METHODS We undertook a cross-sectional study of a nationally representative sample of 2,668 US adults aged 65 years and older from the 2003 National Assessment of Adult Literacy. Multiple regression analysis was used to assess for evidence of mediation.

RESULTS Of older adults in the United States, 29% reported fair or poor health status, and 27% to 39% reported not utilizing 3 recommended preventive health care services in the year preceding the assessment (influenza vaccination 27%, mammography 34%, dental checkup 39%). Health literacy and the 4 health outcomes (self-rated health status and utilization of the 3 preventive health care services) varied by race/ethnicity and educational attainment. Regression analyses indicated that, after controlling for potential confounders, health literacy significantly mediated both racial/ethnic and education-related disparities in self-rated health status and receipt of influenza vaccination, but only education-related disparities in receipt of mammography and dental care.

CONCLUSIONS Health literacy contributes to disparities associated with race/ethnicity and educational attainment in self-rated health and some preventive health behaviors among older adults. Interventions addressing low health literacy may reduce these disparities.

METHODS Data were analyzed from the intervention arm of the ongoing Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized controlled trial to determine the effects of prostate, lung, colorectal, and ovarian cancer screening on disease-specific mortality. The 68,436 participants, aged 55 to 74 years, were randomized to screening or usual care. Women received serial serum tests to detect cancer antigen 125 (CA-125), transvaginal sonograms, posteroanterior-view chest radiographs, and flexible sigmoidoscopies. Men received serial chest radiographs, flexible sigmoidoscopies, digital rectal examinations, and serum prostate-specific antigen tests. Fourteen screening examinations for each sex were possible during the 3-year screening period.

RESULTS After 14 tests, the cumulative risk of having at least 1 false-positive screening test is 60.4% (95% CI, 59.8%–61.0%) for men, and 48.8% (95% CI, 48.1%–49.4%) for women. The cumulative risk after 14 tests of undergoing an invasive diagnostic procedure prompted by a false-positive test is 28.5% (CI, 27.8%–29.3%) for men and 22.1% (95% CI, 21.4%–22.7%) for women.

CONCLUSIONS For an individual in a multimodal cancer screening trial, the risk of a false-positive finding is about 50% or greater by the 14th test. Physicians should educate patients about the likelihood of false positives and resulting diagnostic interventions when counseling about cancer screening.

METHODS Eleven nominal group interviews of patients and primary health care professionals were held in Auckland, New Zealand, during late 2007. Group members reported and helped to classify types of potential error by patients. We synthesized the ideas that emerged from the nominal groups into a taxonomy of patient error.

RESULTS Our taxonomy is a 3-level system encompassing 70 potential types of patient error. The first level classifies 8 categories of error into 2 main groups: action errors and mental errors. The action errors, which result in part or whole from patient behavior, are attendance errors, assertion errors, and adherence errors. The mental errors, which are errors in patient thought processes, comprise memory errors, mindfulness errors, misjudgments, and—more distally—knowledge deficits and attitudes not conducive to health.

CONCLUSION The taxonomy is an early attempt to understand and recognize how patients may err and what clinicians should aim to influence so they can help patients act safely. This approach begins to balance perspectives on error but requires further research. There is a need to move beyond seeing patient, clinician, and system errors as separate categories of error. An important next step may be research that attempts to understand how patients, clinicians, and systems interact to cocreate and reduce errors.

METHODS We studied the performance of the PHQ-15 in comparison with the Structured Clinical Interview for the Diagnostic and Statistical Manual-IV Axis I disorders (SCID-I) as a reference standard. From January through September 2006, we approached patients for participation. This study was conducted in primary care settings in the Netherlands. Patients aged between 18 and 70 years were eligible if they belonged to 1 or more of the following groups: (1) patients with unexplained somatic complaints, (2) frequent attenders, and (3) patients with mental health problems. For the SCID-I interview we invited all patients with a PHQ-15 score of 6 or greater and a random sample of 30% of patients with a PHQ-15 score of less than 6. The primary study outcomes were the sensitivity and specificity for the validity and the coefficient for the test-retest reliability.

RESULTS Of 2,147 eligible patients, 906 (42%) participated (mean age 48 years, 62% female). At a cutoff level of 3 or more severe somatic symptoms during the past 4 weeks, sensitivity was 78% and specificity 71%. The test-retest reliability was 0.60.

CONCLUSIONS The PHQ-15 is a valid and moderately reliable questionnaire for the detection of patients in a primary care setting at risk for somatoform disorders.

METHODS Validation of the CHAT was conducted according to the STAndards for Reporting of Diagnostic accuracy studies statement for diagnostic tests. The setting was Auckland primary care practices with populations ranging from socioeconomically advantaged to deprived. Participants were 755 consecutive primary care patients who completed the CHAT plus the help question and reference standards. Sensitivity, specificity, and likelihood ratios with and without the addition of help the question were calculated.

RESULTS Sensitivity ranged from 80% to 98% for the more-common conditions (depression, nicotine dependency, anxiety, problematic drinking). For each condition, specificity increased with the addition of the help question: depression increased from 73% to 98%; anxiety 77% to 99%; drinking 85% to 99%; verbal anger 92% to 99%; verbal abuse 97% to 99%; problematic drinking and gambling 98% to 99%.

CONCLUSIONS The help question increased specificity without compromising sensitivity and reduced false positives, thereby increasing the positive predictive value. It allowed patients with comorbidities to prioritize issues they wished to address, indicate their readiness to change, promote self-determination, and give the clinician an indication of which topics to pursue.

METHODS We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders.

RESULTS Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase.

CONCLUSIONS Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

METHODS We undertook a conceptual analysis based on the ethics of informed consent, a qualitative study of how surrogates of seriously ill patients experience the surrogate’s role, and descriptions of decision making.

RESULTS When the surrogate can meet the substituted judgment standard, the experience of the surrogate should be understood as providing a report, not making a decision. Surrogate decisions based on the best interest standard are experienced as genuine decisions, and the label "surrogate decision making" should be reserved to characterize only these experiences.

CONCLUSIONS Physicians should identify clinically reasonable options and elicit the surrogate’s sense of decision-making burden. Some surrogates will be able to make reports, and the physician should make a clear recommendation that implements the patient’s reported preference. Some surrogates will confront genuine decisions, which should be managed by negotiating treatment goals. Requests by the surrogate that everything be done may represent a psychosocially burdensome decision, and support should be provided to help the surrogate work through the decision-making process.