Health Care Research and Evaluation

Despite broad agreement among researchers about the value of examining how context shapes implementation of improvement programs and projects, limited attention has been paid to contextual effects on implementation of Lean. To help reduce gaps in knowledge of effects of intraorganizational context, we researched Lean implementation initiatives in five organizations and examined 12 of their Lean rapid improvement projects. All projects aimed at improving clinical care delivery. On the basis of the literature on Lean, innovation, and quality improvement, we developed a framework of factors likely to affect Lean implementation and outcomes. Drawing on the framework, we conducted semistructured interviews and applied qualitative codes to the transcribed interviews. Available documents, data, and observations supplemented the interviews. We constructed case studies of Lean implementation in each organization, compared implementation across organizations, and compared the 12 projects. Int...

Understanding health insurance is central to affording and accessing health care in the United States. Efforts to support consumers in making wise purchasing decisions and using health insurance to their advantage would benefit from the development of a valid and reliable measure to assess health insurance literacy. This article reports on the development of the Health Insurance Literacy Measure (HILM), a selfassessment measure of consumers' ability to select and use private health insurance. The authors developed a conceptual model of health insurance literacy based on formative research and stakeholder guidance. Survey items were drafted using the conceptual model as a guide then tested in two rounds of cognitive interviews. After a field test with 828 respondents, exploratory factor analysis revealed two HILM scales, choosing health insurance and using health insurance, each of which is divided into a confidence subscale and likelihood of behavior subscale. Correlations between the HILM scales and an objective measure of health insurance

The quality of communication between patients and clinicians can have a ma- jor impact on health outcomes, and limited English proficiency can interfere with effective communication. More than ten million U.S. residents speak English poorly or not at all, con- stituting a language chasm in the health care system. This paper reviews the evidence on the link between linguistic competence

Background: Randomized controlled trials that test the effectiveness of mobile health-based weight loss programs are attractive to participants, funders, and researchers because of the low implementation cost, minimal participant burden, and the ability to recruit participants from longer distances. Collecting weight data from geographically dispersed participants is a challenge. Relying on participant self-report is one approach to data collection, but epidemiologic studies indicate that self-reported anthropometric data may be inaccurate. Methods: We provided women enrolled in a randomized controlled trial (RCT) of postpartum weight loss after gestational diabetes with a digital scale and training to collect and report weight via a web-based survey. To validate self-reported weights and heights, we visited 30 randomly selected women in their homes, with a reference scale and stadiometer, a mean of 34 days after the self-report. We ran linear regression models to identify characteristics that were associated with underreporting or overreporting of anthropometric measures. Results: Of the 30 women we visited, 11 women (37%) were assigned to the weight loss intervention group and 19 women (63%) were in the control group. Mean age was 38.5 years (SD 4.5). The overall mean difference between participants' self-reported weights and the weights obtained at their home visit was 0.70 kg (+1.92). Women assigned to the intervention group underreported their weight in comparison with the control group by 1.29 kg (95% CI −2.52, −0.06). The overall difference in collected to self-reported height was −0.56 cm (±1.91). No characteristics were associated with underreporting or overreporting of height. Conclusions: Our research suggests that by providing a digital scale and developing a weight collection protocol, researchers can train women to collect and record their own study weights with reasonable validity. To achieve the level of validity required for clinical trials, researchers should consider additional strategies to assure the validity of the data. Trial registration: NCT01923350.

Doctoral students and new faculty members often seek advice from more senior faculty on how to advance their program of research. Students may ask whether they should choose the manuscript option for their dissertation or whether they should seek a postdoctoral fellowship. New faculty members wonder whether they should pursue a career development (K) award and whether they need a mentor as they strive to advance their research while carrying out teaching, service, and practice responsibilities. In this paper, we describe literature on the impact of selected aspects of pre and postdoctoral training and faculty strategies on scholarly productivity in the faculty role. We also combine our experiences at a school of nursing within a research-intensive university to suggest strategies for success. Noting the scarcity of research that evaluates the effect of these strategies we are actively engaged in collecting data on their relationship to the scholarly productivity of students and faculty members within our own institution. Keywords nursing; doctoral; students; research; faculty When It comes to advising doctoral students and new faculty members on advancing their program of research, the published evidence on which to ground this advice is admittedly weak. In a systematic review of literature on the promotion of faculty research productivity, Segrott,

Purpose: To evaluate the cost-effectiveness of case management by a nurse practitioner (NP) to lower blood lipids in patients with coronary heart disease (CHD) from a managed care perspective. Data sources: A total of 228 consecutive, eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization. Patients were randomized to receive lipid management, including individualized lifestyle modification and pharmacologic intervention from an NP for 1 year after discharge in addition to their usual care (NURS) or to receive usual care (EUC) enhanced with feedback on lipids to their primary provider and/or cardiologist. A cost-effectiveness ratio was calculated using incremental costs of the NURS group per unit change and percent change in low-density lipoprotein cholesterol (LDL-C) for 1 year at 2004 values. Conclusions: The annual incremental cost-effectiveness of NP case management was $26.03 per mg/dL and $39.05 per percent reduction in LDL-C. When costs of NURS care for the second 6 months of management were compared to the first 6 months of management, nursing salary costs were lower as patients were established on cholesterol management regimens, but the reduction in costs was offset by the increase in incremental costs of drug treatment as the NP titrated the patient to higher drug dosages that were more costly. Implications for practice: The findings suggest that case management by an NP is a cost-effective approach for a managed care organization to consider in improving the care of patients with cardiovascular disease.

