Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians

BACKGROUND

Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care.

OBJECTIVE

To compare rates of inappropriate prescribing among NPs and primary care physicians.

DESIGN

Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state.

SETTING

29 states that had granted NPs prescriptive authority by 2019.

PATIENTS

Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019.

MEASUREMENTS

Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society's Beers Criteria.

RESULTS

Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states.

LIMITATION

The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings.

CONCLUSION

Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians.

PRIMARY FUNDING SOURCE

The Robert Wood Johnson Foundation and National Science Foundation.

Protection against Omicron from Vaccination and Previous Infection in a Prison System

BACKGROUND

Information regarding the protection conferred by vaccination and previous infection against infection with the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is limited.

METHODS

We evaluated the protection conferred by mRNA vaccines and previous infection against infection with the omicron variant in two high-risk populations: residents and staff in the California state prison system. We used a retrospective cohort design to analyze the risk of infection during the omicron wave using data collected from December 24, 2021, through April 14, 2022. Weighted Cox models were used to compare the effectiveness (measured as 1 minus the hazard ratio) of vaccination and previous infection across combinations of vaccination history (stratified according to the number of mRNA doses received) and infection history (none or infection before or during the period of B.1.617.2 [delta]-variant predominance). A secondary analysis used a rolling matched-cohort design to evaluate the effectiveness of three vaccine doses as compared with two doses.

RESULTS

Among 59,794 residents and 16,572 staff, the estimated effectiveness of previous infection against omicron infection among unvaccinated persons who had been infected before or during the period of delta predominance ranged from 16.3% (95% confidence interval [CI], 8.1 to 23.7) to 48.9% (95% CI, 41.6 to 55.3). Depending on previous infection status, the estimated effectiveness of vaccination (relative to being unvaccinated and without previous documented infection) ranged from 18.6% (95% CI, 7.7 to 28.1) to 83.2% (95% CI, 77.7 to 87.4) with two vaccine doses and from 40.9% (95% CI, 31.9 to 48.7) to 87.9% (95% CI, 76.0 to 93.9) with three vaccine doses. Incremental effectiveness estimates of a third (booster) dose (relative to two doses) ranged from 25.0% (95% CI, 16.6 to 32.5) to 57.9% (95% CI, 48.4 to 65.7) among persons who either had not had previous documented infection or had been infected before the period of delta predominance.

CONCLUSIONS

Our findings in two high-risk populations suggest that mRNA vaccination and previous infection were effective against omicron infection, with lower estimates among those infected before the period of delta predominance. Three vaccine doses offered significantly more protection than two doses, including among previously infected persons.

Effectiveness of Coronavirus Disease 2019 (COVID-19) Vaccines Among Incarcerated People in California State Prisons: Retrospective Cohort Study

BACKGROUND

Prisons and jails are high-risk settings for coronavirus disease 2019 (COVID-19). Vaccines may substantially reduce these risks, but evidence is needed on COVID-19 vaccine effectiveness for incarcerated people, who are confined in large, risky congregate settings.

METHODS

We conducted a retrospective cohort study to estimate effectiveness of messenger RNA (mRNA) vaccines, BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna), against confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections among incarcerated people in California prisons from 22 December 2020 through 1 March 2021. The California Department of Corrections and Rehabilitation provided daily data for all prison residents including demographic, clinical, and carceral characteristics, as well as COVID-19 testing, vaccination, and outcomes. We estimated vaccine effectiveness using multivariable Cox models with time-varying covariates, adjusted for resident characteristics and infection rates across prisons.

RESULTS

Among 60 707 cohort members, 49% received at least 1 BNT162b2 or mRNA-1273 dose during the study period. Estimated vaccine effectiveness was 74% (95% confidence interval [CI], 64%-82%) from day 14 after first dose until receipt of second dose and 97% (95% CI, 88%-99%) from day 14 after second dose. Effectiveness was similar among the subset of residents who were medically vulnerable: 74% (95% CI, 62%-82%) and 92% (95% CI, 74%-98%) from 14 days after first and second doses, respectively.

CONCLUSIONS

Consistent with results from randomized trials and observational studies in other populations, mRNA vaccines were highly effective in preventing SARS-CoV-2 infections among incarcerated people. Prioritizing incarcerated people for vaccination, redoubling efforts to boost vaccination, and continuing other ongoing mitigation practices are essential in preventing COVID-19 in this disproportionately affected population.

Suicide Deaths Among Women in California Living With Handgun Owners vs Those Living With Other Adults in Handgun-Free Homes, 2004-2016

IMPORTANCE

Little is known about the extent to which secondhand exposure to household firearms is associated with risk of suicide in adults who do not own guns, most of whom are women.

OBJECTIVE

To evaluate changes in risk of suicide among women living in gun-free households after one of their cohabitants became a handgun owner.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study observed participants for up to 12 years and 2 months from October 18, 2004, to December 31, 2016. Data were analyzed from April to November 2021. The study population included 9.5 million adult women in California who did not own guns and who entered the study while living with 1 or more adults in a handgun-free home.

EXPOSURES

Secondhand exposure to household handguns.

MAIN OUTCOMES AND MEASURES

Suicide, firearm suicide, nonfirearm suicide.

RESULTS

Of 9.5 million women living in handgun-free homes, 331 968 women (3.5% of the study population; mean [SD] age, 41.6 [18.0] years) became exposed to household handguns during the study period. In the entire study population, 294 959 women died: 2197 (1%) of these were by suicide, 337 (15%) of which were suicides by firearm. Rates of suicide by any method during follow-up were higher among cohort members residing with handgun owners compared with those residing in handgun-free homes (hazard ratio, 1.43; 95% CI, 1.11-1.84). The excess suicide rate was accounted for by higher rates of suicide by firearm (hazard ratio, 4.32; 95% CI, 2.89-6.46). Women in households with and without handguns had similar rates of suicide by nonfirearm methods (hazard ratio, 0.90; 95% CI, 0.63-1.27).

CONCLUSIONS AND RELEVANCE

In this study, the rate of suicide among women was significantly higher after a cohabitant of theirs became a handgun owner compared with the rate observed while they lived in handgun-free homes.

Homicide Deaths Among Adult Cohabitants of Handgun Owners in California, 2004 to 2016 : A Cohort Study

BACKGROUND

Although personal protection is a major motivation for purchasing firearms, existing studies suggest that people living in homes with firearms have higher risks for dying by homicide. Distribution of those risks among household members is poorly understood.

OBJECTIVE

To estimate the association between living with a lawful handgun owner and risk for homicide victimization.

DESIGN

This retrospective cohort study followed 17.6 million adult residents of California for up to 12 years 2 months (18 October 2004 through 31 December 2016). Cohort members did not own handguns, but some started residing with lawful handgun owners during follow-up.

