General health status of youth with autism with and without intellectual disabilities transitioning from special education, and its relationship to personal and family circumstances: longitudinal cohort study.

Objective: Transition from school to early adulthood incurs many changes and may be associated with deterioration in general health in youth with autism. We aimed to investigate this. Method: The National Longitudinal Transitions Study-2 is a USA nationally representative sample of youth receiving special education services, aged 13-17 at wave 1, followed-up over 10 years in five data collection waves. We conducted random-effects ordered logistic regressions to determine the odds ratios (OR) with 95% confidence intervals of wave, age, sex, ethnicity/race, additional intellectual disabilities, parental/guardian relationship status, and household income being associated with general health status in youth with autism. Results: Across waves, only between 74.3%-69.6% had excellent/very good health (71.7%-58.8% in those with co-occurring intellectual disabilities), but wave was not associated with health status. Associations were with age OR = 1.18 (1.04, 1.33), co-occurring intellectual disabilities OR = 1.56 (1.00, 2.44), and household income OR = 0.61 (0.40, 0.94) at $30,001-$50,000, OR = 0.44 (0.27, 0.72) at $50,001-$70,000, and OR = 0.34 (0.20, 0.56) at $70,001+. Sex, ethnicity/race, and parental/guardian relationship status were not associated with health status. Conclusion: There was little change in general health status longitudinally across the transitional period, but the proportion with excellent/very good health was low at each wave. Transitional planning should consider co-occurring intellectual disabilities, and the wider socioeconomic context in which children/youth with autism are raised. Lack of other longitudinal studies indicates a need for replication.

An Intercompany Perspective on Biopharmaceutical Drug Product Robustness Studies.

The Biophorum Development Group (BPDG) is an industry-wide consortium enabling networking and sharing of best practices for the development of biopharmaceuticals. To gain a better understanding of current industry approaches for establishing biopharmaceutical drug product (DP) robustness, the BPDG-Formulation Point Share group conducted an intercompany collaboration exercise, which included a bench-marking survey and extensive group discussions around the scope, design, and execution of robustness studies. The results of this industry collaboration revealed several key common themes: (1) overall DP robustness is defined by both the formulation and the manufacturing process robustness; (2) robustness integrates the principles of quality by design (QbD); (3) DP robustness is an important factor in setting critical quality attribute control strategies and commercial specifications; (4) most companies employ robustness studies, along with prior knowledge, risk assessments, and statistics, to develop the DP design space; (5) studies are tailored to commercial development needs and the practices of each company. Three case studies further illustrate how a robustness study design for a biopharmaceutical DP balances experimental complexity, statistical power, scientific understanding, and risk assessment to provide the desired product and process knowledge. The BPDG-Formulation Point Share discusses identified industry challenges with regard to biopharmaceutical DP robustness and presents some recommendations for best practices.

Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease.

PURPOSE: Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease. METHODS: Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months. RESULTS: Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50-0.77) and lower medical care costs (-$556; 95% CI, -$781 to -$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09-1.94) and greater costs ($506; 95% CI, $202-$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes. CONCLUSIONS: Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost.

Registered dietitian nutritionists bring value to emerging health care delivery models.

Health care in the United States is the most expensive in the world; however, most citizens do not receive quality care that is comprehensive and coordinated. To address this gap, the Institute for Healthcare Improvement developed the Triple Aim (ie, improving population health, improving the patient experience, and reducing costs), which has been adopted by patient-centered medical homes and accountable care organizations. The patient-centered medical home and other population health models focus on improving the care for all people, particularly those with multiple morbidities. The Joint Principles of the Patient-Centered Medical Home, developed by the major primary care physician organizations in 2007, recognizes the key role of the multidisciplinary team in meeting the challenge of caring for these individuals. Registered dietitian nutritionists (RDNs) bring value to this multidisciplinary team by providing care coordination, evidence-based care, and quality-improvement leadership. RDNs have demonstrated efficacy for improvements in outcomes for patients with a wide variety of medical conditions. Primary care physicians, as well as several patient-centered medical home and population health demonstration projects, have reported the benefits of RDNs as part of the integrated primary care team. One of the most significant barriers to integrating RDNs into primary care has been an insufficient reimbursement model. Newer innovative payment models provide the opportunity to overcome this barrier. In order to achieve this integration, the Academy of Nutrition and Dietetics and RDNs must fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead the necessary changes. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on the multidisciplinary team. The Academy's Patient-Centered Medical Home/Accountable Care Organizations Workgroup Report provides a framework for the Academy, its members, and key partners to use to achieve this goal.

Informing the 'early years' agenda in Scotland: understanding infant feeding patterns using linked datasets.

