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Figure 7.1: Number of Pregnancies(%) as Reported by Jamaican Females 15-74 Years, crack/cocaine and an increase in marijuana use (22). 2.0 1.8 1.9. “MY CLIENTS FALL THROUGH EVERY CRACK IN THE SYSTEM”: ASSESSING THE METHODS: HCNI members identified key topics for the interview and. There was a decrease in the quantity of seizures for a number of drugs including. herbal cannabis, cannabis resin, cocaine, crack and heroin. InterNetView crack serial keygen

Component Management™ (TCM™) solution, the company’s VMI service is central to its belief that OEMs can gain substantial benefits by outsourcing procurement, supply chain management and logistics to a specialist company. InterNetView crack serial keygen their VMI service, Paragon establishes line side stores at customer premises, enabling instant access to high volumes of parts, onsite. InterNetView crack serial keygen as ‘consigned stock’, these parts are only invoiced for when used, InterNetView crack serial keygen, reducing customer risk and streamlining supply. Not only does VMI significantly improve cash flow and improve stock

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New Products

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Shine™ glass and surface cleaner and EcoShower™ cleaner and degreaser. Both are effective, safe and eco-friendly, and feature the following advantages: Non-flammable; biodegradable; low VOC, zero GWP; non-ozone depleting. The benefits of the Renew product line include low ecological impact, low VOCs and no global warming, sustainable and biodegradable, InterNetView crack serial keygen, recycled/ recyclable packaging and regulatory compliance—they fully meet European REACH and WEEE requirements. Verigy announces mixed-signal testing capability for V101 platform

Intertronics unveils “GREEN” Techspray Renew™ cleaners

Intertronics announced a new range of environmentally friendly Techspray Renew products. Two innovative products are designed specifically for a range of industrial applications from engineering to electronics and laboratories to offices: Eco-

44 – Global SMT & Packaging – Celebrating 10 Years – July 2010

Verigy has enhanced its V101 platform by adding new capability for testing mixedsignal semiconductor devices. The versatile V101 platform, designed for high-volume testing of cost-sensitive ICs at both the wafer sort and final test production steps, now delivers mixed-signal capability designed for testing devices with audio and video signals. The V101’s mixedsignal capability is enabled by a plugand-play module that can be quickly and easily installed into the V101 for testing mixed-signal ICs used in applications such as automotive, communications, data processing, and audio and video consumer electronics. The zero-footprint V101 platform can cost-effectively test microcontrollers and other low-pin-count, low-cost ICs in the high-mix manufacturing environments where these devices are typically produced. Absolute Turnkey introduces Absolute Advantage program to the OEM and EMS marketplace Absolute Turnkey announces the Absolute Advantage program for OEMs and the EMS marketplace. The Absolute Advantage program was developed to provide customers with the ultimate in flexibility, while getting their products

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Low outgassing properties are essential for aerospace applications, particularly in vacuum environments where volatiles from other adhesives often condense on optics and electronics, adversely affecting their function, InterNetView crack serial keygen. With a typical total mass loss of 0.35% and typical collected volatile condensable materials of 0.03% (tested per ASTM-E-595-93), these low-outgassing epoxies meet NASA requirements for most spacecraft materials. Guide to Understanding Electrical Test and Measurement

Keithley Instruments, InterNetView crack serial keygen, Inc. released a tutorial CD that offers practical and helpful techniques for obtaining the most accurate and precise measurements

possible. Keithley’s “A Guide to Understanding Electrical Test and Measurement” CD is the most in-depth knowledge center that Keithley has ever created, and covers all aspects of measurement performance, including how to troubleshoot, how to connect, how to select instruments and much more. The CD contains a large number of application notes, white papers and webcasts on a wide variety of test and measurement topics. To receive your free copy of Keithley’s A Guide to Understanding Electrical Test and Measurement CD, visit For beautiful marking results—fast TRUMPF introduces two new marking lasers—the TruMark 6030 and TruMark 6140—to its TruMark Series 6000. Users can now choose from six high performance machines that are available in any wavelength needed for surface processing. The TruMark 6030 and 6140 lasers feature considerably InterNetView crack serial keygen marking times when compared to other products in the TruMark Series 6000. TRUMPF has increased the output of these new marking lasers by about 35 percent.

