Publications

BACKGROUND

Reporting of quality indicators (QIs) in Veterans Health Administration Medical Centers is complicated by estimation error caused by small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation in addressing this issue in performance reporting of stroke care quality in the Medical Centers.

METHODS AND RESULTS

We studied a retrospective cohort of 3812 veterans admitted to 106 Medical Centers with ischemic stroke during fiscal year 2007. The median number of study patients per facility was 34 (range, 12-105). Inpatient stroke care quality was measured with 13 evidence-based QIs. Eligible patients could either pass or fail each indicator. Multilevel modeling of a patient's pass/fail on individual QIs was used to produce facility-level EB-estimated QI pass rates and confidence intervals. The EB estimation reduced interfacility variation in QI rates. Small facilities and those with exceptionally high or low rates were most affected. We recommended 8 of the 13 QIs for performance reporting: dysphagia screening, National Institutes of Health Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining 5 QIs were not recommended because of too few eligible patients or high pass rates with little variation.

CONCLUSIONS

Considerations of statistical uncertainty should inform the choice of QIs and their application to performance reporting.

Recent studies have shown that osteopontin, a cytokine with suggested immunoregulatory functions, may contribute to pathogenesis of asthma. To determine whether single-nucleotide polymorphisms (SNPs) in SPP1, the gene encoding osteopontin, are associated with risk of asthma, we genotyped 6 known SNPs in SPP1 in the well-characterized Genetics of Asthma in Latino Americans population of 294 Mexican and 365 Puerto Rican parent-child asthma trios. The associations between SNPs and asthma or asthma-related phenotypes were examined by transmission disequilibrium tests as implemented in the family-based association test program. Three polymorphisms, 1 in exon 7 (rs1126616C) and 2 in the 3'-untranslated region (rs1126772A and rs9138A) of SPP1, were associated with diagnosis of asthma, severity of asthma, asthma in subjects with elevated immunoglobulin E (IgE) (IgE >100 IU/mL), and postbronchodilator FEV(1) in Puerto Ricans (P values=0.00007-0.04). The CC genotype of rs1126616 conferred an odds ratio of 1.7 (95% CI=[1.3, 2.3], P value adjusted for multiple comparisons=0.001) for asthma compared with the CT and TT genotypes. Furthermore, haplotype analysis identified rs1126616C-rs1126772A-rs9138A to be associated with an increased risk for asthma, severity of asthma, and asthma in subjects with elevated IgE (P=0.03). There was no association between the SPP1 SNPs and asthma outcomes in Mexicans. Our findings suggest that the SPP1 gene is a risk factor for asthma and asthma-related phenotypes in Puerto Ricans, and are consistent with previous animal and human studies on the role of osteopontin in pathogenesis of asthma.

OBJECTIVES

Patients with inflammatory bowel disease (IBD) often experience barriers to subspecialty access. We applied telemedicine, using a new computerized system called Collaborative Imaging, to resolve these barriers. We studied patients' experience and satisfaction, and clinic throughput.

METHODS

We performed a prospective randomized controlled pilot study at a Veterans Affairs hospital, assigning patients into two groups: telemedicine encounter, with the IBD specialist remotely located, and standard encounter. We assessed patient experience and measured differences in satisfaction as well as clinic metrics such as appointment duration, wait time, and throughput.

RESULTS

We enrolled 34 patients with Crohn's disease and ulcerative colitis who underwent 57 encounters in 9 months. Patients were mostly Caucasian men, with a mean age of 61 years. The two groups similarly rated as excellent their clinic experience and the major clinical satisfaction indices of attention to patient concerns, bedside manner, and perceived skill level of the doctor. The total clinic duration, wait time, and median number of patients per clinic were also similar. The fellow and subspecialist highly rated the technical and informational quality of the telemedicine sessions.

CONCLUSIONS

IBD outpatient service may be delivered via a novel telemedicine system. In this pilot study, we observed a high level of patient satisfaction similar to that achieved with a direct clinical encounter.