Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

BACKGROUND: Gulf War illness (GWI) is an archetypal, medically unexplained, chronic condition characterised by persistent sickness behaviour and neuroimmune and neuroinflammatory components. An estimated 25-32% of the over 900,000 veterans of the 1991 Gulf War fulfil the requirements of a GWI diagnosis. It has been hypothesised that the high physical and psychological stress of combat may have increased vulnerability to irreversible acetylcholinesterase (AChE) inhibitors leading to a priming of the neuroimmune system. A number of studies have linked high levels of psychophysiological stress and toxicant exposures to epigenetic modifications that regulate gene expression. Recent research in a mouse model of GWI has shown that pre-exposure with the stress hormone corticosterone (CORT) causes an increase in expression of specific chemokines and cytokines in response to diisopropyl fluorophosphate (DFP), a sarin surrogate and irreversible AChE inhibitor. METHODS: C57BL/6J mice were exposed to CORT for 4 days, and exposed to DFP on day 5, before sacrifice 6 h later. The transcriptome was examined using RNA-seq, and the epigenome was examined using reduced representation bisulfite sequencing and H3K27ac ChIP-seq. RESULTS: We show transcriptional, histone modification (H3K27ac) and DNA methylation changes in genes related to the immune and neuronal system, potentially relevant to neuroinflammatory and cognitive symptoms of GWI. Further evidence suggests altered proportions of myelinating oligodendrocytes in the frontal cortex, perhaps connected to white matter deficits seen in GWI sufferers. CONCLUSIONS: Our findings may reflect the early changes which occurred in GWI veterans, and we observe alterations in several pathways altered in GWI sufferers. These close links to changes seen in veterans with GWI indicates that this model reflects the environmental exposures related to GWI and may provide a model for biomarker development and testing future treatments.

The healthcare system in the U.S., particularly outpatient, office-based care, has been shifting toward service delivery by advanced practice providers, particularly nurse practitioners (NPs) and physician assistants (PAs). The National Ambulatory Medical Care Survey (NAMCS), conducted by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention, is the leading source of nationally representative data on care delivered by office-based physicians. This paper first describes NAMCS, then discusses key NAMCS expansion efforts, and finally presents major findings from two exploratory studies that assess the feasibility of collecting data from NPs and PAs as sampled providers in NAMCS. The first NAMCS expansion effort began in 2006 when the NAMCS sample was expanded to include community health centers and started collecting and disseminating data on physicians, NPs, PAs, and nurse midwives in these settings. Then, in 2013, NCHS included workforce questions in NAMCS on the composition and clinical tasks of all healthcare staff in physician offices. Finally, in 2013-2014, NCHS conducted two exploratory studies and found that collecting data from NPs and PAs as sampled providers in NAMCS is feasible. However, modifications to the current NAMCS procedures may be necessary, for example, changing recruitment strategies, visit sampling procedures, and physician-centric survey items. Collectively, these NCHS initiatives are important for healthcare research, practice, and policy communities in their efforts toward providing a more complete picture of the changing outpatient, office-based workforce, team-based care approach, and service utilization in the U.S.

OBJECTIVE: Examine availability of physician assistants (PAs) or nurse practitioners (NPs) in primary care physician practices by state and by state PA and NP scope-of-practice laws. METHODS: Availability of PAs and NPs in primary care practices was examined in multivariate analysis using a 2012 state-based, nationally representative survey of office-based physicians. Covariates included practice characteristics, state, and in a separate model, PA and NP scope-of-practice variables. RESULTS: After controlling for practice characteristics, higher use of PAs and NPs was found in three states (Minnesota, Montana, and South Dakota). In a separate model, higher use of PAs or NPs was associated with favorable PA scope-of-practice laws, but not with NP scope-of-practice laws. CONCLUSIONS: Higher availability of PAs or NPs was associated with favorable PA scope-of-practice laws. Lack of association between PA or NP availability and NP scope-of-practice laws requires further investigation.

