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Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation., (© 2024 Annals of Family Medicine, Inc.)

Importance: Bivalent mRNA COVID-19 vaccines were recommended in the US for children and adolescents aged 12 years or older on September 1, 2022, and for children aged 5 to 11 years on October 12, 2022; however, data demonstrating the effectiveness of bivalent COVID-19 vaccines are limited., Objective: To assess the effectiveness of bivalent COVID-19 vaccines against SARS-CoV-2 infection and symptomatic COVID-19 among children and adolescents., Design, Setting, and Participants: Data for the period September 4, 2022, to January 31, 2023, were combined from 3 prospective US cohort studies (6 sites total) and used to estimate COVID-19 vaccine effectiveness among children and adolescents aged 5 to 17 years. A total of 2959 participants completed periodic surveys (demographics, household characteristics, chronic medical conditions, and COVID-19 symptoms) and submitted weekly self-collected nasal swabs (irrespective of symptoms); participants submitted additional nasal swabs at the onset of any symptoms., Exposure: Vaccination status was captured from the periodic surveys and supplemented with data from state immunization information systems and electronic medical records., Main Outcome and Measures: Respiratory swabs were tested for the presence of the SARS-CoV-2 virus using reverse transcriptase-polymerase chain reaction. SARS-CoV-2 infection was defined as a positive test regardless of symptoms. Symptomatic COVID-19 was defined as a positive test and 2 or more COVID-19 symptoms within 7 days of specimen collection. Cox proportional hazards models were used to estimate hazard ratios for SARS-CoV-2 infection and symptomatic COVID-19 among participants who received a bivalent COVID-19 vaccine dose vs participants who received no vaccine or monovalent vaccine doses only. Models were adjusted for age, sex, race, ethnicity, underlying health conditions, prior SARS-CoV-2 infection status, geographic site, proportion of circulating variants by site, and local virus prevalence., Results: Of the 2959 participants (47.8% were female; median age, 10.6 years [IQR, 8.0-13.2 years]; 64.6% were non-Hispanic White) included in this analysis, 25.4% received a bivalent COVID-19 vaccine dose. During the study period, 426 participants (14.4%) had laboratory-confirmed SARS-CoV-2 infection. Among these 426 participants, 184 (43.2%) had symptomatic COVID-19, 383 (89.9%) were not vaccinated or had received only monovalent COVID-19 vaccine doses (1.38 SARS-CoV-2 infections per 1000 person-days), and 43 (10.1%) had received a bivalent COVID-19 vaccine dose (0.84 SARS-CoV-2 infections per 1000 person-days). Bivalent vaccine effectiveness against SARS-CoV-2 infection was 54.0% (95% CI, 36.6%-69.1%) and vaccine effectiveness against symptomatic COVID-19 was 49.4% (95% CI, 22.2%-70.7%). The median observation time after vaccination was 276 days (IQR, 142-350 days) for participants who received only monovalent COVID-19 vaccine doses vs 50 days (IQR, 27-74 days) for those who received a bivalent COVID-19 vaccine dose., Conclusion and Relevance: The bivalent COVID-19 vaccines protected children and adolescents against SARS-CoV-2 infection and symptomatic COVID-19. These data demonstrate the benefit of COVID-19 vaccine in children and adolescents. All eligible children and adolescents should remain up to date with recommended COVID-19 vaccinations.

Per- and polyfluoroalkyl substances (PFAS) are ubiquitous throughout the United States. Previous studies have shown PFAS exposure to be associated with a reduced immune response. However, the relationship between serum PFAS and antibody levels following SARS-CoV-2 infection or COVID-19 vaccination has not been examined. We examined differences in peak immune response and the longitudinal decline of antibodies following SARS-CoV-2 infection and COVID-19 vaccination by serum PFAS levels in a cohort of essential workers in the United States. We measured serum antibodies using an in-house semi-quantitative enzyme-linked immunosorbent assay (ELISA). Two cohorts contributed blood samples following SARS-CoV-2 infection or COVID-19 vaccination. We used linear mixed regression models, adjusting for age, race/ethnicity, gender, presence of chronic conditions, location, and occupation, to estimate differences in immune response with respect to serum PFAS levels. Our study populations included 153 unvaccinated participants that contributed 316 blood draws over a 14-month period following infection, and 860 participants and 2451 blood draws over a 12-month period following vaccination. Higher perfluorooctane sulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA) concentrations were associated with a lower peak antibody response after infection (p = 0.009, 0.031, 0.015). Higher PFOS, perfluorooctanoic acid (PFOA), PFHxS, and PFNA concentrations were associated with slower declines in antibodies over time after infection (p = 0.003, 0.014, 0.026, 0.025). PFOA, PFOS, PFHxS, and PFNA serum concentrations prior to vaccination were not associated with differences in peak antibody response after vaccination or with differences in decline of antibodies over time after vaccination. These results suggest that elevated PFAS may impede potential immune response to SARS-CoV-2 infection by blunting peak antibody levels following infection; the same finding was not observed for immune response to vaccination., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Allison L Naleway reports a relationship with Pfizer Inc that includes: funding grants. Allison L Naleway reports a relationship with Vir Biotechnology Inc that includes: funding grants. Kurt Hegmann reports a relationship with American College of Occupational and Environmental Medicine that includes: consulting or advisory. Kurt Hegmann reports a relationship with National Institute for Occupational Safety and Health that includes: funding grants. Manjusha Gaglani reports a relationship with Westat Inc that includes: funding grants. Manjusha Gaglani reports a relationship with Vanderbilt University Medical Center that includes: funding grants. Manjusha Gaglani reports a relationship with Abt Associates Inc that includes: funding grants. Manjusha Gaglani reports a relationship with Infectious Diseases and Immunization Committee, Texas Pediatric Society, Texas Chapter of the American Academy of Pediatrics that includes: board membership. Ryan Sprissler reports a relationship with American Council of Life Insurers that includes: speaking and lecture fees. Ryan Sprissler reports a relationship with California legal case Ebers v. Castle Park that includes: consulting or advisory. Ryan Sprissler reports a relationship with Geneticure, Inc. that includes: equity or stocks. Ryan Sprissler reports a relationship with Beckman Coulter that includes: speaking and lecture fees. Ryan Sprissler reports a relationship with Shay Emma Hammer Research Foundation that includes: board membership. Ryan Sprissler has patent issued to Arizona Board of Regents on Behalf of the University of Arizona., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Data on the epidemiology of mild to moderately severe COVID-19 are needed to inform public health guidance., Objective: To evaluate associations between 2 or 3 doses of mRNA COVID-19 vaccine and attenuation of symptoms and viral RNA load across SARS-CoV-2 viral lineages., Design, Setting, and Participants: A prospective cohort study of essential and frontline workers in Arizona, Florida, Minnesota, Oregon, Texas, and Utah with COVID-19 infection confirmed by reverse transcriptase-polymerase chain reaction testing and lineage classified by whole genome sequencing of specimens self-collected weekly and at COVID-19 illness symptom onset. This analysis was conducted among 1199 participants with SARS-CoV-2 from December 14, 2020, to April 19, 2022, with follow-up until May 9, 2022, reported., Exposures: SARS-CoV-2 lineage (origin strain, Delta variant, Omicron variant) and COVID-19 vaccination status., Main Outcomes and Measures: Clinical outcomes included presence of symptoms, specific symptoms (including fever or chills), illness duration, and medical care seeking. Virologic outcomes included viral load by quantitative reverse transcriptase-polymerase chain reaction testing along with viral viability., Results: Among 1199 participants with COVID-19 infection (714 [59.5%] women; median age, 41 years), 14.0% were infected with the origin strain, 24.0% with the Delta variant, and 62.0% with the Omicron variant. Participants vaccinated with the second vaccine dose 14 to 149 days before Delta infection were significantly less likely to be symptomatic compared with unvaccinated participants (21/27 [77.8%] vs 74/77 [96.1%]; OR, 0.13 [95% CI, 0-0.6]) and, when symptomatic, those vaccinated with the third dose 7 to 149 days before infection were significantly less likely to report fever or chills (5/13 [38.5%] vs 62/73 [84.9%]; OR, 0.07 [95% CI, 0.0-0.3]) and reported significantly fewer days of symptoms (10.2 vs 16.4; difference, -6.1 [95% CI, -11.8 to -0.4] days). Among those with Omicron infection, the risk of symptomatic infection did not differ significantly for the 2-dose vaccination status vs unvaccinated status and was significantly higher for the 3-dose recipients vs those who were unvaccinated (327/370 [88.4%] vs 85/107 [79.4%]; OR, 2.0 [95% CI, 1.1-3.5]). Among symptomatic Omicron infections, those vaccinated with the third dose 7 to 149 days before infection compared with those who were unvaccinated were significantly less likely to report fever or chills (160/311 [51.5%] vs 64/81 [79.0%]; OR, 0.25 [95% CI, 0.1-0.5]) or seek medical care (45/308 [14.6%] vs 20/81 [24.7%]; OR, 0.45 [95% CI, 0.2-0.9]). Participants with Delta and Omicron infections who received the second dose 14 to 149 days before infection had a significantly lower mean viral load compared with unvaccinated participants (3 vs 4.1 log10 copies/μL; difference, -1.0 [95% CI, -1.7 to -0.2] for Delta and 2.8 vs 3.5 log10 copies/μL, difference, -1.0 [95% CI, -1.7 to -0.3] for Omicron)., Conclusions and Relevance: In a cohort of US essential and frontline workers with SARS-CoV-2 infections, recent vaccination with 2 or 3 mRNA vaccine doses less than 150 days before infection with Delta or Omicron variants, compared with being unvaccinated, was associated with attenuated symptoms, duration of illness, medical care seeking, or viral load for some comparisons, although the precision and statistical significance of specific estimates varied.