SETTING

California.

PARTICIPANTS

17 569 096 voter registrants aged 21 years or older.

MEASUREMENTS

Homicide (overall, by firearm, and by other methods) and homicide occurring in the victim's home.

RESULTS

Of 595 448 cohort members who commenced residing with handgun owners, two thirds were women. A total of 737 012 cohort members died; 2293 died by homicide. Overall rates of homicide were more than twice as high among cohabitants of handgun owners than among cohabitants of nonowners (adjusted hazard ratio, 2.33 [95% CI, 1.78 to 3.05]). These elevated rates were driven largely by higher rates of homicide by firearm (adjusted hazard ratio, 2.83 [CI, 2.05 to 3.91]). Among homicides occurring at home, cohabitants of owners had sevenfold higher rates of being fatally shot by a spouse or intimate partner (adjusted hazard ratio, 7.16 [CI, 4.04 to 12.69]); 84% of these victims were female.

LIMITATIONS

Some cohort members classified as unexposed may have lived in homes with handguns. Residents of homes with and without handguns may have differed on unobserved traits associated with homicide risk.

CONCLUSION

Living with a handgun owner is associated with substantially elevated risk for dying by homicide. Women are disproportionately affected.

PRIMARY FUNDING SOURCE

The National Collaborative on Gun Violence Research, the Fund for a Safer Future, the Joyce Foundation, Stanford Law School, and the Stanford University School of Medicine.

Uptake of COVID-19 Vaccination Among Frontline Workers in California State Prisons

Question

In California prisons, what proportion of prison staff who have direct contact with residents are unvaccinated, and what are their characteristics?

Findings

In this cohort study of 23 472 custody staff and 7617 health care staff in California state prisons, 14 317 custody staff (61%) and 2819 (36%) health care staff remained unvaccinated through June 30, 2021, despite widespread vaccine availability. Unvaccinated staff were younger and more likely to have had COVID-19; they were also more likely to work alongside other unvaccinated staff and live in communities with relatively low rates of vaccination.

Meaning

The study results suggest that low vaccination rates among prison staff pose continuing risks.

Importance

Prisons and jails are high-risk environments for COVID-19. Vaccination levels among workers in many such settings remain markedly lower than those of residents and members of surrounding communities. The situation is troubling because prison staff are a key vector for COVID-19 transmission.

Objective

To assess patterns and timing of staff vaccination in California state prisons and identify individual-level and community-level factors associated with remaining unvaccinated.

Design, Setting, and Participants

This cohort study used data from December 22, 2020, through June 30, 2021, to quantify the fractions of staff and incarcerated residents who remained unvaccinated among 23 472 custody and 7617 health care staff who worked in roles requiring direct contact with residents at 33 of the 35 prisons operated by the California Department of Corrections and Rehabilitation. Multivariable probit regressions assessed demographic, community, and peer factors associated with staff vaccination uptake.

Main Outcomes and Measures

Remaining unvaccinated throughout the study period.

Results

Of 23 472 custody staff, 3751 (16%) were women, and 1454 (6%) were Asian/Pacific Islander individuals, 1571 (7%) Black individuals, 9008 (38%) Hispanic individuals, and 6666 (28%) White individuals. Of 7617 health care staff, 5434 (71%) were women, and 2148 (28%) were Asian/Pacific Islander individuals, 1201 (16%) Black individuals, 1409 (18%) Hispanic individuals, and 1771 (23%) White individuals. A total of 6103 custody staff (26%) and 3961 health care staff (52%) received 1 or more doses of a COVID-19 vaccine during the first 2 months vaccines were offered, but vaccination rates stagnated thereafter. By June 30, 2021, 14 317 custody staff (61%) and 2819 health care staff (37%) remained unvaccinated. In adjusted analyses, remaining unvaccinated was positively associated with younger age (custody staff: age, 18-29 years vs ≥60 years, 75% [95% CI, 73%-76%] vs 45% [95% CI, 42%-48%]; health care staff: 52% [95% CI, 48%-56%] vs 29% [95% CI, 27%-32%]), prior COVID-19 infection (custody staff: 67% [95% CI, 66%-68%] vs 59% [95% CI, 59%-60%]; health care staff: 44% [95% CI, 42%-47%] vs 36% [95% CI, 36%-36%]), residing in a community with relatively low rates of vaccination (custody staff: 75th vs 25th percentile:, 63% [95% CI, 62%-63%] vs 60% [95% CI, 59%-60%]; health care staff: 40% [95% CI, 39%-41%] vs 34% [95% CI, 33%-35%]), and sharing shifts with coworkers who had relatively low rates of vaccination (custody staff: 75th vs 25th percentile, 64% [95% CI, 62%-66%] vs 59% [95% CI, 57%-61%]; health care staff: 38% [95% CI, 36%-41%] vs 35% [95% CI, 31%-39%]).

Conclusions and Relevance

This cohort study of California state prison custody and health care staff found that vaccination uptake plateaued at levels that posed ongoing risks of further outbreaks in the prisons and continuing transmission from prisons to surrounding communities. Prison staff decisions to forgo vaccination appear to be multifactorial, and vaccine mandates may be necessary to achieve adequate levels of immunity in this high-risk setting.

Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study

OBJECTIVE

To measure and compare mortality outcomes between dually eligible veterans transported by ambulance to a Veterans Affairs hospital and those transported to a non-Veterans Affairs hospital.

DESIGN

Retrospective cohort study using data from medical charts and administrative files.

SETTING

Emergency visits by ambulance to 140 Veteran Affairs and 2622 non-Veteran Affairs hospitals across 46 US states and the District of Columbia in 2001-18.

PARTICIPANTS

National cohort of 583 248 veterans (aged ≥65 years) enrolled in both the Veterans Health Administration and Medicare programs, who resided within 20 miles of at least one Veterans Affairs hospital and at least one non-Veterans Affairs hospital, in areas where ambulances regularly transported patients to both types of hospitals.

INTERVENTION

Emergency treatment at a Veterans Affairs hospital.

MAIN OUTCOME MEASURE

Deaths in the 30 day period after the ambulance ride. Linear probability models of mortality were used, with adjustment for patients' demographic characteristics, residential zip codes, comorbid conditions, and other variables.

RESULTS

Of 1 470 157 ambulance rides, 231 611 (15.8%) went to Veterans Affairs hospitals and 1 238 546 (84.2%) went to non-Veterans Affairs hospitals. The adjusted mortality rate at 30 days was 20.1% lower among patients taken to Veterans Affairs hospitals than among patients taken to non-Veterans Affairs hospitals (9.32 deaths per 100 patients (95% confidence interval 9.15 to 9.50) v 11.67 (11.58 to 11.76)). The mortality advantage associated with Veterans Affairs hospitals was particularly large for patients who were black (-25.8%), were Hispanic (-22.7%), and had received care at the same hospital in the previous year.

