Family Medicine Residency Program Directors' Perception of Curricular Elements Related to Autism: A CERA Study.

BACKGROUND AND OBJECTIVES: The family medicine (FM) approach to health care across the life span is well-suited to providing care for persons living with autism spectrum disorder (ASD). Little is known about ASD curricula in FM residency training and the characteristics of FM residency programs that prepare their residents to care for persons with this disorder. METHODS: Our study questions were part of a larger omnibus survey by the Council of Academic Family Medicine Educational Research Alliance (CERA) with data collection from November 16 to December 18, 2022, from FM residency program directors (PDs). ASD curricula were investigated using 10 questions, with descriptive analyses and nonparametric comparisons between program variables and ASD curriculum. RESULTS: The response rate was 42.18%, with FM PDs reporting that their programs were preparing residents in the care of youth (71.53%) and adults (68.33%) with ASD, but to a lesser extent (58.89%) in facilitating transitions of care. Programs with faculty champions, access to published curricula, sufficient patients with ASD, and engagement of interprofessional faculty reported a higher proportion of resident preparedness. PDs of community-based programs were most confident in their ability to teach ASD care and transitions of care. CONCLUSIONS: Most FM PDs modestly agreed that they are preparing residents to provide care to patients with ASD and their families. PDs of programs with greater access to resources (ie, published curriculum, faculty champions, sufficient patients with ASD, interprofessional faculty experts) believed that their residents were more prepared. Community-based FM educators may help lead the way in providing models for care and education in this regard.

Value of Modeling Violent Relationships.

Intimate partner violence (IPV) is a scar on human society. Growing evidence demonstrates that relationships involving IPV and women's decisionmaking about violence represent complex phenomena, best studied as complex adaptive systems. Unfortunately, that complexity limits our ability to fully understand it. This paper presents findings from a series of agent-based models (ABMs) that were created from studies involving multiple time series of couples' daily reports of violence, perceptions and behaviors. To identify potential influencing variables, we modeled the impact that random stress and intentional behavior of the women could have on men's violence and stalking. ABM models of IPV noted the lack of violence at baseline without influence, and found that three variable parameters (Distance-Distance+, HerViolence-HerViolence+, Distance-Distance-) accounted for most patterns of violence development. Random stress and arguments had little effect and the nature of the alcoholviolence relationship remained unclear, however, her violence could increase his violence and stalking. One important difference between ABMs was the importance of the persistence of her concern about the effects of violence on children. Although only modeled in the second ABM, it proved critical to results. When modeling women's decision-making, her abstinence from arguments, alcohol use and violence had no effect on whether to seek help, take legal action or leave; random stress and her daily violence did not affect seeking counseling. However, daily arguments, forgiveness and heavy alcohol use did impact actiontaking, increasing counseling, legal action and leaving generally. The addition of catastrophe equations could alter these outcomes, resulting in more counseling but less legal action. In addition, children are very important when considering decision-making; concern for children affects violence while number of children affects decision-making. In conclusion, ABM can yield important insights into IPV and have clinical implications. It can provide greater understanding of the phenomenon and allow us to test the nature of correlations. (i.e., between alcohol use and violence). ABM can clarify the inherent complexity within violent couples and facilitate sense-making. Finally, it can allow clinicians to test interventions in vitro without risk to vulnerable women.

Same-Day Correlates and Prior-Day Predictors of Couples' Violent Behaviors Based upon Partners' Daily Reports.

Although previous research identified predictors of violent events within violent heterosexual couples, findings were limited to the woman's reports, to her perceptions; his assessments were not obtained. This exploratory study was conducted to gain understanding of proximal predictors of violence assessed in "real-time" from the perspective of both partners. Fifteen adult heterosexual couples in which the woman reported experiencing partner violence in the prior 30 days were enrolled in a primary care clinic. Each partner provided separate daily telephone reports for eight weeks via an automated Interactive Voice Response (IVR), concerning the previous day's violence, alcohol use, stressors, emotional reactions and concerns for children. Same-day correlates were determined by Pearson correlations while prior-day predictors were identified via vector autoregression. Same-day correlations show that men's violence was associated with almost every other variable while women's violence correlated with men's violence, men's drug use, women's alcohol use, anger, closeness, hassles, and all men's negative feelings. Using prior-day predictors, men's violence was related to feelings (primarily hers), but women's violence was more dependent upon feelings of both of them as well as women's prior-day violence and alcohol use. Men's violence was dependent upon their partners' prior-day feelings and the men's lack of concern about effects of violence on children. Women's violence was also dependent upon women's prior-day feelings, as well as women's violence, alcohol use, marital closeness, and men's concern for children. Although the co-occurrence of men's and women's violence has been seen before, in this study only women's violence was linked to alcohol use.

