Healthcare practitioner experiences and willingness to prescribe pre-exposure prophylaxis in the US.

BACKGROUND AND OBJECTIVES: Less than 10 percent of the more than one million people vulnerable to HIV are using pre-exposure prophylaxis (PrEP). Practitioners are critical to ensuring the delivery of PrEP across care settings. In this study, we target a group of prescribers focused on providing HIV care and seeking up-to-date information about HIV. We assessed their experiences prescribing PrEP, whether these experiences differed by clinical specialty, and examined associations between willingness to prescribe PrEP as a "best first step" and different hypothetical prescribing scenarios. SETTING AND METHODS: Between March and May 2015, we circulated a paper survey to 954 participants ((652 of whom met our inclusion criteria of being independent prescribers and 519 of those (80%) responded to the survey)) at continuing medical education advanced-level HIV courses in five locations across the US on practitioner practices and preferences of PrEP. We employed multivariable logistic regression analysis for binary and collapsed ordinal outcomes. RESULTS: Among this highly motivated group of practitioners, only 54% reported ever prescribing PrEP. Internal medicine practitioners were 1.6 times more likely than infectious disease practitioners to have prescribed PrEP (95% CI: 0.99-2.60, p = .0524) and age, years of training, and sex were significantly associated with prescribing experience. Based on clinical vignettes describing different hypothetical prescribing scenarios, practitioners who viewed PrEP as the first clinical step for persons who inject drugs (PWID) were twice as likely to have also considered PrEP as the first clinical option for safer conception, and vice-a-versa (95% CI: 1.4-3.2, p < .001). Practitioners considering PrEP as the first preventive option for MSM were nearly six times as likely to also consider PrEP as the first clinical step for PWID, and vice-a-versa (95% CI: 2.28-13.56, p = .0002). CONCLUSIONS: Our findings indicate that even among a subset of HIV-focused practitioners, PrEP prescribing is not routine. This group of practitioners could be an optimal group to engage individuals that could most benefit from PrEP.

Dense Breast Notification Laws: Impact on Downstream Imaging After Screening Mammography.

Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Many states have recently enacted dense breast notification (DBN) laws to provide patients with information to help them make better-informed decisions about their health. To test whether DBN legislation affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI), we examined the proportion of times screening mammography was followed by ultrasound or MRI for a series of months pre- and post-legislation. The subjects were women aged 40 to 64 years, covered by private health insurance, undergoing screening mammography from 2007 to 2014. Except for Hawaii, Maryland, and New York, DBN legislation significantly increased the probability of ultrasound follow-up in all states that implemented DBN legislation before December 2014. It also increased the probability of MRI follow-up in California, North Carolina, Pennsylvania, and Texas. The financial and access consequences merit further study.

Inappropriate Antibiotic Prescribing for Acute Bronchitis in Children and Impact on Subsequent Episodes of Care and Treatment.

BACKGROUND: To examine whether inappropriate antibiotic treatment for an initial bout of acute bronchitis in childhood affects patterns of future healthcare utilization and antibiotic prescribing. METHODS: We conducted a retrospective analysis of children with at least 1 acute bronchitis episode, defined as the 14-day period after an acute bronchitis visit, born in 2008 and followed through 2015 in a nationally representative commercial claims database. We predicted the likelihood of returning for a subsequent acute bronchitis episode, and being prescribed an antibiotic as part of that episode, as a function of whether or not the child was prescribed an antibiotic as part of the first acute bronchitis episode controlling for patient, provider and practice characteristics. RESULTS: Children prescribed an antibiotic as part of their initial acute bronchitis episode were more likely both to have a subsequent acute bronchitis episode (hazard ratio = 1.23; 95% confidence interval: 1.17-1.30) and to be prescribed an antibiotic as part of that second episode (hazard ratio = 2.13; 95% confidence interval: 1.99-2.28) compared with children who were not prescribed as part of their first episode. Children diagnosed with asthma were more likely to experience a second visit for acute bronchitis, but less likely to receive an antibiotic as part of that second episode. CONCLUSIONS: Inappropriate antibiotic prescribing for a child's initial acute bronchitis episode of care predicted likelihood of subsequent acute bronchitis episodes and antibiotic prescriptions. Providers should consider the downstream effect of inappropriate antibiotic prescribing for acute bronchitis in childhood.

