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This article provides U.S. national estimates for six common nosocomial pathogens. The incidence of infection decreased for four (MRSA, vancomycin-resistant enterococcus, carbapenem-resistant acinetobacter species, and multidrug-resistant P. aeruginosa ), was constant for one (carbapenem-resistant Enterobacteriaceae), and increased for one (ESBL-producing Enterobacteriaceae).

The role that traditional and hybrid in-person schooling modes contribute to the community incidence of SARS-CoV-2 infections relative to fully remote schooling is unknown. We conducted an event study using a retrospective nationwide cohort evaluating the effect of school mode on SARS-CoV-2 cases during the 12 weeks after school opening (July–September 2020, before the Delta variant was predominant), stratified by US Census region. After controlling for case rate trends before school start, state-level mitigation measures and community activity level, SARS-CoV-2 incidence rates were not statistically different in counties with in-person learning versus remote school modes in most regions of the United States. In the South, there was a significant and sustained increase in cases per week among counties that opened in a hybrid or traditional mode versus remote, with weekly effects ranging from 9.8 (95% confidence interval (CI) = 2.7–16.1) to 21.3 (95% CI = 9.9–32.7) additional cases per 100,000 persons, driven by increasing cases among 0–9 year olds and adults. Schools can reopen for in-person learning without substantially increasing community case rates of SARS-CoV-2; however, the impacts are variable. Additional studies are needed to elucidate the underlying reasons for the observed regional differences more fully. Results from a nationwide cohort study in the United States indicates that schools can reopen for in-person learning without substantially increasing community case rates of SARS-CoV-2.

OBJECTIVE The purpose of this study was to quantify the effect of multidrug-resistant (MDR) gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) on mortality following infection, regardless of patient location. METHODS We conducted a retrospective cohort study of patients with an inpatient admission in the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. We constructed multivariate log-binomial regressions to assess the impact of a positive culture on mortality in the 30- and 90-day periods following the first positive culture, using a propensity-score-matched subsample. RESULTS Patients identified with positive cultures due to MDR Acinetobacter (n=218), MDR Pseudomonas aeruginosa (n=1,026), and MDR Enterobacteriaceae (n=3,498) were propensity-score matched to 14,591 patients without positive cultures due to these organisms. In addition, 3,471 patients with positive cultures due to MRSA were propensity-score matched to 12,499 patients without positive MRSA cultures. Multidrug-resistant gram-negative bacteria were associated with a significantly elevated risk of mortality both for invasive (RR, 2.32; 95% CI, 1.85-2.92) and noninvasive cultures (RR, 1.33; 95% CI, 1.22-1.44) during the 30-day period. Similarly, patients with MRSA HAIs (RR, 2.77; 95% CI, 2.39-3.21) and colonizations (RR, 1.32; 95% CI, 1.22-1.50) had an increased risk of death at 30 days. CONCLUSIONS We found that HAIs due to gram-negative bacteria and MRSA conferred significantly elevated 30- and 90-day risks of mortality. This finding held true both for invasive cultures, which are likely to be true infections, and noninvasive infections, which are possibly colonizations. Infect Control Hosp Epidemiol 2017;38:848-856.

Background Homeless-experienced Veterans (HEVs) have higher rates of substance use disorders (SUDs) than housed Veterans, which impairs their ability to retain housing. The Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) initiative, which provides subsidized permanent housing and supportive services, contributed to the 50% reduction in Veteran homelessness over the past decade. However, ~ 40% of Veterans exit HUD-VASH within two years, often due to untreated SUDs. We will use two strategies to support the implementation of Medications for Addiction Treatment (MAT) and Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD) in 12 HUD-VASH sites; conduct an evaluation of this implementation effort; and generate an implementation playbook to support continued spread of MAT and CBT-SUD in HUD-VASH. Methods We will use Replicating Effective Programs (REP) to implement MAT and CBT-SUD at 12 sites over 18 months. After 9 months of REP alone, half (n = 6) of these sites will also receive Consumer Engagement (CE) for 9 months, activating HEVs to adopt these practices via peer coaching. We will conduct a type 3 hybrid cluster-randomized trial to compare the impacts of REP versus REP + CE. Randomization will occur at two levels: implementation start date (3 cohorts) and the implementation strategy (REP versus REP + CE). We will use stratified block randomization to balance site size among sites receiving each strategy across cohorts. We will use mixed methods to assess the impacts of REP versus REP + CE on implementation outcomes (reach [primary outcome], adoption, and sustainment); Veteran outcomes (primarily housing); provider and Veteran experiences; and costs and budget impacts. We hypothesize that REP + CE will have higher implementation costs than REP but result in improved MAT and CBT-SUD implementation and Veteran outcomes, leading to a business case for REP + CE. Discussion Implementing MAT and CBT-SUD within HUD-VASH can improve HEVs’ housing and health. By identifying effective strategies to support the implementation of these practices, we aim to inform other implementation efforts of behavioral health practices in homeless service settings. Trial registration This project was registered with ClincialTrials.gov as “Coordinated Access for Addiction Recovery and Equity in VA Supportive Housing.” Trial registration NCT07141394, registered 8/26/2025 ( https://clinicaltrials.gov/study/NCT07141394?term=CARE-VASH&rank=1 ).

