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Background: The 2014 Veterans Access, Choice and Accountability Act (i.e., "Choice") allows eligible Veterans to receive covered health care outside the Veterans Affairs (VA) Healthcare System. The initial implementation of Choice was challenging, and use was limited in the first year.Objective: To assess satisfaction with Choice, and identify reasons for satisfaction and dissatisfaction during its early implementation.Design and Participants: Semi-structured telephone interviews from July to September 2015 with Choice-eligible Veterans from 25 VA facilities across the USA.Main Measures: Satisfaction was assessed with 5-point Likert scales and open-ended questions. We compared ratings of satisfaction with Choice and VA health care, and identified reasons for satisfaction/dissatisfaction with Choice in a thematic analysis of open-ended qualitative data.Results: Of 195 participants, 35 had not attempted to use Choice; 43 attempted but had not received Choice care (i.e., attempted only); and 117 attempted and received Choice care. Among those who attempted only, a smaller percentage were somewhat/very satisfied with Choice than with VA health care (17.9% and 71.8%, p < 0.001); among participants who received Choice, similar percentages were somewhat/very satisfied with Choice and VA health care (66.6% and 71.1%, p = 0.45). When asked what contributed to Choice ratings, participants who attempted but did not receive Choice care reported poor access (50%), scheduling problems (20%), and care coordination issues (10%); participants who received Choice care reported improved access (27%), good quality of care (19%), and good distance to Choice provider (16%). Regardless of receipt of Choice care, most participants expressed interest in using Choice in the future (70-82%).Conclusions: Access and scheduling barriers contributed to dissatisfaction for Veterans unsuccessfully attempting to use Choice during its initial implementation, whereas improved access and good care contributed to satisfaction for those receiving Choice care. With Veterans' continued interest in using services outside VA facilities, subsequent policy changes should address Veterans' barriers to care. [ABSTRACT FROM AUTHOR]

Background: Ambulatory antibiotic prescribing contributes to the development of antibiotic resistance and increases societal costs. Here, we estimate the hidden societal cost of antibiotic resistance per antibiotic prescribed in the United States. Methods: In an exploratory analysis, we used published data to develop point and range estimates for the hidden societal cost of antibiotic resistance (SCAR) attributable to each ambulatory antibiotic prescription in the United States. We developed four estimation methods that focused on the antibiotic-resistance attributable costs of hospitalization, second-line inpatient antibiotic use, second-line outpatient antibiotic use, and antibiotic stewardship, then summed the estimates across all methods. Results: The total SCAR attributable to each ambulatory antibiotic prescription was estimated to be $13 (range: $3-$95). The greatest contributor to the total SCAR was the cost of hospitalization ($9; 69 % of the total SCAR). The costs of second-line inpatient antibiotic use ($1; 8 % of the total SCAR), second-line outpatient antibiotic use ($2; 15 % of the total SCAR) and antibiotic stewardship ($1; 8 %). This apperars to be an error.; of the total SCAR) were modest contributors to the total SCAR. Assuming an average antibiotic cost of $20, the total SCAR attributable to each ambulatory antibiotic prescription would increase antibiotic costs by 65 % (range: 15-475 %) if incorporated into antibiotic costs paid by patients or payers. Conclusions: Each ambulatory antibiotic prescription is associated with a hidden SCAR that substantially increases the cost of an antibiotic prescription in the United States. This finding raises concerns regarding the magnitude of misalignment between individual and societal antibiotic costs. [ABSTRACT FROM AUTHOR]

Background: Over half of veterans enrolled in the Veterans Health Administration (VA) are also enrolled in Medicare, potentially increasing their opportunity to receive low-value health services within and outside VA. Objectives: To characterize the use and cost of low-value services delivered to dually enrolled veterans from VA and Medicare. Design: Retrospective cross-sectional. Participants: Veterans enrolled in VA and fee-for-service Medicare (FY 2017–2018). Main Measures: We used VA and Medicare administrative data to identify 29 low-value services across 6 established domains: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing, and surgery. We determined the count of low-value services per 100 veterans delivered in VA and Medicare in FY 2018 overall, by domain, and by individual service. We applied standardized estimates to determine each service's cost. Key Results: Among 1.6 million dually enrolled veterans, the mean age was 73, 97% were men, and 77% were non-Hispanic White. Overall, 63.2 low-value services per 100 veterans were delivered, affecting 32% of veterans; 22.9 services per 100 veterans were delivered in VA and 40.3 services per 100 veterans were delivered in Medicare. The total cost was $226.3 million (M), of which $62.6 M was spent in VA and $163.7 M in Medicare. The most common low-value service was prostate-specific antigen testing at 17.3 per 100 veterans (VA 55.9%, Medicare 44.1%). The costliest low-value service was percutaneous coronary intervention (VA $10.1 M, Medicare $32.8 M). Conclusions: Nearly 1 in 3 dually enrolled veterans received a low-value service in FY18, with twice as many low-value services delivered in Medicare vs VA. Interventions to reduce low-value services for veterans should consider their substantial use of such services in Medicare. [ABSTRACT FROM AUTHOR]

