Nurse Work Environment and Hospital-Onset Clostridioides difficile Infection.

BACKGROUND: Clostridioides difficile is the leading cause of hospital-onset diarrhea and is associated with increased lengths of stay and mortality. While some hospitals have successfully reduced the burden of C. difficile infection (CDI), many still struggle to reduce hospital-onset CDI. Nurses-because of their close proximity to patients-are an important resource in the prevention of hospital-onset CDI. OBJECTIVE: Determine whether there is an association between the nurse work environment and hospital-onset CDI. METHODS: Survey data of 2016 were available from 15,982 nurses employed in 353 acute care hospitals. These data, aggregated to the hospital level, provided measures of the nurse work environments. They were merged with 2016 hospital-onset CDI data from Hospital Compare, which provided our outcome measure-whether a hospital had a standardized infection ratio (SIR) above or below the national average SIR. Hospitals above the average SIR had more infections than predicted when compared to the national average. RESULTS: In all, 188 hospitals (53%) had SIRs higher than the national average. The odds of hospitals having higher than average SIRs were significantly lower, with odds ratios ranging from 0.35 to 0.45, in hospitals in the highest quartile for all four nurse work environment subscales (managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing) than in hospitals in the lowest quartile. CONCLUSIONS: Findings show an association between the work environment of nurses and hospital-onset CDI. A promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by hospital leaders to significantly improve nurse work environments.

Urban-rural differences in healthcare utilization among beneficiaries in China's new cooperative medical scheme.

BACKGROUND: The New Cooperative Medical Scheme (NCMS) is a voluntary social health insurance program launched in 2002 for rural Chinese residents where 80% of people were without health insurance of any kind. Over time, several concerns about this program have been raised related to healthcare utilization disparities for NCMS participants in urban versus rural regions. Our study uses 2015 national survey data to evaluate the extent of these urban and rural disparities among NCMS beneficiaries. METHODS: Data for our study are based on the Chinese Health and Retirement Longitudinal Study (CHARLS) for 2015. Our 12,190-patient sample are urban and rural patients insured by NCMS. We use logistic regression analyses to compare the extent of disparities for urban and rural residence of NCMS beneficiaries in (1) whether individuals received any inpatient or outpatient care during 2015 and (2) for those individuals that did receive care, the extent of the variation in the number of inpatient and outpatient visits among each group. RESULTS: Our regression results reveal that for urban and rural NCMS patients in 2015, there were no significant differences in inpatient or outpatient utilization for either of the dependent variables - 1) whether or not the patient had a visit during the last year, or 2) for those that had a visit, the number of visits they had. Patient characteristics: age, sex, employment, health status, chronic conditions, and per capita annual expenditures - all had significant impacts on whether or not there was an inpatient or outpatient visit but less influence on the number of inpatient or outpatient visits. CONCLUSIONS: For both access to inpatient and outpatient facilities and the level of utilization of these facilities, our results reveal that both urban and rural NCMS patients have similar levels of resource utilization. These results from 2015 indicate that utilization angst about urban and rural disparities in NCMS patients do not appear to be a significant concern.

The cost-saving effect of continuity of care (COC): an analysis of institutional COC on diabetic treatment costs using panel 2SLS regressions.

BACKGROUND: The high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC). METHODS: We analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs. RESULTS: Our results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care. CONCLUSIONS: Institutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect.

Index of cardiometabolic health: a new method of measuring allostatic load using electronic health records.

OBJECTIVE: We developed a measure of allostatic load from electronic medical records (EMRs), which we named "Index of Cardiometabolic Health" (ICMH). METHODS: Data were collected from participants' EMRs and a written survey in 2005. We computed allostatic load scores using the ICMH score and two previously described approaches. RESULTS: We included 1865 employed adults who were 25-59 years old. Although the magnitude of the association was small, all methods of were predictive of SF-12 physical component subscales (all p < 0.001). CONCLUSION: We found that the ICMH had similar relationships with health-related quality of life as previously reported in the literature.

Evidence that electronic health records can promote physician counseling for healthy behaviors.

