No Improvement In Mental Health Treatment Or Patient-Reported Outcomes At Medicare ACOs For Depression And Anxiety Disorders.

Accountable care organizations (ACOs) have become Medicare's dominant care model because policy makers believe that ACOs will improve the quality and efficiency of care for chronic conditions. Depression and anxiety disorders are the most prevalent and undertreated chronic mental health conditions in Medicare. Yet it is unknown whether ACOs influence treatment and outcomes for these conditions. To explore these questions, this longitudinal study used data from the 2016-19 Medicare Current Beneficiary Survey, linked to validated depression and anxiety symptom instruments, among diagnosed and undiagnosed fee-for-service Medicare patients with these conditions. Among patients not enrolled in ACOs at baseline, those who newly enrolled in ACOs in the following year were 24 percent less likely to have their depression or anxiety treated during the year than patients who remained unenrolled in ACOs, and they saw no relative improvements at twelve months in their depression and anxiety symptoms. Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment.

Comparative effectiveness of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and sulfonylureas on risk of major adverse cardiovascular events: emulation of a randomised target trial using electronic health records.

BACKGROUND: Randomised clinical trials showed that compared with placebo, SGLT2 inhibitors and GLP-1 receptor agonists reduced risk of adverse cardiovascular events. The evidence base for the older antihyperglycaemic drug classes (DPP-4 inhibitors and sulfonylureas) is generally less well developed. Because most randomised trials evaluated one antihyperglycaemic medication versus placebo, a head-to-head comparative effectiveness analysis of the newer drug classes (SGLT2 inhibitors vs GLP-1 receptor agonists) or newer (SGLT2 inhibitors or GLP-1 receptor agonists) versus older (DPP-4 inhibitors or sulfonylureas) drug classes on risk of major adverse cardiovascular events (MACE) is not available. In this study, we aimed to evaluate the comparative effectiveness of incident use of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or sulfonylureas on risk of MACE. METHODS: We first specified the protocol of a four-arm randomised pragmatic clinical trial and then emulated it using the health-care databases of the US Department of Veterans Affairs. We built a cohort of metformin users with incident use of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or sulfonylureas between Oct 1, 2016 and Sept 30, 2021, and followed up until Dec 31, 2022. We used the overlap weighting approach to balance the treatment groups using a battery of predefined variables and a set of algorithmically selected variables from high-dimensional data domains. Both intention-to-treat and per-protocol analyses (the latter estimated the effect of maintained use of the antihyperglycaemic throughout follow-up) were conducted to estimate risk of MACE-defined as a composite endpoint of stroke, myocardial infarction, and all-cause mortality. FINDINGS: The final cohort consisted of 283 998 new users of SGLT2 inhibitors (n=46 516), GLP-1 receptor agonists (n=26 038), DPP-4 inhibitors (n=55 310), or sulfonylureas (n=156 134). In intention-to-treat analyses, compared with sulfonylureas, SGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors were associated with lower risk of MACE (hazard ratio [HR] 0·77 [95% CI 0·74-0.80], 0·78 [0·74-0·81), and 0·90 [0·86-0.93], respectively). Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of MACE when compared with DPP-4 inhibitors (HR 0·86 [0·82-0·89] and 0·86 [0·82-0·90], respectively). The risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists yielded an HR of 0·99 (0·94-1·04). In per-protocol analyses, compared with sulfonylureas, SGLT2 inhibitors, GLP1 receptor agonists, and DPP-4 inhibitors were associated with reduced risk of MACE (HR 0·77 [95% CI 0·73-0·82], 0·77 [0·72-0·82], and 0·88 [0·83-0·93], respectively). Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of MACE when compared with DPP-4 inhibitors (HR 0·88 [0·83-0·93] and 0·88 [0·82-0·93], respectively). The risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists yielded an HR of 1·01 (0·94-1·07). INTERPRETATION: Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with reduced risk of MACE compared with DPP-4 inhibitors or sulfonylureas. DPP-4 inhibitors were associated with reduced risk of MACE compared with sulfonylureas. There was no statistically significant difference in risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists. The results provide evidence of the real-world comparative effectiveness of the four most commonly used second-line antihyperglycaemics and could guide choice of antihyperglycaemic therapy. FUNDING: US Department of Veterans Affairs and the American Society of Nephrology.

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia.

BACKGROUND: Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown. OBJECTIVE: The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status. RESEARCH DESIGN: Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns. SUBJECTS: A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey. MEASURES: We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status. RESULTS: Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05). CONCLUSION: Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.

