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Cheryl Modica,1 Joy H Lewis,2 R Curtis Bay3 1National Association of Community Health Centers, Bethesda, MD, USA; 2Department of Medicine and Public Health, A.T. Still University, School of Osteopathic Medicine, Mesa, AZ, USA; 3Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USACorrespondence: Cheryl Modica, National Association of Community Health Centers, Inc, 7501 Wisconsin Avenue, Suite 1100W, Bethesda, MD, 20814, USA, Tel +1 301 310 2250, Email cmodica@nachc.orgIntroduction: Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers.Objective: This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures.Methods: A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared.Results: A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p< 0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p< 0.001).Conclusion: Health centers applying the Value Transformation Framework’s organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.Plain Language Summary: The Value Transformation Framework (VTF) was designed by the lead author to serve as an organizing framework for health center systems change and advancement toward the Quintuple Aim: improved health outcomes, improved patient experiences, improved staff experiences, reduced costs, and equity. When applied in the health care setting, the VTF translates research, evidence-based solutions, and promising practices into clear and practical steps that health centers can use to achieve value-driven care. In this paper, the authors report on results from a study where the VTF’s organizing approach was combined with evidence-based virtual care models supported by patient self-care tools, technology, and education with improvements seen in measures for colorectal cancer screening, hypertension control, diabetes control, weight, patient reported depression, and patient experience. The action steps taken by health centers participating in this quality improvement project can be replicated by other health centers.The impact of colon cancer, hypertension, diabetes, obesity, and depression, particularly among health center patients, is substantial. Identifying strategies to change health center systems in ways that improve performance is critically important. The authors demonstrated that implementing the VTF can provide health centers with a practical and actionable approach to health center systems change to achieve significant improvements in clinical measurements, patient-reported depression, and patient experience with care.Keywords: vulnerable populations, colorectal cancer screening, hemoglobin A1c, obesity, depression, patient experience

Kate Whelihan,1 Cheryl Modica,2 R Curtis Bay,3 Joy H Lewis1 1Department of Public Health, A.T. Still University of Health Sciences, School of Osteopathic Medicine in Arizona, Mesa, AZ, USA; 2Quality Center, National Association of Community Health Centers, Bethesda, MD, USA; 3Department of Interdisciplinary Health Sciences, A.T. Still University of Health Sciences, Arizona School of Health Sciences, Mesa, AZ, USACorrespondence: Joy H Lewis, 5850 E. Still Circle, Mesa, AZ, 85206, USA, Tel + 1 480 219 6000, Fax + 1 480 389 3661, Email JHLewis@atsu.eduIntroduction: Patient satisfaction and experience are important measures of overall quality of care. In 2017, the National Association of Community Health Centers (NACHC) launched an initiative to facilitate changes across organizational systems within Federally Qualified Health Centers (FQHCs) with the goal of improving value-driven care.Methods: NACHC worked with eight health centers, four in Georgia and four in Iowa, along with their state Primary Care Associations, to apply the Value Transformation Framework (VTF). This framework distills evidence-based practices into practical knowledge for goal-driven systems change. It provides actionable steps to help health centers reach value-driven goals of improved health outcomes, improved patient and staff experience, reduced costs, and improved equity (referred to as the Quintuple Aim goals). This paper reports on the patient and staff experience when applying VTF systems changes to improve colorectal cancer screening rates.Results: Patient and staff satisfaction and experience remained highly rated even after extensive organizational changes were implemented as part of this project. Implementation of a systems-approach to organizational change, through application of the VTF, did not negatively impact patient or staff experiences.Conclusion: Patient and staff satisfaction and experience were positive despite the application of the VTF and systems-wide organizational changes. These experience results were alongside improved cancer screening rates, as observed from full project results. Investigators are encouraged that the application of systems change using the VTF may result in the achievement of Quintuple Aim goals without disrupting the experience of patients and staff. Investigators recommend continued exploration of this transformation approach.Keywords: Quadruple Aim, Quintuple Aim, healthcare experience, cancer screening, primary care, prevention, community health

Cheryl Modica,1 Joy H Lewis,2 R Curtis Bay3 1National Association of Community Health Centers, Bethesda, MD, USA; 2Medicine and Public Health, SOMA Department of Public Health, School of Osteopathic Medicine in Arizona, A.T. Still University, Meza, AZ, USA; 3Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USACorrespondence: Cheryl ModicaNational Association of Community Health Centers, Inc., 7501 Wisconsin Avenue, Suite 1100W, Bethesda, MD, 20814, USATel +1 301 310 2250Email cmodica@nachc.orgIntroduction: Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications.Objective: By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers’ infrastructure, people systems and care delivery systems.Methods: Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project.Results: During the one-year intervention (January 2017–December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7– 70.4%) in January to 27.5% (range, 13.6– 37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level.Conclusion: A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.Keywords: vulnerable populations, hemoglobin A1c, quality improvement, health systems, interdisciplinary care

OBJECTIVE: To evaluate the concussion history of young athletes using three questions on the preparticipation screening (PPS) and a concussion symptom survey (CSS). DESIGN: Descriptive survey. SETTING: Mass high school PPS. PATIENTS OR OTHER PARTICIPANTS: Five hundred twenty young athletes. INTERVENTIONS: Athletes were asked about their concussion history using three different questions on the PPS. The CSS, a list of concussion-related symptoms, was also given to assess the history of concussion-related symptoms associated with a previous injury to the head. MAIN OUTCOME MEASURES: Positive concussion history was determined as a positive response on one of the three PPS questions or any one of the CSS responses and reported as frequencies and percentages. Kappa coefficients were used to evaluate the agreement between the responses on the three PPS questions. RESULTS: There was little agreement among the three PPS questions, with kappa coefficients ranging from kappa = -0.018 to 0.342. Analysis of the CSS revealed that 286 athletes (55.0%) reported having at least one concussion symptom after a head injury. Of those reporting symptoms, 86.4% did not report a concussion history in sport, and 92.7% did not report a concussion history in recreational activities. CONCLUSIONS: The identification of concussion history may depend on the phrasing of questions on the PPS. Simply asking an athlete whether they had a concussion may not adequately identify athletes with concussion histories. Although recommendations have been made to avoid the terminology of ding and bell rung, it seems these terms may be needed to ensure adequate reporting of previous concussions in young athletes. [ABSTRACT FROM AUTHOR]

Little research has been done into the concurrent use by different ethnic groups of alternative and conventional medicine, including the use of alternative medicine modalities by Hispanic and Anglo patients. A cross-sectional survey was conducted of 516 low-income Hispanic and Anglo patients at eight community-based family practice clinics located in low-income, ethnically diverse areas of greater Phoenix, Arizona. A related questionnaire examined the awareness of and attitudes about alternative medicine use by the patients' physicians. In different ways, most of the Anglo and Hispanic patients are using alternative medicine concurrently. This suggests the possibility that conventional medicine is not meeting their health care needs. Differences between Anglo and Hispanic patients in the use of alternative practitioners and therapies were identified. The findings indicated a frequent lack of communication between physicians and their patients regarding alternative medicine use among both Hispanics and Anglos. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To provide an overview of clinical outcomes assessment, discuss the classification of outcomes measures, present considerations for choosing outcomes scales, identify the importance of assessing clinical outcomes, and describe the critical link between the utilization of disablement models and clinical outcomes assessment. BACKGROUND: Clinical outcomes are the end result of health care services. Clinical outcomes assessment is based on the conceptual framework of disablement models and serves as the measurement method for the collection of patient-oriented evidence, a concept central to evidence-based practice. DESCRIPTION: Clinical outcomes management refers to the use of outcomes measures in the course of routine clinical care and provides athletic trainers with a mechanism to assess treatment progress and to measure the end results of the services they provide. Outcomes measures can be classified as either clinician based or patient based. Clinician-based measures, such as range of motion and strength, are taken directly by clinicians. Patient-based measures solicit a patient's perception as to health status in the form of questionnaires and survey scales. Clinician-based measures may assist with patient evaluation, but patient-based measures should always be included in clinical assessment to identify what is important to the patient. CLINICAL AND RESEARCH ADVANTAGES: Evidence-based athletic training practice depends on clinical outcomes research to provide the foundation of patient-oriented evidence. The widespread use of clinical outcomes assessment, based on the disablement model framework, will be necessary for athletic trainers to demonstrate the effectiveness of therapies and interventions, the provision of patient-centered care, and the development of evidence-based practice guidelines. [ABSTRACT FROM AUTHOR]

