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The article discusses the intersection of chemical dependency and mental health issues with the timelines associated with America's juvenile protection system as of 2014, and it mentions the legal aspects of concurrent planning and the termination of parental rights in places such as Minnesota. The legal rights of abused children are examined, along with child protection laws, the enactment of Minnesota's neglect statute in 1905, and the U.S. Adoption Assistance of Child Welfare Act of 1980.

Eastern North Carolina is a major contributor to both turkey and swine production in the United States. In this region, turkeys and swine are frequently grown in close proximity and by common growers. To further characterize colonization of turkeys and swine with Campylobacter in such a setting, we investigated the prevalence of thermophilic campylobacters in eight paired operations involving turkey farms in close proximity to finishing swine farms. All 15 surveyed flocks and 15 herds were Campylobacter positive at one or more sampling times. Campylobacter was isolated from 1,310 (87%) of the 1,512 turkey samples and 1,116 (77%) of the 1,448 swine samples. Most (>99%) campylobacters from swine samples were Campylobacter coli, found in 59 to 97% of the samples from the different herds. Both Campylobacter jejuni and C. coli were recovered from the turkey flocks (overall prevalences of 52 and 35%, respectively). Prevalence among flocks ranged from 31 to 86% for C. jejuni and 0 to 67% for C. coli, and both species were recovered from most flocks. Relative prevalence of C. coli was higher in young birds (brooders), whereas C. jejuni predominated in grow-out birds (P < 0.0001). The prevalence of C. coli in a swine herd was generally not a good predictor for prevalence of this species in the corresponding turkey flock. These findings indicate that even though turkeys and swine grown in proximity to each other were commonly colonized with thermophilic campylobacters, the relative prevalences of C. jejuni and C. coli appear to be host associated. [ABSTRACT FROM AUTHOR]

Provides information on the Hazardous Substances Emergency Events Surveillance (HSEES) system of the U.S. Agency for Toxic Substances and Disease Registry regarding public health consequences associated with hazardous-substance-release events during railroad transit. Summary of railroad events from several states reported to the HSEES; Most common substances released in railroad events; Percentage of the known quantities released that were measured in gallons.

In the 1995-96 and 1996-97 school years, 37 elementary schools in Memphis, TN began implementation of 1 of 8 comprehensive school reform designs. The effectiveness and mobility of teachers at these schools were examined longitudinally relative to teachers at 63 nonrestructuring schools. Analyses of teacher effectiveness scores, derived from student "value-added" achievement scores, indicate that the 1995 reform cohort only showed significantly greater gains in effectiveness relative to the nonrestructuring group. This pattern was most strongly pronounced for highly experienced teachers. Teacher mobility was found to increase minimally as a function of restructuring, largely due to district policy changes. [ABSTRACT FROM AUTHOR]

Objective: To determine the positive predictive value of ICD-9-CM coding of acute myocardial infarction and cardiac procedures.Methods: Using chart-abstracted data as the standard, we examined administrative data from the Veterans Health Administration for a national random sample of 5,151 discharges.Main Results: The positive predictive value of acute myocardial infarction coding in the primary position was 96.9%. The sensitivity and specificity of coding were, respectively, 96% and 99% for catheterization, 95.7% and 100% for coronary artery bypass graft surgery, and 90.3% and 99. 7% for percutaneous transluminal coronary angioplasty.Conclusions: The positive predictive value of acute myocardial infarction and related procedure coding is comparable to or better than previously reported observations of administrative databases. [ABSTRACT FROM AUTHOR]

This study examines temporal trends in the use and outcomes of cardiac procedures for patients hospitalized with acute myocardial infarction in Department of Veterans Affairs (VA) hospitals with and without invasive cardiac services. Between 1988 and 1994, there was striking overall growth in the use of cardiac procedures in the VA. Over this time period, the authors found persistent variation in the use of cardiac procedures but diminished differences in patient survival among patients admitted to different types of hospitals. Growth of cardiac procedure use and improvements in patient survival were most significant in hospitals without on-site invasive cardiac services. We were unable to determine whether survival gains were associated with increased procedure use or unmeasured improvements in the process of care. These trends raise intriguing questions about access to and outcomes of cardiac procedures in health systems composed of hospitals with and without a full complement of on-site invasive cardiac services. [ABSTRACT FROM AUTHOR]

The article presents information on tropical mountain cradles of dry forest diversity. Of all ecosystems in tropical America, seasonally dry forests, patchily distributed where relatively fertile soils, annual rainfall less than 1,600 mm, and strong seasonal drought coincide, are perhaps the least understood and most endangered. Mesoamerican dry forest diversity peaks in southwest Mexico, where up to 16% of tree species are local endemics. The North American dispersal hypothesis is compelling. The most important dry forest tree family, Leguminosae, has numerous recent clades with species in Africa and tropical America, whose geographic distributions can be explained only by oceanic dispersal.

Examines veterans' dual use of health services provided by the Department of Veterans Affairs and other insurance providers in the U.S. Advantages of having a single primary care provider; Impcat on taxpayers; Policy implications of the research.

Deaf epistemology made a crucial contribution to an understanding of a Deaf worldview, yet did not quite encompass the "D/deaf experience." It started the conversation but seemingly stalled. In an expansion on earlier studies of Deaf epistemology, the researchers considered the question "What does it mean to be D/deaf?" D/deaf participants submitted narratives that were analyzed for common themes via grounded theory research methodology. Six open codes were identified: school, cultural capital, deficit/The Struggle, difference/empowerment, accessibility/technology, hearing technology. These themes were captured by two axial codes: journey and sense of belonging. The core category was determined to be situated homecoming , reflecting the apex of a long, frustrating journey. In a transition from a largely etic to an emic exploration of Deaf epistemology, new insights were developed about what it means to be D/deaf, as well as a new way of theorizing about Deaf epistemology. [ABSTRACT FROM AUTHOR]

