Small area estimation and hotspot identification of opioid use disorder among military veterans living in the Southern United States.

BACKGROUND: The purpose of this study was to estimate opioid use disorder prevalence rates at the county level among veterans in Alabama and to determine hotspots of said rates. Methods: By combining data from the National Survey on Drug Use and Health and the American Community Survey, we developed a mixed-effects generalized linear model of opioid use disorder and modeled probabilities onto veteran-specific population counts at the county level in Alabama. Results: The average model-based estimate for opioid use disorder prevalence among veterans in Alabama from 2015 to 2017 was 0.79% (SD = 0.16), with a minimum of 0.52% (i.e., Lowndes county, Alabama) and a maximum of 1.10% (Dale county, Alabama). Hotspot analysis revealed a significant cluster of "high-high" veteran opioid use disorder prevalence in neighboring Marion, Winston, and Cullman counties. Conclusions: The application of the statistical technique presented in this study can provide feasible, cost-effective, and practical county-level prevalence estimates of veteran-specific opioid use disorder and should be widely applied by states and counties so that they can more accurately and efficiently allocate resources to caring for veterans with an opioid use disorder.

The Hospital Readmissions Reduction Program's Impact on Readmissions From Skilled Nursing Facilities.

EXECUTIVE SUMMARY: Hospital readmissions have long served as an indicator of patient recovery and the effectiveness of care. The present study examines the Hospital Readmissions Reduction Program's (HRRP's) impact on hospital readmissions from skilled nursing facilities (SNFs) and the characteristics of SNFs that were predictive of lower readmission rates. Adjusted 30-day readmission rates among 14,666 SNFs in the United States from 2011 through 2015 were examined using linear regression with generalized estimating equations to determine the relationship of the HRRP mandate to readmission rates from SNFs. Findings indicate a significant downward trend in adjusted 30-day readmission rates over time, decreasing 1.4% from 2011 to 2015. Furthermore, lower readmission rates were associated with SNF characteristics including location in a hospital facility, rural designation, higher registered nurse-to-nurse ratios, and not-for-profit status. We found a substantial decrease in SNF-related readmissions associated with HRRP, which may limit the impact of the Protecting Access to Medicare Act. Policy-makers may consider these systemic and structural differences before drafting future legislation targeting hospital readmission from SNFs. In addition, acute care facility operators who do not have an SNF may consider adding one to their facility and/or consider partnering with SNFs to ensure that high-quality programs in these SNFs are in place to reduce 30-day readmissions to the acute care facilities.

Barriers to electronic cigarette use.

OBJECTIVE: Recent studies suggest that electronic cigarettes (e-cigarettes) may be a better alternative to traditional smoking cessation therapies for cigarette smokers. This study explores the barriers traditional smokers face when switching to e-cigarettes. DESIGN AND SAMPLE: A convenience sample of adult male and female tobacco and/or e-cigarette smokers (n = 446) were recruited through an online survey. MEASUREMENTS: The survey included questions used to determine the barriers a smoker may experience in regards to their use of e-cigarettes, as well as the characteristics regarding their use of tobacco and/or e-cigarettes. RESULTS: The majority (74%) of tobacco smokers who tried e-cigarettes did not perceive e-cigarettes to be an effective replacement for tobacco cigarettes, and 69% indicated the initial cost and health concerns as reasons to not continue using e-cigarettes. Both current e-cigarette users and those who discontinued use of e-cigarettes noted health or lack of information on side effects as a concern. The majority of e-cigarette users indicated that it took more than a week to settle on a proper dose. We found that for each additional cigarette smoked per day individuals were 4.0% (p = .001) more likely to use e-cigarettes. CONCLUSION: This exploratory study informs future cessation trials involving e-cigarettes about the barriers users face. Given that individuals who smoke a greater number of tobacco cigarettes are more likely to try e-cigarettes, greater attention to nicotine dosing is necessary.

The Impact of Patient Navigation on Diabetes.