BACKGROUND: Health behavior counseling services may help patients manage chronic conditions effectively and slow disease progression. Studies show, however, that many providers fail to provide these services because of time constraints and inability to tailor counseling to individual patient needs. Electronic health records (EHRs) have the potential to increase appropriate counseling by providing pertinent patient information at the point of care and clinical decision support. PURPOSE: This study estimates the impact of select EHR functionalities on the rate of health behavior counseling provided during primary care visits. METHODOLOGY: Multivariable regression analyses of the 2007-2010 National Ambulatory Medical Care Survey were conducted to examine whether eight EHR components representing four core functionalities of EHR systems were correlated with the rate of health behavior counseling services. Propensity score matching was used to control for confounding factors given the use of observational data. To address concerns that EHR may only lead to improved documentation of counseling services and not necessarily improved care, the association of EHR functionalities with prescriptions for smoking cessation medications was also estimated. FINDINGS: The use of an EHR system with health information and data, order entry and management, result management, decision support, and a notification system for abnormal test results was associated with an approximately 25% increase in the probability of health behavior counseling delivered. Clinical reminders were associated with more health behavior counseling services when available in combination with patient problem lists. The laboratory results viewer was also associated with more counseling services when implemented with a notification system for abnormal results. PRACTICE IMPLICATION: An EHR system with key supportive functionalities can enhance delivery of preventive health behavior counseling services in primary care settings. Meaningful use criteria should be evaluated to ensure that they encourage the adoption of EHR systems with those functionalities shown to improve clinical care.

The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study.

BACKGROUND: Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals. OBJECTIVE: To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP. DESIGN: Cross-sectional analysis. SETTING: United States in 2014. PARTICIPANTS: 3022 acute care hospitals participating in VBP and the HRRP. MEASUREMENTS: Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods. RESULTS: Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115 900 vs. $66 600 and $150 100 vs. $54 900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures. LIMITATION: Only 2 measures of safety-net status were included in the analyses. CONCLUSION: Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery in the infant aphakia treatment study at age 5 years.

PURPOSE: To analyze differences in the cost of treatment for infants randomized to primary intraocular lens (IOL) implantation versus optical correction with a contact lens (CL) after unilateral cataract surgery in the Infant Aphakia Treatment Study (IATS). DESIGN: Retrospective cost analysis of a prospective, randomized clinical trial based on Georgia Medicaid reimbursement data as well as actual costs of supplies used during the study, adjusted for inflation. PARTICIPANTS: The IATS is a multicenter (n = 12), randomized clinical trial comparing the optical treatment of aphakia with either primary IOL implantation (n = 57) or CL correction (n = 57) in 114 infants with unilateral congenital cataract. INTERVENTION: One hundred fourteen infants underwent unilateral cataract surgery and were either corrected optically by primary IOL implantation at the time of surgery or were corrected with a CL after surgery. MAIN OUTCOME MEASURES: The mean cost of cataract surgery and all additional surgeries, examinations, and supplies used up to 5 years of age. RESULTS: The 5-year treatment cost of an infant with a unilateral congenital cataract corrected optically with an IOL was $27 090 versus $25 331 for a patient treated with a CL after initial cataract surgery. The total cost of supplies was $3204 in the IOL group versus $7728 in the CL group. CONCLUSIONS: Unilateral cataract surgery in infancy coupled with primary IOL implantation is approximately 7% more expensive than aphakia and CL correction. Patient costs are more than double with CL versus IOL treatment.

Determining the impact of US mammography screening guidelines on patient survival in a predominantly African American population treated in a public hospital during 2008.

BACKGROUND: In November 2009, the US Preventive Service Task Force (USPSTF) published updated breast cancer screening guidelines. This marked a change from the 2002 recommendations and a significant divergence from the American Cancer Society (ACS) guidelines. In the current study, the potential effect of using the revised 2009 USPSTF guidelines on patient disease stage and survival were evaluated and compared with those actually observed and to predicted under ACS recommendations. METHODS: A retrospective chart review was performed for 84 patients who were diagnosed with stage I through III breast cancer at Grady Memorial Hospital during 2008. Previously published tumor volume doubling times were used to model an equation that would estimate tumor sizes. For each patient, a disease stage at diagnosis was predicted, and outcomes were modeled as though the patient had been screened according to the recommended versions of the ACS and USPSTF guidelines. Patient survival rates were then estimated based on prognostic data according to disease stage. RESULTS: The average age of patients in the study was 55 years, and 85% were African American. The USPSTF guidelines predicted later stages at diagnosis (14% stage I, 73% stage II), whereas the ACS guidelines predicted earlier stages (47% stage I, 53% stage II). CONCLUSIONS: A large stage migration was predicted, indicating significantly earlier diagnosis, when the ACS-recommended screening guidelines were followed. The authors concluded that practitioners should understand how race and/or socioeconomic factors increase the risk of breast cancer and should be encouraged to prioritize discussions regarding the benefits and risks of annual mammographic screening, especially among women who have a potentially greater risk of developing breast cancer at a younger age.