It is known that transgender people experience health inequalities. Disparities in hospital outcomes impacting transgender individuals have been inadequately explored. We conducted this retrospective cohort study using the National Inpatient Sample (01/2018-12/2019) to compare in-hospital mortality and utilization variables between cisgender and transgender individuals using regression analyses. Approximately two-thirds of hospitalizations for transgender patients (n = 10,245) were for psychiatric diagnoses. Compared to cisgender patients, there were no significant differences in adjusted means differences (aMD) in length of stay (LOS) (aMD = -0.29; p = .16) or total charges (aMD = -$486; p = .56). An additional 4870 transgender patients were admitted for medical diagnoses. Transgender and cisgender individuals had similar adjusted odds ratios (aOR) for in-hospital mortality (aOR = 0.96; p = .88) and total hospital charges (aMD = -$3118; p = .21). However, transgender individuals had longer LOS (aMD = +0.46 days; confidence interval [CI]: 0.15-0.90; p = .04). When comparing mortality and resource utilization between cisgender and transgender individuals, differences were negligible., (© 2024 Society of Hospital Medicine.)

Kink practitioners are marginalized and experience adverse health and social outcomes, which are exacerbated by consent violations. This study aims to understand experiences of reporting consent violations within a kink context. Kink practitioners ( N  = 2,888) completed a survey focused on consent violations, reporting, and recommendations, with 767 (25.56%) of them reporting consent violations in the kink context. The type of consent violation (sexual assault or kink-related behaviors), disclosure, and reporting significantly differed based on gender, sexual orientation, and injury status, but not age. Additionally, recommended steps included avoidance of police and others in positions of power and increased accountability., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Inequities in health and health care in the United States have persisted for decades, and the impacts on equity from the COVID-19 pandemic were no exception. In addition to the disproportionate burden of the disease across various populations, the pandemic posed several challenges, which exacerbated these existing inequities. This has undoubtedly contributed to deeply rooted public mistrust in medical research and healthcare delivery, particularly among historically and structurally oppressed populations. In the summer of 2020, given the series of social injustices posed by the pandemic and highly publicized incidents of police brutality, notably the murder of George Floyd, the Association of American Medical Colleges (AAMC) enlisted the help of a national collaborative, the AAMC Collaborative for Health Equity: Act, Research, Generate Evidence (CHARGE) to establish a three-way partnership that would gather and prioritize community perspectives and lived experiences from multiple regions across the US on the role of academic medicals centers (AMCs) in advancing health and social justice. Given physical gathering constraints posed by the pandemic, virtual interviews were conducted with 30 racially and ethnically diverse community members across the country who expressed their views on how medical education, clinical care, and research could or did impact their health experiences. These interviews were framed within the context of the relationship between historically oppressed groups and the COVID-19 vaccine clinical trials underway. From the three-way partnership formed with the AAMC, AAMC CHARGE participants, and 30 community members from racially and ethnically diverse groups, qualitative methods provided lived experiences supporting other literature on the lack of trust between oppressed communities and AMCs. This led to the development of the Principles of Trustworthiness (PoT) Toolkit, which features ten principles inspired by community members' insights into how AMCs can demonstrate they are worthy of their community's trust. In the end, the three-way partnership serves as a successful model for other national medical and health organizations to establish community engaged processes that elicit and prioritize lived experiences describing relationships between AMCs and oppressed communities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Chinekezi, Andress, Agonafer, Massick, Piepenbrink, Sutton, Alberti, de la Torre, Guillot-Wright and Lee.)

In the United States, the public health response to control COVID-19 required rapid expansion of the contact tracing workforce from approximately 2200 personnel prepandemic to more than 100 000 during the pandemic. We describe the development and implementation of a free nationwide training course for COVID-19 contact tracers that launched April 28, 2020, and summarize participant characteristics and evaluation findings through December 31, 2020. Uptake of the online asynchronous training was substantial: 90 643 registrants completed the course during the first 8 months. In an analysis of a subset of course participants (n = 13 697), 7724 (56.4%) reported having no prepandemic public health experience and 7178 (52.4%) reported currently serving as case investigators, contact tracers, or both. Most participants who completed a course evaluation reported satisfaction with course utility (94.8%; 59 497 of 62 753) and improved understanding of contact tracing practice (93.0%; 66 107 of 71 048). These findings suggest that the course successfully reached the intended audience of new public health practitioners. Lessons learned from this implementation indicate that an introductory course level is appropriate for a national knowledge-based training that aims to complement jurisdiction-specific training. In addition, offering a range of implementation options can promote course uptake among public health agency staff. This course supported the emerging needs of the public health practice community by training a workforce to fill an important gap during the COVID-19 pandemic and could serve as a feasible model for enhancing workforce knowledge for future and ongoing public health threats.

Background: Lactation support, defined here as the access to educational resources, supplies, mental health and psychosocial support, skilled lactation counseling, and peer support, has been identified as critical to optimal health outcomes for birthing parents and infants. People who give birth while incarcerated are likely to receive suboptimal lactation support. The purpose of this review is to explore the literature on lactation support for incarcerated people to identify existing programs and policies, gaps in lactation support and ways to address the gaps, and incarcerated people's perspectives on breastfeeding and lactation support. Methods: We conducted a systematic review of the peer-reviewed literature to identify studies that addressed two main concepts: (1) breastfeeding and (2) incarcerated populations in the United States. Results: After meeting the eligibility criteria, 29 studies were included in the qualitative synthesis of the findings. Studies highlight the importance of supporting birthing people who want to provide milk to their infants in a way that is desired, psychologically safe, and structurally supported. Programs are needed to delay or prevent parent-infant separation after birth, provide education around breastfeeding misconceptions, and link to resources and ongoing support for both breastfeeding and milk expression. Implementation of breastfeeding programs may be most effectively undertaken with clear policies and dedicated leadership either internally or through community or health care partnerships. Discussion: This review highlights the policies and practices that hinder adequate lactation support for birthing parent-infant dyads who are incarcerated and describes feasible policies, education, and clinical support that can be used to improve care.

