Objective. To study the association between procedure volume and patient-centered outcomes such as functional status.Methods. We performed an observational study of a stratified random sample of Medicare beneficiaries who underwent primary total knee replacement (TKR) in 2000. Low-volume surgeons were defined as surgeons performing <6 TKRs per year in the Medicare population, and low-volume centers were defined as those in which <25 TKRs per year were performed. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional status score (0-100 scale; 100 ‫؍‬ best) 2 years after TKR. We defined a WOMAC functional status score of <60 as a poor functional outcome. Analyses were adjusted for sociodemographic factors, preoperative functional status, and comorbidities.Results. Fifty-eight percent of 1,597 eligible patients agreed to participate. Twelve percent of participating patients had a WOMAC score <60 2 years following TKR. Patients operated upon by low-volume surgeons in low-volume hospitals were twice as likely to have a poor WOMAC functional status score as patients operated upon by higher volume surgeons and in higher volume hospitals (odds ratio 2.1, 95% confidence interval 1.1-4.2).Conclusion. Patients operated upon in lowvolume hospitals by low-volume surgeons had worse functional outcomes 2 years after TKR. These findings add a new and important dimension to the discussion of whether to promote selective referral of procedures such as TKR to high-volume centers.

Mental health problems in service members often go untreated. This study focused on factors related to interest in receiving help in a survey sample of 577 combat veterans who were screened positive for posttraumatic stress disorder, depression, or generalized anxiety disorder 3 months after returning from Iraq. Over three quarters of respondents recognized that they had a current problem, but only 40% were interested in receiving help. Interest in receiving help was associated with recognizing a problem and receiving mental health services in the past year. More negative attitudes toward mental health care were associated with lower interest in receiving help; paradoxically, more negative perceptions of unit stigma were associated with increased interest in receiving help. Further studies are needed to better define the relationship between stigma perceptions, interest in receiving care, and actual care utilization and to determine whether attitudes toward mental health care can be modified through changes in how care is delivered. Attitudes toward mental health care should be considered in treatment interventions.

The risk perception attitude framework can serve as a theoretically sound audience segmentation technique that can be used to determine whether messages should augment perceptions of risk, beliefs about personal efficacy, or both.