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Brian Kendall,1 Kade M Ancell,2 Ke Tom Xu,1,3 James Morris1 1Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX, USA; 2Texas Tech University Health Science Center School of Medicine, Lubbock, TX, USA; 3Department of Family & Community Medicine, TTUHSC SOM, Lubbock, TX, USACorrespondence: Brian Kendall, Department of Surgery, Texas Tech University Health Science Center, 3601 4th St, MS 6211, Lubbock, TX, 79430, USA, Tel +1 806-761-0559, Email Brian.kendall@ttuhsc.eduPurpose: The Match for Emergency Medicine residency has presented new challenges over the past 2 years (2022– 2023). Use of a post-clerkship survey given to clerkship students could improve outcomes in The Match by helping the program identify its different strengths and weaknesses.Methods: A post-clerkship survey, sent after The Match, was sent to Emergency Medicine bound students who completed our Emergency Medicine clerkship. This data was then collected and analyzed and, in collaboration with our faculty and residents, changes were made to the clerkship and residency program with the intention that these changes would improve our program and therefore our competitiveness in the upcoming cycle of The Match. These changes were analyzed in the subsequent post-clerkship survey. The survey included questions that asked students to reflect on their experiences with various aspects of the program and how these experiences influenced their personal ranking of our program compared to other emergency medicine residency programs they might have interacted with.Results: Results from the initial post-clerkship survey revealed that students found our faculty and residents (55% ranked higher), County hospital (55% ranked higher), and SLOE transparency (64% ranked higher) as the main aspects of our program that led them to rank the program higher. Living in Lubbock, TX was found to be the biggest drawback for students, with 55% ranking our program lower. The 2023 post-clerkship survey revealed that the changes we made to our clerkship and program were effective, with an overall decrease of 10 points in students who ranked our program lower based on “Living in Lubbock, TX”. We also were able to keep 4 of our rotators, as opposed to 2 the year before. Lastly, we also did not need to go as far down our rank list in the 2023 cycle of The Match.Conclusion: Using a post-clerkship survey to evaluate strengths and weaknesses of a program through a student’s perspective can be an effective tool to help programs in their outcomes from The Match. Further study is necessary to validate these findings.Keywords: clerkship, survey, emergency medicine, match

Overweight and obese hypertensive patients can greatly benefit from high adherence rates for lifestyle modifications. The objectives of this paper were to investigate how patients'weight status affected physicians'recommendations of lifestyle modifications and patients'adherence after they received the recommendations. The patients were adults (18+years of age) with hypertension (prehypertension, Stage I and Stage II hypertension). The National Health and Nutrition Examination Survey (NHANES) 1999-2000 was used. Weight status was categorized as normal/underweight, overweight and obese. Physicians'recommendations of and patients'adherence to lifestyle modifications (weight control, exercise, sodium intake reduction, alcohol intake reduction) were examined using descriptive and multivariate analyses, controlling for weight status, hypertension stage, comorbidities and demographic characteristics. About 57.0%of the US adult population in 1999-2000 had prehypertension, Stages I or II hypertension. Among the hypertensive adults, 30.3%were normal/underweight, 32.6%were overweight and 37.2%were obese. We found that physicians were more aggressive in recommending lifestyle modification for obese patients. In contrast, obese hypertensive patients were not found to be more likely than normal/underweight patients to adhere to lifestyle modification recommendations. In addition, adherence rates for sodium and alcohol consumption reduction were higher than that for either exercise or weight control. In conclusion, more aggressive approaches should be taken by physicians to educate obese patients about the benefits of lifestyle modifications and to improve adherence to enhance the effects of antihypertensive medications.Journal of Human Hypertension (2005) 19, 365-371. doi:10.1038/sj.jhh.1001828 Published online 24 February 2005 [ABSTRACT FROM AUTHOR]