Im/migrants in the United States are at heightened risk for a host of adverse behavioral, mental, and physical health disparities, which increase their vulnerability to disease and death. Our review of the literature shows how their health disparities are linked to structural factors that can limit their access to political, legal, and economic resources and manifest at different levels of social influence. However, scholars studying structural violence also show how im/migrants simultaneously are subject to and subvert structural violence. Efforts to address health inequities and learning how to dismantle structural violence must center im/migrant experiences and voices., Competing Interests: Conflict of interest statement Nothing declared., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) provides breast cancer screening services to underserved women to mitigate disparities in access to care. The authors sought to characterize this understudied population., Methods: Women 21 years old or older who underwent their first breast cancer screen through NC BCCCP from 2008 to 2018 were included. Demographic factors associated with the timeline of care and odds of a breast cancer diagnosis were identified with negative binomial and logistic regression, respectively., Results: Of the 88,893 women identified, 45.5% were non-Hispanic (NH) White, 30.9% were NH Black, 19.6% were Hispanic, 1.7% were American Indian, and 1.1% were Asian. Breast cancer was diagnosed in 2.5% of the women (n = 2255). Hispanic women were the least likely to be diagnosed with breast cancer (odds ratio vs NH White women, 0.40; 95% confidence interval [CI], 0.34-0.47). Among patients with breast pathology, the median time to diagnosis was 19 days (interquartile range [IQR], 10-33 days), and the time to treatment was 33 days (IQR, 19-54 days). After adjustments, a longer time to diagnosis was significantly associated with age (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) and being NH Black (vs NH White; IRR, 1.17; 95% CI, 1.06-1.29). A longer time to treatment was significantly associated with age (IRR, 1.01; 95% CI, 1.01-1.01), being NH Black (vs NH White; IRR, 1.20; 95% CI, 1.10-1.31), and being Hispanic (vs NH White; IRR, 1.22; 95% CI, 1.05-1.41)., Conclusions: NC BCCCP participants with breast cancer received treatment within approximately 1 month of presentation, and this finding aligns with quality care benchmarks. Nevertheless, racial/ethnic disparities in timeliness of care persist, and this suggests opportunities for improvement., Lay Summary: This review of approximately 90,000 participants in a breast cancer screening program for uninsured and underinsured women highlights the importance of safety net programs in providing timely care to underserved patients. The authors found that the North Carolina Breast and Cervical Cancer Control Program met timeliness benchmarks from the Centers for Disease Control and Prevention across all racial/ethnic groups. However, non-Hispanic Black women experienced relative delays in the time to diagnosis, and both non-Hispanic Black women and Hispanic women experienced relative delays in the time to treatment. These findings demonstrate how racial/ethnic disparities in the timeliness of care can persist even within a program intended to reduce barriers to access., (© 2021 American Cancer Society.)

Background: Data on the risk of inflammatory bowel disease (IBD) among isotretinoin-exposed patients with acne vulgaris (AV) is controversial., Objective: To compare IBD risk in isotretinoin-exposed and unexposed patients with AV., Methods: Retrospective cohort analysis of patients with AV with and without isotretinoin exposure identified using electronic health records. Primary outcomes were 6-month and 1-year IBD incidence., Results: The crude 6-month IBD incidence was 0.08% (21/27,230) among isotretinoin-exposed patients with AV compared to 0.04% (254/631,089) among those unexposed. The crude 1-year IBD incidence was 0.10% (28/27,230) among isotretinoin exposed patients with AV and 0.08% (477/631,089) among those unexposed. The odds of developing IBD within 6 months were 87% higher among isotretinoin-exposed patients with AV compared to those unexposed (adjusted odds ratio, 1.87; 95% confidence interval [CI], 1.20-2.93), although the absolute difference was small (risk difference, 2.6 more cases per 10,000 patients; 95% CI, 0.7-4.5). There was no significant difference in the odds of developing IBD at 1 year between isotretinoin-exposed and unexposed patients with AV (adjusted odds ratio, 1.40; 95% CI, 0.95-2.05)., Limitations: Isotretinoin-exposed patients may be more likely to have IBD detected by a health care provider., Conclusions: IBD incidence among isotretinoin-exposed patients with AV is very low, and the risk appears similar to that for unexposed patients with AV., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

The fastest-growing demographic in the United States is people aged 65 and over. Because elderly drivers may experience decline in the physical and mental faculties required for driving (which could lead to unsafe driving behaviors), it is critical to determine whether elderly drivers are more likely than younger drivers to be at fault in a crash. This study uses Kentucky crash data and linked hospital and emergency department records to evaluate whether linked data can more accurately estimate the crash propensity of elderly drivers to be at-fault in injury crashes. The Kentucky crash data is edited to conform to the General Use Model (GUM), with crash propensities for linked data compared to propensities developed using the GUM dataset alone. The quasi-induced exposure method is used to determine crash exposure. Factors such as age, gender, and crash location are explored to assess their influence on the risk of a driver being at fault in an injury crash. The overall findings are consistent with previous research - elderly drivers are more likely than younger drivers to be at fault in a crash. Linking crash with hospital and emergency department records could also establish a clearer understanding of the injury crash propensity of all age groups. Equipped with this knowledge, transportation practitioners can design more targeted and effective countermeasures and safety programs to improve the safety of all motorists., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Crash data, from the state of Kentucky, for the 2015-2016 period, show that per capita crash rates and increases in crash-related fatalities were higher than the national average. In an effort to explain why the U.S. Southeast experiences higher crash rates than other regions of the country, previous research has argued the regions unique socioeconomic conditions provide a compelling explanation. Taking this observation as a starting point, this study examines the relationship between highway safety and socioeconomic and demographic characteristics, using an extensive crash dataset from Kentucky. Its focus is single- and two-unit crashes that involve commercial motor vehicles (CMVs) and automobiles. Using binary logistic regression and the quasi-induced exposure technique to analyze data on the socioeconomic and demographic attributes of the zip codes in which drivers reside, factors are identified which can serve as indicators of crash occurrence. Variables such as income, education level, poverty level, employment, age, gender, and rurality of the driver's zip code influence the likelihood of a driver being at fault in a crash. Socioeconomic factors exert a similar influence on CMV and automobile crashes, irrespective of the number of vehicles involved. Research findings can be used to identify groups of drivers most likely to be involved in crashes and develop targeted and efficient safety programs., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes., Objective: We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers., Design: Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey., Main Measures: Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences., Key Results: Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs., Conclusions: IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.

