Search

Working with U.S. policymakers to redesign national organ allocation The Organ Procurement & Transplantation Network (OPTN), which manages transplantation activities in the United States, recently partnered with the MIT Operations Research Center to design and implement novel organ allocation policies that are more equitable, efficient, and inclusive. National organ allocation policies need to strike a delicate balance between efficiency and fairness in multiple objectives, reconciling often disparate value judgments and priorities from many different stakeholders. In "Reshaping National Organ Allocation Policy," T. Papalexopoulos, J. Alcorn, and D. Bertsimas et al. introduced a novel optimization- and machine learning-based framework to aid policy design and navigate challenging fairness-efficiency tradeoffs. The authors collaborated with the OPTN to apply the framework to the design of a new national allocation policy for lungs, which was implemented in March 2023 and is anticipated to reduce waitlist mortality by approximately 20%. Based on this success, the authors are now working toward the redesign of the entire U.S. organ allocation system, including kidneys, pancreata, hearts, and livers. The Organ Procurement & Transplantation Network (OPTN) initiated in 2018 a major overhaul of all U.S. deceased-donor organ allocation policies, aiming to gradually migrate them to a so-called continuous distribution model, with the goal of creating an allocation system that is more efficient, more equitable, and more inclusive. Development of policies within this model, however, represents a major challenge because multiple efficiency and fairness objectives need to be delicately balanced. We introduce a novel analytical framework that leverages machine learning, simulation, and optimization to illuminate policy tradeoffs and enable dynamic exploration of the efficient frontier of policy options. In collaboration with the OPTN, we applied the framework to design a new national allocation policy for lungs. Since March 9, 2023, all deceased-donor lungs in the United States have been allocated according to this policy that we helped design, projected to reduce waitlist mortality by approximately 20% compared with current policy based on simulations. We discuss how we extended our collaboration with the OPTN to the redesign of kidney, pancreas, heart, and liver allocation and how our framework can be applied to other application domains, such as school choice or public housing allocation systems. Supplemental Material: The e-companion is available at https://doi.org/10.1287/opre.2022.0035. [ABSTRACT FROM AUTHOR]

Background Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts. Methods Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists. Results Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P  < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P  < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P  < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P  < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P  = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P  < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P  < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs. Conclusions After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States. [ABSTRACT FROM AUTHOR]

Much of the research on parents of children with intellectual and developmental disabilities (IDD) has focused on the negative effects on the couple relationship. The current study contributes to the understanding of parental relationship satisfaction in a sample of parents of children with Down syndrome (DS), through a mixed methods study that included data from a large national sample. Parents of children with DS were divided into two groups based on high and low relationship satisfaction scores, with quantitative and qualitative data analyses comparing these two groups. Results indicated differences between high relationship satisfaction and low relationship satisfaction groups on measures of hope, life satisfaction, and coping scores. Qualitative results also indicated group differences. Future research and implications for professionals working with parents of children with DS and other IDD diagnoses should include understanding the unique factors that affect interpersonal functioning. [ABSTRACT FROM AUTHOR]

Most meatpacking workers are Black, Latinx, and immigrant workers earning low wages and at high risk for occupational injury. Most meat and poultry plants have on-site workplace clinics (OWCs) where workers are required to obtain care for work-related injuries or illnesses before seeking outside clinical assessment or intervention. Although OWCs can help plant managers identify and mitigate hazards, government and other investigations reveal that OWCs in meatpacking plants not only fail to advocate for safer work conditions, but also nurture conditions that exacerbate injury and illness. This article explores ethical challenges for health care professionals in OWCs, including companies' pressure to keep so-called "recordable" injuries low. This article also suggests changes to support OWCs' roles in safety and injury prevention. [ABSTRACT FROM AUTHOR]

Deployments can be difficult for military service members and their spouses, with consequences often lasting well beyond when the service member has returned home. Feelings of uncertainty, stress, anxiety, loneliness, and depression are common throughout all stages of deployment. The current study is a 10-year follow-up, which explores the relational impact of deployment and trauma in married, veteran couples and their support needs. This study identified themes including: the impact of deployment (intrapersonal effects, interpersonal effects, communication effects, and impact on the parenting relationship) and coping with deployment (common bonds, formal resources, and barriers to accessing support systems). Themes are considered during pre-deployment, deployment, and post-deployment stages. [ABSTRACT FROM AUTHOR]

PURPOSE To quantify early dissemination patterns, factors influencing use, and costs of bevacizumab (BEV) for the treatment of newly diagnosed ovarian cancer (OC) in the United States before its regulatory approval for this indication (off-label use). METHODS We identified women 18-65 years of age with newly diagnosed OC treated with surgery and platinumbased chemotherapy from 2008 to 2016 through the MarketScan database (N = 8,109). The proportion of women receiving BEV over time was calculated, multivariate logistic regression used to determine factors associated with BEV use, and total costs per cycle of chemotherapy with and without BEV abstracted. RESULTS BEV utilization rose 1.8-fold during the study period, from 4.1% (2008) to 7.4%(2016). BEV was used with non-platinum/taxane regimens over a third of the time (37.2%). Physician specialty (medical oncology v gyn oncology) and geography (southeast region) were significantly associated with higher rates of use. Clinical factors associated with BEV use were metastatic disease and presence of ascites. The median cost of one cycle of platinum/taxane chemotherapy plus BEV was $10,897 in US dollars (USD) (interquartile range $7,573-$18,133 USD), compared with $1,629 USD (interquartile range, $683.0-$4,461 USD) for platinum/taxane alone. CONCLUSION Off-label use of BEV for newly diagnosed OC was rare (< 10%), but doubled following presentation of phase II and III data at international meetings. Both clinical (ascites, metastatic disease, and age) and nonclinical (specialty and region) factors were associated with BEV use, and its use was accompanied by a sixfold increase in the cost of one cycle of treatment. [ABSTRACT FROM AUTHOR]