CONCLUSIONS

These findings indicate that within a month of being treated with emergency care at Veterans Affairs hospitals, dually eligible veterans had substantially lower risk of death than those treated at non-Veterans Affairs hospitals. The nature of this mortality advantage warrants further investigation, as does its generalizability to other types of patients and care. Nonetheless, the finding is relevant to assessments of the merit of policies that encourage private healthcare alternatives for veterans.

Patterns of handgun divestment among handgun owners in California

Background

Little is known about voluntary divestment of firearms among US firearm owners. Here, we aim to estimate the proportion of handgun owners who divest their handguns in the years following their initial acquisition; examine the timing, duration, and dynamics of those divestments; and describe characteristics of those who divest.

Methods

We use data from the Longitudinal Study of Handgun Ownership and Transfer, a cohort of registered voters in California with detailed information on 626,756 adults who became handgun owners during the 12-year study period, 2004–2016. For the current study, persons were followed from the time of their initial handgun acquisition until divestment, loss to follow-up, death, or the end of the study period. We describe the cumulative proportion who divest overall and by personal and area-level characteristics. We also estimate the proportion who reacquired handguns among persons who divested.

Results

Overall, 4.5% (95% CI 4.5–4.6) of handgun owners divested within 5 years of their first acquisition, with divestment relatively more common among women and among younger adults. Among those who divested, 36.6% (95% CI 35.8–37.5) reacquired a handgun within 5 years.

Conclusions

Handgun divestment is rare, with the vast majority of new handgun owners retaining them for years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00362-6.

Dependence of COVID-19 Policies on End-of-Year Holiday Contacts in Mexico City Metropolitan Area: A Modeling Study

Background. Mexico City Metropolitan Area (MCMA) has the largest number of COVID-19 (coronavirus disease 2019) cases in Mexico and is at risk of exceeding its hospital capacity in early 2021. Methods. We used the Stanford-CIDE Coronavirus Simulation Model (SC-COSMO), a dynamic transmission model of COVID-19, to evaluate the effect of policies considering increased contacts during the end-of-year holidays, intensification of physical distancing, and school reopening on projected confirmed cases and deaths, hospital demand, and hospital capacity exceedance. Model parameters were derived from primary data, literature, and calibrated. Results. Following high levels of holiday contacts even with no in-person schooling, MCMA will have 0.9 million (95% prediction interval 0.3-1.6) additional COVID-19 cases between December 7, 2020, and March 7, 2021, and hospitalizations will peak at 26,000 (8,300-54,500) on January 25, 2021, with a 97% chance of exceeding COVID-19-specific capacity (9,667 beds). If MCMA were to control holiday contacts, the city could reopen in-person schools, provided they increase physical distancing with 0.5 million (0.2-0.9) additional cases and hospitalizations peaking at 12,000 (3,700-27,000) on January 19, 2021 (60% chance of exceedance). Conclusion. MCMA must increase COVID-19 hospital capacity under all scenarios considered. MCMA's ability to reopen schools in early 2021 depends on sustaining physical distancing and on controlling contacts during the end-of-year holiday.

Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies

BACKGROUND

Residents of prisons have experienced disproportionate COVID-19-related health harms. To control outbreaks, many prisons in the USA restricted in-person activities, which are now resuming even as viral variants proliferate. This study aims to use mathematical modelling to assess the risks and harms of COVID-19 outbreaks in prisons under a range of policies, including resumption of activities.

METHODS

We obtained daily resident-level data for all California state prisons from Jan 1, 2020, to May 15, 2021, describing prison layouts, housing status, sociodemographic and health characteristics, participation in activities, and COVID-19 testing, infection, and vaccination status. We developed a transmission-dynamic stochastic microsimulation parameterised by the California data and published literature. After an initial infection is introduced to a prison, the model evaluates the effect of various policy scenarios on infections and hospitalisations over 200 days. Scenarios vary by vaccine coverage, baseline immunity (0%, 25%, or 50%), resumption of activities, and use of non-pharmaceutical interventions (NPIs) that reduce transmission by 75%. We simulated five prison types that differ by residential layout and demographics, and estimated outcomes with and without repeated infection introductions over the 200 days.

FINDINGS

If a viral variant is introduced into a prison that has resumed pre-2020 contact levels, has moderate vaccine coverage (ranging from 36% to 76% among residents, dependent on age, with 40% coverage for staff), and has no baseline immunity, 23-74% of residents are expected to be infected over 200 days. High vaccination coverage (90%) coupled with NPIs reduces cumulative infections to 2-54%. Even in prisons with low room occupancies (ie, no more than two occupants) and low levels of cumulative infections (ie, <10%), hospitalisation risks are substantial when these prisons house medically vulnerable populations. Risks of large outbreaks (>20% of residents infected) are substantially higher if infections are repeatedly introduced.

INTERPRETATION

Balancing benefits of resuming activities against risks of outbreaks presents challenging trade-offs. After achieving high vaccine coverage, prisons with mostly one-to-two-person cells that have higher baseline immunity from previous outbreaks can resume in-person activities with low risk of a widespread new outbreak, provided they maintain widespread NPIs, continue testing, and take measures to protect the medically vulnerable.

FUNDING

Horowitz Family Foundation, National Institute on Drug Abuse, Centers for Disease Control and Prevention, National Science Foundation, Open Society Foundation, Advanced Micro Devices.

COVID-19 in the California State Prison System: an Observational Study of Decarceration, Ongoing Risks, and Risk Factors

BACKGROUND

Correctional institutions nationwide are seeking to mitigate COVID-19-related risks.

OBJECTIVE

To quantify changes to California's prison population since the pandemic began and identify risk factors for COVID-19 infection.

DESIGN

For California state prisons (March 1-October 10, 2020), we described residents' demographic characteristics, health status, COVID-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of COVID-19 infection and room occupancy and out-of-room labor, respectively.

PARTICIPANTS

Residents of California state prisons.

MAIN MEASURES

Changes in the incarcerated population's size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs. dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident COVID-19 case rates.

KEY RESULTS

The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≥60, 18.3% had high COVID-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≥10 occupants. Nearly 40% of residents with high COVID-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95% CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95% CI, 1.39-1.74).

CONCLUSION

Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.

Effectiveness of COVID-19 Vaccines among Incarcerated People in California State Prisons: A Retrospective Cohort Study

Background

Prisons and jails are high-risk settings for COVID-19 transmission, morbidity, and mortality. COVID-19 vaccines may substantially reduce these risks, but evidence is needed of their effectiveness for incarcerated people, who are confined in large, risky congregate settings.

