Background:

There is increased interest in quantitative ultrasound for osteoporosis screening because it predicts fracture risk, is portable, and is relatively inexpensive. However, there is no consensus regarding its accuracy for identifying patients with osteoporosis.

Purpose:

To determine the sensitivity and specificity of calcaneal quantitative ultrasound for identifying patients who meet the World Health Organization's diagnostic criteria for osteoporosis. Dual-energy x-ray absorptiometry (DXA) was used as the reference standard.

Data Sources:

MEDLINE (1966 to October 2005), EMBASE (1993 to May 2004), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (1952 to March 2004), and the Science Citation Index (1945 to April 2004).

Study Selection:

English-language articles that evaluated the sensitivity and specificity of calcaneal quantitative ultrasound for identifying adults with DXA T-scores of -2.5 or less at the hip or spine.

Data Extraction:

Two authors independently reviewed articles and abstracted data.

Data Synthesis:

The authors identified 1908 potentially relevant articles, of which 25 met the inclusion criteria, and calculated the sensitivity and specificity of quantitative ultrasound over a range of thresholds. For the quantitative ultrasound index parameter T-score cutoff threshold of -1, sensitivity was 79% (95% CI, 69% to 86%) and specificity was 58% (CI, 44% to 70%) for identifying individuals with DXA T-scores of -2.5 or less at the hip or spine. For a T-score threshold of 0, sensitivity improved to 93% (CI, 87% to 97%) but specificity decreased to 24% (CI, 10% to 47%). At a pretest probability of 22% (for example, a 65-year-old white woman at average risk), the post-test probability of DXA-determined osteoporosis was 34% (CI, 26% to 41%) after a positive result and 10% (CI, 5% to 12%) after a negative result when using a T-score cutoff threshold of -1. Analysis of other quantitative ultrasound parameters (for example, broadband ultrasound attenuation) revealed similar estimates of accuracy.

Limitations:

The relatively small number of included studies limited the authors' ability to evaluate the effects of heterogeneous study characteristics on the diagnostic accuracy of quantitative ultrasound.

Conclusions:

The currently available literature suggests that results of calcaneal quantitative ultrasound at commonly used cutoff thresholds do not definitively exclude or confirm DXA-determined osteoporosis. Additional research is needed before use of this test can be recommended in evidence-based screening programs for osteoporosis.

Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

As Vietnam opens its economy to privatization, its system of healthcare will face a series of crucial tests. Vietnam's system of private healthcare -- once comprised only of individual physicians holding clinic hours in their homes -- has come to also include larger customer-oriented clinics based on an American business model. As the two models compete in the expanding private market, it becomes increasingly important to understand patients' perceptions of the alternative models of care.

This study reports on interviews with 194 patients in two different types of private-sector clinics in Vietnam: a western-style clinic and a traditional style, after-hours clinic. In bivariate and multivariate analyses, we found that patients at the western style clinic reported both higher expectations of the facility and higher satisfaction with many

aspects of care than patients at the after-hours clinic. These different perceptions appear to be based on the interpersonal manner of the physician seen and the clinic's delivery methods rather than perceptions of the physician's technical skill and method of treatment. These fndings were unaffected by the ethnicity of physician seen.

These fndings suggest that patients in Vietnam recognize and prefer more customer-oriented care and amenities, regardless of physician ethnicity and perceive no signiccant differences in technical skill between the private delivery models.

This report documents the work undertaken in Phase I of a two-phase process to develop the Pediatric Quality Indicators as part of the Agency for Healthcare Research and Quality (AHRQ) contract, "Support for Quality Indicators II" under subcontract with

Battelle Memorial Institute by Stanford University and the University of California at

Davis. This work was initiated in response to a charge to develop indicators of children's health care utilizing inpatient administrative data. These indicators examine both the quality of inpatient care, as well as the quality of outpatient care that can be inferred from inpatient data, such as potentially preventable hospitalizations.

The report contains three main sections:

1. The introduction section launches the actual technical report and provides background

regarding pediatric indicator development and the current effort to develop an indicator

set based on administrative data.

2. The methods section outlines the approach used to gather evidence to identify and

evaluate potential patient safety indicators, including the literature review, empirical

analyses, and clinician panel review, as well as the operationalization of indicators and

evaluation of risk adjustment approaches.

3. The results section is divided into two parts. The first part highlights general themes

and summarizes the overall results. The second part provides detailed results for each

AHRQ QI examined.

Several appendixes provide additional detail regarding methods and results.