Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers.

Background: Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange. Aims and objectives: We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs). Methods: We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors. Findings: Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic. Discussion and conclusion: Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

It takes a village: A pilot study of a group telehealth intervention for support persons affected by opioid use disorder.

INTRODUCTION: Opioid use disorder (OUD) has devastating effects on individuals, families, and communities. The Community Reinforcement and Family Training (CRAFT) is a Support Person (SP)-focused intervention that aims to increase SPs' communication strategies, positive reinforcement/rewards, and social support. This pilot study, called eINSPIRE (INtegrating Support Persons Into REcovery), adapted CRAFT for delivery via group telehealth. The aims were to evaluate the feasibility, acceptability, and preliminary effectiveness of this intervention on patient buprenorphine retention and SP mental health. METHODS: The study recruited patients receiving buprenorphine treatment in a primary care setting across five community health centers with their SP (N = 100 dyads). SP participants were randomly assigned to receive usual care (UC) or the eINSPIRE intervention. We interviewed Patients and SPs at baseline and three months later. The study collected patient buprenorphine retention data from the electronic medical record three months post-baseline. RESULTS: About 88 % (656/742) of potentially eligible patients were able to nominate a SP and 69 % (100/145) of nominated SPs were eligible and consented to the study. eINSPIRE groups had low reach (25 % of SPs attended), but high exposure (M = 7 of 10 sessions attended) and acceptability (classes helped them with their patient's OUD). The proportion of eINSPIRE patients (68 %) and UC patients (53 %) retained on buprenorphine at follow-up were similar (p = 0.203). SPs in both conditions reported similar reductions in their depression, anxiety, and impairment symptoms. CONCLUSIONS: Preliminary data suggest that eINSPIRE groups may not be feasible in primary care without further adaptations for this population. A future study with a larger sample size is needed to elucidate the observed distribution differences in buprenorphine retention. Future research should also explore methods to reduce barriers to SP session attendance to improve the reach of this evidence-based intervention.

Exploring Which Patients Use Their Closest Emergency Departments Using Geocoded Data.

BACKGROUND: Each year, roughly 20% of U.S. adults visit an emergency department (ED), but little is known about patients' choice of ED. OBJECTIVES: Examine the discretion patients have to choose among EDs, characteristics associated with ED choice, and relationship between ED choice and self-reported care experiences of ED patients. METHODS: We surveyed adult patients discharged to the community (DTC) in January-March 2018 from 16 geographically dispersed hospital-based EDs, geocoded patient and hospital-based ED addresses within 100 miles of patient addresses, and calculated travel distances. We examined the likelihood of visiting the closest ED based on patient and ED characteristics. Linear regression models examined the association of choosing the closest ED with seven measures of patient experience of care (scaled 0-100), adjusting for patient characteristics. RESULTS: 43.6% of 4647 responding patients visited the ED nearest their home (on average, 5.7 miles away). Patients who chose a farther ED had more urgent conditions, were more educated, and were less likely to be non-Hispanic White. They were significantly more likely to have visited an ED in a higher-rated, metropolitan, network hospital with major teaching status, a cardiac intensive care unit, and a certified trauma center. Patients who chose a farther ED were more likely to recommend that ED, with "medium-to-large" differences in scores (+4.3% more selected "definitely yes", p < 0.05). CONCLUSIONS: Fewer than half of patients visited the closest ED. Patients who chose a farther ED tended to seek higher-rated hospitals and report more favorable experiences.

Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico.

BACKGROUND: Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses. METHODS: This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios. RESULTS: Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%). CONCLUSIONS: Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.

National travel distances for emergency care.

