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ObjectiveTo identify genetic associations with severity of radiographic damage in ankylosing spondylitis (AS).MethodWe studied 1537 AS cases of European descent; all fulfilled the modified New York Criteria. Radiographic severity was assessed from digitised lateral radiographs of the cervical and lumbar spine using the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). A two-phase genotyping design was used. In phase 1, 498 single nucleotide polymorphisms (SNPs) were genotyped in 688 cases; these were selected to capture >90% of the common haplotypic variation in the exons, exon-intron boundaries, and 5 kb flanking DNA in the 5' and 3' UTR of 74 genes involved in anabolic or catabolic bone pathways. In phase 2, 15 SNPs exhibiting p

Background: Treatment of patients with rheumatoid arthritis (RA) has improved markedly over the past 25 years.Objective: To investigate whether rates of joint surgery, a long-term consequence of poorly controlled RA, have changed over this period.Methods: In this population-based, serial cross-sectional study of patients with RA aged >or=40 years in California, trends in annual rates of total knee arthroplasty, total hip arthroplasty, total ankle arthroplasty or arthrodesis and total wrist arthroplasty or arthrodesis from 1983 to 2007 were examined.Results: Rates of joint surgery peaked in the 1990 s and since have decreased. Among patients aged 40-59 years, rates of knee surgery in 2003-2007 were 19% lower than in 1983-1987 (adjusted rate ratio 0.81; 95% CI 0.74 to 0.87, p<0.0001), while rates of hip surgery in 2003-2007 were 40% lower (p<0.0001). Rates of knee and hip surgery did not decrease in patients aged >or=60 years but increased as observed in the general population. Compared with rates of ankle and wrist surgery in the mid-1980s, rates in the mid-2000s decreased significantly in both age groups.Conclusions: Rates of joint surgery in RA peaked in the 1990 s and have declined thereafter, suggesting that longterm outcomes of RA are improving. [ABSTRACT FROM AUTHOR]

BACKGROUND: Persons of low socioeconomic status (SES) may be at increased risk of end-stage renal disease (ESRD). This study examines the association between SES and incidence of ESRD caused by all primary renal diseases and caused by 3 diseases that differ in the availability of effective treatment: diabetes mellitus, lupus nephritis, and autosomal dominant polycystic kidney disease (ADPKD). STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults with incident ESRD in the United States from January 1, 1996, to June 30, 2004 (N = 747,556). PREDICTOR: SES, based on characteristics of the patient's ZIP code of residence. OUTCOMES: Incidence of ESRD. RESULTS: In all sex-race groups, the incidence of ESRD caused by all primary renal diseases was greatest in those in the lowest SES score quartile and decreased progressively with higher SES. For example, for white women, the incidence of ESRD was 388.9 per million in the lowest quartile of SES and 200.8 per million in the highest quartile of SES (relative risk, 1.92; 95% confidence interval, 1.89 to 1.95). However, this association differed among patients with primary renal diseases. There were strong associations between SES and ESRD caused by diabetes mellitus, weaker associations for ESRD caused by lupus nephritis, and generally no associations for ESRD caused by ADPKD. For example, for white women, relative risks of ESRD in the lowest compared with the highest SES quartile were 2.84 for ESRD caused by diabetes mellitus, 1.63 for ESRD caused by lupus nephritis, and 1.27 for ESRD caused by ADPKD. LIMITATIONS: Use of an area-based measure of SES. CONCLUSIONS: The strength of the association between SES and ESRD differs among patients with diabetes mellitus, lupus nephritis, and ADPKD, suggesting that socioeconomic factors act differently in the progression of chronic kidney disease in these conditions. Copyright © 2008 by the National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

BACKGROUND: Health information technology (HIT) is designed to help reduce medical errors and improve quality of care and efficiency by providing the right information for the right patients in the right place at the right time. Nevertheless, substantial variation currently exists in the adoption of electronic medical records (EMRs) resulting in differences in hospital HIT capacity. PURPOSE: The purpose of this article is to examine the impact of different types of multihospital system affiliation on EMR adoption in hospitals in the United States. METHODOLOGY: A cross-sectional design was used with a sample of 4,017 hospitals in the United States. Secondary data were retrieved from the Health Information and Management Systems Society Analytics Database. Multiple regression analysis was used to examine the impact of multihospital system affiliation on EMR level of adoption. FINDINGS: The mean EMR adoption level varies significantly between independent hospitals and hospitals owned by a system for small hospitals. After adjusting for the number of operating rooms, the number of emergency room visits, and the number of hospital total full-time equivalent staff, small hospitals owned by multihospital systems were associated with 0.25 higher mean EMR adoption level (p < .05) than independent hospitals and no significant relationship was observed for hospitals that were leased/managed by a system. There was no significant effect of multihospital system membership on EMR level of adoption for medium and large hospitals. PRACTICE IMPLICATIONS: Small hospitals owned by multihospital systems had a significantly higher EMR level compared with independent hospitals. These findings have significant implications for small hospitals that are struggling to improve their HIT capacity. Smaller hospitals in ownership arrangements with larger health care systems have an advantage over small independent hospitals in HIT capacity possibly because of the greater availability of capital, access to shared HIT capacity, and other resources including technical expertise. [ABSTRACT FROM AUTHOR]