Modeling Daily Partner Violence and Substance Use Based upon Couple's Reporting.

While agent-based models (ABMs) have successfully modeled violence and women's decision-making, they relied upon studies of her daily reports of violence and household environment; these models were not based upon descriptions of his emotions and perceptions. The purpose of this study was to improve our understanding of the triggers of violent events within violent relationships through agent-based modeling by including men's perceptions and emotions. An agent-based model was created of couples with history of violence based upon results of a study involving multiple time series of partner violence, including couples' daily reports of their emotions and perceptions. To explore factors that may alter model results, seven continuous variable parameters were created based upon significant (p ≤ .05) but discrepant (opposite directions) in prior studies. To assess the potential impact that influencing factors such as random stress as well as his and her feelings and behaviors could have on violence and stalking, the impact of these factors was also assessed. Results found that, at baseline, which included no extremes in variable parameters, no violence emerged. One prior-day→same-day relationship (HerConcern→HerConcern) was particularly important in this ABM. Men's and women's drug use and refraining from arguments had little impact on any outcome, but his and her alcohol use, his sense of insult and her violence all had significant effects. In fact, women's alcohol use interacted with other influencing variables and was a source of atypical patterns. In conclusion, incorporating men's perceptions into an ABM of partner violence resulted in important differences compared with ABMs based solely on women's input. Not only were women's daily concerns about the effect of violence on children was critical to results, but this ABM demonstrated the complexity of partner violence in response to influences as illustrated by contextual dependence, interaction effects and synergy.

Violence towards women and their decisions to take action: A complex systems approach.

Intimate partner violence (IPV) is a blight on society. Our traditional understanding suggests that interventions should be straightforward, leading to predictable positive results. However, these assumptions do not reflect the reality of IPV, which continues to frustrate physicians. While IPV research has thoroughly described the developmental risks and impacts of IPV, the violent incident itself remains largely unstudied and poorly understood. Although this lack of research may partially explain physician frustration and the limitations of our interventions, the greater problem may be our reliance upon the wrong paradigm in guiding our understanding. Complexity science says that systems are globally understandable, but not completely knowable. Our hypothesis is that IPV needs to be viewed as a complex adaptive system if we are to understand the phenomenon, identify expectations and appropriately intervene. When viewed through the lens of complexity science, IPV becomes less knowable and predictable, suggesting that interventionists should expect variable response. Research has indeed demonstrated that partner violence is a complex phenomenon with multiple, interdependent factors and a nonlinear trajectory. This nonlinearity/unpredictability can impact outcomes in IPV, often more so than the frequency or severity of the violence. Similarly, women's decision-making concerning the violence is also a nonlinear process dependent upon multiple factors and catastrophic influences. Once recognized, complexity science offers a novel approach to explain IPV's obfuscation and resistance to predictable change. Using the tempered expectations of a systems lens, the violent interdependencies can be clarified, the obscure causes of events can be visualized, and the temporal irregularities can be mapped. Not only can the disruptive tipping points, system feedforward propagations, powerful attractors and discontinuities compromise reasoned intervention, but these same factors, if understood, can be harnessed to foster and magnify circumstances that enable positive change.

Outcomes of a Scholarly Activity Curriculum for Family Medicine Residents.

BACKGROUND AND OBJECTIVES: Scholarship is essential to growth and innovation in family medicine. Moreover, the Accreditation Council for Graduate Medical Education Review Committee-Family Medicine requires family medicine residents to complete scholarly activities. However, many residents lack the training and confidence to successfully conduct such activities. In the year 2014, our residency implemented a scholarly activity curriculum to train our residents to plan, complete, and disseminate research and quality improvement projects. We sought to evaluate the impact of one institution's scholarly activity curriculum for family medicine residents on resident scholarly activity productivity. METHODS: We reviewed the scholarly activities conducted by our family medicine residents in the 5 years after initiation of the scholarly activity curriculum and compared them to those conducted in the 5 years prior to initiation of the curriculum. RESULTS: Since 2014, the percentage of residents who coauthored at least one poster increased significantly, from 55.2% in 2009-2014, to 82.5% in 2014-2019 (P<.001). In the academic years 2014 to 2019, residents also coauthored significantly more book chapters compared to the 5 years prior to the curriculum. CONCLUSIONS: Our curriculum has been successful in improving resident scholarly activity productivity as evidenced by a significant increase in the percentage of residents coauthoring posters and the total number of book chapters written by residents.

