Approaches for Implementing App-Based Digital Treatments for Drug Use Disorders Into Primary Care: A Qualitative, User-Centered Design Study of Patient Perspectives.

BACKGROUND: Digital interventions, such as websites and smartphone apps, can be effective in treating drug use disorders (DUDs). However, their implementation in primary care is hindered, in part, by a lack of knowledge on how patients might like these treatments delivered to them. OBJECTIVE: This study aims to increase the understanding of how patients with DUDs prefer to receive app-based treatments to inform the implementation of these treatments in primary care. METHODS: The methods of user-centered design were combined with qualitative research methods to inform the design of workflows for offering app-based treatments in primary care. Adult patients (n=14) with past-year cannabis, stimulant, or opioid use disorder from 5 primary care clinics of Kaiser Permanente Washington in the Seattle area participated in this study. Semistructured interviews were recorded, transcribed, and analyzed using qualitative template analysis. The coding scheme included deductive codes based on interview topics, which primarily focused on workflow design. Inductive codes emerged from the data. RESULTS: Participants wanted to learn about apps during visits where drug use was discussed and felt that app-related conversations should be incorporated into the existing care whenever possible, as opposed to creating new health care visits to facilitate the use of the app. Nearly all participants preferred receiving clinician support for using apps over using them without support. They desired a trusting, supportive relationship with a clinician who could guide them as they used the app. Participants wanted follow-up support via phone calls or secure messaging because these modes of communication were perceived as a convenient and low burden (eg, no copays or appointment travel). CONCLUSIONS: A user-centered implementation of treatment apps for DUDs in primary care will require health systems to design workflows that account for patients' needs for structure, support in and outside of visits, and desire for convenience.

If You Listen, I Will Talk: the Experience of Being Asked About Suicidality During Routine Primary Care.

BACKGROUND: Routine population-based screening for depression is an essential part of evolving health care models integrating care for mental health in primary care. Depression instruments often include questions about suicidal thoughts, but how patients experience these questions in primary care is not known and may have implications for accurate identification of patients at risk. OBJECTIVES: To explore the patient experience of routine population-based depression screening/assessment followed, for some, by suicide risk assessment and discussions with providers. DESIGN: Qualitative, interview-based study. PARTICIPANTS: Thirty-seven patients from Kaiser Permanente Washington who had recently screened positive for depression on the 2-item Patient Health Questionnaire [PHQ] and completed the full PHQ-9. APPROACH: Criterion sampling identified patients who had recently completed the PHQ-9 ninth question which asks about the frequency of thoughts about self-harm. Patients completed semi-structured interviews by phone, which were recorded and transcribed. Directive and conventional content analyses were used to apply knowledge from prior research and elucidate new information from interviews; thematic analysis was used to organize key content overall and across groups based on endorsement of suicide ideation. KEY RESULTS: Four main organizing themes emerged from analyses: (1) Participants believed being asked about suicidality was contextually appropriate and valuable, (2) some participants described a mismatch between their lived experience and the PHQ-9 ninth question, (3) suicidality disclosures involved weighing hope for help against fears of negative consequences, and (4) provider relationships and acts of listening and caring facilitated discussions about suicidality. CONCLUSIONS: All participants believed being asked questions about suicidal thoughts was appropriate, though some who disclosed suicidal thoughts described experiencing stigma and sometimes distanced themselves from suicidality. Direct communication with trusted providers, who listened and expressed empathy, bolstered comfort with disclosure. Future research should consider strategies for reducing stigma and encouraging fearless disclosure among primary care patients experiencing suicidality.

Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters.

Background: "Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. Objective: The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. Methods: The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide. Results: The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians. Conclusions: Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.

Integrating Alcohol-Related Prevention and Treatment Into Primary Care: A Cluster Randomized Implementation Trial.

