Trends in heart failure costs for commercially insured patients in the United States (2006-2021).

BACKGROUND: Although prior research has estimated the overarching cost burden of heart failure (HF), a thorough analysis examining medical expense differences and trends, specifically among commercially insured patients with heart failure, is still lacking. Thus, the study aims to examine historical trends and differences in medical costs for commercially insured heart failure patients in the United States from 2006 to 2021. METHODS: A population-based, cross-sectional analysis of medical and pharmacy claims data (IQVIA PharMetrics® Plus for Academic) from 2006 to 2021 was conducted. The cohort included adult patients (age > = 18) who were enrolled in commercial insurance plans and had healthcare encounters with a primary diagnosis of HF. The primary outcome measures were the average total annual payment per patient and per cost categories encompassing hospitalization, surgery, emergency department (ED) visits, outpatient care, post-discharge care, and medications. The sub-group measures included systolic, diastolic, and systolic combined with diastolic, age, gender, comorbidity, regions, states, insurance payment, and self-payment. RESULTS: The study included 422,289 commercially insured heart failure (HF) patients in the U.S. evaluated from 2006 to 2021. The average total annual cost per patient decreased overall from $9,636.99 to $8,201.89, with an average annual percentage change (AAPC) of -1.11% (95% CI: -2% to -0.26%). Hospitalization and medication costs decreased with an AAPC of -1.99% (95% CI: -3.25% to -0.8%) and - 3.1% (95% CI: -6.86-0.69%). On the other hand, post-discharge, outpatient, ED visit, and surgery costs increased by an AAPC of 0.84% (95% CI: 0.12-1.49%), 4.31% (95% CI: 1.03-7.63%), 7.21% (95% CI: 6.44-8.12%), and 9.36% (95% CI: 8.61-10.19%). CONCLUSIONS: The study's findings reveal a rising trend in average total annual payments per patient from 2006 to 2015, followed by a subsequent decrease from 2016 to 2021. This decrease was attributed to the decline in average patient costs within the Medicare Cost insurance category after 2016, coinciding with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, expenses related to surgical procedures, emergency department (ED) visits, and outpatient care have shown substantial growth over time. Moreover, significant differences across various variables have been identified.

Glycemic status, non-traditional risk and left ventricular structure and function in the Jackson Heart Study.

BACKGROUND: Left ventricular structure and function abnormalities may be an early marker of cardiomyopathy among African Americans with diabetes (DM) even in the absence of coronary artery disease (CAD), arrhythmia, valvular heart disease and end-stage renal disease (ESRD). This study examined the association of prediabetes (PDM), DM and HbA1c with left ventricular structure and function among Jackson Heart Study (JHS) participants without traditional risk factors. METHODS: Retrospective cross-sectional analyses of the association of PDM, DM and HbA1c with, left ventricular ejection fraction (LV EF), fractional shortening (LV FS), stroke volume index (SVI), cardiac index (CI), left ventricular end diastolic volume index (LVEDVI), left ventricular end systolic volume index (LVESVI), relative wall thickness (RWT), myocardial contraction fraction (MCF) and left ventricular mass index (LVMI). The study was conducted in 2234 adult JHS participants without preexisting CAD, arrhythmia, valvular heart disease or ESRD. Statistical analyses included descriptive, univariate and covariate adjusted linear regression analyses. Sensitivity analyses to explore the impact of hypertension on study outcomes were also carried out. RESULTS: DM compared with no DM was associated with lower, SVI (- 0.96 ml/m2, p = 0.029), LVEDVI (- 1.44 ml/m2 p = 0.015), and MCF (- 1.90% p = 0.007) but higher CI (0.14 L/min/m2, p < 0.001), RWT (0.01 cm, p = 0.002) and LVMI (2.29 g/m2, p = 0.009). After further control for DM duration, only CI remaining significantly higher for DM compared with no DM participants (0.12 L/min/m2, p = 0.009). PDM compared with no PDM was associated with lower, SVI (- 0.87 ml/m2, P = 0.024), LVEDVI (- 1.15 ml/m2 p = 0.003) and LVESVI (- 0.62 ml/m2 p = 0.025). HbA1c ≥ 8.0% compared with HbA1c < 5.7% was associated with lower SVI (- 2.09 ml/m2, p = 0.004), LVEDVI (- 2.11 ml/m2 p = 0.032) and MCF (- 2.94% p = 0.011) but higher CI (0.11 L/min/m2, p = 0.043) and RWT (0.01 cm, p = 0.035). CONCLUSIONS: Glycemic status is associated with important left ventricular structure and function changes among African Americans without prior CAD, arrhythmia, valvular heart disease and ESRD. Longitudinal studies may further elucidate these relationships.

