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Many examination timetabling procedures employ a phased approach in which the first phase is often the allocation of a large set of mutually conflicting examinations which form a clique in the associated problem graph. The usual practice is to identify a single maximum clique, often quite arbitrarily, in this first phase. We show that in typical examination timetabling problems, unlike random graphs, there are often many alternative maximum cliques, and even larger dense subsets of nodes that are almost cliques. A number of methods are proposed for extending the scope of the clique initialisation to include a larger subset of examinations by considering sub-maximum cliques and/or quasi-cliques. Keywords: timetabling; graph; clique

OBJECTIVE: Patients in the emergency department (ED) who have been admitted to hospital (inpatient 'boarders') are associated with ED overcrowding. They are also a symptom of a hospital-wide imbalance between demand and supply of resources. We analyzed the trends of inpatient admissions, ED boarding volumes, lengths of stay and bed resources of 3 major admitting services at our teaching institution. METHODS: We used hospital databases from Jan. 1, 2004, to Dec. 31, 2007, to analyze ED visits that resulted in admission to hospital. RESULTS: During the study period, 21 986 ED patients were admitted to hospital. The percentage of cancer-related admissions to the oncology admitting service decreased from 48% in 2004 to 24% in 2007, and admissions to general internal medicine (GIM) increased nearly 2-fold, from 28% in 2004 to 54% in 2007. In addition, GIM admitted about 10% more myocardial infarction and heart failure patients than did cardiology. General internal medicine constituted the majority of ED boarders and had a median boarding length of stay of approximately 15 hours. Inpatient beds on oncology and cardiology services remained static. CONCLUSION: Without bed capacity to admit more patients, our specialty services relied on GIM to serve as a safety net. At the same time, GIM was cited as a main source of ED congestion as their patients occupied more ED beds for longer periods than any other admitting service. The data presented in this study has helped effect positive change within our institution. Other hospitals running at or near capacity and faced with similar ED congestion may apply the methods we used in this study to analyze the cause and nature of their situation. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The Canadian Emergency Department Triage and Acuity Scale (CTAS) is a 5-level triage tool used to determine the priority by which patients should be treated in Canadian emergency departments (EDs). To determine emergency physician (EP) workload and staffing needs, many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level. The purpose of our study was to describe the distribution of EP time by activity during a shift in order to estimate the amount of time required by an EP to assess and treat patients in each triage category and to determine the variability in the distribution of CTAS scoring between hospital sites. METHODS: Research assistants directly observed EPs for 592 shifts and electronically recorded their activities on a moment-by-moment basis. The duration of all activities associated with a given patient were summed to derive a directly observed estimate of the amount of EP time required to treat the patient. RESULTS: We observed treatment times for 11 716 patients in 11 hospital-based EDs. The mean time for physicians to treat patients was 73.6 minutes (95% confidence interval [CI] 63.6-83.7) for CTAS level 1, 38.9 minutes (95% CI 36.0-41.8) for CTAS-2, 26.3 minutes (95% CI 25.4-27.2) for CTAS-3, 15.0 minutes (95% CI 14.6-15.4) for CTAS-4 and 10.9 minutes (95% CI 10.1-11.6) for CTAS-5. Physician time related to patient care activities accounted for 84.2% of physicians' ED shifts. CONCLUSION: In our study, EPs had very limited downtime. There was significant variability in the distribution of CTAS scores between sites and also marked variation in EP time related to each triage category. This brings into question the appropriateness of using CTAS alone to determine physician staffing levels in EDs. [ABSTRACT FROM AUTHOR]

This paper describes a decision tool created for the Simcoe County Community Care Access Center (SCCCAC) in Ontario. The tool allows the SCCCAC to quantitatively assess the trade-offs between cost, quality, and waiting time of their home care patients. This information can then be used to negotiate reasonable funding levels with the Ontario government and to appropriately allocate this funding among the various patient groups at the SCCCAC. This work can be expanded to other health care organizations that use prioritized waiting lists. [ABSTRACT FROM AUTHOR]

This study examines how resident risk of hospitalization varies in relation to facility performance on select quality indicators (QIs). Using a 15% sample, three years of Medicaid reimbursement data from over 525 nursing homes (NHs) were linked with four years of hospital claims data and facility-level data to investigate whether residents of NHs with worse (better) than expected performance on QIs experienced increased (decreased) risk of hospitalization. Logistic regression results indicate that variations in hospitalization risk among NH residents are explained in part by facility performance on QIs. Residents from NHs with more decubitus ulcers, with greater use of physical restraints, and with a higher than expected incidence of unexplained weight loss/gain experienced increased risk of hospitalization. [ABSTRACT FROM AUTHOR]

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper. [ABSTRACT FROM AUTHOR]

This study examined patient-level, facility-level, and area market-level factors affecting ambulatory care-sensitive hospitalization (ACSH) rates among nursing home residents. Although ACSH has long been used to monitor accessibility to health care services among community-dwelling populations, the use of ACSH rates as an indicator of potential quality-of-care problems affecting nursing home residents has not been employed. METHODS. Three years of quarterly Medicaid reimbursement data from more than 500 nursing homes were linked to 4 years of Medicare Provider Analysis and Review hospital claims data, nursing facility attribute data, and Area Resource File data to investigate the relative contribution of patient-, facility-, and market-level risk factors to ACSH among nursing home residents. RESULTS. Logistic regression results indicate that facility-level factors and nursing home quality-of-care indicators significantly contribute to the risk of ACSH. DISCUSSION. Findings underscore the need for continuing efforts to improve quality-of-care practices in nursing homes, particularly with respect to associations between quality-of-care indicators and facility structural/organizational characteristics with ACSHs. [ABSTRACT FROM AUTHOR]

