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Importance In 2016, approximately 676 000 children in the United States experienced maltreatment (abuse, neglect, or both), with 75% of these children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1700 children died as a result of maltreatment. Objective To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on primary care interventions to prevent child maltreatment. Evidence Review The USPSTF commissioned a review of the evidence on primary care interventions to prevent maltreatment in children and adolescents without signs or symptoms of maltreatment. Findings The USPSTF found limited and inconsistent evidence on the benefits of primary care interventions, including home visitation programs, to prevent child maltreatment and found no evidence related to the harms of such interventions. The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The level of certainty of the magnitude of the benefits and harms of these interventions is low. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement)

In December 2017, Ohio passed into law legislation that prohibited physicians from performing abortions if the pregnant woman’s decision was influenced by her belief that the fetus has Down syndrome. Physicians who perform abortions in these cases would face fourth-degree felony charges and revocation of their medical license. No other state bans abortion specifically for Down syndrome, but several ban abortions in cases of genetic diseases. Lower courts have struck down most such laws, holding they violate the constitutional rights of women. In February 2, a federal district court judge blocked enforcement of Ohio’s law pending a final determination. This article explores the compelling legal and ethical issues raised by the Ohio statute. It compares the statute with similar bans on abortion in other states and considers why courts have struck many of these bans down as unconstitutional. The article also examines the potential consequences of the Ohio statute for women and their families; for the patient-physician relationship; and for persons with disabilities. Ultimately, such laws do little to advance the values that are at the heart of both reproductive rights and disability rights movements, namely bodily autonomy, self-determination, equality, and inclusion.

Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences.To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force.PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018.English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization).Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted.Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms.Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified.Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.

November 2013, Vol 310, No. 17 > < Previous Article Full content is available to subscribers Subscribe/Learn More Next Article > Viewpoint | November 6, 2013 Managing the Human Toll Caused by Seasonal InfluenzaNew York State�s Mandate to Vaccinate or Mask Arthur Caplan, PhD1; Nirav R. Shah, MD, MPH2 [+] Author Affiliations JAMA. 2013;310(17):1797-1798. doi:10.1001/jama.2013.280633. Text Size: A A A Article References New York State and the nation as a whole experienced one of the worst influenza seasons in a decade during the winter of 2012-2013. In the peak week ending January 19, 2013, New York alone reported more than 5000 cases of laboratory-confirmed influenza, more than 1120 hospitalizations as a result of influenza, and 5 flu-related pediatric deaths. By the season�s end, more than 45 000 cases had been confirmed, more than 9500 people had been hospitalized, and 14 children had died.1

In June 2013, the World Health Organization (WHO) published Responding to Intimate Partner Violence and Sexual Violence Against Women,1 providing evidence-based recommendations to guide clinicians. This guidance is important because a clinician may be the first professional contact for persons exposed to intimate partner violence (IPV). The guidelines are based on systematic reviews of a range of topics, including identification and approaches to providing care for women and their children after disclosure of IPV and sexual violence. Although there is overlap in the guidance for both conditions, in terms of first-line response and subsequent follow-up care, there are also specific recommendations related to sexual violence (ie, postexposure prophylaxis for infection and emergency contraception). Even though men also experience IPV, the guidelines focus on women because women experience substantially more IPV than men and the morbidity and mortality are more severe. In this Viewpoint, we summarize and discuss the IPV recommendations (Table).