Strong Association Between Migraine and Transient Global Amnesia: A National Inpatient Sample Analysis.

The purpose of this article was to explore sex- and race-specific variables and comorbidities associated with transient global amnesia (TGA) using a nationally representative database. Data were obtained from the Nationwide Inpatient Sample using ICD-9 and procedure codes. Descriptive and survey logistic regression analyses were conducted and adjusted for influence of comorbidities, demographic characteristics, and hospitalization-related factors. Patients with migraines were 5.98 times more likely to also have a diagnosis of TGA compared with patients without migraines. Similarly, patients with TGA were more likely to have hypertension, precerebral disease, and hyperlipidemia. The odds of being diagnosed with TGA was lower among African Americans and Hispanics as well as among patients classified as Asian/Other, compared with Caucasians. TGA was associated with lower hospital charges ($14,242 versus $21,319), shorter hospital stays (mean days: 2.49 [SE=0.036] versus 4.72 [SE=0.025]), and routine hospital discharges (91.4% versus 74.5%). Patients with migraines and patients classified as Caucasian had higher odds of being diagnosed with TGA. All minority populations showed a lower rate of diagnosis that fell short of statistical significance.

Variations in organism-specific severe sepsis mortality in the United States: 1999-2008.

OBJECTIVE: Recent studies have reported decreased overall severe sepsis mortality, but associations with organism trends have not yet been investigated. This study explored organism-specific severe sepsis mortality trends from 1999 to 2008 in a large hospital-based administrative database. DESIGN: Secondary data analysis using the Nationwide Inpatient Sample. SETTING: United States hospitals sampled in the Nationwide Inpatient Sample dataset. PATIENTS: This sample approximates a stratified 20% sample of all nonfederal, short-term, general, and specialty hospitals serving adults in the United States. Severe sepsis hospitalizations and organism-specific causes were identified using predetermined International Classification of Diseases, 9th Revision, Clinical Modification codes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Analysis was conducted using descriptive Cox proportional hazards and linear regression trend analysis. Adjustments were made for the influence of demographics, comorbidities, number of organisms, and number of organ failures on hospital mortality. The data for 5,033,257 severe sepsis hospitalizations were examined and revealed decreased in-hospital mortality from 40.0% to 27.8% during the study period. The leading cause of severe sepsis was 51.5% Gram-negative bacteria, followed by 45.6% Gram-positive, 1.7% anaerobic, and 1.2% fungal species. The most common Gram-negative organisms were 39.9% Escherichia coli and 17.6% Pseudomonas. Staphylococcus species (62.2% methicillin-sensitive Staphylococcus aureus and 22.6% Streptococcus) were the most commonly reported Gram-positive organisms. Crude mortality estimates were higher for anaerobic and fungal organisms, 34.5% and 31.4%, respectively. Among Gram-positive bacteria, mortality was highest for methicillin-sensitive S. aureus, 30.9%, whereas Pseudomonas was associated with the highest mortality for Gram-negative septicemia cases, 29.5%. After adjusting for covariates, anaerobes were associated with the highest mortality hazard of 1.31 (95% CI, 1.23-1.40). Methicillin-resistant S. aureus had the highest mortality hazard of 1.38 (1.33-1.44) for Gram-positive organisms, whereas all Gram-negative bacteria had decreased mortality hazards. CONCLUSIONS: We not only confirmed an overall decline in severe sepsis mortality from 1999 to 2008 but also identified previously unreported variations in organism-specific severe sepsis mortality. Gram-negative organisms predominate, whereas anaerobes and methicillin-resistant S. aureus are significant predictors of mortality. Future clinical trials exploring new treatments in severe sepsis should incorporate individual organism trends to elucidate potential effect on mortality.

Trends and racial disparity in primary pressure ulcer hospitalizations outcomes in the US from 2005 to 2014.

