Sedative Prescriptions Are Common at Opioid Initiation: An Observational Study in the Veterans Health Administration.

Background: Concurrent use of sedatives, especially anxiolytics, and opioids is associated with increased risk of medication-related harms. To the extent that multiple prescribers are involved, approaches to influence patterns of coprescribing will differ from those to influence prescribing within a single drug class. Objectives: Describe the proportion of new opioid recipients with concurrent sedative medications at opioid initiation and determine whether these medications were prescribed by the same prescriber. Methods: We used national Department of Veterans Affairs (VA) outpatient pharmacy administration data to identify veterans who received a new opioid prescription between October 20, 2010, and September 1, 2011 (FY 2011), preceded by a 365-day opioid-free period. Concurrent sedative use was defined as a skeletal muscle relaxant, benzodiazepine, atypical antipsychotic, or hypnotic filled on the opioid start date or before and after the opioid start date with a gap of less than twice the day supply of the prior fill. Results: Concurrent sedative use at opioid initiation was 21.4% (112,408/526,499) in FY 2011. The proportion of concurrent recipients who received at least one concurrent sedative prescribed by a provider other than the opioid prescriber was 61.4% (69,002/112,408). The proportion of recipients who received a sedative concurrent with opioid initiation from the same prescriber varied across sedative class. Benzodiazepines and opioids were prescribed by the same provider in 41.1% (15,520/37,750) of concurrent users. Conclusion: One in five patients newly prescribed opioids also had a sedative prescription. Less than half of patients with concurrent opioid and benzodiazepine prescriptions received these from the same provider. Efforts to reduce concurrent opioid and sedative prescribing will require addressing care coordination.

Antimicrobial Nonsusceptibility of Gram-Negative Bloodstream Isolates, Veterans Health Administration System, United States, 2003-20131.

Bacteremia caused by gram-negative bacteria is associated with serious illness and death, and emergence of antimicrobial drug resistance in these bacteria is a major concern. Using national microbiology and patient data for 2003-2013 from the US Veterans Health Administration, we characterized nonsusceptibility trends of community-acquired, community-onset; healthcare-associated, community-onset; and hospital-onset bacteremia for selected gram-negative bacteria (Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter spp.). For 47,746 episodes of bacteremia, the incidence rate was 6.37 episodes/10,000 person-years for community-onset bacteremia and 4.53 episodes/10,000 patient-days for hospital-onset bacteremia. For Klebsiella spp., P. aeruginosa, and Acinetobacter spp., we observed a decreasing proportion of nonsusceptibility across nearly all antimicrobial drug classes for patients with healthcare exposure; trends for community-acquired, community-onset isolates were stable or increasing. The role of infection control and antimicrobial stewardship efforts in inpatient settings in the decrease in drug resistance rates for hospital-onset isolates needs to be determined.

The Effect of a Nationwide Infection Control Program Expansion on Hospital-Onset Gram-Negative Rod Bacteremia in 130 Veterans Health Administration Medical Centers: An Interrupted Time-Series Analysis.

BACKGROUND: The Veterans Health Administration (VHA) introduced the Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in March 2007. Although the initiative has been perceived as a vertical intervention focusing on MRSA, it also expanded infection prevention and control programs and resources. We aimed to assess the horizontal effect of the initiative on hospital-onset (HO) gram-negative rod (GNR) bacteremia. METHODS: This retrospective cohort included all patients who had HO bacteremia due to Escherichia coli, Klebsiella species, or Pseudomonas aeruginosa at 130 VHA facilities from January 2003 to December 2013. The effects were assessed using segmented linear regression with autoregressive error models, incorporating autocorrelation, immediate effect, and time before and after the initiative. Community-acquired (CA) bacteremia with same species was also analyzed as nonequivalent dependent controls. RESULTS: A total of 11 196 patients experienced HO-GNR bacteremia during the study period. There was a significant change of slope in HO-GNR bacteremia incidence rates from before the initiative (+0.3%/month) to after (-0.4%/month) (P < .01), while CA GNR incidence rates did not significantly change (P = .08). Cumulative effect of the intervention on HO-GNR bacteremia incidence rates at the end of the study period was estimated to be -43.2% (95% confidence interval, -51.6% to -32.4%). Similar effects were observed in subgroup analyses of each species and antimicrobial susceptibility profile. CONCLUSIONS: Within 130 VHA facilities, there was a sustained decline in HO-GNR bacteremia incidence rates after the implementation of the MRSA Prevention Initiative. As these organisms were not specifically targeted, it is likely that horizontal components of the initiative contributed to this decline.