Cost-effectiveness of preexposure prophylaxis for HIV prevention for conception in the United States.

OBJECTIVE: The aim of this study was to investigate the value of coformulated Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) for preexposure prophylaxis (PrEP) for conception in the U.S. and to identify scenarios in which 'Undetectable = Untransmittable' (U = U) may not be adequate, and rather, PrEP or assisted reproduction would improve outcomes. DESIGN: We developed a Markov cohort simulation model to estimate the incremental benefits and cost-effectiveness of PrEP compared with alternative safer conception strategies, including combination antiretroviral therapy (cART) alone for the HIV-infected partner and assisted reproductive technologies. We modelled various scenarios in which HIV RNA suppression in the male partner was less than perfect. SETTING: U.S. healthcare sector perspective. PARTICIPANTS: Serodiscordant couples in the U.S. was composed of an HIV-infected male and HIV-uninfected female seeking conception. INTERVENTION: Economic analysis. MAIN OUTCOME MEASURE(S): Cumulative risks of HIV transmission to women and babies, maternal life expectancy, discounted quality-adjusted life years (QALY), discounted lifetime medical costs and incremental cost-effectiveness ratios. RESULTS: cART with condomless intercourse limited to ovulation was the preferred HIV prevention strategy among women seeking to conceive with an HIV-infected partner who is HIV-suppressed. PrEP was not cost-effective for women who had partners who were virologically suppressed. When the probability of male partner HIV suppression was low and we assumed generic pricing of PrEP, PrEP was cost-effective, and sometimes even cost-saving compared with cART alone. CONCLUSION: From a U.S. healthcare sector perspective, when the male partner was not reliably suppressed, PrEP became economically attractive, and in some cases, cost-saving.

Characteristics of State Policies Impact Health Care Delivery: An Analysis of Mammographic Dense Breast Notification and Insurance Legislation.

BACKGROUND: Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies. OBJECTIVE: To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound. RESEARCH DESIGN: This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws. SUBJECTS: A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40-64 years that resided in a state that had implemented relevant legislation during that period. MEASURES: The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators. RESULTS: Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect. CONCLUSIONS: The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

Meta-Analysis of Sulfonylurea Therapy on Long-Term Risk of Mortality and Cardiovascular Events Compared to Other Oral Glucose-Lowering Treatments.

INTRODUCTION: Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies. METHODS: The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses. RESULTS: SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise. CONCLUSION: Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.

Hepatitis C Is Poorly Associated With Drug Use in Cambodian Americans in Lowell, Massachusetts.

Background. Hepatitis C (HCV) is the most common chronic blood-borne infection in the United States and affects Asian and non-Asian Americans comparably. Injection drug use, the most common national transmission risk, is not as prevalent in Asian-Americans, but prior studies do not include many Cambodian Americans. Lowell, Massachusetts has the second largest population of Cambodian Americans, allowing a direct comparison of HCV-infected Cambodian and non-Cambodian Americans not previously done. Improving our understanding of HCV risks in this unique community may improve their linkage to care. Methods. In this cross-sectional study, medical data were collected regarding HCV risk factors for HCV-infected Cambodian and non-Cambodian Americans seen at Lowell Community Health Center from 2009 to 2012. Results. Cambodian Americans (n = 128) were older (mean age 53 vs 43 years old) and less likely to be male (41% vs 67%, P < .001) compared with non-Cambodians (n = 541). Cambodians had lower rates of injection drug use (1.6% vs 33.6%, P < .001) and any drug use (2.3% vs 82.1%, P < .001). More Cambodians were born between 1945 and 1965 (66.4% vs 44.5%). Within this birth cohort, more Cambodians had no other risk factor (82% vs 69%, P = .02). Fewer Cambodians had chronic HCV (53% vs 74%, P < .001). Conclusions. Birth between 1945 and 1965 was the major HCV risk factor for Cambodian Americans. Cambodians had lower rates of injection drug use or any drug use history. Risk behavior screening fails to describe HCV transmission for Cambodian Americans and creates a barrier to their linkage to care.

