Community referral for promoting physical activity among primary care patients

Introduction. There is a need for physical activity interventions based in primary care clinics that take advantage of community resources. The purpose of this randomized controlled trial was to compare the effects of two physical activity interventions: (1) physical activity prescription by a primary care provider plus referral to community physical activity resources and (2) physical activity prescription only. ^ Methods. Sedentary adult patients recruited from a general medicine clinic were randomized to receive a physical activity prescription, delivered by the primary care provider, plus referral to community physical activity resources (n=38) or physical activity prescription only (n=32). Outcomes were use of community resources (exercise facility and personal trainers), physical activity levels (self-report questionnaire and pedometer), and attitudes regarding physical activity assessed at 8 weeks. ^ Results. Three of 38 (7.9%) subjects referred to the community resources and none of the 32 subjects in the prescription only group used the community resources during the 8 week trial. Sixteen of 32 subjects in the prescription plus referral group and 19 of 38 in the prescription group completed the self-report follow-up forms at 8 weeks. For minutes of moderate- or vigorous-intensity physical activity per week, there were no between-group differences at baseline, follow-up, or change from baseline to follow-up. However, for moderate- and vigorous-intensity physical activity, there were significant improvements from baseline to follow-up within each group. For attitudes related to physical activity, there were no between-group differences at baseline, follow-up, or change from baseline to follow-up; neither were there any within-group changes. ^ Discussion. Physical activity prescription delivered by a healthcare provider in the context of a routine primary care visit can improve physical activity levels, with no additional improvement gained by referring to community resources. The intervention was feasible for primary care providers to deliver, but only 50% of subjects returned the self-report physical activity questionnaire at the 8 week assessment. ^

Demographics of having a gun in the home in Columbia, SC as reported by women primary care patients

Objectives. To determine demographic correlates of having one or more guns in the household of women primary care patients in the southern USA. ^ Methods. All participants in this cross-sectional study were women aged 18-65 who were insured by either Medicaid or a managed care provider and had ever had an intimate sexual relationship with a male partner that lasted at least three months. Prevalence rate ratios and 95% confidence intervals were calculated using stratified analyses for having a gun in the home and the following demographic factors: age, race, educational attainment, marital status, employment status, and alcohol/drug use. ^ Results. Twenty six percent of households had at least one gun and 6.5% had 3 or more guns. The following demographic characteristics of women were associated with having a gun in the household: age (>40) (prevalence rate ratio [PRR] = 1.4; 95% confidence interval [CI] = 1.1–1.8); White race (PRR = 1.89; 95% CI = 1.61–2.27); currently being employed (PRR = 1.72; 95% CI = 1.22–2.44); higher education; and being insured by an HMO (PRR = 1.92; 95% CI = 1.47–2.50). Neither the partner's unemployment nor his substance use was associated with having a gun. While White households were more likely to have a gun, the same correlates of gun ownership held for both White and African-American households; being married or living as married and higher socio-economic status (i.e. HMO insurance and being employed) were strongly correlated with gun in the household. The following were correlated with having multiple guns in the household: White race (p < 0.0001); increased age (p = 0.005); being currently married or living as married (p < 0.0001); and HMO insured status (p < 0.0001). Among those households with at least one gun, White race and married or currently living as married were associated with having 2 or more guns relative to one gun in the household. ^ Conclusions. Currently living with a man and being of higher socio-economic status were strong correlates of household gun ownership among both Whites and African-Americans. Substance use was not associated with household gun ownership. ^

Hemodynamic changes associated with manual and automated lateral rotation in mechanically ventilated intensive care patients