Medicare's Accountable Care Organization (ACO) Investment Model (AIM) provided up-front funding to forty-one small, rurally located ACOs to encourage their participation in the Medicare Shared Savings Program. We estimate net savings to Medicare of $381.5 million over three years, driven by utilization reductions in inpatient and other institutional care and by the absence of shared risk for potential increases in Medicare spending incurred by participants. These savings suggest that population-based payment models can enable providers to better meet the needs of rural populations through greater flexibility in care delivery. However, nearly two-thirds of AIM ACOs exited the Medicare Shared Savings Program when faced with the requirement to assume downside financial risk, starting in year four of participation. As the Centers for Medicare and Medicaid Services builds on AIM and rural hospital global payment models, our findings suggest that new payment models can support more efficient use of resources to meet the health care needs of rural populations. However, the findings also caution against the vigorous pursuit of savings as a primary goal of payment models in traditionally underserved communities.

Purpose: This feasibility study assessed if the Patient-Reported Outcomes Measurement Information System (PROMIS®) 10-item Global Health Survey (PROMIS-10) could be a reliable and valid patient-reported outcome measure (PROM) for a population of cognitively intact home health (HH) patients., Methods: The Centers for Medicare and Medicaid Services (CMS) along with their measurement contractor, Abt Associates, held a field test (2016-2017) to test the feasibility of the PROMIS-10 in in the Outcome and Assessment Information Set (OASIS). Home Health clinician data collectors (registered nurses and physical therapists) were trained to complete the PROMIS-10 along with procedures to facilitate patient self-administration of PROMIS-10. These clinicians provided feedback about their experiences at a focus group at the end of data collection., Results: 213 HH patients comprised the field test sample, 150 of whom completed PROMIS-10 surveys. Clinicians reported they found the PROMIS-10 relevant and acceptable for their HH patients, and noted the surveys provided insight into patients' views of their health. The PROMIS-10 measured the full range of patient-reported health and was sensitive to change between admission and discharge., Conclusions: The study confirmed that the PROMIS-10 can be implemented in the HH setting, opening the door for consideration for implementing the PROMIS-10 in post-acute care (PAC) settings. This study is a first step toward establishing an assessment that captures the patient's voice and could be reported by the CMS PAC quality reporting programs., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: Assess whether frequently-used claims-based end-of-life (EOL) measures are associated with higher ratings of care quality., Design: Retrospective cohort study., Setting/participants: Deceased fee-for-service Medicare beneficiaries with cancer who underwent chemotherapy during July 2016 to January 2017 and died within 12 months and their caregiver respondents to an after-death survey (n = 2,559)., Measurements: We examined claims-based measures of EOL care: chemotherapy 14 days or more before death; inpatient admissions, intensive care unit (ICU) use, and emergency department (ED) visits 30 days or more before death; hospice election and the timing of election before death. Primary outcomes are family ratings of "excellent" care in the last month of life and reports that hospice care began "at the right time." Associations were assessed with logistic regression, adjusted by patient characteristics., Results: Family rated EOL care as excellent less often, if within 30 days before death the cancer patient had inpatient admissions (1 hospitalization = 41.5% vs 51.5% none, adjusted difference -10.1 percentage points), ICU use (38.6% for any ICU use vs 47.4% none; adjusted difference -8.8 percentage points), ED visits (41.0% 1 visit vs 51.6% no visits; adjusted difference -10.6 percentage points), or elected hospice within 7 days before death. Among hospice enrollees, family more often reported that hospice began at the right time if it started at least 7 days before death (hospice 1-2 days before death 60.2% vs hospice 7-13 days 74.9%; adjusted difference +14.7 percentage points)., Conclusions: Claims-based measures of EOL care for cancer patients that reflect avoidance of hospital-based care and earlier hospice enrollment are associated with higher ratings of care quality by bereaved family members., (© 2020 The American Geriatrics Society.)

The revised Standards for Adult Immunization Practice ("Standards"), published in 2014, recommend routine vaccination assessment, strong provider recommendation, vaccine administration or referral, and documentation of vaccines administered into immunization information systems (IIS). We assessed clinician and pharmacist implementation of the Standards in the United States from 2016 to 2018. Participating clinicians (family and internal medicine physicians, obstetricians-gynecologists, specialty physicians, physician assistants, and nurse practitioners) and pharmacists responded using an internet panel survey. Weighted proportion of clinicians and pharmacists reporting full implementation of each component of the Standards were calculated. Adjusted prevalence ratio (APR) estimates of practice characteristics associated with self-reported implementation of the Standards are also presented. Across all medical specialties, the percentages of clinicians and pharmacists implementing the vaccine assessment and recommendation components of the Standards were >80.0%. However, due to low IIS documentation, full implementation of the Standards was low overall, ranging from 30.4% for specialty medicine to 45.8% in family medicine clinicians. The presence of an immunization champion (APR, 1.40 [95% confidence interval {CI}, 1.26 to 1.54]), use of standing orders (APR, 1.41 [95% CI, 1.27 to 1.57]), and use of a patient reminder-recall system (APR, 1.39 [95% CI, 1.26 to 1.54]) were positively associated with adherence to the Standards by clinicians. Similar results were observed for pharmacists. Nonetheless, vaccination improvement strategies, i.e., having standing orders in place, empowering an immunization champion, and using patient recall-reminder systems were underutilized in clinical settings; full implementation of the Standards was inconsistent across all health care provider practices., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Regarding the present manuscript, the following co-authors do not report and conflicts of interest: Charleigh J. Granade, Amy Parker-Fiebelkorn, Carla L. Black, Anup Srivastav, Chelsea S. Lutz, Carolyn B. Bridges, and David K. Kim. Because the data presented in this manuscript was collected through a contractual agreement between CDC and Abt. Associates, the following co-authors report a conflict of interest: Sarah W. Ball, Rebecca G. Devlin, and Ann J. Cloud.., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: Few existing instruments measure recovery-oriented organizational climate and culture. This study developed, psychometrically assessed, and validated an instrument to measure recovery climate and culture., Methods: Organizational theory and an evidence-based conceptualization of mental health recovery guided instrument development. Items from existing instruments were reviewed and adapted, and new items were developed as needed. All items were rated by recovery experts. A 35-item instrument was pilot-tested and administered to a national sample of mental health staff in U.S. Department of Veterans Affairs Psychosocial Rehabilitation and Recovery Centers (PRRCs). Analysis entailed an exploratory factor analysis (EFA) and inter-item reliability and scale correlation assessment. Blinded site visits to four PRRCs were performed to validate the instrument., Results: The EFA determined a seven-factor solution for the data. The factors identified were staff expectations, values, leadership, rewards, policies, education and training, and quality improvement. Seven items did not meet retention criteria and were dropped from the final instrument. The instrument exhibited good internal consistency (Cronbach's α=0.81; subscales, α=0.84-0.88). Scale correlations were between 0.16 and 0.61, well below the threshold (α=0.9) for indicating overlapping constructs. Site visitors validated the instrument by correctly identifying high-scoring and low-scoring centers., Conclusions: These findings provide a psychometrically tested and validated instrument for measuring recovery climate and culture in mental health programs. This instrument can be used in evaluation of mental health services to determine the extent to which programs possess the organizational precursors that drive recovery-oriented service delivery.