Children with disabilities are at increased risk for maltreatment,1,2 and neglect accounts for the majority of such cases.3 Although most cases of suspected neglect are unsubstantiated at the time of the initial report to child protective services (CPS),4 meaning there is insufficient legal evidence of maltreatment, these children are at risk for subsequent maltreatment.5

Context Public reporting of patient outcomes is an important tool to improve quality of care, but some observers worry that such efforts will lead clinicians to avoid high-risk patients. Objective To determine whether public reporting for percutaneous coronary intervention (PCI) is associated with lower rates of PCI for patients with acute myocardial infarction (MI) or with higher mortality rates in this population. Design, Setting, and Patients Retrospective observational study conducted using data from fee-for-service Medicare patients (49 660 from reporting states and 48 142 from nonreporting states) admitted with acute MI to US acute care hospitals between 2002 and 2010. Logistic regression was used to compare PCI and mortality rates between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware). Changes in PCI rates over time in Massachusetts compared with nonreporting states were also examined. Main Outcome Measures Risk-adjusted PCI and mortality rates. Results In 2010, patients with acute MI were less likely to receive PCI in public reporting states than in nonreporting states (unadjusted rates, 37.7% vs 42.7%, respectively; risk-adjusted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]; P = .003). Differences were greatest among the 6708 patients with ST-segment elevation MI (61.8% vs 68.0%; OR, 0.73 [95% CI, 0.59-0.89]; P = .002) and the 2194 patients with cardiogenic shock or cardiac arrest (41.5% vs 46.7%; OR, 0.79 [95% CI, 0.64-0.98]; P = .03). There were no differences in overall mortality among patients with acute MI in reporting vs nonreporting states. In Massachusetts, odds of PCI for acute MI were comparable with odds in nonreporting states prior to public reporting (40.6% vs 41.8%; OR, 1.00 [95% CI, 0.71-1.41]). However, after implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% vs 45.6%; OR, 0.81 [95% CI, 0.47-1.38]; P = .03 for difference in differences). Differences were most pronounced for the 6081 patients with cardiogenic shock or cardiac arrest (prereporting: 44.2% vs 36.6%; OR, 1.40 [95% CI, 0.85-2.32]; postreporting: 43.9% vs 44.8%; OR, 0.92 [95% CI, 0.38-2.22]; P = .03 for difference in differences). Conclusions Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute MI mortality between states with and without public reporting.

What is the appropriate course for promoting prompt reporting of abuse, while still ensuring that respected individuals are not falsely accused? Ideally, state law would place a clear duty on all those in a position of trust to report promptly, not only to their supervisors but also to civil or criminal authorities. Given the vulnerability of young people under the supervision of a sports coach or clergyman, the law should require that abuse of adolescents, as well as children, be mandatorily reportable. The law should also have meaningful penalties for failure to report in cases in which there is good reason to suspect abuse. In the case of Penn State, failure to report is a criminal misdemeanor with limited legal ramifications. In addition to legal changes, institutions should develop internal, transparent processes to prevent and report abuse, such as employee background checks, impartial and anonymous reporting outlets, open-door policies, and ombudsmen charged with educating staff and uncovering abuse. Language: en

To the Editor: Dr Adashi and Senator Wyden (D-OR) commented on the Centers for Disease Control and Prevention’s (CDC’s) National Assisted Reproductive Technology Surveillance System (NASS). The Society for Assisted Reproductive Technology started collecting assisted reproductive technology (ART) data from member-clinics in 1986; the CDC has been collecting detailed information on all ART procedures performed annually in the United States since 1995 and has been monitoring ART effectiveness and safety. Several factors contribute to the high quality of surveillance data, including support of professional societies and consumer organizations, as well as annual data validation of a sample of ART programs. However, there are areas for improvement. Currently, ART programs submit their data to the CDC 1 year after the end of the reporting year to allow collection of complete information about births following successful ART procedures. Another year is needed for statistical analyses, preparation, and publication of the ART Success Rates Report. Thus, the report describing ART procedures performed in 2009 is published at the end of 2011. To improve the timeliness of publishing clinic-specific success rates, the CDC plans to release these rates in advance of the aggregate national data beginning in 2012. Outreach to the few nonreporting ART clinics, which tend to be smaller and may not belong to the relevant professional societies, could improve completeness of the NASS. The quality of reported data can be further improved by prospective reporting, ie, initial reporting of ART procedure (cycle start date and patient’s demographic information) within 4 days of procedure initiation, and complete reporting when the outcome of the procedure is known. All member-clinics of the Society for Assisted Reproductive Technology are now required to report prospectively. Extension of prospective reporting to non–member-clinics (approximately 15% of ART clinics) could further improve data quality and accountability. The growing population of ART-conceived children and the contribution of ART to multiple and preterm births makes ART an important public health issue, which the NASS can help to address. However, the NASS only contains limited pregnancy outcome information. Linking ART surveillance data with other surveillance systems could be an efficient approach to monitor long-term outcomes of ART. In collaboration with the health departments of Massachusetts, Michigan, and Florida, NASS data are being linked to vital records, hospital discharge data, birth defects’ registries, cancer registries, and other surveillance systems. This project, the States Monitoring ART Collaborative, provides an opportunity to establish state-based patientfocused (vs cycle-focused) public health surveillance of ART, infertility, and related issues. Dmitry M. Kissin, MD, MPH Denise J. Jamieson, MD, MPH Wanda D. Barfield, MD, MPH

