Fentanyl in the labor epidural impacts the results of intrapartum and postpartum maternal and neonatal toxicology tests.

BACKGROUND: A positive urine fentanyl toxicology test may have considerable consequences for peripartum individuals, yet the extent to which fentanyl administration in a labor epidural may lead to such a positive test is poorly characterized. OBJECTIVE: This study aimed to quantify the extent to which neuraxial fentanyl in labor neuraxial analgesia can lead to a positive peripartum maternal or neonatal urine toxicology test. STUDY DESIGN: We performed a prospective cohort study of pregnant participants planning a vaginal delivery with neuraxial analgesia. Participants with a history of substance use disorder, hypertension, or renal or liver disease were excluded. A urine sample was collected before initiation of neuraxial analgesia, each time the bladder was emptied during labor, and up to 4 times postpartum. Neonatal urine was collected once. Urine fentanyl testing was performed using 2 common toxicology testing methods, namely immunoassay and liquid chromatography with tandem mass spectrometric detection. RESULTS: A total of 33 maternal-infant dyads yielded a total of 178 urine specimens. All maternal specimens were negative for fentanyl using liquid chromatography with tandem mass spectrometric analysis and immunoassay before initiation of neuraxial analgesia. Intrapartum, 26 of 30 (76.7%) participants had positive liquid chromatography with tandem mass spectrometry results for fentanyl or its metabolites, and 12 of 30 (40%) participants had positive immunoassay results. Postpartum, 19 of 21 (90.5%) participants had positive liquid chromatograph with tandem mass spectrometric results, and 13 of 21 (61.9%) had a positive immunoassay result. Of the 13 neonatal specimens collected, 10 (76.9%) were positive on liquid chromatography with tandem mass spectrometry analysis, the last of which remained positive 29 hours and 50 minutes after delivery. CONCLUSION: Neuraxial fentanyl for labor analgesia may lead to positive maternal and neonatal toxicology tests at various times after epidural initiation and cessation and at different rates depending on the testing method used. Caution should be used in interpreting toxicology test results of individuals who received neuraxial analgesia to avoid false assumptions about nonprescribed use.

The Association Between Neighborhood Environment and Mortality: Results from a National Study of Veterans.

BACKGROUND: As the largest integrated US health system, the Veterans Health Administration (VHA) provides unique national data to expand knowledge about the association between neighborhood socioeconomic status (NSES) and health. Although living in areas of lower NSES has been associated with higher mortality, previous studies have been limited to higher-income, less diverse populations than those who receive VHA care. OBJECTIVE: To describe the association between NSES and all-cause mortality in a national sample of veterans enrolled in VHA primary care. DESIGN: One-year observational cohort of veterans who were alive on December 31, 2011. Data on individual veterans (vital status, and clinical and demographic characteristics) were abstracted from the VHA Corporate Data Warehouse. Census tract information was obtained from the US Census Bureau American Community Survey. Logistic regression was used to model the association between NSES deciles and all-cause mortality during 2012, adjusting for individual-level income and demographics, and accounting for spatial autocorrelation. PARTICIPANTS: Veterans who had vital status, demographic, and NSES data, and who were both assigned a primary care physician and alive on December 31, 2011 (n = 4,814,631). MAIN MEASURES: Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized NSES. Veteran addresses were geocoded and linked to census tract NSES scores. Census tracts were divided into NSES deciles. KEY RESULTS: In adjusted analysis, veterans living in the lowest-decile NSES tract were 10 % (OR 1.10, 95 % CI 1.07, 1.14) more likely to die than those living in the highest-decile NSES tract. CONCLUSIONS: Lower neighborhood SES is associated with all-cause mortality among veterans after adjusting for individual-level socioeconomic characteristics. NSES should be considered in risk adjustment models for veteran mortality, and may need to be incorporated into strategies aimed at improving veteran health.