Objective: To investigate hemodynamic responses to lateral rotation. ^ Design: Time-series within a randomized controlled trial pilot study. ^ Setting: A medical intensive care unit (ICU) and a medical-surgical ICU in two tertiary care hospitals. ^ Patients: Adult patients receiving mechanical ventilation. ^ Interventions: Two-hourly manual or continuous automated lateral rotation. ^ Measurements and Main Results: Heart rate (HR) and arterial pressure were sampled every 6 seconds for > 24 hours, and pulse pressure (PP) was computed. Turn data were obtained from a turning flow sheet (manual turn) or with an angle sensor (automated turn). Within-subject ensemble averages were computed for HR, mean arterial pressure (MAP), and PP across turns. Sixteen patients were randomized to either the manual (n = 8) or automated (n = 8) turn. Three patients did not complete the study due to hemodynamic instability, bed malfunction or extubation, leaving 13 patients (n = 6 manual turn and n = 7 automated turn) for analysis. Seven patients (54%) had an arterial line. Changes in hemodynamic variables were statistically significant increases ( p < .05), but few changes were clinically important, defined as ≥ 10 bpm (HR) or ≥ 10 mmHg (MAP and PP), and were observed only in the manual-turn group. All manual-turn patients had prolonged recovery to baseline in HR, MAP and PP of up to 45 minutes (p ≤ .05). No significant turning-related periodicities were found for HR, MAP, or PP. Cross-correlations between variables showed variable lead-lag relations in both groups. A statistically, but not clinically, significant increase in HR of 3 bpm was found for the manual-turn group in the back compared with the right lateral position ( F = 14.37, df = 1, 11, p = .003). ^ Conclusions: Mechanically ventilated critically ill patients experience modest hemodynamic changes with manual lateral rotation. A clinically inconsequential increase in HR, MAP, and PP may persist for up to 45 minutes. Automated lateral rotation has negligible hemodynamic effects. ^

Patient satisfaction and nursing staff work satisfaction in an urban public teaching hospital

This study examined the level of patient satisfaction and nursing staff work satisfaction at an urban public hospital in the Southwestern United States. The primary objectives of this study were to determine: (1) the level of overall patient satisfaction and satisfaction with specific dimensions of hospital care; (2) the differences in patient satisfaction according to demographic characteristics (age, gender, ethnicity, and education completed) and predispositional factors (perceived health status, perceived level of pain, prior contact with the hospital, and hospital image) and the relative importance of each variable on patient satisfaction; (3) the level of overall work satisfaction and satisfaction with specific dimensions of work experienced by the medical/surgical nursing staff; (4) the differences in work satisfaction experienced by the nursing staff based on demographic variables (age, gender, ethnicity, and marital status) and professional factors (education completed, staff position, the number of years employed with the hospital, and number of years employed in nursing) and the relative importance of each variable on work satisfaction; and (5) to determine the effect of the nursing work milieu on patient and staff satisfaction.^ The study findings showed that patients experienced a moderate to low level of satisfaction with the dimensions of hospital care (admission process, daily care, information, nursing care, physician care, other hospital staff, living arrangements, and overall care). Of the eight dimensions of care, patients reported a relatively positive level of satisfaction (75 percent or better) with only one dimension: physician care. Ethnicity, perceived health status, and hospital image were significantly related to patient satisfaction. Hispanic patients, those who were in good health, and those who felt the hospital had a good image in their community were most satisfied with hospital care. Patients also reported areas of hospital care that needed the most improvement. Responses included: rude staff, better nursing care, and better communication.^ Findings from the nursing satisfaction survey indicated a low level of satisfaction with the dimensions of work (autonomy, pay, professional status, interaction, task requirements, and organizational policies). Only one dimension of work, professional status, received a mean satisfaction score in the positive range. Additionally, staff members were unanimously dissatisfied with their salaries. Frequently mentioned work-related problems reported by the staff included: staffing shortages, heavy patient loads. and excessive paperwork.^ The nursing milieu appeared to have had a significant effect on the satisfaction levels of patients nursing staff employees. The nursing staff were often short staffed, which increased the patient-to-nurse ratio. Consequently, patients did not receive the amount of attention and care they expected from the nursing staff. Crowded patient rooms allowed for little personal space and privacy. Dissatisfaction with living conditions served to influence patients' attitudes and satisfaction levels. These frustrations were often directed toward their primary caregivers, the nursing staff. Consequently, the nursing milieu appeared to directly affect and influence the satisfaction levels of both patients and staff. (Abstract shortened by UMI). ^

The effect of triage team on time-in-department in a pediatric emergency department

