using generalizability coefficients. Components of variance and clinician-director differences were estimated using hierarchical regression models with survey items and informants nested within organizations. PRINCIPAL FINDINGS: There is substantial item- and informant-related variability in clinic assessments that results in modest or low clinic-level reliability for many measures. Directors occasionally gave more optimistic assessments of clinics than did clinicians. CONCLUSIONS: For most measures studied, obtaining adequate reliability requires multiple informants. Using multiple-item scales or multiple informants can improve the psychometric performance of measures of organizational characteristics. Studies of such characteristics should report the organizational level reliability of the measures used.

Adult↗

PubMed2005

Quality of HIV care provided by nurse practitioners, physician assistants, and physicians.

BACKGROUND: Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide. OBJECTIVE: To compare the quality of care provided by NPs and PAs with that provided by physicians. DESIGN: Cross-sectional analysis. SETTING: 68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states. PARTICIPANTS: The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS. MEASUREMENTS: 8 quality-of-care measures assessed by medical record review. RESULTS: After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P < 0.001] and 0.62 [P = 0.025], respectively). Nurse practitioners and PAs had statistically significantly higher performance scores than generalist non-HIV experts on 6 of the 8 quality measures. LIMITATIONS: These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes. CONCLUSIONS: For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non-HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.

Acquired Immunodeficiency Syndrome↗

PubMed2005

Physician specialization and the quality of care for human immunodeficiency virus infection.

BACKGROUND: There is debate over the types of physicians who should treat patients with complex chronic medical conditions such as human immunodeficiency virus (HIV) infection. We sought to assess the relationship between specialty training and expertise and the quality of care delivered to patients with HIV infection. METHODS: We selected random samples of HIV-infected patients receiving care at 64 Ryan White CARE (Comprehensive AIDS Resources Emergency) Act-funded clinics throughout the country and their primary HIV physicians for an observational cohort study in which quality-of-care measures were assessed by medical record review. RESULTS: We studied 5247 patients linked to 177 physicians who responded to a survey. Fifty-eight percent of the physicians were general medicine physicians ("generalists") and 42% were infectious diseases specialists. Sixty-three percent of the generalists (37% overall) considered themselves expert in HIV care. In hierarchical logistic regression models that controlled for patient characteristics, infectious diseases physicians and expert generalists had similar performance. In contrast, nonexpert generalists delivered lower quality care. More than 80% of the appropriate patients being cared for by infectious diseases physicians and expert generalists were receiving highly active antiretroviral therapy, compared with 73% of appropriate patients of nonexpert generalists (P<.001). Physicians with fewer than 20 patients with active HIV had fewer appropriate patients on highly active antiretroviral therapy (73% vs 82% of physicians with >/=20 such patients, P = .04) and saw patients less frequently. CONCLUSION: These findings extend previous work by examining a range of quality-of-care measures and suggest that generalists with appropriate experience and expertise in HIV care can provide high-quality care to patients with this complex chronic illness.

Adult↗

PubMed2005

Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users.

BACKGROUND: We evaluated physicians' training, experience, and practice characteristics and examined associations between their attitudes toward human immunodeficiency virus (HIV)-infected persons who are injection drug users (IDUs) and quality of care. METHODS: Cross-sectional surveys were conducted among a probability sample of noninstitutionalized HIV-infected individuals in the United States and their main HIV care physicians. Physician and practice characteristics, training, HIV knowledge, experience, attitudes toward HIV-infected IDUs, stress levels, and satisfaction with practice were assessed. The main quality-of-care measures were patient exposure to highly active antiretroviral therapy, reported problems, satisfaction with care, unmet needs, and perceived access to care. RESULTS: Nationally, 23.2% of HIV-infected patients had physicians with negative attitudes toward IDUs. Seeing more IDUs, having higher HIV treatment knowledge scores, and treating fewer patients per week were independently associated with more positive attitudes toward IDUs. Injection drug users who were cared for by physicians with negative attitudes had a significantly lower adjusted rate of exposure to highly active antiretroviral therapy by December 1996 (13.5%) than non-IDUs who were cared for by such physicians (36.1%) or IDUs who were cared for by physicians with positive attitudes (32.3%). Physician attitudes were not associated with other problems with care, satisfaction with care, unmet needs, or perceived access to care. CONCLUSIONS: Negative attitudes may lead to less than optimal care for IDUs and other marginalized populations. Providing education or experience-based exercises or ensuring that clinicians have adequate time to deal with complex problems might result in better attitudes and higher quality of care.

