Joyce Adair Bird

Characterization of geriatric drug-related hospital readmissions.

Although some factors placing geriatric patients at risk for hospitalization have been identified, little is known about drug-related problems that contribute to admissions. This study describes a protocol for characterizing drug-related problems that are associated with hospital readmissions. The protocol achieves significant improvements over other studies because geriatric readmissions to a community hospital are classified and the type of drug-related problem and relative contribution of the problem to the readmission are assessed. Thirty-five percent of study patients (n=706) were readmitted within 6 months of their former discharge and 45 of the readmissions were drug-related. The assessments of three reviewers working independently agreed for 82% of the readmissions (kappa=0.64). Eighteen percent of the cases identified as drug-related using the protocol were also classified as drug-related according to the hospital ICD-9 coding procedure. One percent of the readmissions classified according to the protocol as not drug-related received ICD-9 codes indicating drug-related problems. These findings suggest that the protocol identified drug-related hospital readmissions with good reliability and sensitivity. The most frequently identified drug-related problems were unexpected adverse drug reactions (n=10), patient noncompliance (10), overdose (8), lack of a necessary drug therapy (6) and underdose (5). Drug-related factors were a major reason, rather than a contributory reason, for readmission in half of the cases. The study identifies specific drug-related problems that could become targets for preventive interventions. The majority (76%) of the problems identified were potentially preventable and the types of problems found indicate that interventions should be focused on both physicians and patients.

Quality of data in multiethnic health surveys.

Objective. There has been insufficient research on the influence of ethno-cultural and language differences in public health surveys. Using data from three independent studies, the authors examine methods to assess data quality and to identify causes of problematic survey questions. Methods. Qualitative and quantitative methods were used in this exploratory study, including secondary analyses of data from three baseline surveys (conducted in English, Spanish, Cantonese, Mandarin, and Vietnamese). Collection of additional data included interviews with investigators and interviewers; observations of item development; focus groups; think-aloud interviews; a test-retest assessment survey; and a pilot test of alternatively worded questions. Results. The authors identify underlying causes for the 12 most problematic variables in three multiethnic surveys and describe them in terms of ethnic differences in reliability, validity, and cognitive processes (interpretation, memory retrieval, judgment formation, and response editing), and differences with regard to cultural appropriateness and translation problems. Conclusions. Multiple complex elements affect measurement in a multiethnic survey, many of which are neither readily observed nor understood through standard tests of data quality. Multiethnic survey questions are best evaluated using a variety of quantitative and qualitative methods that reveal different types and causes of problems.

Drug utilization review in ambulatory settings: state of the science and directions for outcomes research.

There are escalating national pressures to analyze pharmaceutical outcomes and to develop drug-related clinical guidelines. These interests coincide with passage of the Medicaid Rebate Law (OBRA, 1990), which mandates the implementation of prospective and retrospective drug utilization review (DUR) programs by Medicaid in 1993. This report investigates DUR programs that target outpatient drug therapies. The authors present a conceptual framework that identifies the factors influencing drug prescribing and the range of potential patient outcomes. Current types of DUR interventions and their applications are described, in addition to problems that hinder implementation or evaluation of DUR programs. DUR evaluation studies are reviewed, and a critique identifies the limitations of available DUR research. The authors recommend an expanded DUR policy research agenda, strongly suggesting that priority be given to studies in the following areas: DUR criteria development and validation; prevalence of prescribing problems and their association with patient outcomes; efficacy, toxicity and costs of therapeutic alternatives; and DUR program evaluation. The overall conclusion is that the state of the science pertaining to DUR is not well developed. The potential of DUR may not be realized due to the lack of resources needed to design, implement, and evaluate effective programs. Instead, DUR efforts may be limited to cost-containment issues without due consideration of quality-of-care outcomes. The authors call for rigorous evaluation efforts to inform DUR design and implementation, thereby assuring more rational prescribing and enhancing patient outcomes.