Hemoglobin Level and Hospital Mortality Among ICU Patients With Cardiac Disease Who Received Transfusions.

BACKGROUND: There is a paucity of randomized clinical trial data on the use of red blood cell (RBC) transfusion in critically ill patients, specifically in the setting of cardiac disease. OBJECTIVES: This study examined how hemoglobin (Hgb) level and cardiac disease modify the relationship of RBC transfusion with hospital mortality. The aim was to estimate the Hgb level threshold below which transfusion would be associated with reduced hospital mortality. METHODS: We performed secondary data analyses of Veterans Affairs intensive care unit (ICU) episodes across 5 years. Logistic regression quantified the effect of transfusion on hospital mortality while adjusting for nadir Hgb level, demographic characteristics, admission information, comorbid conditions, and ICU admission diagnoses. RESULTS: Among 258,826 ICU episodes, 12.4% involved transfusions. Hospital death occurred in 11.6%. Without comorbid heart disease, transfusion was associated with decreased adjusted hospital mortality when Hgb was approximately <7.7 g/dl, but transfusion increased mortality above this Hgb level. Corresponding Hgb level thresholds were approximately 8.7 g/dl when comorbid heart disease was present and approximately 10 g/dl when the ICU admission diagnosis was acute myocardial infarction (AMI). Sensitivity analysis using additional adjustment for selected blood tests in a subgroup of 182,792 ICU episodes lowered these thresholds by approximately 1 g/dl. CONCLUSIONS: Transfusion of critically ill patients was associated with reduced hospital mortality when Hgb level was <8 to 9 g/dl in the presence of comorbid heart disease. This Hgb level threshold for transfusion was 9 to 10 g/dl when AMI was the ICU admission diagnosis.

Effect of Right-Sided Versus Left-Sided Contrast Injection on Intra-arterial Opacification Characteristics of Head and Neck Computed Tomography Angiograms and Interactions With Patient Sex, Weight, and Cardiac Output.

OBJECTIVE: The aims of this study were to support the standard clinical assumption that preferential right-sided injection (RSI) over left-sided injection (LSI) results in improved head and neck computed tomography angiograms and to determine which patients most benefit from RSIs. METHODS: Head and neck computed tomography angiograms of 453 RSIs and 419 LSIs were included. Interactions between injection side, age, weight, body mass index, and left ventricular ejection fraction with mean vessel Hounsfield units (HU) were compared. Statistical analysis was performed using 2-tailed Student t tests, Mann-Whitney U tests, and simple linear (SL) and multiple linear regressions. RESULTS: Right-sided injection yielded higher HU for patients older than 40 years (eg, RSI of the right common carotid artery [RCCA] vs LSI of the RCCA; P < 0.01). Body mass index (eg, RCCA; r = -0.31, P < 0.01 [SL]) and weight (eg, RCCA; r = -0.39, P < 0.01 [SL]) were negatively correlated with HU. Female had higher HU (mean ± SE, +39.7 ± 7.6 HU; P < 0.01 [multiple linear]). Left ventricular ejection fraction had no interactions with injection side or HU. CONCLUSIONS: The findings support preferential RSI in patients older than 40 years with higher body mass index and weight, particularly male.

Antibiotics for respiratory tract infections: a comparison of prescribing in an outpatient setting.

