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Importance: Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes., Objectives: To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care., Design, Setting, and Participants: Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS)., Main Outcomes and Measures: Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics., Results: Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission., Conclusions and Relevance: Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

Background and Objectives: Depressive symptoms and pain are common in patients receiving chronic hemodialysis, yet their effect on dialysis adherence, health resource utilization, and mortality is not fully understood. This study sought to characterize the longitudinal associations of these symptoms with dialysis adherence, emergency department (ED) visits, hospitalizations, and mortality., Design, Setting, Participants, & Measurements: As part of a trial comparing symptom management strategies in patients receiving chronic hemodialysis, this study prospectively assessed depressive symptoms using the Patient Health Questionnaire 9, and pain using the Short-Form McGill Pain Questionnaire, monthly between 2009 and 2011. This study used negative binomial, Poisson, and proportional hazards regression to analyze the longitudinal associations of depressive symptoms and pain, scaled based on 5-point increments in symptom scores, with missed and abbreviated hemodialysis treatments, ED visits, hospitalizations, and mortality, respectively., Results: Among 286 patients, moderate-to-severe depressive symptoms were identified on 788 of 4452 (18%) assessments and pain was reported on 3537 of 4459 (79%) assessments. Depressive symptoms were independently associated with missed (incident rate ratio [IRR], 1.21; 95% confidence interval [95% CI], 1.10 to 1.33) and abbreviated (IRR, 1.08; 95% CI, 1.03 to 1.14) hemodialysis treatments, ED visits (IRR, 1.24; 95% CI, 1.12 to 1.37), hospitalizations (IRR, 1.19; 95% CI, 1.10 to 1.30), and mortality (IRR, 1.40; 95% CI, 1.11 to 1.77). Pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.03; 95% CI, 1.01 to 1.06) and hospitalizations (IRR, 1.05; 95% CI, 1.00 to 1.10). Severe pain was independently associated with abbreviated hemodialysis treatments (IRR, 1.16; 95% CI, 1.06 to 1.28), ED visits (IRR, 1.58; 95% CI, 1.28 to 1.94), and hospitalizations (IRR, 1.22; 95% CI, 1.03 to 1.45), but not mortality (hazard ratio, 1.71; 95% CI, 0.81 to 2.96)., Conclusions: Depressive symptoms and pain are independently associated with dialysis nonadherence and health services utilization. Depressive symptoms are also associated with mortality. Interventions to alleviate these symptoms have the potential to reduce costs and improve patient-centered outcomes., (Copyright © 2014 by the American Society of Nephrology.)

Pneumonia remains a leading cause of morbidity and mortality despite advances in treatment and therapy. The "Pneumonia: Treatment and Diagnosis" session of the Pittsburgh International Lung Conference examined topics related to improving care of patients with pneumonia. These topics included the process and quality of care for community-acquired pneumonia (CAP), diagnosis and treatment of emerging fungal pathogens, an overview of the strengths and weaknesses of different diagnostic modalities, and an example of how basic science is exploring immunomodulatory strategies for pneumonia treatment. Systematic health care provider and institutional improvements can decrease mortality rates in CAP, particularly in patients with increasingly complex comorbidities. Aspects of current guidelines for the diagnosis and treatment of fungal pneumonia were reviewed through a series of case presentations. Proper treatment of pneumonia hinges on correct pathogen identification but is complicated by the variety of diagnostic assays with variable specificity, sensitivity, and interpretation. In addressing this topic, Dr. Patrick Murray, Ph.D., discussed a range of diagnostic tests for a variety of pathogens and guidelines for their use. In addition to the current state of CAP treatment, Bill (Beibei) Chen, M.D., Ph.D., presented a new potential therapeutic agent called forsythin, an immunomodulatory compound derived from a plant used in traditional Chinese medicine. These topics, ranging from institution-sized policy to interactions at the molecular scale, paint a broad perspective of the efforts against pneumonia.

Importance: Although clinical practice guidelines recommend combination therapy with macrolides, including azithromycin, as first-line therapy for patients hospitalized with pneumonia, recent research suggests that azithromycin may be associated with increased cardiovascular events., Objective: To examine the association of azithromycin use with all-cause mortality and cardiovascular events for patients hospitalized with pneumonia., Design: Retrospective cohort study comparing older patients hospitalized with pneumonia from fiscal years 2002 through 2012 prescribed azithromycin therapy and patients receiving other guideline-concordant antibiotic therapy., Setting: This study was conducted using national Department of Veterans Affairs administrative data of patients hospitalized at any Veterans Administration acute care hospital., Participants: Patients were included if they were aged 65 years or older, were hospitalized with pneumonia, and received antibiotic therapy concordant with national clinical practice guidelines., Main Outcomes and Measures: Outcomes included 30- and 90-day all-cause mortality and 90-day cardiac arrhythmias, heart failure, myocardial infarction, and any cardiac event. Propensity score matching was used to control for the possible effects of known confounders with conditional logistic regression., Results: Of 73,690 patients from 118 hospitals identified, propensity-matched groups were composed of 31,863 patients exposed to azithromycin and 31,863 matched patients who were not exposed. There were no significant differences in potential confounders between groups after matching. Ninety-day mortality was significantly lower in those who received azithromycin (exposed, 17.4%, vs unexposed, 22.3%; odds ratio [OR], 0.73; 95% CI, 0.70-0.76). However, we found significantly increased odds of myocardial infarction (5.1% vs 4.4%; OR, 1.17; 95% CI, 1.08-1.25) but not any cardiac event (43.0% vs 42.7%; OR, 1.01; 95% CI, 0.98-1.05), cardiac arrhythmias (25.8% vs 26.0%; OR, 0.99; 95% CI, 0.95-1.02), or heart failure (26.3% vs 26.2%; OR, 1.01; 95% CI, 0.97-1.04)., Conclusions and Relevance: Among older patients hospitalized with pneumonia, treatment that included azithromycin compared with other antibiotics was associated with a lower risk of 90-day mortality and a smaller increased risk of myocardial infarction. These findings are consistent with a net benefit associated with azithromycin use.

Objective: Systemic sclerosis (SSc) is associated with a reduction in life expectancy, but there are no validated prognostic models for determining short-term mortality. The objective of this study was to derive and validate a prediction rule for 2-year mortality in patients with early diffuse cutaneous SSc (dcSSc)., Methods: We studied a prospectively enrolled cohort of 387 US Caucasian patients with early dcSSc (<2 years from the appearance of the first symptom), randomly divided into a derivation cohort (n = 260) and a validation cohort (n = 127). Predefined baseline predictor variables were analyzed in a stepwise multivariable logistic regression model in order to identify factors independently associated with 2-year all-cause mortality using a cutoff of P < 0.05. We rounded the beta values to the nearest integer and summed the points assigned to each variable in order to stratify patients into low-risk, moderate-risk, and high-risk groups. We then applied this rule to an external validation cohort of 110 Caucasian patients with early dcSSc from a single UK center and compared stratum-specific mortality using chi-square statistics., Results: Four independent predictor variables (with assigned integer values) comprised the model: age at first visit (points allotted: -1, 0, or 1), skin thickness progression rate (points allotted: 0 or 1), gastrointestinal tract severity (points allotted: 0, 1, or 2), and anemia (points allotted: 0 or 2). The prediction model performed well, with no significant differences between the derivation cohort and the US or UK validation cohorts in the low-risk and moderate-risk groups., Conclusion: We derived a 4-variable prediction rule that can be used to stratify patients with early dcSSc into groups by risk of 2-year mortality, and we validated that prediction rule in US and UK cohorts., (Copyright © 2014 by the American College of Rheumatology.)

