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Whether a Mediterranean-style diet reduces cardiovascular events and mortality more than a low-fat diet is uncertain. The objectives of this study were to actively compare low-fat and Mediterranean-style diets after first myocardial infarction (MI) in a randomized, controlled clinical trial and to compare dietary intervention per se with usual care in a case-control analysis. First MI survivors were randomized to a low-fat (n = 50) or Mediterranean-style (n = 51) diet. The 2 diets were low in saturated fat (< or =7% kcal) and cholesterol (< or =200 mg/day); the Mediterranean-style diet was distinguished by greater omega-3 fat intake (>0.75% kcal). Participants received individual dietary counseling sessions, 2 within the first month and again at 3, 6, 12, 18, and 24 months, along with 6 group sessions. Combined dietary intervention groups (cases, n = 101) were compared with a usual-care group (controls, n = 101) matched for age, gender, MI type and treatment, and status of diabetes mellitus and hypertension. Primary-outcome-free survival (a composite of all-cause and cardiac deaths, MI, hospital admissions for heart failure, unstable angina pectoris, or stroke) did not differ between low-fat (42 of 50) and Mediterranean-style (43 of 51) diet groups over a median follow-up period of 46 months (range 18 to 72; log-rank p = 0.81). Patients receiving dietary intervention had better primary-outcome-free survival (85 of 101) than usual-care controls (61 of 101) (log-rank p <0.001), with unadjusted and adjusted odds ratios of 0.33 (95% confidence interval 0.18 to 0.60, p <0.001) and 0.28 (95% confidence interval 0.13 to 0.63, p = 0.002), respectively. In conclusion, active intervention with either a low-fat or a Mediterranean-style diet similarly and significantly benefits overall and cardiovascular-event-free survival after MI. [ABSTRACT FROM AUTHOR]

Aim: Guideline-directed medical therapy (GDMT) is designed to improve clinical outcomes. The study aim was to assess GDMT prescribing rates and prescribing-persistence predictors in patients with diabetes and chronic kidney disease (CKD) from the Center for Kidney Disease Research, Education, and Hope Registry., Materials and Methods: Data were obtained from adults ≥18 years old with diabetes and CKD between 1 January 2019 and 31 December 2020 (N = 39 158). Baseline and persistent (≥90 days) prescriptions for GDMT, including angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 (GLP-1) receptor agonist were assessed., Results: The population age (mean ± SD) was 70 ± 14 years, and 49.6% (n = 19 415) were women. Baseline estimated glomerular filtration rate (2021 CKD-Epidemiology Collaboration creatinine equation) was 57.5 ± 23.0 ml/min/1.73 m 2 and urine albumin/creatinine 57.5 mg/g (31.7-158.2; median, interquartile range). Baseline and ≥90-day persistent prescribing rates, respectively, were 70.7% and 40.4% for ACE inhibitor/ARB, 6.0% and 5.0% for SGLT2 inhibitors, and 6.8% and 6.3% for GLP-1 receptor agonist (all p < .001). Patients lacking primary commercial health insurance coverage were less likely to be prescribed an ACE inhibitor/ARB [odds ratio (OR) = 0.89; 95% confidence interval (CI) 0.84-0.95; p < .001], SGLT2 inhibitor (OR 0.72; 95% CI 0.64-0.81; p < .001) or GLP-1 receptor agonist (OR 0.89; 95% CI 0.80-0.98; p = .02). GDMT prescribing rates were lower at Providence than UCLA Health., Conclusions: Prescribing for GDMT was suboptimal and waned quickly in patients with diabetes and CKD. Type of primary health insurance coverage and health system were associated with GDMT prescribing., (© 2023 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Acute kidney injury (AKI) is a serious postoperative complication that increases patients' risk for long- and shortterm morbidity and mortality. Risk for developing AKI increases following intraoperative hypotension (IOH). This project aimed to describe the rate of and establish IOH as an independent risk factor for AKI among adults undergoing non-cardiac surgery at a large tertiary care medical center. An observational, retrospective, evidence-based practice project was conducted. Records were extracted for adults undergoing general anesthesia for non-cardiac surgery from 2015 to 2019 with available serum creatinine laboratory results. The primary project outcome was postoperative AKI. Among 4,603 cases, 8.9% experienced postoperative AKI. Cases with IOH (MAPs less than 60 mmHg for at least 10 minutes) compared to cases without IOH had increased risks for AKI (RR 1.48, 95% CI [1.19-1.84], P<.001). In a fully adjusted model, IOH was an independent risk factor for AKI (OR 1.50, 95% CI [1.18-1.92], P=.001). Among cases with serum creatinine laboratory results, the rate of AKI was higher than reported literature rates. IOH was confirmed as an independent risk factor. Quantifying the rate of and risk factors for AKI may precipitate heightened attention to prevention strategies and encourage quality improvement initiatives., Competing Interests: Name: Elizabeth Davison, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Amanda Affleck, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Kenn B. Daratha, PhD Contribution: This author made significant contributions to the conception, synthesis, writing and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright © by the American Association of Nurse Anesthetists.)

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Objective: The purpose of this study was to assess whether bundled team training interventions for surgeons and office staff could effectively improve the accuracy of surgery scheduling, minimizing scheduling factors that may contribute to occurrence of wrong site surgery., Methods: This quasi-experimental observational study used an interrupted time series design to explore surgery scheduling errors (SSEs) and implemented bundled team training interventions intended to reduce SSEs at a Pacific Northwest Regional Surgery Scheduling Department. Each preintervention and postintervention segment consisted of 16 weekly data points. The bundled team training interventions included disclosure of preintervention scheduling errors, a scheduling verification checklist, an updated surgery scheduling policy and procedure, and toolkit to improve office scheduling of surgeries., Results: Improvements in SSEs were observed preintervention to postintervention, with decreased surgery SSE rate from 0.51% to 0.13% (P < 0.001). Reductions were observed in all SSE types. The segmented linear trend demonstrated an observed reduction of 42.70 SSE (P < 0.001)., Conclusions: This is the first study conducted at a large healthcare system with a regional surgery scheduling department to demonstrate that statistically significant and clinically important reductions in SSEs can be achieved. The findings demonstrate that SSEs can be minimized and confirm that verification processes must begin in the surgeon's office once a decision has been reached to proceed with surgery. The study confirms the need for additional research targeted at understanding why SSEs occur at the time of scheduling., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

The purpose of this randomized controlled trial ( n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.

Volatile anesthetic agents act as greenhouse gases. Low-flow anesthesia techniques (≤1 L/min) are associated with lower costs. Decreasing volatile anesthetic delivery provides safe and effective strategies for anesthesia providers to decrease costs and reduce environmental pollution. This evidence-based project aimed to estimate cost savings and reduction in the environmental release of anesthetic gases, under simulated lower fresh gas flow (FGF) practices. For each surgical case, the exhaled anesthetic gas percent and FGF data were used to calculate the volume of fluid volatile anesthetic. The fluid volatile anesthetic for each case was then estimated using simulated FGFs. Changes in volatile agent cost and environmental release of anesthetic gases were predicted. Sevoflurane was the most commonly used volatile agent. The mean FGF for cases using sevoflurane was 2.5 L/min. The simulated FGF of 1 L/min FGF across all agents predicted a 48% ($50,892) reduction in costs of volatile anesthetics and a 42% (33 metric tons of carbon dioxide equivalent) decrease in carbon emissions. Simulated low-flow anesthesia demonstrated cost savings and environmental conservation. Project findings align with current literature showing that lowering FGFs represents an area of cost containment and an opportunity to lessen the environmental impact of anesthesia., Competing Interests: The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright © by the American Association of Nurse Anesthetists.)