Modeling Women's Need For Action in Violent Relationships.

We are beginning to understand that intimate partner violence (IPV) and women's decision-making about that violence are nonlinear phenomena. IPV and decision-making are influenced by variables feedforwarding upon themselves with multiple interconnected predictors and circularly causal relationships. Computer models can help us gain a systems perspective on these relationships and enable hypothesis-testing without engendering risk to women in these relationships. The purpose of this study was to develop a mathematical model of women's decision-making concerning her violent relationship and assess the impact of random stress and her controllable behaviors on violence and decision-making. An agent-based model was created using data from couples with history of violence, based upon results of multiple time series of partner violence. To explore factors that may alter model results, eight continuous variable parameters were created based upon significant (p ≤ .05) but discrepant (opposite directions) results from two prior time series studies. Overall, 13 unique patterns of violence in five categories were identified, but none of these categories included his violence alone without some additional influence (i.e., marital distance leading to marital distance the following day). To assess the potential impact that random stress and behaviors under her control (arguments, forgiveness, alcohol use, violence) could have on need-for-action and actions taken, the effects of variable parameter settings on these outcomes were also assessed. While random stress had little effect on outcomes, her interventions could have an impact but were pattern-specific. Her daily participation in arguments correlated with more violence. The need-for and actually taking action were at times independent of each other. This mathematical model yielded results that generally involved her violence with or without his violence. Thus, modeling partner violence and women's decision-making is possible, yielding diverse patterns. However, the complexity of interdependent predictors unique to each relationship means that targeted interventions will need to be couple-specific.

Complex Relationship Between Daily Partner Violence and Alcohol Use Among Violent Heterosexual Men.

Although alcohol use and partner violence are consistently associated, the nature of the alcohol-violence relationship is still unclear. The purpose of this pilot study was to use longitudinal daily assessments of male partners' alcohol use and violent events to identify the nature of the alcohol-violence relationship, employing both linear and nonlinear analyses. The participants were 20 adult heterosexual couples of whom the woman reported experiencing partner violence in the prior 30 days. Each partner provided a separate daily telephone report for 8 weeks via an automated interactive voice response (IVR), concerning the previous day's violence, alcohol use, stressors, emotional reactions, and concerns for children. Individual IVR databases were merged to form a combined couple's IVR time series. Time series were analyzed using graphic, linear, and nonlinear methods. Graphic analysis using state space grids found no consistent pattern across couples. Similarly, linear analysis using same-day cross-correlation and prior-day beta statistics found no significant group-level alcohol-violence relationship. Using cross-approximate entropy statistics and differential structural equation modeling, no nonlinear relationships between alcohol use and violence were noted either. Whether applying linear or nonlinear analytic methods, there is no group-level relationship between alcohol use by male perpetrators and their violent acts. The implications are significant. First, the alcohol-violence relationship may differ among subgroups. Second, couples need to be assessed thoroughly to determine their unique relationship with alcohol use, so that couple-specific interventions can be designed. Third, if perpetrators believe that their violence is facilitated by their alcohol use, then alcohol reduction should be encouraged despite any evidence suggesting a different alcohol-violence relationship. Finally, the accepted alcohol-causes-violence belief held by many providers needs to be reconsidered. Because the nature of the alcohol-violence relationship varies considerably across couples, clinicians should seek to understand their unique relationship applying across-the-board management approaches.

Is Perceived Need for Action Among Women in Violent Relationships Nonlinear and, If So, Why?

