Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: the Corpus Christi Heart Project

PURPOSE: Previous comparisons of coronary heart disease mortality between Mexican Americans and non-Hispanic whites have given paradoxic results: despite their adverse cardiovascular risk profiles, especially a greater prevalence of diabetes, Mexican Americans are reported to have lower rates of mortality from coronary heart disease. SUBJECTS AND METHODS: We performed a community-based surveillance among all residents of Nueces County, Texas, aged 25 to 74 years, from 1990 to 1994. All death certificates were obtained and coded, and deaths potentially related to coronary heart disease were selected and validated by standardized methods blinded to ethnicity. Validated in-hospital and out-of-hospital coronary heart disease mortality was compared between 785 Mexican Americans and 862 non-Hispanic white women and men. RESULTS: Validated coronary heart disease mortality in Mexican Americans exceeded that for non-Hispanic whites in the same community. Among women, definite coronary heart disease mortality was 40% greater among Mexican Americans (rate ratio [RR] 1.43, 95% confidence interval [CI]: 1.12 to 1.82), as was all coronary heart disease mortality (RR, 1.32, 95% CI: 1.08 to 1.63). Among men, Mexican Americans had greater rates of all (RR, 1.11; 95% CI: 0.96 to 1.28) and definite coronary heart disease mortality (RR, 1.16; 95% CI: 0.91 to 1.47), but the associations were not statistically significant. CONCLUSIONS: When community-wide mortality rates from coronary heart disease are properly validated, Mexican Americans have rates equal to or higher than those of non-Hispanic whites. Community-based surveillance with validation of coronary heart disease as the cause of death is necessary to avoid the errors that occur with the use of death certificates alone.     

Patterns and predictors of asthma-related emergency department use in Harlem

STUDY OBJECTIVES: To assess the roles of poor access to care, psychological risk factors, and asthma severity in frequent emergency department (ED) use. DESIGN: A cross-sectional survey. SETTING: Harlem Hospital Center ED and outpatient chest clinic. PARTICIPANTS: Three hundred seventy-five adult residents of Harlem, a predominantly African-American community in New York City. MEASUREMENTS: Asthma severity was assessed by self-reported symptoms using National Asthma Education and Prevention Program guidelines, health-care utilization, and psychometric scales. RESULTS: Respondents with more severe asthma were more likely to have a primary asthma care provider, and to have had more scheduled office visits for asthma in the year prior to the interview (mean number of visits for patients with severe asthma, 3.6 visits; moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Despite having a regular source of care, 69% of respondents identified the ED as their preferred source of care; 82% visited the ED more than once in the year prior to interview (median, four visits). Persons with moderate or severe asthma were 3.8 times more likely to be frequent ED users compared to those with mild asthma (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2 to 6.6). This was the strongest predictor of frequent ED use. Other predictors of ED use were number of comorbid disorders (OR, 1.5; 95% CI, 1.1 to 2.1) and self-reported global health in the year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7). Psychological characteristics were not predictive of frequent ED use when controlling for disease severity. CONCLUSIONS: Frequent ED users present with serious medical conditions. They do not substitute physician care with ED care; they augment it to address serious health needs.     

Mortality and adverse health events in newly admitted nursing home residents with and without dementia

OBJECTIVES: To evaluate the association between dementia and mortality, adverse health events, and discharge disposition of newly admitted nursing home residents. It was hypothesized that residents with dementia would die at a higher rate and develop more adverse health events (e.g., infections, fevers, pressure ulcers, falls) than residents without dementia because of communication and self-care difficulties. DESIGN: An expert clinician panel diagnosed an admission cohort from a stratified random sample of 59 Maryland nursing homes, between 1992 and 1995. The cohort was followed for up to 2 years or until discharge. SETTING: Fifty-nine Maryland nursing homes. PARTICIPANTS: Two thousand one hundred fifty-three newly admitted residents aged 65 and older not having resided in a nursing home for 8 or more days in the previous year. MEASUREMENTS: Mortality, infection, fever, pressure ulcers, fractures, and discharge home. RESULTS: Residents with dementia had significantly lower overall rates of infection (relative risk (RR)=0.77, 95% confidence interval (CI)=0.70-0.85) and mortality (RR=0.61, 95% CI=0.53-0.71) than those without dementia, whereas rates of fever, pressure ulcers, and fractures were similar for the two groups. These results persisted when rates were adjusted for demographic characteristics, comorbid conditions, and functional status. During the first 90 days of the nursing home stay, residents with dementia had significantly lower rates of mortality if not admitted for rehabilitative care under a Medicare qualifying stay (RR=0.25, 95% CI=0.14-0.45), were less often discharged home (RR=0.33, 95% CI=0.28-0.38), and tended to have lower fever rates (RR=0.78, 95% CI=0.63-0.96) than residents without dementia. CONCLUSION: Newly admitted nursing home residents with dementia have a profile of health events that is distinct from that of residents without dementia, indicating that the two groups have different long-term care needs. Results suggest that further investigation of whether residents with dementia can be well managed in alternative residential settings would be valuable.     