Background: Although measuring albuminuria is the preferred method for defining and staging chronic kidney disease (CKD), total urine protein or dipstick protein is often measured instead., Objective: To develop equations for converting urine protein-creatinine ratio (PCR) and dipstick protein to urine albumin-creatinine ratio (ACR) and to test their diagnostic accuracy in CKD screening and staging., Design: Individual participant-based meta-analysis., Setting: 12 research and 21 clinical cohorts., Participants: 919 383 adults with same-day measures of ACR and PCR or dipstick protein., Measurements: Equations to convert urine PCR and dipstick protein to ACR were developed and tested for purposes of CKD screening (ACR ≥30 mg/g) and staging (stage A2: ACR of 30 to 299 mg/g; stage A3: ACR ≥300 mg/g)., Results: Median ACR was 14 mg/g (25th to 75th percentile of cohorts, 5 to 25 mg/g). The association between PCR and ACR was inconsistent for PCR values less than 50 mg/g. For higher PCR values, the PCR conversion equations demonstrated moderate sensitivity (91%, 75%, and 87%) and specificity (87%, 89%, and 98%) for screening (ACR >30 mg/g) and classification into stages A2 and A3, respectively. Urine dipstick categories of trace or greater, trace to +, and ++ for screening for ACR values greater than 30 mg/g and classification into stages A2 and A3, respectively, had moderate sensitivity (62%, 36%, and 78%) and high specificity (88%, 88%, and 98%). For individual risk prediction, the estimated 2-year 4-variable kidney failure risk equation using predicted ACR from PCR had discrimination similar to that of using observed ACR., Limitation: Diverse methods of ACR and PCR quantification were used; measurements were not always performed in the same urine sample., Conclusion: Urine ACR is the preferred measure of albuminuria; however, if ACR is not available, predicted ACR from PCR or urine dipstick protein may help in CKD screening, staging, and prognosis., Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases and National Kidney Foundation.

Objectives: The aims of this secondary analysis were to: (a) characterize medication use following hospital discharge for patients with chronic kidney disease (CKD), and (b) investigate relationships of medication use with the primary composite outcome of acute care utilization 90 days after hospitalization., Methods: The CKD-Medication Intervention Trial (CKD-MIT) enrolled acutely ill hospitalized patients with CKD stages 3-5 not dialyzed (CKD 3-5 ND). In this post hoc analysis, data for medication use were characterized, and the relationship of medication use with the primary outcome was evaluated using Cox proportional hazards models., Results: Participants were taking a mean of 12.6 (standard deviation=5.1) medications, including medications from a wide variety of medication classes. Nearly half of study participants were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB). ACE inhibitor/ARB use was associated with decreased risk of the primary outcome (hazard ratio=0.51; 95% confidence interval 0.28-0.95; p =0.03) after adjustment for baseline estimated glomerular filtration rate, age, sex, race, blood pressure, albuminuria, and potential nephrotoxin use., Conclusions: A large number, variety, and complexity of medications were used by hospitalized patients with CKD 3-5 ND. ACE inhibitor or ARB use at hospital discharge was associated with a decreased risk of 90-day acute care utilization.

Importance: Chronic kidney disease (CKD) is serious and common, yet recognition and public health responses are limited., Objective: To describe clinical features of, prevalence of, major risk factors for, and care for CKD among patients treated in 2 large US health care systems., Design, Setting, and Participants: This cohort study collected data from the Center for Kidney Disease Research, Education, and Hope (CURE-CKD) registry, an electronic health record-based registry jointly curated and sponsored by Providence St Joseph Health and the University of California, Los Angeles. Patients were adults and children with CKD (excluding end-stage kidney disease) and adults at risk of CKD (ie, with diabetes, hypertension, or prediabetes) identified by laboratory values, vital signs, prescriptions, and administrative codes. Data were collected from January 2006 through December 2017, with analyses performed from March 2019 through November 2019., Exposures: Diabetes, hypertension, and prediabetes., Main Outcomes and Measures: Clinical and demographic characteristics, prevalence, and prescribed medications., Results: Of 2 625 963 adults and children in the sample, 606 064 adults (23.1%) with CKD had a median (interquartile range [IQR]) age of 70 (59-81) years, with 338 785 women (55.9%) and 434 474 non-Latino white individuals (71.7%). A total of 12 591 children (0.4%) with CKD had a median (IQR) age of 6 (1-13) years, with 7079 girls (56.2%) and 6653 non-Latino white children (52.8%). Median (IQR) estimated glomerular filtration rate was 53 (41-61) mL/min/1.73 m2 among adults and 70 (50-95) mL/min/1.73 m2 in children. Prevalence rates for CKD in adults were 4.8% overall (606 064 of 12 669 700) with 1.6% (93 644 of 6 011 129) during 2006 to 2009, 5.7% (393 455 of 6 903 084) during 2010 to 2013, and 8.4% (683 574 of 8 179 860) during 2014 to 2017 (P < .001). A total of 226 693 patients (37.4%) had category 3a CKD; 100 239 (16.5%), category 3b CKD; 39 125 (6.5%), category 4 CKD; and 20 328 (3.4%), category 5 CKD. Among adults with CKD, albuminuria and proteinuria assessments were available in 52 551 (8.7%) and 25 035 (4.1%) patients, respectively. A renin-angiotensin system inhibitor was prescribed to 124 575 patients (20.6%), and 204 307 (33.7%) received nonsteroidal anti-inflammatory drugs or proton pump inhibitors. Of 1 973 258 adults (75.1%) at risk, one-quarter had diabetes or prediabetes (512 299 [26.0%]), nearly half had hypertension (955 812 [48.4%]), and one-quarter had both hypertension and diabetes or prediabetes (505 147 [25.6%])., Conclusions and Relevance: This registry-based cohort study revealed a burgeoning number of patients with CKD and its major risk factors. Rates of identification and use of kidney protective agents were low, while potential nephrotoxin use was widespread, underscoring the pressing need for practice-based improvements in CKD prevention, recognition, and treatment.