Background: Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner. Objective: To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021. Design: Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. Participants: Respondents to the 2016–2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. Measures: Care ratings in nine domains. Key Results: The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from − 0.04 to − 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted. Conclusions: This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care. [ABSTRACT FROM AUTHOR]

OBJECTIVE To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity. RESULTS Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34-0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57-0.99]) or to achieve an LDL <100 mg/dL (OR 0.74 [95% CI 0.55-0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49-0.84]). CONCLUSIONS Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors. [ABSTRACT FROM AUTHOR]

The article investigates the association between marital status and the presentation and outcomes of pneumonia. The authors used data from U.S. Veterans Affairs (VA) administrative databases comprised of male veterans aged 65 or older hospitalized for pneumonia during the period 2002-2007. They reveal that unmarried elderly male veterans hospitalized for pneumonia demonstrated a higher risk of in-hospital and postdischarge mortality, but also showed a lower degree of comorbidity.

The prognosis of community-acquired pneumonia ranges from rapid resolution of symptoms and full recovery of functional status to the development of severe medical complications and death. The pneumonia severity index is a rigorously studied prediction rule for prognosis that objectively stratifies patients into quintiles of risk for short-term mortality on the basis of 20 demographic and clinical variables routinely available at presentation. The pneumonia severity index was derived and validated with data on >50,000 patients with community-acquired pneumonia by use of well-accepted methodological standards and is the only pneumonia decision aid that has been empirically shown to safely increase the proportion of patients given treatment in the outpatient setting. Because of its prognostic accuracy, methodological rigor, and effectiveness and safety as a decision aid, the pneumonia severity index has become the reference standard for risk stratification of community-acquired pneumonia. [ABSTRACT FROM AUTHOR]

This article reflects on the role of race and genetics in health disparities research. There are advantages and disadvantages in using a biological definition of race in medical research. Advantages include a delineation of genetic clusters by racial group and specificity of race of rare genetic variants. One of the disadvantages of using a biological definition of race in medical research is the premise that the species Homo sapiens consists of a single population and biologically distinct human races do not exist.

Objectives. We identified race-associated differences in survival among HIV-positive US veterans to examine possible etiologies for these differences. Methods. We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients' health status, clinical management, and adherence to medication by race. Results. Nationally, minority veterans had higher mortality rates than did white veterans with HIV. Minority veterans had poorer health than white veterans with HIV. No significant differences were found in clinical management or adherence. Conclusions. HIV-positive minority veterans experience poorer survival than white veterans. This difference may derive from differences in comorbidities and in the severity of illness of HIV-related disease. (Am J Public Health. 2003;93:1728-1733) [ABSTRACT FROM AUTHOR]

: PurposePatients with pneumonia often remain hospitalized after they are stable clinically, and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge. The purpose of this study was to determine whether implementation of an evidence-based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia.: MethodsIn a seven-site, cluster randomized clinical trial, we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups. Within site, physician groups were assigned randomly to receive a practice guideline alone (control arm) or a practice guideline that was implemented using a multifaceted strategy (intervention arm). The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models. Medical outcomes were assessed at 30 days.: ResultsIntravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group (hazard ratio [HR] =1.23; 95% confidence interval [CI]: 1.00 to 1.52; P = 0.06) than in the control group. Intervention patients were discharged more quickly, but the difference was not statistically significant (HR = 1.16; 95% CI: 0.97 to 1.38; P = 0.11). Fewer intervention (55% [157/283]) than control (63% [206/325]) patients had medical complications during the index hospitalization (P = 0.04), with no differences in other medical outcomes, including mortality, rehospitalization, and return to usual activities, between treatment arms.: ConclusionThe multifaceted guideline implementation strategy resulted in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay, without affecting patient outcomes. [Copyright &y& Elsevier]

The initial management of patients suspected of having community-acquired pneumonia is challenging because of the broad range of clinical presentations, potential life-threatening nature of the illness, and associated high costs of care. The initial testing strategies should accurately establish a diagnosis and prognosis in order to determine the optimal treatment strategy. The diagnosis is important in determining the need for antibiotic therapy, and the prognosis is important in determining the site of care. This paper reviews the test characteristics of the history, physical examination, and laboratory findings, individually and in combination, in diagnosing community-acquired pneumonia and predicting short-term risk for death from the infection. In addition, we consider the implications of these test characteristics from the perspective of decision thresholds. The history and physical examination cannot provide a high level of certainty in the diagnosis of community-acquired pneumonia, but the absence of vital sign abnormalities substantially reduces the probability of the infection. Chest radiography is considered the gold standard for pneumonia diagnosis; however, we do not know its sensitivity and specificity, and we have limited data on the costs of false-positive and false-negative results. In the absence of empirical evidence, the decision to order a chest radiograph needs to rely on expert opinion in seeking strategies to optimize the balance between harms and benefits. Once community-acquired pneumonia is diagnosed, a combination of history, physical examination, and laboratory items can help estimate the short-term risk for death and, along with the patient's psychosocial characteristics, determine the appropriate site of treatment. [ABSTRACT FROM AUTHOR]