BACKGROUND: Providing infants with the 'best possible start in life' is a priority for the Scottish Government. This is reflected in policy and health promotion strategies to increase breast feeding, which gives the best source of nutrients for healthy infant growth and development. However, the rate of breast feeding in Scotland remains one of the lowest in Europe. Information is needed to provide a better understanding of infant feeding and its impact on child health. This paper describes the development of a unique population-wide resource created to explore infant feeding and child health in Scotland. METHODS: Descriptive and multivariate analyses of linked routine/administrative maternal and infant health records for 731,595 infants born in Scotland between 1997 and 2009. RESULTS: A linked dataset was created containing a wide range of background, parental, maternal, birth and health service characteristics for a representative sample of infants born in Scotland over the study period. There was high coverage and completeness of infant feeding and other demographic, maternal and infant records. The results confirmed the importance of an enabling environment--cultural, family, health service and other maternal and infant health-related factors--in increasing the likelihood to breast feed. CONCLUSIONS: Using the linked dataset, it was possible to investigate the determinants of breast feeding for a representative sample of Scottish infants born between 1997 and 2009. The linked dataset is an important resource that has potential uses in research, policy design and targeting intervention programmes.

The Mentoring Competency Assessment: validation of a new instrument to evaluate skills of research mentors.

PURPOSE: To determine the psychometric properties of the Mentoring Competency Assessment (MCA), a 26-item skills inventory that enables research mentors and mentees to evaluate six competencies of mentors: maintaining effective communication, aligning expectations, assessing understanding, addressing diversity, fostering independence, and promoting professional development. METHOD: In 2010, investigators administered the MCA to 283 mentor-mentee pairs from 16 universities participating in a trial of a mentoring curriculum for clinical and translational research mentors. The authors analyzed baseline MCA data to describe the instrument's psychometric properties. RESULTS: Coefficient alpha scores for the MCA showed reliability (internal consistency). The hypothesized model with its six latent constructs (competencies) resulted in an acceptable fit to the data. For the instrument completed by mentors, chi-square = 663.20; df = 284; P < .001; root mean square error of approximation (RMSEA) = 0.069 (90% CI, 0.062-0.076); comparative fit index (CFI) = 0.85; and Tucker-Lewis index (TLI) = 0.83. For the instrument completed by mentees, chi-square = 840.62; df = 284; P < .001; RMSEA = 0.080 (90% CI, 0.063-0.077); CFI = 0.87; and TLI = 0.85. The correlations among the six competencies were high: 0.49-0.87 for mentors, 0.58-0.92 for mentees. All parameter estimates for the individual items were significant; standardized factor loadings ranged from 0.32 to 0.81 for mentors and 0.56 to 0.86 for mentees. CONCLUSIONS: The findings demonstrate that the MCA has reliability and validity. In addition, this study provides preliminary norms derived from a national sample of mentors and mentees.

Improving patient outcomes with better care transitions: the role for home health.

Patients, particularly the old and frail, are especially vulnerable at the time of hospital discharge. Fragmentation of care, characterized by miscommunications and lack of follow-up, can lead to oversights in diagnosis and management. The frequent result is avoidable rehospitalization. Amedisys, a home health and hospice organization, created and tested a care transitions initiative for its impact on patients' quality of life and avoidable rehospitalizations. The initiative was carried out in three academic institutions with 12 months of observation. The results suggested reduced hospital readmissions and a critical role for the home health industry in improving patient outcomes and reducing costs.

Total economic cost and burden of dengue in Nicaragua: 1996-2010.

The burden of dengue in Nicaragua has been steadily rising during the last three decades; however, there have been few efforts to quantify the burden (measured in disability-adjusted life years [DALYs]) and cost to society. Using primary data from the Nicaraguan Ministry of Health (MINSA), the total cost and burden of dengue were calculated from 1996 to 2010. Total costs included both direct costs from medical expenditures and prevention activities and indirect costs from lost productivity. The annual disease burden ranged from 99 to 805 DALYs per million, with a majority associated with classic dengue fever. The total cost was estimated to be US$13.5 million/year (range: US$5.1-27.6 million). This analysis can help improve allocation of dengue control resources in Nicaragua and the region. As one of the most comprehensive analyses of its type to date in Nicaragua and Latin America, this study can serve as a model to determine the burden and cost of dengue.

Strengthening the career development of clinical translational scientist trainees: a consensus statement of the Clinical Translational Science Award (CTSA) Research Education and Career Development Committees.