Background: Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function., Methods: We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data., Results: The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials., Discussion: CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Rationale and Objective: In the Systolic Blood Pressure Intervention Trial, the possible relationships between acute kidney injury (AKI) and risk of major cardiovascular events and death are not known., Study Design: Post hoc analysis of a multicenter, randomized, controlled, open-label clinical trial., Setting and Participants: Hypertensive adults without diabetes who were ≥50 years of age with prior cardiovascular disease, chronic kidney disease (CKD), 10-year Framingham risk score > 15%, or age > 75 years were assigned to a systolic blood pressure target of < 120 mm Hg (intensive) or < 140 mm Hg (standard)., Predictor: AKI episodes., Outcomes: The primary outcome was a composite of myocardial infarction, acute coronary syndrome, stroke, decompensated heart failure, or cardiovascular death. The secondary outcome was death from any cause. Analytical Approach: AKI was defined using the Kidney Disease: Improving Global Outcomes modified criteria based solely upon serum creatinine. AKI episodes were identified by serious adverse events or emergency room visits. Cox proportional hazards models assessed the risk for the primary and secondary outcomes by AKI status., Results: Participants were 68 ± 9 years of age, 36% women (3,332/9,361), and 30% Black race (2,802/9,361), and 17% (1,562/9,361) with cardiovascular disease. Systolic blood pressure was 140 ± 16 mm Hg at study entry. AKI occurred in 4.4% (204/4,678) and 2.6% (120/4,683) in the intensive and standard treatment groups respectively (p < 0.001). Those who experienced AKI had higher risk of cardiovascular events (hazard ratio [HR] 1.52, 95% CI 1.05-2.20, p = 0.026) and death from any cause (HR 2.33, 95% CI 1.56-3.48, p < 0.001) controlling for age, sex, race, baseline systolic blood pressure, body mass index, number of antihypertensive medications, cardiovascular disease and CKD status, hypotensive episodes, and treatment assignment., Limitations: The study was not prospectively designed to determine relationships between AKI, cardiovascular events, and death., Conclusions: Among older adults with hypertension at high cardiovascular risk, intensive treatment of blood pressure independently increased risk of AKI, which substantially raised risks of major cardiovascular events and death., (© 2019 S. Karger AG, Basel.)

Nurses in acute care settings are affected by the technologies they use, including electronic health records. This study investigated the impacts of adoption of a comprehensive electronic health record by measuring nursing locations and interventions in three units before and 12 months after adoption. Time-motion methodology with a handheld recording platform based on Omaha System standardized terminology was used to collect location and intervention data. In addition, investigators administered the Caring Efficacy Scale to better understand the effects of the electronic health record on nursing care efficacy. Several differences were noted after the electronic health record was adopted. Nurses spent significantly more time in patient rooms and less in other measured locations. They spent more time overall performing nursing interventions, with increased time in documentation and medication administration, but less time reporting and providing patient-family teaching. Both before and after electronic health record adoption, nurses spent most of their time in case management interventions (coordinating, planning, and communicating). Nurses showed a slight decrease in perceived caring efficacy after adoption. While initial findings demonstrated a trend toward increased time efficiency, questions remain regarding nurse satisfaction, patient satisfaction, quality and safety outcomes, and cost.

Background: More than a million people a year in the United States experience sepsis or sepsis-related complications, and sepsis remains the leading cause of in-hospital deaths. Unlike many other leading causes of in-hospital mortality, sepsis detection and treatment are not dependent on the presence of any technology or services that differ between tertiary and non-tertiary hospitals., Objective: To compare sepsis mortality rates between tertiary and non-tertiary hospitals in Washington State., Methods: A retrospective longitudinal, observational cohort study of 73 Washington State hospitals for 2010-2015 using data from a standardized state database of hospital abstracts. Abstract records on adult patients (n = 86,378) admitted through the emergency department (ED) from 2010 through 2015 in all tertiary (n = 7) and non-tertiary (n = 66) hospitals in Washington State., Results: The overall mortality rate for all hospitals was 6.5%. In the fully adjusted model, the odds ratio for in-hospital death was higher in non-tertiary hospitals compared with tertiary hospitals (odds ratio 1.25; 95% confidence interval 1.17-1.35; p < 0.001)., Conclusions: We observed higher sepsis mortality rates in non-tertiary hospitals, compared with tertiary hospitals. Because most patients who are treated for sepsis are treated outside of tertiary hospitals, and the number of patients treated for sepsis in non-tertiary hospitals seems to be rising, a better understanding of the cause or causes for this differential is crucial., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Infrequent and late referral to hospice among patients on dialysis likely reflects the impact of a Medicare payment policy that discourages the concurrent receipt of these services, but it may also reflect these patients' less predictable illness trajectories. Among a national cohort of patients on hemodialysis, we identified four distinct spending trajectories during the last year of life that represented markedly different intensities of care. Within the cohort, 9 percent had escalating spending and 13 percent had persistently high spending throughout the last year of life, while 41 percent had relatively low spending with late escalation, and 37 percent had moderate spending with late escalation. Across the four groups, the percentages of patients enrolled in hospice at the time of death were uniformly low ranging from only 19 percent of those with persistently high costs to 21 percent of those with moderate costs and the median number of days spent in hospice during the last year of life was virtually the same (either five or six days). These findings signal the need for greater flexibility in the provision of end-of-life care in this population.

Background and Objectives: CKD is characterized by remarkably high hospitalization and readmission rates. Our study aim was to test a medication therapy management intervention to reduce subsequent acute care utilization., Design, Setting, Participants, & Measurements: The CKD Medication Intervention Trial was a single-blind (investigators), randomized clinical trial conducted at Providence Health Care in Spokane, Washington. Patients with CKD stages 3-5 not treated by dialysis who were hospitalized for acute illness were recruited. The intervention was designed to improve posthospitalization care by medication therapy management. A pharmacist delivered the intervention as a single home visit within 7 days of discharge. The intervention included these fundamental elements: comprehensive medication review, medication action plan, and a personal medication list. The primary outcome was a composite of acute care utilization (hospital readmissions and emergency department and urgent care visits) for 90 days after hospitalization., Results: Baseline characteristics of participants ( n =141) included the following: age, 69±11 (mean±SD) years old; women, 48% (67 of 141); diabetes, 56% (79 of 141); hypertension, 83% (117 of 141); eGFR, 41±14 ml/min per 1.73 m 2 (serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation); and urine albumin-to-creatinine ratio median, 43 mg/g (interquartile range, 8-528) creatinine. The most common primary diagnoses for hospitalization were the following: cardiovascular events, 36% (51 of 141); infections, 18% (26 of 141); and kidney diseases, 12% (17 of 141). The primary outcome occurred in 32 of 72 (44%) of the medication intervention group and 28 of 69 (41%) of those in usual care (log rank P =0.72). For only hospital readmission, the rate was 19 of 72 (26%) in the medication intervention group and 18 of 69 (26%) in the usual care group (log rank P =0.95). There was no between-group difference in achievement of guideline-based goals for use of renin-angiotensin system inhibition or for BP, hemoglobin, phosphorus, or parathyroid hormone., Conclusions: Acute care utilization after hospitalization was not reduced by a pharmacist-led medication therapy management intervention at the transition from hospital to home., (Copyright © 2018 by the American Society of Nephrology.)

