Building RECOVERY: development of the registry of eating disorders and their co-morbidities OVER time in youth.

BACKGROUND: Eating disorder (ED) research is limited by the lack of longitudinal cohort studies, particularly those in adolescents, and the lack of inclusion of multiple perspectives and diagnoses. The objective of this study was to describe the development of a longitudinal cohort of adolescents/young adults representing varied ED diagnoses and including perspectives of parents and multi-disciplinary clinicians in addition to those of patients. METHODS: Patients of an outpatient ED program who were age 10-27 years, along with their parents and clinicians, were recruited to participate in a longitudinal web-based study. Using univariate, bivariate, and multivariate analyses, we assessed rates of participation among different groups (i.e., parents, patients, different clinical disciplines) as well as factors related to attrition. RESULTS: 71% of patients, 75% of parents, 56% of adolescent medicine providers, 20% of primary care physicians, 83% of dietitians, and 80% of mental health clinicians invited agreed to participate. At 12 months, 32% of patient participants had not completed their on-line surveys. Attrition rates were higher for parents (55%) and clinicians (45% of nutritionists, 55% of primary care physicians, 51% of Adolescent/Young Adult providers, and 64% of mental health providers) at 12 months. CONCLUSIONS: A longitudinal registry of patients with EDs is feasible and efficient when using web-based surveys. However, clinician participation is particularly hard to secure and maintain.

We report on the development of a longitudinal cohort of just over 160 youth with eating disorders. In order to have additional perspectives on illness course, we recruited parents and clinicians of patient participants. We demonstrate willingness to participate in patient participants with acceptable rates of attrition. Community providers were more difficult to recruit and retain.

COVID-19 related familial economic disruptions and eating disorder patients' mental health concerns and motivation to recover.

BACKGROUND: Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED. METHODS: AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis. RESULTS: Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption. CONCLUSIONS: Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Following the adoption of stay-at-home regulations to curb the spread of the COVID-19 pandemic, children's hospitals and emergency rooms across the United States saw a tremendous uptick in adolescents and young adults with eating disorders (ED) and mental health (MH) concerns. COVID-19 related regulations had economic consequences, with family members reduction in work hours, temporary or permanent termination from work, and/or loss of their health insurance or benefits. This study sheds light on the association between COVID-19 related familial economic disruptions and mental health and eating disorders (MH/ED) concerns and motivation to recover from an ED in patients receiving care for ED (89 participants). Of patients reporting some economic familial disruption, three-fourths self-reported worsening mental health (i.e, worsening feelings of depression, anxiety, isolation, or intrusive eating disorder thoughts). Patients who perceived familial economic disruption due to the COVID-19 pandemic had almost a two-fold increased likelihood of worsening eating disorders and mental health (ED/MH) concerns and/or motivation to recover. Our study underscores the need to consider the economic effects of the pandemic on the well-being of adolescents/young-adults with ED, particularly those from financially vulnerable families.

Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume.

Importance: The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. Objective: To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. Design, Setting, and Participants: Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. Exposures: Onset of the COVID-19 pandemic. Main Outcomes and Measures: Monthly number of patients seeking inpatient/outpatient ED-related care. Results: Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic. Conclusions and Relevance: In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.

Evaluation of a one-hour asynchronous video training for eating disorder screening and referral in U.S. Pediatric Primary Care: A pilot study.

OBJECTIVE: Develop and pilot-test the efficacy of an online training in improving comfort, knowledge, and behaviors related to eating disorders (EDs) screening among U.S.-based pediatric primary care providers (PCPs). METHODS: PCPs (N = 84) completed a baseline survey assessing comfort, knowledge, and behaviors regarding ED screening and referral, then watched a 1-h training video followed by a post-video survey. Half of the participants were randomly assigned to complete spaced-education questions in the following 2 months. All participants completed a 2-month follow-up survey. We used McNemar's and McNemar-Bowker tests to assess differences from baseline to post-video and post-video to follow-up, and logistic models to assess differences by spaced-education condition. RESULTS: From baseline to post-video, there were significant improvements in PCPs' knowledge about and comfort in screening and making referrals for EDs (p < .05). There were no differences between spaced-education conditions in knowledge and behaviors from baseline or post-video to follow-up, but spaced-education participants reported significantly greater comfort in screening for BN (p < .01) and BED (p < .01) compared to non-spaced-education participants. DISCUSSION: Findings suggest that a 1-h asynchronous training can improve PCP comfort, knowledge, and behavior in screening for EDs; spaced-education may provide slight additional benefits in PCP comfort. PUBLIC SIGNIFICANCE: The delivery of an 1-h asynchronous online video training helped to improve PCPs' comfort, knowledge, and behavior in screening and referral for EDs among pediatric populations. This has implications for future evaluations of brief trainings among this provider population, which could ultimately help to improve early identification of EDs and referrals to appropriate treatment.