Despite the prevalence and impact of partner violence, we understand little about women's action taking except that it seems an unpredictable, nonlinear process. This article determines the degree of nonlinearity in perceived need for help, legal action, or leaving among women in violent relationships. The participants included 143 women who experienced violence in the previous month, enrolled from six primary care clinics. Baseline surveys assessed background characteristics and factors which may affect perceived need for action. Multiple times series assessments of violence and need for action were collected daily for 8 weeks via telephone Interactive Voice Response. Measures of nonlinearity of violence, perceived need for help, legal action, and leaving were computed. Repeated measures ANOVA assessed differences across measures of nonlinearity. To identify factors contributing to nonlinearity, staged multiple regression assessed the relationship between nonlinearity measures and outcomes. Ninety-three women completed sufficient time series for nonlinearity assessment. Measures of nonlinearity were lower for need for legal action compared with needs for help and leaving. Regression analysis suggested that isolation, social networks, and lack of awareness contribute to nonlinearity. Women's perceived need for legal action and its level of nonlinearity were lowest compared with those of help seeking and leaving. Although its relative linearity suggests that the need for legal action may be the most predictable, its lower mean rating suggests that legal action is a low priority. Although need for help and leaving are of higher priorities, their nonlinearity suggests that intervention will not yield predictable results.

He Said, She Said: Comparing Men's and Women's Descriptions of Men's Partner Violence.

More than one in three women and one in four men in the United States report victimization by intimate partner violence. Women and men often disagree about the frequency or severity of violent acts, and researchers have proposed various reasons for discordant reports. Using daily surveys and qualitative interviews, we compared men's and women's reports about men's partner aggression and examined language they used to describe their experiences. Fifteen heterosexual couples in violent relationships completed an 8-week study that involved daily telephone surveys about violent behaviors and household environment; baseline and end-of-study surveys addressing predictors and outcomes of violence; and qualitative end-of-study interviews to provide perspective about their relationships. Most participants were Latinos with low income. Relationship length was 5.5 years, median. In daily surveys, both partners reported similar frequencies of men's physical violence (4% of days), but men reported more physical violence by women than women did (8% vs. 3% of days). The qualitative analysts compared men's and women's accounts of male-to-female violence and observed gender-specific variations in style of reporting. Men used indirect language to describe their violent behavior, implied definitions of abuse, and justified their aggression. These findings have implications for clinical guidelines to screen and intervene with victims and perpetrators of intimate partner violence in primary care and emergency settings. Future research should focus on perpetrators of violence and examine effective ways for health care providers to identify and manage their care.

Act Scholarly! Embrace your inner behavioral scientist.

Fifty years of scholarship by behavioral science faculty shaped the training and practice of family physicians. One can trace behavioral science influence from the philosophical underpinnings of family medicine (whole-person, patient-centered, biopsychosocial care), to the translation of psychotherapy skills into tools for family physicians, to the discovery of successful, integrated healthcare teams of family physicians and behavioral science professionals. Family medicine as we know it today rests on the shoulders of scholars who collaborated to conceive, experiment, evaluate, improve, and innovate. The purpose of this paper is to recruit you - behavioral science professionals - to continue this tradition of scholarship in Family Medicine. To advance your scholarly efforts, start by understanding that "scholarship" is not limited to research. "Scholarship" is sharing your good work with other professionals; through that interchange, you and they can improve. Next, surround yourself with people who will help you learn and succeed: mentors, collaborators, and helpers. Select a focus for your scholarship and read scientific literature for a thorough understanding of the topic. Identify a methodology that fits your values, interests, skills and resources. Start small, then grow. Sharpen your skills in writing and, if necessary, in statistics. Finally, Act Scholarly! by sharing your work with other behavioral science scholars.

Effect of Incorporating Catastrophic Equations into an Agent-Based Model of Women's Action-Taking in Violent Relationships.

Based upon multiple time series studies, an agent-based model (ABM) of women's decision-making related to partner violence was developed. However, help-seeking, legal action and leaving could be modeled as catastrophic phenomena, but catastrophic effects were not included in this prior ABM. The purpose of this study was to incorporate cusp catastrophe equations into the prior ABM to determine the impact upon her action-taking. Building upon this prior ABM of women's decision-making, we added cusp-related equations and compared resultant patterns and impacts of stress and interventions against those of the prior ABM. To assess the potential impact that random stress and her behavior could have on violence and stalking, the effect of variable parameter settings of these factors were assessed. Adding cusp equations to the prior ABM resulted in more legal action-taking for most of these patterns, many showing the effects of the bifurcation variables, and more women leaving in half of the patterns, but at the expense of increasing instability and more distortion effects. However, help-seeking was most impacted by possible interventions. In conclu-sion, adding cusp equations to the model had significant effects on modeling action-taking, especially for legal action and leaving while affecting the impact of interventions on help-seeking.