Background: Hospital electronic health record (EHR) data are increasingly being called upon for research purposes, yet only recently has it been tested to examine its reliability. Studies that have examined reliability of EHR data for research purposes have varied widely in methods used and field of inquiry, with little reporting of the reliability of perinatal and obstetric variables in the current literature., Objective: To assess the reliability of data extracted from a commercially available inpatient EHR as compared with manually abstracted data for common attributes used in obstetrical research., Methods: Data extracted through automated EHR reports for 3,250 women who delivered a live infant at a large hospital in the Pacific Northwest were compared with manual chart abstraction for the following perinatal measures: delivery method, labor induction, labor augmentation, cervical ripening, vertex presentation, and postpartum hemorrhage., Results: Almost perfect agreement was observed for all four modes of delivery (vacuum assisted: kappa = 0.92; 95% confidence interval [CI] = 0.88-0.95, forceps assisted: kappa = 0.90; 95%CI = 0.76-1.00, cesarean delivery: kappa = 0.91; 95%CI = 0.90-0.93, and spontaneous vaginal delivery: kappa = 0.91; 95%CI = 0.90-0.93). Cervical ripening demonstrated substantial agreement (kappa = 0.77; 95%CI = 0.73-0.80); labor induction (kappa = 0.65; 95%CI = 0.62-0.68) and augmentation (kappa = 0.54; 95%CI = 0.49-0.58) demonstrated moderate agreement between the two data sources. Vertex presentation (kappa = 0.35; 95%CI = 0.31-0.40) and post-partum hemorrhage (kappa = 0.21; 95%CI = 0.13-0.28) demonstrated fair agreement., Conclusion: Our study demonstrates variability in the reliability of obstetrical data collected and reported through the EHR. While delivery method was satisfactorily reliable in our sample, other examined perinatal measures were less so when compared with manual chart abstraction. The use of multiple modalities for assessing reliability presents a more consistent and rigorous approach for assessing reliability of data from EHR systems and underscores the importance of requiring validation of automated EHR data for research purposes., Competing Interests: None., (Schattauer GmbH Stuttgart.)

Aim: This study examined nurses' work, comparing nursing interventions and locations across three units in a United States hospital using Omaha System standardized terminology as the organizing framework., Background: The differences in nurses' acute-care work across unit types are not well understood. Prior investigators have used time-motion methodologies; few have compared differences across units, nor used standardized terminology., Methods: Nurse-observers recorded locations and interventions of nurses on three acute-care units using hand-held devices and web-based TimeCaT ™ software. Nursing interventions were mapped to Omaha System terms. Unit-differences were analysed., Results: Nurses changed locations approximately every 2 min, and averaged approximately one intervention/minute. Unit differences were found in both the interventions performed and the locations. Most interventions were case-management related, demonstrating the nurses' patient management/coordination role., Conclusions: Unit differences in nursing interventions and location were found among three unit types. Omaha System terminology, as well as the observational method used, were found to be feasible and practical., Implications for Nursing Management: Nursing work varies by unit, yet managers have not been armed with empirical data with which to make more informed decisions about nurses' work priorities, clinical outcomes, patient satisfaction, staff satisfaction and cost. The results from this study will help them to do so., (© 2017 John Wiley & Sons Ltd.)

Introduction: Obstetrical care often involves multiple expensive, and often elective, interventions that may increase costs to patients, payers, and the health care system with little effect on patient outcomes. The objectives of this study were to examine the following hospital related outcomes: 1) use of labor and birth interventions, 2) inpatient duration of stay, and 3) total direct health care costs for patients attended by a certified nurse-midwife (CNM) compared with those attended by an obstetrician-gynecologist (OB-GYN), within an environment of safe and high-quality care., Material and Methods: Electronic health records for 1,441 medically low-risk women who gave birth at a hospital located in the U.S. Pacific Northwest between January and September 2013 were sampled. Multilevel regression and generalized linear models were used for analysis., Results: Reduced use of selected labor and birth interventions (cesarean delivery, vacuum-assisted delivery, epidural anesthesia, labor induction, and cervical ripening), reduced maternal duration of stay, and reduced overall costs associated with CNM-led care relative to OB-GYN-led care were observed for medically low-risk women in a hospital setting. Maternal and neonatal outcomes were comparable across groups., Conclusions: This study supports consideration of increased use of CNMs as providers for the care of women at low risk for complications to decrease costs for the health care system. The use of CNMs to the fullest extent within state-regulated scopes of practice could result in more efficient use of hospital resources., (Copyright © 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Background: The value of early invasive revascularization for patients suffering acute myocardial infarction (AMI) is well known. However, access to revascularization services varies geographically and demographically. Previous studies have not examined the influence of rural residence on revascularization rates and outcomes among patients hospitalized with AMI., Methods: Our retrospective cohort study included patients hospitalized in Washington State with a primary diagnosis of AMI from 2009 to 2012. Urban or rural residence was determined using rural-urban commuting area (RUCA) codes. Multivariable models were used to evaluate geographic variation in rates of invasive versus medical management, in-hospital mortality, rehospitalization, and subsequent revascularization procedures., Results: Our study included 25,156 urban dwellers and 2,770 rural residents. Adjusted models found rural patients to be at increased odds of undergoing invasive revascularization during the initial episode of AMI care (OR = 1.11; 95% CI: 1.01-1.21; P = .02) compared to urban dwelling patients. Rural patients were more likely to be transferred for care (OR = 4.28; 95% CI: 3.93-4.66; P < .001) and more likely to undergo coronary artery bypass grafting (CABG) (OR = 1.55; 95% CI: 1.35-1.78; P < .001) compared to the urban cohort. We found no significant geographic cohort differences in in-hospital mortality or subsequent revascularization rates., Conclusion: Our findings suggest that despite limited access to cardiac care facilities, rural patients are accessing revascularization services. However, rural residents are more likely to undergo CABG during their index admission. High transfer rates suggest that rural regions rely on effective transfer networks to access invasive cardiac services., (© 2015 National Rural Health Association.)

Purpose: The purpose of this article is to present an overview of rapid response team (RRT) history in the United States, provide a review of prior RRT effectiveness research, and propose the reframing of four new questions of RRT measurement that are designed to better understand RRTs in the context of contemporary nursing practice as well as patient outcomes., Organizing Construct: RRTs were adopted in the United States because of their intuitive appeal, and despite a lack of evidence for their effectiveness. Subsequent studies used mortality and cardiac arrest rates to measure whether or not RRTs "work." Few studies have thoroughly examined the effect of RRTs on nurses and on nursing practice., Methods: An extensive literature review provided the background. Suppositions and four critical, unanswered questions arising from the literature are suggested., Findings: The results of RRT effectiveness, which have focused on patient-oriented outcomes, have been ambiguous, contradictory, and difficult to interpret. Additionally, they have not taken into account the multiple ways in which these teams have impacted nurses and nursing practice as well as patient outcomes., Conclusions: What happens in terms of RRT process and utilization is likely to have a major impact on nurses and nursing care on general medical and surgical wards. What that impact will be depends on what we can learn from measuring with an expanded yardstick, in order to answer the question, "Do RRTs work?", Clinical Relevance: Evidence for the benefits of RRTs depends on proper framing of questions relating to their effectiveness, including the multiple ways RRTs contribute to nursing efficacy., (© 2016 Sigma Theta Tau International.)