EXECUTIVE SUMMARY: Diabetes is a growing concern in the United States as it is associated with increasing rates of mortality and morbidity, in addition to rising healthcare costs. It is the seventh-leading cause of death in the U.S. From 1980 through 2014, the number of Americans diagnosed with diabetes increased fourfold (from 5.5 million to 22 million). Consequently, costs associated with diabetes have soared to an estimated $245 billion, representing an average annual cost of approximately $13,700 per patient with diabetes. Moreover, approximately 28%, or 8.1 million people, with diabetes are undiagnosed. Type 2 diabetes accounts for 90-95% of all cases and can be managed with appropriate lifestyle interventions. Many patients need assistance understanding and managing their disease. However, effective management is difficult for individuals and their healthcare providers. Physicians typically do not have the time or resources to address these patient factors that may influence health outcomes for people with diabetes: adherence to treatment regimen, beliefs, attitudes, culture, understanding of the disease, language ability and health literacy, socioeconomic status, comorbidities, and social support. Behavior modification poses many challenges. In this study, the authors evaluate the impact of a patient navigation program developed by Pack Health, Birmingham, Alabama, to address these challenges. The patient navigation program motivates and educates patients and supports them in changing behavior to help them manage their diabetes effectively. The authors found that patients enrolled in the patient navigation program had greater understanding of diabetes after the program and, on average, their hemoglobin A1c level decreased by 1%.

Travel Distance to Cancer Treatment Facilities in the Deep South.

EXECUTIVE SUMMARY: Despite ongoing efforts to improve rural healthcare, the health problems facing rural communities persist. The lack of healthcare providers and infrastructure in rural areas has been linked to a number of negative consequences. Among the elderly rural population, the lack of proximal access presents greater barriers because many elderly people are further limited in their ability to travel and pay for services. In the Deep South specifically, rural residents experience limited access to care and overall poor health outcomes. With cancer in particular, the Deep South has been dubbed the "cancer belt," faring far worse in prevalence and mortality rates than other areas of the country. The present study examines the average travel distance for rural elderly patients residing in the Deep South who are receiving treatment for prostate, breast, or colorectal cancer. We analyzed Medicare claims data of beneficiaries residing in the five Deep South states who had received a primary diagnosis of prostate, breast, or colorectal cancer, with a service date ranging from January 1, 2011, through December 31, 2014. The findings reveal that rural Medicare beneficiaries in the Deep South travel significantly greater distances than do their urban counterparts. In addition, travel distances to prostate cancer treatment facilities are significantly greater than those to breast or colorectal cancer treatment facilities. With cancer incidence predicted to increase, the need to reduce travel distances to treatment is vital in efforts to curb the mortality rate in the Deep South.

Topographic anatomy of the great auricular point: landmarks for its localization and classification.

PURPOSE: The great auricular point (GAP) marks the exit of the great auricular nerve at the posterior border of the sternocleidomastoid muscle (SCM). It is a key landmark for the identification of the spinal accessory nerve, and its intraoperative localization is vital to avoid neurological sequelae. This study delineates the topography and surface anatomy landmarks that used to localize the GAP. METHODS: Thirty cadaveric heminecks were dissected on a layer-by-layer approach. The topography of the GAP was examined relative to the insertion point of the SCM at the clavicle, tip of the mastoid process, and angle of the mandible. The GAP and its relation to the SCM were determined as a ratio of the total length of the SCM. RESULTS: The GAP was demonstrated to be in a predictable location. The mean length of the SCM was 131.4 ± 22 mm, and the mean distance between the GAP and the mastoid process was found to be 60.4 ± 13.76 mm. The ratio of the GAP location to the total SCM length ranged between 0.33-0.57. The mean distance between the angle of the mandible and the GAP was determined to be 57 ± 22.2 mm. Based on the midpoint of the SCM, the GAP was above it in 66.7 % of subjects and classified to Type A, and below it in 33.3 % of subjects appointed to Type B. CONCLUSIONS: The anatomical landmarks utilized in this study are helpful in predicting the location of the GAP relative to the midpoint of the SCM and can reduce neural injuries within the posterior triangle of the neck.

Crave-Out: A Distraction/Motivation Mobile Game to Assist in Smoking Cessation.

