Search

Emerging research has examined the prevalence of severe acute respiratory syndrome virus 2 (SARS-CoV-2) infections in numerous settings, but a critical gap in knowledge is an understanding of the rate of infection among first responders.We conducted a prospective serial serologic survey by recruiting public first responders from Cleveland area emergency medical services agencies and fire departments. Volunteers submitted a nasopharyngeal swab for SARS-CoV-2 PCR testing and serum samples to detect the presence of antibodies to SARS-CoV-2 on two visits scheduled approximately 3 weeks apart.296 respondents completed a first visit and 260 completed the second. While 71% of respondents reported exposure to SARS-CoV-2, only 5.4% (95% CI 3.1-8.6) had positive serologic testing. No subjects had a positive PCR. On the first visit, eight (50%) of the test-positive subjects had no symptoms and only one (6.2%) sought healthcare or missed school or work. None of the subjects that tested negative on the first visit were positive on their second.While our results show a relatively low rate of test positivity for SARS-CoV-2 amongst first responders, most were either asymptomatic or mildly symptomatic. The potential risk of asymptomatic transmission both between first responders and from first responders to vulnerable patients requires more study.

Background and objectives National guidelines recommend prescribing naloxone to patients receiving chronic opioids. However, provider adherence to naloxone co-prescribing best practices is poor and knowledge gaps for improvement efforts are large. As part of a system-wide quality improvement intervention to improve opioid safety, we sought to improve access to naloxone for patients with opioid prescriptions. Methods A prompt for naloxone co-prescribing was implemented in the electronic health record. Baseline data and data after implementation were collected for naloxone co-prescribing and fill rates on naloxone prescriptions s (n = 9122 pre, 8368 post). Results In the 9 months following the implementation of the electronic prompt, the total number of naloxone prescriptions increased more than 15-fold. Patients prescribed naloxone filled their naloxone prescriptions similarly (42%) before and after the prompt implementation, resulting in a marked increase in the absolute number of patients with access to naloxone. Patient fill rates varied by clinical area (33% emergency medicine to 47% general medicine). Conclusion and scientific significance An electronic prompt, encouraging providers to prescribe naloxone to at-risk patients led to a marked increase in the percentage of patients with an active naloxone prescription. The availability of naloxone in communities saves lives and this study is the first to demonstrate an intervention, which led to increased naloxone prescribing and reported on actual pharmacy fills of naloxone when co-prescribed with opioids. (Am J Addict 2020;00:00-00).

Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.

Background Despite their placement in Veterans Health Administration centers nationwide, residents' training and assessment in veteran-centered care is variable and often insufficient. Objective We assessed residents' ability to recognize and address mental health issues that affect US military veterans. Methods Two unannounced standardized patient (SP) cases were used to assess internal medicine residents' veteran-centered care skills from September 2014 to March 2016. Residents were assessed on 7 domains: military history taking, communication skills, assessment skills, mental health screening, triage, and professionalism, using a 36-item checklist. After each encounter, residents completed a questionnaire to assess their ability to recognize knowledge deficits. Residents' mean scores were compared across training levels, between the 2 cases, and by SP gender. We conducted analysis of variance (ANOVA) tests to analyze mean performance differences across training levels and descriptive statistics to analyze self-assessment questionnaire results. Results Ninety-eight residents from 2 internal medicine programs completed the encounter and 53 completed the self-assessment questionnaire. Residents performed best on professionalism (0.92 ± 0.20, percentage of the maximal score) and triage (0.87 ± 0.17), and they scored lowest on posttraumatic stress disorder (0.52 ± 0.30) and military sexual trauma (0.33 ± 0.39). Few residents reported that they sought out training to enhance their knowledge and skills in the provision of services and support to military and veteran groups beyond their core curriculum. Conclusions This study suggests that additional education and assessment in veteran-centered care may be needed, particularly in the areas of posttraumatic stress disorder and military sexual trauma.

