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Objective To determine whether deep-infiltrating endometriosis (DE) carries an increased risk of appendiceal endometriosis (AppE) as compared with superficial endometriosis or no endometriosis. Methods In a retrospective study, data were obtained by chart review of an internal database for women who underwent coincidental appendectomy during benign gynecologic surgery between July 2009 and February 2014 at a tertiary referral center in the USA. Univariate, bivariate, and regression analyses were performed. The primary exposure was surgically documented endometriosis (DE, superficial, or no endometriosis). The primary outcome was AppE. Results Endometriosis was diagnosed for 151 (38.2%) of 395 women; 82 (54.3%) had DE. The prevalence of AppE was 13.2% (52/395) overall; 8 (11.6%) of 69 women with superficial endometriosis and 32 (39.0%) of 82 with DE were affected. Frequency of AppE was increased among women with DE, abnormal appendix appearance, and surgical indication (all P

To evaluate whether contraceptive insurance coverage for women who present for an abortion is associated with obtaining long-acting reversible contraception or depot medroxyprogesterone acetate (DMPA) on the day the abortion is completed.We conducted a prospective cohort study of women presenting for medical or surgical abortion at a single health center in North Carolina. Eligible women were 18 years or older and fluent in English or Spanish. Data were from participant questionnaires, medical charts, and financial records. Our main exposure was whether the woman had insurance coverage for contraception at clinic intake. Our primary outcome was receiving DMPA, an intrauterine device, or a contraceptive subdermal implant on the same day of their surgical abortion or at the visit that determined their medication abortion was complete. We used univariable, bivariable, and multivariable analysis to report our findings.Five hundred seventy-five women enrolled in our cohort between September 2015 and April 2016. One hundred twenty-eight (22%) had insurance coverage and 447 (78%) did not. In the group with insurance coverage for contraception, 38% (49/128) received a long-acting reversible contraception method or DMPA compared with 7% (33/447) in the group without insurance coverage for contraception. After adjusting for confounding, women with contraceptive coverage were more than five times as likely to receive immediate postabortion contraception with one of these methods compared with women without coverage (relative risk 5.6, 95% confidence interval 3.8-8.3).Women with contraceptive insurance coverage on the day of their abortion were more likely to leave the abortion clinic with an intrauterine device or implant in place or receive DMPA injection compared with women without coverage.

Objective To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. Methods We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (> 20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. Results We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n = 2494) of patients and use varied widely by hospital, from 5%–55%. High utilization hospitals (n = 1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23–55%), while low utilization hospitals (n = 2671, 14 hospitals) had a median rate of 10% (range 5–17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83–0.97 and HR 0.85 95% CI 0.75–0.95). Conclusions Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.

Study Objective To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women. Design Non-blinded, randomized controlled trial. Setting and Participants Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina. Interventions Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit. Main Outcome Measures Contraceptive implant use at 12 months postpartum. Results Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6-week group (30 of 37, 81% vs 21 of 27, 78%; P = .75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P = .02). Conclusion Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.

Urinary incontinence is common amongst Chinese immigrants. These women are a rapidly growing population in the USA who require unique assessment tools due to language barriers. Presently, there are no Chinese language surveys to assess knowledge of urinary incontinence. Our goal was to translate and validate a urinary incontinence knowledge survey from English into Chinese. The English language Urinary Incontinence Quiz (UIQ) developed and validated by Branch et al. for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly program assesses general knowledge of urinary incontinence as a disease entity. We translated it into Chinese using the forward translation/back translation technique. The Chinese and English versions were then administered to bilingual volunteers in a nonrandomized order during a single encounter. Their responses were analyzed using Cohen’s kappa coefficient to establish the validity of the translated knowledge survey. Minimal reconciliation was needed in construction of the Chinese survey. Minor English grammatical corrections were made to the back-translated English survey. One question testing two knowledge concepts was separated into two questions to allow clear testing of both concepts individually. Twenty-one bilingual participants performed the validity testing. Over 50% (8 out of 15) of the questions showed nearly perfect agreement with a kappa coefficient >0.80, 5 out of the 15 questions showed substantial agreement with kappa coefficients between 0.61 and 0.8 and two questions showed moderate agreement with kappa coefficients between 0.4 and 0.6. We validated a translation of the UIQ for assessment of urinary incontinence knowledge in Chinese-speaking immigrants to the USA.

OBJECTIVE: To compare intrauterine device (IUD) use at 6 months postpartum among women who underwent intracesarean delivery (during cesarean delivery) IUD placement compared with women who planned for interval IUD placement 6 or more weeks postpartum. METHODS: In this nonblinded randomized trial women who were undergoing a cesarean delivery and desired an IUD were randomized to intracesarean delivery or interval IUD placement. The primary outcome was IUD use at 6 months postpartum. A sample size of 112 (56 in each group) was planned to detect a 15% difference in IUD use at 6 months postpartum between groups. RESULTS: From March 2012 to June 2014 172 women were screened and 112 women were randomized into the trial. Baseline characteristics were similar between groups. Data regarding IUD use at 6 months postpartum were available for 98 women 48 and 50 women in the intracesarean delivery and interval groups respectively. A larger proportion of the women in the intracesarean delivery group were using an IUD at 6 months postpartum (40/48 [83%]) compared with those in the interval group (32/50 [64%] relative risk 1.3 95% confidence interval 1.02-1.66). Among the 56 women randomized to interval IUD insertion 22 (39%) of them never received an IUD; 14 (25%) never returned for IUD placement five (9%) women declined an IUD and three (5%) had a failed IUD placement. CONCLUSION: Intrauterine device placement at the time of cesarean delivery leads to a higher proportion of IUD use at 6 months postpartum when compared with interval IUD placement.

Objectives This study aimed to measure the incidence and identify predictors of postpartum visit non-attendance, using medical records of women who received prenatal care and went on to deliver live births at Montefiore Hospital in 2013. Methods Pearson’s Chi square tests were used to assess the association between maternal demographics, insurance status, and delivery information with non-attendance of a postpartum visit. Logistic regression and modified Poisson regression models were then used to identify statistically significant predictors of postpartum visit non-attendance. Results We found that one-third of all women who attended a prenatal visit at Montefiore Hospital did not return for a postpartum visit. Variables significantly associated with non-attendance include having Medicaid or no insurance (RR 1.4, 95 % CI 1.2–1.6), being Hispanic or Latino (RR 1.2, 95 % CI 1.1–1.3), having a vaginal delivery (RR 1.2, 95 % CI 1.1–1.4), and age