Methods

We conducted a retrospective cohort study to estimate effectiveness of mRNA vaccines, BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna), against confirmed SARS-CoV-2 infections among incarcerated people in California prisons from December 22, 2020 through March 1, 2021. The California Department of Corrections and Rehabilitation provided daily data for all prison residents including demographic, clinical, and carceral characteristics, as well as COVID-19 testing, vaccination status, and outcomes. We estimated vaccine effectiveness using multivariable Cox models with time-varying covariates that adjusted for resident characteristics and infection rates across prisons.

Findings

Among 60,707 residents in the cohort, 49% received at least one BNT162b2 or mRNA-1273 dose during the study period. Estimated vaccine effectiveness was 74% (95% confidence interval [CI], 64-82%) from day 14 after first dose until receipt of second dose and 97% (95% CI, 88-99%) from day 14 after second dose. Effectiveness was similar among the subset of residents who were medically vulnerable (74% [95% CI, 62-82%] and 92% [95% CI, 74-98%] from 14 days after first and second doses, respectively), as well as among the subset of residents who received the mRNA-1273 vaccine (71% [95% CI, 58-80%] and 96% [95% CI, 67-99%]).

Conclusions

Consistent with results from randomized trials and observational studies in other populations, mRNA vaccines were highly effective in preventing SARS-CoV-2 infections among incarcerated people. Prioritizing incarcerated people for vaccination, redoubling efforts to boost vaccination and continuing other ongoing mitigation practices are essential in preventing COVID-19 in this disproportionately affected population.

Funding

Horowitz Family Foundation, National Institute on Drug Abuse, Centers for Disease Control and Prevention, National Science Foundation, Open Society Foundation, Advanced Micro Devices.

The Household Secondary Attack Rate of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Rapid Review

BACKGROUND

Although much of the public health effort to combat coronavirus disease 2019 (COVID-19) has focused on disease control strategies in public settings, transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within households remains an important problem. The nature and determinants of household transmission are poorly understood.

METHODS

To address this gap, we gathered and analyzed data from 22 published and prepublished studies from 10 countries (20 291 household contacts) that were available through 2 September 2020. Our goal was to combine estimates of the SARS-CoV-2 household secondary attack rate (SAR) and to explore variation in estimates of the household SAR.

RESULTS

The overall pooled random-effects estimate of the household SAR was 17.1% (95% confidence interval [CI], 13.7-21.2%). In study-level, random-effects meta-regressions stratified by testing frequency (1 test, 2 tests, >2 tests), SAR estimates were 9.2% (95% CI, 6.7-12.3%), 17.5% (95% CI, 13.9-21.8%), and 21.3% (95% CI, 13.8-31.3%), respectively. Household SARs tended to be higher among older adult contacts and among contacts of symptomatic cases.

CONCLUSIONS

These findings suggest that SARs reported using a single follow-up test may be underestimated, and that testing household contacts of COVID-19 cases on multiple occasions may increase the yield for identifying secondary cases.

How US law will evaluate artificial intelligence for covid-19

Daniel E Ho and colleagues explore the legal implications of using artificial intelligence in the response to covid-19 and call for more robust evaluation frameworks

Covid-19 in the California State Prison System: An Observational Study of Decarceration, Ongoing Risks, and Risk Factors

Background:

Correctional institutions nationwide are seeking to mitigate Covid-19-related risks.

Objective:

To quantify changes to California’s prison population since the pandemic began and identify risk factors for Covid-19 infection.

Design:

We described residents’ demographic characteristics, health status, Covid-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of Covid-19 infection and room occupancy and out-of-room labor, respectively.

Setting:

California state prisons (March 1-October 10, 2020).

Participants:

Residents of California state prisons.

Measurements:

Changes in the incarcerated population’s size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident Covid-19 case rates.

Results:

The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≤60, 18.3% had high Covid-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≤10 occupants. Nearly 40% of residents with high Covid-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95%CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95%CI, 1.39-1.74).

Limitations:

Inability to measure density of residents’ living conditions or contact networks among residents and staff.

Conclusion:

Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.

Funding Sources:

Horowitz Family Foundation; National Institute on Drug Abuse; National Science Foundation Graduate Research Fellowship; Open Society Foundations.

Sexual misconduct by health professionals in Australia, 2011-2016: a retrospective analysis of notifications to health regulators

OBJECTIVES

To assess the numbers of notifications to health regulators alleging sexual misconduct by registered health practitioners in Australia, by health care profession.

DESIGN, SETTING

Retrospective cohort study; analysis of Australian Health Practitioner Regulation Agency and NSW Health Professional Councils Authority data on notifications of sexual misconduct during 2011-2016.

PARTICIPANTS

All registered practitioners in 15 health professions.

MAIN OUTCOME MEASURES

Notification rates (per 10 000 practitioner-years) and adjusted rate ratios (aRRs) by age, sex, profession, medical specialty, and practice location.

RESULTS

Regulators received 1507 sexual misconduct notifications for 1167 of 724 649 registered health practitioners (0.2%), including 208 practitioners (18%) who were the subjects of more than one report during 2011-2016; 381 notifications (25%) alleged sexual relationships, 1126 (75%) sexual harassment or assault. Notifications regarding sexual relationships were more frequent for psychiatrists (15.2 notifications per 10 000 practitioner-years), psychologists (5.0 per 10 000 practitioner-years), and general practitioners (6.4 per 10 000 practitioner-years); the rate was higher for regional/rural than metropolitan practitioners (aRR, 1.73; 95% CI, 1.31-2.30). Notifications of sexual harassment or assault more frequently named male than female practitioners (aRR, 37.1; 95% CI, 26.7-51.5). A larger proportion of notifications of sexual misconduct than of other forms of misconduct led to regulatory sanctions (242 of 709 closed cases [34%] v 5727 of 23 855 [24%]).

CONCLUSIONS

While notifications alleging sexual misconduct by health practitioners are rare, such misconduct has serious consequences for patients, practitioners, and the community. Further efforts are needed to prevent sexual misconduct in health care and to ensure thorough investigation of alleged misconduct.

Public views about COVID-19 'Immunity Passports'

IMPORTANCE

Discovery of effective vaccines and increased confidence that infection confers extended protection against coronavirus disease (COVID-19) have renewed discussion of using immunity certificates or 'passports' to selectively reduce ongoing public health restrictions.

OBJECTIVE

To determine public views regarding government and private conferral of immunity privileges.

DESIGN AND SETTING

National on-line survey fielded in June 2020. Participants were randomly asked about either government 'passports' or private 'certificates' for COVID-19 immunity.

PARTICIPANTS

Adults from a standing panel maintained for academic research, selected to approximate national demographics.

MAIN OUTCOMES/MEASURES

Level of support/opposition to immunity privileges, and whether views vary based on: government vs. private adoption; demographics; political affiliation or views; or various COVID19-related attitudes and experiences.