Purpose. Currently, little knowledge exists about the extent to which: 1) nursing home residents perceive their oral health care as being adequate, 2) nursing home residents' perceptions and actual oral health status are congruent, and 3) oral health care outcomes and residents' perceptions of their own oral health care are influenced by levels of physical functioning. The purpose of this study was to evaluate the oral health practices and perceptions of oral health care among cognitively intact nursing home residents. Methods and Materials. Institutional review board approval was obtained, and a modified, one-shot case study design,* a 20-question resident interview, and a 10-category oral health care evaluation were utilized in three encounters with the accepting sample of 10 West Virginia nursing home residents. The interview identified each participant's current and past oral health care practices, perceptions about their current oral practices, and levels of need and functioning in the nursing home. The evaluation assessed the current oral health status of the participants. A licensed West Virgina dentist was present during the evaluations. Results. All participants (N = 10) completed the assessments. Data analyses, including percentages, frequencies, and measures of dispersion, were conducted using the JMP program, version 3. Conclusions. Conclusions that may be drawn from this study include: 1) study participants who are dependent on the nursing home staff for oral health care needs are most likely to receive oral health care, 2) the quality of oral health care performed by the nursing home staff or resident is lower than the current oral health care standards and recommendations, and 3) study participants' barriers for oral health care were commonly influenced by their physical functioning. *A modified, one-shot case study is a descriptive analysis of a particular group of individuals within one setting that reflects moderation, apparent in this study by three discrete visits to the participating nursing home. [ABSTRACT FROM AUTHOR]

Context: In response to the COVID-19 pandemic, Congress passed the American Rescue Plan Act of 2021 (ARPA) that included a historic investment in the public health workforce., Program: Charged with implementing this investment, the U.S. Centers for Disease Control and Prevention (CDC) launched the Public Health Infrastructure Grant (PHIG). PHIG builds on CDC's experience working with state, local, and territorial public health departments and represents a new approach to strengthening the public health workforce., Implementation: Specifically, PHIG incorporates features that allow these public health departments to prioritize and tailor the funding to meet their communities' needs: 1) focus on workforce as core infrastructure, 2) streamlined programmatic and administrative requirements, 3) more equitable funding approach, and 4) enhanced support from national partners and CDC., Discussion: The goal is to optimize the unprecedented opportunity afforded by ARPA and lead to a stronger public health workforce and infrastructure across the United States., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Although seasonal influenza disease spread is a spatio-temporal phenomenon, public surveillance systems aggregate data only spatially, and are rarely predictive. We develop a hierarchical clustering-based machine learning tool to anticipate flu spread patterns based on historical spatio-temporal flu activity, where we use historical influenza-related emergency department records as a proxy for flu prevalence. This analysis replaces conventional geographical hospital clustering with clusters based on both spatial and temporal distance between hospital flu peaks to generate a network illustrating whether flu spreads between pairs of clusters (direction) and how long that spread takes (magnitude). To overcome data sparsity, we take a model-free approach, treating hospital clusters as a fully-connected network, where arcs indicate flu transmission. We perform predictive analysis on the clusters' time series of flu ED visits to determine direction and magnitude of flu travel. Detection of recurrent spatio-temporal patterns may help policymakers and hospitals better prepare for outbreaks. We apply this tool to Ontario, Canada using a five-year historical dataset of daily flu-related ED visits, and find that in addition to expected flu spread between major cities/airport regions, we were able to illuminate previously unsuspected patterns of flu spread between non-major cities, providing new insights for public health officials. We showed that while a spatial clustering outperforms a temporal clustering in terms of the direction of the spread (81% spatial v. 71% temporal), the opposite is true in terms of the magnitude of the time lag (20% spatial v. 70% temporal).

Introduction: This study evaluates the impact of an Internet of Things (IoT) intervention in a hospital unit and provides empirical evidence on the effects of smart technologies on patient safety (patient falls and hand hygiene compliance rate) and staff experiences., Method: We have conducted a post-intervention analysis of hand hygiene (HH) compliance rate, and a pre-and post-intervention interrupted time-series (ITS) analysis of the patient falls rates. Lastly, we investigated staff experiences by conducting semi-structured open-ended interviews based on Roger's Diffusion of Innovation Theory., Results: The results showed that (i) there was no statistically significant change in the mean patient fall rates. ITS analysis revealed non-significant incremental changes in mean patient falls (- 0.14 falls/quarter/1000 patient-days). (ii) HH compliance rates were observed to increase in the first year then decrease in the second year for all staff types and room types. (iii) qualitative interviews with the nurses reported improvement in direct patient care time, and a reduced number of patient falls., Conclusion: This study provides empirical evidence of some positive changes in the outcome variables of interest and the interviews with the staff of that unit reported similar results as well. Notably, our observations identified behavioral and environmental issues as being particularly important for ensuring success during an IoT innovation implementation within a hospital setting., (© 2022. The Author(s).)

The purpose of the study was to examine trends in COVID-19 cases, related deaths, and staffing shortages in nursing homes (NH) by rural and urban status from May 2020 to Feb 2021. Generalized linear mixed models with state-fixed effects were used to estimate the interaction effect of study period and rural/urban status on having at least: one COVID-19 case, one related death, and/or at least one week of staffing shortage using the NH COVID-19 data spanning the 40-week period. The findings revealed shortages in staff, particularly direct care providers, were greatly accelerated in rural NHs as the pandemic wore on over time. Conversely, staffing shortages in urban NHs were relatively stable despite the fluctuating COVID-19 cases over the same time period. The findings highlight the need of identifying effective strategies that prevent rural NHs from encountering staffing deficits in response to long-lasting natural disasters such as the COVID-19 pandemic., Competing Interests: Declaration of Competing Interest None, (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates., Design: Retrospective secondary data analysis at the facility level, using administrative data., Setting and Participants: Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325)., Methods: Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant., Results: We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs., Conclusions and Implications: NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Case investigation and contact tracing are core public health tools used to interrupt transmission of pathogens, including SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19); timeliness is critical to effectiveness (1,2). In May 2020, CDC funded* 64 state, local, and territorial health departments † to support COVID-19 response activities. As part of the monitoring process, case investigation and contact tracing metrics for June 25-July 24, 2020, were submitted to CDC by 62 health departments. Descriptive analyses of case investigation and contact tracing load, timeliness, and yield (i.e., the number of contacts elicited divided by the number of patients prioritized for interview) were performed. A median of 57% of patients were interviewed within 24 hours of report of the case to a health department (interquartile range [IQR] = 27%-82%); a median of 1.15 contacts were identified per patient prioritized for interview § (IQR = 0.62-1.76), and a median of 55% of contacts were notified within 24 hours of identification by a patient (IQR = 32%-79%). With higher caseloads, the percentage of patients interviewed within 24 hours of case report was lower (Spearman coefficient = -0.68), and the number of contacts identified per patient prioritized for interview also decreased (Spearman coefficient = -0.60). The capacity to conduct timely contact tracing varied among health departments, largely driven by investigators' caseloads. Incomplete identification of contacts affects the ability to reduce transmission of SARS-CoV-2. Enhanced staffing capacity and ability and improved community engagement could lead to more timely interviews and identification of more contacts., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Alison Stargel reports employment as the duty epidemiologist on the Washington State Department of Health COVID-19 response during April–June 2020. No other potential conflicts of interest were disclosed.

