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BACKGROUND: Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes. METHODS: IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes. RESULTS: For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04). CONCLUSION: Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.

Objectives The price of analogue insulin has increased dramatically, making it unaffordable for many patients and insurance carriers. By contrast, human synthetic insulins are available at a fraction of the cost. The objective of this study was to examine whether patients with financial constraints were more likely to use low-cost human insulins compared with higher-cost analogue insulins and to determine whether outcomes differ between users of each type of insulin. Study design Retrospective cohort study. Methods Analysis of 4 cycles of the National Health and Nutrition Examination Survey was performed. Adults with diabetes who reported use of insulin were included. The primary outcome was use of human insulin or analogue insulin. The dependent variable was self-reported financial constraints, a composite variable. Secondary analysis examined the association between use of human vs analogue insulin and patient outcomes. Results Of 22,263 eligible respondents, 698 (3.1%) reported use of insulin and the type of insulin used, representing 485,228 patients nationally. Patients with 1 or more financial risk factors were more likely to use human insulin compared with patients without any financial risk factors (88.5% vs 76.7%; P = .014). There was no association between use of human vs analogue insulin on diabetic or other patient outcomes among patients regardless of financial risk. Conclusions Patients with financial risk factors may be more likely to use low-cost human synthetic insulins compared with insulin analogues. Outcomes were similar, even when stratified by financial risk.

Philanthropic partners have always played a critical role in the management and maintenance of national parks in the U.S. Cultivating strong relationships with the communities of color, particularly African Americans, has been a major challenge for the National Park Service (NPS). As ethnic populations increase in share of the U.S. total population, the lack of diversity in NPS partnerships will be increasingly problematic for national parks funding and stewardship. Building philanthropic partnerships with African American audiences will be critical to the long-term sustainability of the NPS. While philanthropy is present and strong in the Black community, further research is needed to ascertain how the NPS can inspire and sustain philanthropic actions among Black donors in support of national parks. This paper presents an overview of the literature on Black philanthropy and the findings from focus group interviews to understand how African Americans perceive their philanthropy and the ways they connect their giving to national parks. The focus group interviews occurred between February and June 2018 in Raleigh, NC; Atlanta, GA; Charlotte, NC; and Washington, DC. Participants included mostly African American donors who were actively involved in community foundations, philanthropic associations, and giving circles. The study found that Black philanthropy is embedded in the community life; measured not only in money, but also in time and talent; and, driven by race and humanity. Participants also noted that a general lack of awareness as an important reason why they had not considered giving in support of national parks in the past. They suggested that making more visible the Black history of national parks would likely increase African American donors’ interests and stewardship. We suggest the NPS broaden its lens in forming strategies for connecting to Black donors (and audiences in general). Findings in this report present unique opportunities for the NPS to cultivate enduring and meaningful relationships with African American communities in support of national parks. Specifically, the NPS should leverage Black philanthropy to build partnerships, recognize the importance of social empowerment, expand cultural memory as part of the NPS visitor experience, and build on the concept of giving circles.Subscribe to JPRA

Background Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus is a current pandemic. We initiated a program of systematic SARS-CoV-2 polymerase chain reaction (PCR) testing in all asymptomatic patients receiving radiotherapy (RT) at a large radiation oncology network in the Charlotte, NC metropolitan region and report adherence and results of the testing program. Methods Patients undergoing simulation for RT between May 18, 2020 and July 10, 2020 within the Levine Cancer Institute radiation oncology network who were asymptomatic for COVID-19 associated symptoms, without previous positive SARS-CoV-2 testing, and without recent high-risk contacts were included. PCR testing was performed on nasal cavity or nasopharyngeal swab samples. Testing was performed within 2 weeks of RT start (pre-RT) and at least every 4 weeks during RT for patients with prolonged RT courses (intra-RT). An automated task based process using the oncology electronic medical record (EMR) was developed specifically for this purpose. Results A total of 604 unique patients were included in the cohort. Details on testing workflow and implementation are described herein. Pre-RT PCR testing was performed in 573 (94.9%) patients, of which 4 (0.7%) were positive. The adherence rate to intra-RT testing overall was 91.6%. Four additional patients (0.7%) tested positive during their RT course, of whom 3 were tested due to symptom development and 1 was asymptomatic and identified via systematic testing. A total of 8 (1.3%) patients tested positive overall. There were no known cases of SARS-CoV-2 transmission from infected patients to clinic staff and/or other patients. Conclusions We detailed the workflows used to implement systematic SARS-CoV-2 for asymptomatic patients at a large radiation oncology network. Adherence rates for pre-RT and intra-RT testing were high using this process. This information allowed for appropriate delay in initiating RT, minimizing the occurrence of RT treatment interruptions, and no known cases of transmission from infected patients to clinic staff and/or other patients.

