Duncan Neuhauser | Case Western Reserve University (original) (raw)

Papers by Duncan Neuhauser

Research paper thumbnail of American football and other sports injuries may cause migraine/ persistent pain decades later and can be treated successfully with electrical twitch-obtaining intramuscular stimulation (ETOIMS

http://innovations.bmj.com/content/early/2017/03/24/bmjinnov-2016-000151 Abstract Introduction A... more http://innovations.bmj.com/content/early/2017/03/24/bmjinnov-2016-000151

Abstract
Introduction Autonomous twitch elicitation at myofascial trigger points from spondylotic radiculopathies-induced denervation supersensitivity can provide favourable pain relief using electrical twitch-obtaining intramuscular stimulation (ETOIMS).
Aim To provide objective evidence that ETOIMS is safe and efficacious in migraine and persistent pain management due to decades-old injuries to head and spine from paediatric American football.
Methods and materials An 83-year-old mildly hypertensive patient with 25-year history of refractory migraine and persistent pain self-selected to regularly receive fee-for-service ETOIMS 2/week over 20 months. He had 180 sessions of ETOIMS. Pain levels, blood pressure (BP) and heart rate/pulse were recorded before and immediately after each treatment alongside highest level of clinically elicitable twitch forces/session, session duration and intervals between treatments. Twitch force grades recorded were from 1 to 5, grade 5 twitch force being strongest.
Results Initially, there was hypersensitivity to electrical stimulation with low stimulus parameters (500 µs pulse-width, 30 mA stimulus intensity, frequency 1.3 Hz). This resolved with gradual stimulus increments as tolerated during successive treatments. By treatment 27, autonomous twitches were noted. Spearman's correlation coefficients showed that pain levels are negatively related to twitch force, number of treatments, treatment session duration and directly related to BP and heart rate/pulse. Treatment numbers and session durations directly influence twitch force. At end of study, headaches and quality of life improved, hypertension resolved and antihypertensive medication had been discontinued.
Conclusions Using statistical process control methodology in an individual patient, we showed long-term safety and effectiveness of ETOIMS in simultaneous diagnosis, treatment, prognosis and prevention of migraine and persistent pain in real time obviating necessity for randomised controlled studies.

Research paper thumbnail of An Exploration of Differences in Sleep Characteristics between Mexico-born US Immigrants and Other Americans to Address the Hispanic Paradox

Research paper thumbnail of Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms

Journal of neurosurgery, Jan 10, 2015

OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adve... more OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms. METHODS The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hour...

Research paper thumbnail of Smoking and postoperative outcomes in elective cranial surgery

Journal of Neurosurgery, 2014

The goal in this study was to assess whether a current or prior history of smoking and the number... more The goal in this study was to assess whether a current or prior history of smoking and the number of smoking pack years affect the risk for adverse outcomes in the 30-day postoperative period in patients who undergo elective cranial surgery. Data from the 2006-2011 American College of Surgeons' National Surgical Quality Improvement Project were used in this study. The authors identified 8296 patients who underwent elective cranial surgery, of whom 1718 were current smokers, 854 were prior smokers, and 5724 were never smokers. Using propensity scores and age, the authors matched current and prior smokers to never smokers. Odds ratios for adverse postoperative outcomes were predicted with logistic regression. The relationship between number of pack years and poor outcomes was also examined. In unadjusted analyses, prior and current smokers did not differ from never smokers for having poor outcomes postoperatively. Similarly, in matched analyses, no association was found between smoking and adverse outcomes. Number of pack years in propensity-matched analyses did not predict worse outcomes in prior or current smokers versus never smokers. The authors did not find smoking to be associated with 30-day postoperative morbidity or mortality. Although smoking cessation is beneficial for overall health, it may not improve the short-term (≤ 30 days) outcome of elective cranial surgery. Thus postponement of elective cranial cases only for smoking cessation may not be necessary.