Cost of intraocular lens versus contact lens treatment after unilateral congenital cataract surgery: retrospective analysis at age 1 year.

PURPOSE: To describe the differences in treatment costs for infants randomized to contact lens correction versus primary intraocular lens (IOL) implantation after unilateral cataract surgery in the Infant Aphakia Treatment Study (IATS). DESIGN: Retrospective cost analysis of a prospective, randomized clinical trial based on Georgia Medicaid data and the actual costs of supplies used. PARTICIPANTS: The IATS is a randomized, multicenter (n=12) clinical trial comparing treatment of aphakia with a primary IOL or contact lens in 114 infants with unilateral congenital cataract. INTERVENTION: Infants underwent cataract surgery with or without placement of an IOL. MAIN OUTCOME MEASURES: The mean cost of cataract surgery and all additional surgeries, examinations, and supplies used up to 12 months of age. RESULTS: The mean cost of treatment for a unilateral congenital cataract with primary IOL implantation was $14 752 versus $10 726 with contact lens correction. The initial cataract surgery accounted for approximately 50% of the treatment costs for both groups. Contact lens costs accounted for 15% ($1600/patient) in the aphakic group, whereas glasses costs represented only 4% ($535/patient) in the IOL group. The increased costs in the IOL group were primarily due to the higher cost of cataract surgery in this group ($7302 vs. $5357) and the cost of additional operations. CONCLUSIONS: For IATS patients up to 12 months of age, cataract surgery coupled with IOL implantation and spectacle correction was 37.5% (∼$4000) more expensive than cataract surgery coupled with contact lens correction. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Improving psychotherapeutic medication prescribing in Florida: implementation of the Florida Medicaid Drug Therapy Management Program (MDTMP).

This paper describes a program that was established by Florida Medicaid to improve the quality of prescribing of psychotherapeutic medications. It relates the process used for defining quality medication treatment including the definitions of unusual psychotherapeutic medication indicators (UPMI). It details the results of analysis of FY 2007-2008 pharmacy claims data using these indicators that enabled the Program to identify practices and prescribers that required targeted interventions. The most frequently triggered UPMI for adults involved the use of 2 or more antipsychotics for greater than 60 days; high doses of psychotherapeutic medications was the indicator most frequently triggered for children closely followed by the use of 2 or more antipsychotics for more than 45 days. Prescriptions that triggered UPMI were concentrated in a small number of prescribers. These results led to the Program focusing on these high frequency practices and on the prescribers most associated with them. They also led to the implementation of new quality improvement initiatives like the implementation of a psychiatric telephone consultation line for pediatricians who are treating children with serious emotional disturbances who do not have access to child psychiatrists.

Antipsychotic polypharmacy prescribing patterns and costs in the Florida adult and child Medicaid populations.

The rapid growth in the use of antipsychotic medications and their related costs have resulted in states developing programs to measure, monitor, and insure their beneficial relevance to public program populations. One such program developed in the state of Florida has adopted an evidence-based approach to identify prescribers with unusual psychotherapeutic prescription patterns and track their utilization and costs among Florida Medicaid patients. This study reports on the prescriber prescription and cost patterns for adults and children using three measures of unusual antipsychotic prescribing patterns: (1) two antipsychotics for 60 days (2AP60), (2) three antipsychotics for 60 days (3AP60), and (2) two antipsychotics for 90 or more days (2AP90). We find that over the four-year study period there were substantial increases in several aspects of the Florida Medicaid behavioral drug program. Overall, for adults and children, patient participation increased by 29 percent, the number of prescriptions grew by 30 percent, and the number of prescribers that wrote at least one prescription grew 48.5 percent, while Medicaid costs for behavioral drugs increased by 32 percent. But the results are highly skewed. We find that a relatively small number of prescribers account for a disproportionately large share of prescriptions and costs of the unusual antipsychotic prescriptions. In general, the top 350 Medicaid prescribers accounted for more than 70 percent of the unusual antipsychotic prescriptions, and we find that this disparity in unusual prescribing patterns appears to be substantially more pronounced in adults than in children prescribers. For just the top 13 adult and children prescribers, their practice patterns accounted for 11 percent to 21 percent of the unusual prescribing activity and, overall, these 13 top prescribers accounted for 13 percent of the total spent on antipsychotics by the Florida Medicaid program and 9.3 percent of the total expenditure by the state for all drugs. Our findings suggest that a strategy to monitor and ensure patient safety and prescribing patterns that targets a relatively small number of Medicaid providers could have a substantial benefit and prove to be cost effective.

