Integrated Behavioral Health Care in Family Medicine Residencies A CERA Survey

BACKGROUND AND OBJECTIVES

Behavioral health integration (BHI) in primary care settings is critical to mental health care in the United States. Family medicine resident experience in BHI in family medicine residency (FMR) continuity clinics is essential preparation for practice. We surveyed FMR program directors to characterize the status of BHI in FMR training.

METHODS

Using the Council of Academic Family Medicine Educational Research Alliance (CERA) 2017 survey, FMR program directors (n=478, 261 respondents, 54.6% response rate) were queried regarding the stage of BHI within the residency family medicine center (FMC), integration activities at the FMC, and the professions of the BH faculty. BHI was characterized by Substance Abuse and Mental Health Services Agency (SAMHSA) designations within FMRs, and chi-square or ANOVA with Tukey honest significant difference (HSD) post hoc testing was used to assess differences in reported BHI attributes.

RESULTS

Program directors reported a high level of BHI in their FMCs (44.1% full integration, 33.7% colocated). Higher levels of BHI were associated with increased use of warm handoffs, same day consultation, shared health records, and the use of behavioral health (BH) professionals for both mental health and medical issues. Family physicians, psychiatrists, and psychologists were most likely to be training residents in BHI.

CONCLUSIONS

Almost half of FMR programs have colocated BH care or fully integrated BH as defined by SAMHSA. Highly integrated FMRs use a diversity of behavioral professionals and activities. Residencies currently at the collaboration stage could increase BH provider types and BHI practices to better prepare residents for practice. Residencies with full BHI may consider focusing on supporting BHI-trained residents transitioning into practice, or disseminating the model in the general primary care community.

Validation of the ANCA-associated vasculitis patient-reported outcomes (AAV-PRO) questionnaire

OBJECTIVES

To finalise and validate a disease-specific patient-reported outcome (PRO) measure: the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire. Using a 35-item candidate questionnaire developed following 50 qualitative interviews in the UK, USA and Canada, a longitudinal survey was conducted to determine the final scale structure and validate the AAV-PRO.

METHODS

Participants were recruited via Vasculitis UK and the Vasculitis Patient-Powered Research Network. The 35-item candidate questionnaire was completed at baseline and 3 months; UK participants completed the EuroQol-5D-5L (EQ-5D-5L), while US participants completed a test-retest exercise, 3-5 days after baseline. Scale structure was defined using exploratory factor analysis (EFA) and Rasch analysis. Convergent and known groups validity, test-retest reliability and longitudinal construct validity were assessed.

RESULTS

There were 626 participants with AAV; >25% reporting 'active disease'. EFA and Rasch analysis supported a 29-item profile measure comprising six domains: 'organ-specific symptoms', 'systemic symptoms', 'treatment side effects', 'social and emotional impact', 'concerns about the future' and 'physical function'. Mean domain scores were higher for participants with 'active disease' versus 'remission' (p<0.001). Construct validity was demonstrated by correlations between domain scores and the EQ-5D-5L (range r=-0.55 to 0.78), all p<0.0001. In participants reporting 'no change' (n=97) during the test-retest, intraclass correlation coefficient values were high (range 0.89-0.96) for each domain.

CONCLUSIONS

The AAV-PRO, a new disease-specific PRO measure for AAV, has good face and construct validity, is reliable, feasible and discriminates among disease states.

