BACKGROUND: There is little understanding about the experiences and preferences at the end of life (EOL) for people from unique cultural and socioeconomic backgrounds. Homeless individuals are extreme examples of these overlooked populations; they have the greatest risk of death, encounter barriers to health care, and lack the resources and relationships assumed necessary for appropriate EOL care. Exploring their desires and concerns will provide insight for the care of this vulnerable and disenfranchised population, as well as others who are underserved.OBJECTIVE: Explore the concerns and desires for EOL care among homeless persons. DESIGN: Qualitative study utilizing focus groups.PARTICIPANTS: Fifty-three homeless persons recruited from agencies providing homeless services. MEASUREMENTS:In-depth interviews, which were audiotaped and transcribed. RESULTS:We present 3 domains encompassing 11 themes arising from our investigation, some of which are previously unreported. Homeless persons worried about dying and EOL care; had frequent encounters with death; voiced many unique fears, such as dying anonymously and undiscovered; favored EOL documentation, such as advance directives; and demonstrated ambivalence towards contacting family. They also spoke of barriers to EOL care and shared interventions to improve dying among the very poor and estranged.CONCLUSIONS: Homeless persons have significant personal experience and feelings about death, dying, and EOL care, much of which is different from those previously described in the EOL literature about other populations. These findings have implications not only for homeless persons, but for others who are poor and disenfranchised.
PURPOSE Increasing numbers of primary care practice-based research networks (PBRNs) are being developed in the United States to perform research relevant to everyday practice. To assess the current status and potential value of this resource, we surveyed US primary care PBRNs in operation from late 2003 to early 2004. METHODSWe performed a Web-based survey and structured interviews with PBRN directors and administrative offi cers, assessing PBRNs' history, size, location, organization, resources, operations, and productivity (funding obtained, studies performed, and articles published). RESULTSOf 111 primary care PBRNs identifi ed, 89 (80%) responded to the survey. The 86 (77%) meeting the criteria for primary care PBRNs contained 1,871 practices, 12,957 physicians (mean 152 per PBRN, median 100), and 14.7 million patients (mean 229,880 per PBRN, median 105,000). Minority and underinsured patients were overrepresented. The average PBRN was young (4.4 ± 5.7 years): one-half had performed 3 or fewer studies. Three-quarters were affi liated with universities. Common research foci included prevention, diabetes, cardiovascular risk factors, and mental health. Respondent PBRNs had published more than 600 articles in peer-reviewed journals. PBRNs studying questions posed by outside researchers had more federal funding (84% vs 27%, P = .006). PBRNs citing funding as a weakness relied more on local resources to fund research projects (70% vs 40%, P = .036).CONCLUSIONS American primary care PBRNs are mainly young, diverse, and pursuing a variety of research foci. Most have university links and provide a dynamic town-gown relationship that could be a vital national resource for improving primary care, translating research into practice, and meeting the National Institutes of Health Roadmap goals. PBRNs merit further attention from both private and public funding agencies and researchers interested in studying the delivery of primary care.
BACKGROUND: Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population. OBJECTIVE:To explore the experiences and attitudes toward death and dying among homeless persons. DESIGN: Qualitative study utilizing focus groups.PARTICIPANTS: Fifty-three homeless persons recruited from homeless service agencies. MEASUREMENTS:In-depth interviews, which were audiotaped and transcribed. RESULTS:We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants' attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL. CONCLUSIONS:Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.
Well-designed and properly supported PBRN infrastructures can support a wide range of research of great direct value to patients and society. Increased and more consistent infrastructure support could generate an explosion of pragmatic, generalizable knowledge about currently understudied populations, settings, and health care problems.
PURPOSE In this study, we developed and fi eld tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy offi ce practices. METHODSWe conducted a 10-week fi eld test of MEADERS in which 220 physicians and offi ce staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with offi ce managers and lead physicians, and (2) distributions of characteristics of the medication event reports.RESULTS A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication err ors and adverse drug events were communication problems (41%) and knowledge defi cits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in offi ce medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS It is feasible for primary care clinicians and offi ce staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.
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