PURPOSE: Community health centers (CHCs) fill a vital role in providing health care to underserved populations. This project compares characteristics of patient visits to nurse practitioners (NPs), physician assistants (PAs), and physicians in CHCs. METHODS: This study analyzes 2006-2010 annual survey data from the National Ambulatory Medical Care Survey CHC sample, a representative national sample of CHC providers and patient visits. We examine trends in provider mix in CHCs and compare NPs, PAs, and physicians with regard to patient and visit attributes. Survey weights are used to produce national estimates. RESULTS: There were, on average, 36,469,000 patient visits per year to 150,100 providers at CHCs; 69% of visits were to physicians, 21% were to NPs, and 10% were to PAs. Compared to visits to NPs, visits made to physicians and PAs tended to be for chronic disease treatment and for patients whom they serve as primary care providers. Visits to NPs tended to be for preventive care. CONCLUSIONS: This study found more similarities than differences in characteristics of patients and patient visits to physicians, NPs, and PAs in CHCs. When statistical differences were observed, NP patient and visit characteristics tended to be different from those of physicians. IMPLICATIONS: Results provide detailed information about visits to NPs and PAs in a setting where they constitute a significant portion of providers and care for vulnerable populations. Results can inform future workforce approaches.

OBJECTIVES: Examine the extent to which office-based physicians in the United States receive patient health information necessary to coordinate care across settings and determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT) (defined by presence or absence of electronic health record system and electronic sharing of information). RESEARCH DESIGN: Cross-sectional study using the 2012 National Electronic Health Records Survey (65% weighted response rate). SUBJECTS: Office-based physicians. MEASURES: Use of HIT and 3 types of patient health information needed to coordinate care. RESULTS: In 2012, 64% of physicians routinely received the results of a patient's consultation with a provider outside of their practice, whereas 46% routinely received a patient's history and reason for a referred consultation from a provider outside of their practice. About 54% of physicians reported routinely receiving a patient's hospital discharge information. In adjusted analysis, significant differences in receiving necessary information were observed by use of HIT. Compared with those not using HIT, a lower percentage of physicians who used an electronic health record system and shared patient health information electronically failed to receive the results of outside consultations or patient's history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. Among physicians routinely receiving information needed for care coordination, at least 54% of them did not receive the information electronically. CONCLUSIONS: Although a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one third did not routinely receive the needed patient information at all.

BACKGROUND: As health systems struggle to meet access, cost and quality goals in the setting of increased demand, nurse practitioners (NPs) and physician assistants (PAs) are expected to help meet the need for care. The amount of time spent with each patient can affect the clinical productivity, quality of care, and satisfaction of patients and clinicians. This paper compares time spent per patient in community health centers by whether the provider is a physician, NP, or PA. METHODS: This paper uses National Ambulatory Medical Care Survey (NAMCS) Community Health Center (CHC) data from 2006-2010. The NAMCS CHC strata is a national sample of CHCs, providers within CHCs, and patient visits to CHCs. Provider characteristics and variables related to time spent with patients across provider types were compared using t tests and chi square tests of association. Multivariate linear regression analysis was used to compare time spent with patients, controlling for patient and visit characteristics. RESULTS: There were no differences in the number of visits by provider type, but PAs saw patients for a slightly larger portion of the week (3.8 days) than did physicians (3.5 days, p<0.05) or NPs (3.4 days, p<0.05). There were no statistical differences in the mean time spent per patient in the crude and adjusted analyses. CONCLUSION: Time spent per patient in CHCs is similar for physicians, NPs and PAs. This information may be useful to planners concerned with health system capacity and cost efficiency, and has implications for patient and provider satisfaction.

A well-woman preventive care visit is a core service supported by the Human Resources and Services Administration,1 yet it is unclear which preventive services are provided by primary care physicians (PCPs) and which are provided by obstetrician/gynecologists (OB/GYNs).2,3 We examined patterns of selected age-appropriate preventive care visits across a woman’s lifespan, focusing on the wide range of preventive services provided to nonpregnant women.

This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001–2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.

