Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment

BACKGROUND

The United States (US) Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE) systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system) in the ambulatory setting.

METHODS

Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17) and staff (n = 53) perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory). Two coders independently coded to theoretical saturation and resolved discrepancies through discussions.

RESULTS

Ten themes emerged that describe perceptions of e-prescribing implementation: 1) improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2) improved documentation resulted in safer care; 3) efficiencies were gained by using fewer paper charts; 4) organizational support facilitated adoption; 5) transition required time; resulted in workload shift to staff; 6) hardware configurations and network stability were important in facilitating workflow; 7) e-prescribing was time-neutral or time-saving; 8) changes in patient interactions enhanced patient care but required education; 9) pharmacy communications were enhanced but required education; 10) positive attitudes facilitated adoption.

CONCLUSIONS

Prescribers and staff worked through the transition to successfully adopt e-prescribing, and noted the benefits. Overall impressions were favorable. No one wished to return to paper-based prescribing.

Associations between state minimum wage policy and health care access: a multi-level analysis of the 2004 Behavioral Risk Factor survey

Minimum wage policies have been advanced as mechanisms to improve the economic conditions of the working poor. Both positive and negative effects of such policies on health care access have been hypothesized, but associations have yet to be thoroughly tested. To examine whether the presence of minimum wage policies in excess of the federal standard of $5.15 per hour was associated with health care access indicators among low-skilled adults of working age, a cross-sectional analysis of 2004 Behavioral Risk Factor Surveillance System data was conducted. Self-reported health insurance status and experience with cost-related barriers to needed medical care were adjusted in multi-level logistic regression models to control for potential confounding at the state, county, and individual levels. State-level wage policy was not found to be associated with insurance status or unmet medical need in the models, providing early evidence that increased minimum wage rates may neither strengthen nor weaken access to care as previously predicted.

The impact of computerized provider order entry on medication errors in a multispecialty group practice

OBJECTIVE

Computerized provider order entry (CPOE) has been shown to improve patient safety by reducing medication errors and subsequent adverse drug events (ADEs). Studies demonstrating these benefits have been conducted primarily in the inpatient setting, with fewer in the ambulatory setting. The objective was to evaluate the effect of a basic, ambulatory CPOE system on medication errors and associated ADEs.

DESIGN

This quasiexperimental, pretest-post-test study was conducted in a community-based, multispecialty health system not affiliated with an academic medical center. The intervention was a basic CPOE system with limited clinical decision support capabilities.

MEASUREMENT

Comparison of prescriptions written before (n=5016 handwritten) to after (n=5153 electronically prescribed) implementation of the CPOE system. The primary outcome was the occurrence of error(s); secondary outcomes were types and severity of errors.

RESULTS

Frequency of errors declined from 18.2% to 8.2%-a reduction in adjusted odds of 70% (OR: 0.30; 95% CI 0.23 to 0.40). The largest reductions were seen in adjusted odds of errors of illegibility (97%), use of inappropriate abbreviations (94%) and missing information (85%). There was a 57% reduction in adjusted odds of errors that did not cause harm (potential ADEs) (OR 0.43; 95% CI 0.38 to 0.49). The reduction in the number of errors that caused harm (preventable ADEs) was not statistically significant, perhaps due to few errors in this category.

CONCLUSIONS

A basic CPOE system in a community setting was associated with a significant reduction in medication errors of most types and severity levels.

Electronic prescribing at the point of care: a time-motion study in the primary care setting

OBJECTIVE

To evaluate the impact of an ambulatory computerized provider order entry (CPOE ) system on the time efficiency of prescribers. Two primary aims were to compare prescribing time between (1) handwritten and electronic (e-) prescriptions and (2) e-prescriptions using differing hardware configurations.

DATA SOURCES/STUDY SETTING

Primary data on prescribers/staff were collected (2005-2007) at three primary care clinics in a community based, multispecialty health system.