Objective. To determine whether the use of a triage team would reduce the average time-in-department in a pediatric emergency department by 25%.^ Methods. A triage team consisting of a physician, a nurse, and a nurse's assistant initiated work-ups and saw patients who required minimal lab work-up and were likely to be discharged. Study days were randomized. Our inclusion criteria were all children seen in the emergency center between 6p and 2a Monday-Friday. Our exclusion criteria included resuscitations, inpatient-inpatient transfers, left without being seen, leaving against medical advice, any child seen outside of 6p-2am Monday-Friday and on the weekends. A Pearson-Chi square was used for comparison of the two groups for heterogeneity. For the time-in-department analysis, we performed a 2 sided t-test with a set alpha of 0.05 using Mann Whitney U looking for differences in time-in-department based on acuity level, disposition, and acuity level stratified by disposition. ^ Results. Among urgent and non-urgent patients, we found a statistically significant decrease in time-in-department in a pediatric emergency department. Urgent patients had a time-in-department that was 51 minutes shorter than patients seen on non-triage team days (p=0.007), which represents a 14% decrease in time-in-department. Non-urgent patients seen on triage team days had a time-in-department that was 24 minutes shorter than non-urgent patients seen on non-triage team days (p=0.009). From the disposition perspective, discharged patients seen on triage team days had a shorter time-in-department of 28 minutes as compared to those seen on non-triage team days (p=0.012). ^ Conclusion. Overall, there was a trend towards decreased time-in-department of 19 minutes (5.9% decrease) during triage team times. There was a statistically significant decrease in the time-in-department among urgent patients of 51 minutes (13.9% decrease) and among discharged patients of 28 minutes (8.4% decrease). Urgent care patients make up nearly a quarter of the emergency patient population and decreasing their time-in-department would likely make a significant impact on overall emergency flow.^

The effects of obesity in critical illness

Obesity continues to cripple the United States in terms of increasing health care expenditures and its rising rate of prevalence in epidemic proportions. The comorbidities associated with obesity have continued to represent some of the most deadly chronic health diseases. The most vulnerable subpopulation, the critically ill, suffers from not only the comorbid conditions but also the complications encountered within their specialized care. Taking into account the rising prevalence rates of obesity and critical care patients, it has come to the attention of many researchers to measure the trends associated with these two health conditions. Hospital mortality was found to be lower in higher BMI groups whereas there was no difference between BMI groups for ICU mortality. Length of stay and mechanical ventilation were both higher for obese rather than non-obese patients. The most prevalent disease states among the obese critically injured was cardiovascular and pulmonary disease. In conclusion, obesity is not independently associated with increased ICU mortality, but the comorbidities linked to obesity prove a greater threat to vitality.^

A study of nurses' perceptions of and participation in the resolution of treatment dilemmas for critically ill newborns

This study was an exploratory investigation of variables which are associated with neonatal intensive care nurses' perceptions of and participation in life-sustaining treatment decisions for critically ill newborns. The primary purpose of the research was to examine the extent to which assessment of infants' physical and mental prognoses, parents' preferences regarding treatment, and legal consequences of non-treatment influence nurses' recommendations about life-saving treatment decisions for handicapped newborns. Secondly, the research explored the extent and nature of nurses' reported participation in the resolution of treatment dilemmas for these critically ill newborns. The framework of the study draws upon the work of Crane (1977), Blum (1980), and Pearlman (1982) who have explored the sociological context of decision-making with critical care patients.^ Participants in the study were a volunteer sample of eighty-three registered nurses who were currently working in neonatal intensive care units in five large urban hospitals in Texas. Data were collected through the use of intensive interviews and case study questionnaires. Results from the study indicate that physical and mental prognoses as well as parent preferences and concerns about legal liability are related to nurses' treatment recommendations, but their levels of significance vary according to the type of handicapping condition and whether the treatment questions are posed in terms of initiating aggressive therapy or withdrawing aggressive therapy.^ The majority of nurses reported that the extent of their participation in formal decision-making regarding handicapped newborns was fairly minimal although they provide much of the definitive data used to make decisions by physicians and parents. There was substantial evidence that nurse respondents perceive their primary role as advocates for critically ill newborns, and believe that their involvement in the resolution of treatment dilemmas should be increased. ^

Comparison of cost and outcome of care in patients with low back pain who are managed by physicians or physical therapists in private practice