Evidence on the implementation of health systems strengthening (HSS) interventions is scarce. Donors need this information to prioritise investments and lobby for continued financial support. To develop a deeper understanding of the implementation dynamics of robust HSS interventions, we retrospectively compared five USAID-supported projects in the Dominican Republic, Ethiopia, Kazakhstan, Rwanda, and Zambia. A document review and key informant interviews ( n  = 44) were conducted, coded, and analysed in each of the five cases using an integrated implementation framework. The framework was organised by four phases of implementation. For the pre-condition phase, data-driven HSS interventions were nested in a range of political contexts and with differing levels of financial support. In pre-implementation, cases relied on diverse teams that created a data-informed, inclusive, and transparent project ethos for implementation. Implementation was located at multiple tiers of the health system, used interventions as catalysts for government initiatives, supported governance/accountability initiatives, and responded nimbly to contextual changes in the implementation climate. There was less evidence of maintenance and evolution but all cases were designed with an eye towards sustainability. This research yields important insights about the dynamics of HSS, identifying ways donors can better support countries to achieve universal health coverage.

Objective: Caffeine and dietary supplement (DS) use by college students is not well-documented. Given reported associations between energy drink consumption and sensation seeking, we used the Sensation Seeking Scale Form V (SSS-V) to assess relationships between sensation-seeking, caffeine, and DS use. Participants: Data from 1,248 college students from five US institutions were collected from 2009 to 2011. Methods: Linear regression was used to examine relationships between scores on the SSS-V and caffeine and DS use, demographic, and lifestyle characteristics. Results: Male sex, nonHispanic race-ethnicity, higher family income, tobacco use, consuming caffeinated beverages, more than 400 mg caffeine per day, and energy drinks with alcohol at least 50% of the time, were significantly associated with higher total SSS-V scores ( P  < 0.001). Those using protein DSs had higher total, disinhibition, and boredom susceptibility SSS-V scores ( P s < 0.001). Conclusions: Results demonstrate a positive correlation between sensation-seeking attitudes and habitual caffeine, energy drink, and DS consumption.

Background & Aims: Caffeine intake in a convenience sample of U.S. college students (N = 1248) was surveyed at five geographically-dispersed United States (U.S.) universities., Methods: Intake from coffee, tea, soft drinks, energy drinks, gums, and medications was assessed. Associations between caffeine intake and demographic variables including sex, age, race/ethnicity, family income, general health, exercise, weight variables and tobacco use were examined. Reasons for use of caffeine-containing products were assessed., Results: Caffeine, in any form, was consumed by 92% of students in the past year. Mean daily caffeine consumption for all students, including non-consumers, was 159 mg/d with a mean intake of 173 mg/d among caffeine users. Coffee was the main source of caffeine intake in male (120 mg/d) and female (111 mg/d) consumers. Male and female students consumed 53 vs. 30 mg/d of caffeine in energy drinks, respectively, and 28% consumed energy drinks with alcohol on at least one occasion. Students provided multiple reasons for caffeine use including: to feel awake (79%); enjoy the taste (68%); the social aspects of consumption (39%); improve concentration (31%); increase physical energy (27%); improve mood (18%); and alleviate stress (9%)., Conclusions: As in the general U.S. population, coffee is the primary source of caffeine intake among the college students surveyed. Energy drinks provide less than half of total daily caffeine intake but more than among the general population. Students, especially women, consume somewhat more caffeine than the general population of individuals aged 19-30 y but less than individuals aged 31-50 y., (Published by Elsevier Ltd.)

Objective: To assess the potential impact of a new tax on sweetened beverages on premature deaths associated with noncommunicable diseases in the Philippines., Methods: In January 2018, the Philippines began imposing a tax of 6 Philippine pesos per litre (around 13%) on sweetened beverages to curb the obesity burden. Using national data sources, we conducted an extended cost-effectiveness analysis to estimate the effect of the tax on the numbers of premature deaths averted attributed to type 2 diabetes mellitus, ischaemic heart disease and stroke, across income quintiles over the period 2018-2037. We also estimated the financial benefits of the tax from reductions in out-of-pocket payments, direct medical costs averted and government health-care cost savings., Findings: The tax could avert an estimated 5913 deaths related to diabetes, 10 339 deaths from ischaemic heart disease and 7950 deaths from stroke over 20 years. The largest number of deaths averted could be among the fourth and fifth (highest) income quintiles. The tax could generate total health-care savings of 31.6 billion Philippine pesos (627 million United States dollars, US$) over 20 years, and raise 41.0 billion Philippine pesos (US$ 813 million) in revenue per annum. The poorest quintile could bear the smallest tax burden increase (14% of the additional tax; 5.6 billion Philippine pesos) and have the lowest savings in out-of-pocket payments due to relatively large health-care subsidies. Finally, we estimated that 13 890 cases of catastrophic expenditure could be averted., Conclusion: The new sweetened beverage tax may help to reduce obesity-related premature deaths and improve financial well-being in the Philippines.

In a study aimed at improving the quality of HIV services for inmates, an organizational process improvement strategy using change teams was tested in 14 correctional facilities in 8 US states and Puerto Rico. Data to examine fidelity to the process improvement strategy consisted of quantitative ratings of the structural and process components of the strategy and qualitative notes that explicate challenges in maintaining fidelity to the strategy. Fidelity challenges included (1) lack of communication and leadership within change teams, (2) instability in team membership, and (3) issues with data utilization in decision-making to implement improvements to services delivery.

Competing Interests: Conflicts of interest: Shoemaker serves as a medical advisory board member for Emmi Solutions for their medication adherence module.

