Search

OBJECTIVE: Primary care clinics are frequently placed in neighborhoods to improve access. Little is known whether or not this improves outcomes. We sought to determine if childhood immunization rates and adult blood pressure (BP) levels are related to proximity of home to clinic. METHOD: We conducted a retrospective chart review in a community family medicine clinic in a neighborhood grocery store (CC) and a hospital-based family medicine residency clinic (HC) in Milwaukee, Wisconsin. Randomly selected subjects included children aged 2-5 years (n = 151 CC; 241 HC) and adult continuity patients (n = 197 CC; 242 HC). ARC-GIS was used to geocode patient home addresses, and distances were analyzed using Kruskal-Wallis, Spearman's rank correlation, or Mann-Whitney test. Proportion of primary immunization by age 2 and age at completion, numerical BP, and proportion abnormal BP were each correlated to distance and driving distance to clinic. RESULTS: Median driving distance of patient to clinic was significantly less for CC than HC (children = 1.47 versus 2.35 miles, p < 0.0001; adults = 1.53 versus 3.12, p < 0.001). For each clinic, and for all subjects combined, and for subsets by gender, ethnicity and insurance status, there was no significant correlation between proportion immunized by age 2 or age at completion and linear or categorical driving distance (or linear distance) to clinic (p = 0.12-0.99), or between BP values or proportion abnormal and distances to clinic (p = 0.44-0.97). CONCLUSIONS: In this urban area, proximity of home to clinic did not correlate with primary immunization completion or blood pressure in either a hospital-based or a community clinic. [ABSTRACT FROM AUTHOR]

Background.--Training in child advocacy is now required in pediatric residency program curricula. No national consensus exists regarding the content of such advocacy training. Objective.--To identify an operational definition of advocacy, as well as knowledge, skills, and attitude objectives for advocacy (raining in pediatric residency programs. Methods.--Professionals experienced in pediatric advocacy and training (n = 53) were invited to participate in a sequence of surveys to define the content of a pediatric residency advocacy curriculum that would result in acquisition of appropriate knowledge, skills, and altitudes related to advocacy for children. Three rounds of surveys were distributed, collected, and analyzed using a modified Delphi technique, in which the results from an antecedent survey were used to reline responses in a subsequent survey. Results.--Participants (n = 36). comprising a group of experienced leaders with diverse training and experience in child advocacy and resident education, created a consensus definition for advocacy. They initially identified 179 possible objectives for advocacy curricula. Through the iterative process of the Delphi technique, 32 of those objectives were identified as necessary for inclusion in a child advocacy curriculum for pediatric residents. Conclusions.--Using a modified Delphi technique, a group of experienced leaders in pediatric advocacy were able to reach consensus on an operational definition of child advocacy and a set of objectives for a resident advocacy curriculum. Programs may use these findings to assist in developing an advocacy curriculum based on their own faculty assets and community resources. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Accreditation Council for Graduate Medical Education now requires pediatric residency programs to include advocacy training, but few guidelines for development exist. PURPOSE: To determine faculty and resident attitudes regarding advocacy training, and to develop consensus on the best method to teach and learn advocacy. METHODS: Pediatric residents (n = 28) and faculty (n = 51) participated in a survey about experience and training in advocacy, identified issues important to address in an advocacy curriculum, and rated a variety of learning methods. RESULTS: Nearly 90% of residents felt advocacy training was needed, and 82% felt advocacy activities would continue following residency. Faculty and residents agreed that participation in short-term or longitudinal projects was the best way to teach and learn advocacy skills. Respondents identified and ranked 45 issues to address through advocacy efforts and training, and these results were used to develop and implement an advocacy curriculum. CONCLUSIONS: Residents and faculty were interested in incorporating an advocacy curriculum, and survey results were used to guide curriculum development. [ABSTRACT FROM AUTHOR]

BACKGROUND: This report describes the 48-month efficacy and benefit-cost analysis of Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled trial of brief physician advice for the treatment of problem drinking. METHODS: Four hundred eighty-two men and 292 women, ages 18-65, were randomly assigned to a control (n = 382) or intervention (n = 392) group. The intervention consisted of two physician visits and two nurse follow-up phone calls. Intervention components included a review of normative drinking, patient-specific alcohol effects, a worksheet on drinking cues, drinking diary cards, and a drinking agreement in the form of a prescription. RESULTS: Subjects in the treatment group exhibited significant reductions (p < 0.01) in 7-day alcohol use, number of binge drinking episodes, and frequency of excessive drinking as compared with the control group. The effect occurred within 6 months of the intervention and was maintained over the 48-month follow-up period. The treatment sample also experienced fewer days of hospitalization (p = 0.05) and fewer emergency department visits (p = 0.08). Seven deaths occurred in the control group and three in the treatment group. The benefit-cost analysis suggests a 43,000 dollars reduction in future health care costs for every 10,000 dollars invested in early intervention. The benefit-cost ratio increases when including the societal benefits of fewer motor vehicle events and crimes. CONCLUSIONS: The long-term follow-up of Project TrEAT provides the first direct evidence that brief physician advice is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs. The report suggests that a patient's personal physician can successfully treat alcohol problems and endorses the implementation of alcohol screening and brief intervention in the US health care system. [ABSTRACT FROM AUTHOR]

BACKGROUND: Studies suggest that 14% of women age 18 to 40 drink alcohol above recommended limits. Of special concern is the increasing use of alcohol by women during pregnancy. This article reports 48 month follow-up data from a subanalysis of a trial for early alcohol treatment (Project TrEAT) focused on women of childbearing age. METHODS: Project TrEAT was conducted in the offices of 64 primary care, community-based physicians from 10 Wisconsin counties. Of 5979 female patients ages 18 to 40 who were screened for problem drinking, 205 were randomized into an experimental group (n = 103) or control group (n = 102). The intervention consisted of two 15 min, physician-delivered counseling visits that included advice, education, and contracting by using a scripted workbook. A total of 174 subjects (85%) completed the 48 month follow-up procedures. RESULTS: No significant differences were found between the experimental and control groups at baseline for alcohol use, age, socioeconomic status, smoking, depression or anxiety, conduct disorder, lifetime drug use, or health care utilization. The trial found a significant treatment effect in reducing both 7 day alcohol use (p = 0.0039) and binge drinking episodes (p = 0.0021) over the 48 month follow-up period. Women in the experimental group who became pregnant during the follow-up period had the most dramatic decreases in alcohol use. A logistic regression model based on a 20% or greater reduction in drinking found an odds ratio of 1.93 (confidence interval 1.07-3.46) in the sample exposed to physician intervention. Age, smoking, depression, conduct disorder, antisocial personality disorder, and illicit drug use did not reduce drinking significantly. No significant differences were found in health care utilization and health status between groups. CONCLUSIONS: This trial provides the first direct evidence that brief intervention is associated with sustained reductions in alcohol consumption by women of childbearing age. The results have enormous implications for the U.S. health care system. [ABSTRACT FROM AUTHOR]

The Trial for Early Alcohol Treatment, Project TrEAT, was a randomized controlled trial of screening and brief intervention in primary care clinics. One of the few such trials to be analyzed in terms of cost-effectiveness, Project TrEAT was examined from two perspectives. The analysis from the perspective of medical care providers focused on clinic and hospital costs, contrasting the benefits that directly reduced medical expenditures with the costs to providers. The analysis from the societal perspective took all of the intervention's costs and benefits into account. Both components of this study revealed that Project TrEAT led to a reduction in alcohol consumption by high-risk drinkers and a corresponding reduction in medical and societal costs. Overall, this study supported the cost-effectiveness of Project TrEAT, concluding that its costs were outweighed by its benefits. [ABSTRACT FROM AUTHOR]

Discusses whether brief advice of physicians to patients with drinking problems is cost effective. Consideration of costs from the perspective of the clinic and patient; Total benefit of the brief intervention; Net benefit per patient. INSET: COMMENTARY.

