Clostridium difficile infection (CDI) is the leading cause of bacterial infectious diarrhea in nosocomial settings and approximately 25% of patients with CDI experience disease recurrence. Prior CDI epidemiological investigations are limited though. They do not reflect the burden of CDI in federal facilities, nor do they capture recent estimates on patient health outcomes. Furthermore, few studies have integrated CDI recurrence risk factors into a tool that clinicians can use to identify patients at risk for CDI recurrence. This study 1) described the epidemiology of CDI in the national Veterans Health Administration (VHA), 2) derived and validated a clinical prediction rule for 60-day CDI first recurrence, and 3) derived and validated a clinical prediction rule for 60-day CDI second recurrence. This was a retrospective cohort study of VHA beneficiaries with CDI between October 1, 2001 and September 30, 2012. VHA clinical and pharmacy data were integrated to develop several independent variables, including patient baseline demographics, CDI characteristics, comorbidities, concomitant medications, prior medications, prior hospitalization, hospital length of stay (LOS), and CDI severity. The dependent variables included 30/60/90-day mortality, and 30/60/90-day CDI recurrence. CDI incidence and outcomes were presented descriptively and compared using generalized linear regression models. CDI recurrence prediction rules were derived using multivariable logistic regression models and validated using the area under the receiver-operating-characteristic curve (AUROC), sensitivity, specificity, positive predictive value, and negative predictive value. Our study demonstrated that CDI first episodes, recurrences, and severity increased over the study period, while mortality decreased. Our CDI first recurrence prediction rule included the following predictor variables: dyslipidemia, CDI type, renal disease, hospital LOS <7 days, principal CDI diagnosis, concomitant gastric acid suppressors, and concomitant antibiotics. This model demonstrated moderate 60-day first recurrence discrimination (AUROC=0.62). Our CDI second recurrence prediction rule was similar in predictor variables and validity. In conclusion, CDI is an important, rapidly-emerging public health problem in the VHA. A clinical prediction rule might aid clinicians in directing preventative therapies to patients at high risk for CDI recurrence. / text

Current UK abortion law has been subjected to extensive feminist critique because of the relationships that it constructs between healthcare professionals (HCPs) and women with unwanted pregnancies. The law allows HCPs to opt out of abortion provision on the grounds of conscience, implying that it is not something which they have an automatic duty to provide to their patients. It also gives doctors the authority to decide whether an abortion can legally take place, thus suggesting that women’s reproductive decisions should be regulated by medical ‘experts’. However, little is known about how HCPs who are involved in twenty-first century UK abortion provision define their relationships with their patients in practice. My thesis makes an important empirical contribution by responding to this gap in the literature and exploring the subjectivities which these HCPs construct for themselves and their pregnant patients. I address this issue by analysing Scottish HCPs’ interview accounts of their involvement in (or conscientious objection to) abortion provision, using conceptual tools provided by Science and Technology Studies (STS) and feminist theory. I begin by utilising HCPs’ discussions of the practice of ‘conscientious objection’ as a means of exploring how they define the boundaries of their professional responsibilities for abortion provision. I then move on to address HCPs’ accounts of their interactions with women requesting abortion, and analyse how they define legitimate or ‘expert’ knowledge in this context. A key conclusion of the thesis is that HCPs do concede some authority to women with unwanted pregnancies; this is revealed by their reluctance to suggest that they have the right to prevent individual women from accessing abortion. At the same time, I argue that the legitimacy granted to pregnant women by HCPs is limited. My analysis reveals that, in constructing knowledge claims about the use of abortion, HCPs co-produce troubling definitions of femininity, socio-economic class, age and ethnicity. I develop a strong critique of this process, and highlight its potential implications for women’s experiences in the abortion clinic. However, I conclude that this situation cannot be addressed by simply attacking the practices of HCPs as individuals. Rather, it is necessary to understand and critique the limitations of the discursive context in which HCPs are working, because this context shapes the subjectivities available to pregnant women and HCPs.

