Validation of a spatial agent-based model for Taenia solium transmission ("CystiAgent") against a large prospective trial of control strategies in northern Peru.

BACKGROUND: The pork tapeworm (Taenia solium) is a parasitic helminth that imposes a major health and economic burden on poor rural populations around the world. As recognized by the World Health Organization, a key barrier for achieving control of T. solium is the lack of an accurate and validated simulation model with which to study transmission and evaluate available control and elimination strategies. CystiAgent is a spatially-explicit agent based model for T. solium that is unique among T. solium models in its ability to represent key spatial and environmental features of transmission and simulate spatially targeted interventions, such as ring strategy. METHODS/PRINCIPAL FINDINGS: We validated CystiAgent against results from the Ring Strategy Trial (RST)-a large cluster-randomized trial conducted in northern Peru that evaluated six unique interventions for T. solium control in 23 villages. For the validation, each intervention strategy was replicated in CystiAgent, and the simulated prevalences of human taeniasis, porcine cysticercosis, and porcine seroincidence were compared against prevalence estimates from the trial. Results showed that CystiAgent produced declines in transmission in response to each of the six intervention strategies, but overestimated the effect of interventions in the majority of villages; simulated prevalences for human taenasis and porcine cysticercosis at the end of the trial were a median of 0.53 and 5.0 percentages points less than prevalence observed at the end of the trial, respectively. CONCLUSIONS/SIGNIFICANCE: The validation of CystiAgent represented an important step towards developing an accurate and reliable T. solium transmission model that can be deployed to fill critical gaps in our understanding of T. solium transmission and control. To improve model accuracy, future versions would benefit from improved data on pig immunity and resistance, field effectiveness of anti-helminthic treatment, and factors driving spatial clustering of T. solium infections including dispersion and contact with T. solium eggs in the environment.

Understanding transmission and control of the pork tapeworm with CystiAgent: a spatially explicit agent-based model.

BACKGROUND: The pork tapeworm, Taenia solium, is a serious public health problem in rural low-resource areas of Latin America, Africa and Asia, where the associated conditions of nuerocysticercosis (NCC) and porcine cysticercosis cause substantial health and economic harms. An accurate and validated transmission model for T. solium would serve as an important new tool for control and elimination, as it would allow for comparison of available intervention strategies, and prioritization of the most effective strategies for control and elimination efforts. METHODS: We developed a spatially-explicit agent-based model (ABM) for T. solium ("CystiAgent") that differs from prior T. solium models by including a spatial framework and behavioral parameters such as pig roaming, open human defecation, and human travel. In this article, we introduce the structure and function of the model, describe the data sources used to parameterize the model, and apply sensitivity analyses (Latin hypercube sampling-partial rank correlation coefficient (LHS-PRCC)) to evaluate model parameters. RESULTS: LHS-PRCC analysis of CystiAgent found that the parameters with the greatest impact on model uncertainty were the roaming range of pigs, the infectious duration of human taeniasis, use of latrines, and the set of "tuning" parameters defining the probabilities of infection in humans and pigs given exposure to T. solium. CONCLUSIONS: CystiAgent is a novel ABM that has the ability to model spatial and behavioral features of T. solium transmission not available in other models. There is a small set of impactful model parameters that contribute uncertainty to the model and may impact the accuracy of model projections. Field and laboratory studies to better understand these key components of transmission may help reduce uncertainty, while current applications of CystiAgent may consider calibration of these parameters to improve model performance. These results will ultimately allow for improved interpretation of model validation results, and usage of the model to compare available control and elimination strategies for T. solium.

Dental Caries and Otitis Media Among Schoolchildren in Palau.

Both oral disease and middle ear infections are highly prevalent in Pacific Island children. These diseases are multifactorial and likely attributable in part to both social and environmental factors. It has been two decades since these diseases were defined in Palau, and at the time were noted to be among the most common conditions and presented a substantial burden among Palau's children. In 2006, the Ministry of Health in Palau began conducting comprehensive school health screenings in grades 1-11. While primarily used as a referral tool, this survey can also be used in epidemiologic studies to describe health trends. The current study utilized this screening data from the 2011-12 school year to characterize the prevalence of dental caries and otitis media and explore a previously suggested relationship between the two conditions, including common risk factors. It was found that over one-quarter (28.9%) of Palauan students had abnormal tympanometry results, with up to 17% indicating active otitis media. In addition, 85% of students had at least one decayed or filled tooth, with an average of 3.9 decayed or filled teeth in 12-year-olds. Both conditions were found to be more prevalent in public than in private schools; however, the two disorders were not significantly associated with each other. These findings place the prevalence of decayed, missing, and filled teeth, and otitis media in Palauan schoolchildren among the highest reported in the world. The widely recognized consequences of poor oral health and hearing impairment on learning, nutrition, and chronic disease make urgent the need for early intervention.

