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OBJECTIVES: The goal of this study is to identify clinical variables associated with bacteremia. Such data could provide a rational basis for blood culture testing in emergency department (ED) patients with suspected infection. METHODS: This is a secondary analysis of a prospective cohort of ED patients with suspected infection. Data collected included demographics, vital signs, medical history, suspected source of infection, laboratory and blood culture results and outcomes. Bacteremia was defined as a positive blood culture by Centers for Disease Control criteria. Clinical variables associated with bacteremia on univariate logistic regression were entered into a multivariable model. RESULTS: There were 5630 patients enrolled with an average age of 59.9 ± 19.9 years, and 54% were female. Blood cultures were obtained on 3310 (58.8%). There were 409 (12.4%) positive blood cultures, of which 68 (16.6%) were methicillin-resistant Staphylococcus aureus (MRSA) and 161 (39.4%) were Gram negatives. Ten covariates (respiratory failure, vasopressor use, neutrophilia, bandemia, thrombocytopenia, indwelling venous catheter, abnormal temperature, suspected line or urinary infection, or endocarditis) were associated with all-cause bacteremia in the final model (c-statistic area under the curve [AUC], 0.71). Additional factors associated with MRSA bacteremia included end-stage renal disease (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.9-7.8) and diabetes (OR, 2.0; 95% CI, 1.1-3.6) (AUC, 0.73). Factors strongly associated with Gram-negative bacteremia included vasopressor use in the ED (OR, 2.8; 95% CI, 1.7-4.6), bandemia (OR, 3.5; 95% CI, 2.3-5.3), and suspected urinary infection (OR, 4.0; 95% CI, 2.8-5.8) (AUC, 0.75). CONCLUSIONS: This study identified several clinical factors associated with bacteremia as well as MRSA and Gram-negative subtypes, but the magnitude of their associations is limited. Combining these covariates into a multivariable model moderately increases their predictive value. [ABSTRACT FROM AUTHOR]

Importance: Although older adults may use potentially driver-impairing (PDI) medications that can produce psychomotor impairment, little is known about changes to PDI medication use among older adults from the time before to the time after a motor vehicle crash (MVC)., Objective: To quantify use of and changes in PDI medications among older adults before and after an MVC., Design, Setting, and Participants: This cohort study used linked Medicare claims and police-reported MVC data on 154 096 person-crashes among 121 846 older drivers. Eligible persons were drivers aged 66 years or older, involved in a police-reported MVC in New Jersey from May 1, 2007, through December 31, 2017, and with continuous enrollment in Medicare fee-for-service Parts A and B for at least 12 months and Part D for at least 120 days prior to the MVC. Data were analyzed from January 2022 to May 2024., Main Outcomes and Measures: Use of benzodiazepines, nonbenzodiazepine hypnotics, opioid analgesics, and other PDI medications in the 120 days before and 120 days after the MVC. Because each person could contribute multiple MVCs during the study period if they met eligibility criteria, the unit of analysis was the number of person-crashes. The proportion of person-crashes after which PDI medications were started, discontinued, or continued was quantified as well., Results: Among 154 096 eligible person-crashes, the mean (SD) age of the drivers was 75.2 (6.7) years at the time of the MVC. Of 121 846 unique persons, 51.6% were women. In 80.0% of the person-crashes, drivers used 1 or more PDI medications before the crash, and in 81.0% of the person-crashes, drivers used 1 or more PDI medications after the crash. Use of benzodiazepines (8.1% before the crash and 8.8% after the crash), nonbenzodiazepine hypnotics (5.9% before the crash and 6.0% after the crash), and opioid analgesics (15.4% before the crash and 17.5% after the crash) was slightly higher after the MVC. After the MVC, drivers in 2.1% of person-crashes started benzodiazepines and 1.4% stopped benzodiazepines, drivers in 1.2% of person-crashes started nonbenzodiazepine hypnotics and 1.2% stopped nonbenzodiazepine hypnotics, and drivers in 8.4% of person-crashes started opioid analgesics and 6.3% stopped opioid analgesics., Conclusions and Relevance: This cohort study suggests that most older drivers involved in MVCs did not use fewer PDI medications after crashes than before crashes. Qualitative research of perceived risks vs benefits of PDI medications is necessary to understand the reasons why MVCs do not appear to motivate clinicians to deprescribe PDI medications as a strategy to avert potential harms, including additional MVCs.

In 30 states, licensing agencies can restrict the distance from home that "medically-at-risk" drivers are permitted to drive. However, where older drivers crash relative to their home or how distance to crash varies by medical condition is unknown. Using geocoded crash locations and residential addresses linked to Medicare claims, we describe how the relationship between distance from home to crash varies by driver characteristics. We find that a majority of crashes occur within a few miles from home with little variation across driver demographics or medical conditions. Thus, distance restrictions may not reduce crash rates among older adults, and the tradeoff between safety and mobility warrants consideration.

Background: Administrative healthcare databases, such as Medicare, are increasingly used to identify groups at risk of a crash. However, they only contain information on crash-related injuries, not all crashes. If the driver characteristics associated with crash and crash-related injury differ, conflating the two may result in ineffective or imprecise policy interventions., Methods: We linked 10 years (2008-2017) of Medicare claims to New Jersey police crash reports to compare the demographics, clinical diagnoses, and prescription drug dispensings for crash-involved drivers ≥ 68 years with a police-reported crash to those with a claim for a crash-related injury. We calculated standardized mean differences to compare characteristics between groups., Results: Crash-involved drivers with a Medicare claim for an injury were more likely than those with a police-reported crash to be female (62.4% vs. 51.8%, standardized mean difference [SMD] = 0.30), had more clinical diagnoses including Alzheimer's disease and related dementias (13.0% vs. 9.2%, SMD = 0.20) and rheumatoid arthritis/osteoarthritis (69.5% vs 61.4%, SMD = 0.20), and a higher rate of dispensing for opioids (33.8% vs 27.6%, SMD = 0.18) and antiepileptics (12.9% vs 9.6%, SMD = 0.14) prior to the crash. Despite documented inconsistencies in coding practices, findings were robust when restricted to claims indicating the injured party was the driver or was left unspecified., Conclusions: To identify effective mechanisms for reducing morbidity and mortality from crashes, researchers should consider augmenting administrative datasets with information from police crash reports, and vice versa. When those data are not available, we caution researchers and policymakers against the tendency to conflate crash and crash-related injury when interpreting their findings., (© 2024. The Author(s).)

