This article examines the outcome data for very low birth weight infants in low-volume, mid-volume, and high-volume neonatal ICUs (NICUs) and argues for regionalization of NICU services on the basis of both medical outcomes and economic rationality. It recognizes some of the obstacles to regionalization of these services and presents ways to surmount them.

The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac radionuclide imaging (RNI) is frequently considered. This document is a revision of the original Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) Appropriateness Criteria,1 published 4 years earlier, written to reect changes in test utilization and new clinical data, and to clarify RNI use where omissions or lack of clarity existed in the original criteria. This is in keeping with the commitment to revise and rene appropriate use criteria (AUC) on a frequent basis. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Sixty-seven clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate. In general, use of cardiac RNI for diagnosis and risk assessment in intermediate- and high-risk patients with coronary artery disease (CAD) was viewed favorably, while testing in low-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Additionally, use for perioperative testing was found to be inappropriate except for high selected groups of patients. It is anticipated that these results will have a signicant impact on physician decision making, test performance, and reimbursement policy, and will help guide future research.

The patient was a 41 year-old Mexican American women who presented with a decrease in visual acuity along with periorbital and peripheral edema. She was diagnosed with bilateral serous retinal detachment and diffuse proliferative lupus nephritis. She improved considerably in hospital after treatment with corticosteroids.

OBJECTIVE: To examine parent concerns about development, learning, and behavior for young children of Mexican origin, and to identify whether these reports differ by families' citizenship/documentation status.

METHODS: Data come from the 2005 California Health Interview Survey, a population-based random-digit dial telephone survey of California's noninstitutionalized population. California Health Inerview Survey (CHIS) investigators completed interviews of 43 020 households with a total of 5856 children under age 6 years, of whom 1786 were reported being of Mexican origin. Developmental risk was measured by parent concerns elicited by the Parents' Evaluation of Developmental Status. We used bivariate and multivariate analyses to examine associations between developmental risk and family citizenship/documentation status (parents are undocumented, at least one documented noncitizen parent, or both parents are US citizens) among children of Mexican origin and US-born non-Latino white children, after adjusting for age, income, parental education, and predominant household language.

RESULTS: In multivariate analyses, children of Mexican origin did not differ significantly from US-born white children in developmental risk (odds ratio 1.12, 95% confidence interval 0.88-1.42). In subgroup analyses, children of Mexican origin with undocumented parents had higher odds of developmental risk (odds ratio 1.53, 95% confidence interval 1.00-2.33) than non-Latino white children whose parents were citizens, after adjusting for confounders.

CONCLUSIONS: Mexican children with undocumented parents have greater parent-reported developmental risk than Mexican and white children whose parents are US citizens or otherwise legally documented. More research is needed to understand the roles of immigration stress and home environments on the developmental risks of children in households with undocumented parents.

CONTEXT: Allowing nonelectrophysiologists to perform implantable cardioverter-defibrillator (ICD) procedures is controversial. However, it is not known whether outcomes of ICD implantation vary by physician specialty.

OBJECTIVE: To determine the association of implanting physician certification with outcomes following ICD implantation.

DESIGN, SETTING, AND PATIENTS: Retrospective cohort study using cases submitted to the ICD Registry performed between January 2006 and June 2007. Patients were grouped by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists. Hierarchical logistic regression models were developed to determine the independent association of physician certification with outcomes. MAIN OUTCOME MEASURES: In-hospital procedural complication rates and the proportion of patients meeting criteria for a defibrillator with cardiac resynchronization therapy (CRT-D) who received that device.

RESULTS: Of 111,293 ICD implantations included in the analysis, 78,857 (70.9%) were performed by electrophysiologists, 24,399 (21.9%) by nonelectrophysiologist cardiologists, 1862 (1.7%) by thoracic surgeons, and 6175 (5.5%) by other specialists. Compared with patients whose ICD was implanted by electrophysiologists, patients whose ICD was implanted by either nonelectrophysiologist cardiologists or thoracic surgeons were at increased risk of complications in both unadjusted (electrophysiologists, 3.5% [2743/78,857]; nonelectrophysiologist cardiologists, 4.0% [970/24,399]; thoracic surgeons, 5.8% [108/1862]; P < .001) and adjusted analyses (relative risk [RR] for nonelectrophysiologist cardiologists, 1.11 [95% confidence interval {CI}, 1.01-1.21]; RR for thoracic surgeons, 1.44 [95% CI, 1.15-1.79]). Among 35,841 patients who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist in both unadjusted (electrophysiologists, 83.1% [21 303/25,635]; nonelectrophysiologist cardiologists, 75.8% [5950/7849]; thoracic surgeons, 57.8% [269/465]; other specialists, 74.8% [1416/1892]; P < .001) and adjusted analyses (RR for nonelectrophysiologist cardiologists, 0.93 [95% CI, 0.91-0.95]; RR for thoracic surgeons, 0.81 [95% CI, 0.74-0.88]; RR for other specialists, 0.97 [95% CI, 0.94-0.99]).