Using registry data to characterize the incidence and causes of blindness in Oregon.

In the United States, there is no reliable data to describe the prevalence of eye diseases leading to visual impairment and little active surveillance to address this knowledge gap. Data that is readily available from many state blind registries may provide helpful information on trends and causes of blindness. We analyzed new registrations with the Oregon Commission for the Blind (OCB) and Oregon State Department of Administrative Services (DAS) from 1961 to 2016 for causes of and trends in blindness. Persons with blindness self-refer into the OCB registry and the Oregon State Department of Administrative Services (DAS) includes those receiving social security disability financial support and other state services. Data for 9,273 blind persons registered were analyzed. The most frequent causes of blindness were age related macular degeneration (AMD) 3,308 (38%), followed by diabetic retinopathy (DR) 729 (8%), congenital conditions 697 (8%), optic nerve atrophy 611 (7%), glaucoma 549 (6%), retinitis pigmentosa 546 (6%), retinopathy of prematurity192 (2%), cataract 180 (2%), and trauma 174 (2%). The mean age of onset of blindness was younger for Blacks (31 years) and Hispanics (33 years) than for Whites (44 years). Analysis of state-based registries can provide useful and locally relevant vision and eye health data where little information is otherwise available.

Seasonal patterns in risk factors for Taenia solium transmission: a GPS tracking study of pigs and open human defecation in northern Peru.

BACKGROUND: Taenia solium (cysticercosis) is a parasitic cestode that is endemic in rural populations where open defecation is common and free-roaming pigs have access to human feces. The purpose of this study was to examine the roaming patterns of free-range pigs, and identify areas where T. solium transmission could occur via contact with human feces. We did this by using GPS trackers to log the movement of 108 pigs in three villages of northern Peru. Pigs were tracked for approximately six days each and tracking was repeated in the rainy and dry seasons. Maps of pig ranges were analyzed for size, distance from home, land type and contact with human defecation sites, which were assessed in a community-wide defecation survey. RESULTS: Consistent with prior GPS studies and spatial analyses, we found that the majority of pigs remained close to home during the tracking period and had contact with human feces in their home areas: pigs spent a median of 79% (IQR: 61-90%) of their active roaming time within 50 m of their homes and a median of 60% of their contact with open defecation within 100 m of home. Extended away-from-home roaming was predominately observed during the rainy season; overall, home range areas were 61% larger during the rainy season compared to the dry season (95% CI: 41-73%). Both home range size and contact with open defecation sites showed substantial variation between villages, and contact with open defecation sites was more frequent among pigs with larger home ranges and pigs living in higher density areas of their village. CONCLUSIONS: Our study builds upon prior work showing that pigs predominately roam and have contact with human feces within 50-100 m of the home, and that T. solium transmission is most likely to occur in these concentrated areas of contact. This finding, therefore, supports control strategies that target treatment resources to these areas of increased transmission. Our finding of a seasonal trend in roaming ranges may be useful for control programs relying on pig interventions, and in the field of transmission modeling, which require precise estimates of pig behavior and risk.

Open versus robot-assisted radical cystectomy: 30-day perioperative comparison and predictors for cost-to-patient, complication, and readmission.