Context: The Single Assessment Numeric Evaluation (SANE) is a widely used patient-reported outcome (PRO) measure that provides an efficient but limited view of patient perceptions of health. Knowledge of what throwing athletes with upper extremity injury consider when answering the SANE would inform score interpretation and increase its value for clinical decision-making in this patient population., Objective: To investigate the global rating of the SANE and its ability to capture constructs of health reflected in PRO measures that are commonly used in throwing athletes with upper extremity sport-related injury., Design: Cross-sectional study., Setting: Retrospective database review., Patients or Other Participants: De-identified patient records of baseball and softball athletes diagnosed with upper extremity sport-related injury between October 2009 and June 2021 were reviewed., Main Outcome Measure(s): Primary outcomes were scores on the SANE; Functional Arm Scale for Throwers total; Disabilities of the Arm, Shoulder, and Hand total; and Global Rating of Daily Activities. The first administration of all PROs that patients completed postinjury was analyzed as a potential predictor of SANE scores. The proportion of variance uniquely accounted for in the SANE by each predictor (R2) variable was estimated., Results: Fifty-five patients completed PRO measures. The Functional Arm Scale for Throwers total uniquely accounted for 32.9% (P < .001), the Global Rating of Daily Activities uniquely accounted for 11.6% (P < .001), and the Disabilities of the Arm, Shoulder, and Hand total uniquely accounted for 4.6% (P = .036) of the variance in the SANE score. Overall, the predictors accounted for 49.2% of the variance in the SANE score (P < .001)., Conclusions: Given that the SANE captures multiple constructs of health, it may be useful in gathering a quick, broad view of throwing athletes' perception of their health. When SANE scores suggest diminished health, then multi-item PROs should be considered to further explore constructs of health most affected., (© by the National Athletic Trainers' Association, Inc.)

Context: Athletic trainers (ATs) have reported the need for more educational resources about clinical documentation., Objective: To investigate the effectiveness of passive and active educational interventions to improve practicing ATs' clinical documentation knowledge., Design: Randomized controlled trial, sequential explanatory mixed methods study., Setting: Online module(s), knowledge assessment, and interviews., Patients or Other Participants: We emailed 18 981 practicing ATs across employment settings, of which 524 ATs were enrolled into a group (personalized learning pathway [PLP = 178], passive reading list [PAS = 176], control [CON = 170]) then took the knowledge assessment. A total of 364 ATs did not complete the intervention or postknowledge assessment; therefore, complete responses from 160 ATs (PLP = 39, PAS = 44, CON = 77; age = 36.6 ± 11.2 years, years certified = 13.9 ± 10.7) were analyzed., Main Outcome Measure(s): Knowledge assessment (34 items) and interview guides (12-13 items) were developed, validated, and piloted with ATs before study commencement. We summed correct responses (1 point each, 34 points maximum) and calculated percentages and preknowledge and postknowledge mean change scores. Differences among groups (PLP, PAS, CON) and time (preintervention, postintervention) were calculated using a 3 × 2 repeated-measures analysis of variance (P ≤ .05) with post hoc Tukey HSD. Semistructured interviews were conducted (PLP = 15, PAS = 14), recorded, transcribed, and analyzed following the consensual qualitative research tradition., Results: No differences in the preknowledge assessment were observed between groups. We observed a group × time interaction (F2,157 = 15.30, P < .001; partial η2 = 0.16). The PLP group exhibited greater mean change (M = 3.0 ± 2.7) than the PAS (M = 1.7 ± 3.0, P = .049) and CON (M = 0.4 ± 2.2, P < .001) groups. Descriptively, ATs scored lowest on the legal (61.3% ± 2.1%), value of the AT (63.7% ± 4.3%), and health information technology (65.3% ± 3.7%) items. Whereas ATs described being confident in their documentation knowledge, they also identified key content (eg, legal considerations, strategies) which they deemed valuable., Conclusions: The educational interventions improved ATs' knowledge of clinical documentation and provided valuable resources for their clinical practice; however, targeted continuing education is needed to address knowledge gaps., (© by the National Athletic Trainers’ Association, Inc.)

The disruption in daily activity performance during COVID-19 lockdowns is widely understood to have impacted health, but a better understanding of how restricted performance of specific activities are associated with health is needed. This cross-sectional study answers the following question: How were changes in the performance of 16 daily activities associated with health during COVID-19 lockdowns? A total of 116 participants completed an online survey rating their health before and during COVID-19 lockdowns and comparing their recollection of the performance of 16 activities before COVID-19 with their performance during lockdowns. Multiple stepwise linear regression analysis was used to estimate the relationship between self-reported changes in activities during lockdowns and concurrent (during-lockdown) health status, while controlling for pre-COVID-19 health status. Only changes in activities that were uniquely and significantly associated with lockdown health status were retained in the final model. Health before COVID-19 accounted for 3.7% ( P  = 0.039) of the variance in health during COVID-19 lockdowns. After controlling for health before COVID-19, five types of activity were significantly and uniquely predictive of health during lockdowns, together accounting for 48.3% of the variance. These activities and the variances they accounted for were rest and sleep (29.5%, P  < 0.001), play and recreational activities (8%, P  < 0.001), work (4.8%, P  = 0.002), personal hygiene (3.2%, P  = 0.01), and healthy eating (2.8%, P  = 0.013). The study suggests that these five types of activity should be prioritized in policy or interventions when participation in activity is constrained by lockdowns or comparable factors., Competing Interests: The authors declare there are no competing interests., (©2024 Muriithi and Bay.)

Background: The six-minute walk test (6MWT) is considered reliable and valid for assessing walking capacity in people with neurologic conditions. However, the consistency in the test length and configuration used is unclear., Purpose: To determine how the 6MWT was configured by licensed physical therapists working with patients with neurologic conditions in clinical practice, identify their knowledge of the American Thoracic Society (ATS) and Academy of Neurologic Physical Therapy (ANPT) guidelines for the 6MWT and assess relationships between therapist demographic characteristics and knowledge of the 6MWT guidelines., Methods: One hundred forty-six therapists completed a survey related to the configuration they used for the 6MWT., Results: Configuration of the 6MWT varied widely. Space limitation was the most frequently selected reason for reported configurations. Over half had available the standardized 100-feet straight walkway but fewer than one-third used this configuration of the ATS guidelines. Fewer than half knew of the ATS guidelines and nearly three-fourths knew of the ANPT guidelines. American Physical Therapy Association membership and having a higher percentage of neurologic patients were associated with knowledge of both guidelines., Conclusion: The 6MWT must be completed within the constraints of the working environment, and this requirement is clinically relevant when comparing patient results to normative values and measurements across clinics. Our results suggest a need for updated norms that are more congruent with space constraints in current practice settings.