Background: Investigating claims that patients are being sent home from the hospital "quicker and sicker" requires a way of objectively measuring appropriateness of hospital discharge. Objective: To define and validate a simple, usable measure of clinical stability on discharge for patients with community-acquired pneumonia. Methods: Information on daily vital signs and clinical status was collected in a prospective, multicenter, observational cohort study. Unstable factors in the 24 hours prior to discharge were temperature greater than 37.8°C, heart rate greater than 100/min, respiratory rate greater than 24/min, systolic blood pressure lower than 90 mm Hg, oxygen saturation lower than 90%, inability to maintain oral intake, and abnormal mental status. Outcomes were deaths, readmissions, and failure to return to usual activities within 30 days of discharge. Results: Of the 680 patients, 19.1% left the hospital with 1 or more instabilities. Overall, 10.5% of patients with no instabilities on discharge died or were readmitted compared with 13.7% of those with 1 instability and 46.2% of those with 2 or more instabilities (P<.003). Instability on discharge (≥ 1 unstable factor) was associated with higher risk-adjusted rates of death or readmission (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.8) and failure to return to usual activities (OR, 1.5; 95% CI, 1.0-2.4). Patients with 2 or more instabilities had a 5-fold greater risk-adjusted odds of death or readmission (OR, 5.4; 95% CI, 1.6-18.4). Conclusions: Instability on discharge is associated with adverse clinical outcomes. Pneumonia guidelines and pathways should include objective criteria for judging stability on discharge to ensure that efforts to shorten length of stay do not jeopardize patient safety. [ABSTRACT FROM AUTHOR]

Background: Unexplained wide variability exists in the performance of key initial processes of care associated with improved survival of elderly patients (those ≥65 years) hospitalized with pneumonia. The objective of this study was to assess which patient and hospital characteristics are associated with performance of these key initial processes of care for hospitalized elderly patients with pneumonia. Methods: A retrospective cohort analysis was performed using data from the Medicare Quality Indicator System Pneumonia Module for 14 069 patients 65 years or older hospitalized with pneumonia throughout the United States. Associations were calculated using multivariate logistic regression analysis between specific patient and hospital characteristics and 2 processes of care associated with improved 30-day survival: administration of antibiotics within 8 hours of hospital arrival and blood culture collection within 24 hours of arrival. Results: Timely antibiotic administration was negatively associated with nonwhite race (African American: odds ratio [OR], 0.71; 95% confidence interval [CI], 0.60-0.85; and other racial minorities: OR, 0.79; 95% CI, 0.68-0.92), major hospital teaching status (OR, 0.79; 95% CI, 0.67-0.93), and larger hospital size (≥250 beds vs <100 beds: OR, 0.68; 95% CI, 0.59-0.80). Timely blood culture collection was positively associated with larger hospital size (OR, 1.61; 95% CI, 1.39-1.87). Performance of both processes of care were positively associated with registered nurse–bed ratios of 1.25 or higher (for antibiotic administration: OR, 1.23; 95% CI, 1.10-1.38; and for blood culture collection: OR, 1.43; 95% CI, 1.26-1.61) and fever (for antibiotic administration: OR, 1.35; 95% CI, 1.23-1.49; and for blood culture collection: OR, 3.07; 95% CI, 2.81-3.34) and were negatively associated with hospital location in the South (for antibiotic administration: OR, 0.77; 95% CI, 0.69-0.86; and for blood culture collection: OR,... [ABSTRACT FROM AUTHOR]

Focuses on community-acquired pneumonia in adults and do not resuscitate orders. Prevalence of pneumonia in older people; Aversion of cardiopulmonary resuscitation in patients; Development of do not resuscitate policies.

Purpose: Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia.Subjects and Methods: As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports.Results: The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P <0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay.Conclusions: Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings. [ABSTRACT FROM AUTHOR]

Background: Veterans dually enrolled in the Veterans Health Administration (VA) and Medicare commonly experience downstream services as part of a care cascade after an initial low‐value service. Our objective was to characterize the frequency and cost of low‐value cervical cancer screening and subsequent care cascades among Veterans dually enrolled in VA and Medicare. Methods: This retrospective cohort study used VA and Medicare administrative data from fiscal years 2015 to 2019. The study cohort was comprised of female Veterans aged >65 years and at low risk of cervical cancer who were dually enrolled in VA and Medicare. Within this cohort, we compared differences in the rates and costs of cascade services related to low‐value cervical cancer screening for Veterans who received and did not receive screening in FY2018, adjusting for baseline patient‐ and facility‐level covariates using inverse probability of treatment weighting. Results: Among 20,972 cohort‐eligible Veterans, 494 (2.4%) underwent low‐value cervical cancer screening with 301 (60.9%) initial screens occurring in VA and 193 (39%) occurring in Medicare. Veterans who were screened experienced an additional 26.7 (95% CI, 16.4–37.0) cascade services per 100 Veterans compared to those who were not screened, contributing to $2919.4 (95% CI, −265 to 6104.7) per 100 Veterans in excess costs. Care cascades consisted predominantly of subsequent cervical cancer screening procedures and related outpatient visits with low rates of invasive procedures and occurred in both VA and Medicare. Conclusions: Veterans dually enrolled in VA and Medicare commonly receive related downstream tests and visits as part of care cascades following low‐value cervical cancer screening. Our findings demonstrate that to fully capture the extent to which individuals are subject to low‐value care, it is important to examine downstream care stemming from initial low‐value services across all systems from which individuals receive care. [ABSTRACT FROM AUTHOR]

Examines the processes and outcomes of care for patients with community-acquired pneumonia (CAP) through the Pneumonia Patient Outcomes Research Team project. Requirement for improving the quality of medical treatment for patients with CAP; Assessment of processes of care instituted at the discretion of physicians in the routine management of the patients.