Personal Location as Health-Related Data: Public Knowledge, Public Concern, and Personal Action.

OBJECTIVES: Personal health information (PHI), including health status and behaviors, are often associated with personal locations. Smart devices and other technologies routinely collect personal location. Therefore, technologies collecting personal location do not just create generic questions of privacy, but specific concerns related to PHI. METHODS: To assess public opinion on the relationship between health, personal location, and privacy, a national survey of US residents was administered online in March 2020. Respondents answered questions about their use of smart devices and knowledge of location tracking. They also identified which of the locations they could visit were most private and how to balance possibilities that locations may be private but can also be useful to share. RESULTS: Of respondents that used smart devices (n = 688), a majority (71.1%) indicated they knew they had applications tracking their location, with respondents who were younger (P < .001) and male (P = .002) and with more education (P = .045) more likely to indicate "yes." When all respondents (N = 828) identified the locations on a hypothetical map they felt were most private, health-related locations (substance use treatment center, hospital, urgent care) were the most selected. CONCLUSIONS: The historical notion of PHI is no longer adequate and the public need greater education on how data from smart devices may be used to predict health status and behaviors. The COVID-19 pandemic brought increased attention to personal location as a tool for public health. Given healthcare's dependence upon trust, the field needs to lead the conversation and be viewed as protecting privacy while usefully leveraging location data.

Assessing classroom and laboratory spread of COVID-19 in a university after elimination of physical distancing.

The objective of this study was to assess COVID-19 classroom transmission in the university setting when physical distancing was eliminated. Data was collected in fall 2021 at a private university. Universal masking, robust contact tracing, vaccination requirement, and enforced testing were in place. Exposures were classified as classroom versus non-classroom. ANOVA and chi-squared tests were used to identify significant relationships between predictors and COVID-19 test result. Logistic regression was conducted to investigate the relationship between exposure type and test result. A total of 162 student cases were identified with 1,658 associated close contacts. One-third of contacts (31.1%, n = 516) only had a non-classroom exposure, 63.8% (n = 1,057) only had a classroom exposure, and 5.1% (n = 85) had both. Close contacts were significantly more likely to test positive if they had a non-classroom exposure (60 of 601; 10.0%) compared to a classroom exposure (1 of 1057; 0.1%) (OR 58.8, CI 18.5-333.3, p < 0.001). Removing physical distancing in classrooms that had universal masking did not result in high rates of COVID-19 transmission. This has policy implications because eliminating physical distancing does not greatly increase transmission risk when universal masking is in place.

Trends in U.S. adolescent physical activity and obesity: A 20-year age-period-cohort analysis.

BACKGROUND: Adolescent obesity can lead to long-term health problems and is a topic of major concern in pediatric and broader medical and public health spheres. Numerous national and state-wide initiatives aimed at increasing physical activity and/or improving nutrition in this age group have assumed the goal of reducing the prevalence adolescent obesity. OBJECTIVES: We assess trends in U.S. adolescent physical activity and body mass index between 1999 and 2019. METHODS: Using data from the U.S. Youth Risk Behaviour Surveillance System, we analyse data from 144 544 14-to-18-year-old respondents. We use multilevel linear and logistic regression to perform age-period-cohort analyses attributing changes in physical activity and body mass index over time to these three sources. RESULTS: Age and period effects are strong in all outcomes studied. Physical activity consistently decreases with age across the study period. Age trends in obesity have reversed in recent years, with older adolescents now more likely to be have obesity than younger adolescents. Both female and Asian adolescents report less physical activity but lower rates of obesity than their male and non-Asian counterparts. CONCLUSIONS: The reversal of obesity trends by age with little change in physical activity over the study period suggests other lifestyle factors have changed over the study period to increase the prevalence of obesity in older adolescents.

Racial disparity in gestational diabetes mellitus and the association with sleep-disordered breathing and smoking cigarettes: a cross-sectional study.

