Evaluation Design for the Department of the Air Force's True North Program: Development of a Logic Model and Program Measures.

Developing strong resiliency and care solutions for airmen and guardians is key to human capital development and force readiness. The True North program is one of the Department of the Air Force's (DAF's) most significant recent investments in promoting the resiliency of its people. Assessing the program's level of success, justifying funding, and informing decisions about the program's future will require a rigorous evaluation. The authors of this study (1) identify desired outcomes for members participating in the program, (2) define appropriate measures of effectiveness that could be used in evaluating the True North program, and (3) make recommendations for ongoing internal evaluation of the program. The True North program encompasses selected installation welcome centers, embedded religious support teams (RSTs), and embedded mental health (EMH) teams. To determine how DAF might evaluate this program and its components, the authors reviewed relevant policies and procedures and literature relevant to the program components and conducted interviews with 17 True North program personnel and 21 group and squadron commanders. They present a program logic model to determine potential evaluation measures.

Veteran Single Parents: Surviving but Not Thriving.

The demographics of the veteran population are changing. Veterans who served after September 11, 2001 (post-9/11 veterans), are more likely to be female and identify as a person of color than their older counterparts. They are also more likely to be raising children, many of them without support from a partner. This study provides a comprehensive look at the financial, physical, and mental health of veteran single parents; explores the differences across these factors by race, ethnicity, and gender; and includes recommendations on policies and programs that can better support veteran single parents and their children.

Psychological Harms and Treatment of Sexual Assault and Sexual Harassment in Adults: Systematic and Scoping Reviews to Inform Improved Care for Military Populations.

Victims of sexual assault and sexual harassment often experience a variety of psychological outcomes and mental health symptoms related to posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse, suicidal ideation, and self-harm. Sexual trauma also might affect careers. Despite a need to address these harms, some service members have reported that connecting to health care or mental health services following sexual assault or sexual harassment can be difficult-in part because of a lack of leadership support. Given these persistent challenges, the Psychological Health Center of Excellence identified an urgent need to better understand research that is pertinent to sexual assault and sexual harassment during military service so that the U.S. Department of Defense and the military services can improve the health care response for service members. RAND researchers investigated and synthesized relevant research in three topic areas: (1) the effectiveness of psychotherapy treatments designed for adult victims of sexual assault or sexual harassment in military settings; (2) barriers faced by U.S. military members to accessing and remaining in mental health care settings; and (3) associations between sexual assault or sexual harassment and mental health conditions.

Considerations Around the Use of Intensive Outpatient Programs for Service Members Who Experienced Sexual Trauma in the U.S. Military.

Section 702 of the fiscal year 2019 National Defense Authorization Act directed the U.S. Department of Defense (DoD) to conduct a pilot study to assess the feasibility and advisability of using intensive outpatient treatment programs to address posttraumatic stress disorder (PTSD) and associated mental health problems among service members who have experienced sexual harassment or sexual assault while in the military. RAND researchers conducted a programmatic review of four intensive outpatient programs (IOPs)-two in the private sector and two in DoD-to understand different program components available to active-duty service members who have suffered sexual trauma and other trauma. A review of policies to understand TRICARE authorization procedures and other regulations governing IOPs and an analysis of data from the 2014 RAND Military Workplace Study survey on the prevalence of sexual trauma among personnel with mental health conditions helped obtain contextual information to inform the Psychological Health Center of Excellence's response to Congress. The review identified evidence-based approaches that IOPs have successfully used in programs designed for military service members and barriers to using this type of care to treat members of the military community. While examining the IOP model of care, the research team identified knowledge gaps surrounding the experiences, treatment needs, and effectiveness of different treatment components and models of care for active-duty service members affected by the mental health consequences of sexual harassment and sexual assault in the military.

Improving Sexual Assault and Sexual Harassment Prevention from the Bottom-up: a Pilot of Getting To Outcomes in the US Military.