Non-benzodiazepine hypnotics ( "Z-drugs") are prescribed for insomnia, but might increase risk of motor vehicle crash (MVC) among older adults through prolonged drowsiness and delayed reaction times. We estimated the effect of initiating Z-drug treatment on the 12-week risk of MVC in a sequential target trial emulation. After linking New Jersey driver licensing and police-reported MVC data to Medicare claims, we emulated a new target trial each week (July 1, 2007 - October 7, 2017) in which Medicare fee-for-service beneficiaries were classified as Z-drug-treated or untreated at baseline and followed for an MVC. We used inverse probability of treatment and censoring weighted pooled logistic regression models to estimate risk ratios (RR) and risk differences with 95% bootstrap confidence limits (CLs). There were 257,554 person-trials, of which 103,371 were Z-drug-treated and 154,183 untreated, giving rise to 976 and 1,249 MVCs, respectively. The intention-to-treat RR was 1.06 (95%CLs 0.95, 1.16). For the per-protocol estimand, there were 800 MVCs and 1,241 MVCs among treated and untreated person-trials, respectively, suggesting a reduced MVC risk (RR 0.83 [95%CLs 0.74, 0.92]) with sustained Z-drug treatment. Z-drugs should be prescribed to older patients judiciously but not withheld entirely over concerns about MVC risk., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Tropical cyclones are associated with acute increases in mortality and morbidity, but few studies have examined their longer-term health consequences. We assessed whether tropical cyclones are associated with a higher frequency of symptom exacerbation among children with asthma in the following 12 months in eastern United States counties, 2000-2018., Methods: We defined exposure to tropical cyclones as a maximum sustained windspeed >21 meters/second at the county center and used coarsened exact matching to match each exposed county to one or more unexposed counties. We used longitudinal, de-identified administrative claims data to estimate the county-level, monthly risk of experiencing at least one asthma exacerbation requiring medical attention among commercially insured children aged 5-17 with prior diagnosis of asthma. We used a difference-in-differences approach implemented via a Poisson fixed effects model to compare the risk of asthma exacerbation in the 12 months before versus after each storm in exposed versus unexposed counties., Results: Across 43 tropical cyclones impacting the eastern United States, we did not observe evidence of an increase in the risk of symptom exacerbation in the 12 months following the storm (random-effects meta-analytic summary estimate: risk ratio = 1.03 [95% confidence interval = 0.96, 1.10], I2 = 17%). However, certain storms, such as Hurricane Sandy, were associated with a higher risk of symptom exacerbation., Conclusions: These findings are consistent with the hypothesis that some tropical cyclones are detrimental to children's respiratory health. However, tropical cyclones were not associated in aggregate with long-term exacerbation of clinically apparent asthma symptoms among a population of children with commercial health insurance., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Medications are one of the most easily modifiable risk factors for motor vehicle crashes (MVCs) among older adults, yet limited information exists on how the use of potentially driver-impairing (PDI) medications changes following an MVC. Therefore, we examined the number and types of PDI medication classes dispensed before and after an MVC., Methods: This observational study included Medicare fee-for-service beneficiaries aged ≥67 years who were involved in a police-reported MVC in New Jersey as a driver between 2008 and 2017. Analyses were conducted at the "person-crash" level because participants could be involved in more than one MVC. We examined the use of 36 PDI medication classes in the 120 days before and 120 days after MVC. We described the number and prevalence of PDI medication classes in the pre-MVC and post-MVC periods as well as the most common PDI medication classes started and stopped following the MVC., Results: Among 124,954 person-crashes, the mean (SD) age was 76.0 (6.5) years, 51.3% were female, and 83.9% were non-Hispanic White. The median (Q 1 , Q 3 ) number of PDI medication classes was 2 (1, 4) in both the pre-MVC and post-MVC periods. Overall, 20.3% had a net increase, 15.9% had a net decrease, and 63.8% had no net change in the number of PDI medication classes after MVC. Opioids, antihistamines, and thiazide diuretics were the top PDI medication classes stopped following MVC, at incidences of 6.2%, 2.1%, and 1.7%, respectively. The top medication classes started were opioids (8.3%), skeletal muscle relaxants (2.2%), and benzodiazepines (2.1%)., Conclusions: A majority of crash-involved older adults were exposed to multiple PDI medications before and after MVC. A greater proportion of person-crashes were associated with an increased rather than decreased number of PDI medications. The reasons why clinicians refrain from stopping PDI medications following an MVC remain to be elucidated., (© 2023 The American Geriatrics Society.)