BACKGROUND: Gestational diabetes mellitus (GDM) prevalence has risen in the U.S. and worldwide over the past decade. Minority groups, especially Asian and Hispanic women, are often disproportionately affected by GDM. Identifying modifiable risk factors such as sleep-disordered breathing and smoking and their interaction with race/ethnicity could play a pivotal role in preventing GDM. METHODS: Data from the 2017-2018 National Health and Nutrition Examination Surveys (NHANES) were used to run a survey-weighted multivariable logistic regression assessing the association between sleep-disordered breathing and smoking with GDM among women aged 15-60 (n = 1326). The interaction term of the two predictors and race/ethnicity was introduced to the model to assess the interaction effect. The analyses were adjusted for age, marital status, education level, and BMI. RESULTS: Approximately 13% of the participants reported having GDM. The lowest prevalence was observed among Non-Hispanic Blacks (7.8%) and the highest was among Other (15.5%). Sleep-disordered breathing was significantly associated with GDM (OR = 1.69, 95% CI 1.05, 2.73). No statistically significant association was observed between smoking and GDM (OR = 1.03, 95% CI 0.47, 2.27), and neither was the association between race/ethnicity and GDM. Furthermore, none of the interaction effects were statistically significant. CONCLUSION: Preventive strategies targeting GDM should focus on improving modifiable risk factors, such as sleep-disordered breathing. It is important to screen women with sleep-disordered breathing and monitor their blood sugar before becoming pregnant to prevent the development of GDM. Future studies are recommended to understand the lower prevalence of GDM among Black women and the higher prevalence among "Other" race group which mostly includes Asian women.

Barriers to human papillomavirus (HPV) vaccination among young adults, aged 18-35.

In the United States (US), an estimated 35,900 human papillomavirus (HPV)-related cancers are diagnosed annually. HPV vaccines are projected to eliminate âˆ¼90% of these cancers. Routine vaccination is recommended at age 11-12 with "catch-up" vaccination through age 26 and shared clinical decision making for ages 27-45. However, vaccine uptake has been slow with many young adults remaining unvaccinated. This study examined barriers to HPV vaccination among individuals aged 18-35 years and assessed likelihood of future HPV vaccination. Age-eligible participants (n = 499) recruited through Facebook advertisements, Facebook posts, and clinics (6/2019-3/2020) completed an online survey. Descriptive statistics and bivariate analysis examined HPV vaccine barriers and intent. Logistic regression models examined predictors of HPV vaccine intent. Most (57.1%) reported they were not at all likely to get vaccinated for HPV in the future. Lower intent was associated with belief that the vaccine is not necessary (aOR: 0.134, 95% CI: 0.073, 0.246) and not safe (aOR: 0.312, 95% CI: 0.126, 0.773). Intent was positively associated with the belief that health insurance would not cover vaccination (aOR: 2.226, 95% CI: 1.070, 4.631). Provider recommendation was not significantly associated with vaccine intention. This study highlights challenges to HPV vaccine uptake for young adults. Though several successful interventions exist, most target adolescents and their parents or providers. Future steps should use this evidence to inform development of targeted interventions to increase HPV vaccine intention and uptake in adults, ultimately reducing the burden of HPV-related cancers.

The Longitudinal Impact of Maternal Depression and Neighborhood Social Context on Adolescent Mental Health.

Purpose: Maternal depression and neighborhood characteristics are known to be associated both with each other and with adolescent mental health outcomes. These exposures are also subject to change throughout the life of a child. This study sought to identify multi-trajectories of maternal depression (MD) and self-reported neighborhood collective efficacy (NCE) over a 12-year period and determine whether these trajectories are differentially associated with adolescent mental health. Methods: Data from the Fragile Families and Child Wellbeing study, a longitudinal cohort study of new parents and their children, were used. Maternal depression (MD) and self-reported NCE when the child was 3, 5, 9, and 15 years of age were the primary exposures of interest. Adolescent depression and anxiety symptomology when the child was 15 years of age were the primary outcomes. Primary analyses were conducted using multi-trajectory modeling and linear regressions. Results: Five multi-trajectories were identified, two of which were characterized by no MD but either high or low NCE, and three of which were characterized by similarly moderate levels of NCE but either increasing, decreasing, or consistently high MD. Children of mothers with increasing or consistently high depressive symptomology and moderate NCE had significantly higher depression and anxiety scores compared to children of mothers with no depressive symptomology and high NCE. Conclusion: Adolescents with consistent and proximal exposure to MD are most likely to suffer from adverse mental health and should be provided with appropriate support systems to mitigate these outcomes.

Evaluation of the effectiveness of an automated sepsis predictive tool on patient outcomes.