This study examines how job satisfaction in six subscales and select stressors and demographic covariates influence nursing home administrator's (NHA) intentions to quit. Quantitative and qualitative data were collected from 311 NHAs in five states. Adjusted odds ratios and 95% confidence intervals for the ordered logistic regression models indicated that NHAs with satisfying work demands, rewards, and coworkers, and who experienced less role conflict and had fewer prior nursing home jobs had lower turnover intentions. Although generally satisfied, roughly 24% reported intending to quit. Surprisingly, NHAs reporting higher job skills were more likely to consider leaving, suggesting that talented NHAs may choose career advancement eased by stigma-free job-hopping in an industry with high mobility norms. Qualitative data suggested that job satisfaction/dissatisfaction was influenced by a more nuanced interpretation of satisfying and more taxing job facets and quitting triggers, including themes such as helping residents and struggling with regulations.

Objective: We aim to 1) design an evaluation framework to examine the accuracy of automatic privacy auditing tools, 2) apply the evaluation method at a hospital to validate the performance of an auditing tool that uses a machine learning algorithm to automate user access auditing, and 3) recommend further improvements in auditing for the hospital., Materials and Methods: Using the black box method of user acceptance testing, we have designed an evaluation framework consisting of appropriate and inappropriate behaviour scenarios to examine the privacy auditing tools. The scenarios were designed from clinical and non-clinical hospital staff perspective, taking expert opinions from the privacy officers and considering examples from the Information and Privacy Commission (IPC) and were tested using Mackenzie Richmond Hill Hospital's data., Results: The case study using this evaluation framework found that on average 98.09 % of total accesses of the hospital were identified as appropriate and the tool was unable to explain the remaining 1.91 % of accesses. In addition, a statistically significant (P < 0.05) increasing trend on categorizing appropriate accesses by the tool have been observed. Furthermore, an analysis of unexplained accesses revealed the contributing factors and found issues related to hospital workflows and data quality (information was missing about staff roles and departments)., Conclusion: Given that adoption of these machine learning tools is increasing in hospitals, this research provides an evaluation framework and an empirical evidence on the effectiveness of automated privacy auditing and detecting anomalies for dynamic hospital workflows., Competing Interests: Declaration of Competing Interest None of the two authors have any conflict of interests and there is no financial involvement in this research that can influence the results., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Context: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery., Objective: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision., Design and Setting: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs., Participants: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%])., Results: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern., Conclusions: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

Purpose This exploratory study examined speech-language pathologists' (SLPs) clinical experience and work environment characteristics impacting comfort with providing intervention to children with traumatic brain injury (TBI). Method This study included 162 SLPs who responded to a national survey about their comfort providing intervention to children with TBI, clinical experience (i.e., years of experience treating children with TBI, TBI preprofessional training and professional development, and licensure/credentialing), and work environment (i.e., work setting, caseload size, geographic location). Results Findings from latent class analysis revealed 3 distinct groups of SLPs based on their comfort with providing services to children with TBI: those with low comfort, moderate comfort, and high comfort. Further analyses revealed statistically significant differences across the 3 groups in the areas of years of experience treating children with TBI, professional development, work setting, TBI caseload size, and geographic location. Conclusions Our findings reveal that most SLPs feel comfortable providing intervention to children with TBI; however, differences in characteristics across groups suggest that specific steps can be taken to ensure increased comfort for all SLPs working with this population. Practicing SLPs may increase their level of comfort through professional development and hands-on, mentored experience with TBI. Efforts such as these may influence the quality of service provision and expand the population of SLPs who feel comfortable treating children with TBI. Future research is needed to further examine how comfort and SLP characteristics directly impact the quality of speech and language intervention and long-term outcomes of children with TBI.

Objective: This study sought to investigate factors associated with opioid misuse-related emergency department (ED) visits among older adults and changes in outcomes associated with these visits, using multiple years of nationally representative data., Methods: A retrospective analysis of the Nationwide Emergency Department Sample was conducted. Study inclusion was limited to adults aged 65 years and older. Diagnostic codes were used to identify opioid misuse disorder; sampling weights were used to adjust standard estimates of the errors. Descriptive and multivariate procedures were used to describe risk and visit outcomes., Results: ED visits by older adults with opioid misuse identified in the ED increased sharply from 2006 to 2014, representing a nearly 220% increase over the study period. Opioid misuse was associated with an increased number of chronic conditions, greater injury risk, and higher rates of alcohol dependence and mental health diagnoses., Conclusion: The steep increase in opioid misuse observed among older adult ED visits underscores the critical need for additional research to better understand the national scope and impact of opioid misuse on older adults, as well as to better inform policy responses to meet the needs of this particular age group.