Clinician Perceptions of Teamwork in the Emergency Department: Does Nurse and Medical Provider Workspace Placement Make a Difference?

OBJECTIVE: This study was intended to determine whether positioning emergency department (ED) physicians, physician assistants, and nurse practitioners at the same workstations as registered nurses (RNs) improved communication and teamwork. BACKGROUND: Historically in this organization, providers and staff had separate physical locations (workstations). Construction of a new ED provided the opportunity to redesign the physical layout and to study whether a new design improved the perception of communication and teamwork among medical providers. METHODS: A prospective, self-administered presurvey-postsurvey using the TeamSTEPPS Teamwork Perceptions Questionnaire (TPQ) was completed at 2 medical centers with the same staff premove and postmove but different ED designs. The presurvey was conducted while the staff were at the older facility with a more linear floor design and separated nurse and physician stations. The postsurvey was conducted 3 months after employees and physicians were relocated to a new hospital with a pod design and communal workstations in the ED. RESULTS: Forty-six staff members completed both the presurvey and the postsurvey. There was a statistically significant improvement in the total TPQ scores (P = .0009) and 4 of the 5 components of the TPQ: team structure (P = .0283), situation monitoring (P = .0006), mutual support (P < .0001), and communication (P < .0001). There was no change in the leadership component (P = .4519). CONCLUSIONS: Adopting a more communal physical layout was associated with improved overall TPQ scores and most of the TPQ components. The lack of change in the leadership component was explained by the lack of change in leadership structure. The physical placement of medical providers and RNs in an ED is important and can increase the perception of communication and teamwork and thereby improve patient outcomes.

A First Look at PCMH Implementation for Minority Veterans: Room for Improvement.

BACKGROUND: Implementation of Patient Aligned Care Teams (PACT), a patient-centered medical home model, has been inconsistent among the >900 primary care facilities in the Veterans Health Administration. OBJECTIVE: Estimate if the degree of PACT implementation at a facility varied with the percentage of minority veteran patients at the facility. RESEARCH DESIGN: Cross-sectional, facility-level analysis of PACT implementation measures in 2012. SUBJECTS: Veterans Health Administration hospital-based and community-based primary care facilities. MEASURES: We used a previously validated PACT Implementation Progress Index (Pi) and its 8 domains: access, continuity of care, care coordination, comprehensiveness, self-management support, and patient-centered care and communication, shared decision-making domains, and team functioning. Facilities were categorized as low (<5.2%, n=208), medium (5.2%-25.8%, n=413), and high (>25.8%, n=206) percent minority based on the percent of their own veteran population. RESULTS: Most minority veterans received care in high minority (69%) and medium minority facilities (29%). In adjusted analyses, medium and high minority facilities scored 0.773 (P=0.009) and 0.930 (P=0.008) points lower on the Pi score relative to low minority facilities. Relative to low minority facilities, both medium and high minority facilities were less likely of having high Pi scores (≥2) and more likely of having low Pi scores (≤-2). Both medium and high minority facilities had the same 3 domain scores lower than low minority facilities (care coordination, comprehensiveness, and self-management). CONCLUSION: Overall PACT implementation varied with respect to the racial/ethnic composition of a facility, with medium and high minority facilities having a lower implementation scores.

Association between local area unemployment rates and use of Veterans Affairs outpatient health services.