Importance: Smoking is the leading preventable cause of death and illness in the US. Identifying cost-effective smoking cessation treatment may increase the likelihood that health systems deliver such treatment to their patients who smoke., Objective: To evaluate the cost-effectiveness of standard vs enhanced varenicline use (extended varenicline treatment or varenicline in combination with nicotine replacement therapy) among individuals trying to quit smoking., Design, Setting, and Participants: This economic evaluation assesses the Quitting Using Intensive Treatments Study (QUITS), which randomized 1251 study participants who smoked into 4 conditions: (1) 12-week varenicline monotherapy (n = 315); (2) 24-week varenicline monotherapy (n = 311); (3) 12-week varenicline combination treatment with nicotine replacement therapy patch (n = 314); or (4) 24-week varenicline combination treatment with nicotine replacement therapy patch (n = 311). Study enrollment occurred in Madison and Milwaukee, Wisconsin, between November 11, 2017, and July 2, 2020. Statistical analysis took place from May to October 2023., Main Outcomes and Measures: The primary outcome was 7-day point prevalence abstinence (biochemically confirmed with exhaled carbon monoxide level ≤5 ppm) at 52 weeks. The incremental cost-effectiveness ratio (ICER), or cost per additional person who quit smoking, was calculated using decision tree analysis based on abstinence and cost for each arm of the trial., Results: Of the 1251 participants, mean (SD) age was 49.1 (11.9) years, 675 (54.0%) were women, and 881 (70.4%) completed the 52-week follow-up. Tobacco cessation at 52 weeks was 25.1% (79 of 315) for 12-week monotherapy, 24.4% (76 of 311) for 24-week monotherapy, 23.6% (74 of 314) for 12-week combination therapy, and 25.1% (78 of 311) for 24-week combination therapy, respectively. The total mean (SD) cost was $1175 ($365) for 12-week monotherapy, $1374 ($412) for 12-week combination therapy, $2022 ($813) for 24-week monotherapy, and $2118 ($1058) for 24-week combination therapy. The ICER for 12-week varenicline monotherapy was $4681 per individual who quit smoking and $4579 per quality-adjusted life-year (QALY) added. The ICER for 24-week varenicline combination therapy relative to 12-week monotherapy was $92 000 000 per additional individual who quit smoking and $90 000 000 (95% CI, $15 703 to dominated or more costly and less efficacious) per additional QALY., Conclusions and Relevance: This economic evaluation of standard vs enhanced varenicline treatment for smoking cessation suggests that 12-week varenicline monotherapy was the most cost-effective treatment option at the commonly cited threshold of $100 000/QALY. This study provides patients, health care professionals, and other stakeholders with increased understanding of the health and economic impact of more intensive varenicline treatment options.

Background: Nurses play a critical role in providing evidence-based, high-quality care to optimize patient outcomes. Models from implementation science suggest social networks may influence the adoption of evidence-based practices (EBPs). However, few studies have examined this relationship among hospital nurses. Social network analysis (SNA) mathematically evaluates patterns of communication, a critical step in implementation. Exploring hospital nurses' communication networks may provide insight into influences on the adoption of EBPs., Aims: This study aimed to describe complete communication networks of hospital nurses for practice changes on inpatient units, including upper level nursing administrators., Methods: This descriptive, exploratory, cross-sectional study used SNA on two inpatient units from one hospital. A sociometric survey was completed by nurses (unit to executive level) regarding communication frequency about practice changes. Network-level density, diameter, average path length, centralization, and arc reciprocity were measured. Attribute data were used to explore subnetworks., Results: Surveys from 148 nurses on two inpatient adult intensive care units (response rates 90% and 98%) revealed high communication frequency. Network measures were similar across the two units and among subnetworks. Analysis identified central (charge nurses and nurse leaders) and peripheral members of the network (new-to-practice nurses). Subnetworks aligned with the weekend and shift worked., Linking Evidence to Action: Established communication channels, including subnetworks and opinion leaders, should be used to maximize and optimize implementation strategies and facilitate the uptake of EBPs. Future work should employ SNA to measure the impact of communication networks on promoting the uptake of EBP and to improve patient outcomes., (© 2024 The Authors. Worldviews on Evidence‐based Nursing published by Wiley Periodicals LLC on behalf of Sigma Theta Tau International.)

Introduction: Smoking is the leading preventable cause of death and disease in the U.S. This study evaluates the cost-effectiveness from a healthcare system perspective of a comprehensive primary care intervention to reduce smoking rates., Methods: This pragmatic trial implemented electronic health record prompts during primary care visits and employed certified tobacco cessation specialists to offer proactive outreach and smoking cessation treatment to patients who smoke. The data, analyzed in 2022, included 10,683 patients in the smoking registry from 2017 to 2020. Pre-post analyses compared intervention costs to treatment engagement, successful self-reported smoking cessation, and acute health care utilization (urgent care, emergency department visits, and inpatient hospitalization). Cost per quality-adjusted life year was determined by applying conversion factors obtained from the tobacco research literature to the cost per patient who quit smoking., Results: Tobacco cessation outreach, medication, and counseling costs increased from $2.64 to $6.44 per patient per month, for a total post-implementation intervention cost of $500,216. Smoking cessation rates increased from 1.3% pre-implementation to 8.7% post-implementation, for an incremental effectiveness of 7.4%. The incremental cost-effectiveness ratio was $628 (95% CI: $568, $695) per person who quit smoking, and $905 (95% CI: $822, $1,001) per quality-adjusted life year gained. Acute health care costs decreased by an average of $42 (95% CI: -$59, $145) per patient per month for patients in the smoking registry., Conclusions: Implementation of a comprehensive and proactive smoking cessation outreach and treatment program for adult primary care patients who smoke meets typical cost-effectiveness thresholds for healthcare., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess whether the use of rapid influenza diagnostic tests (RIDTs) for long-term care facility (LTCF) residents with acute respiratory infection is associated with increased antiviral use and decreased health care utilization., Design: Nonblinded, pragmatic, randomized controlled trial evaluating a 2-part intervention with modified case identification criteria and nursing staff-initiated collection of nasal swab specimen for on-site RIDT., Setting and Participants: Residents of 20 LTCFs in Wisconsin matched by bed capacity and geographic location and then randomized., Methods: Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, antiviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalizations, hospitalizations for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over 3 influenza seasons., Results: Oseltamivir use for prophylaxis was higher at intervention LTCFs [2.6 vs 1.9 courses per 1000 person-weeks; rate ratio (RR) 1.38, 95% CI 1.24-1.54; P < .001]; rates of oseltamivir use for influenza treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR 0.78, 95% CI 0.64-0.92; P = .004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR 0.79, 95% CI 0.67-0.93; P = .004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR 0.64, 95% CI 0.0.59-0.69; P < .001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality., Conclusions and Implications: The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across 3 combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Overprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model., Methods: Following qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout., Discussion: This study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings., Trial Registration: ClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303 ., (© 2023. The Author(s).)