The 1-Year Treatment Course of New Opioid Recipients in Veterans Health Administration.

BACKGROUND: Understanding opioid prescribing trends requires differentiating clinically distinct short- and long-term receipt patterns. OBJECTIVES: Describe the one-year course of opioid receipt among new opioid recipients and determine the proportion with subsequent long-term opioid therapy. Discern variation in proportion with long-term therapy initiation by geographic region and across Veterans Health Administration (VHA) medical centers. METHODS: Longitudinal course of opioid receipt was analyzed using a cabinet supply approach. Short-term receipt was defined as index treatment episode lasting no longer than 30 days; long-term therapy as treatment episode of >90 days that began within the first 30 days following opioid index date. PATIENTS: All VHA pharmacy users in 2004 and to 2011 who received a new prescription for an opioid (incident opioid recipients) preceded by 365 days with no opioid prescribed. RESULTS: The proportion of all incident recipients who met the definition for long-term therapy within the first year decreased from 20.4% (N = 76,280) in 2004 to 18.3% (N = 96,166) in 2011. The proportion of incident recipients with chronic pain was unchanged between 2004 and 2011. Hydrocodone and tramadol increased as a proportion of initial opioids prescribed. Median days initially supplied decreased from 30 to 20 days. A greater percentage of new opioid prescriptions were for 7 days or fewer (20.9% in 2004; 27.9% in 2011). The proportion of new recipients who initiated long-term opioid therapy varied widely by medical center. Medical centers with higher proportions of new long-term recipients in 2004 saw greater decreases in this metric by 2011. CONCLUSION: The proportion of new opioid recipients who initiated long-term opioid therapy declined between 2004 and 2011.

Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care.

BACKGROUND: Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States. METHOD: The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data. SIGNIFICANCE: Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

HIV quality report cards: impact of case-mix adjustment and statistical methods.

BACKGROUND: There will be increasing pressure to publicly report and rank the performance of healthcare systems on human immunodeficiency virus (HIV) quality measures. To inform discussion of public reporting, we evaluated the influence of case-mix adjustment when ranking individual care systems on the viral control quality measure. METHODS: We used data from the Veterans Health Administration (VHA) HIV Clinical Case Registry and administrative databases to estimate case-mix adjusted viral control for 91 local systems caring for 12 368 patients. We compared results using 2 adjustment methods, the observed-to-expected estimator and the risk-standardized ratio. RESULTS: Overall, 10 913 patients (88.2%) achieved viral control (viral load ≤400 copies/mL). Prior to case-mix adjustment, system-level viral control ranged from 51% to 100%. Seventeen (19%) systems were labeled as low outliers (performance significantly below the overall mean) and 11 (12%) as high outliers. Adjustment for case mix (patient demographics, comorbidity, CD4 nadir, time on therapy, and income from VHA administrative databases) reduced the number of low outliers by approximately one-third, but results differed by method. The adjustment model had moderate discrimination (c statistic = 0.66), suggesting potential for unadjusted risk when using administrative data to measure case mix. CONCLUSIONS: Case-mix adjustment affects rankings of care systems on the viral control quality measure. Given the sensitivity of rankings to selection of case-mix adjustment methods-and potential for unadjusted risk when using variables limited to current administrative databases-the HIV care community should explore optimal methods for case-mix adjustment before moving forward with public reporting.

