Resilience among racially diverse adolescent patients with chronic orthopedic conditions.

The theoretical literature on resilience shows there is no consensus regarding whether resilience is an ability; interactive process involving the individual, group, and community; both ability and process; or favorable outcome. A definitive part of the research on children's resilience featured the assessment of an indicator of resilience (e.g., health-related quality of life) and involved pediatric patients with prolonged illnesses. The present study examined resilience directly as an ability and process, and related protective or risk variables, with validated instruments among adolescent patients with chronic orthopedic conditions. One-hundred fifteen adolescent patients assented (parents/legally authorized representatives consented), with 73 completing the study questionnaire. Fifteen, 47, and 10 scored low, normal, or high, respectively, on resilience-ability (one with missing data). These three groups differed significantly on the number of years living with family, individual personal skills, self-esteem, negative affect, anxiety, and depression. Resilience-ability positively correlated with number of years living with family, individual personal skills, and self-esteem, but negatively with duration of chronic orthopedic condition, negative affect, anxiety, and depression. Duration of chronic orthopedic condition negatively correlated with individual peer support among those scoring high on resilience-ability. For girls, duration of chronic orthopedic condition negatively correlated with resilience-ability, educational context, and self-esteem, but positively correlated with caregiver physical and psychological caregiving for boys. Findings underscored the consequence of resilience for these adolescent patients, with their chronic orthopedic conditions affecting daily function and life quality. Implementation of best practices to nurture and enhance their health-related resilience will promote a lifetime of well-being.

Econometric evaluation of implementing a behavioral health integration intervention in primary care settings.

Integrated behavioral health (IBH) is an approach to patient care that brings medical and behavioral health providers (BHPs) together to address both behavioral and medical needs within primary care settings. A large, pragmatic, national study aimed to test the effectiveness and measure the implementation costs of an intervention to improve IBH integration within primary care practices (IBH-PC). Assess the time and cost to practices of implementing a comprehensive practice-level intervention designed from the perspective of clinic owners to move behavioral service integration from co-location toward full integration as part of the IBH-PC study. IBH-PC program implementation costs were estimated in a representative sample of 8 practices using standard micro-econometric evaluation of activities outlined in the implementation workbook, including program implementation tasks, remote quality improvement coaching services, educational curricula, and learning community activities, over a 24-month period. The total median cost of implementing the IBH-PC program across all stages was $20,726 (range: $12,381 - $60,427). The median cost of the Planning Stage was $10,258 (range: $4,625 - $14,840), while the median cost of the Implementation Stage was $9,208 (range: $6,017 - 49,993). There were no statistically significant differences in practice or patient characteristics between the 8 selected practices and the larger IBH-PC practice sample (N=34). This study aimed to quantify the relative costs associated with integrating behavioral health into primary care. Although the cost assessment approach did not include all costs (fixed, variable, operational, and opportunity costs), the study aimed to develop a replicable and pragmatic measurement process with flexibility to adapt to emerging developments in each practice environment, providing a reasonable ballpark estimate of costs associated with implementation to help guide future executive decisions.

This study estimated the cost of implementing a program that helped 8 primary care practices transition from a co-located behavioral health services model to greater integration. Our study was part of a larger study across the United States. The authors found that the per-practice program implementation cost ranged between $12,381 and $60,427 and the median cost was $20,726. Leaders of healthcare organizations that participated in this study thought that these costs represented the work of program implementation and that they were reasonable and acceptable.

A Culture-Based Family-Centered Health Navigation Intervention for Chronic Disease Management in Native Hawaiians.

Greater medical and psychological concerns coupled with disparities in income and education and experiences with cultural distress have created an unprecedented demand for health and mental health services for Native Hawaiians. With 75% of the healthcare system moving to a value-based system within the next 2 years, a low-cost workforce that brings added value will be in high demand. The addition of community health navigators to an existing integrated patient-centered medical home may result in a culturally congruent, preventive, and responsive model of wellness that promotes health equity. The purpose of this paper is to discuss the culturally-based navigation framework we used to implement a pilot program in an integrated primary care setting, describe the intervention that was used, and examine the lessons learned throughout the process. Outcomes will be provided at a later date. We believe that our model will not only redesign an existing clinical practice but also will provide a reproducible model that can be translated into other settings to increase the health care utilization among Native Hawaiians and lead to improved outcomes.