Background: The clinical narrative in electronic health records (EHRs) carries valuable information for predictive analytics; however, its free-text form is difficult to mine and analyze for clinical decision support (CDS). Large-scale clinical natural language processing (NLP) pipelines have focused on data warehouse applications for retrospective research efforts. There remains a paucity of evidence for implementing NLP pipelines at the bedside for health care delivery., Objective: We aimed to detail a hospital-wide, operational pipeline to implement a real-time NLP-driven CDS tool and describe a protocol for an implementation framework with a user-centered design of the CDS tool., Methods: The pipeline integrated a previously trained open-source convolutional neural network model for screening opioid misuse that leveraged EHR notes mapped to standardized medical vocabularies in the Unified Medical Language System. A sample of 100 adult encounters were reviewed by a physician informaticist for silent testing of the deep learning algorithm before deployment. An end user interview survey was developed to examine the user acceptability of a best practice alert (BPA) to provide the screening results with recommendations. The planned implementation also included a human-centered design with user feedback on the BPA, an implementation framework with cost-effectiveness, and a noninferiority patient outcome analysis plan., Results: The pipeline was a reproducible workflow with a shared pseudocode for a cloud service to ingest, process, and store clinical notes as Health Level 7 messages from a major EHR vendor in an elastic cloud computing environment. Feature engineering of the notes used an open-source NLP engine, and the features were fed into the deep learning algorithm, with the results returned as a BPA in the EHR. On-site silent testing of the deep learning algorithm demonstrated a sensitivity of 93% (95% CI 66%-99%) and specificity of 92% (95% CI 84%-96%), similar to published validation studies. Before deployment, approvals were received across hospital committees for inpatient operations. Five interviews were conducted; they informed the development of an educational flyer and further modified the BPA to exclude certain patients and allow the refusal of recommendations. The longest delay in pipeline development was because of cybersecurity approvals, especially because of the exchange of protected health information between the Microsoft (Microsoft Corp) and Epic (Epic Systems Corp) cloud vendors. In silent testing, the resultant pipeline provided a BPA to the bedside within minutes of a provider entering a note in the EHR., Conclusions: The components of the real-time NLP pipeline were detailed with open-source tools and pseudocode for other health systems to benchmark. The deployment of medical artificial intelligence systems in routine clinical care presents an important yet unfulfilled opportunity, and our protocol aimed to close the gap in the implementation of artificial intelligence-driven CDS., Trial Registration: ClinicalTrials.gov NCT05745480; https://www.clinicaltrials.gov/ct2/show/NCT05745480., (©Majid Afshar, Sabrina Adelaine, Felice Resnik, Marlon P Mundt, John Long, Margaret Leaf, Theodore Ampian, Graham J Wills, Benjamin Schnapp, Michael Chao, Randy Brown, Cara Joyce, Brihat Sharma, Dmitriy Dligach, Elizabeth S Burnside, Jane Mahoney, Matthew M Churpek, Brian W Patterson, Frank Liao. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 20.04.2023.)

Aims: The aim of this study is to describe primary care nurses' perceptions of their formal leaders' leadership behaviours and outcomes and explore differences based upon nurses' individual and work setting characteristics., Background: Formal nursing leadership is positively associated with patient, nurse workforce and organizational outcomes, yet no studies have examined primary care nurses' perception of formal leadership behaviours and outcomes in the United States., Methods: Cross-sectional survey data from 335 primary care nurses were analysed to assess perceived leadership behaviours associated with transformational, transactional and passive-avoidant leadership styles, perceived leadership outcomes and individual and work setting characteristics., Results: Positive leadership behaviours (transformational) were lower than those reported for other settings. There were significant differences in nurses' perceptions of their leaders' leadership behaviours and outcomes based upon individual and work setting characteristics., Conclusion: This study confirmed differences in perception of leadership and that individual and work setting characteristics influence nurses' perception of their leaders in primary care., Implications for Nursing Management: Leaders must be versatile and consider the unique needs of each staff member and the influence of clinic characteristics., (© 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.)

Objective: This study evaluates the association between primary care team job satisfaction and urgent care, emergency department, and hospital costs for their patients with cardiovascular disease (CVD)., Study Design: Electronic health record (EHR)-extracted observational study alongside a cross-sectional health care professional survey., Methods: A total of 143 health professionals, including physicians and clinical staff, at 5 US primary care clinics participated in a cross-sectional survey about job satisfaction. Urgent care visits, emergency department visits, hospital visit days, and medical costs in the past 12 months for each care team's panel of patients were extracted from the EHR. Three-level hierarchical modelling evaluated the link between team job satisfaction, urgent care visits, emergency department visits, hospital visit days, and medical care costs in the past 12 months for the team's patients with diagnosed CVD., Results: Teams with higher satisfaction with their freedom of work methods, work hours, and income were associated with fewer hospital days (odds ratio = 0.85, 0.72, and 0.81, respectively) and lower medical care costs -$474, -$650, and -$397 per patient, respectively) for their patients with CVD. Overall job satisfaction was not significantly associated with cost of care., Conclusions: Health care employee job satisfaction in primary care is an important factor to consider in efforts to lower medical costs for patients with CVD., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Maternal smoking increases mortality and morbidity risks for both mother and infant. The First Breath Wisconsin study examined the cost-effectiveness of providing incentives to pregnant women who smoked to engage in stop smoking treatment. Participants (N = 1014) were Medicaid-enrolled pregnant women recruited from September 2012 to April 2015 through public health departments, private, and community health clinics in Wisconsin. The incentive group (n = 505) could receive $460 for completing pre-birth visits ($25 each), post-birth home visits ($40, $25, $25, $40 for 1-week, 2-month, 4-month and 6-month visits), monthly smoking cessation phone calls post-birth ($20 each), and biochemically-verified tobacco abstinence at 1-week ($40) and 6-months ($40) post-birth. The control group (n = 509) received up to $80 for 1-week ($40) and 6-month ($40) post-birth assessments. Intervention costs included incentive payments to participants, counselor and administrative staff time, and smoking cessation medications. Cost-effectiveness analysis calculated the incremental cost-effectiveness ratio (ICER) per one additional smoker who quit. The incentive group had higher 6-month post-birth biochemically-confirmed tobacco abstinence than the control group (14.7% vs. 9.2%). Incremental costs averaged $184 per participant for the incentive group compared to controls ($317 vs $133). The ICER of financial incentives was $3399 (95% CI $2228 to $8509) per additional woman who was tobacco abstinent at 6 months post-birth. The ICER was lower ($2518 vs $4760) for women who did not live with another smoker. This study shows use of financial incentives for stop smoking treatment is a cost-effective option for low-income pregnant women who smoke., (Copyright © 2021. Published by Elsevier Inc.)