Research paper thumbnail of The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now

Research paper thumbnail of Collaborating for Improvement in Health Professions Education

Quality Management in Health Care, 1998

Continual improvement efforts have been slower in health professions education than in health car... more Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

Research paper thumbnail of Patient satisfaction, feasibility and reliability of satisfaction questionnaire among patients with pulmonary tuberculosis in urban Uganda: a cross-sectional study

Health Research Policy and Systems, 2011

A comprehensive understanding of the barriers to and facilitators of poor tuberculosis (TB) treat... more A comprehensive understanding of the barriers to and facilitators of poor tuberculosis (TB) treatment outcome is still lacking; posing a major obstacle to finding effective solutions. Assessment of patient satisfaction in TB programs would contribute to the understanding of gaps in healthcare delivery and the specific needs of individual patients. However, tools for assessing patient satisfaction are lacking. To establish patient satisfaction, the feasibility and reliability of a questionnaire for healthcare service satisfaction and a questionnaire for satisfaction with information received about TB medicines among adult TB patients attending public and private program clinics in Kampala, Uganda. In a cross-sectional study, we recruited 133 patients of known HIV status and confirmed pulmonary TB receiving care at the public and private hospitals in Kampala, Uganda. Participants were enrolled based on length of TB treatment as follows: starting therapy, completed two months of therapy, and completed eight months of therapy. A translated and standardized 13-item patient healthcare service satisfaction questionnaire (PS-13) and the Satisfaction with Information about Medicines Scale (SIMS) tool were administered by trained interviewers. Factor analysis was used to systematically group the PS-13 questionnaire into three factors of technical quality of care, responsiveness to patient preference, and management of patient preference satisfaction subscales. The SIMS tool was analyzed with two subscales of information about the action and usage of medication and the potential problems with medication. Of the 133 participants, 35% (46/133) were starting, 33% (44/133) had completed two months, and 32% (43/133) had completed eight months of TB therapy. The male to female and public to private hospital ratios in the study population were 1:1. The PS-13 and the SIMS tools were highly acceptable and easily administered. Both scales and the subscales demonstrated acceptable internal consistency with Cronbach's alpha above 0.70. Patients that were enrolled at the public hospital had relatively lower PS-13 satisfaction scores (0.48 (95% confidence interval (CI), 0.42 - 0.52)), (0.86 (95% CI, 0.81 - 0.90)) for technical quality of care and responsiveness to patient preferences, respectively compared to patients that were enrolled at the private hospital. For potential problems SIMS subscale, male patients that were recruited at the public hospital had relatively lower satisfaction scores (0.58 (95% CI, 0.40 - 0.86)) compared to female patients after adjusting for other factors. Similarly, patients that had completed eight months of TB treatment had relatively higher satisfaction scores (1.23 (95% CI, 1.06 - 1.44)) for action and usage SIMS subscale, and higher satisfaction scores (1.09 (95% CI, 1.03 - 1.16)) for management of patient preference (PS-13 satisfaction subscale) compared to patients that were starting treatment, respectively. The study provides preliminary evidence that the PS-13 service satisfaction and the SIMS tools are reliable measures of patient satisfaction in TB programs. Satisfaction score findings suggest differences in patient satisfaction levels between public and private hospitals; between patients starting and those completing TB therapy.

Research paper thumbnail of Health services research in sub-Saharan Africa: thirty recommended examples

Journal of health services research & policy, 2010

Research paper thumbnail of Medical decision-making and the patient: understanding preference patterns for growth hormone therapy using conjoint analysis

Medical Care

This study examines two questions that relate to patients' role in medical decision making: (... more This study examines two questions that relate to patients' role in medical decision making: (1) Do patients utilize multiple attributes in evaluating different treatment options?, and (2) Do patient treatment preferences evidence heterogeneity and disparate patterns? Although research has examined these questions by using either individual- or aggregate-level approaches, the authors demonstrate an intermediate level approach (ie, relating to patient subgroups). The authors utilize growth augmentation therapy (GAT) as a context for analyzing these questions because GAT reflects a class of nonemergency treatments that (1) are based on genetic technology, (2) aim to improve the quality (rather than quantity) of life, and (3) offer useful insights for the patient's role in medical decision making. Using conjoint analysis, a methodology especially suited for the study of patient-consumer preferences but largely unexplored in the medical field, data were obtained from 154 parents ...

