Lois Downey

Herpes Simplex Virus Type 1 as a Cause of Genital Herpes: Impact on Surveillance and Prevention

This study compared characteristics of patients who had herpes simplex virus (HSV) type 1 with characteristics of patients who had HSV-2, by use of data from a cross-sectional analysis. Data were collected in an urban sexually transmitted diseases clinic from patients who had positive genital HSV cultures. Overall, 17.1% (95% confidence interval [CI], 14.9%-19.3%) of 1145 genital HSV isolates obtained during 1993-1997 were HSV-1. The proportion of HSV-1 among initial genital herpes infections was higher among men who had sex with men (46.9%) than among women (21.4%) and was lowest among heterosexual men (14.6%). White race (odds ratio [OR], 3.7; 95% CI, 2.3-5.9) and receptive oral sex in the preceding 2 months (OR, 2.8; 95% CI, 1.9-4.3) significantly increased the odds that initial infections were HSV-1 rather than HSV-2. Genital HSV-1 may often be acquired through contact with a partners mouth. These data suggest that seroprevalence studies based solely on HSV-2 type-specific assays underestimate overall prevalence of genital HSV infection.

Effect of a quality-improvement intervention on end-of-life care in the intensive care unit a randomized trial

RATIONALE Because of high mortality, end-of-life care is an important component of intensive care. OBJECTIVES We evaluated the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care. METHODS We conducted a cluster-randomized trial randomizing 12 hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICU discharge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). We used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. MEASUREMENTS AND MAIN RESULTS All hospitals completed the trial with 2,318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81). CONCLUSIONS We found this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustaining measures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

Integrating Palliative and Critical Care: Evaluation of a Quality Improvement Intervention

RATIONALE Palliative care in the intensive care unit (ICU) is an important focus for quality improvement. OBJECTIVES To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU. METHODS We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results. MEASUREMENTS AND MAIN RESULTS There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01). CONCLUSIONS We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey.

Objectives: To refine the Family Satisfaction in the Intensive Care Unit (FS‐ICU) survey and develop a validated method for scoring the instrument. Design: Instrument development study, using data from two prospective cohort studies. Setting: Intensive care units in seven university‐affiliated hospitals (six Canadian, one United States). Subjects: Family members of ICU patients. Interventions: Based on a priori criteria, items were tagged for potential removal and discussed with the FS‐ICU developers. Factor analysis was used to test the conceptual structure of the instrument and develop a scoring method based on scales and subscales. The new scoring method was validated in the U.S. cohort using the Quality of Dying and Death (QODD) instrument and nurse‐assessed quality indicators. Measurements and Main Results: A total of 1,038 family members completed the FS‐ICU across seven sites. Fifteen items were initially tagged for possible removal. After consensus with the developers, ten items were dropped (and 24 were retained in the final instrument). Factor analysis explained 61.3% of the total variance using a two‐factor model. The first factor pertained to satisfaction with care (14 items). The second factor encompassed satisfaction with decision making (10 items). A scoring method was developed based on this conceptual model. In validity testing, the FS‐ICU was significantly correlated with the Family‐QODD total score (Spearman’s .56, p < .001) as well as individual QODD items such as quality of care by all providers (.64, p < .001). The FS‐ICU also correlated significantly with multiple nurse‐assessed quality indicators. Conclusions: The shortened FS‐ICU measures two main conceptual domains—satisfaction with care and satisfaction with decision making. Scores on the FS‐ICU show good validity against other indicators of ICU quality. The instrument holds promise as a useful outcome measure in studies that attempt to improve this component of ICU care.

Using the medical record to evaluate the quality of end-of-life care in the intensive care unit*

Rationale:We investigated whether proposed “quality markers” within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU). Objective:To identify chart-based markers that could be used as measures for improving the quality of end-of-life care. Design:A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU. Setting:ICUs at ten hospitals in the northwest United States. Patients:Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU. Measurements:The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1). Analysis:The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearmans rank-correlation coefficients as appropriate. Results:Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patients wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p ≤ .05). Conclusions:We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.

How Could I Forget? Inaccurate memories of sexually intimate moments

This study was based on data collected from 87 men during and immediately following participation in a counseling program aimed at assisting them to reduce sexual behaviors associated with high HIV risk. All the men reported having engaged in same‐gender anal or oral sex without condoms during the year prior to enrollment. Three‐month retrospective reports of sexual behavior, solicited just after participation, were compared with reports collected weekly during the same three‐month period. Accuracy of recall over an ensemble of 10 behavior items was quite low, with amount of error positively associated with behavior frequency. In general, exaggerated reports were associated with low‐frequency behavior and underreports with high‐frequency behavior. Because of observed differences in the average frequency of occurrence of the various specific types of sexual behavior, adjustment for event frequency was required to provide adequate analysis of between‐behavior differences in memory error. Estimated functiona...