Background: The Medicare Rural Hospital Flexibility Program of the 1997 Balanced Budget Act allowed hospitals meeting certain criteria to convert to critical access hospitals (CAH) and changed their Medicare reimbursement mechanism from prospective payment system (PPS) to cost-based.Objective: To examine the impact of CAH conversion on hospital patient safety.Data Source: Secondary data on hospital patient safety indicators (PSIs), hospital CAH status, patient case-mix, and market variables, for 89 Iowa rural hospitals during 1997-2004.Study Design: We employed quasi-experimental designs that use both control groups and pretests. The hospital-year was the unit of analysis. We used generalized estimating equations logit and random-effects Tobit models to assess the effects of CAH conversion on hospital patient safety. The models were adjusted for patient case-mix and market variables. Sensitivity analyses, which varied by sample and statistical model, were used to examine the robustness of our findings.Data Extraction Methods: PSIs were computed from Iowa State Inpatient Databases (SIDs) using Agency for Healthcare Research and Quality indicators software. Hospital CAH status was extracted from Iowa Hospital Association. Patient case-mix variables were extracted from Iowa SIDs. Market variables came from Area Resource File (ARF).Principal Findings: CAH conversion in Iowa rural hospitals was associated with better performance of risk-adjusted rates of iatrogenic pneumothorax, selected infections due to medical care, accidental puncture or laceration, and composite score of four PSIs, but had no significant impact on the observed rates of death in low-mortality diagnosis-related groups (DRGs), foreign body left during procedure, risk-adjusted rate of decubitus ulcer, or composite score of six PSIs. Conclusion. CAH conversion is associated with enhanced performance of certain PSIs. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Measurement of physical function at one point in time cannot distinguish impairment caused by the active disease process from chronic irreversible impairment. We aimed to dissect these two components of functional limitation in rheumatoid arthritis (RA) by using the disability index of the Health Assessment Questionnaire (HAQ) as the measure of function. METHODS: We performed a secondary analysis of data from 6 contemporary clinical trials of RA (2,763 patients). Patients in whom remission was achieved in the trials, based on a simplified disease activity index, were identified. In an individual patient, HAQ scores at trial entry represented both reversible and irreversible impairments, while HAQ scores at the time of RA remission represented the mostly irreversible component, and the difference between these corresponded to the component related to disease activity. We tested the concept that the HAQ has a reversible and an irreversible component by associating the HAQ score during remission with 2 measures associated with the degree of accrued damage: duration of RA and radiographic severity. RESULTS: Among patients in whom clinical remission was achieved (n = 295), average HAQ scores despite clinical remission increased progressively with the duration of RA, from 0.19 (<2 years of RA) to 0.36 (2-<5 years) to 0.38 (5-<10 years) to 0.55 (>/=10 years) (P < 0.001). The reversibility of HAQ scores decreased with the duration of RA (median 100%, 83.3%, 81.9%, and 66.7%, respectively; P < 0.001). Findings were similar in patients subgrouped by quartile of radiographic scores. CONCLUSION: Differences in the sources of functional limitations should be considered in the interpretation of functional measures, and in their use for prediction and in cost analyses. [ABSTRACT FROM AUTHOR]

The National Quality Forum (NQF) recently released a list of '30 Safe Practices' that were identified as relevant for all hospitals. The purpose of the present analysis was to assess hospitals' perceptions of each of the NQF 30 Safe Practices in terms of priority and progress. One hundred of Iowa's hospitals (86%) completed a survey. The highest progress ratings were for items involving hand washing, unit-dose medication dispensing, influenza vaccinations, implementing protocols to prevent wrong-site procedures, and standardized methods for labeling and storing medications. The lowest progress ratings were for intensive care units staffed by intensivists and implementing a computerized provider order entry system. Overall, safe practices that have been recommended for some time had higher priority and progress ratings. Most safe practices were equally endorsed by large and small hospitals, suggesting that the NQF goal of identifying safe hospital practices may be attainable for most of the safe practices. [ABSTRACT FROM AUTHOR]