Research paper thumbnail of Patient and hospital characteristics associated with patient assessments of hospital obstetrical care

Medical Care

The goals of this study were to examine the relationship of patient assessments of hospital care ... more The goals of this study were to examine the relationship of patient assessments of hospital care with patient and hospital characteristics. In addition, the authors sought to assess relationships between patient assessments and other patient-derived measures of care (eg, how much they were helped by the hospitalization and amount of pain experienced). The authors surveyed 16,051 women (response rate, 58%) discharged after labor and delivery from 18 hospitals during the study period of 1992 to 1994. Patient assessments were obtained using a previously validated survey instrument, Patient Judgment of Hospital Quality, that includes eight scales assessing different aspects of the process of care (eg, physician care, discharge procedures) and other single item assessments (eg, overall quality). For this study, we utilized five of the scales (physician care, nursing care, information, discharge preparation, global assessments [willingness to brag, recommend or return to the hospital]). F...

Research paper thumbnail of Medical Decision-Making and the Patient

Medical Care

Objectives. This study examines two questions that relate to patients' role in medical decisi... more Objectives. This study examines two questions that relate to patients' role in medical decision making: (1) Do patients utilize multiple attributes in evaluating different treatment options?, and (2) Do patient treatment preferences evidence heterogeneity and disparate patterns? Although research has examined these questions by using either individual- or aggregate-level approaches, the authors demonstrate an intermediate level approach (ie, relating to patient subgroups). Methods. The authors utilize growth augmentation therapy (GAT) as a context for analyzing these questions because GAT reflects a class of nonemergency treatments that (1) are based on genetic technology, (2) aim to improve the quality (rather than quantity) of life, and (3) offer useful insights for the patient's role in medical decision making. Using conjoint analysis, a methodology especially suited for the study of patient-consumer preferences but largely unexplored in the medical field, data were obtai...

Research paper thumbnail of Risk-adjusted inpatient mortality rate and the Surgical Care Improvement Project

Journal of the American College of Surgeons

Score less than 5 (n ϭ 302) had an adjusted complication rate of 32.9% (relative risk [RR], 3.6, ... more Score less than 5 (n ϭ 302) had an adjusted complication rate of 32.9% (relative risk [RR], 3.6, 95% confidence interval [CI], 2.9-4.5), while those with a score of 10 (n ϭ 238) had a 3.0% risk for complication (RR, 0.3; 95% CI, 0.1-1.1). The c-statistic for the model for any complication is 0.70, while for death it is 0.77.

Research paper thumbnail of Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor

Journal of Clinical Neuroscience, 2015

We studied the impact of preoperative steroids on 30day morbidity and mortality of craniotomy for... more We studied the impact of preoperative steroids on 30day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾10days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.

Research paper thumbnail of Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms

Journal of neurosurgery, Jan 10, 2015

OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adve... more OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms. METHODS The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hour...

Research paper thumbnail of Functional status decline as a measure of adverse events in home health care: an observational study

BMC health services research, 2006

Research that examines the quality of home health care is complex because no gold standard exists... more Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research. Data come from the Outcomes and Assessment Information Set (OASIS) from a large urban home health care agency and other agency data. Prognostic data yields 49,437 episodes, while follow-up data yields 47,684 episodes. We tested three indices defined as substantial decline in three or more (gt3_ADLs), two or more (gt2_ADLs), and one or more (gt1_ADLs) ADLs. Multivariate logistic regression determines the performance of the models for each index as measured by the c-statistic and Hosmer-Lemeshow chi square (chi2). Frequenci...

Research paper thumbnail of The effect of blood transfusion on short-term, perioperative outcomes in elective spine surgery

Journal of Clinical Neuroscience, 2014

Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) incre... more Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) increases the risk of postoperative morbidity and mortality. Impact of blood transfusion in patients undergoing spine surgery is not well-described. We assessed the impact of intra and postoperative transfusion on postoperative morbidity and mortality in patients undergoing elective spine surgery. We used the American College of Surgeons' National Surgical Quality Improvement Program to identify a retrospective cohort of 36,901 adult patients who underwent elective spine surgery between 2006 and 2011. Patients who received intra or postoperative transfusion (n=3262) were matched to those who did not using propensity scores. Logistic regression predicted adverse postoperative outcomes. We conducted sensitivity analysis in a subset of patients in whom the number of intraoperatively transfused units of RBC or whole blood was known. Upon matching, preoperative hematocrit, length of surgery, and percentage of spinal fusion surgery were not significantly different between transfused and non-transfused patients. After matching, transfusion remained adversely associated with prolonged length of stay (LOS) in hospital (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.3-2.9), postoperative complications (OR 1.6, 95% CI 1.4-1.9), and an increased 30 day return to operation room (OR 1.7, 95% CI 1.3-2.2). Transfusion of even one unit of blood intraoperatively was associated with prolonged LOS (OR 2.0, 95% CI 1.5-2.6) and minor complications (OR 2.4, 95% CI 1.3-4.3). Therefore, transfusion of RBC or whole blood, even a single unit, increased LOS and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities.