said President BarackObama while trying to console the nation in the wake ofthe January 2011 attempted assassination of Rep GabrielleGiffords in Tucson, Arizona. The shooting at a civic gath-ering left 6 bystanders dead, renewing the politically divi-sivedebateabouttheappropriateresponsetoviolence:bandangerousweaponsorprohibitdangerousindividualsfrompossessing firearms?The public overwhelmingly supports limiting access tofirearms for children, violent criminals, and persons withmental illness, which is consistent with the National RifleAssociation’sinsistencethat“gunsdon’tkillpeople,peoplekillpeople.”Childrenlackthecompetencyandmaturitytouse firearms wisely, whereas most convicted felons have ahistory of violence. Singling out persons with mental ill-ness,however,isfarmorecomplexbecausetheyrepresentabroadspectrumofindividuals,someofwhomalreadyhavebeensubjectedtosocialostracism,butthemajorityofwhomare not violent.TheUSSupremeCourt’srecentdecisionthattheSecondAmendmentconfersanindividual’srighttobeararmsren-dersitincreasinglydifficulttoenactgenerallyapplicablelawsregardingfirearms,butthecourtexplicitlysupports“long-standing prohibitions” on possession of firearms by indi-vidualswithmentalillness.

S THE FLIGHT BEGINS ITS DESCENT, A CALL COMES over the intercom: “Is there a physician on board?” Three internists traveling together to a meeting respond. A woman has lost consciousness. She is incontinent and unresponsive, with a strong pulse and intermittent breathing. The physicians ultimately determine the patient has hypoglycemia and a seizure. It takes multiple requests before the flight attendants provide the physicians with the emergency medical kit. When the kit arrives, the flight attendants disappear, and the physicians search in vain for glucagon or intravenous dextrose. The physicians massage oral glucose gel into the patient’s buccal mucosa, and the seizure eventually stops. After landing, the cabin crew records the names and contact information of the physicians, with no discussion of the incident. Other reports have recounted physicians having chal

Context Peer monitoring and reporting are the primary mechanisms for identifying physicians who are impaired or otherwise incompetent to practice, but data suggest that the rate of such reporting is lower than it should be. Objective To understand physicians' beliefs, preparedness, and actual experiences related to colleagues who are impaired or incompetent to practice medicine. Design, Setting, and Participants Nationally representative survey of 2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded. Main Outcome Measures Beliefs about and preparedness for reporting and experiences with colleagues who practice medicine while impaired or who are incompetent in their medical practice. Results Sixty-four percent (n = 1120) of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice. Nonetheless, only 69% (n = 1208) of physicians reported being prepared to effectively deal with impaired colleagues in their medical practice, and 64% (n = 1126) reported being so prepared to deal with incompetent colleagues. Seventeen percent (n = 309) of physicians had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, 67% (n = 204) reported this colleague to the relevant authority. Underrepresented minorities and graduates of non-US medical schools were less likely than their counterparts to report, and physicians working in hospitals or medical schools were most likely to report. The most frequently cited reason for taking no action was the belief that someone else was taking care of the problem (19% [n = 58]), followed by the belief that nothing would happen as a result of the report (15% [n = 46]) and fear of retribution (12% [n = 36]). Conclusion Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.