Despite their medical training, record of military service, and the unmet needs within the health care sector, numerous challenges face veterans who seek to leverage their health care skills for employment after leaving the military. Creative solutions are necessary to successfully leverage these skills into jobs for returning medics that also meet the needs of health care systems. To achieve this goal, we created a novel ambulatory care health technician position on the basis of existing literature and modeled after a program which incorporates former military medics in emergency departments. Through a quality improvement approach, a position description, interview process, training program with clinical competencies, and team integration plan were developed and implemented. To date, two medics have been hired, successfully trained on relevant skill sets, and are currently caring for medical outpatients (under the supervision of licensed clinical personnel) as crucial interdisciplinary team members. Taken together, a multifaceted approach is required to effectively harness military medics' skills and experiences to meet identified health delivery needs.

Purpose To describe and interpret pay-for-performance (P4P) systems as perceived by internal medicine residents to develop curricula that relate P4P measures to quality improvement initiatives. Method In 2008-2009, the authors conducted a qualitative study in which 97 internal medicine residents completed a mandatory survey soliciting their views of the advantages and disadvantages of P4P. The authors analyzed responses to identify and categorize emergent themes. Results Eighty-two residents (85%) noted advantages, from which 13 themes emerged. Two were general themes: P4P improves overall delivery of quality care by enabling quality care and by motivating providers to improve or provide quality care. The other themes formed three categories: P4P enables contemplation and knowledge enhancement (e.g., by promoting reflection) and has potential impacts both on physicians' delivery of better care (e.g., by facilitating vigilance and closer follow-up) and on the care delivery process (e.g., by increasing pay/satisfaction). Eighty-seven residents (90%) indicated disadvantages, from which 16 themes emerged. The four categories of the themes reflected P4P's impacts on patient perceptions (e.g., by decreasing patient satisfaction and access), on clinical care (e.g., by fostering abuse/gaming and compromising focus, care, and safety), on resources and efficiency, and on providers that may undermine morale. Conclusions Residents' reported advantages and disadvantages were often in direct opposition to each other (e.g., P4P enables quality care but also compromises focus, care, and safety). These opposing responses form a continuum that the authors believe will require providers to perform a balancing act to practice successfully in a P4P environment.

CONTEXT Pay-for-performance programs may be widely implemented, but gaps remain in our understanding of the implementation of performance measurement approaches. OBJECTIVES To compare 3 approaches to hypertension quality measurement as applied to high-quality care delivered by a hypertension expert. METHODS Care of 23 patients treated by a single hypertension expert was assessed by 3 measurement approaches: (1) outcome, (2) a multicomponent process, and (3) "outcome-linked" process. Exemplary case studies were identified to illustrate additional challenges to applying the approaches. RESULTS Forty-four percent of patients (n = 10) had complete concordance between the outcome and outcome-linked process approaches, 22% of patients (n = 5) had complete concordance between the outcome and multicomponent process approaches, 52% of patients (n = 12) had complete concordance between outcome-linked process and multicomponent process approaches, and 22% of patients (n = 5) had uniform agreement among all 3 approaches. Case studies revealed numerous opportunities for misinterpretation or gaming by providers. CONCLUSIONS Currently available measurement approaches resulted in a varied assessment of provider performance under optimal hypertension care conditions suggesting that caution is required before their use for provider compensation.

Cardiovascular risk factor control is inadequate in many high-risk patients. Although many provider-directed educational interventions attempt to address this issue by enhancing provider self-efficacy, a link between greater self-efficacy and better patient outcomes has not been established. Primary care providers (PCPs) in outpatient clinics of a large Veteran's Administration (VA) facility were asked to complete 4 subscales assessing self-efficacy and attitudes related to cardiovascular prevention (CVP). Using a cross-sectional study design, responses were linked with process and CVP outcomes related to blood pressure (BP) and low-density lipoprotein-cholesterol (LDL-C) control and the Framingham Risk Score (FRS), a summary measure of risk factor control, in diabetic patients observed by participating PCPs between December 1, 2004 and December 31, 2005. Multivariable, multilevel models assessed associations between these patient outcomes and provider self-efficacy and CVP-related attitudes, after accounting for patient characteristics, including baseline risk factor control, provider characteristics, and patient clustering within provider practices. Fifty-nine PCPs (86%) providing care to 1495 patients with diabetes completed the survey. Mean scores for provider efficacy and CVP-related attitudes were moderate to high. Higher self-efficacy scores were associated with initiation of medications in previously untreated individuals with inadequate BP or lipid control at baseline. Despite adequate power, however, multilevel models demonstrated neither consistent nor substantive associations between providers' self-efficacy and CVP-related attitudes and patient outcome measures. These findings underscore the need for interventions to enhance cardiovascular risk factor control that look beyond educational strategies to address a broader range of factors with potential influence on patient outcomes and the delivery of preventive care.