Research paper thumbnail of Finding the best examples of healthcare quality improvement in Sub-Saharan Africa

BMJ Quality & Safety, 2010

The purpose of this study was to summarise the current state of healthcare quality improvement li... more The purpose of this study was to summarise the current state of healthcare quality improvement literature focusing on sub-Saharan Africa. Conventional methods of searching the literature were quickly found to be inadequate or inappropriate, given the different needs of practitioners in sub-Saharan Africa, and the inaccessibility of the literature. The group derived a core list of what were deemed exemplary quality improvement articles, based on consensus and a search into the "grey" literature of quality improvement. Quality improvement articles from sub-Saharan Africa are difficult to find, and suffer from a lack of centrality and organisation of literature. Efforts to address this are critical to fostering the growth of quality improvement literature in developing country settings.

Research paper thumbnail of Book Review History and Health Policy in the United States: Putting the Past Back in (Critical Issues in Health and Medicine.) Edited by Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns. 364 pp

New England Journal of Medicine, 2007

Research paper thumbnail of Making the right decision: Benjamin Franklin's son dies of smallpox in 1736

Quality and Safety in Health Care, 2007

Research paper thumbnail of Deciding Whether a New Test/Measure Is Useful

Medical Care, 1991

Medical Care frequently receives manuscripts and publishes articles describing new tests or measu... more Medical Care frequently receives manuscripts and publishes articles describing new tests or measures. Physicians tend to call it a test, while social scientists tend to call it a measure. In spite of the difference in words, testing and measuring are much the same process and we ...

Research paper thumbnail of American football and other sports injuries may cause migraine/ persistent pain decades later and can be treated successfully with electrical twitch-obtaining intramuscular stimulation (ETOIMS

http://innovations.bmj.com/content/early/2017/03/24/bmjinnov-2016-000151 Abstract Introduction A... more http://innovations.bmj.com/content/early/2017/03/24/bmjinnov-2016-000151

Abstract
Introduction Autonomous twitch elicitation at myofascial trigger points from spondylotic radiculopathies-induced denervation supersensitivity can provide favourable pain relief using electrical twitch-obtaining intramuscular stimulation (ETOIMS).
Aim To provide objective evidence that ETOIMS is safe and efficacious in migraine and persistent pain management due to decades-old injuries to head and spine from paediatric American football.
Methods and materials An 83-year-old mildly hypertensive patient with 25-year history of refractory migraine and persistent pain self-selected to regularly receive fee-for-service ETOIMS 2/week over 20 months. He had 180 sessions of ETOIMS. Pain levels, blood pressure (BP) and heart rate/pulse were recorded before and immediately after each treatment alongside highest level of clinically elicitable twitch forces/session, session duration and intervals between treatments. Twitch force grades recorded were from 1 to 5, grade 5 twitch force being strongest.
Results Initially, there was hypersensitivity to electrical stimulation with low stimulus parameters (500 µs pulse-width, 30 mA stimulus intensity, frequency 1.3 Hz). This resolved with gradual stimulus increments as tolerated during successive treatments. By treatment 27, autonomous twitches were noted. Spearman's correlation coefficients showed that pain levels are negatively related to twitch force, number of treatments, treatment session duration and directly related to BP and heart rate/pulse. Treatment numbers and session durations directly influence twitch force. At end of study, headaches and quality of life improved, hypertension resolved and antihypertensive medication had been discontinued.
Conclusions Using statistical process control methodology in an individual patient, we showed long-term safety and effectiveness of ETOIMS in simultaneous diagnosis, treatment, prognosis and prevention of migraine and persistent pain in real time obviating necessity for randomised controlled studies.