Purpose: To assess the variation in length of stay for patients hospitalized with community-acquired pneumonia and to determine whether patients who are treated in hospitals with shorter mean stays have worse medical outcomes.Subjects and Methods: We prospectively studied a cohort of 1,188 adult patients with community-acquired pneumonia who had been admitted to one community and three university teaching hospitals. We compared patients' mean length of stay, mortality, hospital readmission, return to usual activities, return to work, and pneumonia-related symptoms among the four study hospitals. All outcomes were adjusted for baseline differences in severity of illness and comorbidity.Results: Adjusted interhospital differences in mean length of stay ranged from 0.9 to 2.3 days (P <0.001). When the risk of each medical outcome was compared between patients admitted to the hospital with the shortest length of stay and those admitted to longer stay hospitals, there were no differences in mortality [relative risk (RR) = 0.7; 95% CI, 0.3 to 1.7], hospital readmission (RR = 0.8; 95% CI, 0.5 to 1.2), return to usual activities (RR = 1.1; 95% CI, 0.9 to 1.3), or return to work (RR = 1.2; 95% CI, 0.8 to 2.0) during the first 14 days after discharge, or in the mean number of pneumonia-related symptoms 30 days after admission (P = 0.54).Conclusions: We observed substantial interhospital variation in the lengths of stay for patients hospitalized with community-acquired pneumonia. The finding that medical outcomes were similar in patients admitted to the hospital with the shortest length of stay and those admitted to hospitals with longer mean lengths of stay suggests that hospitals with longer stays may be able to reduce the mean duration of hospitalization for this disease without adversely affecting patient outcomes. [ABSTRACT FROM AUTHOR]

Identifies the etiologies and risk factors associated with fever of nosocomical origin. Comparison of outcomes of patients with and without nosocomical fever; Assignment of etiologies by the consensus of three independent reviewers using Centers for Disease Control guidelines; Potential use in the prediction of patients at high risk for an infectious process.

Validates the performance of a pneumonia prognostic index. Confirmation of the importance of six predictors of prognosis in patients with community-acquired pneumonia; 1989 MedisGroups Comparative Hospital Database as the validation cohort; Index as a means of helping doctors identify patients who could be managed as outpatients or treated with abbreviated inpatient care.

PURPOSE: To identify a low-risk subset of patients with community-acquired pneumonia that could safely be treated in the ambulatory setting; and to assess how clinicians make the hospitalization decision. PATIENTS AND METHODS: We performed a prospective, observational study of 280 ambulatory and hospitalized adults with clinical and radiographic evidence of pneumonia. Patients were followed to assess all potential morbid complications and 6-week mortality. Physicians responsible for managing these patients were surveyed to assess the reasons for treating in a hospital or ambulatory setting and the therapies that dictate hospitalization. RESULTS: Sixty-one percent (170 of 280) of patients did not have an indication for admission at presentation using modified Appropriateness Evaluation Protocol criteria (a severe vital sign abnormality, alteration in mental status, suppurative complication, arterial hypoxemia, severe laboratory abnormality, or an acute coexistent medical problem requiring admission independent of the pneumonia). Among these 170 patients, 38% had a complicated course defined as death within 6 weeks, development of a new suppurative or medical complication due to pneumonia, intensive care unit admission, persistent fever or use of intravenous fluids or oxygen beyond 3 days, hospitalization lasting more than 3 days, or subsequent hospitalization in patients initially treated in the ambulatory setting. Five predisposing factors for a complicated course were identified in logistic regression models. The odds ratio for age more than 65 years was 2.7; for comorbid illness, 3.2; for temperature more than 38.3°C (101°F), 4.1; for immunosuppression, 12.0; and for a high-risk etiology, 23.3. The risk of a complicated course increased linearly with the number of risk factors, from 12% with none to 100% with four or more factors (p <0.001). Physicians most often relied on the general clinical appearance of the patient when making the triage decisi... [ABSTRACT FROM AUTHOR]

Reviews the medical literature on the prognosis and outcomes of patients with community-acquired pneumonia (CAP). Data sources; Selection; Qualitative assessment of studies' data; Overall mortality rates; Mortality variation by pneumonia etiology; Prognostic factors associated with mortality; Other medical outcomes.

Presents research which described the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia. Assessment of clinical outcomes after achieving stability; Role of costs in length of stay for pneumonia; Design; Setting; Patients; Main outcome measures; Results; Provision of evidence-based estimate of optimal length of stay; Improving efficiency of inpatient management.

