Breast cancer is one of the most common causes of death for women in their 40s in the United States. Individualized risk assessment plays an important role when making decisions about screening mammography, especially for women 49 years of age or younger. The purpose of this guideline is to present the available evidence for screening mammography in women 40 to 49 years of age and to increase clinicians' understanding of the benefits and risks of screening mammography.

Summary

Screening mammography probably reduces breast cancer mortality in women 40 to 49 years of age modestly. However, the reduction in this age group is smaller than that in women 50 years of age or older, is subject to greater uncertainty about the exact reduction in risk, and comes with the risk for potential harms (such as false-positive and false-negative results, exposure to radiation, discomfort, and anxiety).

Because of the variation in benefits and harms associated with screening mammography, we recommend tailoring the decision to screen women on the basis of women's concerns about mammography and breast cancer, as well as their risk for breast cancer. Assessment of an individual woman's risk for breast cancer is important because the balance of harms and benefits will shift to net benefit as a woman's baseline risk for breast cancer increases, all other factors being equal. For many women, the potential reduction in risk for death due to breast cancer associated with screening mammography will outweigh other considerations.

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

• two Veterans Affairs-related items -- this year's recipient of the Under Secretary's Award for Health Science Research, and the Health Services Research & Development Annual meeting;
• the importance of proper HIV resource allocation: What method of allocation is best to ensure that HIV prevention and treatment program funds are being used effectively? One study looks at this issue from an aggregate-level analysis;
• the use of functional magnetic resonance imaging technology to examine how financial decisions are made. Researchers were able to identify specific areas of the brain that are activated prior to when individuals actually make purchasing decisions;
• the report series concerning the quality gap, as identified by the Institute of Medicine. Two recently-released reports about the quality gap in asthma care and healthcare-associated infections are covered;
• CHP/PCOR research activities and updates, including a year-in-review of the Patient Safety Research Group that examines the notion of safety culture;
• a Research in Brief selection that highlights recently-published CHP/PCOR research. This piece examines the public-private partnerships model used to improve health and welfare systems.

Objective: To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.

Data Sources/Study Setting: Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.

Study Design: Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.

Data Collection: We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).

Principal Findings: We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's  coefficients ranged from 0.50 to 0.89.

Conclusions: It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

Objective: To understand better the relationship between substance-use disorder treatment and abstinence self-efficacy, more information is needed about what factors predict greater abstinence self-efficacy.

Method: Participants (n = 2,350) from 88 community residential facilities were assessed at treatment entry and 1-year follow-up. Treatment providers reported on patients' engagement in specific components of treatment. After examining univariate associations with self-efficacy, a multiple regression analysis was used to test a model of patient- and treatment-related predictors of self-efficacy 1 year after treatment.

Results: More years of education, lower baseline substance- related problems, and higher baseline confidence in abstinence were associated with higher posttreatment self-efficacy. After controlling for these patient factors, patients who were more engaged in skills-training activities and who inspired providers' confidence in their ability to remain abstinent had higher 1-year self-efficacy.

Conclusions: The development of higher levels of posttreatment abstinence self-efficacy is driven not only by what a patient brings to treatment but by the activities a patient engages in during treatment. Because of the close relationship between self-efficacy and treatment outcomes, providers may want to target patients with low self- efficacy for interventions that focus on skills-training techniques.

Aim: This study examined indices of personal and social resources drawn from social learning, behavioral economics, and social control theories as predictors of medium- and long-term alcohol use disorder outcomes.

Design and Measure: Individuals (N = 461) who initiated help-seeking for alcohol-related problems were surveyed at baseline and 1, 3, 8, and 16 years later. At baseline and each follow-up, participants provided information about their personal and social resources and alcohol-related and psychosocial functioning.

Findings: In general, protective resources associated with social learning (self-efficacy and approach coping), behavioral economics (health and financial resources and resources associated with Alcoholics Anonymous), and social control theory (bonding with family members, friends, and coworkers) predicted better alcohol-related and psychosocial outcomes. A summary index of protective resources associated with all three theories significantly predicted remission. Protective resources strengthened the positive influence of treatment on short-term remission and partially mediated the association between treatment and remission.

Conclusions: Application of social learning, behavior economic, and social control theories may help to identify predictors of remission and thus to allocate treatment more efficiently.