Introduction: Although some factors associated with rehospitalization after community-acquired pneumonia have been identified, other factors such as medical care utilization and medication usage have not been previously studied. We investigated novel predictors of rehospitalization in patients admitted with pneumonia., Methods: Using Department of Veteran Affairs (VA) administrative data from October 2001 to September 2007, we examined a cohort of patients 65 years old and older, who were hospitalized with pneumonia, in 150 VA acute care hospitals. The cohort was randomly split into derivation and validation samples, and then logistic regression models were used to identify and validate predictors of all-cause rehospitalization within 30 days., Results: Of the 45,134 subjects, 13% were rehospitalized within 30 days. No significant differences were noted between the derivation and validation cohorts. Factors associated with readmission included age, marital status, chronic renal disease, prior malignancy, nursing home residence, congestive heart failure, use of oral corticosteroids, number of emergency department visits a year prior, prior admission, number of outpatient clinic visits in a year prior, and length of hospital stay. The C statistics for the derivation and validation models were 0.615 and 0.613, respectively., Conclusions: Factors associated with readmission were largely unrelated to the underlying pneumonia, but were related to demographics, comorbidities, healthcare utilization, and length of stay on index admission., (2014 Society of Hospital Medicine. This article is a US government work and, as such, is in the public domain in the United States of America.)

OBJECTIVE To assess racial differences in diabetes processes and intermediate outcomes of care in an internal medicine, patient-centered medical home (PCMH) group practice. RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study of 1,457 adults with diabetes receiving care from 89 medical providers within a PCMH-designated academic practice between 1 July 2009 and 31 July 2010. We used mixed models to assess independent associations between patient race (non-Hispanic white or black) and 1) receipt of processes of care (A1C and LDL testing, foot and retinal examination, and influenza and pneumococcal vaccination) and 2) achievement of intermediate outcomes (LDL <100 mg/dL, blood pressure [BP] <140/90 mmHg, A1C <7.0% [<53 mmol/mol], and A1C >9.0% [>75 mmol/mol]), controlling for sociodemographic factors, health status, treatment intensity, and clinical continuity. RESULTS Compared with non-Hispanic white patients, black patients were younger, were more often single, had lower educational attainment, and were less likely to have commercial insurance. In unadjusted analyses, fewer black patients received a retinal examination and influenza vaccination during the study period or any lifetime pneumococcal vaccination (P < 0.05 [all comparisons]). Fewer black patients achieved an LDL <100 mg/dL, BP <140/90 mmHg, or A1C <7.0% (<53 mmol/mol), while more black patients had an A1C >9.0% (>75 mmol/mol) (P < 0.05 [all comparisons]). In multivariable models, black patients were less likely to receive A1C testing (odds ratio [OR] 0.57 [95% CI 0.34-0.95]) or influenza vaccination (OR 0.75 [95% CI 0.57-0.99]) or to achieve an LDL <100 mg/dL (OR 0.74 [95% CI 0.55-0.99]) or BP <140/90 mmHg (OR 0.64 [95% CI 0.49-0.84]). CONCLUSIONS Racial differences in processes and intermediate outcomes of diabetes care were present within this PCMH-designated practice, controlling for differences in sociodemographic, clinical, and treatment factors.

Background: Clinical prediction models are formal combinations of historical, physical examination and laboratory or radiographic test data elements designed to accurately estimate the probability that a specific illness is present (diagnostic model), will respond to a form of treatment (therapeutic model) or will have a well-defined outcome (prognostic model) in an individual patient. They are derived and validated using empirical data and used to assist physicians in their clinical decision-making that requires a quantitative assessment of diagnostic, therapeutic or prognostic probabilities at the bedside., Purpose: To provide intensivists with a comprehensive overview of the empirical development and testing phases that a clinical prediction model must satisfy before its implementation into clinical practice., Results: The development of a clinical prediction model encompasses three consecutive phases, namely derivation, (external) validation and impact analysis. The derivation phase consists of building a multivariable model, estimating its apparent predictive performance in terms of both calibration and discrimination, and assessing the potential for statistical over-fitting using internal validation techniques (i.e. split-sampling, cross-validation or bootstrapping). External validation consists of testing the predictive performance of a model by assessing its calibration and discrimination in different but plausibly related patients. Impact analysis involves comparative research [i.e. (cluster) randomized trials] to determine whether clinical use of a prediction model affects physician practices, patient outcomes or the cost of healthcare delivery., Conclusions: This narrative review introduces a checklist of 19 items designed to help intensivists develop and transparently report valid clinical prediction models.

Background: Two clinical trials suggest that procalcitonin-guided antibiotic therapy can safely reduce antibiotic prescribing in outpatient management of acute respiratory tract infections (ARTIs) in adults. Yet, it remains unclear whether procalcitonin testing is cost-effective in this setting., Objective: To evaluate the cost-effectiveness of procalcitonin-guided antibiotic therapy in outpatient management of ARTIs in adults., Design: Cost-effectiveness model based on results from two published European clinical trials, with all parameters varied widely in sensitivity analyses., Patients: Two hypothetical cohorts were modeled in separate trial-based analyses: adults with ARTIs judged by their physicians to require antibiotics and all adults with ARTIs., Interventions: Procalcitonin-guided antibiotic therapy protocols versus usual care., Main Measures: Costs and cost per antibiotic prescription safely avoided., Key Results: We estimated the health care system willingness-to-pay threshold as $43 (range $0–$333) per antibiotic safely avoided, reflecting the estimated cost of antibiotic resistance per outpatient antibiotic prescribed. In the cohort including all adult ARTIs judged to require antibiotics by their physicians, procalcitonin cost $31 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored compared to usual care was 58.4 % in a probabilistic sensitivity analysis. In the analysis that included all adult ARTIs, procalcitonin cost $149 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored was 2.8 %., Conclusions: Procalcitonin-guided antibiotic therapy for outpatient management of ARTIs in adults would be cost-effective when the costs of antibiotic resistance are considered and procalcitonin testing is limited to adults with ARTIs judged by their physicians to require antibiotics.

Background: Few studies have assessed sex or racial/ethnic differences in inpatient experiences in the Veterans Affairs (VA) Healthcare System., Objectives: This study aimed to compare inpatient experiences by sex and race/ethnicity within and between VA hospitals., Research Design: We used mixed-effects multinomial regression to assess within-facility and between-facility sex and racial/ethnic differences in the 2010 VA Survey of Healthcare Experiences of Patients., Subjects: 50,471 respondents from 144 VA hospitals (4.5% female; 75.4% non-Hispanic white, 14.7% non-Hispanic black, 5.4% Hispanic, and 4.4% other race/ethnicity)., Measures: Negative and positive patient-reported experiences in 13 health care domains were included., Results: Adjusted within-facility sex differences indicated that women reported more negative and less positive experiences than men in 4 domains, and less negative and more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics reported less negative and/or more positive experiences than whites within the same facility, although patients at facilities with more black and Hispanic patients reported more negative and less positive experiences overall. There were few and inconsistent within-facility differences between other racial/ethnic patients and whites. Patients at facilities with more other racial/ethnic patients reported slightly less negative and more positive experiences., Conclusions: Male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities. However, less positive experiences are reported by patients overall in hospitals that serve larger populations of women and racial/ethnic minorities.

Parkinson's disease (PD), the second-most common neurodegenerative disease, is characterized by motor and nonmotor symptoms. PD is often misdiagnosed; inappropriate treatment due to misdiagnosis has undesired consequences, as does delayed diagnosis. Unfortunately, most people with PD receive a diagnosis only after motor symptoms have emerged, by which time 40% to 60% of dopamine neurons have already been lost. Advances in imaging techniques have provided clinicians with increasingly sophisticated tools. In 2011, the US Food and Drug Administration approved ioflupane I-123 injection (DaTscanTM) for striatal dopamine transporter visualization using single-photon emission computed tomography (SPECT) imaging, which provides an effective tool for assessing striatal dopaminergic deficiency. Among patients with suspected parkinsonian syndromes, of which PD is one, the diagnostic sensitivity and specificity of DaTscan SPECT imaging are high. In clinical studies that were part of the DaTscan new drug application, no serious drug-related adverse events reported by the 1236 participants were attributed to DaTscan. The introduction of DaTscan imaging and its utility necessitate the development of clinical recommendations for appropriate use; thus, a multidisciplinary panel of experts was convened to develop clinical criteria and algorithms to help guide clinicians and managed care organizations in the application of DaTscan SPECT imaging. Based on the consensus of this expert panel, appropriate use of DaTscan SPECT imaging includes cases where: (1) PD diagnosis is uncertain; (2) tremor of uncertain etiology is present; and (3) nonmotor and/ or supportive symptoms and features associated with PD are present but the classical motor syndrome is absent or atypical.