Background: Syringe service programs (SSPs) are safe, highly effective programs for promoting health among people who inject drugs. However, resource limitations prevent the delivery of a full package of prevention services to many clients in need. Computer-tailored interventions may represent a promising approach for providing prevention information to people who inject drugs in resource-constrained settings., Objective: The aim of this paper is to assess the effect of a computer-tailored behavioral intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among SSP clients., Methods: Using a social network-based recruitment strategy, we recruited clients of an established SSP in Wisconsin and peers from their social networks. Participants completed a computerized baseline survey and were then randomly assigned to receive the Hep-Net intervention. Components of the intervention included an overall risk synthesis, participants' selection of a behavioral goal, and an individualized risk reduction exercise. Individuals were followed up 3 months later to assess their behavior change. The effect of Hep-Net on receiving an HCV screening test, undergoing Narcan training, reducing the frequency of drug use, and sharing drug equipment was assessed. The individual's readiness to change each behavior was also examined., Results: From 2014 to 2015, a total of 235 people who injected drugs enrolled into the Hep-Net study. Of these, 64.3% (151/235) completed the follow-up survey 3-6 months postenrollment. Compared with the control group, individuals who received the Hep-Net intervention were more likely to undergo HCV testing (odds ratio [OR] 2.23, 95% CI 1.05-4.74; P=.04) and receive Narcan training (OR 2.25, 95% CI 0.83-6.06; P=.11), and they shared drug equipment less frequently (OR 0.06, 95% CI 0.55-0.65; P<.001). Similarly, individuals who received the intervention were more likely to advance in their stage of readiness to change these 3 behaviors. However, intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants, despite the fact that the majority of the intervention participants selected this as the primary goal to focus on after participation in the baseline survey., Conclusions: Implementing computer-based risk reduction interventions in SSPs may reduce harms associated with the sharing of injection equipment and prevent overdose deaths; however, brief computerized interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use when implemented in settings centered on the delivery of prevention services., Trial Registration: ClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043., International Registered Report Identifier (irrid): RR1-10.2196/resprot.4830., (©Karli R Hochstatter, Shawnika J Hull, Ajay K Sethi, Marguerite E Burns, Marlon P Mundt, Ryan P Westergaard. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 29.09.2020.)

Background: Low-income smokers experience greater difficulty in quitting smoking than do other smokers. Providing financial incentives for treatment engagement increases smoking cessation success. This study models the cost-effectiveness of varying levels of financial incentives to maximise return on investment (ROI) for engaging low-income Medicaid recipients who smoke to take calls from a tobacco quit line., Methods: Participants (N=1900) were recruited from May 2013 to June 2015 through quit line-based (n=980), clinic-based (n=444) or community-based referrals (n=476) into the Wisconsin Medicaid Quit Line Incentive project. Incentive (n=948) and control group participants (n=952) received $30 versus $0 per call, respectively, for taking up to five Wisconsin Tobacco Quit Line (WTQL) calls. Cost-effectiveness analyses estimated the incremental cost-effectiveness ratio for alternative financial incentives for engagement with WTQL calls. Probabilistic sensitivity analysis was employed to determine an optimal strategy for financial incentives to minimise the cost per individual who quit smoking., Results: Using fixed payments, the incremental cost-effectiveness ratio of $2316 per smoker who quit in the randomised trial decreased to $2150 per smoker who quit when the incentives were modelled at $20 per each of five WTQL calls taken. Using variable payments, the minimal cost per additional smoker who quit was $2125 when incentives for the first four WTQL calls were set at $20, and the financial payment for the fifth WTQL call was set at $70., Conclusions: Modelling suggests that financial incentives in the amount of $20 per call for taking the first four quit line calls and $70 for taking a fifth quit line call maximise ROI to engage low-income smokers with evidence-based smoking cessation treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Whereas communication among health care professionals plays an important role in providing the best quality of care for primary care patients, little evidence exists regarding how professional communication contributes to job satisfaction among health care providers, including physicians and clinical staff, in primary care clinics. This study evaluates the extent to which professional communication networks contribute to job satisfaction among health care professionals in primary care clinics., Methods: A total of 143 health care professionals, including physicians and clinical staff, at 5 US primary care clinics participated in a cross-sectional survey on their communication connections regarding patient care with other care team members and their job satisfaction. Social network analysis calculated core-periphery measures to identify individuals located in a dense cohesive core and in a sparse, loosely connected periphery in the communication network. Generalized linear mixed modeling related core-periphery position of clinic employees in the communication network to job satisfaction, after adjusting for job title, sex, number of years working at the clinic, and percent full-time employment., Results: Average job satisfaction was 5.8 on a scale of 1 to 7. Generalized linear mixed modeling showed that individuals who were in the core of the communication network had significantly greater job satisfaction than those who were on the periphery. Female physicians had lesser overall job satisfaction than other clinic employees., Conclusions: Interventions targeting professional communication networks might improve health care employee job satisfaction at primary care clinics., (© 2019 Annals of Family Medicine, Inc.)

Objectives: To assess the effects of mindfulness-based relapse prevention for alcohol dependence (MBRP-A) intervention on drinking and related consequences., Methods: 123 alcohol-dependent adults in early recovery, recruited from outpatient treatment programs, were randomly assigned to MBRP-A (intervention plus usual-care; N = 64) or Control (usual-care-alone; N = 59) group. MBRP-A consisted of eight-weekly sessions and home practice. Outcomes were assessed at baseline, 8 weeks and 26 weeks (18 weeks post-intervention), and compared between groups using repeated measures analysis., Results: Outcome analysis included 112 participants (57 MBRP-A; 55 Control) who provided follow-up data. Participants were 41.0 ± 12.2 years old, 56.2% male, and 91% white. Prior to "quit date," they reported drinking on 59.4 ± 34.8% (averaging 6.1 ± 5.0 drinks/day) and heavy drinking (HD) on 50.4 ± 35.5% of days. Their drinking reduced after the "quit date" (before enrollment) to 0.4 ± 1.7% (HD: 0.1 ± 0.7%) of days. At 26 weeks, the MBRP-A and control groups reported any drinking on 11.5 ± 22.5% and 5.9 ± 11.6% of days and HD on 4.5 ± 9.3% and 3.2 ± 8.7% of days, respectively, without between-group differences (ps ≥ 0.05) in drinking or related consequences during the follow-up period. Three MBRP-A participants reported "relapse," defined as three-consecutive HD days, during the study. Subgroup analysis indicated that greater adherence to session attendance and weekly home practice minutes were associated with improved outcomes., Conclusions: MBRP-A as an adjunct to usual-care did not show to improve outcomes in alcohol-dependent adults in early recovery compared to usual-care-alone; a return to drinking and relapse to HD were rare in both groups. However, greater adherence to MBRP-A intervention may improve long-term drinking-related outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To determine the cost-effectiveness of an incentive-based stop-smoking intervention that paid Medicaid recipients who smoke to take calls from a tobacco quit line., Methods: A cost-effectiveness analysis was conducted alongside a randomized controlled trial. The analysis was conducted from a health care systems perspective on the basis of costs and effectiveness over a 6-month follow-up. Participants (n = 1900) were recruited from May 2013 to June 2015 through quit line (n = 980), clinic-based (n = 444), or community-based (n = 476) referrals. Incentive group participants (n = 948) received $30 a call for taking up to five tobacco quit line calls and $40 for biochemically verified tobacco abstinence at 6 months. Control group participants (n = 952) did not receive financial incentives for taking quit line calls. Intervention resource costs included incentive payments to participants, counselor and administrative staff time, and smoking cessation medications. Smoking status at baseline and 6 months was determined for all study participants via carbon monoxide (CO) breath tests (abstinence: CO < 7 ppm). Cost-effectiveness analysis calculated the incremental cost-effectiveness ratio (ICER)., Results: Incentive treatment produced higher 6-month CO-confirmed 7-day point-prevalence abstinence than did the control treatment (21.6 vs. 13.8%; P < 0.001). The ICER of the financial incentives intervention was $2316 (95% confidence interval $1582-$4270) per additional person who quit. The study ICER compares favorably with other smoking treatments, such as varenicline combined with proactive telephone counseling, whose ICER has been estimated at $2600 per additional smoker who quits., Conclusions: Use of financial incentives to engage with tobacco quit line treatment is a cost-effective option to enhance smoking cessation rates for low-income smokers., (Copyright © 2019 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