Presents a study to assess the quality of care for elderly Medicare patients hospitalized with pneumonia and to determine if the care performance is associated with lower 30-day mortality. Design and setting of the study; Patients; Main outcome measures; Results and conclusions.

Determines which factors medical practitioners consider in making hospital admission decision for patients with community-acquired pneumonia in the United States. Description of patients' characteristics at initial examination; Availability of health services; Identification of low-risk patients with community-acquired pneumonia.

Focuses on the hospital discharge decision for patients with community-acquired pneumonia the United States. Factors responsible for extending the length of hospital stay; Investigation of medical services that allow earlier hospital discharge; Suggestions for decreasing the length of hospital stay.

Objectives: To study the effect of previously administered antibiotics on the antibiotic susceptibility profile of Enterobacter, the factors affecting mortality, and the emergence of antibiotic resistance during therapy for Enterobacter bacteremia.Design: Prospective, observational study of consecutive patients with Enterobacter bacteremia.Setting: Three university tertiary care centers, one major university-affiliated hospital, and two university-affiliated Veterans Affairs medical centers.Patients: A total of 129 adult patients were studied.Measurements: The two main end points were emergence of resistance during antibiotic therapy and death.Main Results: Previous administration of third-generation cephalosporins was more likely to be associated with multiresistant Enterobacter isolates in an initial, positive blood culture (22 of 32, 69%) than was administration of antibiotics that did not include a third-generation cephalosporin (14 of 71, 20%; P less than 0.001). Isolation of multiresistant Enterobacter sp. in the initial blood culture was associated with a higher mortality rate (12 of 37, 32%) than was isolation of a more sensitive Enterobacter sp. (14 of 92, 15%; P = 0.03). Emergence of resistance to third-generation cephalosporin therapy (6 of 31, 19%) occurred more often than did emergence of resistance to aminoglycoside (1 of 89, 0.01%; P = 0.001) or other beta-lactam (0 of 50; P = 0.002) therapy.Conclusions: More judicious use of third-generation cephalosporins may decrease the incidence of nosocomial multiresistant Enterobacter spp., which in turn may result in a lower mortality for Enterobacter bacteremia. When Enterobacter organisms are isolated from blood, it may be prudent to avoid third-generation cephalosporin therapy regardless of in-vitro susceptibility. [ABSTRACT FROM AUTHOR]

Background: Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. Objective: To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities. Design: Retrospective cohort study. Participants: Black and White patients enrolled in the VA with incident AF from 2020 through 2021. Main Measures: The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant [DOAC]) or any DOAC therapy within 90 days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference. Key Results: In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from − 29.9 (95% CI, − 54.9 to − 4.8) to 14.2 (95% CI, − 9.1 to 25.0) across facilities for any anticoagulant therapy and from − 28.8 (95% CI, − 58.3 to 0.8) to 15.0 (95% CI, − 8.0 to 38.1) for DOAC therapy. For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities. Conclusions: In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care. [ABSTRACT FROM AUTHOR]

Editorial The incidence of type 2 diabetes continues to rise and affects an estimated more than 37 million individuals in the US.[1] Type 2 diabetes is the seventh leading cause of mortality and is a risk factor for serious medical comorbidity, including atherosclerotic cardiovascular disease (ASCVD), heart failure, and chronic kidney disease (CKD).[1] Several underrepresented racial and ethnic groups, including American Indian, Asian, Black, and Hispanic individuals, experience a higher prevalence of type 2 diabetes and higher rates of disease-attributable morbidity and mortality than White individuals.[2] A central objective of clinical guidelines for type 2 diabetes is to develop a patient-centered glycemic management plan with the goals of preventing complications and optimizing quality of life.[3] Whereas such plans are multifaceted and comprise lifestyle modification, physical activity, nutrition, and weight management, pharmacologic approaches have an ever-evolving therapeutic role. Consistent with the recent non-VA studies,[[6]] overall prescribing rates for SGLT2i and GLP-1 RA were low in the VHA (10.7% and 7.7%, respectively) and the absolute differences in prescribing for White patients compared with patients from all other racial groups were 2.5 percentage points or less.

The article deals with the collaboration of the U.S. The Department of Veterans Affairs (VA) Health Services Research and Development Service with the "American Journal of Public Health" to publish this special edition highlighting the Third Annual National Minority Health Leadership Summit. The summit was held in Pittsburgh, Pennsylvania in January 2003 and was organized by the Center for Minority Health at the University of Pittsburgh Graduate School of Public Health.

The article identifies emerging issues and trends that will influence healthcare, health systems and the pharmacy profession and provides recommendations to inform strategic planning for pharmacy departments in hospitals and health care systems. It presents results of surveys on urgent public health priorities, response to the mental health crisis, achieving care equity, new disease paradigms and treatment innovations, workforce culture, ethics ,and regulation of artificial intelligence (AI).

A letter to the editor is presented that responds to the article "Association of Admission to Veterans Affairs Hospitals vs non-Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia" by S. V. Nuti, L. Qin, J. S. Rumsfeld, et al.