Background: Manufacturer prescription assistance programs (PAPs) have been developed to provide medications at little or no cost to eligible patients. There are over 200 PAPs available from pharmaceutical companies, and each may have different eligibility requirements and assistance guidelines. A formalized community-based patient prescription coordinator can help patients navigate these programs by reviewing an applicant's financial information and medication requirements to identify which PAPs are most appropriate. Little is known, however, about whether providing such guidance is associated with a reduction in acute care utilization., Objective: To evaluate changes in emergency department and hospital utilization among patients who received care coordination and financial assistance with prescribed medications., Methods: This single-cohort interrupted time-series study included participants in eastern Washington state who enrolled in the Spokane Prescription Assistance Network (SPAN) program between March 1, 2009, and August 31, 2012. Referrals to the SPAN patient prescription coordinator were made by a social service agency or medical provider for patients who may have difficulty paying for prescribed medications. Initial patient contact occurred while the patient was still being treated in a clinic or hospital or through a direct visit to the coordinator's community-based office. Participants were contacted 6 months after the initial appointment and then annually thereafter to review current medications and health status. A review of electronic health records provided information on hospitalizations and emergency department visits in the 12 months before and after program entry., Results: Among SPAN participants (n = 310), emergency department and hospital encounters declined from 0.38 per participant in the year before enrollment to 0.20 encounters in the year following program entry. A repeated-measures mixed-effects model indicated SPAN participation was associated with a 51% decline in the rate of emergency department and hospital utilization (incidence rate ratio [IRR] = 0.49; 95% CI = 0.31-0.77; P = 0.002). Observed effects differed by prescription class. Factor interactions revealed significant reductions in utilization for participants with prescribed pulmonary medications (IRR = 0.58; 95% CI = 0.37-0.92; P = 0.019). Assistance with mental health (psychotropic) medications was associated with increased incidence of utilization (IRR = 2.07; 95% CI = 1.32-3.24; P = 0.001). At the time of SPAN enrollment, 60% of participants had prescriptions for psychotropic medications., Conclusions: A formalized patient prescription coordinator can help patients access prescribed medications at low cost and remain compliant with treatment plans. In a study of a coordination pilot program, reductions in hospital admissions and emergency department visits were observed following program participation., Disclosures: This study was not supported by any outside funding. The authors declare no conflicts of interest. Study design was created by Burley, McPherson, and Daratha. Burley Daratha, Selinger, and Armstrong collected the data, with interpretation performed by Burley, Daratha, and Tuttle, assisted by McPherson. The manuscript was written by Burley, Daratha, and Selinger, with assistance from White, and revised by Burley, White, and Selinger, with assistance from Daratha and Tuttle.

Background: Increased surgical volume is associated with better patient outcomes and shorter lengths of hospitalization. As a consequence, traveling to receive care from a high volume provider may be associated with better outcomes. However, travel may also be associated with a decision by the healthcare provider to increase the length of stay due to a decreased ability to return to the primary hospital should complications arise. Thus, research is needed to understand the relationship between the distance a patient must travel and their outcomes following urologic surgery. Objective: The purpose of this study was to determine whether the distance a patient travels to receive urologic surgery is associated with their length of hospital stay and direct medical hospitalization costs. Methods: This was a retrospective observational cohort study of 12 106 patients over 50 years of age undergoing transurethral resection of the prostate (TURP), radical prostatectomy (RP) or radical cystectomy (RC) in Washington State hospitals between 2009 and 2013. Distance traveled was determined by calculating the linear distance between zip code centroids of patient residence and the hospital performing their procedure. Patients were sorted into four groups classified by distance traveled (≤5 miles, 6-20 miles, 21-50 miles and ≥51 miles) and cost calculated using a charges-to-reimbursement ratio for each hospital. Statistical significance was determined using a Kruskal-Wallis test. Results: Patients traveling greater distances had significantly lower median medical costs compared with patients who lived closer to the hospitals where they underwent TURP and RP (TURP: ≤5 miles, $6243 and ≥51 miles, $5105, p≤0.001; RP: ≤5 miles, $12 407 and ≥51 miles, $11 882, p≤0.001), whereas there was no significant difference for patients undergoing RC (≤5 miles, $27 554 and ≥51 miles, $26 761, p=0.17). Likewise, patients traveling greater distances had significantly lower median lengths of hospitalization for TURP and RP (TURP: p≤0.001, RP: p≤0.001), while there was no difference for RC (p=0.50). Conclusions: Patient travel burden does appear to play a role in cost and length of hospital stay for select urologic procedures with variable levels of morbidity and recovery time. Although these findings are statistically significant, the magnitude of the effect is small.

Objective: To examine hospital-level variation in outcomes following benign urologic surgeries given that hospital-level variation in surgical outcomes can portend quality and appropriateness of care concerns and identify quality improvement opportunities in perioperative care., Materials and Methods: Using the Washington State Comprehensive Hospital Abstract Reporting System, we identified patients who underwent transurethral resection of the prostate (TURP), percutaneous nephrostolithotomy (PCNL), and pyeloplasty from 2003 to 2008. We classified prolonged postoperative length of stay (LOS) as that exceeding the 75th percentile, and we measured the rate of Agency for Healthcare Quality Patient Safety Indicators, readmissions, and death. We calculated hospital-specific observed-to-expected event rates using random effects multilevel multivariable models adjusted for age and comorbidity., Results: We identified 6699 TURP patients at 54 hospitals, 2541 PCNL patients at 45 hospitals, and 584 pyeloplasty patients at 36 hospitals. Complication rates were highest after PCNL (22.9% prolonged LOS vs 17.3% for TURP and 13.9% for pyeloplasty, P < .001; 3.4% 90-day mortality vs 0.6% for TURP and 0% for pyeloplasty). Hospital-level variation was most substantial for LOS after TURP and pyeloplasty (8.1% and 14.3% of variance in prolonged LOS, respectively)., Conclusion: Hospital-level variation is common after benign inpatient urologic surgeries and may relate to difference in perioperative provider practice patterns. The morbidity of PCNL in this study was higher than expected and merits further investigation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The hospital readmission rate in the population with chronic kidney disease (CKD) is high and strategies to reduce this risk are urgently needed., Methods: The CKD-Medication Intervention Trial (CKD-MIT; www.clinicaltrials.gov; NCTO1459770) is a single-blind (investigators), randomized, clinical trial conducted at Providence Health Care in Spokane, Washington. Study participants are hospitalized patients with CKD stages 3-5 (not treated with kidney replacement therapy) and acute illness. The study intervention is a pharmacist-led, home-based, medication management intervention delivered within 7 days after hospital discharge. The primary outcome is a composite of hospital readmissions and visits to emergency departments and urgent care centers for 90 days following hospital discharge. Secondary outcomes are achievements of guideline-based targets for CKD risk factors and complications., Results: Enrollment began in February 2012 and ended in May 2015. At baseline, the age of participants was 69 ± 11 years (mean ± SD), 50% (77 of 155) were women, 83% (117 of 141) had hypertension and 56% (79 of 141) had diabetes. At baseline, the estimated glomerular filtration rate was 41 ± 14 ml/min/1.73 m2 and urine albumin-to-creatinine ratio was 43 mg/g (interquartile range 8-528 mg/g). The most frequent diagnosis category for the index hospital admission was cardiovascular diseases at 34% (53 of 155), but the most common single diagnosis for admission was community-acquired acute kidney injury at 10% (16 of 155)., Conclusion: Participants in CKD-MIT are typical of acutely ill hospitalized patients with CKD. A medication management intervention after hospital discharge is under study to reduce post-hospitalization acute care utilization and to improve CKD management., (© 2016 S. Karger AG, Basel.)

