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CONTEXT: Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, where patients take a leading role and responsibility. OBJECTIVE: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine whether access, quality, and cost impacts differ by chronic condition status. DESIGN, SETTING, AND PATIENTS: This study conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. OUTCOME MEASURES: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. RESULTS: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care. CONCLUSIONS: Results suggest focusing first on patients with chronic conditions given the greater potential for early gains.

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The Patient Protection and Affordable Care Act recently passed into law is poised to profoundly affect the provision of medical care in the United States. In today's environment, the foundation for most ongoing comparative effectiveness research is financial claims data. However, there is an alternative that possesses much richer data. That alternative, uniquely positioned to serve as a test system for national health reform efforts, is the Department of Defense Military Health System. This article describes how to leverage the Military Health System and provide effective solutions to current health care reform challenges in the United States.

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OBJECTIVE: This study describes and categorizes the cultural frictions and conflicts within a successfully implemented Internal Medicine Patient-Centered Medical Home (PCMH) clinic at the National Naval Medical Center, and provides lessons learned for combating these concerns. METHODS: A semistructured interview protocol was developed, focusing on unique tenets of the PCMH, benefits of the model, and perceived obstacles to practicing medicine within this delivery system. The interviews included questions regarding efforts to foster team cohesion and impediments within the PCMH, as well as unique influences of the larger organization and the patient population, and lingering concerns about threats to the PCMH's viability. KEY RESULTS: Cultural tensions were revealed in four areas: perceived competing values within PCMH, individual resistance to PCMH values, within-team conflicts threatening the acculturation of PCMH values, and threats to the culture from external stakeholders. CONCLUSIONS: Recommendations for addressing these areas include values clarification and empowerment, training for socialization, realistic job previews, selective personnel retention, team building and conflict resolution mechanisms, and increased senior managerial support.

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BACKGROUND: Nonaspirin, nonsteroidal anti-inflammatory drugs (NANSAIDs) have been associated with arterial thromboembolic events in the general population. Our objective was to determine the prevalence of NANSAID use in patients diagnosed with cryptogenic emboli or paradoxical embolic events from a patent foramen ovale (PFO) or atrial septal defect (ASD) compared with a control population with an incidental PFO/ASD and no history of embolic events. METHODS: We performed a retrospective case-control study of 90 age-matched patients to assess the association of NANSAIDs with cryptogenic arterial embolic events in patients with and without a history of PFO/ASD. Odds ratios (ORs) were obtained by chi2 analysis. Multivariate analysis was conducted with a logistical regression method. RESULTS: Patients with cryptogenic embolic events had a high prevalence of prescription NANSAID use regardless of the presence of a PFO/ASD and were far more likely to have a history of NANSAID use than those with an incidentally discovered PFO/ASD and no history of arterial emboli (OR 4.30, 95% confidence interval 1.14-13.07, p = 0.01). CONCLUSIONS: Many patients previously diagnosed with paradoxical emboli may be experiencing the prothrombotic effects of NANSAIDs rather than a paradoxical mechanism for their arterial embolic event.

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Although acute urinary retention (AUR) is not commonly thought of as a life-threatening condition, its presentation in orbit can lead to a number of medical complications that could compromise a space mission. We report on a middle-aged astronaut who developed urinary retention during two spaceflights. On the first mission of note, the astronaut initially took standard doses of promethazine and scopolamine before launch, and developed AUR immediately after entering orbit. For the first 3 d, the astronaut underwent intermittent catheterizations with a single balloon-tipped catheter. Due to the lack of iodine solution on board and the need for the astronaut to complete certain duties without interruption, the catheter was left in place for a total of 4 d. Although the ability to void returned after day 7, a bout of AUR reemerged on day 10, 1 d before landing. On return to Earth, a cystometrogram was unremarkable. During the astronaut's next mission, AUR again recurred for the first 24 h of microgravity exposure, and the astronaut was subsequently able to void spontaneously while in space. This report details the presentation of this astronaut, the precautions that were taken for space travel subsequent to the initial episode of AUR, and the possible reasons why space travel can predispose astronauts to urinary retention while in orbit. The four major causes of AUR--obstructive, pharmacologic, psychogenic, and neurogenic-are discussed, with an emphasis on how these may have played a role in this case.

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India has approximately 5.2 million persons infected with HIV. Although antiretroviral therapy (ART) is being widely introduced in public clinics, many HIV-infected persons still seek care via the private sector. A cross-sectional survey was conducted in 2004 at six public and private sites to characterize the knowledge, attitudes, and practices (KAP) of ART among patients with HIV receiving care in India. Of 1667 persons surveyed, 609 (36%) had heard of ART and 19% of these persons reported that ART could cure HIV. Twenty-four percent reported that they were currently taking ART, with 18% of these patients not actually on ART according to their provider. Major barriers to taking ART were cost (33%), lack of knowledge of ART (41%), and deferral by physician (30%). More than half of all public and private patients had not heard of CD4 (57%) or viral load testing (80%), and even fewer had received these tests (32% and 11%, respectively). Private clinic attendees were almost 4 times more likely to be on ART (35% versus 9%, p < 0.0001), more likely to be male, have a higher education, be partnered, have a higher income, and have had a CD4 or viral load (p < 0.0001). Overall, low levels of ART knowledge and access were observed among HIV infected patients, with access to ART being particularly low among patients attending public clinics. In order to make widespread dissemination of ART effective in India, further educational and programmatic efforts are likely needed to optimize access, treatment awareness, and compliance among patients with HIV.

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Current evidence suggests that routine invasive therapy in the setting of unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) reduces the incidence of composite end points (i.e., death, myocardial infarction, or angina.). The 2002 American College of Cardiology/American Heart Association guidelines recommend invasive therapy in high-risk patients, although it is unknown if such an approach improves survival. We conducted a meta-analysis on 5 studies in 6,766 UA/NSTEMI patients who were randomized to either routine invasive versus conservative therapy in the era of glycoprotein IIb/IIIa inhibitors and intracoronary stents. Compared with conservative therapy, an invasive approach suggested a reduction in mortality at 6 to 12 months (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.63 to 1.03) and at 24 months (RR 0.77, 95% CI 0.60 to 0.99). The composite end point of death or myocardial infarction was reduced throughout all periods of follow-up: at 30 days (RR 0.61, 95% CI 0.45 to 0.84), at 6 months (RR 0.75, 95% CI 0.63 to 0.89), and at 12 months (RR 0.78, 95% CI 0.65 to 0.92). For the same composite end point at 6 to 12 months, men benefited from invasive therapy (RR 0.68, 95% CI 0.57 to 0.81), as did troponin-positive patients (RR 0.74, 95% CI 0.59 to 0.94). The results for women (RR 1.07, 95% CI 0.82 to 1.41) and troponin-negative patients (RR 0.82, 95% CI 0.59 to 1.14) were equivocal. Routine invasive therapy in UA/NSTEMI patients along with adjunctive use of glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival. Enhanced risk stratification is needed in women and troponin-negative patients so that invasive therapy may be more effectively recommended in these groups.

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