Objective: To evaluate content validity (CV) and interrater reliability (IRR) of an acuity scoring tool developed for the couplet care/postpartum/nursery patient population and to determine if there was agreement between supervisor or director scoring and staff scoring., Design: A scoring tool to assess the acuity of the couplet care/postpartum/nursery patients was developed., Setting: Two hospitals: one Level 2 hospital, one Level 3 hospital. Unit-based patient care councils participated in the development, and all couplet care nurses participated in scoring patients for testing., Measurements: The final tool was evaluated for CV and IRR using expert review, universal agreement scores, and discriminant content validation., Results: Regarding CV for the Couplet Care Acuity Scoring Tool, the average of the number of experts in agreement divided by the total number of experts across all items was 1.00. Regarding IRR, the intraclass correlation coefficient was 0.85, indicating that the tool is valid and reliable for the study sample., Conclusion: The tool was reliable and valid in this study. Future testing is needed with larger samples and different health care facilities., (Copyright © 2023 AWHONN. Published by Elsevier Inc. All rights reserved.)

Introduction The COVID-19 pandemic resulted in the cancellation of high school sports in spring 2020, a modified resumption of sports in the 2020-2021 academic year, and a return to pre-pandemic sports in 2021-2022. This cancellation had a major impact on the quality of life of adolescent athletes, but it is unknown exactly how these pandemic-driven sports disruptions on athlete baseline (preseason) symptoms affected quality of life. Therefore, the current study retrospectively evaluated symptom inventories from Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) assessments to determine whether the cancellation of sports during the COVID-19 pandemic affected baseline (preseason) self-reported symptoms among adolescent athletes. Methods Our study used a retrospective cohort design to evaluate high school athletes with complete ImPACT assessments in the academic years before (2018-2019 and 2019-2020), during (2020-2021), and after (2021-2022) the pandemic. Specifically, data from a 22-item symptom report called the Post-Concussion Symptom Scale (PCSS) assessed during ImPACT was collected and analyzed using generalized linear models with a Tweedie exponential dispersion model and post hoc Tukey's honestly significant difference tests. The main outcomes were the total symptom severity score and the affective cluster score. Secondary outcomes were the analysis of the vestibular-somatic, cognitive-sensory, and sleep-arousal symptom clusters. Results Of the 104,274 ImPACT assessments, the total symptom severity score on the PCSS was different across years (p<0.001). There were lower symptom scores in 2020-2021 (5.33, 95% CI = 5.13-5.54) than in 2018-2019 (6.82, 95% CI = 6.63-7.01), 2019-2020 (6.94, 95% CI = 6.75-7.14), and 2021-2022 (6.44, 95% CI = 6.25-6.64). The cluster scores on the PCSS for affective, cognitive-sensory, sleep-arousal, and vestibular-somatic were also lower (p<0.001) in 2020-2021 than in 2018-2019, 2019-2020, and 2021-2022. Conclusion Contrary to our expectations, total symptom severity and cluster scores on the PCSS during the pandemic (2020-2021) were significantly lower than during the years before and after the pandemic-driven sports disruptions, suggesting the pandemic did not negatively affect these athletes as expected. These results also suggested that self-reported symptoms utilized in the PCSS component of ImPACT may not be as sensitive to sports disruption among adolescent athletes as other quality-of-life measures, especially during the COVID-19 pandemic., Competing Interests: The views expressed in this material are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense, or the Department of the Air Force., (Copyright © 2024, Rivera et al.)

Abstract: The early period of the COVID-19 pandemic necessitated a rapid increase in out-of-office care. To capture the impact from COVID-19 on care for patients with hypertension, a questionnaire was disseminated to community health center clinicians. The extent, types, and causes of care delays and disruptions were assessed along with adaptations and innovations used to address them. Clinician attitudinal changes and perspectives on future hypertension care were also assessed. Of the 65 respondents, most (90.8%) reported their patients with hypertension experienced care delays or disruptions, including lack of follow-up, lack of blood pressure assessment, and missed medication refills or orders. To address care delays and disruptions for patients with hypertension, respondents indicated that their health center increased the use of telehealth or other technology, made home blood pressure devices available to patients, expanded outreach and care coordination, provided medication refills for longer periods of time, and used new care delivery options. The use of self-measured blood pressure monitoring (58.5%) and telehealth (43.1%) was identified as the top adaptations that should be sustained to increase access to and patient engagement with hypertension care; however, barriers to both remain. Policy and system level changes are needed to support value-based care models that include self-measured blood pressure and telehealth., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association for Healthcare Quality.)

Objective: The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients after concussion., Data Sources: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search through PubMed, Ovid MEDLINE, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searches of included articles., Study Selection: Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool., Data Extraction: After quality assessment was completed, the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies., Data Synthesis: Data were critically analyzed by 2 of the authors and categorized into tables regarding the ability of researchers of each article to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not., Conclusions: Researchers routinely reported that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to consistently predict longer recovery., (© by the National Athletic Trainers’ Association, Inc.)

Objective: The purpose of this study was to evaluate the impact of a novel training programme on dental hygiene students' knowledge, attitudes, and beliefs about caring for individuals with disabilities., Methods: A mixed methods approach was used. Students from five dental hygiene programmes based at community colleges completed a two-hour didactic training session to supplement their existing special care dentistry coursework. Students completed an original 14-item pretest and posttest before and after the training that assessed attitudes and beliefs, and two validated posttests that assessed knowledge. Afterwards, students completed a clinical rotation in an advanced care dental clinic at a local academic institution, gaining hands-on experience with equipment and patient treatment. Descriptive statistics were used to report training scores, types of services rendered, and modifications to treatment. Student comments about their experiences were assessed using thematic analysis., Results: Two hundred and ninety-four students completed didactic training, and 261 completed clinical rotations. Posttest scores indicated positive improvements in knowledge, attitudes, and beliefs. All students provided direct patient care. Sixty-nine percent treated patients with intellectual and developmental disabilities; 75% placed silver diamine fluoride or fluoride varnish. Altered patient positioning was used by 70.5%. Most students (95.4%) reported that their experience positively changed their attitudes towards caring for patients with disabilities in the future. Eight themes emerged, notably increased comfort and confidence, a willingness and desire to treat patients, the acquisition of new skills, and clinician behaviours of empathy and compassion towards others., Conclusion: Training can help prepare dental hygiene students with the confidence and skills to address the oral health needs of individuals with disabilities., (© 2023 The Authors. International Journal of Dental Hygiene published by John Wiley & Sons Ltd.)

Context: Limited evidence exists regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return to sport after a lateral ankle sprain (LAS) injury., Objective: To evaluate self-reports of improvement in health status, pain, function, and disability at return to sport after an LAS., Design: Descriptive study., Setting: Sixty-nine athletic training facilities across 24 states., Patients or Other Participants: A total of 637 patients (males = 53.2%) who were diagnosed with an LAS, restricted from sport after injury, and subsequently medically cleared to return to sport within 60 days were included., Main Outcome Measure(s): Descriptive statistics were used to summarize scores for health status (Global Rating of Change), pain (Numeric Pain Rating Scale), function (Global Rating of Function), and disability (Global Rating of Disability). Mann-Whitney U tests were used to compare score differences between sexes. A Kaplan-Meier analysis was performed to provide a visual depiction of sex differences in the time to return to sport., Results: Most patients sustained an LAS injury while participating in basketball, football, or soccer and were cleared to return to sport 8 days after injury. More than two-thirds of patients reported a meaningful improvement in health status between the time of injury and return to sport. However, many noted deficits related to pain (65.1%), function (86.2%), or disability (35.8%) at return to sport. No differences were seen between males and females for pain (P = .90), function (P = .68), change in health status (P = .45), or disability (P = .21) at return to sport, although males returned to sport slightly sooner than females (P = .025)., Conclusions: Despite self-perceived improvements in health status since the time of injury, patients typically returned to sport with deficits in pain, function, and disability after an LAS. Patients may be returning to unrestricted sport participation before they feel their bodies have fully recovered from the injury., (© by the National Athletic Trainers’ Association, Inc.)