BACKGROUND: Most emergency department (ED) patients arrive by their own transport and, for various reasons, may not choose the nearest ED. How far patients travel for ED treatment may reflect both patients' access to care and severity of illness. In this study, we aimed to examine the travel distance and travel time between a patient's home and ED they visited and investigate how these distances/times vary by patient and hospital characteristics. METHODS: We randomly sampled and collected data from 14,812 patients discharged to the community (DTC) between January and March 2016 from 50 hospital-based EDs nationwide. We geocoded and calculated the distance and travel time between patient and hospital-based ED addresses, examined the travel distances/ times between patients' home and the ED they visited, and used mixed-effects regression models to investigate how these distances/times vary by patient and hospital characteristics. RESULTS: Patients travelled an average of 8.0 (SD = 10.9) miles and 17.3 (SD = 18.0) driving minutes to the ED. Patients travelled significantly farther to avoid EDs in lower performing hospitals (p < 0.01) and in the West (p < 0.05) and Midwest (p < 0.05). Patients travelled farther when visiting EDs in rural areas. Younger patients travelled farther than older patients. CONCLUSIONS: Understanding how far patients are willing to travel is indicative of whether patient populations have adequate access to ED services. By showing that patients travel farther to avoid a low-performing hospital, we provide evidence that DTC patients likely do exercise some choice among EDs, indicating some market incentives for higher-quality care, even for some ED admissions. Understanding these issues will help policymakers better define access to ED care and assist in directing quality improvement efforts. To our knowledge, our study is the most comprehensive nationwide characterization of patient travel for ED treatment to date.

Development and validation of a patient experience of care survey for emergency departments.

OBJECTIVES: To (1) develop a survey to assess the patient experience of care in hospital-based emergency departments (ED) and (2) evaluate the reliability and validity of composite measures of patient experience using data collected through the experimental implementation of the newly developed Emergency Department Patient Experience of Care (EDPEC) Discharged to Community (DTC) Survey. DATA SOURCE: 4893 adult patients were treated in the ED of 16 hospitals across the United States in 2018. STUDY DESIGN: The study utilized a cross-sectional survey. DATA COLLECTION: Survey development activities included a literature review, focus groups, and cognitive interviews with recently discharged ED patients, technical expert panels, and multiple field experiments. Survey development resulted in a 34-item instrument; the analysis reported here focuses on 18 items on patient experience of care. Using data from the EDPEC DTC Survey in the 2018 Feasibility Test, we performed confirmatory factor analysis to group 15 evaluative survey items into composite measures. We examined internal consistency reliability, interunit reliability, and associations between each composite measure and patients' overall rating and willingness to recommend the ED. PRINCIPAL FINDINGS: Analyses of 15 evaluative items identified four composite measures: Getting Timely Care, How Well Doctors and Nurses Communicate, Communication about Medications, and Communication about Follow-up. Patient-level internal consistency reliability exceeded 0.75 for two of four composites; ED-level internal consistency reliability exceeded 0.83 for all four composites. Interunit reliability estimates indicated that 450 survey completes per ED results in at least 0.70 reliability for all composites. Higher scores on each composite were associated with higher overall ratings and willingness to recommend the ED. CONCLUSIONS: The composite measures derived from the EDPEC DTC Survey are statistically reliable and valid. These results provide guidance for EDPEC DTC Survey adopters on how to construct meaningful and psychometrically-sound composite measures for monitoring the quality of care they provide.

Study design to evaluate a group-based therapy for support persons of adults on buprenorphine/naloxone.

BACKGROUND: Opioid use disorders (OUDs) have devastating effects on individuals, families, and communities. While medication treatments for OUD save lives and are increasingly utilized, rates of treatment dropout are very high. In addition, most existing medication treatments for OUD may often neglect the impact of untreated OUD on relationships and ignore the potential role support persons (SPs) could have on encouraging long-term recovery, which can also impact patient treatment retention. METHODS/DESIGN: The current study adapts Community Reinforcement and Family Training (CRAFT) for use with SPs (family member, spouse or friend) of patients using buprenorphine/naloxone (buprenorphine) in an outpatient community clinic setting. The study will evaluate whether the adapted intervention, also known as integrating support persons into recovery (INSPIRE), is effective in increasing patient retention on buprenorphine when compared to usual care. We will utilize a two-group randomized design where patients starting or restarting buprenorphine will be screened for support person status and recruited with their support person if eligible. Support persons will be randomly assigned to the INSPIRE intervention, which will consist of 10 rolling group sessions led by two facilitators. Patients and SPs will each be assessed at baseline, 3 months post-baseline, and 12 months post-baseline. Patient electronic medical record data will be collected at six and 12 months post-baseline. We will examine mechanisms of intervention effectiveness and also conduct pre/post-implementation surveys with clinic staff to assess issues that would affect sustainability. DISCUSSION: Incorporating the patient's support system may be an important way to improve treatment retention in medication treatments for OUD. If SPs can serve to support patient retention, this study would significantly advance work to help support the delivery of effective treatments that prevent the devastating consequences associated with OUD. Trial registration This study was registered with ClinicalTrials.gov, NCT04239235. Registered 27 January 2020, https://clinicaltrials.gov/ct2/show/NCT04239235 .