Background: Lack of racial concordance between physicians and patients has been linked to health disparities and inequities. Studies show that patients prefer physicians who look like them; however, there are too few underrepresented minority physicians in the workforce. Hospitalists are Internal Medicine physicians who specialize in inpatient medicine. At our hospital, hospitalists care for 60% of hospitalized medical patients. We utilized the validated Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) to assess the effect of patient-provider race and gender concordance on patients' assessment of their physician's performance., Methods: Four hundred thirty-seven inpatients admitted to the non-teaching hospitalist service, cared for by a unique hospitalist physician for two or more consecutive days, were surveyed using the validated TAISCH instrument. The influence of gender and racial concordance on TAISCH scores for patient - hospitalist pairs were assessed by comparing the specific dyads with the overall mean scores. T-tests were used to compare the means. Generalized estimating equations were used to account for clustering., Results: Of the 34 hospitalist physicians in the analysis, 20% were African American (AA-non-Hispanic), 15% were Caucasians (non-Hispanic) and 65% were in the "other" category. The "other" category consisted of predominantly physicians of South East Asian decent (i.e. Indian subcontinent) and Hispanic. Of the 437 patients, 66% were Caucasians, and 32% were AA. The overall mean TAISCH score, as these 437 patients assessed their hospitalist provider was 3.8 (se = 0.60). The highest mean TAISCH score was for the Caucasian provider-AA patient dyads at 4.2 (se = 0.21, p = 0.05 compared to overall mean). The lowest mean TAISCH score was 3.5 (se = 0.14) seen in the AA provider/AA patient dyads, significantly lower than the overall mean (p = 0.013). There were no statistically significant differences noted between mean TAISCH scores of gender and racially concordant versus discordant doctor-patient dyads (all p's > 0.05)., Conclusions: In the inpatient setting, it appears as if neither race nor gender concordance with the provider affects a patient's assessment of a hospitalist's performance.

Background: The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood., Objective: We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals., Methods: A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs., Results: We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P  > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals ( P  = .019) but not at nonteaching hospitals ( P  = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (-$52.28; 95% confidence interval -$116.90 to -$12.32; P  = .026) at teaching relative to nonteaching hospitals., Conclusions: There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Purpose: Public health and criminal justice stalking victimization data collection efforts are plagued by subjective definitions and lack of known psychosocial correlates. The present study assesses the question of stalking victimization prevalence among three groups. Psychosocial risk and protective factors associated with stalking victimization experiences were assessed., Methods: Archival data (n = 2159) were drawn from a three-sample (i.e., U.S. nationwide sexual diversity special interest group, college student, and general population adult) cross-sectional survey of victimization, sexuality, and health., Results: The range of endorsement of stalking-related victimization experiences was 13.0-47.9%. Reported perpetrators were both commonly known and unknown persons to the victim. Participants disclosed the victimization primarily to nobody or a family member/friend. Bivariate correlates of stalking victimization were female gender, Associates/Bachelor-level education, bisexual or other sexual orientation minority status, hypertension, diabetes, older age, higher weekly drug use, elevated trait aggression, higher cognitive reappraisal skills, lower rape myth acceptance, and elevated psychiatric symptoms. Logistic regression results showed the strongest factors in identifying elevated stalking victimization risk were: older age, elevated aggression, higher cognitive reappraisal skills, lesser low self-control, increased symptoms of suicidality and PTSD re-experiencing, and female and other gender minority status., Conclusions: Behavioral approaches to epidemiological and criminal justice stalking victimization are recommended. Victimization under reporting to healthcare and legal professionals were observed. Further research and prevention programming is needed to capitalize on data concerning personality and coping skills, sexual diversity, and trauma-related psychiatric symptoms.

Grateful patients provide substantial philanthropic funding for health care institutions, resulting in important societal benefits. Although grateful patient fundraising (GPFR) is widespread, it raises an array of ethical issues for patients, physicians, development professionals, and institutions. These issues have not been described comprehensively, and there is insufficient guidance to inform the ethical practice of GPFR. Consequently, the authors convened a "Summit on the Ethics of Grateful Patient Fundraising," with the goal of identifying primary ethical issues in GPFR and offering recommendations regarding how to manage them. Participants were 29 experts from across the United States who represented the perspectives of bioethics, clinical practice, development, law, patients, philanthropy, psychology, and regulatory compliance. Intensive discussions resulted in articulating ethical issues for physicians and other clinicians (discussions with patients about philanthropy; physician-initiated discussions; clinically vulnerable patients; conflicts of obligation and equity regarding physician's time, attention, and responsiveness and the provision of special services; and transparency and respecting donor intent) as well as for development officers and institutions (transparency in the development professional-donor relationship; impact on clinical care; confidentiality and privacy; conflicts of interest; institution-patient/donor relationship; concierge services for grateful patients; scientific merit and research integrity; transparency in use of philanthropic gifts; and institutional policies and training in responsible GPFR). While these recommendations promise to mitigate some of the ethical issues associated with GPFR, important next steps include conducting research on the ethical issues in GPFR, disseminating these recommendations, developing standardized training for clinicians regarding them, and revising them as warranted.

