Promoting community stakeholder engagement in research on treatment for pregnant women with opioid use disorder.

Aim: Community stakeholder engagement in research (CSER) can improve research relevance and efficiency as well as prevent harmful practices, particularly for vulnerable populations. Despite potential benefits, researchers lack familiarity with CSER methods. Methods: We describe CSER strategies used across the research continuum, including proposal development, study planning and the first years of a comparative effectiveness study of care for pregnant women with opioid use disorder. Results: We highlight successful strategies, grounded in principles of engagement, to establish and maintain stakeholder relationships, foster bidirectional communication and trust and support active participation of women with opioid use disorder in the research process. Conclusion: CSER methods support research with a disenfranchised population. Future work will evaluate the impact of CSER strategies on study outcomes and dissemination.

Community stakeholder engagement in research on treatment for pregnant women with opioid use disorder builds and maintains stakeholder relationships, fosters communication and trust and supports active patient participation.

Quad-dimensional acculturation, cultural integration, and life satisfaction of South Sudanese refugee young adults in the United States: A quasilongitudinal qualitative study.

OBJECTIVE: This study aims to describe acculturation among South Sudanese refugees (SSRes) as young adults in the U.S. based on a tridimensional (3D) acculturation framework. METHOD: Aligning with a community-based participatory research (CBPR) approach, the present study was designed to investigate in-depth individual experiences of SSRes in two phases, conducting 19 interviews in 2007 and 11 interviews in 2014-2015. The data analysis employed a modified grounded theory approach. RESULTS: A grounded theory emerged indicating that, over time, SSRes experienced quad-dimensional acculturation that included South Sudanese, mainstream American, African American, and African cultures and orientations. Although bidimensional acculturation was prominent in Phase 1, quad-dimensional acculturation emerged and was salient in Phase 2. Furthermore, participants who demonstrated an integrated perspective toward their acculturation tended to report higher life satisfaction scores than those who expressed conflicted perspectives. CONCLUSIONS: The findings have theoretical and practical implications for African refugees' adjustment and psychological well-being. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attenuation of the Köhler Effect in Racially Dissimilar Partnered Exercise Reversed Using Team Identity Strategy.

The authors describe two research experiments exploring the influence of race on the Köhler motivation gain effect with exercise tasks. Experiment 1 tested whether partner racial dissimilarity affects individual performance. Experiment 2 created a team identity recategorization intervention to potentially counter the influence on performance observed in Experiment 1. White male participants were partnered with either a Black or Asian partner (Experiment 1) or with a Black partner utilizing team names and shirt colors as a team identity recategorization strategy (Experiment 2). Racially dissimilar dyads completed two sets of abdominal plank exercises with a Köhler conjunctive task paradigm (stronger partner; team performance outcome dependent upon the weaker-ability participant's performance). The results of Experiment 1 suggest attenuation of the previously successful group motivation gain effect in the racially dissimilar condition. The simple recategorization strategy utilized in Experiment 2 appeared to reverse motivation losses under conjunctive-task conditions in racially dissimilar exercise dyads.

Private well water testing promotion in pediatric preventive care: A randomized intervention study.

Over 43 million U.S. residents rely on private unregulated wells for their drinking water, raising public health concerns, particularly in regions like northern New England where widespread groundwater arsenic contamination is now recognized. Children are particularly vulnerable to adverse health effects from arsenic exposure. Despite AAP Guidelines, approaches to engage pediatric clinicians in promoting private well testing have not been previously described. We sought to determine the most effective practice approaches to achieve successful well water testing in routine pediatric care. 12 primary care clinics were block randomized to one of four study arms. Two intervention variables were assessed: (1) test results access (parent only vs. parent and clinic) and (2) follow up approaches (yes/no). Parents of children under 12 months using a private well were eligible. Prepaid water tests were provided. Primary outcome was parental water test completion. Eleven clinics successfully implemented processes identifying well users. 240 testing kits were dispensed. Completion rates averaged 29% (range 10 to 61%). The study arm with both clinic results access and staff follow up system was 2.3 times more likely to achieve test completion than other arms (95% CI 1.12-4.86, p = .03). Kit distribution by clinicians versus nursing staff, irrespective of study arm, had 2.4 times greater completion (95% CI 1.13-5.11, p = .02). Systematic drinking water source screening can be improved in pediatric care. Higher testing completion was found in practices randomized to reminders and structured follow up versus single visit discussion, but clinician involvement was the most predictive factor.

Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff.

BACKGROUND: There is limited evidence on how to implement shared decision-making (SDM) interventions in routine practice. We conducted a qualitative study, embedded within a 2 × 2 factorial cluster randomized controlled trial, to assess the acceptability and feasibility of two interventions for facilitating SDM about contraceptive methods in primary care and family planning clinics. The two SDM interventions comprised a patient-targeted intervention (video and prompt card) and a provider-targeted intervention (encounter decision aids and training). METHODS: Participants were clinical and administrative staff aged 18 years or older who worked in one of the 12 clinics in the intervention arm, had email access, and consented to being audio-recorded. Semi-structured telephone interviews were conducted upon completion of the trial. Audio recordings were transcribed verbatim. Data collection and thematic analysis were informed by the 14 domains of the Theoretical Domains Framework, which are relevant to the successful implementation of provider behaviour change interventions. RESULTS: Interviews (n = 29) indicated that the interventions were not systematically implemented in the majority of clinics. Participants felt the interventions were aligned with their role and they had confidence in their skills to use the decision aids. However, the novelty of the interventions, especially a need to modify workflows and change behavior to use them with patients, were implementation challenges. The interventions were not deeply embedded in clinic routines and their use was threatened by lack of understanding of their purpose and effect, and staff absence or turnover. Participants from clinics that had an enthusiastic study champion or team-based organizational culture found these social supports had a positive role in implementing the interventions. CONCLUSIONS: Variation in capabilities and motivation among clinical and administrative staff, coupled with inconsistent use of the interventions in routine workflow contributed to suboptimal implementation of the interventions. Future trials may benefit by using implementation strategies that embed SDM in the organizational culture of clinical settings.

Smoke-Free Moms: Financial Rewards for Smoking Cessation by Low-Income Rural Pregnant Women.

INTRODUCTION: Maternal smoking places the child at risk during pregnancy and postpartum. Most women who quit smoking do so early when they first learn of pregnancy. Few low-income women quit once they enter prenatal care. The purpose of this study is to test in a clinical prenatal care setting the effectiveness of the Smoke-Free Moms intervention, which provides pregnant women a series of financial incentives for smoking cessation. STUDY DESIGN: A prospective nonrandomized controlled trial that collected control population data of smoking-cessation rates at each clincal visit during pregnancy and postpartum with usual smoking counseling in 2013-2014. In 2015-2016, the same data were collected during the implementation of the Smoke-Free Moms intervention of financial incentives. Data analysis occurred in 2017. SETTING/PARTICIPANTS: Women who were smoking at the first prenatal visit at four federally qualified health centers in rural New Hampshire. INTERVENTION: All women received 5A's smoking counseling from clinic staff. At each clinic visit, with point-of-care confirmed negative urinary cotinine, intervention women received gift cards. MAIN OUTCOME MEASURES: Cotinine confirmed smoking cessation without relapse: (1) during pregnancy and (2) smoking cessation in both pregnancy and postpartum. RESULTS: Of 175 eligible pregnant women enrolled, 134 women were followed to the postpartum visit (Intervention n=66, Control n=68). The quit rates during pregnancy did not differ between groups (Intervention 36.4%, Control 29.4%, p=0.46). However, significantly more intervention mothers quit and continued as nonsmokers postpartum (Intervention 31.8%, Control 16.2%, p=0.04). In a logistic regression model including baseline sociodemographic, depressed mood, stress, and readiness to quit items, confidence in being able to quit predicted both cessation outcomes. The financial incentive intervention was an independent predictor of cessation in pregnancy through postpartum. CONCLUSIONS: Financial incentives with existing smoking-cessation counseling by staff in low-income clinical prenatal programs led to cessation that continued during the postpartum period. Further study in larger populations is indicated.

Ethnic socialization, ethnic identity, life satisfaction and school achievement of Roma ethnic minority youth.