PURPOSE: To evaluate the effectiveness of a multidisciplinary, hospital-wide program as part of an electronic sepsis alert tool. MATERIALS AND METHODS: We used data from 15 hospitals about adult patients with severe sepsis or septic shock. Nine intervention hospitals implemented an Epic sepsis prediction tool, education, and standardized order sets (six control hospitals did not). A difference-in-difference approach evaluated their effectiveness: 1) pre-implementation period (January 1, 2016-November 15, 2018) and 2) implementation period (November 16, 2018-June 30, 2019). RESULTS: Outcomes included mortality, receipt of the SEP-1 bundle of care, broad spectrum antibiotic use, ICU stay, and length of stay of 6926 patients. The difference of 6.7 percentage points between the intervention and control groups in SEP-1 bundle completion was not statistically significant (p = 0.105). The increase over time for antibiotic administration ≤1 h of time zero was not larger for hospitals in the intervention group (11.7%) compared to the control-group (7.6%, p = 0.084). Differences among hospitals in both groups were not statistically different for mortality (p = 0.174), ICU stays (p = 0.174), and length of stay (p = 0.652) from pre- to implementation period. CONCLUSIONS: The intervention to facilitate timely sepsis care did not improve patient outcomes among those with severe sepsis or septic shock.

Prevalence and correlates of antisocial personality disorder in older adults.

OBJECTIVES: There is a paucity of research on antisocial personality disorder (ASPD) in the geriatric population and the majority of knowledge on the disorder is drawn from young adult samples. Researchers posit that the prevalence of ASPD as well as other personality disorders (PDs) is underestimated among older adults. Using a nationally representative sample, the present study examines the prevalence and correlates of ASPD in adults ages 50 and older. METHODS: We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions Waves I and III. Multivariate logistic regression analyses were employed to investigate associations between ASPD and sociodemographic characteristics. A series of logistic regression analyses were also conducted to study associations between ASPD and medical conditions (liver and cardiovascular disease, arthritis, and stomach ulcer), major psychiatric disorders (lifetime major depressive disorder, mania, and generalized anxiety disorder), and substance use disorders (lifetime alcohol, marijuana, cocaine, heroin, and nicotine use disorders). RESULTS: Findings indicated that the prevalence of ASPD increases through early adulthood, with a peak at 3.91% in younger adults and decline to 0.78% in adults ages ≥65. Older adults with ASPD are more likely to be diagnosed with a substance use disorder, major depression, mania, and generalized anxiety disorder as well as each medical condition. CONCLUSION: Older adults with ASPD experience increased rates of medical and psychiatric comorbidities. These conditions exacerbate the existing challenges associated with diagnosing and treating this population and may have serious consequences for the patient, their caregivers and society.

SARS-CoV-2 Transmission to Masked and Unmasked Close Contacts of University Students with COVID-19 - St. Louis, Missouri, January-May 2021.

Universities open for in-person instruction during the 2020-21 academic year implemented a range of prevention strategies to limit the transmission of SARS-CoV-2, the virus that causes COVID-19, including physical distancing, mask use, vaccination, contact tracing, case investigation, and quarantine protocols (1). However, in some academic programs, such as health-related programs, aviation, and kindergarten through grade 12 (K-12) education, maintaining physical distance while still providing instruction is difficult; for universities with such programs, a single confirmed case of COVID-19 could result in a large number of students, staff members, and instructors being designated close contacts and requiring quarantine if they are not fully vaccinated, even if masks were worn when contact occurred. In January 2021, the St. Louis City Health Department allowed Saint Louis University (SLU) to implement a modified quarantine protocol that considered mask use when determining which close contacts required quarantine.* To assess the impact of the protocol, SLU assessed positive SARS-CoV-2 test result rates by masking status of the persons with COVID-19 and their close contacts. During January-May 2021, 265 students received a positive SARS-CoV-2 test result; these students named 378 close contacts. Compared with close contacts whose exposure only occurred when both persons were masked (7.7%), close contacts with any unmasked exposure (32.4%) had higher adjusted odds ratios (aORs) of receiving a positive SARS-CoV-2 test result (aOR = 4.9; 95% confidence interval [CI] = 1.4-31.1). Any additional exposures were associated with a 40.0% increase in odds of a positive test result (aOR = 1.4; 95% CI = 1.2-1.6). These findings reinforce that universal masking and having fewer encounters in close contact with persons with COVID-19 prevents the spread of SARS-CoV-2 in a university setting. Universities opening for in-person instruction could consider taking mask use into account when determining which unvaccinated close contacts require quarantine if enforced testing protocols are in place. However, this study was conducted before the B.1.617.2 (Delta) variant became the dominant strain of SARS-CoV-2 in the United States, which could have affected these findings given that the Delta variant has been found to be associated with increased transmissibility compared to previous variants.

Exploring the Acoustic Perceptual Relationship of Speech in Parkinson's Disease.