BACKGROUND: Prior research indicates that federal spending on Medicare, Medicaid, and other government health programs accelerated during the Great Recession. OBJECTIVES: To examine whether local unemployment was associated with utilization of Veterans Affairs Health Care System (VA) primary care, specialty care, and mental health services during 2004-2012. RESEARCH DESIGN: We analyzed utilization of VA health services at the clinic level using fixed-effects negative binomial models. We stratified analyses by veterans' copayment status (exempt and nonexempt) and age (under 65 and 65+) to account for differences in VA utilization because of Medicare eligibility. SUBJECTS: A total of 11,041,855 veterans assigned to 892 clinics identified in the VA Primary Care Management Module, representing nearly all veterans receiving primary care from VA, were included. MEASURES: Clinic-level utilization was calculated quarterly as the total number of visits for patients assigned to a clinic. Local area unemployment rates were defined as quarterly unemployment rates within VA geographical planning sectors. RESULTS: Higher local unemployment was associated with greater use of VA care in all categories among veterans exempt from copayments. The association between local unemployment and utilization differed by age group among veterans subject to copayments. Higher local unemployment was associated with lower use of primary and specialty care among Medicare-eligible veterans aged 65+, but greater use of primary care among veterans under age 65. CONCLUSIONS: Our findings highlight the importance of the state of the economy in interpreting and forecasting demand for government health programs including VA, particularly during periods focused on deficit reduction.

Patient-centered medical home implementation and primary care provider turnover.

BACKGROUND: The Veterans Health Administration (VHA) began implementing a patient-centered medical home (PCMH) model of care delivery in April 2010 through its Patient Aligned Care Team (PACT) initiative. PACT represents a substantial system reengineering of VHA primary care and its potential effect on primary care provider (PCP) turnover is an important but unexplored relationship. This study examined the association between a system-wide PCMH implementation and PCP turnover. METHODS: This was a retrospective, longitudinal study of VHA-employed PCPs spanning 29 calendar quarters before PACT and eight quarters of PACT implementation. PCP employment periods were identified from administrative data and turnover was defined by an indicator on the last quarter of each uncensored period. An interrupted time series model was used to estimate the association between PACT and turnover, adjusting for secular trend and seasonality, provider and job characteristics, and local unemployment. We calculated average marginal effects (AME), which reflected the change in turnover probability associated with PACT implementation. RESULTS: The quarterly rate of PCP turnover was 3.06% before PACT and 3.38% after initiation of PACT. In adjusted analysis, PACT was associated with a modest increase in turnover (AME=4.0 additional PCPs per 1000 PCPs per quarter, P=0.004). Models with interaction terms suggested that the PACT-related change in turnover was increasing in provider age and experience. CONCLUSIONS: PACT was associated with a modest increase in PCP turnover, concentrated among older and more experienced providers, during initial implementation. Our findings suggest that policymakers should evaluate potential workforce effects when implementing PCMH.

Emerging lessons from regional and state innovation in value-based payment reform: balancing collaboration and disruptive innovation.

CONTEXT: In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. METHODS: As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. FINDINGS: The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. CONCLUSIONS: From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments.

Patient-centered innovation in health care organizations: a conceptual framework and case study application.

BACKGROUND: Patient-centered innovation is spreading at the federal and state levels. A conceptual framework can help frame real-world examples and extract systematic learning from an array of innovative applications currently underway. The statutory, economic, and political environment in Washington State offers a special contextual laboratory for observing the interplay of these factors. PURPOSE: We propose a framework for understanding the process of initiating patient-centered innovations-particularly innovations addressing patient-centered goals of improved access, continuity, communication and coordination, cultural competency, and family- and person-focused care over time. The framework to a case study of a provider organization in Washington State actively engaged in such innovations was applied in this article. METHODS: We conducted a selective review of peer-reviewed evidence and theory regarding determinants of organizational change. On the basis of the literature review and the particular examples of patient-centric innovation, we developed a conceptual framework. Semistructured key informant interviews were conducted to illustrate the framework with concrete examples of patient-centered innovation. FINDINGS: The primary determinants of initiating patient-centered innovation are (a) effective leadership, with the necessary technical and professional expertise and creative skills; (b) strong internal and external motivation to change; (c) clear and internally consistent organizational mission; (d) aligned organizational strategy; (e) robust organizational capability; and (f) continuous feedback and organizational learning. The internal hierarchy of actors is important in shaping patient-centered innovation. External financial incentives and government regulations also significantly shape innovation. PRACTICE IMPLICATIONS: Patient-centered care innovation is a complex process. A general framework that could help managers and executives organize their thoughts around innovation within their organization is presented.

