Is Bigger Better?: A Closer Look at Small Health Systems in the United States.

BACKGROUND: Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems. OBJECTIVES: Compare the characteristics, quality, and costs of care between small and large health systems. RESEARCH DESIGN: Retrospective, repeated cross-sectional analysis. SUBJECTS: Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017. MEASURES: We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs. RESULTS: The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care. CONCLUSIONS: Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.

Longitudinal Associations Between Changes in Cigarette Smoking and Alcohol Use, Eating Behavior, Perceived Stress, and Self-Rated Health in a Cohort of Low-Income Black Adults.

BACKGROUND: Black adults in the U.S. experience significant health disparities related to tobacco use and obesity. Conducting observational studies of the associations between smoking and other health behaviors and indicators among Black adults may contribute to the development of tailored interventions. PURPOSE: We examined associations between change in cigarette smoking and alcohol use, body mass index, eating behavior, perceived stress, and self-rated health in a cohort of Black adults who resided in low-income urban neighborhoods and participated in an ongoing longitudinal study. METHODS: Interviews were conducted in 2011, 2014, and 2018; participants (N = 904) provided at least two waves of data. We fit linear and logistic mixed-effects models to evaluate how changes in smoking status from the previous wave to the subsequent wave were related to each outcome at that subsequent wave. RESULTS: Compared to repeated smoking (smoking at previous and subsequent wave), repeated nonsmoking (nonsmoking at previous and subsequent wave) was associated with greater likelihood of recent dieting (OR = 1.59, 95% CI [1.13, 2.23], p = .007) and future intention (OR = 2.19, 95% CI [1.61, 2.98], p < .001) and self-efficacy (OR = 1.64, 95% CI [1.21, 2.23], p = .002) to eat low calorie foods, and greater odds of excellent or very good self-rated health (OR = 2.47, 95% CI [1.53, 3.99], p < .001). Transitioning from smoking to nonsmoking was associated with greater self-efficacy to eat low calorie foods (OR = 1.89, 95% CI [1.1, 3.26], p = .021), and lower perceived stress (ß = -0.69, 95% CI [-1.34, -0.05], p = .036). CONCLUSIONS: We found significant longitudinal associations between smoking behavior and eating behavior, perceived stress, and self-rated health. These findings have implications for the development of multiple behavior change programs and community-level interventions and policies.

Factors related to health civic engagement: results from the 2018 National Survey of Health Attitudes to understand progress towards a Culture of Health.

BACKGROUND: Civic engagement, including voting, volunteering, and participating in civic organizations, is associated with better psychological, physical and behavioral health and well-being. In addition, civic engagement is increasingly viewed (e.g., in Robert Wood Johnson Foundation's Culture of Health action framework) as a potentially important driver for raising awareness of and addressing unhealthy conditions in communities. As such, it is important to understand the factors that may promote civic engagement, with a particular focus on the less-understood, health civic engagement, or civic engagement in health-related and health-specific activities. Using data from a nationally representative sample of adults in the United States (U.S.), we examined whether the extent to which individuals feel they belong in their community (i.e., perceived sense of community) and the value they placed on investing in community health were associated with individuals' health civic engagement. METHODS: Using data collected on 7187 nationally representative respondents from the 2018 National Survey of Health Attitudes, we examined associations between sense of community, valued investment in community health, and perceived barriers to taking action to invest in community health, with health civic engagement. We constructed continuous scales for each of these constructs and employed multiple linear regressions adjusting for multiple covariates including U.S. region and city size of residence, educational attainment, family income, race/ethnicity, household size, employment status, and years living in the community. RESULTS: Participants who endorsed (i.e., responded with mostly or completely) all 16 sense of community scale items endorsed an average of 22.8% (95%CI: 19.8-25.7%) more of the health civic engagement scale items compared with respondents who did not endorse any of the sense of community items. Those who endorsed (responded that it was an important or top priority) all items capturing valued investment in community health endorsed 14.0% (95%CI: 11.2-16.8%) more of the health civic engagement items than those who did not endorse any valued investment in community health items. CONCLUSIONS: Health civic engagement, including voting and volunteering to ultimately guide government decisions about health issues, may help improve conditions that influence health and well-being for all. Focusing on individuals' sense of community and highlighting investments in community health may concurrently be associated with increased health civic engagement and improved community and population health.

Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use.

BACKGROUND: Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes. OBJECTIVES: To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior RESEARCH DESIGN: Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system. PARTICIPANTS: A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews. MAIN MEASURES: Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up. KEY RESULTS: The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated. CONCLUSIONS: This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.

Boosting medical diagnostics by pooling independent judgments.

Collective intelligence refers to the ability of groups to outperform individual decision makers when solving complex cognitive problems. Despite its potential to revolutionize decision making in a wide range of domains, including medical, economic, and political decision making, at present, little is known about the conditions underlying collective intelligence in real-world contexts. We here focus on two key areas of medical diagnostics, breast and skin cancer detection. Using a simulation study that draws on large real-world datasets, involving more than 140 doctors making more than 20,000 diagnoses, we investigate when combining the independent judgments of multiple doctors outperforms the best doctor in a group. We find that similarity in diagnostic accuracy is a key condition for collective intelligence: Aggregating the independent judgments of doctors outperforms the best doctor in a group whenever the diagnostic accuracy of doctors is relatively similar, but not when doctors' diagnostic accuracy differs too much. This intriguingly simple result is highly robust and holds across different group sizes, performance levels of the best doctor, and collective intelligence rules. The enabling role of similarity, in turn, is explained by its systematic effects on the number of correct and incorrect decisions of the best doctor that are overruled by the collective. By identifying a key factor underlying collective intelligence in two important real-world contexts, our findings pave the way for innovative and more effective approaches to complex real-world decision making, and to the scientific analyses of those approaches.

Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care: A Matched Cohort Study.

Background: Bariatric surgery improves glycemic control in patients with type 2 diabetes mellitus (T2DM), but less is known about microvascular outcomes. Objective: To investigate the relationship between bariatric surgery and incident microvascular complications of T2DM. Design: Retrospective matched cohort study from 2005 to 2011 with follow-up through September 2015. Setting: 4 integrated health systems in the United States. Participants: Patients aged 19 to 79 years with T2DM who had bariatric surgery (n = 4024) were matched on age, sex, body mass index, hemoglobin A1c level, insulin use, diabetes duration, and intensity of health care use up to 3 nonsurgical participants (n = 11 059). Intervention: Bariatric procedures (76% gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) compared with usual care. Measurements: Adjusted Cox regression analysis investigated time to incident microvascular disease, defined as first occurrence of diabetic retinopathy, neuropathy, or nephropathy. Results: Median follow-up was 4.3 years for both surgical and nonsurgical patients. Bariatric surgery was associated with significantly lower risk for incident microvascular disease at 5 years (16.9% for surgical vs. 34.7% for nonsurgical patients; adjusted hazard ratio [HR], 0.41 [95% CI, 0.34 to 0.48]). Bariatric surgery was associated with lower cumulative incidence at 5 years of diabetic neuropathy (7.2% for surgical vs. 21.4% for nonsurgical patients; HR, 0.37 [CI, 0.30 to 0.47]), nephropathy (4.9% for surgical vs. 10.0% for nonsurgical patients; HR, 0.41 [CI, 0.29 to 0.58]), and retinopathy (7.2% for surgical vs. 11.2% for nonsurgical patients; HR, 0.55 [CI, 0.42 to 0.73]). Limitation: Electronic health record databases could misclassify microvascular disease status for some patients. Conclusion: In this large, multicenter study of adults with T2DM, bariatric surgery was associated with lower overall incidence of microvascular disease (including lower risk for neuropathy, nephropathy, and retinopathy) than usual care. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

Does Documented Brief Intervention Predict Decreases in Alcohol Use in Primary Care?