This study investigates how adolescent peer friendship formation relates to help-seeking behavior and how the structure of peer social networks contributes to the creation of social connections by psychological counseling recipients. The study sample comprised 2,264 adolescents ages 12-19 from the National Longitudinal Study of Adolescent Health (Add Health). Stochastic actor-based modeling simulated the co-dependence of peer friendship networks and adolescent help-seeking behavior from an initial data state to a final data state while accounting for social selection and influence effects in the same model. Results indicated that adolescents who sought psychological counseling in the past year nominated 65% more peers as friends than otherwise identical adolescents who did not use psychological services. Adolescent psychological counseling did not contribute to the loss of friends. Users of psychological services were twice as likely to be named as friends in highly interconnected peer social networks (i.e. more friendship connections among their friends), as opposed to individuals in less interconnected peer groups. The findings indicate improved social functioning of adolescents as a result of psychological counseling. The results advocate for use of psychological services and point to the necessity of wide-spread screening and early detection and treatment of mental ill-health among U.S. adolescents. Group interventions targeting building social skills to enhance peer group social network interconnectivity may promote better social connections for adolescent users of psychological counseling.

Objectives: This study seeks to determine how changes in electronic health record (EHR) communication patterns in primary care teams relate to quality of care and costs for patients with diabetes., Study Design: EHR-extracted longitudinal observational study., Methods: A total of 83 health professionals in 19 care teams at 4 primary care clinics associated with a large Midwestern university participated in the study. Counts of messages routed between any 2 team members in the EHR in the past 18 months were extracted. Flow-betweenness, defined as the proportion of information passed indirectly within the team, was calculated. The analysis related changes in team flow-betweenness to changes in emergency department visits, hospital stays, and associated medical costs for the teams' patients with diabetes, while adjusting for team face-to-face communication, patient-level covariates, comorbidities, team size, and clinic fixed effects., Results: Patient hospital visits increased by 13% (standard error [SE] = 6%) for every increase of 1 percentage point in team EHR message forwarding (ie, higher team flow-betweenness). Medical costs increased by $223 (SE = $105) per patient with diabetes in the past 6 months for every increase of 1 percentage point in team flow-betweenness., Conclusions: Primary care teams whose EHR communication reached more team members indirectly (ie, via message forwarding) had worse outcomes and higher medical costs for their patients with diabetes. EHR team communication flow patterns may be an important avenue to explore in raising quality of care and lowering costs for patients with diabetes in primary care.

Weapon-related violent crime is a serious, complex, and multifaceted public health problem. The present study uses data from Waves I and III of Add Health (n = 10,482, 54% female) to examine how friendship group integration and cohesion in adolescence (ages 12-19) is associated with weapon-related criminal activity as a young adult (ages 18-26). Results indicate that greater cohesion in friendship groups is associated with significantly lower weapon-related criminal activity in young adulthood. In addition, for adolescent girls, a greater number of close friendship ties-an indicator of friendship group integration-is associated with less weapon-related criminal activity in young adulthood. These findings suggest that school-based initiatives to facilitate inclusive and cohesive adolescent peer communities may be an effective strategy to curb weapon-related criminal activity in young adulthood.

Objective: Opioid-treated chronic low back pain (CLBP) is debilitating, costly, and often refractory to existing treatments. This secondary analysis aims to pilot-test the hypothesis that mindfulness meditation (MM) can reduce economic burden related to opioid-treated CLBP., Design: Twenty-six-week unblinded pilot randomized controlled trial, comparing MM, adjunctive to usual-care, to usual care alone., Setting: Outpatient., Participants: Thirty-five adults with opioid-treated CLBP (≥30 morphine-equivalent mg/day) for 3 + months enrolled; none withdrew., Intervention: Eight weekly therapist-led MM sessions and at-home practice., Outcome Measures: Costs related to self-reported healthcare utilization, medication use (direct costs), lost productivity (indirect costs), and total costs (direct + indirect costs) were calculated for 6-month pre-enrollment and postenrollment periods and compared within and between the groups., Results: Participants (21 MM; 14 control) were 20 percent men, age 51.8 ± 9.7 years, with severe disability, opioid dose of 148.3 ± 129.2 morphine-equivalent mg/d, and individual annual income of $18,291 ± $19,345. At baseline, total costs were estimated at $15,497 ± 13,677 (direct: $10,635 ± 9,897; indirect: $4,862 ± 7,298) per participant. Although MM group participants, compared to controls, reduced their pain severity ratings and pain sensitivity to heat stimuli (p < 0.05), no statistically significant within-group changes or between-group differences in direct and indirect costs were noted., Conclusions: Adults with opioid-treated CLBP experience a high burden of disability despite the high costs of treatment. Although this pilot study did not show a statistically significant impact of MM on costs related to opioid-treated CLBP, MM can improve clinical outcomes and should be assessed in a larger trial with long-term follow-up.

Background: Research shows that high-functioning teams improve patient outcomes in primary care. However, there is no consensus on a conceptual model of team-based primary care that can be used to guide measurement and performance evaluation of teams., Objective: To qualitatively understand whether the Systems Engineering Initiative for Patient Safety (SEIPS) model could serve as a framework for creating and evaluating team-based primary care., Methods: We evaluated qualitative interview data from 19 clinicians and staff members from 6 primary care clinics associated with a large Midwestern university. All health care clinicians and staff in the study clinics completed a survey of their communication connections to team members. Social network analysis identified key informants for interviews by selecting the respondents with the highest frequency of communication ties as reported by their teammates. Semi-structured interviews focused on communication patterns, team climate and teamwork., Results: Themes derived from the interviews lent support to the SEIPS model components, such as the work system (Team, Tools and Technology, Physical Environment, Tasks and Organization), team processes and team outcomes., Conclusions: Our qualitative data support the SEIPS model as a promising conceptual framework for creating and evaluating primary care teams. Future studies of team-based care may benefit from using the SEIPS model to shift clinical practice to high functioning team-based primary care., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care., Objective: To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes., Methods: A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling., Participants: 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013., Results: Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes., Conclusions: Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care information to the PCP, had greater shared team vision, better patient outcomes, and lower medical costs for their diabetes patient panels., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Identifying and engaging excessive alcohol users in primary care may be an effective way to improve patient health outcomes, reduce alcohol-related acute care events, and lower costs. Little is known about what structures of primary care team communication are associated with alcohol-related patient outcomes., Methods: Using a sociometric survey of primary care clinic communication, this study evaluated the relation between team communication networks and alcohol-related utilization of care and costs. Between May 2013 and December 2013, a total of 155 healthcare employees at 6 primary care clinics participated in a survey on team communication. Three-level hierarchical modeling evaluated the link between connectedness within the care team and the number of alcohol-related emergency department visits, hospital days, and associated medical care costs in the past 12 months for each team's primary care patient panel., Results: Teams (n = 31) whose registered nurses displayed more strong (at least daily) face-to-face ties and strong (at least daily) electronic communication ties had 10% fewer alcohol-related hospital days (rate ratio [RR] = 0.90; 95% confidence interval [CI]: 0.84, 0.97). Furthermore, in an average team size of 19, each additional team member with strong interaction ties across the whole team was associated with $1,030 (95% CI: -$1,819, -$241) lower alcohol-related patient healthcare costs per 1,000 team patients in the past 12 months. Conversely, teams whose primary care practitioner (PCP) had more strong face-to-face communication ties and more weak (weekly or several times a week) electronic communication ties had 12% more alcohol-related hospital days (RR = 1.12; 95% CI: 1.03, 1.23) and $1,428 (95% CI: $378, $2,478) higher alcohol-related healthcare costs per 1,000 patients in the past 12 months. The analyses controlled for patient age, gender, insurance, and comorbidity diagnoses., Conclusions: Excessive alcohol-using patients may fair better if cared for by teams whose face-to-face and electronic communication networks include more team members and whose communication to the PCP has been streamlined to fewer team members., (Copyright © 2015 by the Research Society on Alcoholism.)