A Qualitative Exploration of Co-location as an Intervention to Strengthen Home Visiting Implementation in Addressing Maternal Child Health

Objectives The aim of this paper is to explore the process and impact of co-locating evidence-based maternal and child service models to inform future implementation efforts. Methods As part of a state-wide evaluation of maternal and child home visiting programs, we conducted semi-structured interviews with administrators and home visitors from home visiting agencies across Pennsylvania. We collected 33 interviews from 4 co-located agencies. We used the Consolidated Framework for Implementation Research (CFIR) to describe the key elements mitigating implementation of multiple home visiting models. Results A primary advantage of co-location described by participants was the ability to increase the agency's base of eligible clients through the implementation of a model with different program eligibility (e.g. income, child age) than the existing agency offering. Model differences related to curriculum (e.g. content or intensity/meeting frequency) enabled programs to more selectively match clients to models. To recruit eligible clients, new models were able to build upon the existing service networks of the initial program. Co-location provided organizational opportunities for shared trainings, enabling administrative efficiencies and collaborative staff learning. Programs implemented strategies to build synergies with complementary model features, for instance using the additional program option to serve waitlisted clients and to transition services after one model is completed. Conclusions for Practice Considerable benefits are experienced when home visiting models co-locate. This research builds on literature encouraging collaboration among community agencies and provides insight on a specific facilitative approach. This implementation strategy informs policy across the social services spectrum and competitive funding contexts.

Health-related quality of life in ANCA-associated vasculitis and item generation for a disease-specific patient-reported outcome measure

Objective

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are multisystem diseases of the small blood vessels. Patients experience irreversible damage and psychological effects from AAV and its treatment. An international collaboration was created to investigate the impact of AAV on health-related quality of life (HRQoL), and develop a disease-specific patient-reported outcome measure to assess outcomes of importance to patients.

Methods

Patients with AAV from the UK, USA, and Canada were interviewed to identify salient aspects of HRQoL affected by AAV. The study was overseen by a steering committee including four patient research partners. Purposive sampling of interviewees ensured representation of a range of disease manifestations and demographics. Inductive analysis was used to identify themes of importance to patients; these were further confirmed by a free-listing exercise in the US. Individual themes were recast into candidate items, which were scrutinized by patients, piloted through cognitive interviews and received a linguistic and translatability evaluation.

Results

Fifty interviews, conducted to saturation, with patients from the UK, USA, and Canada, identified 55 individual themes of interest within seven broad domains: general health perceptions, impact on function, psychological perceptions, social perceptions, social contact, social role, and symptoms. Individual themes were constructed into >100 candidate questionnaire items, which were then reduced and refined to 35 candidate items.

Conclusion

This is the largest international qualitative analysis of HRQoL in AAV to date, and the results have underpinned the development of 35 candidate items for a disease-specific, patient-reported outcome questionnaire.

A qualitative study of the experience of lower extremity wounds and amputations among people with diabetes in Philadelphia

The purpose of this study was to explore perceptions among people with type 2 diabetes about foot ulcers and lower extremity amputations. This was a qualitative observational study utilizing open-ended, semistructured interviews of 39 people with diabetes who were purposively selected because they had either a foot ulcer (n = 19) or a lower extremity amputation (n = 20). Interviews were audio-recorded, deidentified, and entered into NVivo 10.0 for coding and analysis. Our integrated analytic approach combined inductively and deductively derived codes that were applied to all transcripts. Coded data were summarized and examined for patterns. Participants' description of the relationship between diabetes and their foot ulcer or amputation revealed a limited understanding of the disease process. Disruption and loss of independence was expressed whether the person had a foot ulcer or an amputation. Treatment recommendations for foot ulcers were viewed by most as extremely difficult. Amputation was a feared outcome, but some learned to adapt and, at times felt that the amputation enhanced their quality of life. Clinicians have assumed that a focus on limb salvage is preferred over a major amputation. However, because of the complexity of care requiring frequent healthcare provider visits, the frequency of care failure, the frequency of recurrence, and mortality associated with having had a foot ulcer, it may be more appropriate for clinicians to prioritize quality-of-life salvage. Foot ulcer treatment failure may be due to a lack of providers' understanding of the impact of treatment on a patient's life.

