Steroid hormone-inducible biosensor based on EGFP-tagged and environmental application.

Steroid hormones as a class of emerging organic pollutant and high concern, due to their potential risks for human and environmental. Accurate analytical methods of steroid hormones are necessary in quantifying and monitoring. Biosensor is a promising technique. In this study, though part of 3α-HSD DNA to construct a regulatory plasmid and with the EGFP reporter gene to generate a reporter plasmid. Separately transformed into Escherichia coli strain BL21 and extracted the cell lysates as novel biosensor reagents. Analyzed the total amounts of steroid hormones in water, sediment, and soil samples using biosensor reagents, and compared these results with those obtained by HPLC. In summary, detection method using an EGFP reporter that can detect trace amounts of steroid hormones to reached fg/L. The optimal reaction time range and temperature were 30 min and 30 °C, respectively, while the most suitable organic solvent for the steroid hormone was 100% ethanol, up to 96-well plate format. This method is very suitable for high-throughput detection of environmental steroid hormone pollutants.

Perception of Safety of Surgical Practice Among Operating Room Personnel From Survey Data Is Associated With All-cause 30-day Postoperative Death Rate in South Carolina.

OBJECTIVE: To evaluate whether the perception of safety of surgical practice among operating room (OR) personnel is associated with hospital-level 30-day postoperative death. BACKGROUND: The relationship between improvements in the safety of surgical practice and benefits to postoperative outcomes has not been demonstrated empirically. METHODS: As part of the Safe Surgery 2015: South Carolina initiative, a baseline survey measuring the perception of safety of surgical practice among OR personnel was completed. We evaluated the relationship between hospital-level mean item survey scores and rates of all-cause 30-day postoperative death using binomial regression. Models were controlled for multiple patient, hospital, and procedure covariates using supervised principal components regression. RESULTS: The overall survey response rate was 38.1% (1793/4707) among 31 hospitals. For every 1 point increase in the hospital-level mean score for respect [adjusted relative risk (aRR) 0.78, 95% CI 0.65-0.93, P = 0.0059], clinical leadership (aRR 0.86, 95% CI 0.74-0.9932, P = 0.0401), and assertiveness (aRR 0.71, 95% CI 0.54-0.93, P = 0.01) among all survey respondents, there were associated decreases in the hospital-level 30-day postoperative death rate after inpatient surgery ranging from 14% to 29%. Higher hospital-level mean scores for the statement, "I would feel safe being treated here as a patient," were associated with significantly lower hospital-level 30-day postoperative death rates (aRR 0.83, 95% CI 0.70-0.97, P = 0.02). Although most findings seen among all OR personnel were seen among nurses, they were often absent among surgeons. CONCLUSIONS: Perception of OR safety of surgical practice was associated with hospital-level 30-day postoperative death rates.

The influence of fasudil on renal proximal tubular cell epithelial-mesenchymal transition induced by parathormone.

BACKGROUND: Renal fibrosis is a common pathway through which a variety of chronic kidney diseases progress to end-stage renal disease. Epithelial-mesenchymal transition (EMT) of renal proximal tubular cells is one of the most important factors in renal fibrosis. This study investigates if fasudil could influence EMT of renal proximal tubular cells. METHODS: HK-2 cells in passage 3-4 were used for all experiments. The cells were divided into five groups and treated with different concentrations of PTH and then observe cellular morphological changes at 0, 24 and 48 h using an inverted microscope and investigate the expression of the epithelial cell marker E-cadherin and the renal fibroblast marker α-smooth muscle actin (α-SMA). RESULTS: PTH significantly induced EMT, fasudil-inhibited EMT induced by PTH to different degrees, and the inhibitory effect of fasudil was most pronounced at 20 µmol/L. CONCLUSION: Monitoring PTH levels, early prevention and control of hyperparathyroidism and reducing the concentration of PTH are important means to improve prognosis and delay the progression of chronic kidney disease. Fasudil can restrain EMT induced by PTH; this conclusion provides experimental data for the application of fasudil in the clinical prevention and treatment of renal fibrosis.

A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot.