Objectives: To measure disparities in experience of police use of force and injury among persons with serious mental illnesses. Methods: We gathered novel police use of force and suspect injury data from 2011 to 2017 from a nonrandom sample of nine police departments in the United States and used synthetic methods to estimate the share of the local population with serious mental illness. We estimate disparities using multi-level models estimated in a Bayesian framework. Results: Persons with serious mental illness constitute 17.0% of use of force cases (SD = 5.8) and 20.2% of suspects injured in police interaction (SD = 9.0) in sample cities. The risk that persons with serious mental illness will experience police use of force is 11.6 times higher (95% CI, 10.7–12.6) than persons without serious mental illness. Persons with serious mental illness are also at a higher risk of experiencing injury, 10.7 times (95% CI, 9.6–11.8), relative to persons without serious mental illness. These relative risk ratios are several times larger than racial and ethnic disparities estimated in the same cities. Conclusion: Persons with serious mental are at a significantly elevated risk of experiencing police use of force and injury in police encounters than the general public. The disparities we estimate are several times higher than racial/ethnic disparities in force and injury. Efforts to reform police practices and reimagine public safety in the United States should address significant disparities in police use of force against those with serious mental illness. [ABSTRACT FROM AUTHOR]

One of the paramount goals of oyster reef living shorelines is to achieve sustained and adaptive coastal protection, which requires meeting ecological (i.e., develop a self‐sustaining oyster population) and engineering (i.e., provide coastal defense) targets. In a large‐scale comparison along the Atlantic and Gulf coasts of the United States, the efficacy of various designs of oyster reef living shorelines at providing wave attenuation was evaluated accounting for the ecological limitations of oysters with regard to inundation duration. A critical threshold for intertidal oyster reef establishment is 50% inundation duration. Living shorelines that spent less than one‐half of the time (<50%) inundated were not considered suitable habitat for oysters, however, were effective at wave attenuation (68% reduction in wave height). Reefs that experienced >50% inundation were considered suitable habitat for oysters, but wave attenuation was similar to controls (no reef; ~5% reduction in wave height). Many of the oyster reef living shoreline approaches therefore failed to optimize the ecological and engineering goals. In both inundation regimes, wave transmission decreased with an increasing freeboard (difference between reef crest elevation and water level), supporting its importance in the wave attenuation capacity of oyster reef living shorelines. However, given that the reef crest elevation (and thus freeboard) should be determined by the inundation duration requirements of oysters, research needs to be refocused on understanding the implications of other reef parameters (e.g., width) for optimizing wave attenuation. A broader understanding of the reef characteristics and seascape contexts that result in effective coastal defense by oyster reefs is needed to inform appropriate design and implementation of oyster‐based living shorelines globally. [ABSTRACT FROM AUTHOR]

Our study examines the impact of the transition from NCAA Football Championship Series (FCS) participation to Football Bowl Series (FBS) participation on demand for university football. The primary empirical analysis uses 23 schools that transitioned to the FBS between 1987 and 2013 to examine attendance effects. We first examine the change as a type of event study and estimate the impact in a short run "transition window" of the 5 years leading up to and after the transition. We then estimate the long run impact of membership on annual attendance over a period extending from 5 years before transition through 2013 for all transition schools. Finally, we estimate impact on an alternative sample that includes a control group of top performing FCS schools that have not transitioned to FBS. The results derived from these panel regressions indicate a substantial positive impact on per game attendance over the transition period and for many years beyond the transition. [ABSTRACT FROM AUTHOR]

Lung transplantation in the United States, under oversight by the Organ Procurement Transplantation Network (OPTN) in the 1990s, operated under a system of allocation based on location within geographic donor service areas, wait time of potential recipients, and ABO compatibility. On May 4, 2005, the lung allocation score (LAS) was implemented by the OPTN Thoracic Organ Transplantation Committee to prioritize patients on the wait list based on a balance of wait list mortality and posttransplant survival, thus eliminating time on the wait list as a factor of prioritization. Patients were categorized into four main disease categories labeled group A (obstructive lung disease), B (pulmonary hypertension), C (cystic fibrosis), and D (restrictive lung disease/interstitial lung disease) with variables within each group impacting the calculation of the LAS. Implementation of the LAS led to a decrease in the number of wait list deaths without an increase in 1-year posttransplant survival. LAS adjustments through the addition, modification or elimination of covariates to improve the estimates of patient severity of illness, have since been made in addition to establishing criteria for LAS value exceptions for pulmonary hypertension patients. Despite the success of the LAS, concerns about the prioritization, and transplantation of older, sicker individuals have made some aspects of the LAS controversial. Future changes in US lung allocation are anticipated with the current development of a continuous distribution model that incorporates the LAS, geographic distribution, and unaccounted aspects of organ allocation into an integrated score. [ABSTRACT FROM AUTHOR]

The article argues that unilateral presidential waivers violate the U.S. Constitution's guarantee of equal protection. Topics discussed include various uses of arbitrary waivers by presidents, consequence of executive waivers and exemptions, and different approaches taken by courts in interpreting and applying equal protection principles at the federal level.

Background: The patient ranking process for donor lung allocation in the United States is carried out by a classification-based, computerized algorithm, known as the match system. Experts have suggested that a continuous, points-based allocation framework would better serve waiting list candidates by removing hard boundaries and increasing transparency into the relative importance of factors used to prioritize candidates. We applied discrete choice modeling to match run data to determine the feasibility of approximating current lung allocation policy by one or more composite scores. Our study aimed to demystify the points-based approach to organ allocation policy; quantify the relative importance of factors used in current policy; and provide a viable policy option that adapts the current, classification-based system to the continuous allocation framework.Methods: Rank ordered logistic regression models were estimated using 6466 match runs for 5913 adult donors and 534 match runs for 488 pediatric donors from 2018. Four primary attributes are used to rank candidates and were included in the models: (1) medical priority, (2) candidate age, (3) candidate's transplant center proximity to the donor hospital, and (4) blood type compatibility with the donor.Results: Two composite scores were developed, one for adult and one for pediatric donor allocation. Candidate rankings based on the composite scores were highly correlated with current policy rankings (Kendall's Tau ~ 0.80, Spearman correlation > 90%), indicating both scores strongly reflect current policy. In both models, candidates are ranked higher if they have higher medical priority, are registered at a transplant center closer to the donor hospital, or have an identical blood type to the donor. Proximity was the most important attribute. Under a points-based scoring system, candidates in further away zones are sometimes ranked higher than more proximal candidates compared to current policy.Conclusions: Revealed preference analysis of lung allocation match runs produced composite scores that capture the essence of current policy while removing rigid boundaries of the current classification-based system. A carefully crafted, continuous version of lung allocation policy has the potential to make better use of the limited supply of donor lungs in a manner consistent with the priorities of the transplant community. [ABSTRACT FROM AUTHOR]