STUDY DESIGN

This was a quasi-experimental, direct observation, time-motion study conducted in two phases. In phase 1 (n=69 subjects), each site used a unique combination of CPOE software/hardware (paper-based, desktops in prescriber offices or hallway workstations, or laptops). In phase 2 (n=77), all sites used CPOE software on desktops in examination rooms (at point of care).

DATA COLLECTION METHODS

Data were collected using TimerPro software on a Palm device.

PRINCIPAL FINDINGS

Average time to e-prescribe using CPOE in the examination room was 69 seconds/prescription-event (new/renewed combined)-25 seconds longer than to handwrite (99.5 percent confidence interval [CI] 12.38), and 24 seconds longer than to e-prescribe at offices/workstations (99.5 percent CI 8.39). Each calculates to 20 seconds longer per patient.

CONCLUSIONS

E-prescribing takes longer than handwriting. E-prescribing at the point of care takes longer than e-prescribing in offices/workstations. Improvements in safety and quality may be worth the investment of time.

Initial test of the seattle asthma severity and control questionnaire: a multidimensional assessment of asthma severity and control

BACKGROUND

The Seattle Asthma Severity and Control Questionnaire (SASCQ) was designed as a short, sensitive, and quantitative measure of asthma severity, impairment, and risk.

OBJECTIVES

To evaluate the distribution of responses to the SASCQ in a diverse asthma population and to determine whether the questionnaire is associated with other measures of asthma severity and control.

METHODS

A cross-sectional study of 188 asthmatic patients was conducted in a large academic primary care network. Asthma severity was confirmed in a subgroup of 44 patients by means of an in-person interview and lung function measurement.

RESULTS

The SASCQ score had a nearly normal distribution across the heterogeneous population and less of a floor effect than the number of asthma-free days. The SASCQ score showed a higher symptom burden in the mildest asthmatic patients compared with nonasthmatic controls. Asthma severity evaluated using the questionnaire was correlated with asthma severity evaluated by means of in-person interview and with controller medication class. The SASCQ score was associated with primary care visits for asthma, emergency department treatment for asthma, days missed from work, and confidence to control asthma symptoms; the associations between these measures of impairment and risk were all stronger for the SASCQ score than for asthma-free days.

CONCLUSIONS

The SASCQ is a quantitative measure of asthma that accurately discriminates between established levels of asthma severity and that is associated with other measures of asthma control and risk.

Adaptive changes in HIV-1 subtype C proteins during early infection are driven by changes in HLA-associated immune pressure

It is unresolved whether recently transmitted human immunodeficiency viruses (HIV) have genetic features that specifically favour their transmissibility. To identify potential "transmission signatures", we compared 20 full-length HIV-1 subtype C genomes from primary infections, with 66 sampled from ethnically and geographically matched individuals with chronic infections. Controlling for recombination and phylogenetic relatedness, we identified 39 sites at which amino acid frequency spectra differed significantly between groups. These sites were predominantly located within Env, Pol and Gag (14/39, 9/39 and 6/39 respectively) and were significantly clustered (33/39) within known immunoreactive peptides. Within 6 months of infection, we detected reversion-to-consensus mutations at 14 sites and potential CTL escape mutations at seven. Here we provide evidence that frequent reversion mutations probably allows the virus to recover replicative fitness which, together with immune escape driven by the HLA alleles of the new hosts, differentiate sequences from chronic infections from those sampled shortly after transmission.

Discussion and revision of the mathematical modeling tool described in the previously published article "Modeling HIV Transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy"