RESULTS

Of 1315 respondents, 45.2% supported immunity privileges, with slightly more favoring private certificates than government passports (48.1% vs 42.6%, p = 0.04). Support was greater for using passports or certificates to enable returns to high-risk jobs or attendance at large recreational events than for returning to work generally. Levels of support did not vary significantly according to age groups, socioeconomic or employment status, urbanicity, political affiliation or views, or whether the respondent had chronic disease(s). However, estimates from adjusted analyses showed less support among women (odds ratio, 0.64; 95% confidence interval, 0.51 to 0.80), and among Hispanics (0.56; 0.40 to 0.78) and other minorities (0.58; 0.40 to 0.85) compared with whites, but not among blacks (0.83; 0.60 to 1.15). Support was much higher among those who personally wanted a passport or certificate (75.6% vs 24.4%) and much lower among those who believed this would harm the social fabric of their community (22.9% vs 77.1%).

CONCLUSIONS AND RELEVANCE

Public views are divided on both government or private uses of immunity certificates, but, prior to any efforts to politicize the issues, these views did not vary along usual political lines or by characteristics that indicate individual vulnerability to infection. Social consensus on the desirability of an immunity privileges programs may be difficult to achieve.

How do Covid-19 policy options depend on end-of-year holiday contacts in Mexico City Metropolitan Area? A Modeling Study

BACKGROUND

With more than 20 million residents, Mexico City Metropolitan Area (MCMA) has the largest number of Covid-19 cases in Mexico and is at risk of exceeding its hospital capacity in late December 2020.

METHODS

We used SC-COSMO, a dynamic compartmental Covid-19 model, to evaluate scenarios considering combinations of increased contacts during the holiday season, intensification of social distancing, and school reopening. Model parameters were derived from primary data from MCMA, published literature, and calibrated to time-series of incident confirmed cases, deaths, and hospital occupancy. Outcomes included projected confirmed cases and deaths, hospital demand, and magnitude of hospital capacity exceedance.

FINDINGS

Following high levels of holiday contacts even with no in-person schooling, we predict that MCMA will have 1·0 million (95% prediction interval 0·5 - 1·7) additional Covid-19 cases between December 7, 2020 and March 7, 2021 and that hospitalizations will peak at 35,000 (14,700 - 67,500) on January 27, 2021, with a >99% chance of exceeding Covid-19-specific capacity (9,667 beds). If holiday contacts can be controlled, MCMA can reopen in-person schools provided social distancing is increased with 0·5 million (0·2 - 1·0) additional cases and hospitalizations peaking at 14,900 (5,600 - 32,000) on January 23, 2021 (77% chance of exceedance).

INTERPRETATION

MCMA must substantially increase Covid-19 hospital capacity under all scenarios considered. MCMA's ability to reopen schools in mid-January 2021 depends on sustaining social distancing and that contacts during the end-of-year holiday were well controlled.

FUNDING

Society for Medical Decision Making, Gordon and Betty Moore Foundation, and Wadhwani Institute for Artificial Intelligence Foundation.

RESEARCH IN CONTEXT

Evidence before this study: As of mid-December 2020, Mexico has the twelfth highest incidence of confirmed cases of Covid-19 worldwide and its epidemic is currently growing. Mexico's case fatality ratio (CFR) - 9·1% - is the second highest in the world. With more than 20 million residents, Mexico City Metropolitan Area (MCMA) has the highest number and incidence rate of Covid-19 confirmed cases in Mexico and a CFR of 8·1%. MCMA is nearing its current hospital capacity even as it faces the prospect of increased social contacts during the 2020 end-of-year holidays. There is limited Mexico-specific evidence available on epidemic, such as parameters governing time-dependent mortality, hospitalization and transmission. Literature searches required supplementation through primary data analysis and model calibration to support the first realistic model-based Covid-19 policy evaluation for Mexico, which makes this analysis relevant and timely.Added value of this study: Study strengths include the use of detailed primary data provided by MCMA; the Bayesian model calibration to enable evaluation of projections and their uncertainty; and consideration of both epidemic and health system outcomes. The model projects that failure to limit social contacts during the end-of-year holidays will substantially accelerate MCMA's epidemic (1·0 million (95% prediction interval 0·5 - 1·7) additional cases by early March 2021). Hospitalization demand could reach 35,000 (14,700 - 67,500), with a >99% chance of exceeding current capacity (9,667 beds). Controlling social contacts during the holidays could enable MCMA to reopen in-person schooling without greatly exacerbating the epidemic provided social distancing in both schools and the community were maintained. Under all scenarios and policies, current hospital capacity appears insufficient, highlighting the need for rapid capacity expansion.Implications of all the available evidence: MCMA officials should prioritize rapid hospital capacity expansion. MCMA's ability to reopen schools in mid-January 2021 depends on sustaining social distancing and that contacts during the end-of-year holiday were well controlled.

Characteristics and predictors of regulatory immediate action imposed on registered health practitioners in Australia: a retrospective cohort study

Objective Immediate action is an emergency power available to Australian health practitioner regulatory boards to protect the public. The aim of this study was to better understand the frequency, determinants and characteristics of immediate action use in Australia. Methods This was a retrospective cohort study of 11200 health practitioners named in notifications to the Australian Health Practitioner Regulation Agency (AHPRA) between January 2011 and December 2013. All cases were followed until December 2016 to determine their final outcome. Results Of 13939 finalised notifications, 3.7% involved immediate action and 9.7% resulted in restrictive final action. Among notifications where restrictive final action was taken, 79% did not involve prior immediate action. Among notifications where immediate action was taken, 48% did not result in restrictive final action. Compared with notifications from the public, the odds of immediate action were higher for notifications lodged by employers (mandatory notifications OR=21.3, 95% CI 13.7-33.2; non-mandatory notifications OR=10.9, 95% CI 6.7-17.8) and by other health practitioners (mandatory notifications OR=11.6, 95% CI 7.6-17.8). Odds of immediate action were also higher if the notification was regulator-initiated (OR=11.6, 95% CI 7.6-17.8), lodged by an external agency such as the police (OR=11.8, 95% CI 7.7-18.1) or was a self-notification by the health practitioner themselves (OR=9.4, 95% CI 5.5-16.0). The odds of immediate action were higher for notifications about substance abuse (OR=9.9, 95% CI 6.9-14.2) and sexual misconduct (OR=5.3, 95% CI 3.5-8.3) than for notifications about communication and clinical care. Conclusions Health practitioner regulatory boards in Australia rarely used immediate action as a regulatory tool, but were more likely to do so in response to mandatory notifications or notifications pertaining to substance abuse or sexual misconduct. What is known about this topic Health practitioner regulatory boards protect the public from harm and maintain quality and standards of health care. Where the perceived risk to public safety is high, boards may suspend or restrict the practice of health practitioners before an investigation has concluded. What does this paper add? This paper is the first study in Australia, and the largest internationally, to examine the frequency, characteristics and predictors of the use of immediate action by health regulatory boards. Although immediate action is rarely used, it is most commonly employed in response to mandatory notifications or notifications pertaining to substance abuse or sexual misconduct. What are the implications for practitioners? Immediate action is a vital regulatory tool. Failing to immediately sanction a health practitioner may expose the public to preventable harm, whereas imposing immediate action where allegations are unfounded can irreparably damage a health practitioner's career. We hope that this study will assist boards to balance the interests of the public with those of health practitioners.

