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Background The risk of severe COVID-19 varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). Objective To examine whether deficits in IR that antedate or are induced by SARS-CoV-2 infection independently predict COVID-19 mortality. Methods IR levels were quantified with two novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n=522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n=13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to clinical outcomes. Results IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection associated with underrepresentation of IHG-I (21%) vs. overrepresentation (77%) of IHG-II or IHG-IV, especially in males vs. females (P Conclusion Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19. Clinical implications Biomarkers tracking immunologic resilience may have broad prognostic utility, as they associated with longevity, as well as resistance to a progressive disease course during SARS-CoV-2, influenza, or HIV infection.

Background Signifying the 2-compartments/1-disease paradigm, allergic rhinoconjunctivitis (ARC) and asthma (AA) are prevalent, comorbid conditions triggered by environmental factors (eg, house dust mites [HDMs]). However, despite the ubiquity of triggers, progression to severe ARC/AA is infrequent, suggesting either resilience or adaptation. Objective We sought to determine whether ARC/AA severity relates to maladaptive responses to disease triggers. Methods Adults with HDM-associated ARC were challenged repetitively with HDMs in an aeroallergen challenge chamber. Mechanistic traits associated with disease severity were identified. Results HDM challenges evoked maladaptive (persistently higher ARC symptoms), adaptive (progressive symptom reduction), and resilient (resistance to symptom induction) phenotypes. Symptom severity in the natural environment was an imprecise correlate of the phenotypes. Nasal airway traits, defined by low inflammation-effectual epithelial integrity, moderate inflammation-effectual epithelial integrity, and higher inflammation-ineffectual epithelial integrity, were hallmarks of the resilient, adaptive, and maladaptive evoked phenotypes, respectively. Highlighting a crosstalk mechanism, peripheral blood inflammatory tone calibrated these traits: ineffectual epithelial integrity associated with CD8+ T cells, whereas airway inflammation associated with both CD8+ T cells and eosinophils. Hallmark peripheral blood maladaptive traits were increased natural killer and CD8+ T cells, lower CD4+ mucosal-associated invariant T cells, and deficiencies along the TLR-IRF-IFN antiviral pathway. Maladaptive traits tracking HDM-associated ARC also contributed to AA risk and severity models. Conclusions Repetitive challenges with HDMs revealed that maladaptation to disease triggers may underpin ARC/AA disease severity. A combinatorial therapeutic approach may involve reversal of loss-of-beneficial-function traits (ineffectual epithelial integrity, TLR-IRF-IFN deficiencies), mitigation of gain-of-adverse-function traits (inflammation), and blocking of a detrimental crosstalk between the peripheral blood and airway compartments.

BACKGROUND: The successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and recognition rates, factors associated with these rates, and evaluate the effect of CKD awareness on delivery of care. METHODS: A retrospective cohort study of veterans enrolled with Veterans Integrated Service Network 17 who had hypertension (HTN) and/or diabetes (DM) and were seen at least twice in primary care clinics within 18 months. The final cohort of 270,170 patients (52% HTN, 5% DM, and 44% both) was examined for serum creatinine/eGFR, urine protein/albumin, International Classification of Diseases (ICD) codes for CKD, and nephrology referral. CKD was defined as eGFR 30 mg/g at least twice 90 days apart. Clinical covariates, HTN control, and prescription rates of renal prudent medications and nonsteroidal anti-inflammatory drugs (NSAIDs) were assessed. RESULTS: Overall, 254,831 (94%) patients had either eGFR, urine protein/albumin, or both. However, screening for protein/albuminuria was low (56%), particularly in patients with isolated HTN (35%). Of 254,831 patients, 92,900 (36%) had laboratory evidence of CKD and, of these, 40,586 (44%) were recognized to have CKD by ICD code and/or nephrology referral. CKD due to presence of uACR criteria alone had the lowest recognition (19%) as compared with CKD due to eGFR criteria (44%) or both (67%). Frequency of emergency room visits, hospitalization, and cardiac and endovascular procedures requiring contrast had the highest odds and races other than white had the lower odds of screening. In contrast, CKD recognition was high in races other than white and increased with worsening eGFR and increasing uACR. In screened and recognized CKD, prescription was higher for angiotensin inhibitors, statins, and diuretics, and was lower for NSAIDs. CONCLUSIONS: Although overall CKD screening rate was high, screening of protein/albuminuria in isolated HTN and overall recognition of CKD was low in at-risk veterans. Increased recognition was associated with a favorable prescription rate for renal prudent medications.

OBJECTIVE: To understand Veterans', caregivers', and stakeholders' perceptions of home‐based and caregiver support services and their suggestions for improvement to better align services with needs. DATA SOURCES: We identified Veterans and caregivers at four EDCoE sites using the VA high‐need, high‐risk list, representing Veterans who qualify for home‐based primary care. We randomly selected Veterans and their caregivers, stratifying by age. We also identified leaders and clinicians involved in clinical service delivery. STUDY DESIGN: Between February and November 2019, we conducted in‐person and telephone interviews and focus groups using semi‐structured questions tailored to each group, analyzing them through a rapid qualitative analysis approach and providing real‐time feedback to operational partners. DATA COLLECTION: Thirty‐four Veterans, 24 caregivers, and 39 leaders and clinicians participated. PRINCIPAL FINDINGS: Respondents identified key categories of experience that could be monitored and improved, including navigating an increasingly complex system, coordinating and communicating across services, and unmet household and financial needs. Veterans and caregivers described quality in terms of reliability, timeliness, standardization, and accountability. Summaries were created to contextualize results and to highlight gaps and opportunities for new measures and policy development. CONCLUSIONS: Collaborating with Veterans, caregivers, and stakeholders enables us to understand their daily experiences and to develop meaningful approaches to evaluating services that incorporate their perspectives. Providing regular, actionable feedback to operational partners informs policy and operational initiatives, such as the scope of services and infrastructure for system navigation.