Mathematical models are increasingly used in social and behavioral studies of HIV transmission; however, model structures must be chosen carefully to best answer the question at hand and conclusions must be interpreted cautiously. In Pearson et al. (2007), we presented a simple analytically tractable deterministic model to estimate the number of secondary HIV infections stemming from a population of HIV-positive Mozambicans and to evaluate how the estimate would change under different treatment and behavioral scenarios. In a subsequent application of the model with a different data set, we observed that the model produced an unduly conservative estimate of the number of new HIV-1 infections. In this brief report, our first aim is to describe a revision of the model to correct for this underestimation. Specifically, we recommend adjusting the population-level sexually transmitted infection (STI) parameters to be applicable to the individual-level model specification by accounting for the proportion of individuals uninfected with an STI. In applying the revised model to the original data, we noted an estimated 40 infections/1000 HIV-positive persons per year (versus the original 23 infections/1000 HIV-positive persons per year). In addition, the revised model estimated that highly active antiretroviral therapy (HAART) along with syphilis and herpes simplex virus type 2 (HSV-2) treatments combined could reduce HIV-1 transmission by 72% (versus 86% according to the original model). The second aim of this report is to discuss the advantages and disadvantages of mathematical models in the field and the implications of model interpretation. We caution that simple models should be used for heuristic purposes only. Since these models do not account for heterogeneity in the population and significantly simplify HIV transmission dynamics, they should be used to describe general characteristics of the epidemic and demonstrate the importance or sensitivity of parameters in the model.

Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis

OBJECTIVE

To test the hypothesis that electronic patient-provider messaging is associated with high care quality for diabetes and lower outpatient utilization.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional analysis of electronic patient-provider messaging over a 15-month period between 1 January 2004 and 31 March 2005. The study was set at Group Health Cooperative--a consumer-governed, nonprofit health care system that operates in Washington and Idaho. Participants included all patients aged >or=18 years with a diagnosis of diabetes. In addition to usual care, all patients had the option to use electronic messaging to communicate with their care providers. The primary outcome measures were diabetes-related quality-of-care indicators (A1C, blood pressure, and LDL cholesterol) and outpatient visits (primary care, specialty care, and emergency).

RESULTS

Nineteen percent of patients with diabetes used electronic messaging to communicate with their care providers during the study period (n = 2,924) (overall study cohort: 15,427 subjects). In multivariate models, frequent use of electronic messaging was associated with A1C <7% (relative risk [RR] 1.36 [95% CI 1.16-1.58]). Contrary to our hypothesis, frequent use of electronic messaging was also associated with a higher rate of outpatient visits (1.39 [1.26-1.53]).

CONCLUSIONS

Frequent use of electronic secure messaging is associated with better glycemic control and increased outpatient utilization. Electronic patient-provider communication may represent one strategy to meet the health care needs of this unique population. More research is necessary to assess the effect of electronic messaging on care quality and utilization.

Health services research doctoral core competencies

This manuscript presents an initial description of doctoral level core competencies for health services research (HSR). The competencies were developed by a review of the literature, text analysis of institutional accreditation self-studies submitted to the Council on Education for Public Health, and a consensus conference of HSR educators from US educational institutions. The competencies are described in broad terms which reflect the unique expertise, interests, and preferred learning methods of academic HSR programs. This initial set of core competencies is published to generate further dialogue within and outside of the US about the most important learning objectives and methods for HSR training and to clarify the unique skills of HSR training program graduates.

Group health cooperative's transformation toward patient-centered access

The Institute of Medicine suggests redesigning health care to ensure safe, effective, timely, efficient, equitable, and patient-centered care. The concept of patient-centered access supports these goals. Group Health, a mixed-model health care system, attempted to improve patients' access to care through the following changes: (a) offering a patient Web site with patient access to patient-physician secure e-mail, electronic medical records, and health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance care efficiency; (d) offering direct access to physician specialists; and (e) aligning primary physician compensation through incentives for patient satisfaction, productivity, and secure messaging with patients. In the 2 years following the redesign, patients reported higher satisfaction with certain aspects of access to care, providers reported improvements in the quality of service given to patients, and enrollment in Group Health stayed aligned with statewide trends in health care coverage.

Predisposing and enabling factors associated with mammography use among Hispanic and non-Hispanic white women living in a rural area

CONTEXT

Women who do not receive regular mammograms are more likely than others to have breast cancer diagnosed at an advanced stage.

PURPOSE

To examine predisposing and enabling factors associated with mammography use among Hispanic and non-Hispanic White women.