Adult↗

PubMed2005

Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey.

UNLABELLED: Persons aged >65 years with pain caused by postherpetic neuralgia (PHN) were recruited via advertisements in 24 US newspapers and were mailed a questionnaire that addressed pain intensity (average, worst, least, current), pain interference (with general activity, mood, relations with other people, sleep, enjoyment of life), and health-related quality of life (using the EuroQoL health measure [EQ-5D] and a global rating scale). Respondents also were asked about their use of medication for shingles pain. A total of 385 persons completed the survey; 61% were >75 years of age. Mean (+/-standard deviation) duration of PHN was 3.3 (+/-4.0) years. Only about one half had taken prescription medication for shingles pain during the prior week; dosages were typically low. Mean average, worst, least, and current pain caused by shingles (0- to 10-point scale) was 4.6 (+/-2.1), 6.0 (+/-2.4), 2.9 (+/-2.3), and 4.0 (+/-2.7), respectively. Mean pain interference with general activity, mood, relations with other people, sleep, and enjoyment of life (0- to 10-point scale) was 3.7 (+/-3.1), 4.3 (+/-2.9), 3.0 (+/-2.8), 3.8 (+/-2.9), and 4.5 (+/-3.1), respectively. The mean EQ-5D health index score was 0.61; respondents rated their overall health as 65.7 (+/-21.1) on a 100-point scale. PHN causes substantial pain, dysfunction, and poor health-related quality of life in older persons, many of whom might be suboptimally treated. PERSPECTIVE: Many older persons (age >65 years) with PHN experience longstanding, severe, and debilitating pain and poor health-related quality of life; levels of dissatisfaction with treatment are high. Our study highlights the need for improved management of this disease.

Activities of Daily Living↗

PubMed2005

Case-mix adjustment of the CAHPS Hospital Survey.

OBJECTIVES: To develop a model for case-mix adjustment of Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital survey responses, and to assess the impact of adjustment on comparisons of hospital quality. DATA SOURCES: Survey of 19,720 patients discharged from 132 hospitals. METHODS: We analyzed CAHPS Hospital survey data to assess the extent to which patient characteristics predict patient ratings ("predictive power") and the heterogeneity of the characteristics across hospitals. We combined the measures to estimate the impact of each predictor ("impact factor") and selected high impact variables for adjusting ratings from the CAHPS Hospital survey. PRINCIPLE FINDINGS: The most important case-mix variables are: hospital service (surgery, obstetric, medical), age, race (non-Hispanic black), education, general health status (GHS), speaking Spanish at home, having a circulatory disorder, and interactions of each of these variables with service. Adjustment for GHS and education affected scores in each of the three services, while age and being non-Hispanic black had important impacts for those receiving surgery or medical services. Circulatory disorder, Spanish language, and Hispanic affected scores for those treated on surgery, obstetrics, and medical services, respectively. Of the 20 medical conditions we tested, only circulatory problems had an important impact within any of the services. Results were consistent for the overall ratings of nurse, doctor, and hospital. Although the overall impact of case-mix adjustment is modest, the rankings of some hospitals may be substantially affected. CONCLUSIONS: Case-mix adjustment has a small impact on hospital ratings, but can lead to important reductions in the bias in comparisons between hospitals.

Adolescent↗

PubMed2005

Exploratory factor analyses of the CAHPS Hospital Pilot Survey responses across and within medical, surgical, and obstetric services.