Patient perceptions of glucocorticoids in anti-neutrophil cytoplasmic antibody-associated vasculitis

Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) are multisystem diseases of small blood vessels, collectively known as the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). This study explores the patient’s perspective on the use of glucocorticoids, which are still a mainstay of treatment in AAV. Patients with AAV from the UK, USA, and Canada were interviewed, using purposive sampling to include a range of disease manifestations and demographics. The project steering committee, including patient partners, designed the interview prompts and cues about AAV, its treatment, and impact on health-related quality of life. Interviews were transcribed and analysed to establish themes grounded in the data. A treatment-related code was used to focus analysis of salient themes related to glucocorticoid therapy. Fifty interviews were conducted. Individual themes related to therapy with glucocorticoids emerged from the data and were analysed. Three overarching themes emerged: (1) Glucocorticoids are effective at the time of diagnosis and during relapse, and withdrawal can potentiate a flare, (2) glucocorticoids are associated with salient emotional, physical, and social effects (depression, anxiety, irritation, weight gain and change in appearance, diabetes mellitus, effect on family and work); and (3) patient perceptions of balancing the risks and benefits of glucocorticoids. Patients identified the positive aspects of treatment with glucocorticoids; they are fast-acting and effective, but, they voiced concerns about adverse effects and the uncertainty of the dose-reduction process. These results may be informative in the development of novel glucocorticoid-sparing regimens.

Development of a Core Set of Outcome Measures for Large-vessel Vasculitis: Report from OMERACT 2016

OBJECTIVE

Among the challenges in conducting clinical trials in large-vessel vasculitis (LVV), including both giant cell arteritis (GCA) and Takayasu arteritis (TA), is the lack of standardized and meaningful outcome measures. The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group initiated an international effort to develop and validate data-driven outcome tools for clinical investigation in LVV.

METHODS

An international Delphi exercise was completed to gather opinions from clinical experts on LVV-related domains considered important to measure in trials. Patient interviews and focus groups were completed to identify outcomes of importance to patients. The results of these activities were presented and discussed in a "Virtual Special Interest Group" using telephone- and Internet-based conferences, discussions through electronic mail, and an in-person session at the 2016 OMERACT meeting. A preliminary core set of domains common for all forms of LVV with disease-specific elements was proposed.

RESULTS

The majority of experts agree with using common outcome measures for GCA and TA, with the option of supplementation with disease-specific items. Following interviews and focus groups, pain, fatigue, and emotional effect emerged as health-related quality of life domains important to patients. Current disease assessment tools, including the Birmingham Vasculitis Activity Score, were found to be inadequate to assess disease activity in GCA and standardized assessment of imaging tests were felt crucial to study LVV, especially TA.

CONCLUSION

Initial data from a clinician Delphi exercise and structured patient interviews have provided themes toward an OMERACT-endorsed core set of domains and outcome measures.

OMERACT Endorsement of Patient-reported Outcome Instruments in Antineutrophil Cytoplasmic Antibody-associated Vasculitis

OBJECTIVE

The antineutrophil cytoplasmic antibody-associated vasculitides (AAV) are multiorgan diseases. Patients with AAV report impairment in their health-related quality of life (HRQOL) and have different priorities regarding disease assessment compared with physicians. The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group previously received endorsement for a core set of domains in AAV. Two approaches to measure patient-reported outcomes (PRO) were presented at OMERACT 2016.

METHODS

A novel 5-step tool was used to facilitate assessment of the instruments by delegates: the OMERACT Filter 2.0 Instrument Selection Algorithm, with a red-amber-green checklist of questions, including (1) good match with domain (face and content validity), (2) feasibility, (3) do numeric scores make sense (construct validity)?, (4) overall ratings of discrimination, and (5) can individual thresholds of meaning be defined? Delegates gave an overall endorsement. Three generic Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (fatigue, physical functioning, and pain interference) and a disease-specific PRO, the AAV-PRO (6 domains related to symptoms and HRQOL), were presented.

RESULTS

OMERACT delegates endorsed the use of the PROMIS instruments for fatigue, physical functioning, and pain interference (87.6% overall endorsement) and the disease-specific AAV-PRO instrument (89.4% overall endorsement).