Fee-based care is important for access to prompt treatment of hip fractures among veterans.

BACKGROUND: Hip fracture is a medical emergency for which delayed treatment increases risk of disability and death. In emergencies, veterans without access to a Veterans Administration (VA) hospital may be admitted to non-VA hospitals under fee-based (NVA-FB) care paid by the VA. The affect of NVA-FB care for treatment and outcomes of hip fractures is unknown. QUESTIONS/PURPOSES: This research seeks to answer three questions: (1) What patient characteristics determine use of VA versus NVA-FB hospitals for hip fracture? (2) Does time between admission and surgery differ by hospital (VA versus NVA-FB)? (3) Does mortality differ by hospital? METHODS: Veterans admitted for hip fractures to VA (n = 9308) and NVA-FB (n = 1881) hospitals from 2003 to 2008 were identified. Primary outcomes were time to surgery and death. Logistic regression identified patient characteristics associated with NVA-FB hospital admissions; differences in time to surgery and death were evaluated using Cox proportional hazards regression, controlling for patient covariates. RESULTS: Patients admitted to NVA-FB hospitals were more likely to be younger, have service-connected disabilities, and live more than 50 miles from a VA hospital. Median days to surgery were less for NVA-FB admissions compared with VA admissions (1 versus 3 days, respectively). NVA-FB admissions were associated with 21% lower relative risk of death within 1 year compared with VA hospital admissions. CONCLUSIONS: For veterans with hip fractures, NVA-FB hospital admission was associated with shorter time to surgery and lower 1-year mortality. These findings suggest fee-based care, especially for veterans living greater distances from VA hospitals, may improve access to care and health outcomes. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Development of a fully automated surgical site infection detection algorithm for use in cardiac and orthopedic surgery research.

OBJECTIVE: To develop a fully automated algorithm using data from the Veterans' Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies. DESIGN: Retrospective cohort study. SETTING: This study was conducted in 11 VA hospitals. PARTICIPANTS: Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort). METHODS: Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans' Affairs Surgical Quality Improvement Program (VASQIP). RESULTS: Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively. CONCLUSIONS: Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.

The "dark side" of the strength of weak ties: the diffusion of suicidal thoughts.

Granovetter's theory on the strength of weak ties motivates hypotheses on the difusive nature of suicidal thoughts in the friendship networks of adolescents. Using data from the National Longitudinal Study of Adolescent Health, the effects of friends-of-friends attempting suicide on the suicidal thoughts of respondents are estimated. A focus on friends-of-friends permits a test of the weak-ties thesis because respondents are indirectly linked to friends-of-friends by "open ties" that are both structurally weak and used as bridges. Results for "at-risk" respondents--or those with certain behaviors, statuses, and experiences that create psychological predispositions to suicide-are consistent with Granovetter's theory and thus reveal the "dark side" of the strength of weak ties as at-risk respondents are more likely to seriously think about committing suicide when a friend-of-a-friend attempts suicide, controlling for past suicidal thoughts by the respondent and attempts by friends, family, and students in the respondent's school, among other control factors. Barriers to diffusion are also considered.

Attributable mortality due to fluoroquinolone and extended-spectrum cephalosporin resistance in hospital-onset Escherichia coli and Klebsiella spp bacteremia: A matched cohort study in 129 Veterans Health Administration medical centers.

In this cohort of Escherichia coli and Klebsiella spp hospital-onset bacteremia, isolated fluoroquinolone resistance had a larger relative impact on mortality than other phenotypic resistance patterns. This finding may support stewardship efforts targeting unnecessary fluoroquinolone use and increased attention from infection prevention and control departments.

Emergency department utilization patterns among older adults.

BACKGROUND: We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them. METHODS: A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used. RESULTS: The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns. CONCLUSIONS: Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.

Retirement and weight changes among men and women in the health and retirement study.