Background: Patients with cardiovascular disease (CVD) are especially vulnerable to respiratory infections caused by the coronavirus. The underlying effect of cardiovascular comorbidities on patients with COVID-19, however, remains to be sufficiently understood. Methods: Hospitalized COVID-19 patients from a state-wide large health care system with completed historical clinical conditions during March - June of 2020 were included in this study. The impact of CVD on the mortality, resources utility including the uses of intensive care unit (ICU) and ventilator, length of stay (LOS) and financial burden of COVID-19 inpatients were examined. Logistic analysis was applied to analyze the relationship between CVD and mortality, and non-parametric methods were used to evaluate the impact of CVD on resources utility. Random forest method was used to rank the importance of risk factors. Results: Among 811 hospitalized COVID-19 patients, 228 (28.11%) were placed in ICU, 105 (12.95%) spent on ventilators, and there were 94 deaths (11.59%). The mean LOS was 11.93 ± 11.26 (SD, standard deviation), mean time a patient in an ICU was 2.41 ± 5.49 days, and mean ventilator time was 1.29 ± 4.62 days. The mean charge of a patient was $55242 ± 71742) with inter-quarter range of $44124. Age, gender, and race were the top 3 factors of mortality and utilities. Patients who present with heart failure vs. those who do not, have increased mortality (21.47% vs 8.97%; odds ratio [OR], 2.00 (95% CI: 1.25-3.21; P=0.004), longer LOS (12.97 ±10.09 vs. 11.61±11.46), p=0.18), higher ICU usage ( 3.32 ± 6.04 vs. 2.14 ±5.26, p=0.02) and ICU requiring ventilator (1.86 ± 4.90 vs. 1.15 ± 4.56, p=0.09), and significant higher charge ($ 66175 ± 68773 vs $ 50736 ±64142, mean difference $15439± 65193 with 95% CI: $4537-26340, p=0.01). Similar results were shown for patients with coronary artery disease or arrhythmia. Patients with hypertension vs those who do not, have increased mortality (14.81% vs. 4.92%; OR=3.22 (95% CI: 1.76-5.90, p=0.01), but the impact was not significant after adjusted by age, race and gender. Conclusions: Among COVID-19 hospitalized patients with established cardiovascular disease, there was a worse survival and adverse utility outcomes in hospital resources and financial charges.

Diverting loop ileostomies are common procedures for protecting high-risk anastomoses. There is little consensus on the most ideal technique both in terms of cost efficiency and outcome. Data for this study were collected from 101 patients who underwent loop ileostomy reversal between 2009 and 2014 at Morristown Medical Center. Of the 101 patients included in the review, 57 received a hand-sewn anastomosis (HS-A) and 44 received a stapled anastomosis (S-A). Average total hospital charges for stapled anastomoses were significantly greater than that for hand-sewn anastomoses, as were total operating room supply costs. When the total cost of the operation itself was considered, S-A cases were still found to be significantly greater than HS-A cases. Hospital room charges, total lab charges, pathology charges, and EKG/ECG charges were all greater for S-A cases than HS-A cases. Overall costs were greater for S-As than hand-sewn anastomoses and because of a lack of difference in procedure length, stapler supply costs were not offset. Complication rates and length of stay were also similar between the techniques. We found S-A cases to be more costly and have a greater cost/hour than HS-A cases.

Accurate control and measurement of propellant flow to a thruster is one of the most basic and fundamental requirements for operation of electric propulsion systems, whether they be in the laboratory or on flight spacecraft. Hence, it is important for the electric propulsion community to have a common understanding of typical methods for flow control and measurement. This paper addresses the topic of propellant flow primarily for the gaseous propellant systems that have dominated laboratory research and flight application over the last few decades, although other types of systems are also briefly discussed. Although most flight systems have employed a type of pressure-fed flow restrictor for flow control, both thermal-based and pressure-based mass flow controllers are routinely used in laboratories. Fundamentals and theory of operation of these types of controllers are presented, along with sources of uncertainty associated with their use. Methods of calibration and recommendations for calibration process...

Objective To conduct a proof-of-concept pilot evaluation of the self-directed format of Walk With Ease (WWE), a 6-week walking program developed for adults with arthritis, in patients with systemic lupus erythematosus (SLE). Methods This was a single arm, 6-week pre- and post-evaluation of the self-directed WWE program to assess feasibility, tolerability, safety, acceptability, and effectiveness. Adult patients with physician-diagnosed SLE were recruited to participate during regularly scheduled visits to an academic rheumatology clinic. Self-reported outcomes of pain, stiffness, and fatigue were assessed by visual analog scales (VAS) and the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-fatigue) scale at baseline and at completion of the 6-week program. Patients also completed a satisfaction survey at the end of the program. Multivariate linear regression models were used to calculate mean changes between baseline and 6-week follow-up scores, adjusting for covariates. Mean change scores were used to estimate effect sizes (ES). Results At 6 weeks, 48 of the 75 recruited participants completed the WWE program. Participants experienced modest improvements in stiffness and fatigue (ES = 0.12 and ES = 0.23, respectively, for VAS scores; ES = 0.16 for FACIT-fatigue score) following the intervention. The majority of participants reported satisfaction with the program (98%) and benefitted from the workbook (96%). Conclusions The self-directed format of WWE appears to reduce stiffness and fatigue in patients with SLE. It also seems to be a feasible and acceptable exercise program to patients with SLE. Larger studies are needed to confirm these findings.

Background Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries. Methods Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed. Results Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30). Conclusion The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale. Electronic supplementary material The online version of this article (10.1186/s12913-019-3982-8) contains supplementary material, which is available to authorized users.