Temporal trend of diabetes in pregnant women and its association with birth outcomes, 2011 to 2017

AimTo assess changes in the prevalence of diabetes in pregnant women, and its association with selected birth outcomes (including caesarean section, episiotomy, admission to the special care nursery/neonatal intensive care unit, postpartum haemorrhage and neonatal birth weight) from 2011 to 2017.MethodsIn a single-centre, retrospective cohort study, we examined records of pregnant women who attended an Australian tertiary hospital between 2011 and 2017, identifying women with gestational diabetes mellitus and pre-existing diabetes mellitus, and examined trends associated with diabetes and their effects on birth outcomes.ResultsThe average incidence of women with diabetes increased by 9% annually (RR = 0.09, 95% CI = 1.08–1.11), which was 6% greater in women who received antenatal doctor-led care (RR = 1.06, 95% CI = 1.01–1.13), 42% greater in women who had other endocrine diseases (including thyroid, adrenal or pituitary diseases) (RR = 1.42, 95% CI = 1.31–1.53), and 61% greater in women with hypertension during pregnancy (RR = 1.61, 95% CI = 1.47–1.78). The presence of diabetes did not affect the relative risks of caesarean section, episiotomy, postpartum haemorrhage, decreased neonatal birth weight or special care nursery/neonatal intensive care unit admission, after adjustment for demographics and health and care status and behaviours.ConclusionsThe rate of diabetes during pregnancy increased from 2011 to 2017. Diabetes did not affect the relative risk of untoward birth outcomes.     

Suicide in Older Adults in Long‐Term Care: 1990 to 2005

OBJECTIVES: To describe the characteristics associated with suicide in older persons residing in long‐term care (LTC) facilities, to compare the characteristics of suicide cases in LTC with those of cases in the community, and to evaluate trends in suicide in these settings over the past 15 years. SETTING: The New York City (NYC) Office of the Chief Medical Examiner (OCME). PARTICIPANTS: Suicide deaths in NYC from 1990 to 2005. MEASUREMENTS: Location and method of suicide death reported by OCME. METHODS: Suicides in older persons in LTC and community‐dwelling older adults were compared in terms of demographic characteristics and method used. Trends in suicide rate ratios (RRs) were examined using zero‐inflated Poisson regression. RESULTS: Over the study period, there were 1,771 suicides among NYC residents aged 60 and older: 47 in LTC and 1,724 in the community. Cases in LTC tended to be older (P<.02) but did not differ from community cases in terms of race or sex. Suicides in LTC were significantly less likely (RR=0.05, P<.002) to be due to firearms and 2.49 times as likely to be due to a long fall (P<.002) as community cases. Over the 15‐year period, there was a significant decrease in the relative rate of suicide in community‐dwelling adults (RR=0.97, P<.001) but no change in residents of LTC (RR=1.05, P<.17). CONCLUSIONS: Suicide risk in community‐dwelling older adults has declined over the past 15 years but has not changed in LTC facilities. This suggests that prevention efforts may not be reaching this population effectively.     

Predictors of postpartum HIV care engagement for women enrolled in prevention of mother-to-child transmission (PMTCT) programs in Tanzania

Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200?copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR: .53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time.     