The Epidemiology of Slipped Capital Femoral Epiphysis in American Samoa.

The Maori of New Zealand have been identified as a high-risk population for slipped capital femoral epiphysis (SCFE). This study assessed whether the burden of disease from SCFE in the American Territory of American Samoa is similar to that identified in the Maori. This was a retrospective review of children from American Samoa treated for SCFE at a tertiary care pediatric hospital between 2005-2014. Demographic, clinical, and radiographic information was collected. All patients were followed for at least one year after surgery and prophylactically pinned hips were not included. Data for determining incidence was obtained from the United States Census Bureau. Between 2005-2014, 55 American Samoan youth were treated for 73 SCFE. The incidence in the "at-risk" population 5-14 years of age was 53.1 per 100,000. Patients had a mean BMI of 29.5 (19.4-46.4) and mean weight of 76.7 kg (45.9-139 kg). Southwick angle was a mean 40.6°+/- 20.4° (6-83°). Overall, 82.2% of hips were treated with in-situ cannulated screw fixation. At a minimum one-year after initial surgery, 22 hips (30.1%) required major surgery including intertrochanteric osteotomy, osteochondroplasty, or total hip replacement. The incidence of SCFE in American Samoa is extremely high, 53.1 per 100,000 of "at-risk" population 5-14 years old. The mean weight and BMI in SCFE patients from American Samoa is substantially higher than previously published reports. Furthermore, morbidity from SCFE in this population is substantial with 30.1% requiring major surgery either at the time of physeal stabilization or in subsequent years.

Comparing Weight Loss-Maintenance Outcomes of a Worksite-Based Lifestyle Program Delivered via DVD and Face-to-Face: A Randomized Trial.

BACKGROUND: Native Hawaiians and other Pacific Islanders have high rates of overweight and obesity compared with other ethnic groups in Hawai'i. Effective weight loss and weight loss-maintenance programs are needed to address obesity and obesity-related health inequities for this group. AIMS: Compare the effectiveness of a 9-month, worksite-based, weight loss-maintenance intervention delivered via DVD versus face-to-face in continued weight reduction and weight loss maintenance beyond the initial weight loss phase. METHOD: We tested DVD versus face-to-face delivery of the PILI@Work Program's 9-month, weight loss-maintenance phase in Native Hawaiian-serving organizations. After completing the 3-month weight loss phase, participants ( n = 217) were randomized to receive the weight loss-maintenance phase delivered via trained peer facilitators or DVDs. Participant assessments at randomization and postintervention included weight, height, blood pressure, physical functioning, exercise frequency, and fat intake. RESULTS: Eighty-three face-to-face participants were retained at 12 months (74.1%) compared with 73 DVD participants (69.5%). There was no significant difference between groups in weight loss or weight loss maintenance. The number of lessons attended in Phase 1 of the intervention (ß = 0.358, p = .022) and baseline systolic blood pressure (ß = -0.038, p = .048) predicted percent weight loss at 12 months. DISCUSSION AND CONCLUSION: Weight loss maintenance was similar across groups. This suggests that low-cost delivery methods for worksite-based interventions targeting at-risk populations can help address obesity and obesity-related disparities. Additionally, attendance during the weight loss phase and lower baseline systolic blood pressure predicted greater percent weight loss during the weight loss-maintenance phase, suggesting that early engagement and initial physical functioning improve long-term weight loss outcomes.

The PILI@Work Program: a translation of the diabetes prevention program to Native Hawaiian-serving worksites in Hawai'i.

A previously translated Diabetes Prevention Program Lifestyle Intervention (DPP-LI) was adapted for delivery as a worksite-based intervention, called PILI@Work, to address obesity disparities in Native Hawaiians/Pacific Islanders. This study examined the effectiveness of PILI@Work and factors associated with weight loss at post-intervention. Overweight/obese employees of 15 Native Hawaiian-serving organizations received the 3-month component of PILI@Work. Assessments included weight, systolic/diastolic blood pressure, physical activity and functioning, fat intake, locus of weight control, social support, and self-efficacy. Weight, systolic/diastolic blood pressure, physical functioning, physical activity frequency, fat intake, family support, and eating self-efficacy improved from pre- to post-intervention. Regression analysis indicated that worksite type, decreased diastolic blood pressure, increased physical activity, and more internalized locus of weight control were significantly associated with 3-month weight loss. PILI@Work initiated weight loss in Native Hawaiians/Pacific Islanders. DPP-LI translated to worksite settings and tailored for specific populations can be effective for addressing obesity.