Background Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in improving this training gap. Due to travel restrictions and physical distancing requirements during the COVID-19 pandemic, most in-person POCUS training courses were cancelled. Though tele-ultrasound technology has existed for several years, use of tele-ultrasound technology to deliver hands-on training during a POCUS CME course has not been previously described. Methods We conducted a retrospective observational study comparing educational outcomes, course evaluations, and learner and faculty feedback from in-person versus tele-ultrasound POCUS courses. The same POCUS educational curriculum was delivered to learners by the two course formats. Data from the most recent pre-pandemic in-person course were compared to tele-ultrasound courses during the COVID-19 pandemic. Results Pre- and post-course knowledge test scores of learners from the in-person (n = 88) and tele-ultrasound course (n = 52) were compared. Though mean pre-course knowledge test scores were higher among learners of the tele-ultrasound versus in-person course (78% vs. 71%; p = 0.001), there was no significant difference in the post-course test scores between learners of the two course formats (89% vs. 87%; p = 0.069). Both learners and faculty rated the tele-ultrasound course highly (4.6–5.0 on a 5-point scale) for effectiveness of virtual lectures, tele-ultrasound hands-on scanning sessions, and course administration. Faculty generally expressed less satisfaction with their ability to engage with learners, troubleshoot image acquisition, and provide feedback during the tele-ultrasound course but felt learners completed the tele-ultrasound course with a better basic POCUS skillset. Conclusions Compared to a traditional in-person course, tele-ultrasound POCUS CME courses appeared to be as effective for improving POCUS knowledge post-course and fulfilling learning objectives. Our findings can serve as a roadmap for educators seeking guidance on development of a tele-ultrasound POCUS training course whose demand will likely persist beyond the COVID-19 pandemic.

BACKGROUND Allergic asthma (AA) and allergic rhinoconjunctivitis (ARC) are common comorbid environmentally triggered diseases. We hypothesized that severe AA/ARC reflects a maladaptive or unrestrained response to ubiquitous aeroallergens. METHODS We performed provocation studies wherein six separate cohorts of persons (total n = 217) with ARC, with or without AA, were challenged once or more with fixed concentrations of seasonal or perennial aeroallergens in an aeroallergen challenge chamber (ACC). RESULTS Aeroallergen challenges elicited fully or partially restrained vs. unrestrained evoked symptom responsiveness, corresponding to the resilient and adaptive vs. maladaptive AA/ARC phenotypes, respectively. The maladaptive phenotype was evoked more commonly during challenge with a non-endemic versus endemic seasonal aeroallergen. In an AA cohort, symptom responses evoked after house dust mite (HDM) challenges vs. recorded in the natural environment were more accurate and precise predictors of asthma severity and control, lung function (FEV1), and mechanistic correlates of maladaptation. Correlates included elevated levels of peripheral blood CD4+ and CD8+ T-cells, eosinophils, and T-cell activation, as well as gene expression proxies for ineffectual epithelial injury/repair responses. Evoked symptom severity after HDM challenge appeared to be more closely related to levels of CD4+ and CD8+ T-cells than eosinophils, neutrophils, or HDM-specific IgE. CONCLUSIONS Provocation studies support the concept that resilience, adaptation, and maladaptation to environmental disease triggers calibrate AA/ARC severity. Despite the ubiquity of aeroallergens, in response to these disease triggers in controlled settings (ie, ACC), most atopic persons manifest the resilient or adaptive phenotype. Thus, ARC/AA disease progression may reflect the failure to preserve the resilient or adaptive phenotype. The triangulation of CD8+ T-cell activation, airway epithelial injury/repair processes and maladaptation in mediating AA disease severity needs more investigation.

From the hospitalist perspective, triaging involves the evaluation of a patient for potential admission to an inpatient service. Although traditionally done by residents, many academic hospitalist groups have assumed the responsibility for triaging. We conducted a cross-sectional survey of 235 adult hospitalists at 10 academic medical centers (AMCs) to describe the similarities and differences in the triagist role and assess the activities and skills associated with the role. Eight AMCs have a defined triagist role; at the others, hospitalists supervise residents/advanced practice providers. The triagist role is generally filled by a faculty physician and shared by all hospitalists.We found significant variability in verbal communication practices (P = .02) and electronic communication practices (P < .0001) between the triagist and the current provider (eg, emergency department, clinic provider), and in the percentage of patients evaluated in person (P < .0001). Communication skills, personal efficiency, and systems knowledge are dominant themes of attributes of an effective triagist.

(i) To describe an integrated model of psychiatric care for the treatment of posttraumatic stress disorder (PTSD) in veterans with mild traumatic brain injury (mTBI). (ii) To evaluate access to and engagement in psychiatric care among veterans with comorbid PTSD and mTBI after implementation of an Integrated Care (IC) model compared to the previous Usual Care (UC). 100 randomly selected charts, 50 from each of UC and IC were reviewed in this non-concurrent case- control study. Polytrauma Network Site (PNS), an outpatient rehabilitation clinic, for veterans who suffered from brain and other traumatic injuries at an urban VA Polytrauma Rehabilitation Center. Veterans receiving treatment for mTBI symptoms by the rehabilitation team were referred for medication management for PTSD to UC and IC. Co-located access to psychiatric care for medication management as part of the interdisciplinary team with the goal of expediting rehabilitation and functional recovery. Number of consults for psychiatric care for medication management scheduled and completed within 30 days, and number of veterans offered, initiating, and completing evidence-based psychotherapies for PTSD in UC compared to IC. After implementation of IC there were significant improvements in timely completion of consults and patient engagement with a psychiatrist. There also were improvements in number of referrals, initiation, and completion of evidence-based psychotherapies for the treatment of PTSD. IC within the PNS shows promise as an effective care model for increasing access and engagement in care for veterans with comorbid PTSD/mTBI. Future research is needed to examine the utility of this model in other sites.