Objectives: We investigated whether there were Mexican-American versus non-Hispanic white disparities in parents' reports of problems with 4 dimensions of children's medical care access after controlling for a range of demographic, social, economic, and health status factors.Methods: Data were collected through a telephone survey of 5941 parents residing in Texas. The survey questionnaire included measures of the parent's demographic and socioeconomic status and the child's health-related quality of life. The behavioral model was used to guide the inclusion of factors in multivariate logistic regression analyses of parents' reports of their children's ability to obtain an appointment for routine/regular care, obtain care for illness/injury, obtain help/advice over the phone when calling the doctor's office, and having to wait more than 15 minutes in the doctor's office.Results: Mexican-American parents had worse reports of all 4 dimensions of their children's access even after controlling for predisposing, enabling, and need factors. Among Mexican-Americans, there were no differences between those who primarily spoke English versus Spanish. Other factors that were significantly associated with at least 2 reports of access were household income, the child's insurance status, and the child's health-related quality of life.Conclusions: Mexican-American children face problems accessing medical care in a timely manner that are not fully explained by parents' demographic, social, and economic status or children's health-related quality of life. Health policy makers, managers, and clinicians should further consider how they could reduce the inequity of access to medical services among Mexican-American children. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To test whether concordance or discordance of patient participation between patients and physicians is associated with higher satisfaction, and to examine the effects of patients' and physicians' participatory styles on patients' satisfaction with their physicians. DATA: Data collected in the Texas Tech 5000 Survey of elderly patients in West Texas were used. Patient satisfaction with their physicians was measured by a single item from the Consumer Assessment of Health Plans (CAHPS), representing patients' ratings of their physicians. Patient participation was measured by an index derived from a three-item instrument and physicians' participatory decision-making (PDM) style was measured by a three-item instrument developed by the Medical Outcomes Study. METHODS: An ordered logit multivariate regression was used to investigate the effects of patients' and physicians' participatory styles on satisfaction with physicians. The interaction between patients' participation and physicians' participatory styles was also included to examine the dependency of the two variables. RESULTS: Controlling for confounding factors, a higher PDM score was associated with a higher rating of patient satisfaction with physicians. A higher patient participation score was related to a lower physician satisfaction rating. The combined effect of patients' and physicians' participation styles indicated that for a low patient participation score, a high PDM score was not needed to produce high satisfaction. The greater the discordance in this direction, the higher the satisfaction. However, with a high patient participation score, only an extremely high PDM score would produce relatively high satisfaction. CONCLUSIONS: The current study supports the discordance hypothesis. Participatory physicians and patient-physician communications concerning patient participation can promote higher satisfaction. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to test whether there are ethnic differences in parents' perceptions of the participatory styles of their children's physicians, and to determine how Hispanic ethnicity influences the factors that are correlated with the perceptions of participatory styles.Study Design: We conducted a population-based cross-sectional telephone survey in 111 counties of West Texas. Parents of children and adolescents 3 to 18 years of age (n = 3876) were included in analyses.Methods: The participatory decision-making (PDM) style of physicians was measured by a 3-item instrument used in the Medical Outcomes Study. Multivariate analyses were performed to identify ethnic differences and whether the effect of independent variables on participatory style varied by ethnicity.Results: The t test showed that the mean participatory decision-making score for Hispanics was significantly lower than that for non-Hispanic whites (P <0.01). However, the variance of the PDM score among Hispanics was greater than that among non-Hispanic whites using an F test (P = 0.03). After controlling for other independent variables, the effect of ethnicity was still significant. The association between PDM scores and a child's insurance and the parent's age varied by ethnicity. Parents' age, education, self-employment status, and income were associated with non-Hispanic white parents' perceptions of physicians' PDM, whereas children's insurance, parents' education and income were associated with Hispanic parents' perceptions of physicians' PDM (P <0.05).Conclusions: Because patient participation is closely related to health outcomes and patient satisfaction, improving Hispanic patients' participation can be 1 avenue for diminishing ethnic disparities in health. Further research is needed to establish whether ethnic differences in children's physicians' participation style exist from physicians' perspective and whether the differences are associated with physicians' characteristics. [ABSTRACT FROM AUTHOR]

Objectives: To identify factors related to elderly consumers' choice of pharmacy types and their overall satisfaction with pharmacy services provided by: a single community pharmacy, multiple pharmacies with a primary community pharmacy, a single mail order pharmacy, and multiple pharmacies with a primary mail order pharmacy.Data: Data were extracted from the Texas Tech 5000 survey of consumers, age 65 years or older, in West Texas. The survey contains information about the respondents' health services use, pharmacy service use, satisfaction with accessibility and quality, health insurance coverage, health beliefs, health status, and demographics, as well as other health-related factors.Methods: An endogenous treatment effect model was used to examine elderly consumers' choice of and satisfaction with different types of pharmacies. The first stage of the estimation identified factors related to consumers' choice of pharmacies. The second stage estimated the effects of pharmacy types on consumers' overall satisfaction with pharmacy services, controlling for self-selection.Results: The type of pharmacy was a significant determinant of satisfaction. Self-selection was found in the determination of consumers' overall satisfaction with pharmacy services. Controlling for self-selection, elderly consumers who used a single community pharmacy and who used multiple pharmacies with a primary mail order pharmacy were the most satisfied with their pharmacy services. The type of pharmacy that ranked lowest in overall consumer satisfaction was multiple pharmacies with a primary community pharmacy. Insurance coverage of prescription drugs was significantly associated with consumers' choice of pharmacy. The greater the number of prescription drugs a consumer took, the higher the odds were that they used multiple pharmacies.Conclusions: Although using a single community pharmacy may create close patient-pharmacist relationships and improve health outcomes, consumers may be diverted from this choice because of price concerns and insurance diversification. [ABSTRACT FROM AUTHOR]