BACKGROUND: Smoking is still the number one preventable cause of death. Cravings-an intense desire or longing for a cigarette-are a major contributor to quit attempt failure. New tools to help smokers' manage their cravings are needed. OBJECTIVE: To present a case study of the development process and testing of a distraction/motivation game (Crave-Out) to help manage cravings. METHODS: We used a phased approach: in Phase 1 (alpha testing), we tested and refined the game concept, using a Web-based prototype. In Phase 2 (beta testing), we evaluated the distraction/motivation potential of the mobile game prototype, using a prepost design. After varying duration of abstinence, smokers completed the Questionnaire of Smoking Urge-Brief (QSU-Brief) measurement before and after playing Crave-Out. Paired t tests were used to compare pregame and postgame QSU-Brief levels. To test dissemination potential, we released the game on the Apple iTunes App Store and tracked downloads between December 22, 2011, and May 5, 2014. RESULTS: Our concept refinement resulted in a multilevel, pattern memory challenge game, with each level increasing in difficulty. Smokers could play the game as long as they wanted. At the end of each level, smokers were provided clear goals for the next level and rewards (positive reinforcement using motivational tokens that represented a benefit of quitting smoking). Negative reinforcement was removed in alpha testing as smokers felt it reminded them of smoking. Measurement of QSU-Brief (N=30) resulted in a pregame mean of 3.24 (SD 1.65) and postgame mean of 2.99 (SD 1.40) with an overall decrease of 0.25 in cravings (not statistically significant). In a subset analysis, the QSU-Brief decrease was significant for smokers abstinent for more than 48 hours (N=5) with a pregame mean of 2.84 (SD 1.16) and a postgame mean of 2.0 (SD 0.94; change=0.84; P =.03). Between December 22, 2011, and May 29, 2014, the game was downloaded 3372 times from the App-Store, with 1526 smokers visiting the online resource www.decide2quit.org linked to the game. CONCLUSIONS: Overall, playing the game resulted in small, but nonsignificant decreases in cravings, with changes greater for those had already quit for more than 48 hours. Lessons learned can inform further development. Future research could incorporate mHealth games in multicomponent cessation interventions. TRIAL REGISTRATION: Clinicaltrials.gov NCT00797628; https://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/6hbJr6LWG).

Evaluating the QUIT-PRIMO clinical practice ePortal to increase smoker engagement with online cessation interventions: a national hybrid type 2 implementation study.

BACKGROUND: Effective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; moreover, despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and finally augmentations of the WATI would result in more smokers quitting at 6 months. METHODS: Practice ePortal Implementation Trial: Practices (n = 174) were randomized to an online practice ePortal with an "e-referral tool" to the WATI (e-referred smokers received automated email reminders from the practice) and with practice feedback reports with patient tracking and practice-to-patient secure messaging versus comparison (a paper "referral prescription"). Implementation success was measured by the number of smokers referred and smokers registering. Clinical Effectiveness Trial: To estimate the effectiveness of the WATI components on 6-month smoking cessation, registered smokers were randomized into three groups: a state-of-the-art tailored WATI control [control], the WATI enhanced with proactive, pushed tailored email motivational messaging (messaging), and the WATI with messaging further enhanced with personal secure messaging with a tobacco treatment specialist and an online support group (personalized). RESULTS: Practice ePortal Trial results: A total of 4789 smokers were referred. The mean smokers referred per practice was not statistically different by group (ePortal 24.89 (SD 22.29) versus comparison 30.15 (SD 25.45), p = 0.15). The e-referral portal implementation program resulted in nearly triple the rate of smoker registration (31 % of all smokers referred registered online) versus comparison (11 %, p < 0.001). Clinical Effectiveness Trial results: Active smokers randomized to the personalized group had a 6-month cessation rate of 25.2 %, compared with the messaging group (26.7 %) and the control (17 %). Next, when using an inverse probability weighted selection model to account for attrition, those randomized to the two groups that received motivational messaging (messaging or personalized) were more likely to quit than those in the control (p = 0.04). CONCLUSIONS: Among all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %). The practice ePortal smokers received multiple reminders (increasing registration opportunities), and the practices could track patient progress. The result was more smokers registering and, thus, more cessation opportunities. Combining the proactive referral and the WATI resulted in higher rates of smoking cessation. TRIAL REGISTRATION: Web-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628 .

Vancomycin Combined With Clindamycin for the Treatment of Acute Bacterial Skin and Skin-Structure Infections.

