Cost-of-Care Conversations During Clinical Visits in Federally Qualified Health Centers: An Observational Study.

Background: The Centers for Disease Control and Prevention estimates that 10% of the U.S. population delays or avoids health care because of cost concerns. It is unknown whether and how cost-of-care conversations occur in primary encounters, especially settings that provide care to vulnerable patients. Objective: To describe cost-of-care conversations with financially vulnerable (<400% federal poverty level) adult patients during clinical encounters. Design: Five observers shadowed a convenience sample of patients during encounters and then interviewed patients and clinicians after the encounter. Setting: Federally Qualified Health Centers in Texas (n = 2) and Pennsylvania (n = 2). Participants: A convenience sample of 67 adult patients seeking chronic disease management or prenatal care from 9 clinicians (5 medical doctors, 2 physician assistants, and 2 nurse practitioners). Measurements: Self-reported characteristics of patients, and frequency and characteristics of interviewer-observed cost-of-care conversations. Results: Because of missing responses from patient and clinician interviews, data are reported for 67 consenting patients. During 46.3% of encounters, some discussion of costs of care was observed. Discussion of indirect costs (lost work time or transportation) was observed in only 2.9% of encounters. In only 11.9% of encounters did the physician discuss costs of care. When costs were discussed, the conversation was not organized and did not take place in conjunction with the discussion of the treatment plan. Limitations: This exploratory work involved a small convenience sample, and generalizability to other settings is uncertain. Missing data prohibited meaningful analysis of patient and clinician interview data. Conclusion: In the 4 federally funded health centers studied, cost-of-care conversations occurred in a minority of clinical visits, discussions were unorganized, and indirect costs of care were rarely addressed. Whether more frequent discussion of the costs of care improves patient adherence and outcomes requires further study. Primary Funding Source: Robert Wood Johnson Foundation.

VHA Multiple Sclerosis Surveillance Registry and its similarities to other contemporary multiple sclerosis cohorts.

The Veterans Health Administration (VHA) has provided important contributions to our understanding of multiple sclerosis (MS); however, the characteristics of the modern VHA MS population have not been adequately characterized. Our objectives were to compare and contrast characteristics of the VHA MS population with other contemporary MS cohorts. A cross-sectional, mail-based survey of a stratified, random sample of 3,905 VHA users with MS was conducted. Detailed demographic and clinical data were collected as well as patient-reported outcomes assessing disability and quality of life. A total of 1,379 Veterans were enrolled into the MS Surveillance Registry (MSSR). Respondents did not differ from nonrespondents with regard to demographics or region. When compared to several other contemporary MS cohorts, some demographic differences were noted; however, the age of MS onset and diagnosis, subtype distribution, and most prevalent symptoms were very similar across MS cohorts. The MSSR appears to be representative of the general MS population. Combining the extensive VHA health services encounter data with the MSSR provides a rich and unique cohort for study.

Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study.

BACKGROUND: Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. METHODS: This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. RESULTS: In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. CONCLUSIONS: Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.

Visit length in pediatric primary care: lessons from a pilot study.

As business drivers create pressure to see more patients in a given period, there is no reliable guidance regarding the optimal allocation of resources in ambulatory visits. Many pediatric primary clinics set appointment lengths in increments of "five minutes." Defining the appointment lengths for potentially longer visits by arbitrary increments (e.g., twice the time for an acute visit) is a common "experiential" scheme. However, how much additional time is really needed if the patient is new to practice or when the visit is arranged for preventive services is unknown. Identifying the misallocation of clinic resources is fundamental because misallocation reduces access for patients and increases practice costs. In this study, using a time-motion approach, we examined the characteristics of 372 visits in a pediatric primary care clinic.

Factors associated with program utilization of radiation therapy treatment for VHA and medicare dually enrolled patients.

We examine how distance to a Veterans Health Administration (VHA) facility, patient hometown classification (e.g., small rural town), and service-connected disability are associated with veterans' utilization of radiation therapy services across the VHA and Medicare. In 2008, 45,914 dually-enrolled veteran patients received radiation therapy. Over 3-quarters (35,513) of the patients received radiation therapy from the Medicare program. Younger age, male gender, shorter distance to a VHA facility, and VHA priority or disability status increased the odds of utilizing the VHA. However, veterans residing in urban areas were less likely to utilize the VHA. Urban dwelling patients' utilization of Medicare instead of the VHA suggests a complex decision that incorporates geographic access to VHA services, financial implications of veteran priority status, and the potential availability of multiple sources of radiation therapy in competitive urban markets.