A community-based study of barriers to HIV care initiation

Timely treatment of HIV infection is a public health priority, yet many HIV-positive persons delay treatment initiation. We conducted a community-based study comparing HIV-positive persons who received an HIV diagnosis at least 3 months ago but had not initiated care (n=100) with a reference population of HIV-positive persons currently in care (n=115) to identify potential barriers to treatment initiation. Study participants were mostly male (78.0%), and persons of color (54.9% Latino, 26.3% black), with median age 37.8 years. Median time since HIV diagnosis was 3.7 years. Univariate analysis revealed that those never in care differed substantially from those currently in care with regard to sociodemographics; HIV testing and counseling experiences; perceived barriers to care; and knowledge, attitudes, and beliefs regarding HIV. Factors independently associated with never initiating HIV care were younger age (adjusted odds ratio [AOR]=0.93; 95% confidence interval [CI]: 0.88, 0.99), shorter time since diagnosis (AOR=0.87; 95% CI: 0.77, 0.98), lacking insurance (AOR=0.11; 95% CI: 0.03, 0.35), not knowing someone with HIV/AIDS (AOR=0.09; 95% CI: 0.03, 0.30) not disclosing HIV status (AOR=0.13; 95% CI: 0.02, 0.70), not receiving help making an HIV care appointment after diagnosis (AOR=0.04; 95% CI: 0.01, 0.14), and not wanting to think about being HIV positive (AOR=3.57; 95% CI: 1.22, 10.46). Our findings suggest that isolation and stigma remain significant barriers to initiating HIV care in populations consisting primarily of persons of color, and that direct linkages to HIV care at the time of diagnosis are critical to promoting timely care initiation in these populations.     

Prospective study of 424 cases of Staphylococcus aureus bacteraemia: determination of factors affecting incidence and mortality

Background: Staphylococcus aureus bacteraemia (SAB) is a common complication of S. aureus infection and is associated with a high mortality. Aims: To document prospectively the pattern of ill‐ ness associated with SAB in New Zealand and, by recording patient demographic factors and clinical features, to identify risk factors associated with a poor outcome. Methods: From 1 July 1996 to 31 December 1997, adults with SAB were prospectively studied in six tertiary care hospitals. All information obtained from patients’ records was recorded on worksheets and transferred to a computerized spreadsheet for analysis. Results: There were 424 patients with SAB. Maori (relative risk (RR) = 1.8, 95% confidence interval (CI) = 1.3–2.6) and Pacific Island people (RR = 4.0, 95% CI = 3.1–5.3) were significantly more likely than people of European descent to acquire SAB, but not to die from the infection. Fifty per cent of cases were community acquired. A source was identified for 85%: intravenous catheter (31%), primarily hospital acquired, and skin/soft tissue (22%), primarily community acquired, were the most common foci. The 30‐day mortality was 19%, 83% of whom died within 2 weeks. Risk factors for a poor outcome were: increasing age above 60, female sex (RR = 1.4, 95% CI = 1.0–2.1), diabetes mellitus (RR = 1.5, 95% CI = 1.0–2.4), immunosuppression (RR = 1.5, 95% CI = 1.0–2.4), pre‐existing renal impairment (RR = 1.8, 95% CI = 1.2–2.7), malignancy (RR = 2.2, 95% CI = 1.4–3.5), lung as a source (RR = 2.8, 95% CI = 1.9–4.2) and unknown source (RR = 2.3, 95% CI = 1.5–3.3). Mortality was also accurately predicted by two multifactor scoring systems. There was a low rate of methicillin resistance (5%). Conclusions: Staphylococcus aureus bacteraemia is more likely to occur in certain ethnic groups, while mortality is associated with other identifiable risk factors and continues to be high. Intravenous catheters remain the most common and most preventable cause of SAB. (Intern Med J 2001; 31: 97–103)     

Relative activity and referral patterns for diabetes and non-diabetes in general practice.