METHODS

Baseline data were used from a larger study on cancer prevention in rural Washington state. In a sample of 20 communities, 537 women formed the sample for this study. The main outcomes were ever having had a mammogram and having had a mammogram within the past 2 years.

FINDINGS

Reporting ever having had a mammogram was inversely associated with lack of health insurance (OR = 0.37, 95% CI: 0.16-0.84), ages under 50 years (OR = 0.23, 95% CI: 0.12-0.45), high cost of exams (OR = 0.48, 95% CI: 0.27-0.87), and lack of mammography knowledge (OR = 0.16, 95% CI: 0.07-0.37), while increasing education levels were positively associated (OR = 1.72, 95% CI: 1.09-2.70). Reporting mammography use within the past 2 years was inversely associated with ages under 50 years (OR = 0.49, 95% CI: 0.27-0.88) and over 70 years (OR = 0.47, 95% CI: 0.24-0.94), lack of health insurance (OR = 0.23, 95% CI: 0.10-0.50), and high cost of exams (OR = 0.55, 95% CI: 0.35-0.87).

CONCLUSIONS

Continued resources and programs for cancer screening are needed to improve mammography participation among women without health insurance or low levels of education.

Web-based collaborative care for type 1 diabetes: a pilot randomized trial

BACKGROUND

To determine whether a Web-based diabetes case management program based in an electronic medical record can improve glycemic control (primary outcome) and diabetes-specific self-efficacy (secondary outcome) in adults with type 1 diabetes, a pilot randomized controlled trial was conducted.

METHODS

A 12-month randomized trial tested a Web-based case management program in a diabetes specialty clinic. Patients 21-49 years old with type 1 diabetes receiving multiple daily injections with insulin glargine and rapid-acting analogs who had a recent A1C >7.0% were eligible for inclusion. Participants were randomized to receive either (1) usual care plus the nurse-practitioner-aided Web-based case management program (intervention) or (2) usual clinic care alone (control). We compared patients in the two study arms for changes in A1C and self-efficacy measured with the Diabetes Empowerment Scale.

RESULTS

A total of 77 patients were recruited from the diabetes clinic and enrolled in the trial. The mean baseline A1C among study participants was 8.0%. We observed a nonsignificant decrease in average A1C (-0.48; 95% confidence interval -1.22 to 0.27; P = 0.160) in the intervention group compared to the usual care group. The intervention group had a significant increase in diabetes-related self-efficacy compared to usual care (group difference of 0.30; 95% confidence interval 0.01 to 0.59; P = 0.04).

CONCLUSIONS

Use of a Web-based case management program was associated with a beneficial treatment effect on self-efficacy, but change in glycemic control did not reach statistical significance in this trial of patients with moderately poorly controlled type 1 diabetes. Larger studies may be necessary to further clarify the intervention's impact on health outcomes.

Widely conserved recombination patterns among single-stranded DNA viruses

The combinatorial nature of genetic recombination can potentially provide organisms with immediate access to many more positions in sequence space than can be reached by mutation alone. Recombination features particularly prominently in the evolution of a diverse range of viruses. Despite rapid progress having been made in the characterization of discrete recombination events for many species, little is currently known about either gross patterns of recombination across related virus families or the underlying processes that determine genome-wide recombination breakpoint distributions observable in nature. It has been hypothesized that the networks of coevolved molecular interactions that define the epistatic architectures of virus genomes might be damaged by recombination and therefore that selection strongly influences observable recombination patterns. For recombinants to thrive in nature, it is probably important that the portions of their genomes that they have inherited from different parents work well together. Here we describe a comparative analysis of recombination breakpoint distributions within the genomes of diverse single-stranded DNA (ssDNA) virus families. We show that whereas nonrandom breakpoint distributions in ssDNA virus genomes are partially attributable to mechanistic aspects of the recombination process, there is also a significant tendency for recombination breakpoints to fall either outside or on the peripheries of genes. In particular, we found significantly fewer recombination breakpoints within structural protein genes than within other gene types. Collectively, these results imply that natural selection acting against viruses expressing recombinant proteins is a major determinant of nonrandom recombination breakpoint distributions observable in most ssDNA virus families.