This survey study evaluates the frequency of sales of over-the-counter insulin at US pharmacies.

Introduction Low flow alarms (LFA's) in LVAD can occur due to a multitude of conditions. The differential diagnosis includes: hypovolemia, tamponade, right ventricular failure, hypertension, arrythmias, inflow cannula malposition, outflow cannula obstruction, and pre-pump inflow cannula thrombosis. We present a case of a patient with an HVAD with persistent LFA's and apparent myocardial recovery. Case Report A 44 y/o female who underwent destination therapy HVAD placement three years prior presented with one week of asymptomatic LFA's with low pulsatility. Device speed prior to presentation was 2400 RPM (flow 3 L/min, 6.4 L pulsatility, power 2.7 W); on presentation mean flows were 0.5 L/min, peak and trough 2.4 and 0 L/min, MAP was 59 mm Hg. TTE showed normal cannula position, closed aortic valve, mild right ventricular dysfunction. No arrythmias were present. LDH and plasma free Hgb were within normal limits. A controller exchange did not resolve LFA's. CT angiography showed no outflow graft obstruction. Invasive hemodynamics at 3100 RPM showed (mm Hg): RA pressure 8, RV pressure 42/8, PA pressure 40/14/28, PCWP 14/14/11, and cardiac index 4.3 L/min/m2. Given no obvious cause of LFA and apparent myocardial recovery, we opted for percutaneous device decommissioning, given poor candidacy for surgical explant. Under general anesthesia and full heparinization, device speed was lowered to 1800 RPM for 5 minutes, during which invasive hemodynamics remained stable. A 0.035 inch Rosen wire was placed into the outflow graft with subsequent exchange to a long 6-French sheath into the outflow graft. A 12-mm Amplatzer vascular plug was then deployed into the outflow graft with subsequent ventriculogram demonstrating retrograde flow (Figure). The device was powered off, the driveline buried, and the patient discharged with lifelong coumadin (INR 2-3) & Aspirin 81 mg. Summary This case demonstrates feasibility of percutaneous LVAD decommissioning in patients with myocardial recovery or device-related complications not amenable to surgical explant.

Background With the introduction of stapling devices (SDs), the proportion of hand-sewn (HS) intestinal anastomoses (IAs) has declined. As more IAs are constructed with SDs, there are fewer opportunities for general surgery residents (GSRs) to acquire the skills for HS techniques during their training. Study Design Data for this study were extracted from an existing database of all IAs performed at the Department of Surgery of the Morristown Medical Center since 2003. For the purposes of this study, a 5.5-year timeframe was used between July 2006 and 2011, which contained 1659 IA operations on adult patients with resident involvement. GSRs of the 5-year general surgery residency program were grouped by postgraduate year (PGY) for further analysis. Results The number of all IAs created by each resident during the 5-year training was 67.2 on average. Most of these operations were done in the last 2 years of the training: 45.1% of all IAs in PGY5 and 37.3% of all IAs in PGY4. Of all, 1659 IAs performed in the study period, 711 (42.9% of total) were done laparoscopically and 948 (57.1% of all IAs) were done as open operations. Laparoscopic operations had a proportionally higher rate of SD use when compared to open cases (90.9% vs 82.4%). On average, each resident constructed 9.4 HS IAs (13.98% of all IAs) and 57.8 SD IAs (86.02% of total). Out of all anastomoses, ostomy reversals (30.7%) had the highest percentage of HS suturing followed by right colectomies (27.5%), ileal pouch-anal anastomoses and total colectomies and proctocolectomies (23.3%), small bowel resection (17.0%), and left colectomies (5.5%). Regardless of the location of the operation, stapled and sutured anastomoses had similar outcomes measured by the rate of anastomotic leaks. Residents used significantly more SDs in the creation of anastomoses than HS suturing in the PGY3, PGY4, and PGY5 years. We also documented that attending surgeons who are older more often used HS suturing than their younger colleagues when creating IAs. Conclusions The experiences of GSRs in IA operations are heavily weighted toward the use of SDs. There are select cases, however, when HS suturing can have an advantage over stapler use in anastomosis creation. Therefore, we believe that GSRs should continue learning, perfecting, and using the both techniques.

It is widely hypothesized that improvement in transitions of care will reduce unplanned hospital readmissions. However, the association between the Care Transitions Measure, the national quality metric for transitions of care and readmission risk, has not been established. We aimed to determine the association between the Care Transition Measure and readmission. This was a single-center, prospective cohort study. Convenience sample of 2,963 patients enrolled in the “Bridging the Divides” program, a longitudinal care management program for patients with coronary revascularization, from 2013 to 2014. Of these, 1594 (54 %) patients completed a post-discharge Care Transition Measure questionnaire. Care Transition Measure scores were collected by trained research staff blinded to study hypothesis, by telephone, within 30 days of discharge. Higher Care Transition Measure scores reflect a higher quality transition of care. 30-day readmission was measured. Of the1594 patients that completed the Care Transition Measure survey, 1216 (76 %) received percutaneous coronary intervention and 378 (24 %) received coronary artery bypass grafting. Mean Care Transition Measure scores were significantly lower among patients who had a prior admission (77.2 vs. 82.1, p

Background Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries. Methods We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated. Results After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24). Conclusions Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.

