State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2006 quarter, includes articles about:

• research by CHP/PCOR investigators that influenced the Centers for Disease Control and Prevention to recommend widespread voluntary HIV screening for all Americans ages 13 to 64 -- a significant change from the CDC's previous HIV screening guidelines;
• a CHP/PCOR study on patient safety culture in U.S. hospitals -- the largest effort to date to measure hospitals' safety culture and seek to improve it through an intervention that gets hospital executives out of their offices and on to the hospital floors;
• an early-stage project in which CHP/PCOR is collaborating with the Center on Democracy, Development and the Rule of Law to study the relationship between health interventions, governance and development;
• an evidence report examining the challenges of diagnosing and treating anthrax in children, prepared by the Stanford-UCSF Evidence-based Practice Center; and
• a study by CHP/PCOR fellow Kate Bundorf which found that depending on the definition of "affordability" that is used, health insurance is "affordable" to between one-quarter and three-quarters of the uninsured -- and many of those who can't afford insurance purchase it anyway.

Several factors are changing the landscape of cervical cancer control, including a better understanding of the natural history of human papillomavirus (HPV), reliable assays for detecting high-risk HPV infections, and a soon to be available HPV-16/18 vaccine. There are important differences in the relevant policy questions for different settings. By synthesizing and integrating the best available data, the use of modeling in a decision analytic framework can identify those factors most likely to influence outcomes, can guide the design of future clinical studies and operational research, can provide insight into the cost-effectiveness of different strategies, and can assist in early decision-making when considered with criteria such as equity, public preferences, and political and cultural constraints

Objectives:

To systematically review the literature about children with anthrax to describe their clinical course, treatment responses, and the predictors of disease progression and mortality.

Data Sources:

MEDLINE® (1966-2005), 14 selected journal indexes (1900-1966) and bibliographies of all retrieved articles.

Review Methods:

We sought case reports of pediatric anthrax published between 1900 and 2005 meeting predefined criteria. We abstracted three types of data from the English-language reports:

Patient information (e.g., age, gender, nationality).

Symptom and disease progression information (e.g., whether the patient developed meningitis).

Treatment information (e.g., treatments received, year of treatment).

We compared the clinical symptoms and disease progression variables for the pediatric cases with data on adult anthrax cases reviewed previously.

Results:

We identified 246 titles of potentially relevant articles from our MEDLINE® search and 2253 additional references from our manual search of the bibliographies of retrieved articles and the indexes of the 14 selected journals. We included 62 case reports of pediatric anthrax including two inhalational cases, 20 gastrointestinal cases, 37 cutaneous cases, and three atypical cases.

Anthrax is a relatively common and historically well-recognized disease and yet rarely reported among children, suggesting the possibility of significant under-diagnosis, underreporting, and/or publication bias. Children with anthrax present with a wide range of clinical signs and symptoms, which differ somewhat from the presenting features of adults with anthrax. Like adults, children with gastrointestinal anthrax have two distinct clinical presentations:

Upper tract disease characterized by dysphagia and oropharyngeal findings.

Lower tract disease characterized by fever, abdominal pain, and nausea and vomiting.

Additionally, children with inhalational disease may have "atypical" presentations including primary meningoencephalitis. Children with inhalational anthrax have abnormal chest roentgenograms; however, children with other forms of anthrax usually have normal roentgenograms. Nineteen of the 30 children (63%) who received penicillin-based antibiotics survived; whereas nine of 11 children (82%) who received anthrax antiserum survived.

Conclusions:

There is a broad spectrum of clinical signs and symptoms associated with pediatric anthrax. The limited data available regarding disease progression and treatment responses for children infected with anthrax suggest some differences from adult populations. Preparedness planning efforts should specifically address the needs of pediatric victims.

During the 2001 US anthrax attacks, mortality from inhalational anthrax was significantly lower than had been reported historically, which was attributed in part to early identification and timely treatment. During future attacks, clinicians will rely on published descriptions of the clinical features of inhalational anthrax to rapidly diagnose patients and institute appropriate treatment. Published descriptions of typical inhalation anthrax usually include patients presenting with cough, dyspnea, or chest pain and found to have abnormal lung examination results with pleural effusions or enlarged mediastinum.

The purpose of this article is to evaluate whether atypical presentations of inhalational anthrax occur and to describe the features of these presentations. We define atypical presentations as those in patients with confirmed anthrax infection who do not have known cutaneous, gastrointestinal, or inhalational ports of entry. We reviewed the case reports of 42 patients with atypical anthrax (published between 1900 and 2004) that may have had an inhalational source of infection to evaluate whether their clinical presentations differed from the typical findings of inhalational anthrax. Patients with atypical anthrax were less likely to have cough, chest pain, or abnormal lung examination results than patients with typical inhalational anthrax (P.05 for all comparisons). A previously published screening protocol for patients with suspected anthrax correctly identified 91% of patients with atypical presentations.

We conclude that although uncommon, atypical presentations of inhalational anthrax likely occur. Timely diagnosis and treatment of patients with inhalational anthrax require clinical awareness of the full spectrum of signs and symptoms associated with inhalational anthrax.

Objective:

To describe an academic medical center's experience with housestaff involvement in the implementation of a new clinical information system, with particular emphasis on resident contributions in tailoring the technology to meet the workflow needs of the center.

Methods:

A resident advisory group was formed to tailor the new system. Housestaff developed user interface screens to streamline presentation of patient data. Order sets were developed, offering an opportunity for education in standardized care and "best practice." A rounds report displays aggregated patient specific data for use in prerounding and rapid assessment of patient information. A sign-out tool was designed to facilitate transfer of information during change of shift.

Results:

Residents contributed in tailoring the technology to meet the workflow needs of our academic medical center setting.

Conclusion:

The design and implementation of a new clinical information system can be used to introduce concepts important in practice-based learning and systems-based practice.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the spring 2006 quarter, includes articles about:

• a study led by CHP/PCOR trainee Hau Liu which found that teriparatide (Forteo) -- the first in a new class of osteoporosis drugs -- is not cost-effective compared with the most commonly prescribed osteoporosis drug, alendronate (Fosamax), due largely to teriparatide's much higher price;
• an update on projects and priorities at CADMA (the Center on Advancing Decision Making in Aging) and CDEHA (the Center on the Demography and Economics of Health and Aging), two multidisciplinary research centers based at CHP/PCOR that support promising early-stage projects on health, economics and aging;
• an April working trip by CHP/PCOR research assistants Meghan Fay and Raina Mahajan, in which they traveled to San Lucas Toliman, Guatemala, with faculty member Paul Wise, assisting him with various medical treatment and health promotion activities in the region; and
• a meta-analysis led by CHP/PCOR trainee Smita Nayak which evaluated the accuracy of an emerging screening test for osteoporosis -- heel ultrasound -- compared with the standard test, known as DXA. The study found that there is not enough evidence to recommend heel ultrasound over DXA as an osteoporosis screening tool.