Context: Community education and engagement are important for informing family planning projects. The objective of this study was to update two prior systematic reviews assessing the impact of community education and engagement interventions on family planning outcomes., Evidence Acquisition: Sixteen electronic databases were searched for studies relevant to a priori determined inclusion/exclusion criteria in high development settings, published from March 2011 through April 2016, updating two reviews that included studies from 1985 through February 2011., Evidence Synthesis: Nine relevant studies were included in this updated review related to community education, in addition to 17 from the prior review. No new community engagement studies met inclusion criteria, as occurred in the prior review. Of new studies, community education modalities included mass media, print/mail, web-based, text messaging, and interpersonal interventions. One study on mass media intervention demonstrated a positive impact on reducing teen and unintended pregnancies. Three of four studies on interpersonal interventions demonstrated positive impacts on medium-term family planning outcomes, such as contraception and condom use. Three new studies demonstrated mostly positive, but inconsistent, results on short-term family planning outcomes., Conclusions: Findings from this systematic review update are in line with a previous review showing the positive impact of community education using traditional modalities on short-term family planning outcomes, identifying additional impacts on long-term outcomes, and highlighting new evidence for education using modern modalities, such as text messaging and web-based education. More research is necessary to provide a stronger evidence base for directing community education and engagement efforts in family planning contexts., Theme Information: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services., (Copyright © 2018. Published by Elsevier Inc.)

Background: Referrals to other medical services are central to healthcare, including family planning service providers; however, little information exists on the nature of referral practices among health centers that offer family planning., Materials and Methods: We used a nationally representative survey of administrators from 1,615 publicly funded health centers that offered family planning in 2013-14 to describe the use of six referral practices. We focused on associations between various health center characteristics and frequent use of three active referral practices., Results: In the prior 3 months, a majority of health centers (73%) frequently asked clients about referrals at clients' next visit. Under half (43%) reported frequently following up with referral sources to find out if their clients had been seen. A third (32%) of all health centers reported frequently using three active referral practices. In adjusted analysis, Planned Parenthood clinics (adjusted odds ratio 0.55) and hospital-based clinics (AOR 0.39) had lower odds of using the three active referral practices compared with health departments, and Title X funding status was not associated with the outcome. The outcome was positively associated with serving rural areas (AOR 1.39), having a larger client volume (AOR 3.16), being a part of an insurance network (AOR 1.42), and using electronic health records (AOR 1.62)., Conclusions: Publicly funded family planning providers were heavily engaged in referrals. Specific referral practices varied widely and by type of care. More assessment of these and other aspects of referral systems and practices is needed to better characterize the quality of care.

This study determines outcomes and costs of similar hip fracture patients that were discharged from hospital to a rehabilitation facility or to the community within 1 year. Community patients had worse outcomes and lower costs compared to rehabilitation facility patients. This study contributes to understanding hip fracture quality of care., Purpose: The purpose of this study is to determine the impact on mortality and rehospitalization, as well as health system cost, of similar hip fracture patients being discharged to an inpatient rehabilitation facility or directly to the community within 1 year in Ontario, Canada., Methods: This was a retrospective study of a propensity-matched cohort completed from the health system perspective. Administrative databases were used to identify and match two groups of older adults (total n = 18,773) discharged alive from acute care for hip fracture repair: patients discharged to inpatient rehabilitation were matched to patients discharged to the community., Results: A higher proportion of patients discharged to the community (27-42%) died or were rehospitalized (SD highipr  = 0.21, SD lowipr  = 0.33) and had substantially lower health system costs (SD highipr  = 0.65, SD lowipr  = 0.42) up to 1 year post-acute discharge compared to similar patients discharged to inpatient rehabilitation facilities (IPR) (10-11%)., Conclusions: This study demonstrates that similar hip fracture patients are discharged to different post-acute settings (i.e., home-based rehabilitation and inpatient rehabilitation) and have different outcomes, thereby calling into question the appropriateness of post-acute rehabilitation delivery in Ontario, Canada. Future research should focus on determining how trade-offs in resource allocation between settings would impact patient outcomes.

Context: Federal and clinical guidelines recommend integrating reproductive life plan assessments into routine family planning encounters to increase provision of preconception care. Yet, the prevalence of clinical protocols and of relevant practices at publicly funded health centers is unknown., Methods: Administrators and providers at a nationally representative sample of publicly funded health centers that provide family planning services were surveyed in 2013-2014; data from 1,039 linked pairs were used to explore the reported prevalence of reproductive life plan protocols, frequent assessment of patients' reproductive life plan and frequent provision of preconception care. Chi-square tests and multivariable general linear models were used to examine differences in reports of protocols and related practices., Results: Overall, 58% of centers reported having reproductive life plan assessment protocols, 87% reported frequently assessing reproductive life plans and 55% reported frequently providing preconception care. The proportions reporting protocols were lower in community health centers than in other center types (32% vs. 52-91%), in primary care centers than in those with another focus (33% vs. 77-80%) and in centers not receiving Title X funding than in those with such support (36% vs. 77%). Reported existence of a written protocol was positively associated with reported frequent assessment (prevalence ratio, 1.1), and the latter was positively associated with reported frequent preconception care (1.4)., Conclusion: Further research is needed on associations between written protocols and clinical practice, and to elucidate the preconception care services that may be associated with reproductive life plan assessment., (Copyright © 2017 by the Guttmacher Institute.)

