Expanding Primary Care Experiences With Novel Rotations for Residents at a VA Medical Center.

BACKGROUND: The number of graduating primary care physicians will not meet the demands of the growing and aging US population. In 2011, the Veterans Affairs (VA) Office of Academic Affiliations established 5 Centers of Excellence in Primary Care Education (CoEPCE) to transform primary care training. OBJECTIVE: We created an innovative training model with immersive primary care experiences to foster careers in primary care for residents. METHODS: As a CoEPCE, the Seattle VA partnered with the University of Washington internal medicine residency program to form a Center of Excellence (CoE) pathway with increased outpatient training time. The CoEPCE created a longitudinal curriculum of continuity clinic immersion and new thematically based rotations (eg, Homeless Health) for CoE residents. These rotations expanded primary care experiences and allowed for in-depth opportunities to care for the unique needs of veterans. Resident feedback was solicited through program evaluations, and career choices were tracked. RESULTS: Eighty-five of 102 (83%) possible rotation evaluations from 2014 to 2017 were reviewed. Residents reported that CoEPCE rotations had a positive effect on their care of patients and career choice, and provided opportunities to interface with faculty role models. Seventy-five percent of Seattle VA CoE residents selected primary care careers compared to 36% of historical controls. CONCLUSIONS: The CoEPCE rotation curriculum offers in-depth primary care training and may contribute to trainees maintaining interest in primary care careers.

Breast cancer screening: Does tomosynthesis augment mammography?

Digital breast tomosynthesis (DBT) is a relatively new imaging technology that is being adopted widely for breast cancer screening. Initial evidence suggests that it may reduce recall rates and increase cancer detection rates when added to digital mammography screening. However, more rigorous, prospective studies are needed to determine whether it improves long-term clinical outcomes of breast cancer screening.

Menopause.

Women generally spend the last third of their lifetime in menopause, after their reproductive years have ended. During menopause, women experience a variety of predictable symptoms and conditions related to changes in sex hormone levels and aging. The menopausal transition precedes menopause by several years and is usually characterized by irregularity of the menstrual cycle and by hot flashes and night sweats. After menopause, genitourinary symptoms predominate, including vulvovaginal atrophy and dryness and lower urinary tract symptoms, including urinary frequency, urgency, and nocturia. Hormonal treatment is effective for vasomotor and genitourinary symptoms, but the understanding of its impact on cardiovascular disease, cognitive dysfunction, and depression continues to evolve.

US hospitalizations and costs for illicit drug users with soft tissue infections.

Skin and soft tissue infections (SSTIs) are common complications of illicit drug use. Studies at single, urban hospitals demonstrate high rates of emergency department visits and hospitalizations for these infections. This study sought to estimate nationwide and regional incidence and costs of hospitalizations for illicit drug users with SSTIs in the US. AHRQ's Nationwide Inpatient Sample was used to conduct a retrospective cross-sectional, time-series study. Hospitalizations of illicit drug users with SSTIs were identified using International Classification of Diseases, 9th Revision Clinical Modification codes. An estimated 106,126 hospitalizations for illicit drug users with SSTIs represented 0.07% of all US non-Federal hospitalizations from 1998 to 2001 and cost over 193 million dollars in 2001. Higher rates of hospitalization were found in the West, Northeast, and urban teaching hospitals. Hospitalization rates for illicit drug users with SSTIs vary significantly according to US region. Resources to reduce the incidence and severity of these infections should be targeted accordingly.

Drug users seeking emergency care for soft tissue infection at high risk for subsequent hospitalization and death.

OBJECTIVE: Although soft tissue infections are common among injection drug users (IDUs), little is known about the health outcomes among those who seek care for these infections. Emergency department visits are an important point-of-health-care contact for IDUs. In this prospective cohort study, we aimed to determine the hospitalization and mortality rates and factors associated with hospitalization or death among IDUs seeking emergency care for soft tissue infection. METHOD: Participants were English-speaking IDUs, 18 years of age and older, who sought initial care for soft tissue infection in an urban emergency department. We conducted semistructured interviews, identified hospitalizations from hospital records, and identified deaths using the National Death Index. Cox proportional hazards regression was used to investigate associations between baseline characteristics and hospitalizations or death. RESULTS: Of 211 eligible patients, 156 (74%) participated (mean age = 42 years). There were 255 subsequent hospitalizations over a mean of 3.9 years follow-up. The hospitalization rate was 42 hospitalizations per 100 person-years (95% confidence interval [CI]: 38-48). The mortality rate was 2.0 per 100 person-years (95% CI: 1.1-3.7). Factors associated with increased risk for hospitalization or death included living on the street or in a shelter (adjusted odds ratio [AOR] = 1.75, 95% CI: 1.10-2.79), being recently incarcerated (AOR = 1.90, 95% CI: 1.05-3.44), and having insurance (AOR: 1.98, 95% CI: 1.22-3.23). CONCLUSIONS: IDUs who sought care in the emergency department for soft tissue infections were at high risk for subsequent hospitalization and death. Visits for soft tissue infections represent missed opportunities for preventive care.

Predictors of hospitalization for injection drug users seeking care for soft tissue infections.

