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Background Care partners are key members of patients’ health care teams, yet little is known about their experiences accessing patient information via electronic portals. Objective To better understand the characteristics and perceptions of care partners who read patients’ electronic visit notes. Patient involvement Focus groups with diverse patients from a community health center provided input into survey development. Methods We contacted patient portal users at 3 geographically distinct sites in the US via email in 2017 for an online survey including open ended questions which we qualitatively analyzed. Results Respondents chose whether to answer as care partners (N = 874) or patients (N = 28,782). Among care partner respondents, 44% were spouses, 43% children/other family members, and 14% friends/neighbors/other. Both care partners and patients reported that access to electronic notes was very important for promoting positive health behaviors, but care partners’ perceptions of importance were consistently more positive than patients’ perceptions of engagement behaviors. Open-ended comments included positive benefits such as: help with remembering the plan for care, coordinating care with other doctors, decreasing stress of care giving, improving efficiency of visits, and supporting patients from a geographical distance. They also offered suggestions for improving electronic portal and note experience for care partners such as having a separate log on for care partners; having doctors avoid judgmental language in their notes; and the ability to prompt needed medical care for patients. Discussion Care partners value electronic access to patients’ health information even more than patients. The majority of care partners were family members, whose feedback is important for improving portal design that effectively engages these care team members. Practical value Patient care in the time of COVID-19 increasingly requires social distancing which may place additional burden on care partners supporting vulnerable patients. Access to patient notes may promote quality of care by keeping care partners informed, and care partner’s input should be used to optimize portal design and electronic access to patient information.

Electronic consultations (eConsultations) are increasingly used to obtain specialist guidance, avoiding unnecessary face-to-face patient visits for certain clinical questions. During the COVID-19 pandemic, when in-person care was limited, eConsultations may have helped clinicians obtain specialist input to guide patient care.To understand how the use of eConsultations changed during the COVID-19 pandemic and whether trends in eConsultation utilization differed based on patient's payer and primary language.This retrospective cohort study was conducted at 6 academic medical centers in the United States, all participating in the Association of American Colleges Coordinating Optimal Referral Experiences program. Participants included adult patients who had an outpatient visit, referral, or eConsultation during the study period. Data were analyzed from June 4, 2019, to July 28, 2020.The primary outcome was the eConsultation proportion of specialty contact, defined as the number of completed eConsultations divided by the sum of the number of completed eConsultations and specialty referrals, expressed as a percentage. eConsultation percentages of specialty contact were further stratified by payer type and language. Payers included commercial, Medicare, Medicaid, self-pay or uninsured, and other. Primary language included English and non-English languages.A total of 14 545 completed eConsultations and 189 776 referrals were included. More eConsultations were completed for English-speaking patients (11 363 eConsultations [95.0%]) than non-English-speaking patients (597 eConsultations [5.0%]). Patients with commercial insurance represented the highest number of completed eConsultations (8848 eConsultations [60.8%]) followed by Medicare (3891 eConsultations [26.8%]), Medicaid (930 eConsultations [6.4%]), other insurance (745 eConsultations [5.1%]), and self-pay or no insurance (131 eConsultations [0.9%]). At the start of the pandemic, across all academic medical centers, the percentage of specialty contact conducted via eConsultation significantly increased by 6.21% (95% CI, 4.97%-7.44%; P .001). When stratified by payer and language, the percentage of specialty contact conducted via eConsultation significantly increased at the beginning of the pandemic for both English-speaking patients (change, 6.09% (95% CI, 4.82% to 7.37%; P .001) and non-English-speaking patients (change, 8.48% [95% CI, 5.79% to 11.16%]; P .001) and for all payers, except self-pay and uninsured patients (change, -0.21% [95% CI, [-1.35% to 0.92%]; P = .70).This retrospective cohort study found that eConsultations provided an accessible mechanism for clinicians to receive specialist input when in-person care was limited.

BACKGROUND: Patients actively involved in their care demonstrate better health outcomes. Using secure internet portals, clinicians are increasingly offering patients access to their narrative visit notes (open notes), but we know little about their understanding of notes written by clinicians. OBJECTIVE: We examined patients’ views on the clarity, accuracy, and thoroughness of notes, their suggestions for improvement, and associations between their perceptions and willingness to recommend clinicians to others. DESIGN: We conducted an online survey of patients in 3 large health systems, June–October 2017. We performed a mixed methods analysis of survey responses regarding a self-selected note. PARTICIPANTS: Respondents were 21,664 patients aged 18 years or older who had read at least 1 open note in the previous 12 months. MAIN MEASURES: We asked to what degree the patient recalled understanding the note, whether it described the visit accurately, whether anything important was missing, for suggestions to improve the note, and whether they would recommend the authoring clinician to others. KEY RESULTS: Nearly all patients (96%) reported they understood all or nearly all of the self-selected note, with few differences by clinician type or specialty. Overall, 93% agreed or somewhat agreed the note accurately described the visit, and 6% reported something important missing from the note. The most common suggestions for improvement related to structure and content, jargon, and accuracy. Patients who reported understanding only some or very little of the note, or found inaccuracies or omissions, were much less likely to recommend the clinician to family and friends. CONCLUSIONS: Patients overwhelmingly report understanding their visit notes and usually find them accurate, with few disparities according to sociodemographic or health characteristics. They have many suggestions for improving their quality, and if they understand a note poorly or find inaccuracies, they often have less confidence in their clinicians.

Introduction/Objectives We examined an initial step towards co-generation of clinic notes by inviting patients to complete a pre-visit questionnaire that could be inserted into clinic notes by providers and describe the experience in a safety-net and non-safety-net clinic. Methods We sent an electronic pre-visit questionnaire on visit goals and interim history to patients at a safety-net clinic and a non-safety-net clinic before clinic visits. We compared questionnaire utilization between clinics during a one-year period and performed a chart review of a sample of patients to examine demographics, content and usage of patient responses to the questionnaire. Results While use was low in both clinics, it was lower in the safety-net clinic (3%) compared to the non-safety-net clinic (10%). We reviewed a sample of respondents and found they were more likely to be White compared to the overall clinic populations ( p Conclusions Given potential benefits of this questionnaire as a communication tool, addressing barriers to use of technology among vulnerable patients is needed, including access to devices and internet, and support from caregivers or culturally concordant peer navigators.

