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Objectives To assess what patient, family supporter, and call characteristics predicted whether patients completed automated and coach-provided calls in a telehealth diabetes intervention. Study design A total of 123 adults with type 2 diabetes and high glycated hemoglobin A1c (HbA1c) or blood pressure, enrolled with a family supporter, received automated interactive voice response (IVR) and coach-provided visit preparation calls over 12 months. Methods Data from baseline surveys and diabetes-related clinical information from patient medical records were entered into multilevel, multivariate regression models of associations between participant and call characteristics with call completion. Results A total of 76.3% of 2784 IVR calls and 75.8% of 367 visit preparation calls were completed. For IVR calls, patients with recent call-triggered provider alerts had higher odds of call completion (adjusted odds ratio [AOR], 3.5; 95% CI, 2.2-5.5); those with depressive symptoms (AOR, 0.4; 95% CI, 0.2-0.9), higher HbA1c (AOR, 0.8; 95% CI, 0.6-0.99), and more months in the study (AOR, 0.9; 95% CI, 0.87-0.94 per month) had lower odds. For visit preparation calls, higher patient activation scores predicted higher call completion (AOR, 1.4; 95% CI, 1.1-1.9); patient college education predicted less call completion (AOR, 0.3; 95% CI, 0.2-0.6). Supporter help taking medications predicted less completion of both call types. Patient age did not predict call completion. Conclusions Patients of all ages completed telehealth calls at a high rate. Automated IVR calls were completed more often when urgent issues were identified to patients' providers, but less often if patients had high HbA1c or depression. Visit preparation call content should be tailored to patient education level. Family help with medications may identify patients needing additional support to engage with telehealth.

Background Patients with diabetes (PWD) often experience diabetes distress which is associated with worse self-management and glycemic control. In contrast, PWD who receive support from family and friends (supporters) have better diabetes outcomes. Purpose To examine the associations of PWD diabetes distress and supporters’ distress about PWDs’ diabetes with supporters’ roles and PWD cardiometabolic outcomes. Methods We used baseline data from 239 adults with Type 2 diabetes and their supporters participating in a longitudinal trial. PWD and supporter diabetes distress (high vs. low) were determined using the Problem Areas in Diabetes Scale-5. Outcomes included PWD-reported help from supporters with self-care activities, supporter-reported strain, PWD metabolic outcomes (glycemic control [HbA1c], systolic blood pressure [SBP], and non-HDL cholesterol) and 5 and 10 year risk of cardiac event (calculated using the United Kingdom Prospective Diabetes Study algorithm). Results PWDs with high diabetes distress were more likely to report that their supporters helped with taking medications, coordinating medical care, and home glucose testing (p’s < .05), but not more likely to report help with diet or exercise. High supporter distress was associated with greater supporter strain (p < .001). High supporter diabetes distress was associated with higher PWD HbA1c (p = .045), non-HDL cholesterol (p = .011), and 5 (p = .002) and 10 year (p = .001) cardiac risk. Conclusions Adults with high diabetes distress report more supporter help with medically focused self-management but not with diet and exercise. Supporter distress about PWD diabetes was consistently associated with worse outcomes. PWD diabetes distress had mixed associations with their diabetes outcomes.

ImportanceMore than 75% of US adults with diabetes do not meet treatment goals. More effective support from family and friends (“supporters”) may improve diabetes management and outcomes.ObjectiveTo determine if the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention improves patient activation, diabetes management, and outcomes compared with standard care.Design, Setting, and ParticipantsThis randomized clinical trial was conducted from November 2016 to August 2019 among participants recruited from 2 Veterans Health Administration primary care sites. All patient participants were adults aged 30 to 70 years with diabetes who had hemoglobin A1c (HbA1c) levels greater than 8% of total hemoglobin (to convert to proportion of total hemoglobin, multiply by 0.01) or systolic blood pressure (SBP) higher than 150 mm Hg; each participating patient had an adult supporter. Of 1119 recruited, 239 patient-supporter dyads were enrolled between November 2016 and May 2018, randomized 1:1 to receive the CO-IMPACT intervention or standard care, and followed up for 12 to 15 months. Investigators and analysts were blinded to group assignment.InterventionsPatient-supporter dyads received a health coaching session focused on dyadic information sharing and positive support techniques, then 12 months of biweekly automated monitoring telephone calls to prompt dyadic actions to meet diabetes goals, coaching calls to help dyads prepare for primary care visits, and after-visit summaries. Standard-care dyads received general diabetes education materials only.Main Outcomes and MeasuresIntent-to-treat analyses were conducted according to baseline dyad assignment. Primary prespecified outcomes were 12-month changes in Patient Activation Measure–13 (PAM-13) and UK Prospective Diabetes Study (UKPDS) 5-year diabetes-specific cardiac event risk scores. Secondary outcomes included 12-month changes in HbA1c levels, SBP, diabetes self-management behaviors, diabetes distress, diabetes management self-efficacy, and satisfaction with health system support for the involvement of family supporters. Changes in outcome measures between baseline and 12 months were analyzed using linear regression models.ResultsA total of 239 dyads enrolled; among patient participants, the mean (SD) age was 60 (8.9) years, and 231 (96.7%) were male. The mean (SD) baseline HbA1c level was 8.5% (1.6%) and SBP was 140.2 mm Hg (18.4 mm Hg). A total of 168 patients (70.3%) lived with their enrolled supporter; 229 patients (95.8%) had complete 12-month outcome data. In intention-to-treat analyses vs standard care, CO-IMPACT patients had greater 12-month improvements in PAM-13 scores (intervention effect, 2.60 points; 95% CI, 0.02-5.18 points; P = .048) but nonsignificant differences in UKPDS 5-year cardiac risk (intervention effect, 1.01 points; 95% CI, −0.74 to 2.77 points; P = .26). Patients in the CO-IMPACT arm also had greater 12-month improvements in healthy eating (intervention effect, 0.71 d/wk; 95% CI, 0.20-1.22 d/wk; P = .007), diabetes self-efficacy (intervention effect, 0.40 points; 95% CI, 0.09-0.71 points; P = .01), and satisfaction with health system support for the family supporter participants’ involvement (intervention effect, 0.28 points; 95% CI, 0.07-0.49 points; P = .009); however, the 2 arms had similar improvements in HbA1c levels and in other measures.Conclusions and RelevanceIn this randomized clinical trial, the CO-IMPACT intervention successfully engaged patient-supporter dyads and led to improved patient activation and self-efficacy. Physiological outcomes improved similarly in both arms. More intensive direct coaching of supporters, or targeting patients with less preexisting support or fewer diabetes management resources, may have greater impact.Trial RegistrationClinicalTrials.gov Identifier: NCT02328326

