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Women continue to be underrepresented in medicine, especially in senior leadership positions, and they experience challenges related to gender bias and sexual harassment. Women who are members of multiple groups that experience marginalization, including, for example, women who are American Indian, Alaskan native, indigenous, Black, or Hispanic, face a compounded challenge. In this article, we explore how institutions and professional organizations in medicine can use metrics to better understand the structural disparities that create and promote gender inequity in the work environment and how to employ these metrics to track progress in narrowing these gaps. Examples in health care (clinical medicine, scientific organizations, scientific publishing), business, and law are used to illustrate how impactful metrics can promote accountability when coupled with transparent reporting.

Various factors have been shown to affect the rehabilitation outcome of hip fractured patients. Considering the decrease in muscle mass with aging and its impact on mobility, we hypothesized that a relationship exists between hand grip strength and rehabilitation outcome. We retrospectively studied 373 post-hip fracture patients, admitted for rehabilitation. Muscle strength was measured by hand grip dynamometer. Main outcome measures: functional independence measure motor functional independence measure, motor functional independence measure effectiveness and length of stay). A favorable functional gain was defined as a motor Functional Independence Measure effectiveness score > 0.5. The Spearman correlation assessed the associations between hand grip strength and outcome measures. A multiple linear regression model tested whether hand grip strength was an independent predictor of discharge motor Functional Independence Measure scores and length of stay Significant correlations were found between hand grip strength and functional outcomes. A significant independent association was found between hand grip strength and discharge motor Functional Independence Measure score after adjustment for confounding demographic and clinical variables. High hand grip strength on admission was significantly associated with a greater chance of achieving a favorable functional gain (OR 1.064, 95% CI, 1.01–1.13; p = 0.032). Hand grip strength was not found to be associated with length of stay. Hand grip strength is independently associated with rehabilitation outcome in post-acute frail hip fractured patients. Initial screening for hand grip strength on admission may help identify patients who require an intensive resistance exercise program.

Pancreatic ductal adenocarcinoma (PDAC) remains one of the most deadly types of cancer, and the majority of pancreatic cancer deaths is caused by metastasis. Therapeutic options for systemic disease are limited, in particular due to the heterogeneous events leading to tumor dissemination. Previous studies highlighted an association of the homeodomain transcription factor MEIS1 with a ductal phenotype in pancreatic tissue architecture. Using immunohistochemistry, we demonstrate that MEIS1 is expressed in aberrant duct structures of Ela-TGFα transgenic mice as well as in pancreatic intraepithelial neoplasia (PanINs), primary PDAC, and metastatic disease in Ptf1aCre/+ ;LSL-KrasG12D/+ mice. To assess a putative role of MEIS1 in the progression of PDAC, MEIS1 overexpressing pancreatic cancer cell lines were generated by retroviral gene delivery and assessed for proliferation and migration. MEIS1 did not affect proliferation but increased migration in a subset of cell lines tested. Subsequent genome wide expression analysis identified upregulation of the pro-metastatic gene melanoma cell adhesion molecule (Mcam) in migrating cells. Employing DNA-pulldown and chromatin immunoprecipitation (ChIP) assays we reveal interaction of MEIS1 with the enhancer-DNA of Mcam and its transcriptional activation to facilitate migration of pancreatic cancer cells in vitro. Activation of Mcam through MEIS1 occurs in a cell type dependent fashion, reflecting the different routes that lead to metastasis in vivo. To our knowledge, these results show for the first time a pro-metastatic function of Mcam in pancreatic cancer. © 2016 Wiley Periodicals, Inc.

[Extract] Healthcare disparities in quality represent one of the greatest challenges in achieving uniformly high-quality care. Research reporting disparities in surgical outcomes are abundant. The cornerstone of delivering high-quality healthcare is ensuring optimal access for all patients. A relative lack of access to surgical services might be a contributing factor to disparities in surgical outcomes. Access is "the timely use of personal health services to achieve the best possible outcomes." Use of services, the process of entering and staying in the system, and the actual quality of care received are all involved. Disparities in access arise when the system disproportionately underperforms for a specific group of patients relative to the historically advantaged population.8, 9 Surgery, because of its time sensitive, often high-acuity nature, is greatly dependent on access.