Background: Media literacy programs have shown potential for reduction of adolescent tobacco use. We aimed to determine if an anti-smoking media literacy curriculum improves students' media literacy and affects factors related to adolescent smoking., Methods: We recruited 1170 9th-grade students from 64 classrooms in 3 public urban high schools. Students were randomized by classroom to a media literacy curriculum versus a standard educational program. In an intent-to-treat analysis, we used multilevel modeling to determine if changes in study outcomes were associated with the curricular intervention, controlling for baseline student covariates and the clustering of students within classrooms., Results: Among participants, mean age was 14.5 years and 51% were male, with no significant differences in baseline characteristics between groups. Smoking media literacy changed more among intervention participants compared with control participants (0.24 vs. 0.08, p < .001). Compared with controls, intervention students exhibited a greater reduction in the perceived prevalence of smoking (-14.0% vs. -4.6%, p < .001). Among those initially susceptible to smoking, intervention participants more commonly reverted to being nonsusceptible post-intervention (24% vs. 16%, p = .08)., Conclusions: A school-based media literacy curriculum is more effective than a standard educational program in teaching media literacy and improving perceptions of the true prevalence of smoking among adolescents., (© 2014, American School Health Association.)

Introduction: Little research has examined whether cardiovascular medications, other than statins, are associated with improved outcomes after pneumonia. Our aim was to examine the association between the use of beta-blockers, statins, angiotensin converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) with pneumonia-related outcomes., Materials and Methods: We conducted a retrospective population-based study on male patients ≥ 65 years of age hospitalized with pneumonia and who did not have pre-existing cardiac disease. Our primary analyses were multilevel regression models that examined the association between cardiovascular medication classes and either mortality or cardiovascular events., Results: Our cohort included 21,985 patients: 22% died within 90 days of admission, and 22% had a cardiac event within 90 days. The cardiovascular medications studied that were associated with decreased 90-day mortality included: statins (OR 0.70, 95% CI 0.63-0.77), ACE inhibitors (OR 0.82, 95% CI 0.74-0.91), and ARBs (OR 0.58, 95% CI 0.44-0.77). However, none of the medications were significantly associated with decreased cardiovascular events., Discussion: While statins, ACE inhibitors, and ARBs, were associated with decreased mortality, there was no significant association with decreased CV events. These results indicate that this decreased mortality is unlikely due to their potential cardioprotective effects.

We surveyed a random sample of 852 students at a large university in 2010-2011 to clarify associations between waterpipe tobacco smoking (WTS), ethnicity, and religion. Current (past 30 day) WTS was reported by 116 (14%) students, and 331 (39%) reported ever WTS. Middle Eastern ethnicity was associated with current WTS (odds ratio [OR] = 2.37; 95% confidence interval [CI] = 1.06, 5.34) and ever WTS (OR = 2.59; 95% CI = 1.22, 5.47). South Asian ethnicity was associated with lower odds for ever WTS (OR = 0.42; 95% CI = 0.21, 0.86), but there was no significant association between South Asian ethnicity and current WTS. Being an atheist and having lower religiosity were associated with both WTS outcomes.

Objective: To derive and validate a clinical rule that stratifies the risk of cardiac complications in patients hospitalized for community-acquired pneumonia (CAP) and compare its performance to the pneumonia severity index (PSI) score., Patients and Methods: Two cohorts of patients hospitalized for CAP were selected for the study. We used regression techniques in the derivation cohort (1343 patients enrolled in the Pneumonia Patient Outcomes Research Team study between October 1991 and March 1994) to generate a prediction rule that we validated in the validation cohort (608 patients enrolled in the Dissemination of Guidelines for Length of Stay study between February 1998 and March 1999). Discrimination and reclassification analyses compared its performance against the PSI score., Results: A prediction model for cardiac complications in the derivation cohort included age, 3 preexisting conditions, 2 vital signs, and 7 common laboratory or radiographic parameters. Discrimination (C statistic, 0.81; 95% CI, 0.78-0.84) and calibration (Hosmer-Lemeshow goodness-of-fit test, χ(2)=13.0; P=.11) were good. We derived a point score system from this model that when applied to the validation cohort also had good discrimination (C statistic, 0.78; 95% CI, 0.74-0.83) and calibration (Hosmer-Lemeshow, χ(2)=9.0; P=.34). On the basis of this score, we defined 4 categories of incremental risk of cardiac complications. The incidence of cardiac complications across risk categories increased linearly (from lowest to highest) in both the derivation (3.0%, 17.8%, 35.2%, and 72.2%) and validation (5.0%, 8.2%, 28.3%, and 48.9%) cohorts (Cochran-Armitage linear trend test, P<.01). The new score outperformed the PSI score in predicting cardiac complications in the validation cohort (C statistic, 0.78 vs 0.74; P=.03; proportion of patients correctly reclassified by the new score, 44%)., Conclusion: We derived and validated a clinical rule that accurately stratifies the risk of cardiac complications in patients hospitalized for CAP., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Past studies that demonstrated that sexual dysfunction is common among women receiving chronic hemodialysis did not distinguish sexual dysfunction/difficulty from sexual inactivity. This study sought to differentiate these in order to elucidate the prevalence of true "sexual dysfunction" in this population., Design, Setting, Participants, & Measurements: As part of a clinical trial of symptom management strategies in patients receiving chronic hemodialysis, female sexual function was prospectively assessed monthly for 6 months and quarterly thereafter using the Female Sexual Function Index, to which questions were added differentiating sexual dysfunction/difficulty from sexual inactivity. Beginning in month 7, patients were asked three questions about sexual activity, difficulty, and satisfaction monthly., Results: Of the women enrolled in the clinical trial,125 participants completed 1721 assessments between 2009 and 2011. Scores on 574 of 643 (89%) quarterly Female Sexual Function Index assessments were consistent with sexual dysfunction, due largely to sexual inactivity, which was reported on 525 (82%) quarterly assessments. When reported (n=1663), the most frequently described reasons for sexual inactivity were lack of interest in sex (n=715; 43%) and lack of a partner (n=647; 39%), but rarely sexual difficulty (n=36; 2%). When reported (n=1582), women were moderately to very satisfied with their sexual life on 1020 (64%) assessments and on 513 of 671 (76%) assessments in which lack of interest was cited as a reason for sexual inactivity. Women indicated an interest in learning about the causes of and treatment for sexual dysfunction on just 5% of all assessments., Conclusions: Although many women receiving chronic hemodialysis are sexually inactive, few describe sexual difficulty. Most, including those with a lack of interest in sex, are satisfied with their sexual life and few wish to learn about treatment options. These findings suggest that true sexual dysfunction is uncommon in this population and that treatment opportunities are rare.

Background: Although prior randomized trials have demonstrated that procalcitonin-guided antibiotic therapy effectively reduces antibiotic use in patients with community-acquired pneumonia (CAP), uncertainties remain regarding use of procalcitonin protocols in practice., Objective: To estimate the cost-effectiveness of procalcitonin protocols in CAP., Design: Decision analysis using published observational and clinical trial data, with variation of all parameter values in sensitivity analyses., Patients: Hypothetical patient cohorts who were hospitalized for CAP., Interventions: Procalcitonin protocols vs. usual care., Main Measures: Costs and cost per quality adjusted life year gained., Key Results: When no differences in clinical outcomes were assumed, consistent with clinical trials and observational data, procalcitonin protocols cost $10-$54 more per patient than usual care in CAP patients. Under these assumptions, results were most sensitive to variations in: antibiotic cost, the likelihood that antibiotic therapy was initiated less frequently or over shorter durations, and the likelihood that physicians were nonadherent to procalcitonin protocols. Probabilistic sensitivity analyses, incorporating procalcitonin protocol-related changes in quality of life, found that protocol use was unlikely to be economically reasonable if physician protocol nonadherence was high, as observational study data suggest. However, procalcitonin protocols were favored if they decreased hospital length of stay., Conclusions: Procalcitonin protocol use in hospitalized CAP patients, although promising, lacks physician nonadherence and resource use data in routine care settings, which are needed to evaluate its potential role in patient care.