Methods for extending-generalizing or transporting-inferences from a randomized trial to a target population involve conditioning on a large set of covariates that is sufficient for rendering the randomized and nonrandomized groups exchangeable. Yet, decision makers are often interested in examining treatment effects in subgroups of the target population defined in terms of only a few discrete covariates. Here, we propose methods for estimating subgroup-specific potential outcome means and average treatment effects in generalizability and transportability analyses, using outcome model--based (g-formula), weighting, and augmented weighting estimators. We consider estimating subgroup-specific average treatment effects in the target population and its nonrandomized subset, and we provide methods that are appropriate both for nested and non-nested trial designs. As an illustration, we apply the methods to data from the Coronary Artery Surgery Study (North America, 1975-1996) to compare the effect of surgery plus medical therapy versus medical therapy alone for chronic coronary artery disease in subgroups defined by history of myocardial infarction., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: The National Lung Screening Trial (NLST) found that screening for lung cancer with low-dose computed tomography (CT) reduced lung cancer-specific and all-cause mortality compared with chest radiography. It is uncertain whether these results apply to a nationally representative target population., Objective: To extend inferences about the effects of lung cancer screening strategies from the NLST to a nationally representative target population of NLST-eligible US adults., Design, Setting, and Participants: This comparative effectiveness study included NLST data from US adults at 33 participating centers enrolled between August 2002 and April 2004 with follow-up through 2009 along with National Health Interview Survey (NHIS) cross-sectional household interview survey data from 2010. Eligible participants were adults aged 55 to 74 years, and were current or former smokers with at least 30 pack-years of smoking (former smokers were required to have quit within the last 15 years). Transportability analyses combined baseline covariate, treatment, and outcome data from the NLST with covariate data from the NHIS and reweighted the trial data to the target population. Data were analyzed from March 2020 to May 2023., Interventions: Low-dose CT or chest radiography screening with a screening assessment at baseline, then yearly for 2 more years., Main Outcomes and Measures: For the outcomes of lung-cancer specific and all-cause death, mortality rates, rate differences, and ratios were calculated at a median (25th percentile and 75th percentile) follow-up of 5.5 (5.2-5.9) years for lung cancer-specific mortality and 6.5 (6.1-6.9) years for all-cause mortality., Results: The transportability analysis included 51 274 NLST participants and 685 NHIS participants representing the target population (of approximately 5 700 000 individuals after survey-weighting). Compared with the target population, NLST participants were younger (median [25th percentile and 75th percentile] age, 60 [57 to 65] years vs 63 [58 to 67] years), had fewer comorbidities (eg, heart disease, 6551 of 51 274 [12.8%] vs 1 025 951 of 5 739 532 [17.9%]), and were more educated (bachelor's degree or higher, 16 349 of 51 274 [31.9%] vs 859 812 of 5 739 532 [15.0%]). In the target population, for lung cancer-specific mortality, the estimated relative rate reduction was 18% (95% CI, 1% to 33%) and the estimated absolute rate reduction with low-dose CT vs chest radiography was 71 deaths per 100 000 person-years (95% CI, 4 to 138 deaths per 100 000 person-years); for all-cause mortality the estimated relative rate reduction was 6% (95% CI, -2% to 12%). In the NLST, for lung cancer-specific mortality, the estimated relative rate reduction was 21% (95% CI, 9% to 32%) and the estimated absolute rate reduction was 67 deaths per 100 000 person-years (95% CI, 27 to 106 deaths per 100 000 person-years); for all-cause mortality, the estimated relative rate reduction was 7% (95% CI, 0% to 12%)., Conclusions and Relevance: Estimates of the comparative effectiveness of low-dose CT screening compared with chest radiography in a nationally representative target population were similar to those from unweighted NLST analyses, particularly on the relative scale. Increased uncertainty around effect estimates for the target population reflects large differences in the observed characteristics of trial participants and the target population.

Background/aims: When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home-based pragmatic cluster randomized trials to compare nursing home and resident characteristics in randomized facilities to eligible non-randomized and ineligible facilities., Methods: We linked data from the high-dose influenza vaccine trial and the Music & Memory Pragmatic TRIal for Nursing Home Residents with ALzheimer's Disease (METRICaL) to nursing home assessments and Medicare fee-for-service claims. The target population for the high-dose trial comprised Medicare-certified nursing homes; the target population for the METRICaL trial comprised nursing homes in one of four US-based nursing home chains. We used standardized mean differences to compare facility and individual characteristics across the three groups and logistic regression to model the probability of nursing home trial participation., Results: In the high-dose trial, 4476 (29%) of the 15,502 nursing homes in the target population were eligible for the trial, of which 818 (18%) were randomized. Of the 1,361,122 residents, 91,179 (6.7%) were residents of randomized facilities, 463,703 (34.0%) of eligible non-randomized facilities, and 806,205 (59.3%) of ineligible facilities. In the METRICaL trial, 160 (59%) of the 270 nursing homes in the target population were eligible for the trial, of which 80 (50%) were randomized. Of the 20,262 residents, 973 (34.4%) were residents of randomized facilities, 7431 (36.7%) of eligible non-randomized facilities, and 5858 (28.9%) of ineligible facilities. In the high-dose trial, randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (132.5 vs 145.9 and 91.9, respectively), for-profit status (91.8% vs 66.8% and 68.8%), belonging to a nursing home chain (85.8% vs 49.9% and 54.7%), and presence of a special care unit (19.8% vs 25.9% and 14.4%). In the METRICaL trial randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (103.7 vs 110.5 and 67.0), resource-poor status (4.6% vs 10.0% and 18.8%), and presence of a special care unit (26.3% vs 33.8% and 10.9%). In both trials, the characteristics of residents in randomized facilities were similar across the three groups., Conclusion: In both trials, facility-level characteristics of randomized nursing homes differed considerably from those of eligible non-randomized and ineligible facilities, while there was little difference in resident-level characteristics across the three groups. Investigators should assess the characteristics of clusters that participate in cluster randomized trials, not just the individuals within the clusters, when examining the applicability of trial results beyond participating clusters., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: V.M. is a member of the Sanofi Portfolio Advisory Board for which he is paid an honorarium. I.J.D. reports consulting for Moderna on methods for observational analyses. I.J.D. is also the Principal Investigator of a research agreement between Harvard University and Sanofi Pasteur for a pilot study on methods for transportability analyses using individually randomized vaccine trials. Moderna and Sanofi Pasteur did not have any role in the planning or conduct of the research reported in this paper. S.G. is a consultant for Sanofi Pasteur, Janssen, Pfizer, GlaxoSmithKline, Novavax, and Vaxart, and receives research funding from Sanofi Pasteur, Pfizer, and Genentech. E.H.D. has received research funding from Sanofi Pasteur and Genentech.