Introduction Among adults with Type 2 diabetes, low health literacy (HL) is a risk factor for negative health outcomes. Support from family and friends can improve adults' self-management and health-related outcomes. We examined whether supporters provided unique help to adults with diabetes and low HL and whether HL was associated with adults' perception of supporter helpfulness. Methods We used cross-sectional baseline survey data from 239 adult patients with diabetes enrolled in a randomized controlled trial with a support person. Patients reported level of supporter involvement with self-management roles. HL among patients and supporters was assessed using a validated HL screening tool. Patient perception of supporter helpfulness was assessed with a single item. We used multivariable logistic regression to examine associations of patient and supporter HL levels with supporter roles and patients' perception of supporter helpfulness. Results Patients with low HL were more likely to have a supporter with low HL (39% vs. 26%, p = .04). Patients with low HL had higher odds of receiving supporter help with calling health care providers (adjusted odds ratio [AOR] = 2.09, 95% CI [1.00, 4.39]), remembering medical appointments (AOR = 2.24, 95% CI [1.07, 4.69]), and giving directions when blood sugars were low (AOR = 2.51, 95% CI [1.20, 5.37]). Neither patient nor supporter HL was significantly associated with patients' perception of supporter helpfulness. Discussion Adults with diabetes and low HL reported more supporter involvement with specific self-management tasks than patients with adequate HL. Providers could consider targeted involvement of supporters to assist patients with chronic diseases and low HL, although they should be aware that supporters may be challenged by low HL. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Veterans are three times more likely to have diabetes than the general population. Diabetes self-management education and support (DSMES) is a critical component of diabetes care that galvanizes more informed and engaged patients. Many Veterans are disabled or reside in rural areas and have limited access to comprehensive DSMES. Clinical Video Telehealth (CVT) extends access to specialty services from regional Veterans Affairs (VA) Healthcare Centers to Community-Based Outpatient Clinics where many Veterans receive healthcare. The purpose of this study was to examine and compare proximal (3-6 month) and distal (12 and 18 month) metabolic outcomes (A1C, lipids, BMI and blood pressure) of Veterans who received comprehensive group DSMES via CVT vs. in-person . Veterans who received DSMES from 2012 to 2017 by CVT (n=197) and in-person (n=359) were identified in the VA computerized medical record. The CVT group was similar to those that attended in-person, but were less racially diverse. A linear mixed model was used to compare changes in metabolic outcomes within and between groups over time. A1C improved at 3 months and was sustained for 12-18 months in both groups. Neither group showed changes in lipids, BMI, or blood pressure. In conclusion, CVT is an effective means of improving A1C by expanding DSMES access to Veterans who receive community care. Disclosure M. DiNardo: None. A.O. Youk: None. N. Beyer: None. J.N. Beattie: None. D. Obrosky: None.

We evaluated the effectiveness of an intervention for patient-family dyads aimed at improving diabetes self-management and outcomes for adults with T2DM (AWD) at risk for complications. AWD were randomized with a family supporter to an intervention vs. usual care for 12 months. The intervention provided dyads: one health coaching session, biweekly automated phone calls to prompt action plans on new diabetes health concerns, coaching calls to prepare for medical visits, and medical visit summaries. 239 AWD-supporter dyads were enrolled at two Veterans Health Administration sites. AWD eligibility criteria included baseline HbA1c>8% or systolic blood pressure (SBP)>150mmHg. Intention-to-treat analyses of changes in outcomes were adjusted for baseline outcome levels, patient-supporter cohabitation, and patients’ baseline insulin use. 96% of dyads had complete 12-month outcome data. Enrolled patients were on average 60±9 years old and had HbA1c levels of 8.5±1.6% and SBP 140mmHg (IQR 128,150). 70% lived with their supporter. Over 12 months, Patient Activation Measure scores (pre-specified primary outcome) increased significantly more in the intervention group (intervention effect +2.6 points (95%CI 0.005, 5.149). There were no statistically significant differences by arm in diabetes-specific cardiac risk score, HbA1c, or SBP change. Patient self-reported adherence to healthy eating increased significantly more in the intervention group (intervention effect +0.7 days/week (95% CI 0.2, 1.2) but not for other self-management behaviors. 97% of patients and 94% of supporters in the intervention group agreed they would recommend the program to others. This family supporter-patient dyadic intervention successfully increased patient activation and one health behavior but not physiologic outcomes over a 12 month period. Improving sustained engagement of family supporters in care of diabetes for adults is feasible and could serve as an additional source of support for diabetes care. Disclosure A. Rosland: None. J. Piette: None. R.B. Trivedi: None. A.A. Lee: None. S.C. Stoll: None. M.K. Mor: None. D. Obrosky: None. E.A. Kerr: Advisory Panel; Self; Bind Insurance. M. Heisler: None. Funding Health Services Research and Development (IIR 14–074-1); Michigan Center for Diabetes Translational Research (5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (AG-024824); VA Ann Arbor Center for Clinical Management Research

Many adults with DM have a family supporter (FS) involved in their care. Informal support has been linked with better DM management and outcomes. We evaluated the effect of a patient and FS engagement intervention on FS roles in DM care, and the impact of those roles on HbA1c. Two-hundred and thirty-nine adult Veterans with type 2 DM and a FS were randomized to intervention vs. usual care for 12 months. Intervention dyads received one coaching session, biweekly automated calls to prompt action planning on new DM concerns, coaching calls to prepare for clinic visits, and summaries of primary care visits and DM complication risk. All models were controlled for baseline HbA1c, age, sex, insulin use, and FS cohabitation with patient. Over 12 months, participants in the intervention group were more likely to have increased involvement in several FS roles, including: deciding when to contact healthcare providers about concerns (AOR 2.080, 95% CI 1.137,3.804), remembering to go to appointments (AOR 2.852, 95% CI 1.503, 5.412), take (1.853, 95% CI 1.001, 3.428) and refill (AOR 2.193, 1.196, 4.019) medications, and perform (AOR 2.615, 95% CI 1.405, 4.867) and review (AOR 2.822, 95% CI 1.506, 5.290) home testing. Changes in help navigating the healthcare system, and encouraging healthy eating and exercise were not different by intervention arm. Help remembering to take medications at baseline was associated with 0.457% increase in HbA1c over 12 months (95% CI 0.107, 0.807, p=0.011), and no support roles were significantly associated with HbA1c decrease. In conclusion, this intervention increased FS involvement in diabetes-specific self-management, with less impact on general lifestyle support. Patients with support for taking medication prior to the intervention had significant subsequent increases in HbA1c. This may indicate family are recognizing which patients have challenges with medication taking, but need more training to effectively help improve subsequent patient outcomes. Disclosure M. Zupa: None. M. Heisler: None. J. Piette: None. R.B. Trivedi: None. S.C. Stoll: None. D. Obrosky: None. E.Z. Lovelace: None. M.K. Mor: None. A. Rosland: None. Funding VA Health Services Research and Development (IIR 14–074-1); Michigan Center for Diabetes Translational Research (5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (AG-024824); VA Ann Arbor Center for Clinical Management Research; University of Pittsburgh (5T32DK007052-45)