OBJECTIVE: To examine inappropriate antibiotic prescribing for acute respiratory tract infections (RTIs) in ambulatory care to help target antimicrobial stewardship interventions. Design and Setting Retrospective analysis of RTI visits within general internal medicine (GIM) and family medicine (FM) ambulatory practices at an inner-city academic medical center from 2008 to 2010. METHODS: Patient, physician, and practice characteristics were analyzed using multivariable logistic regression to determine factors predictive of inappropriate prescribing; physicians in the highest and lowest antibiotic-prescribing quartiles were compared using χ2 analysis. RESULTS: Visits with FM providers, female gender, and self-reported race/ethnicity as white or Hispanic were significantly associated with inappropriate antibiotic prescribing. Physicians in the lowest quartile prescribed antibiotics for 5%-28% (mean, 21%) of RTI visits; physicians in the highest quartile prescribed antibiotics for 54%-85% (mean, 65%) of RTI visits. High prescribers had fewer African-American patients and more patients who were younger and privately insured. High prescribers had more patients with chronic lung disease. A GIM practice pod with a low prescriber was 3.0 times more likely to have a second low prescriber than other practice pods, whereas pods with a high prescriber were 1.3 times more likely to have a second high prescriber. CONCLUSIONS: Medical specialty was the only physician factor predictive of inappropriate prescribing when patient gender, race, and comorbidities were taken into account. Possible disparities in care need further study. Stewardship education in medical school, enlisting low prescribers as physician leaders, and targeting interventions to the highest prescribers might be more effective approaches to antimicrobial stewardship.

Suicide risk in Veterans Health Administration patients with mental health diagnoses initiating lithium or valproate: a historical prospective cohort study.

BACKGROUND: Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate. METHODS: A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008. RESULTS: Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015). CONCLUSIONS: In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.

A probability metric for identifying high-performing facilities: an application for pay-for-performance programs.

BACKGROUND: Two approaches are commonly used for identifying high-performing facilities on a performance measure: one, that the facility is in a top quantile (eg, quintile or quartile); and two, that a confidence interval is below (or above) the average of the measure for all facilities. This type of yes/no designation often does not do well in distinguishing high-performing from average-performing facilities. OBJECTIVE: To illustrate an alternative continuous-valued metric for profiling facilities--the probability a facility is in a top quantile--and show the implications of using this metric for profiling and pay-for-performance. METHODS: We created a composite measure of quality from fiscal year 2007 data based on 28 quality indicators from 112 Veterans Health Administration nursing homes. A Bayesian hierarchical multivariate normal-binomial model was used to estimate shrunken rates of the 28 quality indicators, which were combined into a composite measure using opportunity-based weights. Rates were estimated using Markov Chain Monte Carlo methods as implemented in WinBUGS. The probability metric was calculated from the simulation replications. RESULTS: Our probability metric allowed better discrimination of high performers than the point or interval estimate of the composite score. In a pay-for-performance program, a smaller top quantile (eg, a quintile) resulted in more resources being allocated to the highest performers, whereas a larger top quantile (eg, being above the median) distinguished less among high performers and allocated more resources to average performers. CONCLUSION: The probability metric has potential but needs to be evaluated by stakeholders in different types of delivery systems.

Physician nonadherence with a hepatitis C screening program.