BACKGROUND Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs. OBJECTIVE To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization. DESIGN/SETTING Observational study using electronic medical record and administrative data from a regional health system. PATIENTS 1323 community-dwelling Medicare patients admitted under observation status. MEASUREMENTS Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit. RESULTS Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P ⟨ 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118). CONCLUSIONS Medicare observation patients' potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172.

The burden of chronic obstructive pulmonary disease (COPD) in the United States is high, especially with regard to readmission rates and annual cost of health care. However, to date, there is little consensus about which clinical interventions have the greatest impact on reducing COPD readmissions. We reviewed literature in PubMed/MEDLINE to identify interventions that have the greatest impact on COPD readmissions, stratified by four clinical domains: patient risk factors, longitudinal care, acute care, and post-discharge care. Patients with more severe disease and fewer social supports are most vulnerable to COPD readmission. Chronic treatment with combined inhaled corticosteroids-long-acting beta-agonists or tiotropium as well as early antibiotic treatment during acute hospitalization decrease readmission rates. After discharge, the greatest effect on readmission rates was seen with early pulmonary rehabilitation, outpatient follow-up within 30 days, and enrollment in an integrated care program. While the standard of care in reducing COPD readmission rates remains to be elucidated, a multi-faceted approach that targets high-risk populations is likely to be most effective.

Hurricane Sandy was a particularly unusual storm with regard to both size and location of landfall. The storm landed in New Jersey, which is unusual for a tropical storm of such scale, and created hazardous conditions which caused injury to residents during the storm and in the months following. This study aims to describe differences in trauma center admissions and patterns of injury during this time period when compared to a period with no such storm. Data were collected for this study from patients who were admitted to the trauma center at Morristown Medical Center during Hurricane Sandy or the ensuing cleanup efforts (patients admitted between 29 October 2012 and 27 December 2012) as well as a control group consisting of all patients admitted to the trauma center between 29 October 2013 and 27 December 2013. Patient information was collected to compare the admissions of the trauma center during the period of the storm and cleanup to the control period. A total of 419 cases were identified in the storm and cleanup period. 427 were identified for the control. Striking injuries were more common in the storm and cleanup group by 266.7% (p = 0.0107); cuts were more common by 650.8% (p = 0.0044). Medical records indicate that many of these injuries were caused by Hurricane Sandy. Self-inflicted injuries were more common by 301.3% (p = 0.0294). There were no significant differences in the total number of patients, mortality, or injury severity score between the two cohorts. The data we have collected show that the conditions caused by Hurricane Sandy and the following cleanup had a significant effect on injury patterns, with more patients having been injured by being struck by falling or thrown objects, cut while using tools, or causing self-inflicted injuries. These changes, particularly during the cleanup period, are indicative of environmental changes following the storm which increase these risks of injury.

We present a novel musical system for learning the Curwen-Kodaly hand signs, which stand for solfege syllables and pitches (do, re, mi, etc.). These hand postures comprise a system of musical notation typically used in sight-singing training to familiarize with patterns of musical tones. Therefore, what concerns us is music literacy as opposed to practice with any particular instrument. Our system uses a Leap motion sensor to recognize the hand signs and produce corresponding user-recorded sounds. For each hand sign, the system also displays a natural 3D scenery, which is intended to match the metaphorical nature of the tone and has a resemblance to the hand posture (e.g. mi is a steady or calm tone, so the hand sign is an open hand with palm downwards and the scenery is a calm but moving ocean).

There is a need to back up critical timing infrastructure at the national level. This paper describes a joint project employing commercial equipment to send national timing signals through a telecommunication network. This experiment connects UTC(NIST) in Boulder, Colorado with UTC(USNO) at the Alternate Master Clock at Schriever AFB via a telecommunication provider's optical network using the Precise Time Protocol (PTP) to compare the time standards. The experiment was started in April 2014 and will run through the end of 2014. The paper provides insight into both the planning and validation of the transport path as well as analysis of the experimental data. The focus here is using a US commercial telecom carrier to transfer time between two national real-time standards of UTC.

Primary care site may play an important role in cardiovascular disease prevalence; however, the distribution of risk factors and outcomes across care sites is not known. In this study, a cross-sectional analysis of 21,778 adult participants from the National Health and Nutrition Examination Survey (NHANES; 1999 to 2008) using multivariate logistic regression was conducted to assess the relation between site of usual care and disease prevalence. Patients' self-reported histories of several chronic conditions (hypertension, diabetes, and hypercholesterolemia), awareness of chronic conditions, and associated cardiovascular events (angina, coronary heart disease, cardiovascular disease, myocardial infarction, and stroke) were examined. After adjustment for demographic and health care utilization characteristics, there were no significant differences in the prevalence of diabetes or hypercholesterolemia among patients receiving usual care at private doctors' offices, hospital outpatient clinics, community-based clinics, and emergency rooms (ER). However, participants without usual sources of care and those receiving usual care at ERs had significantly lower awareness of their chronic conditions than participants at other sites. The odds of having a history of each of the adverse cardiovascular events ranged from 2.21 to 4.18 times higher for patients receiving usual care at ERs relative to private doctors' offices. In conclusion, participants who report using ERs as their usual sites of care are disproportionately more likely to have histories of poor cardiovascular outcomes and are more likely to be unaware of having hypertension or hypercholesterolemia. As health care reform takes place and millions more begin seeking care, it is imperative to ensure access to longitudinal care sites designed for continuous disease management.