Introduction: Despite efforts to improve postpartum health care in the United States, little is known about patterns of postpartum care beyond routine postpartum visit attendance. This study aimed to describe variation in outpatient postpartum care patterns., Methods: In this longitudinal cohort study of national commercial claims data, we used latent class analysis to identify subgroups of patients (classes) with similar outpatient postpartum care patterns (defined by the number of preventive, problem, and emergency department outpatient visits in the 60 days after birth). We also compared classes in terms of maternal sociodemographics and clinical characteristics measured at childbirth, as well as total health spending and rates of adverse events (all-cause hospitalizations and severe maternal morbidity) measured from childbirth to the late postpartum period (61-365 days after birth)., Results: The study cohort included 250,048 patients hospitalized for childbirth in 2016. We identified six classes with distinct outpatient postpartum care patterns in the 60 days after birth, which we classified into three broad groups: no care (class 1 [32.4% of the total sample]); preventive care only (class 2 [18.3%]); and problem care (classes 3-6 [49.3%]). The prevalence of clinical risk factors at childbirth increased progressively from class 1 to class 6; for example, 6.7% of class 1 patients had any chronic disease compared with 15.5% of class 5 patients. Severe maternal morbidity was highest among the high problem care classes (classes 5 and 6): 1.5% of class 6 patients experienced severe maternal morbidity in the postpartum period and 0.5% in the late postpartum period, compared with less than 0.1% of patients in classes 1 and 2., Conclusions: Efforts to redesign and measure postpartum care should reflect the current heterogeneity in care patterns and clinical risks in the postpartum population., (Copyright © 2023 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.)

While expanded HIV testing is needed in South Africa, increasing accurate self-report of HIV status is an essential parallel goal in this highly mobile population. If self-report can ascertain true HIV-positive status, persons with HIV (PWH) could be linked to life-saving care without the existing delays required by producing medical records or undergoing confirmatory testing, which are especially burdensome for the country's high prevalence of circular migrants. We used Wave 1 data from The Migration and Health Follow-Up Study, a representative adult cohort, including circular migrants and permanent residents, randomly sampled from the Agincourt Health and Demographic Surveillance System in a rural area of Mpumalanga Province. Within the analytic sample (n = 1,918), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-report were calculated with dried blood spot (DBS) HIV test results as the standard. Among in-person participants (n = 2,468), 88.8% consented to DBS-HIV testing. HIV prevalence was 25.3%. Sensitivity of self-report was 43.9% (95% CI: 39.5-48.5), PPV was 93.4% (95% CI: 89.5-96.0); specificity was 99.0% (95% CI: 98.3-99.4) and NPV was 83.9% (95% CI: 82.8-84.9). Self-report of an HIV-positive status was predictive of true status for both migrants and permanent residents in this high-prevalence setting. Persons who self-reported as living with HIV were almost always truly positive, supporting a change to clinical protocol to immediately connect persons who say they are HIV-positive to ART and counselling. However, 56% of PWH did not report as HIV-positive, highlighting the imperative to address barriers to disclosure., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Although administrative claims data can be used to identify high-need (HN) Medicare beneficiaries, persistence in HN status among beneficiaries and subsequent variation in outcomes are unknown. We use national-level claims data to classify Fee-for-Service (FFS) Medicare beneficiaries as HN annually among beneficiaries continuously enrolled between 2013 and 2015. To examine persistence of HN status over time, we categorize longitudinal patterns in HN status into being never, newly, transiently, and persistently HN and examine differences in patients' demographic characteristics and outcomes. Among survivors, 23% of beneficiaries were HN at any time-4% persistently HN, 13% transiently HN, and 6% newly HN. While beneficiaries who were persistently HN had higher mortality, utilization, and expenditures, classification as HN at any time was associated with poor outcomes. These findings demonstrate longitudinal variability of HN status among FFS beneficiaries and reveal the pervasiveness of poor outcomes associated with even transitory HN status over time.

Introduction: Although access to a motor vehicle is essential for pursuing social and economic opportunity and ensuring health and well-being, states have increasingly used driver's license suspensions as a means of compelling compliance with a variety of laws and regulations unrelated to driving, including failure to pay a fine or appear in court. Little known about the population of suspended drivers and what geographic resources may be available to them to help mitigate the impact of a suspension., Methods: Using data from the New Jersey Safety Health Outcomes (NJ-SHO) data warehouse 2004-2018, we compared characteristics of suspended drivers, their residential census tract, as well as access to public transportation and jobs, by reason for the suspension (driving or non-driving related). In addition, we examined trends in the incidence and prevalence of driving- and non-driving-related suspensions by sub-type over time., Results: We found that the vast majority (91%) of license suspensions were for non-driving-related events, with the most common reason for a suspension being failure to pay a fine. Compared to drivers with a driving-related suspension or no suspension, non-driving-related suspended drivers lived in census tracts with a lower household median income, higher proportion of black and Hispanic residents and higher unemployment rates, but also better walkability scores and better access to public transportation and jobs., Conclusions: Our study contributes to a growing literature that shows, despite public perception that they are meant to address traffic safety, the majority of suspensions are for non-driving-related events. Further, these non-driving-related suspensions are most common in low-income communities and communities with a high-proportion of black and Hispanic residents. Although non-driving-related suspensions are also concentrated in communities with better access to public transportation and nearby jobs, additional work is needed to determine what effect this has for the social and economic well-being of suspended drivers.