Background Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes. Objective This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention. Methods Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements. Results Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits. Conclusions OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

BACKGROUND Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes. OBJECTIVE This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention. METHODS Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements. RESULTS Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits. CONCLUSIONS OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

Key Points Question Is there a quantifiable association between the coronavirus disease 2019 (COVID-19) pandemic and the volume, type, and content of primary care encounters in the US? Findings In this cross-sectional analysis of the US National Disease and Therapeutic Index audit of more than 125.8 million primary care visits in the 10 calendar quarters between quarter 1 of 2018 and quarter 2 of 2020, primary care visits decreased by 21.4% during the second quarter of 2020 compared with the average quarterly visit volume of the second quarters of 2018 and 2019. Evaluations of blood pressure and cholesterol levels decreased owing to fewer total visits and less frequent assessment during telemedicine encounters. Meaning The COVID-19 pandemic was associated with changes in the structure of primary care delivery during the second quarter of 2020, with the content of telemedicine visits differing from that of office-based encounters., Importance Little is known about the association between the coronavirus disease 2019 (COVID-19) pandemic and the level and content of primary care delivery in the US. Objective To quantify national changes in the volume, type, and content of primary care delivered during the COVID-19 pandemic, especially with regard to office-based vs telemedicine encounters. Design, Setting, and Participants Analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index, a 2-stage, stratified nationally representative audit of outpatient care in the US from the first calendar quarter (Q1) of 2018 to the second calendar quarter (Q2) of 2020. Main Outcomes and Measures Visit type (office-based or telemedicine), overall and stratified by patient population and geographic region; assessment of blood pressure or cholesterol measurement; and initiation or continuation of prescription medications. Results In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million (95% CI, 117.3-127.5 million) and 130.3 million (95% CI, 124.7-135.9 million) quarterly primary care visits occurred in the US (mean, 125.8 million; 95% CI, 121.7-129.9 million), most of which were office-based (92.9%). In 2020, the total number of encounters decreased to 117.9 million (95% CI, 112.6-123.2 million) in Q1 and 99.3 million (95% CI, 94.9-103.8 million) in Q2, a decrease of 21.4% (27.0 million visits) from the average of Q2 levels during 2018 and 2019. Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits). Decreases occurred in blood pressure level assessment (50.1% decrease, 44.4 million visits) and cholesterol level assessment (36.9% decrease, 10.2 million visits) in Q2 of 2020 compared with Q2 2018-2019 levels, and assessment was less common during telemedicine than during office-based visits (9.6% vs 69.7% for blood pressure; P, This cross-sectional study uses data from the National Disease and Therapeutic Index to quantify changes in volume and type of primary care visits and changes in visit content associated with the COVID-19 pandemic in the US.

Background Persons with substance use disorders face major barriers to hepatitis C virus (HCV) treatment. Co-location of addiction and HCV treatment is appealing, yet there are limited data on outcomes using this model. This study evaluated HCV outcomes of patients treated with direct-acting antivirals (DAAs) by primary care providers in two sites of co-located addiction/HCV care. Methods The study conducted a retrospective chart review for all patients receiving DAA treatment from 2016 to 2018 at 1) a hospital-based primary care clinic with an office-based buprenorphine program, and 2) a primary care clinic within an opioid treatment program (i.e. methadone clinic). The study classified patients into 3 groups according to treatment status: buprenorphine maintenance, methadone maintenance, or neither. Descriptive analyses compared patient demographics, clinical characteristics, adherence to monitoring and treatment, and the primary outcome of sustained virologic response at 12 weeks (SVR12), defined as an undetectable HCV viral load at least 12 weeks after completing treatment. Results This study included 50 patients who initiated DAA treatment. The majority of patients were unemployed (74.0%), did not smoke tobacco (54.0%), and had psychiatric comorbidities (80.0%). Many also experienced homelessness during treatment (22.0%) and experienced previous incarceration (36.0%). Only a few had recently injected drugs (4.0%). Seven of 7 (100%) patients were treated with buprenorphine, 21 of 24 (87.5%) patients were treated with methadone, and 17 of 19 (89.5%) patients receiving no opioid addiction treatment fully completed HCV DAA treatment. When including patients with missing SVR12 data with the cohort that did not achieve cure, we observe that 44 of 50 patients (88.0%) achieved SVR12. Excluding patients missing SVR12 data, we observed that 44 of 46 patients (95.7%) achieved SVR12. Conclusion Persons with substance use disorders treated with DAAs in co-located primary care and addiction treatment settings can achieve high rates of cure despite significant comorbidities and barriers. DAA treatment should be expanded to co-located HCV and addiction settings.

We launched Infectious Disease electronic consultations (eConsults) in 2018. During the first 15.5 months, primary care practitioners submitted 328 eConsults; the most frequent reasons were a positive culture or polymerase chain reaction (PCR) result, syphilis, and latent tuberculosis. Practitioners commonly requested advice on antimicrobial choice, clinical evaluation, and indications for treatment. Internal phone consultations decreased after eConsult implementation., Electronic consultations (eConsults) provide PCPs with rapid access to specialist advice. Few evaluations of optimal usage for Infectious Diseases exist. This study reviews ID eConsult implementation at an academic institution, plus consult topics, response time, and changes to in-person referrals.

A foundational understanding of the management of type 2 diabetes is critical for all medical students and residents. This chalk talk emphasizes the importance and key considerations for individualized HbA1c targets and patient-centered treatment, highlighting the mechanism and efficacy of newer pharmacologic options.

We examine contradictions of populism and resource extraction in Mongolia in the context of the recent presidential election of Khaltmaa Battulga, who is often portrayed as dangerously populist. We...