Background: Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers.Objectives: The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty).Research Design and Subjects: The authors conducted a post hoc cross-sectional analysis of 279 physician-patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas.Main Outcome Measures: The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations.Results: The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients.Conclusions: Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Systemic lupus erythematosus (SLE) is an uncommon, clinically complex disease for which prior experience treating similar patients may be particularly important. This study was undertaken to determine if physician volume is associated with the outcome of hospitalization of patients with SLE. METHODS: Data on in-hospital mortality in a population-based sample of 15,509 patients with SLE ages 18 years or older who were hospitalized in 2000, 2001, or 2002 in New York or Pennsylvania were obtained from state health planning agencies. Risks of in-hospital mortality were examined in relation to the average annual number of patients with SLE hospitalized by the admitting physician. RESULTS: Physician volume was inversely associated with mortality. Mortality was 4.1% among patients of physicians who treated <1 hospitalized patient with SLE per year, 3.5% among patients of physicians who treated 1-3 patients per year, and 2.5% among patients of physicians who treated >3 patients per year. After adjustment for demographic characteristics, severity of illness, and hospital characteristics, the mortality risk was 20% lower among patients in the middle category of physician volume (odds ratio 0.80, 95% confidence interval 0.66-0.96, P =0.02), and 42% lower among patients in the highest category of physician volume (odds ratio 0.58, 95% confidence interval 0.42-0.82, P = 0.002), compared with patients in the lowest category. The association was stronger among patients with nephritis (n = 2,673), for whom the adjusted odds of mortality were approximately 60% lower among those in the highest category of physician volume. CONCLUSION: Our findings indicate that higher disease-specific physician volume is associated with lower risks of in-hospital mortality in patients with SLE. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to estimate the costs of implementing computerized physician order entry (CPOE) systems in hospitals in a rural state and to evaluate the financial implications of statewide CPOE implementation. METHODS: A simulation model was constructed using estimates of initial and ongoing CPOE costs mapped onto all general hospitals in Iowa by bed quantity and current clinical information system (CIS) status. CPOE cost estimates were obtained from a leading CPOE vendor. Current CIS status was determined through mail survey of Iowa hospitals. Patient care revenue and operating cost data published by the Iowa Hospital Association were used to simulate the financial impact of CPOE adoption on hospitals. RESULTS: CPOE implementation would dramatically increase operating costs for rural and critical access hospitals in the absence of substantial costs savings associated with improved efficiency or improved patient safety. For urban and rural referral hospitals, the cost impact is less dramatic but still substantial. However, relatively modest benefits in the form of patient care cost savings or revenue enhancement would be sufficient to offset CPOE costs for these larger hospitals. CONCLUSION: Implementation of CPOE in rural or critical access hospitals may depend on net increase in operating costs. Adoption of CPOE may be financially infeasible for these small hospitals in the absence of increases in hospital payments or ongoing subsidies from third parties. [ABSTRACT FROM AUTHOR]

Hospitals use numerous guideline implementation approaches with varying success. Approaches have been classified as consistently, variably, or minimally effective, with multiple approaches being most effective. This project assesses the Department of Veterans Affairs (VA) use of effective guideline implementation approaches. A survey of 123 VA quality managers assessed the approaches used to implement the chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and major depressive disorder guidelines. Approaches were categorized based on their effectiveness, and the total number of approaches used was calculated. Commonly used approaches were clinical meetings, summaries, and revised forms. Consistently and minimally effective approaches were used most frequently. Most hospitals used 4-7 approaches. Odds ratios demonstrated that consistently effective approaches were paired with minimally and variably effective approaches. The frequent use of consistently effective approaches and multiple approaches benefits VA adherence. However, VA hospitals should consider selective combinations of approaches to ensure the use of the most effective implementation methods. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether the rates of hospitalization for 4 manifestations of severe rheumatoid arthritis (RA), which are used as indicators of long-term health outcomes, have changed from 1983 to 2001. METHODS: Data on all patients with RA who were hospitalized with rheumatoid vasculitis or to undergo splenectomy for Felty's syndrome, cervical spine fusion for myelopathy, or total knee arthroplasty at hospitals in California were abstracted from a state hospitalization database. Changes in rates of hospitalization from 1983 to 2001 were examined in this serial cross-sectional study. RESULTS: Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome decreased progressively over time. The risk of hospitalization for rheumatoid vasculitis was one-third lower in 1998-2001 than in 1983-1987. The risk of hospitalization for splenectomy in Felty's syndrome was 71% lower in 1998-2001 than in 1983-1987. There were no significant decreases in the rates of hospitalization for cervical spine surgery or total knee arthroplasty (primary and revision), although in 1998-2001 there was a reversal of the trend of increasing rates of total knee arthroplasty. The risk of hospitalization for primary total knee arthroplasty was significantly lower in 1998-2001 than in 1990-1993 (rate ratio 0.90, 95% confidence interval 0.86-0.95; P < 0.0001). CONCLUSION: Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome have decreased over the past 19 years, and there has been a recent decrease in the rates of primary total knee arthroplasty in patients with RA. Although several factors may account for these decreases, these findings suggest that since the early 1980s, the long-term health outcomes of patients with RA have improved. [ABSTRACT FROM AUTHOR]