OBJECTIVES: To estimate the associations among hospital-level scores from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital pilot survey within and across different services (surgery, obstetrics, medical), and to evaluate differences between hospital- and patient-level analyses. DATA SOURCE: CAHPS Hospital pilot survey data provided by the Centers for Medicare and Medicaid Services. STUDY DESIGN: Responses to 33 questionnaire items were analyzed using patient- and hospital-level exploratory factor analytic (EFA) methods to identify both a patient-level and hospital-level composite structures for the CAHPS Hospital survey. The latter EFA was corrected for patient-level sampling variability using a hierarchical model. We compared results of these analyses with each other and to separate EFAs conducted at the service level. To quantify the similarity of assessments across services, we compared correlations of different composites within the same service with those of the same composite across different services. DATA COLLECTION: Cross-sectional data were collected during the summer of 2003 via mail and telephone from 19,720 patients discharged from November 2002 through January 2003 from 132 hospitals in three states. PRINCIPAL FINDINGS: Six factors provided the best description of inter-item covariation at the patient level. Analyses that assessed variability across both services and hospitals suggested that three dimensions provide a parsimonious summary of inter-item covariation at the hospital level. Hospital-level factor structures also differed across services; as much variation in quality reports was explained by service as by composite. CONCLUSIONS: Variability of CAHPS scores across hospitals can be reported parsimoniously using a limited number of composites. There is at least as much distinct information in composite scores from different services as in different composite scores within each service. Because items cluster slightly differently in the different services, service-specific composites may be more informative when comparing patients in a given service across hospitals. When studying individual-level variability, a more differentiated structure is probably more appropriate.

Attitude of Health Personnel↗

PubMed2005

Methods used to streamline the CAHPS Hospital Survey.

OBJECTIVE: To identify a parsimonious subset of reliable, valid, and consumer-salient items from 33 questions asking for patient reports about hospital care quality. DATA SOURCE: CAHPS Hospital Survey pilot data were collected during the summer of 2003 using mail and telephone from 19,720 patients who had been treated in 132 hospitals in three states and discharged from November 2002 to January 2003. METHODS: Standard psychometric methods were used to assess the reliability (internal consistency reliability and hospital-level reliability) and construct validity (exploratory and confirmatory factor analyses, strength of relationship to overall rating of hospital) of the 33 report items. The best subset of items from among the 33 was selected based on their statistical properties in conjunction with the importance assigned to each item by participants in 14 focus groups. PRINCIPAL FINDINGS: Confirmatory factor analysis (CFA) indicated that a subset of 16 questions proposed to measure seven aspects of hospital care (communication with nurses, communication with doctors, responsiveness to patient needs, physical environment, pain control, communication about medication, and discharge information) demonstrated excellent fit to the data. Scales in each of these areas had acceptable levels of reliability to discriminate among hospitals and internal consistency reliability estimates comparable with previously developed CAHPS instruments. CONCLUSION: Although half the length of the original, the shorter CAHPS hospital survey demonstrates promising measurement properties, identifies variations in care among hospitals, and deals with aspects of the hospital stay that are important to patients' evaluations of care quality.

Adolescent↗

PubMed2005

A national study of the relationship of care site HIV specialization to early adoption of highly active antiretroviral therapy.

BACKGROUND: Little is known about characteristics of organizations that predict early adoption of highly active antiretroviral therapy (HAART) for persons with HIV infection. OBJECTIVES: To describe characteristics of sites where HIV care is provided and to assess site characteristics that predict early adoption of HAART. DESIGN: Cross-sectional analysis of survey data from patients, HIV physicians, and medical directors. PATIENTS AND SETTING: Participants in the HIV Cost and Services Utilization Study, a national probability sample of persons with HIV who received outpatient care in the continental United States during 1996. MAIN OUTCOME MEASURE: Rates of exposure to HAART by December 1996. RESULTS: Nationally, 79% of patients were treated at sites specializing in HIV care (HIV sites). Over 90% of patients were cared for by physicians who were experts in HIV care, either infectious disease specialists (46%) or general medicine experts (45%). Adjusted rates of exposure to HAART by December 1996 varied from 0.02 to 0.79 across sites (mean rate, 0.33). In multivariable models, HIV specialization (odds ratio [OR], 3.6; P < 0.001), total patient volume of more than 20,000 visits a year (OR, 2.1; P < 0.01), and educational level of the zip code in which the site was located (OR, 1.2 for each 10% increase in college education) were associated with higher rates of exposure to HAART. These effects persisted after adjustment for physician HIV expertise. Site effects were more important than physician effects in explaining rates of exposure to HAART. CONCLUSION: In 1996 there were wide variations in rates of HAART use by site of care. Low-volume sites that do not specialize in HIV care should take measures to ensure that HIV expertise is available to their patients.

