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1.  Infective Endocarditis in the U.S., 1998–2009: A Nationwide Study 
PLoS ONE  2013;8(3):e60033.
Background
Previous studies based on local case series estimated the annual incidence of endocarditis in the U.S. at about 4 per 100,000 population. Small-scale studies elsewhere have reported similar incidence rates. However, no nationally-representative population-based studies have verified these estimates.
Methods and Findings
Using the 1998–2009 Nationwide Inpatient Sample, which provides diagnoses from about 8 million U.S. hospitalizations annually, we examined endocarditis hospitalizations, bacteriology, co-morbidities, outcomes and costs. Hospital admissions for endocarditis rose from 25,511 in 1998 to 38, 976 in 2009 (12.7 per 100,000 population in 2009). The age-adjusted endocarditis admission rate increased 2.4% annually. The proportion of patients with intra-cardiac devices rose from 13.3% to 18.9%, while the share with drug use and/or HIV fell. Mortality remained stable at about 14.5%, as did cardiac valve replacement (9.6%). Other serious complications increased; 13.3% of patients in 2009 suffered a stroke or CNS infection, and 5.5% suffered myocardial infarction. Amongst cases with identified pathogens, Staphylococcus aureus was the most common, increasing from 37.6% in 1998 to 49.3% in 2009, 53.3% of which were MRSA. Streptococci were mentioned in 24.7% of cases, gram-negatives in 5.6% and Candida species in 1.0%. We detected no inflection in hospitalization rates after changes in prophylaxis recommendations in 2007. Mean age rose from 58.6 to 60.8 years; elderly patients suffered higher rates of myocardial infarction and death, but slightly lower rates of Staphylococcus aureus infections and neurologic complications. Our study relied on clinically diagnosed cases of endocarditis that may not meet strict criteria. Moreover, since some patients are discharged and readmitted during a single episode of endocarditis, our hospitalization figures probably slightly overstate the true incidence of this illness.
Conclusions
Endocarditis is more common in the U.S. than previously believed, and is steadily increasing. Preventive efforts should focus on device-associated and health-care-associated infections.
doi:10.1371/journal.pone.0060033
PMCID: PMC3603929  PMID: 23527296
2.  Competition in a publicly funded healthcare system 
BMJ : British Medical Journal  2007;335(7630):1126-1129.
Are the UK and other countries right to adopt a market based model for improving their health services? Steffie Woolhandler and David Himmelstein believe that the appropriate response to the US experience with such policies is quarantine, not replication
doi:10.1136/bmj.39400.549502.94
PMCID: PMC2099512  PMID: 18048539
3.  Sources of U.S. Physician Income: The Contribution of Government Payments to the Specialist–Generalist Income Gap 
Journal of General Internal Medicine  2008;23(9):1477-1481.
Background
Physician income varies threefold among specialties. Lower incomes have produced shortages in primary care fields.
Objective
To investigate the impact of government policy on generating income differentials among specialties.
Design and Participants
Cross-sectional analysis of the 2004 MEPS.
Measurements
For outpatient care, total payments made to 27 different types of specialists from five types of payers: Medicare, Medicaid, other government (the Veterans Administration and other state and local programs), private insurance, and out-of-pocket payments. For inpatient care, aggregate (i.e., all-specialty) inpatient physician reimbursement from the five payers.
Results
In 2004, physicians derived 78.6% of their practice income ($149,684 million, 95% CI, $140,784 million—$158,584 million) from outpatient sources and 21.4% of their income ($40,782 million, 95% CI, $36,839 million—$44,724 million) from inpatient sources. Government payers accounted for 32.7% of total physician income. Four specialties derived > 50% of their outpatient income from public sources, including both the lowest and highest paid specialties (geriatrics and hematology/oncology, respectively).
Conclusions
Inter-specialty income differences result, in part, from government decisions.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0660-7) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-008-0660-7
PMCID: PMC2517994  PMID: 18592323
physician income; contribution of government payments; specialist–generalist income gap
4.  Free Drug Samples in the United States: Characteristics of Pediatric Recipients and Safety Concerns 
Pediatrics  2008;122(4):736-742.
OBJECTIVES
Free drug samples frequently are given to children. We sought to describe characteristics of free sample recipients, to determine whether samples are given primarily to poor and uninsured children, and to examine potential safety issues.
