Rates Of Overall Use Research Articles

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis

Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Continuation of antibiotics after appendectomy. Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Theory, Practice and Future of Corporate Marketing Management Education as Part of Tertiary Education

To update the research priorities, this study aims to define the main content elements of teaching business marketing management in tertiary education. Based on their identification, the aim was to evaluate and compare the overall rate of use of marketing tools in business practice over time. Subsequently, the study aims to measure the dependencies between the level of marketing vitality and the number of employees, the field of business and the year of the company’s founding and to evaluate which online marketing tools companies know, use and plan to use in the future. We aim to evaluate whether real marketing practice corresponds to the topics taught in tertiary education in the Business Marketing Management program. To identify and understand teaching practice, the method of comparative research was used. To evaluate the feasibility of using marketing tools in real practice, multi-stage data collection using interviews and questionnaires was carried out in 2020-2023. The total number of respondents representing business entities in the Czech Republic was 411. Respondents were selected by random selection from the internal database of VŠFS, a.s., containing approximately 4,150 contacts to business entities. Statistical methods were used to evaluate the data and dependencies with verification of the received data using Pearson’s coefficient, Student’s distribution. Furthermore, descriptive exploratory analysis and the method of cluster analysis of the co-occurrence of words were used. The contribution of the study is the created list of topics used in teaching the subject Marketing Management of Enterprises in Tertiary Education. It can be stated that in real business practice, tools are used in accordance with the topics taught, tactical tools of the marketing mix are used as a priority. In the 2021-2023 timeline, the overall marketing vitality of companies is improving, especially in the area of external marketing communication. The findings highlight the importance of a balanced use of classic marketing tools in the offline environment with the incorporation of trendy online technologies into teaching and real business practice. Inevitably, the involvement of artificial intelligence (AI) in the marketing management of a business can be expected. The paper brings a new perspective on the connection between teaching theory and the practice of business entities. It appeals for cooperation between tertiary education and representatives of the business community and the practical application of theory, especially with the use of trendy tools of online marketing and artificial intelligence.

Prescribing trends of proton pump inhibitors, antipsychotics and benzodiazepines of medicare part d providers

BackgroundProton pump inhibitors, benzodiazepines, and antipsychotics are considered potentially inappropriate medications in older adults according to the American Geriatric Society Beers Criteria, and deprescribing algorithms have been developed to guide use of these drug classes. The objective of this study was to describe the number of beneficiaries prescribed these medications, provider specialty and regional trends in prescribing, and the aggregate costs for these claims in Medicare Part D.MethodsThis was a retrospective cross-sectional study using publicly available Medicare Provider Utilization and Payment Data: Part D Prescriber data for years 2013–2019. Descriptive statistics and the Cochrane-Armitage test were used to summarize the trends.ResultsOverall, 30.1%, 25.6%, 4.6% of Medicare Part D beneficiaries had a proton pump inhibitor, benzodiazepine, and antipsychotic claim in 2013, respectively. These rates decreased to 27.5%, 17.5%, 4.1% in 2019 (p-value < 0.0001). However, the number of standardized 30-day claims increased from 63 million in 2013 to 84 million in 2019 for proton pump inhibitors, remained steady for benzodiazepines and slightly increased (10 million to 13 million) for antipsychotics. Total aggregate costs decreased by almost $1.5 billion for proton pump inhibitor, $100 million for benzodiazepine, and $700 million for antipsychotic from 2013 to 2019 (p-value < 0.0001). Almost 93% of gastroenterologists prescribed a proton pump inhibitor, and 60% of psychiatrists prescribed benzodiazepines and antipsychotics all seven years. The Other region had the highest percentage of providers prescribing all three classes and the highest number of standardized 30-day benzodiazepine claims.ConclusionsThe overall rate of use of proton pump inhibitors, benzodiazepines, and antipsychotics decreased from 2013–2019 among Medicare Part D beneficiaries. Despite the increase in raw number of standardized 30-day claims, the costs decreased which is likely due to generics made available. These prescribing trends may aid in identifying and targeting potential deprescribing interventions.