Quality measurement is fundamental to systematic improvement of the healthcare system. Whilst the United States has made significant investments in healthcare quality measurement and improvement, progress has been somewhat limited. Public and private payers in the United States increasingly mandate measurement and reporting as part of pay-for-performance programmes. Numerous issues have limited improvement, including lack of alignment in the use of measures and improvement strategies, the fragmentation of the U.S. healthcare system, and the lack of national electronic systems for measurement, reporting, benchmarking and improvement. Here, we provide an overview of the evolution of U.S. quality measurement efforts, including the role of the National Quality Forum. Important contextual changes such as the growing shift towards electronic data sources and clinical registries are discussed together with international comparisons. In future, the U.S. healthcare system needs to focus greater attention on the development and use of measures that matter. The three-part aim of effective care, affordable care and healthy communities in the U.S. National Quality Strategy focuses attention on population health and reduction in healthcare disparities. To make significant improvements in U.S. health care, a closer connection between measurement and both evolving national data systems and evidence-based improvement strategies is needed.

Pancreatic cancer is one of the deadliest cancers with poor survival rates and limited therapeutic options. To improve the understanding of this disease's biology, a prerequisite for the generation of novel therapeutics, new platforms for rapid and efficient genetic and therapeutic screening are needed. Therefore, a combined in vitro/in vivo hybrid shRNA assay was developed using isolated murine primary pancreatic ductal cells (PDCs), in which oncogenic KrasG12D could be activated in vitro by genomic recombination through 4OH-tamoxifen–induced nuclear translocation of Cre-ERT2 expressed under control of the ROSA26 promoter. Further genetic manipulation was achieved through selective and stable RNAi against the tumor suppressors p16Ink4a (CDKN2A) or Trp53 (TP53) using lentiviral gene delivery. Treatment of PDCs with 4OH-tamoxifen increased phosphorylation of ERK downstream of KRAS, and subsequent lentiviral transduction resulted in sustained target gene repression. Double-mutant PDCs were then reintroduced into the pancreata of NOD-SCID-gamma (NSG) mice and monitored for tumor growth. Orthotopic implantation of PDCs carrying the activated KrasG12D -allele and shRNA against p16Ink4a or Trp53 resulted in tumor growth, metastasis, and reduced survival of NSG mice. In contrast, KrasG12D alone was not sufficient to induce tumor growth. Implications: The combinatory in vitro / in vivo approach described in this study allows for rapid and efficient identification of genes involved in carcinogenesis and opens new avenues for the development of therapeutic strategies to improve cancer treatment. Mol Cancer Res; 13(5); 863–9. ©2015 AACR . This article is featured in Highlights of This Issue, [p. 807][1] [1]: /lookup/volpage/13/807?iss=5

International audience; Pea forms symbiotic nodules with Rhizobium leguminosarum sv. viciae (Rlv). In the field, pea roots can be exposed to multiple compatible Rlv strains. Little is known about the mechanisms underlying the competitiveness for nodulation of Rlv strains and the ability of pea to choose between diverse compatible Rlv strains. The variability of pea-Rlv partner choice was investigated by co-inoculation with a mixture of five diverse Rlv strains of a 104-pea collection representative of the variability encountered in the genus Pisum. The nitrogen fixation efficiency conferred by each strain was determined in additional mono-inoculation experiments on a subset of 18 pea lines displaying contrasted Rlv choice. Differences in Rlv choice were observed within the pea collection according to their genetic or geographical diversities. The competitiveness for nodulation of a given pea-Rlv association evaluated in the multi-inoculated experiment was poorly correlated with its nitrogen fixation efficiency determined in mono-inoculation. Both plant and bacterial genetic determinants contribute to pea-Rlv partner choice. No evidence was found for co-selection of competitiveness for nodulation and nitrogen fixation efficiency. Plant and inoculant for an improved symbiotic association in the field must be selected not only on nitrogen fixation efficiency but also for competitiveness for nodulation.

Objective To examine the impact of acute hepatitis A on health care utilization and cost in a commercially insured population. Study Design This observational, retrospective cohort study used medical and pharmacy claims data from January 1, 2004 through October 31, 2009. A matched control group consisted of patients without hepatitis A during the study period. Descriptive statistics were used to assess differences between hepatitis A patients (cases) and controls. Results The case and control groups each contained 2331 patients. In the 12-month post-index period, 482 (20.7%) cases and 193 (8.3%; P P P P P P P Conclusions Patients with hepatitis A had significantly higher health care resource utilization and costs during the 1-year post-index period, compared with controls.

Performance measures (PMs) are specified metrics by which a health-care provider's care can be compared with national benchmarks. The use of PMs is a key component of efforts to improve the quality and value of health care. The National Quality Forum (NQF) is the federally recognized endorser of PMs. From 2006 to 2009, the Quality Improvement Committee (QIC) of the American College of Chest Physicians engaged in the review of proposed PMs as a member of the NQF. This article provides a review of the QIC's experience with PMs and NQF membership and the lessons learned, an overview of the enhancements made to the NQF endorsement process in 2010 and 2011, and a discussion of the next steps that would further strengthen the measure development and endorsement processes and increase the likelihood of measurement leading to better patient outcomes.