Background Patient portals are expanding as a means to engage patients and have evidence for benefit in the outpatient setting. However, few studies have evaluated their use in the inpatient setting, or with vulnerable patient populations. Objective This article assesses an intervention to teach hospitalized vulnerable patients to access their discharge summaries using electronic patient portals. Methods Patients at a safety net hospital were randomly assigned to portal use education or usual care. Surveys assessed perceptions of discharge paperwork and the electronic portal. Results Of the 202 prescreened eligible patients (e.g., deemed mentally competent, spoke English, and had a telephone), only 43% had working emails. Forty-four percent of participants did not remember receiving or reading discharge paperwork. Patients trained in portal use (n = 47) or receiving usual care (n = 23) preferred hospitals with online record access (85 and 83%, respectively), and felt that online access would increase their trust in doctors (85 and 87%) and satisfaction with care (91% each). Those who received training in portal use were more likely to register for the portal (48% vs. 11%; p Conclusion Patients had positive perceptions of portals, and education increased portal use. Lack of email access is a notable barrier to electronic communication with vulnerable patients.

Objective Chronic disease management can require daily attention, and increased levels of patient activation and engagement. We examined whether patients with diabetes perceive a greater benefit to having electronic access to their doctors’ clinic notes compared to patients without diabetes. We hypothesized that easy electronic access to these notes may help patients with self-care by improving education and communication. Methods Survey of patients with and without diabetes in Massachusetts and Pennsylvania about perceptions of potential benefits and risks of reading their visit notes via an electronic patient information portal. Administrative data were used to identify patients with diabetes; we compared their perceptions to those of patients without diabetes. Results The majority of patients (both with and without diabetes) perceived a positive impact of using the portal. Patients with diabetes were significantly more likely to believe that having access to and reading their notes would help them take their medication better and take better care of themselves. Conclusions Patients with chronic diseases such as diabetes might receive an even greater benefit from access to their doctors’ notes than the general patient population. Practice implications Doctors should encourage their patients with diabetes (or other chronic diseases) to use patient portals.

Background Patients are increasingly offered electronic access to their doctors' notes, and many consistently receive paper After-Visit Summaries. Specific feedback from patients about notes and summaries are lacking, particularly within safety-net settings. Design A mixed methods study SETTING AND PARTICIPANTS: Patients with poorly controlled diabetes attending two urban safety-net primary care clinics in Washington State. Methods Patients read their own most recent clinic note and After-Visit Summary, then completed a brief survey followed by a focus group discussion (3 groups in a large general medicine teaching clinic and 1 in an HIV/AIDS clinic) about their perceptions of the clinic note and After-Visit Summary. Results Twenty-seven patients participated; 70% were male, 41% were Black, 48% were unemployed or disabled, 56% reported fair/poor health, and 37% had accessed the electronic patient portal. A majority of patients felt their note content was useful (89%); a minority reported that their notes were not accurate (19%), had too much medical jargon (29%), or were too long (26%). Themes identified from the discussions included reliance on the provider to explain confusing content; a desire for more rather than less detail; and perceived inaccuracies, particularly in heavily templated notes. In each focus group, one or more portal users were enthusiastically willing to teach other patients. Conclusions The majority of focus group participants at this safety-net site had not accessed the electronic patient portal, but those who had were willing to promote the portal benefits and assist others. Patients identified specific opportunities to improve clinic notes and After-Visit Summaries.

Purpose The purpose of the study was to evaluate patient factors associated with nonengagement in a Diabetes Collaborative Care Team (DCCT) program in a safety-net clinic. Methods The first 18 months of a multidisciplinary care, team-based diabetes care management program in a safety-net primary care clinic were studied. Nonengagement was defined as fewer than 2 visits with a team member during the 18 months of the program. Patients who did not engage in the program were compared with those who did engage on demographics, comorbid medical and psychiatric diagnoses, and cardiovascular risk factors, using univariate and multivariable analyses. Results Of the 151 patients referred to the DCCT, 68 (45%) were nonengaged. In unadjusted analyses, patients who did not engage were more likely to be female and have higher baseline A1C values; they were less likely to have major depressive disorder, anxiety disorder, any depression diagnosis, and hyperlipidemia. Female gender and chronic pain were independently associated with nonengagement after multivariable adjustment. Conclusions The findings suggest that among patients with uncontrolled diabetes in an urban safety-net primary care clinic, there is a need to address barriers to engagement for female patients and to integrate chronic pain management strategies within multicondition collaborative care models.

Collaborative visit agenda setting between patient and doctor is recommended. We assessed the feasibility, acceptability, and utility of patients attending a large primary care safety-net clinic typing their agendas into the electronic visit note before seeing their clinicians. One hundred and one patients and their 28 clinicians completed post-visit surveys. Patients and clinicians agreed that the agendas improved patient-clinician communication (patients 79%, clinician 74%), and wanted to continue having patients type agendas in the future (73%, 82%). Enabling patients to type visit agendas may enhance care by engaging patients and giving clinicians an efficient way to prioritize patients' concerns.

Surgeons may receive a different diagnosis when a breast biopsy is interpreted by a second pathologist. The extent to which diagnostic agreement by the same pathologist varies at two time points is unknown. Pathologists from eight U.S. states independently interpreted 60 breast specimens, one glass slide per case, on two occasions separated by ≥9 months. Reproducibility was assessed by comparing interpretations between the two time points; associations between reproducibility (intraobserver agreement rates); and characteristics of pathologists and cases were determined and also compared with interobserver agreement of baseline interpretations. Sixty-five percent of invited, responding pathologists were eligible and consented; 49 interpreted glass slides in both study phases, resulting in 2940 interpretations. Intraobserver agreement rates between the two phases were 92% [95% confidence interval (CI) 88–95] for invasive breast cancer, 84% (95% CI 81–87) for ductal carcinoma-in-situ, 53% (95% CI 47–59) for atypia, and 84% (95% CI 81–86) for benign without atypia. When comparing all study participants’ case interpretations at baseline, interobserver agreement rates were 89% (95% CI 84–92) for invasive cancer, 79% (95% CI 76–81) for ductal carcinoma-in-situ, 43% (95% CI 41–45) for atypia, and 77% (95% CI 74–79) for benign without atypia. Interpretive agreement between two time points by the same individual pathologist was low for atypia and was similar to observed rates of agreement for atypia between different pathologists. Physicians and patients should be aware of the diagnostic challenges associated with a breast biopsy diagnosis of atypia when considering treatment and surveillance decisions.