To assess health status among student veterans at a community college utilizing a partnership between a Veterans Affairs Medical Center and a community college.Student veterans at Cuyahoga Community College in Cleveland, Ohio, in January to April 2013.A health assessment survey was sent to 978 veteran students. Descriptive analyses to assess prevalence of clinical diagnoses and health behaviors were performed. Logistic regression analyses were performed to assess for independent predictors of functional limitations.204 students participated in the survey (21% response rate). Self-reported depression and unhealthy behaviors were high. Physical and emotional limitations (45% and 35%, respectively), and pain interfering with work (42%) were reported. Logistic regression analyses confirmed the independent association of self-reported depression with functional limitation (odds ratio [OR] = 3.3, 95% confidence interval [CI] 1.4-7.8, p0.05, and C statistic 0.72) and of post-traumatic stress disorder with pain interfering with work (OR 3.9, CI 1.1-13.6, p0.05, and C statistic 0.75).A health assessment survey identified priority areas to inform targeted health promotion for student veterans at a community college. A partnership between a Veterans Affairs Medical Center and a community college can be utilized to help understand the health needs of veteran students.

Access to care at Veterans Affairs facilities may be limited by long wait times; however, additional barriers may prevent US military veterans from seeking help at all. We sought to understand the health needs of veterans in the community to identify possible barriers to health-seeking behavior.Focus groups were conducted with veteran students at a community college until thematic saturation was reached. Qualitative data analysis involved both an inductive content analysis approach and deductive elements.A total of 17 veteran students participated in 6 separate focus groups. Health needs affecting health-seeking behavior were identified. Themes included lack of motivation to improve health, concern about social exclusion and stigma, social interactions and behavior, limited access to affordable and convenient health care, unmet basic needs for self and family, and academics competing with health needs.Veterans face a range of personal, societal, and logistical barriers to accessing care. In addition to decreasing wait times for appointments, efforts to improve the transition to civilian life; reduce stigma; and offer assistance related to work, housing, and convenient access to health care may improve health in veteran students.

Diagnosis of chronic hepatitis C virus (HCV) is a 2-step process involving hepatitis C antibody (HCVab) testing followed by viral ribonucleic acid (RNA) testing. The HCV status of those with a positive HCVab without viral testing cannot be determined. This study sought to describe the HCV-related care provided to patients in this care gap.Retrospective cohort study of active patients with a positive HCVab test who did not complete viral testing.Electronic medical records (EMRs) were reviewed to determine if each subject's first positive HCVab result was acknowledged by a provider. For results acknowledged, we described provider actions in response to the result. When providers performed specific clinical actions within 1 year of the positive HCVab test, we captured the type of action taken. When the unsubstantiated diagnosis was documented in the EMR, we determined if the diagnosis was mentioned by subsequent providers.Positive HCVab results were not acknowledged in 31% of subjects. In 35%, providers added chronic HCV to the problem list in the EMR, resulting in a higher likelihood of subsequent providers mentioning the diagnosis in their EMR documentation. In 143 subjects whose providers recommended HCV-related clinical actions within 1 year of the positive result, 45% were educated about HCV and 42% had their liver enzymes monitored.With more widespread testing anticipated and more effective treatments available, health systems should ensure the HCV diagnostic process results in the delivery of an accurate and timely HCV diagnosis, to reduce the risk of harm to patients.