COVID-19 and eating disorder and mental health concerns in patients with eating disorders.

BACKGROUND: The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery. METHODS: Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms. RESULTS: The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment. CONCLUSIONS: Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

The COVID-19 pandemic and subsequent stay-at-home orders implemented across the world dramatically altered daily life for people of all ages. Previous research has detailed the profound impact the pandemic has had on mental health (MH), particularly among individuals with eating disorders (ED) [22]. This study explored how individuals with eating disorders perceive the COVID-19 pandemic to have impacted their ED symptoms and overall MH. Participants included adolescent/young adults (AYAs) with a diagnosed ED who were given a four-part survey on how they perceive the COVID-19 pandemic to have affected their ED symptoms and treatment and MH (89 participants). AYAs in the study reported feeling that their ED symptoms and MH concerns worsened due to the pandemic. Those who reported concern that their ED would worsen due to a "triggering" living environment were even more likely to report feeling that their ED and MH worsened due to the pandemic. A large percentage of participants also reported a decreased motivation to recover from their ED that they attributed to the pandemic. Overall, individuals with EDs may be at risk for worsening symptoms during the COVID-19 pandemic. Our results underscore the need for increased monitoring of patients with EDs during the pandemic.

The Impact of the COVID-19 Pandemic on the Number of Adolescents/Young Adults Seeking Eating Disorder-Related Care.

PURPOSE: The COVID-19 pandemic has led to the development and worsening of eating disorder (ED) symptoms in adolescents and young adults. In order to examine COVID-19-related trends in ED care-seeking at our institution. METHODS: We used interrupted time series regression to examine pre- and postpandemic monthly summary data of the following: (1) ED-related inpatient admissions for medical stabilization; (2) ED-related hospital bed-days; (3) completed outpatient ED assessments; and (4) ED outpatient care-related inquiries at a children's hospital in Boston, MA. RESULTS: Inpatient admissions, hospital bed-days, and outpatient care-related inquiries increased on average over time postpandemic compared to stable volume over time prepandemic (p < .01). Outpatient assessments decreased precipitously initially following COVID-19-related limitations, and rose quickly back to baseline. CONCLUSION: These results indicate increased need for ED-related care during the pandemic. Bolstering resources to meet the needs of these vulnerable patients is critical as the effects of the pandemic continue to be felt.

Access to care and worsening eating disorder symptomatology in youth during the COVID-19 pandemic.

BACKGROUND: Shelter-in-place orders and social distancing guidelines, in response to the COVID-19 pandemic, have limited traditional face-to-face interactions and led to many clinical providers transitioning to the use of videoconferencing platforms. The present study aims to assess how the COVID-19 pandemic has impacted adolescents'/young adults' (AYA) eating disorder (ED)-related care, and how access to, changes in, perceived disruptions to, and quality of care are associated with ED thoughts and behaviors. METHODS: AYA enrolled in the RECOVERY study, a pre-existing web-based longitudinal study, and completed a COVID-19-specific survey (n = 89). We examined bivariate associations of four markers of care: i) access to care, ii) changes in care, iii) perceived disruption to care, and iv) quality of care. Using multiple logistic regression, we examined the associations of pandemic-related markers of care with changes in ED thoughts and behaviors. We excluded those not engaged in treatment pre-pandemic (n = 16). RESULTS: In the remaining 73 participants, reported access to care was high, with 92% of respondents continuing care with at least one ED provider during the pandemic; however, 47% stopped some treatment during the pandemic. Nearly one-third (32%) perceived a disruption in treatment. Quality of care remained high with 67% reporting care to be better than or as good as pre-pandemic. Respondents acknowledged heightened symptomatology: 81% reported increased ED thoughts and 81% reported increased ED behaviors due to COVID-19-related factors. However, none of the markers of care described were significantly associated with ED thoughts or behaviors in regression analyses adjusting for demographic variables and baseline characteristics, except our quality of care measure which was approaching significance (p = 0.07). CONCLUSIONS: Our findings show the majority of AYA who had care prior to the pandemic continued receiving some element of their multi-disciplinary ED treatment and perceived their care as high quality. None of the markers of care described were statistically associated with increased ED thoughts and behaviors.