Fast myocardial T1 mapping using cardiac motion correction.

PURPOSE: To improve the efficiency of native and postcontrast high-resolution cardiac T1 mapping by utilizing cardiac motion correction. METHODS: Common cardiac T1 mapping techniques only acquire data in a small part of the cardiac cycle, leading to inefficient data sampling. Here, we present an approach in which 80% of each cardiac cycle is used for T1 mapping by integration of cardiac motion correction. Golden angle radial data was acquired continuously for 8 s with in-plane resolution of 1.3 × 1.3 mm2 . Cine images were reconstructed for nonrigid cardiac motion estimation. Images at different TIs were reconstructed from the same data, and motion correction was performed prior to T1 mapping. Native T1 mapping was evaluated in healthy subjects. Furthermore, the technique was applied for postcontrast T1 mapping in 5 patients with suspected fibrosis. RESULTS: Cine images with high contrast were obtained, leading to robust cardiac motion estimation. Motion-corrected T1 maps showed myocardial T1 times similar to cardiac-triggered T1 maps obtained from the same data (1288 ± 49 ms and 1259 ± 55 ms, respectively) but with a 34% improved precision (spatial variation: 57.0 ± 12.5 ms and 94.8 ± 15.4 ms, respectively, P < 0.0001) due to the increased amount of data. In postcontrast T1 maps, focal fibrosis could be confirmed with late contrast-enhancement images. CONCLUSION: The proposed approach provides high-resolution T1 maps within 8 s. Data acquisition efficiency for T1 mapping was improved by a factor of 5 by integration of cardiac motion correction, resulting in precise T1 maps.

Simultaneous high-resolution cardiac T1 mapping and cine imaging using model-based iterative image reconstruction.

PURPOSE: To provide high-resolution cardiac T1 mapping of various cardiac phases and cine imaging within a single breath-hold using continuous golden ratio-based radial acquisition and model-based iterative image reconstruction. METHODS: Data acquisition was performed continuously using golden ratio-based radial sampling and multiple inversion pulses were applied independent of the heart rate. Native T1 maps of diastole and systole were reconstructed with in-plane resolution of 1.3 × 1.3 mm2 using model-based iterative image reconstruction. Cine images with 30 cardiac phases were reconstructed from the same data using kt-SENSE. The method was evaluated in a commercially available T1 phantom and 10 healthy subjects. In vivo T1 assessment was carried out segment-wise. RESULTS: Evaluation in the phantom demonstrated accurate T1 times (R2 > 0.99) and insensitivity to the heart rate. In vivo T1 values did not differ between systole and diastole, and T1 times assessed by the proposed approach were longer than measured with a modified Look-Locker inversion recovery (MOLLI) sequence, except for lateral segments. Cine images had a consistent dark-blood contrast and functional assessment was in agreement with assessment based on Cartesian cine scans (difference in ejection fraction: 0.26 ± 2.65%, P = 0.65). CONCLUSION: The proposed approach provides native T1 maps of diastole and systole with high spatial resolution and cine images simultaneously within 16 s, which could strongly improve the scan efficiency.

National Testing of the Emergency Department Patient Experience of Care Discharged to Community Survey and Implications for Adjustment in Scoring.