While the Department of Defense (DoD) has given increased attention and priority to preventing sexual assault and sexual harassment (SA/SH), it remains a problem. To build its prevention capacity, DoD piloted Getting To Outcomes® (GTO®) from 2019 to 2022 at 10 military installations. GTO is an evidence-based planning and implementation support that has been used in many civilian contexts but has only recently been adapted for military SA/SH. The purpose of this study was to describe GTO use, identify its benefits and challenges, and discuss lessons the GTO effort yielded for prevention more broadly using a framework of organizational and program-level capacities needed for successful prevention in the military context, called the Prevention Evaluation Framework (PEF). GTO was piloted with 10 military installations ("sites") representing all Military Services, plus the Coast Guard and National Guard. GTO is comprised of a written guide, training, and ongoing coaching. The pilot's goal was for each site to use GTO to implement a SA/SH prevention program twice. Participants from each site were interviewed and data was collected on GTO steps completed, whether GTO spurred new evaluation activities and collaborations, and the degree of leadership support for GTO. Most sites completed all GTO steps at least once. Interviews showed that DoD participants believe GTO improved prevention understanding, planning, and evaluation capacity; strengthened confidence in chosen programs; and helped sites tailor programs to the military context. Barriers were the complexity of GTO, DoD personnel turnover, and the disruption that the COVID pandemic caused in sexual assault prevention program delivery. Many respondents were unsure if they would continue all of GTO after the coaching ended, but many believed they would continue at least some parts. According to the PEF, the GTO pilot revealed several additional prevention system gaps (e.g., need for leadership support) and changes needed to GTO (e.g., stronger leader and champion engagement), to support quality prevention. The military and other large organizations will need to focus on these issues to ensure prevention implementation and evaluation are conducted with quality.

A randomized controlled trial of an online alcohol and sexual risk prevention program for college students studying abroad.

INTRODUCTION: American college students who study abroad experience increases in their drinking behavior, concerning risky sexual behaviors, and high rates of sexual violence while abroad. Despite these concerns, institutions offer limited programming to students prior to departure to address these risks and no empirically supported interventions currently exist that are targeted toward preventing increased drinking, risky sexual behavior, and sexual violence abroad. To help address alcohol and sexual risk abroad, we designed a brief, single-session online predeparture intervention focused on risk and protective factors known to associate with alcohol and sexual risk abroad. METHODS: Using a sample of 650 college students from 40 home institutions, we conducted a randomized controlled trial of the intervention and tested its effects on drinking (drinks per week, binge drinking frequency, alcohol related-consequences), risky sexual behaviors, and sexual violence victimization during the trip abroad (first month, last month abroad) and one-month and three-months after return home. RESULTS: We observed small, but nonsignificant, intervention effects on drinks per week and binge drinking days during the first month abroad and three months after they had returned home to the United States, and small, significant effects on risky sexual behaviors during the first month abroad. The study found no observable effects at any time point for alcohol-related consequences or for sexual violence victimization abroad. CONCLUSIONS: Though mostly nonsignificant, small initial intervention effects were promising in this first empirical test of an alcohol and sexual risk prevention program for study abroad students. However, students may need more intensive programming with booster sessions to experience lasting intervention effects during this particularly high-risk period. GOV IDENTIFIER: NCT03928067.

Sexual violence victimization among American college students studying abroad.

Objective: Research has just begun to identify American college students who study abroad as a group at-risk for sexual violence victimization. The purpose of the current study was to examine the context of these incidents. Participants: We utilized a large longitudinal sample of 2,428 United States college students studying abroad for between 4 and 21 weeks in 12 different foreign countries. Methods: We estimated descriptive statistics and logistic regression models to assess prevalence and correlates of sexual victimization abroad, as well as effect size comparisons to quantify changes in drinking abroad. Results: Over one-fifth of students experienced sexual violence while abroad, including sexual assault and verbal coercion. Women, younger students, those who experienced sexual violence prior, and heavier drinkers had the greatest odds of sexual violence victimization abroad. Conclusions: Findings point to the need for evidence-based programming to reduce sexual violence risk among American college students studying in foreign countries.

Alcohol and Sexual Risk among American College Students Studying Abroad.

Recent studies show that during study abroad experiences, college students greatly increase their drinking behavior, experience multiple alcohol-related consequences, engage in sexual risk behaviors, and are at-risk for sexual violence victimization. These studies, however, have been limited by small sample sizes of students from single institutions who are often studying in a particular country or region. To better understand the extent of the risks experienced by college students studying abroad, we conducted a longitudinal survey study of 2630 students from 65 different US colleges and universities studying in 12 diverse locations abroad. Total drinks per week and heavy drinking days more than doubled while students were abroad, with heavier predeparture drinkers, men, and students under age 21 experiencing the greatest increases. There were few observed overall changes in alcohol-related consequences and risky sexual behaviors; however, specific groups, such as those with heavier predeparture consequences and sexual risk behaviors, men, and those on longer abroad programs reported greater consequences and risky sex abroad. One in five students (21%) experienced sexual violence abroad, with non-consensual physical contact the most prevalent form. Women, those under age 21, and those with a history of sexual violence were most likely to experience sexual violence abroad. Findings indicate that study abroad students may warrant targeted predeparture programming to help prevent heavy drinking and sexual violence experiences abroad.