BACKGROUND: Brief intervention (BI) is recommended for patients with unhealthy alcohol use, but the effectiveness of BI in usual care settings remains unclear. OBJECTIVE: We evaluated whether BI predicts decreases in drinking 6 months after a positive screen for unhealthy alcohol use. METHOD: We enrolled patients who recently screened positive for unhealthy alcohol use during a routine screen in Veterans Health Administration primary care. We conducted medical record review to assess whether providers documented advice to reduce or abstain, feedback about risks to health, feedback about how patient drinking compares to norms or recommended limits, and discussion of drinking-related goals. BI elements were coded from 7 days before the date of the positive screen to 60 days after. We conducted baseline and 6-month follow-up telephone interviews to assess change in past 30-day drinking. We fit regression models examining each BI element and another model for the total count of instances of any combination of elements. RESULTS: Of the 327 patients included, 86% had at least one documented instance of receiving advice, 86% had risk feedback, 55% had normative feedback, 38% had goal discussion, and 75% had three or more instances of any combination of elements of BI. None of the individual BI elements, nor the total number of instances, were significantly associated with decreased drinking. CONCLUSIONS: Results suggest that provider documentation of elements of BI and increasing numbers of instances of BI elements were not associated with decreased heavy drinking at 6-month follow-up among patients identified with unhealthy alcohol use.

Association Between Bariatric Surgery and Macrovascular Disease Outcomes in Patients With Type 2 Diabetes and Severe Obesity.

Importance: Macrovascular disease is a leading cause of morbidity and mortality for patients with type 2 diabetes, and medical management, including lifestyle changes, may not be successful at lowering risk. Objective: To investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. Design, Setting, and Participants: In this retrospective, matched cohort study, patients with severe obesity (body mass index ≥35) aged 19 to 79 years with diabetes who underwent bariatric surgery from 2005 to 2011 in 4 integrated health systems in the United States (n = 5301) were matched to 14 934 control patients on site, age, sex, body mass index, hemoglobin A1c, insulin use, observed diabetes duration, and prior health care utilization, with follow-up through September 2015. Exposures: Bariatric procedures (76% Roux-en-Y gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) were compared with usual care for diabetes. Main Outcomes and Measures: Multivariable-adjusted Cox regression analysis investigated time to incident macrovascular disease (defined as first occurrence of coronary artery disease [acute myocardial infarction, unstable angina, percutaneous coronary intervention, or coronary artery bypass grafting] or cerebrovascular events [ischemic stroke, hemorrhagic stroke, carotid stenting, or carotid endarterectomy]). Secondary outcomes included coronary artery disease and cerebrovascular outcomes separately. Results: Among a combined 20 235 surgical and nonsurgical patients, the mean (SD) age was 50 (10) years; 76% of the surgical and 75% of the nonsurgical patients were female; and the baseline mean (SD) body mass index was 44.7 (6.9) and 43.8 (6.7) in the surgical and nonsurgical groups, respectively. At the end of the study period, there were 106 macrovascular events in surgical patients (including 37 cerebrovascular and 78 coronary artery events over a median of 4.7 years; interquartile range, 3.2-6.2 years) and 596 events in the matched control patients (including 227 cerebrovascular and 398 coronary artery events over a median of 4.6 years; interquartile range, 3.1-6.1 years). Bariatric surgery was associated with a lower composite incidence of macrovascular events at 5 years (2.1% in the surgical group vs 4.3% in the nonsurgical group; hazard ratio, 0.60 [95% CI, 0.42-0.86]), as well as a lower incidence of coronary artery disease (1.6% in the surgical group vs 2.8% in the nonsurgical group; hazard ratio, 0.64 [95% CI, 0.42-0.99]). The incidence of cerebrovascular disease was not significantly different between groups at 5 years (0.7% in the surgical group vs 1.7% in the nonsurgical group; hazard ratio, 0.69 [95% CI, 0.38-1.25]). Conclusions and Relevance: In this observational study of patients with type 2 diabetes and severe obesity who underwent surgery, compared with those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes. The findings require confirmation in randomized clinical trials. Health care professionals should engage patients with severe obesity and type 2 diabetes in a shared decision making conversation about the potential role of bariatric surgery in the prevention of macrovascular events.

Learning About Missing Data Mechanisms in Electronic Health Records-based Research: A Survey-based Approach.