AIMS: To describe and compare general practice (GP) activity for patients with and without diabetes using a survey of general practices representing over 10% of the Welsh population. METHODS: The Welsh GP Morbidity Database Project (GPMDP) collected data including demographic and lifestyle information and consultation data such as diagnosis, referral and surgical procedures. These data were analysed to establish the annual period prevalence of diabetes and compare the relative number of consultations and referrals. RESULTS: A total of 4,182 diabetic patients were recorded (prevalence 1.41%) and accounted for 77,371 (4.4%) consultations. Patients with diabetes were four-times more likely to be referred to community services (relative risk (RR) 4.1, 95% CI 3.7-4.7), in particular district nursing (RR 3.8, 1.9-7.7), optician services (RR 8.9, 5.0-15.7), chiropody (RR 8.2 6.4-10.5) and dietician services (RR 21.2, 17.6-25.5). Patients with diabetes were also more likely to be followed-up in general practice (RR 6.7, 6.2-7.2) both within 1 month (RR 6.7, 6.2-7.2) and 1 month to 1 year (RR 9.7, 8.9-10.7). Emergency admissions were also more likely for patients with diabetes (RR 6.8, 6.2-7.5) as were elective admissions to general medicine (RR 5.6, 4.6-6.7), surgery (RR 1.8, 1.5-2.0) and opthalmology (4.2, 3.4-5.2). CONCLUSION: The increased utilization of health services apparent in secondary care was confirmed in primary care. Further research is required to determine levels of community activity after initial referral.     

Personal barriers to diabetes care: lessons from a multi-ethnic community in New Zealand

The aim of this study was to identify and quantify barriers to diabetes care perceived by diabetic subjects from a multiethnic, urban community (mainly New Zealand Europeans, Maori, and Pacific Islanders). A qualitative survey including 57 diabetic subjects and health care providers from a diverse range of backgrounds was followed by a cross-sectional household survey. Barriers to care were quantified among 1862 (2.1 %) diabetic residents of a total surveyed population of 90 477. Thirty barriers to care categories were generated incorporating patient beliefs, internal and external physical barriers, educational, psycho-social and psychological barriers. In spite of major difference in culture, acculturation, and socio-economic status, the top 10 barriers were similar between the ethnic groups. The most important barriers were perceiving that the benefits of self-care were outweighed by the disadvantages (20 % Europeans, 20 % Maori, 29 % Pacific Islanders, 16 % others, p < 0.001), lack of community-based services (13 % Europeans, 27 % Maori, 25 % Pacific Islanders, 11 % others, p < 0.001) and the limited range of services available (15 % Europeans, 22 % Maori, 20 % Pacific Islanders, 14 % others, p < 0.05). It is postulated that definition of these barriers, with subsequent, systematic action to reduce their impact, in both patients and populations could result in an improvement in diabetes outcomes. © 1998 John Wiley & Sons, Ltd.     

The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial

OBJECTIVES: To test whether Stepping On, a multifaceted community-based program using a small-group learning environment, is effective in reducing falls in at-risk people living at home. DESIGN: A randomized trial with subjects followed for 14 months. SETTING: The interventions were conducted in community venues, with a follow-up home visit. PARTICIPANTS: Three hundred ten community residents aged 70 and older who had had a fall in the previous 12 months or were concerned about falling. INTERVENTION: The Stepping On program aims to improve fall self-efficacy, encourage behavioral change, and reduce falls. Key aspects of the program are improving lower-limb balance and strength, improving home and community environmental and behavioral safety, encouraging regular visual screening, making adaptations to low vision, and encouraging medication review. Two-hour sessions were conducted weekly for 7 weeks, with a follow-up occupational therapy home visit. MEASUREMENTS: The primary outcome measure was falls, ascertained using a monthly calendar mailed by each participant. RESULTS: The intervention group experienced a 31% reduction in falls (relative risk (RR)=0.69, 95% confidence interval (CI)=0.50-0.96; P=.025). This was a clinically meaningful result demonstrating that the Stepping On program was effective for community-residing elderly people. Secondary analysis of subgroups showed that it was particularly effective for men (n=80; RR=0.32, 95% CI=0.17-0.59). CONCLUSION: The results of this study renew attention to the idea that cognitive-behavioral learning in a small-group environment can reduce falls. Stepping On offers a successful fall-prevention option.     