Background and Aims: Early play behaviors may provide important information regarding later-diagnosed developmental delays. Play behaviors of young children with autism spectrum disorder (ASD) are restricted in diversity, frequency, and complexity. Most ASD research focuses on play in children over 18 months of age. This study examined three groups of infants (later diagnosed with ASD, later diagnosed with other developmental disorders, and typically developing) with the aims of: (1) describing the play behaviors of the three groups of infants at two time points (9-12 months and 15-18 months); (2) examining group differences in four hierarchical levels of play at both time points; (3) comparing groups with respect to the highest level of play achieved; and (4) determining if the highest level of play achieved by infants with developmental delays, including ASD, correlated with later developmental outcomes., Methods: The current study used longitudinal retrospective video analysis to examine object play behaviors of the three groups of infants (total n=92) at two time points (time 1: 9-12 months of age, and time 2: 15-18 months of age). Coding of play behaviors was based on existing literature and distribution of data from the current study. Developmental outcomes examined were measured using the Vineland Adaptive Behavior Scales , Childhood Autism Rating Scale , and a non-verbal developmental quotient calculated using visual reception scores from the Mullen Scales for Early Learning ., Results: Results indicate group differences in play, with infants later diagnosed with ASD showing significantly less sophisticated play than those with typical development. In addition, modest but significant correlations were found between highest level of play achieved at time 2 (15-18 months) and later outcomes for those with developmental disorders, including ASD., Conclusions and Implications: Results suggest that examination of infant play behaviors is important for early screening and intervention planning to potentially mitigate effects on later developmental outcomes., Competing Interests: The authors declare that there is no conflict of interest.

Background: In 2008, the line item supporting sexually transmitted disease (STD) services in the Massachusetts state budget was cut as a result of budget shortfalls. Shortly thereafter, direct provision of STD clinical services supported by the Massachusetts Department of Public Health (MDPH) was suspended. Massachusetts Department of Public Health requested an initial assessment of its internal response and impact in 2010. A follow-up assessment occurred in September 2013., Methods: In 2010 and 2013, 39 and 46 staff, respectively, from MDPH and from clinical partner agencies, were interviewed about changes in the role of the MDPH, partnerships, STD services, challenges, and recommendations. Interview notes were summarized, analyzed, and synthesized by coauthors using qualitative analysis techniques and NVivo software., Results: The withdrawal of state funding for STD services, and the subsequent reduction in clinical service hours, erected numerous barriers for Disease Intervention Specialists (DIS) seeking to ensure timely STD treatment for index cases and their partners. After initial instability, MDPH operations stabilized due partly to strong management, new staff, and intensified integration with human immunodeficiency virus services. Existing contracts with human immunodeficiency virus providers were leveraged to support alternative STD testing and care sites. Massachusetts Department of Public Health strengthened its clinical and epidemiologic expertise. The DIS expanded their scope of work and were outposted to select new sites. Challenges remained, however, such as a shortage of DIS staff to meet the needs., Conclusions: Although unique in many ways, MA offers experiences and lessons for how a state STD program can adapt to a changing public health context.

Objectives: This study aims to describe aspects of the scope and quality of family planning services provided by US publicly funded health centers before the release of relevant federal recommendations., Study Design: Using nationally representative survey data (N=1615), we describe four aspects of service delivery: family planning services provided, contraceptive methods provided onsite, written contraceptive counseling protocols and youth-friendly services. We created a count index for each issue and used multivariable ordered logistic regression to identify health center characteristics associated with scoring higher on each., Results: Half of the sample received Title X funding and about a third each were a community health center or health department clinic. The vast majority reported frequently providing contraceptive services (89%) and STD services (87%) for women in the past 3 months. Service provision to males was substantially lower except for STD screening. A total of 63% and 48% of health centers provided hormonal IUDs and implants onsite in the past 3 months, respectively. Forty percent of health centers included all five recommended contraceptive counseling practices in written protocols. Of youth-friendly services, active promotion of confidential services was among the most commonly reported (83%); offering weekend/evening hours was among the least (42%). In multivariable analyses, receiving Title X funding, having larger volumes of family planning clients and being a Planned Parenthood clinic were associated with higher scores on most indices., Conclusion: Many services were consistent with the recommendations for providing quality family planning services, but there was room for improvement across domains and health centers types., Implications Statement: As assessed in this paper, the scope and quality of these family planning services was relatively high, particularly among Planned Parenthood clinics and Title X-funded centers. However, results point to important areas for improvement. Future studies should assess change as implementation of recent family planning service recommendations continues., (Published by Elsevier Inc.)

Introduction: Federal recommendations for providing quality family planning services were published in 2014 and included preconception care (PCC). This paper aims to describe the prevalence of PCC delivery among publicly funded clinics, prior to the recommendations., Methods: Prevalence of providing occasional or frequent PCC in the last 3 months and having written protocols for recommended PCC screenings were estimated in 2015 using survey data collected from a nationally representative sample of publicly funded clinic administrators (2013-2014, N=1,615). Analyses included examination of differential distributions of outcomes by clinic characteristics (p<0.05) and multivariable regression., Results: Prevalence of occasional or frequent PCC delivery was 81% for women and 38% for men. The percentage of clinics with written protocols for specific PCC screenings ranged from 74% to 88% (women) and 66% to 83% (men). Prevalence of having written protocols for all PCC screenings was 29% for women and 22% for men. Characteristics negatively associated with having written protocols for all PCC screenings for women and men (respectively) were as follows: not receiving Title X funding (adjusted prevalence ratio [APR]=0.6, 95% CI=0.50, 0.76; APR=0.6, 95% CI=0.47, 0.77) and being a community health center (APR=0.5, 95% CI=0.37, 0.72; APR=0.5, 95% CI=0.30, 0.67); health department (APR=0.7, 95% CI=0.61, 0.87; APR=0.6, 95% CI=0.49, 0.76); or hospital/other (APR=0.6, 95% CI=0.50, 0.79; APR=0.6, 95% CI=0.43, 0.75) (versus Planned Parenthood)., Conclusions: Provision of PCC appears to differ by clinic characteristics and by interpretation of the phrase "preconception care," suggesting opportunities for education and improvement., (Published by Elsevier Inc.)

Background: Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system., Methods: This study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients' post-acute destinations within each region were retrieved by linking patients' records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values., Results: Thirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region., Conclusions: The observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.