Aim: This study compared matched samples of substance use disorder (SUD) patients in Swiss and United States (US) residential treatment programs and examined the relationship of program characteristics to patients' substance use and psychosocial functioning at a 1-year follow-up.

Design and Setting: The study used a prospective, naturalistic design and a sample of 10 public programs in the German-speaking part of Switzerland and 15 US public treatment programs.

Participants: A total of 358 male patients in Swiss programs were matched on age, marital status and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care staff members also participated.

Measurement: Patients completed comparable inventories at admission, discharge and 1-year follow-up to assess their substance use and psychological functioning and receipt of continuing care. Staff members reported on program characteristics and their beliefs about substance use.

Findings: Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and although they did not differ on abstinence and remission at follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and included more individual treatment sessions; US programs included more group sessions and were more oriented toward a disease model of treatment. Overall, length of program, treatment intensity and 12-step orientation were associated with better 1-year outcomes for patients in both Swiss and US programs.

Conclusions: The sample of Swiss and US programs studied here differed in patient and treatment characteristics; however, in general, there were comparable associations between program characteristics and patients' 1-year outcomes. These findings suggest that associations between treatment processes and patients' outcomes may generalize from one cultural context to another.

Objective: To determine the effects of quality improvement strategies on promoting adherence to interventions for prevention of selected (surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheterassociated urinary tract infections (CAUTI)) healthcare-associated infections (HAIs), and on HAI rates.

Data Sources: MEDLINE® and Cochrane Collaboration's Effective Practice and Organisation of Care registry. We also reviewed the reference lists of systematic reviews and included studies, and contacted experts.

Search Strategy and Inclusion Criteria: We included randomized and quasi-randomized controlled trials, controlled before-after studies, interrupted time series, and simple before-after studies that reported either HAI rates or rates of adherence to target preventive quality improvement (QI) interventions for any of the four target HAIs. QI strategies were classified as clinician education, patient education, audit and feedback, clinician reminders, organizational change (including revision of professional roles, staffing changes, and total quality management/continuous quality improvement), and financial or regulatory incentives. We targeted hand hygiene as a preventive intervention for all HAIs. The target preventive interventions specific to SSI were appropriate perioperative antibiotic prophylaxis (including appropriate antibiotic selection, timing, and duration), perioperative glucose control, and decreasing shaving of the operative site. For CLABSI, we targeted adherence to maximal sterile barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral catheterization. For VAP, we targeted semirecumbent patient positioning and daily assessment of readiness for ventilator weaning. For CAUTI, we targeted reduction in unnecessary catheter use and adherence to aseptic catheter insertion and catheter care. Our primary outcomes were the rate of HAI (defined as infections per 100 cases for SSI and infections per 1,000 device-days for CLABSI, VAP, and CAUTI) and the rate of adherence to preventive interventions (defined as the percentage of patients at risk who received the preventive intervention). Secondary outcomes included effects on costs and adverse effects associated with the interventions.

Data Collection and Analysis: Two reviewers independently abstracted data. Due to heterogeneity in study populations, QI strategies, preventive interventions, and outcomes, no formal quantitative analysis was attempted. We assessed study quality based on prespecified criteria for internal and external validity.

Main Results: Sixty-four studies met all inclusion criteria; 28 studies addressed prevention of SSI, 19 CLABSI prevention, 12 VAP prevention, and 10 CAUTI prevention. Three studies targeted prevention of multiple HAIs. The study methodologic quality was generally poor, as 52 of 64 included studies were simple before-after studies, and most of these (33 of 52) reported data at only one time point before and after the intervention. The majority of included studies reported infection rates, but did not report rate of adherence to preventive interventions. Baseline HAI rates were generally above the median rates reported by the Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS).