Role of Diffusion Tensor Imaging in Prognostication and Treatment Monitoring in Niemann-Pick Disease Type C1.

Niemann-Pick Disease, type C1 (NPC1) is a rapidly progressive neurodegenerative disorder characterized by cholesterol sequestration within late endosomes and lysosomes, for which no reliable imaging marker exists for prognostication and management. Cerebellar volume deficits are found to correlate with disease severity and diffusion tensor imaging (DTI) of the corpus callosum and brainstem, which has shown that microstructural disorganization is associated with NPC1 severity. This study investigates the utility of cerebellar DTI in clinical severity assessment. We hypothesize that cerebellar volume, fractional anisotropy (FA) and mean diffusivity (MD) negatively correlate with NIH NPC neurological severity score (NNSS) and motor severity subscores. Magnetic resonance imaging (MRI) was obtained for thirty-nine NPC1 subjects, ages 1-21.9 years (mean = 11.1, SD = 6.1). Using an atlas-based automated approach, the cerebellum of each patient was measured for FA, MD and volume. Additionally, each patient was given an NNSS. Decreased cerebellar FA and volume, and elevated MD correlate with higher NNSS. The cognition subscore and motor subscores for eye movement, ambulation, speech, swallowing, and fine motor skills were also statistically significant. Microstructural disorganization negatively correlated with motor severity in subjects. Additionally, Miglustat therapy correlated with lower severity scores across ranges of FA, MD and volume in all regions except the inferior peduncle, where a paradoxical effect was observed at high FA values. These findings suggest that DTI is a promising prognostication tool.

Home-based preventative care in high-risk dialysis patients: a pilot study.

OBJECTIVE: Most dialysis patients have multiple comorbidities with complex healthcare needs and consume a disproportionate share of medical resources. We conducted a pilot study employing telehealth technology to determine whether home-based preventative care can improve healthcare outcomes, impact quality of life (QOL), and be cost effective by proactively managing underlying chronic conditions that place the patient at risk. MATERIALS AND METHODS: Forty-four patients (19 in the remote technology group [RT] and 25 in the usual care group [UC]) participated in this study. The mean age was 57 for those in the RT group (7 females and 12 males) and 62 for those receiving UC (11 females and 14 males). Health outcome measurements included hospitalizations, emergency room visits, and the number of days hospitalized. Economic analysis included total hospital and emergency room charges. QOL was measured using the medical outcomes survey instrument 36-Item Short Form Health Survey (SF-36). RESULTS: Hospitalizations (RT 0.0018 and UC 0.0056 per study day), hospital days (RT 0.008 and UC 0.036 per study day), emergency room visits (RT 0.0003 and UC 0.0019 per study day), and associated charges (RT $114 and UC $322 per study day) were significantly less in the RT group of the study compared with patients receiving UC. The perceived QOL remained the same in the UC group from outset to midpoint of the study (59.1, 59.5), whereas it decreased slightly in the RT group (63.9, 60.76). CONCLUSIONS: The results suggest that remote telehealth technology can play an important role in improving health outcomes and the cost of care of patients with end-stage renal disease who have complex healthcare needs.

Billing effectively with the new health and behavior current procedural terminology codes in primary care and specialty clinics.

The health and behavior current procedural terminology (CPT) codes introduced in 2003 have gained nationwide acceptance through Medicare and limited acceptance through third party payers. The codes facilitate accurate description and quantification of behavioral medicine services within a primary care or specialty clinic setting. The author reviews their appropriate utilization to enhance reimbursement and facilitate development of self-sustaining behavioral medicine programs. Information is provided on increased use and reimbursement of codes within psychology. Future directions for continued advocacy, increased acceptance, training, and research are discussed.

The National Center on Indigenous Hawaiian Behavioral Health study of prevalence of psychiatric disorders in native Hawaiian adolescents.

