Shortened leukocyte telomere length is associated with reduced pulmonary function and greater subsequent decline in function in a sample of World Trade Center responders.

The objective of this study was to examine whether shorter leukocyte telomere length (LTL) is associated with more rapid pulmonary function decline in a longitudinal study of World Trade Center (WTC) responders. WTC responders (N = 284) participating in a monitoring study underwent blood sampling and were followed prospectively for spirometric outcomes. A single blood sample was taken to measure LTL using southern blotting. Outcomes included percent-predicted one-second forced expiratory volume (FEV1%), forced vital capacity (FVC%), and the FEV1/FVC ratio. In a subset, percent-predicted diffusing capacity (DLCO%) was also measured. Longitudinal modeling examined prospectively collected information over five years since blood was banked was used to examine the rate of change in pulmonary functioning over time. Severity of WTC exposure was assessed. Shorter LTL was associated with lower FEV1% and FVC% at baseline. For example, 29.9% of those with LTL <6.5 kbps had FEV1% <80% whereas only 12.4% of those with LTL ≥6.5 had FEV1% <80% (RR = 2.53, 95%CI = [1.70-3.76]). Lower DLCO% was also significantly associated with shorter LTL. Longitudinal models identified a prospective association between shorter LTL and greater yearly rates of decline in FEV1% (0.46%/year, 95%CI = [0.05-0.87]) and in the FEV1/FVC ratio (0.19%/year, 95%CI = [0.03-0.36]). There were no associations between severity of exposure and either LTL or pulmonary function. Longitudinal analyses revealed that shorter LTL, but not severity of WTC exposures, was associated with poorer pulmonary functioning and with greater subsequent decline in pulmonary functioning over time. These findings are consistent with the idea that shortened LTL may act as a biomarker for enhanced pulmonary vulnerability in the face of acute severe toxic inhalation exposures.

Low Income Suburban Residents Perceive a Greater Lack of Specialty But not Primary Care Physicians than Those with Higher Incomes.

As the number of low income residents in suburban areas increases, they may present new healthcare delivery challenges. We compared residents' perceptions of access to primary care (PCP) and specialty (SCP) physicians by income categories in two adjacent counties of New York, which differ in physician density and public healthcare delivery models. Telephone interviews of 812 residents of Nassau (NC, 6.9 physicians/1000) and Suffolk (SC, 3.5 physicians/1000) counties were conducted, assessing perceptions of whether there were "too few," or "about the right number" of PCPs and SCPs. Counties were compared using bivariate analysis; multivariate analyses examined the association of perceptions of PCP and SCP access with demographic variables, including income. Twice as many SC respondents perceived too few SCPs compared to NC (35.31 vs. 18.27%, p = .001) and 50% more perceived too few PCPs (32.56 vs. 23.85%, p = .06). Thus, physician access was a perceived problem for many in SC despite a supply greater than the national average. For both counties combined, those with household incomes less than $35,000/year were twice as likely to perceive too few SCPs (p = .05), while in SC, this group was more than three times as likely to perceive too few SCPs (p = .02). There were no significant associations between income and perception of PCP availability. Thus, both counties have eliminated income-related differences in perceived access to PCPs. However, this is not the case for SCPs, especially in SC, which, unlike NC, has no publically supported specialty care. As the number of low income suburban residents increases, access to specialty care presents an important challenge for some areas.

Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD.

BACKGROUND: Prescriber disagreement is among the reasons for poor adherence to COPD treatment guidelines; it is yet not clear whether this leads to adverse outcomes. We tested whether undertreatment according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines led to increased exacerbations. METHODS: Records of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one Veterans Administration (VA) Medical Center were analyzed. Analysis of variance was performed to assess differences in exacerbation rates between severity groups. Logistic regression analysis was performed to assess the relationship between noncompliance with guidelines and exacerbation rates. FINDINGS: About 19% were appropriately treated by guidelines; 14% overtreated, 44% under-treated, and in 23% treatment did not follow any guideline. Logistic regression revealed a strong inverse relationship between undertreatment and exacerbation rate when severity of obstruction was held constant. Exacerbations per year by GOLD stage were significantly different from each other: mild 0.15, moderate 0.27, severe 0.38, very severe 0.72, and substantially fewer than previously reported. INTERPRETATION: The guidelines were largely not followed. Undertreatment predominated but, contrary to expectations, was associated with fewer exacerbations. Thus, clinicians were likely advancing therapy primarily based upon exacerbation rates as was subsequently recommended in revised GOLD and other more recent guidelines. In retrospect, a substantial lack of prescriber adherence to treatment guidelines may have been a signal that they required re-evaluation. This is likely to be a general principle regarding therapeutic guidelines. The identification of fewer exacerbations in this cohort than has been generally reported probably reflects the comprehensive nature of the VA system, which is more likely to identify relatively asymptomatic (ie, nonexacerbating) COPD patients. Accordingly, these rates may better reflect those in the general population. In addition, the lower rates may reflect the more complete preventive care provided by the VA.

