The 2016 Academic Emergency Medicine Consensus Conference, "Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda" Diagnostic Testing Breakout Session Report.

Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude "worst-case" diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients to more closely tailor testing to patient risk. This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM, 2) critical elements of and potential barriers to SDM discussions on diagnostic testing, and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus.

Funding Research in Emergency Department Shared Decision Making: A Summary of the 2016 Academic Emergency Medicine Consensus Conference Panel Discussion.

As part of the 2016 Academic Emergency Medicine Consensus Conference, "Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda," a panel of representatives from the Office of Emergency Care Research, the Patient-Centered Outcomes Research Institute, the American Heart Association, the John A. Hartford Foundation, and the Emergency Care Coordination Center were assembled to discuss funding opportunities for future research in this field. This article summarizes their discussion of funding priorities and examples of successfully funded projects related to shared decision making in emergency medicine.

Multilevel correlates of physical activity for early, mid, and late adolescent girls.

BACKGROUND: We examined associations among multilevel variables and girls' physical activity to determine whether they vary at different adolescent ages. METHODS: All field sites of the Trial of Activity for Adolescent Girls contributed participants from 6th (n = 1576) and 8th grades (n = 3085). The Maryland site contributed an 11th grade sample (n = 589). Questionnaires were used to obtain demographic and psychosocial information (individual- and social-level variables); height, weight, and triceps skinfold to assess body composition; interviews and surveys for school-level data; and geographical information systems and self-report for neighborhood-level variables. Moderate to vigorous physical activity minutes (MVPA) were assessed from accelerometers. Mixed models (13 individual, 5 social, 15 school, 12 neighborhood variables) were used to determine multilevel associations. RESULTS: Variables at individual, social, school, and neighborhood levels were associated with MVPA, but differed across grades. Lower percent body fat, higher social support from friends, and lower school math scores were associated with higher MVPA at 6th and 8th grade. Higher physical activity self-efficacy was associated with higher MVPA at 11th grade. Only lower physical activity barriers were associated with higher MVPA at all grades. CONCLUSION: MVPA is a complex behavior with fluid, multilevel correlates that differ among girls across middle and high school.

Adolescent girls' exposure to physical activity-promoting environments.

OBJECTIVES: To examine self-reported exposure to a physical activity (PA) promoting intervention and changes to school environmental PA factors. METHODS: Randomly selected 8(th) grade girls in year 2 (N = 3469) and year 3 (N = 3462) completed surveys on exposure to the health education, PE components, PA programming, and PA supporting messages. Girls' perceptions of their school-environment and an assessment of school environmental factors by principals in support of PA also were measured. Analysis included generalized linear mixed models with random effects for site and school comparing intervention and control schools. RESULTS: Year 2 intervention girls reported greater exposure to all 4 components of the intervention compared to control school girls. In year 3, differences by treatment disappeared in all but 2 components. CONCLUSIONS: Intervention girls were exposed to TAAG in year 2 with effects diminishing in year 3.

Recruiting adolescent girls into a follow-up study: benefits of using a social networking website.

BACKGROUND: Recruitment and retention of adolescent research participants presents unique challenges and considerations when conducting epidemiological studies. PURPOSE: To describe the use of the social networking website in the re-recruitment and tracking of adolescent girls into a follow-up study of the Trial of Activity for Adolescent Girls (TAAG) at the University of Maryland field site. METHODS: 730 girls were recruited as 8th graders into TAAG. Re-recruitment efforts were conducted when they were 11th graders (TAAG 2). Traditional methods, including mailings and school visits, were conducted. A TAAG 2 Facebook site was created to search for girls not found through traditional recruitment methods. Chi-square and t-tests were conducted to identify differences in characteristics between those found and "friended" through Facebook and through traditional recruitment methods. RESULTS: There were 175 girls we were unable to locate using traditional recruitment methods. Of these, 78 were found on Facebook, 68 responded to our friend request, and 43 girls (6% of the girls previously recruited) participated in the study. Demographic data were similar for those who friended us on Facebook and traditional methods. 8th grade body mass index and percent body fat were lower for those recruited from Facebook (p=0.03 and 0.04, respectively). Number of daily minutes of moderate-to-vigorous physical activity tended to be lower among the TAAG 2 Facebook friends (19 ± 11 vs 21 ± 11, p=0.06). CONCLUSIONS: Loss to follow-up was minimized by contacting potential participants through Facebook. Social networking websites are a promising method to recruit adolescents.

Recruiting a diverse group of middle school girls into the trial of activity for adolescent girls.

BACKGROUND: School-based study recruitment efforts are both time consuming and challenging. This paper highlights the recruitment strategies employed by the national, multisite Trial of Activity for Adolescent Girls (TAAG), a study designed to measure the effectiveness of an intervention to reduce the decline of physical activity levels among middle school-aged girls. TAAG provided a unique opportunity to recruit large cohorts of randomly sampled girls within 36 diverse middle schools across the United States. METHODS: Key elements of the formative planning, coordination, and design of TAAG's recruitment efforts included flexibility, tailoring, and the use of incentives. Various barriers, including a natural disaster, political tension, and district regulations, were encountered throughout the recruitment process, but coordinated strategies and frequent communication between the 6 TAAG sites were helpful in tailoring the recruitment process at the 36 intervention and control schools. RESULTS: Progressively refined recruitment strategies and specific attention to the target audience of middle school girls resulted in overall study recruitment rates of 80%, 85%, and 89%, for the baseline, posttest, and follow-up period, respectively. DISCUSSION: The steady increase in recruitment rates over time is attributed to an emphasis on successful strategies and a willingness to modify less successful methods. Open and consistent communication, an increasingly coordinated recruitment strategy, interactive recruitment presentations, and participant incentives resulted in an effective recruitment campaign.