Effects of Three Methods of Restraint on Intravenous Glucose Tolerance Testing in Rhesus and African Green Monkeys

The intravenous administration of 0.75 gm glucose per kg and the measurement of serum glucose pretest and at 10, 20, 30, 60, 90 and 120 minutes constitute a satisfactory protocol for intravenous glucose tolerance testing of Rhesus (Macaca mulatto) and African Green (Cercopithecus aethiops) monkeys. No significant differences were noted between animals restrained with ketamine hydrochloride and those restrained with sodium pentobarbital, but the African Green males and females and the male Rhesus monkeys yielded significantly different results while being manually restrained.

Evaluation of the group health cooperative access initiative: study design challenges in estimating the impact of a large-scale organizational transformation

The Institute of Medicine argues that poorly designed delivery systems are a major cause of low-quality care in the United States but does not present methods for evaluating whether its recommendations, when implemented by a health care organization, actually improve quality of care. We describe how time-series study designs using individual-level longitudinal data can be applied to address methodological challenges in our evaluation of the impact of the Group Health Cooperative "Access Initiative," an integrated set of 7 "patient-centered" reforms in its integrated delivery system that are consistent with the Institute of Medicine's recommendations. The methods may be generalizable to evaluating similar reforms in other integrated delivery systems with representative patient and physician data sources.

Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study

BACKGROUND

Patient-centered access is a philosophy and a method that supports efforts to redesign health-care delivery systems to deliver higher quality care and to better meet the needs and preferences of patients. Since mid-2000, Group Health Cooperative has pursued an ensemble of strategic initiatives aimed at promoting patient-centered access, referred to as the Access Initiative. In support of this strategy, Group Health has also engaged in enterprise implementation of an electronic medical record and clinical information system that is integrated with their patient Web site, MyGroupHealth.

OBJECTIVE

To elicit, describe, and characterize providers' perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access.

DESIGN

Thematic analysis of semi-structured in-depth interviews.

PARTICIPANTS

Twenty-two care providers representing 14 primary care, medical, and surgical specialties at Group Health Cooperative, an integrated health-care system based in Seattle, Washington.

FINDINGS

Analyses of the interview transcripts revealed nine emergent themes, five of which have particular relevance for health-care organizations pursuing patient-centered access: the Access Initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers' focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists.

CONCLUSIONS

Providers like that the Access Initiative is mostly good for their patients, but dislike the negative effects on their own quality of life - especially in primary care. These reforms may not be sustainable under current models of organization and financing.

Rural trauma: is trauma designation associated with better hospital outcomes?

CONTEXT

While trauma designation has been associated with lower risk of death in large urban settings, relatively little attention has been given to this issue in small rural hospitals.

PURPOSE

To examine factors related to in-hospital mortality and delayed transfer in small rural hospitals with and without trauma designation.

METHODS

Analysis of data from the Nationwide Inpatient Sample for discharges between 1998 and 2003 of patients hospitalized with moderate to major traumatic injury in nonfederal, short-stay rural hospitals with annual discharges of 1,500 or fewer patients (N = 9,590). Logistic regression was used to control for patient and hospital characteristics, stratifying by hospital volume. Main outcome measures were in-hospital death and transfer to another acute care facility after initial admission.

FINDINGS

A total of 333 patients (3.5%) died in-hospital. After adjusting for patient, injury and hospital characteristics, in-hospital death was more likely among patients treated at the non-designated hospitals with fewer than 500 discharges per year (OR 2.35; 95% CI 1.25-4.41) than among patients treated at similar trauma-designated hospitals. Patients admitted to non-designated hospitals were more likely to be transferred after admission, although this finding was significant only in the larger-volume hospitals with discharges of 500-1,500 per year (OR 1.41, 95% CI 1.08-1.83).