The impact of the individual mandate and Internal Revenue Service Form 990 Schedule H on community benefits from nonprofit hospitals.

In response to a growing concern that nonprofit hospitals are not providing sufficient benefit to their communities in return for their tax-exempt status, the Internal Revenue Service (IRS) now requires nonprofit hospitals to formally document the extent of their community contributions. While the IRS is increasing financial scrutiny of nonprofit hospitals, many provisions in the recently passed historical health reform legislation will also have a significant impact on the provision of uncompensated care and other community benefits. We argue that health reform does not render the nonprofit organizational form obsolete. Rather, health reform should strengthen the nonprofit hospitals' ability to fulfill their missions by better targeting subsidies for uncompensated care and potentially increasing subsidized health services provision, many of which affect the public's health.

Association of Registered Nurse Staffing With Mortality Risk of Medicare Beneficiaries Hospitalized With Sepsis.

Importance: Sepsis is a major physiologic response to infection that if not managed properly can lead to multiorgan failure and death. The US Centers for Medicare & Medicaid Services (CMS) requires that hospitals collect data on core sepsis measure Severe Sepsis and Septic Shock Management Bundle (SEP-1) in an effort to promote the early recognition and treatment of sepsis. Despite implementation of the SEP-1 measure, sepsis-related mortality continues to challenge acute care hospitals nationwide. Objective: To determine if registered nurse workload was associated with mortality in Medicare beneficiaries admitted to an acute care hospital with sepsis. Design Setting and Participants: This cross-sectional study used 2018 data from the American Hospital Association Annual Survey, CMS Hospital Compare, and Medicare claims on Medicare beneficiaries age 65 to 99 years with a primary diagnosis of sepsis that was present on admission to 1 of 1958 nonfederal, general acute care hospitals that had data on CMS SEP-1 scores and registered nurse workload (indicated by registered nurse hours per patient day [HPPD]). Patients with sepsis were identified based on 29 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Data were analyzed throughout 2021. Exposures: SEP-1 score and registered nurse staffing. Main Outcomes and Measures: The patient outcome of interest was mortality within 60 days of admission. Hospital characteristics included number of beds, ownership, teaching status, technology status, rurality, and region. Patient characteristics included age, sex, transfer status, intensive care unit admission, palliative care, do-not-resuscitate order, and a series of 29 comorbid diseases based on the Elixhauser Comorbidity Index. Results: In total, 702 140 Medicare beneficiaries (mean [SD] age, 78.2 [8.7] years; 360 804 women [51%]) had a diagnosis of sepsis. The mean SEP-1 score was 56.1, and registered nurse HPPD was 6.2. In a multivariable regression model, each additional registered nurse HPPD was associated with a 3% decrease in the odds of 60-day mortality (odds ratio, 0.97; 95% CI 0.96-0.99) controlling for SEP-1 score and hospital and patient characteristics. Conclusions and Relevance: The results of this cross-sectional study suggest that hospitals that provide more registered nurse hours of care could likely improve SEP-1 bundle compliance and decrease the likelihood of mortality in Medicare beneficiaries with sepsis.

Trends in In-hospital Coronary Artery Bypass Surgery Mortality by Gender and Race/Ethnicity --1998-2015: Why Do the Differences Remain?