Most people spend a greater amount of time indoors rather than outdoors, so it follows that it's composition could directly affect occupants, thereby providing a new demand for sensors that will monitor indoor air pollution. In this paper, bioluminescent bacteria were used as bioreporters for the determination of air toxicity. Bacteria were immobilized in 96 well plates with matrices of different types and volumes, and exposed to a selection of model toxic compounds in air. TV1061 strain immobilized in alginate in wells of a microtiter plate showed the best response to a low concentration of chloroform (6.65 ppb), while US permission limits stands now at 50 ppm. This system was then adapted to the end face of a portable fiber optic biosensor, and we predict that one day it could be used as an air pollution alert system in an indoor environment.

Pancreatic ductal adenocarcinoma (PDAC) is a fatal disease with poor patient outcome often resulting from late diagnosis in advanced stages. To date methods to diagnose early-stage PDAC are limited and in vivo detection of pancreatic intraepithelial neoplasia (PanIN), a preinvasive precursor of PDAC, is impossible. Using a cathepsin-activatable near-infrared probe in combination with flexible confocal fluorescence lasermicroscopy (CFL) in a genetically defined mouse model of PDAC we were able to detect and grade murine PanIN lesions in real time in vivo. Our diagnostic approach is highly sensitive and specific and proved superior to clinically established fluorescein-enhanced imaging. Translation of this endoscopic technique into the clinic should tremendously improve detection of pancreatic neoplasia, thus reforming management of patients at risk for PDAC.

Bryostatin 1, a macrocyclic lactone that has been widely characterized as an ultrapotent protein kinase C (PKC) activator, displays marked pharmacological differences with the typical phorbol ester tumor promoters. Bryostatin 1 impairs phorbol 12-myristate 13-acetate (PMA)-induced tumor promotion in mice and is in clinical trials as an anticancer agent for a number of hematopoietic malignancies and solid tumors. In this study, we characterized the effect of bryostatin 1 on LNCaP prostate cancer cells, a cellular model in which PKC isozymes play important roles in the control of growth and survival. Although phorbol esters promote a strong apoptotic response in LNCaP cells via PKCdelta-mediated release of TNFalpha, bryostatin 1 failed to trigger a death effect even at high concentrations, and it prevented PMA-induced apoptosis in these cells. Mechanistic analysis revealed that bryostatin 1 is unable to induce TNFalpha release, and it impairs the secretion of this cytokine from LNCaP cells in response to PMA. Unlike PMA, bryostatin 1 failed to promote the translocation of PKCdelta to the plasma membrane. Moreover, bryostatin 1 prevented PMA-induced PKCdelta peripheral translocation. Studies using a membrane-targeted PKCdelta construct revealed that the peripheral localization of the kinase is a requisite for triggering apoptosis in LNCaP cells, arguing that mislocalization of PKCdelta may explain the actions of bryostatin 1. The identification of an antiapoptotic effect of bryostatin 1 may have significant relevance in the context of its therapeutic efficacy.

Introduction In the era of evidence-based practice, more evidence of the beneficial impact of physical therapy and rehabilitation interventions have emerged. Kwakkel and Wagenaar's meta-analysis, Carr and Shepherd's work relating to the motor learning concept, and Fiatarone's research of strength training, emphasize the influence of rehabilitation in outcome gains by demonstrating that in conjunction with the therapist's expertise, the most influencing factors are therapy frequency and intensity. Aim To show the problem which is the gap between this knowledge and reality. Discusion Recently published observational studies revealed that patients in rehabilitation facilities receive a very small amount of therapy time during rehabilitation. Virtual reality (VR) technology offers assistance, as it enables patients who have difficulties coping in the “real world” to gradually deal with their problems via the “virtual world”. It provides the user with a real time interactive experience, through visual, audible, tactile or any other kind of feedback. Individuals find themselves in a pleasant, challenging, motivating and “inviting” functional environment, thus tending to forget their limitations or disability. In addition, VR encourages them to reach their goals which are difficult to achieve in any other treatment setting. Conclusions VR is a new, innovative technology utilizing virtual and adaptable worlds, created by sophisticated computer systems with improved graphic capability (hardware) and interactive software allowing one to interact “naturally” with the virtual environment, without the risk and cost of moving the patient into the “real world”. The interactive experience is perceived by both, therapist and patient, as very positive, enabling treatment to continue over time without feelings fatigue or boredom. VR can be created through a variety of tools, simple to complex, cheap to expensive. Basic computer systems with different input and output devices, such as different types of monitors or expensive and sophisticated systems using helmets with small video screens head mounted display have been used. Recently, cheap “on the shelf” video game consoles were adopted by clinicians as valuable tools in treating patients suffering from various pathologies and disabilities. Therefore, therapists are required to manoeuvre and plan treatments in systems where the delineation between therapy and fun is not always clear or controlled. The common practice has to be, as always, somewhere in between the most expensive and sophisticated systems and the “non adaptable” video game consoles. We estimate that in the near future, VR technology will be widely used. Meanwhile, today's technology allows us to take more of the VR advantages to the clinical world.