Background Carbapenem-resistant Enterobacteriaceae (CRE) pose an urgent public health threat in the United States. An important step in planning and monitoring a national response to CRE is understanding its epidemiology and associated outcomes. We conducted a systematic literature review of studies that investigated incidence and outcomes of CRE infection in the US. Methods We performed searches in MEDLINE via Ovid, CDSR, DARE, CENTRAL, NHS EED, Scopus, and Web of Science for articles published from 1/1/2000 to 2/1/2016 about the incidence and outcomes of CRE at US sites. Results Five studies evaluated incidence, but many used differing definitions for cases. Across the entire US population, the reported incidence of CRE was 0.3–2.93 infections per 100,000 person-years. Infection rates were highest in long-term acute-care (LTAC) hospitals. There was insufficient data to assess trends in infection rates over time. Four studies evaluated outcomes. Mortality was higher in CRE patients in some but not all studies. Conclusion While the incidence of CRE infections in the United States remains low on a national level, the incidence is highest in LTACs. Studies assessing outcomes in CRE-infected patients are limited in number, small in size, and have reached conflicting results. Future research should measure a variety of clinical outcomes and adequately adjust for confounders to better assess the full burden of CRE.

Objective This study aimed to estimate the cost effectiveness of non-vitamin K oral anticoagulants (NOACs) compared with warfarin for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in Thailand where suboptimal anticoagulation control is common. Materials and Methods A hypothetical cohort of 65-year-old patients with NVAF and their disease progression was simulated in the Markov model. The following anticoagulant agents were used: warfarin, dabigatran, rivaroxaban, and apixaban. Warfarin with high, intermediate, and low time in therapeutic ranges (TTR) was used as the three different reference treatments. Baseline clinical events were obtained from a recently published real-world study in Thailand. A lifetime horizon was utilized in this model, and all analyses were performed from societal and healthcare perspectives. The results were reported as incremental cost-effectiveness ratios (ICERs) in 2021 US dollars per quality-adjusted life-year (QALY) gained. The sensitivity analyses were performed to assess the influence of parameter uncertainty. Results Apixaban was a cost-effective intervention compared with warfarin with low and intermediate TTR groups. In the low TTR group, the ICERs were $779 and $816 per QALY gained from the societal and healthcare perspectives, respectively, and in the intermediate TTR group, the ICERs were $2038 and $3159 per QALY gained from the societal and healthcare perspectives, respectively. Both ICERs were below the accepted willingness-to-pay threshold ($4806) in the context of Thailand’s healthcare. Conclusions In a developing country where suboptimal anticoagulation control is common, apixaban was the cost-effective alternative to warfarin for patients with both low and intermediate TTR control.

Non-invasive prenatal testing (NIPT) is a relatively new technology for diagnosis of fetal aneuploidies. NIPT is more accurate than conventional maternal serum screening (MSS) but is also more costly. Contingent NIPT may provide a cost-effective alternative to universal NIPT screening. Contingent screening used a two-stage process in which risk is assessed by MSS in the first stage and, based on a risk cutoff, high-risk pregnancies are referred for NIPT. The objective of this study was to (1) determine the optimum MSS risk cutoff for contingent NIPT and (2) compare the cost effectiveness of optimized contingent NIPT to universal NIPT and conventional MSS. Decision-analytic model using micro-simulation and probabilistic sensitivity analysis. We evaluated cost effectiveness from three perspectives: societal, governmental, and payer. From a societal perspective, universal NIPT dominated both contingent NIPT and MSS. From a government and payer perspective, contingent NIPT dominated MSS. Compared to contingent NIPT, adopting a universal NIPT would cost $203,088 for each additional case detected from a government perspective and $263,922 for each additional case detected from a payer perspective. From a societal perspective, universal NIPT is a cost-effective alternative to MSS and contingent NIPT. When viewed from narrower perspectives, contingent NIPT is less costly than universal NIPT and provides a cost-effective alternative to MSS.

