BACKGROUND: Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions. OBJECTIVES: To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline. RESEARCH DESIGN: We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals. SUBJECTS: We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response). MEASURES: The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines. RESULTS: Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area. CONCLUSIONS: Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.

The American College of Physicians (ACP) developed this guidance statement to present the available evidence on screening for HIV in health care settings. METHODS: This guidance statement is derived from an appraisal of available guidelines on screening for HIV. Authors searched the National Guideline Clearinghouse to identify guidelines on screening for HIV in the United States and used the AGREE (Appraisal of Guidelines Research and Evaluation) instrument to evaluate guidelines from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention. GUIDANCE STATEMENT 1: ACP recommends that clinicians adopt routine screening for HIV and encourage patients to be tested. GUIDANCE STATEMENT 2: ACP recommends that clinicians determine the need for repeat screening on an individual basis.

Russia has one of the world's fastest growing HIV epidemics, and HIV screening has been widespread. Whether such screening is an effective use of resources is unclear. We used epidemiologic and economic data from Russia to develop a Markov model to estimate costs, quality of life and survival associated with a voluntary HIV screening programme compared with no screening in Russia. We measured discounted lifetime health-care costs and quality-adjusted life years (QALYs) gained. We varied our inputs in sensitivity analysis. Early identification of HIV through screening provided a substantial benefit to persons with HIV, increasing life expectancy by 2.1 years and 1.7 QALYs. At a base-case prevalence of 1.2%, once-per-lifetime screening cost $13,396 per QALY gained, exclusive of benefit from reduced transmission. Cost-effectiveness of screening remained favourable until prevalence dropped below 0.04%. When HIV-transmission-related costs and benefits were included, once-per-lifetime screening cost $6910 per QALY gained and screening every two years cost $27,696 per QALY gained. An important determinant of the cost-effectiveness of screening was effectiveness of counselling about risk reduction. Early identification of HIV infection through screening in Russia is effective and cost-effective in all but the lowest prevalence groups.

Study objective

There is increasing concern that decreasing reimbursements to emergency departments (EDs) will negatively affect their functioning, but little evidence has been published identifying trends in reimbursement rates. We seek to examine and document the trends in reimbursement for outpatient ED visits throughout the past decade.

Methods

We use Medical Expenditure Panel Survey data covering a 9-year span from 1996 to 2004, using outpatient ED visits as the unit of analysis. Our primary outcome variables were total and per-visit charges and payments across insurance. Using regression analyses with a generalized linear models approach, we also derived the adjusted mean payment and mean charge for each ED visit, as well as the average payment ratio.

Results

Overall, adjusted mean charges for an outpatient ED visit increased from $713 (95% confidence interval [CI] $665 to $771) in 1996 to $1,390 (95% CI $1,317 to $1,462) in 2004. The adjusted mean payment also increased from $410 (95% CI $366 to $453) in 1996 to $592 (95% CI $551 to $634) in 2004. Because payments increased at a slower rate in all payer groups compared with charges, the overall share of charges that were paid decreased over time from 57% in 1996 (n=3,433) to 42% in 2004 (n=5,763; P<.001). The proportion of total charges paid in 2004 was highest for privately insured visits (56%; n=2,005) and lowest for Medicaid visits (33%; n=1,618). For visits by uninsured patients (n=996), 35% of charges were paid in 2004.

Conclusion

The proportion of charges paid for outpatient ED visits from Medicaid, Medicare, and privately insured and uninsured patients persistently decreased from 1996 to 2004. These concerning decreases may threaten the survival of EDs and their ability to continue to provide care as safety nets in the US health care system.

ABSTRACT

Control of infectious diseases is a key global health priority. This paper describes the role that simulation can play in evaluating policies for infectious disease control. We describe ongoing simulation studies in three different areas: HIV prevention and treatment, contact tracing, and hepatitis B prevention and control.

OBJECTIVE. The purpose of our work was to determine whether children with very low birth weight (<1500 g) who are at high risk for vision and hearing problems and enrolled in Medicaid receive recommended follow-up vision and hearing services and to examine predictors of services.

PATIENTS AND METHODS. We conducted a retrospective analysis of 2182 children born in South Carolina from 1996 to 1998 with birth weights of 401 to 1499 g, gestations of ≥24 weeks, and survival of ≥90 days of life. Receipt of services for Medicaid-enrolled children was assessed by using a linked data set that included files from vital records, death certificates, Medicaid, Chronic Rehabilitative Services, and the Early Intervention Program. We assessed the receipt of hearing rehabilitation by 6 months of age for children with nonconductive hearing loss and routine ophthalmologic examination between ages of 1 and 2 years for all children with very low birth weight. Multivariate logistic regression was restricted to ophthalmologic examinations because of sample size.