BACKGROUND: Research on the effects of patient-centered medical homes on quality and cost of care is mixed, so further study is needed to understand how and in what contexts they are effective. OBJECTIVE: We aimed to evaluate effects of a multi-payer pilot promoting patient-centered medical home implementation in 15 small and medium-sized primary care groups in Colorado. DESIGN: We conducted difference-in-difference analyses, comparing changes in utilization, costs, and quality between patients attributed to pilot and non-pilot practices. PARTICIPANTS: Approximately 98,000 patients attributed to 15 pilot and 66 comparison practices 2 years before and 3 years after the pilot launch. MAIN MEASURES: Healthcare Effectiveness Data and Information Set (HEDIS) derived measures of diabetes care, cancer screening, utilization, and costs to payers. KEY RESULTS: At the end of two years, we found a statistically significant reduction in emergency department use by 1.4 visits per 1000 member months, or approximately 7.9 % (p = 0.02). At the end of three years, pilot practices sustained this difference with 1.6 fewer emergency department visits per 1000 member months, or a 9.3 % reduction from baseline (p = 0.01). Emergency department costs were lower in the pilot practices after two (13.9 % reduction, p < 0.001) and three years (11.8 % reduction, p = 0.001). After three years, compared to control practices, primary care visits in the pilot practices decreased significantly (1.5 % reduction, p = 0.02). The pilot was associated with increased cervical cancer screening after two (12.5 % increase, p < 0.001) and three years (9.0 % increase, p < 0.001), but lower rates of HbA1c testing in patients with diabetes (0.7 % reduction at three years, p = 0.03) and colon cancer screening (21.1 % and 18.1 % at two and three years, respectively, p < 0.001). For patients with two or more comorbidities, similar patterns of association were found, except that there was also a reduction in ambulatory care sensitive inpatient admissions (10.3 %; p = 0.05). CONCLUSION: Our findings suggest that a multi-payer, patient-centered medical home initiative that provides financial and technical support to participating practices can produce sustained reductions in utilization with mixed results on process measures of quality.

Impact of a pay for performance program to improve diabetes care in the safety net.

OBJECTIVE: To evaluate the impact of a "piece-rate" pay for performance (P4P) program aimed at improving diabetes care processes, outcomes and related healthcare utilization for patients enrolled in a not-for-profit Medicaid-focused managed care plan. METHODS: To evaluate Hudson Health Plan's P4P program in New York (2003-2007), we conducted: (1) a case-comparison difference-in-difference study using plan-level administrative data; (2) a patient-level claims data analysis; and (3) a cross-sectional survey. RESULTS: The case-comparison study found that diabetes care processes (e.g., HbA1c, lipid, and dilated eye exam rates) and outcomes (e.g., LDL-C<100mg/dL) did not improve significantly over the study period. Claims analysis showed that younger adults had significantly increased odds (OR 3.50-3.56, p<0.001) of using emergency and hospital-based services and similarly decreased odds of receiving recommended care process (OR 0.22-0.36, p<0.01-0.001). Survey study indicated that practices lack fundamental quality improvement infrastructures and training. CONCLUSIONS: Recent health legislation mandates the use of P4P incentives in government programs that disproportionately care for patients with lower socioeconomic or minority backgrounds (e.g., Medicaid, Veterans Health Administration, and Tricare). More research is needed in order to understand how to tailor P4P programs for vulnerable care settings.

Effects of saline-alkali stress on bacterial and fungal community diversity in Leymus chinensis rhizosphere soil.

The salinization of grassland in arid and semi-arid areas is a serious environmental issue in China. Halophytes show extreme salt tolerance and are grown in saline-alkaline environments. Their rhizosphere microorganisms contribute significantly to plant stress tolerance. To study bacterial and fungal community structure changes in Chinese ryegrass (Leymus chinensis) rhizosphere soil under salt and alkali stress, pot experiments were conducted with different salt and alkali stress intensities. High-throughput sequencing was conducted, and the microbial diversity, community structure, and driving factors were analyzed in rhizosphere soil. The salinization of grassland in arid and semi-arid areas is a serious environmental issue in China. Halophytes show extreme salt tolerance and grow in saline-alkaline environments. A total of 549 species of bacteria from 28 phyla and 250 species from 11 phyla of fungi were detected in the rhizosphere soil of Leymus chinensis with different saline-alkali gradients. Alpha diversity analysis along saline-alkali gradients showed that bacterial community richness and diversity were the highest in the moderate saline-alkali group (pH = 8.28, EC = 160.4 µS·cm-1), while fungi had high richness and diversity in the control group (pH = 7.35, EC = 134.5 µS·cm-1). The bacteriophyta Proteobacteria, Acidobacteria, Plantomycetes, and the eumycota Ascomycota, Basidiomycota, and Glomeromycota were found with relative abundances of more than 10%. Saline-alkali gradients had significant effects on the abundance of the bacterial and fungal groups in the rhizosphere. The distribution of bacterial colony structure was not significant at the species level (P > 0.05). However, there were significant differences in the distribution of fungal structure and considerable differences in the composition of fungal species among the moderate saline-alkali group, severe saline-alkali group, and control group (P < 0.05). Correlation analysis showed that the bacterial phylum Gemmatimonadetes had a highly significant positive correlation with pH and EC (P < 0. 01). Saline-alkali stress significantly inhibited the abundance of the bacteria Latescibacteria, Cyanobacteria, and Bacteroides, and the fungi Zoopagomycota, Mortierllomycota, and Cryptomycota (P < 0. 05). Compared with fungi, bacterial community composition was most closely correlated with soil salinization. This report provided new insights into the responses of relationships between rhizosphere soil microorganisms and salt and alkali tolerance of plants.

