Patient safety has been a priority in health care since Hippocrates admonished physicians to "first do no harm." Even so, the Institute of Medicine found in 2000 that approximately 98 000 patients die from preventable medical errors each year. Recent US Centers for Disease Control and Prevention estimates project that 270 individuals die each day from hospital-acquired infections. Despite substantial efforts and investments, widespread and substantial improvement is not evident.

The problem is not in knowing what to do. Techniques, tools, and some best practices are available, and many health care organizations are making efforts to apply them. The importance of creating a "culture of safety" has also been noted. This involves continuous vigilance or mindfulness, learning, and accountability. A greater emphasis on safety over productivity and on teamwork over individual autonomy, increased standardization and simplification, and the implementation of an environment in which personnel are encouraged and feel comfortable to report errors and mistakes are needed.

Although creating a culture of safety is important, creating a culture of systems is a more fundamental challenge. In this Commentary, the term systems means systems of care that occur both within and across organizations. For example, in studies involving causes of adverse events in cardiac surgery, more than two-thirds were classified as nontechnical or systems-oriented issues including delays and missing equipment, and more of these problems occurred in cases with adverse outcomes than in successful cases. The greatest barrier to patient safety and safety culture is the inherent fragmentation of the US system of care. Safety will improve when the underlying system of care improves.

This issue of CHP/PCOR's Quarterly Update covers news from the Fall 2007 quarter and includes articles about:

• the 2007 Eisenberg Legacy Lecture event, featuring CHP/PCOR core faculty member Victor R. Fuchs;
• annual meeting and conference coverage, including the Society for Medical Decision Meeting's Annual Meeting, and the Freeman Spogli Institute for International Studies conference;
• two Research in Brief selections -- one highlights differences in gender use care in the VA system, and the second examines health risk assessment tools;
• how the Geriatrics Research team at the VA is using informatics to improve quality of health care;
• international health features from the field and from a research perspective;
• a Q & A with senior scholar Dena M. Bravata, who led a popular pedometer that received lots of media attention in past months.

The newsletter also contains various other news items that may be of interest to our readers.

Note to the reader:

The newsletter is fully-navigational. Any text that is surrounded by a dashed box is clickable and will allow the reader to navigate the newsletter more efficiently. The end of each article contains a special symbol (§) that, when clicked, will take the reader back to the table of contents. Please feel free to contact Amber Hsiao with any questions.

Despite an association between violence perpetration and substance use, the characteristics associated with violence among patients in treatment for substance use disorders (SUDs) are not well documented. Data were gathered from a national sample of men (n = 4,459) and women (n = 1,774) entering SUD treatment on history of violence perpetration, exposure to childhood physical abuse (CPA) and childhood sexual abuse (CSA), and reasons for entering treatment. Rates of violence perpetration were high (72% of men, 50% of women), and violence was associated with being referred by family members, prior SUD treatment, CPA, and CSA. In multivariate analyses, CPA was a significant correlate of violence perpetration across gender; however, CSA was only significant among women. Findings highlight the need for increased screening and treatment of violence perpetration among patients with SUD and suggest that CSA may be an important correlate of violence perpetration among women.

BACKGROUND: Recent work has shown that rates of severe disability, measured by the inability to perform basic activities of daily living, have been rising in working age populations. At the same time, the prevalence of important chronic diseases has been rising, while others falling, among working age populations. Chronically ill individuals are more likely than others to have activity of daily living limitations.

OBJECTIVE: We examine the extent to which chronic disease trends can explain these disability trends. DATA: We use nationally representative survey data from the 1984-1996 National Interview Survey, which posed a consistent set of questions regarding limitations in activities of daily living over that period.

METHODS: We decompose trends in disability into 2 parts-1 part due to trends in the prevalence of chronic disease and the other due to trends in disability prevalence among those with chronic disease.

RESULTS:: Our primary findings are that for working age populations between 1984 and 1996: (1) disability prevalence fell dramatically among the nonchronically ill; (2) rising obesity prevalence explains about 40% of the rise in disability attributable to trends chronic illness; and (3) rising disability prevalence among the chronically ill explains about 60% of the rise in disability attributable to trends in chronic illness.

CONCLUSIONS: Disability prevention efforts in working age populations should focus on reductions in obesity prevalence and limiting disability among chronically ill populations. Given the rise in disability among these population subgroups, it is unclear whether further substantial declines in elderly disability can be expected.

Abstract

PURPOSE:

Given the prevalence of physical inactivity among American adults, convenient, low-cost interventions are strongly indicated. This study determined the 6- and 12-month effectiveness of telephone interventions delivered by health educators or by an automated computer system in promoting physical activity.

DESIGN:

Initially inactive men and women age 55 years and older (N = 218) in stable health participated. Participants were randomly assigned to human advice, automated advice, or health education control.

MEASURES:

The validated 7-day physical activity recall interview was used to estimate minutes of moderate to vigorous physical activity. Physical activity differences by experimental arm were verified on a random subsample via accelerometry.

RESULTS:

Using intention-to-treat analysis, at 6 months, participants in both interventions, although not differing from one another, showed significant improvements in weekly physical activity compared with controls. These differences were generally maintained at 12 months, with both intervention arms remaining above the target of 150 min per week of moderate to vigorous physical activity on average.

CONCLUSION:

Automated telephone-linked delivery systems represent an effective alternative for delivering physical activity advice to inactive older adults.