Background: Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans.Objective: To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans.Design: Observational study using Veterans Health Administration (VA) encounter and prescription data.Setting and Participants: Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve").Measurements: We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses.Results: We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004).Conclusions: ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF. Objective: To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF. Design: Retrospective cohort study. Participants: A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study. Main Measures: The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates. Key Results: Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2–Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84–0.94) in Q2 to 0.77 (95% CI, 0.73–0.83) in Q5 compared to Q1 (p<.0001). Conclusions: Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities. [ABSTRACT FROM AUTHOR]

The authors comment on a study which investigated the effect of procalcitonin (PCT)-based guidelines against standard guidelines on antibiotic use in lower respiratory tract infections (LRTI) in Switzerland. An overview of the study is presented which includes the types of patients involved and treatment recommendations. Among the issues raised by the authors before the results of the study can be translated into clinical practice is the basis of the assessment of PCT-guided management. The authors also cited the relevance of PCT-guided care.

Background: Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA). Objective: To examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery. Design: Retrospective cohort study using VHA administrative data from fiscal years 2017–2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not. Participants: National cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery. Main Measures: Difference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not Key Results: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7–57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19–150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8–66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66–157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services. Conclusions: Among a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly. [ABSTRACT FROM AUTHOR]

Background: The Procalcitonin Antibiotic Consensus Trial (ProACT) found provision of a procalcitonin antibiotic prescribing guideline to hospital-based clinicians did not reduce antibiotic use. Possible reasons include clinician reluctance to follow the guideline, with an observed 64.8% adherence rate. In this study we sought to determine the threshold adherence rate for reduction in antibiotic use, and to explore opportunities to increase adherence. Methods: This study is a retrospective analysis of ProACT data. ProACT randomized 1656 patients presenting to 14 U.S. hospitals with suspected lower respiratory tract infection to usual care or provision of procalcitonin assay results and an antibiotic prescribing guideline to the treating clinicians. We simulated varying adherence to guideline recommendations for low procalcitonin levels and determined which threshold adherence rate could have resulted in rejection of the null hypothesis of no difference between groups at alpha = 0.05. We also performed sensitivity analyses within specific clinical settings and grouped patients initially prescribed antibiotics despite low procalcitonin into low, medium, and high risk of illness severity or bacterial infection. Results: Our primary outcome was number of antibiotic-days by day 30 using an intention-to-treat approach and a null hypothesis of no difference in antibiotic use. We determined that an 84% adherence rate in the hospital setting (emergency department and inpatient) for low procalcitonin could have allowed rejection of the null hypothesis (3.7 vs 4.3 antibiotic-days, p = 0.048). The threshold adherence rate was 76% for continued guideline adherence after discharge. Even 100% adherence in the emergency department alone failed to reduce antibiotic-days. Of the 218 patients prescribed antibiotics in the emergency department despite low procalcitonin, 153 (70.2%) were categorized as low or medium risk. Conclusions: High adherence in the hospital setting to a procalcitonin antibiotic prescribing guideline is necessary to reduce antibiotic use in suspected lower respiratory tract infection. Continued guideline adherence after discharge and withholding of antibiotics in low and medium risk patients with low procalcitonin may offer impactful potential opportunities for antibiotic reduction. Trial registration Procalcitonin Antibiotic Consensus Trial (ProACT), ClinicalTrials.gov Identifier: NCT02130986. First posted May 6, 2014. [ABSTRACT FROM AUTHOR]

This section introduces a series of articles on the promise genetics research holds for advancing the medical sciences. They include a discussion on the use of the pharmaceutical industry of its economic force to leverage the widespread use of race as a biological marker in the field of pharmacogenomics, an article which examined the application of genomics to public health and an article which discussed the nonscientific, historical basis for the use of race as a biological concept in medical research.

This article discusses the importance of culture and health communication in resolving health disparities. The root causes of health disparities are numerous and relate to individual behaviors, provider knowledge and attitudes, organization of health care system and societal and cultural values. Disparities have been well documented, even in systems that provide unencumbered access to healthcare. Efforts to eliminate health disparities must be informed by the influence of culture on the attitudes, beliefs, and practices of not only minority populations but also public health policymakers and the health professionals responsible for the delivery of medical services and public health interventions designed to close the health gap. There is credible evidence suggesting that cultural norms within Western societies contribute to lifestyles and behaviors associated with risk factors for chronic diseases. Matching the cultural characteristics of minority populations with public health interventions designed to affect individuals within the group may enhance receptivity to, acceptance of, and salience of health information and programs. Efforts toward the elimination of racial and ethnic health disparities must address social, cultural, and environmental factors beyond the biomedical model.

Responds to comments made on the authors' article on diagnostic and prognostic testing in pneumonia. Accuracy of physical examination in the diagnosis of community-acquired pneumonia; Development of training programs for undergraduate and graduate medical students in the skills of bedside examination; Deficiencies of physical examination.