Sun exposure, vitamin D intake and progression to disability among veterans with progressive multiple sclerosis.

BACKGROUND: Early life events have been suggested to influence multiple sclerosis (MS) susceptibility, and to potentially modulate its clinical course. We assessed vitamin D-related exposures from childhood to disease onset and their associations with MS progression. METHODS: Among veterans in the Multiple Sclerosis Surveillance Registry, 219 reported having the progressive form and met the inclusion criteria. Participants reported their past sun exposure, vitamin D-related intake and age at disability milestones using the Patient-Determined Disease Steps (PDDS). The Cox proportional hazards model was used to examine the association between vitamin D-related exposures and time (years) to disability. RESULTS: Low average sun exposure in the fall/winter before disease onset was associated with an increased risk of progressing to a PDDS score of 8 (hazard ratio, HR: 2.13, 95% confidence interval, CI: 1.20-3.78), whereas use of cod liver oil during childhood and adolescence was associated with a reduced risk (HR: 0.44, 95% CI: 0.20-0.96). CONCLUSIONS: These results suggest that exposure to vitamin D before MS onset might slow disease-related neurodegeneration and thus delay progression to disability among patients with the progressive subtype.

Preliminary benefits of information therapy.

UNLABELLED: Information therapy (ie, information prescriptions) is a potential new tool for primary care physicians that could improve patient knowledge, decision making, and communication between physicians and patients. Although patients have access to numerous health-related articles online, the availability of this health information does not ensure improved knowledge or better health decisions by patients. Communication between patients and physicians is often limited and messages are commonly misunderstood. Information therapy offers a potential solution for the primary care environment. METHOD: Two employers, in different geographical locations of the Midwest, offered the MedEncentive program to employees and their dependents as a part of their health plans. This program also offers primary care physicians the opportunity to prescribe information to patients during office visits. Patients were then eligible to participate in this information therapy (Ix) through a Web-based platform. Both primary care physicians and patients were financially incentivized for participation. Physicians received a monetary stipend for prescribing evidence-based information therapy and patients were refunded part or all of their copayment for reading their condition-specific Ix and answering questions about knowledge, compliance, health status, and satisfaction with the care they received compared to the evidence from the Ix. RESULTS: Patients received information therapy from their primary care physicians and reported a high level of satisfaction with care, improved health status, and compliance with pharmaceutical prescriptions. DISCUSSION: This case study had a number of limitations and as such the results should be interpreted with caution. However, there is a need for an immediate solution as patient satisfaction with their care and compliance with pharmaceutical prescriptions continue to decrease, despite the amounts of widely available health information. These preliminary findings suggest that information therapy through a Web-based platform, augmented by doctor-patient mutual accountability, could be part of the solution for the current ambulatory health care environment.

Sun exposure, vitamin D and age at disease onset in relapsing multiple sclerosis.

BACKGROUND: Current evidence suggests that sun exposure and vitamin D intake, during childhood and adolescence, are associated with a reduced risk of multiple sclerosis (MS). However, the role of these environmental agents in the timing of disease symptom onset remains to be investigated. METHODS: Using a cross-sectional study design, we recruited participants from the Veterans Health Administration-Multiple Sclerosis Surveillance Registry. Self-reported histories of residential locations, sun exposure and intake of vitamin D were used to estimate vitamin-D-related exposures. Multivariable linear regression analysis was used to examine the associations between these variables and age at MS onset. RESULTS: Among veterans with relapsing MS who resided in low-to-medium solar radiation areas (n = 540), low sun exposure in the fall/winter during the ages of 6-15 years was significantly associated with earlier symptom onset by 2.1 years (p = 0.02). Intake of cod liver oil during the same age period was associated with later onset of MS symptoms by 4 years (p = 0.02). CONCLUSIONS: The current study provides evidence for an association between vitamin-D-related exposures during childhood and early adolescence and the timing of MS symptom onset, and supports vitamin D as a potential modulator of the clinical course of this disease.

Improving efficiency in active surveillance for methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus at hospital admission.