A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013-2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals.

Objective: To evaluate the association between long-term exposure to ambient air pollution and cognitive decline in older adults residing in an urban area., Methods: Data for this study were obtained from 2 prospective cohorts of residents in the northern Manhattan area of New York City: the Washington Heights-Inwood Community Aging Project (WHICAP) and the Northern Manhattan Study (NOMAS). Participants of both cohorts received in-depth neuropsychological testing at enrollment and during follow-up. In each cohort, we used inverse probability weighted linear mixed models to evaluate the cross-sectional and longitudinal associations between markers of average residential ambient air pollution (nitrogen dioxide [NO 2 ], fine particulate matter [PM 2.5 ], and respirable particulate matter [PM 10 ]) levels in the year prior to enrollment and measures of global and domain-specific cognition, adjusting for sociodemographic factors, temporal trends, and censoring., Results: Among 5,330 participants in WHICAP, an increase in NO 2 was associated with a 0.22 SD lower global cognitive score at enrollment (95% confidence interval [CI], -0.30, -0.14) and 0.06 SD (95% CI, -0.08, -0.04) more rapid decline in cognitive scores between visits. Results were similar for PM 2.5 and PM 10 and across functional cognitive domains. We found no evidence of an association between pollution and cognitive function in NOMAS., Conclusion: WHICAP participants living in areas with higher levels of ambient air pollutants have lower cognitive scores at enrollment and more rapid rates of cognitive decline over time. In NOMAS, a smaller cohort with fewer repeat measurements, we found no statistically significant associations. These results add to the evidence regarding the adverse effect of air pollution on cognitive aging and brain health., (© 2020 American Academy of Neurology.)

Background: There is mounting evidence that long-term exposure to air pollution is related to accelerated cognitive decline in aging populations. Factors that influence individual susceptibility remain largely unknown, but may involve the apolipoprotein E genotype E4 (APOE-ε4) allele., Objectives: We assessed whether the association between long-term exposure to ambient air pollution and cognitive decline differed by APOE-ε4 status and cognitive risk factors., Methods: The Washington Heights Inwood Community Aging Project (WHICAP) is a prospective study of aging and dementia. Neuropsychological testing and medical examinations occur every 18-24 months. We used mixed-effects models to evaluate whether the association between markers of ambient air pollution (nitrogen dioxide [NO 2 ]), fine [PM 2.5 ], and coarse [PM 10 ] particulate matter) and the rate of decline in global and domain-specific cognition differed across strata defined by APOE-ε4 genotypes and cognitive risk factors, adjusting for sociodemographic factors and temporal trends., Results: Among 4821 participants with an average of 6 years follow-up, higher concentrations of ambient air pollution were associated with more rapid cognitive decline. This association was more pronounced among APOE-ε4 carriers (p < 0.001). A one interquartile range increase in NO 2 was associated with an additional decline of 0.09 standard deviations (SD) (95%CI -0.1, -0.06) in global cognition across biennial visits among APOE-ε4 positive individuals and a 0.07 SD (95%CI -0.09, -0.05) decline among APOE-ε4 negative individuals. Results for PM 2.5, PM 10 and cognitive domains were similar. The association between air pollutants and rate of cognitive decline also varied across strata of race-ethnicity with the association strongest among White non-Hispanic participants., Conclusions: These results add to the body of evidence on the adverse impact of ambient air pollution on cognitive aging and brain health and provide new insights into the genetic and behavioral factors that may impact individual susceptibility., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes., Design: Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data., Setting: Not applicable., Participants: Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643)., Measurements: The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes., Results: Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4., Conclusions: Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019., (© 2019 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Objectives: To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI., Design: Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities. Data were obtained from the 2006-2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database., Setting: Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents., Participants: A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes., Measurements: Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s)., Results: For individuals with SMI, admission to a high-SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4-6.0) increase in the probability of feeding tube use relative to individuals admitted to a low-SMI facility. Among individuals without SMI, admission to a high-SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03-3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16-5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43-3.74)., Conclusion: Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI. J Am Geriatr Soc 67:2346-2352, 2019., (© 2019 The American Geriatrics Society.)

Background: Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature., Methods: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively., Results: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%., Conclusions: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.

Objective: To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia., Data Sources/study Setting: National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database., Study Design: We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument., Data Collection/extraction Methods: Minimum dataset assessments performed at NH admission and every quarter thereafter., Principal Findings: Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality., Conclusions: Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted., (© Health Research and Educational Trust.)

Objectives: To examine the association between health plan out-of-pocket (OOP) costs for antiepileptic drugs and healthcare utilization (HCU) and overall plan spending among US-based commercial health plan beneficiaries with epilepsy., Study Design: Retrospective cohort., Methods: The Truven MarketScan Commercial Claims database for January 1, 2009, to June 30, 2015, was used. Patients 65 years or younger with epilepsy and at least 12 months of continuous enrollment before index (date meeting first epilepsy diagnostic criteria) were included. Analyses were adjusted for age group, gender, beneficiary relationship, insurance plan type, and Charlson Comorbidity Index score. Primary outcomes included proportion of days covered (PDC), HCU, and healthcare spending in 90-day postindex periods. Associations between OOP costs and mean PDC, HCU, and plan healthcare spending per 90-day period were estimated., Results: Across 5159 plans, 187,241 beneficiaries met eligibility criteria; 54.3% were female, 41.7% were aged 45 to 65 years, and 62.4% were in preferred provider organization plans. Across postindex 90-day periods, mean (SD) PDC, epilepsy-specific hospitalizations, outpatient visits, and emergency department visits were 0.85 (0.26), 0.02 (0.13), 0.34 (0.47), and 0.05 (0.22), respectively. Median (interquartile range) spending per 90-day period was $1488 ($459-$4705); median epilepsy-specific spending was $139 ($18-$623). Multivariable linear regression without health plan fixed effects revealed that higher OOP spending was associated with a decrease in PDC (coefficient, -0.008; 95% CI, -0.009 to -0.006; P <.001) and an increase in overall spending (218.6; 95% CI, 47.9-389.2; P = .012). Health plan fixed effects model estimates were similar, except for epilepsy-specific spending, which was significant (120.6; 95% CI, 29.2-211.9; P = .010)., Conclusions: Increases in beneficiaries' OOP costs led to higher overall spending and lower PDC.