Adult↗

PubMed2005

Adjusting Pediatric Consumer Assessment of Health Plans Study (CAHPS) Scores to Ensure Fair Comparison of Health Plan Performances.

OBJECTIVES: When comparing the scores from Consumer Assessment of Health Plans Study (CAHPS) surveys across health plans, it is important to adjust for patient characteristics (casemix) that are not under the control of the plan but that affect plan ratings. Our goal was to develop casemix models for pediatric CAHPS surveys. METHODS: We analyzed responses to the pediatric CAHPS 2.0 surveys from 50,583 Medicaid beneficiaries and 43,579 persons with private health insurance. We identified patient characteristics with the most substantial impact on scores and assessed casemix models that include different combinations of adjusters. In addition, we tested whether casemix coefficients differed between the Medicaid and commercial samples and across health plans. RESULTS: Parent age and education and child health status and race were important casemix adjustment variables for pediatric CAHPS surveys. Child age and gender had smaller effects. The relationship between patient characteristics and CAHPS scores was different in the Medicaid and commercial samples for some variables. The effects of a patient's characteristics on ratings and report scores were not consistent across Medicaid plans but more consistent for commercial plans. CONCLUSIONS: Our analyses indicate that plan scores on the pediatric CAHPS survey should be adjusted for plan differences in casemix. Users should consider estimating separate models for Medicaid and commercially insured respondents. Such models should adjust for child health status, parent age, and parent education.

Adolescent↗

PubMed2005

Psychometric properties of a group-level Consumer Assessment of Health Plans Study (CAHPS) instrument.

BACKGROUND: Many different surveys have been used to evaluate the performance of medical groups, but there is a growing recognition that standardization could be helpful to consumers, purchasers, and others. OBJECTIVES: We sought to develop a version of the Consumer Assessment of Health Plans Study (CAHPS) survey for use with medical groups (G-CAHPS) and assess its reliability and validity. RESEARCH DESIGN: The research team reviewed existing instruments and conducted patient focus groups in 4 sites to identify aspects of care that were especially important to patients when evaluating medical groups. We tested a draft instrument in 75 cognitive interviews with adults 18 years of age or older in Knoxville, St. Louis, and California and pretests in 4 groups of adults in Boston and Denver. We then surveyed random samples of patients from medical groups and practice sites in California, Knoxville, St. Louis, and Denver. We analyzed the psychometric characteristics of the instrument. RESULTS: Data support the reliability and validity of 3 multi-item measures of access, office staff service, and patient clinician communication. Measures related to specialty care and preventive counseling did not differentiate among medical groups. CONCLUSIONS: The G-CAHPS instrument provides an assessment of selected aspects of care that are important to consumers and could be a useful complement to the plan-level CAHPS instrument.

Adult↗

PubMed2004

Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study.