Correlations between diabetes knowledge and ADDQoL, EQ-5D and SF-6D scores were 0.26, 0.30 and 0.21 respectively. Although none of the independent variables was associated significantly with HRQoL scores in any MLR model (p > 0.05), a trend of association was nevertheless observed. CONCLUSIONS: Our results showed diabetes knowledge to be weakly correlated with both diabetes-specific and generic health related quality of life. In addition, diabetes knowledge may be positively associated with diabetes-specific HRQoL but further studies utilizing larger sample size are required to confirm this observation.

Infections due to medical care were associated with significantly higher length of stay and costs. On average, hospital stays with infections due to medical care were 19.2 days longer and the cost was nearly $43,000 greater than stays without infections. ■ Males and females were nearly equally affected by infections due to medical care (49.1 and 50.9 percent of the stays with an infection, respectively). This differed from all other hospital stays, where one-third of stays were males. ■ Stays with infections were more likely to be at hospitals with any of the following characteristics: size of 500 or more beds; located in a metropolitan area; private, for profit; and teaching hospital. ■ The most common principal diagnoses for stays with infections due to medical care were septicemia (11.8 percent of infections had this principal diagnosis); adult respiratory failure (5.9 percent); and complications of surgical procedures or medical care (4.1 percent). ■ The rate of infections among medical and surgical discharges peaked in 2004 and 2005 at 2.30 per 1,000 stays, then declined to 2.03, a rate similar to year 2000. ■ From 2004 to 2007, the infection rate was highest in the 45 to 64 year group (2.58 per 1,000 in 2007) and lowest in the 18 to 44 year group (1.38 per 1,000 in 2007). The 45 to 64 year group also saw the greatest reduction in rate from 2004 to 2007, falling by 0.48 per 1,000, a 15.7 percent reduction over the four-year period.

PURPOSE Engaging patients, caregivers, and other health care stakeholders as partners in planning, conducting, and disseminating research is a promising way to improve clinical decision making and outcomes. Many researchers, patients, and other stakeholders, however, lack clarity about when and how to engage as partners within the clinical research process. To address the need for guidance on creating meaningful stakeholder partnerships in patient-centered clinical comparative effectiveness research, the Patient-Centered Outcomes Research Institute (PCORI) developed the PCORI Engagement Rubric (Rubric). METHODS PCORI developed the Rubric drawing from a synthesis of the literature, a qualitative study with patients, a targeted review of engagement plans from PCORI-funded project applications, and a moderated discussion and review with PCORI's Advisory Panel on Patient Engagement. RESULTS The Rubric provides a framework for operationalizing engagement to incorporate patients and other stakeholders in all phases of research. It includes: principles of engagement; definitions of stakeholder types; key considerations for planning, conducting, and disseminating engaged research; potential engagement activities; and examples of promising practices from PCORI-funded projects. CONCLUSIONS PCORI designed the Rubric to illustrate opportunities for engagement to researchers interested in applying for PCORI funding and to patients and other stakeholders interested in greater involvement in research. By encouraging PCORI applicants, awardees, and others to apply the rubric, PCORI hopes to shift the research paradigm from one of conducting research on patients as subjects to a pursuit carried out in collaboration with patients and other stakeholders to better reflect the values, preferences, and outcomes that matter to the patient community.

The oral route is compromised for nearly all patients at the end of life (EOL). This article reviews the benefits and burdens of the usual alternative routes of medication delivery when the oral route fails and presents a case study on the use of a new innovation for the rectal delivery of medication to control EOL symptoms. A 62-year-old male hospice patient with end-stage metastatic prostate cancer presented with severe symptoms (Face, Legs, Activity, Cry and Consolability scale score, 9/10) that were uncontrollable with medications given via oral or sublingual routes. The patient goals were to remain at home with optimal symptom management. Rapid relief of symptoms was accomplished by the administration of medications already present in the home delivered with a new rectal catheter that provides discreet access for ongoing medication administration. Significant relief was noted within 20 minutes of dosing. The patient died peacefully 18 hours later, meeting his EOL goals, and the family was empowered to provide effective care for the patient at home. The family found the intervention easy to use. This case demonstrates how this new innovation can be used to ensure rapid symptom management and decreased burden of care by facilitating immediate and easy use of medications already present in the home.