CONCLUSION

The OMERACT Vasculitis Working Group gained endorsement by OMERACT for use of the PROMIS and the AAV-PRO in clinical trials of vasculitis. These instruments are complementary to each other. The PROMIS and the AAV-PRO need further work to assess their utility in longitudinal settings, including their ability to discriminate between treatments of varying efficacy in the setting of a randomized controlled trial.

Convergence Insufficiency Identifies Athletes at Risk of Prolonged Recovery From Sport-Related Concussion

BACKGROUND

Sensitive and specific screening methods are needed to identify athletes at risk of prolonged recovery after sport-related concussion (SRC). Convergence insufficiency (CI) is a common finding in concussed athletes.

PURPOSE

To assess the relationship between CI and recovery after SRC at the initial office visit.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

In this retrospective cohort study, 270 athletes (147 male, 123 female), mean ± SD age 14.7 ± 2.0 years (range, 10-21 years), with the diagnosis of SRC who presented for initial office visit between January 2014 and January 2016 were evaluated for near point of convergence (NPC). The athletes were categorized into 2 groups: normal near point of convergence (NPC ≤6 cm), and convergence insufficiency (NPC >6 cm). These athletes were then followed to determine recovery time.

RESULTS

Athletes presented for initial office visit at a mean of 5.2 ± 4.2 days (range, 1-21 days) after SRC. Half of the athletes had CI after SRC (50.4%; n = 136). Athletes with CI (NPC 12.3 ± 4.7 cm) took significantly longer to recover after SRC, requiring 51.6 ± 53.9 days, compared with athletes with normal NPC (4.1 ± 1.3 cm), who required 19.2 ± 14.7 days ( P < .001). After controlling for potential confounding variables, CI significantly increased the odds of prolonged recovery (≥28 days from injury) by 12.3-fold ( P < .001; 95% confidence interval, 6.6-23.0). CI screening correctly classified 75.2% of our sample with 84.2% sensitivity and 70.0% specificity. The positive predictive value for CI and prolonged recovery was 62.5%, and the negative predictive value was 88.1%.

CONCLUSION

CI at the initial office visit identified athletes at increased risk of prolonged recovery after SCR. Clinicians should consider measuring NPC in concussed athletes as a quick and inexpensive prognostic screening method.

"In Principle We Have Agreement, But in Practice It Is a Bit More Difficult": Obtaining Organizational Buy-In to Patient-Centered Medical Home Transformation

The patient-centered medical home (PCMH) is a model of care that emphasizes the coordination of patient treatment among health care providers. Practice transformation to this model, however, presents a number of challenges. One of these challenges is getting the buy-in of all personnel to commit to making organizational changes in the journey to becoming a nationally recognized medical home. This study investigated internal messages of buy-in as communicated by practices transitioning to this type of care. Grounding itself in stakeholder theory, this study analyzed interviews with staff, administration, and practitioners from 20 medical practices in a mid-Atlantic state. The analysis revealed three overarching themes: (a) communication among staff that is open, consistent; (b) implementation of reinforcement techniques; and (c) access to a change implementer who encourages successful evolution. Discussion of these themes provides recommendations for communication approaches to organizational buy-in for medical practices hoping to become a PCMH.

Developing a Core Set of Outcome Measures for Behçet Disease: Report from OMERACT 2016

OBJECTIVE

The Outcome Measures in Rheumatology (OMERACT) Vasculitis Working Group has been working toward developing a data-driven core set of outcome measures for use in clinical trials of Behçet's syndrome [Behçet disease (BD)]. This paper summarizes the group's work through OMERACT 2016, discussions during the meeting, and the future research agenda.

METHODS

Qualitative patient interviews were conducted among 20 patients with BD who have different types of organ involvement. A 3-round Delphi among BD experts and patients was initiated to identify domains, subdomains, and outcomes to be assessed in clinical trials of BD. The results of these studies were discussed during OMERACT 2016 and next steps were planned.