Background: Leprosy has long been associated with stigma and the disease causes a lot of suffering to those affected, not only physically but also emotionally and psychologically due to the effects of stigma. Aim: To describe the nurse’s experiences of leprosy related stigma in the Central Region of Ghana. Methods: A qualitative interview study with semi-structured interviews. Seven individual interviews were conducted four with nurses working at a hospital, specializing in leprosy care, at in the Central Region of Ghana. The data was analyzed using a content analysis based on Graneheim and Lundmans concept. Results: The nurses described an exclusion affecting leprosy patients because of their disease. Significant factors, such as lack of knowledge and social circumstances, could be linked to leprosy related stigma. Discussions: The result was discussed using Watson's theory of human, referring to eight of her ten carative factors. Three main subjects were identified and discussed related to the result. These were educational factors, social factors and stigmatization.

UK Health policy over the past decade has sought to accelerate established trends of moving services for type 2 diabetes into primary care. This has aimed to make services more accessible and to enable patients to benefit from having their diabetes care incorporated into the “generic and holistic” approach of primary care. However, in 2004 the introduction of a new General Medical Services (nGMS) contract signalled a change in primary care by linking clinical targets to financial rewards on a larger scale than ever before. Diabetes is one of nineteen financially incentivised clinical areas under the nGMS contract (2006). This thesis considers how these health policies may have influenced the organisation and experience of providing and receiving care for type 2 diabetes in Scottish primary care settings. It also aims to bridge two usually separate areas of sociological interest: how health professionals interpret and implement policy, and how patients experience and perceive chronic illness and their health care. A multiple case study approach was employed in order to compare and explore the organisation and experience of type 2 diabetes care associated with three general practices of differing size and location. In each case study a period of non participant observation was undertaken and in-depth interviews conducted with health professionals and their type 2 diabetes patients. Analysis of these data shows that multiple factors influence the way diabetes care is organised and experienced in primary care. I argue that the local context of interpersonal relationships of trust, professional identities and role expectations influence both the organisation of care and the way patients interpret that organisation. Moreover, the meanings patients attribute to the local organisation of diabetes care can inform their perceptions of their condition and influence their desire to be involved in diabetes management.