From noble beginnings as a prospective forage, polyploid Sorghum halepense ('Johnsongrass') is both an invasive species and one of the world's worst agricultural weeds. Formed by S. bicolor x S. propinquum hybridization, we show S. halepense to have S. bicolor -enriched allele composition and striking mutations in 5,957 genes that differentiate it from representatives of its progenitor species and an outgroup. The spread of S. halepense may have been facilitated by introgression from closely-related cultivated sorghum near genetic loci affecting rhizome development, seed size, and levels of lutein, a photochemical protectant and abscisic acid precursor. Rhizomes, subterranean stems that store carbohydrates and spawn clonal propagules, have growth correlated with reproductive rather than other vegetative tissues, and increase survival of both temperate cold seasons and tropical dry seasons. Rhizomes of S. halepense are more extensive than those of its rhizomatous progenitor S. propinquum , with gene expression including many alleles from its non-rhizomatous S. bicolor progenitor. The first surviving polyploid in its lineage in ∼96 million years, its post-Columbian spread across six continents carried rich genetic diversity that in the United States has facilitated transition from agricultural to non-agricultural niches. Projected to spread another 200–600 km northward in the coming century, despite its drawbacks S. halepense may offer novel alleles and traits of value to improvement of sorghum. [ABSTRACT FROM AUTHOR]

Background: This study aimed to characterize bodily injury patterns associated with helmet usage by comparing trauma sustained by helmeted and helmetless cyclists admitted to a large US health-care system. Materials and Methods: A prospective trauma registry associated with a large regional United States health-care network was queried for bicycle injuries resulting in hospital admission over a 5-year period. Data pertaining to helmet usage, demographics, injury description (s), Abbreviated Injury Scale score, Injury Severity Score, and hospital length of stay were collected from 140 patients treated for bicycle-related injuries. Mann–Whitney tests were performed. Results: Fifty-six of the injured cyclists were helmeted (40%) and 84 were not helmeted (60%). A significantly greater proportion of helmeted cyclists exhibited abrasions and a higher incidence of injury across all injury types (P = <0.001 and 0.003). The number and severity of injury to the external body (P = <0.001 and 0.001) and overall injury severity (P = 0.004) for patients with multiple injuries were also significantly greater among helmeted cyclists. Helmeted cyclists did demonstrate significantly shorter hospital stays (P = 0.021). Conclusion: While the helmeted and helmetless riders admitted to the emergency department exhibit few differences in injury patterns, when significant injury differences were detected, they were more prevalent in helmeted riders. These differences were represented by minor-to-moderate injuries relative to morbidity and mortality, suggesting that the trauma profile of the helmeted and helmetless riders is relatively comparable. Yet, helmetless wearers did have significantly longer hospital stays, which may indicate underlying health disparities and/or behavioral differences. [ABSTRACT FROM AUTHOR]

The trend of increasing major party polarization in the United States has raised concerns about the quality of representation and governance. One potential corrective is third parties, as they can hold the major parties accountable and instigate positive change. We, however, highlight limits to their influence. Two factors dampened the electoral support for third party candidates in the 2016 U.S. presidential election despite favorable conditions. First, the cost of third party voting is higher in the current polarized era, since casting a vote for a third party can lead to their less-favored major party candidate winning. Voters today have especially negative feelings toward their less-favored major party. Second, Trump co-opted voters distrustful of the government, which is a group that tends to support third parties. Our analysis of American National Election Studies (ANES) data from 1992 and 2016 shows support for both factors. [ABSTRACT FROM AUTHOR]

Background: Despite 50 years since the passage of the Fair Housing Act of 1968, the majority of black Americans continue to live in highly segregated communities. Differing exposure to obesogenic environments in segregated neighborhoods may contribute to racial disparities in obesity prevalence.Methods: We used prospective data from the Coronary Artery Risk Development in Young Adults (CARDIA) study to examine associations between levels of neighborhood-level racial residential segregation and incident obesity in black men and women. Obesity, determined by measured anthropometry, and residential segregation, measured using the local Gi*statistic, were recorded at baseline and follow-up at years 7, 10, 15, 20, and 25. We used marginal structural survival models to account for time-dependent confounding and for loss to follow-up.Results: Black women living in highly segregated neighborhoods at the prior exam were 30% more likely to become obese during the follow-up period as compared with women living in neighborhoods with low levels of segregation after adjustment for sociodemographic and cardiovascular risk covariates (hazard ratio = 1.3 [95% confidence interval = 1.0, 1.7]). Cumulatively high exposure to segregation averaged across time points was associated with 50% higher hazard of obesity (hazard ratio = 1.5 [95% confidence interval = 1.0, 2.3]) among women. We observed few differences in obesity incidence among men by segregation levels.Conclusions: Fewer health-promoting resources, stressful neighborhood context, and social norms that are less stigmatizing of obesity may contribute to these findings, but more research on specific pathways leading from segregation to obesity is needed to understand differing patterns between men and women. [ABSTRACT FROM AUTHOR]

It is important for university decision makers to carefully scrutinize empirical data concerning the impacts of college athletics on the university as a whole in formulating strategies for athletic programs. This paper reviews and extends existing statistical work on the effects of college athletics using basic concepts from economics as guideposts. Current evidence indicates that success. and at times merely participation, in college athletics provides several benefits including direct financial gain and such indirect benefits as increased university exposure and, in turn, increased financial contributions and increased student applications and enrollment. Evidence concerning negative exposure from events such as NCAA sanctions is sparse but suggests opposite effects of smaller magnitude. [ABSTRACT FROM AUTHOR]