Objective The purpose of this study was to examine the effect of pain severity on activity levels and physical disability in the context of high pain acceptance. We hypothesized that pain acceptance moderates the effect of pain severity on general activity and physical disability, such that at higher levels of acceptance, the deleterious effect of pain is mitigated. Methods Two hundred seven patients with chronic pain were recruited from three clinics in a large southwestern military treatment facility. Participants completed an anonymous self-report battery of standardized measures, including the Chronic Pain Acceptance Questionnaire, modified Oswestry Disability Index, and Pain Severity and General Activity subscales of the West Haven-Yale Multidimensional Pain Inventory. Results Chronic pain acceptance was found to significantly moderate relations between pain severity and general activity (b = 0.0061, t(198) = 2.75, P = 0.007, 95% confidence interval [CI] = 0.002 to 0.011) and pain severity and disability (b = 0.036, t(193) = –2.564, P = 0.011, 95% CI = –0.063 to –0.008). In the context of higher acceptance, the negative effect of pain on activity and disability appeared reduced. Conversely, in the context of low acceptance, the effect of pain on disability appeared accentuated at all levels of pain severity. Conclusions Higher acceptance mitigated both activity level and disability in a military-affiliated clinical sample of patients with chronic pain. Results further establish the role of acceptance in relation to functioning in a unique sample of people with chronic pain. These findings have implications for understanding and enhancing functioning in chronic pain populations.

Background 30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR). Methods Design: Mixed method, multi-stepped observational study. Data collection occurred 2014–2018 with data analyses completed in 2021. Setting: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. Participants: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. Exposure: Frequency of use of twenty recommended care transition processes, scored 0–3. Sites’ individual process scores and cumulative total scores were tested for correlation with RSRR. Outcome: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits. Results Total scores: Mean 38.3 (range 24–47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p Conclusions Sites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.

Background We describe the way psychiatric issues are addressed by inpatient medical teams through analysis of discussions of patients with behavioral health concerns and examination of teams’ subsequent consultation practices. Methods We observed morning rounds for nine inpatient medical teams for approximately month-long periods, for a total of 1941 observations. We compared discussions of patients admitted for behavioral health related medical conditions between those who did and did not receive a psychiatric consultation, developing categories to describe factors influencing consultation or other management. Results Out of 536 patients, 40 (7.5%) received a psychiatry consult. Evaluation of a known concern (i.e., substance use, affective disorder, or suicidal ideation) was the most common reason for referral (41.7%). Requests for medication review were second (30.6%). Thirty patients with concomitant behavioral and medical health issues did not receive a psychiatry consult. Cirrhosis with active substance use was the most common medical diagnosis (15), followed by alcohol withdrawal (9). Conclusions Four primary themes emerged from our data: positive identification of behavioral health issues by physicians, medication management as a primary reason for referral, patient preference in physician decision-making, and poor management of substance abuse. Our results identify two potential areas where skills-building for inpatient physicians could have a positive impact: management of medication and of substance abuse management.

BACKGROUND: Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds. OBJECTIVE: To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables. DESIGN: Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4 weeks. PARTICIPANTS: Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students. MAIN MEASURES: The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient’s admission. KEY RESULTS: We observed 12 teams, 1994 discussions (approximately 373 h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient’s admission; F[8,549] = 6.90, p

BACKGROUND/OBJECTIVE: Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. METHODS: In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. RESULTS: The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. CONCLUSIONS: A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

Post-traumatic stress disorder (PTSD) affects nearly one-fifth of Iraq and Afghanistan Veterans (IAV). The Department of Veterans Affairs (VA) has invested in making evidence-based psychotherapies for PTSD available at every VA facility nationwide; however, an unknown number of veterans opt to receive care in the community rather than with VA. We compared PTSD care utilization patterns among Texas IAV with PTSD, an ethnically, geographically, and economically diverse group.To identify IAV in Texas with service-connected disability for PTSD, we used a crosswalk of VA administrative data from the Operation Enduring Freedom/Operation Iraqi Freedom Roster and service-connected disability data from the Veterans Benefits Administration. We then surveyed a random sample of 1,128 veterans from the cohort, stratified by sex, rurality, and past use/nonuse of any VA care. Respondents were classified into current utilization groups (VA only, non-VA only, dual care, and no professional PTSD treatment) on the basis of reported PTSD care in the prior 12 months. Responses were weighted to account for sample stratification and for response rate within each strata. Utilization group characteristics were compared to the population mean using the one sample Z-test for proportions, or the t-test for means. A multinomial logistic regression model was used to identify survey variables significantly associated with current utilization group.249 IAV completed the survey (28.4% response rate). Respondents reported receiving PTSD care: in the VA only (58.3%); in military or community-based settings (including private practitioners) (non-VA only, 8.7%); and in both VA and non-VA settings (dual care, 14.5%). The remainder (18.5%) reported no professional PTSD care in the prior year. Veterans ineligible for Department of Defense care, uncomfortable talking about their problems, and opposed to medication were more likely to receive non-VA care only, whereas those with lower household income,50% service connection for PTSD, and reporting high stoicism were more likely to receive no professional treatment. The best model constructed from survey variables correctly predicted utilization group 76% of the time, whereas a model constructed only from variables currently available in VA data predicted utilization group correctly 64% of the time. Important variables distinguishing utilization groups included household income, percent PTSD service connection, routine use of VA health care, having non-VA insurance, past PTSD care at a VA facility or at a community-based facility, attitudes regarding medication, discomfort with mental health care seeking, and perceived treatment efficacy in community-based settings.These findings suggest that preferences for care setting among IAV with PTSD have less influence on care utilization than actual access factors such as household income and service connection. Given that nearly a quarter of respondents indicated receiving as least some PTSD care in community settings, working toward seamless VA/non-VA care coordination remains an important goal for ensuring high-quality care.

OBJECTIVES: Identify predictors of persistence with adalimumab (ADA) among veterans and privately insured patients with inflammatory bowel disease (IBD) in the United States. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with IBD taking ADA as their first biologic were identified from the Veterans Health Administration (VHA) database from 2009 to 2013 and the Truven Health MarketScan database from 2009 to 2012 with a 12-month follow-up. Persistence was defined as continued use 1 year after initiation. Adherence was assessed by calculating a medication possession ratio, which was dichotomized as greater than 0.86 or less than or equal to 0.86. Multivariable logistic regression was used to evaluate predictors of persistence. RESULTS: There were 1030 patients in the VHA population compared with 3264 patients in the privately insured (MarketScan) cohort. In MarketScan, 1800 patients (55%) remained on ADA compared with 755 (73%) in the VHA cohort. In multivariable analysis, male sex (odds ratio [OR], 1.38; 95% CI, 1.16–1.63; P