The challenges for scholars committed to successful careers in clinical and translational science are increasingly well recognized. The Education and Career Development (EdCD) of the national Clinical and Translational Science Award consortium gathered thought leaders to propose sustainable solutions and an agenda for future studies that would strengthen the infrastructure across the spectrum of pre- and postdoctoral, MD and PhD, scholars. Six consensus statements were prepared that include: (1) the requirement for career development of a qualitatively different investigator; (2) the implications of interdisciplinary science for career advancement including institutional promotion and tenure actions that were developed for discipline-specific accomplishments; (3) the need for long-term commitment of institutions to scholars; (4) discipline-specific curricula are still required but curricula designed to promote team work and interdisciplinary training will promote innovation; (5) PhD trainees have many pathways to career satisfaction and success; and (6) a centralized infrastructure to enhance and reward mentoring is required. Several themes cut across all of the recommendations including team science, innovation, and sustained institutional commitment. Implied themes include an effective and diverse job force and the requirement for a well-crafted public policy that supports continued investments in science education.

Trends in socioeconomic inequalities in risk of sudden infant death syndrome, other causes of infant mortality, and stillbirth in Scotland: population based study.

OBJECTIVES: To compare changes in inequalities in sudden infant death syndrome with other causes of infant mortality and stillbirth in Scotland, 1985-2008. DESIGN: Retrospective cohort study. SETTING: Scotland 1985-2008, analysed by four epochs of six years. PARTICIPANTS: Singleton births of infants with birth weight >500 g born at 28-43 weeks' gestation. MAIN OUTCOME MEASURES: Sudden infant death syndrome, other causes of postneonatal infant death, neonatal death, and stillbirth. Odds ratios expressed as the association across the range of seven categories of Carstairs deprivation score. RESULTS: The association between deprivation and the risk of all cause stillbirth and infant death varied between the four epochs (P=0.04). This was wholly explained by variation in the risk of sudden infant death syndrome (P<0.001 for interaction). Among women living in areas of low deprivation, there was a sharp decline in the rate of sudden infant death syndrome from 1990 to 1993. Among women living in areas of high deprivation, there was a slower decline in sudden infant death syndrome rates between 1992 and 2004. Consequently, the odds ratio for the association between socioeconomic deprivation and sudden infant death syndrome increased from 2.04 (95% confidence interval 1.53 to 2.72) in 1985-90, to 7.52 (4.62 to 12.25) in 1991-6, and 9.50 (5.46 to 16.53) in 1997-2002 but fell to 1.78 (0.87 to 3.65) in 2002-8. The interaction remained significant after adjustment for maternal characteristics. CONCLUSION: The rate of sudden infant death syndrome declined throughout Scotland in the early 1990s. The decline had a later onset and was slower among women living in areas of high deprivation, probably because of slower uptake of recommended changes in infant sleeping position. The effect was to create a strong independent association between deprivation and sudden infant death syndrome where one did not exist before.

Racial Disparities in Pain Management in Primary Care.

This descriptive, cross-sectional, secondary data analysis was conducted to examine racial disparities in pain management of primary care patients with chronic nonmalignant pain using chronic opioid therapy. Data from 891 patients, including 201 African Americans and 691 Caucasians were used to test an explanatory model for these disparities. We predicted that: (1) African American patients would report worse pain management and poor quality of life (QOL) than Caucasians; (2) the association between race and pain management would be mediated by perceived discrimination relating to hopelessness; and (3) poor pain management would negatively affect QOL. Results revealed significant differences between African Americans and Caucasians on pain management and QOL, with African Americans faring worse. The proposed mediational model, which included race, perceived discrimination, hopelessness, and pain management was supported: (1) African Americans compared to Caucasians had higher perceived discrimination, (2) perceived discrimination was positively associated with hopelessness, and (3) higher hopelessness was associated with worse pain management. Further, pain management predicted QOL. This is the first study in which an explanatory model for the racial disparities in pain management of primary care patients with chronic nonmalignant pain was examined. Perceived discrimination and hopelessness were implicated as explanatory factors for the disparities.

Mentoring K scholars: strategies to support research mentors.

The goal of this paper is to present strategies utilized to support K scholar research mentors. K scholars are generally assistant professors who are close to developing independent research programs. Of all the various types of mentees, K scholars offer the greatest challenges, as well as the greatest rewards, for research mentors. To see one's mentee achieve independent PI status and become an established investigator is one of the great joys of being a research mentor. Research mentors for K scholars, however, may not directly benefit from their mentoring relationship, neither in terms of obtaining data to support their research program or laboratory, nor in assistance with grants or scientific papers. There is a pressing need for the research community to address the workload, institutional expectations, and reward system for research mentors. The dearth of research mentors and role models in clinical translational science parallels the decreasing number of physicians choosing careers in clinical research. While there is limited empirical information on the effectiveness of mentor support mechanisms, this white paper concludes that providing mentor support is critical to expanding the available pool of mentors, as well as providing training opportunities for K scholars.

Identifying and aligning expectations in a mentoring relationship.