Scientometric analysis and scientific trends on microplastics research.

In recent years, the environmental pollution of microplastics has attracted much attention. To date, there have been a lot of researches on microplastics and a series of studies published. In this study, by bibliometric analysis method to evaluated the development and evolution on microplastics research trends and hot spots. A total of 2872 literature information was collected from the Web of Science (2004-2020), which was used for bibliometric visual analysis by CiteSpace. It was possible to see the contributing countries, institutions, authors, keywords, and future study directions in the microplastics sectors by looking at the visual representation of the results. (1) Since 2004, scientific advancements in this sector have advanced significantly, with a significant increase in speed since 2012. (2) China and the United States are the world's leading researchers in microplastics. (3) The study of microplastics was multidisciplinary, comprising researchers from the fields of ecology, chemistry, molecular biology, environmental science, and oceanography. (4) In recent years, researchers have concentrated their attention on the distribution and toxicity of microplastics in the environment, as well as their coupled pollution with heavy metal contaminants. In conclusion microplastics study in environmental science has become increasingly popular in recent years. Topics include dispersion, toxicity, and coupled pollution with heavy metal pollutants. Researchers in a wide range of fields are involved in microplastics research. Furthermore, policies and regulations about microplastics in global were summarized, and membrane technology has potential to remove microplastics from water. The above findings help to clearly grasp the content and development trend of microplastics research, point out the future research direction for scholars, and promote microplastics research and pollution prevention and control.

A predictive score for progression of COVID-19 in hospitalized persons: a cohort study.

Accurate prediction of the risk of progression of coronavirus disease (COVID-19) is needed at the time of hospitalization. Logistic regression analyses are used to interrogate clinical and laboratory co-variates from every hospital admission from an area of 2 million people with sporadic cases. From a total of 98 subjects, 3 were severe COVID-19 on admission. From the remaining subjects, 24 developed severe/critical symptoms. The predictive model includes four co-variates: age (>60 years; odds ratio [OR] = 12 [2.3, 62]); blood oxygen saturation (<97%; OR = 10.4 [2.04, 53]); C-reactive protein (>5.75 mg/L; OR = 9.3 [1.5, 58]); and prothrombin time (>12.3 s; OR = 6.7 [1.1, 41]). Cutoff value is two factors, and the sensitivity and specificity are 96% and 78% respectively. The area under the receiver-operator characteristic curve is 0.937. This model is suitable in predicting which unselected newly hospitalized persons are at-risk to develop severe/critical COVID-19.

The CES-D in Chinese American women: construct validity, diagnostic validity for major depression, and cultural response bias.

Previous studies of the Center for Epidemiologic Studies Depression Scale (CES-D) in Chinese Americans describe internal reliability and factor structure. We report CES-D construct validity and diagnostic validity for major depression in a probability sample of 168 community-dwelling Chinese American women. Internal consistency was satisfactory (Cronbach's alpha=0.86). Good construct validity was indicated by significantly higher mean CES-D scores for respondents who reported lower social support, worse self-perceived general health, or stressful life events, including intimate partner violence. Cultural response bias was found, with positively-stated CES-D items (e.g. "I was happy") producing higher depression scores in immigrants and subjects who preferred to speak Chinese. Diagnostic validity for major depression was assessed using the Composite International Diagnostic Interview. A CES-D cut-off score of 16 had sensitivity of 100% (95% CI: 44% to 100%), specificity of 76% (95% CI: 69% to 82%), PPV of 7% (95% CI: 3% to 19%) and NPV of 100% (95% CI: 97% to 100%). Our findings suggest that the CES-D is useful for screening out non-depressed subjects in a first-stage assessment. However, it should be followed by a diagnostic tool in Chinese American women with scores above the cut-off in order to identify those with clinical depression.