Background Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. Objective The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. Methods A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. Results Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. Conclusions In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

Over the last two decades and particularly in the last 10 years, Chinese investment in Mongolia has skyrocketed, with the vast majority of the country’s exports now flowing to China. As foreign investment has grown in Mongolia, particularly in the mining sector, apprehension circulates about the extension and meaning of increased Chinese power. We argue that contemporary anxieties about China’s economic influence in Mongolia go beyond recent and contemporary political economic issues and are tied to memories of the Qing Dynasty. Controversies surrounding Mongolia’s flagship mine, the Oyu Tolgoi copper–gold mine in South Gobi province, demonstrate how even non-Chinese foreign mining operations are intertwined with Mongolia’s past and future relationships with China. Rather than acting simply as resource nationalists, the people and government of Mongolia often see contemporary Chinese economic power through a historical lens, with fears of declining sovereignty and becoming Chinese through control ...

The growing and continued popularity of light rail transit systems in major United States metropolitan areas is leading to growing research on land use impacts, value generation, and contributions to gentrification. While various studies explore the fiscal and environmental influences of light rail transit development in the Denver Metropolitan Area, only recently have scholars turned their attention to gentrification and social influences. This paper analyzes how one station shapes residents' sense of place, providing more nuanced understandings of the role light rail and transit-oriented development affects perceptions of neighborhood character and place attachment. We argue that gentrification can be measured and understood not only quantitatively, but also by how people feel light rail influences their attachment to place. Residents within half a mile of the Evans Light Rail Station were randomly and anonymously surveyed with a series of demographic questions and asked to provide their experiences, observations, and opinions. With 166 household responses, we examine residents' perceptions of Evans Station and sense of place to investigate relationships between factors such as race, age, income, education, length of residency, and walking distance from the light rail station. Analysis of their responses creates a more nuanced understanding of the ways that light rail contributes to positive, neutral, and negative emotions associated with gentrification ranging from appreciation of increased accessibility, younger residents, increased property values, and new commercial development to complaints about increased density, higher rents, traffic, noise, and loss of community.

BACKGROUND: Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized. OBJECTIVE: To evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids. DESIGN: Retrospective cohort study of patients with chronic pain enrolled in an opioid registry as of May 2010. PARTICIPANTS: Patients with chronic pain enrolled in the opioid registry of a primary care clinic at an urban safety-net hospital in Seattle, WA. MAIN OUTCOMES AND MEASURES: Discontinuation from the opioid registry was the exposure of interest. Pre-specified main outcomes included mortality, prescription and primary care utilization data, and reasons for discontinuation. Data was collected through March 2015. KEY RESULTS: The study cohort comprised 572 patients with a mean age of 54.9 ± 10.1 years. COT was discontinued in 344 patients (60.1%); 254 (73.8%) discontinued patients subsequently filled at least one opioid prescription in Washington State, and 187 (54.4%) continued to visit the clinic. During the study period, 119 (20.8%) registry patients died, and 21 (3.7%) died of definite or possible overdose: 17 (4.9%) discontinued patients died of overdose, whereas 4 (1.75%) retained patients died of overdose. Most patients had at least one provider-initiated reason for COT discontinuation. Discontinuation of COT was associated with a hazard ratio for death of 1.35 (95% CI, 0.92 to 1.98, p = 0.122) and for overdose death of 2.94 (1.01–8.61, p = 0.049), after adjusting for age and race. CONCLUSIONS: In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this high-risk group. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05301-2) contains supplementary material, which is available to authorized users.

Background Office-based buprenorphine treatment is effective for opioid use disorder. Scant research has examined programmatic factors impacting successful initiation of treatment. To increase initiation of eligible patients, our buprenorphine program implemented changes to lower treatment thresholds. Most notable among these was elimination of a requirement that patients demonstrate abstinence from stimulants prior to initiating buprenorphine. Methods This observational, retrospective study included patients screened for primary care-based buprenorphine treatment under high- and low-threshold conditions from 2015 to 2017. Background characteristics and treatment data were extracted from the electronic medical record and clinical registry. Chi-squared tests were used to compare proportions of patients initiated within 90 days of screening and retained to 60 days after initiation, under both conditions. Multivariate logistic regression was employed to compare relative odds of buprenorphine initiation after adjustment for several covariates. All analyses were stratified by recent stimulant use. Results The sample of 168 patients included 96 in the high-threshold group and 72 in the low-threshold group. Among patients with recent stimulant use, low-threshold conditions were associated with a higher proportion of patients initiated (69% versus 35%, p = 0.002) and higher relative odds of initiation (aOR = 7.01, 95% CI = 2.26–21.80) but also with a lower proportion of patients retained (63% versus 100%, p = 0.004). Among patients without recent stimulant use, low-threshold conditions did not change these measures by a statistically significant margin. Conclusions Lower-threshold policies may increase buprenorphine treatment initiation for patients with co-occurring stimulant use. However, patients using stimulants may require additional supports to remain engaged.