Objective: To determine if anterior cruciate ligament (ACL) injuries in female athletes occur randomly or correlate with a specific phase of the menstrual cycle.Design and Setting: Female athletes who sustained ACL injuries reported the days of their menstrual cycles and provided saliva samples for sex-hormone determination. Salivary sexhormone profiles were assessed to confirm the self-reported menstrual histories.Subjects: A total of 38 female athletes (20 college, 15 high school, 1 middle school, 2 recreational) with recent ACL injuries participated in the study over a 3-year period.Measurements: Athletes with recent ACL injuries completed a questionnaire defining the injury, the last menstrual cycle, prior knee injury, school, and type of birth control used (if any). Each subject provided a 30-cc saliva sample within 72 hours of injury. Saliva samples were placed into sealed containers and frozen at -20 degrees C. We obtained 13 additional control samples from uninjured females to test the correlation between saliva and serum sex-hormone levels. Progesterone and estrogen were assayed by radioimmunoassay. Physical examination, magnetic resonance imaging, or surgery confirmed the injury in all subjects.Results: The correlations between saliva and serum estrogen and progesterone were 0.73 (alpha = .01) and 0.72 (alpha = .01), respectively. Ten of 27 athletes who reported their cycle day at time of injury sustained an ACL injury immediately before or 1 to 2 days after the onset of menses. We rejected the null hypothesis that such high frequency was due to random chance.Conclusions: A significantly greater number of ACL injuries occurred on days 1 and 2 of the menstrual cycle. Salivary sex-hormone levels correlated with the reported cycle day. [ABSTRACT FROM AUTHOR]

Background: Racial inequities exist in treatment and outcomes in patients with acute stroke., Objectives: Our objective was to determine if racial inequities exist in the time-lapse between patient presentation and provider assessment in patients with stroke-like symptoms in Emergency Departments (ED) across the U.S., Methods: This study is a retrospective, observational study of the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2014-2018. We identified visits with stroke-like symptoms and stratified the proportion of door-to-provider (DTP) times by racial groups. We used broad and narrow definitions of stroke-like symptoms. We performed bivariate and multivariate analyses using race and clinical and demographic characteristics as covariates., Results: Between 2014-2018, there were an average of 138.58 million annual ED visits. Of the total ED visits, 0.36% to 7.39% of the ED visits presented with stroke-like symptoms, and the average DTP time ranged from 39 to 49 min. The proportion of the visits with a triage level of 1 (immediate) or 2 (emergent) ranged from 16.03% to 23.27% for stroke-like symptoms. We did not find statistically significant racial inequities in DTP or ED triage level. We found significantly longer DTP times in non-Hispanic blacks (15.88 min, 95% CI: 4.29-27.48) and Hispanics (by 14.77 min, 95% CI: 3.37-26.16) than non-Hispanic whites that presented with atypical stroke-like symptoms. We observed that non-Hispanic whites were significantly more diagnosed with a stroke/TIA than other racial minority groups (p = 0.045) for atypical stroke-like symptoms., Conclusion: In our population-based analysis, we did not identify systemic racial inequities in the DTP times or ED triage level at ED triage for stroke-like symptoms., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Competing Interests: There are no conflicts of interest.

Introduction: We sought to examine the utility of self-reported pain scale by comparing emergency department (ED) triage pain scores of self-reported but non-verifiable painful conditions with those of verifiable painful conditions using a large, nationally representative sample., Methods: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2015. Verifiable painful conditions were identified based on the final diagnoses in the five included International Classification of Diseases 9th revision codes. Non-verifiable painful conditions were identified by the five main reasons for visit. Only adults 18 years of age or older were included. The primary outcome variable was the pain scale from 0 to 10 at triage. We performed descriptive and multivariate analyses to investigate the relationships between the pain scale and whether the painful condition was verifiable, controlling for patient characteristics., Results: There were 55 million pain-related adult ED visits in 2015. The average pain scale was 6.49. For verifiable painful diagnoses, which were about 24% of the total visits, the average was 6.27, statistically significantly lower than that for non-verifiable painful conditions, 6.56. Even after controlling for the confounding of patient characteristics and comorbidities, verifiable painful diagnoses still presented less pain than those with non-verifiable painful complaints. Older age, female gender, and urban residents had significantly higher pain scores than their respective counterparts, controlling for other confounding factors. Psychiatric disorders were independently associated with higher pain scores by about a half point., Conclusion: Self-reported pain scales obtained at ED triage likely have a larger psychological component than a physiological one. Close attention to clinical appropriateness and overall patient comfort are more likely to lead to better health outcomes and patient experiences than focusing on self-reported pain alone.