This article is part of a Special Issue entitled Explaining Positive Adaptation of Immigrant Youth across Cultures. This study tested a mediation model of ethnic socialization (i.e., parental practices that promote children's knowledge about their history, heritage culture, cultural authenticity, and ethnic bias management) in Roma youth. Roma are the largest ethnic minority group in Europe subjected to severe discrimination, both currently and historically. Participants were 202 Roma youth aged 14 to 19 years old (M = 16.25, 53% females), who provided self-reports on their experience of ethnic socialization, ethnic identity, school achievement, and life satisfaction. Cultural pride reinforcement was related to better school achievement, whereas cultural coping with antagonism was positively related to life satisfaction. The study confirmed the model in that ethnic socialization was positively related to life satisfaction through effects on ethnic identity but negatively associated with school achievement. Findings have implications for adaptive cultural mechanisms promoting positive developmental outcomes among historically disadvantaged groups including those intersecting immigrant and multigenerational ethnic minority group categories.

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

INTRODUCTION: Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. METHODS AND ANALYSIS: We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. ETHICS AND DISSEMINATION: We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02759939.

Screening for Adverse Childhood Experiences in a Family Medicine Setting: A Feasibility Study.

INTRODUCTION: The role of adverse childhood experiences (ACEs) in predicting later adverse adult health outcomes is being widely recognized by makers of public policy. ACE questionnaires have the potential to identify in clinical practice unaddressed key social issues that can influence current health risks, morbidity, and early mortality. This study seeks to explore the feasibility of implementing the ACE screening of adults during routine family medicine office visits. METHODS: At 3 rural clinical practices, the 10-question ACE screen was used before visits with 111 consecutive patients of 7 clinicians. Clinician surveys about the use of the results and the effect on the visits were completed immediately after the visits. The presence of any ACE risk and "high-risk" ACE scores (≥4) were compared with clinician survey responses. RESULTS: A risk of ACEs was present in 62% of patients; 22% had scores ≥4. Clinicians were more likely to have discussed ACE issues for high-risk patients (score 0-3, 36.8%; score ≥4, 83.3%; P =. 00). Clinicians also perceived that they gained new information (score 0-3, 35.6%; score ≥4, 83.3%; P = .00). Clinical care changed for a small proportion of high-risk patients, with no change in immediate referrals or plan for follow-up. In 91% of visits where a risk of ACEs was present, visit length increased by ≤5 minutes. CONCLUSIONS: Incorporation of ACE screening during routine care is feasible and merits further study. ACE screening offers clinicians a more complete picture of important social determinants of health. Primary care-specific interventions that incorporate treatment of early life trauma are needed.

'They don't look at what affects us': the role of ecodevelopmental factors on alcohol and drug use among Latinos with physical disabilities.

Objectives. Latinos with disabilities disproportionately report substance use, including binge drinking and drug use. Ecodevelopmental factors, including socioeconomic patterning of poverty, social exclusion, and post-colonial racism, have been shown to impact alcohol and drug use. However, this line of research remains underdeveloped among Latinos with disabilities. The purpose of this study was to obtain rich descriptions of the role of ecodevelopmental factors, including family and community, on alcohol and drug use among Latinos with physical disabilities. Methods. We utilized a community-based participatory research design, in conjunction with an innovative methodology referred to as photovoice. Three rounds of photography and focus group interviews were conducted with a total of 17 focus groups. Reflections in each focus group interview were aloud and digitally audiotaped. A total of 28 participants 19-35 years of age (mean age = 27.65, SD = 5.48) participated in each round of photography and focus group interviews. Data analyses followed the tenets of descriptive phenomenology. Results. Findings highlight ecodevelopmental family and community risk and protective factors. At the family level, participants reflected on the ways in which family functioning, including family support, communication, and cohesion, can serve as risk and promotive factors for alcohol and drug use. Additionally, participants described in detail how experiences of poverty, stigma and discrimination, violence, accessibility to alcohol and drugs, accessibility for persons with disabilities, transportation, community support and cohesion, and access to health and mental health services constitute risk and promotive factors at the community level. Conclusion. Findings are suggestive of how ecodevelopmental family and community factors might increase the risk of alcohol and drug use among Latinos with physical disabilities. From this qualitative research, we derive a series of testable hypotheses. For example, future studies should examine the impact of family functioning on alcohol and drug use among Latinos with physical disabilities over time. Study findings may have great utility to inform the development of preventive interventions for this at-risk group.