Importance: Unhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment. Objective: To test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration. Design, Setting, and Participants: The Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021. Interventions: The implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice's intervention period. Main Outcomes and Measures: Coprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression. Results: A total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P < .001). The proportion with AUD treatment engagement did not differ during intervention and usual care (1.4 vs 1.8 per 10 000 patients; P = .30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P < .001), new AUD diagnosis (33.8 vs 28.8 per 10 000; P = .003), and treatment initiation (7.8 vs 6.2 per 10 000; P = .04). Conclusions and Relevance: In this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation. Trial Registration: ClinicalTrials.gov Identifier: NCT02675777.

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention: A Qualitative Study.

Importance: US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention. Objective: To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters. Design, Setting, and Participants: Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs). Main Outcomes and Measures: Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives. Results: Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews. Conclusions and Relevance: In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.

Prevalence of anthelmintic resistant cyathostomins in Prince Edward Island, Canada.

Cyathostomins are the most common parasites of adult horses worldwide. Currently, the three classes of anthelmintics used to treat cyathostomin infections includes benzimidazoles, pyrimidines and macrocyclic lactones. However, due to widespread overuse, cyathostomins have developed varying degrees of resistance to all classes of anthelmintics. Fecal egg count reduction tests (FECRT) are currently used to determine the presence of anthelmintic resistance (AR), while egg reappearance periods (ERP) are used to investigate early macrocyclic lactone resistance. The objective of this study was to investigate the prevalence of cyathostomin pyrantel pamoate and ivermectin resistance, and to determine ERP at Prince Edward Island (PEI), Canada horse farms. In addition, fecal cultures and larval identification were performed to evaluate the prevalence of small and large strongyle egg shedding in PEI. Fecal egg counts (FEC) were performed on 270 horses on 14 horse farms across PEI. Horses with≥ 200 eggs per gram (EPG) met the inclusion criteria and were enrolled in the study (n = 101). The median (range) horses per farm was 7.5 (4-11) and 6.0 (4-8) for pyrantel pamoate and ivermectin groups, respectively. Horses were initially treated with 6.6 mg/kg of pyrantel pamoate orally (n = 101). Fecal egg counts were conducted every two weeks for 8 weeks post treatment. Once individual FEC were ≥ 200 EPG, horses were dewormed with 0.2 mg/kg of ivermectin orally (n = 80), and FEC were performed every 2-3 weeks for seven weeks. In this study the ERP was defined as the week the mean FECR were 10% below the initial mean two-week post treatment FECR. Fecal egg count reduction tests and ERP were used to evaluate the efficacy of each anthelmintic. Fecal culture was performed to confirm the shedding of cyathostomin eggs. Fecal egg count reduction tests detected pyrantel pamoate resistance on 5/14 farms. No signs of ivermectin AR were detected, while reappearance of eggs occurred at 4-6 weeks and 7-9 weeks for pyrantel pamoate and ivermectin, respectively. Fecal culture detected large strongyles on 5/14 farms, which accounted for 0.3% of strongyle type eggs cultured. The prevalence of Strongylus vulgaris among individual horses in this study was 2.8% and was detected on 2/14 farms. These findings will allow us to educate owners and veterinarians on appropriate anthelmintic protocols in PEI and can be used as a baseline for continued monitoring of ERP and anthelmintic resistance in this region.

Key opportunities and challenges for the use of big data in migration research and policy.

Migration is one of the defining issues of the 21st century. Better data is required to improve understanding about how and why people are moving, target interventions and support evidence-based migration policy. Big data, defined as large, complex data from diverse sources, is regularly proposed as a solution to help address current gaps in knowledge. The authors participated in a workshop held in London, UK, in July 2019, that brought together experts from the United Nations (UN), humanitarian non-governmental organisations (NGOs), policy and academia to develop a better understanding of how big data could be used for migration research and policy. We identified six key areas regarding the application of big data in migration research and policy: accessing and utilising data; integrating data sources and knowledge; understanding environmental drivers of migration; improving healthcare access for migrant populations; ethical and security concerns around the use of big data; and addressing political narratives. We advocate the need for careful consideration of the challenges faced by the use of big data, as well as increased cross-disciplinary collaborations to advance the use of big data in migration research whilst safeguarding vulnerable migrant communities.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use.