BACKGROUND: The emergency department (ED) setting is unique and measuring quality of care in the ED requires the development of ED-specific tools. The Emergency Department Patient Experience of Care Discharged to Community Survey was designed to measure patient experience in the ED setting. OBJECTIVES: Describe results from the Emergency Department Patient Experience of Care Discharged to Community Survey including respondent characteristics and reported patient experience, and examine factors, including mode of survey administration, associated with response propensity and response patterns. RESEARCH DESIGN: In total, 16,006 discharges were sampled from 50 hospitals nationwide to receive the survey using a mode experiment design. Logistic regression modeled response propensity; linear regression examined associations between response patterns and patient characteristics and mode. SUBJECTS: In total, 3122 survey respondents. MEASURES: Measures of patient experience. RESULTS: Patients reported that hospitals consistently informed them of the purpose of any new medications (84% yes, definitely), but did not consistently explain their possible side effects (53%). Age, education, health, and arrival by ambulance were significantly associated with response patterns. There were significant differences in response rate by mode: 29% mixed mode, 22% telephone only and 14% mail only. Mode of administration was significantly associated with response patterns whereby patients surveyed using telephone-only or mixed mode tended to respond more positively than those surveyed using mail only. CONCLUSIONS: There is room for improvement in terms of patient experience in the ED setting. Effects of patient characteristics and survey mode on responses were large enough to necessitate appropriate adjustments if hospitals are to be compared in the future.

Persistence of Shifts in Beliefs Associated With Exposure to Alcohol Advertising Among Adolescents.

OBJECTIVE: The purpose of this study was to quantify the persistence of immediate changes in adolescents' alcohol-related beliefs associated with exposure to alcohol advertising. METHOD: Middle school students (N = 606) carried handheld devices for 14 days and logged all of their exposures to alcohol advertisements as they naturally occurred. Perceptions of the typical person one's age who drinks ("prototype perceptions") and perceived norms regarding alcohol use were assessed after each exposure to advertising and at random prompts issued daily throughout the assessment period. Generalized additive modeling was used to determine how long pro-drinking shifts in beliefs persisted after exposure to advertising. RESULTS: Following exposure to advertisements, positivity of youth's prototype perceptions immediately increased (ß = .07, 95% CI [.06, .09]) and then decreased (ß = -.05, 95% CI [-.07, -.03]) over the subsequent 1.5 days, whereas perceived normativeness of alcohol use immediately increased (ß = .04, 95% CI [.01, .06]) and then decreased (ß = -.03, 95% CI [-.05, -.01]) over the subsequent 2 days. Changes in beliefs occurring after 1.5 days for prototype perceptions and after 2 days for perceived norms were not statistically significant, suggesting that these beliefs were no longer affected by the advertising exposure. CONCLUSIONS: Findings are consistent with theories of alcohol advertising effects that presume that repeated exposure results in cumulative, enduring effects on beliefs. Given the rate of decay of alcohol advertising effects, it may be important to limit youth exposures to one every 2 days to avoid cumulative, lasting pro-drinking shifts in beliefs or to devise ways to interrupt cumulative effects with counter-messaging through media, parents, or other influential others at similar intervals.

Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study.

BACKGROUND: Millions of people with substance use disorders (SUDs) need, but do not receive, treatment. Delivering SUD treatment in primary care settings could increase access to treatment because most people visit their primary care doctors at least once a year, but evidence-based SUD treatments are underutilized in primary care settings. We used an organizational readiness intervention comprised of a cluster of implementation strategies to prepare a federally qualified health center to deliver SUD screening and evidence-based treatments (extended-release injectable naltrexone (XR-NTX) for alcohol use disorders, buprenorphine/naloxone (BUP/NX) for opioid use disorders and a brief motivational interviewing/cognitive behavioral -based psychotherapy for both disorders). This article reports the effects of the intervention on key implementation outcomes. METHODS: To assess changes in organizational readiness we conducted pre- and post-intervention surveys with prescribing medical providers, behavioral health providers and general clinic staff (N = 69). We report on changes in implementation outcomes: acceptability, perceptions of appropriateness and feasibility, and intention to adopt the evidence-based treatments. We used Wilcoxon signed rank tests to analyze pre- to post-intervention changes. RESULTS: After 18 months, prescribing medical providers agreed more that XR-NTX was easier to use for patients with alcohol use disorders than before the intervention, but their opinions about the effectiveness and ease of use of BUP/NX for patients with opioid use disorders did not improve. Prescribing medical providers also felt more strongly after the intervention that XR-NTX for alcohol use disorders was compatible with current practices. Opinions of general clinic staff about the appropriateness of SUD treatment in primary care improved significantly. CONCLUSIONS: Consistent with implementation theory, we found that an organizational readiness implementation intervention enhanced perceptions in some domains of practice acceptability and appropriateness. Further research will assess whether these factors, which focus on individual staff readiness, change over time and ultimately predict adoption of SUD treatments in primary care.

