Direct-to-consumer genetic testing is an unavoidable consequence of our ability to cheaply and accurately measure the genome. Some are troubled by the loss of control over how and when this information is disclosed to individuals, but it is difficult to imagine any way to prevent the wide availability of these data. Therefore, the key challenge is to set up social, educational, and technical means to support individuals who have access to their genome.

This study examined whether externally rated job demand and control were associated with depression diagnosis claims in a heavy industrial cohort. The retrospective cohort sample consisted of 7,566 hourly workers aged 18-64 years who were actively employed at 11 US plants between January 1, 1996, and December 31, 2003, and free of depression diagnosis claims during an initial 2-year run-in period. Logistic regression analysis was used to model the effect of tertiles of demand and control exposure on depression diagnosis claims. Demand had a significant positive association with depression diagnosis claims in bivariate models and models adjusted for demographic (age, gender, race, education, job grade, tenure) and lifestyle (smoking status, body mass index, cholesterol level) variables (high demand odds ratio = 1.39, 95% confidence interval: 1.04, 1.86). Control was associated with greater risk of depression diagnosis at moderate levels in unadjusted models only (odds ratio = 1.47, 95% confidence interval: 1.12, 1.93), while low control, contrary to expectation, was not associated with depression. The effects of the externally rated demand exposure were lost with adjustment for location. This may reflect differences in measurement or classification of exposure, differences in depression diagnosis by location, or other location-specific factors.

Background and objectives. Rates of dialysis withdrawal are higher among the elderly and lower among Blacks, yet it is unknown whether preferences for withdrawal and engagement in advance care planning also vary by age and race or ethnicity.

Design, setting, participants and methods. We recruited 61 participants from two dialysis clinics to complete questionnaires regarding dialysis withdrawal preferences in five different health states. Engagement in advance care planning (end-of-life discussions), completion of advance directives and ‘do not resuscitate' or ‘do not intubate' (DNR/DNI) orders were ascertained by a questionnaire and from dialysis unit records.

Results. The mean age was 62 ± 15 years; 38% were Black, 11% were Latino, 34% were White and 16% of participants were Asian. Blacks were less likely to prefer dialysis withdrawal as compared with Whites (odds ratio 0.16, 95% confidence interval 0.03-0.88) and other race/ethnicity groups, and this difference was not explained by age, education, comorbidity and other confounders. In contrast, older age was not associated with preferences for withdrawal. Rates of engagement in end-of-life discussions were higher than for documentation of advance care planning for all age and most race/ethnicity groups. Although younger participants and minorities were generally less likely to document treatment preferences as compared with older patients and Whites, they were not less likely to engage in end-of-life discussions.

Conclusions. Preferences for withdrawal vary by race/ ethnicity, whereas the pattern of engagement in advance care planning varies by age and race/ethnicity. Knowledge of these differences may be useful for improving communication about end-of-life preferences and in implementing effective advance care planning strategies among diverse haemodialysis patients.

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0-11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent's language, parental education, ethnicity, and children's insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.

Objective To evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient pediatric asthma care.

Data Sources Cochrane Effective Practice and Organisation of Care Group database (January 1966 to April 2006), MEDLINE (January 1966 to April 2006), Cochrane Consumers and Communication Group database (January 1966 to May 2006), and bibliographies of retrieved articles.

Study Selection Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations.

Interventions Must have included 1 or more QI strategies for the outpatient management of children with asthma.

Main Outcome Measures Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions).

Results Seventy-nine studies met inclusion criteria: 69 included at least some component of patient education, self-monitoring, or self-management; 13 included some component of organizational change; and 7 included provider education. Self-management interventions increased symptom-free days by approximately 10 days/y (P = .02) and reduced school absenteeism by about 0.1 day/mo (P = .03). Interventions of provider education and those that incorporated organizational changes were likely to report improvements in medication use. Quality improvement interventions that provided multiple educational sessions, had longer durations, and used combinations of instructional modalities were more likely to result in improvements for patients than interventions lacking these characteristics.

Conclusions A variety of QI interventions improve the outcomes and processes of care for children with asthma. Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care.

Abstract

Some people find it more difficult to delay rewards than others. In three experiments, we tested a "future self-continuity" hypothesis that individual differences in the perception of one's present self as continuous with a future self would be associated with measures of saving in the laboratory and everyday life. Higher future self-continuity (assessed by a novel index) predicted reduced discounting of future rewards in a laboratory task, more matches in adjectival descriptions of present and future selves, and greater lifetime accumulation of financial assets (even after controlling for age and education). In addition to demonstrating the reliability and validity of the future self-continuity index, these findings are consistent with the notion that increased future self-continuity might promote saving for the future.

Background

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

Methods

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

Results

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

Conclusions

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

AIMS: The purpose of these analyses was to examine the persistence and predictors of elevated depressive symptoms in 884 women over their children's preschool years. RESULTS: Depressive symptoms in women with young children are surprisingly consistent throughout their children's preschool years. Of the 82.6% of women without elevated depressive symptoms at the initial assessment (study child was 11-42 months of age), 82.4% remained without symptoms over two follow-up assessments. Of 17.4% of women with elevated symptoms at baseline, 35.6% had elevated symptoms at one of the two follow-ups, and 27.4% had elevated symptoms at both follow-ups. Persistently elevated depressive symptoms were related to low education, high levels of anxiety, high parenting distress, and low levels of emotional support at baseline. CONCLUSIONS: Women who report symptoms of depression when their children are young are highly likely to continue to report such symptoms. These results support the need to screen for elevated depressive symptoms at varying intervals depending on prior screening results and for screening in locations where women most at risk routinely visit, such as well-child clinics. Further, these results point to the need for a system to identify and manage this common treatable condition because these elevated symptoms continue throughout their children's preschool years for a substantial portion of women.

OBJECTIVE: To examine parent concerns about development, learning, and behavior for young children of Mexican origin, and to identify whether these reports differ by families' citizenship/documentation status.

METHODS: Data come from the 2005 California Health Interview Survey, a population-based random-digit dial telephone survey of California's noninstitutionalized population. California Health Inerview Survey (CHIS) investigators completed interviews of 43 020 households with a total of 5856 children under age 6 years, of whom 1786 were reported being of Mexican origin. Developmental risk was measured by parent concerns elicited by the Parents' Evaluation of Developmental Status. We used bivariate and multivariate analyses to examine associations between developmental risk and family citizenship/documentation status (parents are undocumented, at least one documented noncitizen parent, or both parents are US citizens) among children of Mexican origin and US-born non-Latino white children, after adjusting for age, income, parental education, and predominant household language.

RESULTS: In multivariate analyses, children of Mexican origin did not differ significantly from US-born white children in developmental risk (odds ratio 1.12, 95% confidence interval 0.88-1.42). In subgroup analyses, children of Mexican origin with undocumented parents had higher odds of developmental risk (odds ratio 1.53, 95% confidence interval 1.00-2.33) than non-Latino white children whose parents were citizens, after adjusting for confounders.

CONCLUSIONS: Mexican children with undocumented parents have greater parent-reported developmental risk than Mexican and white children whose parents are US citizens or otherwise legally documented. More research is needed to understand the roles of immigration stress and home environments on the developmental risks of children in households with undocumented parents.