RESULTS

Patients' perspectives and priorities were identified through qualitative interviews that identified candidate domains and subdomains for inclusion in the Delphi and characterized some shortcomings of the currently used patient-reported outcomes in BD. The first round of the Delphi was completed and several domains or subdomains were endorsed by the experts and/or the patients. Because many more items were endorsed than would be feasible to assess during a clinical trial, rating and ranking of items by physicians and patients was planned as a next critical step. The challenges of assessing specific organ system involvement was also discussed.

CONCLUSION

The OMERACT Behçet Syndrome Working Group research program will identify core domains for assessment in BD with the goal of developing a core set of outcome measures for use in all trials of BD with the option to incorporate additional outcomes for specific organ involvement.

Experience With Direct-to-Patient Recruitment for Enrollment Into a Clinical Trial in a Rare Disease: A Web-Based Study

Background

The target sample size for clinical trials often necessitates a multicenter (center of excellence, CoE) approach with associated added complexity, cost, and regulatory requirements. Alternative recruitment strategies need to be tested against this standard model.

Objectives

The aim of our study was to test whether a Web-based direct recruitment approach (patient-centric, PC) using social marketing strategies provides a viable option to the CoE recruitment method.

Methods

PC recruitment and Web-based informed consent was compared with CoE recruitment for a randomized controlled trial (RCT) of continuing versus stopping low-dose prednisone for maintenance of remission of patients with granulomatosis with polyangiitis (GPA).

Results

The PC approach was not as successful as the CoE approach. Enrollment of those confirmed eligible by their physician was 10 of 13 (77%) and 49 of 51 (96%) in the PC and CoE arms, respectively (P=.05). The two approaches were not significantly different in terms of eligibility with 34% of potential participants in the CoE found to be ineligible as compared with 22% in the PC arm (P=.11) nor in provider acceptance, 22% versus 26% (P=.78). There was no difference in the understanding of the trial as reflected in the knowledge surveys of individuals in the PC and CoE arms.

Conclusions

PC recruitment was substantially less successful than that achieved by the CoE approach. However, the PC approach was good at confirming eligibility and was as acceptable to providers and as understandable to patients as the CoE approach. The PC approach should be evaluated in other clinical settings to get a better sense of its potential.

Working to define professionalism in pediatric anesthesiology: a qualitative study of domains of the expert pediatric anesthesiologist as valued by interdisciplinary stakeholders

BACKGROUND

Unprofessional behavior is a significant problem throughout graduate medical education programs and medical centers. Some authors have suggested that professionalism curricula should be focused toward faculty, not trainees, to interrupt the modeling of unprofessionalism. Developing such curricula requires a needs assessment and is challenging given data indicating that the definition of professionalism varies based on medical specialty. Thus, a specialty-specific definition of professionalism is needed as a first step in any curriculum development.

AIM

The aim of this study was to define professionalism in pediatric anesthesiology.

METHODS

This is a qualitative study using focus groups for data collection and a grounded theory approach for analysis. Four relevant stakeholder groups, pediatric surgeons and endoscopists, perioperative nurses, pediatric anesthesiologists, and parents of children who had undergone surgery at our facility, were recruited for participation. De-identified transcripts were analyzed and coded to derive major domains and component themes relevant to the definition of professionalism for pediatric anesthesiology. Member checking with participants from our stakeholder groups was used to validate thematic development and increase the trustworthiness of our findings.

RESULTS

Focus group participants included 20 individuals, 14 of whom were female. Analysis of transcripts identified 11 major domains across the four groups: Patient Ownership, Specialty Expertise, Continuous Team Improvement, Expressive Communication, Active Listening, Care Coordination, Medical Hierarchy, Leadership, Teamwork, Personality Traits, and Physical Image. The data uncovered several controversies for future study.

