International treaties have mostly failed to produce their intended effects.

There are over 250,000 international treaties that aim to foster global cooperation. But are treaties actually helpful for addressing global challenges? This systematic field-wide evidence synthesis of 224 primary studies and meta-analysis of the higher-quality 82 studies finds treaties have mostly failed to produce their intended effects. The only exceptions are treaties governing international trade and finance, which consistently produced intended effects. We also found evidence that impactful treaties achieve their effects through socialization and normative processes rather than longer-term legal processes and that enforcement mechanisms are the only modifiable treaty design choice with the potential to improve the effectiveness of treaties governing environmental, human rights, humanitarian, maritime, and security policy domains. This evidence synthesis raises doubts about the value of international treaties that neither regulate trade or finance nor contain enforcement mechanisms.

Global incidence of suicide among Indigenous peoples: a systematic review.

BACKGROUND: Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available. Our objective was to examine the global incidence of suicide among Indigenous peoples and assess disparities through comparisons with non-Indigenous populations. METHODS: We conducted a systematic review of suicide rates among Indigenous peoples worldwide and assessed disparities between Indigenous and non-Indigenous populations. We performed text word and Medical Subject Headings searches in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO) for observational studies in any language, indexed from database inception until June 1, 2017. Eligible studies examined crude or standardized suicide rates in Indigenous populations at national, regional, or local levels, and examined rate ratios for comparisons to non-Indigenous populations. RESULTS: The search identified 13,736 papers and we included 99. Eligible studies examined suicide rates among Indigenous peoples in 30 countries and territories, though the majority focused on populations in high-income nations. Results showed that suicide rates are elevated in many Indigenous populations worldwide, though rate variation is common, and suicide incidence ranges from 0 to 187.5 suicide deaths per 100,000 population. We found evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples. CONCLUSIONS: This review showed that suicide rates in Indigenous populations vary globally, and that suicide rate disparities between Indigenous and non-Indigenous populations are substantial in some settings but not universal. Including Indigenous identifiers and disaggregating national suicide mortality data by geography and ethnicity will improve the quality and relevance of evidence that informs community, clinical, and public health practice in Indigenous suicide prevention.

Developmental pathways linking childhood and adolescent internalizing, externalizing, academic competence, and adolescent depression.

This study examined longitudinal pathways through three domains of adaptation from ages 4-5 to 14-15 (internalizing problems, externalizing problems, and academic competence) towards depressive symptoms at age 16-17. Participants were 6425 Canadian children followed bi-annually as part of the National Longitudinal Study of Children and Youth. Within-domain (i.e., stability) effects were moderate in strength. We found longitudinal cross-domain effects across one time point (i.e., one-lag cascades) between internalizing and externalizing in early childhood (positive associations), and between academic competence and externalizing in later childhood and adolescence (negative associations). We also found cascade effects over multiple time points (i.e., multi-lag cascades); lower academic competence at age 4-5 and greater internalizing at age 6-7 predicted greater age 12-13 externalizing, and greater age 6-7 externalizing predicted greater age 16-17 depression. Important pathways towards adolescent depression include a stability path through childhood and adolescent internalizing, as well as a number of potential paths involving all domains of adaptation, highlighting the multifactorial nature of adolescent depression.

Social inequalities in early childhood health and development: a European-wide systematic review.

The evidence examining the relationship between specific social factors and early childhood health and developmental outcomes has never been systematically collated or synthesized. This review aims to identify the key social factors operating at the household, neighborhood, and country levels that drive inequalities in child health and development. Medline and CHICOS (a European child-cohort inventory) were systematically searched to identify all European studies published within the past 10 y. 13,270 Medline articles and 77 European child cohorts were searched, identifying 201 studies from 32 European countries. Neighborhood deprivation, lower parental income/wealth, educational attainment, and occupational social class, higher parental job strain, parental unemployment, lack of housing tenure, and household material deprivation were identified as the key social factors associated with a wide range of adverse child health and developmental outcomes. Similar association trends were observed across most European countries, with only minor country-level differences. Multiple adverse social factors operating at both the household and neighborhood levels are independently associated with a range of adverse health and developmental outcomes throughout early childhood. The social gradient in health and developmental outcomes observed throughout the remaining life course may be partly explained by gradients initiated in early childhood.