Background: The value of secure messaging in streamlining routine patient care activities is generally agreed upon. However, the differences in how patients use secure messaging, including for communicating both routine and nonroutine issues, and the implications of these differences in use are less well understood. Objective: The purpose of this study was to examine secure messaging use to extend current knowledge of how this tool is being used in outpatient care settings and generate new research questions to improve our understanding of the role of secure messaging in the patient-provider communication toolbox. Methods: We conducted an in-depth qualitative analysis of secure message threads in 12 US Department of Veterans Affairs outpatient clinics in south Texas. We analyzed 70 secure message threads with a total of 179 unique communications between patients and their outpatient teams for patterns in communication and secure message content. We used theories from information systems and complexity science in organizations to explain our observations. Results: Analysis identified content relating to 3 main themes: (1) information management, (2) uncertainty management, and (3) patient safety and engagement risks and opportunities. Within these themes, we identified 2 subcategories of information management (information exchange and problem solving), 2 subcategories of uncertainty management (relationship building and sensemaking), and 3 subcategories of patient safety and engagement risks and opportunities (unresolved issues, tone mismatch, and urgent medical issues). Secure messages were most often used to communicate routine issues (eg, information exchange and problem solving). However, the presence of subcategories pertaining to nonroutine issues (eg, relationship building, sensemaking, tone mismatch, urgent issues, and unresolved issues) requires attention, particularly for improving opportunities in outpatient care settings using secure messaging. Conclusions: Patients use secure messaging for both routine and nonroutine purposes. Our analysis sheds light on potentially new patient safety concerns, particularly when using secure messaging to address some of the more complex issues patients are communicating with providers. Secure messaging is an asynchronous communication information system operated by patients and providers who are often characterized as having significant differences in knowledge, experience and expectations. As such, justification for its use beyond routine purposes is limited—yet this occurs, presenting a multifaceted dilemma for health care organizations. Secure messaging use in outpatient care settings may be more nuanced, and thus more challenging to understand and manage than previously recognized. New information system designs that acknowledge the use of secure messaging for nonroutine and complex health topics are needed.

Background Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes. Methods We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness. Results Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005). Conclusions Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission. Electronic supplementary material The online version of this article (10.1186/s12913-018-3712-7) contains supplementary material, which is available to authorized users.

Introduction Effective delivery of healthcare in complex systems requires managing interdependencies between professions and organisational units. Reducing 30-day hospital readmissions may be one of the most complex tasks that a healthcare system can undertake. We propose that these less than optimal outcomes are related to difficulties managing the complex interdependencies among organisational units and to a lack of effective sensemaking among individuals and organisational units regarding how best to coordinate patient needs. Methods and analysis This is a mixed method, multistepped study. We will conduct in-depth qualitative organisational case studies in 10 Veterans Health Administration facilities (6 with improving and 4 with worsening readmission rates), focusing on relationships, sensemaking and improvisation around care transition processes intended to reduce early readmissions. Data will be gathered through multiple methods (eg, chart reviews, surveys, interviews, observations) and analysed using analytic memos, qualitative coding and statistical analyses. We will construct an agent-based model based on those results to explore the influence of sensemaking and specific care transition processes on early readmissions. Ethics and dissemination Ethical approval has been obtained through the Institutional Review Board of the University of Texas Health Science Center at San Antonio (approval number: 14–258 hour). We will disseminate our findings in manuscripts in peer-reviewed journals, professional conferences and through short reports back to participating entities and stakeholders.

BACKGROUND Care fragmentation is common and contributes to communication errors and adverse events. Handoff tools were developed to reduce the potential for these errors. Despite their widespread adoption, there is little information describing their impact on clinical work. Understanding their impact could be helpful in improving handoffs and transitions. OBJECTIVE To better understand what clinical work is done overnight, the housestaff perceptions of overnight clinical work, and how handoff instruments support this work. DESIGN Real-time data collection and survey. PARTICIPANTS Internal medicine resident physicians. MAIN MEASURES Data collection measured information related to nighttime clinical encounters, including the information sources and actions taken. Surveys assessed resident perceptions toward care transitions. KEY RESULTS Of 299 encounters, 289 contained complete data. The tool was used as an information source in 27.7% of encounters, whereas the information source was either the nurse or the chart in 94.4% of encounters. Many encounters resulted in a new order for a medication, whereas 3.8% resulted in documentation. In the survey data, 73.6% residents reported the sign-out procedure was safe. CONCLUSION These data suggest that a handoff tool is not sufficient to address nighttime clinical issues and suggest that effective care requires more than just the information transfer. It may also reflect that electronic medical records have become a readily available information source at the point of care. Sign-out should support residents' ability to make sense of what is happening and integrate care of day and night teams, rather than solely transfer information. Journal of Hospital Medicine 2015;10:142–146. 2015 Society of Hospital Medicine

Background Health care huddles are increasingly employed in a range of formats but theoretical mechanisms underlying huddles remain relatively uncharted. Purpose A complexity science view implies that essential managerial strategies for high-performing health care organizations include meaningful conversations, enhanced relationships, and a learning culture. These three dimensions informed our approach to studying huddles. We explore new theories for how and why huddles have been useful in health care organizations. Methods We used a study design incorporating literature review, direct observation, and semistructured interviews. A complexity science framework guided data collection in three health care settings; we also incorporated theories on high-reliability organizations to analyze our observations and interpret huddle participants' perspectives. Findings We identify theoretical paths that could link huddles to improvement in patient safety outcomes. Huddles create time and space for conversations, enhance relationships, and strengthen a culture of safety. Huddles can be of particular value to health care organizations seeking or sustaining high reliability. Practice implications Achieving high reliability, the organizational capacity to deliver what is intended to be delivered every time is difficult in complex systems. Managers have potential to create conditions from which huddle outcomes that support high reliability are more likely to emerge. Huddles support efforts to improve patient safety when they afford opportunities for heedful interactions to take place among individuals caring for patients and embed mindfulness into the organization.