Purpose: The methods and processes utilized to deploy the Pharmacists Achieve Results with Medications Documentation (PhARMD) Project intervention template across the largest integrated healthcare system in the United States are described., Summary: The PhARMD Project team at the Department of Veterans Affairs (VA) designed, developed, and deployed a standardized template within VA's electronic health record (EHR) that allows the clinical pharmacy specialist (CPS) to efficiently document select interventions made during patient care encounters that specifically contribute to the overall care provided and patient outcomes. The template is completed by the CPSs as part of progress note documentation within the EHR. Using point-and-click functionality, a CPS selects the check boxes corresponding to specific interventions made during that patient care encounter. This improves workflow and negates the need to document interventions in a separate software system, streamlining documentation. The implementation and use of the PhARMD template at each VA facility are voluntary. From October 1, 2016, to September 30, 2017, 4,728 CPSs documented 3,805,323 interventions during 2,384,771 patient care encounters. These interventions were documented across 592,126 unique patients, with a mean of 6.4 interventions per patient during this period. Most interventions (95%) were performed by CPSs functioning as advanced practice providers and with autonomous prescriptive authority authorized under their scope of practice., Conclusion: The PhARMD template demonstrated that the capture of clinical pharmacy interventions and outcomes can be achieved across a large integrated healthcare system by thousands of CPSs in numerous practice settings., (Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Human papillomavirus (HPV) causes oropharyngeal squamous cell carcinoma (OPSCC), although strongly divergent results have been reported regarding the prevalence of HPV16 in different countries, whether this represents important differences in etiology remains unclear. Applying rigorous protocols for sample processing, we centrally evaluated 1,420 head and neck tumors (533 oropharynx, 395 oral cavity and 482 larynx) from studies conducted in the US, Europe and Brazil for mucosal HPV DNA and p16 INK4a expression to evaluate regional heterogeneity in the proportion of HPV16-associated OPSCC and other head and neck cancer, and to assess covariates associated with the risk of HPV16-positive OPSCC. While majority of OPSCC in the US (60%) were HPV16-positive, this proportion was 31% in Europe and only 4% in Brazil (p < 0.01). Similar differences were observed for other head and neck tumors, ranging from 7% in the US and 5% in Europe, to 0% in South America. The odds of HPV16-positive OPSCC declined with increasing pack years of smoking (OR: 0.75; 95% CI: 0.64-0.87) and drink years of alcohol use (OR: 0.64; 95% CI: 0.54-0.76). These results suggest that while the contribution of HPV16 is substantial for the oropharynx, it remains limited for oral cavity and laryngeal cancers., (© 2017 IARC/WHO.)

Objectives: To assess the impact of dysphagia on clinical and operational outcomes in hospitalized patients with dementia., Design: Retrospective cohort study., Setting: 2012 Nationwide Inpatient Sample., Participants: All patients discharged with a diagnosis of dementia (N = 234,006) from US hospitals in 2012., Measurements: Univariate and multivariate regression models, adjusting for stroke and patient characteristics, to assess the impact of dysphagia on the prevalence of comorbidities, including pneumonia, sepsis, and malnutrition; complications, including mechanical ventilation and death; and operational outcomes, including length of stay (LOS) and total charges for patients with dementia., Results: Patients having dementia with dysphagia (DWD) had significantly higher odds of having percutaneous endoscopic gastrostomy placement during the admission (odds ratio [OR]: 13.68, 95% confidence interval [CI]: 12.53-14.95, P < .001), aspiration pneumonia (OR: 6.27, 95% CI: 5.87-6.72, P < .001), pneumonia (OR: 2.84, 95% CI: 2.67-3.02, P < .001), malnutrition (OR: 2.5, 95% CI: 2.27-2.75, P < .001), mechanical ventilation (OR: 1.69, 95% CI: 1.51-1.9, P < .001), sepsis (OR: 1.52, 95% CI: 1.39-1.67, P < .001), and anorexia (OR: 1.29, 95% CI: 1.01-1.65, P = .04). Mean LOS was 2.16 days longer (95% CI: 1.98-2.35, P < .001), mean charge per case was US$10,703 higher (95% CI: US$9396-US$12,010, P < .001), and the odds of being discharged to a skilled nursing, rehabilitation, or long-term facility was 1.59 times higher (95% CI: 1.49-1.69, P < .001) in the DWD cohort compared to patients having dementia without dysphagia., Conclusion: Dysphagia is a significant predictor of worse clinical and operational outcomes including a 38% longer LOS and a 30% increase in charge per case among hospitalized patients with dementia. Although these findings may not be surprising, this new evidence might bring heightened awareness for the need to more thoughtfully support patients with dementia and dysphagia who are hospitalized.

Marijuana use can cause concerning physical, psychomotor, cognitive, and psychiatric effects, not to mention a near-doubling of car accidents.

With medical marijuana available in more and more states, family physicians need to know what the evidence says about its use. This review includes a step-by-step guide and a list of red flags to watch for.

Objectives: Obesity affects a large proportion of the U.S. population, and hospitalizations may serve as an opportunity to promote weight loss. We sought to determine if multidisciplinary patient-centered inpatient weight loss intervention that included counseling, consults, post-discharge telephone text messages, and primary care follow up was feasible., Methods: We conducted a feasibility study focusing on 25 obese hospitalized patients to understand the issues related to rolling out an intensive intervention. Actual weight loss was a secondary outcome and we compared these 25 patients to 28 control patients who were exposed to usual care; weight change was assessed at 1 and 6 months., Results: Ninety-six percent (24/25) of nutritional consults and 92% (23/25) of physical therapy consults were submitted by hospital providers. All of these doctors were also reminded to counsel their patients about the detrimental health consequences. Fifty-two percent (13/25) and 40% (10/25) were actually seen and counseled by nutrition and physical therapy services respectively, before being discharged. Sixty-eight percent (17/25) received a motivational interviewing counseling session from the principal investigator. All patients were sent text messages and followed with their primary care provider after discharge who received the personalized weight loss discharge instructions that had been given to the patient. The feasibility group lost a mean of 3.0 kg at 6 months and the control group gained an average of 0.20 kg at 6 months post discharge (p = 0.03)., Conclusion: Executing a multifaceted weight loss intervention for hospitalized obese patients is feasible, and there may be associated persistent improvements in weight status over time.