Protective factors against depression during the transition from adolescence to adulthood: findings from a national Canadian cohort.

OBJECTIVE: This study sought to identify factors protective against the onset or recurrence of depression in early adulthood, and to describe their interactions with stressors during this transitional period. METHODS: 1137 members of Canada's National Population Health Survey were followed from ages 12 to 17 in 1994/95 and contacted every two years until 2008/09. Protective factors measured at age 16/17 included social support, physical activity, mastery, self-esteem, and education level. General linear mixed models were used to examine the relationship between the protective factors and five assessments of depression, including interactions between protective factors and four types of stress: stressful life events, and work, financial, and personal stress. RESULTS: High mastery in adolescence had a significant protective effect against depression in early adulthood. Participants with high social support in adolescence were significantly less likely to become depressed after experiencing work or financial stress, compared to those with low social support. Those who were physically active in adolescence were less likely to become depressed after experiencing work stress, and higher overall education level reduced depression risk following personal stress or major life events. CONCLUSION: Social support and physical activity may be ideal targets for school-based depression interventions during a potentially stressful transitional period.

Early-life predictors of internalizing symptom trajectories in Canadian children.

BACKGROUND: Previous research examining the development of anxious and depressive symptoms (i.e., internalizing symptoms) from childhood to adolescence has often assumed that trajectories of these symptoms do not vary across individuals. The purpose of this study was to identify distinct trajectories of internalizing symptoms from childhood to adolescence, and to identify risk factors for membership in these trajectory groups. In particular, we sought to identify risk factors associated with early appearing (i.e., child onset) symptoms versus symptoms that increase in adolescence (i.e., adolescent onset). METHOD: Drawing on longitudinal data from the National Longitudinal Survey of Children and Youth, latent class growth modeling (LCGM) was used to identify distinct trajectories of internalizing symptoms for 6,337 individuals, from age 4-5 to 14-15. Multinomial regression was used to examine potential early-life risk factors for membership in a particular trajectory group. RESULTS: Five trajectories were identified as follows: "low stable" (68%; reference group), "adolescent onset" (10%), "moderate stable" (12%), "high childhood" (6%), and "high stable" (4%). Membership in the "adolescent onset" group was predicted by child gender (greater odds for girls), stressful life events, hostile parenting, aggression, and hyperactivity. Membership in the "high stable" and "high childhood" trajectory groups (i.e., child-onset) was additionally predicted by maternal depression, family dysfunction, and difficult temperament. Also, several significant gender interactions were observed. CONCLUSIONS: Causal mechanisms for child and adolescent depression and anxiety may differ according to time of onset, as well as child gender. Some early factors may put girls at greater risk for internalizing problems than boys.

Quality of cardiovascular disease care in Ontario's primary care practices: a cross sectional study examining differences in guideline adherence by patient sex.