Black, Hispanic, and white girls' perceptions of environmental and social support and enjoyment of physical activity.

BACKGROUND: This study examines the differences among black, Hispanic, and white adolescent girls in their perceptions surrounding physical activity (PA), including support within the school climate, friend and family social support, and personal enjoyment. METHODS: Participants included 1466 sixth-grade girls from 36 middle schools across the United States. Participants were 20% black, 21% Hispanic, 47% white, and 12% of other or mixed races. Multivariate analyses were performed on each scale, adjusting for body mass index and free and reduced-price lunch status. RESULTS: Results showed racial differences on several variables. Black girls, compared with white girls, perceived significantly lower PA enjoyment (p<.001) and teacher support for PA (p=.004). Hispanic girls experienced less PA enjoyment (p=.003) and perceived less support for PA from boys (p=.001) and their families (p=.008) than white girls. Black girls reported significantly higher levels of physical education (PE) enjoyment than did white girls (p=.003). CONCLUSIONS: Differences in perceived PA support and enjoyment across race raise questions about why these differences exist and how best to address disparities within interventions.

Policies and opportunities for physical activity in middle school environments.

BACKGROUND: This study examined physical activity opportunities and barriers at 36 geographically diverse middle schools participating in the Trial of Activity for Adolescent Girls. METHODS: Principals, physical education and health education department heads, and program leaders were interviewed to assess policies and instructional practices that support physical activity. RESULTS: Schools provided approximately 110 hours per year in physical education instruction. Approximately 20% of students walked or bicycled to school. Eighty-three percent of schools offered interscholastic sports and 69% offered intramural sports. Most schools offered programs for girls, but on average, only 24 girls ( approximately 5%) in the schools attended any programs. Only 25% of schools allowed after school free play. An overall score created to assess school environmental support for physical activity indicated that, on average, schools met 6.7 items of 10 items. Free/reduced lunch program participation versus not (p = .04), perceived priority of physical education instruction over coaching (p = .02), and safety for walking/bicycling to school (p = .02) predicted environmental support score. CONCLUSIONS: Schools have policies and practices that support physical activity, although unfavorable practices exist. Schools must work with community partners and officials to provide environments that optimally support physical activity, especially schools that serve low-income students.

Girls' activity levels and lesson contexts in middle school PE: TAAG baseline.

PURPOSE: To assess girls' physical activity (PA) in middle school physical education (PE) as it relates to field site, lesson context and location, teacher gender, and class composition. METHODS: We observed girls' PA levels, lesson contexts, and activity promotion by teachers in 431 lessons in 36 schools from six field sites participating in the Trial of Activity for Adolescent Girls. Interobserver reliabilities exceeded 90% for all three categories. Data were analyzed using mixed-model ANOVA with controls for clustering effects by field site and school. RESULTS: Mean lesson length was 37.3 (+/-9.4) min. Time (13.9+/-7.0 min) and proportion of lessons (37.9+/-18.5%) spent in moderate to vigorous PA (MVPA), and time (4.8+/-4.2 min) and proportion of lessons (13.1+/-11.7%) in vigorous PA (VPA) differed by field site (P<0.004). Lesson time for instructional contexts differed by field site, with overall proportions as follows: game play (27.3%), management (26.1%), fitness activities (19.7%), skill drills (12.1%), knowledge (10.6%), and free play (4.4%). Coed classes were 7.9 min longer than girls-only classes (P=0.03). Although 27 s shorter, outdoor lessons were more intense (MVPA%=45.7 vs 33.7% of lesson, P<0.001) and provided 4.0 more MVPA minutes (P<0.001). MVPA, VPA, and lesson contexts did not differ by teacher gender. There was little direct promotion of PA by teachers during lessons. CONCLUSIONS: Substantial variation in the conduct of PE exists. Proportion of lesson time girls spent accruing MVPA (i.e., 37.9%) fell short of the Healthy People 2010 objective of 50%. Numerous possibilities exist for improving girls' PA in PE.

Formative research in school and community-based health programs and studies: "state of the art" and the TAAG approach.

Formative research uses qualitative and quantitative methods to provide information for researchers to plan intervention programs. Gaps in the formative research literature include how to define goals, implementation plans, and research questions; select methods; analyze data; and develop interventions. The National Heart, Lung, and Blood Institute funded the Trial of Activity for Adolescent Girls (TAAG), a randomized, multicenter field trial, to reduce the decline in physical activity in adolescent girls. The goals of the TAAG formative research are to (a) describe study communities and schools, (b) help design the trial's interventions, (c) develop effective recruitment and retention strategies, and (d) design evaluation instruments. To meet these goals, a variety of methods, including telephone interviews, surveys and checklists, semistructured interviews, and focus group discussions, are employed. The purpose, method of development, and analyses are explained for each method.

Physical activity attitudes, preferences, and practices in African American, Hispanic, and Caucasian girls.

Physical activity levels in girls decline dramatically during adolescence, most profoundly among minorities. To explore ethnic and racial variation in attitudes toward physical activity, semistructured interviews (n = 80) and physical activity checklists (n = 130) are conducted with African American, Hispanic, and Caucasian middle school girls in six locations across the United States. Girls from all groups have similar perceptions of the benefits of physical activity, with staying in shape as the most important. Girls have similar negative perceptions of physical activity, including getting hurt, sweating, aggressive players, and embarrassment. Chores, running or jogging, exercises, and dance are common activities for girls regardless of ethnicity. Basketball, swimming, running, and dance are commonly cited favorite activities, although there are slight differences between ethnic groups. The results suggest that factors other than ethnicity contribute to girls' physical activity preferences and that distinct interventions may not be needed for each ethnic group.