Journal of the American College of Cardiology Ó 2014 by the American College of Cardiology Foundation, American Heart Association, Inc., American Medical Association, and National Committee for Quality Assurance Published by Elsevier Inc. Vol. 63, No. 7, 2014 ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2013.12.003 PERFORMANCE MEASURES ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance Developed in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation and Mended Hearts Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and Mended Hearts WRITING COMMITTEE MEMBERS Brahmajee K. Nallamothu, MD, MPH, FACC, FAHA, Co-Chair*; Carl L. Tommaso, MD, FACC, FAHA, FSCAI, Co-Chairy; H. Vernon Anderson, MD, FACC, FAHA, FSCAI*; Jeffrey L. Anderson, MD, FACC, FAHA, MACP*; Joseph C. Cleveland, J R , MDz; R. Adams Dudley, MD, MBA; Peter Louis Duffy, MD, MMM, FACC, FSCAIy; David P. Faxon, MD, FACC, FAHA*; Hitinder S. Gurm, MD, FACC; Lawrence A. Hamilton, Neil C. Jensen, MHA, MBA; Richard A. Josephson, MD, MS, FACC, FAHA, FAACVPRx; David J. Malenka, MD, FACC, FAHA*; Calin V. Maniu, MD, FACC, FAHA, FSCAIy; Kevin W. McCabe, MD; James D. Mortimer, Manesh R. Patel, MD, FACC*; Stephen D. Persell, MD, MPH; John S. Rumsfeld, MD, PhD, FACC, FAHAjj; Kendrick A. Shunk, MD, PhD, FACC, FAHA, FSCAI*; Sidney C. Smith, J R , MD, FACC, FAHA, FACP{; Stephen J. Stanko, MBA, BA, AA#; Brook Watts, MD, MS *ACC/AHA Representative. ySociety of Cardiovascular Angiography and Interventions Representative. zSociety of Thoracic Surgeons Representative. xAmerican Association of Cardiovascular and Pulmonary Rehabilitation Representative. kACC/AHA Task Force on Performance Measures Liaison. {National Heart Lung and Blood Institute Representative. #Mended Hearts Representative. The measure specifications were approved by the American College of Cardiology Board of Trustees, American Heart Association Science Advisory and Coordinating Committee, in January 2013 and the American Medical Association–Physician Consortium for Performance Improvement in February 2013. This document was approved by the American College of Cardiology Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in October 2013, and the Society of Cardiovascular Angiography and Interventions in December 2013. The American College of Cardiology requests that this document be cited as follows: Nallamothu BK, Tommaso CL, Anderson HV, Anderson JL, Cleveland JC, Dudley RA, Duffy PL, Faxon DP, Gurm HS, Hamilton LA, Jensen NC, Josephson RA, Malenka DJ, Maniu CV, McCabe KW, Mortimer JD, Patel MR, Persell SD, Rumsfeld JS, Shunk KA, Smith SC, Stanko SJ, Watts B. ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 perfor- mance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association–Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance. J Am Coll Cardiol 2014;63:722–45. This article has been copublished in Circulation. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Asso- ciation (http://my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/obtaining- permission-to-re-use-elsevier-material). This Physician Performance Measurement Set (PPMS) and related data specifications were developed by the Physician Consortium for Performance Improvement (the Consortium), including the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Medical Association (AMA), to facilitate quality-improvement activities by physicians. The performance measures contained in this PPMS are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. Although copyrighted, they can be reproduced and distributed, without modification, for noncommercial purposesdfor example, use by health care prov

Background: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects. Objective: To ( a) identify opportunities and challenges to QI efforts in a large primary care practice in order to ( b) develop action plans to facilitate QI work into primary care teams. Design: We obtained qualitative and quantitative information about existing primary care team QI initiatives. Participants: Eleven interdisciplinary primary care teams and 4 facilitators/coaches. Methods: We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to ( a) characterize team-based QI progress and ( b) identify barriers and facilitators. Results: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress. Conclusions: In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

Objective: To initiate a long-term care facility (LTCF) infectious disease (LID) service that provides on-site consultations to LTCF residents to improve the care of residents with possible infections. Design: Clinical demonstration project. Setting: A 160-bed LTCF affiliated with a tertiary care Veterans Affairs (VA) hospital. Participants: Residents referred to the LID team. Measurements: The reason for and source of LTCF residents' referral to the LID team and their demographic characteristics, infectious disease diagnoses, interventions, and hospitalizations were determined. Results: Between July 2009 and December 2010, the LID consultation service provided 291 consultations for 250 LTCF residents. Referrals came from LTCF staff (75%) or the VA hospital's ID consult service (25%). The most common diagnoses were Clostridium difficile infection (14%), asymptomatic bacteriuria (10%), and urinary tract infection (10%). More than half of referred residents were receiving antibiotic therapy when they first saw the LID team; 46% of residents required an intervention. The most common interventions, stopping (32%) or starting (26%) antibiotics, were made in accordance with principles of antibiotic stewardship. Conclusion: The LID team represents a novel and effective means to bring subspecialty care to LTCF residents.