BACKGROUND: Women are disproportionately affected by cardiovascular disease, often experiencing poorer outcomes following a cardiovascular event. Evidence points to inequities in processes of care as a potential contributing factor. This study sought to determine whether any sex differences exist in adherence to process of care guidelines for cardiovascular disease within primary care practices in Ontario, Canada. METHODS: This is a secondary analysis of pooled cross-sectional baseline data collected through a larger quality improvement initiative known as the Improved Delivery of Cardiovascular Care (IDOCC). Chart abstraction was performed for 4,931 patients from 84 primary care practices in Eastern Ontario who had, or were at high risk of, cardiovascular disease. Measures examining adherence to guidelines associated with nine areas of cardiovascular care (coronary artery disease, peripheral vascular disease (PVD), stroke/transient ischemic attack, chronic kidney disease, diabetes, dyslipidemia, hypertension, smoking cessation, and weight management) were collected. Multivariable logistic regression analysis was performed to evaluate sex differences, adjusting for age, physician remuneration, and rurality. RESULTS: Women were significantly less likely to have their lipid profiles taken (OR=1.17, 95% CI 1.03-1.33), be prescribed lipid lowering medication for dyslipidemia (OR=1.54, 95% CI 1.20-1.97), and to be prescribed ASA following stroke (OR=1.56, 95% CI 1.39-1.75). Women with PVD were significantly less likely to be prescribed ACE inhibitors and/or angiotensin receptor blockers (OR=1.74, 95% CI 1.25-2.41) and lipid lowering medications (OR=1.95, 95% CI 1.46-2.62) or ASA (OR=1.59, 95% CI 1.43-1.78). However, women were more likely to have two blood pressure measurements taken and to be referred to a dietician or weight loss program. Male patients with diabetes were less likely to be prescribed glycemic control medication (OR=0.84, 95% CI 0.74-0.86). CONCLUSIONS: Sex disparities exist in the quality of cardiovascular care in Canadian primary care practices, which tend to favour men. Women with PVD have a particularly high risk of not receiving appropriate medications. Our findings indicate that improvements in care delivery should be made to address these issues, particularly with regard to the prescribing of recommended medications for women, and preventive measures for men.

Stress and development of depression and heavy drinking in adulthood: moderating effects of childhood trauma.

PURPOSE: Studies suggest that childhood trauma is linked to both depression and heavy drinking in adulthood, and may create a lifelong vulnerability to stress. Few studies have explored the effects of stress sensitization on the development of depression or heavy drinking among those who have experienced traumatic childhood events. This study aimed to determine the effect of childhood trauma on the odds of experiencing depression or heavy drinking in the face of an adult life stressor, using a large population-based Canadian cohort. METHODS: A total of 3,930 participants were included from the National Population Health Survey. The associations among childhood trauma, recent stress and depression/heavy drinking from 1994/1995 to 2008/2009 were explored using logistic regression, as were interactions between childhood trauma and recent stress. A generalized linear mixed model was used to determine the effects of childhood trauma and stressful events on depression/heavy drinking. Analyses were stratified by sex. RESULTS: Childhood trauma significantly increased the odds of becoming depressed (following 1 event: OR = 1.66; 95%CI 1.01, 2.71; 2+ events, OR = 3.89; 95%CI 2.44, 6.22) and drinking heavily (2+ events: OR = 1.79; 95%CI 1.03, 3.13). Recent stressful events were associated with depression, but not heavy drinking. While most interaction terms were not significant, in 2004/2005 the association between recent stress and depression was stronger in those who reported childhood trauma compared to those with no childhood trauma. CONCLUSIONS: Childhood trauma increases risk for both depression and heavy drinking. Trauma may moderate the effect of stress on depression; the relationship among trauma, stress and heavy drinking is less clear.

Predictors of long-term prognosis of depression.

BACKGROUND: Many people with depression experience repeated episodes. Previous research into the predictors of chronic depression has focused primarily on the clinical features of the disease; however, little is known about the broader spectrum of sociodemographic and health factors inherent in its development. Our aim was to identify factors associated with a long-term negative prognosis of depression. METHODS: We included 585 people aged 16 years and older who participated in the 2000/01 cycle of the National Population Health Survey and who reported experiencing a major depressive episode in 2000/01. The primary outcome was the course of depression until 2006/07. We grouped individuals into trajectories of depression using growth trajectory models. We included demographic, mental and physical health factors as predictors in the multivariable regression model to compare people with different trajectories. RESULTS: Participants fell into two main depression trajectories: those whose depression resolved and did not recur (44.7%) and those who experienced repeated episodes (55.3%). In the multivariable model, daily smoking (OR 2.68, 95% CI 1.54-4.67), low mastery (i.e., feeling that life circumstances are beyond one's control) (OR 1.10, 95% CI 1.03-1.18) and history of depression (OR 3.5, 95% CI 1.95-6.27) were significant predictors (p < 0.05) of repeated episodes of depression. INTERPRETATION: People with major depression who were current smokers or had low levels of mastery were at an increased risk of repeated episodes of depression. Future studies are needed to confirm the predictive value of these variables and to evaluate their accuracy for diagnosis and as a guide to treatment.