Innovation in patient-centered care: lessons from a qualitative study of innovative health care organizations in Washington State.

BACKGROUND: Growing interest in the promise of patient-centered care has led to numerous health care innovations, including the patient-centered medical home, shared decision-making, and payment reforms. How best to vet and adopt innovations is an open question. Washington State has been a leader in health care reform and is a rich laboratory for patient-centered innovations. We sought to understand the process of patient-centered care innovation undertaken by innovative health care organizations - from strategic planning to goal selection to implementation to maintenance. METHODS: We conducted key-informant interviews with executives at five health plans, five provider organizations, and ten primary care clinics in Washington State. At least two readers of each interview transcript identified themes inductively; final themes were determined by consensus. RESULTS: Innovation in patient-centered care was a strategic objective chosen by nearly every organization in this study. However, other goals were paramount: cost containment, quality improvement, and organization survival. Organizations commonly perceived effective chronic disease management and integrated health information technology as key elements for successful patient-centered care innovation. Inertia, resource deficits, fee-for-service payment, and regulatory limits on scope of practice were cited as barriers to innovation, while organization leadership, human capital, and adaptive culture facilitated innovation. CONCLUSIONS: Patient-centered care innovations reflected organizational perspectives: health plans emphasized cost-effectiveness while providers emphasized health care delivery processes. Health plans and providers shared many objectives, yet the two rarely collaborated to achieve them. The process of innovation is heavily dependent on organizational culture and leadership. Policymakers can improve the pace and quality of patient-centered innovation by setting targets and addressing conditions for innovation.

Behavioral Health Integration in Community Health Centers and Emergency Department Use.

Medicaid enrollees with behavioral health disorders often experience fragmented care, leading to high rates of preventable use of emergency departments (EDs). As part of its Medicaid Transformation Program, the Washington Health Care Authority partnered with regional accountable communities of health to collect data on behavioral health integration in community health centers. Clinics who participated in the integrated care demonstration received technical and financial support to increase capacity for integration. This column describes results from an analysis that linked clinic surveys to Medicaid claims to explore characteristics of highly integrated clinics and assess whether clinic capacity for behavioral health integration is associated with ED visit frequency.

Rolling Up the Sleeve: Equitable, Efficient, and Safe COVID-19 Mass Immunization for Academic Medical Center Employees.

BACKGROUND: Novel coronavirus disease 2019 (COVID-19) vaccine administration has faced distribution barriers across the United States. We sought to delineate our vaccine delivery experience in the first week of vaccine availability, and our effort to prioritize employees based on risk with a goal of providing an efficient infrastructure to optimize speed and efficiency of vaccine delivery while minimizing risk of infection during the immunization process. OBJECTIVE: This article aims to evaluate an employee prioritization/invitation/scheduling system, leveraging an integrated electronic health record patient portal framework for employee COVID-19 immunizations at an academic medical center. METHODS: We conducted an observational cross-sectional study during January 2021 at a single urban academic center. All employees who met COVID-19 allocation vaccine criteria for phase 1a.1 to 1a.4 were included. We implemented a prioritization/invitation/scheduling framework and evaluated time from invitation to scheduling as a proxy for vaccine interest and arrival to vaccine administration to measure operational throughput. RESULTS: We allotted vaccines for 13,753 employees but only 10,662 employees with an active patient portal account received an invitation. Of those with an active account, 6,483 (61%) scheduled an appointment and 6,251 (59%) were immunized in the first 7 days. About 66% of invited providers were vaccinated in the first 7 days. In contrast, only 41% of invited facility/food service employees received the first dose of the vaccine in the first 7 days (p < 0.001). At the vaccination site, employees waited 5.6 minutes (interquartile range [IQR]: 3.9-8.3) from arrival to vaccination. CONCLUSION: We developed a system of early COVID-19 vaccine prioritization and administration in our health care system. We saw strong early acceptance in those with proximal exposure to COVID-19 but noticed significant difference in the willingness of different employee groups to receive the vaccine.