To estimate the effect of body mass index (BMI) on several outcomes in laparoscopic hysterectomy, in particular in the extremes of obesity.Retrospective cohort study (Canadian Task Force classification II-3).Tertiary-care university-based teaching hospital.Eight hundred thirty-four patients who underwent laparoscopic hysterectomy from January 2007 to October 2011.Laparoscopic hysterectomy for benign indications.Demographic, operative, and postoperative data were abstracted from medical records. The primary outcome was a composite index score that took into account operative time, nonsurgical operating room time, estimated blood loss, length of hospital stay, number of complications, and severity of complications according to the Dindo-Clavien classification. We individually examined elements of the composite index as a secondary outcome. Models were developed to assess the association of BMI with the composite index score and the components of the index, controlling for age, presence of diabetes, tobacco use, surgeon, type of hysterectomy (total vs supracervical), use of robotics, uterine weight, number of additional procedures performed, presence of adhesions requiring lysis, and deeply infiltrating endometriosis as potential confounders. Mean (SD) BMI was 31.4 (8.1). Mean (SD) uterine weight was 345 (388) g. Mean operative time was 150 (61) minutes. Increasing BMI was associated with a worse composite score (p.01); longer operative time (p = .03), nonsurgical operating room time (p = .02), and total operating room time (p.01); greater estimated blood loss (p.01); and complication severity (p = .01).These data suggest that there is a significant association of BMI with surgical outcomes in laparoscopic hysterectomy, and the effect is most pronounced in the morbidly obese. These patients may stand to gain the greatest differential benefit from a laparoscopic approach to surgery. However, they should be properly counseled about the challenge that obesity poses to the operation.

To compare the safety and effectiveness of dilation and evacuation (DE) and labor-induction abortion performed for fetal anomalies or fetal death in the second trimester.We performed a retrospective cohort study of second-trimester abortions performed for fetal indications. We compared the frequency of complications and effectiveness of abortions performed at 13-24 weeks for these indications. We calculated proportions of patients with complications for these two methods and controlled for confounding using a log binomial model.Labor-induction abortions had higher complication rates and lower effectiveness than did DE. Thirty-two of 136 women undergoing labor induction (24%) experienced one or more complications, in contrast to 9 of 263 women (3%) undergoing DE (unadjusted relative risk 6.9 [95% confidence interval 3.4-14.0]). When controlled for confounding, the adjusted risk ratio for labor induction was 8.5 (95% confidence interval 3.7-19.8) compared with DE.Dilation and evacuation is significantly safer and more effective than labor induction for second-trimester abortion for fetal indications. Bias and chance are unlikely explanations for these large discrepancies. Women facing this difficult decision should be offered a choice of methods and be provided information about their comparative safety and effectiveness.II.

Background: Public willingness to donate tissue samples is critical to genetic research. Prior work has linked minority status and mistrust with less willingness to provide specimens. Some have suggested recruitment of prior research participants to address these barriers. We present data from a genetic epidemiology study with a request for blood and/or saliva specimens to (1) measure willingness to donate tissue/blood samples, (2) identify demographic, trust, and other factors associated with willingness to donate samples, and (3) measure willingness to participate in future genetic research. Methods: We surveyed participants in the North Carolina Colorectal Cancer Study, which included biologic sample collection from consenting participants. Participants were later asked about sample provision; trust in researchers, and future research participation. Results: African Americans were less likely to give a blood sample, when compared with whites (21% vs. 13%, P < 0.05). After controlling for “trust,” this difference was no longer statistically significant (17% vs. 13%, P = 0.27). Those who had given samples were more likely to express willingness to participate in future research. Conclusion: Despite prior participation in a genetic epidemiology study, factors associated with provision of tissue samples reflected many previously identified demographic factors (race and trust). Interventions to improve and demonstrate the trustworthiness of the research team and recruitment of subjects with a record of sample donation might enhance future study participation.

Tube feeding is increasingly common, despite evidence for limited medical benefits. We interviewed treating physicians to describe their expectation of benefit for patients receiving a new feeding tube, and to determine whether expected benefits vary by patient characteristics.We recruited treating physicians and surrogate decision-makers for 288 hospitalized patients in a prospective study of new feeding tube decisions. In structured interviews, physicians provided information on patients' diagnosis and whether they expected any of eight potential medical benefits for a specific patient; surrogates provided information about the patients' function, race, age, prior residence, and ability to eat by mouth.We completed interviews with 173 physicians about tube feeding for 280 patients (response rate, 97%). Patients commonly had acute stroke (30%), neurodegenerative disease (16%), or head and neck cancer (22%); 70% were somewhat or severely malnourished. In half or more cases, physicians expected benefits of improved nutrition (93%), hydration (60%), prolonged life (58%), ease providing medication (55%), and less aspiration risk (49%). Physicians endorsed more expected benefits for patients with stroke or those completely unable to eat by mouth (p0.05).Treating physicians expected multiple medical benefits for a diverse population of patients receiving feeding tubes. Physicians may be unaware of evidence, or expect more optimistic outcomes for their specific patient population. Further education and decision support may improve evidence-based decision-making about feeding tubes.

A measure that identifies patients who are at high risk of mortality after prolonged ventilation will help physicians communicate prognoses to patients or surrogate decision makers. Our objective was to develop and validate a prognostic model for 1-yr mortality in patients ventilated for 21 days or more.The authors conducted a prospective cohort study.The study took place at a university-based tertiary care hospital.Three hundred consecutive medical, surgical, and trauma patients requiring mechanical ventilation for at least 21 days were prospectively enrolled.Predictive variables were measured on day 21 of ventilation for the first 200 patients and entered into logistic regression models with 1-yr and 3-mo mortality as outcomes. Final models were validated using data from 100 subsequent patients. One-year mortality was 51% in the development set and 58% in the validation set. Independent predictors of mortality included requirement for vasopressors, hemodialysis, platelet countor = 150 x 10(9)/L, and ageor = 50 yrs. Areas under the receiver operating characteristic curve for the development model and validation model were .82 (SE .03) and .82 (SE .05), respectively. The model had sensitivity of .42 (SE .12) and specificity of .99 (SE .01) for identifying patients who hador = 90% risk of death at 1 yr. Observed mortality was highly consistent with both 3- and 12-mo predicted mortality. These four predictive variables can be used in a simple prognostic score that clearly identifies low-risk patients (no risk factors, 15% mortality) and high-risk patients (three or four risk factors, 97% mortality).Simple clinical variables measured on day 21 of mechanical ventilation can identify patients at highest and lowest risk of death from prolonged ventilation.

STUDY DESIGN: This is a secondary analysis of a prospective cohort of 295 patients with acute low back pain presenting to 31 primary care physicians in North Carolina. OBJECTIVE: This study examines the hypothesis that dissatisfaction with job tasks and lack of social support from coworkers and supervisor are associated with poorer low back pain outcomes. SUMMARY OF BACKGROUND DATA: Psychosocial work characteristics are thought to be associated with the occurrence, report, and development of long-term disability from low back pain, but the studies are inconclusive. METHOD.: Three psychosocial work characteristics were separately compared to these outcomes: time to functional recovery, attainment of complete recovery, and clinically relevant change on the Modified Roland Scale. RESULTS: Relative to subjects with more social support from coworkers, subjects with less social support from coworkers have 1.55 (95% CI = 1.04-2.34) times the risk of not attaining complete recovery from low back pain at 8 weeks. For all other outcomes evaluated in this study, there was not an association with the psychosocial work characteristics. Biomechanical demands were found not to modify this association. CONCLUSION: This analysis provides evidence that social support in the workplace from coworkers but not social support from a supervisor or job task satisfaction are likely targets for intervention.

