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Abstract Background Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. Methods 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. Results Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. Conclusions Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. Trial Registration ClinicalTrials.gov: NCT00827710

Background: Against the backdrop of hundreds of studies documenting negative stereotypes and stigma held by the public regarding people who stutter, a substantial number of investigations have attempted to improve public attitudes and measure their results with a standard instrument, the Public Opinion Survey of Human Attributes-Stuttering (POSHA-S). Although the majority of interventions have been moderately to quite successful, a substantial minority have been unsuccessful., Purpose: This study sought to determine what properties of interventions and demographic variables were predictive of least to most successful interventions. Preliminary to that, however, it required the division of samples into clearly differentiated categories of success., Method: Twenty-nine different study samples containing 934 participants were categorized into four levels of success of interventions according to pre versus post POSHA-S summary mean ratings. Intervention properties and demographic characteristics and for each success category were analyzed for their predictive potential of successful attitude improvement., Results: Interventions characterized by high interest or involvement, meaningful material, and content that respondents found to be relevant, but not excessive, tended to be associated with more successful interventions. In contrast, demographic variables were weak predictors of intervention success., Conclusion: The authors hypothesize that maximally effective interventions reflect optimal matches between participant characteristics and intervention features, although the critical variables in each are not yet apparent., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Currently, the first generation of solar panels are reaching their end-of-life, however so far, there is no best available technology (BAT) to deal with solar panel waste in terms of the optimized circular economy of metals. In this brief communication, electro-hydraulic fragmentation (EHF) is explored as an initial conditioning stage of photovoltaic (PV) modules to facilitate the recovery of valuable metals with the main goal to produce liberated fractions that are suitable for the retrieval of materials like Si, Ag, Cu, Sn, Pb, and Al. When compared to traditional crushing, the results suggest that dismantling of PV panels using EHF shows more selectivity by concentrating metals among well-defined particle size fractions. Using this method, the subsequent recovery of metals from PV panels can be achieved in a straightforward manner by simple means like sieving. The fragmentation achievable with EHF technology allowed approximately 99% Cu, 60% Ag, 80% of Pb, Sn and Al total elemental weight within the solar panels to be concentrated solely within the >4 mm size range, whereas high purity (>99%) Si could be found in the fractions between >0.50 mm and <2 mm. To the best of the authors' knowledge, this paper presents for the first time a comparative analysis on the use of EHF technique and conventional crushing for the processing of PV solar panel waste., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: We compared the effectiveness and cost-effectiveness of: 1) centralized reminder/recall (C-R/R) using the Colorado Immunization Information System (CIIS) versus practice-based reminder/recall (PB-R/R) approaches to increase immunization rates; 2) different levels of C-R/R intensity; and 3) C-R/R with versus without the name of the child's provider., Methods: We conducted 3 sequential cluster-randomized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 (trial 1), October 2013 (trial 2), and May 2014 (trial 3). In C-R/R counties, the intensity of the intervention decreased sequentially in trials 1 through 3, from 3 to 1 recall messages. In PB-R/R counties, practices were offered training using CIIS and financial support. The percentage of children with up-to-date (UTD) vaccinations was compared 6 months after recall. A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates., Results: C-R/R was more effective in trials 1 to 3 (relative risk = 1.11; 95% confidence interval 1.01-1.20; P = .009). Effectiveness did not decrease with decreasing intervention intensity (P = .59). Costs decreased with decreasing intensity in the C-R/R arm, from $18.72 per child brought UTD in trial 1 to $10.11 in trial 3. Costs were higher and more variable in the PB-R/R arm, ranging from $20.63 to $237.81 per child brought UTD. C-R/R was significantly more effective if the child's practice name was included (P < .0001)., Conclusions: C-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the child's provider name. Three reminders were not more effective than one, which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the effectiveness and cost of bidirectional short messaging service in increasing rates of vaccination and well child care (WCC) among adolescents., Methods: We included all adolescents needing a recommended adolescent vaccine (n = 4587) whose parents had a cell-phone number in 5 private and 2 safety-net pediatric practices. Adolescents were randomized to intervention (n = 2228) or control (n = 2359). Parents in the intervention group received up to 3 personalized short messaging services with response options 1 (clinic will call to schedule), 2 (parent will call clinic), or STOP (no further short messaging service). Primary outcomes included completion of all needed services, WCC only, all needed vaccinations, any vaccination, and missed opportunity for vaccination., Results: Intervention patients were more likely to complete all needed services (risk ratio [RR] 1.31, 95% confidence interval [CI] 1.12-1.53), all needed vaccinations (RR 1.29, 95% CI 1.12-1.50), and any vaccination (RR 1.36, 95% CI 1.20-1.54). Seventy-five percent of control patients had a missed opportunity versus 69% of intervention (P = .002). There was not a significant difference for WCC visits. Responding that the clinic should call to schedule ("1") was associated with the highest effect size for completion of all needed services (RR 1.89, 95% CI 1.41-2.54). Net cost ranged from $855 to $3394 per practice., Conclusions: Bidirectional short messaging service to parents was effective at improving rates for all adolescent vaccinations and for all needed services, especially among parents who responded they desired a call from the practice., (Copyright © 2015 by the American Academy of Pediatrics.)