Team-Based Primary Care Practice Transformation Initiative and Changes in Patient Experience and Recommended Cancer Screening Rates.

Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices' successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Impact of Risk Adjustment Using Clinical vs Administrative Data on Hospital Sepsis Mortality Comparisons.

BACKGROUND: A reliable risk-adjusted sepsis outcome measure could complement current national process metrics by identifying outlier hospitals and catalyzing additional improvements in care. However, it is unclear whether integrating clinical data into risk adjustment models identifies similar high- and low-performing hospitals compared with administrative data alone, which are simpler to acquire and analyze. METHODS: We ranked 200 US hospitals by their Centers for Disease Control and Prevention Adult Sepsis Event (ASE) mortality rates and assessed how rankings changed after applying (1) an administrative risk adjustment model incorporating demographics, comorbidities, and codes for severe illness and (2) an integrated clinical and administrative model replacing severity-of-illness codes with laboratory results, vasopressors, and mechanical ventilation. We assessed agreement between hospitals' risk-adjusted ASE mortality rates when ranked into quartiles using weighted kappa statistics (к). RESULTS: The cohort included 4 009 631 hospitalizations, of which 245 808 met ASE criteria. Risk-adjustment had a large effect on rankings: 22/50 hospitals (44%) in the worst quartile using crude mortality rates shifted into better quartiles after administrative risk adjustment, and a further 21/50 (42%) of hospitals in the worst quartile using administrative risk adjustment shifted to better quartiles after incorporating clinical data. Conversely, 14/50 (28%) hospitals in the best quartile using administrative risk adjustment shifted to worse quartiles with clinical data. Overall agreement between hospital quartile rankings when risk-adjusted using administrative vs clinical data was moderate (к = 0.55). CONCLUSIONS: Incorporating clinical data into risk adjustment substantially changes rankings of hospitals' sepsis mortality rates compared with using administrative data alone. Comprehensive risk adjustment using both administrative and clinical data is necessary before comparing hospitals by sepsis mortality rates.

Effect of SARS-CoV-2 Infection on the Microbial Composition of Upper Airway.

METHODS: Forty-four COVID-19 patients (severe/critical: N = 8, non-severe: N = 36) were examined by next generation sequencing (NGS) of nasopharyngeal test paper to observe the effect of novel coronavirus infection to the microbial composition in upper airway. RESULTS: In these nasopharyngeal test paper samples, 38 kinds of bacteria, 10 kinds of viruses except SARS-CoV-2, nine kinds of fungi and three kinds of atypical pathogens had been found. There was some difference in microbial composition in the upper airway between severe and non-severe cases. SUMMARY: These results are important for us to study the effect of SARS-CoV-2 on the local microbial composition of upper airway and prevent opportunistic infection in severe patients.

Preliminary evidence from a multicenter prospective observational study of the safety and efficacy of chloroquine for the treatment of COVID-19.

Effective therapies are urgently needed for the SARS-CoV-2 pandemic. Chloroquine has been proved to have antiviral effect against coronavirus in vitro. In this study, we aimed to assess the efficacy and safety of chloroquine with different doses in COVID-19. In this multicenter prospective observational study, we enrolled patients older than 18 years old with confirmed SARS-CoV-2 infection excluding critical cases from 12 hospitals in Guangdong and Hubei Provinces. Eligible patients received chloroquine phosphate 500 mg, orally, once (half dose) or twice (full dose) daily. Patients treated with non-chloroquine therapy were included as historical controls. The primary endpoint is the time to undetectable viral RNA. Secondary outcomes include the proportion of patients with undetectable viral RNA by day 10 and 14, hospitalization time, duration of fever, and adverse events. A total of 197 patients completed chloroquine treatment, and 176 patients were included as historical controls. The median time to achieve an undetectable viral RNA was shorter in chloroquine than in non-chloroquine (absolute difference in medians -6.0 days; 95% CI -6.0 to -4.0). The duration of fever is shorter in chloroquine (geometric mean ratio 0.6; 95% CI 0.5 to 0.8). No serious adverse events were observed in the chloroquine group. Patients treated with half dose experienced lower rate of adverse events than with full dose. Although randomized trials are needed for further evaluation, this study provides evidence for safety and efficacy of chloroquine in COVID-19 and suggests that chloroquine can be a cost-effective therapy for combating the COVID-19 pandemic.