There has been—and continues to be—tension between Native peoples and museums in the United States due to past collecting practices and exhibitions that strive to interpret their culture and history without their involvement. Previously, many of these exhibitions stereotyped and lumped Native peoples together, depicting their cultures as static and interpreting them and their material culture from a Western scientific perspective. Changes are being made. Collaboration between Native peoples and museums in all areas of museum work, including exhibitions, is beginning to be considered by many as a best practice. Exhibitions developed in collaboration with Native peoples, with shared curatorial authority, decidedly help ease the historic tension between the two, and they are much more vibrant and accurate than when collaboration is lacking. This article will provide three examples of collaboration, defined with our tribal partners, to develop exhibitions at History Colorado, the state history museum, concluding with lessons learned. [ABSTRACT FROM AUTHOR]

Oyster reef living shorelines have been proposed as an effective alternative to traditional coastal defence structures (e.g. bulkheads, breakwaters), with the benefit that they may keep pace with sea‐level rise and provide co‐benefits, such as habitat provision. However, there remains uncertainty about the effectiveness of shoreline protection provided by oyster reefs, which limits their broader application.We draw evidence from studies along the east and gulf coasts of the United States, where much research and implementation of oyster reef restoration has occurred, to better define the existing gaps in our understanding of the use of restored oyster reefs for shoreline protection.We find potential disconnects between ecological and engineering functions of reefs. In response, we outline how engineering and ecological principles are used in the design of oyster reef living shorelines and highlight knowledge gaps where an integration of these disciplines will lead to their more effective application.Synthesis and applications. This work highlights the necessary steps to advance the application of oyster reef living shorelines. Importantly, future research should focus on appropriate designs and conditions needed for these structures to effectively protect our coasts from erosion, while supporting a sustainable oyster population, thereby providing actionable nature‐based alternatives for coastal defence to diverse end‐users. This work highlights the necessary steps to advance the application of oyster reef living shorelines. Importantly, future research should focus on appropriate designs and conditions needed for these structures to effectively protect our coasts from erosion, while supporting a sustainable oyster population, thereby providing actionable nature‐based alternatives for coastal defence to diverse end‐users. [ABSTRACT FROM AUTHOR]

Background: Despite considerable health and environmental benefits, cycling is also associated with a risk of injury. Yet, variation in the patterns of cycling trauma which manifests by gender, age, and race/ethnicity is ill-defined. This retrospective study aims to characterize injury patterns in different demographic groups of bicyclists admitted to the Greenville Health System in South Carolina. Patients and methods: In this IRB-approved, retrospective study, five years of patient data (2010–2014) were gathered from seven emergency departments associated with the Greenville Health System. A total of 155 adult patients hospitalized for bicycle-related trauma were examined in terms of demographics (age, gender, and race) and injury. Injuries were categorized by type, region, and severity. Non-parametric tests were performed to study the effect of demographic characteristics on injury presentation. Results: Spinal cord (p = 0.003) and internal organ injuries (p = 0.000) were significantly more common in men. External body injuries were also more prevalent and severe in men (p = 0.05), while injury to the extremities and pelvic region was more common and severe in women (p = 0.02). Herniations (p = 0.028), internal organ injuries (p = 0.000), and abrasions (p = 0.04) occurred more often in White cyclists. This group was also more likely to be wearing a helmet at the time of accident (p = 0.00). Finally, while hematomas were more prevalent in older adults (≥55 years) cyclists (p = 0.01), this population was also more also likely to wear a helmet than young adults (18–34 years) cyclists (p = 0.025). Conclusion: Demographic differences exist in the types and severity of cycling trauma. These differences should be considered during the identification and management of bicycle-related trauma. [ABSTRACT FROM AUTHOR]

In Terry v. Ohio, the US Supreme Court relied on a balancing test to uphold the reasonableness of the practice known as "stop and frisk," balancing the contribution of the practice to effective crime prevention and detection against the nature and quality of the intrusion to individual rights. In recent years, statistics have been powerfully deployed by legal scholars, jurists, and policymakers to challenge the assumption that stop and frisk leads to frequent discovery of contraband or other criminal behavior, and to address stark racial and ethnic disparities in the deployment of stop and frisk. However, the other side of the Terry equation-the nature and quality of the intrusion-has received far less attention from the legal community. With few exceptions, Terry jurisprudence portrays the Terry frisk simply as a brief pat-down of the outer clothing and treats each Terry stop as an isolated encounter for purposes of measuring the harm involved. Yet there is a robust social science literature on the effects of stop and frisk on individuals, including data on its effects on individuals from marginalized or vulnerable groups, on individuals over time, and on communities as a whole. Moreover, stop and frisk in the current era has evolved from a tool in the arsenal of individual officers to a systematic, widely deployed strategy. This article argues that the failure to grapple with the application of modern knowledge to modern policing practices leads to a mismeasurement on both sides of the Terry equation. Not only does stop and frisk cause a wide range of emotional and psychological harms; these harms may also interfere with the ability of law enforcement to prevent and investigate crime. Even apart from any legal doctrinal implications for stop and frisk jurisprudence, recognizing the flawed assumptions described in this article should encourage all the relevant stakeholders to re-evaluate the consequences of the Terry regime. [ABSTRACT FROM AUTHOR]

The link between happiness and overall inequality is best studied using an index that incorporates different aspects of inequality, and is measured consistently in different countries. One such index is the degree to which happiness itself varies among individuals. Its correlation with both happiness levels and social trust is substantially stronger than the corresponding correlation for income inequality. This remains so after allowing for bounded scale reporting, including a purely ordinal measure of dispersion. Moreover, the correlation is stronger for individuals who profess to care most about inequality. The link between happiness and inequality may thus be stronger than previously appreciated. (JEL I31, D6, D63, D31) [ABSTRACT FROM AUTHOR]

This article presents a challenge to the theory of optimal seigniorage, which predicts that governments use taxes and inflation to raise revenue when needed. It is based on the assumption that currency boards choose how much money to create, produce the money at zero cost, and transfer all the money to the fiscal branch, or the treasury. The authors show that each of these is flawed and that the theory does not always predict when the tax rate on money and output move synchronously. This only happens in certain circumstances.