[Comparison between five growth curves used in a public hospital]. / Comparación de cinco curvas de crecimiento de uso habitual para prematuros en un hospital público.

OBJECTIVE: To compare five curves routinely used for growth evaluation in preterm newborns in a public hospital in Leon, Guanajuato, and to identify those with similar diagnosis according to the reference curve (Williams) in order to determine their usefulness in the clinical practice. METHODS: Analytical, prospective, comparative and cross sectional study in 100 preterm infants, of both sexes, 30 to 36 weeks of gestation without congenital malformations. We obtained the weight and length for their interpretation and to compare the nutritional diagnosis, between five curves routinely used for growth evaluation in preterm newborns: Babson-Benda, Fenton, Jurado-Garcia, Battaglia-Lubchenco and Williams, subsequently, four of the curves were compared against the reference curve (Williams). To analyse the proportions, the chi2 statistic was used. RESULTS: The average age of the preterm infants was 34 +/- 2 gestation weeks, with birth weight 1932 +/- 699 g. When the combination between them were, it was noted that Babson and Benda-Fenton showed similar distribution for the diagnosis of small for gestional age by 50%. Small for gestational age was diagnosed with the Jurado-Garcia, Williams, Battaglia-Lubchenco curves in 43, 38 and 29% respectively. The comparison showed that the curves of Jurado-Garcia and Battaglia-Lubchenco rendered a similar diagnosis, respect to the curve of Williams. CONCLUSIONS: According to this study, the curves of Jurado-Garcia and Battaglia- Lubchenco are recommended for evaluating the extra uterine and intrauterine growth of preterm infants.

Developing an Algorithm for Combining Race and Ethnicity Data Sources in the Veterans Health Administration.

INTRODUCTION: Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration's (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA's completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year. MATERIALS AND METHODS: We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare. RESULTS: Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare. CONCLUSIONS: We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense's VADIR, and (4) Medicare.

Latino access to the patient-centered medical home.

BACKGROUND: Disparities can be caused by minorities receiving care in low-quality settings. The patient-centered medical home (PCMH) has been identified as a model of high-quality primary care that can eliminate disparities. However, Latinos are less likely to have PCMHs. OBJECTIVE: To identify Latino subgroup variations in having a PCMH, its impact on disparities, and to identify factors associated with Latinos having a PCMH. DESIGN: Analysis of the 2005 MEPS Household Component, a nationally representative survey with an oversample of Latino adults. The total sample was 24,000 adults, including 6,200 Latinos. MEASUREMENTS: The PCMH was defined as having a regular provider, who provides total care, fosters patient engagement in care, and offers easy access to care. Self reports of preventive care (cholesterol screening, blood pressure check, mammography, and prostate-specific antigen screening) and patient experiences were examined. RESULTS: White (57.1%) and Puerto Rican (59.3%) adults were most likely to have a PCMH, while Mexican/Mexican Americans (35.4%) and Central and South Americans (34.2%) were least likely. Much of the disparity was caused by lack of access to a regular provider. Respondents with a PCMH had higher rates of preventive care and positive patient experiences. Disparities in care were eliminated or reduced for Latinos with PCMHs. The regression models showed private insurance, which is less common among all Latinos, was an important predictor of having a PCMH. CONCLUSIONS: Eliminating health-care disparities will require assuring access to the PCMH. Addressing differences in health-care coverage that contribute to lower rates of Latino access to the PCMH will also reduce disparities.

Rat neuronal nicotinic acetylcholine receptors containing alpha7 subunit: pharmacological properties of ligand binding and function.