Purpose To assess the associations of self-identified lesbian, gay, bisexual, and questioning sexual orientation or transgender status (LGBTQ) and military experience with health indicators. Methods We used data from the Fall 2012 National College Health Assessment. The survey included self-identified sociodemographic characteristics, mental (e.g., depression) and physical (e.g., human immunodeficiency virus) conditions, health risk behaviors (e.g., smoking), and social stressors (e.g., victimization). We used modified Poisson regression models, stratified by self-reported military service, to examine LGBTQ-related differences in health indicators, whereas adjusting for sociodemographic characteristics. Results Of 27,176 in the sample, among the military-experienced group, LGBTQ individuals had increased adjusted risks of reporting a past-year suicide attempt (adjusted risk ratio [aRR] = 4.37; 95% confidence interval [CI] = 1.39–13.67), human immunodeficiency virus (aRR = 9.90; 95% CI = 1.04–79.67), and discrimination (aRR = 4.67; 95% CI = 2.05–10.66) than their non-LGBTQ peers. Among LGBTQ individuals, military experience was associated with a nearly four-fold increased risk of reporting a past-year suicide attempt (aRR = 3.61; 95% CI = 1.46–8.91) adjusting for age, sex, race and ethnicity, marital status, depression, and other psychiatric diagnoses. Conclusions Military experience may moderate health indicators among LGBTQ populations, and likewise, LGBTQ status likely modifies health conditions among military-experienced populations. Results suggest that agencies serving military populations should assess how and if the health needs of LGBTQ individuals are met. [ABSTRACT FROM AUTHOR]

Background Previous studies of surgeon behavior report that surgeons rarely meet basic standards of informed consent, raising concerns that current practice requires urgent remediation. We wondered if the Veterans Affairs Healthcare System's recent implementation of standardized, procedure-specific consent forms might produce a better practice of informed consent than has been reported previously. Our goal was to determine how the discussions shared between surgeons and patients correspond to the VA's standardized consent forms. Methods We enrolled a prospective cohort of patients presenting for possible cholecystectomy or inguinal herniorrhaphy and the surgical providers for those patients. Audio recordings captured the clinical encounter(s) culminating in a decision to have surgery. Each patient's informed consent was documented using a standardized, computer-generated form. We abstracted and compared the information documented with the information discussed. Results Of 75 consecutively enrolled patients, 37 eventually decided to have surgery and signed the standardized consent form. Patients and providers discussed 37% (95% confidence interval, 0.07-0.67) and 33% (95% confidence interval, 0.21-0.43) of the information found on the cholecystectomy and herniorrhaphy consent forms, respectively. However, the patient-provider discussions frequently included relevant details nowhere documented on the standardized forms, culminating in discussions that included a median 27.5 information items for cholecystectomy and 20 items for herniorrhaphy. Fully, 80% of cholecystectomy discussions and 76% of herniorrhaphy discussions mentioned at least one risk, benefit or alternative, indication for, and description of the procedure. Conclusions The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality. While neighborhood-level factors, such as poverty, have been related to prevalence of AF risk factors, the association between neighborhood poverty and incident AF has been limited.Objective: Using a large cohort from a health system serving the greater Chicago area, we sought to determine the association between neighborhood-level poverty and incident AF.Design: Retrospective cohort study.Participants: Adults, aged 30 to 80 years, without baseline cardiovascular disease from January 1, 2005, to December 31, 2018.Main Measures: We geocoded and matched residential addresses of all eligible patients to census-level poverty estimates from the American Community Survey. Neighborhood-level poverty (low, intermediate, and high) was defined as the proportion of residents in the census tract living below the federal poverty threshold. We used generalized linear mixed effects models with a logit link function to examine the association between neighborhood poverty and incident AF, adjusting for patient demographic and clinical AF risk factors.Key Results: Among 28,858 in the cohort, patients in the high poverty group were more often non-Hispanic Black or Hispanic and had higher rates of AF risk factors. Over 5 years of follow-up, 971 (3.4%) patients developed incident AF. Of these, 502 (51.7%) were in the low poverty, 327 (33.7%) in the intermediate poverty, and 142 (14.6%) in the high poverty group. The adjusted odds ratio (aOR) of AF was higher for the intermediate poverty compared with that for the low poverty group (aOR 1.23 [95% CI 1.01-1.48]). The point estimate for the aOR of AF incidence was similar, but not statistically significant, for the high poverty compared with the low poverty group (aOR 1.25 [95% CI 0.98-1.59]).Conclusion: In adults without baseline cardiovascular disease managed in a large, integrated health system, intermediate neighborhood poverty was significantly associated with incident AF. Understanding neighborhood-level drivers of AF disparities will help achieve equitable care. [ABSTRACT FROM AUTHOR]

A response by Michael J. Fine, Thomas E. Auble, Barbara H. Hanusa, and Daniel E. Singer to letters to the editor about their article "A prediction rule to identify low-risk patients with community-acquired pneumonia" in the January 23, 1997 issue is presented.