BACKGROUND: Testing for patients at risk for hepatitis C virus (HCV) infection is recommended, but it is unclear whether providers adhere to testing guidelines. We aimed to measure adherence to an HCV screening protocol during a multifaceted continuous intervention. SUBJECTS AND METHODS: Prospective cohort design to examine the associations between patient-level, physician-level, and visit-level characteristics and adherence to an HCV screening protocol. Study participants included all patients with a visit to 1 of the 3 study clinics and the physicians who cared for them. Adherence to the HCV screening protocol and patient-level, physician-level, and visit-level predictors of adherence were measured. RESULTS: A total of 8981 patients and 154 physicians were examined. Overall protocol adherence rate was 36.1%. In multivariate analysis, patient male sex (odds ratio [OR] = 1.18), new patient (OR = 1.23), morning visit (OR = 1.32), and patients' preferred language being non-English (OR = 0.87) were significantly associated with screening adherence. There was a wide variation in overall adherence among physicians (range, 0%-92.4%). Screening adherence continuously declined from 59.1% in week 1 of the study to 13.7% in week 15 (final week). When implementing complex clinical practice guidelines, planners should address physician attitudinal barriers as well as gaps in knowledge to maximize adherence.

Melanoma epidemic: an analysis of six decades of data from the Connecticut Tumor Registry.

PURPOSE: Melanoma is the most commonly fatal form of skin cancer, with nearly 50,000 annual deaths worldwide. We sought to assess long-term trends in the incidence and mortality of melanoma in a state with complete and consistent registration. METHODS: We used data from the Connecticut Tumor Registry, the original National Cancer Institute SEER site, to determine trends in invasive melanoma (1950-2007), in situ melanoma (1973-2007), tumor thickness (1993-2007), mortality (1950-2007), and mortality to incidence (1950-2007) among the 19,973 and 3,635 Connecticut residents diagnosed with invasive melanoma (1950-2007) and who died as a result of melanoma (1950-2007), respectively. Main outcome measures included trends in incidence and mortality by age, sex, and birth cohort. RESULTS: In the initial period (1950-1954), a diagnosis of invasive melanoma was rare, with 1.9 patient cases per 100,000 for men and 2.6 patient cases per 100,000 for women. Between 1950 and 2007, overall incidence rates rose more than 17-fold in men (1.9 to 33.5 per 100,000) and more than nine-fold in women (2.6 to 25.3 per 100,000). During these six decades, mortality rates more than tripled in men (1.6 to 4.9 per 100,000) and doubled in women (1.3 to 2.6 per 100,000). Mortality rates were generally stable or decreasing in men and women through age 54 years. CONCLUSION: Unremitting increases in incidence and mortality of melanoma call for a nationally coordinated effort to encourage and promote innovative prevention and early-detection efforts.

Cardiovascular disease risk factors among women veterans at VA medical facilities.

BACKGROUND: Hypertension, hyperlipidemia, diabetes, and obesity in middle adulthood each elevate the long-term risk of cardiovascular disease (CVD). The prevalence of these conditions among women veterans is incompletely described. OBJECTIVE: To describe the prevalence of CVD risk factors among women veterans in middle adulthood. DESIGN: Serial cross-sectional studies of data from the Diabetes Epidemiologic Cohorts (DEpiC), a national, longitudinal data set including information on all patients in the Veterans Health Administration (VA). PARTICIPANTS: Women veterans (n = 255,891) and men veterans (n = 2,271,605) aged 35-64 receiving VA care in fiscal year (FY) 2010. MAIN MEASURES: Prevalence of CVD risk factors in FY2010 by age and, for those aged 45-54 years, by race, region, period of military service, priority status, and mental illness or substance abuse; prevalence by year from 2000 to 2010 in women veterans receiving VA care in both 2000 and 2010 who were free of the factor in 2000. KEY RESULTS: Hypertension, hyperlipidemia, and diabetes were common among women and men, although more so among men. Hypertension was present in 13 % of women aged 35-44 years, 28 % of women aged 45-54, and 42 % of women aged 55-64. Hyperlipidemia prevalence was similar. Diabetes affected 4 % of women aged 35-44, and increased more than four-fold in prevalence to 18 % by age 55-64. The prevalence of obesity increased from 14 % to 18 % with age among women and was similarly prevalent in men. The relative rate of having two or more CVD risk factors in women compared to men increased progressively with age, from 0.55 (35-44 years) to 0.71 (45-54) to 0.73 (55-64). Most of the women with a factor present in 2010 were first diagnosed with the condition in the 10 years between 2000 and 2010. CONCLUSIONS: CVD risk factors are common among women veterans aged 35-64. Future research should investigate which interventions would most effectively reduce risk in this population.