In the United States (US), pressure ulcers affect ≤3 million people and costs exceed 26.8 billion US dollars in spending. To examine trends in primary pressure ulcer (PPU) hospitalization mortality, length of hospital stay (LOS), and inflation-adjusted charges (IAC) in the US from 2005 to 2014 by race/ethnicity. We secondarily examined the relationship between race/ethnicity with PPU mortality, LOS, and IAC with race/ethnicity. This cross-sectional study used Nationwide Inpatient Sample (NIS) data from 2005 to 2014. The study sample included all hospitalizations with the designated ICD-9-CM code of 707.20-25 (pressure ulcer). There was a notable decline in PPU hospitalization from 11.5% to 7.77 % between 2005 and 2014. The mean mortality decreased from 2.32% to 1.12% (P < .001), the mean LOS declined from 9.39 days (P < .001), and the mean IAC per hospitalization decreased from $30,935 to $29,432 (P < .001). Positive changes observed in mortality, LOS, and IAC trends were consistent across different racial and ethnic groups. The results of multivariable logistic and linear regression analyses revealed that Black patients (ß = 0.68, 95% CI 0.36-1.01, P < .001) and patients belonging to the Other race/ethnic category (ß = 0.93, 95% CI 0.18-1.69) had longer hospital stays compared to their White counterparts. Regarding IAC, Black patients (ß = 2846, 95% CI 1254-4439, P < .005), Hispanic patients (ß = 6527, 95% CI 4925-8130), and patients from the Other race/ethnic category (ß = 3473, 95% CI 1771-5174) had higher IAC for PPU treatment compared to their White counterparts. PPU hospitalization discharges, as well as hospitalization mortality, LOS, and IAC, decreased during the study period, however, our findings revealed disparities in PPU outcomes among different racial/ethnic groups. Implications of the findings are discussed.

Posterior circulation stroke: animal models and mechanism of disease.

Posterior circulation stroke refers to the vascular occlusion or bleeding, arising from the vertebrobasilar vasculature of the brain. Clinical studies show that individuals who experience posterior circulation stroke will develop significant brain injury, neurologic dysfunction, or death. Yet the therapeutic needs of this patient subpopulation remain largely unknown. Thus understanding the causative factors and the pathogenesis of brain damage is important, if posterior circulation stroke is to be prevented or treated. Appropriate animal models are necessary to achieve this understanding. This paper critically integrates the neurovascular and pathophysiological features gleaned from posterior circulation stroke animal models into clinical correlations.

Morphine-induced cardiogenic shock.

OBJECTIVE: Although animal and human models suggest that direct suppression of myocardial contractility may occur with morphine administration, to our knowledge, clinical observation of this potentially important effect has not been reported. This case report presents a unique case of morphine-induced transient reversible cardiogenic shock. CASE SUMMARY: A 44-year-old woman with a history of hypertension, diabetes, and asthma presented with a 3-day history of epigastric pain. Initial investigation results revealed elevated serum lipase level and computed tomography imaging that was consistent with a diagnosis of mild acute pancreatitis. Intravenous fluids and morphine, via patient-controlled analgesia, were started and the patient was admitted. The next day, she developed cardiogenic shock with a globally reduced left ventricular ejection fraction (LVEF) of 26% and was admitted to the intensive care unit. Morphine was discontinued and norepinephrine and naloxone were concurrently administered. Over the next 24 hours her clinical status improved, and an echocardiogram 29 hours after the initial echocardiogram showed normal LV function (LVEF 62%). DISCUSSION: To our knowledge, this represents the first reported case of clinically significant morphine-induced cardiogenic shock. An objective causality assessment using the Naranjo probability scale suggests that the cardiogenic shock was probably related to morphine. Other causes of shock were ruled out. Additionally, the fact that the transient nature of the observed LV dysfunction reversed with discontinuation of morphine and administration of naloxone provides further support, particularly with the evidence that opiates may depress cardiac myocytes and cardiac output in animal and human models. CONCLUSIONS: Opiates can cause severe LV dysfunction. Physicians should consider emergent evaluation for myocardial depression in patients who are receiving opioids and present with persistent hypotension or pulmonary edema without other known etiology.

A Veterans Affairs Primary Care Same-Day Open Access for New Patients Optimized Redesigned System (VA-HONORS): A Six-Year Analysis of 22,220 Patient Records.