Importance: Firearms are the most common method of suicide, one of the "diseases of despair" driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown. Objective: To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access. Design Setting and Participants: Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system. Main Outcomes and Measures: Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021. Results: Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access. Conclusions and Relevance: In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

A Critical Analysis of the Drivers of Human Migration Patterns in the Presence of Climate Change: A New Conceptual Model.

Both climate change and migration present key concerns for global health progress. Despite this, a transparent method for identifying and understanding the relationship between climate change, migration and other contextual factors remains a knowledge gap. Existing conceptual models are useful in understanding the complexities of climate migration, but provide varying degrees of applicability to quantitative studies, resulting in non-homogenous transferability of knowledge in this important area. This paper attempts to provide a critical review of climate migration literature, as well as presenting a new conceptual model for the identification of the drivers of migration in the context of climate change. It focuses on the interactions and the dynamics of drivers over time, space and society. Through systematic, pan-disciplinary and homogenous application of theory to different geographical contexts, we aim to improve understanding of the impacts of climate change on migration. A brief case study of Malawi is provided to demonstrate how this global conceptual model can be applied into local contextual scenarios. In doing so, we hope to provide insights that help in the more homogenous applications of conceptual frameworks for this area and more generally.

Effects of corrective strabismus surgery on social anxiety and self-consciousness in adults.

PURPOSE: To report the results of a questionnaire-based interventional study to evaluate the effects of strabismus surgery on private self-consciousness, public self-consciousness, and social anxiety using a validated self-consciousness survey instrument. METHODS: Patients who underwent strabismus surgery completed a demographics and a self-consciousness scale form both pre- and postoperatively. The total and subscale (private self-consciousness, public self-consciousness, and social anxiety) summative scores were compared using the Wilcoxon signed-rank test, with statistically significant relationships defined as P < 0.05. Total and subscale summative scores were analyzed as such and by strabismus type, years of education, and marital status. RESULTS: Overall improvement was found postoperatively in total scores (P = 0.012), public self-consciousness scores (P = 0.009), and social anxiety scores (P = 0.028). Although improvement was noted for the private self-consciousness subscale (P = 0.188), it did not reach statistical significance. Subdivided according to strabismic and demographic subgroups, significant improvement was only noted in esotropic patients, college graduates, married/living partner/widowed patients, and separated/divorced patients. CONCLUSIONS: This study suggests that beyond functional and cosmetic improvements, strabismus surgery can result in improved public self-consciousness and social anxiety, with greatest effect noted in esotropic, college graduates, and nonsingle patients.

Costs of using evidence-based implementation strategies for behavioral health integration in a large primary care system.

OBJECTIVE: To describe the cost of using evidence-based implementation strategies for sustained behavioral health integration (BHI) involving population-based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015-2018). DATA SOURCES/STUDY SETTING: Project records, surveys, Bureau of Labor Statistics compensation data. STUDY DESIGN: Labor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback. DATA COLLECTION/EXTRACTION METHODS: Personnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members. PRINCIPAL FINDING: Implementation involved 286 persons, 18 131 person-hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person-hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites. CONCLUSIONS: When spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population-based BHI.

Unique, Diverged, and Conserved Mitochondrial Functions Influencing Candida albicans Respiration.