METHODS
We analyzed data on 10 295 US residents <18 years of age from the 2004 Medical Expenditure Panel Survey, a nationally representative survey that includes questions on receipt of free drug samples. We performed bivariate and multivariate analyses to evaluate characteristics associated with receipt of ≥1 free drug sample in 2004. We identified the most frequently reported sample medications and reviewed potential safety issues.
RESULTS
Ten percent of children who received prescription medications and 4.9% of all children received ≥1 free drug sample in 2004. In bivariate analyses, poor children (family incomes of <200% of the federal poverty level) were no more likely to receive free samples than were those with incomes of ≥400% of the poverty level (3.8% vs 5.9%). Children who were uninsured for part or all of the year were no more likely to receive free samples than were those who were insured all year (4.5% vs 5.1%); 84.3% of all sample recipients were insured. In multivariate analyses, routine access to health care (≥3 provider visits in 2004) was associated with free sample receipt. The 15 most frequently distributed pediatric free samples in 2004 included 1 schedule II controlled medication, Adderall (amphetamine/dextroamphetamine), and 4 medications that received new or revised black box warnings between 2004 and 2007, Elidel (pimecrolimus), Advair (fluticasone/salmeterol), Strattera (atomoxetine), and Adderall (amphetamine/dextroamphetamine).
CONCLUSIONS
Poor and uninsured children are not the main recipients of free drug samples. Free samples do not target the neediest children selectively, and they have significant safety considerations.
doi:10.1542/peds.2007-2928
PMCID: PMC2680431  PMID: 18829796
free drug samples; drug safety; medically underserved; access to health care; black box warning; uninsured; drug packaging; health insurance
5.  U.S. Physicians’ Views on Financing Options to Expand Health Insurance Coverage: A National Survey 
BACKGROUND
Physician opinion can influence the prospects for health care reform, yet there are few recent data on physician views on reform proposals or access to medical care in the United States.
OBJECTIVE
To assess physician views on financing options for expanding health care coverage and on access to health care.
DESIGN AND PARTICIPANTS
Nationally representative mail survey conducted between March 2007 and October 2007 of U.S. physicians engaged in direct patient care.
MEASUREMENTS
Rated support for reform options including financial incentives to induce individuals to purchase health insurance and single-payer national health insurance; rated views of several dimensions of access to care.
MAIN RESULTS
1,675 of 3,300 physicians responded (50.8%). Only 9% of physicians preferred the current employer-based financing system. Forty-nine percent favored either tax incentives or penalties to encourage the purchase of medical insurance, and 42% preferred a government-run, taxpayer-financed single-payer national health insurance program. The majority of respondents believed that all Americans should receive needed medical care regardless of ability to pay (89%); 33% believed that the uninsured currently have access to needed care. Nearly one fifth of respondents (19.3%) believed that even the insured lack access to needed care. Views about access were independently associated with support for single-payer national health insurance.
CONCLUSIONS
The vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.
doi:10.1007/s11606-009-0916-x
PMCID: PMC2659157  PMID: 19184240
access to care; health care reform; physician behavior
6.  Author Reply 
doi:10.1007/s11606-007-0261-x
PMCID: PMC2305841
7.  Consumer Directed Healthcare: Except for the Healthy and Wealthy It’s Unwise 
Many politicians and business leaders are advocating high deductible health insurance plans linked with health savings accounts—so-called consumer-directed healthcare. These policies penalize the sick, discourage needed care (especially primary and preventive care), and direct tax subsidies towards the wealthiest Americans. They offer little hope of slowing the growth of health care costs and add further bureaucratic costs and complexity to our health care financing system.
doi:10.1007/s11606-007-0187-3
PMCID: PMC2071952  PMID: 17394044
health care financing; health insurance; access to care
8.  Consumer Directed Healthcare: Except for the Healthy and Wealthy It’s Unwise 
Many politicians and business leaders are advocating high deductible health insurance plans linked with health savings accounts—so-called consumer-directed healthcare. These policies penalize the sick, discourage needed care (especially primary and preventive care), and direct tax subsidies towards the wealthiest Americans. They offer little hope of slowing the growth of health care costs and add further bureaucratic costs and complexity to our health care financing system.
doi:10.1007/s11606-007-0187-3
PMCID: PMC2071952  PMID: 17394044
health care financing; health insurance; access to care
9.  BRIEF REPORT: Influenza Vaccination and Health Care Workers in the United States 
OBJECTIVE
To determine influenza vaccination rates among U.S. health care workers (HCWs) by demographic and occupational categories.