BACKGROUND: Soft tissue infections (STIs) from injection drug use are a common cause of Emergency Department visits, hospitalizations, and operating room procedures, yet little is known about factors that may predict the need for these costly medical services. OBJECTIVE: To describe a cohort of injection drug users seeking Emergency Department care for STIs and to identify risk factors associated with hospitalization. We hypothesized that participants who delayed seeking care would be hospitalized more often than those who did not. DESIGN: Cohort study using in-person structured interviews and medical record review. Logistic regression assessed the association between hospital admission and delay in seeking care as well as other demographic, clinical, and psychosocial factors. PARTICIPANTS: Injection drug users who sought Emergency Department care for STIs from May 2001 to March 2002. RESULTS: Of the 136 participants, 55 (40%) were admitted to the hospital. Delay in seeking care was not associated with hospital admission. Participants admitted for their infection were significantly more likely to be living in a shelter (P = .01) and to report being hospitalized 2 or more times in the past year (P < .01). CONCLUSIONS: We identified a subpopulation of injection drug users, mostly living in shelters, who were hospitalized frequently in the past year and who were more likely to be hospitalized for their current infections compared to others. As members of this subpopulation can be easily identified and located, they may benefit from interventions to reduce the health care utilization resulting from these infections.

The microbiology of bacteriuria in men: a 5-year study at a Veterans' Affairs hospital.

Bacteriuria and urinary tract infection occur relatively frequently in older men, but data regarding the causative microorganisms are limited. We retrospectively identified all positive cultures of urine specimens (n = 4943) obtained over a 5-year period at our institution. We determined the frequency of causative microorganisms and grouped these by Gram type, setting of patient care, and method of urine specimen collection. We also assessed the performance characteristics of the Gram-stained smear of uncentrifuged urine. Among our patients, Gram-positive cocci (GPC) were isolated as often as Gram-negative rods (GNR). Escherichia coli was the single or predominant isolate in only 14% of cases, and Enterococcus was the single most commonly identified genus (22.5%). The Gram stain was accurate in predicting the culture results (positive likelihood ratio, 7.0 for GPC and 8.1 for GNR). We conclude that the microorganisms causing bacteriuria in older male veterans are substantially different from those found in women, and the Gram-stained smear provides useful information on the causative organisms.

A population-based study of HIV testing practices and perceptions in 4 U.S. states.

OBJECTIVE: To evaluate testing practices and perceptions of HIV risk among a geographically diverse, population-based sample of sexually active adults who reported behaviors that could transmit HIV. DESIGN: Secondary analysis of the Centers for Disease Control and Preventions Behavioral Risk Factor Surveillance System (BRFSS) 2000 survey. PATIENTS/PARTICIPANTS: Sexually active adults less than 50 years old, who completed the Sexual Behavior Module of the BRFSS 2000 survey administered in 4 U.S. states. MEASUREMENTS AND MAIN RESULTS: Nineteen percent of the study population reported one or more behaviors in the past year that increased their risk of HIV infection (men 23%; women 15%). In this subgroup at any increased risk of HIV infection, 49% reported having had an HIV test in the past year. For 71% of those tested, the HIV test was self-initiated. Younger age was the only factor independently associated with whether or not individuals with behaviors that increased their risk of HIV infection had had a recent HIV test. Among the 51% of individuals at risk who reported no recent HIV test, 84% perceived their risk as low or none. CONCLUSIONS: In this study, about half of the individuals who reported behaviors that could transmit HIV had not been recently tested for HIV. Of those not tested, most considered their risk of HIV to be low or none. Interventions to expand HIV testing and increase awareness of HIV risk appear to be needed to increase early detection of HIV infection and to reduce its spread.

Type and location of injection drug use-related soft tissue infections predict hospitalization.

The prevalence of soft tissue infections (abscesses, cellulitides, infected ulcers) among injection drug users (IDUs) is estimated to be between 21% and 32%. Little is known regarding the health care utilization associated with these infections. This study describes IDUs seeking emergency department (ED) care for soft tissue infections, their inpatient health care utilization, including operating room procedures, and the types and locations of infections associated with increased inpatient health care utilization. This study used a medical record case series of all IDUs seeking initial care for soft tissue infections at an urban, public emergency department from November 1999 through April 2000. Initial care for IDU-related soft tissue infections was sought by 242 patients. Most were male (63.6%), Caucasian (69.4%) and without health insurance (52.0%), and most had abscesses (72.3%). All patients with only cellulitis had arm or leg infections, while most abscesses were arm, deltoid, or buttock infections (81.1%). Forty percent of the patients were hospitalized, and 44.3% of the hospitalizations were for 3 or more days. Patients with only cellulitis were more likely to be hospitalized compared to those with abscesses. Among those with abscesses, deltoid abscesses were 5.2 times more likely to receive an operating room procedure compared to other abscess locations. IDUs with cellulitis and deltoid abscesses commonly required inpatient care and operating room procedures. The morbidity associated with such infections and the intensive use of hospital services needed to treat these infections provide strong rationale for the development of preventive interventions and improved care for this neglected clinical problem.