Katie Couric's televised colon cancer awareness campaign was temporally associated with an increase in colonoscopy use in 2 different data sets. These findings suggest that a celebrity spokesperson can have a substantial impact on public participation in preventive care programs.

In this paper, we propose a flexible "two-part" random Effects model (Olsen and Schafer 2001;Tooze, Grunwald, and Jones 2002) for correlated medical cost data. Typically, medical cost data are right-skewed, involve a substantial proportion of zero values, and may exhibit heteroscedasticity. In many cases, such data is also obtained in hierarchical form, e.g., on patients served by the same physician. The proposed model specification therefore consists of two generalized linear mixed models (GLMM), linked together by correlated random Effects. Respectively, and conditionally on the random Effects and covariates, we model the odds of cost being positive (Part I) using a GLMM with a logistic link and the mean cost (Part II) given that costs were actually incurred using a generalized gamma regression model with random Effects and a scale parameter that is allowed to depend on covariates (c.f. Manning, Basu, and Mullahy 2005). The class of generalized gamma distributions is very flexible and includes the lognormal, gamma, inverse gamma and Weibull distributions as special cases. We demonstrate how to carry out estimation using the Gaussian quadrature techniques conveniently implemented in SAS Proc NLMIXED. The proposed model is used to analyze pharmacy cost data on 56,245 adult patients clustered within 239 physicians in a mid-western U.S. managed care organization.

The CCHPR method appears to be a promising tool to understand variability in physician resource utilization in managed care.

IMPORTANCE There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). OBJECTIVE To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA. DESIGN, SETTING, AND PARTICIPANTS Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan. The study included 41 537 patients who underwent primary TKA between April 1, 2013, and October 31, 2015. Clinical events were monitored for 90 days after surgery. Data were analyzed between September and October 2016.EXPOSURES The method of pharmacologic prophylaxis: neither aspirin nor anticoagulants for 668 patients (1.6%), aspirin only for 12 831 patients (30.9%), anticoagulant only (eg, low-molecular-weight heparin, warfarin, and Xa inhibitors) for 22 620 patients (54.5%), and both aspirin/anticoagulant for 5418 patients (13.0%). Most patients were also using intermittent pneumatic compression stockings. MAIN OUTCOME AND MEASURES The primary composite outcome was the first occurrence of VTE or death. The noninferiority margin was specified as 0.3. The secondary outcome was bleeding events. RESULTSOf the 41 537 patients, 14 966 were men (36%), and the mean age was 65.8 years. A VTE event occurred in 573 of 41 537 patients (1.38%); 32 of 668 (4.79%) who received no pharmacologic prophylaxis, 149 of 12 831 (1.16%) treated with aspirin alone, 321 of 22 620 (1.42%) with anticoagulation alone, and 71 of 5418 (1.31%) prescribed both aspirin and anticoagulation. Aspirin only was noninferior for the composite VTE outcome compared with those receiving other chemoprophylaxis (adjusted odds ratio, 0.85; 95% CI, 0.68-1.07, P for inferiority = .007). Bleeding occurred in 457 of 41 537 patients (1.10%), 10 of 668 (1.50%) without prophylaxis, 116 of 12 831 (0.90%) in the aspirin group, 258 of 22 620 (1.14%) with anticoagulation, and 73 of 5418 (1.35%) of those receiving both. Aspirin alone was also noninferior for bleeding complications (adjusted odds ratio, 0.80; 95% CI, 0.63-1.00, P for inferiority <.001).CONCLUSIONS AND RELEVANCE In this study of patients undergoing TKA, aspirin was not inferior to other anticoagulants in the postoperative rate of VTE or death. Aspirin alone may provide similar protection from postoperative VTE compared with other anticoagulation treatments.

Overall life expectancy can be predicted with a moderate degree of accuracy, sufficient for informing patient-clinician discussions but inadequate as the only determinant of the optimal management approach.

Background Disease management programs for patients hospitalized with heart failure (HF) although effective, are often resource intensive, limiting their uptake. Peer support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for HF patients. Methods and Results In this randomized controlled trial, Reciprocal Peer Support (RSP) arm patients participated in a HF nurse practitioner (NP)-led goal setting group session, received brief training in peer communication skills, and were paired with another participant in their cohort with whom they were encouraged to talk weekly using a telephone platform. Participants were also encouraged to attend three NP-facilitated peer support group sessions. Patients in the Nurse Care Management (NCM) arm attended a NP-led session to address their HF care questions and receive HF educational materials and information on how to access care management services. The median age of the patients was 69 years, 51% were female, and 26% were racial/ethnic minorities. Only 55% of RPS patients participated in peer calls or group sessions. In intention-to-treat analyses, the RPS and NCM groups did not differ in time to first all-cause rehospitalization or death or in mean numbers of rehospitalizations or deaths. There were no differences in improvements in 6-month measures of HF-specific quality of life or social support. Conclusions Among patients recently hospitalized for HF, over half of RPS participants had no or minimal engagement with the reciprocal peer support program, and the program did not improve outcomes compared to usual HF-nurse care management.

BACKGROUND Favorable health outcomes are more likely to occur when the clinical team recognizes patients at risk and intervenes in consort. Prediction rules can identify high‐risk subsets, but the availability of multiple rules for various conditions present implementation and assimilation challenges. METHODS A prediction rule for 30‐day mortality at the beginning of the hospitalization was derived in a retrospective cohort of adult inpatients from a community hospital in the Midwestern United States from 2008 to 2009, using clinical laboratory values, past medical history, and diagnoses present on admission. It was validated using 2010 data from the same and from a different hospital. The calculated mortality risk was then used to predict unplanned transfers to intensive care units, resuscitation attempts for cardiopulmonary arrests, a condition not present on admission (complications), intensive care unit utilization, palliative care status, in‐hospital death, rehospitalizations within 30 days, and 180‐day mortality. RESULTS The predictions of 30‐day mortality for the derivation and validation datasets had areas under the receiver operating characteristic curve of 0.88. The 30‐day mortality risk was in turn a strong predictor for in‐hospital death, palliative care status, 180‐day mortality; a modest predictor for unplanned transfers and cardiopulmonary arrests; and a weaker predictor for the other events of interest. CONCLUSIONS The probability of 30‐day mortality provides health systems with an array of prognostic information that may provide a common reference point for organizing the clinical activities of the many health professionals involved in the care of the patient. Journal of Hospital Medicine 2013;8:229–235 © 2012 Society of Hospital Medicine

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