BACKGROUND: The elderly constitute the fastest-growing segment of the end-stage renal disease (ESRD) population, but the epidemiology and outcomes of dialysis among the very elderly, that is, those 80 years of age and older, have not been previously examined at a national level. OBJECTIVE: To describe recent trends in the incidence and outcomes of octogenarians and nonagenarians starting dialysis. DESIGN: Observational study. SETTING: U.S. Renal Data System, a comprehensive, national registry of patients with ESRD. PARTICIPANTS: Octogenarians and nonagenarians initiating dialysis between 1996 and 2003. MEASUREMENTS: Rates of dialysis initiation and survival. RESULTS: The number of octogenarians and nonagenarians starting dialysis increased from 7054 persons in 1996 to 13,577 persons in 2003, corresponding to an average annual increase in dialysis initiation of 9.8%. After we accounted for population growth, the rate of dialysis initiation increased by 57% (rate ratio, 1.57 [95% CI, 1.53 to 1.62]) between 1996 and 2003. One-year mortality for octogenarians and nonagenarians after dialysis initiation was 46%. Compared with octogenarians and nonagenarians initiating dialysis in 1996, those starting dialysis in 2003 had a higher glomerular filtration rate and less morbidity related to chronic kidney disease but no difference in 1-year survival. Clinical characteristics strongly associated with death were older age, nonambulatory status, and more comorbid conditions. LIMITATIONS: Survival of patients with incident ESRD who did not begin dialysis could not be assessed. CONCLUSIONS: The number of octogenarians and nonagenarians initiating dialysis has increased considerably over the past decade, while overall survival for patients on dialysis remains modest. Estimates of prognosis based on patient characteristics, when considered in conjunction with individual values and preferences, may aid in dialysis decision making for the very elderly.

OBJECTIVES: We sought to determine the prevalence of HIV in both inpatient and outpatient settings in 6 Department of Veterans Affairs (VA) health care sites. METHODS: We collected demographic data and data on comorbid conditions and then conducted blinded, anonymous HIV testing. We conducted a multivariate analysis to determine predictors of HIV infection. RESULTS: We tested 4500 outpatient blood specimens and 4205 inpatient blood specimens; 326 (3.7%) patients tested positive for HIV. Inpatient HIV prevalence ranged from 1.2% to 6.9%; outpatient HIV prevalence ranged from 0.9% to 8.9%. Having a history of hepatitis B or C infection, a sexually transmitted disease, or pneumonia also predicted HIV infection. The prevalence of previously undocumented HIV infection varied from 0.1% to 2.8% among outpatients and from 0.0% to 1.7% among inpatients. CONCLUSIONS: The prevalence of undocumented HIV infection was sufficiently high for routine voluntary screening to be cost effective in each of the 6 sites we evaluated. Many VA health care systems should consider expanded routine voluntary HIV screening.

OBJECTIVES: To determine whether gaps exist in published cost-utility analyses as measured by their coverage of topics addressed in current HIV guidelines from the Department of Health and Human Services (DHHS).

DESIGN: A systematic review of US-based cost-effectiveness analyses of HIV/AIDS prevention and management strategies, based on original, published research.

METHODS: Predefined criteria were used to identify all analyses pertaining to prevention and management of HIV/AIDS; information was collected on type of strategy, patient demographics, study perspective, quality of the study, effectiveness measures, costs, and cost-effectiveness ratios.

RESULTS: One hundred and six studies were identified; 62 described strategies for averting new HIV infections, and 44 dealt with managing persons who are HIV positive. The quality of studies was generally high, but gaps were found in all studies. Especially common were omissions in reporting data abstraction methodology and discussions of direction and magnitude of potential biases. Among the 22 most highly rated papers (score of 90 or higher), only 1 was cited in the guidelines, and 3 papers reported on interventions that were superseded by newer approaches. Using a USD 100,000 threshold, the guidelines usually endorsed interventions found to be cost-effective. Exceptions included recommending postexposure prophylaxis (PEP) for populations in which PEP is unlikely to be cost-effective and not recommending primary resistance testing in treatment-naive persons, although the intervention was reported to have a cost-effectiveness ratio of less than USD 50,000.

CONCLUSIONS: Despite an abundant literature on the cost-utility of HIV/AIDS-targeted strategies, guidelines cite relatively few of these papers, and gaps exist regarding assessments of some strategies and special populations.

We developed a mathematical model to simulate the impact of various partially effective preventive HIV vaccination scenarios in a population at high risk for heterosexually transmitted HIV. We considered an adult population defined by gender (male/female), disease stage (HIV-negative, HIV-positive, AIDS, and death), and vaccination status (unvaccinated/vaccinated) in Soweto, South Africa. Input data included initial HIV prevalence of 20% (women) and 12% (men), vaccination coverage of 75%, and exclusive male negotiation of condom use.

We explored how changes in vaccine efficacy and postvaccination condom use would affect HIV prevalence and total HIV infections prevented over a 10-year period. In the base-case scenario, a 40% effective HIV vaccine would avert 61,000 infections and reduce future HIV prevalence from 20% to 13%. A 25% increase (or decrease) in condom use among vaccinated individuals would instead avert 75,000 (or only 46,000) infections and reduce the HIV prevalence to 12% (or only 15%). Furthermore, certain combinations of increased risk behavior and vaccines with <43% efficacy could worsen the epidemic. Even modestly effective HIV vaccines can confer enormous benefits in terms of HIV infections averted and decreased HIV prevalence. However, programs to reduce risk behavior may be important components of successful vaccination campaigns.