Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors.

OBJECTIVES: This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness. METHODS: Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts. RESULTS: Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes. CONCLUSIONS: Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership

Outpatient Antipsychotic Treatment and Inpatient Costs of Schizophrenia

Objective: To estimate the proportions of acute care inpatient admissions and hospital days for schizophrenia patients in the Medicaid program that are attributable to gaps in outpatient antipsychotic treatment and to calculate the corresponding total health care costs of this care. Methods: A series of multivariate regressions were performed with statewide 2001–2003 California Medicaid data to estimate the fraction of acute care hospital admissions and hospital days for schizophrenia attributable to gaps in antipsychotic medication treatment. This fraction was then applied to national estimates of the number and costs of inpatient treatment episodes for patients with schizophrenia in the national Medicaid program. Results: In the United States, there are roughly 87 000 annual acute care inpatient admissions of Medicaid patients for the treatment of schizophrenia. These admissions include a total of approximately 930 000 hospital days at a total cost of $806 million. Improving adherence to eliminate gaps in antipsychotic medication treatment could lower the number of acute care admissions by approximately 12.3$106 million (95% CI: $79.0 million–$133.0 million) in inpatient care costs for the national Medicaid system. Conclusions: Nonadherence to antipsychotic medication treatment accounts for a considerable proportion of inpatient treatment costs of Medicaid patients with schizophrenia. Improving continuity of antipsychotic medications could lead to savings by reducing the frequency and duration of inpatient treatment

The Direction of Denominational Switching in Judaism

This paper examines patterns of denominational switching and the characteristics of switchers within Judaism in the United States. Viewing Orthodox, Conservative, and Reform Judaism and a fourth non-specific group as categories that range from the most traditional to the least traditional respectively, it focuses on the movement of individuals toward or away from a more traditional denomination in comparison with remaining in the same denomination in which they were raised. Data used to conduct this study are drawn from the National Jewish Population Survey 2000-01 (National Jewish Population Survey [NJPS] 2003). We found that 62% stay within the same group, 29% move away from tradition, and 9% move to a more traditional denomination. Multivariate logistic regression analyses show that a lower level of Jewish background, higher previous travel to Israel, a greater extent of organizational affiliation, and a higher level of spiritual feelings and beliefs are associated with moving to a more traditional denomination whereas a higher level of Jewish background, lower previous travel to Israel, and a lower level of spiritual feelings and beliefs are associated with moving to a less traditional denomination. In addition, a few sociodemographic factors (previously married, has a child at home, lives in a Western state) are associated with movement toward tradition whereas others (older age, female, not living in the Northeast or West) are associated with movement in the other direction

Treatment of Schizophrenia With Long-Acting Fluphenazine, Haloperidol, or Risperidone

Objective: This study compares 3 cohorts of patients with schizophrenia before, during, and after initiating treatment with fluphenazine decanoate (FD), haloperidol decanoate (HD), or long-acting injectable risperidone (LAR). Methods: Administrative data are analyzed from California Medicaid (Medi-Cal) beneficiaries with schizophrenia who initiated FD, HD, or LAR treatment. Patients were required to have been continuously enrolled in Medi-Cal for 180 days before and 180 days after the start of the new episode of long-acting antipsychotic therapy. Results: There were few demographic and clinical differences among patients initiating FD, HD, and LAR. During the 180 days before starting long-acting injections, most patients initiating FD (53.5%), HD (58.5%), and LAR (61.2%) received oral antipsychotic medications for <80% of the days in this period (medication possession ratio: <0.80). The mean duration of depot treatment episodes was 58.3 days (SD = 53.6) for FD, 71.7 days (SD = 56.4) for HD, and 60.6 days (SD = 48.8) for LAR (F = 18.3, df = 2, 2694, P < .0001, HD > FD). Few patients who started on FD (5.4%), HD (9.7%), or LAR (2.6%) continued for at least 180 days. Most patients in each group (FD [77.4%], HD [78.9%], and LAR [75.5%]) received oral antipsychotic medications during the 45 days after discontinuing long-acting injections. Coprescription with antidepressants, mood stabilizers, and benzodiazepines was common. Conclusions: Patients treated with long-acting antipsychotic injections tend to have complex pharmacological regimens and recent medication nonadherence. A great majority of patients initiating long-acting antipsychotic medications discontinue use within the first few months of treatment

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

Multiple barriers to quality health care may affect the outcomes of postacute treatment for individuals with serious mental illness (SMI). This study examined rehospitalization for medical and surgical inpatients with and without a comorbid diagnosis of SMI which included psychotic disorders, bipolar disorder and major depressio

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

Multiple barriers to quality health care may affect the outcomes of postacute treatment for individuals with serious mental illness (SMI). This study examined rehospitalization for medical and surgical inpatients with and without a comorbid diagnosis of SMI which included psychotic disorders, bipolar disorder and major depressio

Future Arctic temperature change resulting from a range of aerosol emissions scenarios