Statins are an important but underutilized therapy to prevent cardiovascular events, particularly in high-risk patients. To increase use of statin therapy in high-risk patients, the Centers for Disease Control and Prevention funded a project led by the National Association of Community Health Centers to discover reasons for statin underuse in health centers and identify possible leverage points, particularly among vulnerable and underserved patients. The project further sought to develop training and educational materials to improve statin prescribing for and acceptance in eligible high-risk patients. As a first step, investigators implemented a questionnaire to clinical providers ( n = 45) at health centers participating in the project to obtain their perspective on barriers to optimal statin use. We used the practical robust implementation and sustainability model (PRISM) domains to frame the overall project and guide the development of our questionnaire. This paper summarizes top perceived barriers to patient and health system/provider statin initiation and sustainment, as well as facilitators to prescribing, using PRISM as an organizing framework. Our questionnaire yielded important suggestions related to public awareness, education materials, health information technology (HIT)/data solutions, and clinical guidelines as key factors in optimizing statin use. It also informed the design of patient education resources and provider training tools. Future directions include using the full application of the PRISM implementation science model to assess how well our educational and training resources help overcome barriers to statin use in high-risk patients, including evaluating how key contextual factors influence successful implementation.

Context: Health professions education programs incorporate clinical education to prepare students for autonomous clinical practice. Although preceptor-student gender dyads impact student evaluations, specific influences of gender dyad pairings on student autonomy and behavior implementation have not been identified., Objective: To examine the influence of preceptor-student gender dyads on athletic training student opportunities to engage in clinical practice during clinical experiences and to determine whether constitution of preceptor-student gender dyads influenced student ability to enact professional behaviors during patient encounters (PEs)., Methods: Multisite panel design involving 12 professional athletic training programs (ATPs, 5 undergraduate, 7 graduate). Participants included 338 athletic training students enrolled in ATPs that used E*Value to document PEs during clinical experiences. Student gender, student role in the PE (observe, assist, or perform), preceptor gender, and student implementation of behaviors associated with core competencies during the PE were measured outcomes., Results: The 30,446 PEs were categorized into 4 preceptor-student dyad categories. Female students with male preceptors were less likely to perform PEs than they were to observe them (OR 0.76; 95%CI 0.69, 0.83; p<0.001). Female students with female preceptors reported fewer opportunities for behaviors associated with interprofessional education and collaborative practice (IPECP) (X2(3)=16.6, p=0.001)., Conclusions: Female athletic training students under male preceptorship had fewer opportunities to perform during PEs, and female students under female preceptorship had limited opportunities to participate in IPECP. Health professions education program administrators should encourage students to advocate for opportunities in autonomous practice and implementation of professional behaviors.

The role that social determinants of health (SDHs) play in athletic healthcare is gaining attention, yet little is known about athletic trainers' (ATs) perceptions of and encounters with the impact of SDHs. The purpose of this study was to evaluate ATs' perceptions of various SDHs and their experience treating patients whose health and well-being were influenced by SDHs. This was a cross-sectional, web-based survey completed by 1694 ATs (completion rate = 92.6%; 61.1% female; age = 36.6 ± 10.8 years). The survey consisted of several multipart questions focusing on specific SDHs. Descriptive statistics were used to report frequencies and percentages. Results indicated widespread agreement that SDHs matter to patient health and are of concern in athletic healthcare. The SDHs that ATs most commonly reported encountering included lifestyle choices (n = 1306/1406; 93.0%), social support (n = 1185/1427; 83.0%), income (n = 1167/1502; 77.7%), and access to quality and timely healthcare (n = 1093/1420, 77.0%). The SDHs that ATs least commonly reported having experience with was governmental policy (n = 684/1411; 48%). The perceived importance of SDHs among ATs and their commonly reported experiences managing patient cases in which SDHs negatively influence patients' health and healthcare suggest that efforts to assess these factors are needed so that strategies to address their influence on athletic healthcare can be identified.

Patient-centered care (PCC) is a core competency that should be required by all healthcare education programs, but little is known about its implementation in athletic training clinical experiences. Therefore, we examined characteristics of patient encounters documented by athletic training students implementing PCC behaviors. A multisite panel design was used to recruit 363 students from twelve professional athletic training programs (five undergraduate, seven graduate). Over 1.5 years, clinical experience patient encounter data were logged in E*Value Case Logs, including student role during the encounter, length of encounter, and clinical site. Generalized estimating equations models characterized the likelihood students included PCC behaviors in 30,522 encounters. Discussing patient goals was associated with student role (χ 2 (2) = 40.6, p < 0.001) and length of encounter (χ 2 (4) = 67.6, p < 0.001). Using patient-reported outcome measures was associated with student role (χ 2 (2) = 21.6, p < 0.001), length of encounter (χ 2 (4) = 34.5, p < 0.001), and clinical site (χ 2 (3) = 17.3, p = 0.001). Implementing clinician-rated outcome measures was affected by length of encounter (χ 2 (4) = 27.9, p < 0.001) and clinical site (χ 2 (3) = 8.6, p = 0.04). PCC behaviors were largely associated with student role and length of encounters; clinical site had less impact. Athletic training educators should emphasize progressive autonomous supervision with preceptors and encourage students to facilitate slightly longer patient visits, when possible, to incorporate more PCC behaviors.

Purpose: To evaluate content validity and interrater reliability for acuity tools developed for the antepartum and neonatal intensive care unit (NICU) patient population., Study Design and Methods: Antepartum and NICU acuity tools were developed to better evaluate nurse staffing assignment equity and patient needs. Following several iterations with staff nurses and nurse leaders, content validity of the acuity tools was established via a panel of experts in each substantive area using the Content Validity Index. The final tools were then evaluated for interrater reliability using Intraclass Correlation., Results: Content validity for the Antepartum Acuity Tool was S-CVI/Ave = 0.87 and for the NICU Acuity Tool was S-CVI/Ave = 0.98. Interrater Reliability for the Antepartum Acuity tool was ICC = 0.88, and the NICU Acuity Tool was ICC = 0.95., Clinical Implications: These tools have established content validity and interrater reliability and are appropriate for use in the antepartum and NICU settings to determine patient acuity and promote appropriate nurse-to-patient assignments., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled., Methods: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP)., Results: The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021)., Conclusions: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes., (© 2022. The Author(s).)