The purpose of this study was to determine if there were differences in the cost and outcome of care in patients with low back pain who were managed by physicians or physical therapists in private practice in the state of Arizona. A secondary purpose was to describe the current status of private practice physical therapy clinicians who treat patients with low back pain.^ A Survey on Practice was mailed to 194 physical therapists who were listed by the American Physical Therapy Association as being in private practice in Arizona. Eighty-three percent of the surveys were returned after three attempts. Of those which were returned, 72 were complete and included in the analysis.^ The 72 practices were screened to determine those eligible for the second phase of the study. Those eligible for the second phase numbered 52 clinics. Twenty-six practices agreed to participate; however, only 21 did participate. Clinics which participated were sent packets of information which were to be kept on each patient seen with a complaint of low back pain during a three month period. Packets contained a patient-oriented survey on functional activity to be completed before and after the physical therapy course of treatment, as well as a log which was completed by the physical therapist on the type of care given to the patient and an assessment of the outcome of treatment. The patient was asked to fill out a satisfaction survey relative to the care received from the physical therapist and physician, if applicable.^ Although 259 patients were entered into the study, 210 patient logs were available for analysis. Results indicated that generally, there was no difference in cost or outcome as measured by the final functional score, change between the initial and final functional scores, or the therapist-rated outcome between the patients who were managed by physicians or physical therapists when controlling for age and length of time the patient was experiencing pain. Patients were more satisfied with care received from physical therapists as compared to physicians. Age and length of pain were good predictors of the type of referral patients received according to a logistic regression procedure. The initial disability score (IRS) and the time spent in the facility predicted therapist-rated outcome, a good or poor final disability score (FRS), and a good or poor change score. In addition, age predicted FRS and change scores. The time that the therapist spent in direct contact with the patient also predicted the change score.^ These findings of no difference in the cost and outcome of care were discussed as they relate to the practice of medicine and physical therapy. ^

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

Quality of care for uninsured type 2 diabetic patients in a financial assistance medical home model

The medically uninsured population in the United States is 16% or 42 million people and consists of a significant number of Type 2 diabetic patients which is the predominant form of diabetes with 798,000 new cases diagnosed each year. There is limited health services research on uninsured populations concerning health system measures or specific disease conditions. ^ The purpose of this investigation was to determine the impact a newly implemented health care program had on the quality of care provided to patients with Type 2 diabetes. The primary study objective was to compare the quality of care while controlling for utilization, and health status of patients in the new program to their status during the previous financial assistance program. The research design was a retrospective matched-pairs design. The study population consisted of 225 patients who received medical care during 1996 and 1997 at the University Health System in San Antonio, Texas. ^ Six quality of care measures individually failed to demonstrate a statistically significant difference when compared between the two periods. However, an index measure reflecting the number of patients who received all six of the quality of care measures demonstrated a statistically significant increase in 1997 (p-value < 0.05). In 1996, 8 patients (2.6%) received all six medical management components. In 1997, 38 patients (16.8%) received all six medical management components. Four regression models were analyzed; two out of the four models demonstrated inconsistent results based on the program membership variable. ^ It is concluded that there has been a small effect of the Carelink program demonstrated by an increase from 8 to 38 patients receiving all quality of care components for Type 2 diabetics at the UHS. It is recommended that additional research be conducted in order to evaluate the quality of care provided to Type 2 diabetic patients. ^

Prevalence and risk factors of methicillin-resistant Staphylococcus aureus in critically-ill hospitalized patients in a tertiary care center in Houston, Texas: An active surveillance pilot project