OBJECTIVE: Mandatory active surveillance culturing of all patients admitted to Veterans Affairs (VA) hospitals carries substantial economic costs. Clinical prediction rules have been used elsewhere to identify patients at high risk of colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). We aimed to derive and evaluate the clinical efficacy of prediction rules for MRSA and VRE colonization in a VA hospital. Design and setting. Prospective cohort of adult inpatients admitted to the medical and surgical wards of a 119-bed tertiary care VA hospital. METHODS: Within 48 hours after admission, patients gave consent, completed a 44-item risk factor questionnaire, and provided nasal culture samples for MRSA testing. A subset provided perirectal culture samples for VRE testing. RESULTS: Of 598 patients enrolled from August 30, 2007, through October 30, 2009, 585 provided nares samples and 239 provided perirectal samples. The prevalence of MRSA was 10.4% (61 of 585) (15.0% in patients with and 5.6% in patients without electronic medical record (EMR)-documented antibiotic use during the past year; P < .01). The prevalence of VRE was 6.3% (15 of 239) (11.3% in patients with and 0.9% in patients without EMR-documented antibiotic use; P < .01). The use of EMR-documented antibiotic use during the past year as the predictive rule for screening identified 242.8 (84%) of 290.6 subsequent days of exposure to MRSA and 60.0 (98%) of 61.0 subsequent days of exposure to VRE, respectively. EMR documentation of antibiotic use during the past year identified 301 (51%) of 585 patients as high-risk patients for whom additional testing with active surveillance culturing would be appropriate. CONCLUSIONS: EMR documentation of antibiotic use during the year prior to admission identifies most MRSA and nearly all VRE transmission risk with surveillance culture sampling of only 51% of patients. This approach has substantial cost savings compared with the practice of universal active surveillance.

Time of birth, residential solar radiation and age at onset of multiple sclerosis.

UNLABELLED: BACKGROUNDS/AIM: Gestational and early life events have been suggested to contribute to multiple sclerosis (MS) susceptibility. We assessed the effects of time and place of birth on the age at onset of MS symptoms. METHODS: We selected a national cohort of 967 veterans from the Multiple Sclerosis Surveillance Registry for whom month and season (time) of birth, and birthplace (city and state) were available. Multiple linear regression analyses were used to examine the association between time of birth, birthplace latitude and solar radiation, and the age at onset of MS symptoms among the study sample. RESULTS: Patients with a relapsing form of the disease (R-MS), who were born in winter and whose birthplace was in low solar radiation areas, had disease symptom onset on average 2.8 years earlier than those born in seasons other than winter and in medium- and high-solar radiation areas (p = 0.02). CONCLUSIONS: These results suggest that exposure early in life to geographical and seasonal factors, possibly related to the protective effect of sunlight, and thus vitamin D, is associated with a delay in MS symptom onset. Other larger studies are required to examine the period-specific (from conception to adulthood) environmental factors that are associated with MS susceptibility.

A national perspective of Medicare expenditures for elderly veterans with hip fractures.

INTRODUCTION: The Centers for Medicare and Medicaid Services (CMS) recently announced that beginning in October 2008, Medicare will no longer reimburse hospitals for the costs of treating injuries from several preventable conditions, including inpatient falls resulting in hip fracture. If hospitals try to shift this care to other payers, elderly veterans who are dually eligible for care in Medicare and Veterans Health Administration (VHA) facilities may be adversely affected. As health care provided for a hip fracture can be substantial, the goal of this research was to calculate Medicare payments for a national cohort of elderly veterans with hip fractures, beginning with the first inpatient admission and continuing through one year. METHODS: This was a retrospective, secondary data analysis of national VHA-eligible Medicare beneficiaries. The study population was 43,104 veterans with a hip fracture first admitted to a Medicare-eligible facility during 1999-2002. The estimation method was an ordinary least squares regression model of Medicare payments to providers for hip fracture patients over 4 time periods, up to 1 year after discharge, controlling for age, gender, inpatient length of stay, 1-year mortality, and selected Elixhauser comorbidities. RESULTS: Medicare reimbursed providers for nearly $3 billion of health care for hip fracture patients the first year of injury. Approximately 71.4% ($49,544) of the total annual Medicare payments (for all services) occurred within the first 30 days of hospital admission. Inpatient and carrier (physician) providers received the majority of the payments. The average annual payment per individual was $69,389 (99% confidence interval: $68,539-$70,239). Almost 7 in 10 hip fracture patients obtained care in a skilled nursing facility (SNF) during the year, with these providers comprising only 12% of total annual Medicare payments. In this elderly veteran cohort, hip fracture patients with renal failure, diabetes, lymphoma, and metastatic cancer generated the highest payments. CONCLUSION: This analysis provides proxy cost estimates for hip fracture patients useful for the forthcoming CMS reimbursement policy changes for inpatient fall-related injuries. The VHA and dually eligible elderly veterans could be disproportionately exposed to the economic consequences of the new CMS policy change.