Background: The present study was designed to examine the functional recovery following spinal cord injury (SCI) by adjusting the parameters of impact force and dwell-time using the Infinite Horizon (IH) impactor device., Methods: Sprague-Dawley rats (225-240 g) were divided into eight injury groups based on force of injury (Kdyn) and dwell time (seconds), indicated as Force-Dwell time: 150-4, 150-3, 150-2, 150-1, 150-0, 200-0, 90-2 and sham controls, respectively., Results: After T10 SCI, higher injury force produced greater spinal cord displacement (P < 0.05) and showed a significant correlation (r = 0.813) between the displacement and the force (P < 0.05). In neuropathic pain-like behavior, the percent of paw withdrawals scores in the hindpaw for the 150-4, 150-3, 150-2, 150-1 and the 200-0 injury groups were significantly lowered compared with sham controls (P < 0.05). The recovery of locomotion had a significant within-subjects effect of time (P < 0.05) and the 150-0 group had increased recovery compared to other groups (P < 0.05). In addition, the 200-0 and the 90-2 recovered significantly better than all the 150 kdyn impact groups that included a dwell-time (P < 0.05). In recovery of spontaneous bladder function, the 150-4 injury group took significantly longer recovery time whereas the 150-0 and the 90-2 groups had the shortest recovery times., Conclusions: The present study demonstrates SCI parameters optimize development of mechanical allodynia and other pathological outcomes.

Program evaluation is a key tool for gathering evidence about the value and effectiveness of sexually transmitted disease (STD) prevention programs and interventions. Drawing from published literature, the Centers for Disease Control and Prevention evaluation framework, and program examples, this article lays out some of the key principles of program evaluation for STD program staff. The purpose is to offer STD program staff a stronger basis for talking about, planning, conducting, and advocating for evaluation within their respective program contexts.

Background: Sexually transmitted disease (STD) program and clinic staff play an important role in providing linkage and referrals to programs and services that address the complex medical and psychosocial needs of their clients. We synthesized recent published literature related to effective practices for linkage to care for HIV and referral to other medical and social services., Methods: Three PubMed searches were conducted to identify relevant studies published since 2004 on (1) linkage to HIV care, (2) referral within STD clinical contexts, and (3) (review articles only) referral practices among all medical specialties. Systematic review procedures were not used., Results: Thirty-three studies were included in this review. Studies highlight the limited value of passive referral practices and the increased effectiveness of active referral and linkage practices. Numerous studies on linkage to HIV care suggest that case management approaches, cultural-linguistic concordance between linkage staff and clients, and structural features such as colocation facilitate timely linkage to care. Integration of other medical and social services such as family planning and alcohol screening services into STD settings may be optimal but resource-intensive. Active referral practices such as having a written referral protocols and agreements, using information technology to help transfer information between providers, and making appointments for clients may offer some benefit. Few studies included information on program costs associated with linkage and referral., Conclusions: Recent literature provides some guideposts for STD program and clinical staff to use in determining their approach to helping link and refer clients to needed care. Much experience with these issues within STD services remains unpublished, and key gaps in the literature remain.

In this paper, we consider two hospitals with different perceived quality of care competing to capture a fraction of the total market demand. Patients select the hospital that provides the highest utility, which is a function of price and the patient's perceived quality of life during their life expectancy. We consider a market with a single class of patients and show that depending on the market demand and perceived quality of care of the hospitals, patients may enjoy a positive utility. Moreover, hospitals share the market demand based on their perceived quality of care and capacity. We also show that in a monopoly market (a market with a single hospital) the optimal demand captured by the hospital is independent of the perceived quality of care. We investigate the effects of different parameters including the market demand, hospitals' capacities, and perceived quality of care on the fraction of the demand that each hospital captures using some numerical examples.

Context: Community education may involve activities that seek to raise awareness and promote behavior change, using mass media, social media, and other media or interpersonal methods in community settings. This systematic review evaluated the evidence of the effects of community education on select short- and medium-term family planning outcomes., Evidence Acquisition: Using an analytic approach drawn from the U.S. Preventive Services Task Force, multiple databases were searched for articles published from January 1985 through February 2011 describing studies of community education related to family planning in the U.S. Included articles were reviewed and assessed for potential bias using a standardized process in 2011. An updated, targeted review for the 2011-2014 period was conducted in early 2015., Evidence Synthesis: Seventeen papers were identified. Most (nine) related to mass media interventions; three involved targeted print media, two involved text messaging or e-mail, two described outcome workers conducting community education, and one involved community theater. Study designs, strength of evidence, and levels of possible bias varied widely. Twelve of 15 studies that addressed outcomes such as increased awareness found positive associations with those outcomes, with six also reporting null findings. Seven of eight studies that addressed use of services reported positive associations, with two also reporting null findings. The targeted, additional review identified two other studies., Conclusions: Evidence related to community education for family planning purposes is limited and highly variable. As goals of community education are usually limited to shorter-term outcomes, the evidence suggests that a range of approaches may be effective., (Published by Elsevier Inc.)

Context: Community engagement may include activities that involve community members in the design, implementation, and evaluation of services. The objective of this systematic review was to evaluate the evidence on this kind of community engagement in U.S. family planning programs, including its effects on various health outcomes, its perceived value, and the barriers and facilitators to implementation., Evidence Acquisition: Using an analytic approach drawn from U.S. Preventive Services Task Force, multiple databases were searched for articles published from 1985 through February 2011 that described studies about community engagement related to family planning. In 2011, relevant articles were reviewed, summarized, and assessed for potential bias using a standardized abstraction process. An updated, targeted review for the 2011-2014 period was conducted in early 2015., Evidence Synthesis: Eleven papers related to family planning were included. All were qualitative, descriptive, and at high risk for bias. Engagement strategies involved various methods for developing educational materials, program development, or program evaluation. All studies reported benefits to community engagement, such as more-appropriate educational materials or more community support for programs. Barriers to engagement included the substantial time and resources required. Four more articles were identified in the targeted, additional search., Conclusions: Community engagement is described as beneficial across the included studies, but the body of evidence for community engagement in family planning is relatively small. Given the high value ascribed to community engagement, more research and documentation of the various approaches taken and their relative strengths and weaknesses are needed., (Published by Elsevier Inc.)