CONCLUSIONS: In this registry, nonelectrophysiologists implanted 29% of ICDs. Overall, implantations by a nonelectrophysiologist were associated with a higher risk of procedural complications and lower likelihood of receiving a CRT-D device when indicated compared with patients whose ICD was implanted by an electrophysiologist.

There have been many new developments in the broad fields of epidemiology, health services research (HSR), and outcomes research during the past year, many more than can be discussed in detail in this review. We selected articles published since the last article in this series, covering roughly the period April 2007 through March 2008, that examined important issues or advanced research methods in the field.

STUDY DESIGN: Clinical practice guideline.

OBJECTIVE: To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.

SUMMARY OF BACKGROUND DATA: Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain.

METHODS: A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group.

RESULTS: Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations.

CONCLUSION: Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

Background and objectives: Changes in ESRD reimbursement policy, including proposed bundled payment, have raised concern that dialysis facilities may use "cherry picking" practices to attract a healthier, better insured, or more adherent patient population.

Design, setting, participants, & measurements: As part of a national survey to measure beliefs about drivers of quality in dialysis, respondents were asked about their perceptions of cherry picking, including the frequency and effect of various cherry picking strategies on dialysis outcomes. We surveyed a random sample of 250 nurse members of the American Nephrology Nurses Association, 250 nephrologist members of the American Medical Association, 50 key opinion leaders, and 2000 physician members of the Renal Physicians Association. We tested hypothesized predictors of perception, including provider group, region, age, experience, and the main practice facility features.

Results: Three-quarters of respondents reported that cherry picking occurred "sometimes" or "frequently." There were no differences in perceptions by provider or facility characteristics, insurance status, or health status. In multivariable regression, perceived cherry picking was 2.8- and 3.5-fold higher in the northeast and Midwest, respectively, versus the west. Among various cherry picking strategies, having a "low threshold to ‘fire' chronic no-shows/late arrivers," and having a "low threshold to ‘fire' for noncompliance with diet and meds" had the largest perceived association with outcomes.

Conclusions: Under current reimbursement practices, dialysis caregivers perceive that cherry picking is common and important. An improved understanding of cherry picking practices, if evident, may help to protect vulnerable patients if reimbursement practices were to change.

Rationale: Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine. Objectives: To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the VA Health Care System. Methods: We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g. volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1/1/02 and 9/1/05 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and stratified analyses by stage. Measurements and Main Results: Median time to treatment varied widely between (23 to 182 days) and within facilities. Median time to treatment was 90 days in stage I or II patients and 52 days in those with more advanced disease (p<0.0001). Factors associated with shorter times to treatment included a non-academic setting and the existence of a specialized diagnostic clinic (in patients with limited stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained <1% of the observed variation in treatment times. Conclusions: Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.

BACKGROUND:: Hormone replacement therapy (HRT) was widely used among postmenopausal women until 2002 because observational studies suggested that HRT reduced cardiovascular risk. The Womens' Health Initiative randomized trial reported opposite results in 2002, which caused HRT use to drop sharply. OBJECTIVE:: We examine the relationship between HRT use and cardiovascular outcomes (deaths and nonfatal hospitalizations) in the entire US population, which has not been studied in prior clinical trials or observational studies. METHODS:: We use an instrumental variables regression design to analyze the relationship between medication use, cardiovascular risk factors, and acute stroke and myocardial infarction event rates in women aged 40 to 79 years. The natural experiment of the 2002 decline in HRT usage mitigates confounding factors. We use US death records, hospital discharge data obtained from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, and nationally representative surveys of medication usage, and behavioral risk factors. RESULTS:: Decreases in HRT use were not associated with statistically significant changes in hospitalizations or deaths due to acute stroke (0.000002, P = 0.999, 95% CI: -0.0027 to 0.0027). Decreased HRT use was associated with a decrease in the incidence of acute myocardial infarction (-0.0025 or -25 events/10,000 person-years, P = 0.021, 95% CI: -0.0047 to -0.0004). The results were similar in a sensitivity analysis using alternate data sources. CONCLUSIONS:: Decreased HRT use was not associated with reduced acute stroke rate but was associated with a decreased acute myocardial infarction rate among women. Our results suggest that observational data can provide correct inferences on clinical outcomes in the overall population if a suitable natural experiment is identified.