Context Both elder self-neglect and abuse have become increasingly prominent public health issues. The association of either elder self-neglect or abuse with mortality remains unclear. Objective To examine the relationship of elder self-neglect or abuse reported to social services agencies with all-cause mortality among a community-dwelling elderly population. Design, Setting, and Participants Prospective, population-based cohort study (conducted from 1993 to 2005) of residents living in a geographically defined community of 3 adjacent neighborhoods in Chicago, Illinois, who were participating in the Chicago Health and Aging Project (CHAP; a longitudinal, population-based, epidemiological study of residents aged ≥65 years). A subset of these participants had suspected elder self-neglect or abuse reported to social services agencies. Main Outcome Measures Mortality ascertained during follow-up and by use of the National Death Index. Cox proportional hazard models were used to assess independent associations of self-neglect or elder abuse reporting with the risk of all-cause mortality using time-varying covariate analyses. Results Of 9318 CHAP participants, 1544 participants were reported for elder self-neglect and 113 participants were reported for elder abuse from 1993 to 2005. All CHAP participants were followed up for a median of 6.9 years (interquartile range, 7.4 years), during which 4306 deaths occurred. In multivariable analyses, reported elder self-neglect was associated with a significantly increased risk of 1-year mortality (hazard ratio [HR], 5.82; 95% confidence interval [CI], 5.20-6.51). Mortality risk was lower but still elevated after 1 year (HR, 1.88; 95% CI, 1.67-2.14). Reported elder abuse also was associated with significantly increased risk of overall mortality (HR, 1.39; 95% CI, 1.07-1.84). Confirmed elder self-neglect or abuse also was associated with mortality. Increased mortality risks associated with either elder self-neglect or abuse were not restricted to those with the lowest levels of cognitive or physical function. Conclusion Both elder self-neglect and abuse reported to social services agencies were associated with increased risk of mortality.

Sexual assault is common among college-aged women (18 to 25 years), with 1 in 5 reporting having experienced these crimes during their college years. Acute and long-term consequences of sexual assault may include physical trauma, sexually transmitted infections, post-traumatic stress disorder, depression, and substance abuse. Survivors have the option of reporting assaults to the university or to the police, but the goals of these 2 systems — and women’s experiences with them — can be quite different. The criminal justice system’s principal aim is to adjudicate guilt, but the university has the broader purpose of fostering a safe learning environment.This article explores how university administrators can help prevent sexual assaults and, if necessary, fairly adjudicate claims. The critical points of intervention include nurturing a respectful environment; encouraging reporting; ensuring fair and rigorous investigations; implementing appropriate sanctions for inappropriate behavior; and reintegrating survivors back into the academic community. Importantly, coordination and cooperation between the university and criminal justice systems will improve experiences for survivors of sexual assault.

ContextThe Institute of Medicine has recommended establishing mandatory error reporting systems for hospitals and other health settings.ObjectiveTo examine the opinions and experiences of hospital leaders with state reporting systems.Design and SettingSurvey of chief executive and chief operating officers (CEOs/COOs) from randomly selected hospitals in 2 states with mandatory reporting and public disclosure, 2 states with mandatory reporting without public disclosure, and 2 states without mandatory systems in 2002-2003.Main Outcome MeasuresPerceptions of the effects of mandatory systems on error reporting, likelihood of lawsuits, and overall patient safety; attitudes regarding release of incident reports to the public; and likelihood of reporting incidents to the state or to the affected patient based on hypothetical clinical vignettes that varied the type and severity of patient injury.ResultsResponses were received from 203 of 320 hospitals (response rate = 63%). Most CEOs/COOs thought that a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital’s own internal reporting system (69%) and encourage lawsuits (79%) while having no effect or a negative effect on patient safety (73%). More than 80% felt that the names of both the hospital and the involved professionals should be kept confidential, although respondents from states with mandatory public disclosure systems were more willing than respondents from the other states to release the hospital name (22% vs 4%-6%, P = .005). Based on the vignettes, more than 90% of hospital leaders said their hospital would report incidents involving serious injury to the state, but far fewer would report moderate or minor injuries, even when the incident was of sufficient consequence that they would tell the affected patient or family.ConclusionsMost hospital leaders expressed substantial concerns about the impact of mandatory, nonconfidential reporting systems on hospital internal reporting, lawsuits, and overall patient safety. While hospital leaders generally favor disclosure of patient safety incidents to involved patients, fewer would disclose incidents involving moderate or minor injury to state reporting systems.