BACKGROUND Safe use of intravenous heparin is an important safety goal. OBJECTIVE To improve the quality of intravenous heparin use. METHODS A pre-post intervention design assessed the number of patients who reached a therapeutic activated partial thromboplastin time (aPTT), time to aPTT goal, and complications. Fifty traditional care patients were compared with 50 nurse-driven intravenous heparin protocol patients. The data were used to assess the effectiveness of a developed intervention package to improve the quality of intravenous heparin use. RESULTS Sixteen percent of the preintervention group never reached the therapeutic goal compared with 8% in the postintervention group (P < .05). Mean time to achieve first therapeutic aPTT was 18.6 hours in the preintervention group compared with 15.2 hours in the postintervention group (P = .33). Neither group noted complications. CONCLUSIONS The multidisciplinary team approach produced improved patient care outcomes and important lessons for improving the quality of intravenous heparin use.

BACKGROUND While the importance of teaching quality improvement (QI) is recognized, formal opportunities to teach it are limited and are not always successful at getting physician trainee buy-in. We summarize findings that emerged from a QI curriculum designed to promote physician trainee insights into the evaluation and improvement of quality of care. METHODS Grounded-theory approaches to thematic coding of responses from 24 trainees to open-ended items about aspects of a QI curriculum. The 24 trainees were subsequently divided into 9 teams that provided group responses to open-ended items about assessing quality care. Coding was also informed by notes from group discussions. RESULTS Successes associated with QI projects reflected several aspects of optimizing care such as approaches to improving processes and enabling providers. Counterproductive themes included aspects of compromising care such as creating blinders and complicating care delivery. Themes about assessing care included absolute versus process trade-offs, time frame, documentation completeness, and the underrecognized role of the patient/provider dynamic. CONCLUSIONS Our mapping of the themes provides a useful summary of issues and ways to approach the potential lack of buy-in from physician trainees about the value of QI and the "mixed-messages" regarding inconsistencies in the application of presumed objective performance measures.

Article-at-a-Glance Background Given recent advances in hepatitis C virus (HCV) treatment, health systems must ensure that patients with a positive HCV antibody receive timely determination of their HCV status through viral testing. At the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, viral testing was completed within six months of the first instance of a positive HCV antibody test for only 45% of patients. Beginning in 2008, three sequential improvements were implemented to close this care gap. Methods The three sequential improvements phases were as follows: (1) improving patient-centeredness of screening process in ambulatory patients, (2) local implementation of the Department of Veterans Affairs national HCV reflex testing policy, and (3) local evaluation of the efficiency and effectiveness of local implementation of reflex testing. Results From 2005 through 2013, 40 to 150 unique patients/quarter required viral testing following a positive antibody test. The firsts and second-phase improvements resulted in a 68% and 96% completion rate for timely viral testing during respective improvement phases. In the third improvement phase, remaining process problems related to the reflex testing process were identified using a locally developed electronic HCV population management application, resulting in a sustained rate of 100% completion of timely viral testing. Interrupted time series analysis revealed that the implementation of HCV reflex testing had the largest impact on the ability to complete timely viral testing. Conclusions A continuous quality improvement approach, supported by an HCV population management application, achieved the complete closure of an important HCV care gap. Reflex testing should be initiated at facilities that have yet to adopt this approach.