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

SummaryAlthough gastrointestinal cancers are frequently associated with chronic inflammation, the underlying molecular links have not been comprehensively deciphered. Using loss- and gain-of-function mice in a colitis-associated cancer model, we establish here a link comprising the gp130/Stat3 transcription factor signaling axis. Mutagen-induced tumor growth and multiplicity are reduced following intestinal epithelial cell (IEC)-specific Stat3 ablation, while its hyperactivation promotes tumor incidence and growth. Conversely, IEC-specific Stat3 deficiency enhances susceptibility to chemically induced epithelial damage and subsequent mucosal inflammation, while excessive Stat3 activation confers resistance to colitis. Stat3 has the capacity to mediate IL-6- and IL-11-dependent IEC survival and to promote proliferation through G1 and G2/M cell-cycle progression as the common tumor cell-autonomous mechanism that bridges chronic inflammation to tumor promotion.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of CAUTIsa. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter.b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay.c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ.2. Outcomes associated with CAUTIa. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients.b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.

Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Occurrence of VAP in acute care facilities.a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.2. Outcomes associated with VAPa. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.i. The mortality attributable to VAP may exceed 10%.ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.

Among patients with common immune-compromised (IC) conditions in the United States, the healthcare cost associated with herpes zoster (HZ) was sizable and occurred mainly during the first quarter after diagnosis. And HZ-associated costs varied by age and underlying IC conditions., Background. This retrospective study investigates the healthcare costs of herpes zoster (HZ) in patients with selected immune-compromised (IC) conditions in the United States (US). Methods. Patients with incident HZ diagnosis (index date) were selected from nationwide administrative claims databases from 2005 to 2009. Baseline IC groups, analyzed separately, included adults aged 18–64 years with the following: human immunodeficiency virus infection (HIV), solid organ transplant (SOT), bone marrow or stem cell transplant (BMSCT), or cancer; and older adults (aged ≥65 years) with cancer. Herpes zoster patients (n = 2020, n = 1053, n = 286, n = 13 178, and n = 9089, respectively) were 1-to-1 matched to controls without HZ (with randomly selected index date) in the same baseline group. The healthcare resource utilization and costs (2014 US dollars) during the first 2 postindex quarters were compared between matched cohorts with continuous enrollment during the quarter. Results. Herpes zoster patients generally had greater use of inpatient, emergency room and outpatient services, and pain medications than matched controls (P < .05). The incremental costs of HZ during the first postindex quarter were $3056, $2649, $13 332, $2549, and $3108 for HIV, SOT, BMSCT, cancer in adults aged 18–64 years, and cancer in older adults, respectively (each P < .05). The incremental costs of HZ during the second quarter were only significant for adults aged 18–64 years with cancer ($1748, P < .05). The national incremental costs of HZ were projected to be $298 million annually across the 5 IC groups. Conclusions. The healthcare cost associated with HZ among patients with studied IC conditions was sizable and occurred mainly during the first 90 days after diagnosis.