Objective: To determine whether duration and degree of weight gain are differentially associated with diabetes risk in younger versus middle-aged black and white adults.Research Design and Methods: We combined data from three cohort studies: Atherosclerosis Risk in Communities (ARIC), Coronary Artery Risk Development in Young Adults (CARDIA), and the Framingham Heart Study. A total of 17,404 participants (56% women; 21% black) were stratified by baseline age (younger: ≥30 and <45 years; middle-aged: ≥45 and <60 years) and examined for incident diabetes (median follow-up 9 years). Duration and degree of gain in BMI were calculated as "BMI-years" above one's baseline BMI.Results: Diabetes incidence per 1,000 person-years in the younger and middle-aged groups was 7.2 (95% CI 5.7, 8.7) and 24.4 (22.0, 26.8) in blacks, respectively, and 3.4 (2.8, 4.0) and 10.5 (9.9, 11.2) in whites, respectively. After adjusting for sex, baseline BMI and other cardiometabolic factors, and age and race interaction terms, gains in BMI-years were associated with higher risk of diabetes in the younger compared with middle-aged groups: hazard ratios for 1-unit increase in log BMI-years in younger versus middle-aged blacks were 1.18 (P = 0.02) and 1.02 (P = 0.39), respectively (P for interaction by age-group = 0.047), and in whites were 1.35 (P < 0.001) and 1.11 (P < 0.001), respectively (P for interaction by age-group = 0.008).Conclusions: Although middle-aged adults have higher rates of diabetes, younger adults are at greater relative risk of developing diabetes for a given level of duration and degree of weight gain. [ABSTRACT FROM AUTHOR]

Objectives: Osteoporosis is a major public health concern affecting an estimated 10 million people in the United States. To the best of our knowledge, no qualitative study has explored barriers perceived by medicine hospitalists to secondary prevention of osteoporotic hip fractures. We aimed to describe these perceived barriers and recommendations regarding how to optimize secondary prevention of osteoporotic hip fracture.Methods: In-depth, semistructured interviews were performed with 15 internal medicine hospitalists in a tertiary-care referral medical center. The interviews were analyzed with directed content analysis.Results: Internal medicine hospitalists consider secondary osteoporotic hip fracture prevention as the responsibility of outpatient physicians. Identified barriers were stratified based on themes including physicians' perception, patients' characteristics, risks and benefits of osteoporosis treatment, healthcare delivery system, and patient care transition from the inpatient to the outpatient setting. Some of the recommendations include building an integrated system that involves a multidisciplinary team such as the fracture liaison service, initiating a change to the hospital policy to facilitate inpatient care and management of osteoporosis, and creating a smooth patient care transition to the outpatient setting.Conclusions: Our study highlighted how internal medicine hospitalists perceive their role in the secondary prevention of osteoporotic hip fractures and what they perceive as barriers to initiating preventive measures in the hospital. Inconsistency in patient care transition and the fragmented nature of the existing healthcare system were identified as major barriers. A fracture liaison service could remove some of these barriers. [ABSTRACT FROM AUTHOR]

Rationale: Noninvasive ventilation (NIV) is a cornerstone of treatment for patients with severe exacerbations of chronic obstructive pulmonary disease (COPD), where it has been shown to reduce the need for intubation, hospital length of stay, and mortality. Despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals.Objectives: To identify approaches used by hospitals that have been successful in implementing NIV to treat patients with severe exacerbations of COPD.Methods: Adopting a positive deviance approach, in-depth interviews were conducted with key stakeholders from a sample of high-performing hospitals selected from a large and representative network of 386 U.S. hospitals. High performers were defined as hospitals in which a high proportion of patients with COPD requiring mechanical ventilation were treated with NIV, and that also achieved low risk-adjusted mortality for all patients with COPD. Interviews were audio-recorded and transcribed verbatim. Themes and subthemes were identified through iterative readings of the transcripts and discussion until the team agreed that all important themes and subthemes had been identified. All transcripts were coded by three or four researchers. Differences in coding were discussed to negotiate consensus, resulting in a single agreed-on set of coded transcripts.Results: Interviews were conducted with 32 participants from seven hospitals. Hospitals were diverse regarding size, teaching status, and geographic location. Participants included respiratory therapists (n = 15), physicians (n = 10), and nurses (n = 7). The qualitative analyses revealed three interrelated domains that characterized effective NIV use: processes, structural elements, and contextual factors. Several themes comprised each domain. Key processes included timely identification of appropriate patients, early initiation of NIV, frequent reassessment of patients, and attention to patient comfort. Necessary structural elements included adequate equipment, sufficient numbers of qualified respiratory therapists, and flexibility in staffing. Important contextual factors included provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education. Hospital leaders, policies, and protocols were identified as playing a supporting role in promoting essential elements.Conclusions: We identified factors, such as respiratory therapist autonomy, that facilitated essential processes (e.g., timely initiation) of NIV use at high-performing hospitals. These findings may be useful to hospitals seeking to optimize their use of NIV among patients with COPD. [ABSTRACT FROM AUTHOR]

The relationship between political outcome and religiosity is often presented in overly simplistic terms with political parties labeled with a religious categorization or belief system, such as Catholics are Democrats and Baptists are Republicans. We develop a Lancaster-type model of religious and political activity where these choices grow out of underlying endowments, attributes, and production capabilities of consumers along with attributes of religious organizations. Such a model suggests that the relationships between religious and political activity are complex and driven by choice fundamentals. Using county-level data from the 2000 and 2012 presidential elections, we find empirical support for this more complex view of the relationship between religion and politics. [ABSTRACT FROM AUTHOR]

Health-system and community pharmacy practice in the United States is experiencing transformational change; however, this transformation is lagging in the international arena. As a result, efforts are being made to provide support and education to the international pharmacy leaders and practitioners. This article describes one effort, the Mandela Washington Fellows Program, and suggests areas where pharmacy leaders can be involved to help advance the practice of pharmacy on an international level. The Mandela Washington Fellows Program for young Africa leaders consists of a US-Africa pharmacymentoring program identified ranging from educational opportunities to collaboration for implementation of patient care programs. The specifics of the mentoring program include daily meetings, clinic and ward rounds, round table discussions with mentors, and visits to various hospital care systems. Lessons were learned and strategies for sustaining the program are discussed. These types of programs represent leadership opportunities that may not be apparent to most pharmacy directors, but expanding their view to helping international pharmacists expand their practice only strengthens the professional goal of providing patient-centered pharmacy services. [ABSTRACT FROM AUTHOR]