Effective team communication is critical in complex settings like hospital intensive care units. A social network analysis study was conducted in a burn intensive care unit, assuming physicians and key members of the nursing and clinical staff would occupy the core of a robust communication network. Clinical team members reported the frequency (0 to 3+ times) of discussion about patient care issues with every other coworker during a 24-hour period. We calculated the proportion of clinical team members completing the questionnaire, created a map (sociogram) of the network, identified central positions, and searched for weak points. A total of 69 coworkers were listed by 48 clinical team members (70% completion rate). There were 626 connections (arcs) present (density = 13.3%). The analysis revealed three distinct sets of team members caring for two sets of patients. The five clinical team members most central to the network included three physicians, a social worker, and a dietitian. We established the feasibility of collecting social network data on this medical team and identified robust communication patterns. This study will be used to guide subsequent data collection from this and other clinical teams to correlate team structural features with clinical process outcomes and patient safety.

Introduction: Gulf War Illness (GWI) affects 1 in 7 returned Persian Gulf War veterans. Quality-of-life impact is large; there is no cure. Chronic sinus symptoms and fatigue are common. Nasal irrigation with saline (NI-S) or xylitol (NI-X) improve sinus symptoms and fatigue in the general population. This trial will assess the effect of NI-S and NI-X on sinus and fatigue symptoms, economic outcomes and pro-inflammatory milieu among participants with GWI., Methods: 75 participants (age 35 to 65 years, 25 in each of three arms) with GWI will be recruited from the Veteran's Administration and the community. They will use routine care for sinus symptoms and fatigue and be randomized to continued usual care alone or additional therapy with NI-S or NI-X. Participants will be able to adjust specific elements of the NI procedure. The primary outcome (Sinonasal Outcome Test, SNOT-20) and other self-reported assessments will occur at baseline, 8 and 26 weeks; lab assessment of pro-inflammatory cellular and cytokine profiles will occur at baseline and 26 weeks. Other outcomes will include fatigue-specific and overall health-related quality of life, pro-inflammatory cellular and cytokine profiles, cost-effectiveness and participant satisfaction., Results: Baseline demographic and clinical data from the first 10 participants show effective participant recruitment, enrollment, randomization, retention and data collection., Conclusion: Early study conduct suggests that our participant-oriented approach will yield high rates of participant adherence and data capture, facilitating robust analysis. Results of this study will clarify the value of NI for chronic sinus symptoms and fatigue among patients with GWI., Clinical Trial Registration: clinicaltrials.gov identifier NCT01700725., (Published by Elsevier Inc.)

Purpose: Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease., Methods: Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months., Results: Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50-0.77) and lower medical care costs (-$556; 95% CI, -$781 to -$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09-1.94) and greater costs ($506; 95% CI, $202-$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes., Conclusions: Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost., (© 2015 Annals of Family Medicine, Inc.)

Objective: This study assessed associations between staffing of a collaborative care program for depression and enrollment in the program and remission rates., Methods: Data were collected from depression care registries at 63 primary care clinics that participated in the initiative through early 2012. Project leaders at the 12 medical groups that operate the clinics were surveyed about the background of care managers and clinic characteristics. Generalized linear mixed models assessed associations of care manager background and configuration of staffing with enrollment and remission rates., Results: Enrollment was higher (p=.050) and there was a trend toward higher remission rates (p=.105) at clinics where care managers were dedicated exclusively to depression care. No differences in outcomes were obtained by registered nurses versus certified medical assistants and licensed practical nurses., Conclusions: Hiring dedicated paraprofessional care managers may maximize the cost-effectiveness of collaborative care programs and should be supported by regulations and reimbursement policies.

Background: Social connections at all stages of life are essential for physical and mental well-being. Of particular importance are social relationships during adolescence that shape adult health behaviors and health outcomes., Objective: The aim of this study was to estimate the association between adolescent peer status in school and later-life quality-adjusted life-years (QALYs) and healthcare costs., Methods: This study used social network and health outcomes data from Wave I (ages 12-18 years) and Wave III (ages 18-24 years) of the US National Longitudinal Study of Adolescent Health (n = 10,578) to compare QALYs and healthcare costs (in 2012 US$) by adolescent peer status in US schools. Generalized linear models controlled for school fixed effects, individual and family characteristics, and US census block neighborhood effects. Non-parametric bootstrapping accounted for residual skewness in QALYs and healthcare costs. Net monetary benefit (NMB) was calculated by converting adjusted 5-year QALYs into US$ values and subtracting 5-year healthcare costs. NMB was then compared across quintiles of adolescent peer status in school at Wave I., Results: Results obtained from non-parametric bootstrapping indicate that adolescents with higher peer status in school experience significantly better health and lower healthcare costs over the next 5 years. At US$50,000 per QALY, adolescents with 8 or more friends achieved NMB of US$214,300 (95 % CI 212,800-215,800) over a 5-year span, in comparison to adolescents with 0-1 friends, who attained US$209,900 (95 % CI 207,900-211,700) NMB. This difference translates into approximately US$4,440 (95 % CI 2,036-6,825) per socially disengaged adolescent in additional health costs and/or reduced QALYs over 5 years., Conclusion: The study calls for randomized controlled trials targeting adolescent peer group structures in schools as a means to promote better health and lower healthcare costs in adulthood.

We use data from the National Longitudinal Survey of Adolescent Health (Add Health) to study how sociability and adolescent alcohol use impact personal income as a young adult. We find that factors which enhance not only individual sociability but also social interaction at the community level are positively linked to future earnings of adolescents. Adolescents whose friends and friends of friends have greater sociability reap long-term labor market rewards into adulthood. After adjusting for individual and community sociability, the effect of teenage alcohol consumption on labor market earnings as young adults is reduced. Our results suggest that earnings premiums associated with adolescent alcohol consumption may be partially explained by social network dynamics.