An online alcohol and risky sex prevention program for college students studying abroad: study protocol for a randomized controlled trial.

BACKGROUND: This study protocol describes a proposed randomized controlled trial that builds upon a successful pilot intervention study to address problematic and dangerous drinking among young adult college students studying abroad in foreign environments. Despite universities and colleges citing alcohol misuse as the most concerning issue for their students abroad, most institutions offer no empirically-based prevention efforts tailored to this at-risk population. The proposed intervention attempts to fill a major gap for the nearly 333,000 students completing study abroad programs each year by using empirically-based and theoretically-informed risk and protective factors to correct misperceived peer drinking norms and promote cultural engagement abroad. In addition to preventing heavy and problematic drinking, the intervention seeks to prevent risky sexual behaviors (e.g., sex without a condom) and experience of sexual violence victimization, which are strikingly common among study abroad students and have the potential for lasting physical and psychological effects upon return home. METHODS/DESIGN: We will conduct a randomized controlled trial of an intervention with a sample of 1200 college students studying abroad from approximately 50 US universities and colleges. The brief, online intervention is text and video based and contains evidence-based components of personalized normative feedback to correct students' misperceived drinking norms, content to promote engagement with the cultural experience abroad and address difficulties adjusting to life in the foreign environment, and tips and strategies to prevent risky sexual behaviors and sexual violence victimization abroad. Participants will complete online surveys at five time points (predeparture, first month abroad, last month abroad, 1-month post-return, and 3-months post-return) to assess for intervention effects on drinking behavior, drinking consequences, risky sex, and sexual violence outcomes. We will examine whether the mechanisms targeted by the intervention (changes in perceived norms, engagement in the cultural experience abroad) serve as mediators of intervention efficacy. DISCUSSION: The proposed study has the potential to fill an important gap in the research literature and provide empirical support for an online accessible, brief, and targeted approach that can easily be distributed to study abroad students to help prevent heavy alcohol use and sexual risk abroad. Trial registration ClinicalTrials.gov Identifier NCT03928067.

There and Back Again Safely: Examining Students' Reports of Substance Use and Sexual Assault Prevention Program Receipt Prior to Departure Abroad.

Many universities have pre-departure programs that aim to prevent alcohol misuse and sexual assault among college students abroad, yet little is known about students' uptake of this preventative information. In this study, 2,245 study abroad students from 63 different institutions were asked about receiving pre-departure alcohol/drug and sexual assault prevention information. Only 38% of students reported receiving pre-departure information specific to alcohol/drug misuse abroad and only 22% reported receiving sexual assault prevention information prior to departure. Notably, students who were heavier drinkers prior to departure and those who intended to drink the most while abroad reported lower rates of information receipt. Overall, these findings suggest that either students are not receiving the preventative information that universities intend them to receive or the programming is not impactful enough to be recalled. Thus, there may be missed opportunities to better prepare students for risks specific to study abroad programs.

Needs of Male Sexual Assault Victims in the U.S. Armed Forces.

In the National Defense Authorization Act for Fiscal Year 2016, Congress included a requirement to improve prevention of and response to sexual assaults in which the victim is a male member of the U.S. armed forces. To support this effort, RAND researchers reviewed previous research on male sexual assault and specifically considered research on male sexual assault in the U.S. military. The researchers also conducted interviews with individuals who provide support services to U.S. military personnel and with civilian experts who study male sexual assault or provide services to male victims. Although research considering the needs of and services for male sexual assault victims is more limited than research addressing female victims of sexual assault, the available research provides initial information on the prevalence, characteristics, consequences, and public perceptions of male sexual assault. This literature-along with the results of interviews that addressed needs of male sexual assault victims, reporting and help-seeking among victims, and knowledge and perceptions about such assaults-suggests potential avenues for the U.S. Department of Defense to pursue to better address the needs of male sexual assault victims in the U.S. military. These avenues include improvements to reporting procedures, counseling services, outreach, and education and training of service providers and servicemembers.

Serious games may improve physician heuristics in trauma triage.