BACKGROUND: Bias due to missing data is a major concern in electronic health record (EHR)-based research. As part of an ongoing EHR-based study of weight change among patients treated for depression, we conducted a survey to investigate determinants of missingness in the available weight information and to evaluate the missing-at-random assumption. METHODS: We identified 8,345 individuals enrolled in a large EHR-based health care system who had monotherapy treatment for depression from April 2008 to March 2010. A stratified sample of 1,153 individuals completed a detailed survey. Logistic regression was used to investigate determinants of whether a patient (1) had an opportunity to be weighed at treatment initiation (baseline), and (2) had a weight measurement recorded. Parallel analyses were conducted to investigate missingness during follow-up. Throughout, inverse-probability weighting was used to adjust for the design and survey nonresponse. Analyses were also conducted to investigate potential recall bias. RESULTS: Missingness at baseline and during follow-up was associated with numerous factors not routinely collected in the EHR including whether or not the patient had ever chosen not to be weighed, external weight control activities, and self-reported baseline weight. Patient attitudes about their weight and perceptions regarding the potential impact of their depression treatment on weight were not related to missingness. CONCLUSION: Adopting a comprehensive strategy to investigate missingness early in the research process gives researchers information necessary to evaluate key assumptions. While the survey presented focuses on outcome data, the overarching strategy can be applied to any and all data elements subject to missingness.

The Association of Panic Disorder, Posttraumatic Stress Disorder, and Major Depression With Smoking in American Indians.

INTRODUCTION: Rates of cigarette smoking are disproportionately high among American Indian populations, although regional differences exist in smoking prevalence. Previous research has noted that anxiety and depression are associated with higher rates of cigarette use. We asked whether lifetime panic disorder, posttraumatic stress disorder, and major depression were related to lifetime cigarette smoking in two geographically distinct American Indian tribes. METHODS: Data were collected in 1997-1999 from 1506 Northern Plains and 1268 Southwest tribal members; data were analyzed in 2009. Regression analyses examined the association between lifetime anxiety and depressive disorders and odds of lifetime smoking status after controlling for sociodemographic variables and alcohol use disorders. Institutional and tribal approvals were obtained for all study procedures, and all participants provided informed consent. RESULTS: Odds of smoking were two times higher in Southwest participants with panic disorder and major depression, and 1.7 times higher in those with posttraumatic stress disorder, after controlling for sociodemographic variables. After accounting for alcohol use disorders, only major depression remained significantly associated with smoking. In the Northern Plains, psychiatric disorders were not associated with smoking. Increasing psychiatric comorbidity was significantly linked to increased smoking odds in both tribes, especially in the Southwest. CONCLUSIONS: This study is the first to examine the association between psychiatric conditions and lifetime smoking in two large, geographically diverse community samples of American Indians. While the direction of the relationship between nicotine use and psychiatric disorders cannot be determined, understanding unique social, environmental, and cultural differences that contribute to the tobacco-psychiatric disorder relationship may help guide tribe-specific commercial tobacco control strategies.

Radiographers supporting radiologists in the interpretation of screening mammography: a viable strategy to meet the shortage in the number of radiologists.

BACKGROUND: An alternative approach to the traditional model of radiologists interpreting screening mammography is necessary due to the shortage of radiologists to interpret screening mammograms in many countries. METHODS: We evaluated the performance of 15 Mexican radiographers, also known as radiologic technologists, in the interpretation of screening mammography after a 6 months training period in a screening setting. Fifteen radiographers received 6 months standardized training with radiologists in the interpretation of screening mammography using the Breast Imaging Reporting and Data System (BI-RADS) system. A challenging test set of 110 cases developed by the Breast Cancer Surveillance Consortium was used to evaluate their performance. We estimated sensitivity, specificity, false positive rates, likelihood ratio of a positive test (LR+) and the area under the subject-specific Receiver Operating Characteristic (ROC) curve (AUC) for diagnostic accuracy. A mathematical model simulating the consequences in costs and performance of two hypothetical scenarios compared to the status quo in which a radiologist reads all screening mammograms was also performed. RESULTS: Radiographer's sensitivity was comparable to the sensitivity scores achieved by U.S. radiologists who took the test but their false-positive rate was higher. Median sensitivity was 73.3 % (Interquartile range, IQR: 46.7-86.7 %) and the median false positive rate was 49.5 % (IQR: 34.7-57.9 %). The median LR+ was 1.4 (IQR: 1.3-1.7 %) and the median AUC was 0.6 (IQR: 0.6-0.7). A scenario in which a radiographer reads all mammograms first, and a radiologist reads only those that were difficult for the radiographer, was more cost-effective than a scenario in which either the radiographer or radiologist reads all mammograms. CONCLUSIONS: Given the comparable sensitivity achieved by Mexican radiographers and U.S. radiologists on a test set, screening mammography interpretation by radiographers appears to be a possible adjunct to radiologists in countries with shortages of radiologists. Further studies are required to assess the effectiveness of different training programs in order to obtain acceptable screening accuracy, as well as the best approaches for the use of non-physician readers to interpret screening mammography.