The objectives of this study are to evaluate if robotic cystectomy demonstrates reduced complications, readmissions, and cost-to-patient compared to open approach 30-day post-operatively, and to identify predictors of complication, readmission, and cost-to-patient. This retrospective cohort study analyzed 249 patients who underwent open (n = 149) or robotic (n = 100) cystectomy from 2009 to 2015 at our institution. Outcomes included 30-day post-operative complication, readmission, and cost-to-patient charges. We used modified Clavien-Dindo/MSKCC classifications. Multivariable logistic and linear regression models were used to evaluate associations to outcomes and to build predictive models. Patient, clinical, and surgical characteristics differed by open and robotic groups, respectively, only for estimated blood loss (median: 600 versus 150 cc, p < 0.01), operative time (mean: 6.19 versus 6.85 h, p < 0.01), and length of stay (median: 7 versus 5 days, p < 0.01). Complication: frequency of patients with at least one 30-day complication was 85% compared to 66% (p < 0.01). Minor gastrointestinal and bleeding complications were increased in the open group (50% versus 41%, p = 0.01; 52% versus 11%, p < 0.01, respectively). Fifty percent of patients required blood transfusion in open compared to 11% (p < 0.01). Patients in the open group experienced more major complications (19% versus 10%, p = 0.04). Robotic approach was a predictor for fewer complications (OR 0.44, 95% CI 0.20-0.99, p = 0.049). Readmission: no significant difference in number of patients readmitted was found. Cost-to-patient: Robotic approach predicted an 18% reduction in total cost-to-patient compared to open approach (p < 0.01). Robotic cystectomy demonstrated reduced total cost-to-patient when taking into account all 30-day post-operative services with fewer complications compared to open cystectomy.

The association between gabapentin and suicidality in bipolar patients.

The aims of this study were to assess the association between gabapentin and suicidality in patients diagnosed with bipolar disorder (BD) and to determine whether the risk is greater relative to patients prescribed lithium. This retrospective observational study utilizes US population-based claims data assembled by PharMetrics Inc., comprising 47 918 patients diagnosed with BD. Patients were included if they were at least 18 years old and initiated a new monotherapy prescription of either gabapentin (n=2421) or lithium (n=3101). Patients were followed for up to 1 year. Gabapentin patients contributed 915.8 person-years (PY) of follow-up time; lithium patients contributed 1421.3 PY. There were 21 suicide/self-harm events in the gabapentin group and 16 in the lithium group. Unadjusted incidence rates were 22.9 and 11.3/1000 PY in the gabapentin and lithium groups, respectively (P=0.03). After adjusting for concomitant medications, comorbid diagnoses, age, sex, and history of suicide/self-harm, the hazard ratio was 2.3 (95% confidence interval: 1.2-4.5). A propensity score-matched analysis accounting for pre-existing illnesses and medications supports this finding, with an adjusted hazard ratio of 2.1 (95% confidence interval: 1.02-4.5). Relative to lithium, the use of gabapentin is significantly associated with a doubling of the risk of suicidality in patients diagnosed with BD.

Factors Associated With Adherence to Nasoalveolar Molding (NAM) by Caregivers of Infants Born With Cleft Lip and Palate.

OBJECTIVE: Identify factors associated with adherence to nasoalveolar molding (NAM) therapy. DESIGN: Retrospective case-control study. SETTING: Tertiary referral center. PATIENTS, PARTICIPANTS: Infants with cleft lip, with or without cleft palate, referred for NAM. One hundred thirty-five patients met criteria. MAIN OUTCOME MEASURE(S): Adherence to NAM therapy, defined as continuous use of the appliance and attendance of NAM adjustment visits. RESULTS: Female sex (OR = 2.85, 95% CI 1.21-6.74), bilateral cleft (OR = 2.88, 95% CI 1.29-6.46), and travel distance (OR = 1.01, 95% CI 1.00-1.01) were independent predictors of nonadherence. Bilateral clefts (OR = 8.35, 95% CI 2.72-25.64) and public-payer insurance (OR = 3.67, 95% CI 1.13-11.91) for male patients were significantly associated with nonadherence, in our sex-stratified multivariate model. The majority of the families (58%) had public health insurance. Males comprised 77.0% of the cohort. CONCLUSIONS: NAM treatment adherence is impaired by bilateral clefts, female sex, increased travel distance, and public insurance. Further studies are warranted to investigate how these factors affect adherence, and to develop interventions to improve adherence in families at risk due to economic or psychosocial barriers.

Healthy & Empowered Youth: A Positive Youth Development Program for Native Youth.