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 45

Case Study: High qualityA manufacturing need not mean highgrid production costs history of the development of ball array (BGA) and column grid array (CGA) components

Werner Engelmaier “BGAs and CGAs came about, because the solder attachments of leadless ceramic chip carriers (LLCCCs) on FR-4 PCBs could not meet reliability requirements.”

A history of the development of ball grid array (BGA) and column grid array (CGA) components While purely technical treatments of reliability issues are important, it also is important to understand why some of the developments impacting our industry came about. The development of ball grid array (BGA) components as well as column grid array (CGA) components is such a case.

BGAs and CGAs came about because the solder attachments of leadless ceramic chip carriers (LLCCCs) on FR-4 PCBs could not meet reliability requirements. The first large surface Drastic DS Emulator r2.5.0.4a apk Archives (SMT) component was the leadless ceramic chip carrier (LLCCC), with solder joints

Figure 1. Fatigued solder joints of leadless ceramic chip carrier on FR-4 (Courtesy of Dave Hillman, Rockwell Collins, USA).

Figure 2. Fatigued ‘ bulbous’ solder joints of leadless ceramic chip carrier on FR-4 (Courtesy of Gail Love, Martin-Marietta, Florida USA).

46 – Global SMT & Packaging – Celebrating 10 Years – July 2010

formed by bottom soldering pads and soldering areas in ‘castellations’ along the sides. These castellations were the result of the postage-stamp-like perforations of the ceramic in its green stage prior to separation by breaking. As all components in that time frame, it was made of ceramic to be soldered to hybrid substrates, also made of ceramic. That, of course, did not last, and LLCCCs were placed on FR-4 PCBs as well, with the in hindsight fully understandable problem with inadequate solder joint reliability1 as can be seen in Figure 1. Lots of effort went into trying to improve the solder joint reliability of this combination2, see Figure 2. However, for leadless solder joints, there are only four primary parameters determining solder joint reliability: 1. component size, DNP (distance from neutral point) 2. the mismatch in coefficients of thermal expansion, ∆CTE; 3. the cyclic thermal excursion, ∆T; and 4. the solder joint height, h. For ceramic components on FR-4, the ∆CTE is essentially fixed; the component size determining the DNP is a function of functionality, as is ∆T—that leaves only h. Everything else being equal, the cycles-tofailure increase roughly with the power-oftwo of the solder joint height, InterNetView crack serial keygen, h. Thus, at Bell Laboratories, both solder balls and solder columns were utilized to increase h; mind you those initial components had only peripheral rows of

A history of the development of ball grid array (BGA) and column grid array (CGA) components

Figure 4. Fatigued solder columns from a ceramic CGA on FR-4 (Source: Werner Engelmaier, Bell Laboratories, USA).

Forgotten Lessons,” Global SMT & Packaging, Vol. 3, InterNetView crack serial keygen, No. 2, March 2003, pp. 42-43. Hall, P. M., “Forces, Moments, and Displacements During Thermal Chamber Cycling of Leadless Ceramic Chip Carriers Soldered to Printed Boards,” IEEE Trans. Components, Hybrids, and Manufacturing Technology, Vol. CHMT-7, No. 4, December 1984, p. 314. Fisher, J. R., “Cast Solder Leads for Leadless Semiconductor Circuits,” U.S. Patent 4,412,642, November 1, 1983, InterNetView crack serial keygen. Fisher, J. R., “Cast Leads for Surface Attachment,” Proc. 44th Electronic Components Conf., InterNetView crack serial keygen, New Orleans, LA, May 1984, pp. 487-497; also in IEEE Trans. Components, Hybrids, and Manufacturing Technology, Vol. CHMT-7, No. 4, December 1984, pp. 306-313 InterNetView crack serial keygen, F., and M. A. Oien, “A New Soldering Technology for SurfaceMounting Pad Grid Arrays,” Proc. Int. Electronics Packaging Conf. (IEPS), November 1988. Engelmaier, W., “BGA and CGA Solder Attachments: Results of Low-Acceleration Test and Analysis,” Proc. Surface Mount International Conf., San Jose, CA, August 1995, pp. 344-358; also in Proc. Int. Electronics Packaging Conf. (IEPS), San Diego, September 1995, pp. 758-774; also in Proc. NEPCON West ‘96, Anaheim, CA, February 1996, pp. 385-395. Engelmaier, W., InterNetView crack serial keygen, “Achieving Solder Joint Reliability in a Lead-Free World, Part 2,” Global SMT & Packaging, Vol. 7, No. 7, July 2007 [EU-edition], pp. 48-50; No. 8, InterNetView crack serial keygen, August 2007 [USedition], pp. 44-46.