Rehospitalization after hip fracture: predictors and prognosis from a national veterans study.

OBJECTIVES: To estimate the risk and long-term prognostic significance of 30-day readmission postdischarge of a 4-year cohort of elderly veterans first admitted to Medicare hospitals for treatment of hip fractures (HFx), controlling for comorbidities. DESIGN: Retrospective, national secondary data analysis. SETTING: National Medicare and Veterans Health Administration (VHA) facilities. PARTICIPANTS: The study cohort was 41,331 veterans with a HFx first admitted to a Medicare eligible facility during 1999 to 2002. MEASUREMENTS: HFxs were linked with all other Medicare and VHA inpatient discharge files to capture dual inpatient use. Logistic regression was used to examine the relationship between 30-day readmission and age, sex, inpatient length of stay, and selected Elixhauser comorbidities. RESULTS: Approximately 18.3% (7,579/41,331) of HFx patients were readmitted within 30 days. Of those with 30-day readmissions, 48.5% (3,675/7,579) died within 1 year, compared with 24.9% (8,388/33,752) of those without 30-day readmissions. Readmission risk was significantly greater in the presence of specific comorbidities, ranging from 11% greater risk for patients with fluid and electrolyte disorders (95% confidence interval (CI)=1.04-1.20) to 43% for renal failure (95% CI=1.29-1.60). For this cohort, cardiac arrhythmias (24%), chronic pulmonary disease (28%), and congestive heart failure (16%) were common comorbidities, and all affected the risk of 30-day readmission. CONCLUSION: Patients with HFx with 30-day readmissions were nearly twice as likely to die within 1 year. Identification of several predictive comorbidities at discharge and examination of reasons for subsequent readmission suggests that readmission was largely due to active comorbid clinical problems. These comorbidity findings have implications for the current Centers for Medicare and Medicaid Services (CMS) pay-for-performance initiatives, especially those related to better coordination of care for patients with chronic illnesses. These comorbidity findings for elderly patients with HFx may also provide data to enable CMS and healthcare providers to more accurately differentiate between comorbidities and hospital-acquired complications under the current CMS initiative related to nonpayment for certain types of medical conditions and hospital acquired infections.

Relative influence of antibiotic therapy attributes on physician choice in treating acute uncomplicated pyelonephritis.

BACKGROUND: Reducing excess duration of antibiotic therapy is a strategy for limiting the spread of antibiotic resistance, but altering physician practice to accomplish this requires knowledge of the factors that influence physician antibiotic choice. The authors aimed to quantify physician willingness to trade between 4 attributes of antibiotic therapies: different therapy durations, failure rates, dosing frequencies, and days of diarrhea as a side effect when treating acute uncomplicated pyelonephritis. METHODS: The authors distributed conjoint analysis questionnaires to physicians enrolling patients in a randomized trial comparing 2 antibiotics in pyelonephritis treatment. For each question, respondents were required to select 1 of 2 antibiotics based on the values of the 4 attributes. Proportional hazards regression was used to model predictors of physician choice. RESULTS: Eighty-seven of 88 physicians completed the questionnaire. Duration of therapy, days of diarrhea, and failure rate were significant predictors of choice (P < 0.05), but dosing frequency (once daily v. twice daily) was not. Increasing days of diarrhea greatly reduced the probability of an antibiotic being chosen. If failure and side effects were equivalent, physicians were more likely to prescribe a 5- v. 10-day duration of therapy (odds ratio = 4.18, P < 0.01). CONCLUSION: Antibiotic choice is most influenced by physicians' desires to limit treatment failure and side effects, although physicians were willing to accept increases in treatment failure to obtain reduced days of diarrhea as a side effect. Because shorter-course therapy is frequently associated with fewer side effects, efforts to encourage physicians to choose shorter treatment durations should include mention of reduced treatment-associated side effects.