Objectives: By 2014, there were more than 40,000 hospitalists delivering the majority of inpatient care in US hospitals. No empiric research has characterized hospitalist comportment and communication patterns as they care for patients., Methods: The chiefs of hospital medicine at five different hospitals were asked to identify their best hospitalists. These hospitalists were watched during their routine clinical care of patients. An observation tool was developed that focused on elements believed to be associated with excellent comportment and communication. One observer watched the physicians, taking detailed quantitative and qualitative field notes., Results: A total of 26 hospitalists were shadowed. The mean age of the physicians was 38 years, and their average experience in hospital medicine was 6 years. The hospitalists were observed for a mean of 5 hours, during which time they saw an average of 7 patients (patient encounters observed N = 181). Physicians spent an average of 11 minutes with each patient. There was large variation in the extent to which desirable behaviors were performed. For example, most physicians (76%) started encounters with an open-ended question, and relatively few (30%) attempted to integrate nonmedical content into conversation with patients., Conclusions: This study represents a first step in trying to characterize comportment and communication in hospital medicine. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication are clearly defined and established as a goal for every encounter.

Background: In 2010, the Department of Veterans Affairs Healthcare System (VA) implemented policy to provide Comprehensive Primary Care (for acute, chronic, and female-specific care) from designated Women's Health providers (DWHPs) at all VA sites. However, since that time no comparisons of quality measures have been available to assess the level of care for women Veterans assigned to these providers., Objectives: To evaluate the associations between cervical and breast cancer screening rates among age-appropriate women Veterans and designation of primary-care provider (DWHP vs. non-DWHP)., Research Design: Cross-sectional analyses using the fiscal year 2012 data on VA women's health providers, administrative files, and patient-specific quality measures., Subjects: The sample included 37,128 women Veterans aged 21 through 69 years., Measures: Variables included patient demographic and clinical factors (ie, age, race, ethnicity, mental health diagnoses, obesity, and site), and provider factors (ie, DWHP status, sex, and panel size). Screening measures were defined by age-appropriate subgroups using VA national guidelines., Results: Female-specific cancer screening rates were higher among patients assigned to DWHPs (cervical cytology 94.4% vs. 91.9%, P<0.0001; mammography 86.3% vs. 83.3%, P<0.0001). In multivariable models with adjustment for patient and provider characteristics, patients assigned to DWHPs had higher odds of cervical cancer screening (odds ratio, 1.26; 95% confidence interval, 1.07-1.47; P<0.0001) and breast cancer screening (odds ratio, 1.24; 95% CI, 1.10-1.39; P<0.0001)., Conclusions: As the proportion of women Veterans increases, assignment to DWHPs may raise rate of female-specific cancer screening within VA. Separate evaluation of sex neutral measures is needed to determine whether other measures accrue benefits for patients with DWHPs.

Background: In 1998, the Institute of Medicine (IOM) noted that the American healthcare system had many problems. A major concern was the pervasiveness of medical errors. Electronic medical records (EMR) were introduced for myriad of reasons, one being to reduce these errors. Within the EMR, order sets have been shown to reduce variation in clinical practice and improve the quality of care. However, the lack of standardization in these sets enables peculiar orders, such as fecal occult blood test (FOBT) in the heparin drip order set at our hospital, to be surprisingly included. Our study was conducted to evaluate the consequences associated with having FOBT in this order set., Methods: A retrospective study of 898 adult hospitalized patients over a 6-month period, who had a heparin drip ordered at a single academic center, was conducted. The main focus of our study was the 130 patients for whom the FOBT was sent., Results: Fifteen percent (n=130) of patients started on IV heparin had FOBT sent, of which 33 (25%) came back positive. Approximately one-third (36%) of the positive results were documented by a provider, either in a progress note or discharge summary. In eight instances of a positive FOBT (24%), the heparin drip was stopped. For 10 patients with a positive test (30%), gastroenterology was consulted, and 4 (12%) patients had inpatient endoscopy. Five patients with positive FOBT died while in the hospital (15%) as compared to seven patients (7%) in the negative FOBT group, p<0.05., Conclusions: Most patients started on heparin did not have FOBT tested, and the results changed management infrequently, even when positive. The regular review of all order sets is imperative to ensure that they remain evidenced-based and sensible.

Rationale, Aims and Objectives: To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies., Method: We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively)., Results: Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates., Conclusion: We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures., (© 2014 John Wiley & Sons, Ltd.)

Every three days a child dies in an agriculture-related incident, and every day 45 children are injured in the United States. These tragedies should not be regarded as "accidents," as they often follow predictable and preventable patterns. Prevention is not only possible, but vital, since many of these injuries are almost immediately fatal. Major sources of fatal injuries are machinery, motor vehicles, and drowning. Tractor injuries alone account for one-third of all deaths. The leading sources of nonfatal injuries are structures and surfaces, animals (primarily horses), and vehicles (primarily all-terrain vehicles [ATVs]). Children living on farms are at a higher risk than hired workers, and are unprotected by child labor laws. Preschool children and older male youth are at the highest risk for fatal injury, while nonfatal injury was most common among boys aged 10-15 years. Multiple prevention strategies have been developed, yet economic and cultural barriers often impede their implementation. Educational campaigns alone are often ineffective, and must be coupled with re-engineering of machines and safety devices to reduce fatalities. Legislation has the potential to improve child safety, yet political and economic pressures often prohibit changes in child labor laws and mandated safety requirements. Clinicians play a pivotal role in injury prevention, and should actively address common rural risk-taking behaviors as part of the routine office visit in order to help prevent these tragedies., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Interest in global health (GH) among medical students worldwide is measurably increasing. There is a concomitant emphasis on emphasizing globally-relevant health professions education. Through a structured literature review, expert consensus recommendations, and contact with relevant professional organizations, we review the existing state of GH education in US medical schools for which data were available. Several recommendations from professional societies have been developed, along with a renewed emphasis on competencies in global health. The implementation of these recommendations was not observed as being uniform across medical schools, with variation noted in the presence of global health curricula. Recommendations for including GH in medical education are suggested, as well as ways to formalize GH curricula, while providing flexibility for innovation and adaptation.