Childhood maltreatment linked to greater symptom severity and poorer quality of life and function in social anxiety disorder.

BACKGROUND: There is a paucity of data examining the prevalence and impact of childhood maltreatment in patients presenting with a primary diagnosis of social anxiety disorder (SAD). We thus examined the presence of a broad spectrum of childhood maltreatment, including physical, sexual, and emotional abuse and neglect, in treatment-seeking individuals with the generalized subtype of SAD (GSAD). We hypothesized that a history of childhood maltreatment would be associated with greater SAD symptom severity and poorer associated function. METHODS: One hundred and three participants with a primary diagnosis of GSAD (mean age 37+/-14; 70% male) completed the well-validated, self-rated Childhood Trauma Questionnaire (CTQ), as well as measures of SAD symptom severity and quality of life. RESULTS: Fully 70% (n=72) of the GSAD sample met severity criteria for at least one type of childhood abuse or neglect as measured by the CTQ subscales using previously established thresholds. CTQ total score adjusted for age and gender was associated with greater SAD severity, and poorer quality of life, function, and resilience. Further, the number of types of maltreatment present had an additive effect, with specific associations for emotional abuse and neglect with SAD severity. CONCLUSIONS: Despite the use of validated assessments, our findings are limited by the retrospective and subjective nature of self-report measures used to assess childhood maltreatment. Nonetheless, these data suggest a high rate of childhood maltreatment in individuals seeking treatment for GSAD, and the association of maltreatment with greater disorder severity suggests that screening is clinically prudent.

Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients.

Importance: Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions. Objective: To evaluate the association of establishing team-based primary care with patient health care use and costs. Design, Setting, and Participants: We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018. Exposures: Practices participated in a 4-year learning collaborative that created and supported team-based primary care. Main Outcomes and Measures: Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care. Results: Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n = 51 155 [37.0%] vs n = 186 954 [46.6%]), more participants younger than 18 years (n = 337 931 [27.5%] vs n = 74 691 [18.6%]), higher Medicaid enrollment (n = 39 541 [28.6%] vs n = 81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P < .001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P = .03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P = .007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P = .009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P < .001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P = .003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P = .02). Conclusions and Relevance: While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

Care in U.S. hospitals--the Hospital Quality Alliance program.

BACKGROUND: The Hospital Quality Alliance (HQA) is the first initiative that routinely reports data on hospitals' performance nationally. Heretofore, such data have been unavailable. METHODS: We used data collected by the Centers for Medicare and Medicaid Services on 10 indicators of the quality of care for acute myocardial infarction, congestive heart failure, and pneumonia. The main outcome measures were hospitals' performance with respect to each indicator and summary scores for each clinical condition. Predictors of a high level of performance were determined with the use of multivariable linear regression. RESULTS: A total of 3558 hospitals reported data on at least one stable measure (defined as information obtained from discharge data from at least 25 patients) during the first half of 2004. Median performance scores (expressed as the percentage of patients who satisfied the criterion) were at least 90 percent for 5 of the 10 measures but lower for the other 5. Performance varied moderately among large hospital-referral regions, with the top-ranked regions scoring 12 percentage points (for acute myocardial infarction) to 23 percentage points (for pneumonia) higher than the bottom-ranked regions. A high quality of care for acute myocardial infarction predicted a high quality of care for congestive heart failure but was only marginally better than chance at predicting a high quality of care for pneumonia. Characteristics associated with small but significant increases in performance included being an academic hospital, being in the Northeast or Midwest, and being a not-for-profit hospital. CONCLUSIONS: Analysis of data from the new HQA national reporting system shows that performance varies among hospitals and across indicators. Given this variation and small differences based on hospitals' characteristics, performance reporting will probably need to include numerous clinical conditions from a broad range of hospitals.

Racial trends in the use of major procedures among the elderly.