Candida albicans is an opportunistic fungal pathogen of major clinical concern. The virulence of this pathogen is intimately intertwined with its metabolism. Mitochondria, which have a central metabolic role, have undergone many lineage-specific adaptations in association with their eukaryotic host. A screen for lineage-specific genes identified seven such genes specific to the CTG clade of fungi, of which C. albicans is a member. Each is required for respiratory growth and is integral to expression of complex I, III, or IV of the electron transport chain. Two genes, NUO3 and NUO4, encode supernumerary subunits of complex I, whereas NUE1 and NUE2 have nonstructural roles in expression of complex I. Similarly, the other three genes have nonstructural roles in expression of complex III (QCE1) or complex IV (COE1 and COE2). In addition to these novel additions, an alternative functional assignment was found for the mitochondrial protein encoded by MNE1MNE1 was required for complex I expression in C. albicans, whereas the distantly related Saccharomyces cerevisiae ortholog participates in expression of complex III. Phenotypic analysis of deletion mutants showed that fermentative metabolism is unable to support optimal growth rates or yields of C. albicans However, yeast-hypha morphogenesis, an important virulence attribute, did not require respiratory metabolism under hypoxic conditions. The inability to respire also resulted in hypersensitivity to the antifungal fluconazole and in attenuated virulence in a Galleria mellonella infection model. The results show that lineage-specific adaptations have occurred in C. albicans mitochondria and highlight the significance of respiratory metabolism in the pathobiology of C. albicansIMPORTANCECandida albicans is an opportunistic fungal pathogen of major clinical concern. The virulence of this pathogen is intimately intertwined with its metabolic behavior, and mitochondria have a central role in that metabolism. Mitochondria have undergone many evolutionary changes, which include lineage-specific adaptations in association with their eukaryotic host. Seven lineage-specific genes required for electron transport chain function were identified in the CTG clade of fungi, of which C. albicans is a member. Additionally, examination of several highly diverged orthologs encoding mitochondrial proteins demonstrated functional reassignment for one of these. Deficits imparted by deletion of these genes revealed the critical role of respiration in virulence attributes of the fungus and highlight important evolutionary adaptations in C. albicans metabolism.

Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial.

BACKGROUND: Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition. METHODS/DESIGN: This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11-18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline. DISCUSSION: The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03034720 . Registered on January 27, 2017.

Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial).

BACKGROUND: Experts recommend that alcohol-related care be integrated into primary care (PC) to improve prevention and treatment of unhealthy alcohol use. However, few healthcare systems offer such integrated care. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington (KPWA) partnered to design a high-quality program of evidence-based care for unhealthy alcohol use: the Sustained Patient-centered Alcohol-related Care (SPARC) program. SPARC implements systems of clinical care designed to increase both prevention and treatment of unhealthy alcohol use. This clinical care for unhealthy alcohol use was implemented using three strategies: electronic health record (EHR) decision support, performance monitoring and feedback, and front-line support from external practice coaches with expertise in alcohol-related care ("SPARC implementation intervention" hereafter). The purpose of this report is to describe the protocol of the SPARC trial, a pragmatic, cluster-randomized, stepped-wedge implementation trial to evaluate whether the SPARC implementation intervention increased alcohol screening and brief alcohol counseling (so-called brief interventions), and diagnosis and treatment of alcohol use disorders (AUDs) in 22 KPWA PC clinics. METHODS/DESIGN: The SPARC trial sample includes all adult patients who had a visit to any of the 22 primary care sites in the trial during the study period (January 1, 2015-July 31, 2018). The 22 sites were randomized to implement the SPARC program on different dates (in seven waves, approximately every 4 months). Primary outcomes are the proportion of patients with PC visits who (1) screen positive for unhealthy alcohol use and have documented brief interventions and (2) have a newly recognized AUD and subsequently initiate and engage in alcohol-related care. Main analyses compare the rates of these primary outcomes in the pre- and post-implementation periods, following recommended approaches for analyzing stepped-wedge trials. Qualitative analyses assess barriers and facilitators to implementation and required adaptations of implementation strategies. DISCUSSION: The SPARC trial is the first study to our knowledge to use an experimental design to test whether practice coaches with expertise in alcohol-related care, along with EHR clinical decision support and performance monitoring and feedback to sites, increase both preventive care-alcohol screening and brief intervention-as well as diagnosis and treatment of AUDs. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.Gov: NCT02675777. Registered February 5, 2016, https://clinicaltrials.gov/ct2/show/NCT02675777 .