RESULTS. Among children with very low birth weight with nonconductive hearing loss, 20% received hearing rehabilitation by 6 months of age. Twenty-three percent of children with very low birth weight received an ophthalmologic examination between the ages of 1 and 2 years. Limiting our analysis to children <1000 g or extending the measurement period to 7 months (hearing) and age 3 years (vision) did not substantially increase the percentage of children receiving the services. The receipt of an ophthalmologic examination was associated positively with Medicaid enrollment by the time of hospital discharge and birth in a level-3 hospital and negatively associated with higher birth weight, an Apgar score of ≥7, and black maternal race. Among children born at <1000 g, all of whom were eligible for the Early Intervention Program, the receipt of an ophthalmologic examination was positively associated with program enrollment.

CONCLUSIONS. There is a shortfall in the provision of critical services for children with very low birth weight. These findings reinforce the Institute of Medicine's concerns regarding inadequate outcome data and health care services for preterm infants and support the importance of enrollment in the Early Intervention Program for children with very low birth weight.

OBJECTIVES: In response to growing concerns about sexual violence as an underrecognized traumatic consequence of military service, Veterans Health Administration policy requires universal screening for sexual trauma sustained during military service. This prospective study, the first to evaluate national efforts to screen for military sexual trauma, investigated whether sexual trauma screening is associated with increased utilization of mental health services.

METHODS: This study examined data for all male (N=540,381) and female (N=33,259) veterans who had valid responses to screens for military sexual trauma in 2005. The use of mental health services during the three months after screening was examined for persons who screened positive for military sexual trauma and for those who screened negative. Findings were stratified by use of mental health services in the six months before the screening.

RESULTS: Compared with negative screens, positive screens were associated with significantly increased rates of postscreen mental health treatment. A more than twofold increase was observed for patients without previous use of mental health treatment (women: relative risk [RR]=2.52, 95% confidence interval [CI]= 2.38–2.66; men: RR=2.47, 95% CI=2.34–2.61). In this group, the number of positive screens needed for one additional patient to access treatment was 5.5 for women and 7.2 for men.

CONCLUSIONS: Our findings suggest that detection via screening is associated with increased rates of mental health treatment. An effective screening program that promotes detection of sexual trauma and access to mental health care can help to reduce the burden of psychiatric illness for those who have experienced military sexual trauma.

OBJECTIVES: The purposes of this study were to develop a pediatric-focused tool for adverse drug event detection and describe the incidence and characteristics of adverse drug events in children's hospitals identified by this tool.

METHODS: A pediatric-specific trigger tool for adverse drug event detection was developed and tested. Eighty patients from each site were randomly selected for retrospective chart review. All adverse drug events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger and the entire tool were evaluated for positive predictive value.

RESULTS: Review of 960 randomly selected charts from 12 children's hospitals revealed 2388 triggers (2.49 per patient) and 107 unique adverse drug events. Mean adverse drug event rates were 11.1 per 100 patients, 15.7 per 1000 patient-days, and 1.23 per 1000 medication doses. The positive predictive value of the trigger tool was 3.7%. Twenty-two percent of all adverse drug events were deemed preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively. Ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. Only 3.7% of adverse drug events were identified in existing hospital-based occurrence reports. The most common adverse drug events identified were pruritis and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics, and the most common stages of the medication management process associated with preventable adverse drug events were monitoring and prescribing/ordering.

CONCLUSIONS: Adverse drug event rates in hospitalized children are substantially higher than previously described. Most adverse drug events resulted in temporary harm, and 22% were classified as preventable. Only 3.7% were identified by using traditional voluntary reporting methods. Our pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.

OBJECTIVES: Narcotic-related adverse drug events are the most common adverse drug events in hospitalized children. Despite multiple published studies describing interventions that decrease adverse drug events from narcotics, large-scale collaborative quality improvement efforts to address narcotic-related adverse drug events in pediatrics have not been described. The purpose of this study was to evaluate collaborative-wide narcotic-related adverse drug event rates after a collection of expert panel-defined best practices was implemented.

METHODS: All 42 children's hospitals in the Child Health Corporation of America were invited to participate in the Institute for Healthcare Improvement-style quality improvement collaborative aimed at reducing narcotic-related adverse drug events. A collection of interventions known or suspected to reduce narcotic-related adverse drug events was recommended by an expert panel, with each site implementing >or=1 of these best practices on the basis of local need. Narcotic-related adverse drug event rates were compared between the baseline (December 1, 2004, to March 31, 2005) and postimplementation periods (January 1, 2006, to March 31, 2006) after an a priori-defined intervention ramp-up time (April 1, 2005, and December 31, 2005). Secondary outcome measures included constipation rates and narcotic-related automated drug-dispensing-device override percentages.

RESULTS: Median narcotic-related adverse drug event rates decreased 67% between the baseline and postimplementation time frames across the 14-site collaborative. Constipation rates decreased 68.9%, and automated drug-dispensing-device overrides decreased from 10.18% to 5.91% of all narcotic doses administered.

CONCLUSIONS: Implementation of >or=1 expert panel-recommended interventions at each participating site resulted in a significant decrease in narcotic-related adverse drug events, constipation, and automated drug-dispensing-device overrides in a 12-month, 14-site children's hospital quality collaborative.