Arch Intern Med
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Multicenter Study
Regional and institutional variation in the initiation of early do-not-resuscitate orders.
Do-not-resuscitate (DNR) orders are an important step in decision making about aggressiveness of care for patients in hospitals. The use of DNR orders is known to vary with patient characteristics, but few studies have investigated the role of hospital factors or of regional variation. We examined these influences on the use of early DNR orders (written <24 hours after admission). ⋯ Hospital characteristics appear to be associated with the use of DNR orders, even after accounting for differences in patient characteristics. This association reflects institutional culture, technological bent, and physician practice patterns. If these factors do not match patient preferences, then improvements in care are needed.
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Previous studies have investigated the impact of Staphylococcus aureus infections on individual hospitals, but to date, no study using nationally representative data has estimated this burden. ⋯ Staphylococcus aureus infections represent a considerable burden to US hospitals, particularly among high-risk patient populations. The potential benefits to hospitals in terms of reduced use of resources and costs as well as improved outcomes from preventing S aureus infections are significant.
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Comparative Study
Barriers and facilitators to primary care or human immunodeficiency virus clinics providing methadone or buprenorphine for the management of opioid dependence.
Federal initiatives aim to increase office-based treatment of opioid dependence, but, to our knowledge, factors associated with willingness to deliver this care have not been defined. The objective of this study was to describe clinics' willingness to provide methadone hydrochloride or buprenorphine hydrochloride for opioid dependence. ⋯ These clinics serving Medicaid enrollees were more receptive to buprenorphine than methadone treatment. Willingness to provide this care was greater in clinics offering human immunodeficiency virus services, treating more chronic pain, or affiliated with methadone programs. Accessible addiction experts and continuing medical education for training may facilitate adoption of this care.
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Multicenter Study
The role of patient-physician trust in moderating medication nonadherence due to cost pressures.
Prescription drug costs constitute a burden for many chronically ill adults and are strongly related to patients' likelihood of using less medication than prescribed. We examined the extent to which patients' trust in their physicians may moderate the impact of economic constraints and other risk factors for cost-related adherence problems. ⋯ These findings suggest that a trusting physician relationship may moderate the impact of cost pressures on patients' medication adherence. More generally, addressing noncost barriers to adherence may reduce rates of cost-related medication underuse.
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The prognostic role of echocardiographic right ventricular (RV) dysfunction for predicting mortality in patients with acute pulmonary embolism and a preserved systemic arterial pressure remains controversial. ⋯ Among patients with pulmonary embolism who present with a systolic arterial pressure greater than or equal to 90 mm Hg, echocardiographic RV hypokinesis is an independent predictor of early death.