Objective: Timely emergency department (ED) control of hypertension in the acute phase of stroke is associated with improved outcomes. It is unclear how emergency physicians use antihypertensive medications to treat severe hypertension associated with stroke. We sought to determine national patterns of antihypertensive use associated with ED visits for stroke in the United States., Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2008-2017. We included ED visits associated with ischemic stroke (ICD9 433-434, ICD10 I630-I639) or hemorrhagic stroke (ICD9 430-432, ICD10 I600-I629). We estimated the number and proportions of stroke ED visits with triage blood pressure meeting treatment thresholds (triage systolic blood pressure [SBP] ≥180 mm Hg). We identified the frequency of antihypertensive use, as well as the most commonly used agents., Results: Between 2008-2017, of a total 135,012,819 ED visits, 619,791 were associated with stroke (78.3% ischemic strokes and 21.7% hemorrhage strokes). Of all stroke visits, 21.8% received antihypertensive medications. Of the identified visits, 9.0% (95% confidence interval [CI] = 6.0%, 13.1%) ischemic stroke visits and 58.2% (95% CI = 49.0%, 66.9%) hemorrhagic stroke visits met criteria for BP reduction. A total of 47.6% (95% CI = 29.1%, 66.7%) of eligible ischemic stroke visits and 41.5% (95% CI = 30.5%, 53.3%) of eligible hemorrhagic strokes visits received antihypertensives. The most common agents used in ischemic stroke were beta-blockers, calcium-channel blockers, and ACE inhibitors. The most common agents used in hemorrhagic stroke included calcium-channel blockers, beta-blockers, and vasodilators., Conclusion: In this national sample, less than half of strokes presenting to the ED with hypertension received antihypertensive therapy., Competing Interests: None., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Background: Data for hospital antibiograms are typically compiled from all patients, regardless of disposition, demographics and other comorbidities., Objective: We hypothesized that the sensitivity patterns for urinary pathogens would differ significantly from the hospital antibiogram in patients that were discharged from the emergency department (ED)., Methods: We evaluated a retrospective cohort of all adult patients with positive urine cultures treated in the 2016 calendar year at an inner-city academic ED. Positive urine cultures defined by our institution's microbiology department. Investigators conducted a structured review of an electronic medical record (EMR) to collect demographic, historical and microbiology records. We utilized a one-sample test of proportion to compare the sensitivity of each organism for discharged patients to the hospital published antibiogram. Alpha set at 0.05., Results: During the study period, 414 patients were discharged from the ED and found to have positive urine cultures; 20% age > 60 years old, 85% female, 79% Hispanic, 33% diabetic. The most common organisms was E. coli (78%). E. coli was sensitive to Trimethoprim-Sulfamethoxazole for 59% vs. 58% in our antibiogram (p = 0.77), Ciprofloxacin 81% vs. 69% (p < 0. 001), Nitrofurantoin 96% vs 95%; (p = 0.25). K. pneumoniae was sensitive to Trimethoprim-Sulfamethoxazole 87% vs. 80% in our antibiogram (p = 0.26), Ciprofloxacin 100% vs. 92% (p = 0.077), Nitrofurantoin 86% vs 41% (p < 0.001)., Conclusions: For our predominantly Hispanic study group with a high prevalence of diabetes, we found that our hospital antibiogram had relatively good value in guiding antibiotic therapy though for some organism/antibiotic combinations sensitivities were higher than expected.

Background: Patients with renal colic have a 7% chance of annual recurrence. Previous studies evaluating cumulative Abbreviations: computed tomography (CT) exposure for renal colic patients were typically from single centers., Methods: This was an observational cohort study. Inner-city ED patients with a final diagnosis of renal colic were prospectively identified (1/10/16-10/16/16). Authors conducted structured electronic record reviews from a 6-hospital system encompassing over 192,000 annual ED visits. Categorical data analyzed by chi-square; continuous data by t-tests. Primary outcome measure was the proportion of study group patients with prior history CT abdomen/pelvis CT., Results: Two hundred thirteen patients in the study group; 59% male, age 38+/- 10 years, 67% Hispanic, 62% prior stone history, flank pain (78%), dysuria (22%), UA (+) blood (75%). 60% (95% CI = 53-66%) of patients received an EDCV CT; hydronephrosis seen in 55% (95% CI = 46-63%), stone in 90%(95% CI = 83-94%). No significant differences observed in the proportion of EDCV patients who received CT with respect to: female vs. male (62% vs. 56%; p = 0.4), mean age (37+/- 9 years vs. 39+/- 11 years; p = 0.2), and Hispanic vs. non-Hispanic white (63% vs.63%; p = 0.96). Patients with a prior stone history were more likely than those with no history to receive an EDCV CT (88% vs. 16%; p < 0.001). 118 (55%; 95% CI = 49-62%) of patients had at least one prior CT, 46 (22%; 95% CI = 16-28%) had ≥3 prior CTs; 29 (14%; 95% CI = 10-19%), ≥ 10 prior CTs. Patients who did not receive an EDCV CT had a significantly higher mean prior number of CTs than those who had EDCV CT (5.1+/- 7.7 vs 2.2+/- 4.9; p < 0.001). Patients with prior stone were more likely to receive only U/S during EDCV (33% vs. 15%; p = 0.003)., Conclusions: Within our EDCV cohort of renal colic patients, 55% had at least one prior CT. The mean number of prior CTs was lower for patients receiving CT on EDCV, and Ultrasound (US) alone was used more often in patients with prior stone history vs. those with no prior history.