DESIGN AND PARTICIPANTS
We analyzed data from the 2000 National Health Interview Survey (NHIS). Weighted multivariable analyses were used to evaluate the association between HCW occupation and other variables potentially related to receipt of influenza vaccination. HCWs were categorized based on standard occupational classifications as health-diagnosing professions, health-assessing professions, health aides, health technicians; or health administrators.
MAIN INDEPENDENT VARIABLES
Demographic characteristics and occupation category.
MAIN OUTCOME VARIABLES
Receipt of influenza vaccination within 12 months of survey.
ANALYSIS
Descriptive statistics and weighted multivariable logistic regression.
RESULTS
There were 1,651 HCWs in the final sample. The overall influenza vaccination rate for HCWs was 38%. After weighted multivariable analyses, HCWs who were under 50 (odds ratio [OR] 0.67%, 95% confidence interval [CI]: 0.50 to 0.89, compared with HCWs 50 to 64), black (OR 0.57 95% CI: 0.42, 0.78, compared with white HCWs), or were health aides (OR 0.73%, 95% CI: 0.51, 1.04, compared with health care administrators and administrative support staff) had lower odds of having been vaccinated against influenza.
CONCLUSIONS
The overall influenza vaccination rate among HCWs in the United States is low. Workers who are under 50, black, or health aides have the lowest rates of vaccinations. Interventions seeking to improve HCW vaccination rates may need to target these specific subgroups.
doi:10.1111/j.1525-1497.2006.00325.x
PMCID: PMC1484661  PMID: 16606378
Influenza vaccinations; health care workers; National Health Interview Survey; nosocomial infection; employee health
10.  Diabetes and Cardiovascular Disease Among Asian Indians in the United States 
CONTEXT
Studies, mostly from outside the United States, have found high prevalence of diabetes, coronary heart disease (CHD), and hypertension among Asian Indians, despite low rates of associated risk factors.
OBJECTIVE
To analyze the prevalence of obesity, diabetes, CHD, hypertension, and other associated risk factors among Asian Indians in the United States compared to non-Hispanic whites.
DESIGN, SETTING, AND SUBJECTS
Cross-sectional study using data from the National Health Interview Survey (NHIS) for 1997, 1998, 1999, and 2000. We analyzed 87,846 non-Hispanic whites and 555 Asian Indians.
MAIN OUTCOME MEASURES
Whether a subject reported having diabetes, CHD, or hypertension.
RESULTS
Asian Indians had lower average body mass indices (BMIs) than non-Hispanic whites and lower rates of tobacco use, but were less physically active. In multivariate analysis controlling for age and BMI, Asian Indians had significantly higher odds of borderline or overt diabetes (adjusted OR [AOR], 2.70; 95% confidence interval [CI], 1.72 to 4.23). Multivariate analysis also showed that Asian Indians had nonsignificantly lower odds ratios for CHD (AOR, 0.58; 95% CI, 0.25 to 1.35) and significantly lower odds of reporting hypertension (AOR, 0.58; 95% CI, 0.42 to 0.82) compared to non-Hispanic whites.
CONCLUSION
Asian Indians in the United States have higher odds of being diabetic despite lower rates of obesity. Unlike studies on Asian Indians in India and the United Kingdom, we found no evidence of an elevated risk of CHD or hypertension. We need more reliable national data on Asian Indians to understand their particular health behaviors and cardiovascular risks. Research and preventive efforts should focus on reducing diabetes among Asian Indians.
doi:10.1111/j.1525-1497.2005.40294.x
PMCID: PMC1490101  PMID: 15963176
Asian Indian; diabetes; coronary heart disease; hypertension; obesity
11.  The high costs of for-profit care 
doi:10.1503/cmaj.1040779
PMCID: PMC419771  PMID: 15184338
13.  The Silence of the Doctors 
doi:10.1046/j.1525-1497.1998.00125.x
PMCID: PMC1496966  PMID: 9669574

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