Background: Increasing reports of synthetic cannabinoid (SC)-related adverse events have largely comprised case reports and analyses of calls to poison control centers. Existing studies have also mostly involved white male populations. Objectives: The purpose of this study is to systematically describe clinical characteristics of SC use in a relatively large, diverse, urban sample presenting to a psychiatric emergency setting. Methods: SC users (n = 110) were identified by reviewing charts (n = 948) from the psychiatric emergency service of a large, urban public hospital in the United States for November 2014, which was randomly selected from the 12 months of that year. Sociodemographic data were collected from administrative databases and clinical data were collected from the electronic medical record. Results: SC users were mostly non-white (90.0%) males (95.5%), who were likely to be police-involved (34.5%) and homeless (84.5%). SC users also had significant and often pre-existing psychiatric and substance use comorbidity, including acute psychotic symptoms (70.0%), more than one comorbid psychiatric diagnosis (31.8%) and primary psychotic disorder diagnosis (40.0%), past psychiatric visits to the hospital (70.9%), comorbid substance use (62.7%), agitation requiring intervention (22.7%), and the need for extended psychiatric observation (15.5%) and inpatient admission (34.5%). Relatively limited medical complications were identified. Conclusions/Importance: In this sample, SC use affected a sociodemographically disadvantaged and mentally ill population, likely exacerbating existing psychiatric problems. This is one of the only studies to systematically examine the clinical effects of SC use in a significant clinical sample, and the first study in an urban, racial/ethnic minority, and vulnerable sample. [ABSTRACT FROM AUTHOR]

Objectives. To investigate the effects of marijuana in the development of incident cardiovascular and cerebrovascular outcomes. Methods. Participants were 5113 adults aged 18 to 30 years at baseline (1985-1986) from the Coronary Artery Risk Development in Young Adults study, who were followed for more than 25 years. We estimated cumulative lifetime exposure to marijuana using repeated assessments collected at examinations every 2 to 5 years. The primary outcome was incident cardiovascular disease (CVD) through 2013. Results. A total of 84% (n = 4286) reported a history of marijuana use. During a median 26.9 years (131 990 person-years), we identified 215 CVD events, including 62 strokes or transient ischemic attacks, 104 cases of coronary heart disease, and 50 CVD deaths. Compared with no marijuana use, cumulative lifetime and recent marijuana use showed no association with incident CVD, stroke or transient ischemic attacks, coronary heart disease, or CVD mortality. Marijuana use was not associated with CVD when stratified by age, gender, race, or family history of CVD. Conclusions. Neither cumulative lifetime nor recent use of marijuana is associated with the incidence of CVD in middle age. [ABSTRACT FROM AUTHOR]

The article focuses on constitutional infirmity, and public policy all weigh heavily against wealth-based pretrial systems in the U.S. It mentions efforts already undertaken by certain state courts and legislatures to mitigate the harmful consequences of cash bail and shortcomings of pretrial supervised release programs. It also mentions various avenues for achieving the soft-conflicting goals of crime prevention and pretrial liberty.

Background: Whether measuring and reporting of coronary artery calcium scores (CACS) might lead to changes in cardiovascular risk management is not established. In this observational study, we examined whether high baseline CACS were associated with the initiation as well continuation of new lipid-lowering medication (LLM), blood pressure-lowering medication (BPLM), and regular aspirin (ASA) use in a multi-ethnic population-based cohort.Methods and Results: The Multi-Ethnic Study of Atherosclerosis (MESA) is a prospective cohort study of 6814 participants free of clinical cardiovascular disease at entry who underwent CAC testing at baseline examination (examination 1). Information on LLM, BPLM, and regular ASA usage was also obtained at baseline and at exams 2 and 3 (average of 1.6 and 3.2 years after baseline, respectively). In this study, we examined (1) initiation of these medications at examination 2 among participants not taking these medications at baseline; and (2) continuation of medication use to examination 3 among participants already on medication at baseline. Among MESA participants, initiation of LLM, BPLM, and ASA was greater in those with higher CACS. After taking into account age, sex, race, MESA site, LDL cholesterol, diabetes mellitus, body mass index, smoking status, hypertension, systolic blood pressure, and socioeconomic status (income, education, and health insurance), the risk ratios for medication initiation comparing those with CACS >400 versus CACS=0 were 1.53 (95% confidence interval [CI], 1.08, 2.15) for LLM, 1.55 (95% CI, 1.10 to 2.17) for BPLM, and 1.32 (95% CI, 1.03 to 1.69) for ASA initiation, respectively. The risk ratios for medication continuation among those with CAC >400 versus CACS=0 were 1.10 (95% CI, 1.01 to 1.20) for LLM, 1.05 (95% CI, 1.02 to 1.08) for BPLM, and 1.14 (95% CI, 1.04 to 1.25) for ASA initiation, respectively.Conclusions: CACS >400 was associated with a higher likelihood of initiation and continuation of LLM, BPLM, and ASA. The association was weaker for continuation than for initiation of these preventive therapies. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the impact of a client-centered behavioral intervention (Brief Negotiated Interviewing) on mothers’ human papillomavirus (HPV) vaccine knowledge and vaccination initiation for their adolescent daughters. Methods. We randomized mothers to intervention (n = 100) and control (n = 100) groups, and followed them over 12 months. Electronic medical records were reviewed to determine vaccination status. The primary outcome was receipt of the first vaccine. The secondary outcome was HPV vaccine knowledge among mothers. Results. Brief Negotiated Interviewing intervention mothers demonstrated increased knowledge about HPV (pre/post mean score of 5 to 10 out of a possible 11; P < .001) and significantly higher mean knowledge scores (10 vs 6, P < .001) than control mothers. However, initiation and completion rates of the vaccine were not significantly different between groups. Conclusions. Increasing HPV vaccine knowledge did not translate into increased vaccine uptake or completion of vaccination series. Future intervention must explore vaccine reminders to increase HPV vaccination rates. [ABSTRACT FROM AUTHOR]