Background: The objective of this study was to evaluate the costs, characteristics, and outcomes of patients brought to a Texas trauma center emergenct department after apprehension by Border Patrol (BP)/Immigration and Customs Enforcement (BP/ICE)., Materials and Methods: This is a secondary analysis of a trauma registry/financial records (1/1/11-12/31/14). Data were extracted utilizing a structured form. A multivariate ordinary least square was estimated to identify variables associated with hospital charges., Results: A total of 128 patients were enrolled as the study group; mean age was 28.6 ± 6 years, 20.3% were female, 100% were Hispanic, the most common mechanism of injury (MOI) was motor vehicle crash (75%), and mean charge was $162,152 ± $295,441. Mean length of stay (LOS) was 13.2 ± 29.8 days; 92.2% survived to discharge. Bivariate analysis revealed that MOI differed by gender ( P = 0.021). In the multivariate analysis, the only variable that associated with increased charge was LOS. Total charges for the 128 patients were $20.6M, total costs were $4.5M, and total payments were $0.99M., Conclusions: Undocumented immigrants apprehended by BP/ICE and brought to our trauma center utilized significant health-care resources., Competing Interests: There are no conflicts of interest.

Background: Prior research reveals that overweight patients have higher emergency department (ED) utilization rates, longer length of stay, and face increased misdiagnosis risk., Objective: The objective of this study was to evaluate the association between obesity and ED patient satisfaction., Methods: This study was a cross-sectional study. A convenience sample of inner-city ED patients completed a written survey, then rated overall satisfaction with ED care (10-point scale), and rated components of satisfaction (4-point scale; never to always). Body mass index (BMI) was calculated using triage records (obesity = BMI >30)., Results: Five hundred and sixty-four patients were included in the study group (50.5%: obese, 55.4%: female, mean age: 43.2 ± 25.4 years). With respect to overall visit satisfaction (rating 8 or greater on 10-point scale), bivariate analysis revealed no differences between nonobese versus obese patients (74.6% vs. 73.9%; P = 0.85). There were no significant differences for score of 4 (always) for components of ED satisfaction: physician courtesy (87.9% vs. 90.4%; P = 0.34), nurse courtesy/respect (89.2% vs. 88.7%; P = 0.87), doctor listened (85.4% vs. 87.1%; P = 0.5), doctor explained (80.2% vs. 85.0%; P = 0.14), and recommend to friend (72.5% vs. 81.1%; P = 0.02). Within our multivariate model, obesity was not associated with overall satisfaction (scores of 8 or greater) ( P = 0.97; odds ratio = 0.99 [95% confidence interval = 0.65-1.5])., Conclusions: Despite research that suggests that overweight patients have characteristics of their ED visit that might increase dissatisfaction risk, we found no difference in satisfaction scores between nonobese and obese patients., Competing Interests: There are no conflicts of interest.

Background: Recurrent CT imaging is believed to significantly increase lifetime malignancy risk. We previously reported that high acuity, admitted trauma patients who received a whole-body CT in the emergency department (ED) had a history of prior CT imaging in 14% of cases. The primary objective of this study was to determine the CT imaging history for trauma patients who received a whole-body CT but were ultimately deemed safe for discharge directly home from the ED., Methods: This was a retrospective cohort study conducted at an academic ED. All trauma patients who were discharged directly home from the ED after whole-body CT were analyzed. The decision to utilize whole-body CT was at the discretion of the caring physician during the study period. Clinical data for the most recent trauma visit was recorded in a structured fashion on a standardized data collection instrument utilizing the hospital system electronic medical record (EMR). Subsequently, study investigators reviewed a shared, electronic radiological archive for the 6-hospital system to evaluate prior CT exposure for each patient., Results: 165 patients were in the study group. The mean age of the study group was 39+/- 16 years old, 40% were female and 64% were Hispanic. The most common mechanism of injury in our study group was motor vehicle crash (MVC) (66%). In our study group, 25% had at least one prior CT. The most common prior studies performed were: CT abdomen/pelvis (13%), CT head (9.1%), CT face (6.7%), and CT chest (1.8%). Within a multivariate logistic regression model we found that the large majority of patient characteristics and mechanisms of injury were not associated with a positive prior CT imaging history., Conclusion: We found a positive history for prior CT for 25% of trauma patients who received whole-body CT scan but were discharged from the ED to home.