INTRODUCTION: During 2010-2012, Oregon Health & Science University's Prevention Research Center, a Northwest Tribe, and the Northwest Portland Area Indian Health Board, collaborated to evaluate the Healthy & Empowered Youth Project, a school- and community-based positive youth development program for American Indian and Alaska Native high school students. METHODS: The Native STAND (Students Together Against Negative Decisions) curriculum was enhanced with hands-on learning activities in media design to engage students in sexual and reproductive health topics covered by the curriculum. Guest speakers, field trips, and extracurricular activities were added to provide academic enrichment, engage students in cultural activities, and offer opportunities for career development. Students completed comprehensive pre- and post-surveys, and the authors conducted focus groups and key informant interviews with students and teachers. Data analysis was conducted during 2013-2014. RESULTS: Survey findings demonstrated improvements in student leadership and achievement, physical and mental health, and protective sexual health behaviors. The percentage of female teens reporting use of a condom the last time they had sex increased from 17% to 30%, and those who reported ever having been tested for sexually transmitted illnesses doubled from 12% to 24%. Focus group and interview findings indicated similar improvements in student self-esteem, life skills, health behavior, and engagement in community. CONCLUSIONS: The Healthy & Empowered Youth Project educated and empowered Native high school students on a variety of sensitive health topics. The media enhancements were central to the program's success, reinforcing and personalizing classroom lessons and generating health-related videos and posters that resonated with family and friends.

Internet-Based Delivery of Evidence-Based Health Promotion Programs Among American Indian and Alaska Native Youth: A Case Study.

BACKGROUND: American Indian and Alaska Native (AI/AN) youth face multiple health challenges compared to other racial/ethnic groups, which could potentially be ameliorated by the dissemination of evidence-based adolescent health promotion programs. Previous studies have indicated that limited trained personnel, cultural barriers, and geographic isolation may hinder the reach and implementation of evidence-based health promotion programs among AI/AN youth. Although Internet access is variable in AI/AN communities across the United States, it is swiftly and steadily improving, and it may provide a viable strategy to disseminate evidence-based health promotion programs to this underserved population. OBJECTIVE: We explored the potential of using the Internet to disseminate evidence-based health promotion programs on multiple health topics to AI/AN youth living in diverse communities across 3 geographically dispersed regions of the United States. Specifically, we assessed the Internet's potential to increase the reach and implementation of evidence-based health promotion programs for AI/AN youth, and to engage AI/AN youth. METHODS: This randomized controlled trial was conducted in 25 participating sites in Alaska, Arizona, and the Pacific Northwest. Predominantly AI/AN youth, aged 12-14 years, accessed 6 evidence-based health promotion programs delivered via the Internet, which focused on sexual health, hearing loss, alcohol use, tobacco use, drug use, and nutrition and physical activity. Adult site coordinators completed computer-based education inventory surveys, connectivity and bandwidth testing to assess parameters related to program reach (computer access, connectivity, and bandwidth), and implementation logs to assess barriers to implementation (program errors and delivery issues). We assessed youths' perceptions of program engagement via ratings on ease of use, understandability, credibility, likeability, perceived impact, and motivational appeal, using previously established measures. RESULTS: Sites had sufficient computer access and Internet connectivity to implement the 6 programs with adequate fidelity; however, variable bandwidth (ranging from 0.24 to 93.5 megabits per second; mean 25.6) and technical issues led some sites to access programs via back-up modalities (eg, uploading the programs from a Universal Serial Bus drive). The number of youth providing engagement ratings varied by program (n=40-191; 48-60% female, 85-90% self-identified AI/AN). Across programs, youth rated the programs as easy to use (68-91%), trustworthy (61-89%), likeable (59-87%), and impactful (63-91%). Most youth understood the words in the programs (60-83%), although some needed hints to complete the programs (16-49%). Overall, 37-66% of the participants would recommend the programs to a classmate, and 62-87% found the programs enjoyable when compared to other school lessons. CONCLUSIONS: Findings demonstrate the potential of the Internet to enhance the reach and implementation of evidence-based health promotion programs, and to engage AI/AN youth. Provision of back-up modalities is recommended to address possible connectivity or technical issues. The dissemination of Internet-based health promotion programs may be a promising strategy to address health disparities for this underserved population. TRIAL REGISTRATION: Clinicaltrials.gov NCT01303575; https://clinicaltrials.gov/ct2/show/NCT01303575 (Archived by WebCite at http://www.webcitation.org/6m7DO4g7c).

Prenatal Depression Screening by Certified Nurse-Midwives, Oregon.