Patient access to online electronic medical records (EMRs) is increasing and may offer benefits to patients. However, the inherent complexity of medicine may cause confusion. We elucidate characteristics and health behaviors of patients who report confusion after reading their doctors’ notes online. We analyzed data from 4,528 patients in Boston, MA, central Pennsylvania, and Seattle, WA, who were granted online access to their primary care doctors’ clinic notes and who viewed at least one note during the 1-year intervention. Three percent of patients reported confusion after reading their visit notes. These patients were more likely to be at least 70 years of age (p < .0001), have fewer years of education (p < .0017), be unemployed (p < .0001), have lower levels of self-reported health (p < .0043), and worry more after reading visit notes (relative risk [RR] 4.83; confidence interval [CI] 3.17, 7.36) compared to patients who were not confused. In adjusted analyses, they were less likely to report feeling more in control of their health (RR 0.42; CI 0.25, 0.71), remembering their care plan (RR 0.26; CI 0.17, 0.42), and understanding their medical conditions (RR 0.32; CI 0.19, 0.54) as a result of reading their doctors’ notes compared to patients who were not confused. Patients who were confused by reading their doctors’ notes were less likely to report benefits in health behaviors. Understanding this small subset of patients is a critical step in reducing gaps in provider–patient communication and in efforts to tailor educational approaches for patients.

South Gobi province is at the center of Mongolia’s mining boom, where companies began exporting minerals over dirt-track roads in the early 2000s. This paper examines recent controversies surrounding road dust near the Oyu Tolgoi copper–gold mine, the so-called coal road from Tavan Tolgoi mines, and the Chinese border. At the time of the research, local residents, particularly nomadic herders, were concerned that dust produced from unpaved mining roads was coating the pasture, causing illnesses among livestock, and endangering their livelihoods in the region. The presence of dust rendered mining an uncomfortably intimate experience as state and corporate actors negotiated responsibility for infrastructure development. The paper builds on the concept “technologies of distantiation” to reveal the complex ways that dust from unpaved roads creates distances and disconnections between people, livelihoods, and landscapes, representing an enclosure of the pasture. Methods for the paper include interviews, focus groups, and participant observation conducted in South Gobi province and Ulaanbaatar in 2010, 2011, and 2012 as well as follow-up research carried out in spring 2015.

The development of the Oyu Tolgoi copper-gold mine, located in Mongolia's South Gobi province, promises to rebuild the nation after two decades of economic and social instabilities following the 1990 revolution. While the company promotes the mine as the teleological solution to Mongolia's development, the state and public remain ambivalent, as concerns about a resource curse and Dutch Disease loom. In this paper, I argue that Oyu Tolgoi remains contested due to tensions between corporate and state actors as well as public concerns about the potential negative political, economic, and environmental effects of mining. Debates over the Oyu Tolgoi investment agreement negotiations and the immediate repercussions of the agreement signing reveal how the dual teleologies of building mineral nations crystallize in the neologism “Mine-golia.” This paper begins to fill a gap in the literature on mineral nations which privileges the role of the state, leaving how corporations engage in nation-building underexamined.

Patients living with HIV/AIDS face large societal and medical challenges. Inviting patients to read their doctors’ visit notes via secure electronic portals may empower patients and improve health. We investigated whether utilization and perceptions about access to doctors’ notes differed among doctors and patients in an HIV/AIDS clinic versus primary care setting. We analyzed pre- and 1-year postintervention data from 99 doctors and 3819 patients. HIV clinic patients did not report differences in perceived risks and benefits compared to primary care clinic patients, however, they were more likely to share notes with friends (33% versus 9%, P = .002), other health professionals (24% versus 8%, P = .03), or another doctor (38% versus 9%, P < .0001). HIV clinic doctors were less likely than primary care doctors to change the level of candor in visit notes ( P < .04). Our findings suggest that HIV clinic patients and doctors are ready to share visit notes online.

Objective Demonstrate the feasibility of implementing a collaborative care program for poorly-controlled type 2 diabetes and complex behavioral health disorders in an urban academically-affiliated safety net primary care clinic. Methods This retrospective cohort study evaluates multidisciplinary team care approach to diabetes in a safety net clinic, and included 634 primary care clinic patients with hemoglobin A1c (HbA1c) > 9%. HbA1c, blood pressure, and depression severity were assessed at the initial visit and at the end of treatment, and compared to those of patients who were not referred to the team. Results The 151 patients referred to the program between March 2013 and November 2014 had a higher initial mean HbA1c: 10.6% vs. 9.4%, and were more likely to have depression (p = 0.006), anxiety (p = 0.04), and bipolar disorder (p = 0.03), compared to the 483 patients who were not referred. During the 18-month study period, there was a mean decrease in HbA1c of 0.9 (10.6 to 9.4) among those referred to the team, compared to a mean decrease of 0.2 (9.4 to 9.2) among those not referred. This was a significantly greater percent change in HbA1c (p = 0.008). Conclusion The integration of behavioral healthcare into chronic care management of patients with diabetes is a promising strategy to improve outcomes among the high risk population in safety net settings.

The purposes of this study were to determine whether U.S. radiologists accurately estimate their own interpretive performance of screening mammography and to assess how they compare their performance with that of their peers.Between 2005 and 2006, 174 radiologists from six Breast Cancer Surveillance Consortium registries completed a mailed survey. The radiologists' estimated and actual recall, false-positive, and cancer detection rates and positive predictive value of biopsy recommendation (PPV(2)) for screening mammography were compared. Radiologists' ratings of their performance as lower than, similar to, or higher than that of their peers were compared with their actual performance. Associations with radiologist characteristics were estimated with weighted generalized linear models.Although most radiologists accurately estimated their cancer detection and recall rates (74% and 78% of radiologists), fewer accurately estimated their false-positive rate (19%) and PPV(2) (26%). Radiologists reported having recall rates similar to (43%) or lower than (31%) and false-positive rates similar to (52%) or lower than (33%) those of their peers and similar (72%) or higher (23%) cancer detection rates and similar (72%) or higher (38%) PPV(2). Estimation accuracy did not differ by radiologist characteristics except that radiologists who interpreted 1000 or fewer mammograms annually were less accurate at estimating their recall rates.Radiologists perceive their performance to be better than it actually is and at least as good as that of their peers. Radiologists have particular difficulty estimating their false-positive rates and PPV(2).