BACKGROUND: Craniofacial microsomia (CFM) is a congenital condition characterized by microtia and mandibular underdevelopment. Healthcare databases and birth defects surveillance programs could be used to improve knowledge of CFM. However, no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code exists for this condition, which makes standardized data collection challenging. Our aim was to evaluate the validity of existing ICD-9-CM codes to identify individuals with CFM. METHODS: Study sample eligibility criteria were developed by an expert panel and matched to 11 ICD-9-CM codes. We queried hospital discharge data from two craniofacial centers and identified a total of 12,254 individuals who had ≥1 potentially CFM-related code(s). We reviewed all (n = 799) medical records identified at the University of North Carolina (UNC) and 500 randomly selected records at Seattle Children's Hospital (SCH). Individuals were classified as a CFM case or non-case. RESULTS: Thirty-two individuals (6%) at SCH and 93 (12%) at UNC met the CFM eligibility criteria. At both centers, 59% of cases and 95% of non-cases had only one code assigned. At both centers, the most frequent codes were 744.23 (microtia), 754.0 and 756.0 (nonspecific codes), and the code 744.23 had a positive predictive value (PPV) >80% and sensitivity >70%. The code 754.0 had a sensitivity of 3% (PPV <1%) at SCH and 36% (PPV = 5%) at UNC, whereas 756.0 had a sensitivity of 38% (PPV = 5%) at SCH and 18% (PPV = 26%) at UNC. CONCLUSIONS: These findings suggest the need for a specific CFM code to facilitate CFM surveillance and research. (Birth Defects Research (Part A), 2012. (c) 2012 Wiley Periodicals, Inc.)

As more physicians adopt electronic health record systems in their practices, policy interest is focusing on whether physicians are ready to meet the federal "meaningful use" criteria-a vital threshold to qualify for financial incentives. In our analysis of a 2011 nationally representative survey of office-based physicians, we found that 91 percent of physicians were eligible for Medicare or Medicaid meaningful-use incentives. About half of all physicians intended to apply. However, only 11 percent both intended to apply for the incentives and had electronic health record systems with the capabilities to support even two-thirds of the stage 1 core objectives required for meaningful use. Although the federal Medicare incentives will be available through 2016, and Medicaid incentives through 2021, widespread gaps in readiness throughout the states illustrate the challenges physicians face in meeting the federal schedule for the incentive programs.

BACKGROUND: In the United States, liquid-based cytology (LBC) has become a common screening method for cervical cancer. However, the extent of LBC use, and how it varies by patient and practice characteristics, is unknown. OBJECTIVE: This report describes the ordering and provision of Papanicolaou (Pap) tests, with a major focus on the extent to which LBC has supplanted conventional cytology. The type of Pap test is examined for visits made to primary care physicians in 2006-2007 by females aged 15-64. METHODS: Estimates of Pap test cytology use (both LBC and conventional) are based on combined data from the 2006-2007 National Ambulatory Medical Care Survey (NAMCS), an annual nationally representative survey of visits to nonfederal office-based physicians in the United States, as well as on information reported by sample physicians in Cervical Cancer Screening Supplements fielded as part of NAMCS during the same years. RESULTS: In 2006-2007, LBC was used in approximately 75% of Pap tests for which the type of cytology was known. LBC was less likely to be used for Medicare patients than for privately insured patients, although LBC use did not vary significantly according to the other patient or practice characteristics examined. CONCLUSION: The high percentage of LBC use by office-based physicians in 2006-2007 confirms the widespread use of this screening method among primary care providers, as has been reported in the literature.

KEY FINDINGS: In 2008, the majority of visits to primary care delivery sites (84%) occurred in physician offices, 11% in hospital outpatient departments (OPDs), and 5% in community health centers (CHCs). Patients with Medicaid, State Children's Health Insurance Plan (SCHIP) or no insurance accounted for a higher percentage of visits to CHCs (56%) and OPDs (40%) than to physician offices (17%). CHCs had a higher age-adjusted percentage of visits by patients with one or more chronic conditions (56%) compared with visits to physician offices (49%) and OPDs (49%).

We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006-2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.