INTRODUCTION: About 18% of pregnant women have major or minor depression during pregnancy, but many are neither screened nor treated. Lack of treatment can have serious adverse consequences for the woman and her child. Since 2002, the American College of Nurse-Midwives has advised midwives to integrate prevention, universal screening, treatment, and/or referral for depression into the care they provide. The American College of Obstetricians and Gynecologists' 2015 guidelines recommend screening at least once in the perinatal period using a standardized, validated tool. A consensus has not been reached by professional organizations about the specifics of whether and when to screen for prenatal depression. The objective of this study is to understand the prenatal screening practices of midwives who practice in Oregon. METHODS: We surveyed all 162 Oregon-licensed certified nurse-midwives (CNMs). The survey asked about practice characteristics, demographics, screening, and perceived barriers to screening. The survey was administered electronically from October through December 2014. RESULTS: The response rate was 37%. Among the 53 CNM respondents who had provided prenatal care in the previous year, 50 (94%) reported screening for prenatal depression, and 38 (72%) reported the use of a standardized screening tool on more than 90% of prenatal patients. Thirty-five (66%) CNMs reported using the Edinburgh Postnatal Depression Scale. More than 60% of respondents indicated that availability of mental health services and insurance constraints were barriers to screening. DISCUSSION: We explored prenatal depression screening practices of CNMs. Most Oregon CNMs use a standardized screening tool. We suggest 2 strategies to overcome barriers to screening: incorporation of a standardized screening tool into electronic medical records and negotiation with insurance companies. More research is needed to clarify when and how often pregnant women should be screened for depression and how to increase the number of women who receive treatment.

An Evaluation of Oral Midazolam for Anxiety and Pain in First-Trimester Surgical Abortion: A Randomized Controlled Trial.

OBJECTIVE: To estimate the effect of oral midazolam on patient pain and anxiety perception during first-trimester surgical abortion. METHODS: Between May and December 2013, we conducted a randomized, double-blind, placebo-controlled trial. Patients between 6 0/7 and 10 6/7 weeks of gestation received 10 mg oral midazolam or placebo 30-60 minutes before surgical abortion. All patients received ibuprofen and a paracervical block. We powered the study (power=80%; significance level=.025) to detect a 15-mm difference in our two a priori primary outcomes of pain and anxiety with uterine aspiration on a 100-mm visual analog scale. Secondary outcomes were pain and anxiety at additional time points, memory, satisfaction, side effects, and adverse events. RESULTS: Demographics were similar between groups (placebo=62, midazolam=62). Compared with those randomized to placebo, patients who received midazolam had significantly less anxiety preoperatively (room entry: 51.4 mm compared with 34.5 mm, P<.001; positioning: 56.6 mm compared with 45.4 mm, P=.02). There was no difference in pain (P=.28) or anxiety (P=.14) during uterine aspiration or at other procedural time points. A significantly greater number of patients in the midazolam group reported partial amnesia (31/61 compared with 16/61, P=.005) and dizziness (30/61 compared with 18/61, P=.03). Controlling for baseline differences, patients who received midazolam reported more postoperative sleepiness (P<.001) and less postoperative nausea (P=.004). There was no difference in overall satisfaction (P=.88). CONCLUSION: Although oral midazolam reduces preprocedural anxiety, it does not reduce pain or anxiety with uterine aspiration during first-trimester surgical abortions. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01830881. LEVEL OF EVIDENCE: I.

Fear of Falling Is Associated with Recurrent Falls in People with Multiple Sclerosis: A Longitudinal Cohort Study.

BACKGROUND: People with multiple sclerosis (MS) fall frequently, and there are few clinically valid tools to measure the risk factors for falls. We assessed the unidimensionality of the 7-item Falls Efficacy Scale-International (FES-I), a measure of fear of falling, and determined whether the 7-item FES-I is associated with recurrent falls in people with MS. METHODS: Falls were counted prospectively for 6 months using fall calendars in 58 people with MS (age, 18-50 years; Expanded Disability Status Scale score, 0-6). The FES-I was administered at baseline, and its unidimensionality was assessed by confirmatory factor analysis. The relationship between FES-I score and future falls, after adjusting for recurrent falls in the past year, was assessed by logistic regression. RESULTS: Fifty-four participants who completed all assessments were included in the analysis. Goodness-of-fit indices confirmed a single-factor solution for the 7-item FES-I (discrepancy χ(2), P = .101; Tucker-Lewis index, 0.953; comparative fit index, 0.969; root mean square error of approximation, 0.098). There was a significant association between fear of falling and falls in the following 3 months, independent of recurrent falls in the past year (odds ratio = 1.22, 95% confidence interval, 1.04-1.43, P = .016). CONCLUSIONS: The 7-item FES-I demonstrates good construct validity, allowing the total score to be used as a measure of fear of falling in people with MS. Fear of falling, as measured by the 7-item FES-I, is associated with future recurrent falls independent of past recurrent falls in people with MS.