Rationale and Objectives To examine whether an intervention strategy consisting of a tailored web-based intervention, which provides individualized audit data with peer comparisons and other data that can affect recall, can assist radiologists in setting goals for reducing unnecessary recall. Materials and Methods In a multisite randomized controlled study, we used a tailored web-based intervention to assess radiologists’ ability to set goals to improve interpretive performance. The intervention provided peer comparison audit data, profiled breast cancer risk in each radiologist’s respective patient populations, and evaluated the possible impact of medical malpractice concerns. We calculated the percentage of radiologists who would consider changing their recall rates, and examined the specific goals they set to reduce recall rates. We describe characteristics of radiologists who developed realistic goals to reduce their recall rates, and their reactions to the importance of patient risk factors and medical malpractice concerns. Results Forty-one of 46 radiologists (89.1%) who started the intervention completed it. Thirty-one (72.1%) indicated they would like to change their recall rates and 30 (69.8%) entered a text response about changing their rates. Sixteen of the 30 (53.3%) radiologists who included a text response set realistic goals that would likely result in reducing unnecessary recall. The actual recall rates of those who set realistic goals were not statistically different from those who did not (13.8% vs. 15.1%, respectively). The majority of selected goals involved re-reviewing cases initially interpreted as Breast Imaging Reporting and Data System category 0. More than half of radiologists who commented on the influence of patient risk (56.3%) indicated that radiologists planned to pay more attention to risk factors, and 100% of participants commented on concerns radiologists have about malpractice with the primary concern (37.5%) being fear of lawsuits. Conclusions Interventions designed to reduce unnecessary recall can succeed in assisting radiologists to develop goals that may ultimately reduce unnecessary recall.

Fellowship training in breast imaging was the only radiologists’ characteristic significantly associated with greater sensitivity and higher overall accuracy; however, fellowship-trained radiologists also had significantly higher false-positive rates.

Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied.Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided.Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P.001; and PPV2, P.001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses.Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.

Earlier studies of diagnostic mammography found wide unexplained variability in accuracy among radiologists. We assessed patient and radiologist characteristics associated with the interpretive performance of two types of diagnostic mammography.Radiologists interpreting mammograms in seven regions of the United States were invited to participate in a survey that collected information on their demographics, practice setting, breast imaging experience, and self-reported interpretive volume. Survey data from 244 radiologists were linked to data on 274,401 diagnostic mammograms performed for additional evaluation of a recent abnormal screening mammogram or to evaluate a breast problem, between 1998 and 2008. These data were also linked to patients' risk factors and follow-up data on breast cancer. We measured interpretive performance by false-positive rate, sensitivity, and AUC. Using logistic regression, we evaluated patient and radiologist characteristics associated with false-positive rate and sensitivity for each diagnostic mammogram type.Mammograms performed for additional evaluation of a recent mammogram had an overall false-positive rate of 11.9%, sensitivity of 90.2%, and AUC of 0.894; examinations done to evaluate a breast problem had an overall false-positive rate of 7.6%, sensitivity of 83.9%, and AUC of 0.871. Multiple patient characteristics were associated with measures of interpretive performance, and radiologist academic affiliation was associated with higher sensitivity for both indications for diagnostic mammograms.These results indicate the potential for improved radiologist training, using evaluation of their own performance relative to best practices, and for improved clinical outcomes with health care system changes to maximize access to diagnostic mammography interpretation in academic settings.

BACKGROUND: Though breast cancer is the most common malignancy among Chinese women, screening mammography is underutilized. This study examined barriers and facilitators of screening mammography among Chinese Canadian women. METHODS: Using community-based sampling, Chinese women in British Columbia were interviewed in 1999 about multiple preventive health behaviours. We included 213 women in the mammography analysis; main outcome measures were ever having a mammogram and routine mammography. RESULTS: Seventy-five percent of women 50 to 79 years old reported ever having had a mammogram, and 53% had two or more mammograms within the last five years. Receiving a recommendation for a mammogram from medical personnel or from a family member, and believing that cancer cannot be prevented by faith were independently associated with both screening outcomes. CONCLUSIONS: A multifaceted approach to screening mammography promotion in Chinese Canadian women is suggested. Interventions that include education of and by medical providers and family members should be considered.

Women 65 years and older are commonly screened for breast cancer with mammography. Models estimate that screening 1,000 women biannually for 10 years after the age of 69 would result in two fewer cancer deaths, 200 false positive mammograms, and 13 cases of over-diagnosis (breast cancer that would not have been clinically evident otherwise).1 The study by Schonberg et al. evaluates the effects of benign breast biopsies upon older women, using validated scales of psychological and physical consequences measured at the time of biopsy and after 6 months, and uses qualitative data to develop a conceptual model of undergoing a benign breast biopsy.2 At the time of biopsy, 76 % of women reported negative psychological consequences, which persisted at 6 months for 39 %. After 6 months, one in five women felt that worry interfered with their daily activities, and there was a trend for women with ≤ 9 years life expectancy to have higher negative psychological consequences compared to healthier women. Women also noted competing health issues in the qualitative data, all of which support the need for personalized decision making to balance risks and benefits of breast cancer screening in this age group. Opportunities identified for optimizing the experience of breast biopsies for women include positive interactions with radiology staff and physicians and systematic processes that minimize the wait time for test results. Women want information that explains biopsy procedures and diagnosis-specific information post-biopsy. Patient education materials would need to reflect current recommendations,3 particularly for diagnoses that are associated with higher risk for breast cancer, such as atypia, and to acknowledge the paucity of evidence supporting mortality benefit from such follow-up. Delivering this information via the primary care provider, with whom women wanted to communicate, would improve on-going shared decision making about future breast cancer screening. Decision aids that personalize screening recommendations based upon women’s competing medical issues and life expectancy4,5 would ideally be easily accessible in the primary care setting within an electronic medical record. These supports are needed to decrease the harms of breast cancer screening among women 65 years and older.