Demographic and Mental Health Characteristics of Individuals Who Present to Community Health Clinics With Substance Misuse.

INTRODUCTION: Community health clinics (CHCs) are an opportune setting to identify and treat substance misuse. This study assessed the characteristics of patients who presented to a CHC with substance misuse. METHODS: Personnel at a large CHC administered a 5-question screener to patients between June 3, 2014, and January 15, 2016, to assess past 3-month alcohol use, prescription opioid misuse, or illicit drug use. We stratified screen-positive patients into 4 diagnostic groups: (1) probable alcohol use disorder (AUD) and no comorbid opioid use disorder (OUD); (2) probable heroin use disorder; (3) probable prescription OUD, with or without comorbid AUD; and (4) no probable substance use disorder. We describe substance use and mental health characteristics of screen-positive patients and compare the characteristics of patients in the diagnostic groups. RESULTS: Compared to the clinic population, screen-positive patients (N = 733) included more males (P < .0001) and had a higher prevalence of probable bipolar disorder (P < .0001) and schizophrenia (P < .0001). Eighty-seven percent of screen-positive patients had probable AUD or OUD; only 7% were currently receiving substance use treatment. The prescription opioid and heroin groups had higher rates of past bipolar disorder and consequences of mental health conditions than the alcohol only or no diagnosis groups (P < .0001). CONCLUSIONS: Patients presenting to CHCs who screen positive for alcohol or opioid misuse have a high likelihood of having an AUD or OUD, with or without a comorbid serious mental illness. Community health clinics offering substance use treatment may be an important resource for addressing unmet need for substance use treatment and comorbid mental illness.

Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: A qualitative longitudinal study.

Untreated substance use disorders remain a pervasive public health problem in the United States, especially among medically-underserved and low-income populations, with opioid and alcohol use disorders (OAUD) being of particular concern. Primary care is an underutilized resource for delivering treatment for OAUD, but little is known about the organizational capacity of community-based primary care clinics to integrate treatment for OAUD. The objective of this study was to use an organizational capacity framework to examine perceived barriers to implementing the continuum of care for OAUD in a community-based primary care organization over three time points: pre-implementation (preparation), early implementation (practice), and full implementation. Clinic administrators and medical and mental health providers from two clinics participated in interviews and focus groups. Barriers were organized by type and size, and are presented over the three time points. Although some barriers persisted, most barriers decreased over time, and respondents reported feeling more efficacious in their ability to successfully deliver OAUD treatment. Findings contribute to the needed literature on building capacity to implement OAUD treatment in primary care and suggest that while barriers may be sizable and inevitable, successful implementation is still possible.

Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care: The SUMMIT Randomized Clinical Trial.

Importance: Primary care offers an important and underutilized setting to deliver treatment for opioid and/or alcohol use disorders (OAUD). Collaborative care (CC) is effective but has not been tested for OAUD. Objective: To determine whether CC for OAUD improves delivery of evidence-based treatments for OAUD and increases self-reported abstinence compared with usual primary care. Design, Setting, and Participants: A randomized clinical trial of 377 primary care patients with OAUD was conducted in 2 clinics in a federally qualified health center. Participants were recruited from June 3, 2014, to January 15, 2016, and followed for 6 months. Interventions: Of the 377 participants, 187 were randomized to CC and 190 were randomized to usual care; 77 (20.4%) of the participants were female, of whom 39 (20.9%) were randomized to CC and 38 (20.0%) were randomized to UC. The mean (SD) age of all respondents at baseline was 42 (12.0) years, 41(11.7) years for the CC group, and 43 (12.2) yearsfor the UC group. Collaborative care was a system-level intervention, designed to increase the delivery of either a 6-session brief psychotherapy treatment and/or medication-assisted treatment with either sublingual buprenorphine/naloxone for opioid use disorders or long-acting injectable naltrexone for alcohol use disorders. Usual care participants were told that the clinic provided OAUD treatment and given a number for appointment scheduling and list of community referrals. Main Outcomes and Measures: The primary outcomes were use of any evidence-based treatment for OAUD and self-reported abstinence from opioids or alcohol at 6 months. The secondary outcomes included the Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement measures, abstinence from other substances, heavy drinking, health-related quality of life, and consequences from OAUD. Results: At 6 months, the proportion of participants who received any OAUD treatment was higher in the CC group compared with usual care (73 [39.0%] vs 32 [16.8%]; logistic model adjusted OR, 3.97; 95% CI, 2.32-6.79; P < .001). A higher proportion of CC participants reported abstinence from opioids or alcohol at 6 months (32.8% vs 22.3%); after linear probability model adjustment for covariates (ß = 0.12; 95% CI, 0.01-0.23; P = .03). In secondary analyses, the proportion meeting the HEDIS initiation and engagement measures was also higher among CC participants (initiation, 31.6% vs 13.7%; adjusted OR, 3.54; 95% CI, 2.02-6.20; P < .001; engagement, 15.5% vs 4.2%; adjusted OR, 5.89; 95% CI, 2.43-14.32; P < .001) as was abstinence from opioids, cocaine, methamphetamines, marijuana, and any alcohol (26.3% vs 15.6%; effect estimate, ß = 0.13; 95% CI, 0.03-0.23; P = .01). Conclusions and Relevance: Among adults with OAUD in primary care, the SUMMIT collaborative care intervention resulted in significantly more access to treatment and abstinence from alcohol and drugs at 6 months, than usual care. Trial Registration: clinicaltrials.gov Identifier: NCT01810159.