Perceived racial discrimination in health care, completion of standard diabetes services, and diabetes control among a sample of American Indian women.

PURPOSE: The purpose of this study is to examine perceived experiences of racial discrimination (perceived discrimination) in health care and its associations with completing standards of care for diabetes management and diabetes control. METHODS: This cross-sectional study included 200 adult American Indian (AI) women with type 2 diabetes from 4 health care facilities located on tribal reservations in the Pacific Northwest. Participants completed a survey, and medical records were abstracted. Logistic regression was completed to assess associations. RESULTS: Sixty-seven percent of AI women reported discrimination during their lifetime of health care. After adjusting for patient characteristics, perceived discrimination was significantly associated with lower rates of dental exam; checks for blood pressure, creatinine, and total cholesterol; and pneumococcal vaccination. The association between perceived discrimination and total number of diabetes services completed was not statistically significant. Perceived discrimination was associated with having A1C values above target levels for diabetes control in unadjusted and adjusted models, but no association was observed for blood pressure or total cholesterol. CONCLUSIONS: In our sample of AI women with diabetes, two-thirds reported experiencing racial discrimination in their health care experience. Those reporting perceived discrimination completed fewer diabetes services and therefore may be at increased risk for comorbidities of diabetes. This finding supports the continued need for culturally responsive health care and programs of diabetes education to recognize perceived discrimination and its potential to impact success in self-management and services utilization.

Impact of an electronic health record operating room management system in ophthalmology on documentation time, surgical volume, and staffing.

IMPORTANCE: Although electronic health record (EHR) systems have potential benefits, such as improved safety and quality of care, most ophthalmology practices in the United States have not adopted these systems. Concerns persist regarding potential negative impacts on clinical workflow. In particular, the impact of EHR operating room (OR) management systems on clinical efficiency in the ophthalmic surgery setting is unknown. OBJECTIVE: To determine the impact of an EHR OR management system on intraoperative nursing documentation time, surgical volume, and staffing requirements. DESIGN, SETTING, AND PARTICIPANTS: For documentation time and circulating nurses per procedure, a prospective cohort design was used between January 10, 2012, and January 10, 2013. For surgical volume and overall staffing requirements, a case series design was used between January 29, 2011, and January 28, 2013. This study involved ophthalmic OR nurses (n = 13) and surgeons (n = 25) at an academic medical center. EXPOSURES: Electronic health record OR management system implementation. MAIN OUTCOMES AND MEASURES: (1) Documentation time (percentage of operating time documenting [POTD], absolute documentation time in minutes), (2) surgical volume (procedures/time), and (3) staffing requirements (full-time equivalents, circulating nurses/procedure). Outcomes were measured during a baseline period when paper documentation was used and during the early (first 3 months) and late (4-12 months) periods after EHR implementation. RESULTS: There was a worsening in total POTD in the early EHR period (83%) vs paper baseline (41%) (P < .001). This improved to baseline levels by the late EHR period (46%, P = .28), although POTD in the cataract group remained worse than at baseline (64%, P < .001). There was a worsening in absolute mean documentation time in the early EHR period (16.7 minutes) vs paper baseline (7.5 minutes) (P < .001). This improved in the late EHR period (9.2 minutes) but remained worse than in the paper baseline (P < .001). While cataract procedures required more circulating nurses in the early EHR (mean, 1.9 nurses/procedure) and late EHR (mean, 1.5 nurses/procedure) periods than in the paper baseline (mean, 1.0 nurses/procedure) (P < .001), overall staffing requirements and surgical volume were not significantly different between the periods. CONCLUSIONS AND RELEVANCE: Electronic health record OR management system implementation was associated with worsening of intraoperative nursing documentation time especially in shorter procedures. However, it is possible to implement an EHR OR management system without serious negative impacts on surgical volume and staffing requirements.