Objective: To determine the relationship between implementation of rapid response teams and improved mortality rate using a large, uniform dataset from one state in the United States., Design: This observational cohort study included 471,062 adult patients hospitalized between 2001 and 2009., Setting: Ten acute tertiary care hospitals in Washington State., Patients or Other Participants: Hospital abstract records on adult patients (18 years old or older) were examined (n = 471,062). Patients most likely to benefit from rapid response team interventions were included and other prognostic factors of severity of illness and comorbidities were controlled. Each participating hospital provided the implementation date of their rapid response team intervention. Mortality rates in 31 months before rapid response team implementation (pre-rapid response team time period) were compared with mortality rates in 31 months following rapid response team implementation (post-rapid response team time period)., Intervention(s): Implementation of a rapid response team within each acute tertiary care hospital., Measurements and Main Results: In-hospital mortality. Relative risk for in-hospital mortality improved in the post-rapid response team time period compared with the pre-rapid response team time period (relative risk = 0.76; 95% CI = 0.72-0.80; p < 0.001)., Conclusions: In-hospital mortality improved in six of 10 acute tertiary care hospitals in the post-rapid response team time period when compared with the pre-rapid response team time period. Because of a long-term trend of decline in hospital mortality, these decreases could not be unambiguously attributed to rapid response team implementation. Further research should examine additional objective outcomes and optimal configuration of rapid response teams to maximize intervention effectiveness.

Background: The delivery of urologic oncology care is susceptible to regional variation. In the current study, the authors sought to define patterns of care for patients undergoing genitourinary cancer surgery to identify underserved areas for urologic cancer care in Washington State., Methods: The authors accessed the Washington State Comprehensive Hospital Abstract Reporting System from 2003 through 2007. They identified patients undergoing radical prostatectomy, radical cystectomy (RC), partial nephrectomy (PN), radical nephrectomy, and transurethral resection of the prostate (TURP). TURP was included for comparison as a reference procedure indicative of access to urologic care. Hospital service areas (HSAs) are where the majority of local patients are hospitalized; hospital referral regions (HRR) are where most patients receive tertiary care. The authors created multivariate hierarchical logistic regression models to examine patient and HSA characteristics associated with the receipt of urologic oncology care out of the HRR for each procedure., Results: Greater than one-half of patients went out of their HRR in 7 HSAs (11%) for radical prostatectomy, 3 HSAs (5%) for radical nephrectomy, 10 HSAs (15%) for PN, and 14 HSAs (22%) for RC. No HSAs had high export rates for TURP. Few patient factors were found to be associated with surgical care out of the HRR. High-export HSAs for PN and RC exhibited lower socioeconomic characteristics than low-export HSAs, adjusting for HSA population, race, and HSA procedure rates for PN and RC., Conclusions: Patients living in areas with lower socioeconomic status have a greater need to travel for complex urologic surgery. Consideration of geographic delineation in the delivery of urologic oncology care may aid in regional quality improvement initiatives., (© 2014 American Cancer Society.)

Objectives: To (1) elucidate the range of serum uric acid (UA) levels in adolescent sample; (2) examine the relationships of serum UA and 1-year change with gender, anthropometric and cardiometabolic factors., Materials and Methods: Measurements (anthropometrics, fasting venipuncture and blood pressure) were performed at the beginning of the seventh and eighth grades. Descriptive data, differences according to weight, correlations and changes over time were examined., Findings: In 77 adolescents, BMI and serum UA had relationships with several cardiometabolic measures. Males had higher serum UA at follow-up compared to baseline; female change was minimal. Time-by-gender interaction was significant, as were the main effects of gender and BMI classification. Males had lower HDL-C at follow-up than at baseline; females had higher HDL-C at follow-up., Conclusions: Serum UA has importance in cardiometabolic examination of youth risk factors. It should be examined in youth with elevated BMI and/or hypertension. Early adolescence is the period when gender-related metabolic changes occur.

Professional quality of life among healthcare providers can impact the quality and safety of patient care. The purpose of this research was to investigate compassion satisfaction and compassion fatigue levels as measured by the Professional Quality of Life Scale self-report instrument in a community hospital in the United States. A cross-sectional survey study examined differences among 139 RNs, physicians, and nursing assistants. Relationships among individual and organizational variables were explored. Caregivers for critical patients scored significantly lower on the Professional Quality of Life subscale of burnout when compared with those working in a noncritical care unit. Linear regression results indicate that high sleep levels and employment in critical care areas are associated with less burnout. Identification of predictors can be used to design interventions that address modifiable risks., (© 2013 Wiley Publishing Asia Pty Ltd.)

Background: Medical-surgical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the US health care system., Objective: The study's aim was to examine whether co-morbid serious mental illness diagnoses (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes are independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization., Methods: This cohort study of all community hospitals in Washington state evaluated data from 82,060 adults discharged in the state of Washington with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis indicating diabetes mellitus between 2010 and 2011. Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Co-morbid serious mental illness diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox proportional hazard analyses estimated time to rehospitalization for the entire study period., Results: After adjusting for demographics, medical co-morbidity, and characteristics of the index hospitalization, co-morbid serious mental illness diagnosis was independently associated with increased odds of rehospitalization within 1 month among patients with diabetes who had a medical-surgical hospitalization (odds ratio: 1.24, 95% confidence interval: 1.07, 1.44). This increased risk of rehospitalization persisted throughout the study period (up to 24 mo)., Conclusions: Co-morbid serious mental illness in patients with diabetes is independently associated with greater risk of early medical-surgical rehospitalization. Future research is needed to define and specify targets for interventions at points of care transition for this vulnerable patient population., (© 2014 Published by Academy of Psychosomatic Medicine on behalf of Academy of Psychosomatic Medicine.)

Objectives: Asthma is one of the most common chronic conditions among children and is one of the leading causes for pediatric hospitalizations. More evidence is needed to clarify the risks of repeat hospitalization and the underlying factors contributing to adverse health outcomes among pediatric patients hospitalized with asthma. The purpose of this study was to examine the risk of subsequent hospitalizations among pediatric patients hospitalized with asthma compared to a reference cohort of children hospitalized for all other diagnoses., Methods: The Washington State (WA) Comprehensive Hospital Abstract Reporting System (CHARS) was used to obtain data for the study. Data describing 81,946 hospitalized pediatric patients admitted from 2004 to 2008 were available. The risk of subsequent hospitalization among children admitted for asthma as compared to a reference cohort was examined., Results: The asthma cohort had a 33% (HR = 1.33 [99% confidence interval (CI) 1.21-1.46]; p < .001) increased risk of subsequent hospitalization from 2004 to 2008. Children in the asthma cohort under the age of 13 years demonstrated a significant increased risk of subsequent hospitalization as compared to the age-matched reference cohort of children without asthma. Those in the asthma cohort who were 3-5 years old demonstrated the highest risk (50%) of subsequent hospitalization (HR = 1.50 [99% CI 1.23-1.83]; p < .001)., Conclusions: Study results can be utilized in the development of appropriate interventions aimed at preventing and reducing hospital admissions, improving patient care, decreasing overall costs, and lessening complications among pediatric patients with asthma.