Background Low adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers. The goal of this study was to evaluate the impact of provider education and access to a CKD registry on guideline adherence. Methods We conducted a cluster randomized controlled trial at the Louis Stokes Cleveland VAMC. One of two primary care clinics was randomized to intervention. Providers from both clinics received a lecture on CKD guidelines at study initiation. Providers in the intervention clinic were given access to and shown how to use a CKD registry, which identifies patients with CKD and is automatically updated daily. Eligible patients had at least one primary care visit in the last year, had CKD based on eGFR, and had not received renal replacement therapy. The primary outcome was parathyroid hormone (PTH) adherence, defined by at least one PTH measurement during the 12 month study. Secondary outcomes were measurement of phosphorus, hemoglobin, proteinuria, achievement of goal blood pressure, and treatment with a diuretic or renin-angiotensin system blocker. Results There were 418 and 363 eligible patients seen during the study in the control and intervention clinics, respectively. Compared to pre-intervention, measurement of PTH increased in both clinics (control clinic: 16% to 23%; intervention clinic: 13% to 28%). Patients in the intervention clinic were more likely to have a PTH measured during the study (adjusted odds ratio = 1.53; 95% CI (1.01, 2.30); P = 0.04). However, the intervention was not associated with a consistent improvement in secondary outcomes. Only 5 of the 37 providers in the intervention clinic accessed the registry. Conclusions An intervention that included education on CKD guidelines and access to a CKD patient registry marginally improved guideline adherence over education alone. Adherence to the primary process measure improved in both clinics, but no improvement was seen in intermediate clinical outcomes. Improving the care of patients with CKD will likely require a multifaceted approach including system redesign. ClinicalTrials.Gov registration number NCT00921687

Objectives To examine the public health impact of mass vaccination with live attenuated human rotavirus vaccine (RIX4414) in a birth cohort in India, and to estimate the cost effectiveness and affordability of such a programme. Design Decision analytical Markov model encompassing all direct medical costs. Infection risk and severity depended on age, number of previous infections, and vaccination history; probabilities of use of inpatient and outpatient health services depended on symptom severity. Data sources Published clinical, epidemiological, and economic data. When possible, parameter estimates were based on data specific for India. Population Simulated Indian birth cohort followed for five years. Main outcome measures Decrease in rotavirus gastroenteritis episodes (non-severe and severe), deaths, outpatient visits, and admission to hospital; incremental cost effectiveness ratio of vaccination expressed as net cost in 2007 rupees per life year saved. Results In the base case, vaccination prevented 28 943 (29.7%) symptomatic episodes, 6981 (38.2%) severe episodes, 164 deaths (41.0%), 7178 (33.3%) outpatient visits, and 812 (34.3%) admissions to hospital per 100 000 children. Vaccination cost 8023 rupees (about £100, €113, $165) per life year saved, less than India’s per capita gross domestic product, a common criterion for cost effectiveness. The net programme cost would be equivalent to 11.6% of the 2006-7 budget of the Indian Department of Health and Family Welfare. Model results were most sensitive to variations in access to outpatient care for those with severe symptoms. If this parameter was increased to its upper limit, the incremental cost effectiveness ratio for vaccination still fell between one and three times the per capita gross domestic product, meeting the World Health Organization’s criterion for “cost effective” interventions. Uncertainty analysis indicated a 94.7% probability that vaccination would be cost effective according to a criterion of one times per capita gross domestic product per life year saved, and a 97.8% probability that it would be cost effective according to a criterion of three times per capita gross domestic product. Conclusions Across a wide range of assumptions, mass RIX4414 vaccination in India would probably prevent substantial morbidity and mortality at a cost per life year saved below typical thresholds of cost effectiveness. The opportunity costs of such a programme in this or similar settings, however, should be weighed up carefully.

Background Primary care providers do not routinely follow guidelines for the care of patients with chronic kidney disease (CKD). Multidisciplinary efforts may improve care for patients with chronic disease. Pharmacist based interventions have effectively improved management of hypertension. We performed a pragmatic, randomized, controlled trial to evaluate the effect of a pharmacist based quality improvement program on 1) outcomes for patients with CKD and 2) adherence to CKD guidelines in the primary care setting. Methods Patients with moderate to severe CKD receiving primary care services at one of thirteen community-based Veterans Affairs outpatient clinics were randomized to a multifactorial intervention that included a phone-based pharmacist intervention, pharmacist-physician collaboration, patient education, and a CKD registry (n = 1070) or usual care (n = 1129). The primary process outcome was measurement of parathyroid hormone (PTH) during the one year study period. The primary clinical outcome was blood pressure (BP) control in subjects with poorly controlled hypertension at baseline. Results Among those with poorly controlled baseline BP, there was no difference in the last recorded BP or the percent at goal BP during the study period (42.0% vs. 41.2% in the control arm). Subjects in the intervention arm were more likely to have a PTH measured during the study period (46.9% vs. 16.1% in the control arm, P