Handgun Ownership and Suicide in California

BACKGROUND

Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership.

METHODS

We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns).

RESULTS

A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition.

CONCLUSIONS

Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.).

Armed and prohibited: characteristics of unlawful owners of legally purchased firearms

BACKGROUND

A substantial proportion of individuals who lawfully purchase firearms later become unlawful owners ('prohibited firearm owners'), usually following events associated with an increased risk for future violence. This high-risk population has not previously been described. We aimed to characterise all individuals in California's Armed and Prohibited Persons System (APPS), a statewide programme for recovering firearms from individuals who legally purchased them and later became prohibited from ownership.

METHODS

We used univariate and bivariate statistics to describe and compare prohibited firearm owners in APPS with a random sample of non-prohibited firearm owners in relation to age, sex, race/ethnicity and type of firearms owned as of 1 February 2015. We also characterised the geographical distribution of prohibited firearm owners and described their prohibitions.

RESULTS

Of the 18 976 prohibited firearm owners, most were men (93%), half were white (53%) and the mean age was 47 years. Prohibited firearm owners were more likely to be male and to be black or Hispanic people than non-prohibited owners. Both prohibited and non-prohibited firearm owners had an average of 2.6 firearms, mostly handguns. Nearly half (48%) of prohibited firearm owners had a felony conviction. Extrapolating from our findings, we estimated that there are approximately 100 000 persons in the USA who unlawfully maintained ownership of their firearms following a felony conviction.

CONCLUSIONS

Retention of firearms among persons who become lawfully prohibited from possessing them is common in California. Given the nationwide dearth of a programme to recover such weapons, this is likely true in other states as well.

Malpractice Liability and Health Care Quality: A Review

IMPORTANCE

The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients.

OBJECTIVE

To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety.

DATA SOURCES AND STUDY SELECTION

Systematic search of multiple databases for studies published between January 1, 1990, and November 25, 2019, examining the relationship between malpractice liability risk measures and health outcomes or structural and process indicators of health care quality.

DATA EXTRACTION AND SYNTHESIS

Information on the exposure and outcome measures, results, and acknowledged limitations was extracted by 2 reviewers. Meta-analytic pooling was not possible due to variations in study designs; therefore, studies were summarized descriptively and assessed qualitatively.

MAIN OUTCOMES AND MEASURES

Associations between malpractice risk measures and health care quality and safety outcomes. Exposure measures included physicians' malpractice insurance premiums, state tort reforms, frequency of paid claims, average claim payment, physicians' claims history, total malpractice payments, jury awards, the presence of an immunity from malpractice liability, the Centers for Medicare & Medicaid Services' Medicare malpractice geographic practice cost index, and composite measures combining these measures. Outcome measures included patient mortality; hospital readmissions, avoidable admissions, and prolonged length of stay; receipt of cancer screening; Agency for Healthcare Research and Quality patient safety indicators and other measures of adverse events; measures of hospital and nursing home quality; and patient satisfaction.

RESULTS

Thirty-seven studies were included; 28 examined hospital care only and 16 focused on obstetrical care. Among obstetrical care studies, 9 found no significant association between liability risk and outcomes (such as Apgar score and birth injuries) and 7 found limited evidence for an association. Among 20 studies of patient mortality in nonobstetrical care settings, 15 found no evidence of an association with liability risk and 5 found limited evidence. Among 7 studies that examined hospital readmissions and avoidable initial hospitalizations, none found evidence of an association between liability risk and outcomes. Among 12 studies of other measures (eg, patient safety indicators, process-of-care quality measures, patient satisfaction), 7 found no association between liability risk and these outcomes and 5 identified significant associations in some analyses.

CONCLUSIONS AND RELEVANCE

In this systematic review, most studies found no association between measures of malpractice liability risk and health care quality and outcomes. Although gaps in the evidence remain, the available findings suggested that greater tort liability, at least in its current form, was not associated with improved quality of care.

Association of Prior Convictions for Driving Under the Influence With Risk of Subsequent Arrest for Violent Crimes Among Handgun Purchasers

IMPORTANCE

Alcohol use is a risk factor for firearm-related violence, and firearm owners are more likely than others to report risky drinking behaviors.

OBJECTIVE

To study the association between prior convictions for driving under the influence (DUI) and risk of subsequent arrest for violent crimes among handgun purchasers.

DESIGN

In this retrospective, longitudinal cohort study, 79 678 individuals were followed up from their first handgun purchase in 2001 through 2013. The study cohort included all legally authorized handgun purchasers in California aged 21 to 49 years at the time of purchase in 2001. Individuals were identified using the California Department of Justice (CA DOJ) Dealer's Record of Sale (DROS) database, which retains information on all legal handgun transfers in the state.

EXPOSURES

The primary exposure was DUI conviction prior to the first handgun purchase in 2001, as recorded in the CA DOJ Criminal History Information System.

MAIN OUTCOMES AND MEASURES

Prespecified outcomes included arrests for violent crimes listed in the Crime Index published by the Federal Bureau of Investigation (murder, rape, robbery, and aggravated assault), firearm-related violent crimes, and any violent crimes.

RESULTS

Of the study population (N=79 678), 91.0% were males and 68.9% were white individuals; the median age was 34 (range, 21-49) years. The analytic sample for multivariable models included 78 878 purchasers after exclusions. Compared with purchasers who had no prior criminal history, those with prior DUI convictions and no other criminal history were at increased risk of arrest for a Crime Index-listed violent crime (adjusted hazard ratio [AHR], 2.6; 95% CI, 1.7-4.1), a firearm-related violent crime (AHR, 2.8; 95% CI, 1.3-6.4), and any violent crime (AHR, 3.3; 95% CI, 2.4-4.5). Among purchasers with a history of arrests or convictions for crimes other than DUI, associations specifically with DUI conviction remained.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that prior DUI convictions may be associated with the risk of subsequent violence, including firearm-related violence, among legal purchasers of handguns. Although the magnitude was diminished, the risk associated with DUI conviction remained elevated even among those with a history of arrests or convictions for crimes of other types.