ContextLaws requiring mandatory reporting of domestic violence to police exist in 4 states. Controversy exists about the risks and benefits of such laws.ObjectiveTo examine attitudes of female emergency department patients toward mandatory reporting of domestic violence injuries to police and how these attitudes may differ by abuse status.Design, Setting, and ParticipantsCross-sectional survey conducted in 1996 of 1218 women patients (72.8% response rate) in 12 emergency departments in California (a state with a mandatory reporting law) and Pennsylvania (without such a law).Main Outcome MeasuresOpposition to mandatory reporting to police and the characteristics associated with this belief.ResultsTwelve percent of respondents (n = 140) reported physical or sexual abuse within the past year by a current or former partner. Of abused women, 55.7% supported mandatory reporting and 44.3% opposed mandatory reporting (7.9% preferred that physicians never report abuse to police and 36.4% preferred physicians report only with patient consent). Among nonabused women, 70.7% (n = 728) supported mandatory reporting and 29.3% opposed mandatory reporting. Patients currently seeing/living with partners (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.0), non-English speakers (OR, 2.1; 95% CI, 1.4-3.0), and those who had experienced physical or sexual abuse within the last year (OR, 2.2; 95% CI, 1.6-2.9) had higher odds of opposing mandatory reporting of domestic violence injuries. There were no differences in attitudes by location (California vs Pennsylvania).ConclusionsThe efficacy of mandatory reporting of domestic violence to police should be further assessed, and policymakers should consider options that include consent of patients before wider implementation.