Figure 3. Fatigued solder ball from a ceramic BGA on FR-4 (Source: Werner Engelmaier, Bell Laboratories, USA).

soldering pads since they were LLCCCs3-6. Only somewhat later a second row was added. We certainly did not call them the ‘array-anything’ initially, because at that stage they were not arrays. The results of exhausting reliability testing were published rather late because of misplaced management competitive concerns7. Figures 3 and 4 show the first fatigued InterNetView crack serial keygen balls and solder columns. Because of the origin as LLCCCs, the initial soldering pads, both on the components and the PCBs, were not circular, but rectangular or square. Circular pads were only introduced because of the solder columns. Results from accelerated tests show that the solder joint geometries produced by rectangular soldering pads result in slightly higher fatigue lives than those from circular pads7. The insights gained led to the commercialization of BGAs and CGAs; it also led to the development of highmelting 90Pb10Sn solder balls which would not melt and collapse during reflow soldering, thus maintaining the ball diameter as the solder joint height, h. With the soldering temperatures for the Pb-free solders, this technology is no longer available, however, and an alternate technology8 works at least as well. References: 1. Engelmaier, W., “Effects of Power Cycling on Leadless Chip Carrier Mounting Reliability and Technology,” Proc. Int. Electronics Packaging Conf. (IEPS), San Diego, InterNetView crack serial keygen, CA, November 1982, p. 15. 2. Engelmaier, W., “Of Ceramic Components: Failed Solder Joints, LLCCCs, ‘Bulbous’ Solder Joints, ‘Super-Compliant’ Leads, and







Werner Engelmaier will be giving some of his reliability workshops at Conferences in Tallinn, InterNetView crack serial keygen, Estonia, September 21-23, 2010 and GEM Expo Brazil 2010 in Sao Paolo, Brazil, October 5-7, 2010. He will be available for in-house workshops and consulting in both English and German in Europe in the June timeframe; for details of the workshops go to www.engelmaier. com; for more information about the workshops and consulting contact Werner Engelmaier has over 44 years experience in electronic packaging and interconnection technology and has published over 200 papers, columns, book chapters and White Papers. Known as ‘Mr. Reliability’ in the industry, he is the president of Engelmaier Associates, InterNetView crack serial keygen, L.C., a firm providing consulting services on reliability, manufacturing and processing aspects of electronic packaging and interconnection technology. He is the chairman of the IPC Main Committee on Product Reliability. The TGM-Exner Medal was bestowed on him in 2009 in Vienna, Austria, he was elected into the IPC Hall of Fame 2003, and was awarded the IPC President’s Award in 1996 and the IEPS Electronic Packaging Achievement Award in 1987. He also was named a Bell Telephone Laboratories Distinguished Member of Technical Staff in 1986 and an IMAPS Fellow in 1996. More information is available at www.engelmaier. com, MyLanViewer 4.25.0 Enterprise Crack With Serial Code Free Download 2021 he can be reached at engelmaier@

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 47

Case Study:&High qualitynews manufacturing need not mean high production costs Association institutes

