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Background Clostridium difficile is the most common cause of nosocomial infectious diarrhea in the United States. However, recent reports have documented that C. difficile infections (CDIs) are occurring among patients without traditional risk factors. The purpose of this study was to examine the epidemiology of CA-CDI, by estimating the incidence of CA-CDI and HA-CDI, identifying patient-related risk factors for CA-CDI, and describing adverse health outcomes of CA-CDI. Methods We conducted a population-based, retrospective, nested, case-control study within the University of Iowa Wellmark Data Repository from January 2004 to December 2007. We identified persons with CDI, determined whether infection was community-associated (CA) or hospital-acquired (HA), and calculated incidence rates. We collected demographic, clinical, and pharmacologic information for CA-CDI cases and controls (i.e., persons without CDI). We used conditional logistic regression to estimate the odds ratios (ORs) for potential risk factors for CA-CDI. Results The incidence rates for CA-CDI and HA-CDI were 11.16 and 12.1 cases per 100,000 person-years, respectively. CA-CDI cases were more likely than controls to receive antimicrobials (adjusted OR, 6.09 [95% CI 4.59-8.08]) and gastric acid suppressants (adjusted OR, 2.30 [95% CI 1.56-3.39]) in the 180 days before diagnosis. Controlling for other covariates, increased risk for CA-CDI was associated with use of beta-lactam/beta-lactamase inhibitors, cephalosporins, clindamycin, fluoroquinolones, macrolides, and penicillins. However, 27% of CA-CDI cases did not receive antimicrobials in the 180 days before their diagnoses, and 17% did not have any traditional risk factors for CDI. Conclusions Our study documented that the epidemiology of CDI is changing, with CA-CDI occurring in populations not traditionally considered \"high-risk\" for the disease. Clinicians should consider this diagnosis and obtain appropriate diagnostic testing for outpatients with persistent or severe diarrhea who have even remote antimicrobial exposure.

Background The health impacts of community design have been studied extensively over the past two decades. In particular, public transportation use is associated with more walking between transit stops and shops, work, home and other destinations. Change in transit access has been linked with physical activity and obesity but seldom to health outcomes and associated costs, especially within a causal framework. Health related fiscal impacts of transit investment should be a key consideration in major transit investment decisions. Methods The Rails & Health study is a natural experiment evaluating changes in clinical measures, health care utilization and health care costs among Kaiser Permanente Northwest (KPNW) members following the opening of a new light rail transit (LRT) line in Portland, Oregon. The study is prospectively following 3036 adults exposed to the new LRT line and a similar cohort of 4386 adults who do not live close to the new line. Individual-level outcomes and covariates are extracted from the electronic medical record at KPNW, including member demographics and comorbidities, blood pressure, body mass index, lipids, glycosylated hemoglobin, and health care utilization and costs. In addition, participants are surveyed about additional demographics, travel patterns, physical activity (PA), and perceived neighborhood walkability. In a subsample of the study population, we are collecting direct measures of travel-related behavior—physical activity (accelerometry), global positioning system (GPS) tracking, and travel diaries—to document mechanisms responsible for observed changes in health outcomes and cost. Comprehensive measures of the built environment at baseline and after rail construction are also collected. Statistical analyses will (1) examine the effects of opening a new LRT line on chronic disease indicators, health care utilization, and health care costs and (2) evaluate the degree to which observed effects of the LRT line on health measures and costs are mediated by changes in total and transportation-associated PA. Discussion The results of the Rails & Health study will provide urban planners, transportation engineers, health practitioners, developers, and decision makers with critical information needed to document how transit investments impact population health and related costs.

INTRODUCTION Little is known regarding the relationship between anticholinergic medications and frailty in dementia with Lewy bodies (DLB). METHODS Anticholinergic Cognitive Burden Scale (ACB) and Claims‐based Frailty Index scores were calculated for 12 months prior to the dementia diagnosis using electronic medical record and claims data. Logistic regression was used to estimate the association between ACB and odds of frailty. RESULTS Compared to controls (n = 525), a diagnosis of DLB (n = 175; adjusted odds ratio [aOR]: 15.1, 95% confidence interval [CI]: 7.0–33.9) or Alzheimer's disease (AD: n = 525; aOR = 7.7, 95% CI: 4.4–13.7) was associated with an increased odds of frailty. Patients with DLB had greater prescriptions for anticholinergic medications than patients with AD (pB < 0.001; 23%  vs 9.7%). ACB was positively correlated with frailty for all groups (r = 0.30 to 0.47, p < 0.001). DISCUSSION Cumulative anticholinergic burden may be a modifiable predictor of frailty among older adults, including those newly diagnosed with dementia. Highlights Patients with newly diagnosed dementia with Lewy bodies (DLB) are more likely to have prescriptions for anticholinergic medications relative to patients newly diagnosed with Alzheimer's disease (AD) and older adults without documented cognitive impairment. In the year prior to a documented dementia diagnosis, 74% of patients with DLB and 66% of patients with AD had evidence of frailty. Anticholinergic medication burden was associated with frailty among all older adults in the study, including those without a dementia diagnosis.