Specific guidance on the size and composition of respiratory protective device (RPD) stockpiles for use during a pandemic is lacking. We explore the economic aspects of stockpiling various types and combinations of RPDs by adapting a pandemic model that estimates the impact of a severe pandemic on a defined population, the number of potential interactions between patients and health care personnel, and the potential number of health care personnel needed to fulfill those needs. Our model calculates the number of the different types of RPDs that should be stockpiled and the consequent cost of purchase and storage, prorating this cost over the shelf life of the inventory. Compared with disposable N95 or powered air-purifying respirators, we show that stockpiling reusable elastomeric half-face respirators is the least costly approach. Disposable N95 respirators take up significantly more storage space, which increases relative costs. Reusing or extending the usable period of disposable devices may diminish some of these costs. We conclude that stockpiling a combination of disposable N95 and reusable half-face RPDs is the best approach to preparedness for most health care organizations. We recommend against stockpiling powered air-purifying respirators as they are much more costly than alternative approaches.

Importance: Reminder/recall notifications used by primary care practices increase the rates of childhood immunizations, but fewer than 20% of primary care practitioners nationally deliver such reminders. A reminder/recall notification conducted centrally by health departments in collaboration with primary care practices may reduce practice burden, reach children without a primary care practitioner, and decrease the cost of reminders/recalls., Objective: To assess the effectiveness and cost-effectiveness of collaborative centralized (CC) vs practice-based (PB) reminder/recall approaches using the Colorado Immunization Information System (CIIS)., Design, Setting, and Participants: We performed a randomized pragmatic trial from September 7, 2012, through March 17, 2013, including 18,235 children aged 19 to 35 months in 15 Colorado counties., Interventions: In CC counties, children who needed at least 1 immunization were sent as many as 4 reminders/recalls by mail or autodialed telephone calls by the CIIS. Primary care practices in these counties were given the option of endorsing the reminder/recall notification by adding the practice name to the message. In PB counties, primary care practices were invited to web-based reminder/recall training and offered financial support for sending notifications., Main Outcomes and Measures: Documentation of any new immunization within 6 months constituted the primary outcome; achieving up-to-date (UTD) immunization status was secondary. We assessed the cost and cost-effectiveness of each approach and used a generalized linear mixed-effects model to assess the effect of the intervention on outcomes., Results: In PB counties, 24 of 308 primary care practices (7.8%) attended reminder/recall training and 2 primary care practices (0.6%) endorsed reminder/recall notifications. Within CC counties, 129 of 229 practices (56.3%) endorsed the reminder/recall letter. Documentation rates for at least 1 immunization were 26.9% for CC vs 21.7% for PB counties (P < .001); 12.8% vs 9.3% of patients, respectively, achieved UTD status (P < .001). The effect of CC counties on children's UTD status was greater when the reminder/recall notification was endorsed by the primary care practice (19.2% vs 9.8%; P < .001). The total cost of the CC reminder/recall was $28 620 or $11.75 per child for any new immunization and $24.72 per child achieving UTD status; the total cost to the 2 practices that conducted PB reminders/recalls was $74.00 per child for any immunization and $124.45 per child achieving UTD status. The modeling resulted in an adjusted odds ratio of 1.31 (95% CI, 1.16-1.48) for any new immunization in CC vs PB counties., Conclusions and Relevance: A CC reminder/recall notification was more effective and more cost-effective than a PB system, although the effect size was modest. Endorsement by practices may further increase the effectiveness of CC reminder/recall., Trial Registration: clinicaltrials.gov Identifier: NCT01557621.