Association & institutes news SMART Group announce 26th Birthday Conference Following our successful two-day conference last year that celebrated 25 years of the SMART Group’s InterNetView crack serial keygen, SMART Group proudly announces that after a busy year of events, they will celebrate their 26th anniversary with an equally exciting twoday event. The aim and thrust of this year’s InterNetView crack serial keygen is to address many of the issues facing our industry today, InterNetView crack serial keygen. Despite some of the pessimism, the electronics industry here has much still to offer our global customers. InterNetView crack serial keygen an example, SMART Group’s vice InterNetView crack serial keygen, Graham Naisbitt, quoted a recent statement issued by the Chinese government that they were concerned that their industry has a poor reputation for quality and reliability. “They sponsored a delegation to come to the UK, through ITRI, International Tin Research Institute in St Albans,” Naisbitt said, “where a number of persons would make presentations to them on this topic. In particular I was thankful that they consider the UK is still the centre to develop products that have high quality and high reliability. “Shame only that we no longer seemingly have the capacity to produce in large quantities, perhaps that will change.” This year’s conference will look at the supply chain, inform about the latest research projects and explore whether manufacturing standards make things better. Other topics cover production control, the importance of chemistry, what’s happening with RoHS and REACH, why do we clean when we have no clean and what are tin whiskers—all will be explained. The sessions will also cover component tinning and re-tinning good practice, silver vs sulphur—can conformal coating help? We are lining up an eminent worldclass team for this event to be held on 6th & 7th of October. The venue is again The Oxfordshire GC Business Centre.

The full programme of presentations will be announced shortly with a list of exhibitors. For more information contact: Tony Gordon, SMART Group Secretary, Tel: +44 (0)1494 465217 Email: info@ or Mike Judd, SMART Group PR Director, Tel: +44 (0)118 978 4589 Email:

European Parliament Environment Committee vote puts TBBPA on priority assessment list IPC—Association Connecting Electronics Industries® expressed disappointment in the vote by the European Parliament’s Environment Committee to include broad families of chemicals, InterNetView crack serial keygen, such as organobromines, in Annex III for priority assessment. While an outright ban of these chemicals has been averted in this vote, the committee’s decision falls far short of supporting a rigorous scientific assessment that would ensure protection of the environment and human health. IPC is concerned that the process outlined in the amendments InterNetView crack serial keygen today does not define a rigorous scientific methodology. The proposed process “lacks a rigorous scientific methodology and could therefore lead to additional substance restrictions that provide neither environmental nor human health benefits,” says Fern Abrams, IPC director of environmental policy and government relations. The inclusion of broad families of chemicals, such as all organobromines, for priority assessment under Annex III is impractical and unscientific. While some organobromines, such as polybrominated biphenyls (PBBs), have been identified as toxic, restricted under the RoHS Directive and voluntarily withdrawn from the market, other organobromines, InterNetView crack serial keygen, such as TBBPA, have been found to be safe for human health and InterNetView crack serial keygen environment by both the World Health Organization and the European Commission Scientific Committee on Health and Environmental Risks (SCHER).

48 – Global SMT & Packaging – Celebrating 10 Years – July 2010

In direct lobbying efforts over the past year, IPC has urged the European Union to amend the RoHS Directive to introduce rigorous scientific methodology aligned with the comprehensive chemicals evaluations under the REACH (Registration, Evaluation, Authorisation and Restriction of Chemicals) regulation. IPC continues to InterNetView crack serial keygen to ensure the RoHS revision’s process reflects sound scientific methodology. IPC’s white paper, “Recasting the RoHS Directive: An Opportunity to Solidify its Scientific Basis in Support of Comprehensive Environmental Regulation,” advocates for a revised RoHS to be based on sound science and fully aligned with the REACH methodology for substance restrictions. The European Parliament is currently scheduled to vote in July on the Environment Committee’s recommendations for recasting the RoHS Directive. The Environment Committee is also scheduled to vote on the related Waste Electrical and Electronic Equipment (WEEE) Directive later this month, with a plenary vote to take place in July. IPC-2152-DE—Standard for determining current-carrying capacity in printed board design now available in German IPC - Association Connecting Electronics Industries® announced the German language release of IPC-2152-DE, Designrichtlinie für die Bestimmung der Stromtragfähigkeit von Leiterplatten. This document is the translation of IPC-2152, Standard for Determining Current-Carrying Capacity in Printed Board Design, which was released in English in August of 2009. The 97-page document sets the sole industry standard for determining the appropriate sizes of internal and external conductors as a function of the current-carrying capacity required and the acceptable conductor temperature rise. IPC members may request a free, single-user download of IPC-2152-DE by e-mailing MemberTechRequests@ipc. org within 90 days of its release; after 90 days, the price for members is $50, InterNetView crack serial keygen. The nonmember price of IPC-2152-DE is $100. Visit for details and to purchase.