BACKGROUND Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes. OBJECTIVE To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures. DESIGN AND PARTICIPANTS We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987–1989 and returned for follow-up visits every 3 years, for a total of 4 visits. MAIN OUTCOME MEASURES We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions. RESULTS Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22–2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03–1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08–1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00–1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03–1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08–1.39). CONCLUSIONS Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes.

Objective The objective of this work was to evaluate the acceptance, use and recall of an optional advance prescription for emergency contraception (EC). Materials and methods This study used as randomized controlled trial evaluating contraceptive counseling intervention with women aged 16���44 years who were at risk for unintended pregnancy ( N =737). Intervention participants ( n =365) received contraceptive counseling with optional advance EC prescription. Control women ( n =372) received no contraceptive or EC counseling. Among intervention participants, initial acceptance and use of EC in first 2 months were evaluated. Among all participants, differences were evaluated between recall of EC discussion and use of EC. Results Among 365 intervention women, 336 received EC counseling and 51% of these 336 accepted advance EC prescription. At 2 months, among the women who had accepted EC, 6% had filled and used their prescription and 8% had filled but not used their prescription. At 12 months, intervention women were significantly more likely than controls to recall talking about EC (33% vs. 5%) and obtaining a prescription (38% vs. 6%), but there were no differences in the use of EC (6% vs. 6%). Conclusion When the option is available for EC counseling, approximately half of women accepted advance prescription for EC. However, few women who received information and/or an advance prescription remembered discussing EC, filled the prescription or used EC over 12 months.

PURPOSE We wanted to identify characteristics of adults who do not have a usual source of care and then stratify the analysis by those who prefer vs those who do not prefer to have a usual source of care. METHODS We analyzed data from a nationally representative sample of 9,011 adults to identify characteristics of those more likely to not have a usual source of care. Based on stated reasons for lacking a usual source of care, we created 2 subpopulations of adults without a usual source of care: those who had no preference and those who did. We identified and compared characteristics of each subpopulation. RESULTS In the year 2000, 20% of adults did not have a usual source of care. Among all adults, lack of insurance (odds ratio [OR] = 3.2; 95% confidence interval [CI], 2.6–3.9) was independently associated with lacking a usual source of care, as were male sex (OR = 2.1; 95% CI, 1.7–2.4), excellent reported health (OR = 2.0; 95% CI, 1.2–3.2), younger age (for ages 18–29 years, OR = 4.1; 95% CI, 3.1–5.4) and Hispanic ethnicity (OR = 1.5; 95% CI,1.2–1.9). Of those without a usual source of care, 72% cited reasons indicating no preference to have one. Associations among such respondents were similar to those found among adults as a whole. Among respondents who preferred to have a usual source of care, however, the sex of the respondent became less significant, lack of insurance became more significant, and reported health status became nonsignificant. CONCLUSIONS Most adults who lack a usual source of care do so for reasons of preference, evidently placing little value on having a usual source of care. Helping these persons have a usual source of care will likely require different interventions than needed to help those who want a usual source of care but cannot get one.

Objectives (1) To determine surrogates perceptions about who made the decision to place the feeding tube and who they would have preferred to have made the decision. (2) To determine surrogates’ perceptions of the information they received to make this decision. Methods Structured interviews with 246 surrogate decision-makers. Results Fifty-five percent of surrogates felt that the decision was made primarily by the surrogate, but 75% would prefer that the decision be shared with the physician. Surrogates reported that they discussed the benefits (80%) and the risks (72%) of feeding tube placement and discussed what life would be like with the feeding tube (65%) and without the feeding tube (67%). They also reported being asked if they understood the information (85%) and their thoughts about placement (56%). Despite receiving this information, 28 to 41% reported wanting more information about these aspects. Conclusion Surrogates would have preferred greater physician participation in decisions about feeding tube placement and many reported that their informational needs were not completely met. Practice Implications These results suggest that physicians may be justified in taking a more active role in feeding tube decisions with surrogates and that many surrogates desire more information than is required by standards of informed decision making.

Background: 40% of births in the USA are covered by Medicaid and smoking is prevalent among recipients. The objective of this study was to evaluate the association between levels of Medicaid coverage for prenatal smoking cessation interventions on quitting during pregnancy and maintaining cessation after delivery. Methods: Population based survey study of 7513 post-partum women from 15 states who: participated in Pregnancy Risk Assessment Monitoring System (PRAMS) during 1998–2000; smoked at the beginning of their pregnancy; and had Medicaid coverage. Participating states were categorised into three levels of Medicaid coverage for smoking cessation interventions during prenatal care: extensive (pharmacotherapies and counselling); some (pharmacotherapies or counselling); or none. Quit rates among women who smoked before pregnancy and rates of maintaining cessation were examined. Results: Higher levels of coverage during prenatal care for smoking cessation interventions were associated with higher quit rates; 51%, 43%, and 39% of women quit in states with extensive, some, and no coverage, respectively. Compared to women in states with no coverage, women in states with extensive coverage had 1.6 times the odds of quitting smoking (odds ratio (OR) 1.58, 95% confidence interval (CI) 1.00 to 2.49). Maintenance of cessation after delivery was associated with extensive levels of Medicaid coverage; 48% of women maintained cessation in states with extensive coverage compared to 37% of women in states with no coverage. Compared to women in states with no coverage, women with extensive coverage had 1.6 times the odds of maintaining cessation (OR 1.63, 95% CI 1.04 to 2.56). Conclusions: Prenatal Medicaid coverage for both pharmacotherapies and counselling is associated with higher rates of quitting and continued cessation. This suggests policymakers can promote cessation by broadening smoking cessation services in Medicaid prenatal coverage.

Objectives: To determine whether self-reports of delayed care predict increased mortality and functional decline in community-dwelling elderly. Design: Longitudinal cohort study. Setting: Five counties in North Carolina. Participants: A total of 4,162 randomly sampled individuals aged 65 and older. Measurements: The primary outcome was the proportional hazard ratio (HR) for death in cohorts stratified by self-reports of delayed or foregone care. A secondary outcome, functional decline, measured the cohorts' odds of developing increased dependency in activities of daily living (ADLs). Control variables included predisposing, enabling, and need factors. Results: Of 3,964 eligible participants reporting, 61% never, 27% once in a while, and 12% quite often delayed care. Over 3 years, 13% of participants died, and 17% developed increased ADL dependency. Nevertheless, in unadjusted and adjusted models, neither 3-year mortality HRs nor the odds of functional decline differed between cohorts reporting varying degrees of delayed care. Survival probabilities remained higher for 15 years among those reporting delaying care often. Conclusion: The inability of self-reported delay to predict adverse outcomes in community-dwelling elderly suggests the need for better understanding and support of the care-seeking process and additional measures of timeliness of access.