Angiotensin II (Ang II) and endothelin-1 (ET-1) share their effects on growth of myocardial cells but have been shown to elicit different effects on myocardial function. However, these effects vary markedly among species, cardiac regions (atrium or ventricle) and failing or non-failing myocardium. We therefore investigated the effects of both peptides on contractile function of isolated human myocytes from failing and non-failing hearts.Cardiomyocytes were enzymatically isolated and electrically stimulated (15 V, 0.2 Hz). Ang II elicited a positive inotropic effect (PIE) mediated by activation of protein kinase C (PKC) in atrial but no effect in ventricular myocytes. ET-1 (10(-8) M) increased cell-shortening by 146+/-9.3% (p0.05) in atrial myocytes, by 99.1+/-16.5% (p0.05) in non-failing ventricular but only by 40.5+/-6.4% (p0.05) in failing ventricular myocytes. The PIE of ET-1 in failing myocytes was more pronounced at low extracellular pH (+112.6+/-27% at pH 7.0 vs. +40.5+/-6.4% at pH 7.4, p0.05). Amiloride, a sodium-hydrogen-exchange inhibitor, inhibited two thirds of the PIE of ET-1 in failing myocytes. The PKC-inhibitor decreased the PIE by 50% from 113% to 64% in ventricular myocytes under acidotic conditions.Ang II and ET-1 elicited PIE in atrial myocytes, whereas in ventricular myocytes Ang II did not induce PIE in contrast to ET-1. The PIE of ET-1 was markedly attenuated in failing myocytes. Under acidotic conditions, the PIE of ET-1 was more pronounced in failing myocytes, indicating that ET-1 may activate signaling processes in failing myocytes, which are not activated in normal myocytes.

The current transformation of the health care system comes with the increased use of performance measures for various applications, including value-based payment. Although there may be different perspectives on the appropriate approaches to shift from payment for individual services to payment for

The Affordable Care Act (ACA) of 2010 is expanding the use of quality measurement and promulgating new payment models that place downward pressure on health care utilization and costs. As emergency department (ED) computed tomography utilization has tripled in the past decade, stakeholders have identified advanced imaging as an area where quality and efficiency measures should expand. On May 12, 2015, Academic Emergency Medicine convened a consensus conference titled "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." As part of the conference, a panel of health care policy leaders and emergency physicians discussed the effect of the ACA and other quality programs on ED diagnostic imaging, specifically the way that quality metrics may affect ED care and how ED diagnostic imaging fits in the broader strategy of the U.S. government. This article discusses the content of the panel's presentations.

Epithelium of the colon and intestine are renewed every 3 days. In the intestine there are at least two principal stem cell pools. The first contains rapid cycling crypt-based columnar (CBC) Lgr5(+) cells, and the second is composed of slower cycling Bmi1-expressing cells at the +4 position above the crypt base. In the colon, however, the identification of Lgr5(-) stem cell pools has proven more challenging. Here, we demonstrate that the intermediate filament keratin-19 (Krt19) marks long-lived, radiation-resistant cells above the crypt base that generate Lgr5(+) CBCs in the colon and intestine. In colorectal cancer models, Krt19(+) cancer-initiating cells are also radioresistant, while Lgr5(+) stem cells are radiosensitive. Moreover, Lgr5(+) stem cells are dispensable in both the normal and neoplastic colonic epithelium, as ablation of Lgr5(+) stem cells results in their regeneration from Krt19-expressing cells. Thus, Krt19(+) stem cells are a discrete target relevant for cancer therapy.

The primary goal of medical education is to produce physicians who deliver high-quality health care. Recent calls for greater accountability in medical education and the development of outcomes research methodologies should encourage a new research effort to examine the effects of medical training upon clinical outcomes. The authors offer a research agenda that links medical education and quality of health care and give specific examples of potential research projects that would begin to examine that relationship. A proposed model of patient outcomes research in medical education recognizes the contributory effects of health care system-level factors as well as the continuum of medical education, process measures, and individual training and preparedness to deliver high-quality care. There exists an opportunity to create a research agenda in medical education outcomes research that is multidisciplinary, broad based, and focused on patient-centered outcomes.