The association between depression and type of treatments received for chronic low back pain.

BACKGROUND: Depression is associated with receipt of opioids in non-cancer pain. OBJECTIVES: To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments. METHODS: Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments. RESULTS: Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609). CONCLUSION: There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use.

Childhood Trauma, Social Networks, and the Mental Health of Adult Survivors.

The purpose of this study was to investigate the relationship of childhood trauma to the quality of social networks and health outcomes later in adulthood. Data were obtained from a convenience sample of 254 adults seen in one of 10 primary care clinics in the state of Texas. Standardized measures of adverse childhood experiences (ACEs), stressful and supportive social relationships, medical conditions, anxiety, depression, and health-related quality of life were administered. Using latent class analysis, subjects were assigned to one of four ACE classes: (a) minimal childhood abuse (56%), (b) physical/verbal abuse of both child and mother with household alcohol abuse (13%), (c) verbal and physical abuse of child with household mental illness (12%), and (d) verbal abuse only (19%). Statistically significant differences across the four ACE classes were found for mental health outcomes in adulthood. Although respondents who were physically and verbally abused as children reported compromised mental health, this was particularly true for those who witnessed physical abuse of their mother. A similar relationship between ACE class and physical health was not found. The quality of adult social networks partly accounted for the relationship between ACE classes and mental health outcomes. Respondents exposed to ACEs with more supportive social networks as adults had diminished odds of reporting poor mental health. Conversely, increasing numbers of stressful social relationships contributed to adverse mental health outcomes. Although efforts to prevent childhood trauma remain a critical priority, the treatment of adult survivors needs to expand its focus on both strengthening social networks and decreasing the negative effects of stressful ones.

Is Readiness to Take Action Among Women in Violent Relationships a Catastrophic Phenomenon?

Taking action among women in violent relationships appears to involve sudden changes and reversals after periods of building stress, suggesting that decision making is a "catastrophic" phenomenon. This study sought to determine whether readiness-to-change is best modeled as a cusp catastrophic (CCM) phenomenon among women in violent relationships. A total of 143 women who experienced violence in the previous month completed baseline and end-of-study interviews assessing her hope, coping strategies, social network, and readiness-for-action (seeking help, taking legal action, and leaving) concerning the violence. Daily assessments of his violent behavior, forgiveness sought and given, and her perceived need-for-action were collected via telephone Interactive Voice Response for 8 weeks. Using regression analysis, the impact of factor-analyzed asymmetry (violence burden) and bifurcation (hope and cope, support, forgiveness, and number of children) variables on the outcomes (readiness-for-help, legal action, and leaving) was modeled, comparing the CCM against linear models to determine which model accounts for the most variance in each outcome. Cusp catastrophe models for all three actions accounted for more variance than either linear model comparison, but violence burden was only relevant to readiness-for-help and different bifurcation variables were at work for each action. While forgiveness was an important bifurcation factor in readiness-for-help and number of children served as the bifurcation factor for readiness-for-legal-action, readiness-to-leave was more complex with both number of children and hope-and-cope as bifurcation factors. Not only should we expect sudden changes in readiness but efforts to facilitate decision making should focus on addressing the bifurcation factors that may distort her interpretation of reality.

Psychometrics of the Violence Nonlinear Dynamics Scale.

OBJECTIVE: The trajectory of daily partner violence generally demonstrates nonlinear dynamics, and this nonlinearity is important to patient outcomes, as it is sometimes a stronger predictor of outcomes than violence frequency or severity. However, measurement of such dynamics is difficult, requiring complete time series data of sufficient length to yield stable measures. The purpose of this study was to develop a pencil-and-paper instrument to estimate violence nonlinearity and assess its psychometrics. METHODS: Adult women (N = 143) who experienced violence in the previous month were enrolled from 6 primary care clinics. Baseline surveys assessed factors known to correlate with nonlinearity (partner's control strategies, violence appraisal, hope, social support, coping style) and violence dynamics using a 30-item instrument based on traditional characteristics of complex adaptive systems. Participants completed daily assessments of the previous day's violence using interactive voice response via telephone for 8 weeks, with data collection occurring between August 2013 and March 2015. Three different measures of nonlinearity were computed: LZ complexity (algorithmic complexity), approximate entropy (lack of regularity), and Lyapunov exponent (sensitivity to initial conditions). RESULTS: Using factor analysis and reliability measures, the final 10-item Violence Nonlinearity Dynamics Scale (VNDS) was identified. The VNDS was found to have both internal consistency (0.817) and split-half reliability (0.796). In addition, the instrument demonstrated concurrent (correlating with both the combined nonlinearity factor score [r = 0.267] and Grassberger-Procaccia entropy [r = 0.338]) and construct (correlating with 9 of 13 previously identified nonlinearity correlates) validity. CONCLUSIONS: The VNDS has both reliability and validity and could facilitate the inclusion of nonlinearity assessment in both intimate partner violence research and clinical work.