Risk-adjusted mortality rates of elderly veterans with hip fractures.

PURPOSE: The goal of this research was to estimate 12-month survival rates for a large sample of elderly veterans after hip fracture with a risk-adjusted model and to compare the results of men to those of women. METHODS: The study design was a retrospective, secondary data analysis of national Veterans Health Administration (VHA) Medicare beneficiaries. The study population was 43,165 veterans with hip fracture first admitted to a Medicare-eligible facility during our specified enrollment period of 1999-2002. Measurement was a Cox proportional hazard model or survival analysis of hip fracture patients with an outcome of death over a 1 year period after discharge controlled by age, gender, and selected Elixhauser comorbidities. RESULTS: The unadjusted, 1 year mortality rates (30 days = 9.7%, 90 days = 17.5%, 180 days = 24%, 365 days = 32.2%) were slightly higher than the adjusted rates (30 days = 8.9%, 90 days = 15.6%, 180 days = 21.8%, 1 year = 29.9%). The mortality odds for women 12 months after hip fracture were 18%, compared with 32% for men. The comorbidity adjustment suggested that the presence of metastatic cancer increased the risk of death by almost 4 times compared with those patients without this diagnosis. Other particularly high-risk conditions included congestive heart failure, renal failure, liver disease, lymphoma, and weight loss, each of which increased the 1 year mortality risk by approximately two-fold. CONCLUSIONS: One in 3 elderly male veterans who sustain a hip fracture dies within 1 year. Our work represents the first large study of hip fractures with a predominantly male sample and confirms that men have a higher mortality risk than women, as reported by previous researchers who used smaller samples that were mostly female. Fracture patients with metastatic cancer, renal failure, lymphoma, weight loss, and liver disease have higher mortality risks. The adverse outcomes associated with hip fracture argue for clinical intervention strategies, such as gait and balance testing, and osteoporosis diagnosis that may prevent fractures in both genders.

A study design to assess the safety and efficacy of on-pump versus off-pump coronary bypass grafting: the ROOBY trial.

BACKGROUND: Since the late 1960s, coronary artery bypass graft (CABG-only) procedures were traditionally performed using a heart-lung machine on an arrested heart (on-pump). Over the past decade, an increasing number CABG-only procedures were performed on a beating heart (off-pump). Advocates of the off-pump approach expect to reduce many of the adverse side effects related to using the heart-lung machine, while advocates for the on-pump procedure raise concerns related to graft patency rates and long-term event-free survival for the off-pump technique. PURPOSE: The U.S. Department of Veteran Affairs (VA) Cooperative Studies Program funded a randomized, multicenter clinical trial comparing the clinical and resource-related outcomes following on-pump versus off-pump techniques for veterans undergoing a non-emergent CABG-only procedure. The planning committee was faced with several critically important challenges to assure feasibility of study costs and required sample size; generalizability to non-VA surgical practices; and comparability of clinically meaningful results. These challenges are discussed. METHODS: This study is a prospective, randomized, multicenter, single blinded (patient) clinical trial that compares on-pump and off-pump techniques for veterans requiring non-emergent CABG-only procedures. There will be 2200 patients randomized at 17 VA Medical Centers when the five-year recruitment period ends on 15 April 2007. There are two primary objectives: a short-term objective to assess the immediate impact of the two techniques on 30-day mortality/morbidity and a long-term objective to assess one-year mortality/morbidity. Major secondary outcomes are one-year graft patency rates and change in neuropsychological assessments from baseline to one year. All patients are assessed at 30 days post-surgery or discharge from the hospital, whichever is latest, and at one-year post-surgery. RESULTS: During planning, several key issues had to be decided. These included 1) choosing primary objectives: a short-term (30-day) and a long-term (one-year) objective were chosen; 2) choosing primary outcome measures: composite measures were selected to ensure sufficient end-points; 3) standardization of surgical techniques: minimal standardization required but guidelines and continuing discussions on both techniques provided; 4) establishing criteria for surgeons and residents for participation: surgeons required to have completed 20 off-pump procedures prior to doing study procedures and residents, in presence of study surgeon, capable of doing either procedure; 5) identifying metrics of cognitive dysfunction sensitive to treatment: a neuropshychologist hired who centrally monitors cognitive functioning testing; and 6) blinding participants of surgical procedure: attempt to blind participants. LIMITATIONS: Areas of concern are whether all surgeons sufficiently experienced on the off-pump procedure, should residents have been allowed to do study surgeries, should techniques have been standardized more and were the best neurocognitive tests selected. CONCLUSION: The study design presented allows for a balanced and fair assessment of the on-pump and off-pump CABG procedures across a diversity of clinical outcomes and resource use metrics. Its results have the potential to influence clinical cardiac surgical practice in the future.