Complaint risk among mental health practitioners compared with physical health practitioners: a retrospective cohort study of complaints to health regulators in Australia

OBJECTIVES

To understand complaint risk among mental health practitioners compared with physical health practitioners.

DESIGN

Retrospective cohort study, using incidence rate ratios (IRRs) to analyse complaint risk and a multivariate regression model to identify predictors of complaints.

SETTING

National study using complaints data from health regulators in Australia.

PARTICIPANTS

All psychiatrists and psychologists ('mental health practitioners') and all physicians, optometrists, physiotherapists, osteopaths and chiropractors ('physical health practitioners') registered to practice in Australia between 2011 and 2016.

OUTCOME MEASURES

Incidence rates, source and nature of complaints to regulators.

RESULTS

In total, 7903 complaints were lodged with regulators over the 6-year period. Most complaints were lodged by patients and their families. Mental health practitioners had a complaint rate that was more than twice that of physical health practitioners (complaints per 1000 practice years: psychiatrists 119.1 vs physicians 48.0, p<0.001; psychologists 21.9 vs other allied health 7.5, p<0.001). Their risk of complaints was especially high in relation to reports, records, confidentiality, interpersonal behaviour, sexual boundary breaches and the mental health of the practitioner. Among mental health practitioners, male practitioners (psychiatrists IRR: 1.61, 95% CI 1.39 to 1.85; psychologists IRR: 1.85, 95% CI 1.65 to 2.07) and older practitioners (≥65 years compared with 36-45 years: psychiatrists IRR 2.37, 95% CI 1.95 to 2.89; psychologists IRR 1.78, 95% CI 1.47 to 2.14) were at increased risk of complaints.

CONCLUSIONS

Mental health practitioners were more likely to be the subject of complaints than physical health practitioners. Areas of increased risk are related to professional ethics, communication skills and the health of mental health practitioners themselves. Further research could usefully explore whether addressing these risk factors through training, professional development and practitioner health initiatives may reduce the risk of complaints about mental health practitioners.

Assembly of the LongSHOT cohort: public record linkage on a grand scale

BACKGROUND

Virtually all existing evidence linking access to firearms to elevated risks of mortality and morbidity comes from ecological and case-control studies. To improve understanding of the health risks and benefits of firearm ownership, we launched a cohort study: the Longitudinal Study of Handgun Ownership and Transfer (LongSHOT).

METHODS

Using probabilistic matching techniques we linked three sources of individual-level, state-wide data in California: official voter registration records, an archive of lawful handgun transactions and all-cause mortality data. There were nearly 28.8 million unique voter registrants, 5.5 million handgun transfers and 3.1 million deaths during the study period (18 October 2004 to 31 December 2016). The linkage relied on several identifying variables (first, middle and last names; date of birth; sex; residential address) that were available in all three data sets, deploying them in a series of bespoke algorithms.

RESULTS

Assembly of the LongSHOT cohort commenced in January 2016 and was completed in March 2019. Approximately three-quarters of matches identified were exact matches on all link variables. The cohort consists of 28.8 million adult residents of California followed for up to 12.2 years. A total of 1.2 million cohort members purchased at least one handgun during the study period, and 1.6 million died.

CONCLUSIONS

Three steps taken early may be particularly useful in enhancing the efficiency of large-scale data linkage: thorough data cleaning; assessment of the suitability of off-the-shelf data linkage packages relative to bespoke coding; and careful consideration of the minimum sample size and matching precision needed to support rigorous investigation of the study questions.

Identification of practitioners at high risk of complaints to health profession regulators

Background

Some health practitioners pose substantial threats to patient safety, yet early identification of them is notoriously difficult. We aimed to develop an algorithm for use by regulators in prospectively identifying practitioners at high risk of attracting formal complaints about health, conduct or performance issues.

Methods

Using 2011—2016 data from the national regulator of health practitioners in Australia, we conducted a retrospective cohort study of 14 registered health professions. We used recurrent-event survival analysis to estimate the risk of a complaint and used the results of this analysis to develop an algorithm for identifying practitioners at high risk of complaints. We evaluated the algorithm’s discrimination, calibration and predictive properties.

Results

Participants were 715,415 registered health practitioners (55% nurses, 15% doctors, 6% midwives, 5% psychologists, 4% pharmacists, 15% other). The algorithm, PRONE-HP (Predicted Risk of New Event for Health Practitioners), incorporated predictors for sex, age, profession and specialty, number of prior complaints and complaint issue. Discrimination was good (C-index = 0·77, 95% CI 0·76–0·77). PRONE-HP’s score values were closely calibrated with risk of a future complaint: practitioners with a score ≤ 4 had a 1% chance of a complaint within 24 months and those with a score ≥ 35 had a higher than 85% chance. Using the 90th percentile of scores within each profession to define “high risk”, the predictive accuracy of PRONE-HP was good for doctors and dentists (PPV = 93·1% and 91·6%, respectively); moderate for chiropractors (PPV = 71·1%), psychologists (PPV = 54·9%), pharmacists (PPV = 39·9%) and podiatrists (PPV = 34·0%); and poor for other professions.

Conclusions

The performance of PRONE-HP in predicting complaint risks varied substantially across professions. It showed particular promise for flagging doctors and dentists at high risk of accruing further complaints. Close review of available information on flagged practitioners may help to identify troubling patterns and imminent risks to patients.

Accuracy of Valuations of Surgical Procedures in the Medicare Fee Schedule

BACKGROUND

The Relative Value Scale Update Committee (RUC) of the American Medical Association plays a central role in determining physician reimbursement. The RUC's role and performance have been criticized but subjected to little empirical evaluation.

METHODS

We analyzed the accuracy of valuations of 293 common surgical procedures from 2005 through 2015. We compared the RUC's estimates of procedure time with "benchmark" times for the same procedures derived from the clinical registry maintained by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review corrected them.

RESULTS

At the time of 108 RUC reviews, the mean absolute discrepancy between RUC time estimates and benchmark times was 18.5 minutes, or 19.8% of the RUC time. However, RUC time estimates were neither systematically shorter nor longer than benchmark times overall (β, 0.97; 95% confidence interval, 0.94 to 1.01; P = 0.10). Our analyses suggest that whereas orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used ($160 million and $40 million more, respectively, in Medicare reimbursement in 2011 through 2015), cardiothoracic surgeons, neurosurgeons, and vascular surgeons received lower payments ($130 million, $60 million, and $30 million less, respectively). The accuracy of RUC time estimates improved in 47% of RUC revaluations, worsened in 27%, and was unchanged in 25%. (Percentages do not sum to 100 because of rounding.).