The Projected Responses of Residency-Sponsoring Institutions to a Reduction in Medicare Support for Graduate Medical Education: A National Survey.

PURPOSE: To assess the projected responses of residency-sponsoring institutions to the proposed reduction in Medicare's indirect medical education (IME) payments. METHOD: In 2012, the authors surveyed directors of graduate medical education (GME) programs, examining (1) overall responses to a reduction in IME reimbursement and (2) the value of individual residencies to the institution from the economic/operational and educational/public service points of view, to determine which programs may be at risk for downsizing. RESULTS: Responses from 192 of 555 institutions (35% response rate) varied by the size of the institution's GME program. Of large programs (six or more residencies), 33 (33%) would downsize at a 10% reduction in IME reimbursement, focusing cuts on specific programs. Small programs (five or fewer residencies) were more likely to retain their existing residencies with modest IME payment reductions and to make across-the-board cuts. The economic/operational value of specialties varied widely, with hospital-intensive residencies valued highest. Family medicine was valued highly from an economic/operational point of view only by small programs. Educational/public service value scores varied less and were higher for all specialties. Preventive medicine was not highly valued in either category. CONCLUSIONS: Even a modest decrease in IME reimbursement could trigger institutions to downsize their GME programs. Programs at the greatest risk for cuts may be those with modest economic/operational value but high societal value, like family medicine. The retention or expansion of training in family medicine may be most easily accomplished then at smaller institutions.

Institutions with accredited residencies in New York State with an interest in developing new residencies or expanding existing ones.

PURPOSE: In view of the looming physician shortage, especially in primary care specialties, there have been calls for increasing graduate medical education (GME). However, the capacity for increases of GME in institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME) has not been determined. METHOD: In 2009, the authors surveyed the 48 designated institutional officials supervising ACGME-accredited residencies in New York State that were eligible for their study, to determine interest in and capacity for development of new core residencies and expansion of existing ones if additional funds were made available at current Medicare rates. RESULTS: Thirty-six (75%) responded; 39% would add new programs and 47% would expand current programs with additional funding. The major interest in adding new programs was in emergency medicine (35%). Notably, only 11% would add family medicine. The major interest in program expansion was internal medicine (48%), urology (42%), diagnostic radiology (35%), obstetrics-gynecology (26%), and emergency medicine (25%). CONCLUSIONS: Fewer than 50% of current training institutions are interested in or have the capacity for expansion of core residencies. The interest in establishing or expanding primary care is especially problematic. Because 70% of internal medicine residents become subspecialists, additional funds for GME at current rates would largely encourage the training of additional hospital-based and hospital-intensive specialists, with little impact on those who would practice adult primary care medicine. Significantly increasing the physician training for adult primary care medicine will require more substantial institutional incentives.

Leveraging Academic-Service Partnerships: Implications for Implementing the RWJ/IOM's Recommendations to Improve Quality, Access, and Value in Academic Medical Centers.

Transformation of the current healthcare system is critical to achieve improved quality, safety, value, and access. Patients with multiple, chronic health conditions require integrated care coordination yet the current health care system is fragmented and complex. Nursing must play a key role in constructing a system that is value based and patient focused. The Robert Wood Johnson/Institute of Medicine (RWJ/IOM) report on the future of nursing outlines strategic opportunities for nursing to take a lead role in this transformation. Partnerships across academic institutions and health care systems have the potential to address issues through mutual goal setting, sharing of risks, responsibilities, and accountability, and realignment of resources. The purpose of this paper is to present Stony Brook University Medical Center's (SBUMC) academic-service partnership which implemented several of the RWJ/IOM recommendations. The partnership resulted in several initiatives that improved quality, safety, access, and value. It also characterized mutual goal setting, shared missions and values, and a united vision for health care.