Contrast-induced AKI (CI-AKI) is a common condition associated with serious, adverse outcomes. CI-AKI may be preventable because its risk factors are well characterized and the timing of renal insult is commonly known in advance. Intravenous (IV) fluids and N-acetylcysteine (NAC) are two of the most widely studied preventive measures for CI-AKI. Despite a multitude of clinical trials and meta-analyses, the most effective type of IV fluid (sodium bicarbonate versus sodium chloride) and the benefit of NAC remain unclear. Careful review of published trials of these interventions reveals design limitations that contributed to their inconclusive findings. Such design limitations include the enrollment of small numbers of patients, increasing the risk for type I and type II statistical errors; the use of surrogate primary endpoints defined by small increments in serum creatinine, which are associated with, but not necessarily causally related to serious, adverse, patient-centered outcomes; and the inclusion of low-risk patients with intact baseline kidney function, yielding low event rates and reduced generalizability to a higher-risk population. The Prevention of Serious Adverse Events following Angiography (PRESERVE) trial is a randomized, double-blind, multicenter trial that will enroll 8680 high-risk patients undergoing coronary or noncoronary angiography to compare the effectiveness of IV isotonic sodium bicarbonate versus IV isotonic sodium chloride and oral NAC versus oral placebo for the prevention of serious, adverse outcomes associated with CI-AKI. This article discusses key methodological issues of past trials investigating IV fluids and NAC and how they informed the design of the PRESERVE trial.

Background: Limitations of current diagnotic techniques may allow some patients with presumed renal cell carcinoma (RCC) to undergo nephrectomy without definitive confirmation of malignancy., Objectives: To confirm previous estimates of postnephrectomy renal mass diagnosis and to assess the economic impact of nephrectomy., Methods: This retrospective cohort analysis identified commercial enrollees who underwent nephrectomy with a diagnosis of RCC between July 1, 2000, and March 30, 2008. Study subjects were stratified based on medical claims for benign or malignant disease after the nephrectomy date. Cohorts were compared on resource utilization before and after nephrectomy, occurrence of postsurgical complications, and associated 1-year costs of care., Results: Of 10,404 patients undergoing nephrectomy for presumed RCC, 1613 (15.5%) were subsequently identified as having benign disease, despite median presurgical diagnostic expenditures of $1311 per patient (interquartile range [IQR], $467-$2606). Median expenditures for the 12 months postnephrectomy were $26,920 per patient (IQR, $16,851-$46,982) for those with malignant disease and $23,951 per patient (IQR, $14,873-$38,190) for those with benign disease (P<.0001). For patients with benign disease, 17.5% experienced a postsurgical adverse event, resulting in a 1.5-fold increase in expenditures (median $31,838 per patient for those with event vs $22,770 per patient for those without event; P<.0001)., Conclusions: In this study, approximately 1 in 6 patients were found to have a benign renal mass postnephrectomy. Given the risk of surgical complications and related economic consequences, methods for better identifying malignant versus benign disease prior to surgery could provide significant benefits to patients and payers.

Background: Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary., Objective: To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA., Design: Retrospective cohort., Setting: Medicare and the VA, 2008., Patients: 1,061,095 Medicare Part D beneficiaries and 510,485 veterans aged 65 years or older with diabetes., Measurements: Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status-adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other., Results: Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA., Limitation: This analysis cannot fully describe the factors underlying differences in brand-name drug use., Conclusion: Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost.

Background: Although limited health literacy is common in hemodialysis patients, its effects on clinical outcomes are not well understood., Study Design: Observational study., Setting & Participants: 260 maintenance hemodialysis patients enrolled in a randomized clinical trial of symptom management strategies from January 2009 through April 2011., Predictor: Limited health literacy., Outcomes: Dialysis adherence (missed and abbreviated treatments) and health resource utilization (emergency department visits and end-stage renal disease [ESRD]-related hospitalizations)., Measurements: We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) and used negative binomial regression to analyze the independent associations of limited health literacy with dialysis adherence and health resource utilization over 12-24 months., Results: 41 of 260 (16%) patients showed limited health literacy (REALM score, ≤60). There were 1,152 missed treatments, 5,127 abbreviated treatments, 552 emergency department visits, and 463 ESRD-related hospitalizations. Limited health literacy was associated independently with an increased incidence of missed dialysis treatments (missed, 0.6% vs 0.3%; adjusted incidence rate ratio [IRR], 2.14; 95% CI, 1.10-4.17), emergency department visits (annual visits, 1.7 vs 1.0; adjusted IRR, 1.37; 95% CI, 1.01-1.86), and hospitalizations related to ESRD (annual hospitalizations, 0.9 vs 0.5; adjusted IRR, 1.55; 95% CI, 1.03-2.34)., Limitations: Generalizability and potential for residual confounding., Conclusions: Patients receiving maintenance hemodialysis who have limited health literacy are more likely to miss dialysis treatments, use emergency care, and be hospitalized related to their kidney disease. These findings have important clinical practice and cost implications., (Copyright © 2013 National Kidney Foundation, Inc. All rights reserved.)

Background: Racial and ethnic differences in patient health care experiences have not been well examined in the Veterans Affairs (VA) Healthcare System., Objectives: To examine racial/ethnic differences in outpatient health care experiences within and between VA medical facilities., Research Design: We assessed within-facility and between-facility racial/ethnic differences in responses to the 2010 VA Survey of Healthcare Experiences of Patients using mixed-effects multinomial regression., Subjects: A total of 211,459 respondents (53.2%) to a random survey of outpatients from 910 VA medical facilities (71.9% non-Hispanic white, 15.1% non-Hispanic black, 6.4% Hispanic, and 6.7% Other race/ethnicity)., Measures: Negative and positive patient-reported experiences in 8 domains of health care., Results: Between-facility effects for black race were higher for 7 domains of negative experiences [risk differences (RDs): 0.37% to 1.64%] and lower for 6 domains of positive experiences (RDs: -0.69% to -2.54%). Between-facility effects for Hispanic ethnicity were higher for 5 domains of negative experiences (RDs: 0.60%-1.34%) and lower for 5 domains of positive experiences (RDs: -1.00% to -1.88%). Hispanic ethnicity was also associated with higher within-facility rates of positive experiences for 5 domains of care (RDs: 2.97%-4.08%). Other race/ethnicity was associated with significantly higher within-facility rates of negative experiences (RDs: 2.04%-3.95%) and lower rates of positive experiences for all 8 domains (RDs: -2.05% to -4.70%)., Conclusions: In a national random sample of Veterans managed in the VA Healthcare System, we demonstrated significant within-facility and between-facility racial and ethnic differences in outpatient health care experiences, with differing patterns for each minority group.

Hookah tobacco smoking is increasing among US college students, including those who would not otherwise use tobacco. Part of hookah's appeal is attributed to the perception that hookah is less harmful than cigarettes. The aims of this study were to assess knowledge of harmful exposures associated with hookah smoking relative to cigarette smoking and to determine associations between this knowledge and hookah smoking outcomes. Students (N = 852) at the University of Florida were randomly sampled via e-mail to obtain information on demographics, hookah smoking behavior and knowledge of five exposures (e.g. tar and nicotine). Multivariable logistic regression models assessed independent associations between knowledge and hookah smoking outcomes. Of the five factual knowledge items asked, 475 (55.8%) of the respondents answered none correctly. In multivariable models, correct responses to any knowledge items were not associated with lower odds of hookah smoking or susceptibility to hookah smoking in the future. Although college students are largely unaware of the toxicant exposures associated with hookah smoking, there is little association between knowledge and hookah smoking behavior.