Objectives: We compared the effectiveness and cost-effectiveness of population-based recall (Pop-recall) versus practice-based recall (PCP-recall) at increasing immunizations among preschool children., Methods: This cluster-randomized trial involved children aged 19 to 35 months needing immunizations in 8 rural and 6 urban Colorado counties. In Pop-recall counties, recall was conducted centrally using the Colorado Immunization Information System (CIIS). In PCP-recall counties, practices were invited to attend webinar training using CIIS and offered financial support for mailings. The percentage of up-to-date (UTD) and vaccine documentation were compared 6 months after recall. A mixed-effects model assessed the association between intervention and whether a child became UTD., Results: Ten of 195 practices (5%) implemented recall in PCP-recall counties. Among children needing immunizations, 18.7% became UTD in Pop-recall versus 12.8% in PCP-recall counties (P < .001); 31.8% had documented receipt of 1 or more vaccines in Pop-recall versus 22.6% in PCP-recall counties (P < .001). Relative risk estimates from multivariable modeling were 1.23 (95% confidence interval [CI] = 1.10, 1.37) for becoming UTD and 1.26 (95% CI = 1.15, 1.38) for receipt of any vaccine. Costs for Pop-recall versus PCP-recall were $215 versus $1981 per practice and $17 versus $62 per child brought UTD., Conclusions: Population-based recall conducted centrally was more effective and cost-effective at increasing immunization rates in preschool children.

Context: The Centers for Disease Control and Prevention (CDC) recommends routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. The utility of this approach in EDs remains unknown., Objective: To determine whether nontargeted opt-out rapid HIV screening in the ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing., Design, Setting, and Patients: Quasi-experimental equivalent time-samples design in an urban public safety-net hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing., Interventions: Nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 15, 2007, and April 15, 2009., Main Outcome Measures: Number of patients with newly identified HIV infection and the association between nontargeted opt-out rapid HIV screening and identification of HIV infection., Results: In the opt-out phase, of 28,043 eligible ED patients, 6933 patients (25%) completed HIV testing (6702 patients were screened; 231 patients were diagnostically tested). Ten of 6702 patients (0.15%; 95% CI, 0.07%-0.27%) who did not decline HIV screening in the opt-out phase had new HIV diagnoses, and 5 of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new HIV diagnoses. In the diagnostic phase, of 29,925 eligible patients, 243 (0.8%) completed HIV testing. Of these, 4 patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses. The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and 4 in 29,925 (0.01%; 95% CI, 0.004%-0.03%), respectively. Nontargeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status, and whether diagnostic testing was performed in the opt-out phase. The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/microL (IQR, 17-430) and 13/microL (IQR, 11-15) , respectively (P = .02)., Conclusion: Nontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease.

In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.

Purpose: To examine resident workflow as part of an institutional approach to redesigning the processes of health care delivery., Method: In 2003 the authors observed the workflows for 24 hours of seven residents who were at various levels of training (two each from the internal medicine, pediatrics, and obstetrics and gynecology programs, and one from general surgery) at Denver Health Medical Center, an urban, public teaching hospital., Results: Although the residents spent varying proportions of their time in various activities, all had extremely fragmented workflows as they engaged in from 5.0 to 11.3 different activities per hour of nonsleeping time, many of which required only minutes to complete. All residents experienced frequent interruptions and changes in focus. The internal medicine and surgery residents spent large amounts of time traveling, covering three and six miles, respectively, during their 24-hour shifts. Three of the residents slept between one-quarter and one-third of their time on duty (one without any interruption)., Conclusions: The authors suggest that fragmented workflow exists in all residency programs and that applying the same work limitations to all residents in all training programs (to reduce fatigue-related errors) may be overly restrictive. Improving these processes of care will be difficult and will likely require analytic skills and knowledge of systems engineering that most physicians do not have.

