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Biomedical subjects

William B Weeks

Publications and source records attributed to William B Weeks.

At least 19 recordsLinked to original sources
PubMed2006

Women's primary care providers and breast cancer screening: who's following the guidelines?

OBJECTIVE: Screening mammography for woman ages 50 to 69 years has resulted in early breast cancer detection and reduced mortality rates. However, the providers who are responsible for women's preventive health care differ in breast cancer screening guideline adherence. We compared screening practices across provider specialty and training degree types. STUDY DESIGN: Using a retrospective cohort design, we examined 472 patient records that represented 16 million preventive health care visits among women ages 50 to 69 years from the 2000 National Ambulatory Medical Care Survey. We calculated relative risk ratios for breast examination and mammography during preventive visits across provider specialty and training types. RESULTS: Among specialists, gynecologists are more likely than internists or general/family practitioners to follow breast cancer screening guidelines. Across training degree types, mid-level providers are more likely than medical doctors or osteopaths to adhere to guidelines. CONCLUSION: Regardless of specialty type or training degree, women's health care providers should adhere to breast cancer screening guidelines during preventive care visits.

Aged↗
PubMed2006

Who pays for poor surgical quality? Building a business case for quality improvement.

BACKGROUND: Both providers and payors bear the financial risk associated with complications of poor quality care. But the stakeholder who bears the largest burden of this risk has a strong incentive to support quality improvement activities. The goal of the present study was to determine whether hospitals or payors incur a larger burden of increased hospital costs associated with complications. STUDY DESIGN: We merged clinical data for 1,008 surgical patients from the private sector National Surgical Quality Improvement Program to the internal cost-accounting database of a large university hospital. We then determined the marginal costs of surgical complications from the perspective of both hospitals (changes in profit and profit margin) and payors (increase in reimbursement paid to the hospital). In our analyses of cost and reimbursement, we adjusted for procedure complexity and patient characteristics using multivariate linear regression. RESULTS: Reimbursement for patients without complications ($14,266) exceeded hospital costs ($10,978), generating an average hospital profit of $3,288 and a profit margin of 23%. When complications occurred, hospitals still received reimbursement in excess of their costs, but the profit margin declined: reimbursement ($21,911) exceeded hospital costs ($21,156), yielding an average profit of $755 and a profit margin of 3.4%. Complications were always associated with an increase in costs to health-care payors: complications were associated with an average increase in reimbursement of $7,645 (54%) per patient. CONCLUSIONS: Hospitals and payors both suffer financial consequences from poor-quality health care, but the greater burden falls on health-care payors. Strong incentives exist for health-care payors to become more involved in supporting quality improvement activities.

Costs and Cost Analysis↗
PubMed2006

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Angioplasty, Balloon, Coronary↗
PubMed2006

Physical and mental health and access to care among nonmetropolitan Veterans Health Administration patients younger than 65 years.

CONTEXT: The 4.5 million military veterans treated by the Veterans Health Administration (VA) are believed to experience poorer physical and mental health than nonveterans. Furthermore, nonmetropolitan residents have less access to medical services, whether or not they are veterans in VA care. A direct comparison of metropolitan and nonmetropolitan veterans and nonveterans on a national health survey has not been reported, so it is not known whether nonmetropolitan VA patients experience similar medical need or access as other nonmetropolitan residents. PURPOSE: We sought to compare the perceptions of health status and access to care among metropolitan and nonmetropolitan veterans in VA care, other veterans, and nonveterans in a large national sample surveyed under the same conditions. METHODS: Male respondents to the 2000 Behavioral Risk Factor Surveillance System health survey were divided into veterans or nonveterans, VA users or nonusers, metropolitan or nonmetropolitan residents, and 1 of 3 age groups (18-44, 45-64, and 65(+)). Responses to questions about current health status, health coverage, and access to care were submitted to chi-square analyses or analyses of variance, using SUDAAN software to compute survey error variance. FINDINGS: Nonmetropolitan VA patients younger than 65 years consistently reported the worst physical and mental health status and reduced access to care. CONCLUSIONS: VA can anticipate increasing demand for mental and physical health care among rural veterans younger than 65 years.

Adolescent↗
PubMed2006

Mental distress among younger veterans before, during, and after the invasion of Iraq.