The association between gestational diabetes mellitus and cancer in women: A systematic review and meta-analysis of observational studies

AimBoth type 1 and type 2 diabetes are associated with greater risk of a variety of cancers. However, the association between gestational diabetes mellitus (GDM) and risk of cancer has so far not been well addressed. This study aimed to summarize the epidemiological evidence of the association between GDM and subsequent risk of cancer.MethodsPubMed and Embase databases were searched for relevant studies, and a random-effects model was used to calculate the summary relative risks (RRs) along with the corresponding 95% confidence intervals (CIs).ResultsA total of 17 observational studies were selected, comprising 7 case–control and 10 cohort studies. Pooled effect estimates retrieved from these 17 studies showed that GDM was associated with an increased risk of breast cancer in Asia (pooled RR: 1.31, 95% CI: 1.01–1.70), but not in other regions, and also with thyroid cancer (RR: 1.28, 95% CI: 1.16–1.42), stomach cancer (RR: 1.43, 95% CI: 1.02–2.00) and liver cancer (RR: 1.27, 95% CI: 1.03–1.55). However, GDM was not associated with any increased risk of colon (RR: 1.41, 95% CI: 0.90–2.21), colorectal (RR: 1.16, 95% CI: 0.95–1.41), ovarian (RR: 1.14, 95% CI: 0.90–1.44), cervical (RR: 1.02, 95% CI: 0.81–1.29), pancreatic (RR: 3.49, 95% CI: 0.80–15.23), brain and nervous system (RR: 1.26, 95% CI: 0.80–1.97), blood (leukaemia, RR: 0.77, 95% CI: 0.45–1.30), endometrial (RR: 0.77, 95% CI: 0.20–2.98), skin (RR: 1.13, 95% CI: 0.81–1.59) or urological (RR: 0.98, 95% CI: 0.73–1.31) cancers.ConclusionGDM is associated with a greater risk of cancer in women, including breast, thyroid, stomach and liver cancers. However, further investigation is nonetheless warranted.     

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies

Background and aimsItaly has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy.Methods and resultsA multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013–14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16–2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65–1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk.ConclusionAdult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.     

Cluster of deaths from group A streptococcus in a long-term care facility--Georgia, 2001

BACKGROUND: Invasive group A streptococcus (GAS) affects approximately 10,500 persons annually; 1 in 5 patients >/=65 years die. In August 2001, CDC investigated a cluster of GAS deaths in a Georgia long-term care facility (LTCF). METHODS: We screened LTCF residents and staff for GAS carriage and conducted a retrospective cohort study among residents. We defined a case as GAS isolation associated with clinical infection. RESULTS: Eight cases were identified (median age: 79 years); 6 (75%) patients died. Carriage was similar in residents (10%) and staff (9%). All isolates among residents and 63% among staff were type emm 77. Risk factors for GAS disease or carriage among residents were receiving skin treatment (relative risk [RR] = 4.0, 95% confidence interval [CI] = 1.9-11.0) and having an infected or colonized roommate (RR = 2.0, 95% CI = 1.10-5.0). No wound care nurse carried GAS. Interventions included education about standardized infection control guidelines and appropriate hand hygiene; carriers were treated with antibiotics. No subsequent GAS cases were identified in the following year. CONCLUSIONS: Transmission of GAS in this outbreak likely occurred during wound care and ended with improved hand hygiene. This investigation highlights additional research and policy needs for control of severe GAS infections among the high-risk LTCF population.     

Acute Hepatitis B Outbreaks Related to Fingerstick Blood Glucose Monitoring in Two Assisted Living Facilities

OBJECTIVES: To establish the etiology for outbreaks of hepatitis B virus (HBV) infections at two assisted living facilities (ALFs) and devise appropriate control measures. DESIGN: Multisite outbreak investigations, retrospective cohort. SETTING: Two ALFs in Illinois. PARTICIPANTS: Facility A residents (n=120) and Facility B residents (n=105) and nursing staff (n=6). MEASUREMENTS: For Facility A, a retrospective cohort study to identify risk factors for HBV infection through serological testing of all residents and a medical record extraction. For Facility A and B, investigation of fingerstick blood glucose monitoring techniques. For Facility B, serological HBV testing of nurses and residents receiving fingerstick blood glucose monitoring. RESULTS: At Facility A, five confirmed acute, two probable acute, and one probable chronic HBV infections were identified in the 109 residents tested. All of the eight identified residents with HBV infection had diabetes mellitus. HBV deoxyribonucleic acid (DNA) sequences from the chronic and acute cases were identical. Transmission of HBV was associated with fingerstick blood glucose monitoring (relative risk (RR)=28.5, 95% confidence interval (CI)=1.6–498; P<.001) and insulin injections (RR=7.4, 95% CI=1.3–40.8; P=.03). At Facility B, seven of 21 residents (33.3%) receiving fingerstick blood glucose monitoring had evidence of recent HBV infection. CONCLUSION: Nurses probably transmitted HBV infection from resident to resident during fingerstick blood glucose monitoring in two separate ALFs, causing outbreaks. Awareness of the high risk for HBV transmission during procedures for the care of diabetes mellitus was limited. Following established infection control measures is critical to prevent spread of this highly contagious virus.     