Objective Assisted living is a rapidly-growing sector of long-term care, but little research has been done on depression in this setting. Using data from a large sample of assisted-living residents, the authors sought to 1) describe the prevalence of depression and depressive symptoms; 2) identify resident characteristics associated with depression; and 3) examine the relationship between depression and the rate of nursing home placement and mortality. Methods A group of 2,078 residents age 65 and older were enrolled from 193 assisted-living facilities across four states (Florida, Maryland, New Jersey, and North Carolina). Residents were classified as depressed if their score on the Cornell Scale for Depression in Dementia (CSDD) exceeded 7. Results Using this criterion, 13% were depressed, and only 18% of those were on antidepressants. Over one-third of residents had symptoms of depression, such as anxious expression, rumination, or worrying, and 25% displayed sad voice, sad expression, or tearfulness. Depression was significantly associated with medical comorbidity, social withdrawal, psychosis, agitation, and length of residence in the facility. Depressed residents were discharged to nursing homes at 1.5 times the rate of nondepressed residents. Rates of mortality were also higher for depressed residents, but only those with severe depression (CSDD >12) had a statistically significant increased rate of death. Conclusion The mission of assisted living is to help older adults retain autonomy, privacy, and quality of life in a personalized environment. Greater effort should be made to detect and treat depression in this setting, both to reduce suffering and prolong the resident's ability to remain in their preferred environment.

To compare the two published methods of cesarean delivery rate risk adjustment to determine which should be recommended as a national standard.We used 2 years of Washington State Birth Events Record Data (1997 and 1998) to estimate hospitals' risk-adjusted cesarean delivery rates using two different methods: 1) logistic regression modeling and 2) direct standardization. After exclusions, there were 123,850 births and 67 hospitals. Ranked lists of hospitals were produced by each methodology and compared using the Spearman correlation. We used kappa statistics to compare the top 25% and the bottom 25% of the rankings.The Spearman correlation for the ranked lists was strong (.84, P.001). The kappa(s) were .67 for the top 25% and .69 for the bottom 25%. By the logistic regression method, 19 hospitals had rates significantly higher than expected and 15 had rates significantly lower than expected. Because the direct standardization method had 57% of hospitals with no births in at least one of the risk strata, we could not determine whether these hospitals were statistical outliers.Both methods ranked hospitals similarly. If cesarean delivery rate risk adjustment for all hospitals is desirable, the logistic regression method has the advantage of being able to determine if different rates are significantly above or below expected. However, if comparing only two large hospitals is the goal, direct standardization may be simpler to implement, provided all risk strata have at least one delivery.

OBJECTIVE: To determine patient preferences for addressing religion and spirituality in the medical encounter. DESIGN: Multicenter survey verbally administered by trained research assistants. Survey items included questions on demographics, health status, health care utilization, functional status, spiritual well-being, and patient preference for religious/spiritual involvement in their own medical encounters and in hypothetical medical situations. SETTING: Primary care clinics of 6 academic medical centers in 3 states (NC, Fla, Vt). PATIENTS/PARTICIPANTS: Patients 18 years of age and older who were systematically selected from the waiting rooms of their primary care physicians. MEASUREMENTS AND MAIN RESULTS: Four hundred fifty-six patients participated in the study. One third of patients wanted to be asked about their religious beliefs during a routine office visit. Two thirds felt that physicians should be aware of their religious or spiritual beliefs. Patient agreement with physician spiritual interaction increased strongly with the severity of the illness setting, with 19% patient agreement with physician prayer in a routine office visit, 29% agreement in a hospitalized setting, and 50% agreement in a near-death scenario (P

Specific methods of mechanical ventilation management reduce mortality and lower health care costs. However, in the face of a predicted deficit of intensivists, it is unclear whether residency programs are training internists to provide effective care for patients who require mechanical ventilation. To evaluate these educational outcomes, we administered a validated 19-item case-based test and survey to resident physicians at 31 diverse U.S. internal medicine residency programs nationwide. Of 347 senior residents, 259 (75%) responded. The mean test score was 74% correct (SD, 14%; range, 37 to 100%). Important items representing evidence-based standards of critical care answered incorrectly were as follows: use of appropriate tidal volume in the acute respiratory distress syndrome (48% incorrect), identifying a patient ready for a weaning trial (38% incorrect), and recognizing indication for noninvasive ventilation (27% incorrect). Most accurately identified pneumothorax (86% correct) and increased intrathoracic positive end-expiratory pressure (93% correct). Better scores were associated with "closed" versus "open" intensive care unit organization (76 versus 71% correct, p = 0.001), resident perception of greater versus lesser ventilator knowledge (79 versus 71% correct, p = 0.001), and graduation from a U.S. versus international medical school (75 versus 69% correct, p = 0.033). Although overall training satisfaction correlated strongly with program use of learning objectives (r = 0.89, p < 0.0001), only 46% reported being satisfied with their mechanical ventilation training. We conclude that senior residents may not be gaining essential evidence-based knowledge needed to provide effective care for patients who require mechanical ventilation. Residency programs should emphasize evidence-based learning objectives to guide mechanical ventilation instruction.

To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy.The study's primary outcome was the percentage of operations rated "good" or "excellent" in terms of surgical field visualization at the outset of the case by the primary surgeon. Additional measures included assessment of visualization during the case and patient perioperative comfort. The study was powered to detect a 20% absolute difference in the proportion of cases rated as "good" or "excellent."Seventy-three patients were assigned to mechanical bowel preparation and 73 to no mechanical bowel preparation. The groups were comparable regarding patient and surgery characteristics. No differences were found for this rating between groups (mechanical bowel preparation, 64 of 73 patients [87.7%], compared with no mechanical bowel preparation, 60 of 73 patients [82.2%], P=.36). Surgeons guessed patient assignment correctly 59% of the time (42 of 71 patients) with mechanical bowel preparation and 55% of the time (41 of 75 patients) with no mechanical bowel preparation.Mechanical bowel preparation is well-tolerated but does not influence surgical field visualization for laparoscopic hysterectomy.ClinialTrials.gov, www.clinicaltrials.gov, NCT01576965.

The aims of this study were to compare self-reported vigorous physical activity and participation in sports among adolescents with cystic fibrosis (CF) to those of age matched peers from the general population, and to determine which CF patient characteristics are associated with regular physical activity. One hundred and sixteen of 141 (82%) adolescents aged 12-19 years identified through North Carolina CF Care Center registries confidentially completed a self-administered questionnaire (the CDC's Youth Risk Behavior Survey) addressing health-compromising and health-enhancing behaviors, including physical activity. They were age- and gender-matched to adolescents from North Carolina schools who completed the same survey. Adolescents with CF did not differ significantly from their matched peers with regard to participating three or more times a week in activities that "make you sweat or breathe hard" (63% vs. 67%, P = 0.37), physical education class (59% vs. 61%, P = 0.81), or team sports (52% vs. 61%, P = 0.10). For all categories of activity, participation declined among adolescents aged 17 years or older. After adjusting for gender and health status, early (14 years or younger) and middle (15-16 years) adolescents were more likely to participate in all three types of activity than older adolescents with CF. Like their peers in the general population, adolescents aged 17 and older are much less likely to report regular physical activity, or participation in physical education class or in team sports. Healthcare providers should be aware of this decline in activity in late adolescence and should consider efforts to maintain physical activity among older teenagers and young adults.