BACKGROUND: Acute bacterial skin and skin-structure infections (ABSSSIs) are common causes of hospital admissions. These infections are often caused by methicillin-resistant Staphylococcus aureus; therefore, vancomycin remains a commonly used therapy. The purpose of this study was to compare hospital length of stay (LOS) in patients treated with vancomycin monotherapy vs combination therapy with clindamycin for ABSSSIs. METHODS: This was a retrospective analysis of 269 patients admitted with ABSSSIs to a 941-bed hospital in northern Alabama. Patients who received either vancomycin monotherapy or vancomycin in combination with clindamycin were included. The primary outcome was hospital LOS; secondary outcomes included 90-day readmission rate and the impact of the following on the primary outcome: organisms cultured, presence of abscess, incision and debridement (I&D), failure of a trial of outpatient antibiotics, and presence of diabetes. RESULTS: Hospital LOS was similar between groups when evaluating all ABSSSIs (3.7 ± 1.5 days vs 4.0 ± 2.0 days, P = .192, combination and monotherapy, respectively). In patients with abscesses, combination therapy was significantly associated with decreased LOS by 18.2% compared with monotherapy (95% confidence interval [CI], 0.818 [.679 to .985]; P = .034). Among the entire population, significantly fewer patients in the combination group were readmitted within 90 days (5.3% vs 15.3%; P = .006; odds ratio [OR], 3.2; 95% CI [1.35 to 7.66]). The 90-day readmission rates were significantly lower among patients with abscesses as well (2.0% vs 24.3%; P = .0001; OR, 14.6; 95% CI [2.98 to 71.37]). CONCLUSIONS: Combination therapy with vancomycin and clindamycin was associated with decreased hospital LOS for patients with an abscess. The 90-day hospital readmission rates for those with ABSSSIs may be reduced when combination therapy is utilized. A larger, prospective, multicentered study is needed to validate these findings.

Access to care and use of the Internet to search for health information: results from the US National Health Interview Survey.

BACKGROUND: The insurance mandate of the Affordable Care Act has increased the number of people with health coverage in the United States. There is speculation that this increase in the number of insured could make accessing health care services more difficult. Those who are unable to access care in a timely manner may use the Internet to search for information needed to answer their health questions. OBJECTIVE: The aim was to determine whether difficulty accessing health care services for reasons unrelated to insurance coverage is associated with increased use of the Internet to obtain health information. METHODS: Survey data from 32,139 adults in the 2011 National Health Interview Study (NHIS) were used in this study. The exposure for this analysis was reporting difficulty accessing health care services or delaying getting care for a reason unrelated to insurance status. To define this exposure, we examined 8 questions that asked whether different access problems occurred during the previous 12 months. The outcome for this analysis, health information technology (HIT) use, was captured by examining 2 questions that asked survey respondents if they used an online health chat room or searched the Internet to obtain health information in the previous 12 months. Several multinomial logistic regressions estimating the odds of using HIT for each reported access difficulty were conducted to accomplish the study objective. RESULTS: Of a survey population of 32,139 adults, more than 15.90% (n=5109) reported experiencing at least one access to care barrier, whereas 3.63% (1168/32,139) reported using online health chat rooms and 43.55% (13,997/32,139) reported searching the Internet for health information. Adults who reported difficulty accessing health care services for reasons unrelated to their health insurance coverage had greater odds of using the Internet to obtain health information. Those who reported delaying getting care because they could not get an appointment soon enough (OR 2.2, 95% CI 1.9-2.5), were told the doctor would not accept them as a new patient or accept their insurance (OR 2.1, 95% CI 1.7-2.5 and OR 2.1, 95% CI 1.7-2.5, respectively), or because the doctor's office was not open when they could go (OR 2.2, 95% CI 1.9-2.7) had more than twice the odds of using the Internet to obtain health information compared to those who did not report such access difficulties. CONCLUSIONS: People experiencing trouble accessing health care services for reasons unrelated to their insurance status are more likely to report using the Internet to obtain health information. Improving the accuracy and reliability of health information resources that are publicly available online could help those who are searching for information due to trouble accessing health care services.

Identification of Relationships Between Patients Through Elements in a Data Warehouse Using the Familial, Associational, and Incidental Relationship (FAIR) Initiative: A Pilot Study.