AIM: To compare pharmacological properties of heterologously expressed homomeric alpha7 nicotinic acetylcholine receptors (alpha7 nAChRs) with those of native nAChRs containing alpha7 subunit (alpha7* nAChRs) in rat hippocampus and cerebral cortex. METHODS: We established a stably transfected HEK-293 cell line that expresses homomeric rat alpha7 nAChRs. We studies ligand binding profiles and functional properties of nAChRs expressed in this cell line and native rat alpha7* nAChRs in rat hippocampus and cerebral cortex. We used [(125)I]-alpha-bungarotoxin to compare ligand binding profiles in these cells with those in rat hippocampus and cerebral cortex. The functional properties of the alpha7 nAChRs expressed in this cell line were studied using whole-cell current recording. RESULTS: The newly established cell line, KXalpha7R1, expresses homomeric alpha7 nAChRs that bind [(125)I]-alpha-bungarotoxin with a K(d) value of 0.38+/-0.06 nmol/L, similar to K(d) values of native rat alpha7* nAChRs from hippocampus (K(d)=0.28+/-0.03 nmol/L) and cerebral cortex (K(d)=0.33+/-0.05 nmol/L). Using whole-cell current recording, the homomeric alpha7 nAChRs expressed in the cells were activated by acetylcholine and (-)-nicotine with EC(50) values of 280+/-19 micromol/L and 180+/-40 micromol/L, respectively. The acetylcholine activated currents were potently blocked by two selective antagonists of alpha7 nAChRs, alpha-bungarotoxin (IC(50)=19+/-2 nmol/L) and methyllycaconitine (IC(50)=100+/-10 pmol/L). A comparative study of ligand binding profiles, using 13 nicotinic ligands, showed many similarities between the homomeric alpha7 nAChRs and native alpha7* receptors in rat brain, but it also revealed several notable differences. CONCLUSION: This newly established stable cell line should be very useful for studying the properties of homomeric alpha7 nAChRs and comparing these properties to native alpha7* nAChRs.

Longer wait times affect future use of VHA primary care.

BACKGROUND: Improving access to the Veterans Health Administration (VHA) is a high priority, particularly given statutory mandates of the Veterans Access, Choice and Accountability Act. This study examined whether patient-reported wait times for VHA appointments were associated with future reliance on VHA primary care services. METHODS: This observational study examined 13,595 VHA patients dually enrolled in fee-for-service Medicare. Data sources included VHA administrative data, Medicare claims and the Survey of Healthcare Experiences of Patients (SHEP). Primary care use was defined as the number of face-to-face visits from VHA and Medicare in the 12 months following SHEP completion. VHA reliance was defined as the number of VHA visits divided by total visits (VHA+Medicare). Wait times were derived from SHEP responses measuring the usual number of days to a VHA appointment with patients' primary care provider for those seeking immediate care. We defined appointment wait times categorically: 0 days, 1day, 2-3 days, 4-7 days and >7 days. We used fractional logistic regression to examine the relationship between wait times and reliance. RESULTS: Mean VHA reliance was 88.1% (95% CI = 86.7% to 89.5%) for patients reporting 0day waits. Compared with these patients, reliance over the subsequent year was 1.4 (p = 0.041), 2.8 (p = 0.001) and 1.6 (p = 0.014) percentage points lower for patients waiting 2-3 days, 4-7 days and >7 days, respectively. CONCLUSIONS: Patients reporting longer usual wait times for immediate VHA care exhibited lower future reliance on VHA primary care. IMPLICATIONS: Longer wait times may reduce care continuity and impact cost shifting across two federal health programs.

Methods for Measuring Racial Differences in Hospitals Outcomes Attributable to Disparities in Use of High-Quality Hospital Care.