OBJECTIVES: Older adults may experience weight changes upon retirement for a number of reasons, such as being less physically active; having less structured meal times; and consuming food in response to losing personal identity, the potential for social interactions, or the sense of accomplishment derived from working. The purpose of this study was to determine whether retirement was associated with either weight gain or weight loss. METHODS: We used the 1994-2002 Health and Retirement Study to determine whether retirement between biennial interviews was associated with weight change, separately for men (n = 1,966) and women (n = 1,759). We defined weight change as a 5% increase or decrease in body mass index between interviews. RESULT: . We did not find a significant association between retirement and weight change among men. Women who retired were more likely to gain weight than women who continued to work at least 20 hr per week (odds ratio [OR] = 1.24, 95% confidence interval [CI] = 1.04-1.48). We found a significant relationship between retirement and weight gain only for women who were normal weight upon retiring (OR = 1.30, 95% CI = 1.01-1.69) and who retired from blue-collar jobs (OR = 1.58, 95% CI = 1.13-2.21). DISCUSSION: Public health interventions may be indicated for women, particularly those working in blue-collar occupations, in order to prevent weight gain upon retirement.

Impact of functional limitations and medical comorbidity on subsequent weight changes and increased depressive symptoms in older adults.

OBJECTIVE: The primary goal of this study was to determine the effect of the onset of major medical comorbidity and functional decline on subsequent weight change and increased depressive symptoms. METHODS: The sample included a prospective cohort of 53 to 63 year olds (n = 10,150) enrolled in the Health and Retirement Study. Separate lagged covariate models for men and women were used to study the impact of functional decline and medical comorbidity on subsequent increases in depressive symptoms and weight change 2 years later. RESULTS: Functional decline and medical comorbidity were individual predictors of subsequent weight changes but not increased depressive symptoms. Most specific incident medical comorbidities or subtypes of functional decline predicted weight changes in both directions. DISCUSSION: The elevated risk of weight gain subsequent to functional decline or onset of medical comorbidities may require the receipt of preventive measures to reduce further weight-related complications.

Predictors of Long-Term Opioid Use After Opioid Initiation at Discharge From Medical and Surgical Hospitalizations.

Opioid analgesics may be initiated following surgical and medical hospitalization or in ambulatory settings; rates of subsequent long-term opioid (LTO) use have not been directly compared. This retrospective cohort study of the Veterans Health Administration (VHA) included all patients receiving a new outpatient opioid prescription from a VHA provider in fiscal year 2011. If a new outpatient prescription was filled within 2 days following hospital discharge, the initiation was considered a discharge prescription. LTO use was defined as an episode of continuous opioid supply lasting a minimum of 90 days and beginning within 30 days of the initial prescription. We performed bivariate and multivariate analyses to identify the factors associated with LTO use following surgical and medical discharges. Following incident prescription, 5.3% of discharged surgical patients, 15.2% of discharged medical patients, and 19.3% of outpatient opioid initiators received opioids long term. Medical and surgical patients differed; surgical patients were more likely to receive shorter prescription durations. Predictors of LTO use were similar in medical and surgical patients; the most robust predictor in both groups was the number of days' supply of the initial prescription (odds ratio [OR] = 1.24 and 95% confidence interval [CI], 1.12-1.37 for 8-14 days; OR = 1.56 and 95% CI, 1.39-1.76 for 15-29 days; and OR = 2.59 and 95% CI, 2.35-2.86 for >30 days) compared with the reference group receiving =7days. Rates of subsequent LTO use are higher among discharged medical patients than among surgical patients. Characteristics of opioid prescribing within the initial 30 days, including initial dose and days prescribed, were strongly associated with LTO use.

Patient and Facility Correlates of Racial Differences in Viral Control for Black and White Veterans with HIV Infection in the Veterans Administration.