The Arctic temperature response to emissions of aerosols—specifically black carbon (BC), organic carbon (OC), and sulfate—depends on both the sector and the region where these emissions originate. Thus, the net Arctic temperature response to global aerosol emissions reductions will depend strongly on the blend of emissions sources being targeted. We use recently published equilibrium Arctic temperature response factors for BC, OC, and sulfate to estimate the range of present‐day and future Arctic temperature changes from seven different aerosol emissions scenarios. Globally, Arctic temperature changes calculated from all of these emissions scenarios indicate that present‐day emissions from the domestic and transportation sectors generate the majority of present‐day Arctic warming from BC. However, in all of these scenarios, this warming is more than offset by cooling resulting from SO2 emissions from the energy sector. Thus, long‐term climate mitigation strategies that are focused on reducing carbon dioxide (CO2) emissions from the energy sector could generate short‐term, aerosol‐induced Arctic warming. A properly phased approach that targets BC‐rich emissions from the transportation sector as well as the domestic sectors in key regions—while simultaneously working toward longer‐term goals of CO2 mitigation—could potentially avoid some amount of short‐term Arctic warming.Key PointsReductions in anthropogenic black carbon emissions alone could slow Arctic warming by mid‐centuryArctic cooling from reduced BC is more than offset by warming from reduced SO2 across all of the RCP mitigation scenariosDomestic and transport emissions from Asia hold the greatest potential for reducing Arctic warming from anthropogenic aerosolsPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/133610/1/eft2124_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/133610/2/eft2124.pd

Required Sample Size to Detect Mediation in 3-Level Implementation Studies

Background: Statistical tests of mediation are important for advancing implementation science; however, little research has examined the sample sizes needed to detect mediation in 3-level designs (e.g., organization, provider, patient) that are common in implementation research. Using a generalizable Monte Carlo simulation method, this paper examines the sample sizes required to detect mediation in 3-level designs under a range of conditions plausible for implementation studies. Method: Statistical power was estimated for 17,496 3-level mediation designs in which the independent variable (X) resided at the highest cluster level (e.g., organization), the mediator (M) resided at the intermediate nested level (e.g., provider), and the outcome (Y) resided at the lowest nested level (e.g., patient). Designs varied by sample size per level, intraclass correlation coefficients of M and Y, effect sizes of the two paths constituting the indirect (mediation) effect (i.e., X→M and M→Y), and size of the direct effect. Power estimates were generated for all designs using two statistical models—conventional linear multilevel modeling of manifest variables (MVM) and multilevel structural equation modeling (MSEM)—for both 1- and 2-sided hypothesis tests. Results: For 2-sided tests, statistical power to detect mediation was sufficient (≥0.8) in only 463 designs (2.6%) estimated using MVM and 228 designs (1.3%) estimated using MSEM; the minimum number of highest-level units needed to achieve adequate power was 40; the minimum total sample size was 900 observations. For 1-sided tests, 808 designs (4.6%) estimated using MVM and 369 designs (2.1%) estimated using MSEM had adequate power; the minimum number of highest-level units was 20; the minimum total sample was 600. At least one large effect size for either the X→M or M→Y path was necessary to achieve adequate power across all conditions. Conclusions: While our analysis has important limitations, results suggest many of the 3-level mediation designs that can realistically be conducted in implementation research lack statistical power to detect mediation of highest-level independent variables unless effect sizes are large and 40 or more highest-level units are enrolled. We suggest strategies to increase statistical power for multilevel mediation designs and innovations to improve the feasibility of mediation tests in implementation research

The effect of preoperative keratometry on visual outcomes after moderate myopic LASIK

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Perturbed CD8+ T cell TIGIT/CD226/PVR axis despite early initiation of antiretroviral treatment in HIV infected individuals.

HIV-specific CD8+ T cells demonstrate an exhausted phenotype associated with increased expression of inhibitory receptors, decreased functional capacity, and a skewed transcriptional profile, which are only partially restored by antiretroviral treatment (ART). Expression levels of the inhibitory receptor, T cell immunoglobulin and ITIM domain (TIGIT), the co-stimulatory receptor CD226 and their ligand PVR are altered in viral infections and cancer. However, the extent to which the TIGIT/CD226/PVR-axis is affected by HIV-infection has not been characterized. Here, we report that TIGIT expression increased over time despite early initiation of ART. HIV-specific CD8+ T cells were almost exclusively TIGIT+, had an inverse expression of the transcription factors T-bet and Eomes and co-expressed PD-1, CD160 and 2B4. HIV-specific TIGIThi cells were negatively correlated with polyfunctionality and displayed a diminished expression of CD226. Furthermore, expression of PVR was increased on CD4+ T cells, especially T follicular helper (Tfh) cells, in HIV-infected lymph nodes. These results depict a skewing of the TIGIT/CD226 axis from CD226 co-stimulation towards TIGIT-mediated inhibition of CD8+ T cells, despite early ART. These findings highlight the importance of the TIGIT/CD226/PVR axis as an immune checkpoint barrier that could hinder future "cure" strategies requiring potent HIV-specific CD8+ T cells