Objectives: To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant's fracture) and other facility characteristics on outcomes., Design: Prospective observational study., Setting: U.S. skilled nursing facilities (SNFs) admitting individuals discharged from the hospital after treatment for hip fracture between 2000 and 2007 (N = 15,439)., Participants: Community-dwelling fee-for-service Medi-care beneficiaries aged 75 and older admitted to U.S. hospitals for their first hip fracture and discharged to a SNF for postacute care from 2000 to 2007 (N = 512,967)., Measurements: Successful discharge from SNF to community, defined as returning to the community within 30 days of hospital discharge to the SNF and remaining in the community without being institutionalized for at least 30 days, was examined using Medicare administrative data, propensity score matching, and instrumental variables., Results: The overall rate of successful discharge to the community was 31%. Of the 15,439 facilities, the facility interquartile range varied from 0% (25th percentile) to 42% (75th percentile). An important determinant of variation in discharge rate was SNF volume of hip fracture admissions. Unadjusted successful discharge from SNF to community was 43.7% in high-volume facilities (>24 admissions/year), versus 18.8% in low-volume facilities (1-6 admissions/year). This facility volume effect persisted after adjusting for participant and facility characteristics associated with outcomes (e.g., adjusted odds ratio = 2.06, 95% confidence interval = 1.91-2.21 for volume of 25 vs 3 admissions per year)., Conclusion: In community-dwelling persons with their first hip fracture, successful return to the community varies substantially according to SNF provider volume and staffing characteristics., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Background & Aims: Dietary supplements (DS) are popular in many countries but little data are available on their use by sub-populations such as college students. Since students share a variety of characteristics and similar lifestyles, their DS use may differ from the general population. This study assessed DS use, factors associated with DS use, and reasons for use among U.S. college students., Methods: College students (N = 1248) at 5 U.S. universities were surveyed. Survey questions included descriptive demographics, types and frequency of DS used, reasons for use and money spent on supplements. Supplements were classified using standard criteria. Logistic regression analyses examined relationships between demographic and lifestyle factors and DS use., Results: Sixty-six percent of college students surveyed used DS at least once a week, while 12% consumed 5 or more supplements a week. Forty-two percent used multivitamins/multiminerals, 18% vitamin C, 17% protein/amino acids and 13% calcium at least once a week. Factors associated with supplement use included dietary patterns, exercise, and tobacco use. Students used supplements to promote general health (73%), provide more energy (29%), increase muscle strength (20%), and enhance performance (19%)., Conclusions: College students appear more likely to use DS than the general population and many use multiple types of supplements weekly. Habits established at a young age persist throughout life. Therefore, longitudinal research should be conducted to determine whether patterns of DS use established early in adulthood are maintained throughout life. Adequate scientific justification for widespread use of DS in healthy, young populations is lacking., (Published by Elsevier Ltd.)

In the emerging field of implementation science, measuring the extent to which a new or modified healthcare program or practice is successfully implemented following an intervention is a critical component in understanding how evidence-based treatments become part of regular practice. This paper is intended to expand our understanding of factors that influence the successful adoption of new or modified HIV services in correctional settings. The nine-site project developed and directed an organization-level intervention designed to implement improvements in preventing, detecting, and treating HIV for persons under correctional supervision. Using semi-structured interviews to elicit perceptions from Senior Researchers and Executive Sponsors at each of the nine sites, this paper presents their views and observations regarding the success of the experimental intervention in their criminal justice setting. Within the areas of focus for implementation (either HIV prevention, testing, or linkage to community treatment) the complexity of programmatic needs was very influential with regards to perceptions of success. An organization's pre-existing characteristics, staffing, funding, and interorganizational relationships contributed to either the ease or difficulty of programmatic implementation. Results are discussed pertaining to furthering our understanding of why new or modified healthcare interventions achieve success, including whether the intervention is a modification of existing practice or is a new intervention, and the choice of implementation strategy.

The US President's Emergency Plan for AIDS Relief (PEPFAR) has shifted from an emergency response to a sustainable, country-owned response. The process of transition to country ownership is already underway in the Eastern Caribbean; the Office of the US Global AIDS Coordinator (OGAC) has advised the region that PEPFAR funding is being redirected away from the Eastern Caribbean toward Caribbean countries with high disease burden to strengthen services for key populations. This article seeks to highlight and apply lessons learned from other donor transitions to support a successful transition of HIV programs in the Eastern Caribbean. Based on a rapid review of both peer-reviewed and gray literature on donor transitions to country ownership in family planning, HIV, and other areas, we identified 48 resources that addressed key steps in the transition process and determinants of readiness for transition. Analysis of the existing literature revealed 6 steps that could help ensure successful transition, including developing a clear roadmap articulated through high-level diplomacy; investing in extensive stakeholder engagement; and supporting monitoring and evaluation during and after the transition to adjust course as needed. Nine specific areas to assess a country's readiness for transition include: leadership and management capacity, political and economic factors, the policy environment, identification of alternative funding sources, integration of HIV programs into the wider health system, the institutionalization of processes, the strength of procurement and supply chain management, identification of staffing and training needs, and engagement of civil society and the private sector. In the Caribbean, key areas requiring strengthening to ensure countries in the region can maintain the gains made under PEPFAR include further engaging civil society and the private sector, building the capacity of NGOs to take on essential program functions, and maintaining donor support for targeted capacity building and long-term monitoring and evaluation efforts., (© Vogus et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/)

Purpose: This study estimates the prevalence in US counties of opioid patients who use large numbers of prescribers, the amounts of opioids they obtain, and the extent to which their prevalence is predicted by ecological attributes of counties, including general medical exposure to opioids., Methods: Finite mixture models were used to estimate the size of an outlier subpopulation of patients with suspiciously large numbers of prescribers (probable doctor shoppers), using a sample of 146 million opioid prescriptions dispensed during 2008. Ordinary least squares regression models of county-level shopper rates included independent variables measuring ecological attributes of counties, including rates of patients prescribed opioids, socioeconomic characteristics of the resident population, supply of physicians, and measures of healthcare service utilization., Results: The prevalence of shoppers varied widely by county, with rates ranging between 0.6 and 2.5 per 1000 residents. Shopper prevalence was strongly correlated with opioid prescribing for the general population, accounting for 30% of observed county variation in shopper prevalence, after adjusting for physician supply, emergency department visits, in-patient hospital days, poverty rates, percent of county residents living in urban areas, and racial/ethnic composition of resident populations. Approximately 30% of shoppers obtained prescriptions in multiple states., Conclusions: The correlation between prevalence of doctor shoppers and opioid patients in a county could indicate either that easy access to legitimate medical treatment raises the risk of abuse or that drug abusers take advantage of greater opportunities in places where access is easy. Approaches to preventing excessive use of different prescribers are discussed., (Copyright © 2014 John Wiley & Sons, Ltd.)

Objectives: This study aimed to measure awareness and interest among state health information exchanges (HIEs) in a tool that translates long-term post-acute care (LTPAC) patient assessment information to a Continuity of Care Document (CCD) format for sharing; whether any state HIEs currently integrate patient information from LTPAC providers; and the anticipated benefits and barriers to using such a tool., Materials and Methods: The study consisted of an online survey of state HIEs., Results: Responses were received from representatives of 29 of the 51 HIEs (57 percent). Eleven of the 29 respondents (38 percent) were aware of the LTPAC-to-CCD translation tool, and 24 (83 percent of respondents) were interested in it or felt LTPAC providers in their state would be interested. Twenty-one of the 24 interested respondents (88 percent) indicated a desire for more information about this technology., Discussion: Skilled nursing facilities and home health agencies receive no incentives for adoption of electronic health record systems and are not commonly included in HIEs. These organizations do, however collect extensive structured data about their patients (Minimum Data Set for nursing facilities, Outcome and Assessment Information Set for home health agencies) and transmit the data electronically to the Centers for Medicare and Medicaid Services (CMS). A tool is now available that will intercept the transmissions to CMS, transform content extracted from patient assessments into CCDs, and send the CCDs to a designated HIE., Conclusion: Responding HIEs reported almost no experience exchanging patient assessment information from LTPAC providers. Anticipated benefits include safer care transitions; anticipated barriers include information technology constraints in LTPAC settings.

