Nelda P. Wray

Racial and ethnic disparities in the use of health services: Bias, preferences, or poor communication?

African Americans and Latinos use services that require a doctor’s order at lower rates than do whites. Racial bias and patient preferences contribute to disparities, but their effects appear small. Communication during the medical interaction plays a central role in decision making about subsequent interventions and health behaviors. Research has shown that doctors have poorer communication with minority patients than with others, but problems in doctor-patient communication have received little attention as a potential cause, a remediable one, of health disparities. We evaluate the evidence that poor communication is a cause of disparities and propose some remedies drawn from the communication sciences.

Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement

Guidelines for the placement of percutaneous endoscopic gastrostomy (PEG) tubes are not available. We developed a decision-making algorithm by integrating the medical and ethical dimensions of the decision. According to our algorithm, physicians should not offer PEG tubes to patients with anorexia-cachexia syndromes. For patients with permanent vegetative states, physicians should offer and recommend against the procedure. For patients who have dysphagia without other deficits in quality of life, physicians should offer and recommend the procedure. For the the remaining patients who have dysphagia with other deficits in quality of life, the physicians role is to provide non-directive counselling regarding the short and long-term consequences of a trial of PEG tube feeding.

A conceptual framework for the study of early readmission as an indicator of quality of care

Despite the perennial popularity of readmission as an indicator of the quality of hospital care, the empiric evidence linking it to process-of-care problems during the prior hospitalization is inconsistent. We devised a conceptual model for the use of unscheduled readmission within 31 days as an indicator of the quality of medical-surgical inpatient care for adults, and then conducted a systematic review of the readmission literature to determine the extent to which the evidence supports the proposed relationships. A fairly complex web of relationships influences the association between the process of inpatient care and early readmission. From the evidence to date, it is impossible to say with confidence that early readmission is or is not a valid and useful quality indicator. In most negative studies, the absence of an association appears to be explainable on the basis of improper study design, omission of important variables, or mis-specification of variables. Variables intervening between or confounding the relationship of the process of inpatient care to early readmission have received inadequate attention in past work. Investigators can use the proposed model and literature review to ensure their work advances the field and puts the hypothesis that early readmission is a valid quality indicator to a rigorous test. This matter has a certain urgency in view of the vast amount of resources that providers and payers devote to monitoring readmission rates and reviewing readmissions.

Using administrative databases to evaluate the quality of medical care: A conceptual framework

Health care is consuming an ever larger share of national resources in the United States. Measures to contain costs and evidence of unexplained variation in patient outcomes have led to concern about inadequacy in the quality of health care. As a measure of quality, the evaluation of hospitals through analysis of their discharge databases has been suggested because of the scope and economy offered by this methodology. However, the value of the information obtained through these analyses has been questioned because of the inadequacy of the clinical data contained in administrative databases and the resultant inability to control accurately for patient variation. We suggest, however, that the major shortcoming of prior attempts to use large databases to perform across-facility evaluation has resulted from the lack of a conceptual framework to guide the analysis. We propose a framework which identifies component areas and clarifies the underlying assumptions of the analytic process. For each area, criteria are identified which will maximize the validity of the results. Hospitals identified as having unexpectedly high unfavorable outcomes when our framework is applied will be those where poor quality will most likely be found by primary review of the process of care.(ABSTRACT TRUNCATED AT 250 WORDS)

SODA (severity of dyspepsia assessment): A new effective outcome measure for dyspepsia-related health

The aim of this research was to develop and evaluate an instrument for measuring dyspepsia-related health to serve as the primary outcome measure for randomized clinical trials. Building on our previous work we developed SODA (Severity of Dyspepsia Assessment), a multidimensional dyspepsia measure. We evaluated SODA by administering it at enrollment and seven follow-up visits to 98 patients with dyspepsia who were randomized to a 6-week course of omeprazole versus placebo and followed over 1 year. The mean age was 53 years, and six patients (6%) were women. Median Cronbachs alpha reliability estimates over the eight visits for the SODA Pain Intensity, Non-Pain Symptoms, and Satisfaction scales were 0.97, 0.90, and 0.92, respectively. The mean change scores for all three scales discriminated between patients who reported they were improved versus those who were unchanged, providing evidence of validity. The effect sizes for the Pain Intensity (.98) and Satisfaction (.87) scales were large, providing evidence for responsiveness. The effect size for the Non-Pain Symptoms scale was small (.24), indicating lower responsiveness in this study sample. SODA is a new, effective instrument for measuring dyspepsia-related health. SODA is multidimensional and responsive to clinically meaningful change with demonstrated reliability and validity.