BACKGROUND The value of secure messaging in streamlining routine patient care activities is generally agreed upon. However, the differences in how patients use secure messaging, including for communicating both routine and nonroutine issues, and the implications of these differences in use are less well understood. OBJECTIVE The purpose of this study was to examine secure messaging use to extend current knowledge of how this tool is being used in outpatient care settings and generate new research questions to improve our understanding of the role of secure messaging in the patient-provider communication toolbox. METHODS We conducted an in-depth qualitative analysis of secure message threads in 12 US Department of Veterans Affairs outpatient clinics in south Texas. We analyzed 70 secure message threads with a total of 179 unique communications between patients and their outpatient teams for patterns in communication and secure message content. We used theories from information systems and complexity science in organizations to explain our observations. RESULTS Analysis identified content relating to 3 main themes: (1) information management, (2) uncertainty management, and (3) patient safety and engagement risks and opportunities. Within these themes, we identified 2 subcategories of information management (information exchange and problem solving), 2 subcategories of uncertainty management (relationship building and sensemaking), and 3 subcategories of patient safety and engagement risks and opportunities (unresolved issues, tone mismatch, and urgent medical issues). Secure messages were most often used to communicate routine issues (eg, information exchange and problem solving). However, the presence of subcategories pertaining to nonroutine issues (eg, relationship building, sensemaking, tone mismatch, urgent issues, and unresolved issues) requires attention, particularly for improving opportunities in outpatient care settings using secure messaging. CONCLUSIONS Patients use secure messaging for both routine and nonroutine purposes. Our analysis sheds light on potentially new patient safety concerns, particularly when using secure messaging to address some of the more complex issues patients are communicating with providers. Secure messaging is an asynchronous communication information system operated by patients and providers who are often characterized as having significant differences in knowledge, experience and expectations. As such, justification for its use beyond routine purposes is limited—yet this occurs, presenting a multifaceted dilemma for health care organizations. Secure messaging use in outpatient care settings may be more nuanced, and thus more challenging to understand and manage than previously recognized. New information system designs that acknowledge the use of secure messaging for nonroutine and complex health topics are needed.

Significant changes in national health policy, like the Veterans Choice Act, have created growing opportunities for veterans to receive care outside of the Veterans Administration (VA), yet little is known about the attitudes and practices in PTSD care of community providers, particularly their use of evidence-based psychotherapies (EBPs). The authors assessed psychotherapy practices of community providers serving veterans with PTSD in Texas. They surveyed Texas mental health providers regarding their patient population, practice setting, and posttraumatic stress disorder (PTSD)-related screening, assessment, and treatment practices. They identified providers from state licensing board rosters and included a stratified sample of social workers, marriage and family therapists, and professional counselors (500 each), all psychologists with available email addresses (n = 3,986), and 106 providers known to have completed state-sponsored training for 1 of the EBPs for PTSD, cognitive processing therapy. Four hundred sixty-three eligible respondents returned surveys (15% response rate). Providers reported treating a mean of 7.9 veterans with PTSD in the past year (range = 0-200; SD = 20.5), using a variety of therapeutic approaches for PTSD. Only 15.0% of providers reported regularly conducting psychotherapy for PTSD following a treatment manual, and fewer than half reported any use of EBPs for PTSD with patients. Although many veterans are receiving treatment for PTSD in the community, many community-based mental health providers in Texas do not consistently use recommended treatments for PTSD. These findings may suggest an important opportunity for VA to engage and partner with community providers to achieve high-quality care for veterans. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

IMPORTANCE Improving inpatient care delivery has historically focused on improving individual components of the system. Applying the complexity science framework to clinical systems highlights the important role of relationships among providers in influencing system function and clinical outcomes. OBJECTIVE To understand whether inpatient medical physician teams can be differentiated based on the relationships among team members, and whether these relationships are associated with patient outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. DESIGN Eleven inpatient medicine teams were observed daily during attending rounds for 2- to 4-week periods from September 2008 through June 2011. Detailed field notes were taken regarding patient care activities, team behaviors, and patient characteristics and outcomes. Behaviors were categorized using the Lanham relationship framework, giving each team a relationship score. We used factor analysis to assess the pattern of relationship characteristics and assessed the association between relationship characteristics and patient outcomes. SETTING Observations occurred at the Audie L. Murphy Veterans Affairs Hospital and University Hospital in San Antonio, Texas. PARTICIPANTS Physicians were chosen based on rotation schedules, experience, and time of year. Patients were included based on their admission to the inpatient medicine teams that were being observed. MAIN MEASURES Relationship scores were based on the presence or absence of 7 relationship characteristics. LOS, ULOS, and complication rates were assessed based on team discussions and chart review. The association between relationships and outcomes was assessed using the Kruskal-Wallis rank sum test. RESULTS We observed 11 teams over 352.9 hours, observing 1941 discussions of 576 individual patients. Teams exhibited a range of 0 to 7 relationship characteristics. Relationship scores were significantly associated with complication rates, and presence of trust and mindfulness among teams was significantly associated with ULOS and complication rates. CONCLUSIONS Our findings are an important step in understanding the impact of relationships on the outcomes of hospitalized medical patients. This understanding could expand the scope of interventions to improve hospital care to include not only process improvement but also relationships among providers. Journal of Hospital Medicine 2014;9:764–771. © 2014 Society of Hospital Medicine

Objective Electronic health records (EHR) hold great promise for managing patient information in ways that improve healthcare delivery. Physicians differ, however, in their use of this health information technology (IT), and these differences are not well understood. The authors study the differences in individual physicians' EHR use patterns and identify perceptions of uncertainty as an important new variable in understanding EHR use. Design Qualitative study using semi-structured interviews and direct observation of physicians (n=28) working in a multispecialty outpatient care organization. Measurements We identified physicians' perceptions of uncertainty as an important variable in understanding differences in EHR use patterns. Drawing on theories from the medical and organizational literatures, we identified three categories of perceptions of uncertainty: reduction, absorption, and hybrid. We used an existing model of EHR use to categorize physician EHR use patterns as high, medium, and low based on degree of feature use, level of EHR-enabled communication, and frequency that EHR use patterns change. Results Physicians' perceptions of uncertainty were distinctly associated with their EHR use patterns. Uncertainty reductionists tended to exhibit high levels of EHR use, uncertainty absorbers tended to exhibit low levels of EHR use, and physicians demonstrating both perspectives of uncertainty (hybrids) tended to exhibit medium levels of EHR use. Conclusions We find evidence linking physicians' perceptions of uncertainty with EHR use patterns. Study findings have implications for health IT research, practice, and policy, particularly in terms of impacting health IT design and implementation efforts in ways that consider differences in physicians' perceptions of uncertainty.