Computer technology has become an integral part of health care, yet there have been few studies exploring the use of multimedia technology in the prevention of cancer, especially targeting children.The aims of this study were to develop and evaluate a new multimedia computer program for the primary prevention of skin cancer among a childhood population.An interactive CD-ROM program was developed, then pilot tested in a public elementary school in rural North Carolina. This intervention trial involved 8 third- and fourth-grade classes (N = 209 students), randomized into 3 groups: computer intervention, standard teacher-led intervention, and controls.Students were tested using pre- and postintervention surveys that measured knowledge, attitudes, and self-reported behaviors. A 7-month follow-up survey was performed.There was a significant increase in postintervention knowledge for the computer group when compared to either the teacher-led or control groups (mean scores out of 100: 75.2, 59.5, 55.0, respectively; p0.001). Attitudes about suntanning demonstrated a significant difference between the 3 groups (mean scores out of 100: 64.0, 53.0, 48.6, respectively; p = 0.002). There were slight improvements in the behavioral scores, especially among the computer group, but the overall differences were not significant. Similar overall results were found for the long-term follow-up survey, except that attitudes about suntanning no longer demonstrated a significant difference.These results indicate that this new educational tool is an effective way to introduce health education programs for young children in typical classroom settings. This prototype may serve as a model for the development of future preventive school-based programs, including applications to other conditions associated with high-risk behaviors among children.

Objective. To explore the relationship between type of initial care as well as the likelihood of recurrence and consequent care seeking behavior. Research Design. Prospective observational cohort recruited from 208 randomly selected North Carolina practices. Cohort study examined the recurrence of low back pain among patients free of back pain 3 months after their index visit to a practitioner for that problem. The following four practitioner strata were examined: primary care providers, chiropractors, orthopedic surgeons, and practitioners in a group model HMO. Patients were interviewed by telephone at 6 and 22 months after the initial visit. Main Outcome Measures. Rates of disabling and non-disabling low back pain; functional status using the Roland back disability scale; and care seeking. Results. Rates of recurrence were substantial; functionally disabling recurrence rates varied between 8% and 14% between 3 to 6 months, and 20% to 35% between 6 to 22 months. Differences in rates among practitioner strata were statistically significant only between 6 to 22 months with higher recurrence rates for HMO patients. Functional status, number of bed days, and time off work were very similar among the practitioner strata. Care seeking, however, was greater among those patients who had initially seen a chiropractor for their back pain. Patients with recurrence saw the same practitioner type they had seen for the index episode 88% of the time. Satisfaction was slightly greater for patients who saw chiropractors when compared with patients seeing allopathic physicians. Conclusions. The recurrence of low back pain is common. Severe disability is rare. Patients who had sought care from chiropractors are more likely to return for recurrences than patients who had initially sought care from MDs.

OBJECTIVE: To describe the patterns of provider use associated with an acute episode of nonspecific low back pain and their impact on cost. METHODS: The analysis is based on a prospective cohort study of patients with acute low back pain followed until they recovered completely or to 6 months. Patients were followed after an initial visit to one of four provider types: private primary care physician, chiropractor, orthopedic surgeon, or HMO primary care physician. Follow-up interviews were conducted at baseline, 2, 4, 8, 12, and 24 weeks; 1,580 (97%) of the participants completed the 6-month follow-up. MAIN RESULTS: Seventy-nine percent of patients saw only the initial provider who began their care for low back pain. Logistic regression revealed that duration of pain prior to initial visit, sciatica, higher Roland disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and the type of index provider were significantly (p

Background and Purpose. The purposes of this study were (1) to describe the demographic and clinical characteristics of a group of patients with acute low back pain (LBP), (2) to describe those patients who were being treated by physical therapists, and (3) to analyze their use of physical therapy services. Subjects. The study sample consisted of 1,580 patients with acute LBP who were treated by 208 practitioners in North Carolina. The initial providers were primary care physicians, chiropractors, orthopedic surgeons, and primary care providers at a health maintenance organization. Methods. A telephone interview was conducted after the initial office visit to assess demographics and medical history, health care services utilization, and functional status. Follow-up telephone interviews were also conducted 2, 4, 8, 12, and 24 weeks later. Results. One hundred ninety-nine (12.6%) of the subjects reported that they saw a physical therapist either by any provider referral or by direct access. Therapeutic exercise was the most commonly reported treatment procedure. Post–high-school education, receipt of Workers' Compensation, prior physical therapy for LBP, LBP and pain below the knee in one or both legs, and a higher baseline Roland-Morris Questionnaire score were associated with being treated by physical therapists. Conclusion and Discussion. In this study, physical therapists were utilized in the treatment of patients with greater severity of LBP. The findings demonstrate the importance of controlling for baseline characteristics when comparing outcomes of LBP when treated by different types of providers.

Objectives: To profile all patients presenting to an urban ED with any injury, and to determine whether the rate of subsequent injury treated in the ED varied by demographic and E-code (external mechanism of injury) category. The hypothesis that young black males were disproportionately at risk for re-injury was addressed. Methods: A cohort of consecutive patients presenting to an urban ED with any injury between January 1, 1991, and November 31, 1992, were followed prospectively for 1 year from their index visit dates. Any repeat ED visits due to injury were sought. The mean number of injury visits per year (the total number of ED injury visits for each patient divided by 1 year) was computed for the overall population and by race, age, gender, and E-code. Results: The sample consisted of 34,378 patients who made 44,813 visits to the ED for injury. Of these patients, 22% had a repeat injury in 1 year, with a cohort mean of 1.30 injury visits per year. This mean did not vary appreciably by race (black 1.33, white 1.27), age (1–17 yr, 1.21; 18–24 yr, 1.32; 25–64 yr, 1.34; >65 yr, 1.23), gender (males 1.33, females 1.27), or E-code category. Having a prior injury visit in the preceding year was the best predictor of future injury (mean repeat visit rate = 2.08). Conclusions: When examining patients presenting with any injury to an urban ED, the mean numbers of injury visits are remarkably similar across demographic and E-code categories. Although there are factors that place patients at risk for recurrent injury, those factors are not demographic—all patients presenting to an ED with injury should be considered at risk for re-injury.

