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International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority.

Blood pressure exhibits circadian variability, and nighttime blood pressure is one of the best predictors of cardiovascular (CV) events. Adults with hypertension who lack a nighttime dipping pattern are at particularly high risk. Several studies have found that bedtime dosing of antihypertensive agents reduces sleep blood pressure and improves the dipping pattern in nondippers. One small study and 2 substudies of diabetes and chronic kidney disease suggest that bedtime dosing of ≥ 1 antihypertensives significantly reduced CV events. A Cochrane review of 5 studies found no difference in adverse events between morning and evening dosing. However, several evaluations in ophthalmology have found that nocturnal arterial hypotension precipitated ocular vascular disorders such as ischemic optic neuropathy. Some authors have suggested that additional studies of nighttime dosing of antihypertensive agents that evaluate CV events need to be conducted. The authors describe a randomized controlled pragmatic trial that is being planned at the University of Iowa and Duke University. Patients with hypertension and other comorbid conditions will be randomized to either continue morning dosing of all antihypertensive agents or to switch their nondiuretic medications to bedtime dosing. Patients will be followed for 36 to 42 months. This study will determine whether nighttime dosing reduces CV risk when compared with traditional morning dosing of antihypertensive agents.

Specialty hospitals have lower mortality rates for cardiac revascularization than general hospitals, but previous studies have found that this advantage disappears after adjusting for patient characteristics and hospital procedural volume. Questions have been raised about whether simultaneous relationships between volume and mortality might have biased these analyses. We use two-stage least squares with Hospital Quality Alliance scores and estimated market size as instruments for mortality and volume to control for possible simultaneity. After this adjustment, it is still the case that specialty hospitals do not have an advantage over general hospitals in mortality rates after cardiac revascularization. We find evidence of simultaneity in the relationship between volume and mortality.

OBJECTIVE: This study examines two dimensions of racial segregation across hospitals, using a disease for which substantial disparities have been documented. DATA SOURCES: Black (n=32,289) and white (n=244,042) patients 67 years and older admitted for acute myocardial infarction during 2004-2005 in 105 hospital markets were identified from Medicare data. Two measures of segregation were calculated: Dissimilarity (i.e., dissimilar distribution by race across hospitals), and Isolation (i.e., racial isolation within hospitals). For each measure, markets were categorized as having low, medium, or high segregation. STUDY DESIGN: The relationship of hospital segregation to residential segregation and other market characteristics was evaluated. Cox proportional hazards regression was used to evaluate disparities in the use of revascularization within 90 days by segregation level. RESULTS: Agreement of segregation category based on Dissimilarity and Isolation was poor (kappa=0.12), and the relationship of disparities in revascularization to segregation differed by measure. The hazard of revascularization for black relative to white patients was lowest (i.e., greatest disparity) in markets with low Dissimilarity, but it was unrelated to Isolation. CONCLUSIONS: Significant racial segregation across hospitals exists in many U.S. markets, although the magnitude and relationship to disparities depends on definition. Dissimilar distribution of race across hospitals may reflect divergent cultural preferences, social norms, and patient assessments of provider cultural competence, which ultimately impact utilization.

A number of studies over the past two decades have compared outcomes in Department of Veterans Affairs (VA) and private sector hospitals (Department of Veterans Affairs 1987, 1989, 1991, 2003; Rosenthal, Larimer, and Owens 1994; Gordon et al. 2000; Petersen et al. 2000, 2001, 2003; Kaboli et al. 2001; Stineman et al. 2001; Rosenthal, Vaughan-Sarrazin, and Hannan 2003; Rosenthal et al. 2003). While these studies have yielded conflicting results, studies that found worse outcomes in VA hospitals have often led to intense scrutiny of the VA health care system, and efforts to restructure the delivery of care. For example, following a study indicating that VA hospitals had worse outcomes for acute myocardial infarction (AMI) (Department of Veterans Affairs 2003), the VA outlined a number of costly organizational changes in its 162 hospitals (Brown 2003). A limitation of research comparing VA and private sector hospitals is uncertainty about the adequacy of methods used to adjust for severity of illness. Outcomes of hospital care depend on three factors: (1) patients' underlying risk before treatment, (2) random variation, and (3) quality of care (Iezzoni 1997a). By controlling for patients' underlying risk and by using appropriate statistical methods to account for random variation, inferences about hospital quality can be made. However, if the measurement of patient risk is inadequate, differences in outcomes across hospitals may be inappropriately attributed to quality. It is generally recognized that VA patients are subject to unique socioeconomic, clinical, and psychosocial factors that may affect outcomes. For example, VA users may have poorer functional status, which is an important prognostic variable (McCarthy et al. 1995). If methods do not appropriately adjust for such factors, it is difficult to discern whether differences in outcomes between VA and private sector hospitals are due to differences in the effectiveness of care (i.e., quality) or unmeasured patient risk. The goal of this study is to estimate whether the use of VA services is a marker for increased risk among patients in private sector hospitals undergoing revascularization by coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The study used VA and Medicare administrative data to identify patients treated in private sector hospitals who also use VA services (i.e., “VA users”), and then compare outcomes with other private sector patients (“nonusers”), after adjusting for measurable risk factors. Because the availability of coronary revascularization in VA hospitals is limited (e.g., CABG is currently performed in only 42 VA hospitals), it is likely that many VA users undergo revascularization in private sector hospitals. This natural experiment allows us to compare outcomes in VA users and nonusers in similar hospitals. Thus, differences in outcomes between VA users and nonusers represent unmeasured risk for VA users undergoing revascularization in private sector hospitals. We also evaluated whether VA users in private sector hospitals are atypical VA users, in order to assess whether this estimate of unmeasured risk corresponds to the magnitude of unmeasured risk that may confound prior studies comparing VA and private sector hospitals.