Context: A central premise of the literature on healthcare quality is that improving the quality of care will lead to improvements in health outcomes. A systematic review was conducted to better inform quality improvement efforts in the area of family planning. The objective of this systematic review is to update a previous review focused on the quality of family planning services, namely, the impact of quality improvement efforts and client perspectives about what constitutes quality family planning services. In addition, this review includes new literature examining provider perspectives., Evidence Acquisition: Multiple databases from January 1985 through January 2015 were searched within the peer-reviewed literature that described the quality of family planning services. The retrieval and inclusion criteria included full-length articles published in English, which described studies occurring in a clinic-based setting to include family planning services., Evidence Synthesis: Search strategies identified 16,145 articles, 16 of which met the inclusion criteria. No new intervention studies addressing the impact of quality improvement efforts on family planning outcomes were identified. Sixteen articles provided information relevant to client or provider perspectives about what constitutes quality family planning services. Clients and providers mostly identified the need for services that were accessible, client-centered, and equitable. Themes related to effectiveness, efficiency, and safety were mentioned less frequently., Conclusions: Family planning services that account for both patient and provider perspectives may be more effective. Further research is needed to examine the impact of improved quality on provider practices, client behavior, and health outcomes., (Copyright © 2015 American Journal of Preventive Medicine. All rights reserved.)

Background: Black teenagers have relatively high rates of sexually transmitted diseases (STDs), and recent research suggests the role of contextual factors, as well as risk behaviors. We explore the role of 4 categories of risk and protective factors on having a biologically confirmed STD among black, female teenagers., Methods: Black teenage girls (14-19 years old) accessing services at a publicly funded family planning clinic provided a urine specimen for STD testing and completed an audio computer-assisted self-interview that assessed the following: risk behaviors, relationship characteristics, social factors, and psychosocial factors. We examined bivariate associations between each risk and protective factor and having gonorrhea and/or chlamydia, as well as multivariate logistic regression among 339 black female teenagers., Results: More than one-fourth (26.5%) of participants had either gonorrhea and/or chlamydia. In multivariate analyses, having initiated sex before age 15 (adjusted odds ratio [aOR], 1.87) and having concurrent sex partners in the past 6 months (aOR, 1.55) were positively associated with having an STD. Living with her father (aOR, 0.44), believing that an STD is the worst thing that could happen (aOR, 0.50), and believing she would feel dirty and embarrassed about an STD (aOR, 0.44) were negatively associated with having an STD., Conclusions: Social factors and attitudes toward STDs and select risk behaviors were associated with the risk for STDs, suggesting the need for interventions that address more distal factors. Future studies should investigate how such factors influence safer sexual behaviors and the risk for STDs among black female teenagers.

Chemotherapy outpatient scheduling is a complex, dynamic, uncertain problem. Chemotherapy centres are facing increasing demands and they need to increase their efficiency; however there are very few studies looking at using optimization technology on the chemotherapy scheduling problem. We address dynamic uncertainty that arises from requests for appointments that arrive in real time and uncertainty due to last minute scheduling changes. We propose dynamic template scheduling, a novel technique that combines proactive and online optimization and we apply it to the chemotherapy outpatient scheduling problem. We create a proactive template of an expected day in the chemotherapy centre using a deterministic optimization model and a sample of appointments. As requests for appointments arrive, we use the template to schedule them. When a request arrives that does not fit the template, we update the template online using the optimization model and a revised set of appointments. To accommodate last minute additions and cancellations to the schedule, we propose a shuffling algorithm that moves appointment start times within a predefined time limit. We test the use of dynamic template scheduling against the optimal offline solution and the actual performance of the cancer centre. We find improvements in makespan of up to 20 % when using dynamic template scheduling compared to current practice.

Objective: To investigate the long-term effect of medically serious adverse medical events (AMEs) among older adults., Methods: We linked nationally representative survey and claims data from the Medicare Current Beneficiary Survey (1998-2004) with non-response files (1999-2005) and the Area Resource File, providing 12,541 beneficiaries with 428,373 person-months for analysis. Latent class analysis was used to assign severity status to episodes. Multinomial logistic regression was used to identify AME risk factors. The long-term consequences of AMEs on Medicare expenditures were examined by population average models. Survival analyses examined the long-term risk of death., Results: Nearly 19% of participants experienced at least one AME, with 62% from outpatient claims. The risk of AMEs is greater among participants in poorer health, and increases with comorbidity and with impairment in performing activities of daily living or instrumental activities of daily living. Medicare expenditures during an AME episode increased sharply and remained higher than what would have otherwise been expected in quarters following an AME episode, and failed to return to pre-AME expenditure levels. Differences in survival rates were observable long after the AME episode concluded, with only 55% of the patients sustaining an AME surviving to the end of the study. In contrast, nearly 80% of those without an AME were estimated to have survived., Conclusions: The impacts of AMEs are observable over extended periods of time and are associated with considerable excess mortality and costs. Efforts to monitor and prevent AMEs in both acute care and outpatient settings are warranted., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: The objective of this study was to describe patterns of older adult patient visits to emergency departments (EDs) for self-harm and suicide-related injuries., Methods: A retrospective, secondary data analysis of the Nationwide Emergency Department Sample was conducted. Nationally representative estimates of patient visits by older adults attempting suicide were calculated using available sampling weights. Population estimates were calculated using estimates from the US Census Bureau., Results: Findings suggest that 22,444 ED patient visits were made by adults aged 65 years and older for suicide-related injuries, representing an estimated population rate of 63 ED patient visits per 100000 adults aged 65 years and older, with nearly half of all visits involving substance use. Total ED and hospital charges exceeded $353.9 million., Conclusions: Effort is needed to better integrate and deliver suicide screening and support services in the ED, while also connecting at-risk older adults with mental health services before and after the ED encounter., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Evidence exists that clinical outcomes improve for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital created a Neurovascular Unit (NVU) using beds from general internal medicine, Neurology and Neurosurgery to care for patients with stroke and acute neurovascular conditions. Using patient-level data for NVU-eligible patients, a discrete event simulation was created to study changes in patient flow and length of stay pre- and post-NVU implementation. Varying patient volumes and resources were tested to determine the ideal number of beds under various conditions. In the first year of operation, the NVU admitted 507 patients, over 66% of NVU-eligible patient volumes. With the introduction of the NVU, length of stay decreased by around 8%. Scenario testing showed that the current level of 20 beds is sufficient for accommodating the current demand and would continue to be sufficient with an increase in demand of up to 20%.