OBJECTIVES: The Medicare Trust Fund is expected to be bankrupt in the next decade, thus threatening the viability of the Medicare Program. We have ascertained what Medicare enrollees' priorities for insured services would be, and why, if it were fiscally necessary to limit Medicare benefits to maintain the viability of the Program. DESIGN: A cross-sectional survey using anonymous, in-person interviews and an innovative instrument to elicit choices. SETTING: General Internal Medicine outpatient clinic at a university teaching hospital. PARTICIPANTS: One hundred five adults, 65 years of age and older, who had primary care physician visits between July and September 1995. MEASUREMENTS: Desire to personally select insurance benefits, insurance benefit choices, and the reasons for selection or rejection of benefits. RESULTS: Subjects of various educational and economic backgrounds were able to carry out the selection process with relative ease, and four-fifths of respondents preferred to make their own choices about insured services. The most frequently selected services were hospitalization, outpatient care, prescription drugs, eye care, and home care, in descending order. Subjects selected 52 different combinations of services. Only 2% of respondents picked the current Medicare service package. The reasons given for selection varied by service; cost and current or anticipated need for a service were the most frequently cited forces driving the choices made. CONCLUSION: These data suggest that Medicare enrollees prefer some element of choice about their health insurance coverage. Their choices vary widely and differ from the current Medicare package.

OBJECTIVE To assess the effectiveness of a cholesterol-lowering intervention designed to facilitate the management of hypercholesterolemia by primary care clinicians. DESIGN Randomized controlled trial, with randomization of clinician-patient groups. SETTING Twenty-one community and rural health centers in North Carolina and Virginia. PARTICIPANTS Primary care clinicians (n = 42, 71% physicians) and the patients they enrolled with high cholesterol (n = 372). Twenty-two clinicians were randomized to give the special intervention (184 patients) and 20 to give usual care (188 patients). Two thirds of participating patients were women, 40% were African American, and 11% were Native American. INTERVENTION A 90-minute tutorial to train clinicians how to use a structured assessment and treatment program (Food for Heart Program) consisting of a brief dietary assessment and three 5- to 10-minute dietary counseling sessions given by the primary care clinician, referral to a local dietitian if the low-density lipoprotein cholesterol (LDL-C) remained elevated at 4-month follow-up, and a prompt for the clinician to consider lipid-lowering medication based on the LDL-C at 7-month follow-up. MAIN OUTCOME MEASURES Changes in total and LDL cholesterol at 4-month follow-up and averaged over a 1-year follow-up period (4-, 7-, and 12-month follow-up). RESULTS At 4-month follow-up, total cholesterol decreased 0.33 mmol/L (12.6 mg/dL) in the intervention group and 0.21 mmol/L (8.3 mg/dL) in the control group: the difference was 0.11 mmol/L (4.2 mg/dL) (90% confidence interval [CI], -0.02 to 0.24 mmol/L [-0.7 to 9.1 mg/dL]). The average reduction during the 1-year follow-up period was 0.09 mmol/L (3.6 mg/dL) greater in the intervention group (90% CI, -0.01 to 0.19 mmol/L [-0.3 to 7.5 mg/dL]). Eight percent of intervention patients were taking lipid-lowering medication at follow-up visits compared with 15% of control patients. In a subgroup analysis restricted to the 89% of returnees who were not taking lipid-lowering medication, the reduction in total cholesterol at 4-month follow-up was 0.14 mmol/L (5.5 mg/dL) greater in the intervention group (95% CI, 0.01 to 0.28 mmol/L [0.3 to 10.7 mg/dL]); averaged over 1 year, it was 0.14 mmol/L (5.3 mg/dL) greater (95% CI, 0.03 to 0.24 mmol/L [1.2 to 9.4 mg/dL]). Changes in LDL-C were similar. CONCLUSIONS Total cholesterol and LDL-C decreased more in the intervention group than in the control group. Overall, the difference in lipid reduction between groups was modest and of borderline statistical significance; among participants who did not take lipid-lowering medication during follow-up, the difference in lipid reduction between groups was larger. We conclude that primary care clinicians can be trained to give a cholesterol-lowering intervention to low-income patients that results in modest, short-term reductions in total cholesterol and LDL-C.

Objective Subdermal contraceptive implant continuation has not been well studied in Africa. We conducted a secondary data analysis to compare baseline characteristics of Kenyan women who continued to use the subdermal implant at 12 months to those who did not. Study Design Kenyan women aged 18–24 years who presented to a family planning clinic for short-acting hormonal contraception were offered a two-rod subdermal implant instead. Participants were followed for 12 months after initiation of their contraceptive method. Statistical analysis included Pearson's chi-square or Fisher's exact tests for comparisons of proportions. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to determine factors associated with continuation. Results Eighty-six (89%) of the 97 women who chose the implant were followed for 12 months. Of these women, 68 (79%) continued to use the implant. None of the factors we examined had a statistically significant association with continued use of the implant. Duration of intended use was the only strong factor; 83% of women with 3 + years of need continued using the implant, compared to 56% of those with shorter needs (Risk ratio = 1.48, 95% CI = 0.94–2.31). No substantive continuation differences were found when comparing other participant characteristics including months with their current partner, personal desire and partner preference for future children, previous use of modern birth control and other factors. Conclusion High implant continuation rates were noted regardless of previous use of modern birth control, partner preference for children or baseline concern for menstrual change. Implications Contraceptive use in Africa continues to focus on short-acting contraceptives despite the proven superior efficacy of long-acting reversible contraceptives in other settings. The high subdermal implant continuation among Kenyan women in this prospective study, regardless of baseline characteristics, supports the need for increasing access and future research in this population.

Background: Physician specialty training is associated with variations in the use of medical treatment for specific diseases. Objective: To examine whether physicians' specialties predict differences in willingness to use life-sustaining treatments. Methods: One hundred fifty-eight physicians (response rate, 85%) who cared for 378 hospitalized patients with end-stage congestive heart failure, chronic obstructive pulmonary disease, malignant neoplasms, or hepatic cirrhosis were interviewed to assess their thresholds for use of specific life-sustaining treatments. Their patients were then followed up to determine whether decisions were made to use or withhold cardiopulmonary resuscitation, ventilator support, or intensive care. Physicians' attitudes, their stated thresholds for treatment use, and their use of these treatments in daily practice were compared by specialty group. Results: Physicians recommended cardiopulmonary resuscitation and ventilator support for patients with end-stage congestive heart failure or chronic obstructive pulmonary disease if the chance for survival was at least 48%, but they required a predicted survival of at least 74% for patients with cancer. For a patient with end-stage congestive heart failure or chronic obstructive pulmonary disease, cardiologists were consistently more willing than other physicians to use life-sustaining treatments. In practice, decisions to use or withhold such treatments were made for 151 patients with end-stage diseases. Compared with other physicians, cardiologists were least likely to issue orders to withhold treatment and most likely to use life-sustaining treatments for patients they treated. Oncologists rarely used such treatments and issued orders to withhold these treatments much more often. Conclusion: Physician specialty is associated with differences in willingness to use, and in actual use of, life-sustaining treatments. (Arch Intern Med. 1996;156:785-789)

Study Design. A prospective observational cohort was recruited from 208 randomly selected North Carolina practices. Objective. To compare the corse of compensation claimants with gainfully employed patients not so insured fom the time when they first sought care for acute back pain. Summary of Background Data. The human and financial cost attributable to disabling chronic low back pain indemnified by workers' compensation programs continues to escalate. We explored the antecedents to this pehnomenon. Method. Consecutive patients with acute low back pain were interviewed by telephone within 1 week of first seeking care and in follow-up calls after 2, 4, 8, 12, and 24 weeks to monitor functional and work status. Results. Of the 1633 patients enrolled, 505 were insured by workers' compensation. These were compated with 861 who had been employed on any job for pay within 3 months of the onset of their backache but whose care was not so underwritten. Those with compensable back pain were more likely to categorize their tasks as physically demanding and had taken more time off work in the month before the baseline interview (P = 0.02). Recovery of the sense of wellness they enjoyed before this episode of back pain was delayed (Cox Model: Hazard Ratio = 0.822: P

Background Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. Methods Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. Results The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study...