Educational interventions to improve screening mammography interpretation: a randomized controlled trial.

OBJECTIVE: The objective of our study was to conduct a randomized controlled trial of educational interventions that were created to improve performance of screening mammography interpretation. MATERIALS AND METHODS: We randomly assigned physicians who interpret mammography to one of three groups: self-paced DVD, live expert-led educational seminar, or control. The DVD and seminar interventions used mammography cases of varying difficulty and provided associated teaching points. Interpretive performance was compared using a pretest-posttest design. Sensitivity, specificity, and positive predictive value (PPV) were calculated relative to two outcomes: cancer status and consensus of three experts about recall. The performance measures for each group were compared using logistic regression adjusting for pretest performance. RESULTS: One hundred two radiologists completed all aspects of the trial. After adjustment for preintervention performance, the odds of improved sensitivity for correctly identifying a lesion relative to expert recall were 1.34 times higher for DVD participants than for control subjects (95% CI, 1.00-1.81; p = 0.050). The odds of an improved PPV for correctly identifying a lesion relative to both expert recall (odds ratio [OR] = 1.94; 95% CI, 1.24-3.05; p = 0.004) and cancer status (OR = 1.81; 95% CI, 1.01-3.23; p = 0.045) were significantly improved for DVD participants compared with control subjects, with no significant change in specificity. For the seminar group, specificity was significantly lower than the control group (OR relative to expert recall = 0.80; 95% CI, 0.64-1.00; p = 0.048; OR relative to cancer status = 0.79; 95% CI, 0.65-0.95; p = 0.015). CONCLUSION: In this randomized controlled trial, the DVD educational intervention resulted in a significant improvement in screening mammography interpretive performance on a test set, which could translate into improved interpretative performance in clinical practice.

Uptake and positive predictive value of fecal occult blood tests: A randomized controlled trial.

OBJECTIVE: The aim of this study is to compare the uptake of three mailed high-sensitivity fecal occult blood tests (FOBTs). METHODS: We conducted a parallel 3-arm randomized controlled trial in an integrated healthcare delivery system in Washington State. From January 2010 through February 2011, automated data were used to identify potentially eligible patients aged 50-74 due for colorectal cancer screening. Participants were mailed one of three FOBT kits (1-sample OC-Auto® fecal immunochemical test [FIT], 2-sample InSure® FIT, or 3-sample guaiac Hemoccult SENSA®), instructions, and a postage-paid return envelope. We performed a modified intent-to-treat analysis with return of any FOBT within 6 months of randomization as the primary outcome. RESULTS: Of the 9922 people invited, 2873 returned surveys, 2263 were randomized, and 2234 were analyzed. FOBTs were returned by 1431 participants. At 6 months post-randomization, the proportions screened by any FOBT were 0.69 (95% confidence interval [CI] 0.66-0.72) for the OC-Auto arm, 0.64 (95% CI: 0.61-0.68) for the InSure arm, and 0.61 (95% CI: 0.58-0.65) for the Hemoccult SENSA arm (P<0.001 for any difference). Pairwise comparisons showed significant differences between the OC-Auto group and each of the other groups after correction for multiple comparisons. CONCLUSION: Uptake of mailed FOBT kits varies by kit type.

Using multiple imputations to accommodate time-outs in online interventions.