OBJECTIVE: To compare two approaches to measuring racial/ethnic disparities in the use of high-quality hospitals. DATA SOURCES: Simulated data. STUDY DESIGN: Through simulations, we compared the "minority-serving" approach of assessing differences in risk-adjusted outcomes at minority-serving and non-minority-serving hospitals with a "fixed-effect" approach that estimated the reduction in adverse outcomes if the distribution of minority and white patients across hospitals was the same. We evaluated each method's ability to detect and measure a disparity in outcomes caused by minority patients receiving care at poor-quality hospitals, which we label a "between-hospital" disparity, and to reject it when the disparity in outcomes was caused by factors other than hospital quality. PRINCIPAL FINDINGS: The minority-serving and fixed-effect approaches correctly identified between-hospital disparities in quality when they existed and rejected them when racial differences in outcomes were caused by other disparities; however, the fixed-effect approach has many advantages. It does not require an ad hoc definition of a minority-serving hospital, and it estimated the magnitude of the disparity accurately, while the minority-serving approach underestimated the disparity by 35-46 percent. CONCLUSIONS: Researchers should consider using the fixed-effect approach for measuring disparities in use of high-quality hospital care by vulnerable populations.

Local Area Unemployment and the Demand for Inpatient Care Among Veterans Affairs Enrollees.

Prior research examining the relationship between economic conditions and health service demand has focused primarily on outpatient use. This study examines whether local area unemployment, as an indicator of economic conditions, was associated with use of inpatient care, which is theoretically less subject to discretionary use. Using a random sample of 131,603 patients dually enrolled in the Veterans Affairs (VA) Health System and fee-for-service Medicare, we measured VA, Medicare, and total (VA and Medicare) hospitalizations. Overall, local unemployment was not associated with VA, Medicare, or total hospitalization probability. Among low-income veterans exempt from VA copayments, higher local unemployment was moderately associated with a lower probability of hospitalization through Medicare. For veterans subject to VA copayments, higher local unemployment was moderately associated with a higher likelihood of VA hospitalization. These results suggest inpatient use is less sensitive to the economy, although worse economic conditions slightly affected inpatient demand for select veterans.

Enantioselective interactions of dextromethorphan and levomethorphan with the alpha 3 beta 4-nicotinic acetylcholine receptor: comparison of chromatographic and functional data.

The enantioselectivity of the interaction of dextromethorphan (DM) and levomethorphan (LM) with an immobilized alpha 3 beta 4 subtype of the nicotinic acetylcholine receptor (nAChR) liquid chromatographic stationary phase has been compared to DM- and LM-induced non-competitive blockade of nicotine-stimulated 86Rb(+) efflux from cells expressing the alpha 3 beta 4-nAChR. The association rate constants (k(on)) and dissociation rate constants (k(off)) for the formation of the DM and LM complexes with the nAChR were determined using non-linear chromatographic techniques and the k(off) value for DM (1.01+/-0.01 s(-1)) was significantly lower than the k(off) for LM (1.55+/-0.002s(-1)) while the k(on) values did not significantly differ (23.66+/-0.61 and 18.61+/-0.36 microM(-1)s(-1), respectively). In thermodynamic studies using the van't Hoff approach, the enthalpy change (Delta H degrees) of the DM-nAChR complex was 330 calmol(-1) more stable than the LM-nAChR complex, while there was no significant difference in the entropy change (DeltaS degrees ). In the functional in vitro cell-based studies, there was no significant difference in the observed IC(50) values for DM (10.1+/-1.01 microM) and LM (10.9+/-1.08 microM), but the recovery from the DM-induced blockade was slower than the recovery from LM-induced blockade; after 7 min: 38.25+/-15.46% recovery from DM blockade, 63.30+/-16.08% from LM blockade; after 4h: 76.20+/-4.51% recovery from DM blockade and 93.12+/-8.76% from LM blockade. The enantioselective differences in the functional effects are consistent with the chromatographic and thermodynamic data and indicate that this difference is due to increased stability of the DM-nAChR complex. The results suggest that the chromatographic approach can be used to probe the interaction of non-competitive inhibitors (NCIs) with nAChRs and to predict relative duration of functional blockades.