HIV-infected young women in the United States have important reproductive health needs that are made more complex by their HIV status. We searched Pubmed and relevant bibliographies to identify 32 articles published from 2001 to July 2012 that described the prevalence, correlates, and characteristics of the sexual activity, relationships, pregnancy intentions, HIV status disclosure, and contraceptive and condom use among US HIV-infected adolescents and young women. Our synthesis of those articles found that, like youth not infected with HIV, substantial proportions of HIV-infected youth were sexually active, and most sought romantic or sexual relationships, though their serostatus may have affected the pace of physical and emotional intimacy. Disclosure was difficult, and large proportions of HIV-infected youth had not disclosed their serostatus to recent partners. A few studies suggest that most HIV-infected young women hoped to have children in the future, but many wanted to avoid pregnancy until later. Only one study described contraceptive use among this population in detail and found that condoms were a primary method of contraception. The results point to substantial gaps in published research, particularly in the areas of pregnancy intentions and contraceptive use. Much more needs to be done in research and health services to better understand and meet the complex health needs of HIV-infected young women.

Originally developed in the context of publicly traded for-profit companies, theory of constraints (TOC) improves system performance through leveraging the constraint(s). While the theory seems to be a natural fit for resource-constrained publicly funded health systems, there is a lack of literature addressing the modifications required to adopt TOC and define the goal and performance measures. This paper develops a system dynamics representation of the classical TOC's system-wide goal and performance measures for publicly traded for-profit companies, which forms the basis for developing a similar model for publicly funded health systems. The model is then expanded to include some of the factors that affect system performance, providing a framework to apply TOC's process of ongoing improvement in publicly funded health systems. Future research is required to more accurately define the factors affecting system performance and populate the model with evidence-based estimates for various parameters in order to use the model to guide TOC's process of ongoing improvement.

We explored the use of qualitative interviews to discuss discrepancies between two sources of information on unprotected sex: biomarker results and self-reported survey data. The study context was a randomized trial in Kingston, Jamaica examining the effect of STI counseling messages on recent sexual behavior using prostate-specific antigen (PSA) as the primary study outcome. Twenty women were interviewed. Eleven participants were selected because they tested positive for PSA indicating recent semen exposure, yet reported no unprotected sex in a quantitative survey ("discordant"): 5 reported abstinence and 6 reported condom use. Nine participants who also tested positive for PSA but reported unprotected sex in the survey were interviewed for comparison ("concordant"). Qualitative interviews with 6 of the 11 discordant participants provided possible explanations for their PSA test results, and 5 of those were prompted by direct discussion of those results. Rapid PSA testing combined with qualitative interviews provides a novel tool for investigating and complementing self-reported sexual behavior.

Background: This study describes contraceptive understanding, sources of information and consequences of contraceptive misunderstandings among urban, young adults., Study Design: We used qualitative data from 16 focus groups and 53 interviews with Puerto Rican and African American men and women aged 18-25 years from Philadelphia and Hartford. We categorized and compared assertions made about all contraceptive methods' side effects, effectiveness and use using an iterative process., Results: Participants considered contraceptive use worthwhile but felt that it carried risks of problematic side effects and contraceptive failure, with variation among methods. Men knew most about condoms and withdrawal and trusted both more than women. Personal or second-hand experience was the dominant source of information on contraceptive understanding. Misunderstandings about contraception affected their relationships and risk of unintended pregnancy., Conclusion: Contraceptive understanding is a powerful determinant of contraceptive use and limits the options perceived by young adults to prevent pregnancy. Research is needed to strengthen contraceptive counseling and outreach in ways that better leverage peer influence., (Published by Elsevier Inc.)

Objectives: To evaluate the effects of unintentional injuries on the risks of nursing home institutionalization and mortality in older adults., Design: A retrospective analysis of data from the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries., Setting: Noninstitutionalized community residents., Participants: Older adult panel members (N = 12,031) with continuous Medicare eligibility not enrolled in managed care in a cohort starting between 1998 and 2001., Measurements: Cox regression and competing risk survival models were estimated using time-varying injury-status dummy variables and control variables for outcomes measured as time until death and institutionalization, respectively., Results: Almost 4% of persons were institutionalized, 15% died, 14% had a sentinel injury, and 3% had two or more minor nonsentinel injuries within 1-year period. Persons hospitalized for sentinel injury had elevated institutionalization and mortality risks during an injury episode and after the episode ended. Persons receiving outpatient treatment for sentinel injuries had elevated institutionalization risk during injury episodes (subhazard ratio [SHR] = 6.78, 95% confidence interval [CI] = 3.72-12.37) and elevated mortality risk after episodes (hazard ratio [HR] = 1.60, 95% CI = 1.28-2.00). Persons with multiple minor nonsentinel injuries within a year also had elevated mortality (HR = 1.56, 95% CI = 1.15-2.11) and institutionalization (SHR = 3.55, 95% CI = 2.25-5.67) risks., Conclusion: Mortality and institutionalization risks extend well beyond the acute episode of treatment for sentinel and repeated minor injuries. More research is needed on longer-term health outcomes of injury survivors to inform development of evidence-based quality-of-care indicators., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)