HIV-Prevention Group Counseling Delivered by Telephone: An Efficacy Trial with Gay and Bisexual Men

A 14-session cognitive-behavioral group counseling intervention designed to assist gay and bisexual males in reducing their risk of HIV transmission was evaluated in an experimental design. To overcome psychological and geographic barriers to serving individuals at risk, the counseling sessions and all data collection interviews were conducted via telephone. Participants had the option of enrolling anonymously, and a toll-free number was made available. At reassessment, treatment group participants were 80% less likely than controls to report any unprotected anal sex, and were nearly twice as likely to report some condom use with anal and oral sex. Treated participants also reported a significantly greater decline than controls in the proportion of anal sex acts that were unprotected by condoms. While those who were treated maintained a lower risk level over the year following treatment, their initial increase in condom utilization was not maintained. Delivering counseling interventions via the telephone, when coupled with the option for participating anonymously, holds considerable promise in overcoming barriers to reaching and effectively facilitating risk reduction in high-risk populations.

Patient–clinician communication about end-of-life care for Dutch and US patients with COPD

Improving patient–clinician communication about end-of-life care is important in order to enhance quality of care for patients with chronic obstructive pulmonary disease (COPD). Our objective was to compare quality of patient–clinician communication about end-of-life care, and endorsement of barriers and facilitators to this communication in the Netherlands and the USA. The present study was an analysis of survey data from 122 Dutch and 391 US outpatients with COPD. We compared quality of patient–clinician communication about end-of-life care (Quality of Communication questionnaire) and barriers and facilitators to communication about end-of-life care (Barriers and Facilitators Questionnaire) between the Netherlands and the USA, controlling for patients’ demographic and illness characteristics. Although Dutch patients in this study had worse lung function and disease-specific health status than US patients, Dutch patients reported lower quality of communication about end-of-life care (median score 0.0 (interquartile range 0.0–2.0) versus 1.4 (0.0–3.6); adjusted p<0.005). Clinicians in both countries rarely discussed life-sustaining treatment preferences, prognoses, dying processes or spiritual issues. Quality of communication about end-of-life care needs to improve in the Netherlands and the USA. Future studies to improve this communication should be designed to take into account international differences and patient-specific barriers and facilitators to communication about end-of-life care.

Hospital variation and temporal trends in palliative and end-of-life care in the ICU.

Objectives:Although studies have shown regional and interhospital variability in the intensity of end-of-life care, few data are available assessing variability in specific aspects of palliative care in the ICU across hospitals or interhospital variability in family and nurse ratings of this care. Recently, relatively high family satisfaction with ICU end-of-life care has prompted speculation that ICU palliative care has improved over time, but temporal trends have not been documented. Design/Setting:Retrospective cohort study of consecutive patients dying in the ICU in 13 Seattle-Tacoma-area hospitals between 2003 and 2008. Measurements:We examined variability over time and among hospitals in satisfaction and quality of dying assessed by family, quality of dying assessed by nurses, and chart-based indicators of palliative care. We used regression analyses adjusting for patient, family, and nurse characteristics. Main Results:Medical charts were abstracted for 3,065 of 3,246 eligible patients over a 55-month period. There were significant differences between hospitals for all chart-based indicators (p < 0.001), family satisfaction (p < 0.001), family-rated quality of dying (p = 0.03), and nurse-rated quality of dying (p = 0.003). There were few significant changes in these measures over time, although we found a significant increase in pain assessments in the last 24 hours of life (p < 0.001) as well as decreased documentation of family conferences (p < 0.001) and discussion of prognosis (p = 0.020) in the first 72 hours in the ICU. Conclusions:We found significant interhospital variation in ratings and delivery of palliative care, consistent with prior studies showing variation in intensity of care at the end of life. We did not find evidence of temporal changes in most aspects of palliative care, family satisfaction, or nurse/family ratings of the quality of dying. With the possible exception of pain assessment, there is little evidence that the quality of palliative care has improved over the time period studied.

Sources of motivation for abstinence: A replication analysis of the Reasons for Quitting Questionnaire

The Reasons for Quitting Questionnaire (RFQ) as modified by McBride and colleagues (C. M. McBride et al., 1994) for use with substance users other than tobacco smokers, was administered to individuals approved for public-sector addiction treatment. Four motivation dimensions, similar to those found by McBride et al., were identified: self-concept issues, health concerns, legal issues, and social influence. A forced two-component solution yielded dimensions interpretable as intrinsic and extrinsic motivation. Self-concept issues provided the highest levels of motivation for abstinence in this sample, with moderate levels provided by health concerns, and the lowest levels provided by legal and social influence components. Intrinsic motivation was higher than extrinsic motivation. Logistic regression models, with adjustment for total motivation, tested the association of successful abstinence during a follow-up period with baseline extrinsic and intrinsic motivation, and with the difference between intrinsic and extrinsic levels. All three associations were significant: intrinsic motivation (positive association), extrinsic motivation (negative association), and the difference score (positive association). The results suggest the usefulness of the 20-item modified RFQ in evaluating motivation for abstinence among treatment seekers exhibiting severe negative consequences of addiction. Testing with samples varying in severity of addiction consequences is recommended.