Comparison of mortality risk associated with bacteremia due to methicillin-resistant and methicillin-susceptible Staphylococcus aureus.

OBJECTIVE: To quantify the clinical impact of methicillin-resistance in Staphylococcus aureus causing infection complicated by bacteremia in adult patients, while controlling for the severity of patients' underlying illnesses. DESIGN: Retrospective cohort study from October 1, 1995, through December 31, 2003. PATIENTS AND SETTING: A total of 438 patients with S. aureus infection complicated by bacteremia from a single Veterans Affairs healthcare system. RESULTS: We found that 193 (44%) of the 438 patients had methicillin-resistant S. aureus (MRSA) infection and 114 (26%) died of causes attributable to S. aureus infection within 90 days after the infection was identified. Patients with MRSA infection had a higher mortality risk, compared with patients with methicillin-susceptible S. aureus (MSSA) infections (relative risk, 1.7 [95% confidence interval, 1.3-2.4]; P<.01), except for patients with pneumonia (relative risk, 0.7 [95% confidence interval, 0.4-1.3]). Patients with MRSA infections were significantly older (P<.01), had more underlying diseases (P=.02), and were more likely to have severe sepsis in response to their infection (P<.01) compared with patients with MSSA bacteremia. Patients who died within 90 days after S. aureus infection was identified were significantly older (P<.01) and more likely to have severe sepsis (P<.01) and pneumonia (P=.01), compared with patients who survived. After adjusting for age as a confounder, comorbidities, and pneumonia as an effect modifier, S. aureus infection-related mortality remained significantly higher in patients with MRSA infection than in those with MSSA infection, among those without pneumonia (hazard ratio, 1.8 [95% confidence interval, 1.2-3.0]); P<.01. CONCLUSIONS: The results of this study suggest that patients with MRSA infections other than pneumonia have a higher mortality risk than patients with MSSA infections other than pneumonia, independent of the severity of patients' underlying illnesses.

Comorbidity risk-adjustment measures were developed and validated for studies of antibiotic-resistant infections.

OBJECTIVES: Comorbidities are often included in risk-factor models for nosocomial antibiotic-resistant bacterial infections, and aggregate comorbidity measures are valuable because they allow one variable to represent many. This study aimed to develop new aggregate comorbidity measures based upon the Chronic Disease Score (CDS) for assessing the comorbidity-attributable risk of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) nosocomial infections. STUDY DESIGN AND SETTING: For each outcome, two retrospective cohort studies of hospitalized patients were conducted. Outcomes were a first MRSA or VRE positive clinical culture obtained 48 hours or more postadmission. Each cohort was divided into development (July 1998-2001) and validation (August 2001-2003) samples. New comorbidity measures were created for MRSA (CDS-MRSA), VRE (CDS-VRE), or any nosocomial infection outcome (CDS-ID) using logistic regression and subsequently validated. Model discrimination was measured using the c-statistic. RESULTS: Discrimination of the CDS-MRSA (c=0.60), CDS-VRE (c=0.65), and CDS-ID (MRSA: c=0.57; VRE: c=0.64) was greater than that of the original CDS (MRSA: c=0.52; VRE: c=0.57). CONCLUSION: The CDS-MRSA, CDS-VRE, and CDS-ID are new infectious disease specific comorbidity risk-adjustment measures that will be useful for the quality of future epidemiologic studies of MRSA, VRE, and other infectious diseases.

Veterans Health Administration multiple sclerosis surveillance registry: The problem of case-finding from administrative databases.