Objectives: There is a paucity of research evaluating the risk tolerance of Emergency Department (ED) patients. We hypothesized that a significant percentage of ED patients surveyed would be comfortable with ≥5% risk of adverse outcome if they avoided testing in several hypothetical scenarios., Materials and Methods: This was a cross-sectional study of a convenience sample of stable inner-city ED patients. Patients completed a written survey and were asked four closed-answer questions regarding risk tolerance/willingness to refuse a test/procedure, including the following scenarios: #1: LP following CT head; #2 overnight serial troponins for rule out myocardial infarction; #3 CT for possible appendicitis, #4 parent deciding whether child should undergo head CT for low risk head injury. Risk preferences were stratified to ≥5% (high) and <5% (low). Multivariate logistic regressions performed for each scenario to control for confounding factors., Results: There were 217 patients in the study group; mean age 42 ± 15 years, 48% female, 66% Hispanic, 87% income < $40,000 income group. A substantial percentage of patients rated high risk tolerance for each scenario, including 31% for #1 (avoid LP), 25% for #2 (avoid cardiac rule-out admission), 27% for #3 (avoid CT for appendicitis), and 19% for #4 (avoid head CT for child)., Discussion: For 3 of 4 scenarios, 25% or more of our patients would accept a high risk tolerance of adverse outcome to avoid further testing., Conclusion: Our findings contribute further evidence to the growing body of literature supporting patient interest in shared decision making in the ED.

Background. Cultural differences and language barriers may adversely impact patients with respect to understanding the risks/benefits of medical testing. Objective. We hypothesized that there would be no difference in Hispanic vs. non-Hispanic patients' knowledge of radiation risk that results from CT of the abdomen/pelvis (CTAP). Methods. We enrolled a convenience sample of adults at an inner-city emergency department (ED). Patients provided written answers to rate agreement on a 10-point scale for two correct statements comparing radiation exposure equality between: CTAP and 5 years of background radiation (question 1); CTAP and 200 chest x-rays (question 3). Patients also rated their agreement that multiple CT scans increase the lifetime cancer risk (question 2). Scores of >8 were considered good knowledge. Multivariate logistic regression analyses were performed to estimate the independent effect of the Hispanic variable. Results. 600 patients in the study group; 63% Hispanic, mean age 39.2 ± 13.9 years. Hispanics and non-Hispanics whites were similar with respect to good knowledge-level answers to question 1 (17.3 vs. 15.1%; OR = 1.2; 95% CI [0.74-2.0]), question 2 (31.2 vs. 39.3%; OR = 0.76; 95% CI [0.54-1.1]), and question 3 (15.2 vs. 16.5%; OR = 1.1; 95% CI [0.66-1.8]). Compared to patients who earned <20,000, patients with income >40,000 were more likely to answer question 2 with good knowledge (OR = 1.96; 95% CI [1.2-3.1]). Conclusion. The study group's overall knowledge of radiation risk was poor, but we did not find significant differences between Hispanic vs. non-Hispanic patients.

Background: Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US., Methods: Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies., Results: In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors., Conclusion: Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.

Background: Osteoporosis is a major health problem in postmenopausal women. Evidence suggests the importance of oxidative stress in bone metabolism and bone loss. Tea consumption may be beneficial to osteoporosis due to its antioxidant capability. However, lack of objective data characterizing tea consumption has hindered the precise evaluation of the association between tea ingestion and bone mineral density in previous questionnaire-based epidemiological studies. On the other hand, although published studies suggest that Tai Chi (TC) exercise can benefit bone health and may reduce oxidative stress, all studies were conducted using a relatively healthy older population, instead of a high-risk one such as osteopenic postmenopausal women. Therefore, this study was designed to test an intervention including green tea polyphenol (GTP) and TC exercise for feasibility, and to quantitatively assess their individual and interactive effects on postmenopausal women with osteopenia., Methods/design: One hundred and forty postmenopausal women with osteopenia (defined as bone mineral density T-score at the spine and/or hip between 1 to 2.5 SD below the reference database) were randomly assigned to 4 treatment arms: (1) placebo group receiving 500 mg medicinal starch daily, (2) GTP group receiving 500 mg of GTP per day, (3) placebo+TC group receiving both placebo treatment and TC training (60-minute group exercise, 3 times per week), and (4) GTP+TC group receiving both GTP and TC training for 24 weeks. The outcome measures were bone formation biomarker (serum bone alkaline phosphatase), bone resorption biomarker (serum tartrate resistant acid phosphatase), and oxidative DNA damage biomarker (urinary 8-hydroxy-2'-deoxyguanosine). All outcome measures were determined at baseline, 4, 12, and 24 weeks. Urinary and serum GTP concentrations were also determined at baseline, 4, 12, and 24 weeks for bioavailability. Liver function was monitored monthly for safety. A model of repeated measurements with random effect error terms was applied. Traditional procedures such as ANCOVA, chi-squared analysis, and regression were used for comparisons., Discussion: We present the rationale, design, and methodology of a placebo-controlled randomized trial to investigate a new complementary and alternative medicine strategy featuring a dietary supplement and a mind-body exercise for alleviating bone loss in osteopenic postmenopausal women.