Introduction: While cigarette use is declining, smoking tobacco with a waterpipe is an emerging trend. We aimed to determine the prevalence of waterpipe use in a large diverse sample of U.S. university students and to assess the association of waterpipe use with individual and institution-related characteristics., Methods: We assessed students from 152 U.S. universities participating in the National College Health Assessment during 2008-2009. We used multivariable regression models to determine independent associations between individual and institutional characteristics and waterpipe tobacco use in the past 30 days and ever., Results: Of 105,012 respondents included in the analysis, most were female (65.7%), White (71.2%), and attending public (59.7%) nonreligious (83.1%) institutions. Mean age was 22.1 years. A total of 32,013 (30.5%) reported ever using a waterpipe to smoke tobacco. Rates for current tobacco use were 8.4% for waterpipes, 16.8% for cigarettes, 7.4% for cigars (including cigarillos), and 3.5% for smokeless tobacco. Of current waterpipe users, 51.4% were not current cigarette smokers. Although current waterpipe use was reported across all individual and institutional characteristics, fully adjusted multivariable models showed that it was most strongly associated with younger age, male gender, White race, fraternity/sorority membership, and nonreligious institutions in large cities in the western United States., Conclusions: After cigarettes, waterpipe use was the most common form of tobacco use among university students. Because waterpipe use affects groups with a wide variety of individual and institutional characteristics, it should be included with other forms of tobacco in efforts related to tobacco surveillance and intervention.

Background and Objectives: Pain, erectile dysfunction (ED), and depression are common yet frequently untreated in chronic hemodialysis patients. This study compared two management strategies for these symptoms in this patient population., Design, Setting, Participants, & Measurements: Pain, ED, and depression were assessed monthly during an observation usual care phase. Patients were then randomized to 12-month participation in either a feedback arm in which these symptoms were assessed monthly, renal providers were informed of patients' symptoms, and treatment was left treatment at their discretion; or a nurse management arm in which symptoms were assessed monthly and trained nurses were used to evaluate patients and generate and facilitate the implementation of treatment recommendations., Results: Of 288 patients enrolled into observation between January 1, 2009 and March 30, 2010, 220 (76%) were randomized. Compared with the feedback approach, the results (shown as Δ symptom score [95% confidence interval]) indicated that nurse management was not associated with improved pain (0.49 [-0.56, 1.54]), ED (0.20 [-0.55, 0.95]), or depression (0.32 [-0.94, 1.58]). Relative to their symptoms during observation, feedback patients experienced small, statistically significant improvements in pain (-0.98 [-1.67, -0.28]), ED (-0.98 [-1.54, -0.41]), and depression (-1.36 [-2.19, -0.54]), whereas nurse management patients experienced small, statistically significant improvements in ED (-0.78 [-1.41, -0.15]) and depression (-1.04 [-2.04, -0.04])., Conclusions: Compared with informing renal providers of their patients' pain, ED, and depression and leaving management at their discretion, a nurse-implemented management strategy does not improve these symptoms. Both approaches modestly reduced symptoms relative to usual care.

Background: Studies suggest that statins and angiotensin-converting enzyme (ACE) inhibitors might be beneficial for the treatment of infections. Our purpose was to examine the association of statin, ACE inhibitor, and angiotensin II receptor blocker (ARB) use with pneumonia-related outcomes., Methods: We conducted a retrospective cohort study using Department of Veterans Affairs data of patients aged ≥ 65 years hospitalized with pneumonia. We performed propensity-score matching for 3 medication classes simultaneously., Results: Of 50119 potentially eligible patients, we matched 11498 cases with 11498 controls. Mortality at 30 days was 13%; 34% used statins, 30% ACE inhibitors, and 4% ARBs. In adjusted models, prior statin use was associated with decreased mortality (odds ratio [OR], 0.74; 95% confidence interval [CI], .68-.82) and mechanical ventilation (OR, 0.81; 95% CI, .70-.94), and inpatient use with decreased mortality (OR, 0.68; 95% CI, .59-.78) and mechanical ventilation (OR, 0.68; 95% CI, .60-.90). Prior (OR, 0.88; 95% CI, .80-.97) and inpatient (OR, 0.58; 95% CI, .48-.69) ACE inhibitor use was associated with decreased mortality. Prior (OR, 0.73; 95% CI, .58-.92) and inpatient ARB use (OR, 0.47; 95% CI, .30-.72) was only associated with decreased mortality. Use of all 3 medications was associated with reduced length of stay., Conclusions: Statins, and to a lesser extent ACE inhibitors and ARBs, are associated with improved pneumonia-related outcomes. Prospective cohort and randomized controlled trials are needed to examine potential mechanisms of action and whether acute initiation at the time of presentation with these infections is beneficial.

Background: Although accurate health-related representations of medical situations on television can be valuable, inaccurate portrayals can engender misinformation., Objective: The purpose of this study was to compare sociodemographic and medical characteristics of patients depicted on television vs. actual United States (US) Emergency Department (ED) patients., Methods: Two independently working coders analyzed all 22 programs in one complete year of the popular "emergency room" drama ER. Inter-rater reliability was excellent, and all initial coding differences were easily adjudicated. Actual health data were obtained from the National Heath and Ambulatory Medical Care Survey from the same year. Chi-squared goodness-of-fit tests were used to compare televised vs. real distribution across key sociodemographic and medical variables., Results: Ages at the extremes of age (i.e., ≤ 4 and ≥ 45 years) were less commonly represented on television compared with reality. Characters on television vs. reality were less commonly women (31.2% vs. 52.9%, respectively), African-American (12.7% vs. 20.3%), or Hispanic (7.1% vs. 12.5%). The two most common acuity categories for television were the extreme categories "non-urgent" and "emergent," whereas the two most common categories for reality were the middle categories "semi-urgent" and "urgent." Televised visits compared with reality were most commonly due to injury (63.5% vs. 37.0%, respectively), and televised injuries were less commonly work-related (4.2% vs. 14.8%, respectively)., Conclusions: Comparison of represented and actual characteristics of ED patients may be valuable in helping us determine what types of patient misperceptions may exist, as well as what types of interventions may be beneficial in correcting that potential misinformation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Although marital status has been shown to affect the outcomes of many conditions, there are limited data on the relationships between marital status and the presentation and outcomes of pneumonia., Methods: We used Veterans Affairs administrative databases to identify a retrospective cohort of male veterans age ≥ 65 years hospitalized for pneumonia between 2002 and 2007. We assessed unadjusted and adjusted associations between marital status and mortality, hospital length of stay, and readmission to the hospital using generalized linear mixed-effect models with admitting hospital as a random effect and adjusted for baseline patient characteristics., Results: There were 48,635 patients (26,558 married and 22,077 unmarried) in the study. Married men had a slightly higher Charlson comorbidity score (3.0 vs 2.8, P < .0001) but were less likely to require ICU admission, ventilator support, and vasopressor treatment during the first 48 h of hospitalization. Married patients had significantly lower crude and adjusted in-hospital mortality (9.4% vs 10.6%; adjusted OR, 0.87; 95% CI, 0.81-0.93) and mortality during the 90 days after hospital discharge (14.7% vs 16.0%; adjusted OR, 0.92; 95% CI, 0.88-0.98). Their adjusted incidence rate ratio length of stay was also lower (0.92; 95% CI, 0.91-0.92)., Conclusions: Unmarried elderly men admitted to the hospital with pneumonia have a higher risk of in-hospital and postdischarge mortality, despite having a lower degree of comorbidity. Although marital status may be a surrogate marker for other predictors, it is an easily identifiable one. These results should be considered by those responsible for care-transition decisions for patients hospitalized with pneumonia.

Objectives: Although US cigarette smoking is decreasing, hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposure. We assessed how a representative sample of US tobacco control policies may apply to HTS., Methods: We examined municipal, county, and state legal texts applying to the 100 largest US cities. We developed a summary policy variable that distinguished among cities on the basis of how current tobacco control policies may apply to HTS and used multinomial logistic regression to determine associations between community-level sociodemographic variables and the policy outcome variable., Results: Although 73 of the 100 largest US cities have laws that disallow cigarette smoking in bars, 69 of these cities have exemptions that allow HTS; 4 of the 69 have passed legislation specifically exempting HTS, and 65 may permit HTS via generic tobacco retail establishment exemptions. Cities in which HTS may be exempted had denser populations than cities without clean air legislation., Conclusions: Although three fourths of the largest US cities disallow cigarette smoking in bars, nearly 90% of these cities may permit HTS via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS.