Forty-six states and the U.S. Congress have passed funeral protest statutes to counter the notorious practices of the Westboro Baptist Church, but are the statutes constitutional? The recent Supreme Court case of McCullen v. Coakley on the parallel issue of abortion clinic buffer zones suggests that they are not. First, the Court restored speech rights by reaffirming that the governmental interest of protecting people from unwanted communication while in traditional public fora is content based. Second, the Court struck down a statute as failing to be narrowly tailored, despite the Court's application of intermediate scrutiny. While lower courts have upheld broad funeral protest statutes, the Supreme Court now shows that even facially content-neutral statutes do not give legislatures carte blanche to substantially burden speech. The Sixth and Eighth Circuit courts have upheld broad funeral protest statutes, but McCullen shows a far more speech-protective Supreme Court. In light of this precedent, lower courts should rule that existing funeral protest statutes are unconstitutional. However, this article proposes a more moderate "line of sight" legislative solution that would preserve the protestors' First Amendment rights while protecting funeral attendees' interest in avoiding disruptive protests during funerals. This workable solution is narrowly tailored to serve the valid state interest of preventing funeral disruptions. [ABSTRACT FROM AUTHOR]

Antimicrobial stewardship programs (ASPs) are challenged with ensuring appropriate antimicrobial use while minimizing expenditures. ASPs have consistently demonstrated improved patient outcomes and significant cost reductions but are continually required to justify the costs of their existence and interventions due to the silo mentality often adopted by hospital administrators. As new technologies and antimicrobials emerge, ASPs are in a constant tug-of-war between providing optimal clinical outcomes and ensuring cost containment. Additionally, robust data on cost-effectiveness of new rapid diagnostic technologies and antimicrobials with subsequent ASP interventions to provide justification are lacking. As the implementation of an ASP will soon be mandatory for acute care hospitals in the United States, ASPs must find ways to justify novel interventions to align themselves with healthcare administrators. This review provides a framework for the justification of implementing a rapid diagnostic test or adding a new antimicrobial to formulary with ASP intervention, reviews approaches to demonstrating cost-effectiveness, and proposes methods for which ASPs may reduce healthcare expenditures via alternative tactics. [ABSTRACT FROM AUTHOR]

Objective: We sought to describe and find correlates of health-related quality of life among under-served low-income patients in North Carolina with diabetes mellitus.Methods: A telephone survey of 310 patients recording quality of life, patient satisfaction, self-reported health, and patient complaints was conducted as part of a diabetes care improvement project. Demographic and clinical records were available for 249 of these patients: 69% were female, 45% were minority, and 84% had type 2 diabetes. Ages ranged from 18 to 88 years with a mean of 56. Quality of life indices consisted of SF-36 physical functioning, mental health and diabetes-39 sub-scores.Results: Comparison to SF-36 norms showed the sample had lower sub-scores than expected. The multivariate analysis suggested that being within an acceptable metabolic control predicted better quality of life physically, mentally, and sexually. Strong associations were detected between most sub-scores and complaints involving legs and feet, self-rated vision, and hassles in self-management.Conclusions: The consistent associations between the sub-scores and complaints, symptoms, and hassles underscore the strong relationship quality of life may share with the severity of diabetes complications as well as with psychosocial factors. Significantly lower quality of life in this sample highlights the need to improve the care of minority low-income diabetes patients. [ABSTRACT FROM AUTHOR]

The May 2015 release of the report of the President’s Task Force on 21st Century Policing highlighted a fundamental change in the issues dominating discussions about policing in America. That change has moved discussions away from a focus on what is legal or effective in crime control and toward a concern for how the actions of the police influence public trust and confidence in the police. This shift in discourse has been motivated by two factors—first, the recognition by public officials that increases in the professionalism of the police and dramatic declines in the rate of crime have not led to increases in police legitimacy, and second, greater awareness of the limits of the dominant coercive model of policing and of the benefits of an alternative and more consensual model based on public trust and confidence in the police and legal system. Psychological research has played an important role in legitimating this change in the way policymakers think about policing by demonstrating that perceived legitimacy shapes a set of law-related behaviors as well as or better than concerns about the risk of punishment. Those behaviors include compliance with the law and cooperation with legal authorities. These findings demonstrate that legal authorities gain by a focus on legitimacy. Psychological research has further contributed by articulating and demonstrating empirical support for a central role of procedural justice in shaping legitimacy, providing legal authorities with a clear road map of strategies for creating and maintaining public trust. Given evidence of the benefits of legitimacy and a set of guidelines concerning its antecedents, policymakers have increasingly focused on the question of public trust when considering issues in policing. The acceptance of a legitimacy-based consensual model of police authority building on theories and research studies originating within psychology illustrates how psychology can contribute to the development of evidence-based policies in the field of criminal law. [ABSTRACT FROM AUTHOR]

In US culture, slavery is remembered as an agricultural system bound to expansive territory rather than as an ideological system bound to urban spaces. This fixed notion persists despite the fact that nearly a fifth of all American slaves were captive in cities, where African African women were significantly overrepresented among those who did both physical and emotional labor. The elision of urban slaves is particularly curious because of the centrality of Frederick Douglass, who labored on both a plantation on the Eastern Shore of Maryland and on the docks of Baltimore, to national narratives of slavery. "Interior Travelogues and 'Inside Views': Gender, Urbanity, and the Genre of the Slave Narrative" explores the elision of urban slavery as a gendered phenomenon, critiquing the still-present fetish for both great men and great books in studies of the slave narrative. This essay reads The Octoroon —a narrative told to Hiram Mattison by Louisa Picquet, a woman held in sexual slavery in three Southern cities: Columbia, South Carolina; Mobile, Alabama; and New Orleans, Louisiana—as a resistant text that upends conventions of both remembering and failing to remember urban slavery. [ABSTRACT FROM AUTHOR]

We conducted 2 studies to investigate how cultural stereotypes that depict Blacks as criminals affect the way Blacks experience encounters with police officers, expecting that such encounters induce Blacks to feel stereotype threat (i.e., concern about being judged and treated unfairly by police because of the stereotype). In Study 1, we asked Black and White participants to report how they feel when interacting with police officers in general. As predicted, Blacks, but not Whites, reported concern that police officers stereotype them as criminals simply because of their race. In addition, this effect was found for Black men but not Black women. In Study 2, we asked Black and White men to imagine a specific police encounter and assessed potential downstream consequences of stereotype threat. Consistent with Study 1, Black but not White men anticipated feeling stereotype threat in the hypothetical police encounter. Further, racial differences in anticipated threat translated into racial differences in anticipated anxiety, self-regulatory efforts, and behavior that is commonly perceived as suspicious by police officers. By demonstrating that Blacks might expect to be judged and treated unfairly by police because of the negative stereotype of Black criminality, this research extends stereotype threat theory to the new domain of criminal justice encounters. It also has practical implications for understanding how the stereotype could ironically contribute to bias-based policing and racial disparities in the justice system. [ABSTRACT FROM AUTHOR]