BACKGROUND: Delay in primary care access for new patients to US Department of Veterans Affairs (VA) health care services has been a persistent problem. This article presents the evaluation of a quality improvement (QI) intervention that provided new patients with same-day primary care access. It involved redesign of an intake clinic (IC) through which new patients were initially seen and referred to primary care. The redesign included changes in clinic flow and reallocation of two full-time primary care providers (PCPs) from IC to their primary care teams. METHODS: A pre-post retrospective study evaluating a QI intervention at a VA hospital examined 22,220 administrative patient records. Specifically, 9,909 new patients seen in the three years prior to implementation of VA-HONORS (preintervention group) were compared with 12,311 patients seen in the three years after implementation (postintervention group). Study outcomes were (1) number of days to first appointment with PCP, (2) proportion of patients receiving same-day primary care access, and (3) visit cycle time. RESULTS: Preintervention, median first primary care appointment delay was 96 days, compared to 0 days postintervention (p < 0.001). Preintervention, 3.1% of new patients were able to obtain same-day primary care appointment, compared with 91.5% postintervention (p < 0.001). Median visit cycle time was 140 minutes preintervention vs. 148 minutes postintervention (p < 0.001). CONCLUSIONS: New patients' same-day access system redesign at one VA hospital dramatically eliminated first primary care appointment delay. The redesign was feasible and sustainable for a sizable population and serves as a model for similar settings with new patients' primary care access delay.

Schizophrenia hospitalization in the US 2005-2014: Examination of trends in demographics, length of stay, and cost.

ABSTRACT: Primarily we aimed to examine the crude and standardized schizophrenia hospitalization trend from 2005 to 2014. We hypothesized that there will be a statistically significant linear trend in hospitalization rates for schizophrenia from 2005 to 2014. Secondarily we also examined trends in hospitalization by race/ethnicity, age, gender, as well as trends in hospitalization Length of Stay (LOS) and inflation adjusted cost.In this observational study, we used Nationwide Inpatient Sample data and International Classification of Diseases, Eleventh Revisions codes for Schizophrenia, which revealed 6,122,284 cases for this study. Outcomes included crude and standardized hospitalization rates, race/ethnicity, age, cost, and LOS. The analysis included descriptive statistics, indirect standardization, Rao-Scott Chi-Square test, t-test, and adjusted linear regression trend.Hospitalizations were most prevalent for individuals ages 45-64 (38.8%), African Americans were overrepresented (25.8% of hospitalizations), and the gender distribution was nearly equivalent. Mean LOS was 9.08 days (95% confidence interval 8.71-9.45). Medicare was the primary payer for most hospitalizations (55.4%), with most of the costs ranging from $10,000-$49,999 (57.1%). The crude hospitalization rates ranged from 790-1142/100,000 admissions, while the US 2010 census standardized rates were 380-552/100,000 from 2005-2014. Linear regression trend analysis showed no significant difference in trend for race/ethnicity, age, nor gender (P > .001). The hospitalizations' overall rates increased while LOS significantly decreased, while hospitalization costs and Charlson's co-morbidity index increased (P < .001).From 2005-2014, the overall US hospitalization rates significantly increased. Over this period, observed disparities in hospitalizations for middle-aged and African Americans were unchanged, and LOS has gone down while costs have gone up. Further studies addressing the important disparities in race/ethnicity and age and reducing costs of acute hospitalization are needed.

Acute agitated delirious state associated with Taser exposure.

BACKGROUND: The use of the Taser (Taser International, Scottsdale, Arizona) as a form of nonlethal force is increasingly common because of its safety profile. Tasers have been associated with in-custody mortality particularly in agitated individuals, though potential explanatory mechanisms are poorly understood. While Tasers are often used to subdue acutely agitated individuals, no study has reported Taser exposure precipitating agitation or delirium, even though high-voltage electrical exposure is well documented independently to precipitate acute delirium. OBJECTIVES: We present a case of an acute agitated or delirious state occurring post-Taser exposure in a resting, otherwise nonagitated individual. CASE REPORT: The patient was a 37-year-old African American male with no prior psychiatric history, tasered multiple times during an arrest episode. He became delirious and agitated while in the emergency department, requiring sedation and intubation, followed by 3 days of continued refractory delirium. Toxicology screening demonstrated therapeutic doses of methadone and trace amounts of marijuana, not thought to be associated with the acute onset of the patient's agitated or delirious state. Imaging, neurological, and psychiatric assessments were similarly not contributory. CONCLUSION: The occurrence of acute agitation and delirium in this patient without any prior psychiatric history or significant substance use suggests an association with Taser exposure. This case report is thought to be the first report demonstrating a temporal association between Taser exposure and an acute or delirious state. Further studies to explore the association between Taser exposure and acute agitation are needed.