Objective: To estimate scale scores for patient-reported outcome (PRO) measures that classify patients as improved or unimproved at days 3 and 10 post-concussion., Methods: Data from 187 adolescent patients who sustained a concussion (150 males, 32 females, 5 not reported) were analyzed. Patients completed the Pediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), Headache Impact Test (HIT-6), and Global Rating of Change (GROC) on days 3 and 10 post-concussion. Dependent variables: PedsQL total score, 3 MFS subscale scores [general (MFS-GF), sleep (MFS-SLF), cognitive (MFS-CF) fatigue], and HIT-6 total score. Higher scores on PedsQL and MFS indicate better health; lower scores on HIT-6 indicate less impact on headache-related health. GROC ascertained patient-perceived magnitude of change in health status since concussion. Receiver Operating Characteristic Curve analyses estimated PRO cut-point scores that classified patients as improved or unimproved., Results: Day 3 PRO cut-points: PedsQL total = 90; MFS-GF = 73; MSF-CF = 85; MFS-SLF = 81; and HIT-6 total = 54. Day 10 PRO cut-points: PedsQL total = 91; MFS-GF = 85; MFS-CF = 85; MFS-SLF = 90; and HIT-6 total = 51., Conclusions: Our results define PedsQL, MFS, and HIT-6 scores as they relate to perceived improvement following concussive injuries. Cut-point scale scores help clinicians interpret concussion PROs and make informed decisions during the management of patients with concussion.

Context: Preventive training programs (PTPs) reduce injury risk by improving movement control. Corrective feedback is important; however, many cues at once may be too complicated for athletes., Objective: To compare movement control and long-jump (LJ) changes in youth athletes participating in a season-long PTP, with simplified feedback, traditional feedback, or a warmup of the coaches' choosing., Design: Cluster-randomized controlled trial., Setting: Soccer fields., Patients or Other Participants: A total of 420 athletes (simplified feedback = 173, traditional feedback = 118, and control = 129; age = 11 ± 3 years)., Intervention(s): Teams were randomized into the simplified PTP, traditional PTP, or control group. Simplified and traditional PTPs lasted 10 to 12 minutes and used the same exercises. The simplified PTP provided only sagittal-plane feedback (eg, "get low"), and the traditional PTP provided feedback targeting all motion planes (eg, "don't let your knees cave inward"). Research assistants administered the PTP warmups 2 to 3 times/week for the season. Control team coaches chose and ran their own warmup strategies., Main Outcome Measure(s): Participants completed 4 sessions (preseason [PRE], postseason [POST] at approximately 8 weeks after PRE, retention 1 [R1] at 6 weeks postseason, and retention 2 [R2] at 12 weeks postseason). They performed 3 trials of a jump-landing task, which was evaluated using the Landing Error Scoring System (LESS) and 2 recorded standing LJ trials at each test session. A time series panel was used to evaluate group differences across time points for the LESS and LJ., Results: Change score analyses revealed improvements in the LESS score from PRE to POST for all groups. Improvements from PRE were retained at R1 and R2 for the intervention groups (simplified and traditional). The traditional group demonstrated better LJ performance at POST (P < .001) and R1 (P = .049) than the simplified or control group., Conclusions: Simplified cues were as effective as traditional cues in improving LESS scores from PRE to POST season. Participating in PTPs, regardless of their complexity, likely provides movement benefits., (© by the National Athletic Trainers' Association, Inc.)

Context: Ankle sprains are common during sport participation and associated with long-term deficits in self-report of function. However, little is known of short-term changes in self-report of function following injury. The authors aimed to assess statistical and clinically meaningful changes in self-report of function, as measured by the Foot and Ankle Ability Measure (FAAM), during the first 2 weeks after an ankle sprain injury., Design: A retrospective analysis of electronic medical records., Methods: Eighty-eight patients, who were diagnosed with an ankle sprain injury by an athletic trainer, received usual care from an athletic trainer, and completed the FAAM during treatment at weeks 1 and 2 postinjury. The authors calculated the percentage of patients who reported clinically meaningful changes and used Wilcoxon signed-rank tests to compare differences in FAAM scores between time points., Results: Between weeks 1 and 2, significant differences were noted for the FAAM Activities of Daily Living (FAAM-ADL) (P < .001) and FAAM Sport (FAAM-Sport) (P < .001). At the patient level, 86.5% (64/74) and 85.2% (69/81) of patients reported changes that exceeded the minimal clinically important difference value for the FAAM-ADL and FAAM-Sport, respectively, between weeks 1 and 2. At week 2, 31.8% (28/88) and 47.7% (42/88) of patients reported a score below 90% on the FAAM-ADL and below 80% on the FAAM-Sport subscale, respectively. Also, 36.4% (32/88) and 25.0% (22/88) of patients reported a score of 100% on the FAAM-ADL and FAAM-Sport subscales, respectively, at week 2., Conclusions: Patients report statistically significant and meaningful improvements in self-report of function during the first 2 weeks following ankle sprain injury. However, almost half of patients still report deficits in sport function at 2 weeks postinjury. Patient-reported outcome measures such as the FAAM, can help capture the patient's perception of function and inform patient care decisions. Research efforts should explore individual response patterns to treatment.

Context: To enhance the quality of patient care, athletic training students (ATSs) should experience a wide variety of clinical practice settings, interact with diverse patient populations, and engage with patients who have a wide variety of conditions. It is unclear in what ways, if any, ATSs have diverse opportunities during clinical experiences., Objective: To describe the characteristics of patient encounters (PEs) ATSs engaged in during clinical experiences., Design: Multisite panel design., Setting: Twelve professional athletic training programs (5 bachelor's, 7 master's)., Patients or Other Participants: A total of 363 ATSs from the athletic training programs that used E*Value software to document PEs during clinical experiences., Main Outcome Measure(s): During each PE, ATSs were asked to log the clinical site at which the PE occurred (college or university, secondary school, clinic, or other), the procedures performed during the PE (eg, knee evaluation, lower leg flexibility or range of motion, cryotherapy), and the patient's diagnosis, with the International Classification of Diseases, Tenth Revision code (eg, S83.512A knee sprain, anterior cruciate ligament)., Results: A total of 30 630 PEs were entered by 338 ATSs across 278 unique clinical settings. More than 80% of PEs occurred in college or university and secondary school settings. More than half of the diagnoses were categorized as affecting the lower body region. Examination and evaluation procedures and application of therapeutic modality procedures each contributed approximately 27% of procedures., Conclusions: It was surprising that ATSs were not gaining experience in all clinical practice settings in which athletic trainers commonly practice. Our data suggest that students may be consigned to working with patients who have more frequently occurring injuries, which may not prepare them for the realities of autonomous clinical practice. These findings indicate that directed efforts are needed to ensure that ATSs are provided opportunities to engage with diverse patient populations who have a variety of conditions in an array of clinical site types during their clinical experiences., (© by the National Athletic Trainers' Association, Inc.)