Exposure to alcohol advertising and adolescents' drinking beliefs: Role of message interpretation.

OBJECTIVE: Recent research revealed momentary associations between exposure to alcohol advertising and positive beliefs about alcohol among adolescents (Martino et al., 2016). We reanalyzed those data to determine whether associations depend on adolescents' appraisal of ads. METHOD: Over a 10-month period in 2013, 589 youth, ages 11-14, in the Los Angeles, CA, area, participated in a 14-day ecological momentary assessment, logging all exposures to alcohol advertisements as they occurred and completing brief assessments of their skepticism toward, liking of, and identification with any people in each ad, as well as their alcohol-related beliefs at the moment. Participants also completed measures of their alcohol- related beliefs at random moments of nonexposure throughout each day. Mixed-effects regression models compared beliefs about alcohol at moments of exposure to alcohol advertising that was appraised in a particular way (e.g., with liking, without liking) to beliefs at random moments. RESULTS: When youth encountered ads they appraised positively, their beliefs about alcohol were significantly more positive than when they were queried at random moments. Beliefs in the presence of ads that were not positively appraised were generally similar to beliefs at random moments. CONCLUSION: Youth are active participants in the advertising process. How they respond to and process alcohol advertising strongly moderates the association between exposure and alcohol-related beliefs. More effort is needed to identify attributes of alcohol advertisements, and of youth, that determine how youth process alcohol ads. This information can be used to either limit exposure to problematic ads or make youth more resilient to such exposure. (PsycINFO Database Record

Cerebral blood flow response to hypoglycemia is altered in patients with type 1 diabetes and impaired awareness of hypoglycemia.

It is unclear whether cerebral blood flow responses to hypoglycemia are altered in people with type 1 diabetes and impaired awareness of hypoglycemia. The aim of this study was to investigate the effect of hypoglycemia on both global and regional cerebral blood flow in type 1 diabetes patients with impaired awareness of hypoglycemia, type 1 diabetes patients with normal awareness of hypoglycemia and healthy controls ( n = 7 per group). The subjects underwent a hyperinsulinemic euglycemic-hypoglycemic glucose clamp in a 3 T MR system. Global and regional changes in cerebral blood flow were determined by arterial spin labeling magnetic resonance imaging, at the end of both glycemic phases. Hypoglycemia generated typical symptoms in patients with type 1 diabetes and normal awareness of hypoglycemia and healthy controls, but not in patients with impaired awareness of hypoglycemia. Conversely, hypoglycemia increased global cerebral blood flow in patients with impaired awareness of hypoglycemia, which was not observed in the other two groups. Regionally, hypoglycemia caused a redistribution of cerebral blood flow towards the thalamus of both patients with normal awareness of hypoglycemia and healthy controls, consistent with activation of brain regions associated with the autonomic response to hypoglycemia. No such redistribution was found in the patients with impaired awareness of hypoglycemia. An increase in global cerebral blood flow may enhance nutrient supply to the brain, hence suppressing symptomatic awareness of hypoglycemia. Altogether these results suggest that changes in cerebral blood flow during hypoglycemia contribute to impaired awareness of hypoglycemia.