Should incidental findings discovered with whole-genome sequencing or testing be sought and reported to ordering clinicians and to patients (or their surrogates)?—Yes. The use of genomic sequencing in medicine is increasing substantially as this technology becomes less expensive and of demonstrated diagnostic utility.1,2 Potentially clinically relevant incidental findings from clinical exome or genome sequencing (hereafter referred to as genomic sequencing) will arise whenever an individual undergoes genomic sequencing. There is a great deal of controversy regarding how such findings should be addressed by clinical sequencing laboratories because many possible findings are of medical interest and processes for genomic testing and interpretation are not yet standardized. To date, the traditions of genetic testing and reporting have exceptionalized all genetic risk information as potentially dangerous to the well-being of patients. This tradition, in the era of genome sequencing, must be reconsidered. Recently, the American College of Medical Genetics and Genomics (ACMG) issued recommendations3,4 that addressed how incidental test results should be handled by clinical testing laboratories. The recommendations include a list of medically important conditions and genes to be evaluated in every case of clinical genomic sequencing, suggest standards for the laboratory in interpreting and communicating variants, and recommend the routine return of these findings to the ordering clinician whenever genomic sequencing is performed, regardless of the age of the patient. In this way, ambiguity in laboratory reporting can be minimized and a common foundation established for moving forward with the reporting of clinical sequencing in the practice of medicine. The recommendations deliberately diverge in some ways from prior practice standards related to locus-specific testing in clinical genetics. Ethical justifications for these recommendations are addressed elsewhere.5 The return of incidental findings for a small subset of disorders and genes in genomic sequencing is guided by well-established principles underlying the practice of medicine and is in the best interest of the patient. Incidental findings in clinical medicine are often mischaracterized as unintentional observations. However, a better characterization would be that such findings are potentially important observations noted during systematic examination by those with appropriate training. For example, a dermatologist consulted for a rash should not miss or fail to report a nearby mole suggestive of melanoma because he or she is instructed and trained to perform a systematic examination of the skin.6 Similarly, when a radiologist reviews a chest x-ray for the evaluation of a possible rib fracture, he or she has been trained to perform a systematic review of the film, reporting any abnormalities that rise to an established professional standard, regardless of the indication for the study.7 Importantly, radiologists are specifically trained neither to report every conceivable finding, nor to stop after “satisfaction of search”8 reveals an indicated finding. Rather radiologists use professional standards to assess and report a subset of unexpected findings that are likely to be medically important. Even though such findings are not always clinically useful, depriving clinicians and patients of these additional findings would not be in the best interest of patient care. In medicine, the search for, and discovery of low-probability, incidental findings by trained health care professionals is not a specified test to which a patient can consent or refuse, but is a process inherent to the performance of good medical care. The ACMG recommendations have been criticized for ignoring the preferences of patients who might not wish to learn such information. This criticism stems largely from the history of single gene testing in which patients are given a discrete choice about undergoing testing for a specific gene mutation, and are counseled before and after testing because of the emotional repercussions and reproductive implications of positive findings. This practice for single gene testing should not change. But genomic sequencing is a single assay of more than 20 000 genes through which a large amount of unexpected, medically relevant information might be generated. Even though empirical data about the risk of many such variants in the general population (as opposed to a family manifesting the disease) are limited, the ACMG recommendations have proposed a consensus view that for selected variants in selected genes, surveillance and intervention could be lifesaving and such results should be routinely reported. Over time, this list of reportable variants will evolve, expanding and contracting as evidence is amassed regarding the utility of findings or lack thereof. Responses from the leading laboratories performing clinical sequencing in the United States have been encouraging. For instance, the molecular laboratory at Baylor College of Medicine currently does not offer an opt-out for incidental findings considered medically actionable, but requires opt-in for an extended report of additional incidental findings. Some other laboratories are not yet fully following the ACMG recommendations and are maintaining a global opt-in or opt-out for incidental findings, whereas several are including incidental findings without any provision for opt out (oral communication, Heidi Rehm, PhD, June 11, 2013). Even though the ACMG recommendations have only been available for a few months, nearly all of these laboratories are reporting on, or preparing to report on, at least the genes and variants listed in the ACMG recommendations. The Baylor approach was based on extensive experience with structural variant detection using chromosomal microarray analysis (CMA), which can also generate incidental findings, albeit at a lower frequency than does genome sequencing. For example, parental CMA performed as part of a prenatal or pediatric evaluation occasionally identifies a structural variant within a well-established cancer susceptibility gene. Reporting this finding could alert the ordering physician and be lifesaving for the parent in question.9 The Baylor laboratory has found that clinicians and patients, if properly prepared and oriented to this approach to incidental findings, generally react positively to such findings and are willing and able to address the consequences in both CMA and genomic sequencing (written communication, Christine Eng, MD, June 20, 2013). Some critics have suggested that patient autonomy is threatened by this approach to incidental findings. However, this position ironically overvalues the incidental genetic finding as an end in itself, rather than as a clue to be contextualized through education, consultation, and joint decision making by the ordering clinician or consultant and patient. The issue is autonomy, but the salient concern is when in the process of testing should patients exercise their autonomy. Patient autonomy is, of course, available when patients are asked to agree to or decline genome sequencing and are provided an explanation that clinically important incidental findings will occasionally be discovered. But patient autonomy is not necessarily enhanced by the ability to refuse one or all complicated, hypothetical, and low-probability genetic risk variants that may or may not be relevant to that particular patient and family. Informed choice is best exercised when a previously unsuspected risk factor is discovered and can be appropriately contextualized by the clinician working with the patient. Together, they can review the family history, repeat a focused physical examination, or perform additional diagnostic studies. It would be unrealistic to propose to every patient undergoing a physical examination, laboratory testing, or radiological procedure that they consent in advance to the panoply of low-probability findings that might be discovered, or that the clinician, radiologist, or laboratory be required to mask or delete such findings from the report because a patient might be fearful of their discovery. Offering patients a complete opt-out for incidental findings offers only the illusion of autonomy because it does not respect the choices of patients who might wish to hear about some results, but not others. Similarly, categorical statements of preference such as “tell me about treatable conditions, but not untreatable conditions” will never be adequate to guide the management of incidental findings in genomic sequencing because the value of the incidental finding to the health of the individual patient, like any other laboratory value, cannot be accurately assessed until it is clinically contextualized for that patient. The ACMG recommendations stressed that empirical evidence on the penetrance of selected genes and variants in patients without family history is incomplete and data on the benefits and costs of uncovering unexpected genetic risk information are desperately needed. Such evidence should trigger regular reevaluation and modification of the initial list proposed by the ACMG. Medical genomics has arrived, and sequencing a patient’s genome for any purpose provides an opportunity to discover unexpected but medically important information. Incidental findings in genomics should not be handled differently from other incidental findings in medicine. Rather than exceptionalize the return of incidental genomic findings, clinicians and patients should embrace them as adjuvant information of potential utility and as a welcome component of modern medical practice.