BACKGROUND AND AIMS: Between 1998 and 2015, the national coronary artery bypass graft surgery (CABG) in-hospital mortality rate fell nearly 45% to just 2.2% of CABG in-patients. By almost any standards, this large decline in the nation's in-hospital mortality for CABG inpatients has been extraordinary. Yet, over this time period, no studies have detailed these notable trends in in-hospital CABG mortality with an emphasis on the differences by gender and racial/ethnicity. The in-hospital CABG treatment period is the approximately 9 day inpatient length-of-stay the patient is completely under the care of hospital and its staff. Our research seeks to fill this research gap with analyses of 18 years of national data of over 5 million CABG inpatient discharges distinguishing gender by six categories of race/ethnicity (Asian, black, Hispanic, white, other known races/ethnicities, and unknown race/ethnicities) to evaluate three broad questions related to in-hospital CABG mortality: 1) What have been the 18-year national trends in CABG surgeries, length-of-stay, mortality, and type of discharge by gender and race/ethnicity? 2) Over time, what have been the in-hospital mortality trends by gender and race-ethnicity? 3) Using multivariate techniques to control for patient characteristics, risk factors and socioeconomic characteristics of the hospital setting and environment, what is the extent of the variations in in-hospital mortality among the 12 groupings of gender and race-ethnicity? DATA AND METHODS: Data are from the Nationwide Inpatient Sample (NIS) data from the Healthcare Utilization Project (HCUP-NIS) collected yearly. These data represent 858 hospitals, a 20% national sample representing 5,032,985 CABG patient discharges from hospitals over an 18-year period -- 1998 to 2015. Descriptive and logistic regression analyses are used to evaluate the outcomes. RESULTS: The national decline in in-hospital CABG mortality trends over the 18-year period has been dramatic. These declines have substantially impacted all 12 racial/ethnic and gender groupings analyzed during this timeframe. However, over the 18-year period, both univariate and logistic regression results reveal the disadvantages females and black males have in in-hospital CABG mortality rates when compared to the comparison group, white male CABG inpatients. Female CABG inpatients consistently, regardless of their race/ethnicity, have significantly higher in-hospital mortality rates than their corresponding male counterparts even after controlling for patient characteristics and socio-economic status. For males, however, the likelihood of dying in the hospital from a CABG procedure showed wide variation across the four racial/ethnic categories. Compared with white male patients undergoing CABG surgery in the nation's hospitals, after controlling for confounding factors, Hispanic and Asian-American had significantly lower in-hospital CABG mortality rates -9.7% and -17.9% respectively. In contrast, black male CABG patients had a 35.1% higher in-hospital CABG mortality rate than white males. CONCLUSIONS: While considerable progress has been made reducing overall in-hospital CABG mortality over the past 18-years across all gender and racial/ethnic inpatients, significant gaps persist between black males and other racial/ethnic groups.

Trends in U.S. Community hospitalizations due to herpes zoster: 2001-2015.

BACKGROUND: In 2007, based on decisions by the U.S. Advisory Committee on Immunization Practices, the CDC recommended a booster dose at 4-6 years in the varicella vaccine schedule. In 2008, a herpes zoster vaccine was recommended for use in persons age ≥60 years. The purpose of this study was to examine trends in herpes zoster hospitalization rates and assess the impact of both policy recommendations using U.S. hospital discharge data. METHODS: Nationwide Inpatient Sample discharge data from 2001 to 2015 were used to identify primary or secondary herpes zoster diagnoses. Trends in annual total and age-specific herpes zoster hospitalization rates and average length of stay were examined. Average annual rates for the pre (2001-2005) and post (2012-2015)-zoster vaccine policy eras were compared. Absolute change in herpes zoster hospitalizations were calculated. RESULTS: The rate difference of U.S. herpes zoster hospitalizations in the post vs. pre-zoster vaccine policy era was -1.9 per 100,000 population (6,200 fewer hospitalizations in 2015 than expected). Key age group rate differences: 0-3 years (-0.4 per 100,000; 50 fewer), 4-6 years (-0.6 per 100,000; 50 fewer), 7-14 years (-1.3 per 100,000; 400 fewer), 50-59 years (0.7 per 100,000; 300 more), 60-69 years (-2.5 per 100,000; 900 fewer), 70-79 years (-10.2 per 100,000; 2,000 fewer), 80+ years (-29.9 per 100,000; 3,600 fewer). CONCLUSIONS: Reduction of wild-type varicella due to the 2-dose varicella vaccination recommendation may have impacted declining herpes zoster hospitalization rates among children ≤14 years. The 2008 herpes zoster vaccine may have impacted declining herpes zoster hospitalization rates for adults age ≥60 years despite vaccination coverage <31% by 2015.