CONCLUSIONS

Associations between trauma designation and outcomes in rural hospitals warrant further study to determine whether expanding designation to more rural hospitals might lead to further improvement in trauma outcomes.

Colorectal cancer screening practices of primary care physicians in Washington State

BACKGROUND

Colorectal cancer screening reduces death from colorectal cancer, but screening rates are low. While research has identified barriers to screening from the patient perspective, less research has addressed screening from the physician perspective.

METHODS

The Washington Comprehensive Cancer Control Partnership conducted a survey of primary care physicians in Washington State to measure their knowledge, attitudes, and practices for colorectal cancer screening of average-risk patients. The survey was mailed to a simple random sample of 700 primary care physicians in Washington State. Sixty-nine percent of the eligible physicians in the sample participated.

RESULTS

Most respondents (76%) recommended one or more colorectal cancer screening tests in agreement with American Cancer Society guidelines, and 93% perceived patient anxiety about colorectal cancer screening tests to be a significant barrier to screening. Ninety percent of physicians reported using the fecal occult blood test (FOBT) as a screening test, but most did not report performing any tracking or using any mechanism to encourage their patients to complete and return FOBT kits.

CONCLUSIONS

These findings suggest three intervention approaches to increase colorectal cancer screening in primary care settings: improve physicians' knowledge about current screening guidelines (especially appropriate age and screening intervals), encourage physicians to strongly recommend screening to patients, and help physicians adopt tracking systems to follow screening to completion.

First Report of Maize streak virus Field Infection of Sugarcane in South Africa

Prior to the introduction of highly resistant sugarcane varieties, Sugarcane streak virus (SSV) caused serious sugar yield losses in southern Africa. Recently, sugarcane plants with streak symptoms have been identified across South Africa. Unlike the characteristic fine stippling and streaking of SSV, the symptoms resembled the broader, elongated chlorotic lesions commonly observed in wild grasses infected with the related Maize streak virus (MSV). Importantly, these symptoms have been reported on a newly released South African sugarcane cultivar, N44 (resistant to SSV). Following a first report from southern KwaZulu-Natal, South Africa in February 2006, a survey in May 2007 identified numerous plants with identical symptoms in fields of cvs. N44, N27, and N36 across the entire South African sugarcane-growing region. Between 0.04 and 1.6% of the plants in infected fields had streak symptoms. Wild grass species with similar streaking symptoms were observed adjacent to one of these fields. Potted stalks collected from infected N44 plants germinated in a glasshouse exhibited streak symptoms within 10 days. Virus genomes were isolated and sequenced from a symptomatic N44 and Urochloa plantaginea plants collected from one of the surveyed fields (1). Phylogenetic analysis determined that while viruses from both plants closely resembled the South African maize-adapted MSV strain, MSV-A₄ (>98.5% genome-wide sequence identity), they were only very distantly related to SSV (~65% identity; MSV-Sasri_S: EU152254; MSV-Sasri_G: EU152255). To our knowledge, this is the first confirmed report of maize-adapted MSV variants in sugarcane. In the 1980s, "MSV strains" were serologically identified in sugarcane plants exhibiting streak symptoms in Reunion and Mauritius, but these were not genetically characterized (2,3). There have been no subsequent reports on the impact of such MSV infections on sugarcane cultivation on these islands. Also, at least five MSV strains have now been described, only one of which, MSV-A, causes significant disease in maize and it is unknown which strain was responsible for sugarcane diseases on these islands in the 1980s (2,3). MSV-A infections could have serious implications for the South African sugar industry. Besides yield losses in infected plants due to stunting and reduced photosynthesis, the virus could be considerably more difficult to control than it is in maize because sugarcane is vegetatively propagated and individual plants remain within fields for years rather than months. Moreover, there is a large MSV-A reservoir in maize and other grasses everywhere sugarcane is grown in southern Africa. References: (1) B. E. Owor et al. J Virol. Methods 140:100, 2007. (2) M. S. Pinner and P. G. Markham. J. Gen. Virol. 71:1635, 1990. (3) M. S. Pinner et al. Plant Pathol. 37:74, 1998.