The COVID-19 pandemic has had a negative impact on our global community's mental health, in particular those struggling with psychiatric illnesses, such as eating disorders (ED). Stay-at-home orders and social distancing have limited in-person access to ED treatment and as a result, many care providers have transitioned to using videoconferencing platforms. Clinicians who care for patients with EDs worry that these sudden changes in accessing treatment, on top of mental health challenges associated with the pandemic, may contribute to worsening ED symptoms. In this study, we asked adolescent and young adult patients with EDs about their symptoms, access to treatment, changes in care, disruptions in treatment and quality of care since the pandemic started. Our results demonstrate that patients with established care teams have maintained treatment and perceive their care as high quality, though the majority are experiencing worsening ED thoughts and behaviors. Patients who perceive their quality of care as worse than usual might be more likely to have intrusive ED thoughts. Continued access to care could also be protective against increased ED behaviors. Ultimately, our study highlights the need for continued support of patients during this challenging time.

The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study.

BACKGROUND: Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs. METHODS: 145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression. RESULTS: Mean (SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically significant anxiety and/or depression. Degree of malnutrition was not significantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care (p = 0.038). Patients with pre-morbid BMIs ≥75th percentile had lower depression scores than those with pre-morbid BMIs <75th percentile (p = 0.014). CONCLUSIONS: We find high degree of clinically relevant anxiety and depression symptoms in a population of AYAs with EDs. Our findings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

People with eating disorders (EDs) often also struggle with anxiety and depression. Unfortunately, this can mean their disease is more severe, harder to treat, and more dangerous and potentially fatal. ED treatment often primarily focuses on nutrition and weight gain, and sometimes loses focus on the person's mood and anxiety. Additionally, patients can present at any weight, but not enough is known about how baseline weight before weight loss might affect mood. In this study, we focus on adolescents/young adults with restrictive EDs to understand what places them at risk for depression and anxiety. We find that the majority of our participants have clinically significant anxiety and depression. However, degree of malnutrition was not related to level of anxiety and depression. Struggling with an ED for longer time was associated with increased depression and possibly anxiety as well. We also find that those who had relatively high baseline weights prior to weight loss had lower depression and anxiety scores than those who had lower baseline weights. Early identification and treatment of individuals with EDs is important, and there are likely other factors beyond malnutrition that we need to understand in order to identify those at risk for depression and anxiety.

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians.

OBJECTIVE: Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. METHOD: We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type. RESULTS: Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ2 = 9.90, df = 2, p = .007, φc = 0.356) and theme three (χ2 = 6.42, df = 2, p = .04, φc = 0.287) than patients and parents. DISCUSSION: Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

"It'd Be Great to Have the Options There": A Mixed-Methods Study of Gender Identity Questions on Clinic Forms in a Primary Care Setting.

PURPOSE: Transgender youth experience significant barriers to health care. Asking patients about gender identity on clinic intake forms is recommended to improve care in adult populations. Little is known about how to implement these recommendations in adolescent populations. This study aimed to evaluate the addition of gender-related questions in an adolescent primary care setting and to determine if adding these questions to clinic forms could improve documentation of gender identity in the electronic health record (EHR). METHODS: We conducted cognitive interviews with 21 adolescents (n = 11 transgender, n = 10 cisgender) to examine gender-related questions (name, pronoun, gender identity, assigned sex at birth). These questions were added to a clinic intake form. We conducted a retrospective chart review of patients who came to the clinic for a physical examination visit three months before (n = 615) and after (n = 827) the form change and used chi-square tests to examine the differences in EHR documentation of gender identity. RESULTS: In interviews, the new questions were acceptable and interpretable to adolescents of diverse gender identities. Participants described the questions as beneficial to all patients and perceived them as an indicator of a welcoming clinic environment. The retrospective chart review found that provider documentation of gender identity in the EHR significantly increased after the form change from 51.3% to 66.3% (p < .0001). CONCLUSIONS: This intervention was acceptable to adolescents and associated with a significant increase in EHR documentation. Future studies should investigate how the form change may have facilitated discussion about gender and health and implications for provider training and support.

Personal Phone Calls Lead to Decreased Rates of Missed Appointments in an Adolescent/Young Adult Practice.