Predicting adherence to diabetic eye examinations: development of the compliance withAnnual Diabetic Eye Exams Survey.

OBJECTIVE: To identify variables that predict adherence with annual eye examinations using the Compliance with Annual Diabetic Eye Exams Survey (CADEES), a new questionnaire designed to measure health beliefs related to diabetic retinopathy and annual eye examinations. DESIGN: Questionnaire development. PARTICIPANTS: Three hundred sixteen adults with diabetes. METHODS: We developed the CADEES based on a review of the literature, the framework of the Health Belief Model, expert opinion, and pilot study data. To examine content validity, we analyzed participant responses to an open-ended question asking for reasons why people do not obtain annual eye examinations. We evaluated construct validity with principal components analysis and examined internal consistency with Cronbach's α. To assess predictive validity, we used multivariate logistic regression with self-reported adherence as the dependent variable. MAIN OUTCOME MEASURES: Associations with self-reported adherence (defined as having a dilated eye examination in the past year). RESULTS: The content analysis showed that CADEES items covered 89% of the reasons given by participants for not obtaining an annual eye examination. The principal components analysis identified 3 informative components that made up 32% of the variance. Multivariate logistic regression modeling revealed several significant predictors of adherence, including beliefs concerning whether insurance covered most of the eye examination cost (P < 0.01), whether there were general barriers that make it difficult to obtain an eye examination (P < 0.01), whether obtaining an eye examination was a top priority (P = 0.02), and whether diabetic eye disease can be seen with an examination (P = 0.05). Lower hemoglobin A1c levels (P < 0.01), having insurance (P = 0.01), and a longer duration of diabetes (P = 0.02) also were associated with adherence. A multivariate model containing CADEES items and demographic variables classified cases with 72% accuracy and explained approximately 24% of the variance in adherence. CONCLUSIONS: The CADEES showed good content and predictive validity. Although additional research is needed before finalizing a shorter version of the survey, our findings suggest that researchers and clinicians may be able to improve adherence by (1) counseling newly diagnosed patients, as well as those with uncontrolled blood glucose, on the importance of annual eye examinations and (2) discussing perceived barriers and misconceptions.

Psychometrics of a new questionnaire to assess glaucoma adherence: the Glaucoma Treatment Compliance Assessment Tool (an American Ophthalmological Society thesis).

PURPOSE: To report the psychometrics of the Glaucoma Treatment Compliance Assessment Tool (GTCAT), a new questionnaire designed to assess adherence with glaucoma therapy. METHODS: We developed the questionnaire according to the constructs of the Health Belief Model. We evaluated the questionnaire using data from a cross-sectional study with focus groups (n = 20) and a prospective observational case series (n=58). Principal components analysis provided assessment of construct validity. We repeated the questionnaire after 3 months for test-retest reliability. We evaluated predictive validity using an electronic dosing monitor as an objective measure of adherence. RESULTS: Focus group participants provided 931 statements related to adherence, of which 88.7% (826/931) could be categorized into the constructs of the Health Belief Model. Perceived barriers accounted for 31% (288/931) of statements, cues-to-action 14% (131/931), susceptibility 12% (116/931), benefits 12% (115/931), severity 10% (91/931), and self-efficacy 9% (85/931). The principal components analysis explained 77% of the variance with five components representing Health Belief Model constructs. Reliability analyses showed acceptable Cronbach's alphas (>.70) for four of the seven components (severity, susceptibility, barriers [eye drop administration], and barriers [discomfort]). Predictive validity was high, with several Health Belief Model questions significantly associated (P <.05) with adherence and a correlation coefficient (R (2)) of .40. Test-retest reliability was 90%. CONCLUSION: The GTCAT shows excellent repeatability, content, construct, and predictive validity for glaucoma adherence. A multisite trial is needed to determine whether the results can be generalized and whether the questionnaire accurately measures the effect of interventions to increase adherence.

Provider practice characteristics that promote interpersonal continuity.