This paper is a brief discussion of some common mistakes made in the preparation of feasibility studies in the phosphate industry. The main emphasis will be on grassroots projects, which start with an ore deposit. The topics will include: • Inadequate Prospect Data • Insufficient Test Work • Improper Sample Handling • Unrealistic Project Schedule • Understating Infrastructure Requirements • Estimating Errors • Overly Optimistic Economics • Essential Elements in a Well-Run Project

Impact of Resident Workload and Handoff Training on Patient Outcomes Stephanie K. Mueller, MD, Stephanie A. Call, MD, MSPH, Furman S. McDonald, MD, MPH, Andrew J. Halvorsen, MS, Jeffrey L. Schnipper, MD, MPH, LeRoi S. Hicks, MD, MPH Brigham and Women’s-Faulkner Hospital Academic Hospitalist Service, Boston, Mass; Division of General Internal edicine, Brigham and Women’s Hospital, Boston, Mass; Division of General Internal Medicine, Virginia Commonwealth University, Richmond; Divisions of General and Hospital Internal Medicine and Office of Educational Innovations, Internal Medicine Residency, Mayo Clinic, Rochester, Minn; Division of Hospital Medicine, UMass Memorial Healthcare, Worcester; Department of Quantitative Sciences, University of Massachusetts Medical School, Worcester.

Although racial and ethnic minorities are more likely to be involved with the criminal justice system than whites in the U.S.A., critical scientific gaps exist in our understanding of the relationship between the criminal justice system and the persistence of racial/ethnic health disparities. Individuals engaged with the criminal justice system are at risk for poor health outcomes. Furthermore, criminal justice involvement may have direct or indirect effects on health and health care. Racial/ethnic health disparities may be exacerbated or mitigated at several stages of the criminal justice system. Understanding and addressing the health of individuals involved in the criminal justice system is one component of a comprehensive strategy to reduce population health disparities and improve the health of our urban communities.

Objective: Compare the agreement between four third-generation rapid or automated human immunodeficiency virus (HIV) tests vs the fourth-generation Abbott ARCHITECT HIV Ag/Ab Combo assay (Combo Test) (Abbott Laboratories, Abbott Park, IL) in 7 clinical laboratories located throughout the Dallas-Fort Worth, TX, metroplex area. Methods: We tested a total of 220 specimens from the general population of patients being screened for HIV antibody status, including Western blot (WB) and HIV-1 RNA viral load by NAAT in patients with initially positive HIV screening tests. We performed a method precision study of the Combo Test and evaluated the agreement between the 4 comparative methods (CMs) against the Combo Test method (TM) using a 2 × 2 contingency table to determine values for positive percent agreement (PPA), negative percent agreement (NPA), and overall percent agreement (OPA) according to the guideline (EP12-A2) for the evaluation of qualitative assays published by the Clinical Laboratory Standards Institute (CLSI). Results: The Combo Test yielded consistent (reproducible) results when the HIV antibody (or p24 antigen) concentration was 20% away or more from C50. In addition, values for PPA, NPA, and OPA for CM vs TM results were all 100%, or not significantly different from 100%. Conclusion: The high detection rate of the Combo Test, when coupled with its high diagnostic sensitivity and specificity, rapid TAT (

Minorities have a higher prevalence of hypertension, a major risk factor for cardiovascular disease, which contributes to racial/ethnic disparities in morbidity and mortality in the United States. Many modifiable health behaviors have been associated with improved blood pressure control, but it is unclear how racial/ethnic differences in these behaviors are related to the observed disparities in blood pressure control. Cross-sectional analyses were conducted among 21 489 US adults aged >20 years participating in the National Health and Nutrition Examination Survey from 2001 to 2006. Secondary analyses were conducted among those with a self-reported diagnosis of hypertension. Blood pressure control was defined as systolic values P P P

The relative effectiveness of strategies to recruit minority patients, populations traditionally difficult to engage in research, for focus groups is unclear. We conducted a systematic review of all peer-reviewed focus group studies targeting Black and/or Hispanic participants with diabetes, hypertension, asthma, and/or cardiovascular disease reported in Pubmed, MEDLINE, and CINAHL from January 1993 through August 2009. Reviewers extracted data on each study's characteristics, methods, and outcomes. Forty-five studies were eligible. While most described recruitment strategies, only 21 presented any metric of their success in recruiting participants. Among studies with high recruitment success rates, no discernable trends regarding effectiveness of recruitment strategies were found, largely due to variation in reporting of the use of incentives and follow-up mechanisms. Increased rigor is necessary for describing methodology of focus group research in the literature. It is incumbent upon researchers to ensure clear and detailed methodology in qualitative articles.