Black persons with HIV are less likely than white persons to experience viral control even while in treatment. We sought to understand whether patient characteristics and site of care explain these differences using a cross-sectional analysis of medical records. Our cohort included 8779 black and 7836 white patients in the Veterans Administration (VA) health system with HIV who received antiretroviral medication during 2013. Our primary outcome, viral control, was defined as HIV serum RNA <200 copies/mL. We examined the degree to which racial differences in viral control are related to site of care, patient characteristics (demographics, HIV treatment history, comorbid conditions, time in care, and medication adherence), retention in care, and combination antiretroviral therapy (cART) adherence, using multi-variable logistic regression models. Compared to whites, blacks were younger and had lower CD4 counts, more comorbidities, lower retention in care, and poorer medication adherence. The odds of uncontrolled viral load were 2.02 (p < 0.001) for black relative to white patients without risk adjustment (15% vs. 8% uncontrolled viral load, respectively). The odds decreased to 1.83 (p < 0.001), 1.65 (p < 0.001), 1.62 (p < 0.001), and 1.24 (p = 0.01) in models that sequentially controlled for site of care, age and clinical characteristics, care retention, and cART adherence, respectively. Overall, 51% of the viral control difference between blacks and whites was accounted for by adherence; 26% by site of care. We conclude that differences in the site of HIV care and cART adherence account for most of the difference in viral control between black and white persons receiving HIV care, although the exact pathway by which this relationship occurs is unknown. Targeting poorer performing sites for quality improvement and focusing on improving antiretroviral adherence in black patients may help alleviate disparities in viral control.

The use of chiropractors by older adults in the United States.

BACKGROUND: In a nationally representative sample of United States Medicare beneficiaries, we examined the extent of chiropractic use, factors associated with seeing a chiropractor, and predictors of the volume of chiropractic use among those having seen one. METHODS: We performed secondary analyses of baseline interview data on 4,310 self-respondents who were 70 years old or older when they first participated in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). The interview data were then linked to their Medicare claims. Multiple logistic and negative binomial regressions were used. RESULTS: The average annual rate of chiropractic use was 4.6%. During the four-year period (two years before and two years after each respondent's baseline interview), 10.3% had one or more visits to a chiropractor. African Americans and Hispanics, as well as those with multiple depressive symptoms and those who lived in counties with lower than average supplies of chiropractors were much less likely to use them. The use of chiropractors was much more likely among those who drank alcohol, had arthritis, reported pain, and were able to drive. Chiropractic services did not substitute for physician visits. Among those who had seen a chiropractor, the volume of chiropractic visits was lower for those who lived alone, had lower incomes, and poorer cognitive abilities, while it was greater for the overweight and those with lower body limitations. CONCLUSION: Chiropractic use among older adults is less prevalent than has been consistently reported for the United States as a whole, and is most common among Whites, those reporting pain, and those with geographic, financial, and transportation access.

Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014.