Research paper thumbnail of An Exploration of Differences in Sleep Characteristics between Mexico-born US Immigrants and Other Americans to Address the Hispanic Paradox

Research paper thumbnail of Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms

Journal of neurosurgery, Jan 10, 2015

OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adve... more OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms. METHODS The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hour...

Research paper thumbnail of Smoking and postoperative outcomes in elective cranial surgery

Journal of Neurosurgery, 2014

The goal in this study was to assess whether a current or prior history of smoking and the number... more The goal in this study was to assess whether a current or prior history of smoking and the number of smoking pack years affect the risk for adverse outcomes in the 30-day postoperative period in patients who undergo elective cranial surgery. Data from the 2006-2011 American College of Surgeons' National Surgical Quality Improvement Project were used in this study. The authors identified 8296 patients who underwent elective cranial surgery, of whom 1718 were current smokers, 854 were prior smokers, and 5724 were never smokers. Using propensity scores and age, the authors matched current and prior smokers to never smokers. Odds ratios for adverse postoperative outcomes were predicted with logistic regression. The relationship between number of pack years and poor outcomes was also examined. In unadjusted analyses, prior and current smokers did not differ from never smokers for having poor outcomes postoperatively. Similarly, in matched analyses, no association was found between smoking and adverse outcomes. Number of pack years in propensity-matched analyses did not predict worse outcomes in prior or current smokers versus never smokers. The authors did not find smoking to be associated with 30-day postoperative morbidity or mortality. Although smoking cessation is beneficial for overall health, it may not improve the short-term (≤ 30 days) outcome of elective cranial surgery. Thus postponement of elective cranial cases only for smoking cessation may not be necessary.

Research paper thumbnail of The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now

Research paper thumbnail of Collaborating for Improvement in Health Professions Education

Quality Management in Health Care, 1998

Continual improvement efforts have been slower in health professions education than in health car... more Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

Research paper thumbnail of Patient satisfaction, feasibility and reliability of satisfaction questionnaire among patients with pulmonary tuberculosis in urban Uganda: a cross-sectional study

Health Research Policy and Systems, 2011

A comprehensive understanding of the barriers to and facilitators of poor tuberculosis (TB) treat... more A comprehensive understanding of the barriers to and facilitators of poor tuberculosis (TB) treatment outcome is still lacking; posing a major obstacle to finding effective solutions. Assessment of patient satisfaction in TB programs would contribute to the understanding of gaps in healthcare delivery and the specific needs of individual patients. However, tools for assessing patient satisfaction are lacking. To establish patient satisfaction, the feasibility and reliability of a questionnaire for healthcare service satisfaction and a questionnaire for satisfaction with information received about TB medicines among adult TB patients attending public and private program clinics in Kampala, Uganda. In a cross-sectional study, we recruited 133 patients of known HIV status and confirmed pulmonary TB receiving care at the public and private hospitals in Kampala, Uganda. Participants were enrolled based on length of TB treatment as follows: starting therapy, completed two months of therapy, and completed eight months of therapy. A translated and standardized 13-item patient healthcare service satisfaction questionnaire (PS-13) and the Satisfaction with Information about Medicines Scale (SIMS) tool were administered by trained interviewers. Factor analysis was used to systematically group the PS-13 questionnaire into three factors of technical quality of care, responsiveness to patient preference, and management of patient preference satisfaction subscales. The SIMS tool was analyzed with two subscales of information about the action and usage of medication and the potential problems with medication. Of the 133 participants, 35% (46/133) were starting, 33% (44/133) had completed two months, and 32% (43/133) had completed eight months of TB therapy. The male to female and public to private hospital ratios in the study population were 1:1. The PS-13 and the SIMS tools were highly acceptable and easily administered. Both scales and the subscales demonstrated acceptable internal consistency with Cronbach's alpha above 0.70. Patients that were enrolled at the public hospital had relatively lower PS-13 satisfaction scores (0.48 (95% confidence interval (CI), 0.42 - 0.52)), (0.86 (95% CI, 0.81 - 0.90)) for technical quality of care and responsiveness to patient preferences, respectively compared to patients that were enrolled at the private hospital. For potential problems SIMS subscale, male patients that were recruited at the public hospital had relatively lower satisfaction scores (0.58 (95% CI, 0.40 - 0.86)) compared to female patients after adjusting for other factors. Similarly, patients that had completed eight months of TB treatment had relatively higher satisfaction scores (1.23 (95% CI, 1.06 - 1.44)) for action and usage SIMS subscale, and higher satisfaction scores (1.09 (95% CI, 1.03 - 1.16)) for management of patient preference (PS-13 satisfaction subscale) compared to patients that were starting treatment, respectively. The study provides preliminary evidence that the PS-13 service satisfaction and the SIMS tools are reliable measures of patient satisfaction in TB programs. Satisfaction score findings suggest differences in patient satisfaction levels between public and private hospitals; between patients starting and those completing TB therapy.