Human and Donor Milk Use Post NICU Discharge

Background: The health benefits of feeding all infants human milk are well established but the use of human milk after infants are discharged from the Neonatal Intensive Care Unit (NICU) remains low. Aims: Our aim was to investigate which infants were receiving human milk at discharge from the NICU and at varying times after discharge and to explore factors that foster or inhibit increasing human milk use in NICU graduates. Methods: We conducted a prospective, observational study and collected data on the use of human milk at hospital discharge and during follow-up visits in five developmental follow-up programs. These follow up programs were in 5 different large cities in 3 different states in the United States. Results: The overall rate of use of any human milk decreased from 841/1,160 (72.5%) at discharge to 233/791 (29.5%) in participants who were followed for &gt;4 and ≤7 months after birth and this trend continued with later follow-up. In a multivariate logistic analysis, the factors found to be independently associated with the use of human milk at follow-up were: use of human milk at discharge (AOR=39.3, 14-162); white race compared to all other races/ethnicity (AOR= 2.97, 2.1-4.2); being reported preterm at birth (&lt;=32 weeks) compared to more mature gestational age infants (AOR= 2.02, 1.4-2.9); and mother having received a breast pump within 12 hours of the birth of her infant (AOR=1.90, 1.2-3). Conclusions: Health care practices within the NICU affect the continued use of human milk after infants are discharged from the hospital. These practices could be enhanced to increase human milk usage in NICU graduates.

Financial Inclusion and Economic Growth in WAEMU: A Multiscale Heterogeneity Panel Causality Approach

This paper examines the causal relationship between Financial Inclusion and economic growth in the West African Economic and Monetary Union (WAEMU) from 2006 to 2015. We combined the heterogeneity panel causality test proposed by [1] with the Maximal Overlap Discrete Wavelet Transform (MODWT) to analyze the bi-directional causality at different time scales. We used two Financial Inclusion indicators: the overall rate of demographic penetration of financial services (Financial Inclusion supply) and the overall rate of use of financial services (Financial Inclusion demand). Our results show that at scale 1 (2 - 4 years), there is no causality between economic growth and Financial Inclusion indicators. However, at scale 2 (4 - 8 years), we found a bi-directional causality between economic growth and Financial Inclusion. Policymakers should therefore promote reforms that are beneficial to financial inclusion, especially on the supply side, while making the levers for macroeconomic growth more efficient, which also seems to be a decisive factor in financial inclusion.

Disparities in the use of mobile phone for seeking childbirth services among women in the urban areas: Bangladesh Urban Health Survey

BackgroundIn Bangladesh, similar to its other South Asian counterparts, shortage of health workers along with inadequate infrastructure constitute some of the major obstacles for the equitable provision of reproductive healthcare services, particularly among the marginalized and underserved neighbourhoods. However, given the rapidly expanding broadband communication and mobile phone market in the country, the application of eHealth and mHealth technologies offer a window of opportunities to minimise the impact of socioeconomic barriers and promote the utilization of maternal healthcare services thereby. In the present study we aimed to investigate 1) the prevalence of usage of mobile phones for seeking childbirth services, 2) neighbourhood and socioeconomic disparities in the use, and 3) association between using mobile phones and the uptake of postnatal care among mothers and neonates.MethodsData for the present study came from Bangladesh Urban Health Survey 2013. Study subjects were 9014 married women aged between 15 and 49 years.ResultsThe overall rate of use of mobile phone was highest in City Corporation non-Slum areas (16.2%) and lowest in City Corporation Slum areas (7.4%). The odds of using mobile for seeking childbirth services were significantly higher among those who were living in non-slum areas, and lower among those who never attended school and lived in poorer households. Results also indicated that women in the slum areas who used mobile phone for childbirth service seeking, were 4.3 times [OR = 4.250;95% CI = 1.856–9.734] more likely to receive postnatal care for themselves, and those from outside the city-corporation areas were 2.7 times [OR = 2.707;95% CI = 1.712–4.279] more likely to receive postnatal care for the newborn.ConclusionNeighbourhood, educational and economic factors were significantly associated with the mobile phone utilization status among urban women. Promoting access to better education and sustainable income earning should be regarded as an integral part to the expansion of mHealth for maternal healthcare seeking behaviour.

The impact of physical book displays on business e-book use

ABSTRACTThis study examined the effectiveness of a physical display for increasing use of business e-books. The authors created three topical displays and compared the average use of the display titles to the average use of titles in the general collection. The overall rate of use for display e-books (12.3%) was lower than the average rate of use for nondisplay e-books (14.4%), suggesting that displays are not effective tools for increasing business e-book use. However, one display had a significantly higher average rate of e-book use (26.6%), suggesting that factors other than visibility may affect e-book use.