Factors associated with younger adolescents' exposure to online alcohol advertising.

Little is known about the extent and nature of youth exposure to online alcohol advertising, or factors that may be associated with exposure. The current study recruited middle school students who completed a paper survey and then logged each alcohol advertisement that they encountered over a 2-week period using cell phones as part of an ecological momentary assessment design. We examined the percentage of youth who reported exposure to online alcohol advertising in the past 2 weeks, average weekly rate of exposure, types of online alcohol advertisements youth reported seeing, and factors that increased youths' risk of exposure to online alcohol advertising. Analyses are based on 485 participants (47% female; 25% Hispanic, 25% White, 27% Black; 6% Asian, 16% other). Youth logged exposures to a total of 3,966 (16,018 weighted for underreporting) alcohol advertisements across the monitoring period; 154 (568 weighted) or 3.6% were online ads. Seventeen percent of youth reported seeing any online alcohol ad; the majority of online ads seen were video commercials (44.8%) and banner/side ads (26.6%). Factors associated with greater ad exposure were being older, rebellious, and Black race; greater parental monitoring and more hours spent on social media were associated with less exposure. Findings provide important information about adolescents' exposure to online alcohol advertising and what might contribute to a greater likelihood of exposure. Given that online ad exposure is linked to drinking behavior, prevention programming for younger adolescents should continue to address this issue to help youth make healthy choices regarding alcohol use. (PsycINFO Database Record

Alcohol Advertising Exposure Among Middle School-Age Youth: An Assessment Across All Media and Venues.

OBJECTIVE: The purpose of this study was to quantify middle school youth's exposure to alcohol advertisements across media and venues, determine venues of greatest exposure, and identify characteristics of youth who are most exposed. METHOD: Over a 10-month period in 2013, 589 Los Angeles-area youth ages 11-14 from diverse racial/ethnic backgrounds completed a short paper-and-pencil survey assessing background characteristics and then participated in a 14-day ecological momentary assessment, logging all exposures to alcohol advertisements on handheld computers as they occurred. RESULTS: African American and Hispanic youth were exposed to an average of 4.1 and 3.4 advertisements per day, respectively, nearly two times as many as non-Hispanic White youth, who were exposed to 2.0 advertisements per day. Girls were exposed to 30% more advertisements than boys. Most exposures were to outdoor advertisements, with television advertisements a close second. CONCLUSIONS: Exposure to alcohol advertising is frequent among middle school-age youth and may put them at risk for earlier or more frequent underage drinking. Greater restrictions on alcohol advertising outdoors and on television should be considered by regulators and by the alcohol industry and should focus particularly on reducing exposure among minority youth.

Ecological Momentary Assessment of the Association Between Exposure to Alcohol Advertising and Early Adolescents' Beliefs About Alcohol.

PURPOSE: To evaluate the momentary association between exposure to alcohol advertising and middle-school students' beliefs about alcohol in real-world settings and to explore racial/ethnic differences in this association. METHODS: Middle-school students (N = 588) carried handheld data collection devices for 14 days, recording their exposures to all forms of alcohol advertising during the assessment period. Students also responded to three investigator-initiated control prompts (programmed to occur randomly) on each day of the assessment period. After each exposure to advertising and at each control prompt, students reported their beliefs about alcohol. Mixed-effects regression models compared students' beliefs about alcohol between moments of exposure to alcohol advertising and control prompts. RESULTS: Students perceived the typical person their age who drinks alcohol (prototype perceptions) more favorably and perceived alcohol use as more normative at times of exposure to alcohol advertising than at times of nonexposure (i.e., at control prompts). Exposure to alcohol advertising was not associated with shifts in the perceived norms of black and Hispanic students, however, and the association between exposure and prototype perceptions was stronger among non-Hispanic students than among Hispanic students. CONCLUSIONS: Exposure to alcohol advertising is associated with acute shifts in adolescents' perceptions of the typical person that drinks alcohol and the normativeness of drinking. These associations are both statistically and substantively meaningful.