Despite recommendations for voluntary HIV screening, few medical centres have implemented screening programmes. The objective of the study was to determine whether an intervention with computer-based reminders and feedback would increase screening for HIV in a Department of Veterans Affairs (VA) health-care system. The design of the study was a randomized controlled trial at five primary care clinics at the VA Palo Alto Health Care System. All primary care providers were eligible to participate in the study. The study intervention was computer-based reminders to either assess HIV risk behaviours or to offer HIV testing; feedback on adherence to reminders was provided. The main outcome measure was the difference in HIV testing rates between intervention and control group providers. The control group providers tested 1.0% (n = 67) and 1.4% (n = 106) of patients in the preintervention and intervention period, respectively; intervention providers tested 1.8% (n = 98) and 1.9% (n = 114), respectively (P = 0.75).In our random sample of 753 untested patients, 204 (27%) had documented risk behaviours. Providers were more likely to adhere to reminders to test rather than with reminders to perform risk assessment (11% versus 5%, P < 0.01). Sixty-one percent of providers felt that lack of time prevented risk assessment. In conclusion, in primary care clinics in our setting, HIV testing rates were low. Providers were unaware of the high rates of risky behaviour in their patient population and perceived important barriers to testing. Low-intensity clinical reminders and feedback did not increase rates of screening.

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.

This issue of CHP/PCOR's Quarterly Update covers news from the Fall 2007 quarter and includes articles about:

• the 2007 Eisenberg Legacy Lecture event, featuring CHP/PCOR core faculty member Victor R. Fuchs;
• annual meeting and conference coverage, including the Society for Medical Decision Meeting's Annual Meeting, and the Freeman Spogli Institute for International Studies conference;
• two Research in Brief selections -- one highlights differences in gender use care in the VA system, and the second examines health risk assessment tools;
• how the Geriatrics Research team at the VA is using informatics to improve quality of health care;
• international health features from the field and from a research perspective;
• a Q & A with senior scholar Dena M. Bravata, who led a popular pedometer that received lots of media attention in past months.

The newsletter also contains various other news items that may be of interest to our readers.

Note to the reader:

The newsletter is fully-navigational. Any text that is surrounded by a dashed box is clickable and will allow the reader to navigate the newsletter more efficiently. The end of each article contains a special symbol (§) that, when clicked, will take the reader back to the table of contents. Please feel free to contact Amber Hsiao with any questions.

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.

Breast cancer is one of the most common causes of death for women in their 40s in the United States. Individualized risk assessment plays an important role when making decisions about screening mammography, especially for women 49 years of age or younger. The purpose of this guideline is to present the available evidence for screening mammography in women 40 to 49 years of age and to increase clinicians' understanding of the benefits and risks of screening mammography.

Summary

Screening mammography probably reduces breast cancer mortality in women 40 to 49 years of age modestly. However, the reduction in this age group is smaller than that in women 50 years of age or older, is subject to greater uncertainty about the exact reduction in risk, and comes with the risk for potential harms (such as false-positive and false-negative results, exposure to radiation, discomfort, and anxiety).

Because of the variation in benefits and harms associated with screening mammography, we recommend tailoring the decision to screen women on the basis of women's concerns about mammography and breast cancer, as well as their risk for breast cancer. Assessment of an individual woman's risk for breast cancer is important because the balance of harms and benefits will shift to net benefit as a woman's baseline risk for breast cancer increases, all other factors being equal. For many women, the potential reduction in risk for death due to breast cancer associated with screening mammography will outweigh other considerations.

Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

Using data from the National Health and Nutrition Examination Survey, we examine the relationship between nutritional status, poverty, and food insecurity for household members of various ages. Our most striking result is that, while poverty is predictive of poor nutrition among preschool children, food insecurity does not provide any additional predictive power for this age group. Among school age children, neither poverty nor food insecurity is associated with nutritional outcomes, while among adults and the elderly, both food insecurity and poverty are predictive. These results suggest that researchers should be cautious about assuming connections between food insecurity and nutritional outcomes, particularly among children.