Trauma triage depends on fallible human judgment. We created two "serious" video game training interventions to improve that judgment. The interventions' central theoretical construct was the representativeness heuristic, which, in trauma triage, would mean judging the severity of an injury by how well it captures (or "represents") the key features of archetypes of cases requiring transfer to a trauma center. Drawing on clinical experience, medical records, and an expert panel, we identified features characteristic of representative and nonrepresentative cases. The two interventions instantiated both kinds of cases. One was an adventure game, seeking narrative engagement; the second was a puzzle-based game, emphasizing analogical reasoning. Both incorporated feedback on diagnostic errors, explaining their sources and consequences. In a four-arm study, they were compared with an intervention using traditional text-based continuing medical education materials (active control) and a no-intervention (passive control) condition. A sample of 320 physicians working at nontrauma centers in the United States was recruited and randomized to a study arm. The primary outcome was performance on a validated virtual simulation, measured as the proportion of undertriaged patients, defined as ones who had severe injuries (according to American College of Surgeons guidelines) but were not transferred. Compared with the control group, physicians exposed to either game undertriaged fewer such patients [difference = -18%, 95% CI: -30 to -6%, P = 0.002 (adventure game); -17%, 95% CI: -28 to -6%, P = 0.003 (puzzle game)]; those exposed to the text-based education undertriaged similar proportions (difference = +8%, 95% CI: -3 to +19%, P = 0.15).

Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities.

Providing accessible, high-quality care for psychological health (PH) conditions, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is important to maintaining a healthy, mission-ready force. It is unclear whether the current system of care meets the needs of service members with PTSD or MDD, and little is known about the barriers to delivering guideline-concordant care. RAND used existing provider workforce data, a provider survey, and key informant interviews to (1) provide an overview of the PH workforce at military treatment facilities (MTFs), (2) examine the extent to which care for PTSD and MDD in military treatment facilities is consistent with Department of Veterans Affairs/Department of Defense clinical practice guidelines, and (3) identify facilitators and barriers to providing this care. This study provides a comprehensive assessment of providers' perspectives on their capacity to deliver PH care within MTFs and presents detailed results by provider type and service branch. Findings suggest that most providers report using guideline-concordant psychotherapies, but use varied by provider type. The majority of providers reported receiving at least minimal training and supervision in at least one recommended psychotherapy for PTSD and for MDD. Still, more than one-quarter of providers reported that limits on travel and lack of protected time in their schedule affected their ability to access additional professional training. Finally, most providers reported routinely screening patients for PTSD and MDD with a validated screening instrument, but fewer providers reported using a validated screening instrument to monitor treatment progress.

Identification of facilitators and barriers to residents' use of a clinical reasoning tool.

BACKGROUND: While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability. METHODS: We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool. RESULTS: Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias. CONCLUSIONS: A clinical reasoning tool improved residents' diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial.

OBJECTIVE: To determine whether a behavioral intervention delivered through a video game can improve the appropriateness of trauma triage decisions in the emergency department of non-trauma centers. DESIGN: Randomized clinical trial. SETTING: Online intervention in national sample of emergency medicine physicians who make triage decisions at US hospitals. PARTICIPANTS: 368 emergency medicine physicians primarily working at non-trauma centers. A random sample (n=200) of those with primary outcome data was reassessed at six months. INTERVENTIONS: Physicians were randomized in a 1:1 ratio to one hour of exposure to an adventure video game (Night Shift) or apps based on traditional didactic education (myATLS and Trauma Life Support MCQ Review), both on iPads. Night Shift was developed to recalibrate the process of using pattern recognition to recognize moderate-severe injuries (representativeness heuristics) through the use of stories to promote behavior change (narrative engagement). Physicians were randomized with a 2×2 factorial design to intervention (game v traditional education apps) and then to the experimental condition under which they completed the outcome assessment tool (low v high cognitive load). Blinding could not be maintained after allocation but group assignment was masked during the analysis phase. MAIN OUTCOME MEASURES: Outcomes of a virtual simulation that included 10 cases; in four of these the patients had severe injuries. Participants completed the simulation within four weeks of their intervention. Decisions to admit, discharge, or transfer were measured. The proportion of patients under-triaged (patients with severe injuries not transferred to a trauma center) was calculated then (primary outcome) and again six months later, with a different set of cases (primary outcome of follow-up study). The secondary outcome was effect of cognitive load on under-triage. RESULTS: 149 (81%) physicians in the game arm and 148 (80%) in the traditional education arm completed the trial. Of these, 64/100 (64%) and 58/100 (58%), respectively, completed reassessment at six months. The mean age was 40 (SD 8.9), 283 (96%) were trained in emergency medicine, and 207 (70%) were ATLS (advanced trauma life support) certified. Physicians exposed to the game under-triaged fewer severely injured patients than those exposed to didactic education (316/596 (0.53) v 377/592 (0.64), estimated difference 0.11, 95% confidence interval 0.05 to 0.16; P<0.001). Cognitive load did not influence under-triage (161/308 (0.53) v 155/288 (0.54) in the game arm; 197/300 (0.66) v 180/292 (0.62) in the traditional educational apps arm; P=0.66). At six months, physicians exposed to the game remained less likely to under-triage patients (146/256 (0.57) v 172/232 (0.74), estimated difference 0.17, 0.09 to 0.25; P<0.001). No physician reported side effects. The sample might not reflect all emergency medicine physicians, and a small set of cases was used to assess performance. CONCLUSIONS: Compared with apps based on traditional didactic education, exposure of physicians to a theoretically grounded video game improved triage decision making in a validated virtual simulation. Though the observed effect was large, the wide confidence intervals include the possibility of a small benefit, and the real world efficacy of this intervention remains uncertain. TRIAL REGISTRATION: clinicaltrials.gov; NCT02857348 (initial study)/NCT03138304 (follow-up).