Background: The Veterans Affairs Healthcare System implemented a computer-based tool (iMedConsent) to improve the quality of informed consent in 2004. The impact of this tool on the process of informed consent remains unknown. Our aim was to determine the impact of iMedConsent on patient information preference, anxiety, trust in the surgeon, ambivalence about the surgical decision, and comprehension of procedure-specific risk, benefits, and alternatives., Materials and Methods: We prospectively enrolled a consecutive cohort of patients presenting to a general surgery clinic for possible cholecystectomy or inguinal herniorrhaphy from October 2009 to August 2010. We administered questionnaires before and after the clinic visit., Results: Seventy-five patients completed pre-visit questionnaires. After evaluation by the surgeon, 42 patients were offered surgery and documented their informed consent using iMedConsent, of whom 38 (90%) also completed a post-visit questionnaire. Among the participants who completed both pre- and post-visit questionnaires, participant comprehension of procedure-specific risks benefits and alternatives improved from 50% at baseline to 60% after the clinic visit (P < 0.001). No differences were noted in ambivalence, trust, or anxiety. After the clinic visit, significantly more patients expressed a preference for participating in decision making with their surgeon (98% versus 71%, P = 0.008). However, significantly fewer expressed a preference for knowing all possible details about their illness (25% to 83%, P ≤ 0.001)., Conclusions: The informed consent process using iMedConsent improves patient comprehension of procedure-specific risks, benefits, and alternatives. It also increases patient preferences for participating more actively in the decision-making process. However, the process may provide more detail than patients want regarding their illness., (Published by Elsevier Inc.)

Objective: To improve the understanding of the determinants of prognosis and accurate risk stratification in community-acquired pneumonia (CAP)., Design: Multicentre collaboration of prospective cohorts., Setting: 6 cohorts from the USA, Canada, Hong Kong and Spain., Participants: From a published meta-analysis of risk stratification studies in CAP, the authors identified and pooled individual patient-level data from six prospective cohort studies of CAP (three from the USA, one each from Canada, Hong Kong and Spain) to create the International CAP Collaboration Cohort. Initial essential inclusion criteria of meta-analysis were (1) prospective design, (2) in English language, (3) reported 30-day mortality and transfer to an intensive or high dependency care and (4) minimum 1000 participants. Common baseline patient characteristics included demographics, history and physical examination findings, comorbidities and laboratory and radiographic findings., Primary and Secondary Outcome Measures: This paper reports the rationale, hypotheses and analytical framework and also describes study cohorts and patients. The authors aim to (1) compare the prognostic accuracy of existing CAP risk stratification tools, (2) assess patient-level determinants of prognosis, (3) improve risk stratification by combined use of scoring systems and (4) understand prognostic factors for specific patient groups., Results: The six cohorts assembled from 1991 to 2007 included 13 784 patients (median age 71 years, 54% men). Aside from one randomised controlled study, the remaining five were cohort studies, but all had similar inclusion criteria. Overall, there was 0%-6% missing data. A total of 6159 (44%) had severe pneumonia by Pneumonia Severity Index class IV/V. Mortality at 30 days was 8% (1036). Admission to intensive care or high dependency unit was also 8% (1059)., Conclusions: International CAP Collaboration Cohort provides a pooled multicentre data set of patients with CAP, which will help us to better understand the prognosis of CAP.

Background: Previous research demonstrates that organizational culture (OC) and knowledge, attitudes, and practices of health care personnel are associated with the overall success of infection control programs; however, little attention has been given to the relationships among these factors in contributing to the success of quality improvement programs., Methods: Cross-sectional surveys assessing OC and knowledge, attitudes, and practices related to methicillin-resistant Staphylococcus aureus (MRSA) were distributed to 16 medical centers participating in a Veterans Affairs MRSA prevention initiative in 2 time periods. Factor analysis was performed on the OC survey responses, and factor scores were generated. To assess associations between OC and knowledge, attitudes, and practices of health care personnel, regression analyses were performed overall and then stratified by job type., Results: The final analyzable sample included 2,314 surveys (43% completed by nurses, 9% by physicians, and 48% by other health care personnel). Three OC factors emerged accounting for 53% of the total variance: "Staff Engagement," "Overwhelmed/Stress-Chaos," and "Hospital Leadership." Overall, higher Staff Engagement was associated with greater knowledge scores, better hand hygiene practices, fewer reported barriers, and more positive attitudes. Higher Hospital Leadership scores were associated with better hand hygiene practices, fewer reported barriers, and more positive attitudes. Conversely, higher Overwhelmed/Stress-Chaos scores were associated with poorer reported prevention practices, more barriers, and less positive attitudes. When these associations were stratified by job type, there were significant associations between OC factors and knowledge for nurses only, between OC factors and practice items for nurses and other health care personnel, and between OC factors and the barriers and attitudes items for all job types. OC factors were not associated with knowledge and practices among physicians., Conclusions: Three OC factors-Staff Engagement, Overwhelmed/Stress-Chaos, and Hospital Leadership-were found to be significantly associated with individual health care personnel knowledge, attitudes, and self-reported practices regarding MRSA prevention. When developing a prevention intervention program, health care organizations should not only focus on the link between OC and the knowledge, attitudes, and practices of health care personnel, but also target programs based on health care personnel type to maximize their effectiveness., (Published by Mosby, Inc.)

Objectives: The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP)., Methods: This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission., Results: Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p < 0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.42 to 4.90), and no ICU admissions (OR = 3.40; 95% CI = 2.11 to 5.48), but did not differ between early and no ICU admissions (OR = 1.29; 95% CI = 0.79 to 2.09). The median hospital LOS was 10 days for early (interquartile range [IQR] = 7 to 18), 15 days for late (IQR 9 to 23), and 6 days (IQR 4 to 9) for no ICU admissions (p < 0.001)., Conclusions: This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU., (© 2012 by the Society for Academic Emergency Medicine.)

Background: Although pain, sexual dysfunction, and depression are common in patients receiving chronic hemodialysis, these symptoms frequently remain untreated. We sought to characterize renal provider perceptions and practice patterns regarding the treatment of these symptoms., Methods: We surveyed renal providers whose patients were participating in a clinical trial of symptom management at nine hemodialysis units in southwestern Pennsylvania. We used Spearman's correlation to assess the association of provider characteristics with the reported frequency of providing treatment., Results: Overall, 27 of 35 (77%) providers completed the survey. While 21 (78%) believed symptom management to be "very" important and 23 (85%) reported spending a "moderate" to "a lot" of time managing symptoms, <50% reported treating pain and <20% reported treating sexual dysfunction or depression "most" or "all" of the time. Most providers believed it was nonrenal providers' responsibility to treat these symptoms. A greater reported comfort level managing symptoms was associated with a higher reported frequency of treating pain (r=0.6; p<0.01), sexual dysfunction (r=0.67; p<0.01), and depression (r=0.43; p<0.03). Providers who believed it was nonrenal providers' responsibility to treat these symptoms reported treating pain (r=-0.62; p<0.01) and depression (r=-0.48; p=0.02) less frequently., Conclusions: Despite reporting considerable importance and substantial time managing symptoms in general, renal providers commonly describe not treating pain, sexual dysfunction, and depression in hemodialysis patients. Given renal providers' beliefs that nonrenal clinicians are primarily responsible for treating these symptoms, multidisciplinary approaches to symptom management in these patients are needed.