A simple clinical staging system that predicts progression to AIDS using CD4 count, oral thrush, and night sweats

Objective: To develop a simple clinical staging system based on CD4 count and clinical variables that predicts progression to AIDS in HIV-infected non-AIDS patients.Design: Retrospective cohort study.Setting: A primary care outpatient clinic for HIV-infected patients at a VA Medical Center.Patients: One hundred seventy-six HIV-infected non-AIDS patients seen at the Houston VA Special Medicine Clinic between January 1986 and December 1990 and followed for a mean of 22 months. Fifty-four patients (31%) progressed to AIDS during follow-up.Measurements: The medical records were reviewed, and data corresponding to the initial (baseline) clinic visit and subsequent sixmonth visits were extracted.Main results: “Predictive” baseline variables (i.e., those associated with progression to AIDS) were first identified and then examined in Cox proportional hazards modeling. In the final model, CD4 category, oral thrush, and night sweats made significant independent contributions. A three-stage prognostic system was constructed by assigning points to the three variables: CD4>500 cells/mm3=0; 500≥CD4≥200=1; CD4<200=2; presence of oral thrush=1; presence of night sweats=1. Stages were assigned as follows: stage I=0 points, stage II=1−2 points, and stage III=3−4 points. The proportions of patients who progressed to AIDS were: stage I, 6/39 (15%); stage II, 31/106 (29%); and stage III, 17/31 (55%).Conclusion: These results demonstrate that simple, clinically sensible prognostic staging systems that predict progression to AIDS can be constructed using CD4 count and clinical variables.

Dyspepsia: How Should We Measure It?

This study developed and validated a multidimensional measure of dyspepsia. A questionnaire was administered to 126 patients with dyspepsia who presented for care at a VA outpatient clinic and a family physicians private office. Dyspepsia-specific health was measured by self-report using: (1) an existing dyspepsia scale that produces an aggregate score by summing ratings across pain and non-pain symptoms; (2) adaptations of two scales originally designed to measure back pain; and (3) a new scale measuring satisfaction with dyspepsia-related health. Generic health was measured using the SF-36. Results from factor analysis revealed four dimensions of dyspepsia-related health: pain intensity, pain disability, non-pain symptoms, and satisfaction with dyspepsia-related health. After refinements, scales representing the four dimensions conformed to psychometric standards for reliability, and convergent and discriminant validity. The importance of measuring dyspepsia using a multidimensional approach was confirmed by demonstrating that classification of dyspepsia severity depended on the dimension that was assessed. We conclude that dyspepsia is best measured using a multidimensional approach.

A trial for comparing methods for eliciting treatment preferences from men with advanced prostate cancer: results from the initial visit.

Objective.The objective of this study was to evaluate the convergent validity of 3 types of utility measures: standard gamble, time tradeoff, and rating scale. Research Design.A prospective cohort of 120 men with advanced prostate cancer were first asked to rank order 8 health states, and then utility values were obtained from each participant for each of the 8 health states through 2 of the 3 techniques evaluated (standard gamble, time tradeoff and rating scale). Participants were randomly assigned to 1 of 3 possible pairs of techniques. The validity of the 3 methods, as measured by the convergence and raw score differences of the techniques, was assessed with ANOVA. The ability of the techniques to differentiate health states was determined. The inconsistencies between rankings and utility values were also measured. Proportions of illogical utility responses were assessed as the percent of times when states with more symptoms were given higher or equal utility values than states with fewer symptoms. Results.There were significant differences in raw scores between techniques, but the values were correlated across health states. Utility values were often inconsistent with the rank order of health states. In addition, utility assessment did not differentiate the health states as well as the rank order. Furthermore, utility values were often illogical in that states with more symptoms received equal or higher utility values than states with fewer symptoms. Conclusions.Use of the utility techniques in cost-effectiveness analysis and decision making has been widely recommended. The results of this study raise serious questions as to the validity and usefulness of the measures.

A double blind, randomized, placebo-controlled trial of proton pump inhibitor therapy in patients with uninvestigated dyspepsia

A double blind, randomized, placebo-controlled trial of proton pump inhibitor therapy in patients with uninvestigated dyspepsia

Analysis of aryl hydrocarbon hydroxylase activity in human lung tissue, pulmonary macrophages, and blood lymphocytes.

Aryl hydrocarbon hydroxylase (AHH) activity was measured fluorometrically in surgically‐excised fresh lung tissue, pulmonary alveolar macrophages (PAMs), and peripheral blood lymphocytes from 14 cigarette smokers (7 with and 7 without primary lung cancer). Levels of AHH in fresh PAMs and AHH inducibility (expressed as fold‐induction) in cultured, mitogen‐stimulated lymphocytes from individual noncancer patients correlated well (r =0.975, p < 0.001). For individual lung cancer patients, however, these values were dissociated (linear regression not appropriate for this set of values). Levels of AHH in fresh lung tissue and fold‐induction ratios in cultured lymphocytes from individual noncancer patients also exhibited a positive correlation (r =0.976, p < 0.001), while values for individual lung cancer patients did not (r =0.007, p =0.987). A close agreement was noted for AHH in fresh lung tissue and fresh PAMs from individual noncancer patients (r =0.984, p < 0.001), while these values are weakly correlated for lung cancer patients (r =0.658, p < 0.11). When AHH activity in fresh PAMs, in fresh lung tissue, and AHH inducibility in cultured lymphocytes were simultaneously compared, an excellent relationship was observed for values for all 3 tissues for individual noncancer patients (r =0.987, p < 0.001). However, AHH levels in these 3 tissues from individual lung cancer patients were not correlated (r =0.701, p > 0.25). These results indicate similar capacity for AHH induction is present in fresh lung tissue, fresh PAMs, and cultured mitogen‐stimulated lymphocytes from cigarette smokers without evidence of lung cancer, but AHH values are not positively correlated with similar tissues from individual lung cancer patients.