Background: Inviting patients to read their primary care visit notes may improve communication and help them engage more actively in their health care. Little is known about how patients will use the opportunity to share their visit notes with family members or caregivers, or what the benefits might be. Objective: Our goal was to evaluate the characteristics of patients who reported sharing their visit notes during the course of the study, including their views on associated benefits and risks. Methods: The OpenNotes study invited patients to access their primary care providers’ visit notes in Massachusetts, Pennsylvania, and Washington. Pre- and post-intervention surveys assessed patient demographics, standardized measures of patient-doctor communication, sharing of visit notes with others during the study, and specific health behaviors reflecting the potential benefits and risks of offering patients easy access to their visit notes. Results: More than half (55.43%, 2503/4516) of the participants who reported viewing at least one visit note would like the option of letting family members or friends have their own Web access to their visit notes, and 21.70% (980/4516) reported sharing their visit notes with someone during the study year. Men, and those retired or unable to work, were significantly more likely to share visit notes, and those sharing were neither more nor less concerned about their privacy than were non-sharers. Compared to participants who did not share clinic notes, those who shared were more likely to report taking better care of themselves and taking their medications as prescribed, after adjustment for age, gender, employment status, and study site. Conclusions: One in five OpenNotes patients shared a visit note with someone, and those sharing Web access to their visit notes reported better adherence to self-care and medications. As health information technology systems increase patients’ ability to access their medical records, facilitating access to caregivers may improve perceived health behaviors and outcomes. [J Med Internet Res 2014;16(11):e247]

The effect of physician diagnostic variability on accuracy at a population level depends on the prevalence of diagnoses.To estimate how diagnostic variability affects accuracy from the perspective of a U.S. woman aged 50 to 59 years having a breast biopsy.Applied probability using Bayes' theorem.B-Path (Breast Pathology) Study comparing pathologists' interpretations of a single biopsy slide versus a reference consensus interpretation from 3 experts.115 practicing pathologists (6900 total interpretations from 240 distinct cases).A single representative slide from each of the 240 cases was used to estimate the proportion of biopsies with a diagnosis that would be verified if the same slide were interpreted by a reference group of 3 expert pathologists. Probabilities of confirmation (predictive values) were estimated using B-Path Study results and prevalence of biopsy diagnoses for women aged 50 to 59 years in the Breast Cancer Surveillance Consortium.Overall, if 1 representative slide were used per case, 92.3% (95% CI, 91.4% to 93.1%) of breast biopsy diagnoses would be verified by reference consensus diagnoses, with 4.6% (CI, 3.9% to 5.3%) overinterpreted and 3.2% (CI, 2.7% to 3.6%) underinterpreted. Verification of invasive breast cancer and benign without atypia diagnoses is highly probable; estimated predictive values were 97.7% (CI, 96.5% to 98.7%) and 97.1% (CI, 96.7% to 97.4%), respectively. Verification is less probable for atypia (53.6% overinterpreted and 8.6% underinterpreted) and ductal carcinoma in situ (DCIS) (18.5% overinterpreted and 11.8% underinterpreted).Estimates are based on a testing situation with 1 slide used per case and without access to second opinions. Population-adjusted estimates may differ for women from other age groups, unscreened women, or women in different practice settings.This analysis, based on interpretation of a single breast biopsy slide per case, predicts a low likelihood that a diagnosis of atypia or DCIS would be verified by a reference consensus diagnosis. This diagnostic grey zone should be considered in clinical management decisions in patients with these diagnoses.National Cancer Institute.

Rationale and Objectives Mammography quality assurance programs have been in place for more than a decade. We studied radiologists’ self-reported performance goals for accuracy in screening mammography and compared them to published recommendations. Materials and Methods A mailed survey of radiologists at mammography registries in seven states within the Breast Cancer Surveillance Consortium (BCSC) assessed radiologists’ performance goals for interpreting screening mammograms. Self-reported goals were compared to published American College of Radiology (ACR) recommended desirable ranges for recall rate, false-positive rate, positive predictive value of biopsy recommendation (PPV2), and cancer detection rate. Radiologists’ goals for interpretive accuracy within desirable range were evaluated for associations with their demographic characteristics, clinical experience, and receipt of audit reports. Results The survey response rate was 71% (257 of 364 radiologists). The percentage of radiologists reporting goals within desirable ranges was 79% for recall rate, 22% for false-positive rate, 39% for PPV2, and 61% for cancer detection rate. The range of reported goals was 0%–100% for false-positive rate and PPV2. Primary academic affiliation, receiving more hours of breast imaging continuing medical education, and receiving audit reports at least annually were associated with desirable PPV2 goals. Radiologists reporting desirable cancer detection rate goals were more likely to have interpreted mammograms for 10 or more years, and >1000 mammograms per year. Conclusion Many radiologists report goals for their accuracy when interpreting screening mammograms that fall outside of published desirable benchmarks, particularly for false-positive rate and PPV2, indicating an opportunity for education.

We reviewed the current state of knowledge about urinary tract infection in patients with diabetes from the clinical and basic science perspectives. We identified key knowledge gaps and areas for further research.We performed a focused literature search on certain topics, including clinical studies related to etiology and pathophysiology of urinary tract infection in patients with diabetes, urinary tract infection studies in animal models of diabetes and basic science studies of the molecular mechanisms of urinary tract infection.Individuals with diabetes are at higher risk for urinary tract infection. Increased susceptibility in patients with diabetes is positively associated with increased duration and severity of diabetes. Clinical epidemiological data identifying mechanisms of increased urinary tract infection susceptibility in patients with diabetes are generally lacking and indicate only that urinary tract infections in women with and without diabetes are qualitatively similar in bacterial etiology and morbid sequelae. Existing animal models for diabetes have not been well characterized for urinary tract infection research. The increased incidence, prevalence and severity of urinary tract infection in patients with diabetes argue for aggressive antibacterial chemotherapy but novel therapies resulting from urinary tract infection research in nondiabetic animal models are still not available.Future clinical investigations of urinary tract infection in patients with diabetes should focus on how the disease differs from that in patients without diabetes, notably on the role of glycosuria and urinary tract infection risk. Basic science research priorities for urinary tract infection in patients with diabetes should emphasize further development of diabetic animal models for urinary tract infection research and clinical translation of known important virulence determinants into new therapies.