A randomized, controlled trial was conducted to assess the effects of a financial and office systems intervention to increase preventive care in physicians' offices for patients aged 65 years or older. A total of 1,914 patients from 10 primary-care medical practices in central North Carolina were randomized within practices to an intervention and a usual-care control group. The intervention consisted of full Medicare reimbursement to physicians for preventive care and health promotion packages (thus making these services free for patients), regular prompting of physicians to routinely schedule preventive care visits, a new office system in which nurses carried out many preventive procedures, and a form for charting preventive care. The performance of screening tests dramatically increased in the intervention group relative to control (P < 0.001), but there was evidence of lack of follow-up of abnormal findings by physicians. At the 2-year follow-up, there were minimal differences between intervention and control groups in health-related quality-of-life indicators. Relative to the $294 per patient 3-year cost to Medicare for waivered services, the intervention was reimbursed-cost neutral or slightly cost reducing ($190 over 3 years) for Medicare. It is concluded that adding reimbursement for preventive services to Medicare--even with the office systems changes made in this study--will not by itself lead to effective implementation of preventive services in community medical practices. To enhance patient benefit from preventive services, greater attention needs to be focused on an organized approach to patient follow-up.

Study DesignThis was a survey of 235 individuals with and 132 individuals without documented low back pain.ObjectivesTo approximate the magnitude of potential reporting biases in estimates of prevalence of and medical care use in low back pain.Summary of Background DataThe use of survey techniques p

Objectives To test whether a decision aid improves quality of decision-making about feeding options in advanced dementia. Design Cluster randomized controlled trial. Setting Twenty-four nursing homes in North Carolina. Participants Residents with advanced dementia and feeding problems and their surrogates. Intervention Intervention surrogates received an audio or print decision aid on feeding options in advanced dementia. Controls received usual care. Measurements Primary outcome was the Decisional Conflict Scale (range: 1–5) measured at 3 months; other main outcomes were surrogate knowledge, frequency of communication with providers, and feeding treatment use. Results Two hundred fifty-six residents and surrogate decision-makers were recruited. Residents' average age was 85; 67% were Caucasian, and 79% were women. Surrogates' average age was 59; 67% were Caucasian, and 70% were residents' children. The intervention improved knowledge scores (16.8 vs 15.1, P

Many patients who survive the first few days of critical illness do so with multiple persistent organ failures, ultimately becoming dependent on mechanical ventilation for prolonged periods (1). Up to 10% of patients who develop acute respiratory failure require prolonged mechanical ventilation (PMV) (2). The number of patients receiving PMV has increased in recent years, likely as a result of improvements in acute management and supportive care for critically ill patients (2, 3). As the population ages, it is expected that this number will increase further, because advanced age is a key risk factor for PMV (3, 4). One-yr mortality for patients receiving PMV is high (5–9), and only 11% percent of patients are functionally independent and living at home by 1 yr (9, 10). During the year of their illness, 74% of the patients’ days alive are spent in a hospital, postacute care facility, or receiving home health care. Recent empirical studies have documented serious shortcomings in the process of decisionmaking about life support for patients on PMV. Up to 93% of families and surrogate decisionmakers do not receive any information about expected long-term survival despite explicit wishes to have this information (11, 12). In one study, 93% of surrogate decisionmakers had high expectations for survival of patients on PMV compared with only 44% of physicians for the same patients (12). These deficiencies are problematic for two reasons. First, they are a threat to patient-centered care because existing data suggest that patients often prefer treatment focused on palliation in the setting of a poor prognosis (13–15). Second, patients receiving PMV are among the highest consumers of healthcare resources (16) and, from a societal perspective, it is important to ensure that the provision of this very expensive resource is reserved for patients who would choose such treatments after a careful discussion of the risks and benefits. Although there are likely several reasons for suboptimal discussions about prognosis between physicians and families, one important reason is clinicians’ uncertainty about the long-term outcomes of patients on PMV (17–20). This is perhaps not surprising because most intensive care unit (ICU) clinicians have little opportunity to follow patients after they leave the ICU and therefore little opportunity to refine their prognostic abilities regarding long-term outcomes. To address this gap for patients on PMV, the ProVent model was developed and internally validated at a single tertiary care medical center to predict 1-yr mortality for patients receiving at least 21 days of mechanical ventilation after acute illness (5). Using four easily identified clinical variables (age, platelet count, on-going use of vasopressors, and hemodialysis), the ProVent model had very good discrimination (area under the curve [AUC] of the receiver operator characteristic curve 0.81) and calibration for identifying patients who were at high risk of death after PMV. To establish broader applicability, we sought to refine the ProVent model and provide external validity using data from a heterogeneous group of patients from multiple hospitals across the United States.

Human genome research depends upon participants who donate genetic samples, but few studies have explored in depth the motivations of genetic research donors. This mixed methods study examines telephone interviews with 752 sample donors in a U.S. genetic epidemiology study investigating colorectal cancer. Quantitative and qualitative results indicate that most participants wanted to help society, and that many also wanted information about their own health, even though such information was not promised. Qualitative analysis reveals that donors believed their samples contributed to a scientific “common good”; imagined samples as information rather than tissues; and often blurred distinctions between research and diagnostic testing of samples. Differences between African American and White perspectives were distinct from educational and other possible explanatory factors.

Objectives. To determine the priorities of low-income urban residents for interventions that address the socio-economic determinants of health. Methods. We selected and estimated the cost of 16 interventions related to education, housing, nutrition, employment, health care, healthy behavior, neighborhood improvement, and transportation. Low-income residents of Washington, D.C. (N=431) participated in decision exercises to prioritize these interventions. Results. Given a budget valued at approximately twice an estimated cost of medical and dental care ($885), the interventions ultimately prioritized by the greatest percentage of individuals were: health insurance (95%), housing vouchers (82%) dental care (82%), job training (72%), adult education (63%), counseling (68%), healthy behavior incentives (68%), and job placement (67%). The percentages of respondents who received support for housing, adult education, and job training and placement were far less than the percentage who prioritized these interventions. Conclusions. Poor and low-income residents' priorities may usefully inform allocation of social services that affect health.