Background: No studies have examined the effectiveness of influenza vaccine against intensive care unit (ICU) admission associated with influenza virus infection among children., Methods: In 2010-2011 and 2011-2012, children aged 6 months to 17 years admitted to 21 US pediatric intensive care units (PICUs) with acute severe respiratory illness and testing positive for influenza were enrolled as cases; children who tested negative were PICU controls. Community controls were children without an influenza-related hospitalization, matched to cases by comorbidities and geographic region. Vaccine effectiveness was estimated with logistic regression models., Results: We analyzed data from 44 cases, 172 PICU controls, and 93 community controls. Eighteen percent of cases, 31% of PICU controls, and 51% of community controls were fully vaccinated. Compared to unvaccinated children, children who were fully vaccinated were 74% (95% CI, 19% to 91%) or 82% (95% CI, 23% to 96%) less likely to be admitted to a PICU for influenza compared to PICU controls or community controls, respectively. Receipt of 1 dose of vaccine among children for whom 2 doses were recommended was not protective., Conclusions: During the 2010-2011 and 2011-2012 US influenza seasons, influenza vaccination was associated with a three-quarters reduction in the risk of life-threatening influenza illness in children., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objective: Passive, opt-out recruitment strategies have the potential to improve efficiency and enlarge the participant pool for clinical studies. We report on the feasibility of using a passive consent strategy for a multicenter pediatric study., Methods: We assessed the response to passive and active control recruitment strategies used in a multicenter pediatric cohort study and describe the variability in acceptance among institutional review boards (IRBs) and parents of pediatric patients., Results: Twenty-six pediatric centers submitted IRB applications; 24 centers participated. Sixteen IRBs approved the proposed passive recruitment strategy, and 6 IRBs required active consent strategies; 2 centers used a modified participation mode using control subjects from neighboring centers. In all, 4529 potential participants were identified across 22 centers. In the pre-enrollment phase, opt-out rates were significantly lower in the passive consent group compared with the active recruitment centers (1.6% vs. 11.8%; P < .001). During the enrollment phase, however, refusal rates in the passive consent group were significantly higher (38.1% vs. 12.2%; P = .004). The overall refusal rate across both groups was 33.3%., Conclusions: IRB variability in interpretation and application of regulations affects consistency of study procedure across sites and may reduce validity of study findings. Opt-out consent allowed us to create a large representative pool of control subjects. Parents were more likely to refuse to be approached for a study in the pre-enrollment phase when active consent was used, but were more likely to decline actual study enrollment when passive consent was used in the pre-enrollment period., (Copyright © 2014 by the American Academy of Pediatrics.)

Objective: To determine if overweight or obesity is associated with mental health disorder (MHD) symptoms among military personnel Methods: Secondary analysis using the 2005 Department of Defense Health Related Behaviors Survey (N = 15,195). Standard Body Mass Index (BMI) categories were used to classify participants' body composition., Results: For women, obesity was associated with symptoms of serious psychological distress (SPD), post-traumatic stress disorder, and depression. For men, obesity and overweight was associated with symptoms of generalized anxiety disorder and SPD, respectively. Self-reported high personal stress was the strongest predictor of MHD symptoms and suicide attempts., Conclusion: Self-reported stress was a stronger predictor of MHD symptoms than BMI. There is potential value in screening personnel for personal stress as a MHD risk factor.

Background: Pressure ulcers present serious health and economic consequences for nursing home residents. The Agency for Healthcare Research & Quality, in partnership with the New York State Department of Health, implemented the pressure ulcer module of On-Time Quality Improvement for Long Term Care (On-Time), a clinical decision support intervention to reduce pressure ulcer incidence rates., Objective: To evaluate the effectiveness of the On-Time program in reducing the rate of in-house-acquired pressure ulcers among nursing home residents., Research Design and Subjects: We employed an interrupted time-series design to identify impacts of 4 core On-Time program components on resident pressure ulcer incidence in 12 New York State nursing homes implementing the intervention (n=3463 residents). The sample was purposively selected to include nursing homes with high baseline prevalence and incidence of pressure ulcers and high motivation to reduce pressure ulcers. Differential timing and sequencing of 4 core On-Time components across intervention nursing homes and units enabled estimation of separate impacts for each component. Inclusion of a nonequivalent comparison group of 13 nursing homes not implementing On-Time (n=2698 residents) accounts for potential mean-reversion bias. Impacts were estimated via a random-effects Poisson model including resident-level and facility-level covariates., Results: We find a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of 4 core On-Time components (incidence rate ratio=0.409; P=0.035). Impacts vary with implementation of specific component combinations., Conclusions: On-Time implementation is associated with sizable reductions in pressure ulcer incidence.

Background: Low-income, publicly insured admissions historically cost more to treat than does the average patient. To ensure that hospitals are reimbursed an adequate amount for care of indigent populations, Medicare reimburses hospitals an additional percentage amount according to federally set financial schedule. At 15% of a disproportionate patient percentage, a hospital is reimbursed an extra 2.5% of the standard prospective payment rate., Objective: This research seeks to determine whether hospital qualification as a Medicare Disproportionate Share Hospital results in higher patient experience ratings., Methods: A regression discontinuity method was used to determine the effect of lagged Disproportionate Share Hospital (DSH) status on next year patient experience ratings. The Hospital Consumer Assessment of Healthcare Providers and Systems data provide publicly available patient ratings., Results: On average, hospital ratings increase by 6% as a result of DSH status. Hospital ratings increase by an average of 6.5% when nonprofit hospitals are analyzed. This finding is primarily driven by patient facility cleanliness and medical provider communication ratings., Conclusions: The federal mandate that individuals purchase health insurance in the United States coupled with the state expansion of Medicaid coverage will theoretically eliminate the need for Medicare DSH payments. It is calculated, however, that hospitals will need increased Medicaid reimbursements of more than $300 per patient to make up for the loss of Medicare DSH reimbursements. Hospitals will likely suffer financially as a direct result of reduced Medicare reimbursements through the DSH program., (Copyright © 2014 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

In the United States, occupational regulations influence the work tasks that may legally be performed by dentists and dental hygienists. Only a dentist may legally perform most dental procedures; however, a smaller list of basic procedures may be provided by either a dentist or a dental hygienist. Since dentists and hygienists possess different levels of training and skill and receive very different wages, it is plausible that these regulations could distort the optimal allocation of skills to work tasks. We present simple theoretical framework that shows different ways that such regulations might affect the way that dentists and dental hygienists are used in the production of dental services. We then use a large database of dental insurance claims to study the effects of the regulations on the prevailing prices of a set of basic dental services. Our empirical analysis exploits variation across states and over time in the list of services that may be provided by either type of worker. Our main results suggest that the task-specific occupational regulations increase prices by about 12%. We also examine the effects of related occupational regulations on the utilization of basic dental services. We find that allowing insurers to directly reimburse hygienists for their work increases one year utilization rates by 3-4 percentage points., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Purpose: To examine the cost structure of home health agencies by estimating an empirical cost function for those that are Medicare-certified, ten years following the implementation of prospective payment., Design and Methods: 2010 national Medicare cost report data for certified home health agencies were merged with case-mix information from the Outcome and Assessment Information Set (OASIS). We estimated a fully interacted (by tax status) hybrid cost function for 7,064 agencies and calculated marginal costs as percent of total costs for all variables., Results: The home health industry is dominated by for-profit agencies, which tend to be newer than the non-profit agencies and to have higher average costs per patient but lower costs per visit. For-profit agencies tend to have smaller scale operations and different cost structures, and are less likely to be affiliated with chains. Our estimates suggest diseconomies of scale, zero marginal cost for contracting with therapy workers, and a positive marginal cost for contracting with nurses, when controlling for quality., Implications: Our findings suggest that efficiencies may be achieved by promoting non-profit, smaller agencies, with fewer contract nursing staff. This conclusion should be tested further in future studies that address some of the limitations of our study.