To estimate the temporal relationship between self-reported urine loss and incident, symptomatic, microbiologically confirmed urinary tract infection (UTI).We used daily diaries to collect information on incontinent episodes during a 2-year prospective study of incident UTI among 913 healthy postmenopausal health maintenance organization enrollees. We calculated the monthly rate of urine loss to assess for association with incident UTI. We also estimated the basal rate of urinary incontinence among women who experienced a UTI (excluding the 14-day time period pre- and post-UTI) and compared this to urine loss during the 3-day time period after UTI, to evaluate changes after infection.Sixty percent of women reported urinary incontinence, at a mean rate of 4.7 times per month. The monthly mean rate of urine loss was 2.64 times per month among women who did not experience a UTI compared with 4.60 times per among women who developed a UTI (P=.04). Among women who developed a UTI (n=78), the rate of urine loss during the 3 days after UTI onset was 1.5 times higher than the basal rate (0.23 compared with 0.15 reports per day, P=.26).After eliminating episodes of incontinence surrounding a UTI, the basal rate of urine loss was higher among women who experienced UTIs compared with those who did not. Additionally, among women who experienced a UTI, an increase in urine loss occurred in the immediate 3-day time period post-UTI, compared with infection-free periods. Urinary incontinence characterizes women who experience UTIs, both intercurrently and during an acute episode.III.

OBJECTIVE—This study evaluates diabetes characteristics and other risk factors for urinary incontinence among community-dwelling postmenopausal women. RESEARCH DESIGN AND METHODS—We performed a cross-sectional analysis of a population-based study of 1,017 postmenopausal women (218 with diabetes), aged 55–75 years, enrolled from a health maintenance organization. Outcomes included any incontinence and severe incontinence in the prior month. RESULTS—Overall, 60% of women had any incontinence in the prior month and 8% had severe incontinence. Parity and postvoid residual bladder volume were not associated with incontinence. Oral estrogen and vaginal estrogen use were positively associated with a report of any incontinence but not severe incontinence. A history of urinary tract infection (UTI) and measures of general health were associated with both outcomes. Women with diabetes reported disproportionately more severe incontinence, difficulty controlling urination, mixed (stress and urge) incontinence, use of pads, inability to completely empty the bladder, being unaware of leakage, and discomfort with urination (P ≤ 0.06). Diabetes duration, treatment type, peripheral neuropathy, and retinopathy were significantly associated with severe incontinence in multiple regression models adjusted for age, education, and history of UTI (P = 0.01–0.06); however, additional adjustment for BMI diminished the strength of association (P = 0.17–0.52). CONCLUSIONS—Urinary incontinence is highly prevalent among postmenopausal women. Women with diabetes are more likely to experience severe and symptomatic urinary incontinence. UTI history is a major risk factor, postvoid residual bladder volume plays no demonstrable role, and BMI confounds the relationship between diabetes and incontinence among healthy postmenopausal women.

To compare screening mammography and Pap testing among Chinese women in Seattle, Washington to Vancouver, and British Columbia.Using community-based sampling methods, trilingual female interviewers surveyed Chinese women in Seattle and Vancouver. Multiple preventive health behaviors and health care access variables were assessed. Mammography analysis included 409 women aged 50-74 years. Pap testing analysis included 973 women aged 20-69 years. Main outcome measures were ever use and use in the last 2 years of screening mammography and Pap testing.Chinese women in Vancouver were younger, more educated and fluent in English. Unadjusted rates of mammography and Pap testing were similar between the two cities. Provider type was consistently associated with screening in both cities; female providers had the highest rates and Chinese male providers the lowest. Adjusted logistic regression analysis demonstrated similar mammography use in the two cities. However, for Pap testing, women in Seattle had higher odds of screening compared to Vancouver.Despite universal health care coverage and baseline characteristics typically associated with greater utilization of preventive screening services, Chinese women in Vancouver did not have higher rates of screening mammography and Pap testing compared to Chinese women in Seattle.

PURPOSE: To describe the incidence of and risk factors for acute cystitis among nondiabetic and diabetic postmenopausal women. METHODS: We conducted a population-based, prospective cohort study of 1017 postmenopausal women, aged 55 to 75 years, who were enrolled in a health maintenance organization and followed for 2 years. A wide range of behavioral and physiologic exposures were assessed at baseline interview and follow-up clinic visits; the main outcome measure was microbiologically confirmed acute symptomatic cystitis. Follow-up was 87% at 12 months and 81% at 24 months. RESULTS: During 1773 person-years of follow-up, 138 symptomatic urinary tract infections occurred (incidence, 0.07 per person-year). Independent predictors of infection included insulin-treated diabetes (hazard ratio [HR] = 3.4; 95% confidence interval [CI]: 1.7 to 7.0) and a lifetime history of urinary tract infection (HR for six or more infections = 6.9; 95% CI: 3.5 to 13.6). Borderline associations included a history of vaginal estrogen cream use in the last month (HR = 1.8; 95% CI: 1.0 to 3.4), a history of kidney stones (HR = 1.9; 95% CI: 1.0 to 3.7), and asymptomatic bacteriuria at baseline (HR = 1.8; 95% CI: 0.9 to 3.5). Sexual activity, urinary incontinence, parity, postcoital urination, vaginal dryness, use of cranberry juice, vaginal bacterial flora, and postvoid residual bladder volume were not associated with incident acute cystitis after multivariable adjustment. CONCLUSION: Insulin-treated diabetes is a potentially modifiable risk factor for incident acute cystitis among postmenopausal women, whereas a lifetime history of urinary tract infection was the strongest predictor. Use of oral or vaginal estrogen was not protective, and a wide range of behavioral and physiologic factors was not associated with acute cystitis episodes in this generally healthy sample.