PURPOSE: Becoming certified as a patient-centered medical home now requires practices to measure how effectively they provide continuity of care. To understand how continuity can be improved, we studied the association between provider practice characteristics and interpersonal continuity using the Usual Provider Continuity Index (UPC). METHODS: We conducted a mixed-methods study of the relationship between provider practice characteristics and UPC in 4 university-based family medicine clinics. For the quantitative part of the study, we analyzed data extracted from monthly provider performance reports for 63 primary care providers (PCPs) between July 2009 and June 2010. We tested the association of 5 practice parameters on UPC: (1) clinic frequency; (2) panel size; (3) patient load (ratio of panel size to clinic frequency); (4) attendance ratio; and (5) duration in practice (number of years working in the current practice). Clinic, care team, provider sex, and provider type (physicians versus nonphysician providers) were analyzed as covariates. Simple and multiple linear regressions were used for statistical modeling. Findings from the quantitative part of the study were validated using qualitative data from provider focus groups that were analyzed using sequential thematic coding. RESULTS: There were strong linear associations between UPC and both clinic frequency (ß = 0.94; 95% CI, 0.62-1.27) and patient load (ß = -0.37; 95% CI, -0.48 to -0.26). A multiple linear regression including clinic frequency, patient load, duration in practice, and provider type explained more than 60% of the variation in UPC (adjusted R(2) = 0.629). UPC for nurse practitioners and physician assistants was more strongly dependent on clinic frequency and was at least as high as it was for physicians. Focus groups identified 6 themes as other potential sources of variability in UPC. CONCLUSIONS: Variability in UPC between providers is strongly correlated with variables that can be modified by practice managers. Our study suggests that patients assigned to nurse practitioners and physician assistants have continuity similar to those assigned to physicians.

The relationship between vehicle roof crush and head, neck and spine injury in rollover crashes.

BACKGROUND: It is well established that rollover crashes are associated with a higher risk of serious injury and death than other types of crashes. Some of the most serious injuries that can result from a rollover crash are those to the head, neck and spine. The mechanism of injury to these body parts in a rollover is a matter of dispute in the literature. Some authors have concluded that the magnitude of vehicle roof deformation or vertical roof crush resulting from a rollover crash is not causally associated with head and neck injury severity, while others offer support for a causal association between roof crush and the degree of injury. A better understanding of the cause of serious injuries resulting from rollover crashes is important for improving injury prevention. METHODS: This study utilized data from the National Automotive Sampling System--Crashworthiness Data System (NASS-CDS) for the years 1997 through 2007. Both cross-sectional and matched case-control designs along with a new composite injury metric termed the Head, Neck and Spine New Injury Severity Score (HNS-NISS) were used to analyze these data. RESULTS: The cross-sectional analysis demonstrated a 64% (95% CI: 26-114%) increase in the odds of a life-threatening injury as estimated by the HNS-NISS with every 10 cm of increased roof crush. The results of the matched case-control analysis demonstrated a 44% (95% CI: 8-91%) increase in the odds of sustaining any injury to the head, neck or spine with every 10 cm increase in roof crush. CONCLUSION: These results lend statistical support to a causal association between roof crush and head, neck and spine injury severity. Though they do not constitute definitive proof, they do contradict previously published theories suggesting that roof deformation is unrelated to such injuries.

Perceived experiences of discrimination in health care: a barrier for cancer screening among American Indian women with type 2 diabetes.

PURPOSE: Breast and cervical cancer-mortality disparities are prominent among American Indian women. These disparities, in part, may result from patients perceived experiences of discrimination in health care. This report evaluates the impact of perceived discrimination on screening for breast and cervical cancer in a sample of 200 American Indian women with type 2 diabetes. METHODS: Data were collected from patient report and medical records. Prevalence of breast and cervical cancer screening were assessed. Unadjusted and adjusted logistic regression analyses were used to assess associations between perceived discrimination, cancer screening status, and patients' health care-seeking behaviors. FINDINGS: Substantial proportions of AI women in our sample were behind the recommended schedules of screening for breast and cervical cancer. Adjusted estimates revealed that perceived discrimination was significantly associated with not being current for clinical breast examination and Pap test, and was close to statistical significance with not being current for mammography. The number of suboptimal health care-seeking behaviors increased with higher mean levels of perceived discrimination. CONCLUSIONS: Among AI women, perceived discrimination in health care may negatively influence use of breast and cancer screening services, and health care-seeking behaviors. More research is needed among AIs to examine features of health care systems related to the phenomenon patients perceived experience of discrimination.