BACKGROUND: Accurately estimating the period of time that individuals are exposed to online intervention content is important for understanding program engagement. This can be calculated from time-stamped data reflecting navigation to and from individual webpages. Prolonged periods of inactivity are commonly handled with a time-out feature and assigned a prespecified exposure duration. Unfortunately, this practice can lead to biased results describing program exposure. OBJECTIVE: The aim of the study was to describe how multiple imputations can be used to better account for the time spent viewing webpages that result in a prolonged period of inactivity or a time-out. METHODS: To illustrate this method, we present data on time-outs collected from the Q(2) randomized smoking cessation trial. For this analysis, we evaluate the effects on intervention exposure of receiving content written in a prescriptive versus motivational tone. Using multiple imputations, we created five complete datasets in which the time spent viewing webpages that resulted in a time-out were replaced with values estimated with imputation models. We calculated standard errors using Rubin's formulas to account for the variability due to the imputations. We also illustrate how current methods of accounting for time-outs (excluding timed-out page views or assigning an arbitrary viewing time) can influence conclusions about participant engagement. RESULTS: A total of 63.00% (1175/1865) of participants accessed the online intervention in the Q(2) trial. Of the 6592 unique page views, 683 (10.36%, 683/6592) resulted in a time-out. The median time spent viewing webpages that did not result in a time-out was 1.07 minutes. Assuming participants did not spend any time viewing a webpage that resulted in a time-out, no difference between the two message tones was observed (ratio of mean time online: 0.87, 95% CI 0.75-1.02). Assigning 30 minutes of viewing time to all page views that resulted in a time-out concludes that participants who received content in a motivational tone spent less time viewing content (ratio of mean time online: 0.86, 95% CI 0.77-0.98) than those participants who received content in a prescriptive tone. Using multiple imputations to account for time-outs concludes that there is no difference in participant engagement between the two message tones (ratio of mean time online: 0.87; 95% CI 0.75-1.01). CONCLUSIONS: The analytic technique chosen can significantly affect conclusions about online intervention engagement. We propose a standardized methodology in which time spent viewing webpages that result in a time-out is treated as missing information and corrected with multiple imputations. TRIAL REGISTRATION: Clinicaltrials.gov NCT00992264; http://clinicaltrials.gov/ct2/show/NCT00992264 (Archived by WebCite at http://www.webcitation.org/6Kw5m8EkP).

The effect of program design on engagement with an internet-based smoking intervention: randomized factorial trial.

BACKGROUND: Participant engagement influences treatment effectiveness, but it is unknown which intervention design features increase treatment engagement for online smoking cessation programs. OBJECTIVE: We explored the effects of 4 design features (ie, factors) on early engagement with an Internet-based, motivational smoking cessation program. METHODS: Smokers (N=1865) were recruited from a large health care organization to participate in an online intervention study, regardless of their interest in quitting smoking. The program was intended to answer smokers' questions about quitting in an effort to motivate and support cessation. Consistent with the screening phase in the multiphase optimization strategy (MOST), we used a 2-level, full-factorial design. Each person was randomized to 1 of 2 levels of each factor, including message tone (prescriptive vs motivational), navigation autonomy (dictated vs not), proactive email reminders (yes vs no), and inclusion of personally tailored testimonials (yes vs no). The effects of each factor level on program engagement during the first 2 months of enrollment were compared, including number of visits to the website resulting in intervention content views (as opposed to supplemental content views), number of intervention content areas viewed, number of intervention content pages viewed, and duration of time spent viewing this content, as applicable to each factor. RESULTS: Adjusting for baseline readiness to quit, persons who received content written in a prescriptive tone made the same number of visits to the website as persons receiving content in a motivational tone, but viewed 1.17 times as many content areas (95% CI 1.08-1.28; P<.001) and 1.15 times as many pages (95% CI 1.04-1.28; P=.009). Time spent viewing materials did not differ among groups (P=.06). Persons required to view content in a dictated order based on their initial readiness to quit made the same number of visits as people able to freely navigate the site, but viewed fewer content areas (ratio of means 0.80, 95% CI 0.74-0.87; P<.001), 1.17 times as many pages (95% CI 1.06-1.31; P=.003), and spent 1.37 times more minutes online (95% CI 1.17-1.59; P<.001). Persons receiving proactive email reminders made 1.20 times as many visits (95% CI 1.09-1.33; P<.001), viewed a similar number of content areas as persons receiving no reminders, viewed 1.58 times as many pages (95% CI 1.48-1.68; P<.001), and spent 1.51 times as many minutes online (95% CI 1.29-1.77; P<.001) as those who did not receive proactive emails. Tailored testimonials did not significantly affect engagement. CONCLUSIONS: Using a prescriptive message tone, dictating content viewing order, and sending reminder emails each resulted in greater program engagement relative to the contrasting level of each experimental factor. The results require replication, but suggest that a more directive interaction style may be preferable for online cessation programs. TRIAL REGISTRATION: clinicaltrials.gov NCT00992264; http://clinicaltrials.gov/ct2/show/NCT00992264 (Archived by WebCite at http://www.webcitation.org/6F7H7lr3P).