Efforts to better understand the impact of clinic member relationships on care quality in primary care clinics have been limited by the absence of a validated instrument to assess these relationships. The purpose of this study was to develop and validate a scale assessing relationships within primary care clinics.The Work Relationships Scale (WRS) was developed and administered as part of a survey of learning and relationships among 17 Department of Veterans Affairs (VA) primary care clinics. A Rasch partial-credit model and principal components analysis were used to evaluate item performance, select the final items for inclusion, and establish unidimensionality for the WRS. The WRS was then validated against semistructured clinic member interviews and VA Survey of Healthcare Experiences of Patients (SHEP) data.Four hundred fifty-seven clinicians and staff completed the clinic survey, and 247 participated in semistructured interviews. WRS scores were significantly associated with clinic-level reporting for 2 SHEP variables: overall rating of personal doctor/nurse (r(2) =0.43, P.01) and overall rating of health care (r(2)= 0.25, P.05). Interview data describing relationship characteristics were consistent with variability in WRS scores across low-scoring and high-scoring clinics.The WRS shows promising validity as a measure assessing the quality of relationships in primary care settings; moreover, primary care clinics with lower WRS scores received poorer patient quality ratings for both individual clinicians and overall health care. Relationships play an important role in shaping care delivery and should be assessed as part of efforts to improve patient care within primary care settings.

To identify and validate trajectories of comorbidity associated with traumatic brain injury in male and female Iraq and Afghanistan war Veterans (IAV).Derivation and validation cohorts were compiled of IAV who entered the Department of Veterans Affairs (VA) care and received 3 years of VA care between 2002-2011. Chronic disease and comorbidities associated with deployment including TBI were identified using diagnosis codes. A latent class analysis (LCA) of longitudinal comorbidity data was used to identify trajectories of comorbidity.LCA revealed five trajectories that were similar for women and men: (1) Healthy, (2) Chronic Disease, (3) Mental Health, (4) Pain and (5) Polytrauma Clinical Triad (PCT: pain, mental health and TBI). Two additional classes found in men were 6) Minor Chronic and 7) PCT with chronic disease. Among these gender-stratified trajectories, it was found that women were more likely to experience headache (Pain trajectory) and depression (Mental Health trajectory), while men were more likely to experience lower back pain (Pain trajectory) and substance use disorder (Mental Health trajectory). The probability of TBI was highest in the PCT-related trajectories, with significantly lower probabilities in other trajectories.It was found that TBI was most common in PCT-related trajectories, indicating that TBI is commonly comorbid with pain and mental health conditions for both men and women. The relatively young age of this cohort raises important questions regarding how disease burden, including the possibility of neurodegenerative sequelae, will accrue alongside normal age-related decline in individuals with TBI. Additional 'big data' methods and a longer observation period may allow the development of predictive models to identify individuals with TBI that are at-risk for adverse outcomes.

Given high dialysis mortality rates for patients older than 60 years, accepting a kidney with a high Kidney Donor Profile Index (KDPI) score could enable earlier and potentially preemptive transplantation (preKT). However, evidence regarding the risks of high KDPI allografts in older patients is limited. Our objective was to determine the relative benefit for older patients of KDPI greater than 85% transplant either preemptively or not compared with remaining on the waitlist.United Network of Organ Sharing data from 2003 to 2012 for adult deceased donor kidney transplant candidates was analyzed to evaluate patient survival in patients older than 60 years for preKT and non-preKT KDPI greater than 85% transplants compared with candidates remaining on the waitlist including patients who received KDPI 0% to 85% transplants according to multivariate Cox regression models.In the first year posttransplant for KDPI greater than 85% of transplants in recipients older than 60 years, preKT had a reduced mortality hazard (hazards ratio [HR], 0.61; 95% confidence interval [95% CI], 0.41-0.90) and non-preKT an increased mortality hazard (HR, 1.15; 95% CI, 1.03-1.27) compared with the waitlist including KDPI 0% to 85% transplant recipients. At 1 to 2 years and after 2 years, both KDPI greater than 85% groups had significant reductions in mortality (1-2 years: preKT HR, 0.38; 95% CI, [0.23-0.60] and non-preKT HR, 0.52; 95% CI, 0.45-0.61; and 2+ years: preKT HR, 0.50; 95% CI, 0.38-0.66 and non-preKT HR, 0.64; 95% CI, 0.58-0.70, respectively).PreKT and non-preKT KDPI greater than 85% transplant was associated with lower mortality hazard after the first year compared with the waitlist including KDPI 0% to 85% transplants in patients older than 60 years. Further consideration should be given to increased utilization of high KDPI grafts in older patients with the goal of avoiding or limiting time on dialysis.

Background Recent studies suggest that angiotensin-converting enzyme (ACE) inhibitors may have beneficial effects for patients with or at risk for pneumonia. However, other studies have not found a survival benefit. Other research suggests that ACE inhibitors that are lipophilic may be superior to hydrophilic ACE inhibitors in terms of tissue penetration and inhibition of ACE. Our aim was to examine the associations of prior outpatient use of lipophilic and hydrophilic ACE inhibitors on mortality for patients hospitalized with community-acquired pneumonia. Methods A retrospective cohort study of subjects hospitalized with pneumonia at 2 tertiary teaching hospitals. We examined whether the prior outpatient use of hydrophilic or lipophilic ACE inhibitors was associated with 30-day mortality in a logistic regression analysis that adjusted for potential confounders using a propensity score. Results Data were abstracted on 787 subjects at the 2 hospitals. In our cohort, 24% (n = 186) were on ACE inhibitors at presentation: 111 lipophilic and 74 hydrophilic. Mortality was 9.2% at 30 days. In the multivariable model, lipophilic ACE inhibitor use (odds ratio 0.3, 95% confidence interval 0.1–0.8), but not hydrophilic ACE inhibitor use (0.7, 0.3–1.7), was significantly associated with 30-day mortality. Conclusions Our study suggests that future research of ACE inhibitors in pneumonia must describe the specific medications received. Confirmatory studies are needed, as well as research to determine the mechanism(s) of this protective effect.