The purpose of this investigation was to determine the validity of 4-compartment (4C) model body fat percent (BF%) estimates when using dual energy x-ray absorptiometry (DXA) derived body volume (BV) equations (4C-DXA1 and 4C-DXA2) in adults with varying body mass index (BMI) and waist circumference (WC) classifications. Each model was compared to a criterion 4C model with air-displacement plethysmography (ADP) generated BV (4C-ADP). Participants were categorized as normal weight (n = 40; NW = BMI

Despite widely documented variations in health care outcomes by insurance status, few nationally representative studies have examined such disparities in the inpatient setting.To determine whether there are insurance-related differences in hospital care for 3 common medical conditions.Retrospective database analysis of 154,381 adult discharges (age 18-64 years) with a principal diagnosis of acute myocardial infarction (AMI), stroke, or pneumonia from the 2005 Nationwide Inpatient Sample (NIS).For each diagnosis, we compared in-hospital mortality, length of stay (LOS), and cost per hospitalization for Medicaid and uninsured patients with the privately insured.Compared with the privately insured, in-hospital mortality among AMI and stroke patients was significantly higher for the uninsured (adjusted odds ratio [OR] 1.52, 95% confidence interval [CI] [1.24-1.85] for AMI and 1.49 [1.29-1.72] for stroke) and among pneumonia patients was significantly higher for Medicaid recipients (1.21 [1.01-1.45]). Excluding patients who died during hospitalization, LOS was consistently longer for Medicaid recipients for all 3 conditions (adjusted ratio 1.07, 95% CI [1.05-1.09] for AMI, 1.17 [1.14-1.20] for stroke, and 1.04 [1.03-1.06] for pneumonia), although costs were significantly higher for Medicaid recipients for only 2 of the 3 conditions (adjusted ratio 1.06, 95% CI [1.04-1.09] for stroke and 1.05 [1.04-1.07] for pneumonia).In this nationally representative study of working-age Americans hospitalized for 3 common medical conditions, significantly lower in-hospital mortality was noted for privately insured patients compared with the uninsured or Medicaid recipients. Interventions to reduce insurance-related gaps in inpatient quality of care should be investigated.

Racial/ethnic disparities exist in the prevalence and outcomes of diabetes and hypertension in the U.S. A better understanding of the health beliefs and experiences of non-Hispanic Blacks and Latinos with these diseases could help to improve their care outcomes.We conducted eight focus groups stratified by participants' race/ethnicity, with 34 non-Hispanic Blacks and Latinos receiving care for diabetes and/or hypertension in one of 7 community health centers in Boston. Focus groups were designed to determine participants' levels of understanding about their chronic illness, assess their barriers to the management of their illness, and inquire about interventions they considered may help achieve better health outcomes.Among both groups of participants, nutrition (traditional diets), genetics and environmental stress (e.g. neighborhood crime and poor conditions) were described as primary contributors to diabetes and hypertension. Unhealthy diets were reported as being a major barrier to disease management. Participants also believed that they would benefit from attending groups on management and education for their conditions that include creative ways to adopt healthy foods that complement their ethnic diets, exercise opportunities, and advice on how to prevent disease manifestation among family members.Interactive discussion groups focused on lifestyle modification and disease management should be created for patients to learn more about their diseases. Future research evaluating the effectiveness of interactive diabetes and hypertension groups that apply patient racial/ethnic traditions should be considered.

Nationally, a higher proportion of the medically underserved than of the general population suffer from hypertension. Poorer adherence to recommended therapies (includ- ing medication regimens, salt intake reduction, and regular visits with provider) has been linked to poorer blood pressure control. To identify whether differences in adherence are associated with racial/ethnic and socioeconomic characteristics, we administered a sur- vey to 141 African American and non-Hispanic White hypertensive patients within two hospital-based clinics in an urban setting in the Northeast U.S. There were no differences in adherence to follow-up appointments or dietary recommendations between racial/ ethnic or income groups. However, there were differences between groups in adherence to medication regimens, with African Americans and lower-income groups significantly more likely to be non-adherent to medication regimens. When treating patients or implementing interventions aimed at improving adherence, special attention should be paid to African Americans and patients from low-income communities.

Background— Consultation with cardiologists may improve the quality of ambulatory care and reduce disparities for patients with heart disease. We assessed the use of cardiology consultations and the associated quality by race/ethnicity, gender, insurance status, and site of care. Methods and Results— In a retrospective cohort, we examined electronic records of 9761 adults with coronary artery disease or congestive heart failure (CHF) receiving primary care at practices affiliated with 2 academic medical centers during 2000 to 2005. During this period, 79.6% of patients with coronary artery disease and 90.3% of patients with CHF had a cardiology consultation. In multivariate analyses, women were less likely to receive a consultation than men for both conditions (coronary artery disease: hazard ratio, 0.89; 95% CI, 0.85 to 0.93; CHF: hazard ratio, 0.93; 95% CI, 0.87 to 0.99). Women also had 15% fewer follow-up consultations than men ( P P P =0.01 and P =0.04, respectively). In adjusted analyses, consultation was associated with better processes of care compared with no consultation ( P P Conclusions— Among ambulatory patients with coronary artery disease or CHF, women and those at community health centers have less access to cardiologists. Consultation is associated with better quality of care and narrows the gender gap in quality.

