Objective: Findings from the Women's Health Initiative (WHI) failed to confirm previous expectations about the net benefits of menopausal hormone therapy and have resulted in reduced use of these medications. The aim of this study was to evaluate women's awareness and knowledge concerning the risks and benefits of hormone therapy.

Design: A nationally representative survey was completed for a sample of 781 women (ages 40-60 y, mean 49 y) drawn from the Knowledge Networks Internet panel 24 months after publication of the first WHI findings, in June 2004. Responses were weighted to reflect the demographics of the US population. The main outcome measures were awareness of WHI and knowledge of its findings. An aggregate score was constructed to assess women's knowledge of the impact of hormone therapy on seven key disease outcomes. Logistic regression determined the independent predictors of (1) WHI awareness and (2) a positive aggregate knowledge score, reflecting appropriate responses about risks and benefits.

Results: Only 29% of women were aware of the WHI results. Only 40% of women had a positive aggregate knowledge score. Aside from awareness of WHI and independent of other factors, knowledge scores were lower for African American women (odds ratio, 0.4; 95% CI: 0.2-0.6) and among women with less education (odds ratio, 0.5; 95% CI: 0.3-0.9). Knowledge was greatest for breast cancer and osteoporosis outcomes and most limited for colorectal cancer and memory loss.

Conclusion: Surveyed women had limited awareness and knowledge of the WHI results, suggesting limited diffusion. Targeting younger, less educated, and African American women is warranted.

The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at euro40,975. Autodialysis, at euro49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (euro111,006 and euro75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

Objective: To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes for non-male factor infertility.

Design: We examined the patient characteristics associated with treatment choice-ICSI and conventional in vitro fertilization (IVF)-among patients without a diagnosis of male factor infertility and compared outcomes between the two groups, adjusting for patient characteristics using multivariate regression models.

Setting: Academic fertility center.

Patient(s): We evaluated 696 consecutive assisted reproductive technology (ART) cycles performed for couples with normal semen analysis at the Stanford Reproductive Endocrinology and Infertility Center between 2002 and 2003. We compared patient characteristics, cycle details, and outcomes for ICSI and IVF.

Main Outcome Measure(s): Fertilization, pregnancy, and live birth rates.

Result(s): Patient characteristics were similar between the two groups, except the proportion of patients with unexplained infertility (IVF 15.1% vs. ICSI 23.5%), previous fertility (IVF 62.6% vs. ICSI 45.5%), and previous ART cycle (IVF 41.2% vs. ICSI 67.7%). More oocytes were fertilized per cycle for the IVF group (6.6 oocytes versus 5.1 oocytes). Fertilization failure, pregnancy, and live birth rates did not differ between IVF and ICSI. Using logistic regressions, having had previous ART was found to be positively associated with ICSI. Treatment choice of ICSI was not associated with fertilization, pregnancy, or live birth rates.

Conclusion(s): No clear evidence of improved outcomes with ICSI was demonstrated for non-male factor infertility.

Background: In 2002, the Accreditation Council on Graduate Medical Education enacted regulations, effective 1 July 2003, that limited work hours for all residency programs in the United States.

Objective: To determine whether work-hour regulations were associated with changes in mortality in hospitalized patients.

Design: Comparison of mortality rates in high-risk teaching service patients hospitalized before and after July 2003, with nonteaching service patients used as a control group.

Setting: 551 U.S. community hospitals included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Survey between January 2001 and December 2004.

Patients: 1,511,945 adult patients admitted for 20 medical and 15 surgical diagnoses.

Measurement: Inpatient mortality.

Results: In 1,268,738 medical patients examined, the regulations were associated with a 0.25% reduction in the absolute mortality rate (P = 0.043) and a 3.75% reduction in the relative risk for death. In subgroup analyses, particularly large improvements in mortality were observed among patients admitted for infectious diseases (change, -0.66%; P = 0.007) and in medical patients older than 80 years of age (change, -0.71%; P = 0.005). By contrast, in 243 207 surgical patients, regulations were not associated with statistically significant changes (change, 0.13%; P = 0.54).

Limitations: Teaching status was assigned according to hospital characteristics because direct information on each patient's provider was not available. Results reflect changes associated with the sum of regulations, not specifically with caps on work hours.

Conclusions: The work-hour regulations were associated with decreased short-term mortality among high-risk medical patients in teaching hospitals but were not associated with statistically significant changes among surgical patients in teaching hospitals.