Cervical cancer screening in the Canadian armed forces: An estimation of screening participation rates using the CF-HERO surveillance system.

BACKGROUND: Military women are faced with unique circumstances, including frequent relocation and occupational factors that may influence their participation in routine cervical cancer screening. No data on programmatic participation in cervical cancer screening in Canadian Armed Forces women has been synthesized to date. OBJECTIVE: To estimate cervical cancer screening rates in Canadian military women using clinical and administrative data sources. METHODS: Actively serving Regular Force females who were >25 years of age between January 1st 2015 and December 31st 2017 were included in the study. Scanned documents containing Papanicolaou (Pap) test results were extracted from electronic health records and further linked to demographic data sources. Screening coverage rates were calculated over the three-year study period, and results were stratified by both military command and rank. RESULTS: The study period yielded over 23,000 person-years of data. The average screening rate over this period was 77.7 %, and was highest in the 45-60 year age group. Variations in rates were observed by rank and command, with higher screening rates observed in Officers and Royal Canadian Navy staff. Overall, screening rates showed a declining trend for all groups across the study period. CONCLUSIONS: Cervical cancer screening rates amongst CAF members are currently below recommended guidelines and appear to be declining. These trends mirror those observed more widely in the general Canadian population, and may be a consequence of recent changes to guidelines for both cervical cancer and human papillomavirus (HPV) screening.

Population attributable fractions for Type 2 diabetes: an examination of multiple risk factors including symptoms of depression and anxiety.

BACKGROUND: Population attributable fractions (PAFs) are frequently used to quantify the proportion of Type 2 diabetes cases due to single risk factors, an approach which may result in an overestimation of their individual contributions. This study aimed to examine Type 2 diabetes incidence associated with multiple risk factor combinations, including the metabolic syndrome, behavioural factors, and specifically, depression and anxiety. METHODS: Using data from the population-based HUNT cohort, we examined incident diabetes in 36,161 Norwegian adults from 1995 to 2008. PAFs were calculated using Miettinen's case-based formula, using relative risks estimated from multivariate regression models. RESULTS: Overall, the studied risk factors accounted for 50.5% of new diabetes cases (78.2% in men and 47.0% in women). Individuals exposed to both behavioural and metabolic factors were at highest risk of diabetes onset (PAF = 22.9%). Baseline anxiety and depression contributed a further 13.6% of new cases to this combination. Men appeared to be particularly vulnerable to the interaction between metabolic, behavioural and psychological risk factors. CONCLUSION: This study highlights the importance of risk factor clustering in diabetes onset, and is the first that we know of to quantify the excess fraction of incident diabetes associated with psychological risk factor interactions.

Type 2 Diabetes and Comorbid Symptoms of Depression and Anxiety: Longitudinal Associations With Mortality Risk.

OBJECTIVE: Depression is strongly linked to increased mortality in individuals with type 2 diabetes. Despite high rates of co-occurring anxiety and depression, the risk of death associated with comorbid anxiety in individuals with type 2 diabetes is poorly understood. This study documented the excess mortality risk associated with symptoms of depression and/or anxiety comorbid with type 2 diabetes. RESEARCH DESIGN AND METHODS: Using data for 64,177 Norwegian adults from the second wave of the Nord-Trøndelag Health Study (HUNT2), with linkage to the Norwegian Causes of Death Registry, we assessed all-cause mortality from survey participation in 1995 through to 2013. We used Cox proportional hazards models to examine mortality risk over 18 years associated with type 2 diabetes status and the presence of comorbid affective symptoms at baseline. RESULTS: Three clear patterns emerged from our findings. First, mortality risk in individuals with diabetes increased in the presence of depression or anxiety, or both. Second, mortality risk was lowest for symptoms of anxiety, higher for comorbid depression-anxiety, and highest for depression. Lastly, excess mortality risk associated with depression and anxiety was observed in men with diabetes but not in women. The highest risk of death was observed in men with diabetes and symptoms of depression only (hazard ratio 3.47, 95% CI 1.96, 6.14). CONCLUSIONS: This study provides evidence that symptoms of anxiety affect mortality risk in individuals with type 2 diabetes independently of symptoms of depression, in addition to attenuating the relationship between depressive symptoms and mortality in these individuals.