• Studies addressing surgical site infections: The majority of studies targeted provision of appropriate antibiotic prophylaxis (22 of 28 studies), using combinations of educational interventions, audit and feedback, and clinician reminders. Sixteen of these studies reported data on adherence to appropriate antibiotic prophylaxis guidelines. Clinician reminders were effective at improving appropriate prophylaxis in two controlled studies; educational interventions with audit and feedback were effective in three multicenter studies (two interrupted time series and one simple before-after study.) No QI strategies were clearly effective at reducing SSI rates or improving adherence to other targeted preventive interventions.
• Studies addressing central line-associated bloodstream infection: Active educational interventions for clinicians appeared effective at reducing CLABSI rates, based on two controlled before-after studies, one interrupted time series, and four simple before-after studies of relatively good methodologic quality. Two of these studies combined education with an explicit checklist for adherence to insertion site practices and allowed nurses to stop the procedure if the checklist was not followed, a strategy worthy of future study.
• Studies addressing ventilator-associated pneumonia: Active educational interventions (including use of Web-based and video tutorials) appeared to reduce VAP rates, based on evidence from two simple before-after studies. Conclusions in this area are especially limited as we did not identify any controlled studies.
• Studies addressing catheter-associated urinary tract infection: Printed or computer-based reminders to physicians, coupled with an "automatic stop order", appear to be effective at reducing the duration of urethral catheterization (based on two controlled studies and three simple before-after studies.)

• Use of printed or computer-based reminders with automatic stop orders to reduce unnecessary urethral catheterization.
• Printed or computer-based reminders to improve surgical antibiotic prophylaxis
• Active educational interventions with use of of checklists to improve adherence to central line insertion practices
• Active educational interventions such as tutorials to improve adherence to preventive interventions for ventilator-associated pneumonia.

Objectives:

Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients. The purpose of this systematic review was to evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient care for children and adults with asthma.

Data Sources:

We searched four literature sources: the Cochrane Effective Practice and Organization of Care (EPOC) Group database (1/1966 to 4/2006), MEDLINE® (1/1966 to 4/2006), the Cochrane Consumers and Communication Group database (1/1966 to 5/2006), and bibliographies of retrieved articles.

Review Methods:

We sought English language studies of interventions that included one or more QI strategies (e.g., patient education, provider education, audit and feedback) for the outpatient management of children or adults with asthma. Included studies were required to be either randomized controlled trials, controlled before-after trials, or interrupted time series trials. The four primary types of outcomes of interest were:

1. Measures of clinical status (e.g., asthma symptoms, spirometric measures).
2. Measures of functional status (e.g., days lost from work or school).
3. Measures of health services utilization (e.g., hospital admissions).
4. Measures of adherence to guidelines (e.g., number of patients given prescriptions for inhaled corticosteroids).

Results:

We identified 3,843 potentially relevant articles, of which 200 articles describing 171 studies met our inclusion criteria. These studies exhibited substantial variation in terms of the types of strategies evaluated. However, using broad, pragmatic categories for quality improvement strategies, 100 included at least some component of patient education, 94 studies included some component of self-monitoring or self-management, 27 included some component of organizational change, and 19 included provider education, among others. The studies also evaluated heterogeneous patient populations, but these could be broadly categorized into those that targeted children or adolescents with asthma or their families (79 studies) and outpatient populations with asthma comprised typically of adults (92 studies).

Among all studies of pediatric asthma evaluating self-monitoring, self-management, or patient education interventions, those directed at parents or caregivers, as opposed to at the children themselves and not their parents, were more likely to be associated with a statistically significant improvement in clinical outcomes (e.g., improvements in asthma symptoms or spirometric measures (p=0.02)). Self-monitoring, self-management, or patient education interventions for general populations or adults with asthma were associated with improvements in percent predicted forced expiratory volume in one second, or FEV1 (weighted mean difference: 2.92 percent predicted FEV1; 95% CI 0.92, 4.92; p=0.004), and mean peak flow (weighted mean difference: 27.95 L/min; 95% CI 10.75, 45.15; (p=0.01).

QI interventions that are based explicitly on a theoretical framework, provide multiple educational sessions, have longer durations, and use combinations of instructional modalities (e.g., small group teaching with role-playing and handouts) are more likely to result in improvements for patients than interventions lacking these characteristics. When taken as a group, the improvements reported in the included studies were often statistically significant but possibly only of borderline clinical significance.

Conclusions:

A wide variety of types of QI interventions have been found to improve the outcomes and processes of care for children and adults with asthma. Young children with asthma benefit most from QI strategies that also include their caregivers or parents. General populations with asthma can have clinically significant improvements in spirometric measures after participating in self-monitoring, self-management, or patient education interventions-especially interventions that are based on theoretical frameworks, are of relatively long durations, and utilize combinations of educational modalities.