Background Little is known about whether diabetes increases the risk of COVID-19 infection and whether measures of diabetes severity are related to COVID-19 outcomes. Objective Investigate diabetes severity measures as potential risk factors for COVID-19 infection and COVID-19 outcomes. Design, Participants, Measures In integrated healthcare systems in Colorado, Oregon, and Washington, we identified a cohort of adults on February 29, 2020 ( n  = 1,086,918) and conducted follow-up through February 28, 2021. Electronic health data and death certificates were used to identify markers of diabetes severity, covariates, and outcomes. Outcomes were COVID-19 infection (positive nucleic acid antigen test, COVID-19 hospitalization, or COVID-19 death) and severe COVID-19 (invasive mechanical ventilation or COVID-19 death). Individuals with diabetes ( n  = 142,340) and categories of diabetes severity measures were compared with a referent group with no diabetes ( n  = 944,578), adjusting for demographic variables, neighborhood deprivation index, body mass index, and comorbidities. Results Of 30,935 patients with COVID-19 infection, 996 met the criteria for severe COVID-19. Type 1 (odds ratio [OR] 1.41, 95% CI 1.27–1.57) and type 2 diabetes (OR 1.27, 95% CI 1.23–1.31) were associated with increased risk of COVID-19 infection. Insulin treatment was associated with greater COVID-19 infection risk (OR 1.43, 95% CI 1.34–1.52) than treatment with non-insulin drugs (OR 1.26, 95% 1.20–1.33) or no treatment (OR 1.24; 1.18–1.29). The relationship between glycemic control and COVID-19 infection risk was dose-dependent: from an OR of 1.21 (95% CI 1.15–1.26) for hemoglobin A1c (HbA1c) < 7% to an OR of 1.62 (95% CI 1.51–1.75) for HbA1c ≥ 9%. Risk factors for severe COVID-19 were type 1 diabetes (OR 2.87; 95% CI 1.99–4.15), type 2 diabetes (OR 1.80; 95% CI 1.55–2.09), insulin treatment (OR 2.65; 95% CI 2.13–3.28), and HbA1c ≥ 9% (OR 2.61; 95% CI 1.94–3.52). Conclusions Diabetes and greater diabetes severity were associated with increased risks of COVID-19 infection and worse COVID-19 outcomes.

Background. Traditional surveillance methods may underestimate the true burden of Clostridium difficile infection (CDI) because they fail to capture cases brought to medical attention in outpatient settings or diagnosed during non-face-to-face patient–provider interactions. Methods. We identified CDIs diagnosed among Kaiser Permanente Northwest patients between 1 June 2005 and 30 December 2012. We categorized infections by whether they were diagnosed during an inpatient or outpatient encounter and whether they were diagnosed during a face-to-face (eg, hospitalization, outpatient visit) or non-face-to-face encounter (eg, phone, e-mail). We constructed a baseline surveillance estimate that included CDIs identified during hospitalization, representing burden captured through traditional surveillance approaches. We then constructed 2 additional estimates: 1 that included CDIs identified during outpatient face-to-face encounters and 1 that also included CDIs identified during non-face-to-face encounters. Results. We identified 8024 CDIs. Twenty-four percent occurred during a hospitalization, while the remaining CDIs were recognized in the outpatient setting. Surveillance focused on hospitalized patients would have captured less than one-quarter of total burden. The addition of cases identified during outpatient face-to-face encounters would account for 80% of CDIs. An additional 1702 CDIs would not be captured without inclusion of non-face-to-face encounters; thus, surveillance approaches that do not include telephone or e-mail encounters would miss 21% of CDIs. Conclusions. Surveillance approaches that do not include outpatient or nontraditional encounters miss a substantial proportion of CDIs. Failure to capture these cases leads to underestimation of disease burden and difficulty in measuring interventions to control CDI.

The updated 2023–24 COVID-19 vaccine was available in the United States beginning September 2023. Our objective was to identify reasons for decisions related to vaccination of children in the household. In December 2023, adults in Oregon and Washington were asked whether they or their household children had received the 2023–24 COVID-19 vaccination. Adults with unvaccinated children were asked about intentions to vaccinate and to rank the top three reasons for their decision. Vaccine concordance between adults and household children was assessed. Among 1067 adult participants, 33 % (n = 352) of adults reported at least one unvaccinated household child: 23 % intended to vaccinate and 10 % did not intend to vaccinate. Among 243 adults who intended to vaccinate, 73 % selected “if there is more severe illness in my school or community”, as a primary reason; the highest ranked reason among those not intending to vaccinate was the belief that their child would not become severely ill (66 %). 78 % of adults made the same vaccine decisions for themselves and their children. Participant's perception of their child's individual risk from SARS-CoV-2 infection was the primary consideration impacting vaccine uptake and intent for 2023–24 COVID-19 vaccine.