Older Australian women's use of dentists: A longitudinal analysis over 6 years

Aim: To identify factors associated with dentist consultation by older Australian women. Methods: Participants from the older cohort of the Australian Longitudinal Study on Women's Health which originally involved 12 432 older women. Results: The percentage of women who consulted a dentist in the years 1999, 2002 and 2005 were 35%, 36% and 37%, respectively. Women were more likely to consult with a dentist if they lived in urban areas (RR = 1.26; 95% CI: 1.21, 1.32), were non‐smokers (RR = 1.38; 95% CI: 1.21, 157), did not have diabetes (RR = 1.16; 95% CI: 1.08, 1.25), had better physical health (RR = 1.02 (95% CI: 1.01, 1.02). Women were less likely to consult with a dentist if they found it difficult to live on their income (RR = 0.90; 95% CI: 085, 0.95). Conclusion: Access to dentists, cost of consultations and poor health appear to be significant factors influencing visits to a dentist by older Australian women.     

Does an all-condition case management program for high-risk patients reduce health care utilization in medicaid and medicare beneficiaries with diabetes?

ObjectiveTo assess whether an all-condition case management program can improve health care utilization and clinical outcomes in patients with diabetes.Research design and methods1342 patients with diabetes were enrolled in the Johns Hopkins Community Health Partnership (J-CHiP) Case Management program for high-risk patients with any chronic disease. We categorized participants into two intervention exposure categories based on the number of contacts with case manager (CM) and community health worker (CHW) per month: low contact (≤1 contact/month), and high contact (>1 contacts/month). The primary outcomes were rates of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions.ResultsIn analyses adjusted for age, sex, race, risk score, and baseline health utilization rate, Medicaid participants in the high contact group had 42% (rate ratio (RR): 1.42; 95% CI: 1.08–1.86) and 64% (RR: 1.64; 95% CI: 1.08–2.48) higher risks for hospital admission and readmission, respectively, than the low contact group. Similar increases were seen in the Medicare participants with 20% (RR: 1.20; 95% 1.02–1.42) and 42% (RR:1.42; 95% 1.09–1.84) higher risks for admission and readmission, respectively. The associations were not statistically significant for ED visits. Subsidiary analysis of a subset with HbA1c available (n = 545) revealed a statistically significant decrease in HbA1c among Medicare participants (mean (SD): −0.17% (1.50%)), with a larger decrease in the high contact group (mean (SD): −0.23% (1.59%)).ConclusionIn an all-condition case management program for high-risk patients, the higher intensity of contacts with CHW and CM was not associated with a reduced health care utilization in adults with diabetes.     

Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials

OBJECTIVES: The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients. BACKGROUND: Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients. METHODS: Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts. RESULTS: Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving. CONCLUSIONS: Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.     

The role of physical proximity in nosocomial diarrhea.

To examine physical proximity as a risk factor for the nosocomial acquisition of Clostridium difficile-associated diarrhea (CDAD) and of antibiotic-associated diarrhea (AAD), we assessed a retrospective cohort of 2859 patients admitted to a community hospital from 1 March 1987 through 31 August 1987. Of these patients, 68 had nosocomial CDAD and 54 had nosocomial AAD. In multivariate analysis, physical proximity to a patient with CDAD (relative risk [RR], 1.86; 95% confidence interval [CI], 1.06-3.28), exposure to clindamycin (RR, 4.22; 95% CI, 2.11-8.45), and the number of antibiotics taken (RR, 1.49; 95% CI, 1.23-1.81) were significant. For patients with nosocomial AAD, exposure to a roommate with AAD (RR, 3.94; 95% CI, 1. 27-12.24), a stay in an intensive care unit or cardiac care unit (RR, 1.93; 95% CI, 1.05-3.53), and the number of antibiotics taken (RR, 2.01; 95% CI, 1.67-2.40) were significant risk factors. Physical proximity may be an independent risk factor for acquisition of nosocomial CDAD and AAD.