Provider knowledge is a potential barrier to adherence to clinical guidelines. The purpose of this study is to assess the impact of organizational, provider, and guideline factors on provider knowledge of a congestive heart failure (CHF) clinical practice guideline (CPG) in the Veterans Health Administration (VHA) health care system. We developed a survey to investigate institution-level factors influencing the effectiveness of guideline implementation, including characteristics of the guideline, providers, hospital culture and structure, and regional network. Survey participants were quality managers, primary care administrators, and other individuals involved in primary care CPG implementation at 143 VHA hospitals with ambulatory care clinics. Potential explanatory variables were grouped into 11 factors. Multivariate regression models assessed the association between these factors and reported levels of provider knowledge regarding the CHF guideline at the hospital level. Two hundred forty surveys from 126 of 143 (88%) VHA hospitals were returned. Provider knowledge of the CHF guideline was estimated as "great" or "very great" by 58% of respondents. Three predictor factors (dissemination approaches, use of technology in guideline implementation, and hospital culture) were independently associated (P < or = .05) with provider knowledge. Specific variables within these categories that were related to greater knowledge included physician belief that guidelines were applicable to their practice, distribution of guideline summaries, use of guideline storyboards in clinic areas, the use of technology (eg, electronic patient records) in CPG implementation, and establishment of implementation checkpoints and deadlines. Provider knowledge of guidelines is affected by factors at various organizational levels: dissemination approaches, use of technology, and hospital culture. Guideline implementation efforts that target multiple organizational levels may increase provider knowledge. [ABSTRACT FROM AUTHOR]

The growth of electronic medical records (EMRs) is driven by the belief that EMRs will significantly improve healthcare providers' performance and reduce healthcare costs. Evidence supporting these beliefs is limited, especially for small rural hospitals. A survey that focused on health information technology (HIT) capacity was administered to all hospitals in Iowa. Structured interviews were conducted with the leadership at 15 critical access hospitals (CAHs) that had implemented EMRs in order to assess the perceived benefits of operational EMRs. The results indicate that most of the hospitals implemented EMRs to improve efficiency, timely access, and quality. Many CAH leaders also viewed EMR implementation as a necessary business strategy to remain viable and improve financial performance. While some reasons reflect external influences, such as perceived future federal mandates, other reasons suggest that the decision was driven by internal forces, including the hospital's culture and the desires of key leaders to embrace HIT. Anticipated benefits were consistent with goals; however, realized benefits were rarely obvious in terms of quantifiable results. These findings expand the limited research on the rationale for implementing EMRs in critical access hospitals. [ABSTRACT FROM AUTHOR]

Background: Concern exists that certain types of exercise, particularly vigorous activity, may increase physical disability among older individuals. We investigated the prevalence of, and risk factors for, physical disability in active older persons (runners), and examined factors influencing the progression of physical disability with age.Methods: Physical disability, measured using the Health Assessment Questionnaire Disability Index, was assessed prospectively in 454 runners, age 50 or greater, over five to seven years by annual mailed questionnaires. Baseline sociodemographic, clinical, and life-style characteristics associated with the presence of any disability over the course of the study were determined and contrasted with those in 292 older non-runners who had been similarly followed.Results: Two hundred twenty-two runners (49%) reported some physical disability during the study. The presence of arthritis symptoms at baseline was the most important risk factor for physical disability; older age, greater body mass index, strenuous work-related physical activity, and the use of more medications were also associated with a greater likelihood of physical disability. Among the non-runners, 224 (77%) reported some physical disability, and the presence of arthritis symptoms was also the most important risk factor for physical disability in this group. Age-related changes in physical disability differed between those with and without arthritis symptoms in both the runner and non-runner groups.Conclusions: The presence of arthritis symptoms was an important risk factor for physical disability among both older runners and non-runners, and also identified subgroups of individuals with different progressions of disability with age. [ABSTRACT FROM AUTHOR]