Purpose Auditory perceptual judgments are commonly used to diagnose dysarthria and assess treatment progress. The purpose of the study was to examine the acoustic underpinnings of perceptual speech abnormalities in individuals with Parkinson's disease (PD). Method Auditory perceptual judgments were obtained from sentences produced by 13 speakers with PD and five healthy older adults. Twenty young listeners rated overall ease of understanding, articulatory precision, voice quality, and prosodic adequacy on a visual analog scale. Acoustic measures associated with the speech subsystems of articulation, phonation, and prosody were obtained, including second formant transitions, articulation rate, cepstral and spectral measures of voice, and pitch variations. Regression analyses were performed to assess the relationships between perceptual judgments and acoustic variables. Results Perceptual impressions of Parkinsonian speech were related to combinations of several acoustic variables. Approximately 36%-49% of the variance in the perceptual ratings were explained by the acoustic measures indicating a modest acoustic perceptual relationship. Conclusions The relationships between perceptual ratings and acoustic signals in Parkinsonian speech are multifactorial and involve a variety of acoustic features simultaneously. The modest acoustic perceptual relationships, however, suggest that future work is needed to further examine the acoustic bases of perceptual judgments in dysarthria.

Age bias in the criteria for antisocial personality disorder.

The prevalence of antisocial personality disorder (ASPD) decreases with age. As such, research regarding ASPD typically focuses on children and younger adults. The apparent age-specific prevalence of ASPD may be due, in part, to diagnostic criteria informed by research excluding older adults. The present study sought to better understand the manifestation of ASPD in older adults and investigate potential age bias in the diagnostic criteria. Item response theory methods were used to the diagnostic criteria for ASPD with data from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III. The measurement of three ASPD criteria showed uniform differential item functioning (DIF), suggesting that older adults were less likely to endorse the item than younger adults despite having the same level of underlying personality disorder. The items with DIF are related to the following criteria for ASPD: Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest (3 items with DIF); irritability and aggressiveness, as indicated by repeated physical fights or assaults (1 item with DIF); and consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations (1 item with DIF). Results of the present study can be used to inform the development of criteria that better capture the age-specific experience of this disorder. Improved criteria will result in increased diagnostic accuracy, systematic estimation of the prevalence, improved assessments, and more effective treatment options for this complex population.

Acoustic characteristics in relation to intelligibility reduction in noise for speakers with Parkinson's disease.

Decreased speech intelligibility in noisy environments is frequently observed in speakers with Parkinson's disease (PD). This study investigated which acoustic characteristics across the speech subsystems contributed to poor intelligibility in noise for speakers with PD. Speech samples were obtained from 13 speakers with PD and five healthy controls reading 56 sentences. Intelligibility analysis was conducted in quiet and noisy listening conditions. Seventy-two young listeners transcribed the recorded sentences in quiet and another 72 listeners transcribed in noise. The acoustic characteristics of the speakers with PD who experienced large intelligibility reduction from quiet to noise were compared to those with smaller intelligibility reduction in noise and healthy controls. The acoustic measures in the study included second formant transitions, cepstral and spectral measures of voice (cepstral peak prominence and low/high spectral ratio), pitch variation, and articulation rate to represent speech components across speech subsystems of articulation, phonation, and prosody. The results show that speakers with PD who had larger intelligibility reduction in noise exhibited decreased second formant transition, limited cepstral and spectral variations, and faster articulation rate. These findings suggest that the adverse effect of noise on speech intelligibility in PD is related to speech changes in the articulatory and phonatory systems.

Willingness to Respond to Radiological Disasters Among First Responders in St. Louis, Missouri.

During radiological disasters, firefighters and emergency medical services personnel are expected to report to work and engage in response activities; however, prior research exploring willingness to respond to radiological disasters among first responders has considered only radiological terrorism scenarios and not nonterrorism radiological scenarios. The goal of this study was to compare willingness to respond to terrorism and nonterrorism radiological disaster scenarios among first responders in St. Louis, Missouri, and to explore determinants of willingness to respond. Firefighters and emergency medical services personnel were surveyed about their willingness to respond to a dirty bomb detonation (terrorism) and a radioactive landfill fire (nonterrorism). McNemar's tests were used to assess differences in individual willingness to respond between the 2 scenarios and differences if requested versus required to respond. Chi-square tests were used to identify significant individual predictors of willingness to respond. Multivariate logistic regressions were used to determine final models of willingness to respond for both scenarios. Willingness to respond was lower for the dirty bomb scenario than the landfill scenario if requested (68.4% vs 73.0%; P < .05). For both scenarios, willingness to respond was lower if requested versus required to respond (dirty bomb: 68.4% vs 85.2%, P < .001; landfill: 73.0% vs 87.3%, P < .001). Normative beliefs, perceived susceptibility, self-efficacy, and perceived barriers were significant predictors of willingness to respond in the final models. Willingness to respond among first responders differed significantly between terrorism and nonterrorism radiological disasters and if requested versus required to respond. Willingness to respond may be increased through interventions targeting significant attitudinal and belief predictors and by establishing organizational policies that define expectations of employee response during disasters.