Background: Adolescents who attend 12-step groups following alcohol and other drug (AOD) treatment are more likely to remain abstinent and to avoid relapse post-treatment. We examined whether 12-step attendance is also associated with a corresponding reduction in health care use and costs., Methods: We used difference-in-difference analysis to compare changes in seven-year follow-up health care use and costs by changes in 12-step participation. Four Kaiser Permanente Northern California AOD treatment programs enrolled 403 adolescents, 13-18-years old, into a longitudinal cohort study upon AOD treatment entry. Participants self-reported 12-step meeting attendance at six-month, one-year, three-year, and five-year follow-up. Outcomes included counts of hospital inpatient days, emergency room (ER) visits, primary care visits, psychiatric visits, AOD treatment costs and total medical care costs., Results: Each additional 12-step meeting attended was associated with an incremental medical cost reduction of 4.7% during seven-year follow-up. The medical cost offset was largely due to reductions in hospital inpatient days, psychiatric visits, and AOD treatment costs. We estimate total medical use cost savings at $145 per year (in 2010 U.S. dollars) per additional 12-step meeting attended., Conclusions: The findings suggest that 12-step participation conveys medical cost offsets for youth who undergo AOD treatment. Reduced costs may be related to improved AOD outcomes due to 12-step participation, improved general health due to changes in social network following 12-step participation, or better compliance to both AOD treatment and 12-step meetings., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Early adolescent alcohol use is a major public health challenge. Without clear guidance on the causal pathways between peers and alcohol use, adolescent alcohol interventions may be incomplete. The objective of this study is to disentangle selection and influence effects associated with the dynamic interplay of adolescent friendships and alcohol use., Methods: The study analyzes data from Add Health, a longitudinal survey of seventh through eleventh grade U.S. students enrolled between 1995 and 1996. A stochastic actor-based model is used to model the co-evolution of alcohol use and friendship connections., Results: Selection effects play a significant role in the creation of peer clusters with similar alcohol use. Friendship nominations between two students who shared the same alcohol use frequency were 3.60 (95% CI: 2.01-9.62) times more likely than between otherwise identical students with differing alcohol use frequency. The model controlled for alternative pathways to friendship nomination including reciprocity, transitivity, and similarities in age, gender, and race/ethnicity. The simulation model did not support a significant friends' influence effect on alcohol behavior., Conclusions: The findings suggest that peer selection plays a major role in alcohol use behavior among adolescent friends. Our simulation results would lend themselves to adolescent alcohol abuse interventions that leverage adolescent social network characteristics.

Fifty percent of college students who drink report alcohol-induced blackouts, and alcohol abusers in general put a heavy burden on the medical care system. Using data drawn from a randomized, controlled alcohol intervention trial at five university sites, our study quantified the costs of visits to emergency departments by college students who experienced blackouts from drinking alcohol. Of 954 students in the study, 52 percent of males and 50 percent of females at the outset of the study had experienced an alcohol-induced blackout in the past year. Of 404 emergency department visits among the study participants over a two-year observation period, about one in eight were associated with blackout drinking. Injuries ranged from broken bones to head and brain injuries requiring computed tomography. We calculate that on a large university campus having more than 40,000 students, blackout-associated emergency department visit costs would range from $469,000 to $546,000 per year. We conclude that blackouts are a strong predictor of emergency department visits for college drinkers and that prevention efforts aimed at students with a history of blackouts might reduce injuries and emergency department costs.

Background: An alcohol-induced memory blackout represents an amnesia to recall events but does not involve a loss of consciousness. Memory blackouts are a common occurrence among college drinkers, but it is not clear if a history of memory blackouts is predictive of future alcohol-related injury above and beyond the risk associated with heavy drinking episodes., Objective: To determine whether baseline memory blackouts can prospectively identify college students with alcohol-related injury in the next 24 months after controlling for heavy drinking days., Methods: Data were analysed from the College Health Intervention Project Study (CHIPS), a randomised controlled trial of screening and brief physician intervention for problem alcohol use among 796 undergraduate and 158 graduate students at four university sites in the USA and one in Canada, conducted from 2004 to 2009. Multivariate analyses used generalised estimating equations with the logit link., Results: The overall 24-month alcohol-related injury rate was 25.6%, with no significant difference between men and women (p=0.51). Alcohol-induced memory blackouts at baseline exhibited a significant dose-response on odds of alcohol-related injury during follow-up, increasing from 1.57 (95% CI 1.13 to 2.19) for subjects reporting 1-2 memory blackouts at baseline to 2.64 (95% CI 1.65 to 4.21) for students acknowledging 6+ memory blackouts at baseline. The link between memory blackouts and injury was mediated by younger age, prior alcohol-related injury, heavy drinking, and sensation-seeking disposition., Conclusions: Memory blackouts are a significant predictor of future alcohol-related injury among college drinkers after adjusting for heavy drinking episodes.

Objective: Early adolescent alcohol use is a major public health problem. Drinking before the 14th birthday is associated with a fourfold increase in risk of alcohol dependence in adulthood. The objective of this study is to evaluate the association between adolescent social network characteristics and alcohol initiation prospectively over time., Methods: The study analyzes data from the National Longitudinal Study of Adolescent Health, a nationally representative survey of 7th- through 11th-grade students enrolled between 1995 and 1996. Generalized estimating equations are used to model the risk of alcohol use initiation at 1-year follow-up among nondrinkers at wave 1 of the study., Results: Both an adolescent's friends' alcohol use and the adolescent's social network characteristics displayed an independent main effect on alcohol initiation. In comparison with abstainers, alcohol initiators had more popular friends as measured by more peer nominations as friends (indegree) and having more friends up to 3 steps removed (3-step reach), and more friends who drank. An adolescent's risk of alcohol use onset increased 13% (95% CI, 4%-22%) for every additional friend with high indegree, 3% (95% CI, 0.3%-6%) for every additional 10 friends within 3-step reach, and 34% (95% CI, 14%-58%) for each additional friend who drank alcohol, and after controlling for confounders., Conclusion: The findings suggest that, in addition to well-established demographic risk factors, adolescents are at heightened risk of alcohol use onset because of their position in the social network in relationship to their friends and the friends of their friends., (Copyright © 2011 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To estimate the familiarity of black inner-city Chicagoans with pediatric folk beliefs identified by key informants., Study Design: Five black staff members at an inner-city clinic identified 10 African American folk beliefs regarding pediatric care. A survey of 606 African American patients in Chicago assessed familiarity with these beliefs, and with medical recommendations regarding immunization and sleep position., Results: The 2 medical recommendations were more familiar and more believed than any of the identified folk beliefs. The most widely known folk belief was that it is dangerous for a woman to go outdoors 4 to 6 weeks after she has a baby, which was familiar to 93% of respondents. The most believed cultural item was that it is bad to stand where an infant has to roll his eyes back to see you, which was familiar to 86% of respondents and thought true by 86% of those familiar with it. Respondents born in a southern state were significantly more likely to have heard of taping a coin over an umbilicus that sticks out (odds ratio [OR], 1.51; 95% confidence interval [Cl], 1.01-2.26; p = .045) and less likely to agree with infant back or side position for sleep (OR, 0.35; 95% CI, 0.14-0.85; p = .021)., Conclusion: The widespread familiarity with specific folk beliefs in this population suggests that an understanding of these beliefs may be important for culturally competent providers of pediatric care in Chicago's inner city. Further research is needed to determine whether these findings are reproducible in other socioeconomic and geographic settings.