Objective. The objective of this study is to determine the prevalence of MRSA colonization in adult patients admitted to intensive care units at an urban tertiary care hospital in Houston, Texas and to evaluate the risk factors associated with colonization during a three month active-screening pilot project. Design. This study used secondary data from a small cross-sectional pilot project. Methods. All patients admitted to the seven specialty ICUs were screened for MRSA by nasal culture. Results were obtained utilizing the BD GeneOhm™ IDI-MRSA assay in vitro diagnostic test, for rapid MRSA detection. Statistical analysis was performed using the STATA 10, Epi Info, and JavaStat. Results . 1283/1531 (83.4%) adult ICU admissions were screened for nasal MRSA colonization. Of those screened, demographic and risk factor data was available for 1260/1283 (98.2%). Unresolved results were obtained for 73 patients. Therefore, a total of 1187/1531 (77.5%) of all ICU admissions during the three month study period are described in this analysis. Risk factors associated with colonization included the following: hospitalization within the last six months (odds ratio 2.48 [95% CI, 1.70-3.63], p=0.000), hospitalization within the last 12 months, (odds ratio 2.27 [95% CI, 1.57-3.80], p=0.000), and having diabetes mellitus (odds ratio 1.63 [95% CI, 1.14-2.32], p=0.007). Conclusion. Based on the literature, the prevalence of MRSA for this population is typical of other prevalence studies conducted in the United States and coincides with the continual increasing trend of MRSA colonization. Significant risk factors were similar to those found in previous studies. Overall, the active surveillance screening pilot project has provided valuable information on a population not widely addressed. These findings can aid in future interventions for the education, control, prevention, and treatment of MRSA. ^

An analysis of the effects of a peer mentor program and other factors on HIV patients' retention in care and clinical outcomes at Thomas Street Health Clinic, Houston Texas

Research examining programs designed to retain patients in health care focus on repeated interactions between outreach workers and patients (Bradford et al. 2007; Cheever 2007). The purpose of this study was to determine if patients who are peer-mentored at their intake exam remain in care longer and attend more physicians' visits than those who were not mentored. Using patients' medical records and a previously created mentor database, the study determined how many patients attended their intake visit but subsequently failed to establish regular care. The cohort study examined risk factors for establishing care, determined if patients lacking a peer mentor failed to establish care more than peer mentor assisted patients, and subsequently if peer mentored patients had better health outcomes. The sample consists of 1639 patients who were entered into the Thomas Street Patient Mentor Database between May 2005 and June 2007. The assignment to the mentored group was haphazardly conducted based on mentor availability. The data from the Mentor Database was then analyzed using descriptive statistical software (SPSS version 15; SPSS Inc., Chicago, Illinois, USA). Results indicated that patients who had a mentor at intake were more likely to return for primary care HIV visits at 90 and 180 days. Mentored patients also were more likely to be prescribed ART within 180 days from intake. Other risk factors that impacted remaining in care included gender, previous care status, time from diagnosis to intake visit, and intravenous drug use. Clinical health outcomes did not differ significantly between groups. This supports that mentoring did improve outcomes. Continuing to use peer-mentoring programs for HIV care may help in increasing retention of patients in care and improving patients' health in a cost effective manner. Future research on the effects of peer mentoring on mentors, and effects of concordance of mentor and patient demographics may help to further improve peer-mentoring programs. ^

Understanding causes of hospitalization and access to care among newly diagnosed HIV patients in Houston, TX

More than a quarter of patients with HIV in the United States are diagnosed in hospital settings most often with advanced HIV related conditions.(1) There has been little research done on the causes of hospitalization when the patients are first diagnosed with HIV. The aim of this study was to determine if the patients are hospitalized due to an HIV related cause or due to some other co-morbidity. Reduced access to care could be one possible reason why patients are diagnosed late in the course of the disease. This study compared the access to care of patients diagnosed with HIV in hospital and outpatient setting. The data used for the study was a part of the ongoing study “Attitudes and Beliefs and Steps of HIV Care”. The participants in the study were newly diagnosed with HIV and recruited from both inpatient and outpatient settings. The primary and the secondary diagnoses from hospital discharge reports were extracted and a primary reason for hospitalization was ascertained. These were classified as HIV-related, other infectious causes, non–infectious causes, other systemic causes, and miscellaneous causes. Access to care was determined by a score based on responses to a set of questions derived from the HIV Cost and Services Utilization Study (HCSUS) on a 6 point scale. The mean score of the hospitalized patients and mean score of the patients diagnosed in an outpatient setting was compared. We used multiple linear regressions to compare mean differences in the two groups after adjusting for age, sex, race, household income educational level and health insurance at the time of diagnosis. There were 185 participants in the study, including 78 who were diagnosed in hospital settings and 107 who were diagnosed in outpatient settings. We found that HIV-related conditions were the leading cause of hospitalization, accounting for 60% of admissions, followed by non-infectious causes (20%) and then other infectious causes (17%). The inpatient diagnosed group did not have greater perceived access-to-care as compared to the outpatient group. Regression analysis demonstrated a statistically significant improvement in access-to-care with advancing education level (p=0.04) and with better health insurance (p=0.004). HIV-related causes account for many hospitalizations when patients are first diagnosed with HIV. Many of these HIV-related hospitalizations could have been prevented if patients were diagnosed early and linked to medical care. Programs to increase HIV awareness need to be an integral part of activities aimed at control of spread of HIV in the community. Routine testing for HIV infection to promote early HIV diagnosis can prevent significant morbidity and mortality.^