OBJECTIVES: The prevalence rates of disorders among a community-based sample of Hawaiian youths were determined and compared to previously published epidemiological studies. METHOD: Using a two-phase design, 7,317 adolescents were surveyed (60% participation rate), from which 619 were selected in a modified random sample during the 1992-1993 to 1995-1996 school years: 590 selected randomly and 29 at risk (i.e., Center for Epidemiologic Studies-Depression score of >or=35 and suicidal risk) from grades 9-12. The Diagnostic Interview Schedule for Children-Version 2.3, was used to determine DSM-III-R diagnoses. Prevalence rates, weighted for ethnicity, Center for Epidemiologic Studies-Depression scores, and suicide attempts, were calculated for any diagnosis and various disorders. Meta-analyses compared the Hawai'i sample to four community-based studies (randomly selected youths from community populations) and two high-risk studies (homeless, low-income, or high unemployment communities). RESULTS: Hawaiian females had the highest rate for any diagnosis (37.7%; 95% confidence interval [CI] 28.4%-48.0%) and non-Hawaiian males had the lowest rate (19.6%; 95% CI 14.8%-25.5%). Hawaiian males (26.8%; 95% CI 18.2%-37.5%) and non-Hawaiian females (27.9%; 95% CI 22.2%-34.4%) had intermediate and comparable rates. Overall, Hawaiians had significantly higher rates (32.7%; 95% CI 26.1%-40.1%) than non-Hawaiians (23.7%; 95% CI 19.9%-28.0%) when controlling for gender, and girls had significantly higher rates (30.8%; 95% CI 25.8%-36.3%) than boys (21.1%; 95% CI 16.8%-26.1%) when controlling for ethnicity. These findings were primarily the result of the significant differences in rates regarding anxiety disorders. Meta-analyses showed the Hawaiian youth rate for any diagnosis was comparable to high-risk studies and nearly three times higher than the community studies. CONCLUSIONS: Hawaiian youths, especially females, are at high risk. Research on the sociocultural factors that underpin both the genesis of and protection from psychopathology is imperative for Hawaiian and non-Hawaiian mixed-ethnicity youths.

Resilience, family adversity and well-being among Hawaiian and non-Hawaiian adolescents.

BACKGROUND: Minorities and indigenous peoples are likely to have poor mental health and physical outcomes. This study examines resiliency indicators in Hawaiian adolescents. AIMS: Multiple resiliency indicators were examined across different domains including individual, family and community in relation to increased psychological well-being. METHODS: Existing data from the Native Hawaiian Mental Health Research Development Program (NHMHRDP) were used. These data included information from a community sample of five high schools on three islands from the state of Hawai'i. The sample included 1,832 students, where 64% were Native Hawaiian and 36% were non-Hawaiian. RESULTS: This study found that Native Hawaiian youth experienced more family adversity compared with non-Hawaiians, but Native Hawaiians were also more likely to have higher levels of family support. For internalizing symptomatology, the most robust resiliency factors were family support and physical fitness/ health for Native Hawaiian and non-Hawaiian adolescents. For externalizing symptomatology, achievement and family support were consistently strong resiliency factors. The indicator for physical fitness and health was more influential among Native Hawaiians than non-Hawaiians for externalizing symptoms, while academic achievement was more influential among non-Hawaiians than for Native Hawaiians for the protection against internalizing symptoms. CONCLUSIONS: Our findings support the need for intervention programs designed to promote resilience in adolescents, including highlighting the importance of the family. Further research is needed to design and evaluate programs that promote well-being, enhance resilience and improve mental health in culturally appropriate ways.

A conceptual model of cultural predictors of anxiety among Japanese American and part-Japanese American adolescents.

A model integrating Japanese ethnicity, cultural identity, and anxiety was developed and assessed in Japanese American and part-Japanese American high school seniors (N = 141). Using measures from the Hawaiian High Schools Health Survey, the model incorporated the State-Trait Anxiety Inventory, the Major Life Events Scale, and the Japanese Culture Scale (JCS). Japanese American adolescents scored higher on the JCS and reported fewer anxiety symptoms than part-Japanese American adolescents. Predictors for anxiety were being Japanese American versus part-Japanese American, income, and culturally intensified events. A significant interaction of behavior by self-identification was obtained. The model had good overall fit, suggesting that cultural identity formation may contribute to anxiety experienced particularly by adolescents of mixed heritage.