Research paper thumbnail of Health services research in sub-Saharan Africa: thirty recommended examples

Journal of health services research & policy, 2010

Research paper thumbnail of Medical decision-making and the patient: understanding preference patterns for growth hormone therapy using conjoint analysis

Medical Care

This study examines two questions that relate to patients' role in medical decision making: (... more This study examines two questions that relate to patients' role in medical decision making: (1) Do patients utilize multiple attributes in evaluating different treatment options?, and (2) Do patient treatment preferences evidence heterogeneity and disparate patterns? Although research has examined these questions by using either individual- or aggregate-level approaches, the authors demonstrate an intermediate level approach (ie, relating to patient subgroups). The authors utilize growth augmentation therapy (GAT) as a context for analyzing these questions because GAT reflects a class of nonemergency treatments that (1) are based on genetic technology, (2) aim to improve the quality (rather than quantity) of life, and (3) offer useful insights for the patient's role in medical decision making. Using conjoint analysis, a methodology especially suited for the study of patient-consumer preferences but largely unexplored in the medical field, data were obtained from 154 parents ...

Research paper thumbnail of Patient and hospital characteristics associated with patient assessments of hospital obstetrical care

Medical Care

The goals of this study were to examine the relationship of patient assessments of hospital care ... more The goals of this study were to examine the relationship of patient assessments of hospital care with patient and hospital characteristics. In addition, the authors sought to assess relationships between patient assessments and other patient-derived measures of care (eg, how much they were helped by the hospitalization and amount of pain experienced). The authors surveyed 16,051 women (response rate, 58%) discharged after labor and delivery from 18 hospitals during the study period of 1992 to 1994. Patient assessments were obtained using a previously validated survey instrument, Patient Judgment of Hospital Quality, that includes eight scales assessing different aspects of the process of care (eg, physician care, discharge procedures) and other single item assessments (eg, overall quality). For this study, we utilized five of the scales (physician care, nursing care, information, discharge preparation, global assessments [willingness to brag, recommend or return to the hospital]). F...

Research paper thumbnail of Medical Decision-Making and the Patient

Medical Care

Objectives. This study examines two questions that relate to patients' role in medical decisi... more Objectives. This study examines two questions that relate to patients' role in medical decision making: (1) Do patients utilize multiple attributes in evaluating different treatment options?, and (2) Do patient treatment preferences evidence heterogeneity and disparate patterns? Although research has examined these questions by using either individual- or aggregate-level approaches, the authors demonstrate an intermediate level approach (ie, relating to patient subgroups). Methods. The authors utilize growth augmentation therapy (GAT) as a context for analyzing these questions because GAT reflects a class of nonemergency treatments that (1) are based on genetic technology, (2) aim to improve the quality (rather than quantity) of life, and (3) offer useful insights for the patient's role in medical decision making. Using conjoint analysis, a methodology especially suited for the study of patient-consumer preferences but largely unexplored in the medical field, data were obtai...

Research paper thumbnail of Risk-adjusted inpatient mortality rate and the Surgical Care Improvement Project

Journal of the American College of Surgeons

Score less than 5 (n ϭ 302) had an adjusted complication rate of 32.9% (relative risk [RR], 3.6, ... more Score less than 5 (n ϭ 302) had an adjusted complication rate of 32.9% (relative risk [RR], 3.6, 95% confidence interval [CI], 2.9-4.5), while those with a score of 10 (n ϭ 238) had a 3.0% risk for complication (RR, 0.3; 95% CI, 0.1-1.1). The c-statistic for the model for any complication is 0.70, while for death it is 0.77.