BACKGROUND: Multi-institution collaborative quality improvement programs are a well-established and broadly applicable quality improvement strategy, but there is little systematic assessment their effectiveness. OBJECTIVE: To evaluate the effectiveness of a quality improvement collaborative in improving the quality of care for HIV-infected patients. DESIGN: Controlled pre- and postintervention study. SETTING: Clinics receiving funding from the Ryan White Comprehensive AIDS Resources Emergency Act. PARTICIPANTS: 44 intervention clinics and 25 control clinics matched by location (urban or rural), region, size, and clinic type. MEASUREMENTS: Changes in quality-of-care measures abstracted from medical records of pre- and postintervention samples of patients at each study clinic. Measures examined included use and effectiveness of antiretroviral therapy, screening and prophylaxis, and access to care. INTERVENTION: A multi-institutional quality improvement collaborative (the "Breakthrough Series"). RESULTS: 9986 patients were studied. Clinical and sociodemographic characteristics of the intervention and control patients were similar (P > 0.05). Differences in changes in the quality of care were not statistically significant. The proportion of patients with a suppressed viral load increased by 11 percentage points (from 40.1% to 51.1%) in the intervention group compared with 5.3 percentage points (from 43.6% to 48.8%) in the control group, but this difference was not statistically significant (P = 0.18). In addition, rates of appropriate screening tests and prophylaxis did not differ between intervention and control sites. LIMITATIONS: It was not possible to perform a pure randomized trial of the intervention or to assess other measures of quality, such as adherence and satisfaction. CONCLUSIONS: This prospective, matched study of almost 10 000 patients found that a quality improvement collaborative did not significantly affect the quality of care. Additional research is needed to improve methods of teaching and implementing quality improvement programs to achieve better results.

AIDS-Related Opportunistic Infections↗

PubMed2004

Comparison of performance of traditional Medicare vs Medicare managed care.

CONTEXT: Since 2000, the Centers for Medicare & Medicaid Services (CMS) has been collecting information on beneficiaries' experiences with health care for Medicare managed care (MMC) and traditional fee-for-service (FFS) Medicare. OBJECTIVES: To compare beneficiary experiences with managed care and FFS arrangements throughout the country and to assess the stability of those differences over time. DESIGN, SETTING, AND PARTICIPANTS: CMS administered managed care and FFS versions of the Consumer Assessment of Health Plans Study (CAHPS) survey to samples of beneficiaries (aged > or =65 years) from Medicare + Choice MMC organizations and from geographic strata within the traditional FFS Medicare program. We analyzed responses collected in 2000 and 2001 from 497,869 respondents: 299,058 beneficiaries enrolled in MMC plans (response rate, 82%) and 198,811 enrolled in FFS Medicare (response rate, 68%). Differences between MMC and FFS within states were assessed after adjustment for case mix and nonresponse. For estimates at the regional and national level, state estimates were combined after weighting by the MMC enrollment in the state. MAIN OUTCOME MEASURES: Four overall ratings (of the plan, personal physician, care received overall, and care received from specialists), 5 measures summarizing beneficiaries' experiences with care (getting care needed; getting care quickly; communication with clinicians; courtesy and respect of physician's office staff; and paperwork, information, and customer service), and reports of receipt of 3 preventive services (flu shots, pneumococcal vaccinations, and being advised to quit smoking) were assessed. RESULTS: Respondents in MMC and FFS plans were similar to each other and to the Medicare population as a whole. Nationally, FFS Medicare beneficiaries rated experiences with care measured by the CAHPS survey higher than did MMC beneficiaries; for instance, in ratings of care received overall (scale of 1-10) (8.91 FFS vs 8.86 MMC, P<.001, in 2000; and 8.88 FFS vs 8.78 MMC, P<.001, in 2001). Differences between FFS and MMC varied across states, however. Managed care enrollees reported significantly fewer problems with paperwork, information, and customer service (2.62 FFS vs 2.55 MMC, P<.001, in 2000; and 2.59 FFS vs 2.51 MMC, P<.001, in 2001). Enrollees in MMC were also more likely to report having received immunizations for influenza and pneumococcus (from any source) (in 2000, 77% of MMC vs 63% of FFS respondents; P<.001), and smokers were more likely to report having received counseling to quit smoking. CONCLUSIONS: Our data suggest that managed care was better at delivering preventive services, whereas traditional Medicare was better in other aspects of care related to access and beneficiary experiences. These relative strengths should be considered when policy decisions are made that affect the availability of choice or influence beneficiaries to choose one model of care over another.