Symptoms of anxiety and depression in type 2 diabetes: Associations with clinical diabetes measures and self-management outcomes in the Norwegian HUNT study.

OBJECTIVE: To determine if symptoms of depression and anxiety are differentially associated with clinical diabetes measures and self-management behaviours in individuals with Type 2 diabetes, and whether these associations vary by patient sex. RESEARCH DESIGN AND METHODS: A cross-sectional analysis using data from 2035 adults with Type 2 diabetes in the Nord-Trøndelag Health Study. Multivariate logistic regression was used to explore associations between symptoms of depression and anxiety and waist girth, HDL cholesterol, systolic blood pressure, triglycerides, c-reactive protein, glycemic control, diet adherence, exercise, glucose monitoring, foot checks for ulcers, and the subjective patient experience. Analyses were stratified by sex. RESULTS: Depression was associated with a lower likelihood of avoiding saturated fats (OR=0.20 [95% CI: 0.06, 0.68]) and increased odds of physical inactivity (OR=1.69 [95% CI: 1.37, 2.72]). Anxiety was associated with increased odds of eating vegetables (OR=1.66 [95% CI: 1.02, 2.73]), and an over two-fold increase of feeling that having diabetes is difficult. In women, anxiety was associated with elevated c-reactive protein levels (OR=1.57 [95% CI: 1.05, 2.34]). In men, depressive symptoms were associated with elevated HbA1c (OR=5.00 [95% CI: 1.15, 8.23). CONCLUSIONS: Symptoms of depression and anxiety were differentially associated with some key diabetes-related measures. Our results suggest sex-specific differences with respect to two important clinical outcomes (i.e., anxiety and CRP in women and depression and glycemic control in men). These findings should alert practitioners to the importance of detection and management of psychological symptoms in individuals with Type 2 diabetes.

CARTOONS KILL: casualties in animated recreational theater in an objective observational new study of kids' introduction to loss of life.

OBJECTIVES: To assess the risk of on-screen death of important characters in children's animated films versus dramatic films for adults. DESIGN: Kaplan-Meier survival analysis with Cox regression comparing time to first on-screen death. SETTING: Authors' television screens, with and without popcorn. PARTICIPANTS: Important characters in 45 top grossing children's animated films and a comparison group of 90 top grossing dramatic films for adults. MAIN OUTCOME MEASURES: Time to first on-screen death. RESULTS: Important characters in children's animated films were at an increased risk of death compared with characters in dramatic films for adults (hazard ratio 2.52, 95% confidence interval 1.30 to 4.90). Risk of on-screen murder of important characters was higher in children's animated films than in comparison films (2.78, 1.02 to 7.58). CONCLUSIONS: Rather than being the innocuous form of entertainment they are assumed to be, children's animated films are rife with on-screen death and murder.

Social, demographic, and health outcomes in the 10 years following adolescent depression.