Is confidence of mammographic assessment a good predictor of accuracy?

OBJECTIVE: Interpretive accuracy varies among radiologists, especially in mammography. This study examines the relationship between radiologists' confidence in their assessments and their accuracy in interpreting mammograms. MATERIALS AND METHODS: In this study, 119 community radiologists interpreted 109 expert-defined screening mammography examinations in test sets and rated their confidence in their assessment for each case. They also provided a global assessment of their ability to interpret mammograms. Positive predictive value (PPV) and negative predictive value (NPV) were modeled as functions of self-rated confidence on each examination using log-linear regression estimated with generalized estimating equations. Reference measures were cancer status and expert-defined need for recall. Effect modification by weekly mammography volume was examined. RESULTS: Radiologists who self-reported higher global interpretive ability tended to interpret more mammograms per week (p = 0.08), were more likely to specialize (p = 0.02) and to have completed a fellowship in breast or women's imaging (p = 0.05), and had a higher PPV for cancer detection (p = 0.01). Examinations for which low-volume radiologists were "very confident" had a PPV of 2.93 times (95% CI, 2.01-4.27) higher than examinations they rated with neutral confidence. Trends of increasing NPVs with increasing confidence were significant for low-volume radiologists relative to noncancers (p = 0.01) and expert nonrecalls (p < 0.001). A trend of significantly increasing NPVs existed for high-volume radiologists relative to expert nonrecall (p = 0.02) but not relative to noncancer status (p = 0.32). CONCLUSION: Confidence in mammography assessments was associated with better accuracy, especially for low-volume readers. Asking for a second opinion when confidence in an assessment is low may increase accuracy.

Smokeless tobacco use and its relation to panic disorder, major depression, and posttraumatic stress disorder in American Indians.

INTRODUCTION: Rates of nicotine use are high in American Indians. Anxiety and depression tend to be associated with cigarette use, but the association of anxiety and depression with smokeless tobacco (ST) is less clear. We asked if panic disorder, major depression, and posttraumatic stress disorder (PTSD) are related to lifetime ST use in 2 American Indian tribes. METHODS: Logistic regression analyses examined the association between lifetime panic disorder, major depression, and PTSD and the odds of lifetime ST use status after controlling for sociodemographic characteristics, smoking status, and alcohol use disorders in 1,506 Northern Plains and 1,268 Southwest tribal members. RESULTS: Odds of lifetime ST use was 1.6 times higher in Northern Plains tribal members with a lifetime history of PTSD after controlling for sociodemographic variables and smoking (95% CI: 1.1, 2.3; p = .01). This association remained significant after further adjustment for panic disorder and major depression (odds ratio [OR] = 1.5; 95% CI: 1.0, 2.2; p = .04) but was diminished after accounting for alcohol use (OR = 1.3; 95% CI: 0.9, 1.9; p = .23). In the Southwest, lifetime psychiatric disorders were not associated with lifetime ST use status. Increasing psychiatric comorbidity was significantly linked to increased odds of ST use in both tribes. CONCLUSIONS: This study is the first to examine psychiatric conditions and lifetime ST use in a large, geographically diverse American Indian community sample. Although approximately 30% of tribal members were lifetime users of ST, the association with lifetime psychiatric disorders was not as strong as those observed with cigarette smoking. Understanding shared mechanisms between all forms of tobacco use with anxiety and depressive disorders remains an important area for investigation.

Barriers and facilitators to walking and physical activity among American Indian elders.