Importance: Depression during childhood and adolescence is heterogeneous. Treatment patterns are often examined in aggregate, yet there is substantial variability across individual treatment trajectories. Understanding this variability can help identify treatment gaps among youths with depression., Objective: To characterize heterogeneity in 12-month trajectories of psychotherapy and antidepressant treatment in youths with depression., Design, Setting, and Participants: This is a longitudinal-cohort study of youths 18 years or younger with a new diagnosis of depression and at least 12 months of follow-up following diagnosis, as determined from commercial insurance claims filed from 2007 to 2014. Latent class models were fit to summary measures of psychotherapy and antidepressant use in the 12 months following the index diagnosis. We examined variation in baseline health, health care utilization, and health outcomes across classes with similar patterns of psychotherapy and antidepressant use. Data analysis took place between June 2016 and March 2017., Main Outcomes and Measures: Psychotherapy and antidepressant use., Results: The cohort included 84 909 individuals with a mean (SD) age at index diagnosis of 15.0 (2.6) years, of whom 49 995 (59%) were female. Attention-deficit/hyperactivity disorder (n = 14 625; 17%) and anxiety (n = 12 358; 15%) were the most common comorbid diagnoses. During the assessment period, 59 023 individuals (70%) received psychotherapy at any point, and 33 997 individuals (40%) were dispensed antidepressants at any point. Eight classes with distinct treatment trajectories were identified, which we classified into 4 broad groups: 3 classes that received dual therapy (n = 18 710; 22%), 2 classes that received antidepressant monotherapy (n = 15 287; 18%), 2 classes that received psychotherapy monotherapy (n = 40 313; 48%) and 1 class that received no treatment (n = 10 599; 13%). The most common class received psychotherapy monotherapy (n = 35 243; 42%) and had the lowest incidence of attempted suicide (0.8 per 100 person-years [PY]) and inpatient hospitalization (3.5 per 100 PY) during the assessment period and postassessment period (0.5 per 100 PY and 1.3 per 100 PY, respectively). The group receiving dual therapy had the highest incidence of attempted suicide during the assessment period (4.7-7.1 per 100 PY, depending on the class) and postassessment period (1.5-1.7 per 100 PY)., Conclusions and Relevance: In our sample, 13% of youths received no treatment, and 18% received antidepressants without concomitant psychotherapy. Summary measures of treatment can mask informative patterns of psychotherapy and antidepressant use. Latent class analysis can be used to identify subgroups of individuals with similar treatment trajectories and help identify treatment gaps under current practice patterns.

In 2009, Blue Cross-Blue Shield of Massachusetts (BCBSMA) implemented the alternative quality contract (AQC), which pays provider organizations a global payment for all services used by enrollees. BCBSMA claims for 2006-2011 were used to compare youths enrolled in provider organizations participating in the AQC (7,407 person-years [PYs]) with those not participating (45,398 PYs). Difference-in-differences models estimated changes in mental health and substance abuse treatment service utilization and spending attributable to the AQC. The AQC was associated with small increases in the probability of any outpatient visits and in the probability and number of medication management visits among children with attention-deficit hyperactivity disorder (ADHD). Spending did not change, and there was no evidence of reductions in service utilization or spending for children with ADHD in the first three years of AQC implementation.