A comparison of cesarean delivery outcomes for rural family physicians and obstetricians.

PURPOSE: Despite declining access to obstetrical care in many regions, family physicians often have difficulty obtaining Cesarean delivery privileges. We compared outcomes of Cesarean deliveries performed by family physicians (FPs) and obstetricians (OBs). The last such study done was more than 15 years ago. METHODS: This study was a chart review of 250 consecutive Cesarean deliveries was done at 2 rural New England hospitals. At one hospital, Cesarean deliveries were performed by FPs; at the other they were done by OBs. Demographics, pregnancy risk factors, and maternal and neonatal complication rates at each site were compared. RESULTS: Demographics, indications for Cesarean delivery, and prenatal risk factors were comparable at both sites except there were more hypertensive patients at the FP site. There were no differences in intraoperative or infectious complications. There were fewer postoperative complications at the FP hospital, which were mostly attributable to fewer blood transfusions and readmissions. There were no differences in neonatal outcomes, although there were more deliveries of fetuses <38 weeks' gestation at the FP site. CONCLUSIONS: Patients did not face increased risk when Cesarean deliveries were performed by FPs rather than OBs. A larger, more geographically diverse study is needed to confirm these findings. Results could support FPs seeking privileges to perform Cesarean deliveries, thus expanding access to care for pregnant women.

Racial/ethnic socialization and parental involvement in education as predictors of cognitive ability and achievement in African American children.

Racial/ethnic socialization has not been studied in the context of other parenting behaviors such as parental involvement in education and its relationship to children's cognitive outcomes. The present study tested the impact of racial/ethnic socialization and parental involvement in education on cognitive ability and achievement in a sample of African American youth. Two dimensions of racial/ethnic socialization, cultural exposure (i.e., exposure to diverse cultures) and cultural socialization (i.e., in-group pride), were examined in a sample of 92 African American mother-child dyads, of which 50% were female. Maternal reports of involvement during their child's 5th grade year were examined as a moderator in the relationship between racial/ethnic socialization and cognitive ability and achievement. Hierarchical regression analyses revealed that mothers' reports of cultural exposure messages measured in 4th grade predicted children's scores on 5th grade assessments of passage comprehension. There was also a significant interaction indicating that greater cultural exposure and more parental involvement in education predicted better reading passage comprehension scores over time. The implications for assessing dimensions relevant to cognitive ability and achievement in African American children are discussed.

Dose dependent effect of statins on postoperative atrial fibrillation after cardiac surgery among patients treated with beta blockers.

BACKGROUND: Previous studies on the effects of Statins in preventing atrial fibrillation (AF) after cardiac surgery have shown conflicting results. Whether statins prevent AF in patients treated with postoperative beta blockers and whether the statin-effect is dose related are unknown. METHODS: We retrospectively studied 1936 consecutive patients who underwent coronary artery bypass graft (CABG) (n = 1493) or valve surgery (n = 443) at the Minneapolis Veterans Affairs Medical Center. All patients were in sinus rhythm before the surgery. Postoperative beta blockers were administered routinely (92% within 24 hours postoperatively). RESULTS: Mean age was 66+10 years and 68% of the patients were taking Statins. Postoperative AF occurred in 588 (30%) patients and led to longer length of stay in the intensive care unit versus those without AF (5.1+7.6 days versus 2.5+2.3 days, p < 0.0001). Patients with a past history of AF had a 5 times higher risk of postoperative AF (odds ratio 5.1; 95% confidence interval 3.4 to 7.7; p < 0.0001). AF occurred in 31% of patients taking statins versus 29% of the others (p = 0.49). In multivariable analysis, statins were not associated with AF (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.7 to 1.2; p = 0.59). However, in a subgroup analysis, the patients treated with Simvastatin >20 mg daily had a 36% reduction in the risk of postoperative AF (OR 0.64, 95% CI 0.43 to 0.6; p = 0.03) in comparison to those taking lower dosages. CONCLUSION: Among cardiac surgery patients treated with postoperative beta blockers Statin treatment reduces the incidence of postoperative AF when used at higher dosages.