Despite the rapid growth in Medicaid managed care (MMC) during the 1990s, there are limited data about the impact of managed care on Medicaid beneficiaries. Although managed care has been shown to improve access to primary care in some communities (e.g., Mitchell et al. 2002 ), its effect on a Medicaid population may depend on constricted levels of funding and other factors. Studies indicate that MMC may have major differences from commercial managed care (Institute of Medicine 2000). Compared with privately insured persons, those under Medicaid are far more vulnerable, have less access to nonmedical services (e.g., transportation to clinic, provision of child care, translation services, and so on), and their experience and capacity to exercise choices are more limited. Based on patient surveys, MMC enrollees were found to be more likely than low-income privately insured managed care enrollees to be poorer, have health problems, and experience access problems (Lillie-Blanton and Lyons 1998). In general, the literature on Medicaid managed care access, utilization, quality, and patient outcome and satisfaction shows mixed results (Rowland et al. 1997). However, results to date have been sufficiently negative to raise some concerns about access to care of these enrollees (Miller 1998). In this article, we will analyze the effects of managed care enrollment on Medicaid enrollees hospitalized in four states. We will address, by examining the hospital admission patterns for preventable conditions, whether managed care differentially impacts access to primary care between Medicaid and commercially insured patients. The preventable conditions, alternatively known as ambulatory care sensitive (ACS) conditions, are used often to measure access to primary care (Bindman et al. 1995; Homer et al. 1996). A higher hospitalization rate from these conditions may suggest less primary and preventive care before hospitalization. Preventable hospitalization rates derived from hospital discharge data are often used as indicators of primary care access. Several studies in the past have examined the predictors of admissions rates for these conditions (e.g., Weissman, Gatsonis, and Epstein 1992; Billings et al. 1993). Preventable hospitalizations are an emerging focus of interest, especially on the part of state Medicaid programs. States are increasingly enrolling their Medicaid population into managed care with the hope that MMC will provide enrollees with a medical home where sufficient preventive and primary care will be available (Long and Coughlin 2001), and the use of costly services such as inpatient care or emergency rooms will be subsequently reduced. Because health maintenance organizations (HMOs) have been known to focus more resources than other health plans on preventive care (Miller and Luft 1994), it can be hypothesized that HMOs would reduce the use of hospitals for preventable conditions. The hypothesis has been validated in a number of studies. For example, a recent study of New York children found that an increase in the penetration of private managed care in a community was associated with a reduction in ACS admission rates in 1994 (Friedman and Basu 2001). Another study using time series data reached the same conclusion for adults in California (Backus et al. 2002). However, there are limited data on preventable hospitalizations among Medicaid enrollees. Several studies reported a weak association between managed care enrollment and ACS hospitalization among Medicaid children (Gadomski, Jenkins, and Nichols 1997; Long and Coughlin 2001). The effect of MMC on preventable admissions among adults has not been sufficiently investigated. A recently completed study on New York adults (Basu, Friedman, and Burstin 2002) provides some evidence that the managed care did not have the expected effect on preventable admissions for this group. However, at the time of the study (1995) Medicaid managed care was still in its early stage of implementation in New York (Cantor, Haslanger, and DeGuire 2000). This study will focus on HMO enrollment among adults enrolled in the Medicaid program in 1997 in four states. By 1997, more than one-quarter of the Medicaid population in 40 states and Washington, DC, were enrolled in managed care. The states, New York, Pennsylvania, Wisconsin, and Tennessee, were selected to represent different levels of MMC penetration in 1997 as well as varying program characteristics (Table 1). Tennessee had full MMC enrollment, and comparisons to fee-for-service (FFS) Medicaid could not be performed. However, this state was included because it added power to the comparisons with the privately insured. We specifically examined whether HMO enrollment was associated with a decline in preventable admissions for Medicaid enrollees, who usually exhibit higher rates of such hospitalizations. Many important research questions distinguish between FFS and those covered by managed care contracts. In this study, we examined the following questions: (1) Does HMO enrollment reduce the likelihood of preventable admissions for Medicaid enrollees? (2) Does HMO enrollment have a greater or lesser impact on preventable admissions in the Medicaid population than in the privately insured population? Table 1 Medicaid Managed Care Plan Type and Penetration Rates by State, 1997 To address these questions, we assessed the association between preventable hospitalization and the types of insurance coverage among nonelderly adults, controlling for various patient and county characteristics. We provided comparisons of preventable hospitalizations with other admissions by using a multivariate cross-sectional framework with patient-level data for each state. Some previous studies analyzed variations across individuals (e.g., Weissman, Gatsonis, and Epstein 1992; Culler, Parchman, and Przybylski 1998). The present study took a different approach and examined the determinants of admission pattern for preventable conditions in comparison to a control group of conditions. Preventable admissions are compared with admissions for “marker conditions,” which are more urgent in nature but not preventable by ambulatory care. These conditions have been defined as diagnoses for which provision of timely and effective ambulatory care immediately before admission will likely have little impact on the need for hospital admission (Billings et al. 1993). Since marker admissions should be insensitive to primary care, they provide an appropriate comparison group (Basu and Clancy 2001) for preventable admissions. By restricting to a specific comparison group, the study will offer less sensitivity to the impact of particular areas with an unusual mixture of admissions (Basu, Friedman, and Burstin 2002).

The Agency for Healthcare Research and Quality submitted the first annual National Healthcare Disparities Report to Congress in December, 2003. This first report will provide a snapshot of the state of racial, ethnic, and socioeconomic disparities in access and quality of care in America. It examines disparities in the general population and within the Agency’s priority populations. While focused on extant data, the first report will form the foundation for future versions, which examines causes of disparities and shape solutions to the problem. As patient advocates and agents of change, primary care physicians play a critical role in efforts to eliminate disparities in health care. Continuing participation by primary care physicians in the development and refinement of the National Healthcare Disparities Report is essential.