Objective: We aimed to assess whether perceived pressure predicts concussion reporting intentions and behavior in youth, high school, and collegiate ice hockey athletes, and, secondarily, whether perceived pressure from stakeholders differed between sex or level of play., Setting: Online survey., Participants: One hundred fifty-two ice hockey athletes (males: n = 96, 63.2%; females: n = 55, 36.2%; missing: n = 1, 0.7%; age = 14.04 ± 3.6 years)., Design: Cross-sectional., Main Measures: Respondents answered a survey that elicited information about demography, perceived pressure from 6 stakeholders, and concussion reporting intentions and behavior. For the first aim, we used a generalized linear model to determine whether perceived pressure from any stakeholder predicted intention (symptom reporting, concussion reporting, and intention beliefs) or behavior ("all concussions," "not obvious concussions"; α < .05) while controlling for level of play. To determine whether pressure from any stakeholder predicted symptom reporting behavior, we used logistic regression while controlling for level of play. For the second aim, to examine sex differences in perceived pressure from each stakeholder, we employed Mann-Whitney tests and to examine level of play differences, we used Kruskal-Wallis tests., Results: Controlling for level of play, a 1-point increase in perceived pressure from parents and athletic administrators decreased concussion reporting intentions by 0.92 (P = .004) and 1.09 (P = .005) points, respectively. Perceived pressure from a sports medicine professional decreased intention beliefs by 0.17 (P = .029) points. Perceived pressure from stakeholders did not predict symptom reporting (P = .440) or "not obvious concussion" reporting (P = .655) behavior. We observed no difference in perceived pressure across stakeholders (all P values >.05); however, collegiate ice hockey respondents perceived greater pressure from coaches than youth or high school athletes (P < .001). We noted no other differences in perceived pressure across levels of play (all P values >.05)., Conclusions: Concussion reporting intentions were negatively influenced by perceived pressure from parents, athletic administrators, and sports medicine professionals, but these findings did not translate to reporting behavior., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Context: To enhance the quality of patient care, it is important that athletic trainers integrate the components of the core competencies (CCs; evidence-based practice [EBP], patient-centered care [PCC], health information technology [HIT], interprofessional education and collaborative practice [IPECP], quality improvement [QI], professionalism) as a part of routine clinical practice. In what ways, if any, athletic training students (ATSs) are currently integrating CCs into patient encounters (PEs) during clinical experiences is unclear., Objective: To describe which professional behaviors associated with the CCs were implemented by ATSs during PEs that occurred during clinical experiences., Design: Multisite panel design., Setting: A total of 12 professional athletic training programs (5 bachelor's, 7 master's level)., Patients or Other Participants: A total of 363 ATSs from the athletic training programs that used E*Value software to document PEs during clinical experiences participated., Main Outcome Measure(s): During each PE, ATSs were asked to report whether professional behaviors reflecting 5 of the CCs occurred (the professionalism CC was excluded). Summary statistics, including means ± SDs, counts, and percentages were tabulated for the professional behaviors of each CC., Results: Data from 30 630 PEs were collected during the study period. Professional behaviors related to EBP were the most frequently incorporated during PEs (74.3%, n = 22 773), followed by QI (72.3%, n = 22 147), PCC (56.6%, n = 17 326), HIT (35.4%, n = 10 857), and IPECP (18.4%, n = 5627)., Conclusions: It is unsurprising that EBP and PCC behaviors were 2 of the most frequently incorporated CCs during PEs due to the emphasis on these competencies during the past several years. However, it is surprising that ATSs did not incorporate behaviors related to either HIT (in 65% of PEs) or IPECP (in 82% of PEs). These findings suggest that directed efforts are needed to ensure that ATSs are provided opportunities to incorporate professional behaviors related to the CCs during clinical experiences., (© by the National Athletic Trainers' Association, Inc.)

Problem Statement: This study assesses the effect of a nurse-designed SMART educational intervention on goal attainment, patient empowerment, and satisfaction., Design: A mixed-methods study design was used., Data Sources: 68 adults with cancer were recruited from an oncology research center and randomized to the immediate or waitlist control group. Empowerment was measured using the Patient Empowerment Scale, and health literacy was measured using the Cancer Health Literacy Test., Analysis: Measures were completed by the immediate group at enrollment and by the waitlist control group after an eight-week waiting period to establish an updated baseline. Participants received four learning modules on goal setting and coaching to facilitate learning and activation of knowledge. Visit data were collected by nurses based on participants' written and oral responses., Findings: Goal attainment ranged from 67% to 100%. Patient empowerment scores were high at baseline and throughout. No significant differences were noted among the groups on goal attainment, empowerment, or satisfaction., Implications for Nursing: RNs can deliver a SMART educational intervention using a universal health literacy approach to support adults with cancer in creating symptom management strategies and attaining self-care goals.

The purpose of this study was to evaluate midpalatal bone density (BD) by using cone-beam computed tomography (CBCT) according to gender, age, and vertical and horizontal skeletal patterns. CBCT images from 126 subjects (64 females and 62 males) were reoriented and analyzed in order to attain BD values at the midpalatal suture. Four age groups were used for classification (adolescence, 10 ≤ early < 14 years, 14 ≤ middle ≤ 17 years, and 17 < late ≤ 21 years; adult > 21 years). Vertical skeletal pattern categories were differentiated by the Frankfort horizontal line to mandibular plane angle (hypodivergent < 22°, 22° ≤ normovergent ≤ 28°, and 28° < hyperdivergent). Horizontal skeletal pattern differentiation was defined by ANB angle (Class III < 0°, 0° ≤ Class I ≤ 4°, and 4° < Class II). Females showed significantly higher BD than males ( p < 0.001). As age increased, BD increased significantly ( p < 0.001). There were no significant differences between vertical skeletal patterns. Class II showed significantly less BD than Class III ( p < 0.05). With this information, clinicians can better understand BD trends of the midpalatal suture and, thus, better understand our patient's anatomy and potential hurdles in successful treatment.

Background: Updated rates and patterns associated with patients with dance-related injuries reporting to US emergency departments (EDs) is needed., Hypothesis: Between the years 2014 and 2018, there will be an observed rise of patients with dance-related injuries seen within US EDs., Study Design: Retrospective analysis., Level of Evidence: Level 4., Methods: Utilizing the National Electronic Injury Surveillance System (NEISS) database, data were abstracted for all structured dance-related injuries for all people who presented to a NEISS participating hospital from January 1, 2014, to December 31, 2018. Data were abstracted on age, sex, race, disposition, location on the body where the injury happened, and free text box regarding the mechanism and nature of the injury. Each patient case was associated with a weight to provide national incidence rate (per 100,000) estimates. Descriptive statistics were used to summarize counts, percentages, and rates across patient cases., Results: Between years 2014 and 2018, 4152 patients reported to the NEISS EDs with a dance-related injury. Most injuries occurred in female patients (83.3%; n = 3459) and among those who were 10 to 18 years old (76.2%; n = 3164). The most common injuries were ankle sprain/strain (12.7%; n = 527) and knee sprain/strain (10.4%; n = 431). Almost all patients were treated and released (97.1%; n = 4033). These data yielded population-weighted estimates of 125,618 injuries for the study period, with an increasing trend over time (19.2% increase over 5 years). Incidence rates were over 4 times higher for female (12.4) than for male patients (3.0) and highest in the 10- to 18-year-old age group (incidence rate = 46.4)., Conclusion: Patients with dance-related injuries reporting to EDs increased over a 5-year period from 2014 to 2018. The majority of dancers in the study were female patients, between the ages of 10 and 18 years, nearly half of the patients reported to the ED with a sprain/strain, and almost all patients were treated and released., Clinical Relevance: An increase in access to proper injury prevention medical services and education should be provided to female dancers between the ages of 10 and 18 years., Strength of Recommendation Taxonomy: B.