CONCLUSION

A composite of these 11 domains may give a more complete image of what surgical and nursing colleagues, patient families, and anesthesiologist partners expect of the pediatric anesthesiologist. Despite some overlap and interdependence between domains, this research may contribute to the creation of future educational curricula and provides domains for evaluation of professionalism in pediatric anesthesiology.

Implementation of Care Management: An Analysis of Recent AHRQ Research

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Resident Engagement in the Patient-Centered Medical Home

BACKGROUND AND OBJECTIVES

This study's objectives were to assess resident understanding and engagement with the patient-centered medical home (PCMH) model and to assess the impact of participation in a PCMH transformation collaborative on residents' experiences and perceptions related to their training environment.

METHODS

Residents from practices participating in the largest state-wide PCMH learning collaborative were asked to complete surveys describing their experiences with the collaborative and the PCMH transformation process. Residents from four representative participating residencies were recruited to participate in focus groups designed to provide qualitative data to augment our understanding of the quantitative survey results.

RESULTS

We had a reasonable average response rate (39%) with a total of 100 completed resident surveys. Quantitative data illustrated high levels of residents' endorsement of PCMH awareness, engagement, and PCMH-related skills acquisition. The analyses suggested higher levels of PCMH engagement, understanding, and sense of adequacy of preparation among residents who attended learning collaborative sessions compared to those who did not. While qualitative data validated many of the quantitative findings, they also illustrated a somewhat detached and peripheral description of resident experiences with the transformation process.

CONCLUSIONS

The presented data describe the complexities of preparing the next generation of providers for practice. Our mixed-methods study illustrated the strengths of participating in the learning collaborative but also areas of focus necessary for improving the experience and educational benefits of PCMH-related curricula involving residents.

Home visiting and perinatal smoking: a mixed-methods exploration of cessation and harm reduction strategies

Background

Home visiting programs represent an important primary prevention strategy for adverse prenatal health behaviors; the various ways in which home visiting programs impact prenatal smoking cessation and reduction behaviors remain understudied.

Methods

Mixed methods approach using a retrospective cohort of propensity score matched home visiting clients and local-area comparison women with first births between 2008–2014 in a large Northeast state. Multivariable logistic and linear regression estimated third trimester prenatal tobacco smoking cessation and reduction. Additionally, qualitative interviews were conducted with 76 home visiting clients.

Results

A program effect was seen for smoking cessation such that clients who smoked less than ten cigarettes per day and those who smoked 20 or more cigarettes per day during the first trimester were more likely to achieve third trimester cessation than comparison women (p <0.01 and p = 0.01, respectively). Only for heavy smokers (20 or more cigarettes during the first trimester) was there a significant reduction in number of cigarettes smoked by the third trimester versus comparison women (p = 0.01). Clients expressed the difficulty of cessation, but addressed several harm-reduction strategies including reducing smoking in the house and wearing a smoking jacket. Clients also described smoking education that empowered them to ask others to not smoke or adopt other harm reducing behaviors when around their children.

Conclusions

While a significant impact on smoking cessation was seen, this study finds a less-clear impact on smoking reduction among women in home visiting programs. As home visiting programs continue to expand, it will be important to best identify effective ways to support tobacco-related harm reduction within vulnerable families.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3464-4) contains supplementary material, which is available to authorized users.

Baseline Time to Stabilization Identifies Anterior Cruciate Ligament Rupture Risk in Collegiate Athletes

BACKGROUND

There is a need for successful screening methods to identify athletes at increased risk of anterior cruciate ligament (ACL) injury. Previous research showed that collegiate athletes with ACL tears demonstrated slower time to stabilization during jump landing after reconstruction.