Importance: Staphylococcus aureus bacteremia is common and frequently associated with poor outcomes. Evidence indicates that specific care processes are associated with improved outcomes for patients with S aureus bacteremia, including appropriate antibiotic prescribing, use of echocardiography to identify endocarditis, and consultation with infectious diseases (ID) specialists. Whether use of these care processes has increased in routine care for S aureus bacteremia or whether use of these processes has led to large-scale improvements in survival is unknown. Objective: To examine the association of evidence-based care processes in routine care for S aureus bacteremia with mortality. Design, Setting, and Participants: This retrospective observational cohort study examined all patients admitted to Veterans Health Administration (VHA) acute care hospitals who had a first episode of S aureus bacteremia from January 1, 2003, through December 31, 2014. Exposures: Use of appropriate antibiotic therapy, echocardiography, and ID consultation. Main Outcomes and Measures: Thirty-day all-cause mortality. Results: Analyses included 36 868 patients in 124 hospitals (mean [SD] age, 66.4 [12.5] years; 36 036 [97.7%] male), including 19 325 (52.4%) with infection due to methicillin-resistant S aureus and 17 543 (47.6%) with infection due to methicillin-susceptible S aureus. Risk-adjusted mortality decreased from 23.5% (95% CI, 23.3%-23.8%) in 2003 to 18.2% (95% CI, 17.9%-18.5%) in 2014. Rates of appropriate antibiotic prescribing increased from 2467 (66.4%) to 1991 (78.9%), echocardiography from 1256 (33.8%) to 1837 (72.8%), and ID consultation from 1390 (37.4%) to 1717 (68.0%). After adjustment for patient characteristics, cohort year, and other care processes, receipt of care processes was associated with lower mortality, with adjusted odds ratios of 0.74 (95% CI, 0.68-0.79) for appropriate antibiotics, 0.73 (95% CI, 0.68-0.78) for echocardiography, and 0.61 (95% CI, 0.56-0.65) for ID consultation. Mortality decreased progressively as the number of care processes that a patient received increased (adjusted odds ratio for all 3 processes compared with none, 0.33; 95% CI, 0.30-0.36). An estimated 57.3% (95% CI, 48.4%-69.9%) of the decrease in mortality between 2003 and 2014 could be attributed to increased use of these evidence-based care processes. Conclusions and Relevance: Mortality associated with S aureus bacteremia decreased significantly in VHA hospitals, and a substantial portion of the decreasing mortality may have been attributable to increased use of evidence-based care processes. The experience in VHA hospitals demonstrates that increasing application of these care processes may improve survival among patients with S aureus bacteremia in routine health care settings.

Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes.

BACKGROUND: Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. METHODS: We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. RESULTS: Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). CONCLUSIONS: Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.

Regional variations in fluoroquinolone non-susceptibility among Escherichia coli bloodstream infections within the Veterans Healthcare Administration.

OBJECTIVES: We sought to define regional variations in fluoroquinolone non-susceptibility (FQ-NS) among bloodstream isolates of Escherichia coli across the Veterans Health Administration (VHA) in the United States. METHODS: We analyzed a retrospective cohort of patients managed at 136 VHA hospitals who had a blood culture positive for E.coli between 2003 and 2013. Hospitals were classified based on US Census Divisions, and regional variations in FQ-NS were analyzed. RESULTS: Twenty-four thousand five hundred twenty-three unique E.coli bloodstream infections (BSIs) were identified between 2003 and 2013. 53.9 % of these were community-acquired, 30.7 % were healthcare-associated, and 15.4 % were hospital-onset BSIs. The proportion of E.coli BSIs with FQ-NS significantly varied across US Census Divisions (p < 0.001). During 2003-2013, the proportion of E.coli BSIs with FQ-NS was highest in the West South-Central Division (32.7 %) and lowest in the Mountain Division (20.0 %). Multivariable analysis showed that there were universal secular trends towards higher FQ-NS rates (p < 0.001) with significant variability of slopes across US Census Divisions (p < 0.001). CONCLUSION: There has been a universal increase in FQ-NS among E.coli BSIs within VHA, but the rate of increase has significantly varied across Census Divisions. The reasons for this variability are unclear. These findings reinforce the importance of using local data to develop and update local antibiograms and antibiotic-prescribing guidelines.

An extension and test of Sutherland's concept of differential social organization: the geographic clustering of Japanese suicide and homicide rates.

In an effort to explain the spatial patterning of violence, we expanded Sutherland's (1947) concept of differential social organization to include the level of deviance exhibited by neighboring areas. To test the value of this extension, the geographic clustering of Japanese suicide and homicide rates is assessed using 1985 and 1995 data for prefectures. Univariate results show that both types of violence cluster significantly in space. Inconsistent with the proposed expansion of differential social organization, multivariate results show that proximity to homicide does not increase the risk of homicide in Japan. Results for suicide are supportive and suggest that proximity to higher rates of suicide exposes residents to cultural values that support suicide and to role models who have committed suicide.