Knowledge, Understanding, and Use of Preventive Strategies against Nonmelanoma Skin Cancer in Healthy and Immunosuppressed Individuals Undergoing Mohs Surgery

Despite various national recommendations advising individuals to reduce their exposure to ultraviolet radiation, many people still do not use these skin cancer prevention strategies. To assess patient sources of medical information, knowledge of sun protection strategies, and barriers to implementing these strategies and to compare the overall rate of use of skin cancer prevention strategies of healthy and immunocompromised patients. Survey-based study conducted on 140 individuals undergoing Mohs surgery. Seventy-three percent of healthy and 74% of immunosuppressed participants identified sunscreen use as a form of protective strategy, whereas 36% and 27%, respectively, used sunscreen daily. Participants cited physicians and the internet as equal sources of medical information. Knowing two or more strategies correlated to a higher self-rating of daily use of any protective strategy. General knowledge regarding sun protection strategies is limited, but awareness of multiple strategies correlated with greater sun protective behavior. Despite having a much higher incidence of skin cancers, the immunosuppressed group did not show more awareness of prevention strategies or higher use than healthy participants.

Performance of Ultrasound in the Diagnosis of Appendicitis in Children in a Multicenter Cohort

The objectives were to assess the test characteristics of ultrasound (US) in diagnosing appendicitis in children and to evaluate site-related variations based on the frequency of its use. Additionally, the authors assessed the test characteristics of US when the appendix was clearly visualized. This was a secondary analysis of a prospective, 10-center observational study. Children aged 3 to 18 years with acute abdominal pain concerning for appendicitis were enrolled. US was performed at the discretion of the treating physician. Of 2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall sensitivity of 72.5% (95% confidence interval [CI] = 58.8% to 86.3%) and specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US sensitivity was 77.7% at the three sites (combined) that used it in 90% of cases, 51.6% at a site that used it in 50% of cases, and 35% at the four remaining sites (combined) that used it in 9% of cases. US retained a high specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites where the appendix was clearly visualized on US, its sensitivity was 97.9% (95% CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%). Ultrasound sensitivity and the rate of visualization of the appendix on US varied across sites and appeared to improve with more frequent use. US had universally high sensitivity and specificity when the appendix was clearly identified. Other diagnostic modalities should be considered when the appendix is not definitively visualized by US.

Better outcomes for acute myocardial infarction patients first admitted to PCI hospitals in Estonia

Objective – The objective of this study was to compare process of care, in-hospital outcomes, and 1-year mortality of patients with acute myocardial infarction (AMI) first admitted to hospitals with and without percutaneous coronary intervention (PCI) facilities in Estonia in 2007.Methods – We conducted a retrospective cross-sectional study on a random sample of hospitalized AMI patients. Data on process of care and in-hospital outcomes were abstracted from patient records in 16 hospitals according to a standardized study form.Results – Patients first admitted to PCI hospitals (n88=88327) had higher rates of overall use of coronary angiography (78.3% vs. 24.7%; P 88<880.001), revascularization (64.2% vs. 20.6%; P 88<880.001), and echocardiography (85.3% vs. 65.3%, P 88<880.001) than those first admitted to non-PCI hospitals (n88=88360). Among the non-PCI hospital patients those selected for cardiac catheterization were younger, healthier, and had better clinical status on presentation. Patients admitted to PCI hospitals had higher prescription rates of in-hospital and discharge evidence-based medications except for beta-blockers. PCI hospitals’ patients had lower in-hospital mortality (11.3% vs. 19.2%, P 88=880.004) and 1-year mortality (24.5% vs. 34.7%, P 88=880.003), results remained significant after adjustment for baseline characteristics (odds ratio 0.47; 95% confidence interval 0.28-0.78, hazard ratio 0.66; 95% confidence interval 0.48-0.90).Conclusions – There are disparities in process of care, in-hospital and 1-year mortality between patients first admitted to PCI vs. non-PCI hospitals in Estonia. Patients admitted to non-PCI hospitals should undergo more vigorous risk stratification using invasive and non-invasive methods; use of evidence-based medicine should be encouraged even if cardiac revascularization is not done.

Trends in thrombolytic use for ischemic stroke in the United States.