OBJECTIVES: To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients. DESIGN: Cross-sectional study. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: One hundred ninety-six outpatients aged 65 and older who were taking five or more medications. MEASUREMENTS: Inappropriate prescribing was assessed using a combination of the Beers drugs-to-avoid criteria (2003 update) and subscales of the Medication Appropriateness Index that assess whether a drug is ineffective, not indicated, or unnecessary duplication of therapy. Underuse was assessed using the Assessment of Underutilization of Medications instrument. All vitamins and minerals, topical and herbal medications, and medications taken as needed were excluded from the analyses. RESULTS: Mean age was 74.6, and patients used a

OBJECTIVES: To determine independent relationships between age and the risk of in-hospital death. DESIGN: Retrospective cohort study. SETTING: Thirty-eight intensive care units (ICUs) in 28 hospitals in a large Midwest metropolitan region. PARTICIPANTS: One hundred fifty-six thousand, one hundred thirty-six consecutive admissions to medical, surgical, neurological, and mixed medical/surgical ICUs between March 1, 1991, and March 31, 1997. MEASUREMENTS: In-hospital death rates were compared at successive 5-year age intervals, adjusting for gender, diagnosis, admission source, comorbidity, and acute physiology scores. Acute physiology scores were determined using a validated methodology based on abnormalities in 17 physiological measures collected during the first 24 hours of ICU admission. RESULTS: The adjusted odds of death increased with each 5-year age increment. For example, relative to patients younger than 35, adjusted odds of death in patients aged 40 to 44, 50 to 54, 60 to 64, 70 to 74, 80 to 84, and 90 and older were 1.51, 1.73, 2.38, 2.98, 3.86, and 4.74, respectively. In stratified analyses, age-related increases in the odds of death were somewhat higher in surgical than medical patients or patients with lower severity of illness at admission. Although acute physiology scores had excellent discrimination in all age groups, discrimination decreased with age (e.g., c-statistics of 0.928 and 0.835 in patients younger than 45 and 85 and older, respectively). CONCLUSION: Our findings demonstrate incremental increases in the risk of hospital death associated with age that was independent of severity of illness and other prognostic factors. Although the current results may be less biased by differences in treatment goals than studies of general hospitalized patients, the lower discrimination of physiology scores in older patients suggests that unmeasured factors (e.g., functional status, patient preferences for care, differences in physician practices) may be of greater prognostic importance in older than in younger patients. From the *Research Service, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; D ivision of General Internal Medicine, Department of Internal Medicine, University of Iowa College of Medicine and University of Iowa Hospital and Clinics, Iowa City, Iowa; and 1 Health Evaluation Systems Delivery Team, Department of Anesthesiology and Critical Care Medicine, University of Pittshurgh School of Medicine, Pittsburgh, Pennsylvania.

Objective To determine the prevalence of complementary and alternative medicine (CAM) use and to identify factors associated with its use in older patients with arthritis. Methods A population-based telephone survey of 480 elderly patients with arthritis was conducted to determine demographics, comorbidities, health status, arthritis symptoms, and the use of CAM and traditional providers and treatments for arthritis. Results CAM provider use was reported by 28% of respondents, and 66% reported using one or more CAM treatments. Factors independently related to CAM provider use (P < 0.05) included podiatrist or orthotist use, physician visits for arthritis, and fair or poor self-reported health. For CAM treatments, independent associations were found with physical or occupational therapist use, physician visits for arthritis, chronic obstructive pulmonary disease, and alcohol abstinence. Rural residence, age, income, education, and health insurance type were unrelated to CAM use. Conclusion Many older patients with arthritis reported seeing CAM providers, and most used CAM treatments. The use of CAM for arthritis was most common among those with poorer self-assessed health and higher use of traditional health care resources.

OBJECTIVE: To identify age-related differences in the treatment of patients with acute myocardial infarction. DESIGN: Retrospective cohort study. SETTING: Two university-affiliated medical centers with integrated clinical programs. PATIENTS: 329 patients admitted with acute myocardial infarction in 1988–1990 for whom complete medical records were available. Study exclusions included patients transferred from other hospitals specifically to undergo angiography or other cardiac procedures, nursing home residents, patients with metastatic cancer or dementia, and patients in whom “do not resuscitate” orders were written during the first 2 hospital days. MEASUREMENTS: Medical records were reviewed to determine socio-demographic data, comorbidity, admission severity of illness, medications, the use of specific diagnostic and therapeutic modalities during and after hospitalization, treatment limitations, and patient outcomes. MAIN RESULTS: Chronological age of patients was related to the use of several diagnostic and therapeutic modalities. Using logistic regression to adjust for comorbidity, severity, infarct size and location, and other covariates, patients 75 years and older were 12 times less likely to receive thrombolytic therapy, 8 times less likely to undergo coronary angiography, and 7 times less likely to undergo coronary angioplasty than patients less than 65 years of age. However, age was not related to the use of other modalities, including echocardiography or gated blood pool scanning, pulmonary artery catheterization, and transvenous pacing. Finally, in a logistic regression model, the risk of in-hospital death was 4 times greater for patients 75 years and older than patients less than 65 years. CONCLUSIONS: Physicians' management of patients with acute myocardial infarction differed greatly according to patient age for some diagnostic and therapeutic modalities, but not for others. These findings indicate that generalizations about age-related practice variations should not be based on analysis of a single procedure. Moreover, judgments about the appropriateness of age-related differences in management require knowledge of the relative effectiveness of management strategies in older and younger patients.