CEDRIC: a computerized chronic disease management system for urban, safety net clinics.

To meet the challenge of improving health care quality in urban, medically underserved areas of the US that have a predominance of chronic diseases such as diabetes, we have developed a new information system called CEDRIC for managing chronic diseases. CEDRIC was developed in collaboration with clinicians at an urban safety net clinic, using a community-participatory partnered research approach, with a view to addressing the particular needs of urban clinics with a high physician turnover and large uninsured/underinsured patient population. The pilot implementation focuses on diabetes management. In this paper, we describe the system's architecture and features.

Pulmonary vs. extra-pulmonary tuberculosis hospitalizations in the US [1998-2014].

BACKGROUND: Few studies have explored the relative burden and trends in pulmonary (PTB) vs. extra-pulmonary (EPTB) tuberculosis in the United States using a nationally representative sample. METHODS: This study examined trends in hospitalization rates, length-of-stay (LOS), in-hospital mortality and inflation-adjusted charges, for PTB vs. EPTB using the Nationwide/National Inpatient Sample (NIS) from 1998 to 2014. Descriptive and multivariable analyses (linear, negative binomial and logistic) were utilized adjusting for demographics, co-morbidity and hospital characteristics. RESULTS: During the study period there were a survey-adjusted, estimated 258,631 PTB (75.5%), 76,476 EPTB (22.3%) and 7552 concurrent PTB and EPTB (2.2%) discharges. Whites accounted for 27.6% of PTB, 21.9% of EPTB and 17.6% of concurrent discharges; and self-pay or no insurance accounted for 22.2%, 18.4%, and 25.9%, respectively. EPTB was more common among blacks (22.5%), and combined TB more common among Hispanics (24.8%). Mean LOS was 11.4 days, 13.2 days, and 19.5 days; with mean nominal charges of $48,031, $62,255, and $89,364 for PTB, EPTB and combined TB respectively. Inpatient mortality for all three groups was approximately 5.7%. Miliary TB and TB of meninges and central nervous system were positively associated with mortality (odds ratios of 2.44 and 2.11, respectively), as was alcohol abuse (OR 1.21). Trend analyses showed decreased hospitalizations for all TB types, no change in LOS trends, decreased mortality for PTB and ETB and increased charges for PTB and ETB from 1998 to 2014. Increased utilization, higher charges and higher risk of mortality (to some extent) among the EPTB cases warrant improved methods for screening, diagnosis and treatment. CONCLUSION: Though rates of TB hospitalization are declining, EPTB is becoming relatively more common and is more costly compared to pulmonary TB. Screening methods that focus on identification of ETB contrary to current practice guidelines are needed to aid ETB case finding.

Elevated red blood cell distribution width predicts mortality in persons with known stroke.

BACKGROUND: Red cell distribution width (RDW) is a hematological parameter routinely obtained as part of the complete blood count. Recently, RDW has emerged as a potential independent predictor of clinical outcome in patients with established cardiovascular disease. However, little is known about the role of RDW as a prognosticator among persons with stroke, especially with regard to an incontrovertible endpoint like mortality. We assessed the association of RDW with stroke, and its effect on mortality among persons with stroke. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) a nationally representative sample of United States adults were analyzed. The study population consisted of 480 individuals aged > or =25 years with a baseline history of stroke followed-up from survey participation (1988-1994) through mortality assessment in 2000. Proportional hazard regression (Cox) was utilized to explore the independent relationship between RDW and mortality after adjusting for potential confounders. RESULTS: Among the cohort, 52.4% were female, 64% aged > or =65 years. Mean RDW was significantly higher among persons with stroke compared to individuals without a stroke (13.7% vs.13.2%,p<0.001). Baseline RDW was higher among persons with known stroke who later died vs. remained alive (13.9% vs.13.4%,p<0.001). After adjusting for confounders, those with elevated RDW (fourth vs. first quartile) were more likely to have experienced a stroke (OR 1.71, CI=1.20-2.45). Higher RDW level (fourth vs. first quartile) among those with known stroke independently predicted subsequent cardiovascular deaths (HR=2.38 and CI=1.41-4.01) and all-cause deaths (HR=2.0, CI=1.25-3.20). CONCLUSIONS: Elevated RDW is associated with stroke occurrence and strongly predicts both cardiovascular and all-cause deaths in persons with known stroke.