Responding to a bioterrorist event calls for critical communication and linkages in real time; among systems of care, the public health infrastructure and individual clinicians, law enforcement agents and emergency responders. In particular, there are many unanswered questions about the health care system's capacity to rapidly respond. How can an overburdened health care system ramp up to handle mass casualties? How will triage decisions be made rapidly and accurately? How can regional resources be used to provide surge capacity in the event of a bioterrorist attack? What are the early warning signs of such an event? To enhance health care system preparedness for bioterrorism, we need health services researchers to rise to the challenge and begin to develop and analyze the best evidence-based models, tools, and knowledge to address these potentially devastating threats.

Summary Public concern about the quality of health care has motivated governments, health-care funders, and clinicians to expand efforts to improve professional performance. In this paper, we illustrate such efforts from the perspective of three countries, the UK, the USA, and the Netherlands. The earliest strategies, which included continuing professional education, clinical audits, and peer review, were aimed at the individual doctor, and produced only modest effects. Other efforts, such as national implementation of practice guidelines, effective use of information technologies, and intensive involvement by doctors in continuous quality-improvement activities, are aimed more broadly at health-care systems. Much is yet unknown about whether these or other strategies—such as centralised supervision or regulation of quality improvement, or use of financial incentives—are effective. As demands for greater public accountability rise, continuing performance improvement efforts of each of our countries offer us opportunities to learn from one another.

Objective: To identify predictors and outcomes associated with frequent emergency department (ED) users. Methods: Cross-sectional intake surveys, medical chart reviews, and telephone follow-up interviews of patients presenting with selected chief complaints were performed at five urban EDs during a one-month study period in 1995. Frequent use was defined by four or more self-reported, prior ED visits. Multivariate logistic regression identified predictors of frequent ED visitors from five domains (demographics, health status, health access, health care preference, and severity of acute illness). Associations between high use and selected outcomes were assessed with logistic regression models. Results: All study components were completed by 2,333 of 3,455 eligible patients (67.5%). Demographics predicting frequent use included being a single parent, single or divorced marital status, high school education or less, and income of less than $10,000 (1995). Health status predictors included hospitalization in the preceding three months, high ratings of psychological distress, and asthma. Health access predictors included identifying an ED or a hospital clinic as the primary care site, having a primary care physician (PCP), and visiting a PCP in the past month. Choosing the ED for free care was the only health preference predictive of heavy use. Illness severity measures were higher in frequent visitors, although these were not independently predictive in the multivariate model. Outcomes correlated with heavy use include increased hospital admissions, higher rates of ED return visits, and lower patient satisfaction, but not willingness to return to the ED or follow-up with a doctor. Conclusions: Frequent ED visits are associated with socioeconomic distress, chronic illness, and high use of other health resources. Efforts to reduce ED visits require addressing the unique needs of these patients in the emergency and primary care settings.

While safety risks are widespread in ambulatory settings, there has been insufficient attention directed at developing the evidence base that is needed to improve ambulatory safety. In this article, the current state of knowledge about ambulatory safety is reviewed. A research agenda in ambulatory safety is proposed, as well as a series of potential interventions that could be used to improve safety in the ambulatory setting.

In 1998, the Institute of Medicine (IOM) issued a report on medical errors, which estimated that up to 98,000 people die in U.S. hospitals each year from errors. This report raised concerns that medical errors have become a national public health problem that should be addressed in the same manner as other epidemics such as heart disease, diabetes, and obesity. In 2001, the IOM released a follow-up report encompassing a broader range of quality issues. They concluded that the U.S. healthcare system is outmoded and incapable of providing consistent, high-quality care. They outlined a strategy for redesigning U.S. healthcare delivery to achieve safe, dependable, high-quality care, which emphasizes information technology as an integral part of the solution. AHRQ’s fiscal year 2001 appropriation included $50 million dollars for initiatives to reduce medical errors and improve patient safety. AHRQ responded to this mandate by developing a series of research solicitations that form an integrated set of activities to design and test best practices for reducing errors in multiple health care settings. This paper discusses the components of this program and the central role of medical informatics research in the Agency’s efforts to improve the safety of medical care in America.