Translating primary care practice climate into patient activation: the role of patient trust in physician.

BACKGROUND: Little is known about processes by which proactive primary care teams might activate their patients. We examine the role of trust in patient-physician relationships for translating practice teamwork into patient activation. METHODS: Data were collected by surveys of adult enrollees and primary care teams of a group-model managed care organization in metropolitan Atlanta. Enrollees who were 25-59 years of age were randomly sampled from 3 condition cohorts (diabetes, elevated lipids but no coronary artery disease history, and low risk). A total of 2224 responded to a mixed mode survey in 2005 (42% response rate). Ninety-seven practitioners and 187 support staff of 16 primary care teams responded to a practice climate survey in 2004 (85% response rate). Practice climate is a multidimensional concept measuring support and collaboration with a team. Linear models of patients nested within their primary care teams were estimated for patient trust in physician as a function of practice climate and for activation as a function of trust, adjusted for other respondent characteristics. RESULTS: We found significant, positive associations between practice climate and patient trust in their primary care physicians and between patient trust and activation in their health. CONCLUSIONS: Our study shows 1 process by which practice climate translates into patient activation. Supportive interactions among practitioners and staff within primary care teams facilitate trust-building interactions between practitioners and patients. Supportive, trustworthy interactions, in turn, help to ameliorate the inherent imbalance in power between patients and physicians, contributing to patients who take a more active role in their health.

The Impact of Electronic Medical Records on Hospital-Acquired Adverse Safety Events: Differential Effects Between Single-Source and Multiple-Source Systems.

The objective was to examine differential impacts between single-source and multiple-source electronic medical record (EMR) systems, as measured by number of vendor products, on hospital-acquired patient safety events. The data source was the 2009-2010 State Inpatient Databases of the Healthcare Cost and Utilization Project for California, New York, and Florida, and the Information Technology Supplement to the American Hospital Association's Annual Survey. Multivariable regression analyses were conducted to estimate the differential impacts of EMRs between single-source and multiple-source EMR systems on hospital-acquired patient safety events. In all, 1.98% of adult surgery hospitalizations had at least 1 hospital-acquired patient safety event. Basic EMRs with a single vendor or self-developed EMR systems were associated with a significant decrease in patient safety events by 0.38 percentage point, or 19.2%, whereas basic EMRs with multiple vendors had an insignificant association. A single-source EMR system enhances the impact of EMRs on reducing patient safety events.

Improved intermediate clinical outcomes from participation in a diabetes health education program.

Diabetes self-management education programs are an essential strategy for improving health behaviors of adults with diabetes and, therefore, intermediate clinical outcomes. We conducted a retrospective observational study using a case:control design to estimate the impact of participation in a diabetes health education program on glycemic and lipid levels, accounting for nonrandom participation of adults with diabetes in the program ("regression to the mean"). Adults with diabetes in a group-model managed care organization who attended the diabetes health education program during the period January 1, 2003, through June 30, 2004 ("participants"), were randomly matched with 4 adults with diabetes who did not participate ("nonparticipants"). Participants (N=1991) and nonparticipants (N=7964) were matched on age group, gender, mean hemoglobin A1c (Hb A1c) (or low-density lipoprotein) in the 6 months prior to the class (or randomly selected index month for nonparticipants), and primary care practice where the patients received regular care. On average, participants had significantly (P < .05) worse glycemic and lipid levels in the 6 months prior to participation compared to nonparticipants. Participation in the diabetes education program significantly improved glycemic and lipid levels between baseline and follow-up periods above the improvement attributable to regression to the mean. For example, nonparticipants with baseline Hb A1c levels greater than 10.0% had improved Hb A1c levels of -1.7% (P < .01); however, among participants, mean Hb A1c levels improved an additional -1.6% (P < .01). Overall, the evidence suggests that participation in a multifactorial diabetes health education program significantly improved glycemic and lipid levels in the short-term, particularly among participants with extremely adverse Hb A1c or low-density lipoprotein levels prior to participation.