Medical care
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Mixed methods research has emerged alongside qualitative and quantitative approaches as an important tool for health services researchers. Despite growing interest, among health services researchers, in using mixed methods designs, little has been done to identify the procedural aspects of doing so. ⋯ "Mixing" in mixed methods is more than just the combination of 2 independent components of the quantitative and qualitative data. The use of "mixing" procedure in health services research involves the integration, connection, and embedding of these 2 data components.
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High-quality care for long-term nursing home residents should include discussions and follow-up on patients' end-of-life care wishes. Yet, recent changes to the Minimum Data Set data collection exclude this information from routine assessment of patients mandated by the Centers for Medicare & Medicaid Services, making the provision of high-quality end-of-life care less likely. We examined the stability of cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders to offer guidance to policy and care practice developments. ⋯ Long-term nursing home patients who enter with full-code CPR have a high probability of changing their status to DNR during their stay. High-quality care should offer them the opportunity to revisit their choice periodically, documenting changes in end-of-life choices when they occur, thus ensuring that care will match patients' wishes. As the Minimum Data Set plays a prominent role in patients' care, Centers for Medicare & Medicaid Services should consider reinstating information about advance directive in it.
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Intensive care unit (ICU) readmission rates are commonly viewed as indicators of ICU quality. However, definitions of ICU readmissions vary, and it is unknown which, if any, readmissions are associated with ICU quality. ⋯ It remains uncertain whether ICU readmission is a valid quality indicator. However, having established 2 full calendar days (not 48 h) after ICU discharge as the optimal interval for measuring ICU readmissions, this study will facilitate future research designed to determine its validity.
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Limited health literacy is a barrier for understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored. ⋯ Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes toward primary care services.
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Electronic clinical data (ECD) will increasingly serve as an important source of information for comparative effectiveness research (CER). Although many retrospective studies have relied on ECD, new study designs propose using ECD for prospective CER. These designs have great potential but they also raise important ethics questions. ⋯ We conclude that a CER-ECD observational study that imposes no or minimal additional risk to or burden on patients may proceed ethically without express informed consent from participants in settings where: (a) patients are regularly informed of the health care institution's commitment to learning through the integration of research and practice; and (b) there are appropriate protections for patients' rights and interests. In addition, where (a) and (b) apply, some pragmatic, randomized trials that similarly impose no or minimal additional risk to or burden on patients may also proceed ethically without express consent, when certain additional conditions are satisfied, including: (c) the trial does not negatively affect patients' prospects for good clinical outcomes; (d) physicians have the option of using an intervention other than the one assigned if they believe doing so is important for a particular patient; and (e) the trial does not engage preferences or values that are meaningful to patients.