Pathways to Early Cancer Detection for Vietnamese Women: Suc Khoe La Vang! (Health is Gold!):

To promote breast and cervical screening among Vietnamese women, a neighborhood-based intervention was developed that included small-group education, distribution of Vietnamese-language educational materials, and health fairs. The rationale for these modes of intervention is described. A pretest/posttest controlled trial is used to evaluate the intervention. San Francisco, California, is the experimental community; Sacramento, California, is the comparison community. The study hypothesizes that postintervention measurements of screening rates will reflect significantly greater increases among women in the experimental community than in the comparison community. This article reports results from the 1992 baseline household survey of 306 Vietnamese women in San Francisco and of 339 Vietnamese women in Sacramento. There were no significant differences in screening rates between the two communities. Only 50-54% of women had received routine checkups; 44-55%, mammograms; 40-45%, clinical breast examinations; 40-46%, Pap smear tests; and 58-65%, pelvic examinations.

Tailoring lay health worker interventions for diverse cultures: lessons learned from Vietnamese and Latina communities

Indigenous lay health workers are presumed to be effective communicators in their communities due to their cultural competence. Lay health worker programs in Vietnamese and Latino communities show the influence of each communitys culture and structure on the intervention designs and recruitment and training of lay health workers. To promote cancer screening. Vietnamese lay health workers conducted educational sessions in neighborhoods, while Latina lay health workers served as networkers and media role models. The studies demonstrated ways to build upon cultural strengths of the community and to tailor interventions to meet community expectations and needs. The authors conclude that ongoing responsiveness to both cultural norms and structural conditions in the community is the sine qua non of successful community programs.

Social and Cultural Meanings of Self-Efficacy

This article describes the influences of social context on women’s health behavior through illustration of the powerful influences of social capital (the benefits and challenges that accrue from participation in social networks and groups) on experiences and perceptions of self-efficacy. The authors conducted inductive interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behaviors such as mammography screening. Iterative thematic analysis identified themes (meanings of efficacy, spheres of efficacy, constraints on efficacy, sources of social capital, and differential access to and quality of social capital) that link the domain of social capital with the behavioral construct perceived self-efficacy. The authors conclude that social capital addresses aspects of social context absent in the current self-efficacy construct and that these aspects have important implications for scholars’ and practitioners’ understandings of health behavior and intervention development.

Implementation of Cancer Prevention Guidelines in Clinical Practice

Data from several sources, including consumer surveys, physician surveys, and medical record audits, indicate that consumers do not receive cancer screening tests as recommended by the National Cancer Institute, the American Cancer Society, and the U.S. Preventive Services Task Force. Performance rates are consistently below published standards for all tests except Pap tests. Major reasons physicians do not perform the recommended tests include physician forgetfulness, disagreement with recommendations, lack of time, and patient refusal. Physicians also tend to overestimate their own performance rates. Barriers to screening test performance can be categorized into patient factors, physician factors, test factors, and health care delivery system factors. Interventions, such as computerized reminder systems, physician audits with feedback, and patient education and reminders, can be effective in promoting performance of such screening. Interventions that target both physician and patient may be particularly effective.

Problems and Progress in Translation of Health Survey Questions: The Pathways Experience:

Pathways to Early Cancer Detection in Four Ethnic Groups is a program project funded by the National Cancer Institute aimed at increasing the use of breast and cervical cancer screening among underserved African American, Chinese, Hispanic, and Vietnamese women. The program project core is dedicated to cross-cultural studies including development of survey questions that are comparable in four languages. This article describes the Pathways surveys, summarizes the challenges encountered in question translation, and presents an adapted approach to translation. Concurrent, multilingual, decentered translation was the process through which an English version of each question was selected only when it could be directly and meaningfully translated into Mandarin, Cantonese, Spanish, and Vietnamese. Examples of challenges and how these were addressed in the Pathways surveys are presented, along with lessons learned throughout this process.

Drug utilization review: State of the art from an academic perspective

Clinical Pharmacology and Therapeutics (1991) 50, 616–619; doi:10.1038/clpt.1991.194