Evaluation of a Pilot Implementation to Integrate Alcohol-Related Care within Primary Care.

Alcohol use is a major cause of disability and death worldwide. To improve prevention and treatment addressing unhealthy alcohol use, experts recommend that alcohol-related care be integrated into primary care (PC). However, few healthcare systems do so. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington partnered to design a high-quality Program of Sustained Patient-centered Alcohol-related Care (SPARC). Here, we describe the SPARC pilot implementation, evaluate its effectiveness within three large pilot sites, and describe the qualitative findings on barriers and facilitators. Across the three sites (N = 74,225 PC patients), alcohol screening increased from 8.9% of patients pre-implementation to 62% post-implementation (p < 0.0001), with a corresponding increase in assessment for alcohol use disorders (AUD) from 1.2 to 75 patients per 10,000 seen (p < 0.0001). Increases were sustained over a year later, with screening at 84.5% and an assessment rate of 81 patients per 10,000 seen across all sites. In addition, there was a 50% increase in the number of new AUD diagnoses (p = 0.0002), and a non-statistically significant 54% increase in treatment within 14 days of new diagnoses (p = 0.083). The pilot informed an ongoing stepped-wedge trial in the remaining 22 PC sites.

Early Verb Learning: How Do Children Learn How to Compare Events?

An important problem verb learners must solve is how to extend verbs. Children could use cross-situational information to guide their extensions, however comparing events is difficult. Two studies test whether children benefit from initially seeing a pair of similar events ('progressive alignment') while learning new verbs, and whether this influence changes with age. In Study 1, 2 ½- and 3 ½-year-old children participated in an interactive task. Children who saw a pair of similar events and then varied events were able to extend verbs at test, differing from a control group; children who saw two pairs of varied events did not differ from the control group. In Study 2, events were presented on a monitor. Following the initial pair of events that varied by condition, a Tobii x120 eye tracker recorded 2 ½-, 3 ½- and 4 ½-year-olds' fixations to specific elements of events (AOIs) during the second pair of events, which were the same across conditions. After seeing the pair of events that were highly similar, 2 ½-year-olds showed significantly longer fixation durations to agents and to affected objects as compared to the all varied condition. At test, 3 ½-year-olds were able to extend the verb, but only in the progressive alignment condition. These results are important because they show children's visual attention to relevant elements in dynamic events is influenced by their prior comparison experience, and they show that young children benefit from seeing similar events as they learn to compare events to each other.

Sample Confirmation Testing: A Short Tandem Repeat-Based Quality Assurance and Quality Control Procedure for the eyeGENE Biorepository.

Quality assurance and quality control (QA/QC) procedures are vital to good biorepository management. The National Eye Institute (NEI) core CLIA-certified laboratory of the eyeGENE(®) Network receives blood from individuals with inherited eye conditions and isolates DNA for clinical genetic diagnostic testing and research. Clinical genetic test results are returned to the affected individuals, making it imperative that sample integrity is preserved throughout laboratory processing. A clinically validated, short tandem repeat (STR)-based approach, termed Sample Confirmation Testing (SCT), was developed to ensure that no significant laboratory errors occurred during processing. SCT uses modified protocols from commercial kits to create and compare STR profiles for each participant's original blood and derived DNA. This QA/QC procedure has been performed on 47% of the more than 6000 participants in the eyeGENE Biorepository and has identified significant laboratory errors in 0.4% of samples tested. SCT improves the quality of the data returned to affected individuals and the data distributed to researchers using eyeGENE samples by ensuring the integrity of the samples and aiding in curation of the biorepository. This approach serves as a model for other repositories to improve sample quality and management procedures.