The Agency for Healthcare Research and Quality (AHRQ) is a lead partner with the Department of Health and Human Services in addressing the issues of the health care system’s preparedness in the event of a bioterrorist event. There is a critical need for the science of health services research and systems research to inform preparedness to achieve maximal system responsiveness and reinforce effective linkages between the health care system and the public health infrastructure. As AHRQ expands research in bioterrorism preparedness, nurse clinicians and nurse investigators are needed to bring the expertise to studies of the health care environments. There is an opportunity to address long-ignored systems and operations issues with collateral and shared benefits to the health care system. The bioterrorism preparedness research can reinvigorate our capacity to rebuild and restore a system responsive to future rare and catastrophic events as well as confront the current challenges of our systems of care.

Payment trends are producing powerful financial incentives that influence how physicians provide patient care. To be effective, these incentives must target the physician responsible for care. The ...

Baker and Chassin present 4 criteria to assess outcome measures. The editorialists discuss these criteria and the need for fairness and precision in measurement and to reduce burden from measures t...

Vaccination rates among United States (US) adults are suboptimal, resulting in morbidity, mortality, and financial burden attributable to potentially vaccine-preventable diseases (VPDs). Unadjusted annual incidence proportions of VPDs were estimated for Medicaid and commercially insured adults aged 19-64 years using 2006-2010 claims, along with age/gender-adjusted incidence proportions for 2010. In 2010, 1.6 million Medicaid adults (mean age 34 ± 12 years; 73.4% female) and 33 million commercially insured (mean age 42 ± 13 years; 52.2% female) were included. Age/gender-adjusted incidence proportions (per 100 000) in 2010 among Medicaid vs commercially insured adults for meningococcal disease were 26.2 (95% CI 22.9-29.8) vs 2.0 (1.9-2.2) (P < 0.001); hepatitis B 88.9 (82.6-95.6) vs 17.5 (17.0-17.9) (P < 0.001); pneumococcal disease 98.2 (91.7-105.1) vs 21.1 (20.7-21.6) (P < 0.001); hepatitis A 19.8 (16.9-23.1) vs 4.5 (4.3-4.7) (P < 0.001); mumps 2.1 (1.3-3.3) vs 1.4 (1.3-1.6) (P = 0.14); measles 0.3 (0.1-1.0) vs 0.3 (0.2-0.3) (P = 0.38); herpes zoster (60- to 64-year-olds only) 459 (408-515) vs 473 (466-481) (P = 0.35); varicella (19- to 39-year-olds only) 6.5 (4.8-8.5) vs 8.0 (7.5-8.5) (P = 0.12); influenza 586 (573-598) vs 633 (631-636) (P < 0.001); and pertussis 1.8 (1.1-2.8) vs 3.2 (3.0-3.4) (P < 0.001). Research is needed to fully understand the causes of the disparity of the coded incidence of some VPDs in adult Medicaid population than commercially insured adults in the US.

Along with the advances in civil rights protections for psychiatric patients since the 1970s, so-called voluntary inpatient psychiatric admissions have become common. In most U.S. states, however, these voluntary admissions abridge the rights of patients through legal provisions that limit the conditions under which patients can be discharged upon their request. This phenomenon, including variations in the state laws governing requests for discharge from voluntary psychiatric hospitalization, has received little attention in the psychiatry literature. Using Lexis-Nexis, PubMed, and Web of Science, we conducted a review of state laws regarding patients' legal rights to request discharge from voluntary hospitalization. Our hypothesis was that most states would have provisions limiting access to immediate discharge for patients whose psychiatric admission had been voluntary. Our findings from the review indicate that 49 of the 51 jurisdictions (50 states plus the District of Columbia) have provisions about patients requesting discharge from voluntary psychiatric admission. The majority of states employ a 72-hour period in which patients can be held following a request for discharge from hospitalization. As a general rule, after this evaluation period, either the patient must be discharged, or the facility must initiate involuntary commitment proceedings. Given these provisions, we explore the range of clinical admission procedures and whether voluntary admissions are truly voluntary. We also discuss the implications of our analysis for assessing the decisional capacity of patients seeking voluntary psychiatric admission.

Background The emergence of community-associated methicillin-resistant Staphylococcus aureus (SA) and its role in skin and soft tissue infections (SSTIs) accentuated the role of SA-SSTIs in hospitalizations. Methods We used the Nationwide Inpatient Sample and Census Bureau data to quantify population-based incidence and associated cost for SA-SSTI hospitalizations. Results SA-SSTI associated hospitalizations increased 123% from 160,811 to 358,212 between 2001 and 2009, and they represented an increasing share of SA- hospitalizations (39% to 51%). SA-SSTI incidence (per 100,000 people) doubled from 57 in 2001 to 117 in 2009 (p