Cultural processes in parenting and youth outcomes: examining a model of racial-ethnic socialization and identity in diverse populations.

We review and summarize the findings across 7 studies contained in the special section titled, "Racial-Ethnic Socialization, Identity, and Youth Outcomes: Excavating Culture." These studies represent a significant advance for research in issues related to the impact of racial-ethnic socialization and identity on child outcomes. All 7 studies attempted to test in whole or part a hypothetical model in which ethnic-racial socialization in families of color is related to child psychosocial and academic outcomes directly and indirectly through effects on self-system variables such as racial-ethnic identity and self-esteem. Two types of racial socialization messages were of particular interest: messages that promote cultural pride (referred to as ethnic or cultural socialization) and messages that address children's exposure to discrimination (referred to as racial socialization). Collectively, the studies suggest that ethnic-racial socialization processes are related to youth outcomes through indirect associations with ethnic-racial identity and self-esteem. Findings were most consistent in the studies with African American youth and some aspects of the model were not supported for American Indian and Chinese youth. Ethnic and racial group differences and directions for future research are discussed.

Utility of N-acetylcysteine to prevent acute kidney injury after cardiac surgery: a randomized controlled trial.

BACKGROUND: Acute kidney injury (AKI) after heart surgery is associated with increased mortality. We sought to determine whether prophylactic perioperative administration of N-acetylcysteine (NAC) prevents postoperative AKI in patients with chronic kidney disease undergoing cardiac surgery (clinical trials.gov identifier NCT00211653). METHODS: In this prospective, randomized, placebo-controlled, double-blinded clinical trial, 102 patients with chronic kidney disease who underwent heart surgery at the Minneapolis Veterans Affairs Medical Center were randomized to either NAC (n = 50) 600 mg PO twice daily or placebo (n = 52) for a total of 14 doses (3 preoperative). The primary outcome was maximum change in creatinine from baseline within 7 days after surgery. Secondary outcome was AKI (ie, >0.5 mg/dL or >or=25% increase in creatinine from baseline). RESULTS: Creatinine increased in both groups (0.45 +/- 0.7 mg/dL in NAC vs 0.55 +/- 0.9 mg/dL in placebo, P = .53) and peaked on postoperative day 5. Acute kidney injury occurred in 41 patients (22 NAC vs 19 placebo, P = .44) by postoperative day 5, but persisted in only 14 (7 NAC vs 7 placebo, P = .94) by day 30. In multivariable analysis, perioperative NAC was unassociated with AKI (relative risk 1.2, 95% CI, 0.8-1.9, P = .34). Five patients (3 NAC vs 2 placebo, P = .68) underwent hemodialysis, and 5 (2 NAC vs 3 placebo, P = 1.0) died perioperatively. There was no difference in lengths of stay in the intensive care unit (4.9 +/- 7 days in NAC vs 6.5 +/- 9 days in placebo, P = .06) and the hospital (13.2 +/- 13 days in NAC vs 16.7 +/- 17 days in placebo, P = .12). CONCLUSION: Prophylactic perioperative NAC administration does not prevent AKI after cardiac surgery.

The impact of primary care patients' pain and emotional problems on their confidence with self-management.

There is a paucity of information about confidence with self-management in primary care practice. This study examines changes over time in patient-reported confidence with self-management on the basis of 1047 patients aged 50-69 who had common chronic diseases, bothersome pain, or emotional problems. We examined the relationship between patients' self-reported confidence, their experiences of medical care, and health outcomes after adjustment for baseline characteristics. We observed that, over a 2-year period, about a third of the patients remained confident and a third remained not confident. Change in pain or emotional problems was strongly associated with whether a patient was confident or not at the end of the follow-up period (P < .001). Persistently good confidence or improved confidence was strongly associated with measures of high-quality medical care. For patients with diabetes, persistent confidence was more often associated with control of blood glucose (P = .004) compared with the control in patients who were not as confident. Confident patients were likely to be fully engaged in everyday work and activities (P < .001). The results suggest that for the majority of patients in primary care practices, the status of their self-reported confidence with self-management persists over time. Their confidence is impacted by their pain or emotional state and strongly associated with their medical care experiences and some outcomes of care.