BACKGROUND: Over the last several years there has been widespread development of medical data warehouses. Current data warehouses focus on individual cases, but lack the ability to identify family members that could be used for dyadic or familial research. Currently, the patient's family history in the medical record is the only documentation we have to understand the health status and social habits of their family members. Identifying familial linkages in a phenotypic data warehouse can be valuable in cohort identification and in beginning to understand the interactions of diseases among families. OBJECTIVE: The goal of the Familial, Associational, & Incidental Relationships (FAIR) initiative is to identify an index set of patients' relationships through elements in a data warehouse. METHODS: Using a test set of 500 children, we measured the sensitivity and specificity of available linkage algorithm identifiers (eg, insurance identification numbers and phone numbers) and validated this tool/algorithm through a manual chart audit. RESULTS: Of all the children, 52.4% (262/500) were male, and the mean age of the cohort was 8 years old (SD 5). Of the children, 51.6% (258/500) were identified as white in race. The identifiers used for FAIR were available for the majority of patients: insurance number (483/500, 96.6%), phone number (500/500, 100%), and address (497/500, 99.4%). When utilizing the FAIR tool and various combinations of identifiers, sensitivity ranged from 15.5% (62/401) to 83.8% (336/401), and specificity from 72% (71/99) to 100% (99/99). The preferred method was matching patients using insurance or phone number, which had a sensitivity of 72.1% (289/401) and a specificity of 94% (93/99). Using the Informatics for Integrating Biology and the Bedside (i2b2) warehouse infrastructure, we have now developed a Web app that facilitates FAIR for any index population. CONCLUSIONS: FAIR is a valuable research and clinical resource that extends the capabilities of existing data warehouses and lays the groundwork for family-based research. FAIR will expedite studies that would otherwise require registry or manual chart abstraction data sources.

Predicting remission of diabetes after RYGB surgery following intensive management to optimize preoperative glucose control.

BACKGROUND: The purpose of the study is to investigate the association of preoperative glucose optimization prior to a Roux-en-Y gastric bypass (RYGB) and diabetes remission. METHODS: The study is a retrospective review of 245 patients with a history of diabetes type II and a RYGB from 2008 to 2012 at UMass Memorial Hospital. RESULTS: Patients that benefited from glucose optimization prior to RYGB were more likely to achieve diabetes remission 1 year after surgery. The preoperative glucose optimization intervention demonstrated that when patients decreased their HbA1c prior to surgery by 1 %, these individuals were 68 % more likely to remit (p = 0.015). Duration of diabetes (p = 0.005) and insulin use (p < 0.001) were also significant predictors of remission, whereas age, race, and gender were not. CONCLUSIONS: Our study results indicate that a greater degree of glycemic improvement in response to presurgical medical intervention is associated with higher rates of diabetes remission post-operatively among obese adults with diabetes type II. Conversely, the lack of favorable glycemic response to intensification of medical management predicts a poor glycemic response to bariatric surgery. Further research is needed to determine if this difference is due to physiological factors or is simply an indicator of patient behavior.

Association Between Specific Depression Symptoms and Glycemic Control Among Patients With Comorbid Type 2 Diabetes and Provisional Depression.

OBJECTIVE: To determine whether specific depression symptoms are associated with glycemic control independent of potential demographic and clinical covariates among primary care patients with comorbid type 2 diabetes and provisional threshold or subthreshold depression. METHOD: We examined a convenience sample of patients diagnosed with type 2 diabetes and provisional threshold or subthreshold depression (N = 82) at 2 family health centers. Cases were identified using a population-based registry of patients diagnosed with type 2 diabetes (ICD-9 codes 250.00 for controlled type 2 diabetes and 250.02 for uncontrolled type 2 diabetes). Data from patients with a primary care provider appointment from the beginning of April 2011 through the end of June 2012 and with at least one 9-item Patient Health Questionnaire (PHQ-9) depression screener and a glycated hemoglobin A1c (HbA1c) laboratory test between 2 weeks before and 10 weeks after PHQ-9 screening were eligible for inclusion. We defined provisional threshold or subthreshold depression using PHQ-9 scoring criteria, which were designed to yield provisional diagnostic information about major depressive disorder based on DSM-5 diagnostic criteria. RESULTS: Patients reporting higher severity of sleep problems on the PHQ-9 had significantly higher HbA1c levels (mean = 8.48, SD = 2.17) compared to patients reporting lower severity or absence of this symptom (mean = 7.19, SD = 1.34, t 48.88 = -3.13, P = .003). Problems with sleep contributed unique variance on glycemic control (ß = 0.27, P = .02) when controlling for potential clinical and demographic covariates, with those reporting more sleep difficulties having higher HbA1c levels. CONCLUSIONS: For patients with type 2 diabetes and provisional threshold or subthreshold depression, it may be prudent to aggressively address sleep problems as a potential mechanism toward improving diabetes control.

A systematic review of electronic portal usage among patients with diabetes.