Preventive, lifestyle, and personal health behaviors among physicians.

OBJECTIVE: This study examines personal health behaviors and wellness, health-related lifestyles, and prevention screening practices among licensed physicians. METHODS: An anonymous questionnaire was mailed to a random sample of 1,875 physicians practicing in California. Data from 763 returned questionnaires (41%) were analyzed. RESULTS: Our data show that 7% of this sample were clinically depressed, 13% reported using sedatives or tranquilizers, over 53% reported severe to moderate stress, and only 38% described their level of daily stress as slight. About 4% self-reported recent marijuana use. More than 6% screened positive for alcohol abuse and 5% for gambling problems. Thirty-five percent of participants reported "no" or "occasional" exercise. About 27% self-reported "never" or "occasionally" eating breakfast. In addition, 34% reported 6 or fewer hours of sleep daily, while 21% self-reported working more than 60 hours per week. Physicians' excessive number of work hours (more than 65 hours per week) was associated with lack of exercise, not eating breakfast, and sleeping fewer than 6 hours per night. California physicians report breast, cervical, colorectal, and prostate cancer screening behaviors that exceeded population estimates in California and Healthy People 2010 national goals. CONCLUSION: Additional interventions designed to improve physicians' lifestyles and personal health behaviors should be encouraged. A focus on creating healthy lifestyles will benefit physicians as much as the general population.

Depression symptomatology and diagnosis: discordance between patients and physicians in primary care settings.

BACKGROUND: To examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and then to examine how the presence of these symptoms affects depression diagnosis in primary care settings. METHODS: Interviewer administered surveys and medical record reviews. A total of 304 participants were recruited from 2321 participants screened for depression at two large urban primary care community settings. RESULTS: Of the 2321 participants screened for depression 304 were positive for depression and of these 75.3% (n = 229) were significantly depressed (PHQ-9 score > or = 10). Of these, 31.0% were diagnosed by a physician with a depressive disorder. A total of 57.6% (n = 175) of study participants had both significant depression symptoms and functional impairment. Of these 37.7% were diagnosed by physicians as depressed. Cohen's Kappa analysis, used to determine the agreement between depression symptoms elicited using the PHQ-9 and physician documentation of these symptoms showed only slight agreement (0.001-0.101) for all depression symptoms using standard agreement rating scales. Further analysis showed that only suicidal ideation and hypersomnia or insomnia were associated with an increased likelihood of physician depression diagnosis (OR 5.41 P sig < .01 and (OR 2.02 P sig < .05 respectively). Other depression symptoms and chronic medical conditions had no affect on physician depression diagnosis. CONCLUSION: Two-thirds of individuals with depression are undiagnosed in primary care settings. While functional impairment increases the rate of physician diagnosis of depression, the agreement between a structured assessment and physician elicited and or documented symptoms during a clinical encounter is very low. Suicidality, hypersomnia and insomnia are associated with an increase in the rate of depression diagnosis even when physician and self report of the symptom differ. Interventions that emphasize the use of routine structured screening of primary care patients might also improve the rate of diagnosis of depression in these settings. Further studies are needed to explore depression symptom assessment during physician patient encounter in primary care settings.

Correlates of readiness to change problem drinking among a sample of problem drinkers receiving care from an inner-city emergency department.

BACKGROUND: The high rate of alcohol use among emergency department (ED) patients makes the ED setting an obvious target for increased screening and interventions. However, interventions to change alcohol behavior may be applied inappropriately if a patient's motivation to change is not factored in. In this study, we identify correlates of readiness to change problem drinking among a sample of ED patients with problem drinking. METHOD: Cross-sectional study of 295 ED patients who scored positive for alcohol problems on the CAGE questionnaire (score > or = 1). Study measures include illicit drug use, exposure to violence, and having a primary care doctor as the main predictor variables and level of readiness to change problem drinking as the outcome measure. RESULTS: Participants were 64% African American, 30% Latino, and 80% male; 46% had less than a high school diploma; 85% were not married; 72% had no health insurance; and 85% had no primary care provider. Whereas 12% of patients were not ready to change their drinking behaviors, 47% and 41% were unsure and ready, respectively. Multiple linear regression analysis showed that only the use of illicit drugs significantly affected the likelihood of changing one's level of readiness-to-change problem drinking (P < .05). Female and married participants were also more likely to be ready to change their alcohol use behaviors. CONCLUSIONS: Recognizing that approximately half of ED patients with problem drinking are ambivalent to changing their behaviors supports further investigation into specific clinical interventions aimed at motivating such individuals along the continuum of readiness to change. Such interventions should also incorporate strategies for addressing the co-occurrence of illicit substance use.