Using incentives to recruit physicians into behavioral trials: lessons learned from four studies.

OBJECTIVE: To describe lessons learned from the use of different strategies for recruiting physicians responsible for trauma triage, we summarize recruitment data from four behavioral trials run in the United States between 2010 and 2016. RESULTS: We ran a series of behavioral trials with the primary objective of understanding the influence of heuristics on physician decision making in trauma triage. Three studies were observational; one tested an intervention. The trials used different methods of recruitment (in-person vs. email), timing of the honorarium (pre-paid vs. conditional on completion), type of honorarium [a $100 gift card (monetary reward) vs. an iPad mini 2 (material incentive)], and study tasks (a vignette-based questionnaire, virtual simulation, and intervention plus virtual simulation). We recruited 989 physicians, asking each to complete a questionnaire or virtual simulation online. Recruitment and response rates were 80% in the study where we approached physicians in person, used a pre-paid material incentive, and required that they complete both an intervention plus a virtual simulation. They were 56% when we recruited physicians via email, used a monetary incentive conditional on completion of the task, and required that they complete a vignette-based questionnaire. Trial registration clinicaltrials.gov; NCT02857348.

The Air Force Deployment Transition Center: Assessment of Program Structure, Process, and Outcomes.

It is often accepted as common knowledge that military personnel benefit from decompression time between a war zone and the home station. To capitalize on the potential benefits of a decompression period paired with support services, the U.S. Air Force established the Deployment Transition Center (DTC) at Ramstein Air Base in Germany in July 2010. The DTC provides airmen returning from combat missions with an opportunity to decompress and share lessons learned before returning to their home stations. The authors of this study evaluate the structure, processes, and outcomes of the DTC program. They find that, although a majority of participants found the DTC program worthwhile, a comparison of DTC participants and similar airmen who did not participate the program shows no evidence that the program helps reduce posttraumatic stress disorder symptoms, depressive symptoms, binge drinking, or social conflicts with family and coworkers. In addition, one of the DTC program elements appears to be similar to posttraumatic debriefing interventions, which several studies have found to be either ineffective or harmful. For these reasons, if the main goals of the DTC program are to improve behavioral health and social conflict outcomes, the authors recommend that the DTC program be discontinued or redesigned and Air Force resources invested in alternative programs. However, if the DTC program has other goals, such as providing rest and relaxation to airmen after a difficult deployment or capturing after-action information, then the authors recommend that these goals be documented and the DTC program be more specifically tailored to them.

Using Claims Data to Examine Hospital Readmission Risk in Patients With Schizophrenia and Comorbid Marijuana Use Disorders.