Single and Repeated Use of the Emergency Department for Chlamydia and Gonorrhea Care.

OBJECTIVE: Chlamydia and gonorrhea infection rates are rising in the United States, and the emergency department (ED) is increasingly a site where individuals seek care for these infections, sometimes more than once. This article investigates how individuals who use the ED more than once and receive chlamydia and gonorrhea care differ from individuals who are single users of the ED, as well as characteristics associated with being a repeat user of the ED. METHODS: We analyzed 46,964 visits made by individuals who attended 1 of 4 EDs from January 1, 2010, to May 31, 2016, and received a test for chlamydia and gonorrhea infection. We used negative binomial regression to test the ability of age, sex, race, infection status, and insurance status to predict number of visits. RESULTS: Individuals who used the ED more than once and received chlamydia and gonorrhea care were at their first visit more likely to be younger (incident rate ratio [IRR], 0.98; 95% confidence interval [CI], 0.97-0.98 per year) nonpregnant female (IRR, 1.23; 95% CI, 1.06-1.42), black (IRR, 1.27; 95% CI, 1.04-1.57), and have no or public insurance compared with single users of the ED. DISCUSSIONS: Individuals likely to make multiple visits to the ED and receive chlamydia and gonorrhea care may be identifiable on their first visit and potentially directed elsewhere during subsequent visits for more comprehensive and potentially less expensive sexually transmitted disease care.

Firefighters' and Emergency Medical Service Personnel's Knowledge and Training on Radiation Exposures and Safety: Results from a Survey.

Little is known about first responders' knowledge of radiation exposure and the training they receive regarding radiological events. Firefighters and emergency medical services (EMS) personnel were surveyed in July 2018 to February 2019 regarding their knowledge of radiation exposure and the radiological event training they had received. Knowledge was assessed using 15 true-false questions. Five types of radiological event training were assessed. A Mann-Whitney test assessed differences in training received by occupation. A linear regression identified predictors of knowledge scores. A total of 433 individuals completed the survey (response rate = 82.9%). Knowledge scores ranged from 5 to 13, with an average of 8.6. Predictors of knowledge included having received more training on radiological transportation incidents or improvised nuclear devices, and being a firefighter. About a quarter (23.6%, n = 102) had not received any of the 5 types of radiological event training. Firefighters received more training than EMS personnel except on nuclear reactor incidents. Only 14% had participated in a radiological event exercise. First responders' knowledge of radiation exposure and prevention measures is low, and many have received either no or very little training on radiological events. The lack of radiation exposure knowledge and radiological event training received, as identified in this study, could result in increased mortality rates. First responder agencies should provide additional radiological event training and exercise opportunities.

Using multilevel regression with poststratification to obtain regional health estimates from a Facebook-recruited sample.

PURPOSE: We assess the effectiveness of multilevel regression with poststratification (MRP) as a tool to mitigate selection bias from online surveys of small geographical regions. METHODS: We collected self-reported health information from an Internet-based sample of adults residing within the St. Louis, MO, metropolitan area in 2017. We created Bayesian hierarchical models with three sets of predictor variables for each of six common health behaviors and outcomes, with results poststratified using the American Community Survey to estimate region and ZIP Code Tabulation Area-level prevalence. RESULTS: When comparing MRP estimates with a population-based sample as a reference, we found that adjustment using MRP can reduce bias in prevalence estimates and provide estimates for local area prevalence. 14 of 18 adjusted estimates were closer to the benchmark than the unadjusted estimates and MRP using all three covariate sets resulted in better overall agreement with the benchmark compared with the unadjusted estimates. CONCLUSIONS: MRP can improve prevalence estimates from self-selected Internet-based samples, although a nonnegligible amount of bias may remain. Illustrating the utility and limitations of this method will help researchers develop relevant estimates of the local public health burden, helping local health officials better understand and reduce poor health outcomes.