Although recombinant tissue plasminogen activator (tPA) improves outcomes from ischemic stroke, prior studies have found low rates of administration. Recent guidelines and regulatory agencies have advocated for increased tPA administration in appropriate patients, but it is unclear how many patients actually receive tPA. To determine whether national rates of tPA use for ischemic stroke have increased over time. We identified all patients with a primary diagnosis of ischemic stroke from years 2001 to 2006 in the National Hospital Discharge Survey (NHDS), a nationally representative sample of inpatient hospitalizations, and searched for procedure codes for intravenous thrombolytic administration. Clinical and demographic factors were obtained from the survey and multivariable logistic regression used to identify independent predictors associated with thrombolytic use. Among the 22,842 patients hospitalized with ischemic stroke, tPA administration rates increased from 0.87% in 2001 to 2.40% in 2006 (P < 0.001 for trend). Older patients were less likely to receive tPA (adjusted odds ratio [OR] and 95% confidence interval [CI]; 0.4 [0.3-0.6] for patients ≥80 years vs. <60 years), as were African American patients (0.4 [0.3-0.7]). Larger hospitals were more likely to administer tPA (3.3 [2.0-5.6] in hospitals with at least 300 beds compared to those with 6-99 beds). Although tPA administration for ischemic stroke has increased nationally in recent years, the overall rate of use remains very low. Larger hospitals were more likely to administer tPA. Further efforts to improve appropriate administration of tPA should be encouraged, particularly as the acceptable time-window for using tPA widens.

Application of a Firearm Seizure Law Aimed at Dangerous Persons: Outcomes From the First Two Years

Application of a Firearm Seizure Law Aimed at Dangerous Persons: Outcomes From the First Two Years

Routine use of fondaparinux in acute coronary syndromes: A 2-year multicenter experience

Fondaparinux has recently been approved in patients with acute coronary syndromes. The primary aim of this study was to describe the changes in use of anticoagulants between January 2006 and December 2007. The secondary aim was to compare 30-day mortality and rate of a combined end point (30-day death or major bleeding) according to the initial and final anticoagulant agent used. The rates of use of unfractionated heparin (UFH), enoxaparin, and fondaparinux were compared by periods of 1 month in a multicenter registry. The initial anticoagulant (first used at admission), the final anticoagulant (last used during hospitalization), and switches in anticoagulation were recorded. Temporal trends in monthly use of each anticoagulant were assessed; 30-day mortality rates and the combined end point were compared according to initial and final anticoagulant. Among 2,874 patients included, the first anticoagulant used was UFH in 26%, enoxaparin in 59%, and fondaparinux in 15%. Respective figures for final anticoagulant were 17%, 56%, and 27%. Although 3 centers did not use fondaparinux (community centers with catheterization laboratory), the overall rate of use of fondaparinux, as initial and final anticoagulant, increased at the expense of the use of enoxaparin. We observed a growing proportion of patients with a switch from UFH to either enoxaparin or fondaparinux, ranging from 5% at the beginning to 25% at the end of the study. Patients treated with UFH were older, had more comorbidities, were at higher risk, and received fewer guidelines-recommended treatments. In patients submitted to angioplasty and treated with fondaparinux, a bolus of 60 IU/kg of UFH was added. After adjustment, 30-day mortality and combined end point rates were higher in patients treated with UFH. Irrespective of the type of acute coronary syndromes, patients treated with enoxaparin or fondaparinux had similar outcomes. Between 2006 and 2007, the use of fondaparinux in patients with acute coronary syndromes increased considerably, either because it was used instead of enoxaparin or because of a switch from UFH. Adjusted mortality in patients treated with fondaparinux was lower than with UFH and similar to enoxaparin.

Patterns of management of atrial fibrillation complicating coronary artery bypass grafting: Results from the PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT-IV) Trial

Current practice related to the management of atrial fibrillation (AF) complicating coronary artery bypass grafting (CABG) is uncertain. We examined management of post-CABG AF in the PREVENT-IV trial, and we explored patterns of use of postoperative rhythm versus rate control and anticoagulation for AF by geographic region and type of site. We also compared outcomes of patients who developed post-CABG AF (663) with those who did not (2,131). The incidence of AF was 24%. Post-CABG AF was treated with a rhythm control strategy in 81% of patients and with warfarin in 23% of patients. Although there were significant variations across sites in the management of post-CABG AF, patterns of use of postoperative rhythm versus rate control and anticoagulation did not differ by geographic region or by whether or not the enrolling site was an academic institution. Mortality was higher in patients with post-CABG AF than patients without AF at 30 days (1.5% vs 0.7%, P = .01) but not at 3 years (6.9% vs 4.9%, P = .41). There was a trend toward a higher risk of mortality or stroke at 30 days in patients with AF (2.4% vs 1.9%, P = .08). Although a rhythm control strategy was used in most of the patients in this trial and the overall rate of use of warfarin was low, the significance of these findings is uncertain because of the lack of data from randomized clinical trials. The substantial variations in the management of post-CABG AF across sites are likely because of definitive data on the most effective therapies, highlighting the need for clinical trials on rate versus rhythm control and on anticoagulation for AF in this setting.