Background: Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain., Methods: For 2076 patients hospitalized with pneumonia from 32 emergency departments, we used multilevel logistic regression modeling to assess independent associations between patient outcomes and the performance of 4 individual processes of care (assessment of oxygenation, blood cultures, and rapid initiation [<4 hours] and appropriate selection of antibiotic therapy) and the cumulative number of processes of care performed., Results: Overall, 141 patients (6.8%) died. Mortality was 0.3% to 1.7% lower for patients who had each of the individual processes of care performed (P≥.13 for each comparison); mortality was 7.5% for patients who had 0 to 2 processes of care, 7.2% for those with 3 processes of care, and 5.8% for those with all 4 processes of care performed (P=.39). Mortality was not significantly associated with either individual or cumulative process measures in multivariable models., Conclusion: Neither the individual processes of care nor the cumulative number performed is associated with short-term mortality for pneumonia., (Published by Elsevier Inc.)

Rationale: Treatment with inhaled corticosteroids (ICS) for those with chronic obstructive pulmonary disease (COPD) has been shown to be associated with an increased incidence of pneumonia. However, it is unclear if this is associated with increased mortality., Objectives: The aim of this study was to examine the effects of prior use of ICS on clinical outcomes for patients with COPD hospitalized with pneumonia., Methods: We conducted a retrospective cohort study using the national administrative databases of the Department of Veterans Affairs. Eligible patients had a preexisting diagnosis of COPD, had a discharge diagnosis of pneumonia, and received treatment with one or more appropriate pulmonary medications before hospitalization. Outcomes included mortality, use of invasive mechanical ventilation, and vasopressor use., Measurements and Main Results: There were 15,768 patients (8,271 with use of ICS and 7,497 with no use of ICS) with COPD who were hospitalized for pneumonia. There was also a significant difference for 90-day mortality (ICS 17.3% vs. no ICS 22.8%; P < 0.001). Multilevel regression analyses demonstrated that prior receipt of ICS was associated with decreased mortality at 30 days (odds ratio [OR] 0.80; 95% confidence interval [CI], 0.72-0.89) and 90 days (OR 0.78; 95% CI, 0.72-0.85), and decreased use of mechanical ventilation (OR 0.83; 95% CI, 0.72-0.94). There was no significant association between receipt of ICS and vasopressor use (OR 0.88; 95% CI, 0.74-1.04)., Conclusions: For patients with COPD, prior use of ICS is independently associated with decreased risk of short-term mortality and use of mechanical ventilation after hospitalization for pneumonia.

Background: Although practice guidelines recommend outpatient care for selected, haemodynamically stable patients with pulmonary embolism, most treatment is presently inpatient based. We aimed to assess non-inferiority of outpatient care compared with inpatient care., Methods: We undertook an open-label, randomised non-inferiority trial at 19 emergency departments in Switzerland, France, Belgium, and the USA. We randomly assigned patients with acute, symptomatic pulmonary embolism and a low risk of death (pulmonary embolism severity index risk classes I or II) with a computer-generated randomisation sequence (blocks of 2-4) in a 1:1 ratio to initial outpatient (ie, discharged from hospital ≤24 h after randomisation) or inpatient treatment with subcutaneous enoxaparin (≥5 days) followed by oral anticoagulation (≥90 days). The primary outcome was symptomatic, recurrent venous thromboembolism within 90 days; safety outcomes included major bleeding within 14 or 90 days and mortality within 90 days. We used a non-inferiority margin of 4% for a difference between inpatient and outpatient groups. We included all enrolled patients in the primary analysis, excluding those lost to follow-up. This trial is registered with ClinicalTrials.gov, number NCT00425542., Findings: Between February, 2007, and June, 2010, we enrolled 344 eligible patients. In the primary analysis, one (0·6%) of 171 outpatients developed recurrent venous thromboembolism within 90 days compared with none of 168 inpatients (95% upper confidence limit [UCL] 2·7%; p=0·011). Only one (0·6%) patient in each treatment group died within 90 days (95% UCL 2·1%; p=0·005), and two (1·2%) of 171 outpatients and no inpatients had major bleeding within 14 days (95% UCL 3·6%; p=0·031). By 90 days, three (1·8%) outpatients but no inpatients had developed major bleeding (95% UCL 4·5%; p=0·086). Mean length of stay was 0·5 days (SD 1·0) for outpatients and 3·9 days (SD 3·1) for inpatients., Interpretation: In selected low-risk patients with pulmonary embolism, outpatient care can safely and effectively be used in place of inpatient care., Funding: Swiss National Science Foundation, Programme Hospitalier de Recherche Clinique, and the US National Heart, Lung, and Blood Institute. Sanofi-Aventis provided free drug supply in the participating European centres., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background and Objectives: Although limited health literacy is estimated to affect over 90 million Americans and is recognized as an important public health concern, there have been few studies examining this issue in patients with chronic kidney disease. We sought to characterize the prevalence of and associations of demographic and clinical characteristics with limited health literacy in patients receiving maintenance hemodialysis., Design, Setting, Participants, & Measurements: As part of a prospective clinical trial of symptom management strategies in 288 patients treated with chronic hemodialysis, we assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM). We defined limited health literacy as a REALM score ≤60 and evaluated independent associations of demographic and baseline clinical characteristics with limited health literacy using multivariable logistic regression., Results: Of the 260 patients who completed the REALM, 41 demonstrated limited health literacy. African-American race, lower educational level, and veteran status were independently associated with limited health literacy. There was no association of limited health literacy with age, gender, serologic values, dialysis adequacy, overall symptom burden, quality of life, or depression., Conclusions: Limited health literacy is common among patients receiving chronic hemodialysis. African-American race and socioeconomic factors are strong independent predictors of limited health literacy. These findings can help inform the design and implementation of interventions to improve health literacy in the hemodialysis population.

Objective: To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI)., Design: Cross-sectional multisite study using structured questionnaires., Setting: Six National SCI Model Systems centers., Participants: People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes)., Interventions: None., Main Outcome Measures: Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey)., Results: African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (β=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (β=.27; 95% CI, .01-.53; P<.05)., Conclusions: In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Rationale: Although associated with adverse outcomes in other cardiopulmonary conditions, the prognostic value of hyponatremia, a marker of neurohormonal activation, in patients with acute pulmonary embolism (PE) is unknown., Objectives: To examine the associations between hyponatremia and mortality and hospital readmission rates for patients hospitalized with PE., Methods: We evaluated 13,728 patient discharges with a primary diagnosis of PE from 185 hospitals in Pennsylvania (January 2000 to November 2002). We used random-intercept logistic regression to assess the independent association between serum sodium levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient (race, insurance, severity of illness, use of thrombolytic therapy) and hospital factors (region, size, teaching status)., Measurements and Main Results: Hyponatremia (sodium ≤135 mmol/L) was present in 2,907 patients (21.1%). Patients with a sodium level greater than 135, 130-135, and less than 130 mmol/L had a cumulative 30-day mortality of 8.0, 13.6, and 28.5% (P < 0.001), and a readmission rate of 11.8, 15.6, and 19.3% (P < 0.001), respectively. Compared with patients with a sodium greater than 135 mmol/L, the adjusted odds of dying were significantly greater for patients with a sodium 130-135 mmol/L (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.33-1.76) and a sodium less than 130 mmol/L (OR, 3.26; 95% CI, 2.48-4.29). The adjusted odds of readmission were also increased for patients with a sodium of 130-135 mmol/L (OR, 1.28; 95% CI, 1.12-1.46) and a sodium less than 130 mmol/L (OR, 1.44; 95% CI, 1.02-2.02)., Conclusions: Hyponatremia is common in patients presenting with PE, and is an independent predictor of short-term mortality and hospital readmission.