Background: Computerized order entry systems have the potential to prevent medication errors and decrease adverse drug events with the use of clinical-decision support systems presenting alerts to providers. Despite the large volume of medications prescribed in the outpatient setting, few studies have assessed the impact of automated alerts on medication errors related to drug-laboratory interactions in an outpatient primary-care setting., Methods and Findings: A primary-care clinic in an integrated safety net institution was the setting for the study. In collaboration with commercial information technology vendors, rules were developed to address a set of drug-laboratory interactions. All patients seen in the clinic during the study period were eligible for the intervention. As providers ordered medications on a computer, an alert was displayed if a relevant drug-laboratory interaction existed. Comparisons were made between baseline and postintervention time periods. Provider ordering behavior was monitored focusing on the number of medication orders not completed and the number of rule-associated laboratory test orders initiated after alert display. Adverse drug events were assessed by doing a random sample of chart reviews using the Naranjo scoring scale. The rule processed 16,291 times during the study period on all possible medication orders: 7,017 during the pre-intervention period and 9,274 during the postintervention period. During the postintervention period, an alert was displayed for 11.8% (1,093 out of 9,274) of the times the rule processed, with 5.6% for only "missing laboratory values," 6.0% for only "abnormal laboratory values," and 0.2% for both types of alerts. Focusing on 18 high-volume and high-risk medications revealed a significant increase in the percentage of time the provider stopped the ordering process and did not complete the medication order when an alert for an abnormal rule-associated laboratory result was displayed (5.6% vs. 10.9%, p = 0.03, Generalized Estimating Equations test). The provider also increased ordering of the rule-associated laboratory test when an alert was displayed (39% at baseline vs. 51% during post intervention, p < 0.001). There was a non-statistically significant difference towards less "definite" or "probable" adverse drug events defined by Naranjo scoring (10.3% at baseline vs. 4.3% during postintervention, p = 0.23)., Conclusion: Providers will adhere to alerts and will use this information to improve patient care. Specifically, in response to drug-laboratory interaction alerts, providers will significantly increase the ordering of appropriate laboratory tests. There may be a concomitant change in adverse drug events that would require a larger study to confirm. Implementation of rules technology to prevent medication errors could be an effective tool for reducing medication errors in an outpatient setting.

Background: The Centers for Disease Control and Prevention (CDC) has published guidelines recommending screening high-risk groups for latent tuberculosis infection (LTBI). The goal of this study was to determine the impact of computerized clinical decision support and guided web-based documentation on screening rates for LTBI., Design: Nonrandomized, prospective, intervention study., Setting and Participants: Participants were 8463 patients seen at two primary care, outpatient, public community health center clinics in late 2002 and early 2003., Intervention: The CDC's LTBI guidelines were encoded into a computerized clinical decision support system that provided an alert recommending further assessment of LTBI risk if certain guideline criteria were met (birth in a high-risk TB country and aged <40). A guided web-based documentation tool was provided to facilitate appropriate adherence to the LTBI screening guideline and to promote accurate documentation and evaluation. Baseline data were collected for 15 weeks and study-phase data were collected for 12 weeks., Main Outcome Measures: Appropriate LTBI screening according to CDC guidelines based on chart review., Results: Among 4135 patients registering during the post-intervention phase, 73% had at least one CDC-defined risk factor, and 610 met the alert criteria (birth in a high-risk TB country and aged <40 years) for potential screening for LTBI. Adherence with the LTBI screening guideline improved significantly from 8.9% at baseline to 25.2% during the study phase (183% increase, p < 0.001)., Conclusions: This study demonstrated that computerized, clinical decision support using alerts and guided web-based documentation increased screening of high-risk patients for LTBI. This type of technology could lead to an improvement in LTBI screening in the United States and also holds promise for improved care for other preventive and chronic conditions.