HYPOTHESIS

Collegiate athletes with baseline deficiencies in time to stabilization are at increased risk of subsequent ACL rupture.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 278 National Collegiate Athletic Association Division I college athletes (166 men, 112 women; mean age, 18.5 years; height, 178.8 cm; mass, 79.9 kg) in the high-risk sports of men's football; women's volleyball and field hockey; and men's and women's lacrosse, basketball, and soccer were measured to obtain baseline time to stabilization for backward, forward, medial, and lateral single-legged jump landing tasks. Athletes were followed for ACL rupture over a 4-year period. Independent t tests were used to evaluate differences in time to stabilization for each jump landing task between athletes with subsequent ACL rupture and uninjured athletes. Logistic regression models were used to assess time to stabilization as a predictor for ACL rupture.

RESULTS

Nine athletes sustained noncontact ACL ruptures (5 men, 4 women). These 9 athletes took significantly longer to stabilize compared with uninjured athletes during baseline backward jump landing (1.58 ± 0.39 and 1.09 ± 0.52 seconds, respectively; P = .0052). The odds of ACL rupture increased 3-fold (odds ratio, 2.95; 95% CI, 1.28-6.77) for every second increase in backward time to stabilization observed between injured and uninjured athletes.

CONCLUSION

Collegiate athletes with slower baseline backward time to stabilization were at increased risk of ACL rupture.

Stakeholder Perspectives on Changes in Hypertension Care Under the Patient-Centered Medical Home

INTRODUCTION

Hypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control.

METHODS

The PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care.

RESULTS

Clinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care.

CONCLUSION

Practices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.

Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population

Adverse Childhood Experiences (ACEs), which include family dysfunction and community-level stressors, negatively impact the health and well being of children throughout the life course. While several studies have examined the impact of these childhood exposures amongst racially and socially diverse populations, the contribution of ACEs in the persistence of socioeconomic disparities in health is poorly understood. To determine the association between ACEs and health outcomes amongst a sample of adults living in Philadelphia and examine the moderating effect of Socioeconomic Status (SES) on this association, we conducted a cross-sectional survey of 1,784 Philadelphia adults, ages 18 and older, using random digit dialing methodology to assess Conventional ACEs (experiences related to family dysfunction), Expanded ACEs (community-level stressors), and health outcomes. Using weighted, multivariable logistic regression analyses along with SES stratified models, we examined the relationship between ACEs and health outcomes as well as the modifying effect of current SES. High Conventional ACE scores were significantly associated with health risk behaviors, physical and mental illness, while elevated Expanded ACE scores were associated only with substance abuse history and sexually transmitted infections. ACEs did have some differential impacts on health outcomes based on SES. Given the robust impact of Conventional ACEs on health, our results support prior research highlighting the primacy of family relationships on a child's life course trajectory and the importance of interventions designed to support families. Our findings related to the modifying effect of SES may provide additional insight into the complex relationship between poverty and childhood adversity.

Exploration, Development, and Validation of Patient-reported Outcomes in Antineutrophil Cytoplasmic Antibody-associated Vasculitis Using the OMERACT Process

OBJECTIVE

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of linked multisystem life- and organ-threatening diseases. The Outcome Measures in Rheumatology (OMERACT) vasculitis working group has been at the forefront of outcome development in the field and has achieved OMERACT endorsement of a core set of outcomes for AAV. Patients with AAV report as important some manifestations of disease not routinely collected through physician-completed outcome tools; and they rate common manifestations differently from investigators. The core set includes the domain of patient-reported outcomes (PRO). However, PRO currently used in clinical trials of AAV do not fully characterize patients' perspectives on their burden of disease. The OMERACT vasculitis working group is addressing the unmet needs for PRO in AAV.

METHODS

Current activities of the working group include (1) evaluating the feasibility and construct validity of instruments within the PROMIS (Patient-Reported Outcome Measurement Information System) to record components of the disease experience among patients with AAV; (2) creating a disease-specific PRO measure for AAV; and (3) applying The International Classification of Functioning, Disability and Health to examine the scope of outcome measures used in AAV.