Background: There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation. Methods: From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of >30 per minute or a temperature of >40°C), and abnormal laboratory findings (such as a pH <7.35, a blood urea nitrogen concentration >30 mg per deciliter [11 mmol per liter] or a sodium concentration <130 mmol per liter) at presentation. Results: There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P = 0.22), from 0.6 to 0.7 percent for class II (P = 0.67), and from 0.9 to 2.8 percent for class III (P = 0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients. Conclusions: The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia. (N Engl J Med 1997;336:243-50.) [ABSTRACT FROM AUTHOR]

Abstract: Background: Although accurate health-related representations of medical situations on television can be valuable, inaccurate portrayals can engender misinformation. Objective: The purpose of this study was to compare sociodemographic and medical characteristics of patients depicted on television vs. actual United States (US) Emergency Department (ED) patients. Methods: Two independently working coders analyzed all 22 programs in one complete year of the popular “emergency room” drama ER. Inter-rater reliability was excellent, and all initial coding differences were easily adjudicated. Actual health data were obtained from the National Heath and Ambulatory Medical Care Survey from the same year. Chi-squared goodness-of-fit tests were used to compare televised vs. real distribution across key sociodemographic and medical variables. Results: Ages at the extremes of age (i.e., ≤ 4 and≥45 years) were less commonly represented on television compared with reality. Characters on television vs. reality were less commonly women (31.2% vs. 52.9%, respectively), African-American (12.7% vs. 20.3%), or Hispanic (7.1% vs. 12.5%). The two most common acuity categories for television were the extreme categories “non-urgent” and “emergent,” whereas the two most common categories for reality were the middle categories “semi-urgent” and “urgent.” Televised visits compared with reality were most commonly due to injury (63.5% vs. 37.0%, respectively), and televised injuries were less commonly work-related (4.2% vs. 14.8%, respectively). Conclusions: Comparison of represented and actual characteristics of ED patients may be valuable in helping us determine what types of patient misperceptions may exist, as well as what types of interventions may be beneficial in correcting that potential misinformation. [Copyright &y& Elsevier]

In this retrospective study of 332 cases of Legionnaires' disease (LD) in 4 Danish counties between 1995 and 2005 we aimed to compare the sensitivity of culture, PCR, urinary antigen testing, and serology to the mode of acquisition, serogroup, and severity of disease. Furthermore, we analyzed time to diagnosis. Laboratory confirmed cases of LD were found through the national Danish surveillance system and departments of clinical microbiology. In our study PCR was more sensitive (79.2%) than urinary antigen testing (70.4%), serology (54.8%), and culture (39.9%) (p<0.001).The sensitivity of Legionella urinary antigen test was higher among travel-associated cases (90.2%) compared to non-travel-associated cases (65.8%) and hospital acquired cases (45.7%) (p<0.001). Overall, the most common species and serogroup identified was L. pneumophila serogroup 1 (64.3% (110/171)). Community acquired cases with serogroup 1 were diagnosed earlier (mean 5 d, IQR: 4-9 d) than community acquired cases with other species or serogroups (mean 10.5 d, IQR: 5-19.5) (p<0.001). In conclusion, the urinary antigen test, PCR, and culture were conducive to the diagnosis of Legionella infection, and ordering of all 3 tests is recommended to ensure a definite and rapid diagnosis of Legionella. [ABSTRACT FROM AUTHOR]

Background: Two thirds of all sexual references in music are degrading in nature, yet it remains uncertain whether these references promote earlier sexual activity. The purpose of this study was to determine if exposure to lyrics describing degrading sex in popular music is independently associated with sexual behavior in a cohort of urban adolescents. Methods: All ninth-grade health students at three large urban high schools completed in-school surveys in 2006 and 2007. Participants'' exposure to lyrics describing degrading sex was computed with overall music exposure and content analyses of their favorite artists'' songs. Outcomes included sexual intercourse and progression along a noncoital sexual continuum. Multivariable regression was used to assess independent associations between exposure to lyrics describing degrading sex and outcomes. Results: The 711 participants were exposed to 14.7 hours each week of songs with lyrics describing degrading sex (SD=17.0). Almost one third of participants (n=216) had previously been sexually active. Compared to those with the least exposure to lyrics describing degrading sex, those with the most exposure were more than twice as likely to have had sexual intercourse (OR=2.07; 95% CI=1.26, 3.41), even after adjusting for all covariates. Similarly, among those who had not had sexual intercourse, those in the highest tertile of exposure to lyrics describing degrading sex were nearly twice as likely to have progressed along a noncoital sexual continuum (OR=1.88; 95% CI=1.23, 2.88) compared to those in the lowest tertile. Finally, the relationships between exposure to lyrics describing nondegrading sex and sexual outcomes were not significant. Conclusions: This study supports an association between exposure to lyrics describing degrading sex in popular music and early sexual experience among adolescents. [Copyright &y& Elsevier]

We aimed to determine which media exposures are most strongly associated with marijuana and alcohol use among adolescents. In 2004, we surveyed 1,211 students at a large high school in suburban Pittsburgh regarding substance use, exposure to entertainment media, and covariates. Of the respondents, 52% were female, 8% were non-White, 27% reported smoking marijuana, and 60% reported using alcohol. They reported average exposure to 8.6 hr of media daily. In adjusted models, exposure to music was independently associated with marijuana use, but exposure to movies was independently associated with alcohol use. Implications, limitations, and suggestions for further research are discussed. [ABSTRACT FROM AUTHOR]