After multiple positive studies, gemcitabine, approved for the treatment of pancreas cancer by the FDA in 1977, became standard of care. Whether this therapeutic advance has translated into longer survival for pancreas cancer patients in general has not been established. This study, derived from SEER (Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute) data, compared the survival experiences of the gemcitabine (1998-2004) and pre-gemcitabine (1988-1997) eras for 7,151 patients who had metastatic disease and did not undergo extirpative surgery, 14,369 patients who had not undergone surgery and had metastases, 5,042 patients who had undergone surgery and did not have metastases, and 5,011 patients who had undergone surgery and had metastases. Calculated survival time ratios (TR) were adjusted for radiotherapy history, grade, nodal status, loco-regional extent of disease, age, race, and gender. For those who did not undergo extirpative surgery, improvements in survival in the gemcitabine era (1998-2004) versus the prior time period (1988-1997) seen for patients with metastatic cancer (TR = 1.20, 95% c.i. 1.15-1.25) were not seen for those without metastatic cancer (TR = 1.05, 95% c.i. 1.00-1.15). For those who did undergo extirpative surgery, improvements were much more dramatic for those with metastatic cancer (TR = 1.61, 95% c.i. 1.45-1.80) than those without metastases (TR = 1.23, 95% c.i. 1.15-1.31). The results are consistent with the notion that the promising findings with respect to gemcitabine in the controlled clinical trials have found expression in the general population of patients with pancreas cancer.

We examine the relationship between distance and access to prescription medications and ancillary pharmacy services among rural elders in west Texas. Further understanding this relationship is important because programs such as telepharmacy are largely justified on the basis of reducing distance barriers. We use data from the Texas Tech 5000 survey to evaluate the relationship between distance and access. In addition, we examine whether regulations that prohibit competition between independent pharmacies and telepharmacies create a distance barrier to prescription medication. Our findings suggest that distance is a barrier to access, but telepharmacy regulations in Texas do not exacerbate the impact of distance.

This study examines racial and ethnic disparities in the financial burden of prescription drugs among older Americans using a market and an egalitarian model. A nationally representative data set, the Medical Expenditure Panel Survey 2002, was used. The financial burden of prescription drugs was measured by the out-of-pocket expenditure and proportion. In the market model (utilization adjustment)., utilization was measured at the annual aggregate level by the total number of prescription drugs, the average refills and the average quantity per prescription drug. In the egalitarian model (need adjustment)., health was measured by 15 chronic and costly diseases and the SF-12. Individuals 65 years or older were included. Nationally representative estimates were calculated. Raw racial and ethnic disparities were observed in the bivariate analyses between non-Hispanic whites and Hispanics in the out-of-pocket expenditure and proportion, and between non-Hispanic whites and non-Hispanic blacks in the out-of-pocket proportion. However, these disparities disappeared after controlling for utilization or health needs. Insurance status contributed the most to the disparities in the financial burden of prescription drugs. In conclusion, The disparities in the financial burden of prescription drugs between non-Hispanic elderly whites and Hispanics may be attributable to differences in utilization patterns. However, whether health disparities contribute to disparities in the financial burden of prescription drugs requires studies of specific diseases.

Background: Although tobacco use in the United States has declined over the past 20 years, cigarette use among college students remains high. Additional research is thus needed to determine how university tobacco control policies and preventive education programs affect college students' smoking behaviors., Methods: Approximately 13,000 undergraduate students at 12 universities or colleges in the state of Texas completed a web-based survey. College smoking policies were obtained from a survey of college administrators and from college websites. Logistic regression analyses were conducted to estimate the effects of individual smoking policies and programs on the odds of cigarette smoking., Results: Of the individual programs, only having a preventive education program on campus was associated with lower odds of smoking. The existence of smoking cessation programs and designated smoking areas were associated with higher odds of smoking. Policies governing the sale and distribution of cigarettes were insignificantly associated with smoking., Conclusion: Rather than focusing on policies restricting cigarette sales and use, college administrators should consider implementing or expanding tobacco prevention and education programs to further reduce student smoking rates.