Study of the demand for home care by the Pamplona Extrahospital Emergency Services in 1995

The present paper is a retrospective descriptive study, carried out in the Special Casualty Service (Servicio Especial de Urgencias) of Pamplona. It evaluates 8,411 cases of calls from homes, extracted from an aleatory sample stratified by day of the week and season of the year, with a N=647. The diagnoses were codified according to the ICHPPC-2 of the WONCA and the statistical study with SPSS/PC+V 4.0. The monthly average was 701 calls from homes, with a daily average of 19 (from Monday to Friday), with 38 on Sundays and holidays. With respect to distribution by time, on working days 66.5% were distributed between 15.00 and 22.00 hours, while on Sundays and holidays 51% fell between 8.00 and 13.00 hours. The overall rate of use was situated at 32.71/1,000 inhabitants and year (with extreme rates in Mendillorri=7.42 and II Ensanche=57.35). In 74% of the cases a doctor or nurse visited the home. The most frequent cause for home care are illnesses of the respiratory apparatus with 23.5%. Some 40.9% of the patients attended were over 75 years of age. The conclusions are: 1. There is a low rate of home care. 2. Those requiring such visits are of an advanced age. 3. Illnesses of the respiratory apparatus are the most frequent cause of demand. 4. The zones of most demand are those where a Health Centre has not been set up as such.

Effectiveness of recombinant human erythropoietin, vitamin D3and iron therapy on long-term survival of patients with end-stage renal disease receiving haemodialysis: analysis of 702 patients after 10-year follow-up

Few studies have been conducted to investigate the influence of recombinant human erythropoietin (rhEPO) on the long-term prognosis of end-stage renal disease (ESRD). A retrospective cohort study. The largest regional hospital renowned for haemodialysis in northern Taiwan. A total of 702 ESRD patients undergoing haemodialysis between 1993 and 2002 were evaluated. The rate of overall use of rhEPO, vitamin D3 or Fe therapy was 62 %. The 10-year survival rate in patients with rhEPO supplementation was statistically more favourable than that in patients without rhEPO (hazard ratio (HR) = 0.38, 95 % CI 0.30, 0.47, P < 0.0001). Similar findings were noted for patients receiving vitamin D3 (HR = 0.36, 95 % CI 0.21, 0.64, P = 0.0004) and Fe (HR = 0.45, 95 % CI 0.33, 0.61, P < 0.0001). After adjusting for age, education and aetiology, the administration of rhEPO resulted in statistically significant improvements in long-term survival rate either with (HR = 0.30, 95 % CI 0.22, 0.42) or without (HR = 0.48, 95 % CI 0.38, 0.61) combined use of Fe or vitamin D3. We demonstrated a reduction in long-term mortality related to supplementation therapy with rhEPO, vitamin D3 and Fe. The findings provide a justification for the administration of combined supplement therapy in patients undergoing haemodialysis.

Child Care in Quebec

Five cycles of data from the Canadian National Longitudinal Survey of Children and Youth (1994/5–2002/3) were used to examine patterns of child care use in Quebec and the rest of Canada to explore the impact of Quebec’s implementation of universal child care. Rates of overall use as well as use of regulated (child care centre, family child care) and non-regulated care (sitter, nanny, relative, family child care) were examined for preschoolers aged 0–5 years in Quebec as compared to the other provinces and by family household income. Chi-square tests were used to examine significance of differences. Since the implementation of Quebec’s child care program, Quebec demonstrated substantial increases in child care use, particularly in the use of regulated care (from 10% prior to program compared to 30% by 2002) whereas the use of unregulated care did not demonstrate a significant increase in Quebec as compared to the other provinces (1994 to 2002). Furthermore, the use of regulated care by low-income families was greater in Quebec than elsewhere in Canada, although the greatest increase in use of regulated care was for children from high-income families. Findings suggest that since the introduction of Quebec’s universal child care program, there was an increase in the use of regulated child care for families of preschoolaged children in the province, although by 2002 Quebec had not achieved the coverage of universal child care programs attained by many European countries.