OBJECTIVE: The purpose of this study was to determine whether patients receiving care from the Department of Veterans Affairs (VA) reported more mental distress as the war in Iraq began or reintensified compared with other respondents to national health surveys. METHODS: Data from the 2000 and 2003 Behavioral Risk Factor Surveillance System (BRFSS) health surveys were analyzed. Unlike in other years, these particular surveys asked respondents whether they were military veterans. As in other years' surveys, these surveys also asked whether respondents used VA medical care. Male respondents were stratified by age and separated into three groups: VA patients, other veterans, and nonveterans. The proportions of respondents who reported five or more recent days of poor mental or physical health were analyzed with chi square tests. RESULTS: Although the number of recent days of poor mental health among nonveterans, other veterans, and older VA patients were stable from 2000 to 2003, younger VA patients in 2003 reported substantially more days of poor mental health in two intervals: during the Iraq war buildup and invasion, and later, when resistance on the ground reintensified. Comparable changes in physical health complaints were not observed. CONCLUSIONS: In times of war, the VA may anticipate more mental health problems among its current patients, particularly younger veterans.

Adolescent↗
PubMed2005

Using aggregate root cause analysis to reduce falls.

BACKGROUND: In certain categories of adverse events, Department of Veterans Affairs (VA) facilities may combine data to produce an aggregate review of the data. Individual root cause analyses are still required for the more serious adverse events. About 100 of the VA acute and long term care facilities contributed data to an analysis of results of 176 root cause analyses (RCAs) for patient falls occurring in the VA system. METHODS: Success was measured through a decreased report of falls and major injures due to falls after each organization's action plans were implemented. In addition, telephone interviews were conducted to understand success factors as well as barriers to implementation of clinical improvements. RESULTS: Of the 745 actions generated (that addressed the root cause), 435 (61.4%) had been fully implemented and another 148 (20.9%) had been partially implemented; 34.4% of the facilities reported reducing falls and 38.9% reported reducing major injuries due to falls. DISCUSSION: The action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff. Specific interventions most highly associated with reductions in falls and injuries included environmental assessments, toileting interventions, and interventions that directly addressed the root cause and were the responsibility of a single person (as opposed to a group).

Accidental Falls↗
PubMed2005

What do we know about financial returns on investments in patient safety? A literature review.

BACKGROUND: A framework was proposed for making a business case for patient safety interventions and to evaluate whether and how thoroughly financial aspects of investments and returns have been reported. METHODS: MEDLINE was searched from inception through January 21, 2005. Articles were selected if they reported on a patient safety intervention or a patient safety related outcome within the United States and indicated that a financial or economic analysis of the intervention was an objective. RESULTS: For 165 articles, a financial or economic analysis was indicated as an objective; 36.4% used original data, 28.5% used referenced data, and 35.2% provided no analysis. Only 13 articles (7.9%) included original data on start-up costs, 45 articles (27.3%) included original data on operating expenses and benefits, and 9 articles (5.5%) provided original financial data on outcomes. Of the 165 articles, 56.4% evaluated technological methods of improving patient safety, such as adoption of computer physician order entry, 20.6% evaluated changes in processes of care, such as staffing changes, and 23% involved other types of interventions or outcomes. DISCUSSION: Few articles provided complete information on the required investment and anticipated return on patient safety interventions. Use of standard financial techniques may strengthen the business case for patient safety interventions.

Costs and Cost Analysis↗
PubMed2005

New York's statistical model accurately predicts mortality risk for veterans who obtain private sector CABG.