The mentoring relationship between a scholar and their primary mentor is a core feature of research training. Anecdotal evidence suggests this relationship is adversely affected when scholar and mentor expectations are not aligned. We examined three questions: (1) What is the value in assuring that the expectations of scholars and mentors are mutually identified and aligned? (2) What types of programmatic interventions facilitate this process? (3) What types of expectations are important to identify and align? We addressed these questions through a systematic literature review, focus group interviews of mentors and scholars, a survey of Clinical and Translational Science Award (CTSA) KL2 program directors, and review of formal programmatic mechanisms used by KL2 programs. We found broad support for the importance of identifying and aligning the expectations of scholars and mentors and evidence that mentoring contracts, agreements, and training programs facilitate this process. These tools focus on aligning expectations with respect to the scholar's research, education, professional development and career advancement as well as support, communication, and personal conduct and interpersonal relations. Research is needed to assess test the efficacy of formal alignment activities.

Alcohol use in students seeking primary care treatment at university health services.

OBJECTIVE: given the high rate of at-risk drinking in college students, the authors examined drinking behaviors and associated factors in students being seen in student health services for primary care visits from October 30, 2004, to February 15, 2007. METHODS: analyses were based on a Health Screening Survey completed by 10,234 college students seeking general medical treatment. RESULTS: alcohol use was similar to other studies with 57% (n = 5,840) meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking. Twenty-six percent of the students reported smoking at least once in the last 3 months. Risk factors for at-risk drinking included young age, white males, drinking at a fraternity/sorority house, and use of tobacco. CONCLUSIONS: these findings support the widespread implementation of alcohol screening and intervention in university health services.

Alcohol consumption and health among elders.

PURPOSE: This article estimates the effects of alcohol consumption on self-reported overall health status, injuries, heart problems, emergency room use, and hospitalizations among persons older than the age of 65. DESIGN AND METHODS: We analyzed data from the first wave of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative study. We used multivariate regression and instrumental variables methods to study the associations between alcohol consumption (current drinking, binge drinking, and average number of drinks consumed) and several indicators of health status and health care utilization. RESULTS: Alcohol consumption by women was associated with better self-perceived health status, improved cardiovascular health, and lower rates of hospitalizations. We detected no significant negative or positive associations for older men. IMPLICATIONS: These findings suggest that light to moderate alcohol use by older women may have beneficial health effects. Experimental trials, however, are needed to more rigorously assess the potential benefits of alcohol use by elders due to the inherent biases of observational studies.

Domestic abuse during the previous year in a sample of postpartum women.

OBJECTIVE: To determine the prevalence and the correlates of domestic abuse in women presenting for a postpartum visit. DESIGN: Data were collected via a cross-sectional survey. Multivariate logistic regression was used to determine characteristics of women reporting abuse. SETTING: Thirty-five obstetric clinics in Wisconsin. PARTICIPANTS: One thousand five hundred nineteen women who presented for a postpartum visit. Most were White, well educated, employed, and married. MAIN OUTCOME MEASURE: Physical and/or emotional abuse in the previous 12 months. RESULTS: One hundred twelve (7.4%) women were victims of abuse. Women who reported abuse were more likely to screen positive for postpartum depression (odds ratio 4.21, 95% confidence interval 2.19-8.09) be unmarried (odds ratio 7.05, 95% confidence interval 3.39-14.64), be older than 35 year (odds ratio 2.45, 95% confidence interval 1.10-5.50), be not in the labor force (odds ratio 2.39, 95% confidence interval 1.16-4.90), be of Hispanic ethnicity (odds ratio 2.73, 95% confidence interval 1.07-6.96), and have a partner who binge drinks (odds ratio 3.09, confidence interval 1.49-6.43). CONCLUSIONS: One in 14 women who present for a postpartum visit report emotional or physical abuse in the previous year. Although certain factors are more highly associated with domestic abuse, the high prevalence of abuse in this population supports the use of routine screening of women for domestic abuse.

Correlates of postpartum alcohol use.

OBJECTIVE: The purposes of this investigation are to (1) describe drinking patterns among women attending a postpartum visit, and (2) identify correlates of postpartum "at risk" drinking. METHODS: A survey was completed by 8706 women at their postpartum visit. We identified correlates of "at risk" drinking, defined as binge drinking (4 or more drinks per occasion at least once in the past month) or consuming an average of > or =7 drinks/wk. RESULTS: A total of 997 women (12%) reported "at risk" drinking. At risk drinkers were more likely than other women to have been frequent drinkers prior to pregnancy (> or =7 drinks/wk), scored 1 or 2 on the CAGE, smoked postpartum, and been unmarried. Black women, those over age 35, "stay-at-home mothers," and women having breastfed were less likely to report "at risk" drinking. CONCLUSION: This study supports routine alcohol screening of women attending a postpartum visit with their obstetrician.