This study utilizes a natural experiment-conditionally random dormitory assignments of first-year US college students-to investigate the influence of obesogenic environmental factors in explaining changes in weight and exercise behavior during the 2009-2010 academic year. The design addresses potential selection biases resulting from the likelihood that individuals sort into built environments that match their preferences for exercise and healthy eating. We find some evidence that the food environment, specifically access to campus dining, significantly affected the weight of female students in our study. Females assigned to dormitories where the nearest campus dining hall was closed on the weekends gained about 1lb less over the course of the year than females assigned to dormitories near dining halls that were open 7 days a week. We also find some evidence that female who lived in close proximity to a grocery store gained less weight over the course of the year. Finally, females who lived closer to campus gym reported more frequent exercise over the course of the year. We do not find significant effects of the built environment on weight changes of males in our sample, but we are cautious to draw strong conclusions from this because the male weight change in our sample was quite small., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Objective: Intake of white potatoes in and out of school was estimated to provide context for a recent proposal by the U.S. Department of Agriculture to limit provision of white potatoes in U.S. school meals., Design: Mean daily servings of white potatoes and other vegetables consumed in and out of school for school-aged children were estimated from two days of 24 h dietary recall data from the National Health and Nutrition Examination Surveys (NHANES). Total energy intake and percentage energy contribution from discretionary oils and solid fats were also estimated for all white potato dishes consumed., Setting: The NHANES is nationally representative of the U.S. civilian noninstitutionalized population., Subjects: Children and adolescents aged 6–19 years (n 8466) from three combined NHANES cycles (2003–2004, 2005–2006 and 2007–2008)., Results: White potatoes represented 32% of all vegetable servings consumed by U.S. children and adolescents. Preparations high in fats and oils, including French fries, were most popular both in and out of school. Mean consumption of white potatoes obtained from school cafeterias was approximately 0.05 servings/d among all children and adolescents, and about 0.15 servings/d among children and adolescents acquiring at least one item from the school cafeteria, implying current weekly intake levels well below the limit of 2 servings/week proposed by the U.S. Department of Agriculture., Conclusions: Although white potatoes represent a substantial proportion of vegetable consumption among school-aged children, it is unclear that proposed limits would influence white potato intake from school cafeterias. Policy makers should consider targeting preparation methods to improve the healthfulness of white potato dishes.

Background: Abuse of prescription opioid analgesics is a serious threat to public health, resulting in rising numbers of overdose deaths and admissions to emergency departments and treatment facilities. Absent adequate patient information systems, "doctor shopping" patients can obtain multiple opioid prescriptions for nonmedical use from different unknowing physicians. Our study estimates the prevalence of doctor shopping in the US and the amounts and types of opioids involved., Methods and Findings: The sample included records for 146.1 million opioid prescriptions dispensed during 2008 by 76% of US retail pharmacies. Prescriptions were linked to unique patients and weighted to estimate all prescriptions and patients in the nation. Finite mixture models were used to estimate different latent patient populations having different patterns of using prescribers. On average, patients in the extreme outlying population (0.7% of purchasers), presumed to be doctor shoppers, obtained 32 opioid prescriptions from 10 different prescribers. They bought 1.9% of all opioid prescriptions, constituting 4% of weighed amounts dispensed., Conclusions: Our data did not provide information to make a clinical diagnosis of individuals. Very few of these patients can be classified with certainty as diverting drugs for nonmedical purposes. However, even patients with legitimate medical need for opioids who use large numbers of prescribers may signal dangerously uncoordinated care. To close the information gap that makes doctor shopping and uncoordinated care possible, states have created prescription drug monitoring programs to collect records of scheduled drugs dispensed, but the majority of physicians do not access this information. To facilitate use by busy practitioners, most monitoring programs should improve access and response time, scan prescription data to flag suspicious purchasing patterns and alert physicians and pharmacists. Physicians could also prevent doctor shopping by adopting procedures to screen new patients for their risk of abuse and to monitor patients' adherence to prescribed treatments.

Background: Since 2003, many states have introduced policies to improve the nutritional content and restrict the availability of competitive foods, which are foods offered outside of the National School Lunch and Breakfast Programs. This article evaluates the impact of 2 types of state-level policies on the availability of competitive foods in a national sample of schools., Methods: Annual state-level data on limits, which restrict the time or venue of competitive foods sales, and standards, which regulate the nutrient content of competitive foods, was obtained from the Trust for America's Health and mapped to a national sample from the Early Childhood Longitudinal Study who were in fifth grade in 2004 and eighth grade in 2007. A logistic regression model with child fixed effects tested the association between policy enactments and changes in reported availability of competitive foods in schools. The analyses controlled for child and school characteristics., Results: Nineteen states introduced a standard or a limit between 2004 and 2007. After adjusting for child and school characteristics, standards were associated with lower child-reported availability of soft drinks (16.5%, p < .001), low-nutrient snacks (22.0%, p < .05), and sweets (18.1%, p < .001). The impact of limits was not statistically significant., Conclusion: Standards introduced between 2004 and 2007 were associated with a decline in the availability of soft drinks, low-nutrient snacks, and sweets as reported by a national sample of children. School compliance with state competitive food policies may increase over time. Research on the impact of existing state policies could inform the development of a national policy to regulate competitive foods in schools., (© 2013, American School Health Association.)

Background: Future climate change may cause air quality degradation via climate-induced changes in meteorology, atmospheric chemistry, and emissions into the air. Few studies have explicitly modeled the potential relationships between climate change, air quality, and human health, and fewer still have investigated the sensitivity of estimates to the underlying modeling choices., Objectives: Our goal was to assess the sensitivity of estimated ozone-related human health impacts of climate change to key modeling choices., Methods: Our analysis included seven modeling systems in which a climate change model is linked to an air quality model, five population projections, and multiple concentration-response functions. Using the U.S. Environmental Protection Agency's (EPA's) Environmental Benefits Mapping and Analysis Program (BenMAP), we estimated future ozone (O(3))-related health effects in the United States attributable to simulated climate change between the years 2000 and approximately 2050, given each combination of modeling choices. Health effects and concentration-response functions were chosen to match those used in the U.S. EPA's 2008 Regulatory Impact Analysis of the National Ambient Air Quality Standards for O(3)., Results: Different combinations of methodological choices produced a range of estimates of national O(3)-related mortality from roughly 600 deaths avoided as a result of climate change to 2,500 deaths attributable to climate change (although the large majority produced increases in mortality). The choice of the climate change and the air quality model reflected the greatest source of uncertainty, with the other modeling choices having lesser but still substantial effects., Conclusions: Our results highlight the need to use an ensemble approach, instead of relying on any one set of modeling choices, to assess the potential risks associated with O(3)-related human health effects resulting from climate change.