Correlates of self-diagnosis of chronic medical and mental health conditions in under-served African American and Latino populations.

OBJECTIVE: This study examines the correlates of self-diagnosis of chronic medical and mental health conditions in under-served minority populations. The Behavioral Model for Vulnerable Populations was employed to compare the predisposing and enabling characteristics of two groups: the first group consisted of individuals who self-reported their medical conditions without a presumptive or definitive physician diagnosis, while the second group consisted of individuals who self-reported their medical conditions with a presumptive or definitive physician diagnosis of their condition. STUDY SETTING: The sample consisted of 287 African American and Latino heads of household. This sample was obtained from a geographically defined random sample of 418 households from three urban public housing communities in Los Angeles County, California. STUDY DESIGN: This study was a cross-sectional, face-to-face, semistructured interview survey. RESULTS: Using logistic regression techniques and controlling for demographic characteristics, the results indicate that accessibility, affordability, continuity of medical care, and financial strains were the core concepts that explain the gap between self vs physician diagnosis of medical conditions. CONCLUSION: This study identifies unique characteristics of minority persons who claimed that their medical conditions had not been presented to or diagnosed by a medical provider in comparison to those who are formally diagnosed by medical providers. The study provides an entry point for further examination of correlates and sequels of self-diagnosis and its resultant effects on professional treatment-seeking in minority populations with certain medically important chronic conditions.

Impact of desire to work in underserved communities on selection of specialty among fourth-year medical students.

OBJECTIVE: The objective of this study was to explore the specific factors that influence medical student's choice of primary care as a specialty. Special attention is given to the influence of desire to work in underserved communities on selection of a specialty. DESIGN AND SETTINGS: A web-based survey of factors affecting choice of specialty was completed by 668 fourth-year students from 32 medical schools. RESULTS: Students interested in primary care reported an increased likelihood of working with underserved populations when compared with other specialties. The independent impact of both student's social compassion attitudes and values, and subjective and reinforcing influences on the selection of primary care, when compared with all other specialties, was strong. Personal practice-oriented considerations showed an independent negative impact on the selection of primary care when compared with surgery and support specialties. Financial considerations strongly influence the selection of support specialties. Medical training experiences showed an independent influence on the selection of surgery over primary care. CONCLUSION: The need for primary care physicians and specialists in underserved communities is considerable. Addressing health disparities in underserved communities requires a concerted effort to increase the availability of primary care providers in these communities. This study observed that primary care practice or specialty selection by medical students is influenced by individual values and subjective external influences other than predicted by medical training alone. This observation necessitates a closer determination of strategies required to ensure an increase in the number of primary care physicians serving underserved communities.

Cuff leak test and laryngeal survey for predicting post-extubation stridor.

BACKGROUND AND AIMS: Evidence for the predictive value of the cuff leak test (CLT) for post-extubation stridor (PES) is conflicting. We evaluated the association and accuracy of CLT alone or combined with other laryngeal parameters with PES. METHODS: Fifty-one mechanically ventilated adult patients in a medical-surgical intensive care unit were tested prior to extubation using; CLT, laryngeal ultrasound and indirect laryngoscopy. Biometric, laryngeal and endotracheal tube (ETT) parameters were recorded. RESULTS: PES incidence was 4%. CLT demonstrated 'no leak' in 20% of patients. Laryngeal oedema was present in 10% of the patients on indirect laryngoscopy, and 71% of the patients had a Grades 1-3 indirect laryngoscopic view. Mean air column width on laryngeal ultrasound was 0.66 ± 0.15 cm (cuff deflated), mean ratio of ETT to laryngeal diameter was 0.48 ± 0.07, and the calculated CLT and laryngeal survey composite was 0.86 ± 1.25 (range 0-5). CLT and the CLT and Laryngeal survey composite measure were not associated with or predict PES. Age, sex, peri-extubation steroid use, intubation duration and body mass index were not associated with PES. CONCLUSION: Even including ultrasonographic and indirect laryngoscopic examination of the airway, no single aspect of the CLT or combination with laryngeal parameters accurately predicts PES.