IntroductionUS military veterans have disproportionately high rates of diabetes and diabetes-related morbidity in addition to being at risk of comorbid stress-related conditions. This study aimed to examine the effects of a technology-supported mindfulness intervention integrated into usual diabetes care and education on psychological and biobehavioral outcomes.Research design and methodsVeterans (N=132) with type 1 or 2 diabetes participated in this two-arm randomized controlled efficacy trial. The intervention arm received a one-session mindfulness intervention integrated into a pre-existing program of diabetes self-management education and support (DSMES) plus one booster session and 24 weeks of home practice supported by a mobile application. The control arm received one 3-hour comprehensive DSMES group session. The primary outcome was change in diabetes distress (DD). The secondary outcomes were diabetes self-care behaviors, diabetes self-efficacy, post-traumatic stress disorder (PTSD), depression, mindfulness, hemoglobin A1C (HbA1C), body weight, and blood pressure. Assessments were conducted at baseline, 12 weeks, and 24 weeks. Participant satisfaction and engagement in home practice were assessed in the intervention group at 12 and 24 weeks.ResultsIntention-to-treat group by time analyses showed a statistically significant improvement in DD in both arms without significant intervention effect from baseline to 24 weeks. Examination of distal effects on DD between weeks 12 and 24 showed significantly greater improvement in the intervention arm. Improvement in DD was greater when baseline HbA1C was ConclusionsA technology-supported mindfulness intervention integrated with DSMES showed stronger distal effects on DD compared with DSMES control. Examination of longer-term outcomes, underlying mechanisms, and the feasibility of virtual delivery is warranted.Trial registration numberNCT02928952.

Knee osteoarthritis is a painful, disabling condition that disproportionately affects African Americans. Existing arthritis treatments yield small to moderate improvements in pain and have not been effective at reducing racial disparities in the management of pain. The biopsychosocial model of pain and evidence from the positive psychology literature, suggest that increasing positive psychological skills (e.g., gratitude, kindness) could improve pain and functioning and reduce disparities in osteoarthritis pain management. Activities to cultivate positive psychological skills have been developed and validated; however, they have not been tested in patients with osteoarthritis, their effects on racial differences in health outcomes have not been examined, and evidence of their effects on health outcomes in patients with other chronic illnesses is of limited quality. In this article we describe the rationale and design of Staying Positive with Arthritis (SPA) study, a randomized controlled trial in which 180 African American and 180 White primary care patients with chronic pain from knee osteoarthritis will be randomized to a 6-week program of either positive skill-building activities or neutral control activities. The primary outcomes will be self-reported pain and functioning as measured by the WOMAC Osteoarthritis Index. We will assess these primary outcomes and potential, exploratory psychosocial mediating variables at an in-person baseline visit and by telephone at 1, 3, and 6 months following completion of the assigned program. If effective, the SPA program would be a novel, theoretically-informed psychosocial intervention to improve quality and equity of care in the management of chronic pain from osteoarthritis.

Many adults with diabetes have family or friend ‘supporters’ involved in their care. Adult-supporter dyads were recruited to a trial comparing usual care to a 12-month program to engage and train supporters. Potentially eligible patients with T2DM and either HbA1c>8% or high systolic BP were identified via medical records. Patients randomized to the program received biweekly automated calls prompting reports on diabetes status, with tailored feedback to patients and supporters. Before primary care appointments, health coaches conducted a ‘visit prep call’ to improve dyad engagement in the visit. We examined patient characteristics predicting enrollment, and patient, supporter, and call characteristics predicting visit prep and automated call completion via separate multi-level regression models. Of 1119 contacted, 239 dyads (21%) enrolled. Patient predictors of enrollment included younger age (M=60y enrolled vs. 62 not, p In conclusion, high BP predicted enrollment and engagement in a dyadic-based diabetes program more than high HbA1c. Programs emphasizing the importance of BP in preventing diabetes complications may increase participant engagement. Disclosure S.C. Stoll: None. J. Piette: None. R.B. Trivedi: None. A.A. Lee: None. D. Obrosky: None. M.K. Mor: Stock/Shareholder; Spouse/Partner; AbbVie Inc. M. Heisler: None. A. Rosland: None. Funding U.S. Department of Veterans Affairs (IIR 14–074-1); Michigan Center for Diabetes Translational Research (NIDDK5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (NIA AG-024824)

Background: It is unknown whether family members or friends (‘supporters’) tailor their assistance to the unique needs of patients with diabetes and low HL. Methods: Surveys were conducted among 239 VA healthcare system patients with type 2 diabetes who were 30-70 years old, had A1c>8% or high blood pressure, did not have dementia or need help with basic activities of daily living, and had an unpaid supporter who was involved in their care. Patients reported the frequency of supporter involvement with diabetes management roles (e.g., help filling medications). HL was assessed using two items from the well-validated Chew scale: 1) How often do you have problems learning about medical conditions because of difficulty understanding written information (0=none of the time, 4=all of the time), and 2) How confident are you filling out medical forms by yourself (0=extremely, 4=not at all). Those responding ‘3’ (somewhat) or greater were designated as low health literacy. Logistic regression models were used to identify the independent association between patient HL and types of supporter assistance. Findings: Patients with low HL were significantly more likely than patients with adequate HL to have a supporter with low HL (32% vs. 18% of supporters, p=0.02). Low patient HL was significantly associated with higher odds of supporters helping with: deciding when to call doctor (AOR=2.21, 95% CI: 1.10-4.42); remembering medical appointments (AOR=2.48, 95% CI: 1.24-4.98); navigating the health system (AOR=2.67, 95% CI: 1.34-5.32); and attending medical appointments with patient (AOR=2.11, 95% CI: 1.11-3.96). Patient HL was not associated with whether supporters helped with filling or taking medications, or managing diet and exercise. Conclusion: Supporters of patients with low HL were more likely to have low HL themselves, and to help patients with care coordination and equally likely to help with carrying out diabetes medication and lifestyle behaviors compared to patients with adequate HL. Disclosure B. Fields: None. A.A. Lee: None. J. Piette: None. R.B. Trivedi: None. D. Obrosky: None. M.K. Mor: Stock/Shareholder; Spouse/Partner; AbbVie Inc. M. Heisler: None. A. Rosland: None. Funding U.S. Department of Veterans Affairs (IIR 14–074-1); Michigan Center for Diabetes Translational Research (NIDDK5P60-DK09292); Michigan Claude D. Pepper Older Americans Independence Center (NIA AG-024824)