Randomized control trial of peer-delivered, modified directly observed therapy for HAART in Mozambique

OBJECTIVE

To assess the efficacy of a peer-delivered intervention to promote short-term (6-month) and long-term (12-month) adherence to HAART in a Mozambican clinic population.

DESIGN

A 2-arm randomized controlled trial was conducted between October 2004 and June 2006.

PARTICIPANTS

Of 350 men and women (> or = 18 years) initiating HAART, 53.7% were female, and 97% were on 1 fixed-dose combination pill twice a day.

INTERVENTION

Participants were randomly assigned to receive 6 weeks (Monday through Friday; 30 daily visits) of peer-delivered, modified directly observed therapy (mDOT) or standard care. Peers provided education about treatment and adherence and sought to identify and mitigate adherence barriers.

OUTCOME

Participants' self-reported medication adherence was assessed 6 months and 12 months after starting HAART. Adherence was defined as the proportion of prescribed doses taken over the previous 7 days. Statistical analyses were performed using intention-to-treat (missing = failure).

RESULTS

Intervention participants, compared to those in standard care, showed significantly higher mean medication adherence at 6 months (92.7% vs. 84.9%, difference 7.8, 95% confidence interval [CI]: 0.0.02, 13.0) and 12 months (94.4% vs. 87.7%, difference 6.8, 95% CI: 0.9, 12.9). There were no between-arm differences in chart-abstracted CD4 counts.

CONCLUSIONS

A peer-delivered mDOT program may be an effective strategy to promote long-term adherence among persons initiating HAART in resource-poor settings.

Begomovirus 'melting pot' in the south-west Indian Ocean islands: molecular diversity and evolution through recombination

During the last few decades, many virus species have emerged, often forming dynamic complexes within which viruses share common hosts and rampantly exchange genetic material through recombination. Begomovirus species complexes are common and represent serious agricultural threats. Characterization of species complex diversity has substantially contributed to our understanding of both begomovirus evolution, and the ecological and epidemiological processes involved in the emergence of new viral pathogens. To date, the only extensively studied emergent African begomovirus species complex is that responsible for cassava mosaic disease. Here we present a study of another emerging begomovirus species complex which is associated with serious disease outbreaks in bean, tobacco and tomato on the south-west Indian Ocean (SWIO) islands off the coast of Africa. On the basis of 14 new complete DNA-A sequences, we describe seven new island monopartite begomovirus species, suggesting the presence of an extraordinary diversity of begomovirus in the SWIO islands. Phylogenetic analyses of these sequences reveal a close relationship between monopartite and bipartite African begomoviruses, supporting the hypothesis that either bipartite African begomoviruses have captured B components from other bipartite viruses, or there have been multiple B-component losses amongst SWIO virus progenitors. Moreover, we present evidence that detectable recombination events amongst African, Mediterranean and SWIO begomoviruses, while substantially contributing to their diversity, have not occurred randomly throughout their genomes. We provide the first statistical support for three recombination hot-spots (V1/C3 interface, C1 centre and the entire IR) and two recombination cold-spots (the V2 and the third quarter of V1) in the genomes of begomoviruses.

Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury

RATIONALE

Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients.

OBJECTIVES

To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA).

METHODS

Cohort study of patients with acute lung injury (ALI).

MEASUREMENTS AND MAIN RESULTS

ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition.

CONCLUSIONS

Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.

Pre-pregnancy body mass index, gestational weight gain, and other maternal characteristics in relation to infant birth weight

OBJECTIVES

Infant birth weight is influenced by modifiable maternal pre-pregnancy behaviors and characteristics. We evaluated the relationship among pre-pregnancy body mass index (BMI), gestational weight gain, and infant birth weight, in a prospective cohort study.