Background: Identifying risk factors for prolonged recovery following concussion can assist clinicians with appropriate management strategies. It is thought that athletes who continue to participate following a hit to the head or body may take longer to recover following a concussion diagnosis., Objective: To systematically review the body of literature regarding the effect of delayed reporting and delayed presentation to medical providers on concussion recovery times., Design: Systematic review with meta-analysis., Data Sources: PubMed, Ovid Medline, SPORTDiscus, Cochrane Central Register of Controlled Trials and hand searches of reference lists. All the searches were performed in April 2020., Eligibility Criteria for Selected Studies: Studies included an investigation of immediate versus delayed reporting or early versus late presentation following a concussion, were published in the past ten years, and were level 4 evidence or higher., Results: 12 studies were included. Patients who continued play or delayed reporting their concussion had significantly longer recovery times (standardized mean difference = 0.36 days (95%CI 0.066, 0.662) than those who immediately reported or were removed from play (p = 0.017). Expressed in raw scores, those who immediately reported recovered in 5.4 days (95% CI - 10.14, - 0.75) fewer than delayed reporters. Comparable results were found for post-concussion symptom scores (p = 0.034) with immediate reporters demonstrating lower symptom severity scores. Our qualitative synthesis found patients who presented earlier to a concussion specialist tended to recover faster than those who presented later., Conclusions: Patients who delayed reporting or continued play had longer recovery times compared to their immediately-reporting peers. Providers should ask concussion patients approximately how long they waited to report their injury, and also focus educational efforts on encouraging immediate reporting of concussion.

Objective: There are conflicting reports on the efficacy of exercise in chronic venous insufficiency (CVI). Exercise in water or aquatic activity (AA) can have additional advantages. We sought to evaluate the clinical effects of AA in CVI in a randomized prospective open label fashion., Methods: A total of 201 patients with advanced CVI were randomized to receive AA vs no such treatment. In the Aquatic Group (AG), 91 patients reached the 24-month follow-up point, and in the Control Group (CG), 90 patients did. The primary efficacy end point was a predefined reduction of ≥4 points in the modified Venous Clinical Severity Score (VCSS) at 3 months. Instruments of venous disease severity and quality of life were compared at baseline, 3 months, and 24 months between and within the two groups. These included the modified VCSS, Villalta score, leg and thigh circumference, the Physical Health Component of the 36-Item Short Form Health Survey, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life/Symptom scores. Aquatic activity consisted of a minimum of 15 minutes of walking in a swimming pool at 1 m/s, 3 times/wk for 3 months., Results: The primary end point of 4-point reduction in the modified VCSS at 3 months was reached in 28% of AG and 3% of CG (odds ratio = 12.08; 95% confidence interval: 3.51, 41.59; P < .001). Comparison of changes in secondary end points from baseline to 24 months between AG and CG demonstrated the following: modified VCSS -4.08 ± 2.08 vs -1.15 ± 1.26, Villalta score -4.00 ± 2.68 vs -1.01 ± 1.34, thigh circumference -3.40 ± 1.78 cm vs -1.40 ± 2.55 cm, leg circumference -1.27 ± 1.34 cm vs -0.49 ± 1.21 cm, Physical Health Component of the 36-Item Short Form Health Survey 3.82 ± 2.36 vs 1.16 ± 1.18, Venous Insufficiency Epidemiological and Economic Study Quality of Life 3.35 ± 1.67 vs 1.30 ± 1.43, and Venous Insufficiency Epidemiological and Economic Study Symptom 3.53 ± 1.71 vs 1.23 ± 1.26 (P < .001 for all comparisons; ± denotes mean ± standard deviation)., Conclusions: The addition of AA to the treatment of patients with advanced CVI is safe and effective, leading to a significant improvement in clinical status and quality of life. These beneficial changes occur rapidly within 3 months of initiation of AA and are continued at a slower rate of improvement from 3 months to 2 years., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: This study evaluated the trends in orthodontic practitioner choice over the past 15 years and explored the lay public's understanding of different orthodontic practitioner options in the U.S., specifically, orthodontists compared with general dentists., Methods: A survey was distributed to a representative sample of laypersons in the U.S. The response rate was 90.2%, and 727 completed responses were analyzed., Results: A 28.2% shift away from orthodontists toward general dentists over the last 15 years was significant (P <0.001). The 2 most frequently endorsed ways respondents found their orthodontic practitioners were a recommendation from another dentist (54.2%) and their family's general dentist who offered orthodontic treatment in-house (22.9%). Respondents' knowledge of orthodontists was limited; 85.0% believed that dentists who perform orthodontic treatment are also orthodontic specialists. Only 17.1% of respondents disagreed with the statement that "a dentist who advertises orthodontic treatment is an orthodontic specialist." In addition, 89.7% were not aware that a dentist could not be called an orthodontist without separate training from an accredited residency program. Finally, 64.2% of respondents did not know that an orthodontist must complete more education than a general dentist., Conclusions: Over the past 15 years, the percentage of orthodontic patients treated by general dentists has increased significantly. The public's ability to differentiate between different types of orthodontic practitioners is poor, showing substantial confusion about orthodontists' qualifications. Most respondents believed that orthodontists are best suited for their orthodontic treatment, but they rely heavily on their general dentists for orthodontic practitioner decisions., (Copyright © 2021 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.)

Context: Plantar fasciitis (PF) is a common condition in active individuals. The lack of agreement on PF etiology makes treatment challenging and highlights the importance of understanding risk factors for preventive efforts., Objective: The purpose of this systematic review and meta-analysis was to determine what factors may put physically active individuals at risk of developing PF., Data Sources: CENTRAL, CINAHL, EMBASE, Gray Lit, LILACS, MEDLINE (PubMed), ProQuest, Scopus, SPORTDiscus, and Web of Science were searched through April 2018 and updated in April 2020., Study Selection: Studies were included if they were original research investigating PF risk factors, compared physically active individuals with and without PF, were written in English, and were accessible as full-length, peer-reviewed articles., Study Design: Systematic review and meta-analysis., Level of Evidence: Level 3, because of inconsistent definitions and blinding used in the included observational studies., Data Extraction: Data on sample characteristics, study design and duration, groups, PF diagnosis, and risk factors were extracted. The methodological quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology statement. When means and standard deviations of a particular risk factor were presented 2 or more times, that risk factor was included in the meta-analysis., Results: Sixteen studies were included in the systematic review and 11 risk factors in the meta-analysis. Increased plantarflexion range of motion (weighted mean difference [MD] = 7.04°; 95% CI, 5.88-8.19; P < 0.001), body mass index (MD = 2.13 kg/m 2 ; 95% CI, 1.40-2.86; P < 0.001; I 2 = 0.00%), and body mass (MD = 4.52 kg; 95% CI, 0.55-8.49; P = 0.026) were risk factors for PF., Conclusion: Interventions focused on addressing a greater degree of plantarflexion range of motion, body mass index, and body mass and their load on the force-absorbing plantar surface structures may be a good starting point in the prevention and treatment of active individuals with PF.

Introduction: Accurately measuring tongue space is challenging, but this information can be useful to many dental specialties. This study was intended to estimate the reliability of using cone-beam computed tomography (CBCT) to measure tongue space, which includes tongue volume and the oral cavity air capacity., Methods: For this preliminary study, CBCT images from ten participants (five females and five males, mean age of 29.8 ± 3.3 years) were available for evaluation. Each participant was radiographed two times (T0 and T1). The average time between T0 and T1 was 15.8 ± 3.7 days. CBCT scans were standardized to reduce variability. Three-dimensional landmarks were established to identify tongue space and 3D image analysis software (SimPlant ® 17 Pro; Materialise Dental, Leuven, Belgium) was used to measure the volume circumscribed by the landmarks. Two investigators independently calculated airway, tongue dimensions, and total tongue space for CBCT image T0 twice (day 1 and day 14), and T1 once. Intraclass correlation coefficients (ICCs) were used to estimate intra-rater and inter-rater reliability. Bland-Altman charts were constructed to demonstrate agreement within and between raters., Results: The intra-rater and inter-rater ICCs of the CBCT measurements at T0 were excellent (> 0.90). Measurements for T0 vs. T1 show good (0.75-0.90) intra-rater and excellent (> 0.90) inter-rater reliability. Bland-Altman charts show that 90-95% of the total measurements fall within the 95% limits of agreement for both intra- and inter-rater pairs CONCLUSIONS: The results of this preliminary study suggest that the landmarks chosen to measure the overall tongue space are reproducible and can be measured clearly using CBCT.