OBJECTIVE: To determine whether patients' use of the Veterans Health Administration health care system (VHA) is an independent risk factor for mortality following coronary artery bypass grafting (CABG) in the private sector in New York. DATA SOURCES: VHA administrative and New York Department of Health Cardiac Surgery Reporting System (CSRS) databases for surgeries performed in 1999 and 2000. STUDY DESIGN: Prospective cohort study comparing observed, expected, and risk-adjusted mortality rates following private sector CABG for 2,326 male New York State residents aged 45 years and older who used the VHA (VHA users) and 21,607 who did not (non-VHA users). DATA COLLECTION METHODS: We linked VHA administrative databases to New York's CSRS to identify VHA users who obtained CABG in the private sector in New York in 1999 and 2000. Using CSRS risk factors and previously validated risk-adjustment model, we compared patient characteristics and expected and risk-adjusted mortality rates of VHA users to non-VHA users. PRINCIPAL FINDINGS: Compared with non-VHA users, patients undergoing private sector CABG who had used the VHA were older, had more severe cardiac disease, and were more likely to have the following comorbidities associated with increased risk of mortality: diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, and history of stroke (p<.001 for all); a calcified aorta (p=.009); and a high creatinine level (p=.003). Observed (2.28 versus 1.80 percent) and expected (2.48 versus 1.78 percent) mortality rates were higher for VHA users than for non-VHA users. The risk-adjusted mortality rate for VHA users (1.70 percent; 95 percent confidence interval [CI]: 1.27-2.22) was not statistically different than that for the non-VHA users (1.87 percent; 95 percent CI: 1.69-2.06). Use of the VHA was not an independent risk factor for mortality in the risk-adjustment model. CONCLUSIONS: Although VHA users had a greater illness burden, use of the VHA was not found to be an independent risk factor for mortality following private sector CABG in New York. The New York Department of Health risk adjustment model adequately applies to veterans who obtain CABG in the private sector in New York.

Aged↗
PubMed2005

Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans.

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.

Aged↗
PubMed2004

Substance abuse intensive outpatient treatment: does program graduation matter?

Program graduation, even after controlling for length of stay, may predict for improved outcomes in some substance abuse treatment settings. We investigated the role of program graduation by comparing social outcomes and inpatient utilization the years before and after treatment among graduates and dropouts of a Veterans Administration substance abuse intensive outpatient program. At enrollment, graduates and dropouts were similar in all spheres measured. Patients who completed the treatment program used significantly fewer psychiatric inpatient bed days of care the year after they completed the program, both in comparison to their own prior use and in comparison to program dropouts. Graduates were more likely to be abstinent and less likely to fully relapse or be incarcerated at 6-month followup. Further research is needed to discern optimal treatment length-that which maximizes both length of stay and completion rates, while optimizing use of limited treatment resources.

Female↗
PubMed2004

Changes in authorship patterns in prestigious US medical journals.

To improve identification of contributors to manuscripts, editors of medical journals have developed authorship responsibility criteria. Some have specified an acceptable number of authors per manuscript. We wanted to examine changes in patterns of authorship in the context of the development of these specifications. Therefore, we used a retrospective cohort design to calculate the average number of authors per manuscript and the prevalence of group and corporate authorship between 1980 and 2000 for original, scientific, non-serial articles published in four prestigious medical journals: the Annals of Internal Medicine, Archives of Internal Medicine, Journal of the American Medical Association, and the New England Journal of Medicine. Group authorship identifies individual authors in the byline who are writing for a group; in corporate authorship, contributors are not individually listed in the byline. We found that the number of authors per article increased dramatically over time in each journal, from an average of 4.5 in 1980 to 6.9 in 2000 across journals. As a proportion of published manuscripts, group authorship (authors listed in the byline) increased from virtually zero to over 15%, while corporate authorship (authors not listed in the byline) remained rare and stagnant. Manuscripts published by single authors all but vanished. Group authorship was most prevalent in journals that limited the acceptable number of authors per manuscript. These findings suggest that the number of authors per manuscript continues to grow. The growth in the number of authors on bylines and the proportion of group-authored manuscripts is likely to reflect the increasing complexity of medical research.

Authorship↗
PubMed2004

Characteristics of successful quality improvement teams: lessons from five collaborative projects in the VHA.

BACKGROUND: A pre-post observational design was used to study the aggregate results of five national Breakthrough Series (BTS) collaboratives run within Veterans Health Administration (VHA) to identify the organizational, interpersonal, and systemic characteristics of successful improvement teams. METHODS: One hundred thirty-one medical quality improvement teams participated in five BTS collaboratives in the VHA between 1999 and 2002. Team characteristics were assessed using a team questionnaire before and after the BTS collaboratives. RESULTS: Fifty-seven percent of participating teams were rated as successful (a > or = 20% improvement from baseline for at least two months before the collaboratives' end). More high-performing medical quality improvement teams perceived their work to be part of their organization's key strategic goals. By the end of the BTS collaboratives, high-performing teams had more front-line staff support and stronger team leadership. DISCUSSION: Strong organizational support, strong team leadership, and high levels of interpersonal team skills help medical quality improvement teams go further to improve clinical care. It is recommended that quality improvement teams become integrated with their organization's key strategic goals, that improvement teams stay together, and that leadership and team training be provided to improve clinical outcomes.