Background: Complex, interconnected issues challenge the United States health care system and the patients and families it serves. System fragmentation, limited resources, rigid disciplinary boundaries, institutional culture, ineffective communication, and uncertainty surrounding health policy legislation are contributing to suboptimal care delivery and patient outcomes., Methods: These problems are too complex to be solved by a single discipline. Interdisciplinary research affords the opportunity to examine and solve some of these problems from a more integrative perspective using innovative and rigorous methodological designs., Results: In this paper, we explore lessons learned from exemplars funded by the Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative., Discussion: The discussion is framed using an adaptation of the Interdisciplinary Research Model to evaluate improvements in individual health outcomes, health systems, and health policy. Barriers and facilitators to designing, conducting, and translating interdisciplinary research are discussed. Implications for health system and policy changes, including the need to provide funding mechanisms to implement interdisciplinary processes in both research and clinical practice, are provided.

Abnormal glucose metabolism is associated with obesity, insulin resistance (IR), and Type 2 diabetes mellitus. The purposes of this study were to describe anthropometric and laboratory markers of adolescents, examine correlates of IR, and test ability of anthropometric and laboratory markers to predict risk of exhibiting IR. A total of 150 early adolescents participated. Participants with obesity had increased IR, high-sensitivity C-reactive protein, triglycerides, and blood pressure. Waist circumference and triglycerides were predictive of IR. Multiple risk factors compound and lead to long-term health consequences among youth. Nurses can evaluate these factors to identify IR., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: The objective was to determine if patients hospitalized with a primary medical diagnosis and any co-occurring serious mental illness (SMI) were more likely than patients without any co-occurring SMI diagnosis to experience a subsequent medical hospitalization., Method: This was a longitudinal cohort study of 925,705 adult persons (aged 18+ years). Patients hospitalized in Washington State from 2004 to 2008 were followed through 2009 (for an average of 43 months)., Results: Compared to patients hospitalized for medical conditions without co-occurring SMI, patients with co-occurring dysthymia, bipolar and major depressive disorders were at an elevated risk for long-term subsequent hospitalization. Patients in the combined co-occurring mood disorders cohort were more likely (hazard ratio=1.13; 99% confidence interval=1.10-1.16; P<.001) than patients in the reference cohort to experience a subsequent medical hospitalization. A significant interaction between substance and mood disorders that increased risk for subsequent hospitalization was also observed., Conclusion: Hospitalized patients with co-occurring mood disorders are at high risk for repeat hospitalization for a medical reason. This high-risk population, including those with substance abuse, should be a focus of research efforts to identify and address ambulatory-care-sensitive conditions amenable to strategies that decrease complications and illness leading to subsequent hospitalizations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Objectives: Rates of hospitalization are known to be high in patients with kidney disease. However, ongoing risks of subsequent hospitalization and mortality are uncertain. The primary objective was to evaluate patients with kidney disease for long-term risks of subsequent hospitalization, including admissions resulting in death., Design, Setting, Participants, & Measurements: Patients hospitalized in Washington State between April of 2006 and December of 2008 who survived to discharge (n=676,343) were classified by International Classification of Disease codes into CKD (n=27,870), dialysis (n=6131), kidney transplant (n=1100), and reference (n=641,242) cohorts. Cox proportional hazard models controlling for age, sex, payer, comorbidity, previous hospitalization, primary diagnosis category, and length of stay were conducted for time to event analyses., Results: Compared with the reference cohort, risks for subsequent hospitalization were increased in the CKD (hazard ratio=1.20, 99% confidence interval=1.18-1.23, P<0.001), dialysis (hazard ratio=1.76, 99% confidence interval=1.69-1.83, P<0.001), and kidney transplant (hazard ratio=1.85, 99% confidence interval=1.68-2.03, P<0.001) cohorts, with a mean follow-up time of 29 months. Similarly, risks for fatal hospitalization were increased for patients in the CKD (hazard ratio=1.41, 99% confidence interval=1.34-1.49, P<0.001), dialysis (hazard ratio=3.04, 99% confidence interval=2.78-3.31, P<0.001), and kidney transplant (hazard ratio=2.25, 99% confidence interval=1.67-3.03, P<0.001) cohorts. Risks for hospitalization and fatal hospitalization increased in a graded manner by CKD stage., Conclusions: Risks of subsequent hospitalization, including admission resulting in death, among patients with kidney disease were substantially increased in a large statewide population. Patients with kidney disease should be a focus of efforts to reduce hospitalizations and mortality.

Background: Unexplained variation in outcomes after common surgeries raises concerns about the quality and appropriateness of surgical care. Understanding variation in surgical outcomes may identify processes that could affect the quality of surgical and postoperative care. The authors of this report examined hospital-level variation in outcomes after inpatient urologic oncology procedures., Methods: Patients who underwent radical cystectomy, radical nephrectomy, and radical prostatectomy were identified from the Washington State Comprehensive Hospital Abstract Reporting System for the years 2003 through 2007. The postoperative length of stay (LOS) was measured, and LOS that exceeded the 75th percentile was classified as prolonged. The occurrence of Agency for Healthcare Quality patient safety indicators (PSIs), readmissions, and deaths also were measured. Analyses were adjusted for patient age and comorbidity in random effects, multilevel, multivariable models that assessed hospital-level outcomes., Results: The authors identified 853 patients from 37 hospitals who underwent cystectomy, 3018 patients who underwent nephrectomy from 51 hospitals, and 8228 patients who underwent prostatectomy from 51 hospitals. Complications captured by PSIs were rare. Hospital-level variation was most profound for LOS outcomes after nephrectomy and prostatectomy (variance in prolonged LOS, 8.1% and 26.7%, respectively), thromboembolic events after nephrectomy (8% of variance), and mortality after cystectomy (7.1% of variance)., Conclusions: Hospital-level variation confounds the care of urologic cancer patients in the state of Washington. The authors concluded that transparent reporting of surgical outcomes and local quality-improvement initiatives should be considered to ameliorate the observed variation and improve the quality of cystectomy, nephrectomy, and prostatectomy care., (Copyright © 2011 American Cancer Society.)

The increase in the prevalence of obesity among youth is alarming. Relationships exist between excess weight and adverse cardiometabolic markers. The aims of this study among adolescents in the Teen Eating and Activity Mentoring in Schools (TEAMS) project were to describe selected demographic characteristics, anthropometric measurements, and laboratory values of middle school students; contrast differences in rates of cardiometabolic markers for participants with body mass index (BMI) ≥ 95th percentile and <95th percentile; examine rates of exceeding cardiometabolic cutoffs by weight status; and predict the odds ratio for one or more adverse cardiometabolic outcomes when BMI ≥95th percentile. Students (N = 151) were significantly more likely to exceed cut-off points for high-density lipoprotein cholesterol (HDL-C) and blood pressure (BP) when BMI was ≥95th percentile. Students whose BMI was ≥the 95th percentile were nearly five times as likely to have the deleterious cardiometabolic outcomes of low HDL-C, high triglycerides, elevated homeostasis model assessment of insulin resistance (HOMA-IR), or elevated systolic BP than those whose BMI was

Objective: Examine the relationship between self-efficacy and various measures of adiposity in a sample of teens., Methods: A total of 132 teens were selected from schools participating in an existing research study titled Teen Eating and Activity Mentoring in Schools (TEAMS). Teens completed demographic questionnaires and healthy eating-specific and physical activity-specific measures of self-efficacy. Waist circumference (WC), triceps skinfold thickness (TSF), and body mass index (BMI) percentile scores were also obtained., Results: Regression analyses indicated that healthy eating-specific and physical activity-specific measures of self-efficacy predicted WC and TSF. ANOVA revealed significant differences in healthy eating-specific self-efficacy levels between students of recommended weight and overweight/obese status. Supplemental analyses showed significant negative relationships between a student's ideal BMI ratio and self-efficacy., Conclusions: Because self-efficacy may be amenable to change, these findings could inform future efforts aimed at increasing behaviors that promote healthy weight status among early adolescents.