INTRODUCTION: Physical inactivity is common among older American Indians. Several barriers impede the establishment and maintenance of routine exercise. We examined personal and built-environment barriers and facilitators to walking and physical activity and their relationship with health-related quality of life in American Indian elders. METHODS: We used descriptive statistics to report barriers and facilitators to walking and physical activity among a sample of 75 American Indians aged 50 to 74 years. Pearson correlation coefficients were used to examine the relationship between health-related quality of life and barriers to walking and physical activity after adjusting for caloric expenditure and total frequency of all exercise activities. RESULTS: Lack of willpower was the most commonly reported barrier. Elders were more likely to report personal as opposed to built-environment reasons for physical inactivity. Better health and being closer to interesting places were common walking facilitators. Health-related quality of life was inversely related to physical activity barriers, and poor mental health quality of life was more strongly associated with total barriers than poor physical health. CONCLUSION: We identified a variety of barriers and facilitators that may influence walking and physical activity among American Indian elders. More research is needed to determine if interventions to reduce barriers and promote facilitators can lead to objective, functional health outcomes.

Mixed Effects of Neighborhood Revitalization on Residents' Cardiometabolic Health.

INTRODUCTION: Despite the growing recognition of the importance of neighborhood conditions for cardiometabolic health, causal relationships have been difficult to establish owing to a reliance on cross-sectional designs and selection bias. This is the first natural experiment to examine the impact of neighborhood revitalization on cardiometabolic outcomes in residents from 2 predominantly African American neighborhoods, one of which has experienced significant revitalization (intervention), whereas the other has not (comparison). METHODS: The sample included 532 adults (95% African American, 80% female, mean age=58.9 years) from 2 sociodemographically similar, low-income neighborhoods in Pittsburgh, PA, with preintervention and postintervention measures (2016 and 2018) of BMI, diastolic and systolic blood pressure, HbA1c, and high-density lipoprotein cholesterol and covariates. Data were collected in 2016 and 2018 and analyzed in 2020. RESULTS: Difference-in-difference analyses showed significant improvement in high-density lipoprotein cholesterol in intervention residents relative to that in the comparison neighborhood (ß=3.88, 95% CI=0.47, 7.29). There was also a significant difference-in-difference estimate in diastolic blood pressure (ß=3.00, 95% CI=0.57, 5.43), with residents of the intervention neighborhood showing a greater increase in diastolic blood pressure than those in the comparison neighborhood. No statistically significant differences were found for other outcomes. CONCLUSIONS: Investing in disadvantaged neighborhoods has been suggested as a strategy to reduce health disparities. Using a natural experiment, findings suggest that improving neighborhood conditions may have a mixed impact on certain aspects of cardiometabolic health. Findings underscore the importance of examining the upstream causes of health disparities using rigorous designs and longer follow-up periods that provide more powerful tests of causality.

The relationship between post-traumatic stress disorder, depression, and lung disorders in Northern Plains and Southwest American Indians.

OBJECTIVE: Research within the past decade has suggested that mental disorders are associated with lung disorders. This study compared the association of lifetime post-traumatic stress disorder (PTSD) and lifetime major depression with lung disorders in two American Indian (AI) tribal communities. DESIGN: A total of 2622 tribal members (1414 in the Northern Plains and 1208 in the Southwest) aged 18-57 years completed an interview assessing psychiatric diagnoses and physical health, including lung disorders. Logistic regression analyses were used to estimate odds ratios for the association of PTSD and major depression with lung disorders. RESULTS: The prevalence of lung disorders was 17% (95% Confidence Interval [CI]: 15, 19) in the Northern Plains and 13% (95% CI: 11, 15) in the Southwest. In the Northern Plains, men with lung disorders had a higher prevalence of PTSD and major depression than men without lung disorders, and women with lung disorders had a higher prevalence of major depression than women without lung disorders. Neither PTSD nor major depression was associated with lung disorders in men or women living in the Southwest. In the Northern Plains, major depression remained significantly associated with lung disorders in both men (OR=3.1, 95% CI: 1.5, 6.4) and women (OR=2.2, 95% CI: 1.2, 4.1) even after adjusting for age, education, smoking, alcohol abuse, and PTSD. CONCLUSIONS: Depression, but not PTSD, was associated with lung disorders in AIs living in the Northern Plains. Differences between the Northern Plains and the Southwest underscore the importance of recognizing unique characteristics of tribes and tribal communities. The increasing prevalence of lung disorders in AIs heightens the need for further work to help explain social, cultural, and clinical determinants of these disorders and their associations to PTSD and depression, and ultimately to help provide more effective clinical treatment and preventive care.