Analysis of Variance↗
PubMed2004

A cognitive aid for cardiac arrest: you can't use it if you don't know about it.

BACKGROUND: A cognitive aid developed by the Department of Veterans Affairs (VA) and distributed to all VA facilities provides caregivers with information to minimize omission of critical steps when diagnosing and treating cardiac arrest. In 2002, caregivers were surveyed about the usefulness of the cognitive aid and the success of its dissemination throughout the VA. METHODS: Fifty randomly selected VA hospitals were sent a letter to alert them of the upcoming survey. Twenty surveys were sent to each of the selected hospitals with instructions to distribute the survey to specific caregiver types. RESULTS: Nine (18%) of the VA hospitals had not used the cognitive aid tool because of dissemination problems. Of the 565 caregivers responding to the survey, 59% (332) were aware of the cognitive aid. Of these 332, 96% agreed that putting the cognitive aid on code carts is a good idea. There were 234 respondents who were both aware of the cognitive aid and had been involved in at least one code within the past 30 days. Of these 234, some 29 (12%) used the aid during a code, 28 of whom agreed that the cognitive aid was helpful during the code. DISCUSSION: Both new and experienced caregivers find the cognitive aid helpful when responding to "code" situations. However, cognitive aids cannot be helpful if theintended users are unaware of their availability. Dissemination and awareness of the aids can be problematic in large health care systems.

Audiovisual Aids↗
PubMed2004

Return on educational investment in geriatrics training.

The graying of America will increase demand for specialists in geriatric medicine, but the proportion of filled fellowship positions in geriatric medicine has been falling recently. The objective of this study was to examine the financial return of additional training in geriatric medicine for general internists by using survey data from the American Medical Association and standard financial techniques. The return on educational investment over a working lifetime for a third-year resident in internal medicine who was considering specialty training in geriatric medicine between 1993 and 1999 was calculated. Physicians self-identified as geriatricians had lower incomes and lower incomes per hour than age-matched general internists, although the disparities decreased somewhat over the period examined. Regression modeling suggested that incomes for geriatricians are lower than expected and that this disparity increased in the last 2 years of the study. Some of the income disparities may be attributable to the fact that geriatricians obtain a greater proportion of their total revenue from Medicare than is optimal in the generalist setting. Returns on educational investment for geriatrics training were negative, although less so in recent years. Analysis suggests that the pursuit of additional specialty training in geriatric medicine has a negative financial return. Financial returns and the incentives they create should be carefully considered in meeting the anticipated geriatrics workforce needs of the nation.

Economics, Medical↗
PubMed2004

Differences in health-related quality of life in rural and urban veterans.

OBJECTIVES: We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. METHODS: We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. RESULTS: Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. CONCLUSIONS: When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.

Chi-Square Distribution↗
PubMed2003

Time and money: a retrospective evaluation of the inputs, outputs, efficiency, and incomes of physicians.

BACKGROUND: Physicians' concerns with the health care system focus on having less time with their patients and needing to work harder to maintain incomes. We sought to determine whether physicians are working longer hours and whether their incomes are declining. METHODS: Using survey data, we conducted a retrospective analysis of physician inputs, outputs, efficiency, and incomes for generalists, general internists, general surgeons, pediatricians, and obstetrician-gynecologists from 1987 to 1998. RESULTS: Physician inputs (as measured by the average hours worked in professional activities) showed little absolute change across specialties over time. Outputs (as measured by the total number of patient visits per week) decreased between 9% and 28%, depending on the specialty. Efficiency (the proportion of time spent in direct patient care and the amount of time spent during a typical office visit) remained stable over the time examined. Consumer price index inflation-adjusted annual incomes increased considerably over the time period examined (42% for general internists, 28% for pediatricians, 13% for generalists, and 8% for general surgeons); only obstetricians-gynecologists showed a net loss of annual income when adjusting for inflation (a 6% loss). CONCLUSIONS: Our findings do not confirm the prevailing concern that physicians are working harder or longer or that their incomes are declining, but they offer an explanation of how physicians are maintaining incomes without increasing work inputs. There is a great deal of dissatisfaction with the health care system among physicians; exploration of perceptual reasons for that dissatisfaction may outline a course of action needed to resolve it.

American Medical Association↗