Introduction: Screening and delivery of evidence-based interventions by dentists is an effective way to reduce tobacco use. However, dental visits remain an underutilized opportunity for the treatment of tobacco dependence. This is, in part, because the current reimbursement structure does not support expansion of dental providers' role in this arena. The purpose of this study was to interview dental insurers to assess attitudes toward tobacco use treatment in dental practice, pros and cons of offering dental provider reimbursement, and barriers to instituting a tobacco use treatment-related payment policy for dental providers., Methods: Semi-structured interviews were conducted with 11 dental insurance company executives. Participants were identified using a targeted sampling method and represented viewpoints from a significant share of companies within the dental insurance industry., Results: All insurers believed that screening and intervention for tobacco use was an appropriate part of routine care during a dental visit. Several indicated a need for more evidence of clinical and cost-effectiveness before reimbursement for these services could be actualized. Lack of purchaser demand, questionable returns on investment, and segregation of the medical and dental insurance markets were cited as additional barriers to coverage., Conclusions: Dissemination of findings on efficacy and additional research on financial returns could help to promote uptake of coverage by insurers. Wider issues of integration between dental and medical care and payment systems must be addressed in order to expand opportunities for preventive services in dental care settings.

Background: The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis therapy at a higher glomerular filtration rate (GFR) has increased during the past decade. Recent data suggest that higher GFR may be associated with increased mortality., Study Design: A meta-analysis of cohort studies and trials., Setting & Population: Patients with advanced CKD., Selection Criteria for Studies: We performed a systematic literature search in MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Society of Nephrology abstracts, and bibliographies of retrieved articles to identify studies reporting on GFR at dialysis therapy initiation and mortality., Predictor: Estimated or calculated GFR at dialysis therapy initiation., Outcome: Pooled adjusted hazard ratio (HR) of continuous GFR for all-cause mortality., Results: 16 cohort studies and 1 randomized controlled trial were identified (n = 1,081,116). By meta-analysis restricted to 15 cohorts (n = 1,079,917), higher GFR at dialysis therapy initiation was associated with a higher pooled adjusted HR for all-cause mortality (1.04; 95% CI, 1.03-1.05; P < 0.001). However, there was significant heterogeneity (I(2) = 97%; P < 0.001). The association persisted among the 9 cohorts that adjusted analytically for nutritional covariates (HR, 1.03; 95% CI, 1.02-1.04; P < 0.001; residual I(2) = 97%). The highest mortality risk was observed in hemodialysis cohorts (HR, 1.05; 95% CI, 1.02-1.08; P < 0.001), whereas there was no association between GFR and mortality in peritoneal dialysis cohorts (HR, 1.04; 95% CI, 0.99-1.08, P = 0.1; residual I(2) = 98%). Finally, higher GFR was associated with a lower mortality risk in cohorts that calculated GFR (HR, 0.80; 95% CI, 0.71-0.91; P = 0.003), contrasting with a higher mortality risk in cohorts that estimated GFR (HR, 1.04; 95% CI, 1.03-1.05; P < 0.001; residual I(2) = 97%)., Limitations: Paucity of randomized controlled trials, different methods for determining GFR, and substantial heterogeneity., Conclusions: Higher estimated rather than calculated GFR at dialysis therapy initiation is associated with a higher mortality risk in patients with advanced CKD, independent of nutritional status. Although there was substantial heterogeneity of effect size estimates across studies, this observation requires further study., (Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Although many employers offer some components of worksite-based population health management (PHM), most do not yet invest in comprehensive programs. This hesitation to invest in comprehensive programs may be attributed to numerous factors, such as other more pressing business priorities, reluctance to intervene in the personal health choices of employees, or insufficient funds for employee health. Many decision makers also remain skeptical about whether investment in comprehensive programs will produce a financial return on investment (ROI). Most peer-reviewed studies assessing the financial impact of PHM were published before 2000 and include a broad array of program and study designs. Many of these studies have also included indirect productivity savings in their assessment of financial outcomes. In contrast, this review includes only peer-reviewed studies of the direct health care cost impact of comprehensive PHM programs that meet rigorous methodological criteria. A systematic search of health sciences databases identified only 5 studies with program designs and study methods meeting these selection criteria published after 2007. This focused review found that comprehensive PHM programs can yield a positive ROI based on their impact on direct health care costs, but the level of ROI achieved was lower than that reported by literature reviews with less focused and restrictive qualifying criteria. To yield substantial short-term health care cost savings, the longer term financial return that can credibly be associated with a comprehensive, prevention-oriented population health program must be augmented by other financial impact strategies.

Background: Hospital Medicine is growing rapidly, and the number of physician assistants (PAs) in this field is expected to grow. However, there is no available data related to the learning needs of PA hospitalists., Objective: To conduct a needs assessment for PA hospitalists who may be embarking on a hospitalist career., Design: Cross-sectional survey based on the Core Competencies in Hospital Medicine., Setting/participants: A sample of hospitalist PAs working in the United States., Measurements: Amount of experience with core diagnoses and procedures, preferences for additional training that would have prepared them to function as hospitalist PAs., Results: Sixty-nine PAs responded (response rate, 67%). Among the core clinical conditions, respondents had the most experience in managing diabetes and urinary tract infections and were least experienced with health care-associated pneumonias and sepsis syndrome. Over 90% rarely performed core competency procedures other than electrocardiogram and chest X-ray interpretations. The top 3 content areas that PA hospitalists believed would have helped to better prepare them to care for inpatients were palliative care (percent of PAs who agreed or strongly agreed: 85%), nutrition for hospitalized patients (84%), and consultations (64%). Almost all (91%) indicated that they would have been interested in formal postgraduate hospital medicine training even if it meant having a lower stipend during the first year on the job., Conclusions: This is the first national data on self-perceived learning needs of PA hospitalists. The results may prove helpful for both PAs entering hospitalist careers and for the physician groups looking to hire them., (Copyright © 2011 Society of Hospital Medicine.)