Unlabelled: Estimates of geographic variation among states and counties in the prevalence of opioid prescribing are developed using data from a large (135 million) representative national sample of opioid prescriptions dispensed during 2008 by 37,000 retail pharmacies. Statistical analyses are used to estimate the extent to which county variation is explained by characteristics of resident populations, their healthcare utilization, proxy measures of morbidity, availability of healthcare resources, and prescription monitoring laws. Geographic variation in prevalence of prescribed opioids is large, greater than the variation observed for other healthcare services. Counties having the highest prescribing rates for opioids were disproportionately located in Appalachia and in southern and western states. The number of available physicians was by far the strongest predictor of amounts prescribed, but only one-third of county variation is explained by the combination of all measured factors. Wide variation in prescribing opioids reflects weak consensus regarding the appropriate use of opioids for treating pain, especially chronic noncancer pain. Patients' demands for treatment have increased, more potent opioids have become available, an epidemic of abuse has emerged, and calls for increased government regulation are growing. Greater guidance, education, and training in opioid prescribing are needed for clinicians to support appropriate prescribing practices., Perspective: Wide geographic variation that does not reflect differences in the prevalence of injuries, surgeries, or conditions requiring analgesics raises questions about opioid prescribing practices. Low prescription rates may indicate undertreatment, while high rates may indicate overprescribing and insufficient attention to risks of misuse., (Copyright © 2012 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Objective: To explore the extent to which commuters reallocate time away from their spouse, children, and friends., Methods: An analytic sample of adult, full-time employed, urban-dwelling respondents is drawn from the nationally representative American Time Use Survey (2003-2010). Seemingly Unrelated Regressions are utilized to calculate adjusted mean number of daily minutes spent with spouse, own children, and friends at several commuting durations., Results: Mean {median} daily commuting time was 54.5 {50} minutes (the range was 6-210 min). For those commuting 60 min daily, a one hour commuting time increase is associated with a 21.8 minute decrease in time males spent with their spouse, an 18.6 minute decrease in time with children, and a 7.2 minute decrease in time with friends. A one hour increase in commuting time is associated with an 11.9 minute decrease in time females spent with friends, only, with no significant impact on time females spent with either spouse or children., Conclusion: This was the first study to utilize time diary data to explore the relationship between commuting length and time spent with others. These estimates will inform researchers interested in time usages' impacts on physical and mental health., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: In 2009, the USDA implemented an interim rule that changed the prescribed foods in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Options for mother and infant dyads include a full breastfeeding package with no infant formula, a partial breastfeeding package with some infant formula, and a full formula package with a smaller postpartum food package for the mother. The changes were designed to encourage WIC mothers to choose breastfeeding for their infants., Objective: The purpose of this study was to measure changes in the following 3 outcomes: WIC food-package assignments, WIC infant formula amounts, and breastfeeding initiation., Design: We compared outcomes before and after implementation of the interim rule in a national random sample of 17 local WIC agencies (LWAs). The data source was administrative records for 206,092 dyads with an infant aged 0-5 mo in the sampled LWAs., Results: There were changes in WIC food-package assignments and infant formula amounts but no change in breastfeeding initiation. For dyads in whom the infant was in his or her birth month, the percentage of mothers who received the partial breastfeeding package fell from 24.7% (preimplementation) to 13.8% (postimplementation), the percentage of mothers who received the full breastfeeding package rose from 9.8% (preimplementation) to 17.1% (postimplementation), and the percentage of mothers who received the full formula package rose from 20.5% (preimplementation) to 28.5% (postimplementation)., Conclusions: After the change, fewer WIC mothers of new infants received the partial breastfeeding package. More WIC mothers received the full breastfeeding package, but more mothers also received the full formula package.

Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President's Emergency Plan for AIDS Relief and other global health initiatives. First, development partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advancements in areas of HIV prevention and treatment and aim to establish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strategic health systems strengthening interventions and address the inherent tension and debate over investments in health systems.

As the largest federal food assistance program, the Supplemental Nutrition Assistance Program (SNAP) has potential to improve food choices among low-income populations. The program's impact on youth is important because they are represented in more than half of all SNAP households. This study estimates the impact of participation in SNAP, also known as the Food Stamp Program, on the frequency of soft drink, 100% fruit juice, and milk consumption among youth (ages 11 through 14) in the United States. A cohort of 3,126 youth from the Early Childhood Longitudinal Survey who were surveyed in 2004 (5th grade) and 2007 (8th grade) were used for the analysis. Multivariate linear regression with individual fixed effects was conducted to estimate the effect of SNAP participation on the frequency of consumption of each beverage type in the preceding week. The fixed effects controlled for factors specific to the youth, such as sex, race/ethnicity, and time-invariant bias in reporting SNAP participation or beverage consumption. Overall participation in SNAP increased from 19.5% to 20.3% between 2004 and 2007, with 14.4% reporting a different participation status in 2007 as compared with 2004. SNAP participation was not found to be predictive of the frequency of soft drink, 100% fruit juice, or milk consumption among youth. In its current state, SNAP may serve to replace lost income for qualifying households, but not alter their food and beverage choices. Interventions that support access to and incentivize the consumption of more healthful foods and beverages may be successful in improving the nutritional quality of intake., (Copyright © 2012 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the quality of the Current Population Survey's (CPS) Child Health Insurance Program (CHIP) data., Data Sources: Linked 2000-2004 Medicaid Statistical Information System (MSIS) and the 2001-2004 CPS., Data Collection Methods: Centers for Medicare & Medicaid Services provided the Census Bureau with its MSIS file. The Census Bureau linked the MSIS to the CPS data within its secure data analysis facilities., Study Design: We compared responses to the CPS health insurance items with Medicaid and CHIP status according to the MSIS., Principal Findings: CHIP reporting in the CPS is unreliable. Only 10-30 percent of those with CHIP (but not Medicaid) report this type of coverage in the CPS. Many with CHIP report Medicaid coverage, so the reporting error for a Medicaid-CHIP composite is smaller, but still substantial., Conclusions: The quality of the CPS CHIP information renders it effectively unusable for health policy analysis. Analysts should consider using a Medicaid-CHIP composite for CPS-based analyses.

Objectives: To describe the features of medication therapy management (MTM) programs, including eligibility criteria, enrollment, services, and reimbursement, and to describe the criteria used to evaluate MTM programs and assess the evidence of relevance to Medicare., Design: Descriptive, exploratory, nonexperimental study., Setting: United States between July 2007 and June 2008., Participants: 60 key informants from 46 different organizations and case studies with 28 representatives from four MTM programs., Intervention: Literature review, key informant interviews, and evaluation of case studies., Main Outcome Measures: MTM program features and evidence of effectiveness., Results: MTM programs used a variety of practice models. Medicare MTM programs used different eligibility criteria than MTM programs sponsored by Medicaid or other payers. MTM programs that required patients to opt-in had less success in enrolling participants than those using opt-out. Most MTM programs conducted annual medication reviews. Most non-Medicare MTM programs provided face-to-face interventions, whereas Medicare MTM programs relied more on telephone or mail; no research tested the effectiveness of different modes. Almost all MTM programs used pharmacists to provide services. Little research on Medicare MTM programs was available. Costs were commonly measured in the MTM literature, although results were inconsistent. A few studies demonstrated significant improvements in intermediate outcomes (e.g., low-density lipoprotein cholesterol), while less studies demonstrated an impact on serious sequelae (e.g., emergency department visits)., Conclusion: Medicare MTM programs were still evolving when this study was conducted, and we found limited evidence to determine which beneficiaries would benefit most from MTM, which features achieved the desired outcomes, and which outcomes should be measured to compare MTM program performance.

Under Executive Order 12898, the U.S. Environmental Protection Agency (EPA) must perform environmental justice (EJ) reviews of its rules and regulations. EJ analyses address the hypothesis that environmental disamenities are experienced disproportionately by poor and/or minority subgroups. Such analyses typically use communities as the unit of analysis. While community-based approaches make sense when considering where polluting sources locate, they are less appropriate for national air quality rules affecting many sources and pollutants that can travel thousands of miles. We compare exposures and health risks of EJ-identified individuals rather than communities to analyze EPA's Heavy Duty Diesel (HDD) rule as an example national air quality rule. Air pollutant exposures are estimated within grid cells by air quality models; all individuals in the same grid cell are assigned the same exposure. Using an inequality index, we find that inequality within racial/ethnic subgroups far outweighs inequality between them. We find, moreover, that the HDD rule leaves between-subgroup inequality essentially unchanged. Changes in health risks depend also on subgroups' baseline incidence rates, which differ across subgroups. Thus, health risk reductions may not follow the same pattern as reductions in exposure. These results are likely representative of other national air quality rules as well.