Shrinkage estimators for a composite measure of quality conceptualized as a formative construct.

OBJECTIVE: To demonstrate the value of shrinkage estimators when calculating a composite quality measure as the weighted average of a set of individual quality indicators. DATA SOURCES: Rates of 28 quality indicators (QIs) calculated from the minimum dataset from residents of 112 Veterans Health Administration nursing homes in fiscal years 2005-2008. STUDY DESIGN: We compared composite scores calculated from the 28 QIs using both observed rates and shrunken rates derived from a Bayesian multivariate normal-binomial model. PRINCIPAL FINDINGS: Shrunken-rate composite scores, because they take into account unreliability of estimates from small samples and the correlation among QIs, have more intuitive appeal than observed-rate composite scores. Facilities can be profiled based on more policy-relevant measures than point estimates of composite scores, and interval estimates can be calculated without assuming the QIs are independent. Usually, shrunken-rate composite scores in 1 year are better able to predict the observed total number of QI events or the observed-rate composite scores in the following year than the initial year observed-rate composite scores. CONCLUSION: Shrinkage estimators can be useful when a composite measure is conceptualized as a formative construct.

Person-centered care practices and quality in Department of Veterans Affairs nursing homes: is there a relationship?

OBJECTIVE: To examine variation in culture change to a person-centered care (PCC) model, and the association between culture change and a composite measure of quality in 107 Department of Veterans Affairs nursing homes. METHODS: We examined the relationship between a composite quality measure calculated from 24 quality indicators (QIs) from the Minimum Data Set (that measure unfavorable events), and PCC summary scores calculated from the 6 domains of the Artifact of Culture Change Tool, using 3 different methods of calculating the summary scores. We also use a Bayesian hierarchical model to analyze the relationship between a latent construct measuring extent of culture change and the composite quality measure. RESULTS: Using the original Artifacts scores, the highest performing facility has a 2.9 times higher score than the lowest. There is a statistically significant relationship between the composite quality measure and each of the 3 summary Artifacts scores. Depending on whether original scores, standardized scores, or optimal scores are used, a facility at the 10th percentile in terms of culture change compared with one at the 90th percentile has 8.0%, 8.9%, or 10.3% more QI events. When PCC implementation is considered as a latent construct, 18 low performance PCC facilities have, on an average, 16.3% more QI events than 13 high performance facilities. CONCLUSIONS: Our results indicate that culture change to a PCC model is associated with higher Minimum Data Set-based quality. Longitudinal data are needed to better assess whether there is a causal relationship between the extent of culture change and quality.

Outcome of a randomized study of a mental health peer education and support group in the VA.

OBJECTIVES: Study objectives were to compare mental health outcomes of a peer-led recovery group, a clinician-led recovery group, and usual treatment and to examine the effect of group attendance on outcomes. METHODS: The study used a randomized design with three groups: a recovery-oriented peer-led group (Vet-to-Vet), a clinician-led recovery group, and usual treatment. The sample included 240 veterans. Recovery and mental health assessments were obtained at enrollment and three months later. Intention-to-treat analysis using mixed-model regression was performed to examine the effect of the intervention. "As treated" analysis was performed to examine the effect of group attendance. RESULTS: There were no statistically significant differences in improvement among the groups. Across groups, depression and functioning, psychotic symptoms, and overall mental health improved significantly. Better group attendance was associated with more improvement. CONCLUSIONS: This study adds to the evidence suggesting no short-term incremental benefit (or harm) from peer services beyond usual care.

Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting.

OBJECTIVES: We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers. METHODS: A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ(2) test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener. RESULTS: Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified. CONCLUSIONS: A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.