Two major pillars of the United States' safety net system are urban public hospitals and community health centers. Their common mission is to care for the uninsured and other vulnerable populations. However, in most communities these important components of the safety net remain organizationally and functionally separate, which inhibits the continuum of care and creates substantial inefficiencies. Denver Health is a long-standing vertically and horizontally integrated system for vulnerable populations. The integration benefits the patient and the system and serves as a model for the U.S. safety net. This paper outlines the benefits of integration to the patient, provider, and health system, using data from the National Association of Public Hospitals and Health Systems, the Bureau of Primary Health Care, and Denver Health.

To determine the impact of information technology on embedding the latent tuberculosis infection (LTBI) screening guidelines in an electronic medical record (EMR) in a large health care system. The long-term goal of the study is to test clinician adherence to LTBI screening guidelines using an EMR system. However, preliminary results are presented on the potential impact on providers on implementing the alerts on targeted high-risk patients.

Objective: To examine differences in health care services utilization between children who are enrolled in the Child Health Insurance Plan (CHIP) and uninsured children and between children before and during their enrollment period in CHIP., Methods: Denver County CHIP enrollment data from 1998 through 2000 were merged with Denver Health utilization data from 1998 through 2000 to determine utilization rates for CHIP-enrolled children at Denver Health (n = 2005). The first method compared the rates of CHIP-enrolled children with those of uninsured children (n = 20 374) during the same time period. The second method compared the utilization of services for children enrolled in CHIP during 1999 before CHIP enrollment (n = 748) and during CHIP enrollment (n = 757). The outcomes measured include emergency, urgent care, specialty care, well-child care, dental visits, and immunizations., Results: For the first method, CHIP children were more likely to have well-child care, dental, and specialty visits and the recommended immunizations than uninsured children. They were less likely to have an emergency care visit than uninsured children. For the second method, before enrolling in CHIP, children had fewer outpatient visits and were less likely to have a well-child care visit than during their enrollment span in CHIP. There was not a significant difference before and during enrollment for the other outcome measures for these children., Conclusions: These results indicate that children who are enrolled in CHIP are more likely to receive preventive care services and less likely to use emergency care than uninsured children, even within a safety net institution, emphasizing the benefits of public insurance programs for children.

Management information systems are an essential tool for health care managers. Denver Health, an integrated safety net institution, upgraded its financial management information system during 1997 and experienced almost an 18 percent or $23 million increase in cash collections from 1997 to 1998 and a 17 percent or over $25 million increase from 1998 to 1999. Cash collections continued to increase in 2000 with a $12.0 million (6.8%) ncrease over 1999. This article explains the information system factors that have contributed to this increase and describes the continued management efforts that are expected to continue to improve cash collections.

During anaesthesia controlled hypotension -- induced by sodium nitroprusside -- was used in 60 patients undergoing intraocular anterior segment surgery. The advantages of this procedure are that the iris-lens diaphragma and the vitreous body have a lesser tendency to protrude than with other techniques despite even more superficial anaesthesia.

General anaesthesia was performed in 75 patients with difficult intraocular procedures in which the standard relaxation and hyperventilation was supplemented by controlled short-term hypotension by sodium-nitroprusside. This resulted in a significant decrease of the "vis a tergo"--e.g. the threatening prolaps of intraocular tissue. Preliminary experience revealed that intraoperative complications in these difficult situations are reduced. As this facilitates also the task of the anaesthesist this broadens our indications for complex intraocular surgery particularly in younger patients.

Mycotic Septicaemia (especially with the Candida species) is not an uncommon hazard of hospitalized patients, especially those on intravenous hyperalimentation. Two such patients with endogenous mycotic bilateral endophthalmitis are presented. In spite of typical ocular symptoms diagnosis was delayed. Two further unilateral cases of a more atypical form of endogenous mycotic endophthalmitis in otherwise seemingly healthy patients are also described. Correlating histopathological findings in three of these 4 cases to the clinical histories, conclusions are drawn to aid an early diagnosis which is of paramount importance if the necessary antimyotic treatment is to preserve visual function.