Correlates of therapy use and expenditures in children in the United States

Introduction: This paper describes correlates of use and expenditures for therapies (physical, occupational, speech or home health services) among children in the US.Methods: It examined data from the Medical Expenditure Panel Survey, a nationally-representative US sample. The characteristics of users and described patterns of expenditures were examined.Results: Use is quite low, only 3.8% of children use services or 4.3% once the use that occurs in the special education system is included. Children more likely to use therapy include those with presumably greater need: children with chronic conditions, functional limitations and/or a history of hospitalizations or injuries. There is a significant interaction of minority status and having a functional limitation. Expenditures are low when examined across the child population. Among a small proportion of high users, therapy expenditures account for a large proportion of overall health expenditures.Conclusions: The educational system adds only slightly to the overall rate of use. In general use appears to be related to the need for such services. Some children, likely including racial/ethnic minority children, may under-use services. Lack of insurance is not related to less use, perhaps because there are other ways to get some services (family care or services provided through the public health system) or because not all insurers cover therapy services. Therapy expenditures account for a high proportion of overall expenditures among the high users of therapy whereas, for the entire child population, therapy expenditures account for a very small part of overall health expenditures.

Use of Environmental Supports Among Patients With Schizophrenia

Cognitive adaptation training is a psychosocial treatment that uses individually tailored environmental supports, such as signs, calendars, hygiene supplies, and pill containers, to cue and sequence adaptive behavior in the client's home environment. Generic environmental supports offer a less costly treatment that provides a predetermined package of helpful supports to clients at the time of their routine clinic visit. Previous studies have demonstrated the efficacy of cognitive adaptation training. The study reported here examined the extent to which environmental supports are used by clients. As part of an ongoing study, persons with schizophrenia were randomly assigned to one of three conditions: cognitive adaptation training, generic environmental supports, or assessment only. Rates of use of supports for the first three months of treatment were examined for the first 64 patients assigned to the first two groups. Rates of overall use averaged approximately 80 percent for cognitive adaptation training and 44 percent for generic environmental supports. Specific categories of supports were also significantly more likely to be used by patients who were receiving cognitive adaptation training. More than 66 percent of patients in cognitive adaptation training were classified as high users of supports (used more than 75 percent of supports provided appropriately), compared with only 13 percent of those who were receiving generic environmental supports. Environmental supports have been found to improve functional behaviors for patients with schizophrenia. However, supports are not likely to be used unless they are customized for individual clients and set up in the home environment.

Hospital-Level Rates of Fluoroquinolone Use and the Risk of Hospital-Acquired Infection with Ciprofloxacin-Nonsusceptible Pseudomonas aeruginosa

In recent years, Pseudomonas aeruginosa has become increasingly resistant to fluoroquinolones, and fluoroquinolone use in the United States has also increased. Our objective was to determine whether higher hospital-level rates of use of ciprofloxacin, levofloxacin, and moxifloxacin antimicrobials were predictors that a higher proportion of P. aeruginosa isolates from hospital-acquired infections (hereafter, "hospital-acquired isolates") would be nonsusceptible to ciprofloxacin. We identified all hospital-acquired isolates from 14 hospitals in the Northern California Kaiser Permanente health care delivery system between 1998 and 2003 and determined their susceptibility to ciprofloxacin. For each facility, we determined the number of days of fluoroquinolone use per 1000 patient-days, by calendar quarter. We used a logistic regression model to analyze the data, with susceptibility status as the outcome variable. Hospital-level rates of use of the 3 fluoroquinolones were the predictors of interest; we adjusted for year, for use of nonquinolone antimicrobials, and for patient variables, including the number of days spent in the hospital in the prior year and fluoroquinolone use in the prior year. The model tested whether isolates from those facilities with higher rates of use of antimicrobials were more likely to be nonsusceptible to ciprofloxacin. Of 6099 isolates tested, 15% were not susceptible to ciprofloxacin. The nonsusceptibility rate increased from 9% to 20% between 1998 and 2003. Both the overall rate of use at the hospital and prior patient-specific use of ciprofloxacin, levofloxacin, and moxifloxacin were found to be independent predictors that a subsequent P. aeruginosa isolate would be nonsusceptible to ciprofloxacin. Higher hospital-level rates of use of ciprofloxacin, levofloxacin, and moxifloxacin are each associated with an increased proportion of hospital-acquired P. aeruginosa isolates being nonsusceptible to ciprofloxacin.