INTRODUCTION: Nationally, hospital practice missed appointment rates are high. Our goal was to reduce the rate of missed appointments in an Adolescent/Young Adult Practice through quality improvement methods. METHODS: During the 12-month intervention period, administrative staff called patients the day before their primary or specialty care appointments to remind them of the date, time, and location, as well as patients who did not attend their appointments to ask about the reason for their missed appointment. We implemented Plan-Do-Study-Act interventions and analyzed data to compare missed appointment rates between the 12 months before and after February 1, 2017, the project intervention date. RESULTS: Results showed significant reductions in the missed appointment rate for the Adolescent/Young Adult Practice. A control chart showed a shift in the mean overall percent of completed appointments from 76.7% to 79.2%. The most common reasons for missed appointments included forgetting (39.2%), conflicts with work/school (11.0%), or emailing the provider without contacting administrative staff (7.8%). There were significant reductions in missed appointment rates for both males and females as well as patients who were ≥20 years old, identified English or Spanish as their primary language, had public or private insurance, identified as Black or Hispanic, or did or did not require an interpreter. CONCLUSION: These data show that targeted interventions such as personalized reminder calls can be effective in reducing patient missed appointment rates in Adolescent/Young Adult Practices.

Effect of Hospitalization on Percent Median Body Mass Index at One Year, in Underweight Youth With Restrictive Eating Disorders.

PURPOSE: Data from low-weight patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED treatment programs were analyzed to determine whether there was an association between hospitalization and gain to at least 90% median body mass index (mBMI) at 1-year follow-up. METHODS: Data were retrospectively collected for 322 low-weight (<85% mBMI at intake) patients aged 9-21 years, who presented with restrictive EDs to 14 adolescent medicine-based ED programs in 2010. Positive outcome was defined as being at least 90% mBMI (%mBMI = patient's body mass index/mBMI for age × 100) at 1-year follow-up. Association between treatment at a higher level of care and gain to at least 90% mBMI was analyzed for 140 patients who were <85% mBMI at the time of presentation, had not been previously hospitalized, and had 1-year follow-up data available. RESULTS: For patients presenting at <85% mBMI, those who were hospitalized in the year following intake had 4.0 (95% confidence interval: 1.6-10.1) times the odds of gain to at least 90% mBMI, compared with patients who were not hospitalized, when controlling for baseline %mBMI. CONCLUSION: In this national cohort of patients with restrictive EDs presenting to adolescent medicine-based ED programs at <85% mBMI, those who were hospitalized had greater odds of being at least 90% mBMI at 1-year follow-up.

Development of a Standardized Kalamazoo Communication Skills Assessment Tool for Radiologists: Validation, Multisource Reliability, and Lessons Learned.

OBJECTIVE: The purpose of this study was to develop and test a standardized communication skills assessment instrument for radiology. MATERIALS AND METHODS: The Delphi method was used to validate the Kalamazoo Communication Skills Assessment instrument for radiology by revising and achieving consensus on the 43 items of the preexisting instrument among an interdisciplinary team of experts consisting of five radiologists and four nonradiologists (two men, seven women). Reviewers assessed the applicability of the instrument to evaluation of conversations between radiology trainees and trained actors portraying concerned parents in enactments about bad news, radiation risks, and diagnostic errors that were video recorded during a communication workshop. Interrater reliability was assessed by use of the revised instrument to rate a series of enactments between trainees and actors video recorded in a hospital-based simulator center. Eight raters evaluated each of seven different video-recorded interactions between physicians and parent-actors. RESULTS: The final instrument contained 43 items. After three review rounds, 42 of 43 (98%) items had an average rating of relevant or very relevant for bad news conversations. All items were rated as relevant or very relevant for conversations about error disclosure and radiation risk. Reliability and rater agreement measures were moderate. The intraclass correlation coefficient range was 0.07-0.58; mean, 0.30; SD, 0.13; and median, 0.30. The range of weighted kappa values was 0.03-0.47; mean, 0.23; SD, 0.12; and median, 0.22. Ratings varied significantly among conversations (χ26 = 1186; p < 0.0001) and varied significantly by viewing order, rater type, and rater sex. CONCLUSION: The adapted communication skills assessment instrument is highly relevant for radiology, having moderate interrater reliability. These findings have important implications for assessing the relational competencies of radiology trainees.

History of Overweight/Obesity as Predictor of Care Received at 1-year Follow-Up in Adolescents With Anorexia Nervosa or Atypical Anorexia Nervosa.