Characterizations of average end-of-life care for people with cancer can obscure important differences in patients' experiences. Using Medicare claims data for 14,257 patients diagnosed with extensive-stage small-cell lung cancer in the period 1995-2009, we used latent class analysis to identify classes of people with different care patterns. We characterized care trajectories from diagnosis to death using time spent in five care settings-home, hospital inpatient unit (acute), hospital intensive care unit (ICU), postacute skilled nursing facility, and hospice-and transitions across these settings. We identified four classes of patients: 66 percent spent the time primarily at home, 11 percent were primarily in hospice, 17 percent were largely in an acute setting, and 6 percent were largely in an ICU. Patients in these classes differed significantly in terms of baseline clinical characteristics, survival length, time spent in hospice, site of death, and spending. The findings show substantial heterogeneity in patterns of care for patients with advanced cancer, which should be accounted for in efforts to improve end-of-life care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objectives: To assess the effect of facility Clostridium difficile infection (CDI) prevalence on risk of healthcare facility (HFC) acquired CDI., Design: Retrospective cohort study., Setting: Medicare fee-for-service (FFS) claims and skilled nursing facility (SNF) Minimum Data Set 3.0 assessments., Participants: Medicare beneficiaries with 90 days or more of no contact with a HCF before a hospital admission without a CDI diagnosis. Participants were separated into two cohorts: discharged to the community and discharged to a SNF., Measurements: Risk of HCF-acquired CDI associated with CDI prevalence at the index facility measured according to 30-day rehospitalization with a discharge diagnosis of CDI or diagnosis in the SNF after admission. Hospital and SNF CDI prevalence were categorized into three groups: 0% and above and below the median value for facilities with greater than 0% prevalence., Results: Of 817,900 eligible individuals, there were 553,423 admissions in the first cohort (discharged to the community) and 315,109 in the second (discharged to a SNF). In the first cohort, the risk of HCF-acquired CDI was higher for individuals admitted to hospitals with CDI prevalence less than the median (relative risk (RR) = 1.58, 95% confidence interval (CI) = 1.18-2.12) and greater than the median (RR = 2.56, 95% CI = 1.91-3.45) than for those with no CDI. In the second cohort, the risk of HCF-acquired CDI was greater for individuals admitted to a hospital (RR = 1.89, 95% CI = 1.49-2.39) and a SNF (RR = 1.48, 95% CI = 1.31-1.67) with CDI prevalence greater than the median., Conclusion: The risk of HCF-acquired CDI is greater for noninfected individuals admitted to hospitals and SNFs with a high prevalence of CDI., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objective: There is increasing evidence of an association between statin use and type 2 diabetes mellitus (T2DM) in adults, yet this relationship has never been studied in children or adolescents and may have important implications for assessing risks and benefits of treatment in this population. We estimated the association between statin use and the risk of T2DM in children with and without a dyslipidemia diagnosis., Methods: Propensity scores were used to match new users of statins with a minimum 50 percent of days covered (PDC) in the first year of use to up to 10 nonusers. Analyses were stratified by a dyslipidemia diagnosis based on recent evidence suggesting a potentially protective effect of familial hypercholesterolemia on T2DM. In sensitivity analyses, we varied this period of exclusion and PDC. Cox proportional hazard models compared the hazard of the outcome between the exposed and unexposed patients., Results: A total of 21,243,305 patients met the eligibility criteria, 2085 (0.01%) of whom met the exposure definition and 1046 (50%) of whom had a dyslipidemia diagnosis. Statin use was associated with an increased risk of T2DM in children without dyslipidemia (hazard ratio 1.96, 95% confidence interval 1.20-3.22), but not in children with dyslipidemia (hazard ratio 1.11, 95% confidence interval 0.65-1.90). The results were consistent across variations in the exclusion period and PDC., Conclusions: Statin use was associated with an increased likelihood of developing T2DM in children without dyslipidemia. Physicians and patients need to weigh the possible risk of T2DM against the long-term benefits of statin therapy at a young age., (Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

The Centers for Medicare and Medicaid Services Financial Alignment Initiative represents the largest effort to date to move beneficiaries who are eligible for both Medicare and Medicaid-known as dual eligibles-into a coordinated care model by the use of passive (automatic) enrollment. Thirteen states are testing integrated payment and delivery demonstration programs in which an estimated 1.3 million dual eligibles are qualified to participate. As of October 2016, passive enrollment had brought over 300,000 dual eligibles into nine capitated programs in eight states. However, program participation levels remained relatively low. Across the eight states, only 26.7 percent of dual eligibles who were qualified to participate were enrolled, ranging from 5.3 percent for the two New York programs together to 62.4 percent in Ohio. Although the exact causes of the high rates of opting out and disenrolling that we observed among passively enrolled dual eligibles are unknown, experience to date suggests that administrative challenges were combined with demand- and supply-side barriers to enrollment. These early findings draw into question whether passive enrollment can encourage dual eligibles to participate in integrated care models., (Project HOPE—The People-to-People Health Foundation, Inc.)

Introduction Earthquake-related trauma results in crush injuries and bony- and soft-tissue trauma. There are no systematic reviews analyzing the typical injury patterns and treatments in "Mega-Mass-Casualty" earthquakes. The characterization of an injury pattern specific to disaster type, be it natural or manmade, is imperative to build an effective disaster preparedness and response system., Methods: The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy was developed to identify all publications relating to earthquakes and the orthopedic treatment in adult patients. The following databases were searched: PubMed (Medline; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Ovid (Ovid Technologies; New York, New York USA), Web of Science (Thomson Reuters; New York, New York USA), and The Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom)., Results: The searches identified 4,704 articles: 4,445 after duplicates were removed. The papers were screened for title and abstract and 65 out of those were selected for full-text analysis. The quality of data does not permit a standard-of-care (SOC) to be defined. Scarcity and poor quality of the data collected also may suggest a low level of accountability of the activity of the international hospital teams. Qualitatively, it is possible to define that there are more open fractures during daytime hours than at night. Excluding data about open and closed fractures, for all types of injuries, the results underline that the higher the impact of the earthquake, as measured by Richter Magnitude Scale (RMS), the higher is the number of injuries. Discussion Regarding orthopedic injuries during earthquakes, special attention must be paid to the management of the lower limbs most frequently injured. Spinal cord involvement following spine fractures is an important issue: this underlines how a neurosurgeon on a disaster team could be an important asset during the response. Conservative treatment for fractures, when possible, should be encouraged in a disaster setting. Regarding amputation, it is important to underline how the response and the quality of health care delivered is different from one team to another. This study shows how important it is to improve, and to require, the accountability of international disaster teams in terms of type and quality of health care delivered, and to standardize the data collection. Bortolin M , Morelli I , Voskanyan A , Joyce NR , Ciottone GR . Earthquake-related orthopedic injuries in adult population: a systematic review. Prehosp Disaster Med. 2017;32(2):201-208.