The aim of this study is to determine the extent to which principals' self-ratings of leadership effectiveness coincide with their teachers' perceptions of their leadership effectiveness. Furthermore, we explore several characteristics of teachers and principals in an attempt to identify the factors that may predict congruence in perceptions of leadership. This study draws from survey data of 76 principals and over 2100 teachers who completed parallel forms of a 72-item Learning-Centered Leadership survey (VAL-ED) in the USA. Teacher and principal characteristics are incorporated into a multivariate regression analysis. Although there is zero difference in the overall sample, teachers and principals within any given school seldom share the same perspective. Principals' self-efficacy was a strong predictor of principals rating themselves higher than the teachers. Interestingly, the more time a teacher spent with a principal, the less congruence they shared. This research has identified rather large disparities in perceptions of leadership between teachers and their principals. Such a gap suggests that teachers have information and perspectives on school leadership distinct from the principals' information and perspectives. This research provides evidence that structured teacher feedback may provide a useful avenue for principals seeking additional perspectives on their leadership effectiveness. [ABSTRACT FROM AUTHOR]

Objective: In a pragmatic clinical trial, this study sought to compare relapses among patients receiving either long-acting injectable or oral second-generation antipsychotics.Methods: PROACTIVE (Preventing Relapse Oral Antipsychotics Compared to Injectables Evaluating Efficacy), a prior 30-month relapse prevention study, compared use of a long-acting injectable second-generation antipsychotic with use of an oral second-generation antipsychotic by 305 patients with schizophrenia or schizoaffective disorder and found similar rates of first relapse between groups (42% with injectable medication, 32% with oral medication). This study examined subsequent relapses among patients who had relapsed in PROACTIVE and who continued in treatment, follow-up, or both.Results: Thirty-two patients (11%) experienced two relapses, and 13 patients (4%) had three relapses. Neither rate of relapse nor time to successive relapses differed between treatment groups.Conclusions: There was an impressively low rate of subsequent relapses in this pragmatic clinical trial. Because all patients had a clinic visit according to the biweekly long-acting injectable medication administration schedule, frequent contact may have contributed to low relapse rates. Maintaining frequent clinical contact may be a valid psychosocial relapse prevention treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND: Studies have shown a mismatch between published cancer screening and genetic counseling referral recommendations and physician-reported screening and referral practices. Inaccurate cancer risk assessment is one potential cause of this mismatch. OBJECTIVE: To assess U.S. physicians' ability to accurately determine a woman's colon and ovarian cancer risk level. DESIGN, PARTICIPANTS: Cross-sectional survey of U.S. family physicians, general internists, and obstetrician-gynecologists. A twelve-page questionnaire with a vignette of a woman's annual examination included a question about the patient's level of colon and ovarian cancer risk. The final study sample included 1,555 physicians weighted to represent practicing U.S. physicians nationally. MAIN MEASURE: Accuracy of physicians' ovarian and colon cancer risk assessments. KEY RESULTS: Overall, most physicians accurately assessed women's risk of ovarian (57.0 %, CI 54.3, 59.6) and colon cancer (62.0 %, CI 59.4, 64.6). However, 27.1 % (CI 23.0, 31.6) of physicians overestimated the ovarian cancer risk among women at the same risk as the general population, and 65.1 % (CI 60.2, 69.7) underestimated ovarian cancer risk among women at much higher risk than the general population. Physicians overestimated colon more than ovarian cancer risk (38.0 %, CI 35.4, 40.6 vs. 27.1 %, CI 23.0, 31.6) for women at the same risk as the general population. CONCLUSIONS: Physicians' misestimation of patient ovarian and colon cancer risk may put average risk patients in jeopardy of unnecessary screening and higher risk patients in jeopardy of missed opportunities for prevention or early detection of cancers. [ABSTRACT FROM AUTHOR]

Purpose: To examine the attitudes toward human papillomavirus (HPV) vaccination among young men from African American, Haitian, Caucasian, and Latino backgrounds. Methods: We used in-person surveys at an urban teaching hospital from 2010 to 2012 to examine the racial and ethnic differences in the perceived benefits and barriers to HPV vaccination and vaccine mandate acceptance among 18- to 22-year-old African American, Haitian, Caucasian, and Latino men. Results: A total of 89 men participated (35% African American, 29% Haitian, 20% Latino, and 16% white). Participants from all ethnic groups perceived benefits to HPV vaccination but differed in their perceptions of barriers to vaccination as well as their acceptance of a vaccine mandate. Conclusions: Culturally competent educational messages may overcome ethnic differences in the attitudes, beliefs, and behaviors regarding vaccination among college-aged men from an urban population. [ABSTRACT FROM PUBLISHER]

With Epic leading the challenge of electronic medical record technology, several tools have been developed within Epic to optimize antimicrobial stewardship programs (ASPs). We cite current examples of Epic stewardship tools from 3 academic medical centers’ ASPs.Antimicrobial stewardship programs (ASPs) are established means for institutions to improve patient outcomes while reducing the emergence of resistant bacteria. With the increased adoption and evolution of electronic medical records (EMRs), there is a need to assimilate the tools of ASPs into EMRs, using decision support and feedback. Third-party software vendors provide the mainstay for integration of individual institutional EMR and ASP efforts. Epic is the leading implementer of EMR technology in the United States. A collaboration of physicians and pharmacists are working closely with Epic to provide a more comprehensive platform of ASP tools that may be institutionally individualized. We review the historical relationship between ASPs and the EMR, cite examples of Epic stewardship tools from 3 academic medical centers’ ASPs, discuss limitations of these Epic tools, and conclude with the current process in evolution to integrate ASP tools and decision support capacities directly into Epic's EMR. [ABSTRACT FROM AUTHOR]