Key Points Question Is positive psychology effective as a treatment for chronic arthritis pain and does it reduce race disparities in pain management? Findings In this randomized clinical trial involving 360 Veterans Affairs patients with chronic pain from osteoarthritis, a 6-week telephone-administered positive psychological intervention did not improve pain or functional difficulty vs a control program. No difference by race was found in the effect of the intervention. Meaning A telephone-administered positive psychological intervention was not associated with improvement in chronic pain or functional difficulty from osteoarthritis for either white or African American patients., Importance Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. Objective To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. Design, Setting, and Participants The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017. Interventions The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists. Main Outcomes and Measures The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction. Results The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P, This randomized clinical trial assesses the effects of a positive psychological intervention on pain and functional difficulty vs a control program in veterans with knee osteoarthritis and evaluates whether this management varies by race.

Background Methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) are a concern in the 22 acute care Veterans Affairs (VA) spinal cord injury units where patients with unique rehabilitation and medical needs and a high risk of infection are treated. Methods A bundle was implemented in VA spinal cord injury units consisting of nasal surveillance for MRSA on admission/in-hospital transfer/discharge, contact precautions for patients colonized or infected with MRSA, an emphasis on hand hygiene, and an institutional culture change where infection control became everyone’s responsibility. Results From October 2007, through June 2011, there were 51,627 admissions/transfers/discharges and 816,254 patient-days of care in VA spinal cord injury units. The percentage of patients screened increased to >95.0%. The mean admission MRSA prevalence was 38.6% ± 19.1%. Monthly HAI rates declined 81% from 1.217 per 1,000 patient-days to 0.237 per 1,000 patient-days (P < .001). Bloodstream infections declined by 100% (P = .002), skin and soft-tissue infections by 60% (P = .007), and urinary tract infections by 33% (P = .07). Conclusion Universal surveillance, contact precautions, hand hygiene, and an institutional culture change was associated with significant declines in MRSA HAIs in a setting with a high prevalence of MRSA colonization and a high risk for infection.

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.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.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).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.

OBJECTIVE We compared the short-term efficacy of home telemonitoring coupled with active medication management by a nurse practitioner with a monthly care coordination telephone call on glycemic control in veterans with type 2 diabetes and entry A1C ≥7.5%. RESEARCH DESIGN AND METHODS Veterans who received primary care at the VA Pittsburgh Healthcare System from June 2004 to December 2005, who were taking oral hypoglycemic agents and/or insulin for ≥1 year, and who had A1C ≥7.5% at enrollment were randomly assigned to either active care management with home telemonitoring (ACM+HT group, n = 73) or a monthly care coordination telephone call (CC group, n = 77). Both groups received monthly calls for diabetes education and self-management review. ACM+HT group participants transmitted blood glucose, blood pressure, and weight to a nurse practitioner using the Viterion 100 TeleHealth Monitor; the nurse practitioner adjusted medications for glucose, blood pressure, and lipid control based on established American Diabetes Association targets. Measures were obtained at baseline, 3-month, and 6-month visits. RESULTS Baseline characteristics were similar in both groups, with mean A1C of 9.4% (CC group) and 9.6% (ACM+HT group). Compared with the CC group, the ACM+HT group demonstrated significantly larger decreases in A1C at 3 months (1.7 vs. 0.7%) and 6 months (1.7 vs. 0.8%; P < 0.001 for each), with most improvement occurring by 3 months. CONCLUSIONS Compared with the CC group, the ACM+HT group demonstrated significantly greater reductions in A1C by 3 and 6 months. However, both interventions improved glycemic control in primary care patients with previously inadequate control.

BACKGROUND: Low-risk patients with community-acquired pneumonia are often hospitalized despite guideline recommendations for outpatient treatment. METHODS: Using data from a randomized trial conducted in 32 emergency departments, we performed a propensity-adjusted analysis to compare 30-day mortality rates, time to the return to work and to usual activities, and patient satisfaction with care between 944 outpatients and 549 inpatients in pneumonia severity index risk classes I to III who did not have evidence of arterial oxygen desaturation, or medical or psychosocial contraindications to outpatient treatment. RESULTS: After adjusting for quintile of propensity score for outpatient treatment, which eliminated all significant differences for baseline characteristics, outpatients were more likely to return to work (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.5 to 2.6) or, for nonworkers, to usual activities (OR, 1.4; 95% CI, 1.1 to 1.8) than were inpatients. Satisfaction with the site-of-treatment decision (OR, 1.1; 95% CI, 0.7 to 1.8), with emergency department care (OR, 1.4; 95% CI, 0.9 to 1.9), and with overall medical care (OR, 1.1; 95% CI, 0.8 to 1.6) was not different between outpatients and inpatients. The overall mortality rate was higher for inpatients than outpatients (2.6% vs 0.1%, respectively; p < 0.01); the mortality rate was not different among the 242 outpatients and 242 inpatients matched by their propensity score (0.4% vs 0.8%, respectively; p = 0.99). CONCLUSIONS: After adjusting for the propensity of site of treatment, outpatient treatment was associated with a more rapid return to usual activities and to work, and with no increased risk of mortality. The higher observed mortality rate among all low-risk inpatients suggests that physician judgment is an important complement to objective risk stratification in the site-of-treatment decision for patients with pneumonia.

International audience; BACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.

Objective To characterize the temporal pattern of depressive disorder in childhood, the first episode of depression was examined, focusing on recovery and its baseline predictors. Method The sample includes 112 clinically referred 8- to 13-year-olds with first-episode major depressive or dysthymic disorder participating in a naturalistic follow-up study. Psychiatric diagnoses were based on standardized interviews and operational criteria. Recovery was modeled by multivariate procedures using baseline clinical and demographic predictors. Results Recovery rates were 86% and 7% for major depression and dysthymia, respectively, 2 years after onset. Median duration of major depression was 9 months and was predicted only by underlying dysthymia. Median duration of dysthymic disorder was 3.9 years and was predicted only by comorbid externalizing disorder. In post hoc analyses, no positive treatment effects were detected. Conclusions First-episode depression in youths is persistent, it generally appears to run its own course, and its naturalistic treatment requires scrutiny. However, because comorbid externalizing disorder apparently affects duration of dysthymia, intervention for behavior problems may shorten this type of depression.