Background Low-income women are disproportionately affected by unintended pregnancy. The Access to Resources in Contraceptive Health Foundation was established to provide free levonorgestrel intrauterine contraceptive systems to uninsured women who meet specific socioeconomic eligibility criteria. The aim of this study was to evaluate the effectiveness of this program at reducing pregnancies among uninsured women attending two North Carolina clinics. Study Design This was a retrospective cohort study including uninsured women (aged 15–44 years) who desired contraception, were deemed eligible for the program and attended one of two North Carolina clinics between January 1, 2003, and June 30, 2009. The primary outcome was pregnancy. Pregnancy rates were compared between those women who had a program-approved intrauterine device placed (exposed group) and those women who were eligible for the program, but did not have a device placed (the unexposed group). Questionnaires were used to determine the numbers of pregnancies (and dates of conception), the types of alternative contraception being used and basic demographic information about program participants. The data were analyzed using survival analysis of time to pregnancy. A Cox proportional hazards model was used to estimate a hazard ratio. Results We attempted to reach 321 patients and obtained 104 responses. After exclusions, data from 90 participants were analyzed. Sixty-five women received a levonorgestrel device, and 25 eligible women did not. Seven pregnancies occurred in the exposed group (11%), all after the IUD was removed; three of these pregnancies were planned. Eight pregnancies occurred in the unexposed group (32%). The median follow-up time was 2.4 years (range: 0.75–4 years) and 1.8 years (0.05–4 years) in the exposed and unexposed groups, respectively. Conclusions Provision of a levonorgestrel-releasing device was associated with significantly lower risk of pregnancy than was use of alternative or no contraception. If these data from North Carolina are representative of experience nationwide, then the public health benefit of the Foundation's philanthropy may be large.

The joint influence of socioeconomic status and John Henryism on blood pressure was examined in a probability sample of 1,784 black adults aged 25-50 years in Pitt County, North Carolina, in 1988. John Henryism was measured by means of the John Henryism Active Coping Scale. Socioeconomic status (low, medium, and high) was based on respondents' education and occupation. Prior research indicated that, for blacks, the inverse association between socioeconomic status and hypertension may be stronger for individuals who score high in John Henryism. In this more urban sample of blacks, the hypothesized interaction achieved modest statistical support (p less than 0.08) only for hypertension prevalence. For individuals with high levels of John Henryism, adjusted prevalences declined with increasing socioeconomic status (29.4%, 26.2%, and 20.5% for low, medium, and high socioeconomic status, respectively); for individuals with low levels of John Henryism, hypertension prevalence was similar in the low (22.6%) and medium (22.8%) socioeconomic categories but higher in the high socioeconomic category (25.9%). Elevated psychological stress in white-collar workers was probably responsible for the nonsignificant inverse gradients between socioeconomic status and mean blood pressures and for the weak interaction between socioeconomic status and John Henryism with regard to hypertension prevalence.

Introduction To improve the public health system's ability to prevent and control chronic diseases, we must first understand current practice and develop appropriate strategies for measuring performance. The objectives of this study were to measure capacity and performance of local health departments in diabetes prevention and control and to investigate characteristics associated with performance. Methods In 2005, we conducted a cross-sectional mailed survey of all 85 North Carolina local health departments to assess capacity and performance in diabetes prevention and control based on the 10 Essential Public Health Services and adapted from the Local Public Health System Performance Assessment Instrument. We linked survey responses to county-level data, including data from a national survey of local health departments. Results Local health departments reported a median of 0.05 full-time equivalent employees in diabetes prevention and 0.1 in control. Performance varied across the 10 Essential Services; activities most commonly reported included providing information to the public and to policy makers (76%), providing diabetes education (58%), and screening (74%). The mean score on a 10-point performance index was 3.5. Characteristics associated with performance were population size, health department size and accreditation status, and diabetes-specific external funding. Performance was not better in localities where the prevalence of diabetes was high or availability of primary care was low. Conclusion Most North Carolina local health departments had limited capacity to conduct diabetes prevention or control programs in their communities. Diabetes is a major cause of illness and death, yet it is neglected in public health practice. These findings suggest opportunities to enhance local public health practice, particularly through targeted funding and technical assistance.

Substance use during pregnancy is associated with poor obstetrical and neonatal outcomes. Although intervention for substance use including alcohol improves pregnancy outcomes, a substantial number of women continue to use drugs or consume alcohol during treatment. To determine whether gestational age at entry into treatment (specifically first trimester enrollment) was associated with lower risk of continued substance use, we analyzed the North Carolina Treatment Outcomes and Program Performance System, an administrative database of drug treatment clinics, between 2000 and 2004. There were 847 pregnant women using substances who met our inclusion criteria. Demographic and other risk factor data were collected. We conducted logistic regression and a Generalized Estimating Equation analysis. Gestational age at enrollment was not associated with continued substance use (odds ratio [OR] = 0.88; 95% confidence interval [CI] = 0.51, 1.51). Women who had child care provided, were less likely to continue substance use (OR = 0.64; 95% CI = 0.48, 0.84), whereas those referred from the criminal justice system were more likely to continue (OR = 1.53; 95% CI = 1.01, 2.30). Although earlier gestational age at enrollment in treatment does not predict greater abstinence at any time point, this data does suggest that the provision of childcare may improve treatment success.

We developed a school-based program to raise community awareness about hypertension. We studied the results of the program on the outcomes of parental knowledge about high blood pressure (BP) and their reports of having seen or intending to see a health professional about their BP.We pilot tested a prototype middle-school curriculum using a crossover design in three fifth-grade classrooms (two designated early and one designated delayed intervention) in a suburban public school. We then used McNemar's test to assess significant differences in proportions responding correctly to BP knowledge questions and proportions reporting having seen or intending to see a health care professional about BP before and after the intervention. We tested for differences at 2-month follow-up in the early intervention classrooms compared to the delayed intervention classroom using chi-square.Seventy-six parents (out of a potential 134) completed baseline questionnaires. Parents had high baseline knowledge about certain aspects of hypertension, but baseline knowledge that high BP could lead to kidney failure was relatively low. The percentage of parents responding correctly to a question of whether high BP could lead to kidney failure increased after the intervention from 45.5% to 64.3%. Among parents in the early intervention classrooms, the percentage who reported having seen or intending to see a health professional about their BP increased from 9.6% to 27.5%. At 2-month follow-up, 27.5% of parents in the early intervention classrooms reported being seen or intending to be seen by a health care provider about their BP compared to only 8.3% of the parents in the delayed intervention classroom.This program may improve parents' knowledge about hypertension and their intent to be seen about BP.

Given the prohibitive cost of recruiting large and diverse populations for genetic explorations in cancer research, there has been a call for genetic studies to engage existing cohorts of research participants. This strategy could lead to more efficient recruitment and potentially result in significant advances in the understanding of cancer etiology and treatment. The Learning About Research in North Carolina (LeARN) study responded to the National Human Genome Research Institute interest in research on how study participants from diverse populations who had participated in genetic research perceived the risks and benefits of participating in combined epidemiologic-genetic research, how well they understand the purpose of the research and the uses to which the research results may be put, and how involvement in such research affects perceptions of disease causality. In this article, we give an overview of the LeARN study, summarizing the methods we used, challenges we encountered, and lessons learned about recruiting participants who have previously participated in genetic research. (Cancer Epidemiol Biomarkers Prev 2008;17(8):2019–24)