The use of exercise is a valuable tool in the healthcare management of young patients with chronic chest diseases (CCD). Indeed, exercise testing yields important prognostic data which are a strong predictor of survival. Such information can indicate to the clinician to increase drug therapy treatment, and functional capacity of the patient can be monitored over time with repeated testing. Exercise training has been shown to improve both aerobic and anaerobic fitness and quality of life in patients with lung disease. The use of exercise testing and training in the healthcare of patients with lung disease in the UK, however, has not been investigated. In order for recommendations for exercise testing and training based on scientific evidence to be implemented, they should relate to current standards and resources. Therefore, the first study of the present thesis sought to characterise the use of both exercise testing and training in UK Cystic fibrosis (CF) clinics through a nationwide audit. Data from the audit showed that exercise testing and training are underused despite recognition of the importance of each in the healthcare of the patient by clinicians and other healthcare providers. Indeed, resources for exercise testing in UK CF clinics are limited. A patient over the age of 8 y will only have a 41.1 % chance of receiving an exercise test of any type over a 12 month period, and the exercise test will be quite crude. Exercise training is frequently discussed with the patient; however, there is a strong likelihood (72.9 %) that the advice given will only be general encouragement. The prognostic value of exercise testing is becoming increasingly recognised. Indeed, peak oxygen uptake (VO2peak) derived through maximal cardiopulmonary exercise testing (CPET) has been reported to be equal or superior to that of resting spirometric lung function tests in the prognostic evaluation of patients with CCD. Furthermore, a high correlation between VO2peak and long term survival in both adults and children with CF has been reported. Other physiological data from CPET, such as oxygen uptake (VO2) recovery following CPET, has not been investigated in young patients with CCD and may provide an additional physiological marker of patient health. The aim of study two, therefore, was to investigate recovery following CPET in young patients with CCD, and determine if any significant relationships exist between VO2 recovery and measures of disease severity in these patients. Data from study two showed that young patients with CCD compared to healthy controls had significantly reduced aerobic fitness (t52 = - 2.64, P = 0.011), and the fast component of the VO2 recovery following CPET, analysed by a mono-exponential model, is significantly prolonged (t52 = 2.63, P = 0.011). Furthermore, the fast component of the VO2 recovery is significantly related to disease severity, as assessed by the Shwachman score (SS), in the CF subgroup (r = - 0.75, P < 0.001), and as assessed by forced expiratory volume in 1 s (FEV1), in the young patients with CCD (r = - 0.49, P = 0.009). Thus, indicating that greater disease severity is associated with a longer VO2 recovery following CPET. A significant relationship between VO2peak and VO2 recovery was shown in the young patients with CCD (r = - 0.45, P = 0.018). Although the relationship is significant, however, it is still quite weak, and, therefore, indicates that the VO2 recovery is not closely related to the VO2peak in these patients. Quality of life and likelihood of survival are greater in patients with CCD with higher levels of aerobic fitness, and regular exercise has been shown to improve both lung function and exercise capacity in these patients. Indeed, exercise training programmes tailored to the individual patient are recommended in the standards of patient healthcare in the UK. Whilst the chronic effects of regular exercise have been investigated, the acute physiological responses to exercise training have not been studied in young patients with CCD. In study three young patients with CCD and healthy controls performed intermittent exercise (IE) designed to replicate the typical activity and exercise patterns of young people. Following IE, in the healthy controls the VO2 required to sustain moderate steady-state exercise fell significantly from 3 min to 1 h and 1 h to 24 h, however, in the young patients with CCD VO2 during moderate steady-state exercise increased significantly from 3 min to 1 h and then decreased significantly from 1 h to 24 h (main effect for time: F1.5,79.2 = 22.82, P < 0.001). A significant time × group interaction between young patients with CCD and controls in VO2 during moderate steady-state exercise 3 min, 1 h and 24 h following IE (interaction: F1.5,79.4 = 30.01, P < 0.001) may suggest that metabolic stress is still evident over this time period, which may be indicative of fatigue. Data from the present thesis shows that exercise is underused in UK CF clinics, with the availability of equipment and personnel both being limiting factors. Furthermore, a lack of standardisation in the provision of exercise between clinics is evident. In studies two and three, data shows different physiological responses following CPET and IE, respectively, between children with CCD and controls. The present thesis has advanced our understanding of the provision of exercise in the healthcare of CF in the UK, and furthered knowledge in how young patients with CCD respond physiologically to exercise.

Class of 2010 Abstract / OBJECTIVES: To determine how an interprofessional education (IPE) activity impacts students' attitudes toward interacting with other health professionals. METHODS: Students who are enrolled as first-­‐year students at the University of Arizona College of Pharmacy in the Fall 2009 semester were eligible for this study. Questionnaires administered during regularly scheduled classes collected levels of agreement with statements relating to working with other health professionals and the importance of IPE. Data on gender, years of undergraduate study, current degrees, type of work experience, and years of work experience were also collected. RESULTS: Questionnaires were completed by 93 students before the IPE activity and 66 students after the IPE activity. Overall, attitudes toward interprofessional learning and working with other healthcare professionals, reflected by student questionnaire ratings, were the same or worse after the IPE activity. CONCLUSIONS: Attitudes toward interprofessional learning and working with other healthcare professionals appeared to have no change or changed for the worse after the IPE activity that took place on September 3, 2009.