OBJECTIVE—The purpose of this study was to examine the relationship between A1C and the extent to which care delivered to patients with type 2 diabetes in primary care clinics is consistent with the chronic care model (CCM), after controlling for self-care behaviors. RESEARCH DESIGN AND METHODS—This was a cross-sectional, observational study of care provided to 618 patients with type 2 diabetes across 20 small, autonomous primary care clinics in South Texas. Subjects completed an exit survey. The medical record was abstracted for A1C values. Clinicians completed the Assessment of Chronic Illness Care (ACIC) survey, a validated measure of the extent to which care delivered is consistent with the CCM. RESULTS—There was a significant relationship between ACIC score and A1C, but this relationship varied according to self-care behavior for exercise and was strongest for those who did not adhere to exercise recommendations: for every 1-point increase in ACIC score, A1C was 0.144% lower (P < 0.001). The relationship between ACIC score and A1C for those who adhered to their diet was similar to that for those who did not, after adjusting for exercise, but the overall level of control was better for those who adhered to their diet. CONCLUSIONS—Characteristics of the primary care clinic where one receives care are an important predictor of glucose control. If resources for implementing the CCM are limited, one might want to focus on clinics with low ACIC scores that serve a population of patients who are sedentary because this population may be likely to realize the most benefit from improved glucose control.

PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A1c) level. METHODS We observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, num- ber of concerns patients raised, and number of topics brought up by the clini- cian. Days to the next scheduled appointment were obtained at patient checkout. Recent A1c values and dates were determined from the chart. RESULTS Among patients with an A1c level greater than 7%, each additional patient concern was associated with a 49% (95% confi dence interval, 35%-60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A1c. Among patients with an A1c level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A1c level, the time to the next scheduled appointment decreased by 8.6 days (P = .001). CONCLUSIONS The concept of clinical inertia is limited and does not fully charac- terize the complexity of primary care encounters. Competing demands is a princi- ple for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings.

Background This research explores the healthy soldier effect (HSE) – a lower mortality risk among veterans relative to the general population—in United States (US) veterans deployed in support of operations in Iraq and Afghanistan (OEF/OIF/OND). While a HSE has been affirmed in other OEF/OIF/OND populations, US veterans of OEF/OIF/OND have not been systematically studied. Methods Using US Department of Veterans Affairs (VA) administrative data, we identified veterans who (1) had been deployed in support of OEF/OIF/OND between 2002 and 2011 and (2) were enrolled in the VA health care system. We divided the VA population into VA health care utilizers and non-utilizers. We obtained Department of Defense (DOD) administrative data on the OEF/OIF/OND population and obtained VA and DOD mortality data excluding combat deaths from the analyses. Indirect standardization was used to compare VA and DOD cohorts to the US population using total population at risk to compute the Standardized Mortality Ratio (SMR). A directly standardized relative risk (DSRR) was calculated to enable comparisons between cohorts. To compare VA enrollee mortality on military specific characteristics, we used a DOD population standard. Results The overall VA SMR of 2.8 (95% Confidence Interval [CI] 2.8-2.9), VA utilizer SMR of 3.2 (95% CI 3.1-3.3), VA non-utilizer SMR of 0.9 (95% CI 0.8-1.1), and DOD SMR of 1.5 (95% CI 1.4-1.5) provide no evidence of a HSE in any cohort relative to the US standard population. Relative to DOD, both the total VA population SMR of 2.1 (95% CI 2.0-2.2) and the SMR for VA utilizers of 2.3 (95% CI 2.3-2.4) indicate mortality twice what would be expected given DOD mortality rates. In contrast, the VA enrollees who had not used clinical services had 40% lower than expected mortality relative to DOD. Conclusions No support was found for the HSE among US veterans of OEF/OIF/OND. These findings may be attributable to a number of factors including post-deployment risk-taking behavior, an abbreviated follow up period, and the nature of the OEF/OIF/OND conflict.

Summary Introduction Hispanics are the fastest growing ethnicity of the US population and the largest subset includes those of Mexican origin. Hispanics, including Mexican Americans (MAs), consistently report less tobacco exposure than European Americans (EAs), but limited data are available regarding differences in the clinical characteristics, severity of airflow obstruction, and functional status between MAs and EAs with chronic obstructive pulmonary disease (COPD). Methods Participants in a community-based study of aging and frailty among MAs and EAs, San Antonio Longitudinal Study of Aging, underwent spirometry. Participants with spirometry values consistent with COPD by Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria are described here. Results Thirty-four percent (248/721) of the participants who underwent spirometry had evidence of GOLD Stages 1–4 COPD. Significantly more MAs with COPD reported being never smokers compared to EAs with COPD. Among those with COPD who also smoked, MAs reported significantly less tobacco exposure than EAs (15.7 vs. 32.4 pack-years, respectively), but both groups had surprisingly similar severities of airflow obstruction. Additionally, MAs had worse functional status and perceived health than did EAs. Conclusions Despite significantly less exposure to tobacco smoke, MAs with COPD had a similar degree of obstruction to airflow compared with EAs with COPD. Healthcare providers should have a high index of suspicion for COPD in MAs who are exposed to even small amounts of cigarette smoke.

This article presents the results of research on a systematic approach to the assignment of primary care work in the Veterans Health Administration. Based on a functional job analysis protocol, the study identified overlap in the performance of primary care tasks among multiple occupational groups as prima facie evidence of opportunities to reallocate work responsibilities. Results show that registered nurses, physicians, advanced practitioners, and licensed vocational nurses reported performing 60 percent to 97 percent of the same tasks, while clerks and health technicians appeared to be underutilized. The frequency and duration with which occupational groups performed each task were also examined, providing additional evidence to be used in improving clinic efficiency. The management of healthcare personnel can be improved through systematic analysis of the work, the worker, and the work organization and through more informed decisions about the appropriateness of task assignment (or reassignment). This article presents an evidence-based approach to personnel management with important implications for clinic efficiency. The approach can be used to guide strategic planning and staffing decisions by identifying not only who currently does the work but, more importantly, who should be doing the work given the full array of data.