Four related theories about the personal and social resources that shield individuals from developing substance use disorders and foster the process of remission from these disorders are described. These theories are social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. Next, the social processes specified by these theories are highlighted, including the provision of support, goal direction, and monitoring; engagement in rewarding activities other than substance use, exposure to abstinence-oriented norms and models, and attempts to build self-efficacy and coping skills.

Then, a review of the literature considers evidence about the association between the personal and social resources specified by the four theories and remission from substance use disorders. The discussion highlights several issues that need to be addressed to enhance our understanding of the protective resources involved in stable remission, such as how to develop integrated measures of the key resources and specify their associations with substance use outcomes, the extent to which the resources amplify or compensate for the influence of treatment, and how treatment and continuing care can be tailored to strengthen the protective resources that promote remission.

Objectives: The goal of this technical review is to critically examine the issue of care coordination for children with special health care needs (CSHCN). Of particular interest is the knowledge base relating to those aspects of care coordination for CSHCN that are of greatest importance to current practice and policy challenges.

Review Methods: A structured search and review of the literature was conducted to address the following issues:

1. Analytic approaches and definitions used for care coordination strategies for CSHCN.
2. Evidence for best practices of care coordination for CSHCN.
3. Evidence for the impact of managed care for CSHCN enrolled in Medicaid.

Results: Among the principal findings are:

1. Despite considerable progress in defining care coordination and CSHCN, there remains considerable variation in current analytic approaches and definitions.
2. Some progress has been made in developing care coordination strategies for CSHCN.
3. There is a major need to evaluate the impact of these strategies on health outcomes and costs.
4. Continued progress in care coordination for CSHCN may depend upon the replication and evaluation of promising strategies in different practice settings and under different reimbursement policies.
5. The constructive assessment of enhanced care coordination programs in managed care systems would be facilitated by new, more focused metrics and performance measures.
6. There is little evidence regarding the impact of managed care systems on CSHCN enrolled in Medicaid.

Recommendations: Among the principal recommendations are:

1. Increase support for efforts to identify in a standard manner CSHCN in large administrative or clinical datasets.
2. Expand efforts to evaluate care coordination interventions for CSHCN, particularly in managed care settings.
3. Develop capacity and performance standards of direct relevance for CSHCN for managed care plans.
4. Link development of care coordination programs for CSHCN to emerging practice and health system reforms.

Objective: The objectives of this study were to characterize (1) families' cumulative burden of health-related social problems regarding access to health care, housing, food security, income security, and intimate partner violence; (2) families' experiences regarding screening and referral for social problems; and (3) parental acceptability of screening and referral.

Methods: We surveyed 205 parents of children who were 0 to 6 years of age and attended 2 urban pediatric clinics for a well-child visit using a self-administered, computer-based questionnaire. The questionnaire included previously validated questions about health-related social problems and new questions about screening and referral in the past 12 months.

Results: A total of 205 (79%) of 260 eligible families participated. Eighty-two percent of families reported > or = 1 health-related social problem; 54% experienced problems in > or = 2 social domains. Families experienced similar types and frequencies of problems despite demographic differences between clinics. One third of families reported no screening in any domain in the previous 12 months. Of 205 families, 143 (70%) identified at least 1 need for a referral; 101 (49%) expressed > or = 1 unmet referral need. Of families who reported receiving referrals, 115 referrals were received by 79 families; of the referrals made, 63% (73 of 115) led to contact with the referral agency, and 82% (60 of 73) of the referral agencies were considered helpful. A computer-based system in a pediatrician's office for future screening and referral for health-related social problems was deemed acceptable by 92% of parents.

Conclusions: Urban children and families reported a significant burden of health-related social problems yet infrequent pediatric screening or referral for these problems. Of families who reported receiving referrals, a majority contacted the recommended agencies and found them helpful. This study also demonstrates the feasibility of using a computer-based questionnaire to identify health-related social problems in a routine outpatient clinic setting.

This paper describes four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. It then provides an overview of the rationale and evidence for four effective psychosocial treatments for substance use disorders: motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive-behavioral treatment and behavioral family counseling, and contingency management and community reinforcement approaches.

The presumed active ingredients of these treatments are described in terms of how they exemplify the social processes highlighted by the four theories. The identified common components of effective treatment include support, goal direction, and structure; an emphasis on rewards that compete with substance use, a focus on abstinence-oriented norms and models, and attempts to develop self-efficacy and coping skills. Several issues that need to be addressed to enhance our understanding of the active ingredients involved in effective treatment are discussed, including how to develop measures of these ingredients, how well the ingredients predict outcomes and influence conceptually comparable aspects of clients' life contexts, and how much their influence varies depending upon clients' demographic and personal characteristics.