Coding Family Medicine Residency Clinic Visits, 99213 or 99214? A Residency Research Network of Texas Study.

BACKGROUND AND OBJECTIVES: The purpose of this study was to characterize Current Procedural Terminology (CPT) coding patterns for professional services in family physician (FP) residency clinics. METHODS: Trained assistants directly observed during every other FP-patient encounter in 10 clinics affiliated with eight residencies of the Residency Research Network of Texas. Three investigators later independently coded each visit for the highest code level reasonably allowed. The primary outcome was the number of clinic visits that were actually coded as a CPT 99203/213 that could have been coded at a higher level. RESULTS: In 850 physician-patient encounters where the CPT code billed was identified, the investigators completely agreed on the allowable code 93% of the time. Overall, a 99203/13 or lower or preventive services code was billed in 651 visits (76.6%), more commonly in resident visits (515/570 [90.4%] vs 136/280 for faculty [48.6%], P<.001). There were 476/660 (72.1%) visits coded at a 99213 or less that could have been coded as a 99204/214 or higher. This was more common in resident visits 385/434 (88.7%), but there was undercoding in faculty patients as well 91/226 (40.3%). We found very few cases of overcoding-16 total. CONCLUSIONS AND RELEVANCE: FPs coding patient encounters in residency clinics undercode for their work, which leads to decreased clinic revenue. This may be because the primary care exception is felt to be too onerous to bill for higher-paid codes, or a lack of knowledge of CMS coding rules among residents and faculty, or other reasons.

Disability Benefits and Change in Prescription Opioid Dose.

Among chronic low back pain (CLBP) patients, workers' compensation is associated with longer term prescription opioid analgesic use (OAU). The aim was to study the association between receiving Social Security Disability Insurance (SSDI) benefits and course of OAU. This prospective cohort study utilized data from primary care patients diagnosed with non-cancer CLBP. The outcomes were morphine equivalent dose (MED) - categorized as no OAU, 1-50mg MED, or >50mg MED - and change in MED over time using mixed multinomial logistic regression models. Covariates included sociodemographics, pain severity, pain management characteristics, continuity of care with their physician, health-related quality of life, number of comorbid health conditions, obesity, depression, and anxiety. In adjusted analysis, SSDI vs. non-SSDI patients were more likely to be receiving >50mg MED vs. no OAU at baseline (OR = 10.19; 95% CI:1.51-68.83). Differences in OAU trajectory between SSDI groups were nonsignificant (P = 0.204). Collection of SSDI benefits was an independent predictor of higher MED at baseline and persistently higher MED during 2 years of follow-up. Providers should consider the risk of persistent, high-dose opioid use in patients receiving SSDI benefits.

Agent-Based Modeling of Day-to-Day Intimate Partner Violence.

The purpose of this study was to develop a mathematical model of mutual partner violence and assess impact of her controllable behaviors on reducing violence. An agent-based model was created of couples with history of violence based upon results of two multiple time series studies of partner violence. To explore factors that may alter model results, eight continuous variable parameters were created based upon significant (p=.05) but discrepant (opposite directions) results from previous studies. To assess the potential impact that random stress and her behavior (arguments, forgiveness, alcohol use, violence) could have on violence and stalking, the impact of variable parameter settings of these factors were also assessed. The model identified 18 unique patterns were observed, grouped into five general categories. Added random stress contributed to his violence in only two patterns. Although avoiding participation in arguments had no effect, her forgiveness and elimination of alcohol use often reduced her violence only. However, consistent violence or nonviolence on her part sometimes affected his violence and stalking. In conclusion, while increasing forgiveness and reducing alcohol intake could reduce her violence, they generally had little effect on his. However, if she eliminated her violence, it could eliminate his violence and stalking in some situations.