The Veterans Affairs methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was implemented in its 133 long-term care facilities in January 2009. Between July 2009 and December 2012, there were ~12.9 million resident-days in these facilities nationwide. During this period, the mean quarterly MRSA admission prevalence increased from 23.3% to 28.7% (P.0001, Poisson regression for trend), but the overall rate of MRSA health care-associated infections decreased by 36%, from 0.25 to 0.16/1,000 resident-days (P.0001, Poisson regression for trend).

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was associated with significant declines in MRSA transmission and MRSA health care-associated infection rates in Veterans Affairs acute care facilities nationwide in the 33-month period from October 2007 through June 2010. Here, we show continuing declines in MRSA transmissions (P = .004 for trend, Poisson regression) and MRSA health care-associated infections (P.001) from July 2010 through June 2012. The Veterans Affairs Initiative was associated with these effects, sustained over 57 months, in a large national health care system.

To verify empirically the most prevalent physical signs and symptoms of diabetes at onset among school-age children, document the distribution of illness-severity, and examine psychosocial and demographic correlates of initial illness severity, the authors analyzed data on 95 school-age children whose diabetes had been newly diagnosed. The most common presenting symptoms were generally consistent with descriptions in the clinical literature. Only 22% of the children presented with severe illness on admission. Children who lived in single-parent households tended to be more ill on admission than children who lived in two-parent households.

In a study of school-age children with new-onset insulin-dependent diabetes mellitus (IDDM), life stress, metabolic control (glycosylated hemoglobin), and psychiatric and psychosocial variables were assessed repeatedly for up to 6 years. Life stress was defined as the number of undesirable life events and extent of life change necessitated by all life events. In univariate longitudinal analyses, total life change units were related to metabolic control, with a trend for number of undesirable events to be associated with metabolic control. In multivariate analyses, metabolic control was related to life change units, whether the glycosylated hemoglobin was in the 1st year of IDDM, IDDM duration, and the diagnosis of pervasive noncompliance with medical regimen. The relationship of life stress to metabolic control among youths with diabetes in significant but clinically modest and may be partially mediated by serious noncompliance with the medical regimen.

Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals.A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections.From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P0.001 for trend).A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.

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.

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 P = 0.2) across the 3 guideline implementation arms. In multivariable analysis, heart rate ≥ 125 per minute (OR = 1.6, 95% CI 1.1-2.3), respiratory rate ≥ 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 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.

OBJECTIVE We compared the short-term efficacy of home telemonitoring coupled with active medication management by a nurse practitioner with a monthly care coordination telephone call on glycemic control in veterans with type 2 diabetes and entry A1Cor =7.5%. RESEARCH DESIGN AND METHODS Veterans who received primary care at the VA Pittsburgh Healthcare System from June 2004 to December 2005, who were taking oral hypoglycemic agents and/or insulin foror =1 year, and who had A1Cor =7.5% at enrollment were randomly assigned to either active care management with home telemonitoring (ACM+HT group, n = 73) or a monthly care coordination telephone call (CC group, n = 77). Both groups received monthly calls for diabetes education and self-management review. ACM+HT group participants transmitted blood glucose, blood pressure, and weight to a nurse practitioner using the Viterion 100 TeleHealth Monitor; the nurse practitioner adjusted medications for glucose, blood pressure, and lipid control based on established American Diabetes Association targets. Measures were obtained at baseline, 3-month, and 6-month visits. RESULTS Baseline characteristics were similar in both groups, with mean A1C of 9.4% (CC group) and 9.6% (ACM+HT group). Compared with the CC group, the ACM+HT group demonstrated significantly larger decreases in A1C at 3 months (1.7 vs. 0.7%) and 6 months (1.7 vs. 0.8%; P0.001 for each), with most improvement occurring by 3 months. CONCLUSIONS Compared with the CC group, the ACM+HT group demonstrated significantly greater reductions in A1C by 3 and 6 months. However, both interventions improved glycemic control in primary care patients with previously inadequate control.

Article-at-a-Glance Background A mixed-methods quality improvement (QI) project for patients with pneumonia hospitalized from the emergency department (ED) was undertaken to (1) delineate the basic steps in the flow of patient care from presentation in the ED to time to first antibiotic dose (TFAD), (2) identify perceived barriers to and facilitators of reduced TFAD within these steps, (3) describe QI strategies to improve TFAD rates, and (4) identify perceived strategies for facilities to enhance performance. Methods The QI project was conducted at 10 lower- and 10 higher-performing Veterans Affairs hospitals on the basis of the proportion of patients whose TFAD was within four hours of presentation. An ED physician, an ED nurse, a radiologist, a pharmacist, and a quality manager from each site were invited to participate in a survey and focus group. Results Of the 82 survey participants, 59 (72%) perceived that ordering and performing the chest radiograph was the step most frequently resulting in TFAD delays. Medical provider assessment, chest radiograph interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy also caused TFAD delays. The most commonly perceived barriers were patient and x-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the ED and physician education. Focus groups emphasized the importance of multifaceted QI approaches and a top-down hospital leadership style to improve TFAD performance. Discussion TFAD relies on a series of complex, stepwise processes of care that involve numerous hospital departments and is often delayed by well-described barriers. Addressing these barriers, as well as involving facility leadership in setting institutional QI goals, could possibly improve performance on this pneumonia quality measure.

BACKGROUND: Many emergency department (ED) providers do not follow guideline recommendations for the use of the pneumonia severity index (PSI) to determine the initial site of treatment for patients with community-acquired pneumonia (CAP). We identified the reasons why ED providers hospitalize low-risk patients or manage higher-risk patients as outpatients. METHODS: As a part of a trial to implement a PSI-based guideline for the initial site of treatment of patients with CAP, we analyzed data for patients managed at 12 EDs allocated to a high-intensity guideline implementation strategy study arm. The guideline recommended outpatient care for low-risk patients (nonhypoxemic patients with a PSI risk classification of I, II, or III) and hospitalization for higher-risk patients (hypoxemic patients or patients with a PSI risk classification of IV or V). We asked providers who made guideline-discordant decisions on site of treatment to detail the reasons for nonadherence to guideline recommendations. RESULTS: There were 1,306 patients with CAP (689 low-risk patients and 617 higher-risk patients). Among these patients, physicians admitted 258 (37.4%) of 689 low-risk patients and treated 20 (3.2%) of 617 higher-risk patients as outpatients. The most commonly reported reasons for admitting low-risk patients were the presence of a comorbid illness (178 [71.5%] of 249 patients); a laboratory value, vital sign, or symptom that precluded ED discharge (73 patients [29.3%]); or a recommendation from a primary care or a consulting physician (48 patients [19.3%]). Higher-risk patients were most often treated as outpatients because of a recommendation by a primary care or consulting physician (6 [40.0%] of 15 patients). CONCLUSION: ED providers hospitalize many low-risk patients with CAP, most frequently for a comorbid illness. Although higher-risk patients are infrequently treated as outpatients, this decision is often based on the request of an involved physician.