Norovirus outbreaks are common among vulnerable, elderly populations in US nursing homes.To assess whether all-cause hospitalization and mortality rates are increased during norovirus outbreak vs nonoutbreak periods in nursing homes, and to identify factors associated with increased risk.A retrospective cohort study of Medicare-certified nursing homes in Oregon, Wisconsin, and Pennsylvania that reported at least 1 confirmed or suspected norovirus outbreak to the Centers for Disease Control and Prevention's National Outbreak Reporting System (NORS), January 2009 to December 2010. Deaths and hospitalizations occurring among residents of these nursing homes were identified through the Medicare Minimum Data Set (MDS).Rates of all-cause hospitalization and mortality during outbreak compared with nonoutbreak periods were estimated using a random-effects Poisson regression model controlling for background seasonality in both outcomes.The cohort consisted of 308 nursing homes that reported 407 norovirus outbreaks to NORS. Per MDS, 67 730 hospitalizations and 26 055 deaths occurred in these homes during the 2-year study. Hospitalization rates were 124.0 (95% CI, 119.4-129.1) vs 109.5 (95% CI, 108.6-110.3) hospitalizations per nursing home−year during outbreak vs nonoutbreak periods, yielding a seasonally adjusted rate ratio (RR) of 1.09 (95% CI, 1.05-1.14). Similarly, mortality rates were 53.7 (95% CI, 50.6-57.0) vs 41.9 (95% CI, 41.4-42.4) deaths per nursing home−year in outbreak vs nonoutbreak periods (seasonally adjusted RR, 1.11; 95% CI, 1.05-1.18). The increases in hospitalizations and mortality were concentrated in the first 2 weeks (week 0 and 1) and the initial week (week 0) of the outbreak, respectively. Homes with lower daily registered nurse (RN) hours per resident (0.75) had increased mortality rates during norovirus outbreaks compared with baseline (RR, 1.26; 95% CI, 1.14-1.40), while no increased risk (RR, 1.03; 95% CI, 0.96-1.12) was observed in homes with higher daily RN hours per resident (P = .007 by likelihood ratio test); the increase in hospitalization rates did not show a similar pattern.Norovirus outbreaks were associated with significant concurrent increases in all-cause hospitalization and mortality in nursing homes.