PURPOSE: Previous research has indicated that patients with anorexia nervosa (AN) or atypical AN with premorbid history of overweight/obesity have greater weight loss and longer illness duration than patients with no such history. However, little is known about the association of premorbid overweight/obesity and receiving inpatient medical care during treatment for an eating disorder. METHODS: Using logistic regression, we sought to determine if history of overweight/obesity was associated with receiving inpatient medical care in a sample of 522 patients (mean age 15.5 years, 88% female) with AN/atypical AN. RESULTS: Binary results demonstrated greater percent weight loss (27.4% vs. 16.2%) and higher percent median body mass index (%mBMI, 99.8% vs. 85.2%) at presentation in those with a history of overweight/obesity (p < .001) but no difference in duration of illness (p = .09). In models adjusted for demographics and percent weight loss, history of overweight/obesity was associated with lower odds of receiving inpatient medical care (odds ratio .60 [95% confidence interval: .45-.80]) at 1-year follow-up. However, these associations were no longer significant after adjusting for %mBMI. Mediation results suggest that %mBMI fully mediates the relationship between history of overweight/obesity and inpatient medical care, in that those with a history of overweight/obesity are less likely to receive care due to presenting at a higher weight. CONCLUSIONS: Our findings suggest that, despite greater degree of weight loss and no difference in duration of illness, participants with a history of overweight/obesity are less likely to receive inpatient medical care.

Implementation and Evaluation of Two Educational Strategies to Improve Screening for Eating Disorders in Pediatric Primary Care.

PURPOSE: Routine screening for disordered eating or body image concerns is recommended by the American Academy of Pediatrics. We evaluated the ability of two educational interventions to increase screening for eating disorders in pediatric primary care practice, predicting that the "active-learning" group would have an increase in documented screening after intervention. METHODS: We studied 303 practitioners in a large independent practice association located in the northeastern United States. We used a quasi-experimental design to test the effect of printed educational materials ("print-learning" group, n = 280 participants) compared with in-person shared learning followed by on-line spaced education ("active-learning" group, n = 23 participants) on documented screening of adolescents for eating disorder symptoms during preventive care visits. A subset of 88 participants completed additional surveys regarding knowledge of eating disorders, comfort screening for, diagnosing, and treating eating disorders, and satisfaction with their training regarding eating disorders. RESULTS: During the preintervention period, 4.5% of patients seen by practitioners in both the print-learning and active-learning groups had chart documentation of screening for eating disorder symptoms or body image concerns. This increased to 22% in the active-learning group and 5.7% in the print-learning group in the postintervention period, a statistically significant result. Compared with print-learning participants, active-learning group participants had greater eating disorder knowledge scores, increases in comfort diagnosing eating disorders, and satisfaction with their training in this area. CONCLUSIONS: In-person shared learning followed by on-line spaced education is more effective than print educational materials for increasing provider documentation of screening for eating disorders in primary care.

Practice-Based Quality Improvement Collaborative to Increase Chlamydia Screening in Young Women.

BACKGROUND AND OBJECTIVE: Chlamydia trachomatis infections are common among sexually active young women. We developed a practice-based quality improvement (QI) collaborative to increase Chlamydia screening in at-risk young women. METHODS: Structured data fields were integrated into the electronic record for practices affiliated with Boston Children's Hospital. A learning community (LC) was developed. Content included the adolescent well visit, assessment of sexual/risk behaviors, epidemiology of sexually transmitted diseases, and screening methods. The QI initiative effectiveness was assessed by comparing preintervention and postintervention rates of Chlamydia screening by using statistical process control analyses and logistic regressions. RESULTS: LC participants demonstrated significant increases in recommended Chlamydia screening, as illustrated by using Healthcare Effectiveness Data and Information Set (HEDIS) screening rates (LC1: 52.8% preintervention vs 66.7% postintervention [P < .0001]; LC2: 57.8% preintervention vs 69.3% postintervention [P < .0001]). Participating practices reported total improvements larger than nonparticipating practices (13.9% LC1, 11.5% LC2, and 7.8% nonparticipants). QI and LC efforts also led to increased documentation of sexual activity status in the record (LC1: 61.2% preintervention to 91.2% postintervention [P < .0001]; LC2: 43.3% preintervention to 61.2% postintervention [P < .0001]). Nonparticipating practices were more likely to perform indiscriminate screening. CONCLUSIONS: Through our QI and LC efforts, statistically and clinically meaningful improvements in Chlamydia screening rates were attained. Differences in rates of improvement indicate that LC participation likely had effects beyond electronic medical record changes alone. During the project time frame, national HEDIS screening rates remained unchanged, suggesting that the observed improvements were related to the interventions and not to a national trend. As a result of QI tools provided through the LCs, HEDIS screening goals were achieved in a primary care setting.