Physical fitness performance is an important health correlate yet is often unrelated to sedentary behaviour in early adolescence. In this study, we examined the association of sedentary behaviour (i.e. screen time) with weight-related health markers and blood pressure, after controlling for cardiorespiratory fitness performance. American middle school students (N = 153, 56% females) aged 11-15 years (mean 12.6 years, s = 0.5) completed assessments of cardiorespiratory fitness performance, screen time, weight status (BMI percentile, waist-to-height ratio), and blood pressure. Multivariate analysis of covariance, controlling for cardiorespiratory fitness performance, found those who met the daily recommendation of 2 h or less of screen time (n = 36, 23.5%) had significantly lower BMI (p < 0.05) and systolic blood pressure (p < 0.01) compared with those who exceeded this recommendation. Findings suggest specific intervention programmes may be designed to target both cardiorespiratory fitness and sedentary behaviours to maximize early adolescent health because these behaviours are likely to have unique and independent effects on youth health markers.

Care transitions are clinically dangerous times, particularly for older adults with complex health problems. This article describes the most common medication discrepancies identified by nurses during patients' (n = 101) hospital to home transition. Findings indicated that medication discrepancies were astoundingly widespread, with 94% of the participants having at least 1 discrepancy. The average number of medication discrepancies identified was 3.3 per participant. Medication discrepancies were identified in virtually all classes of medications, including those with high safety risks. Evidence-based best practices to reduce transition-related medication discrepancies are presented., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Background: Obesity is a significant health problem among today's youth; however, most school-based prevention programs in this area have had limited success. Focus groups were conducted with seventh- to eighth-grade students, parents, and teachers to provide insight into the development of a comprehensive program for the prevention of adolescent obesity: the Teen Eating and Activity Mentoring in Schools project (TEAMS)., Methods: Questions addressed (1) beliefs about the relationship between early adolescent behavior and health; (2) early adolescents' physical activity habits, preferences, influences, and barriers; (3) early adolescents' dietary habits, preferences, influences, and barriers; and (4) recommendations for interventions to promote physical activity and healthy eating in early adolescence., Results: Qualitative analyses revealed that early adolescents had a good understanding of the relationship between their behavior and their health, although they had a limited understanding of what constitutes healthy eating. Youth participants reported preferences for a number of healthy foods and physical activities, but identified numerous barriers preventing their engagement. The major difference between students, parents, and teachers reflected the operation of the fundamental attribution error with early adolescents attributing their unhealthy behaviors to situational factors, teachers blaming parents, and parents blaming their children., Conclusions: Implications of these findings for the development of school-based, integrated strategies for obesity prevention among early adolescents are discussed.

Objective: To determine the prevalence of diabetes in inpatient rehabilitation facilities in Washington State from 2001 to 2007, and to determine the impact of diabetes on length of stay (LOS) and charges per day., Design: Longitudinal retrospective cohort analysis of inpatient rehabilitation discharge data from the Washington State Department of Health Comprehensive Hospital Abstract Reporting System., Setting: Inpatient rehabilitation., Participants: Adults (N=56,382) who were discharged from inpatient rehabilitation in Washington State between 2001 and 2007., Interventions: Not applicable., Main Outcome Measures: Evidence of an established diagnosis of diabetes from International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes; comorbid conditions reported in ICD-9-CM codes; LOS; and charges per stay., Results: For all discharges from 2001 to 2007, diabetes prevalence was 17.8%; prevalence within specific impairment groups was 21.3% for the stroke subgroup, 14.2% for the orthopedic disorders subgroup, and 25% for the medically complex conditions subgroup. For all discharges, and within each impairment subgroup, prevalence did not change significantly from year to year. When adjusted for burden of nondiabetes comorbidities, LOS was significantly shorter for all discharges with diabetes younger than 65 years. The association between a diabetes codiagnosis and LOS in specific impairment groups was complex, ranging from a significantly shorter LOS for discharges with diabetes in the stroke subgroup to a finding of no significant difference in LOS among discharges with or without diabetes in the orthopedic impairments subgroup. Across all discharges, charges per day from 2003 to 2007 were significantly greater in discharges with diabetes. Within each specific impairment subgroup, charges per day across the entire study period were significantly greater for discharges with diabetes., Conclusions: The high prevalence of diabetes, coupled with its impact on resource use, suggests that substantial pressures may be placed on the inpatient rehabilitation care system to respond to the needs of those with diabetes.

Objectives: To examine selected clinical characteristics for cohorts of similar adolescents over 4 survey periods from 1999-2006, to examine changes in rates of adolescents who exceed cutoff points for individual components of metabolic syndrome (MetS), to describe sex differences in individual components of MetS, to describe changes in MetS prevalence from 1999-2006 using 4 common MetS definitions, and to describe sex differences in MetS prevalence from 1999-2006., Design: Cross-sectional, US representational National Health and Nutrition Examination Survey from 1999-2006., Setting: Mobile examination centers conducted by the Centers for Disease Control and Prevention., Participants: For 1999-2000, 613 adolescents (aged 12-19 years); for 2001-2002, 892 adolescents; for 2003-2004, 857 adolescents; and for 2005-2006, 814 adolescents. Exclusions were pregnancy, taking insulin or diabetic pills, and incomplete measurements., Main Outcome Measures: Fasting plasma glucose level, triglyceride level, high-density lipoprotein cholesterol level, waist circumference, and systolic and diastolic blood pressures., Results: Increases in fasting plasma glucose and high-density lipoprotein cholesterol levels and decreases in diastolic blood pressure were observed. Rates of adolescents exceeding cutoff points for fasting plasma glucose levels have increased. Compared with girls, adolescent boys had higher rates exceeding cutoff points for fasting plasma glucose and high-density lipoprotein cholesterol levels. Adolescent girls had higher rates exceeding cutoff points for waist circumference. The prevalence of MetS among adolescents has not changed. No sex differences in MetS prevalence were observed., Conclusions: Some criteria for MetS have remained stable (triglyceride level and systolic blood pressure) and one has improved for boys (high-density lipoprotein cholesterol level), but waist circumference has increased in girls and the rate of an elevated fasting plasma glucose level has nearly doubled for both boys and girls. Adolescent MetS prevalence has remained stable from 1999-2006.