Background: In the management of acute pulmonary embolism, the prevalence of thrombolytic therapy is uncertain, and its benefits compared with standard anticoagulation remain a subject of debate. Methods: This analysis included 15116 patient discharges with a primary diagnosis of pulmonary embolismfrom186acutecarehospitalsinPennsylvania(January 2000 to November 2002). We compared propensity score–adjusted mortality between patients who received thrombolysis and those who did not, using logistic regression to model mortality within 30 days of presentation and Poisson regression to model in-hospital mortality. Results:Ofthe15116patientdischarges,only356(2.4%) received thrombolytic therapy. The overall 30-day mortalityrateforpatientswhoreceivedthrombolytictherapy was 17.4% compared with 8.6% for those who did not. The corresponding in-hospital mortality rates were 19.6 and 8.3, respectively, per 1000 person-days. However, mortality risk associated with thrombolysis varied with the propensity to receive thrombolysis: the odds ratios of 30-day mortality were 2.8 (P=.007), 3.9 (P.001), 1.8 (P=.09), 1.0 (P=.98), and 0.7 (P=.30) for patients in the lowest to the highest quintiles of the propensity score distribution who received thrombolysis. A similar pattern was observed in the risk ratios for in-hospital death. Conclusions: In this large sample of patients hospitalized for acute pulmonary embolism, thrombolytic therapy was used infrequently. Risk of in-hospital and 30-day mortality appears to be elevated for patients who were unlikely candidates for this therapy based on characteristics at presentation, but not for patients with a relatively high predicted probability of receiving thrombolysis.

Objectives. Previous studies reported a higher incidence of in-hospital mortality for Black patients who had pulmonary embolism than for White patients. We used a large statewide database to compare 30-day mortality (defined as death within 30 days from the date of latest hospital admission) for Black and White patients who were hospitalized because of pulmonary embolism. Methods. The study cohort consisted of 15531 discharged patients who had been treated for pulmonary embolism at 186 Pennsylvania hospitals between January 2000 and November 2002. We used random-effects logistic regression to model 30-day mortality for Black and White patients, and adjusted for patient demographic and clinical characteristics. Results. The unadjusted 30-day mortality rates were 9.0% for White patients, 10.3% for Blacks, and 10.9% for patients of other or unknown race. When adjusted for severity of disease using a validated clinical prognostic model for pulmonary embolism, Black patients had 30% higher odds of 30-day mortality compared with White patients at the same site (adjusted odds ratio = 1.3; 95% confidence interval, 1.1,1.6). Neither insurance status nor hospital volume was a significant predictor of 30-day mortality. Conclusion. Black patients who had pulmonary embolism had significantly higher odds of 30-day mortality compared with White patients.

Background:Asimpleprognosticmodelcouldhelpidentifypatientswithpulmonaryembolismwhoareatlowrisk of death and are candidates for outpatient treatment. Methods: We randomly allocated 15531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables. We used data from a European prospective study to externally validate the rule among 221 inpatients with pulmonary embolism. We determined mortality and nonfatal adverse medical outcomes across derivation and validation samples. Results:Our final model consisted of 10 patient factors (age 70 years; history of cancer, heart failure, chronic lung disease, chronic renal disease, and cerebrovascular disease; and clinical variables of pulse rate 110 beats/ min, systolic blood pressure100 mm Hg, altered mental status, and arterial oxygen saturation 90%). Patientswithnoneofthesefactorsweredefinedaslowrisk. The30-daymortalityratesforlow-riskpatientswere0.6%, 1.5%, and 0% in the derivation, internal validation, and externalvalidationsamples,respectively.Theratesofnonfataladversemedicaloutcomeswerelessthan1%among low-risk patients across all study samples. Conclusions:Thissimplepredictionruleaccuratelyidentifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes. Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment. Arch Intern Med. 2006;166:169-175

An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment.To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes.We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France.We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples.The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0-1.6% in class I, 1.7-3.5% in class II, 3.2-7.1% in class III, 4.0-11.4% in class IV, and 10.0-24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications wereor= 1.1% among patients in class I andor= 1.9% among patients in class II.Our rule accurately classifies patients with pulmonary embolism into classes of increasing risk of mortality and other adverse medical outcomes. Further validation of the rule is important before its implementation as a decision aid to guide the initial management of patients with pulmonary embolism.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.

We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores.We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios.The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score1 (51% [1635/3181]) or a CURB-65 score2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score.The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.

OBJECTIVE: To assess the agreement between prospectively and retrospectively determined variables comprising the Pneumonia Severity Index (PSI), assignment to PSI risk class, and designation as low risk, based on these two methods of data collection. STUDY DESIGN AND SETTING: We analyzed data from a randomized trial of patients with community-acquired pneumonia managed in 32 hospital emergency departments (EDs). For all enrolled patients, the 20 PSI variables were collected prospectively by ED providers and retrospectively by medical record abstractors. We examined the agreement for each of the 20 PSI variables, assignment to the five PSI risk classes, and classification of patients as low (classes I-III) vs. high (classes IV and V) risk. Agreement was measured using total percent agreement and the kappa statistic. RESULTS: Among the 3,220 enrolled patients, percent agreement was >90% for 18 of the 20 variables comprising the PSI, with most unweighted kappa's being >0.6. Agreement was substantial for assignment to PSI risk class (percent agreement: 92.7%; weighted kappa: 0.79) and for classification as low vs. high risk (percent agreement: 88.5%; unweighted kappa: 0.74). CONCLUSION: There was substantial agreement between retrospective and prospective assignment to PSI risk class, classification as low vs. high risk, and the determination of most individual variables that constitute the PSI.

Purpose Patients with pneumonia often remain hospitalized after they are stable clinically, and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge. The purpose of this study was to determine whether implementation of an evidence-based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia. Methods In a seven-site, cluster randomized clinical trial, we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups. Within site, physician groups were assigned randomly to receive a practice guideline alone (control arm) or a practice guideline that was implemented using a multifaceted strategy (intervention arm). The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models. Medical outcomes were assessed at 30 days. Results Intravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group (hazard ratio [HR] =1.23; 95% confidence interval [CI]: 1.00 to 1.52; P = 0.06) than in the control group. Intervention patients were discharged more quickly, but the difference was not statistically significant (HR = 1.16; 95% CI: 0.97 to 1.38; P = 0.11). Fewer intervention (55% [157/283]) than control (63% [206/325]) patients had medical complications during the index hospitalization ( P = 0.04), with no differences in other medical outcomes, including mortality, rehospitalization, and return to usual activities, between treatment arms. Conclusion The multifaceted guideline implementation strategy resulted in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay, without affecting patient outcomes.

