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Background: The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative., Methods: The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed., Results: The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%., Conclusions: These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective: To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study., Materials and Methods: In phase 1, from May to August 2010, the effectiveness of a 'retract-and-reorder' measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an 'ID-verify alert', and an 'ID-reentry function'., Results: The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71)., Discussion and Conclusion: Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

Current guidelines call for Papanicolaou (Pap) smear screening of HIV-infected women at least annually. After the initiation of a weekly computer based Pap smear reminder list in an HIV care clinic, the prevalence of scheduled women with up-to-date Pap smears was calculated for the one-year project period and was compared to the prevalence preceding the project. The prevalence of scheduled women with up-to-date Pap smears increased from 61.4% to 73.2% (P <0.001) during the project period. Including Pap smears that were performed elsewhere, the final up-to-date Pap smear rate was 82.7%. The improved rate of up-to-date Pap smears showed no sign of attenuation over time. A computerized report generated from data in the hospital information system increased rates of compliance with Pap smear screening recommendations. Creative utilization of hospital data environments may be an inexpensive route to improved compliance with practice guidelines.

The widespread use of highly active antiretroviral therapy (HAART) since 1996 has led to a substantial decline in morbidity and mortality in patients infected with HIV, although its effect on the incidence of HIV-associated malignancies is unknown. We retrospectively reviewed the annual number of outpatient visits to our HIV clinic, inpatient admissions for HIV disease, and first admissions for patients with cancer and HIV disease at our center between 1990 and 1997. Between 1990 and 1995, there was a progressive increase in the annual number of admissions for HIV disease and HIV-associated cancers that paralleled the increasing HIV clinic volume. In 1997, however, the annual number of first admissions for Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma compared with 1995 decreased by 36% and 63%, respectively, despite a continued increase in the annual number of HIV clinic visits. Similar declines were also noted in the number of new cases of biopsy-confirmed KS and primary central nervous system (CNS) lymphoma. In contrast, there was no decrease in the number of first admissions for patients with HIV infection and other cancers not typically associated with HIV infection. These findings suggest a declining incidence of HIV-associated malignancies since the introduction of HAART.

The incidence of tuberculosis--and, more important, that of multidrug-resistant tuberculosis--have risen drastically in the past decade. Nosocomial outbreaks have alerted health-care workers to the hazards of the spread of tuberculosis. The use of environmental control modalities (e.g., ventilation, air filtration, and ultraviolet irradiation) and personal protective devices has been explored in the medical, legislative, and public forums. New regulations and legislation have created controversy over the recommendations and their interpretation. In this review we present the theory behind the rational selection of environmental-control modalities and personal protective devices. We also offer suggestions about the application of specific control techniques and the revision of existing facilities to comply with new standards.

Background: The incidence of tuberculosis and drug resistance is increasing in the United States, but it is not clear how much of the increase is due to reactivation of latent infection and how much to recent transmission., Methods: We performed DNA fingerprinting using restriction-fragment-length polymorphism (RFLP) analysis of at least one isolate from every patient with confirmed tuberculosis at a major hospital in the Bronx, New York, from December 1, 1989, through December 31, 1992. Medical records and census-tract data were reviewed for relevant clinical, social, and demographic data., Results: Of 130 patients with tuberculosis, 104 adults (80 percent) had complete medical records and isolates whose DNA fingerprints could be evaluated. Isolates from 65 patients (62.5 percent) had unique RFLP patterns, whereas isolates from 39 patients (37.5 percent) had RFLP patterns that were identical to those of an isolate from at least 1 other study patient; the isolates in the latter group were classified into 12 clusters. Patients whose isolates were included in one of the clusters were inferred to have recently transmitted disease. Independent risk factors for having a clustered isolate included seropositivity for the human immunodeficiency virus (HIV) (odds ratio for Hispanic patients, 4.31; P = 0.02; for non-Hispanic patients, 3.12; P = 0.07), Hispanic ethnicity combined with HIV seronegativity (odds ratio, 5.13; P = 0.05), infection with drug-resistant tuberculosis (odds ratio, 4.52; P = 0.005), and younger age (odds ratio, 1.59; P = 0.02). Residence in sections of the Bronx with a median household income below $20,000 was also associated with having a clustered isolate (odds ratio, 3.22; P = 0.04)., Conclusions: In the inner-city community we studied, recently transmitted tuberculosis accounts for approximately 40 percent of the incident cases and almost two thirds of drug-resistant cases. Recent transmission of tuberculosis, and not only reactivation of latent disease, contributes substantially to the increase in tuberculosis.