Background: Pain is highly prevalent among older adults, but little is known about how patient involvement in medical decision-making may play a role in limiting its occurrence or severity. The purpose of this study was to evaluate whether physician-driven and patient-driven participation in decision-making were associated with the odds of frequent and severe pain., Methods: A cross-sectional population-based survey of 3,135 persons age 65 and older was conducted in the 108-county region comprising West Texas. The survey included self-reports of frequent pain and, among those with frequent pain, the severity of pain., Results: Findings from multivariate logistic regression analyses showed that higher patient-driven participation in decision-making was associated with lower odds (OR, 0.82; 95% CI, 0.75-0.89) of frequent pain, but was not significantly associated with severe pain. Physician-driven participation was not significantly associated with frequent or severe pain., Conclusions: The findings suggest that patients may need to initiate involvement in medical decision-making to reduce their chances of experiencing frequent pain. Changes to other modifiable health care characteristics, including access to a personal doctor and health insurance coverage, may be more conducive to limiting the risk of severe pain.

Objective: To describe how skepticism about medical care and other individual differences, including worry about health status, are associated with evaluations of health care among the noninstitutionalized elderly., Data Sources/study Setting: Data were collected through a survey of approximately 5,000 community-dwelling elders (aged 65 and older) in a southwestern region of the United States., Study Design: Global evaluations of health care were measured with two items from the Consumer Assessment of Health Plans Study (CAHPS) instrument, an overall care rating (OCR) and a personal doctor rating (PDR). Multivariate ordered logit regression models were tested to examine how medical skepticism and other factors were associated with ratings of 0-7, 8-9, and 10., Principal Findings: Consumers who were skeptical of prescription drugs relative to home remedies, who held attitudes that they understand their health better than most doctors, and who worried about their health had worse OCR and PDR. Those who held attitudes that individual behavior determines how soon one gets better when sick had better PDR and OCR., Conclusions: Health policymakers, managers, and providers may need to consider the degree to which they should attempt to satisfy skeptical consumers, many of whom may never rate their care highly. Alternatively, they may need to target skeptical consumers with educational efforts explaining the benefits of medical care.

Objectives: To quantify potential cost-savings associated with better compliance with the guidelines of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure UNC V) and to determine whether suboptimal utilization of medications is associated with higher costs for other health services., Study Design: Secondary data analysis using the Medical Expenditure Panel Survey (MEPS) conducted by the Agency for Healthcare Research and Quality and the National Center for Health Statistics. A complex sampling design was used to provide nationally representative estimates., Methods: From interviews with a population-based and nationally representative sample of 22 601 individuals, 1588 patients with essential hypertension without other comorbid cardiovascular conditions were selected, representing 19.6 million patients in the United States in 1996. All medical treatments for essential hypertension in 1996 were extracted from the MEPS. Using the JNC V guidelines, prescriptions used in treating essential hypertension were categorized into first-line drugs (diuretics and beta-blockers), second-line drugs (calcium-channel blockers and angiotensin-converting enzyme inhibitors), and third-line (nonrecommended) drugs. Nonprescription expenditures were calculated. Multivariate analyses were performed to determine whether use of the first-line drugs was associated with cost-savings., Results: Compliance rate with the JNC guidelines was low. About 36%, 67%, and 87% of patients in the nation received first-, second-, and third-line drugs, respectively, at some point during 1996. Prescription expenditure constituted more than 67% of the total expenditures for treating essential hypertension. The use of first-line drugs (vs second-line drugs) was associated with expenditures that were dollar 2.6 billion to dollar 3.2 billion lower., Conclusions: Compliance with the JNC guidelines for treating essential hypertension may reduce the costs of prescriptions and other medical services. Raising awareness of the JNC guidelines is crucial to achieve cost effectiveness in choosing treatment alternatives.

Objective: To compare the effects of having a regular doctor and having a regular site on five preventive services, controlling for the endogeneity of having a usual source of care., Data Source: The Medical Expenditure Panel Survey 1996 conducted by the Agency for Healthcare Research and Quality and the National Center for Health Statistics., Study Design: Mammograms, pap smears, blood pressure checkups, cholesterol level checkups, and flu shots were examined. A modified behavioral model framework was presented, which controlled for the endogeneity of having a usual source of care. Based on this framework, a two-equation empirical model was established to predict the probabilities of having a regular doctor and having a regular site, and use of each type of preventive service., Principal Findings: Having a regular doctor was found to have a greater impact than having a regular site on discretional preventive services, such as blood pressure and cholesterol level checkups. No statistically significant differences were found between the effects a having a regular doctor and having a regular site on the use of flu shots, pap smears, and mammograms. Among the five preventive services, having a usual source of care had the greatest impact on cholesterol level checkups and pap smears., Conclusions: Promoting a stable physician-patient relationship can improve patients' timely receipt of clinical prevention. For certain preventive services, having a regular doctor is more effective than having a regular site.