OBJECTIVES: From a cohort of patients with community-acquired pneumonia (CAP) who required admission to hospital, to describe the subset of patients having a do not resuscitate (DNR) order and to compare them with those who did not have such an order. DESIGN: Retrospective subset analysis of data from the pneumonia patient outcomes research team study. SETTING: Three hospitals in the United States and one in Canada. PARTICIPANTS: Hospitalized patients aged 18 and older with CAP. MEASUREMENTS: Sociodemographic features, severity of illness, antibiotic therapy, length of stay, mortality, admission to special care units, and mortality attributable to pneumonia. RESULTS: The 199 (14.9%) of 1,339 inpatients with CAP who had a DNR order written within 24 hours of admission and an additional 96 (7.2%) patients who had such an order written later were compared with the 1,044 who never had a DNR order. The 199 patients with an initial DNR and 96 later DNR were older (median age 81 and 78 vs 65 years, respectively; P

OBJECTIVE: To describe the features of community-acquired Escherichia coli pneumonia and to compare these patients with patients with pneumonia caused by other etiologic agents. PATIENTS AND METHODS: This prospective study was carried out at five medical institutions in three geographic locations---Pittsburgh, PA, Boston, MA and Halifax, NS. Pneumonia etiology was assigned, based on results of microbiological investigations, by a committee consisting of five investigators using rules established prior to the study. Demographic and clinical features and outcomes of patients with E. coli pneumonia were compared with those of pneumonia due to other microorganisms. RESULTS: Nineteen patients (9 (47.4%) blood culture positive) had pneumonia due to E. coli and 430 (69 (16.0%) blood culture positive) had pneumonia caused by other etiologic agents. E. coli was the second most common cause of bacteremic pneumonia. The E. coli patients were older, and more likely to be female, from a nursing home and confused compared with patients with pneumonia due to other microbial agents. They were more severely ill as measured by a validated pneumonia specific severity of illness scoring measure. Although there was no in-hospital mortality for the patients with E. coli pneumonia, the 90-day mortality was 21%. Thirty-two (7.4%) of the patients with pneumonia due to other agents died in hospital and the 90-day mortality rate was 13.5% (p NS). Eight of the 19 patients with E. coli pneumonia were admitted from a nursing home and an additional four patients (63.2%) were discharged to such a facility. In contrast, only 44 (10.2%) of the patients with pneumonia due to other agents were discharged to a nursing home (p

To describe the presentation, resolution of symptoms, processes of care, and outcomes of pneumococcal pneumonia, and to compare features of the bacteremic and nonbacteremic forms of this illness.A prospective cohort study.Five medical institutions in 3 geographic locations.Inpatients and outpatients with community-acquired pneumonia (CAP).Sociodemographic characteristics, respiratory and nonrespiratory symptoms, and physical examination findings were obtained from interviews or chart review. Severity of illness was assessed using a validated prediction rule for short-term mortality in CAP. Pneumococcal pneumonia was categorized as bacteremic; nonbacteremic, pure etiology; or nonbacteremic, mixed etiology.One hundred fifty-eight (6.9%) of 2,287 patients (944 outpatients, 1,343 inpatients) with CAP had pneumococcal pneumonia. Sixty-five (41%) of the 158 with pneumococcal pneumonia were bacteremic; 74 (47%) were nonbacteremic with S. pneumoniae as sole pathogen; and 19 (12%) were nonbacteremic with S. pneumoniae as one of multiple pathogens. The pneumococcal bacteremia rate for outpatients was 2.6% and for inpatients it was 6.6%. Cough, dyspnea, and pleuritic pain were common respiratory symptoms. Hemoptysis occurred in 16% to 22% of the patients. A large number of nonrespiratory symptoms were noted. Bacteremic patients were less likely than nonbacteremic patients to have sputum production and myalgias (60% vs 82% and 33% vs 57%, respectively; P.01 for both), more likely to have elevated blood urea nitrogen and serum creatinine levels, and more likely to receive penicillin therapy. Half of bacteremic patients were in the low risk category for short-term mortality (groups I to III), similar to the nonbacteremic patients. None of the 32 bacteremic patients in risk groups I to III died, while 7 of 23 (30%) in risk group V died. Intensive care unit admissions and pneumonia-related mortality were similar between bacteremic and nonbacteremic groups, although 46% of the bacteremic group had respiratory failure compared with 32% and 37% for the other groups. The nonbacteremic pure etiology patients returned to household activities faster than bacteremic patients. Symptoms frequently persisted at 30 days: cough (50%); dyspnea (53%); sputum production (48%); pleuritic pain (13%); and fatigue (63%).There were few differences in the presentation of bacteremic and nonbacteremic pneumococcal pneumonia. About half of bacteremic pneumococcal pneumonia patients were at low risk for mortality. Symptom resolution frequently was slow.

Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia.As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports.The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay.Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings.

To assess the variation in length of stay for patients hospitalized with community-acquired pneumonia and to determine whether patients who are treated in hospitals with shorter mean stays have worse medical outcomes.We prospectively studied a cohort of 1,188 adult patients with community-acquired pneumonia who had been admitted to one community and three university teaching hospitals. We compared patients' mean length of stay, mortality, hospital readmission, return to usual activities, return to work, and pneumonia-related symptoms among the four study hospitals. All outcomes were adjusted for baseline differences in severity of illness and comorbidity.Adjusted interhospital differences in mean length of stay ranged from 0.9 to 2.3 days (P0.001). When the risk of each medical outcome was compared between patients admitted to the hospital with the shortest length of stay and those admitted to longer stay hospitals, there were no differences in mortality [relative risk (RR) = 0.7; 95% CI, 0.3 to 1.7], hospital readmission (RR = 0.8; 95% CI, 0.5 to 1.2), return to usual activities (RR = 1.1; 95% CI, 0.9 to 1.3), or return to work (RR = 1.2; 95% CI, 0.8 to 2.0) during the first 14 days after discharge, or in the mean number of pneumonia-related symptoms 30 days after admission (P = 0.54).We observed substantial interhospital variation in the lengths of stay for patients hospitalized with community-acquired pneumonia. The finding that medical outcomes were similar in patients admitted to the hospital with the shortest length of stay and those admitted to hospitals with longer mean lengths of stay suggests that hospitals with longer stays may be able to reduce the mean duration of hospitalization for this disease without adversely affecting patient outcomes.

Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain.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.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.Neither the individual processes of care nor the cumulative number performed is associated with short-term mortality for pneumonia.

School-age children were assessed longitudinally for up to 9 years, after the onset of their insulin-dependent diabetes mellitus (IDDM), to determine the time-dependent risk of the psychiatric diagnosis of noncompliance with medical treatment and to examine protective and risk factors. The cumulative risk for this diagnosis over the 9 years was .45. Noncompliance tended to emerge in middle adolescence and was found to be protracted. Social competence, self-esteem, and aspects of family functioning at IDDM onset and initial psychiatric status did not predict noncompliance. However, noncompliance was associated with having major psychiatric disorder later in the course of IDDM.

Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. Objective: To compare the effectiveness and safety of 3 guideline implementation strategies. Design: Cluster-randomized, controlled trial. Setting: 32 emergency departments in Pennsylvania and Connecticut. Patients: 3219 patients with a clinical and radiographic diagnosis of pneumonia. Interventions: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12). Measurements: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients. Results: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P= 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P< 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P< 0.001). No statistically significant differences in safety outcomes were observed across interventions. Limitations: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. Conclusions: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

Background To our knowledge, no previous study has systematically examined pneumonia-related and pneumonia-unrelated mortality. This study was performed to identify the cause(s) of death and to compare the timing and risk factors associated with pneumonia-related and pneumonia-unrelated mortality. Methods For all deaths within 90 days of presentation, a synopsis of all events preceding death was independently reviewed by 2 members of a 5-member review panel (C.M.C., D.E.S., T.J.M., W.N.K., and M.J.F.). The underlying and immediate causes of death and whether pneumonia had a major, a minor, or no apparent role in the death were determined using consensus. Death was defined as pneumonia related if pneumonia was the underlying or immediate cause of death or played a major role in the cause of death. Competing-risk Cox proportional hazards regression models were used to identify baseline characteristics associated with mortality. Results Patients (944 outpatients and 1343 inpatients) with clinical and radiographic evidence of pneumonia were enrolled, and 208 (9%) died by 90 days. The most frequent immediate causes of death were respiratory failure (38%), cardiac conditions (13%), and infectious conditions (11%); the most frequent underlying causes of death were neurological conditions (29%), malignancies (24%), and cardiac conditions (14%). Mortality was pneumonia related in 110 (53%) of the 208 deaths. Pneumonia-related deaths were 7.7 times more likely to occur within 30 days of presentation compared with pneumonia-unrelated deaths. Factors independently associated with pneumonia-related mortality were hypothermia, altered mental status, elevated serum urea nitrogen level, chronic liver disease, leukopenia, and hypoxemia. Factors independently associated with pneumonia-unrelated mortality were dementia, immunosuppression, active cancer, systolic hypotension, male sex, and multilobar pulmonary infiltrates. Increasing age and evidence of aspiration were independent predictors of both types of mortality. Conclusions For patients with community-acquired pneumonia, only half of all deaths are attributable to their acute illness. Differences in the timing of death and risk factors for mortality suggest that future studies of community-acquired pneumonia should differentiate all-cause and pneumonia-related mortality.

Background Although understanding the processes of care and medical outcomes for patients with community-acquired pneumonia is instrumental to improving the quality and cost-effectiveness of care for this illness, limited information is available on how physicians manage patients with this illness or on medical outcomes other than short-term mortality. Objectives To describe the processes of care and to assess a broad range of medical outcomes for ambulatory and hospitalized patients with community-acquired pneumonia. Methods This prospective, observational study was conducted at 4 hospitals and 1 health maintenance organization in Pittsburgh, Pa, Boston, Mass, and Halifax, Nova Scotia. Data were collected via patient interviews and reviews of medical records for 944 outpatients and 1343 inpatients with clinical and radiographic evidence of community-acquired pneumonia. Processes of care and medical outcomes were assessed 30 days after presentation. Results Only 29.7% of outpatients had 1 or more microbiologic tests performed, and only 5.7% had an assigned microbiologic cause. Although 95.7% of inpatients had 1 or more microbiologic tests performed, a cause was established in only 29.6%. Six outpatients (0.6%) died, and 3 of these deaths were pneumonia related. Of surviving outpatients, 8.0% had 1 or more medical complications. At 30 days, 88.9% (nonemployed) to 95.6% (employed) of the surviving outpatients had returned to usual activities, yet 76.0% of outpatients had 1 or more persisting pneumonia-related symptoms. Overall, 107 inpatients (8.0%) died, and 81 of these deaths were pneumonia related. Most surviving inpatients (69.0%) had 1 or more medical complications. At 30 days, 57.3% (nonemployed) to 82.0% (employed) of surviving inpatients had returned to usual activities, and 86.1% had 1 or more persisting pneumonia-related symptoms. Conclusions In this study, conducted primarily at hospital sites with affiliated medical education training programs, virtually all outpatients and most inpatients had pneumonia of unknown cause. Although outpatients had an excellent prognosis, pneumonia-related symptoms often persisted at 30 days. Inpatients had substantial mortality, morbidity, and pneumonia-related symptoms at 30 days.

Context.—Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs, but the length of time until a patient hospitalized with pneumonia becomes clinically stable has not been established.Objective.—To describe the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability.Design.—Prospective, multicenter, observational cohort study.Setting.—Three university and 1 community teaching hospital in Boston, Mass, Pittsburgh, Pa, and Halifax, Nova Scotia.Patients.—Six hundred eighty-six adults hospitalized with community-acquired pneumonia.Main Outcome Measures.—Time to resolution of vital signs, ability to eat, mental status, hospital length of stay, and admission to an intensive care, coronary care, or telemetry unit.Results.—The median time to stability was 2 days for heart rate (≤100 beats/min) and systolic blood pressure (≥90 mm Hg), and 3 days for respiratory rate (≤24 breaths/min), oxygen saturation (≥90%), and temperature (≤37.2°C [99°F]). The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition. Patients with more severe cases of pneumonia at presentation took longer to reach stability. Once stability was achieved, clinical deterioration requiring intensive care, coronary care, or telemetry monitoring occurred in 1% of cases or fewer. Between 65% to 86% of patients stayed in the hospital more than 1 day after reaching stability, and fewer than 29% to 46% were converted to oral antibiotics within 1 day of stability, depending on the definition of stability.Conclusions.—Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence-based estimate of optimal length of stay, and outline a clinically sensible approach to improving the efficiency of inpatient management.