PURPOSE: Little attention has been paid to the sociodemographic profiles of depressed youth during the vulnerable transition from adolescence to early adulthood. This study aimed to determine and describe the social, demographic, and health outcomes of adolescent depression during a 10-year period of transition into early adulthood, using a population-based cohort of Canadian teenagers. METHODS: Depression status on 1,027 adolescents aged 16-17 years was ascertained from the National Population Health Survey. Social and health outcomes (i.e., employment status, marital status, personal income, education, social support, self-perceived stress, heavy drinking, smoking, migraine headaches, adult depression, antidepressant use, self-rated health, and physical activity) were measured every 2 years until the ages of 26-27 years. Logistic regression was combined with a generalized linear mixed-model approach to determine the odds of health and social outcomes in depressed versus nondepressed adolescents. RESULTS: Proximal effects of adolescent depression were observed (at ages 18-19) on all outcomes with the exception of physical activity. Significant effects that persisted after 10 years included depression recurrence, higher severity of symptoms, migraine headaches, poor self-rated health, and low levels of social support. Adolescent depression did not appear to significantly affect employment status, personal income, marital status, or educational attainment. CONCLUSIONS: The transition from adolescence to adulthood is a particularly vulnerable period due to educational, employment, and social changes that may be occurring. The results of this study indicate that the onset of depression during adolescence may be indicative of problems of adaptation that persist at least a decade into early adulthood.

Timing of first exposure to maternal depression and adolescent emotional disorder in a national Canadian cohort.

OBJECTIVE: Correlations have been reported between behavioral and cognitive outcomes in adolescence and exposure to maternal depression during the first postpartum year, but the effects of timing of maternal depression during subsequent exposure periods have rarely been controlled for. This study aims to methodically investigate the importance of timing of initial exposure to maternal depression with respect to adolescent mental health outcomes. METHODS: This study used data on 937 children from the National Longitudinal Study of Children and Youth (NLSCY), a nationally-representative longitudinal survey established in 1994 by Statistics Canada. Ordinal logistic regression was used to confirm associations between adolescent emotional disorder (at 12-13 years) and initial exposure to maternal depression during 2-year intervals from birth to adolescence. Following their initial exposure to maternal depression, children were dropped from subsequent cycles. Stressful life events, chronic health conditions, maternal alcohol use, maternal marital status, gender, and SES were included as covariates. RESULTS: The results indicated that adolescents who were initially exposed to maternal depression between the ages of 2-3 years and 4-5 years had a two-fold increase in odds of emotional disorder. No increase in odds was observed in those initially exposed during the first postpartum year or later in childhood. CONCLUSIONS: The results demonstrate that a sensitive period of initial exposure to maternal depression may occur between the ages of 2 and 5, and not during the first year of life indicated by previous research. These findings are congruent with the literature on emotional and behavioral development in early childhood.

Birth weight, stress, and symptoms of depression in adolescence: evidence of fetal programming in a national Canadian cohort.

OBJECTIVE: To investigate evidence of fetal programming in humans by studying whether adolescents born at high or low birth weights (LBW) are more likely to experience symptoms of depression and anxiety after experiencing stress. METHOD: The sample included 3732 members of a prospective Canadian cohort study assessed for symptoms of depression and anxiety at age 12 to 15 years (2006/2007), and had birth weight and gestational age (GA) data recorded in 1994/1995. Major stressful life events and chronic stressors were also reported throughout childhood. RESULTS: After adjusting for acute and chronic stress, being born small for GA (SGA) (OR 1.50; 95% CI 1.08 to 2.08) or large (OR 1.31; 95% CI 0.99 to 1.72) for GA was associated with an increased risk of depression and anxiety in adolescence, compared with adolescents who were born at a weight appropriate for their GA. Most interactions between birth weight and stress were not significant; however, the relation between chronic stress and adolescent depression and anxiety was more pronounced in males who were born SGA (interaction P < 0.05). CONCLUSIONS: The link between birth weight and depression is complex and evidence of fetal programming is inconsistent; however, people born at LBW may be at an increased risk of depression in the face of chronic stress.

Using novel Canadian resources to improve medication reconciliation at discharge: study protocol for a randomized controlled trial.

BACKGROUND: Adverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem. METHODS/DESIGN: Participants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units. DISCUSSION: The goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors. TRIAL REGISTRATION: NCT01179867.