Research paper thumbnail of Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor

Journal of Clinical Neuroscience, 2015

We studied the impact of preoperative steroids on 30day morbidity and mortality of craniotomy for... more We studied the impact of preoperative steroids on 30day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾10days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.

Research paper thumbnail of Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms

Journal of neurosurgery, Jan 10, 2015

OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adve... more OBJECT Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms. METHODS The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hour...

Research paper thumbnail of Functional status decline as a measure of adverse events in home health care: an observational study

BMC health services research, 2006

Research that examines the quality of home health care is complex because no gold standard exists... more Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research. Data come from the Outcomes and Assessment Information Set (OASIS) from a large urban home health care agency and other agency data. Prognostic data yields 49,437 episodes, while follow-up data yields 47,684 episodes. We tested three indices defined as substantial decline in three or more (gt3_ADLs), two or more (gt2_ADLs), and one or more (gt1_ADLs) ADLs. Multivariate logistic regression determines the performance of the models for each index as measured by the c-statistic and Hosmer-Lemeshow chi square (chi2). Frequenci...

Research paper thumbnail of The effect of blood transfusion on short-term, perioperative outcomes in elective spine surgery

Journal of Clinical Neuroscience, 2014

Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) incre... more Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) increases the risk of postoperative morbidity and mortality. Impact of blood transfusion in patients undergoing spine surgery is not well-described. We assessed the impact of intra and postoperative transfusion on postoperative morbidity and mortality in patients undergoing elective spine surgery. We used the American College of Surgeons' National Surgical Quality Improvement Program to identify a retrospective cohort of 36,901 adult patients who underwent elective spine surgery between 2006 and 2011. Patients who received intra or postoperative transfusion (n=3262) were matched to those who did not using propensity scores. Logistic regression predicted adverse postoperative outcomes. We conducted sensitivity analysis in a subset of patients in whom the number of intraoperatively transfused units of RBC or whole blood was known. Upon matching, preoperative hematocrit, length of surgery, and percentage of spinal fusion surgery were not significantly different between transfused and non-transfused patients. After matching, transfusion remained adversely associated with prolonged length of stay (LOS) in hospital (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.3-2.9), postoperative complications (OR 1.6, 95% CI 1.4-1.9), and an increased 30 day return to operation room (OR 1.7, 95% CI 1.3-2.2). Transfusion of even one unit of blood intraoperatively was associated with prolonged LOS (OR 2.0, 95% CI 1.5-2.6) and minor complications (OR 2.4, 95% CI 1.3-4.3). Therefore, transfusion of RBC or whole blood, even a single unit, increased LOS and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities.

Research paper thumbnail of Finding the best examples of healthcare quality improvement in Sub-Saharan Africa

BMJ Quality & Safety, 2010

The purpose of this study was to summarise the current state of healthcare quality improvement li... more The purpose of this study was to summarise the current state of healthcare quality improvement literature focusing on sub-Saharan Africa. Conventional methods of searching the literature were quickly found to be inadequate or inappropriate, given the different needs of practitioners in sub-Saharan Africa, and the inaccessibility of the literature. The group derived a core list of what were deemed exemplary quality improvement articles, based on consensus and a search into the "grey" literature of quality improvement. Quality improvement articles from sub-Saharan Africa are difficult to find, and suffer from a lack of centrality and organisation of literature. Efforts to address this are critical to fostering the growth of quality improvement literature in developing country settings.

Research paper thumbnail of Book Review History and Health Policy in the United States: Putting the Past Back in (Critical Issues in Health and Medicine.) Edited by Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns. 364 pp

New England Journal of Medicine, 2007

Research paper thumbnail of Making the right decision: Benjamin Franklin's son dies of smallpox in 1736

Quality and Safety in Health Care, 2007

Research paper thumbnail of Deciding Whether a New Test/Measure Is Useful

Medical Care, 1991

Medical Care frequently receives manuscripts and publishes articles describing new tests or measu... more Medical Care frequently receives manuscripts and publishes articles describing new tests or measures. Physicians tend to call it a test, while social scientists tend to call it a measure. In spite of the difference in words, testing and measuring are much the same process and we ...