Objective: To systematically review the effects of cortical bone thickness (CBT) and bone mass density (BMD) on miniscrew success rates., Methods: MEDLINE, the Cochrane Library and Scopus were searched up to June 2020. Of a total of 5734 articles, seven studies were finally selected for the review., Results: The overall mean success rate weighted by the number of miniscrews was 87.21% (89.87% in the maxilla and 79.24% in the mandible). There was a significantly higher success rate for miniscrews placed in the maxilla compared with those in the mandible (P < .05). CBT showed small positive effect on the success rate of the miniscrews although it failed to reach a statistical significance. The cortical BMD had a minimal effect on the success of the miniscrews. The cancellous BMD demonstrated a very strong effect on the success of the miniscrews in the maxilla, whereas it showed a moderately negative effect in the mandible., Limitations: Because of the small number and clinical heterogeneity of the included studies, the results should be interpreted with caution. Further randomized clinical studies with a large sample size are recommended., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: As the role of a health care system's influence on nurse burnout becomes better understood, an under-standing of the impact of a nurses' work environment on burnout and well-being is also imperative., Objective: To identify the key elements of a healthy work environment associated with burnout, secondary trauma, and compassion satisfaction, as well as the effect of burnout and the work environment on nurse turnover., Methods: A total of 779 nurses in 24 critical care units at 13 hospitals completed a survey measuring burnout and quality of the work environment. Actual unit-level data for nurse turnover during a 5-month period were queried and compared with the survey results., Results: Among nurses in the sample, 61% experience moderate burnout. In models controlling for key nurse characteristics including age, level of education, and professional recognition, 3 key elements of the work environment emerged as significant predictors of burnout: staffing, meaningful recognition, and effective decision-making. The latter 2 elements also predicted more compassion satisfaction among critical care nurses. In line with previous research, these findings affirm that younger age is associated with more burnout and less compassion satisfaction., Conclusions: Efforts are recommended on these 3 elements of the work environment (staffing, meaningful recognition, effective decision-making) as part of a holistic, systems-based approach to addressing burnout and well-being. Such efforts, in addition to supporting personal resilience-building activities, should be undertaken especially with younger members of the workforce in order to begin to address the crisis of burnout in health care., (©2021 American Association of Critical-Care Nurses.)

Objective: The objective of this retrospective study was to investigate the relationship between mandibular symphysis bone density (BD) and mandibular growth direction in adolescent patients by facilitating the measurement of cortical and cancellous BDs at the mandibular symphysis using cone beam computed tomography (CBCT)., Study Design: 224 adolescent patients (98 males and 126 females) were categorized by sex, age, and mandibular growth direction. Cortical and cancellous BDs were measured along with a sagittal slice at multiple locations., Results: Females exhibited higher cortical BD than males at menton (Me, P =0.002). Patients with a posterior growth direction exhibited a higher cortical BD than those with anterior and normal growth direction at Me (P <0.021, P <0.001, respectively), pogonion (Pog, P =0.037, P =0.037, respectively) and genion (Ge, P =0.007, P =0.008, respectively). Patients with a posterior growth direction exhibited a higher cortical BD than those with anterior growth direction at B point (P =0.009)., Conclusions: Significant differences in BD were identified across anthropometric categories. These findings may be useful in determining mandibular growth direction in adolescents.

Purpose: Being swamped is defined as "when you are so overwhelmed with what is occurring that you are unable to focus on the most important thing." The purpose of this study was to explore the experience of being swamped in the clinical setting among nurses who are members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the relationship of the level of being swamped to adherence to the nurse staffing guidelines., Study Design and Methods: A 25-item survey was sent to ~21,000 AWHONN members by email in the Fall of 2018. It was completed by 1,198 members, representing 49 states and the District of Columbia. Questions explored timing and causes of being swamped, its effect on health care team members and patients, what helps when a nurse feels swamped, and nurses' reports of their hospital following the AWHONN nurse staffing guidelines., Results: Twenty-eight percent of nurses reported being swamped daily or multiple times per day. Situations that contribute to being swamped include assignments that are too heavy, interruptions, critical patient situations, and mistakes made by others that nurses are expected to catch and fix. Teamwork and someone stepping in to help without being asked were identified as most helpful when a nurse feels swamped. Nurses practicing in hospitals following the AWHONN nurse staffing guidelines always or most of the time reported less frequency of being swamped as compared with those in hospitals that followed the guidelines some of the time, or rarely (p < 0.001)., Clinical Implications: Being swamped is a common phenomenon among AWHONN members responding to the survey. The reported incidence of being swamped daily is significantly associated with the extent to which hospitals follow the AWHONN nurse staffing guidelines. Nurse leaders, hospital administrators, and staff nurses must work together to identify and initiate timely, feasible nurse staffing solutions that support the safety of patients and nurses.

Context: Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults., Program: We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders' perceptions regarding best practices and policy recommendations for adult vaccinations., Implementation: A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018., Evaluation: A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided., Discussion: Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

Context: Recently, calls to conduct comparative effectiveness research (CER) in athletic training to better support patient care decisions have been circulated. Traditional research methods (eg, randomized controlled trials [RCTs], observational studies) may be ill suited for CER. Thus, innovative research methods are needed to support CER efforts., Objectives: To discuss the limitations of traditional research designs in CER studies, describe a novel methodologic approach called the point-of-care clinical trial (POC-CT), and highlight components of the POC-CT (eg, incorporation of an electronic medical record [EMR], Bayesian adaptive feature) that allow investigators to conduct scientifically rigorous studies at the point of care., Description: Practical concerns (eg, high costs and limited generalizability of RCTs, the inability to control for bias in observational studies) may stall CER efforts in athletic training. In short, the aim of the POC-CT is to embed a randomized pragmatic trial into routine care; thus, patients are randomized to minimize potential bias, but the study is conducted at the point of care to limit cost and improve the generalizability of the findings. Furthermore, the POC-CT uses an EMR to replace much of the infrastructure associated with a traditional RCT (eg, research team, patient and clinician reminders) and a Bayesian adaptive feature to help limit the number of patients needed for the study. Together, the EMR and Bayesian adaptive feature can improve the overall feasibility of the study and preserve the typical clinical experiences of the patient and clinician., Clinical Advantages: The POC-CT includes the basic tenets of practice-based research because studies are conducted at the point of care, in real-life settings, and during routine clinical practice. If implemented effectively, the POC-CT can be seamlessly integrated into daily clinical practice, allowing investigators to establish patient-reported evidence that may be quickly applied to patient care decisions. This design appears to be a promising approach for CER investigations and may help establish a "learning health care system" in the sports medicine community.

This study builds upon a project that developed clinical criteria to identify undiagnosed hypertension patients "hiding in plain sight" (HIPS) by examining patient characteristics to understand whether there are disparities in hypertension diagnosis. We examined electronic health record demographic data for patients identified by the HIPS criteria and subgroups at 3 Missouri health centers. Identified patients who returned for a follow-up visit and were subsequently diagnosed with hypertension tended to be older, black/African American, uninsured, and classified as having obesity. Younger, white, healthy weight females were less likely to be diagnosed. These findings point to exploring possible biases/other nonclinical factors in hypertension diagnosis.