OBJECTIVE: Few epidemiologic studies have examined marijuana use disorder and repeated hospitalizations related to schizophrenia. To address this gap, this study examines time to readmission by indicators for recent marijuana use disorder in the presence of alcohol use disorder (AUD) and other drug use disorder. METHOD: Our sample consisted of 4,349 patients with a primary diagnosis of schizophrenia spectrum disorder (SSD) in 2005 in individually linked California Health Care Cost and Utilization Project (CA HCUP) data. Readmissions were assessed from 2005 to 2011. Predictors for readmission were examined using a stratified, recurrent-event, Cox proportional hazards model. Sensitivity analyses were conducted on patients readmitted in 2010 or 2011. RESULTS: We found that having marijuana use disorder or AUD alone within 90 days of initial hospitalization was associated with longer times until first readmission. A lower risk of readmission for those with recent marijuana use disorder persisted through the fifth readmission (hazard ratio [HR] = 0.92, 95% CI [0.85, 0.99]) but was not significant in the sixth or greater readmission nor in sensitivity analyses. SSD patients with recent other drug use disorder had an increased risk for a second to fifth readmission (HR = 1.13, 95% CI [1.06, 1.20]). Those with recent AUD had an increased risk for a sixth or greater readmission (HR = 1.15, 95% CI [1.07, 1.23]). Both of these results remained significant in the sensitivity analysis. CONCLUSIONS: We found that AUD and other drug use disorder increase readmission risk in patients with SSD after a first hospitalization, whereas marijuana use disorder does not appear to be associated with an increased risk for readmission.

Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial.

BACKGROUND: Between 30 and 40 % of patients with severe injuries receive treatment at non-trauma centers (under-triage), largely because of physician decision making. Existing interventions to improve triage by physicians ignore the role that intuition (heuristics) plays in these decisions. One such heuristic is to form an initial impression based on representativeness (how typical does a patient appear of one with severe injuries). We created a video game (Night Shift) to recalibrate physician's representativeness heuristic in trauma triage. METHODS: We developed Night Shift in collaboration with emergency medicine physicians, trauma surgeons, behavioral scientists, and game designers. Players take on the persona of Andy Jordan, an emergency medicine physician, who accepts a new job in a small town. Through a series of cases that go awry, they gain experience with the contextual cues that distinguish patients with minor and severe injuries (based on the theory of analogical encoding) and receive emotionally-laden feedback on their performance (based on the theory of narrative engagement). The planned study will compare the effect of Night Shift with that of an educational program on physician triage decisions and on physician heuristics. Psychological theory predicts that cognitive load increases reliance on heuristics, thereby increasing the under-triage rate when heuristics are poorly calibrated. We will randomize physicians (n = 366) either to play the game or to review an educational program, and will assess performance using a validated virtual simulation. The validated simulation includes both control and cognitive load conditions. We will compare rates of under-triage after exposure to the two interventions (primary outcome) and will compare the effect of cognitive load on physicians' under-triage rates (secondary outcome). We hypothesize that: a) physicians exposed to Night Shift will have lower rates of under-triage compared to those exposed to the educational program, and b) cognitive load will not degrade triage performance among physicians exposed to Night Shift as much as it will among those exposed to the educational program. DISCUSSION: Serious games offer a new approach to the problem of poorly-calibrated heuristics in trauma triage. The results of this trial will contribute to the understanding of physician quality improvement and the efficacy of video games as behavioral interventions. TRIAL REGISTRATION: clinicaltrials.gov; NCT02857348 ; August 2, 2016.

Acupuncture for Major Depressive Disorder: A Systematic Review.

Major depressive disorder (MDD) is a prevalent condition associated with significant burden in terms of reduced quality of life, lower productivity, increased prevalence of other conditions and increased health care costs. We conducted a systematic review and qualitative summary of randomized controlled trials (RCTs) that assessed the effectiveness and safety of acupuncture for the treatment of MDD. We searched the databases PubMed, CINAHL, PsycINFO, Web of Science, Embase, CDSR, CENTRAL, clinicaltrials.gov, DARE, and PILOTS for English-language RCTs published through January 2015. Two independent reviewers screened the identified literature against inclusion and exclusion criteria, abstracted study level data, and assessed the risk of bias and methodological quality of included studies. The quality of the evidence was assessed using GRADE. Eighteen studies met inclusion criteria. Eleven assessed acupuncture as monotherapy, seven as adjunct depression treatment. Intervention approaches and comparators varied. Evidence on the effectiveness and comparative effectiveness of acupuncture to treat MDD for the outcomes depression improvement, measured as scale score differences and the number of responders, is very weak. Acupuncture may be superior to waitlist (low quality of evidence) but findings for effect estimates compared to other comparators are inconclusive. Few studies reported on patients achieving remission. The effect of acupuncture on relapse rates could not be determined. Too few studies assessed quality of life to estimate treatment effects. Reported adverse events were typically mild in nature, but the assessment lacked rigor and studies were not designed to detect rare events.