BACKGROUND: Differences in the use of major procedures according to patients' race are well known. Whether national and local initiatives to reduce these differences have been successful is unknown. METHODS: We examined data for men and women enrolled in Medicare from 1992 through 2001 on annual age-standardized rates of receipt of nine surgical procedures previously shown to have disparities in the rates at which they were performed in black patients and in white patients. We also examined data according to hospital-referral region for three of the nine procedures: coronary-artery bypass grafting (CABG), carotid endarterectomy, and total hip replacement. RESULTS: Nationally, in 1992, the rates of receipt for all the procedures examined were higher among white patients than among black patients. The difference between the rates among whites and blacks increased significantly between 1992 and 2001 for five of the nine procedures, remained unchanged for three procedures, and narrowed significantly for one procedure. We examined rates of CABG, carotid endarterectomy, and total hip replacement in 158 hospital-referral regions (79 hospital-referral regions for black men and white men and 79 for black women and white women) with an adequate number of persons for each procedure. We found that in the early 1990s, whites had higher rates for these procedures than blacks in every hospital-referral region. By 2001, the difference between whites and blacks (both men and women) in the rates of these procedures narrowed significantly in 22 hospital-referral regions, widened significantly in 42, and were not significantly changed in the remaining hospital-referral regions. At the end of the study period, we found no hospital-referral region in which the difference in rates between whites and blacks was eliminated for men or women with regard to any of these three procedures. CONCLUSIONS: For the decade of the 1990s, we found no evidence, either nationally or locally, that efforts to eliminate racial disparities in the use of high-cost surgical procedures were successful.

Concentration and quality of hospitals that care for elderly black patients.

BACKGROUND: The reasons for racial differences in health care are not well known, but the characteristics of hospitals where people receive care may be an important factor in the quality of care that patients receive. Therefore, we sought to determine the proportion and volume of elderly black vs white patients treated at hospitals and examine the characteristics and performances of hospitals that care for disproportionately high volumes of black patients. METHODS: We used 2004 Medicare data to calculate, for each hospital in our study, the volume and proportion of black patients discharged. We then examined the hospitals' structural characteristics and performances according to quality measures for patients with acute myocardial infarction, congestive heart failure, and pneumonia. RESULTS: The 5% of hospitals with the highest volume of black patients cared for nearly half of all elderly black patients, and the hospitals in the top quartile by volume of patients cared for nearly 90% of elderly black patients. Hospitals with a high volume of black patients were larger and were more often teaching hospitals located in the southern United States (P<.001 for each comparison) than those with a low volume of black patients. Hospitals with a high proportion of black patients had comparable characteristics. After adjusting for hospital characteristics, hospitals that treated a high vs low volume of black patients had worse performance summary scores for acute myocardial infarction (89.0 vs 90.7; P = .002) and pneumonia measures (76.9 vs 79.4; P<.001). Adjusting for hospital referral region eliminated the gap in performance scores for acute myocardial infarction but not for pneumonia. There were comparable differences in performance scores for hospitals that treated a high vs low proportion of black patients. CONCLUSIONS: Hospital care for black patients in the United States is remarkably concentrated in a small percentage of hospitals, although the hospitals that care for a high proportion of black patients have only marginally worse quality of care than those that care for a low proportion of black patients. The level of concentration of black patients provides a fresh opportunity to improve care for black patients by targeting efforts toward a small group of hospitals.

Trends in Beverage Consumption Among Children and Adults, 2003-2014.

OBJECTIVE: This study aimed to provide the most recent national estimates for beverage consumption among children and adults in the United States. METHODS: Dietary data were collected from 18,600 children aged 2 to 19 years and from 27,652 adults aged ≥ 20 years in the 2003 to 2014 National Health and Nutrition Examination Survey. Total beverage and sugar-sweetened beverage (SSB) consumption was measured by 24-hour dietary recall. RESULTS: From 2003 to 2014, per capita consumption of all beverages declined significantly among children (473.8-312.6 calories; P < 0.001) and adults (425.0-341.1 calories; P < 0.001). In the 2013-2014 survey, 60.7% of children and 50.0% of adults drank SSBs on a given day, which is significantly lower than 2003-2004, when 79.7% of children and 61.5% of adults reported drinking SSBs. From 2003 to 2014, per capita consumption of SSBs declined from 224.6 calories to 132.5 calories (P < 0.001) for children and from 190.4 calories to 137.6 calories (P < 0.001) for adults. The absolute levels for the percentage of SSB drinkers and per capita consumption of SSBs were highest among black, Mexican American, and non-Mexican Hispanic children, adolescents, and young adults for all years of the study. CONCLUSIONS: Overall, beverage and SSB consumption declined for children and adults from 2003 to 2014. The levels of consumption are highest among black, Mexican American, and non-Mexican Hispanic participants.

Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations.

OBJECTIVE: To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care. DATA SOURCES: 2009-2011 national Medicare and commercial insurance administrative data. DESIGN: We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. METHODS: We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these. PRINCIPAL FINDINGS: Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. CONCLUSIONS: Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.