CONCLUSIONS

In this analysis of frequently conducted operations, we found substantial absolute discrepancies between intraoperative times as estimated by the RUC and the times recorded for the same procedures in a surgical registry, but the RUC did not systematically overestimate or underestimate times. (Funded by the National Institutes of Health.).

Changes in Practice among Physicians with Malpractice Claims

BACKGROUND

Physicians with poor malpractice liability records may pose a risk to patient safety. There are long-standing concerns that such physicians tend to relocate for a fresh start, but little is known about whether, how, and where they continue to practice.

METHODS

We linked an extract of the National Practitioner Data Bank to the Medicare Data on Provider Practice and Specialty data set to create a national cohort of physicians 35 to 65 years of age who practiced during the period from 2008 through 2015. We analyzed associations between the number of paid malpractice claims that physicians accrued and exits from medical practice, changes in clinical volume, geographic relocation, and change in practice-group size.

RESULTS

The cohort consisted of 480,894 physicians who had 68,956 paid claims from 2003 through 2015. A total of 89.0% of the physicians had no claims, 8.8% had 1 claim, and the remaining 2.3% had 2 or more claims and accounted for 38.9% of all claims. The number of claims was positively associated with the odds of leaving the practice of medicine (odds ratio for 1 claim vs. no claims, 1.09; 95% confidence interval [CI], 1.06 to 1.11; odds ratio for ≥5 claims, 1.45; 95% CI, 1.20 to 1.74). The number of claims was not associated with geographic relocation but was positively associated with shifts into smaller practice settings. For example, physicians with 5 or more claims had more than twice the odds of moving into solo practice than physicians with no claims (odds ratio, 2.39; 95% CI, 1.79 to 3.20).

CONCLUSIONS

Physicians with multiple malpractice claims were no more likely to relocate geographically than those with no claims, but they were more likely to stop practicing medicine or switch to smaller practice settings. (Funded by SUMIT Insurance and the Australian Research Council.).

Development of prediction models of stress and long-term disability among claimants to injury compensation systems: a cohort study

OBJECTIVES

We sought to develop prognostic risk scores for compensation-related stress and long-term disability using markers collected within 3 months of a serious injury.

DESIGN

Cohort study. Predictors were collected at baseline and at 3 months postinjury. Outcome data were collected at 72 months postinjury.

SETTING

Hospitalised patients with serious injuries recruited from four major trauma hospitals in Australia.

PARTICIPANTS

332 participants who made claims for compensation for their injuries to a transport accident scheme or a workers' compensation scheme.

PRIMARY OUTCOME MEASURES

12-item WHO Disability Assessment Schedule and 6 items from the Claims Experience Survey.

RESULTS

Our model for long-term disability had four predictors (unemployed at the time of injury, history of a psychiatric disorder at time of injury, post-traumatic stress disorder symptom severity at 3 months and disability at 3 months). This model had good discrimination (R²=0.37) and calibration. The disability risk score had a score range of 0-180, and at a threshold of 80 had sensitivity of 56% and specificity of 86%. Our model for compensation-related stress had five predictors (intensive care unit admission, discharged to home, number of traumatic events prior to injury, depression at 3 months and not working at 3 months). This model also had good discrimination (area under the curve=0.83) and calibration. The compensation-related stress risk score had score range of 0-220 and at a threshold of 100 had sensitivity of 74% and specificity of 75%. By combining these two scoring systems, we were able to identify the subgroup of claimants at highest risk of experiencing both outcomes.

CONCLUSIONS

The ability to identify at an early stage claimants at high risk of compensation-related stress and poor recovery is potentially valuable for claimants and the compensation agencies that serve them. The scoring systems we developed could be incorporated into the claims-handling processes to guide prevention-oriented interventions.

Correction to: Outcomes of notifications to health practitioner boards: a retrospective cohort study

The original article [1] contains a major error whereby all rates in Table 2 are mistakenly presented as 50% of their true values; this error was caused by a miscalculation in annualising the original values that represented the rates.

Handgun Acquisitions in California After Two Mass Shootings

BACKGROUND

Mass shootings are common in the United States. They are the most visible form of firearm violence. Their effect on personal decisions to purchase firearms is not well-understood.

OBJECTIVE

To determine changes in handgun acquisition patterns after the mass shootings in Newtown, Connecticut, in 2012 and San Bernardino, California, in 2015.

DESIGN

Time-series analysis using seasonal autoregressive integrated moving-average (SARIMA) models.

SETTING

California.

POPULATION

Adults who acquired handguns between 2007 and 2016.

MEASUREMENTS

Excess handgun acquisitions (defined as the difference between actual and expected acquisitions) in the 6-week and 12-week periods after each shooting, overall and within subgroups of acquirers.

RESULTS

In the 6 weeks after the Newtown and San Bernardino shootings, there were 25 705 (95% prediction interval, 17 411 to 32 788) and 27 413 (prediction interval, 15 188 to 37 734) excess acquisitions, respectively, representing increases of 53% (95% CI, 30% to 80%) and 41% (CI, 19% to 68%) over expected volume. Large increases in acquisitions occurred among white and Hispanic persons, but not among black persons, and among persons with no record of having previously acquired a handgun. After the San Bernardino shootings, acquisition rates increased by 85% among residents of that city and adjacent neighborhoods, compared with 35% elsewhere in California.

LIMITATIONS

The data relate to handguns in 1 state. The statistical analysis cannot establish causality.

CONCLUSION

Large increases in handgun acquisitions occurred after these 2 mass shootings. The spikes were short-lived and accounted for less than 10% of annual handgun acquisitions statewide. Further research should examine whether repeated shocks of this kind lead to substantial increases in the prevalence of firearm ownership.

PRIMARY FUNDING SOURCE

None.

The effect of federal and state off-label marketing investigations on drug prescribing: The case of olanzapine

In the past decade, the federal government has frequently investigated and prosecuted pharmaceutical manufacturers for illegal promotion of drugs for indications not approved by the Food and Drug Administration (FDA) (“off-label” uses). State governments can choose to coordinate with the federal investigation, or pursue their own independent state investigations. One of the largest-ever off-label prosecutions relates to the atypical antipsychotic drug olanzapine (Zyprexa). In a series of settlements between 2008 and 2010, Eli Lilly paid $1.4 billion to the federal government and over $290 million to state governments. We examined the effect of these settlements on off-label prescribing of this medication, taking advantage of geographical differences in states’ involvement in the investigations and the timing of the settlements. However, we did not find a reduction in off-label prescribing; rather, there were no prescribing changes among states that joined the federal investigation, those that pursued independent state investigations, and states that pursued no investigations at all. Since the settlements of state investigations of off-label prescribing do not appear to significantly impact prescribing rates, policymakers should consider alternate ways of reducing the prevalence of non-evidence-based off-label use to complement their ongoing investigations.