Parents' ethnic-racial socialization practices: a review of research and directions for future study.

Recently, there has been an emergence of literature on the mechanisms through which parents transmit information, values, and perspectives about ethnicity and race to their children, commonly referred to as racial or ethnic socialization. This literature has sought to document the nature of such socialization, its antecedents in parents' and children's characteristics and experiences, and its consequences for children's well-being and development. In this article, the authors integrate and synthesize what is known about racial and ethnic socialization on the basis of current empirical research, examining studies concerning its nature and frequency; its child, parent, and ecological predictors; and its consequences for children's development, including ethnic identity, self-esteem, coping with discrimination, academic achievement, and psychosocial well-being. The authors also discuss conceptual and methodological limitations of the literature and suggest directions for future research.

A controlled trial of methods for managing pain in primary care patients with or without co-occurring psychosocial problems.

PURPOSE: Pain, a common reason for visits to primary care physicians, is often not well managed. The objective of this study was to determine the effectiveness of pain management interventions suitable for primary care physicians. METHODS: Patients from 14 rural primary care practices (47 physicians) who reported diverse pain problems with (n = 644) or without (n = 693) psychosocial problems were randomized to usual-care or intervention groups. All patients in the intervention group received information tailored to their problems and concerns (INFO). These patients' physicians received feedback about their patients' problems and concerns (FEED). A nurse-educator (NE) telephoned patients with pain and psychosocial problems to teach problem-solving strategies and basic pain management skills. Outcomes were assessed with the Medical Outcomes Study 36-Item Short-Form and the Functional Interference Estimate at baseline, 6 months, and 12 months. RESULTS: Patients with pain and psychosocial problems randomized to INFOFEED+NE significantly improved on the bodily pain (P = .011), role physical (P = .025), vitality (P <.001), role emotional (P = .048), and the Functional Interference Estimate (P = .027) scales compared with usual-care patients at 6 months. These improvements were maintained at the 12-month assessment even though these patients had received, on average, only 3 telephone calls. Compared with usual-care patients, at 6 months patients who received INFOFEED alone experienced minimal improvements that were not sustained at the 12-month assessment. CONCLUSIONS: For patients with pain and psychosocial problems, telephone-based assistance resulted in significant, sustained benefit in pain and psychosocial problems.

Patients report positive impacts of collaborative care.

Collaborative Care refers to a partnership between healthcare professionals and patients who feel confident to manage their health conditions. Using an Internet-based assessment of health needs and healthcare quality, we surveyed 24,609 adult Americans aged 19 to 69 who had common chronic diseases or significant dysfunction. In these patients, we examined the association of Collaborative Care with specific measures for treatment effect, disease control, prevention, and economic impacts. These measures were adjusted for respondents' demographic characteristics, burden of illness, health behaviors, and overall quality of healthcare. Only 21% of respondents participated in good Collaborative Care, 36% attained fair Collaborative Care, and 43% experienced poor Collaborative Care. Regardless of overall care quality or the respondents' personal characteristics, burden of illness, or health behaviors, good Collaborative Care was associated with better control of blood pressure, blood glucose level, serum cholesterol level, and treatment effectiveness for pain and emotional problems. Some preventive actions were better, and some adverse economic impacts of illness were mitigated.

The emergence of Ideal Micro Practices for patient-centered, collaborative care.

Ideal Micro Practices are capable of delivering patient-centered collaborative care. With respect to comparable adult patients in "usual" care settings, twice as many patients who use Ideal Micro Practices report they receive care that is "exactly what they want and need exactly when and how they want and need it" (68% vs 35%). Compared to usual care, these very small, low-overhead practices are more likely to have patients report very high levels of continuity (98% vs 88%), efficiency (95% vs 73%), and access (72% vs 53%). Patient ratings of very good information (83% vs 67%) and clinician awareness of pain or emotional problem are also higher (87% vs 69%). However, only a slim majority of patients using Ideal Micro Practices report that they are confident in their ability to manage and control their health problems or concerns. Ideal Micro Practices are sharing new tools and approaches to better understand their patients' needs and increase patients' confidence in their ability to manage conditions. In addition, these practices are working collaboratively to standardize their approaches and make the essential elements of Ideal Micro Practice replicable.