Background: The American Academy of Pediatrics recommends lipid-lowering therapy (LLT) for children at high risk of cardiovascular disease. However, the use of LLT in children is rare, and rates of nonadherence are unknown., Objective: To identify patterns of use and predictors of nonadherence to LLT in children aged 8 to 20 years and the subgroup with dyslipidemia., Methods: Commercially insured patients with a new dispensing for an LLT were included. Nonadherence was defined as a gap of >90 days between the last dispensing plus the medication days supply and the next dispensing or censoring. Descriptive statistics characterize the patterns of LLT adherence and class-specific drug switching. Kaplan-Meier curves and multivariable Cox proportional hazard models identified time to, and predictors of, nonadherence for the cohort and the dyslipidemia subgroup., Results: Of the 8710 patients meeting inclusion criteria, 87% were nonadherent. Statins were the most common index prescription, and patients with an index statin dispensing were more likely to have multiple comorbidities and other prescription drug use. In multivariable analyses, nonadherence was inversely associated with dyslipidemia (hazard ratio [HR] = 0.61, 95% confidence interval [CI] = 0.57-0.65), chronic kidney disease (HR = 0.69, 95% CI = 0.54-0.88), higher outpatient (HR = 0.87, 95% CI = 0.77-0.98), and inpatient (HR = 0.83, 95% CI = 0.70-0.97) use. When limited to patients with dyslipidemia, nonadherence was related to age (HR = 1.21, 95% CI = 1.07-1.38) and obesity (HR = 1.23, 95% CI = 1.02-1.49)., Conclusions: Despite recommendations to begin continuous treatment early for high-risk children, nonadherence to LLT is frequent in this population, with modestly higher adherence in children with dyslipidemia., Competing Interests: The other authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2016 National Lipid Association. Published by Elsevier Inc. All rights reserved.)

Background: Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy., Methods: This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment., Results: The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012)., Conclusions: Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society., (Published 2015. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Recognizing the diverse presentation of neurological conditions that emergency physicians encounter can be challenging, and management of these patients often requires consultation with a neurologist. Accurate diagnosis is critical in neurological emergencies because patient outcomes are often dependent on timely treatment. Our primary objective was to ascertain whether consultant neurologists understood the reason for consultation in the emergency department., Methods: The authors conducted a prospective study of a non-consecutive sample of 94 patients seen in an academic tertiary care emergency department (ED) who underwent consultation by neurologist over 4 consecutive months. At the time a consult was requested, we independently surveyed the treating ED physician for their differential diagnosis. Neurologists were also queried as to whether there was a clear indication for consultation. We then followed the patients to determine their final diagnosis and outcome., Results: The median age was 57 years (interquartile range 45-78). 45.7 % were male. The clinical reasons for all the consults were 61 % focal symptom, 12 % concern about a specific diagnosis, 9 % radiological finding, 9 % diagnostic ambiguity, and 11 % other. There was no significant difference in the rate of a final neurological diagnosis based on the clinical reason for consult (p = 0.13). In the 17 % of patients for whom the treating neurologist reported a lack of a clear indication for the consultation, 25 % were later admitted to a neurological service, and 69 % ultimately had a neurological diagnosis., Conclusions: Although patients with neurological emergencies can have diverse presentations, emergency physicians appear to utilize neurologic consultation appropriately. Additionally, nearly 70 % of patients for whom the consultant did not precisely understand the need for the consultation had neurological diagnoses. Time and resource constraints in the ED create challenges in making correct diagnosis.

Background: Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability., Objective: The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo., Methods: We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke., Results: There were 325 eligible patients; 131 were ED patients. Patients were 57 (± 18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke., Conclusions: This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: For more than a decade, conflict in the Eastern Democratic Republic of Congo (DRC) has been claiming lives. Within that conflict, sexual violence has been used by militia groups to intimidate and punish communities, and to control territory. This study aimed to: (1) investigate overall frequency in number of Eastern DRC sexual assaults from 2004 to 2008 inclusive; (2) determine if peaks in sexual violence coincide with known military campaigns in Eastern DRC; and (3) study the types of violence and types of perpetrators as a function of time., Methods: This study was a retrospective, descriptive, registry-based evaluation of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008., Results: A total of 4,311 records were reviewed. Throughout the five-year study period, the highest number of reported sexual assaults occurred in 2004, with a steady decrease in the total number of incidents reported at Panzi Hospital from 2004 through 2008. The highest peak of reported sexual assaults coincided with a known militant attack on the city of Bukavu. A smaller sexual violence peak in April 2004 coincided with a known military clash near Bukavu. Over the five-year period, the number of sexual assaults reportedly perpetrated by armed combatants decreased by 77% (p = 0.086) and the number of assaults reportedly perpetrated by non-specified perpetrators decreased by 92% (p < 0.0001). At the same time, according to the hospital registry, the number of sexual assaults reportedly perpetrated by civilians increased 17-fold (p < 0.0001). This study was limited by its retrospective nature, by the inherent selection bias of studying only survivors presenting to Panzi Hospital, and by the use of a convenience sample within Panzi Hospital., Conclusions: After years of military rape in South Kivu Province, civilian adoption of sexual violence may be a growing phenomenon. If this is the case, the social mechanisms that prevent sexual violence will have to be rebuilt and sexual violence laws will have to be fully enforced to bring all perpetrators to justice. Proper rehabilitation and reintegration of ex-combatants may also be an important step towards reducing civilian rape in Eastern DRC.

Emergency medicine (EM) has an important role in public health, but the ideal approach for teaching public health to EM residents is unclear. As part of the national Regional Public Health-Medicine Education Centers-Graduate Medical Education initiative from the CDC and the American Association of Medical Colleges, three EM programs received funding to create public health curricula for EM residents. Curricula approaches varied by residency. One program used a modular, integrative approach to combine public health and EM clinical topics during usual residency didactics, one partnered with local public health organizations to provide real-world experiences for residents, and one drew on existing national as well as departmental resources to seamlessly integrate more public health-oriented educational activities within the existing residency curriculum. The modular and integrative approaches appeared to have a positive impact on resident attitudes toward public health, and a majority of EM residents at that program believed public health training is important. Reliance on pre-existing community partnerships facilitated development of public health rotations for residents. External funding for these efforts was critical to their success, given the time and financial restraints on residency programs. The optimal approach for public health education for EM residents has not been defined., (Copyright © 2011 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)