OBJECTIVE: The objective of this study was to assess whether there are racial and ethnic disparities in the time to development of a pressure ulcer and number of pressure ulcer treatments in individuals aged 65 and older after nursing home admission. METHOD: Multi-level predictors of time to a pressure ulcer from three national surveys were analyzed using Cox proportional hazards regression for White Non-Hispanic residents. Using the Peters-Belson method to assess for disparities, estimates from the regression models were applied to American Indians/Alaskan Natives, Asians/Pacific Islanders, Blacks, and Hispanics separately resulting in estimates of expected outcomes as if they were White Non-Hispanic, and were then compared with their observed outcomes. RESULTS: More Blacks developed pressure ulcers sooner than expected. No disparities in time to a pressure ulcer disadvantaging other racial/ethnic groups were found. There were no disparities in pressure ulcer treatment for any group. DISCUSSION: Reducing disparities in pressure ulcer development offers a strategy to improve the quality of nursing home care.

BACKGROUND AND PURPOSE: Many studies use medical record review for ascertaining outcomes. One large, longitudinal study, the Women's Health Initiative (WHI), ascertains strokes using participant self-report and subsequent physician review of medical records. This is resource-intensive. Herein, we assess whether Medicare data can reliably assess stroke events in the WHI. METHODS: Subjects were WHI participants with fee-for-service Medicare. Four stroke definitions were created for Medicare data using discharge diagnoses in hospitalization claims: definition 1, stroke codes in any position; definition 2, primary position stroke codes; and definitions 3 and 4, hemorrhagic and ischemic stroke codes, respectively. WHI data were randomly split into training (50%) and test sets. A concordance matrix was used to examine the agreement between WHI and Medicare stroke diagnosis. A WHI stroke and a Medicare stroke were considered a match if they occurred within +/-7 days of each other. Refined analyses excluded Medicare events when medical records were unavailable for comparison. RESULTS: Training data consisted of 24 428 randomly selected participants. There were 577 WHI strokes and 557 Medicare strokes using definition 1. Of these, 478 were a match. With regard to algorithm performance, specificity was 99.7%, negative predictive value was 99.7%, sensitivity was 82.8%, positive predictive value was 85.8%, and kappa=0.84. Performance was similar for test data. Whereas specificity and negative predictive value exceeded 99%, sensitivity ranged from 75% to 88% and positive predictive value ranged from 80% to 90% across stroke definitions. CONCLUSIONS: Medicare data seem useful for population-based stroke research; however, performance characteristics depend on the definition selected.

Continuity of care (CoC) is a cornerstone of the patient-centered medical home (PCMH) and one of the primary means for achieving health care quality. Despite decades of study, however, CoC remains difficult to define and quantify. To incorporate patient experiences into health reform evaluations, it is critical to determine if and how well CoC measures traditionally derived from administrative claims capture patient experiences. In this study, we used claims data and self-reported continuity experiences of 2,620 Medicare beneficiaries who completed the National Health and Health Services Use Questionnaire to compare 16 claims-based CoC indices to a multidimensional patient-reported CoC measure. Our results show that most claims-based CoC measures do not reflect older adults' perceptions of continuous patient-provider relationships, indicating that claims-based assessments should be used in tandem with patient reports for defining, quantifying, and evaluating CoC in health care delivery models.

INTRODUCTION In the 1990s, several organizations began recommending evaluation of > 12 lymph nodes during colon resection because of its association with improved survival. We examined practice implications of multispecialty quality guidelines over the past 20 years recommending evaluation of ≥ 12 lymph nodes during colon resection for adequate staging. MATERIALS AND METHODS We used the 1988 to 2009 Surveillance, Epidemiology, and End Results program to conduct a retrospective observational cohort study of 90,203 surgically treated patients with colon cancer. We used Cochran-Armitage tests to examine trends in lymph node examination over time and multivariate logistic regression to identify patient characteristics associated with guideline-recommended lymph node evaluation. RESULTS The introduction of practice guidelines was associated with gradual increases in guideline-recommended lymph node evaluation. From 1988 to 1990, 34% of patients had > 12 lymph nodes evaluated, increasing to 38% in 1994 to 1996 and to > 75% from 2006 to 2009. Younger, white patients and those with more-extensive bowel penetration (T3/4 nonmetastatic) and high tumor grade saw more-rapid increases in lymph node evaluation (P < .001). Multivariate analyses demonstrated a significant interaction between year of diagnosis and both T stage and grade, indicating that those with higher T stage and higher grade were more likely to receive guideline-recommended care earlier. CONCLUSION The implementation of lymph node evaluation guidelines was accepted gradually into practice but adopted more quickly among higher risk patients. By identifying patients who are least likely to receive guideline-recommended care, these findings present a starting point for promoting targeted improvements in cancer care and further understanding underlying contributors to these disparities.

BACKGROUND: Over the past 20 years, surgical practice organizations have recommended the identification of >/=12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines. RESEARCH DESIGN: Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (>/=12) lymph node evaluation compared with initial evaluation levels (1996-1998) using chi tests and multivariate logistic regression analysis, adjusting for patient case-mix. RESULTS: We identified 228 hospitals that performed >/=6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance. CONCLUSIONS: Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.