Smoking cessation is the mainstay of recommended treatment for chronic obstructive pulmonary disease (COPD), yet many continue smoking. This study seeks to understand the characteristics of patients with COPD who have quit and those who have not quit to identify important factors to evaluate in smoking-cessation interventions.A cross-sectional survey of a random sample of 1.5 million, predominantly male Veterans Administration enrollees. Of the respondents (63% [n = 887,775]), those with at least 1 COPD visit, a smoking history, and aged more than 34 years were included in this analysis (n = 89 337). Differences in demographics, functional status, comorbidities, and provider-patient interactions were evaluated for current and former smokers.Ninety-seven percent of the cohort with COPD was male. Former smokers (n = 58 482) were older (mean age of 69.6 vs 62.8, P.001) and had more cardiac comorbidities, but better mental health (Mean Mental Component Summary score from the Veterans Short Form-36 +/- standard deviation of 43.4 +/- 13.2 vs 39.9 +/- 13.7, P.001) than current smokers (n = 25 595), respectively. In addition, former smokers more actively participated in their health care and had a better relationship with their provider than current smokers.Former smokers with COPD were older, had more cardiac comorbidities, better mental health, and better perceived provider-patient interactions than active smokers. This study highlights the importance of screening participants with COPD who are enrolling in forthcoming smoking cessation trials for mental illnesses. In addition, developing interventions that address psychiatric comorbidities and potentially improve provider-patient communication may be other key areas to evaluate in future smoking cessation trials in patients with COPD.

BACKGROUND Both heparin and enoxaparin are effective for the prevention of venous thromboembolism (VTE) in medical patients. On the basis of price, heparin appears preferable because it is less expensive. However, choosing enoxaparin may have greater cost utility when the outcomes of heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are considered. OBJECTIVE To determine the cost utility of substituting enoxaparin for heparin from payer and institutional perspectives. DESIGN A decision analysis model was used. Cost data were based on Medicare reimbursement and the medication and laboratory costs for a multi-institutional healthcare system. Quality-adjusted life years (QALYs) saved by preventing HIT/HITT through the use of enoxaparin were based on published data. Costs are expressed on a per-day basis, and the incremental cost of enoxaparin over that of heparin was used in the calculation of cost/QALY. A sensitivity analysis also was performed. SETTING Inpatient medicine. PATIENTS All medical patients for whom VTE prophylaxis was appropriate. INTERVENTIONS Substitution of enoxaparin for heparin. MEASUREMENT Cost/QALY. RESULTS From a payer perspective, using enoxaparin resulted in a decrease in cost of $28.61 over that of heparin and saved 0.00629 QALYs in the base case, resulting in a savings of $4550.17/QALY. The sensitivity analysis showed this finding of decreased cost and increased effectiveness to be consistent. From an institutional perspective, the use of heparin generally appeared less costly but was dependent on medication price, length of stay required, and bed utilization. CONCLUSIONS From a payer and, by extrapolation, a societal perspective, cost-utility analysis supports the use of enoxaparin in place of heparin for the prevention of VTE in medical inpatients. From an institutional perspective, the decision is more complicated, but in most cases, the use of enoxaparin also is supported. Journal of Hospital Medicine 2006;3:168–176. © 2006 Society of Hospital Medicine.

Objective The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States.

Purpose National practice guidelines have recommended specific initial empiric antimicrobial regimens for patients with community-acquired pneumonia. Our aim was to determine the association between the use of guideline-concordant antimicrobial therapy and 30-day mortality in patients with pneumonia. Methods We conducted a retrospective cohort study at two tertiary teaching hospitals. Eligible patients were admitted with a diagnosis of community-acquired pneumonia, had a chest radiograph consistent with pneumonia, and had a discharge diagnosis of pneumonia. All eligible patients were identified and a random sample was abstracted. We determined whether the use of guideline-concordant antibiotics was associated with 30-day mortality in an analysis that adjusted for potential confounders using propensity scores. Results Information was obtained on 420 patients with pneumonia. The mean (± SD) age was 63 ± 16 years, 355 were men, and 82 patients were initially admitted to the intensive care unit. At 30 days after presentation, 41 patients (9.8%) had died: 21 of 97 (21.7%) in the non–guideline-concordant group and 20 of 323 (6.2%) in the guideline-concordant group. Antibiotics were concordant with national guidelines in 323 patients. In the regression analysis, after adjustment for the propensity score, failure to comply with antimicrobial therapy guidelines was associated with increased 30-day mortality (odds ratio=5.7; 95% confidence interval: 2.0 to 16.0). Conclusion Receipt of antimicrobial regimens concordant with national published guidelines may reduce 30-day mortality among patients hospitalized with pneumonia. Am J Med. 2004;117:726 -731.

OBJECTIVE—To describe the frequency and sequelae of diabetic renal disease in veterans who receive health care from the Veterans Administration (VA). RESEARCH DESIGN AND METHODS—Veterans with a diagnosis of diabetes, diabetic nephropathy, other kidney diseases, and end-stage renal disease (ESRD) were identified by diagnosis codes from national VA databases for FY1998. Data were obtained and analyzed for prevalence of renal disease, comorbid conditions, and 1-year mortality. RESULTS—A total of 44,671 (10.7%) of the 415,910 veterans with diabetes had a concomitant diagnosis of any renal disease. The average age was 67 years; 98% were male and 60% were white. The prevalence of diabetic nephropathy was 6.0% (n = 25,263). ESRD secondary to diabetes was present in 4.2% (17,636) of subjects. The age-standardized prevalence of diabetes and any renal disease was 72.6/1,000 persons and differed by race (white 76.1/1,000, black 103.4/1,000 persons). Diabetes-associated ESRD prevalence was higher among black versus white veterans and male versus female veterans. One-year age-standardized mortality was 10.7%. CONCLUSIONS—Nephropathy is prevalent in veterans with diabetes. Greater mortality is observed among those with renal disease compared with those without renal disease. Additional surveillance is needed to identify persons likely to progress to diabetic nephropathy and to plan for appropriate and timely health care for these individuals.