Background: The Community, Health Center, and Academic Medicine Partnership Project (CHAMPP) is a partnership between medical researchers, community health centers (CHCs), and a community advisory committee focused on reducing cardiovascular morbidity related to hypertension and diabetes for non-Hispanic Black and Hispanic populations in Boston, Massachusetts. Objective: We conducted site visits at seven participating CHCs, located in Boston. The visits were to solicit health center staff opinions about site-specific barriers and enabling factors for optimum preventative cardiovascular care for racial/ethnic minority patients receiving hypertension and diabetes care at their centers. Methods: Site visits included a tour of each health center and a series of directed interviews with center personnel. Site visit notes were reviewed to identify themes that emerged during the course of each site visit. A summary matrix was developed for each health center, which included information regarding the most salient and persistent themes of the visit. Results: Site visits uncovered several patient-, provider-, CHC-, and community-based factors that either facilitate or hinder optimal care of chronic disease patients. Commonly referenced barriers included the need for improved patient adherence to provider recommendations; insufficient time for providers to address complex health issues presented by patients and the need for a broader range of healthier food options in surrounding communities. Interactive patient groups and community health workers (CHWs) have been well received when implemented. Conclusion: Recommendations included adopting case management as a part of usual care for chronic disease patients; additionally, widespread implementation of CHWs may to provide a platform for more comprehensive care for patients.

Significant racial and ethnic differences along several dimensions of patients'experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described.We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients' experiences with care were most important in determining overall levels of satisfaction.Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff.Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.

Although community health centers (CHCs) provide primary health services to the medically underserved and poor, limited access to off-site specialty services may lead to poorer outcomes among underinsured CHC patients. This study evaluates access to specialty health services for patients receiving care in CHCs, using a survey of medical directors of all federally qualified CHCs in the United States in 2004. Respondents reported that uninsured patients had greater difficulty obtaining access to off-site specialty services, including referrals and diagnostic testing, than did patients with Medicaid, Medicare, or private insurance.

The Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) were designed to improve care in community health centers, where many patients from ethnic and racial minority groups and uninsured patients receive treatment.We performed a controlled preintervention and postintervention study of community health centers participating in quality-improvement collaboratives (the Health Disparities Collaboratives sponsored by the HRSA) for the care of patients with diabetes, asthma, or hypertension. We enrolled 9658 patients at 44 intervention centers that had participated in the collaboratives and 20 centers that had not participated (external control centers). Each intervention center also served as an internal control for another condition. Quality measures were abstracted from medical records at each health center. We created overall quality scores by standardizing and averaging the scores from all of the applicable measures. Changes in quality were evaluated with the use of hierarchical regression models that controlled for patient characteristics.Overall, the intervention centers had considerably greater improvement than the external and internal control centers in the composite measures of quality for the care of patients with asthma and diabetes, but not for those with hypertension. As compared with the external control centers, the intervention centers had significant improvements in the measures of prevention and screening, including a 21% increase in foot examinations for patients with diabetes, and in disease treatment and monitoring, including a 14% increase in the use of antiinflammatory medication for asthma and a 16% increase in the assessment of glycated hemoglobin. There was no improvement, however, in any of the intermediate outcomes assessed (urgent care or hospitalization for asthma, control of glycated hemoglobin levels for diabetes, and control of blood pressure for hypertension).The Health Disparities Collaboratives significantly improved the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.

The US Army Research Laboratory's Human Research and Engineering Directorate (ARL/HRED) conducted a software interface assessment of the Centralized Aviation Flight Records System (CAFRS) version 4.0. The assessment was performed to identify CAFRS software design features (e.g., menu screen navigation) that enhanced or degraded user performance. CAFRS is used to manage Army aviation flight and air traffic services records that contain information such as the number of flight hours that pilots have flown and status of pilot and unit flight training requirements. CAFRS provides the Army's senior-level leadership with aviation flight operations information to assist in resource, readiness, and personnel management. Participants were able to effectively use CAFRS to maintain aviation flight records and quickly complete most tasks during the assessment. Software interface and functionality problems were reported by the participants and addressed by the software developers. ARL/HRED will assess future CAFRS versions to enhance the software interface.

BACKGROUND Few studies have examined the impact of inpatient interpreter use for limited English proficient (LEP) patients on length of stay (LOS), 30-day post discharge emergency department (ED) visits and 30-day hospital readmission rates for LEP patients.

Community health centers (CHCs) are responsible for providing care for more than fifteen million Americans, many of whom are members of groups who have been documented to receive low-quality care. This study examines the quality of care for patients with chronic disease in a nationally representative sample of federally funded CHCs. Fewer than half of eligible patients received appropriate care for the majority of indicators measured, and uninsured patients received poorer care than insured patients. Although the quality of chronic disease care in CHCs compares favorably with that of care received in other settings, gaps in quality were observed for the uninsured.

The US Army Research Laboratory s Human Research and Engineering Directorate assesses crewstation design for new and upgraded US Army Aviation aircraft during simulations and operational testing. The assessments are conducted to identify and eliminate human factors design problems. As part of these evaluations, the AH-64 Apache attack helicopter has been a primary focus with respect to crewstation design changes. One of the significant design changes for the Apache crewstation is the integration of unmanned aircraft system (UAS) control. This study investigates the feasibility of controlling multiple UASs from the cockpit of an AH-64 Apache helicopter by examining scientific studies conducted on multi-UAS control that relate to operator and pilot mental workload.