THE PREVALENCE AND EXTENT OF PUBLIC REPORTING of adverse medical outcomes are increasing. Many private, public, and government Web sites rank hospitals and report scores on selected quality measures. Health care consumers, including referring physicians, individual patients, and insurers, can use these data to inform decision making by selecting hospitals with better outcomes. However, the science of outcome reporting is young and lags behind the desires of the public in this information age. Reporting quality measures may have benefits but also may pose risks from unintended consequences. When validating outcome measures, the main focus has been strict definitions for numerators to clearly identify cases and for denominators to identify patients at risk. Standardized surveillance for events within the population of those at risk has received little attention, and as a result, surveillance bias is likely an important source of error in currently reported outcome measures. Surveillance bias, a nonrandom type of information bias, refers to the idea that “the more you look, the more you find.” It occurs when some patients are followed up more closely or have more diagnostic tests performed than others, often leading to an outcome diagnosed more frequently in the more closely monitored group. In an article on biases inherent to clinical research, Sackett used the phrase “unmasking (detection signal) bias” to explain how “an innocent exposure may become suspect if, rather than causing a disease, it causes a sign or symptom which precipitates a search for the disease.” As a result, differences in outcomes may be related to surveillance bias rather than differences in quality. If ignored, flawed causal inferences could be suggested from differential rates identified between groups. Surveillance bias is a well-known concept in epidemiology yet is seldom considered in published clinical studies. For example, deep vein thrombosis (DVT) is a significant cause of preventable harm and a commonly monitored quality-of-care measure. DVT is a common, lifethreatening complication among patients who have sustained trauma. Because injured patients are at increased risk for DVT, some clinicians use duplex ultrasound to screen highrisk asymptomatic trauma patients for DVT. Other clinicians argue this approach is neither clinically necessary nor cost-effective and therefore do not routinely screen for DVT in trauma patients. This clinical uncertainly leads to variability in the use of screening duplex ultrasound, creating variability in rates of DVT identified and reported—a typical example of surveillance bias. Evidence for surveillance bias in DVT reporting after trauma is well documented. For instance, after implementation of a DVT screening guideline at one trauma center, duplex ultrasound rates increased 4-fold and DVT rates increased 10-fold. Within the National Trauma Data Bank, DVT rates were 7-fold higher at hospitals in the highest quartile of use of vascular ultrasound, and patients treated at hospitals that performed more duplex ultrasounds were twice as likely to have DVT reported, even controlling for other patient risk factors. Surveillance bias also is an important factor in other highprofile publicly reported outcome measures. For example, rates of central line–associated bloodstream infections (BSIs) increased 3-fold with the use of computer automated surveillance, suggesting that “surveillance practice may complicate interinstitutional comparisons of publicly reported central line–associated BSI rates.” The hazard of error caused by surveillance bias will likely increase with increasing use of penalties and rewards for performance on quality measures. Surveillance bias also has the potential to pose significant harms. For instance, patients may be harmed because clinicians will not know if quality of care is improving, and incentives to improve outcomes may encourage clinicians to avoid appropriate diagnostic testing to minimize reported complications. Because performance measures do not specify surveillance, outcomes that are not sought ordinarily will not be detected. This potential for unintended consequences was summarized in a comment by Alam and Velmahos as: “No screening, no DVT, no punishment.” Thus

IN MID-NOVEMBER 2009, THE GOVERNMENT ACCOUNTability Office (GAO) released a report documenting the failure of current surveillance systems to capture the extent of work-related injury and illness in the United States. Independent assessments of the national surveillance system demonstrate that up to 80% of worker illness and injury are missed. The GAO documented that more than two-thirds of occupational health physicians report that workers fear disciplinary action for disclosing an injury or illness. More than a third of these physicians reportedly had been asked by company officials or workers to provide care that would not trigger an incident report even when it was “not sufficient to properly treat” the condition. The GAO analysis focuses on the flaws in the contemporary occupational disease surveillance system, but the nation’s reporting mechanism has been hobbled for more than a century. Numerous technical challenges confront any serious occupational disease surveillance effort, yet the problem is not fundamentally technical, but a matter of failed public policy.