Background The Veterans Health Administration (VA) Grant and Per Diem case management “aftercare” program provides 6 months of case management for homeless-experienced veterans (HEVs) undergoing housing transitions. To standardize and improve aftercare services, we will implement critical time intervention (CTI), an evidence-based, structured, and time-limited case management practice. We will use two strategies to support the implementation and sustainment of CTI at 32 aftercare sites, conduct a mixed-methods evaluation of this implementation initiative, and generate a business case analysis and implementation playbook to support the continued spread and sustainment of CTI in aftercare. Methods We will use the Replicating Effective Programs (REP) implementation strategy to support CTI implementation at 32 sites selected by our partners. Half ( n =16) of these sites will also receive 9 months of external facilitation (EF, enhanced REP). We will conduct a type 3 hybrid cluster-randomized trial to compare the impacts of REP versus enhanced REP. We will cluster potential sites into three implementation cohorts staggered in 9-month intervals. Within each cohort, we will use permuted block randomization to balance key site characteristics among sites receiving REP versus enhanced REP; sites will not be blinded to their assigned strategy. We will use mixed methods to assess the impacts of the implementation strategies. As fidelity to CTI influences its effectiveness, fidelity to CTI is our primary outcome, followed by sustainment, quality metrics, and costs. We hypothesize that enhanced REP will have higher costs than REP alone, but will result in stronger CTI fidelity, sustainment, and quality metrics, leading to a business case for enhanced REP. This work will lead to products that will support our partners in spreading and sustaining CTI in aftercare. Discussion Implementing CTI within aftercare holds the potential to enhance HEVs’ housing and health outcomes. Understanding effective strategies to support CTI implementation could assist with a larger CTI roll-out within aftercare and support the implementation of other case management practices within and outside VA. Trial registration This project was registered with ClinicalTrials.gov as “Implementing and sustaining Critical Time Intervention in case management programs for homeless-experienced Veterans.” Trial registration NCT05312229 , registered April 4, 2022.

Introduction Glycemic variability over time is a risk factor for diabetes complications. We studied a new measure of A1c stability, A1c time in range and its association with mortality in adults with diabetes. Methods We conducted a retrospective cohort study of people with type 1 and type 2 diabetes from January 1, 2004 to December 31, 2018. Participants were 18 years or older with at least four A1c tests during a three‐year baseline. A1c time in range was calculated as the percentage of time during baseline when A1c levels were within person‐specific target ranges. We also calculated the percentage of time A1c levels were below target ranges to assess the effects of potential overtreatment. Adjusted models and instrumental variable models were used to measure associations between A1c time in range and mortality. Results We studied 84,229 participants with mean age 58.3 years (SD 12.1). In adjusted Cox models, each 20% decrement in A1c time in range was associated with increased mortality (A1c time in range [0% < 20%] HR, 1.30; 95% CI 1.23–1.37). Instrumental variable models to control for unmeasured confounding also showed associations between reduced A1c time in range (0% < 20%) and mortality (HR, 1.28, 95% CI 1.22–1.35). Mortality risks were similar in subgroups with or without prevalent cardiovascular disease and insulin users but were greater in older adults (≥ 60 years). Greater (≥ 60%) A1c time below range was associated with increased mortality (HR, 1.35, 95% CI 1.29–1.41). Conclusions Reduced A1c time in range and particularly greater time below range are associated with increased mortality in adults with diabetes. A1c stability within person‐specific ranges may be a risk factor for major outcomes in adults with diabetes. Reduced A1c time in range and particularly greater time below range are associated with increased mortality in adults with diabetes. A1c stability within person‐specific ranges may be a risk predictor for major outcomes in adults with diabetes.

IntroductionHemoglobin A1c (A1c) treatment goals in older adults often consider life expectancy and comorbidities. A1c stability may also inform the risks of major outcomes. We studied the association of individualized A1c time-in-range (A1c TIR) with mortality and diabetes complications.Research design and methodsWe conducted a retrospective observational cohort study of patients with diabetes, 65 years or older, from the Department of Veterans Affairs (VA) and Kaiser Permanente (KP) from 2004 to 2018. Patients had at least four A1c tests during a 3-year baseline, and A1c TIR was calculated as the percentage of days when A1c levels were within patient-specific target ranges. We estimated associations among A1c TIR and mortality, cardiovascular, and microvascular outcomes using time to event models and instrumental variable (IV) models.ResultsWe identified 386 287 VA patients and 24 885 KP patients with a mean age of 74.3 years (SD 5.8) and 72.3 years (SD 5.7), respectively. Among VA patients, when compared with higher A1c TIR (80–100%), lower A1c TIR (0% to <20%) was associated with increased mortality (HR, 1.22; 95% CI 1.20 to 1.23) and cardiovascular outcomes (HR, 1.10; 95% CI 1.07 to 1.13). IV models showed similar associations. Among KP patients, lower A1c TIR (0% to <20%) was associated with mortality (HR, 1.36; 95% CI 1.27 to 1.45). IV models showed associations with increased mortality and cardiovascular outcomes. Among both VA and KP patients, greater A1c time below and time above range were associated with increased mortality.ConclusionsA1c stability within patient-specific target ranges is associated with a lower risk of major adverse outcomes among older adults with diabetes.