Comparison of medical care costs, utilization, and satisfaction of AIDS patients with and without home care

A sample of 157 AIDS patients 17 years of age or over were followed for six months from the date of hospital discharge to derive average total cost of medical care, utilization and satisfaction with care. Those referred for home care follow-up after discharge from the hospital were compared with those who did not receive home care.^ The average total cost of medical care for all patients was $34,984. Home care patient costs averaged \$29,614 while patients with no home care averaged $37,091. Private hospital patients had average costs of \$50,650 compared with $25,494 for public hospital patients. Hospital days for the six months period averaged 23.9 per patient for the no home care group and 18.5 days for home care group. Patient satisfaction with care was higher in the home care group than no home care group, with a mean score of 68.2 compared with 61.1.^ Other health services information indicated that 98% of the private hospital patients had insurance while only 2% of public hospital patients had coverage. The time between the initial date of diagnosis with AIDS and admission to the study was longer for private hospital patients, survival time over the study period was shorter, and the number of hospitalizations prior to entering the study was higher for private hospital patients. These results suggest that patients treated in the private hospital were sicker than public hospital patients, which may explain their higher average total cost. Statistical analyses showed that cost and utilization have no significant relationship with home care or no home care when controlling for indicators of the severity of illness and treatment in public or private hospital.^ In future studies, selecting a matched group of patients from the same hospital and following them for nine months to one year would be helpful in making a more realistic comparison of the cost effectiveness of home care. ^

Comparison of clinical and economic outcomes between high-intensity care and hospice care for the end-of-life melanoma patients

The intensity of care for patients at the end-of-life is increasing in recent years. Publications have focused on intensity of care for many cancers, but none on melanoma patients. Substantial gaps exist in knowledge about intensive care and its alternative, hospice care, among the advanced melanoma patients at the end of life. End-of-life care may be used in quite different patterns and induce both intended and unintended clinical and economic consequences. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases to identify patients aged 65 years or older with metastatic melanoma who died between 2000 and 2007. We evaluated trends and associations between sociodemographic and health services characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy and costs. Survival, end-of-life costs, and incremental cost-effectiveness ratio were evaluated using propensity score methods. Costs were analyzed from the perspective of Medicare in 2009 dollars. In the first journal Article we found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), no significant fluctuation in use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P =0.07 for trend). Enrollment in short-term (1-3 days) hospice care use increased, while long-term hospice care (≥ 4 days) remained stable. Patients living in the SEER Northeast and South regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery and radiation therapy. In the second journal article, of 611 patients identified for this study, 358 (59%) received no hospice care after their diagnosis, 168 (27%) received 1 to 3 days of hospice care, and 85 (14%) received 4 or more days of hospice care. The median survival time was 181 days for patients with no hospice care, 196 days for patients enrolled in hospice for 1 to 3 days, and 300 days for patients enrolled for 4 or more days (log-rank test, P < 0.001). The estimated hazard ratios (HR) between 4 or more days hospice use and survival were similar within the original cohort Cox proportional hazard model (HR, 0.62; 95% CI, 0.49-0.78, P < 0.0001) and the propensity score-matched model (HR, 0.61; 95% CI, 0.47-0.78, P = 0.0001). Patients with ≥ 4 days of hospice care incurred lower end-of-life costs than the other two groups ($14,298 versus $19,380 for the 1- to 3-days hospice care, and $24,351 for patients with no hospice care; p < 0.0001). In conclusion, Surgery and hospice care use increased over the years of this study while the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma. Patients diagnosed with advanced melanoma who enrolled in ≥ 4 days of hospice care experienced longer survival than those who had 1-3 days of hospice or no hospice care, and this longer overall survival was accompanied by lower end-of-life costs.^