Although improved control of hypertension is known to attenuate progression of chronic kidney disease (CKD), little is known about the adequacy of hypertension treatment in adults with CKD in the United States. Using data from the Fourth National Health and Nutrition Survey, we assessed adherence to national hypertension guideline targets for patients with CKD (blood pressure 2 or presence of albuminuria (albumin:creatinine ratio >30 μg/mg). Multivariable logistic regression with appropriate weights was used to determine predictors of inadequate hypertension control and related outcomes. Among 3213 participants with CKD, 37% had blood pressure 130 mm Hg, with diastolic ≤80 mm Hg, whereas only 7% (95% CI, 3.9 to 9.8%) had a diastolic pressure >80 mm Hg, with systolic blood pressure ≤130 mm Hg. Non-Hispanic black race (odds ratio [OR], 2.4; 95% CI, 1.5 to 3.9), age >75 years (OR, 4.7; 95% CI, 2.7 to 8.2), and albuminuria (OR, 2.4; 95% CI, 1.4 to 4.1) were independently associated with inadequate blood pressure control. We conclude that control of hypertension is poor in participants with CKD and that lack of control is primarily attributable to systolic hypertension. Future guidelines and antihypertensive therapies for patients with CKD should target isolated systolic hypertension.

The relationship between blood pressure control and racial differences in the processes of hypertension care have not been well examined. We reviewed medical records of 15 768 visits to 12 general internal medicine clinics during July 1, 2001 to June 30, 2002 to determine whether visits were adherent to the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) by identifying medications selected for hypertension therapy. We compared JNC adherence, blood pressure control, and intensification of therapy by patient characteristics. Using repeated measures logistic regression, we determined the adjusted odds of obtaining blood pressure control when therapy was intensified the visit before, and tested the interaction of intensification of therapy and patient race/ethnicity in predicting blood pressure control. JNC adherence was more frequent among blacks (83.7%) and Hispanics (83%) than whites (78.4%) ( P P P =0.02). After adjustment for baseline blood pressure, intensifying therapy was associated with higher odds of subsequent blood pressure control (odds ratio, 1.55; P

An assessment was conducted to determine the minimum cabin dimensions to accommodate infantry Soldiers for the Future Vertical Lift/Joint Multi-Role (FVL/JMR) medium-class aircraft. An adjustable mockup was used to conduct the assessment. The dimensions assessed included seat space widths, cabin ceiling heights, aisle widths, seating configurations, and cabin door widths. Emergency egress trials were conducted to assess the impact of cabin ceiling height on the ability of Soldiers to quickly and safely exit the aircraft. The assessment augmented human-figure modeling of cabin dimensions conducted for the FVL/JMR. Eighteen infantry Soldiers assigned to the Experimental Force at Fort Benning, GA, participated in the assessment. The combat gear they wore was comparable to the Rifle Platoon Basic Load. The Soldiers performed several ingress and egress trials to assess the minimum cabin dimension requirements. Recommendations for the minimum cabin dimensions were 23-in. seat spacing, 66-in. cabin ceiling height, 72-in. floor width, and 32-in. door width. These dimensions will help ensure that Soldiers have adequate space to effectively reposition their upper torso, arms, legs, and feet to minimize fatigue when seated, carry and maneuver their gear during ingress and egress, safely and quickly ingress and egress the cabin, and load supplies and equipment in the cabin.

The U.S. Army Research Laboratory Human Research and Engineering Directorate (ARL/HRED) assesses crewstation design for new and upgraded U.S. Army Aviation aircraft during simulations and operational testing. The assessments are conducted to identify and eliminate human factors design problems. ARL/HRED evaluates pilot workload and situational awareness (SA) during simulations and operational testing to assess crewstation design. To date, more than 12,000 pilot workload ratings and 3000 pilot SA ratings have been collected by ARL/HRED for Army aircraft. This report summarizes the Bedford Workload Rating Scale, Situation Awareness Rating Technique, and China Lake Situational Awareness scale ratings collected during simulations and operational testing to assess crewstation design.

An assessment was conducted to identify design characteristics of the OH-58F crewstation that enhanced or degraded pilot performance. Aircrew workload, aircrew situation awareness, the crewstation interface, visual gaze and dwell times (using a head-eye tracker), and the potential for pilot simulator sickness were assessed in an OH-58F simulator. Pilots flew missions based on a battlefield environment simulating southwest Asia. Each successive mission increased in difficulty in order to impose progressively greater workload on the pilots. Pilots reported that workload was manageable for the tasks they performed during the missions. The overall workload ratings provided by the pilots and subject matter experts (SMEs) were lower than the Objective and Threshold workload rating requirements listed in the OH-58F Capability Development Document. The pilots reported that they had moderate levels of situation awareness during the missions. They commented that the crewstation design aided them in conducting navigation, communication and reconnaissance tasks. The pilots recommended that minor design changes be made to the crewstation to enhance usability. The assessment was the third in a series of evaluations to develop and refine the crewstation design. Additional evaluations included human factors modeling, developmental and operational testing.