Aged↗

PubMed2004

Differences in health-related quality of life and treatment preferences among black and white patients with end-stage renal disease.

BACKGROUND: Relatively little is known about racial differences in health-related quality of life (HRQL) among patients receiving dialysis for end-stage renal disease (ESRD) or how such differences may relate to preferences for renal transplantation. METHODS: We surveyed 1392 patients, ages 18-54 approximately 10 months after they initiated dialysis in 4 regions of the United States. The HRQL measures analyzed were overall health, emotional health, physical activity, energy level, social activity, and effect of ESRD on daily life. We also examined whether the measures of HRQL were associated with patients' preferences for renal transplantation by race. RESULTS: After adjustment for socioeconomic and clinical characteristics, Black women and men reported better overall health than White women and men, respectively. Black women reported higher energy levels than White women, and Black men reported less negative effects of ESRD on daily life compared to White men. Black men with high levels of physical activity were less likely to be certain about preferring a transplant than White men with similar levels of physical activity. CONCLUSIONS: Black patients receiving dialysis reported better HRQL than White patients, even after controlling for potential confounders. Racial differences in preferences for renal transplantation among men may be associated with their levels of physical activity.

Adolescent↗

PubMed2004

Physicians' beliefs about racial differences in referral for renal transplantation.

BACKGROUND: Black patients with end-stage renal disease are much less likely than white patients to undergo renal transplantation, but previous research has shown that black patients are only slightly less likely to desire this procedure. A better understanding of physicians' views about racial differences in access to transplantation may help reduce disparities in care. METHODS: We surveyed 278 nephrologists in 4 US regions about quality of life and survival for black and white patients undergoing renal transplantation and reasons for racial differences in access to transplantation. We also surveyed 606 of their patients about their care. RESULTS: Physicians were less likely to believe transplantation improves survival for blacks than whites (69% versus 81%; P = 0.001), but similarly likely to believe it improves quality of life (84% versus 86%). Factors commonly cited by physicians as important reasons why blacks are less likely than whites to be evaluated for transplantation included patients' preferences (66%), availability of living donors (66%), failure to complete evaluations (53%), and comorbid illnesses (52%). Fewer physicians perceived patient-physician communication and trust (38%) or physician bias (12%) as important reasons. Black patients were less likely than white patients to report receiving some or a lot of information about transplantation (55% versus 74%; P = 0.006) when their physicians did not view patient-physician communication and trust as an important reason for racial differences in care. CONCLUSION: Nephrologists' views about the benefits of renal transplantation and reasons for racial differences in access to this procedure may affect how they present this treatment option to black and white patients.

Adult↗

PubMed2004

Plan, geographical, and temporal variation of consumer assessments of ambulatory health care.

OBJECTIVE: To quantify contributions of health plans and geography to variation in consumer assessments of health plan quality. DATA SOURCES: Responses of beneficiaries of Medicare managed care plans to the Consumer Assessment of Health Plans Study (CAHPS(R)) survey. Our data included more than 700,000 survey responses assessing 381 Medicare managed care (MMC) contracts over a period of five years. STUDY DESIGN: The survey was administered to a nationally representative sample of beneficiaries of Medicare managed care plans. PRINCIPAL FINDINGS: Member assessments of their health plans, customer service functions, and prescription drug benefits varied most across health plans; these also varied the most over time. Assessments of direct interactions with doctors and their practices were more affected by geographical location, and these assessments were quite stable over time. A health plan's global rating often changed significantly between consecutive years, but only rarely were there such changes in ratings of care or doctor. Nationally, mean assessments tended to decrease over the study period. CONCLUSIONS: Our findings suggest that ratings of plans and reports about customer service and prescription access are affected by plan policies, benefits design, and administrative structures that can be changed relatively quickly. Conversely, assessments of other aspects of care are largely determined by characteristics of provider networks that are relatively stable. A consumer survey is unlikely to detect meaningful changes in quality of care from year to year unless quality improvement measures are developed that have substantially larger effects, possibly through area-wide initiatives, than historical temporal variations in quality.

Ambulatory Care↗