To describe the characteristics, access, utilization, satisfaction, and outcomes of Healthy Start participants in eight selected sites, a survey of Healthy Start participants with infants ages 6-12-months-old at time of interview was conducted between October 2006 and January 2007. The response rate was 66% (n = 646), ranging from 37% in one site to >70% in seven sites. Healthy Start participants' outcomes were compared to two national benchmarks. Healthy Start participants reported that they were satisfied with the program (>90% on five measures). Level of unmet need was 6% or less for most services, except for dental appointments (11%), housing (13%), and child care (11%). Infants had significantly better access to medical care than did their mothers, with higher rates of insurance coverage, medical homes, and checkups, and fewer unmet needs for health care. Healthy Start participants' rates of ever breastfeeding (72%) and putting infants to sleep on their backs (70%) were at or near the Healthy People 2010 objectives, and considerably higher than rates among low-income mothers in the ECLS. The high rate of health education (>90%) may have contributed to these outcomes. Elimination of smoking among Healthy Start participants (46%) fell short of the Healthy People 2010 objective (99%). The low-birth weight (LBW) rate among Black Healthy Start participants (14%) was three times higher than the rate for Whites and Hispanics (5% each). Overall, the LBW rate in the eight sites (7.5%) was similar to the rate for low-income mothers in the ECLS, but both rates were above the Healthy People 2010 objective (5%). Challenges remain in reducing disparities in maternal and child health outcomes. Further attention to risk factors associated with LBW (especially smoking) may help close the gaps. The life course theory suggests that improved outcomes may require longer-term investments. Healthy Start's emerging focus on interconception care has the potential to address longer-term needs of participants.

Objective: To determine the predictors of chain acquisition among independent dialysis providers., Data Sources: Retrospective facility-level data combined from CMS Cost Reports, Medical Evidence Forms, Annual Facility Surveys, and claims for 1996-2003., Study Design: Independent dialysis facilities' probability of acquisition by a dialysis chain (overall and by chain size) was estimated using a discrete time hazard rate model, controlling for financial and clinical performance, practice patterns, market factors, and other facility characteristics., Data Collection: The sample includes all U.S. freestanding dialysis facilities that report not being chain affiliated for at least 1 year between 1997 and 2003., Principal Findings: Above-average costs and better quality outcomes are significant determinants of dialysis chain acquisition. Facilities in larger markets were more likely to be acquired by a chain. Furthermore, small dialysis chains have different acquisition strategies than large chains., Conclusions: Dialysis chains appear to employ a mix of turn-around and cream-skimming strategies. Poor financial health is a predictor of chain acquisition as in other health care sectors, but the increased likelihood of chain acquisition among higher quality facilities is unique to the dialysis industry. Significant differences among predictors of acquisition by small and large chains reinforce the importance of using a richer classification for chain status.

In the Institute of Medicine (IOM) macronutrient report the Committee recommended a maximal intake of < or = 25% of energy from added sugars. The primary objectives of this study were to utilize National Health and Nutrition Examination Survey (NHANES) to update the reference table data on intake of added sugars from the IOM report and compute food sources of added sugars. We combined data from NHANES with the United States Department of Agriculture (USDA) MyPyramid Equivalents Database (MPED) and calculated individual added sugars intake as percent of total energy then classified individuals into 8 added sugars percent energy categories, calculated usual intake with the National Cancer Institute (NCI) method, and compared intakes to the Dietary Reference Intakes (DRIs). Nutrients at most risk for inadequacy based on the Estimated Average Requirements (EARs) were vitamins E, A, C, and magnesium. Nutrient intake was less with each 5% increase in added sugars intake above 5-10%. Thirteen percent of the population had added sugars intake > 25%. The mean g-eq added sugars intake of 83.1 g-eq/day and added sugars food sources were comparable to the mid-1990s. Higher added sugars intakes were associated with higher proportions of individuals with nutrient intakes below the EAR, but the overall high calorie and the low quality of the U.S. diet remained the predominant issue. With over 80% of the population at risk for select nutrient inadequacy, guidance may need to focus on targeted healthful diet communication to reach the highest risk demographic groups for specific life stage nutrient inadequacies.

Background: Insufficient research about the economic impact of noncompliance with hypertension treatment guidelines has been published to date., Objectives: The aims of this study were to estimate the following: (1) the prevalence of hypertension in the United States; (2) the proportion of US patients with hypertension who are appropriately and inappropriately treated; and (3) incremental direct expenditures for inappropriate hypertension management in the United States in 2006, from the perspective of society., Methods: Analysis of the 2006 Medical Expenditure Panel Survey (MEPS), a national probability sample survey of the ambulatory civilian US population, was conducted. Definitions of inappropriate and appropriate hypertension treatment were taken from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Hypertensive patients were identified in the MEPS database by medical diagnosis for hypertension based on International Classification of Diseases, Ninth Revision, Clinical Modification codes (401.xx-405.xx), consumption of hypertension-related medical services, self-report of hypertension diagnosis from a physician, or prescription for an antihypertensive medication. Incremental expenditure for inappropriate hypertension management per JNC 7 guidelines was estimated through least-squares regression adjusting for age, sex, race, and education, and for comorbidities using the D'Hoore adaptation of the Charlson comorbidity index. Sample data were extrapolated to the US population and 95% confidence limits for estimates were calculated using the Taylor expansion method. All costs were reported as year-2006 US dollars., Results: Extrapolated estimates based on the MEPS sample data indicated that 19.7% of those aged > or = 18 years in the US population had hypertension in 2006; 64% were treated appropriately and 36% were treated inappropriately. The mean per-person incremental expenditure for inappropriate treatment was $234.60 for 2006, with total incremental annual direct expenditures of $12,747,337,035 after adjusting for patient demographics and comorbidities., Conclusions: Based on this retrospective analysis of year-2006 MEPS data, inappropriate management of hypertension contributes substantially to health care resource utilization and associated costs in the United States. The overall prevalence of hypertension was estimated at 19.7%, with 36% of identified patients treated inappropriately. The per-person cost for inappropriate treatment was $234.60, and the total national cost was approximately $13 billion.

Our purpose was to conduct a new analysis to update and extend previously published trends of fructose availability and estimated fructose intake and food sources of dietary fructose from the 1977-1978 Nationwide Food Consumption Survey (NFCS) data. We estimated fructose usual intake with data from NHANES 1999-2004 for 25,165 individuals (1 y and older, excluding pregnant and lactating women and breast-fed infants) using the Iowa State C-SIDE software. We applied food group-specific conversion factors to individual measures of sugar intakes following the earlier study. Sweetener availability in the United States increased from 1978, peaked in 1999, and declined through 2005. The high-fructose corn syrup percentage of sweeteners increased from 16% in 1978 to 42% in 1998 and then stabilized. Since 1978, mean daily intakes of added and total fructose increased in all gender and age groups, whereas naturally occurring (N) fructose intake decreased or remained constant. Total fructose intake as percentage of energy and as percentage of carbohydrate increased 1 and 1.2%, whereas daily energy and carbohydrate intakes increased 18 and 41%, respectively. Similar to 1978 results, nonalcoholic beverages and grain products were the principal food sources of added fructose. Fruits and fruit products were the main dietary sources of N fructose in 2004; in 1978, grain products and vegetables were more predominant food sources. Although comparison of estimates of fructose intakes between data from the 1977-1978 NFCS and the NHANES 1999-2004 showed an increase, this increase was dwarfed by greater increases in total daily energy and carbohydrate intakes.