Class of 2017 Abstract / Objectives: (1) To assess the access to and quality of primary care for patients living with a psychiatric condition(s). (2) To identify demographic factors that may influence the access and quality of primary care services. Methods: Subjects were recruited at HOPE Inc., a behavioral health resource center, in Tucson, Arizona, during pharmacy student-run health fairs. Participants were surveyed using the Primary Care Assessment Tool (PCAT) a questionnaire developed by Johns Hopkins, which assess four domains of primary care. Participants were also surveyed about demographics, mental health diagnosis and their SMI designation. For objective (1): Descriptive statistics for each domain of the PCAT were performed to assess the level of access and quality of care, including comparison to a hypothesized score. For objective (2): Due to the small sample size only descriptive analysis of the demographic data was performed. Results: A total of 11 subjects were surveyed using the PCAT with an average score of 67.64±12.18. This was higher than the hypothesized score of 46. On average, in all four PCAT domains participants scored higher than the hypothesized, value. The lowest scoring domains were, “Care at first contact - Access” and “Coordination of care” (10.45±3.62, Hypothesized score: 8) and (12.36±5.82, Hypothesized score: 10) respectively. The highest scoring domain was “Care at first contact - utilization” (11.09±1.92, Hypothesized score: 12). Conclusions: This study helped to provide a framework for future studies of primary care services using the PCAT survey.

Class of 2017 Abstract / Objectives: To assess access to and quality of primary health care services by individuals receiving meals at a food bank in a rural location using the Primary Care Assessment Tool- Short Form (PCAT-S). Also, to investigate whether individuals with a mental health condition at a rural community food bank receive different care compared to those without a mental health condition. Methods: The PCAT-S, a survey developed by John Hopkins University, was administered to evaluate care at first contact, ongoing care, coordination of care, and comprehensiveness of care. Demographics data (age, gender, health conditions, insurance status, etc.) was also collected. Results: The majority of our participants surveyed lived within an urban zip code (84.8%), had government insurance (81.4%), were male (61.9%), or were Native American (45%). The groups with the highest mean PCAT-S scores were participants with diabetes (mean score= 96.8), participants with no insurance (94.63), and participants who were female (91). The patient populations with the lowest scores were those with less than a high school education (63.11) with serious mental illness (64), or who had bipolar disorder (69). Groups with higher mean PCAT-S scores indicated more involvement with a primary care provider or overall better care within that section of the PCAT-S. Conclusions: Participants with a mental health condition may be receiving less healthcare than those without a mental health condition, especially in the coordination of care between healthcare services, as indicated by lower mean PCAT-S scores. Those living in a rural community, among our population, do not appear to be receiving less healthcare than those in an urban setting.

Background: Diabetes is one of the most common and pernicious chronic illnesses. Guidelines recommend visiting a physician for the secondary prevention of complications. Many risk factors and barriers exist, which hinder healthcare usage. Males are at higher risk for many health issues, including diabetes, yet research shows that women are more likely to receive preventive services. The purpose of this study is to examine whether putative risk factors and barriers to care are diabetes-specific and whether their impact varies by gender. Methods: The Behavioral Risk Factor Surveillance System was used to assess disparities between genders related to diabetes-specific care. In addition, logistic regression was used to determine whether barriers to healthcare, such as education, lack of health insurance, and out-of-pocket-costs, were also diabetes-specific; and did they significantly vary by gender. Results: Analyses demonstrated that males were less likely to visit the physician for their diabetes care. Results indicated that while there were main effects for the additional barriers, they did not vary by gender. Within-groups analyses showed that the odds of not receiving adequate care for those with a lack of insurance were greater for males. Conclusion: Results demonstrated that in many instances, both gender and the chosen barriers increased the odds that individuals would not receive the optimum level of care, although not varying by gender. The lack of an insurance plan was shown to reduce the likelihood that males would receive the appropriate care. These findings potentially aid in the development of more gender-specific interventions and policies.

In this edition, we take a closer look at compliance in the healthcare industry, and focus on questions arising from the fast-growing healthcare compliance system. Our first set of articles explicitly deals with that issue.