Purpose: Despite the well-established benefits of physical activity (PA), most Americans, especially those in rural, traditionally underserved areas, engage in considerably less PA than recommended. This study examines perceived barriers to and facilitators of PA and promising organized PA programs among rural Appalachians., Design: Eight focus groups and seven group key informant interviews were conducted., Setting: This study was conducted in eastern Kentucky, in central Appalachia., Subjects: One hundred and fourteen rural Appalachian residents (74% female, 91% white) participated., Measures: Open-ended, semistructured, and structured questions regarding perceptions of, barriers to/facilitators of, and examples of successful/failed PA programs were asked., Analysis: Qualitative data analysis was conducted, including codebook development and steps taken to ensure rigor and transferability. Interrater reliability was over 94%., Results: In addition to barriers that are consistent with those found in other populations, rural Appalachian residents indicated that travel time, family commitments, and inadequate community resources undermine PA. Suggested avenues to increase PA include partnership with churches and the U.S. Department of Agriculture's Cooperative Extension Service; programs that include families, are well advertised, and focus on health rather than appearance; and, underlying all suggestions, culturally relevant yet nonstereotyping activities., Conclusions: When developing PA interventions in rural Appalachia, it is important to employ community-based participatory approaches that leverage unique assets of the population and show potential in overcoming challenges to PA.

The Holistic System of Care for Native Americans in an Urban Environment is a community-focused intervention that provides behavioral health care, promotes health, and prevents disease. This approach is based on a community strategic planning process that honored Native American culture and relationships. Substance abuse, mental illness, homelessness, poverty, crime, physical illness, and violence are symptoms of historical trauma, family dysfunction, and spiritual imbalance. The holistic model links treatment, prevention, and recovery. The link between prevention and treatment is early intervention. Peer support is the link between treatment and recovery. Recovering individuals serve as role models linking recovery to prevention. Culture and spirituality build a strong and resilient foundation for recovery. This article documents the effectiveness of the holistic model over a ten-year period that it has been implemented at the Family & Child Guidance Clinic of the Native American Health Center in the San Francisco Bay Area. The holistic model has produced statistically significant reductions in substance abuse among adult Native American women, men, reentry, and homeless populations; reductions in substance abuse among Native American adolescents; reductions in HIV/AIDS high-risk behavior among Native American men, women, and adolescents; and decreases in acting out behavior among Native American severely emotionally disturbed children.

The purpose and goals of the 2010-2011 Home Health Quality Improvement (HHQI) National Campaign are outlined in this manuscript, including key campaign enhancements implemented since the first initiative began in 2007. A summary of the campaign's design and progress to date is also included, featuring HHQI educational and informational resources, participant incentives, and campaign evaluation.

Background: Recent studies have suggested that there is a positive impact of patient-centered care (PCC) on both the patient-physician relationship and subsequent patient health-related behaviors. One recent prospective study reported a significant relationship between the degree of PCC experienced by patients during their hospitalization for acute myocardial infarction (AMI) and their postdischarge cardiac symptoms. A limitation of this study, however, was a lack of information regarding the technical quality of the AMI care, which might have explained at least part of the differences in outcomes. The present study was undertaken to test the influence of both PCC and technical care quality on outcomes among AMI patients., Methods: We analyzed data from a national sample of 1,858 veterans hospitalized for an initial AMI in a Department of Veterans Affairs medical center during fiscal years 2003 and 2004 for whom data had been compiled on evidence-based treatment and who had also completed a Picker questionnaire assessing perceptions of PCC. Cox proportional hazards models were used to estimate the relationship between PCC and survival 1-year postdischarge, controlling for technical quality of care, patient clinical condition and history, admission process characteristics, and patient sociodemographic characteristics. We hypothesized that better PCC would be associated with a lower probability of death 1-year postdischarge, even after controlling for patient characteristics and the technical quality of care., Results: Better PCC was associated with a significantly but modestly lower hazard of death over the 1-year study period (hazard ratio 0.992, 95 percent confidence interval 0.986-0.999)., Conclusions: Providing PCC may result in important clinical benefits, in addition to meeting patient needs and expectations., (Copyright © Health Research and Educational Trust.)

Context: Cross-sectional studies have identified rural-urban disparities in veterans' health-related quality-of-life (HRQOL) scores., Purpose: To determine whether longitudinal analyses confirmed that these disparities in veterans' HRQOL scores persisted., Methods: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans' HRQOL scores were changing at different rates over the time period examined., Findings: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied., Conclusions: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.

The Department of Veterans Affairs (VA) and other federal agencies require funded researchers to include women in their studies. Historically, many researchers have indicated they will include women in proportion to their VA representation or pointed to their numerical minority as justification for exclusion. However, women's participation in the military-currently 14% of active military-is rapidly changing veteran demographics, with women among the fastest growing segments of new VA users. These changes will require researchers to meet the challenge of finding ways to adequately represent women veterans for meaningful analysis. We describe women veterans' health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans' quality improvement, and discuss VA women's health research. We then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.

The pilot study demonstrated facility-based, multidisciplinary team-based education adds significant value to educational practice. We continue to partner with nephrologists and other health care providers to encourage structured education programs, reach more patients to slow the progression of CKD, and manage public policy issues related to reimbursement so patients can receive necessary education. In a time when CKD education is being considered by public policymakers, it is important to demonstrate that there is value in not limiting CKD education to a specific population, and in providing that education through dialysis centers that already have the infrastructure in place to mount an effective, large-scale, standardized program.

Eight years of progress towards the creation of a national health information network has resulted in a plethora of health data exchange relationships, most commonly called regional health information organizations (RHIOs). Various network types reflect both governance decisions and practical aspects, such as the need for a variety of information sharing pathways between and among organizations. Applying systematic business planning approaches will help ensure that decisions about structure, governance, pricing and incentive lead to RHIO arrangements that meet both the RHIOs' and the participants' business goals. This paper describes the model formulation stage of an ongoing project that applies operations research methods to RHIO participation decisions.