Objective: The aim of this study was to test the efficacy of brief physician advice in reducing alcohol use and related harm in college students., Method: The College Health Intervention Projects (CHIPs) is a randomized, controlled clinical trial with 12-month follow-up conducted in five college health clinics in Wisconsin; Washington state; and Vancouver, Canada. Of the 12,900 students screened for high-risk drinking, 484 men and 502 women met inclusion criteria and were randomized into a control (n = 493) or intervention (n = 493) group. Ninety-six percent of students participated in the follow-up procedures. The intervention consisted of two 15-minute counseling visits and two follow-up phone calls, and used motivational interviewing, contracting, diary cards, and take-home exercises., Results: No significant differences were found between groups at baseline on alcohol use, age, socioeconomic or smoking status, rates of depression, or measures of alcohol-related harm. At 12 months, the experimental subjects reduced their 28-day drinking totals by 27.2%, and the control group reduced their totals by 21%. A mixed effects repeated measures model found a statistical difference in favor of the brief-intervention group (beta = 4.7, SE = 2.0, p = .018) in 28-day drinking totals. The total Rutgers Alcohol Problem Index score was also significantly different during the 12-month follow-up period (beta = 0.8, SE = 0.4, p = .033). There was no difference on the other outcome measures of interest, such as frequency of excessive heavy drinking, health care utilization, injuries, drunk driving, depression, or tobacco use., Conclusions: The study supports resource allocation and implementation of alcohol screening and brief physician advice in primary care-based college health clinics.

Purpose: To explore gender differences in prevalence, types, perpetrators, and correlates of recent violence experiences among university students at campus clinics at five universities in the Midwest and Pacific Northwest U.S. and Canada., Methods: Systematic survey of students presenting for routine primary care visits (N=2,091), pencil-and-paper screen for recent emotional and physical violence exposure (past 6 months), demographics, plus sensation-seeking, at-risk alcohol use, and depression. Chi-square tests compared prevalence by gender; correlates for types of violence were analyzed separately for men and women using chi-square with adjusted standardized residuals comparing no violence, intimate partner violence (IPV) and other violence (Other)., Results: Similar rates of men (17%) and women (16%) reported any violence in the past 6 months; women were more likely to report emotional and men to report physical violence. Of those reporting emotional violence, 45.5% women and 50% men indicated it was IPV, and 23.7% women and 20.9% men reported physical IPV. Correlates differed by gender; demographics were not linked to IPV. At-risk drinking was associated with both IPV and Other violence for women, but only Other violence for men. Depression was the only correlate significantly linked to IPV for men., Conclusions: Recent violence exposure among university students affects nearly one in five attending campus clinics. Screening for violence exposure should include both men and women, especially students who indicate heavy drinking patterns or depressive symptoms. Campus health promotion interventions should address healthy dating relationships. Further research on IPV among college men is needed.

Background: Despite the enormous burden of alcohol-related injuries, the direct connection between college drinking and physical injury has not been well understood. The goal of this study was to assess the connection between alcohol consumption levels and college alcohol-related injury risk., Methods: A total of 12,900 college students seeking routine care in 5 college health clinics completed a general Health Screening Survey. Of these, 2,090 students exceeded at-risk alcohol use levels and participated in a face-to-face interview to determine eligibility for a brief alcohol intervention trial. The eligibility interview assessed past 28-day alcohol use and alcohol-related injuries in the past 6 months. Risk of alcohol-related injury was compared across daily drinking quantities and frequencies. Logistic regression analysis and the Bayesian Information Criterion were applied to compute the odds of alcohol-related injury based on daily drinking totals after adjusting for age, race, site, body weight, and sensation seeking., Results: Male college students in the study were 19% more likely (95% CI: 1.12-1.26) to suffer an alcohol-related injury with each additional day of consuming 8 or more drinks. Injury risks among males increased marginally with each day of consuming 5 to 7 drinks (odds ratio = 1.03, 95% CI: 0.94-1.13). Female participants were 10% more likely (95% CI: 1.04-1.16) to suffer an alcohol-related injury with each additional day of drinking 5 or more drinks. Males (OR = 1.69, 95% CI: 1.14-2.50) and females (OR = 1.81, 95% CI: 1.27-2.57) with higher sensation-seeking scores were more likely to suffer alcohol-related injuries., Conclusions: College health clinics may want to focus limited alcohol injury prevention resources on students who frequently engage in extreme drinking, defined in this study as 8+M/5+F drinks per day, and score high on sensation-seeking disposition.

Background: The Wisconsin Upper Respiratory Symptom Survey (WURSS) is an illness-specific health-related quality-of-life questionnaire outcomes instrument., Objectives: Research questions were: 1) How well does the WURSS-21 assess the symptoms and functional impairments associated with common cold? 2) How well can this instrument measure change over time (responsiveness)? 3) What is the minimal important difference (MID) that can be detected by the WURSS-21? 4) What are the descriptive statistics for area under the time severity curve (AUC)? 5) What sample sizes would trials require to detect MID or AUC criteria? 6) What does factor analysis tell us about the underlying dimensional structure of the common cold? 7) How reliable are items, domains, and summary scores represented in WURSS? 8) For each of these considerations, how well does the WURSS-21 compare to the WURSS-44, Jackson, and SF-8?, Study Design and Setting: People with Jackson-defined colds were recruited from the community in and around Madison, Wisconsin. Participants were enrolled within 48 hours of first cold symptom and monitored for up to 14 days of illness. Half the sample filled out the WURSS-21 in the morning and the WURSS-44 in the evening, with the other half reversing the daily order. External comparators were the SF-8, a 24-hour recall general health measure yielding separate physical and mental health scores, and the eight-item Jackson cold index, which assesses symptoms, but not functional impairment or quality of life., Results: In all, 230 participants were monitored for 2,457 person-days. Participants were aged 14 to 83 years (mean 34.1, SD 13.6), majority female (66.5%), mostly white (86.0%), and represented substantive education and income diversity. WURSS-21 items demonstrated similar performance when embedded within the WURSS-44 or in the stand-alone WURSS-21. Minimal important difference (MID) and Guyatt's responsiveness index were 10.3, 0.71 for the WURSS-21 and 18.5, 0.75 for the WURSS-44. Factorial analysis suggested an eight dimension structure for the WURSS-44 and a three dimension structure for the WURSS-21, with composite reliability coefficients ranging from 0.87 to 0.97, and Cronbach's alpha ranging from 0.76 to 0.96. Both WURSS versions correlated significantly with the Jackson scale (W-21 R=0.85; W-44 R=0.88), with the SF-8 physical health (W-21 R=-0.79; W-44 R=-0.80) and SF-8 mental health (W-21 R=-0.55; W-44 R=-0.60)., Conclusion: The WURSS-44 and WURSS-21 perform well as illness-specific quality-of-life evaluative outcome instruments. Construct validity is supported by the data presented here. While the WURSS-44 covers more symptoms, the WURSS-21 exhibits similar performance in terms of reliability, responsiveness, importance-to-patients, and convergence with other measures.

Accidents stemming from alcohol-impaired driving are the leading cause of injury and death among college students. Research has implicated certain driver personality characteristics in the majority of these motor vehicle crashes. Sensation seeking in particular has been linked to risky driving, alcohol consumption, and driving while intoxicated. This study investigated the effect of sensation seeking on self-reported alcohol-impaired driving behavior in a college student population while adjusting for demographics, residence and drinking locations. A total of 1587 college students over the age of 18 completed a health screening survey while presenting for routine, non-urgent care at campus heath services centers. Student demographics, living situation, most common drinking location, heavy episodic drinking, sensation-seeking disposition and alcohol-impaired driving behavior were assessed. Using a full-form logistic regression model to isolate sensation seeking after adjusting for covariates, sensation seeking remains a statistically significant independent predictor of alcohol-impaired driving behavior (OR=1.52; CI=1.19-1.94; p<0.001). Older, white, sensation-seeking college students who engage in heavy episodic drinking, live off-campus, and go to bars are at highest risk for alcohol-impaired driving behaviors. Interventions should target sensation seekers and environmental factors that mediate the link between sensation seeking and alcohol-impaired driving behaviors.