The objectives of this review were (1) to examine characteristics associated with enrollment and utilization of portals among patients with diabetes and (2) to identify barriers and facilitators of electronic patient portal enrollment and utilization. PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were systematically searched for papers reporting original research using quantitative or qualitative methods on characteristics, barriers, and facilitators associated with portal enrollment and utilization among patients with diabetes in the United States. The search was limited to articles published between February 1, 2005 (the date of the national symposium on personal health records) and January 1, 2014. Sixteen articles were identified. Of these, nine were quantitative, three were qualitative, and four used mixed-methods. Several demographic characteristics, having better-controlled diabetes, and providers who engaged in and encouraged portal use were associated with increased portal enrollment and utilization. Barriers to portal enrollment included a lack of patient (1) capacity, (2) desire, and (3) awareness of portal/portal functions. Barriers to portal utilization included (1) patient capacity, (2) lack of provider and patient buy-in to portal benefits, and (3) negative patient experiences using portals. Facilitators of portal enrollment and utilization were providers and family members recommending and engaging in portal use. Improved usability, increased access, educating patients how to use and benefit from portals, and greater endorsement by providers and family members might increase portal enrollment and utilization. As more providers and hospitals offer portals, addressing barriers and leveraging facilitators may help patients with diabetes achieve potential benefits.

Exploration of an automated approach for receiving patient feedback after outpatient acute care visits.

BACKGROUND: To improve and learn from patient outcomes, particularly under new care models such as Accountable Care Organizations and Patient-Centered Medical Homes, requires establishing systems for follow-up and feedback. OBJECTIVE: To provide post-visit feedback to physicians on patient outcomes following acute care visits. DESIGN: A three-phase cross-sectional study [live follow-up call three weeks after acute care visits (baseline), one week post-visit live call, and one week post-visit interactive voice response system (IVRS) call] with three patient cohorts was conducted. A family medicine clinic and an HIV clinic participated in all three phases, and a cerebral palsy clinic participated in the first two phases. Patients answered questions about symptom improvement, medication problems, and interactions with the healthcare system. PATIENTS: A total of 616 patients were included: 142 from Phase 1, 352 from Phase 2 and 122 from Phase 3. MAIN MEASURES: Primary outcomes included: problem resolution, provider satisfaction with the system, and comparison of IVRS with live calls made by research staff. KEY RESULTS: During both live follow-up phases, at least 96% of patients who were reached completed the call compared to only 48% for the IVRS phase. At baseline, 98 of 113 (88%) patients reported improvement, as well as 167 of 196 (85%) in the live one-week follow-up. In the one-week IVRS phase, 25 of 39 (64%) reported improvement. In all phases, the majority of patients in both the improved and unimproved groups had not contacted their provider or another provider. While 63% of providers stated they wanted to receive patient feedback, they varied in the extent to which they used the feedback reports. CONCLUSIONS: Many patients who do not improve as expected do not take action to further address unresolved problems. Systematic follow-up/feedback mechanisms can potentially identify and connect such patients to needed care.

Reporting of interventions in randomised trials: an audit of journal instructions to authors.

BACKGROUND: A complete description of the intervention in a published trial report is necessary for readers to be able to use the intervention, yet the completeness of intervention descriptions in trials is very poor. Low awareness of the issue by authors, reviewers, and editors is part of the cause and providing specific instructions about intervention reporting to authors and encouraging full sharing of intervention materials is important. We assessed the extent to which: 1) journals' Instructions to Authors provide instructions about how interventions that have been evaluated in a randomised controlled trial (RCT) should be reported in the paper; and 2) journals offer the option of authors providing online supplementary materials. METHODS: We examined the web-based Instructions to Authors of 106 journals (the six leading general medical journals, 50 randomly selected journals from the National Library of Medicine's Core Clinical Journals, and 50 randomly selected journals from the remainder of the journal collection indexed by PubMed). To be eligible, each journal must have published at least one randomised trial involving human participants each year from 2008 to 2012. We extracted all information related to the reporting of interventions, reporting of randomised trials in general, and online supplementary materials. RESULTS: Of the 106 journals' Instructions to Authors, only 15 (14%) specifically mentioned the reporting of interventions and most of these provided non-specific advice such as 'describe essential features'. Just over half (62, 58%) of the journals mentioned the Consolidated Standards of Reporting Trials (CONSORT) statement in their author instructions. Seventy-eight (74%) of the journals' instructions mentioned the option of providing supplementary content online as part of the paper; however, only four of these journals explicitly encouraged or mandated use of this option for providing intervention information or materials. CONCLUSIONS: Most journals' Instructions to Authors do not provide any specific instructions regarding reporting of interventions or encourage authors to provide online supplementary materials to enhance intervention reporting. Journals can help to improve the problem of incomplete intervention reporting by providing specific instructions to authors and peer reviewers about intervention reporting and requiring full intervention descriptions to be provided.