Establishment of a national multiple sclerosis (MS) surveillance registry (MSSR) is a primary goal of the Department of Veterans Affairs (VA) MS Center of Excellence. The initial query of Veterans Health Administration (VHA) databases identified 25,712 patients (labeled "VHA MS User Cohort") from fiscal years 1998 to 2002 based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code; service-connection for MS; and/or disease-modifying agent (DMA) use. Because of ICD-9-CM limitations, the initial query was overinclusive and resulted in many non-MS cases. Thus, we needed a more rigorous case-finding method. Our gold standard was chart review of the Computerized Patient Record System for the mid-Atlantic VA medical centers. After chart review, we classified patients as not having MS or having MS/possible MS. We also applied a statistical algorithm to classify cases based on service-connection for MS, DMA use, and/or at least one healthcare encounter a year with MS coded as the primary diagnosis. We completed two analyses with kappa coefficient and sensitivity analysis. The first analysis (efficacy) was limited to cases with a definitive classification based on chart review (n = 600). The kappa coefficient was 0.85, sensitivity was 0.93, and specificity was 0.92. The second analysis (effectiveness) included unknown cases that were classified as MS/possible MS (N = 682). The kappa coefficient was 0.82, sensitivity was 0.93, and specificity was 0.90. These findings suggest that the database algorithm reliably eliminated non-MS cases from the initial MSSR population and is a reasonable case-finding method at this intermediate stage of MSSR development.

Physicians' acceptable treatment failure rates in antibiotic therapy for coagulase-negative staphylococcal catheter-associated bacteremia: implications for reducing treatment duration.

BACKGROUND: Decreasing the duration of antimicrobial therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. Limited data regarding optimal treatment durations for most clinical infections hinder the adoption of this approach and impair optimal physician-patient communication under the shared decision-making model. We aimed to identify acceptable failure rates among infectious disease consultants (IDCs) for treatment of central venous catheter-associated bacteremia. METHODS: A case scenario involving a representative patient who developed central venous catheter-associated bacteremia caused by coagulase-negative staphylococci and who received standard-of-care therapy was distributed to all nonpediatric IDC members of the Infectious Diseases Society of America's Emerging Infections Network in August 2003. Each member was suggested 1 of 10 treatment failure rates and asked whether he or she would accept or reject the given value. Logistic regression was used to evaluate the relationship between specific failure rates offered to respondents and their willingness to accept them using a methodology derived from contingent valuation. RESULTS: Among the 374 respondents (response rate, 54%), the median acceptable failure rate was 6.8%. Thus, one-half of the IDCs would have found a failure rate of 6.8% to be acceptable. Seventy-five percent of IDCs would have found a failure rate of 1.6% to be acceptable, and 25% of IDCs would have found a failure rate as high as 11.9% to be acceptable. CONCLUSIONS: The quantified acceptable failure rates, when used to interpret clinical trial or cohort study results, will help select optimal antimicrobial therapy durations for this specific condition. These findings are a critical step in the development of effective shared decision-making models.

Relationship between objective measures of peripheral arterial disease severity to self-reported quality of life in older adults with intermittent claudication.

OBJECTIVES: The aim of this study was to determine the relation between functional measures of peripheral arterial disease (PAD) severity with both disease-specific and generic self-reported health-related quality-of-life (HR-QOL) measures, as well as the relation between the two types of HR-QOL measures. METHODS: This was a cross-sectional observation of participants from the community and primary care or vascular surgery clinics in an academic Veterans Administration medical center. Eighty patients with symptomatic Fontaine stage II PAD provided physiologic measures and self-response questionnaires. Objective measures included the ankle-brachial index (ABI), time to maximum claudication pain on a graded exercise test, and a 6-minute floor-walking distance. Self-reports included the Walking Impairment Questionnaire (WIQ), a disease-specific HR-QOL measure and the Medical Outcomes Study (MOS) Short-Form 36 (SF-36), a generic HR-QOL measure. RESULTS: Patients (mean age 70 +/- 8 [+/- SD] and 85% men) exhibited moderate-to-severe PAD by objective measures of ABI (0.65 +/- 0.19) and time in minutes to maximal claudication on a graded exercise test (7:54 +/- 4:58). Significant correlations were found between these measures and the WIQ distance, MOS-Physical Function, and MOS-Role Limitations due to physical dysfunction. The SF-36 and the WIQ subscales were significantly correlated. CONCLUSION: In older PAD patients with intermittent claudication, objective measures of disease severity are correlated with a self-reported, disease-specific and generic HR-QOL.