METHODS

Women were enrolled at < or =20 weeks gestation, completed in-person interviews and had their medical records reviewed after delivery. Infant birth weight was first analyzed as a continuous variable, and then grouped into Low birth weight (LBW) (<2,500 g), normal birth weight (2,500-3,999 g), and macrosomia (> or =4,000 g) in categorical analysis. Pre-pregnancy BMI and gestational weight gain were categorized based on Institute of Medicine BMI groups and gestational weight gain guidelines. Associations among infant birth weight and pre-pregnancy BMI, gestational weight gain, and other factors were evaluated using multivariate regression. Risk ratios were estimated using generalized linear modeling procedures.

RESULTS

Pre-pregnancy BMI was independently and positively associated with infant birth weight (beta = 44.7, P = 0.001) after adjusting for confounders, in a quadratic model. Gestational weight gain was positively associated with infant birth weight (beta = 19.5, P < 0.001). Lower infant birth weight was associated with preterm birth (beta = -965.4, P < 0.001), nulliparity (beta = -48.6, P = 0.015), and female babies (beta = -168.7, P < 0.001). Less than median gestational weight gain was associated with twice the risk of LBW (RR = 2.04, 95% CI 1.34-3.11). Risk of macrosomia increased with increasing pre-pregnancy BMI and gestational weight gain (P for linear trend <0.001).

CONCLUSIONS

These findings support the need to balance pre-pregnancy weight and gestational weight gain against the risk of LBW and macrosomia among lean and obese women, respectively.

Racial Disparities in Outcomes of Persons With Moderate to Severe Traumatic Brain Injury

BACKGROUND

Although racial differences in hospital outcomes are well known for medical conditions (eg, cardiovascular disease), it is unknown whether differences exist for patients with traumatic brain injury (TBI).

RESEARCH DESIGN

Using the National Trauma Data Bank, we examined racial and ethnic differences in hospital outcomes of 56,482 patients with moderate to severe TBI who were hospitalized in level I or II trauma-designated hospitals between 2000 and 2003. We examined racial and ethnic disparities in in-hospital mortality and the likelihood of survivors receiving postacute care at a rehabilitation center.

RESULTS

After multivariable adjustment, compared with whites, we observed increased in-hospital mortality for blacks (odds ratio [OR] = 1.19, P = 0.026) and Asians (OR = 1.41, P = 0.005). We observed a trend toward significance for Hispanics (OR = 1.41, P = 0.077), but not for other races. For survivors, compared with whites, blacks and Hispanics were less likely to be discharged to a rehabilitation center (OR = 0.68, P < 0.001, and OR = 0.67, P = 0.002, respectively).

CONCLUSIONS

Racial and ethnic disparities exist both in mortality and in discharge to postacute rehabilitation centers among persons with TBI.

Accuracy of a disability instrument to identify workers likely to develop upper extremity musculoskeletal disorders

BACKGROUND

Work related upper extremity musculoskeletal disorders (MSD) result in substantial disability, and expense. Identifying workers or jobs with high risk can trigger intervention before workers are injured or the condition worsens.

METHODS

We investigated a disability instrument, the QuickDASH, as a workplace screening tool to identify workers at high risk of developing upper extremity MSDs. Subjects included workers reporting recurring upper extremity MSD symptoms in the past 7 days (n = 559).

RESULTS

The QuickDASH was reasonably accurate at baseline with sensitivity of 73% for MSD diagnosis, and 96% for symptom severity. Specificity was 56% for diagnosis, and 53% for symptom severity. At 1-year follow-up sensitivity and specificity for MSD diagnosis was 72% and 54%, respectively, as predicted by the baseline QuickDASH score. For symptom severity, sensitivity and specificity were 86% and 52%. An a priori target sensitivity of 70% and specificity of 50% was met by symptom severity, work pace and quality, and MSD diagnosis.

CONCLUSION

The QuickDASH may be useful for identifying jobs or workers with increased risk for upper extremity MSDs. It may provide an efficient health surveillance screening tool useful for targeting early workplace intervention for prevention of upper extremity MSD problems.