Federated Aggregate Cohort Estimator (FACE): an easy to deploy, vendor neutral, multi-institutional cohort query architecture.

Cross-institutional data sharing for cohort discovery is critical to enabling future research. While particularly useful in rare diseases, the ability to target enrollment and to determine if an institution has a sufficient number of patients is valuable in all research, particularly in the initiation of projects and collaborations. An optimal technology solution would work with any source database with minimal resource investment for deployment and would meet all necessary security and confidentiality requirements of participating organizations. We describe a platform-neutral reference implementation to meet these requirements: the Federated Aggregate Cohort Estimator (FACE). FACE was developed and implemented through a collaboration of The University of Alabama at Birmingham (UAB), The Ohio State University (OSU), the University of Massachusetts Medical School (UMMS), and the Denver Health and Hospital Authority (DHHA) a clinical affiliate of the Colorado Clinical and Translational Sciences Institute. The reference implementation of FACE federated diverse SQL data sources and an i2b2 instance to estimate combined research subject availability from three institutions. It used easily-deployed virtual machines and addressed privacy and security concerns for data sharing.

Telephone follow-up in primary care: can interactive voice response calls work?

UNLABELLED: Follow-up calls after ambulatory visits are not routinely done, yet they can potentially detect and mitigate unresolved problems. Automated calls via an Interactive Voice Response System (IVRS) are an innovative way to conduct follow-up, but patients' attitudes toward follow-up calls are unknown. This study assessed 1) patient perceptions about follow-up calls after visits; 2) differences in perceptions between human and IVRS calls; and 3) association between follow-up calls and patient satisfaction with care. Post-visit follow-up calls in two ambulatory care setting were done in two phases. Phase 1 used a human caller and phase 2 used IVRS. Patient satisfaction questionnaires were completed after each phase. Results showed that 88% of patients favor the idea of the calls and those receiving them found them helpful. There were no differences in attitudes between patients receiving calls from clinic staff or from an IVRS. Patients receiving calls had higher patient satisfaction scores than those not called. CONCLUSION: Patients value follow-up calls and they are associated with patient satisfaction with care. IVRS is an innovative way to conduct post-visit follow-up.

Closing the feedback loop: an interactive voice response system to provide follow-up and feedback in primary care settings.

In primary care settings, follow-up regarding the outcome of acute outpatient visits is largely absent. We sought to develop an automated interactive voice response system (IVRS) for patient follow-up with feedback to providers capable of interfacing with multiple pre-existing electronic medical records (EMRs). A system was designed to extract data from EMRs, integrate with the IVRS, call patients for follow-up, and provide a feedback report to providers. Challenges during the development process were analyzed and summarized. The components of the technological solution and details of its implementation are reported. Lessons learned include: (1) Modular utilization of system components is often needed to adapt to specific clinic workflow and patient population needs (2) Understanding the local telephony environment greatly impacts development and is critical to success, and (3) Ample time for development of the IVRS questionnaire (mapping all branching paths) and speech recognition tuning (sensitivity, use of barge-in tuning, use of "known voice") is needed. With proper attention to design and development, modular follow-up and feedback systems can be integrated into existing EMR systems providing the benefits of IVRS follow-up to patients and providers across diverse practice settings.

Caregivers' baseline understanding and expectations of antibiotic use for their children.

Although there is evidence that oral antibiotic prescriptions for children have decreased since the 1990s, antibiotic resistance continues to be a problem. This study evaluated the caregivers' understanding of antibiotic use for their children and identified demographic characteristics that may contribute to inappropriate antibiotic-seeking behavior. Caregivers were asked how often the child should receive antibiotics for common medical conditions and about factors to improve patient compliance. This study found that caregivers overexpected antibiotic use with upper respiratory infection, ear infection, and pneumonia. Caretakers with lower incomes and on Medicaid comprised the higher percentage of overusers. The most important factors to improve patient compliance were explanation of the name and indication for antibiotic use. This study showed that demographic variables play a role in caregivers' expectations of antibiotic use. Effective communication of physicians with caregivers on antibiotic use can be an important strategy to improve patient compliance.