Despite the high prevalence of pain, sexual dysfunction, and depression in patients on chronic hemodialysis, these symptoms are often unrecognized and under-treated by renal providers. This report describes the rationale and methodology of the SMILE study (Symptom Management Involving End-Stage Renal Disease), a multi-center, randomized clinical trial comparing the effectiveness of two strategies for implementing treatment for these symptoms in patients receiving chronic hemodialysis. Approximately 250 patients from nine outpatient dialysis units will participate. Over a 2-12 month observational phase, participants complete monthly surveys characterizing their pain, sexual dysfunction, and depression. Following this observational period, subjects are randomized to one of two study arms to receive a 12-month intervention. In one study arm (feedback intervention), patients continue to complete the same three symptom surveys, and the presence and severity of the symptoms reported on these surveys is mailed to the patient's renal provider along with evidence-based algorithms outlining treatment options for these symptoms. Decisions on treatment are left at the discretion of the provider. Patients randomized to the other study arm (management intervention) also continue to complete the same monthly symptom surveys and are evaluated by a symptom management nurse trained in the management of these symptoms. This nurse then discusses the patient's symptoms with the renal provider, provides specific recommendations for treatment, and facilitates the implementation of treatment. The primary endpoints are changes in scores on pain, erectile dysfunction, and depression surveys. This report describes the rationale and methodology of this clinical trial., (Published by Elsevier Inc.)

To describe the key strategies and potential pitfalls involved with implementing the Department of Veterans Affairs (VA) Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in a qualitative evaluation, we conducted in-depth interviews with MRSA Prevention Coordinators at 17 VA beta sites at 2 time points during program implementation.

The Ragins and McFarlin Mentor Role Instrument (RMMRI) was originally developed to measure perceptions of mentoring relationships in research and development organizations. The current study was designed to evaluate the RMMRI's reliability and validity when the instrument was administered to clinical and translational science trainees at an academic medical center. The 33-item RMMRI was administered prospectively to a cohort of 141 trainees at the University of Pittsburgh in 2007-2008. Likert-scale items focused on perceptions of five mentoring roles in the career dimension (sponsor, coach, protector, challenger, and promoter) and six mentoring roles in the psychosocial dimension (friend, social associate, parent, role model, counselor, and acceptor). Outcome items included overall perceptions of mentoring satisfaction and effectiveness. Of 141 trainees, 53% were male, 66% were white, 22% were Asian, and 59% were medical doctors. Mean age was 32 years. Analyses showed strong within-factor inter-item correlations (Pearson Coefficients of 0.57-0.93); strong internal consistency (Cronbach alphas of 0.82-0.97); confirmatory factorial validity, as demonstrated by confirmatory factor analysis of the two mentoring dimensions, 11 mentoring roles, and 33 RMMRI items; and concurrent validity, as demonstrated by strong correlations (Pearson Coefficients of 0.56-0.71) between mentoring dimensions, satisfaction, and effectiveness. This article concludes that the RMMRI shows reliability and validity in capturing the multidimensional nature of mentoring when administered to clinical and translational science trainees in the academic setting.

Background: African-Americans admitted to U.S. hospitals with community-acquired pneumonia (CAP) are more likely than Caucasians to experience prolonged hospital length of stay (LOS), possibly due to either differential treatment decisions or patient characteristics., Methods: We assessed associations between race and outcomes (Intensive Care Unit [ICU] variables, LOS, 30-day mortality) for African-American or Caucasian patients over 65 years hospitalized in the Veterans Health Administration (VHA) with CAP (2002-2007). Patients admitted to the ICU were analyzed separately from those not admitted to the ICU. VHA patients who died within 30 days of discharge were excluded from all LOS analyses. We used chi-square and Fisher's exact statistics to compare dichotomous variables, the Wilcoxon Rank Sum test to compare age by race, and Cox Proportional Hazards Regression to analyze hospital LOS. We used separate generalized linear mixed-effect models, with admitting hospital as a random effect, to examine associations between patient race and the receipt of guideline-concordant antibiotics, ICU admission, use of mechanical ventilation, use of vasopressors, LOS, and 30-day mortality. We defined statistical significance as a two-tailed p

Background: Although guidelines currently recommend prevention practices to decrease in-hospital transmission of infections, increasing adherence to the practices remains a challenge. This study assessed the effect of a multicenter methicillin-resistant Staphylococcus aureus (MRSA) prevention initiative on changes in employees' knowledge, attitudes, and practices., Methods: Two cross-sectional surveys were distributed at baseline (October 2006) and follow-up (July 2007) at 17 medical centers participating in the Veterans' Administration (VA) MRSA initiative., Results: Surveys were completed by 1362 employees at baseline and 952 employees at follow-up (representing 57% and 56% of eligible respondents, respectively). Respondents included physicians (9%), nurses (38%), allied health professionals (30%), and other support staff (24%). Of the 5 knowledge items, the mean proportion answered correctly increased slightly from baseline to follow-up (from 71% to 73%; P = .07). The percentage of respondents who believed that MRSA was a problem on their unit increased over time (from 56% to 65%; P < .001). Respondents also reported increased comfort with reminding other staff about proper hand hygiene (from 61% to 70%; P < .001) and contact precautions (from 63% to 70%; P < .002). The percentage of respondents reporting at least one barrier to proper hand hygiene decreased over time (from 25% to 20%; P = .003)., Conclusions: In this multicenter study of VA employees, implementation of a MRSA quality improvement initiative was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention., (Published by Mosby, Inc.)

Introduction: To identify factors associated with timely initiation of antibiotic therapy for patients hospitalized with pneumonia., Design: Secondary analysis of a cluster-randomized, controlled trial., Setting: Thirty- two emergency departments (EDs) in Pennsylvania and Connecticut., Subjects: Patients with a clinical and radiographic diagnosis of community-acquired pneumonia., Interventions: From January to December 2001, EDs were randomly allocated to guideline implementation strategies of low (n = 8), moderate (n = 12), and high intensity (n = 12) to improve the initial site of treatment and the performance of evidence-based processes of care. Our primary outcome was antibiotic initiation within 4 hours of presentation, which at that time was the recommended process of care for inpatients., Results: Of the 2076 inpatients enrolled, 1632 (78.6%) received antibiotic therapy within 4 hours of presentation. Antibiotic timeliness ranged from 55.6% to 100% (P < 0.001) by ED and from 77.0% to 79.7% (P = 0.2) across the 3 guideline implementation arms. In multivariable analysis, heart rate > or =125 per minute (OR = 1.6, 95% CI 1.1-2.3), respiratory rate > or =30 per minute (OR = 2.3, 95% CI 1.6-3.4), and aspiration pneumonia (OR = 3.7, 95% CI 1.1-12.7) were positively associated with timely initiation of antibiotic therapy, whereas a hematocrit <30% (OR = 0.6, 95% CI 0.4-1.0) was negatively associated with this outcome., Conclusions: Timely initiation of antibiotic therapy is associated primarily with patient-related factors that reflect severity of illness at presentation. Although this study demonstrates an opportunity to improve performance on this quality measure in nearly one quarter of inpatients with pneumonia, we failed to identify any modifiable patient, provider, or hospital level factors to target in such quality improvement efforts.

Background: Many physicians recommend that patients receive follow-up chest imaging after the diagnosis of pneumonia to ensure that a pulmonary malignancy is not missed. However, there is little research evidence to support this practice. Our aims were to assess the frequency of the diagnosis of pulmonary malignancy, and to identify risk factors for pulmonary malignancy following hospitalization for pneumonia., Methods: By excluding patients with a prior diagnosis of pulmonary malignancy, we examined the incidence of a new pulmonary malignancy diagnosis in inpatients aged >/=65 years with a discharge diagnosis of pneumonia in fiscal years 2002-2007, and at least 1 year of Department of Veterans Affairs outpatient care before the index admission., Results: Of 40,744 patients hospitalized with pneumonia, 3760 (9.2%) patients were diagnosed with pulmonary malignancy after their index pneumonia admission. Median time to diagnosis was 297 days, with only 27% diagnosed within 90 days of admission. Factors significantly associated with a new diagnosis of pulmonary malignancy included history of chronic pulmonary disease, any prior malignancy, white race, being married, and tobacco use. Increasing age, Hispanic ethnicity, need for intensive care unit admission, and a history of congestive heart failure, stroke, dementia, or diabetes with complications were associated with a lower incidence of pulmonary malignancy., Conclusion: A small, but clinically important, proportion of patients are diagnosed with pulmonary malignancy posthospitalization for pneumonia. Additional research is needed to examine whether previously undiagnosed pulmonary malignancies might be detected at admission, or soon after, for those hospitalized with pneumonia., (Published by Elsevier Inc.)