Few population-based studies have evaluated the importance of pre-existing respiratory syncytial virus (RSV) antibody on RSV susceptibility among children and adults. We conducted a prospective, community-based cohort study among individuals aged 6 months-50 years in Oregon and Washington State, USA (June 2022-May 2023), with weekly symptom surveys and swab collection regardless of symptoms. Swabs were tested for RSV using RT-qPCR. Enrollment sera were tested for RSV prefusion F IgG binding (all participants) and neutralizing antibodies (pediatric participants). We detected 305 RSV illnesses among 3237 participants from 1188 households. Using proportional hazards regression, higher RSV binding antibody titers were associated with a lower estimated hazard of RSV among pediatric participants (hazard ratio=0.66 per 1-unit difference in log 10 -RSV antibody titer; 95% CI: 0.56, 0.78). In a post-pandemic period, pre-existing RSV antibody titers were associated with a lower risk of RSV illness in children aged 6 months-17 years, which could inform vaccine development for this age group. This study found higher RSV antibody levels were associated with lower RSV risk in children outside the hospital. An earlier rise in incidence and higher incidence rates were observed among children <5 years compared to older children and adults.

Abstract Objective To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers. Design Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program. Setting An integrated healthcare system (HCS) in the Northwest United States. Subjects Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff. Methods Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes. Results Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals. Conclusions PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.

BACKGROUND Considerable efforts have been dedicated to developing strategies to prevent and treat recurrent Clostridium difficile infection (rCDI); however, evidence of the impact of rCDI on patient healthcare utilization and outcomes is limited. OBJECTIVE To compare healthcare utilization and 1-year mortality among adults who had rCDI, nonrecurrent CDI, or no CDI. METHODS We performed a nested case-control study among adult Kaiser Foundation Health Plan members from September 1, 2001, through December 31, 2013. We identified CDI through the presence of a positive laboratory test result and divided patients into 3 groups: patients with rCDI, defined as CDI in the 14-57 days after initial CDI; patients with nonrecurrent CDI; and patients who never had CDI. We conducted 3 matched comparisons: (1) rCDI vs no CDI; (2) rCDI vs nonrecurrent CDI; (3) nonrecurrent CDI vs no CDI. We followed patients for 1 year and compared healthcare utilization between groups, after matching patients on age, sex, and comorbidity. RESULTS We found that patients with rCDI consistently have substantially higher levels of healthcare utilization in various settings and greater 1-year mortality risk than both patients who had nonrecurrent CDI and patients who never had CDI. CONCLUSIONS Patients who develop an initial CDI are generally characterized by excess underlying, severe illness and utilization. However, patients with rCDI experience even greater adverse consequences of their disease than patients who do not experience rCDI. Our results further support the need for continued emphasis on identifying and using novel approaches to prevent and treat rCDI. Infect Control Hosp Epidemiol. 2016;1-8.

Vaccines recommended for adolescents are considered safe and effective, however administration may occasionally result in acute pain at the injection site or syncope (fainting). These adverse effects pose a risk to patient safety and are potential barriers to adherence to future vaccinations. We assessed a novel intervention designed to help prevent acute pain and syncope associated with adolescent vaccinations. We conducted a 3-month pilot study to assess the feasibility and acceptability of a vaccination comfort menu within two Kaiser Permanente Northwest pediatric clinics. The menu offered a variety of comfort items (e.g., cold packs, squeeze balls) that children could select prior to their vaccination. We surveyed parents of recently vaccinated adolescents and interviewed providers to assess the implementation and effectiveness of the intervention. Response rate for the parent survey was 33% (378/1136). Only 20% of the parents reported that their provider offered the comfort menu during the vaccination visit. Approximately 50% of the adolescents who were offered the menu selected a comfort item and most of these participants reported that the item was very (35%) or somewhat (38%) helpful in improving their vaccination experience. Per provider interviews, common barriers to implementing the intervention included lack of time and convenience, and the brevity of the pilot period. The comfort menu may improve the vaccination experience of youth and increase the likelihood of adherence with future vaccinations. However, only 20% of the parents reported that their provider offered the menu during the vaccination visit. Additional research is needed to determine the feasibility of implementing this intervention on a larger scale, as well as assessing whether the intervention has a significant impact on reducing adverse events.