RESULTS

The working group has developed a comprehensive research strategy, organized an investigative team, included patient research partners, obtained peer-reviewed funding, and is using a considerable research infrastructure to complete these interrelated projects to develop evidence-based validated outcome instruments that meet the OMERACT filter of truth, discrimination, and feasibility.

CONCLUSION

The OMERACT vasculitis working group is on schedule to achieve its goals of developing validated PRO for use in clinical trials of AAV.

Acute injuries in track and field athletes: a 3-year observational study at the Penn Relays Carnival with epidemiology and medical coverage implications

BACKGROUND

Few studies have examined acute injuries in track and field in both elite and subelite athletes.

PURPOSE

To observe the absolute number and relative rates of injury in track and field athletes across a wide range of competition levels and ages during 3 years of the Penn Relays Carnival to assist with future medical coverage planning and injury prevention strategies.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Over a 3-year period, all injuries treated by the medical staff were recorded on a standardized injury report form. Absolute number of injuries and relative injury rates (number of injuries per 1000 competing athletes) were determined and odds ratios (ORs) of injury rates were calculated between sexes, competition levels, and events. Injuries were also broken down into major or minor medical or orthopaedic injuries.

RESULTS

Throughout the study period, 48,473 competing athletes participated in the Penn Relays Carnival, and 436 injuries were sustained. For medical coverage purposes, the relative rate of injury subtypes was greatest for minor orthopaedic injuries (5.71 injuries per 1000 participants), followed by minor medical injuries (3.42 injuries per 1000 participants), major medical injuries (0.69 injuries per 1000 participants), and major orthopaedic injuries (0.18 injuries per 1000 participants). College/elite athletes displayed the lowest relative injury rate (7.99 injuries per 1000 participants), which was significantly less than that of high school (9.87 injuries per 1000 participants) and masters athletes (16.33 injuries per 1000 participants). Male athletes displayed a greater likelihood of having a minor orthopaedic injury compared with female athletes (OR, 1.36 [95% CI, 1.06-1.75]; χ2 = 5.73; P = .017) but were less likely to sustain a major medical injury (OR, 0.33 [95% CI, 0.15-0.75]; χ2 = 7.75; P = .005). Of the 3 most heavily participated in events, the 4 × 400-m relay displayed the greatest relative injury rate (13.6 injuries per 1000 participants) compared with the 4 × 100-m and 4 × 200-m relays.

CONCLUSION

Medical coverage teams for future large-scale track and field events need to plan for at least 2 major orthopaedic and 7 major medical injuries per 10,000 participants. Male track and field athletes, particularly masters male athletes, are at greater risk of injury compared with other sexes and competition levels.

Trends in violence education in family medicine residency curricula

BACKGROUND AND OBJECTIVES

Violence is a significant public health issue with far-reaching implications for the health of individuals and their communities. Our objective was to describe trends in violence-related training in family medicine residency programs since the last national survey was conducted in 1997.

METHODS

Surveys were sent to 337 US family medicine residency programs with the program director having active Society of Teachers of Family Medicine (STFM) membership. Measures included residency setting and characteristics, violence-related curricular content, teaching techniques and personnel, timing of content, and impact of changes in Residency Review Committee (RRC) and Accreditation Council for Graduate Medical Education (ACGME) requirements. Descriptive statistics and bivariate analyses comparing measures across time were used.

RESULTS

A total of 201 (60%) surveys were completed. The most common violence curricula was child (83%) and elder abuse (76%), and the most common teachers of violence-related content were family physicians, psychologists, and social workers. The most common teaching methods were clinical precepting (94%), lectures (90%), case vignettes (71%), and intimate partner violence (IPV) shelter experiences (67%). ACGME and RRC changes were not reflected in self-reported measures of curricular emphasis or time.

CONCLUSIONS

Violence curricular content and number of hours has been constant in family medicine residencies over time. An increase in the reported use of active learning strategies was identified as a trend across surveys. Next steps for violence curricula involve assessment of residents' competency to identify and intervene in violence.