Global SMT & Packaging – Celebrating 10 Years – July 2010 – 49

IMAPS news

IMAPS Europe news

News from IMAPS Italy On the 20th of May, IMAPS Italy held a workshop on cleaning technologies for electronic assembly at the Crown Plaza hotel San Donato Milan. The event was held in association with Assodel, the Italian electronic suppliers association, InterNetView crack serial keygen, and sponsored by AMES, the microelectronic and semiconductor section of the Italian Electronic and Electrical Association. Over 60 participants attended from 46 technical institutions and companies representing a cross section of companies involved in electronic component and system manufacture. Presentations were given on the potential hazards caused by contaminants in microlectronic assemblies and the identification of associated failure mechanisms, cleaning methods including new developments solvents and plasma cleaning. A particularly interesting problem was outlined by L. Ferruccci of Nokia Siemens Networks showing how miniscule flux residues can vary RF performance.

News from IMAPS Nordic IMAPS Nordic has an old tradition to hold their yearly conference alternating in each of the four Nordic countries. This year Sweden was in tour and Gothenburg on the west coast was chosen as a lot of electronics industry and research is located here. The programme was very rich, with both local speakers and invitees from other regions. Among the best was Jean-Marc Yannou’s presentation on 3D packaging and IPDs. The ELC President Nihal Sinnadurai brought us both technical information and news about the organisational situation within Europe and globally. The event was finished with a visit to IMEGO Institute where applied research and new electronics products are pre-developed in close cooperation with both industry and other R&D institutes. Unfortunately the participation in the conference was lower than ever. This could be due to the fact that this was the first time it was held in June, not September. Perhaps the organisers were not alert to market the event early enough, or is June not a good time for the participants? Next year we will try June again, this time in Finland.

Conference building (C-13) at Wrocław University of Technology. (Source: Maciek Krol) News from IMAPS Poland The 34th IMAPS-CPMT Poland 2010 International Conference organized by Wroclaw University of Technology (Faculty of Microsystem Electronics and Photonics) will be held in Wroclaw on 22-25 September, 2010. This year our conference is organized together with 10th Electron Technology ELTE 2010 Conference (Polish conference organized every three years and devoted to electronic materials, micro- and nanoelectronics, photonics and microsystems). It will be a good opportunity to exchange the scientific results between wide range InterNetView crack serial keygen scientists and specialists from electronic industry. The conference presentations will be divided into InterNetView crack serial keygen sessions, section sessions and poster sessions. The main topics include: • Thin- and thick-film technologies; • Thin- and thick-film sensors; • Modelling, design and simulation of film structures, components and circuits; • Modern technologies and applications of multichip modules; • Electrical, optical, mechanical and thermal characterization of film structures, components and circuits; • Packaging in electronics, photonics and microsystems; • Quality and reliability of film structures and packaging processes.

50 – Global SMT & Packaging – Celebrating 10 Years – July 2010

The exhibition of technological and diagnostic equipment is planned during the conferences. Papers chosen by scientific committees will be recommended for publishing in international and national technical journals. The conference presentations will be divided into plenary sessions, section sessions and poster sessions. Presentations/ posters for IMAPS/CPMT will be prepared in English abstracts, and full texts of papers will be prepared in English. Students, PhD students and young researchers (below 32 years old) can participate in contests for best papers in particular thematic sections. Exhibition of technological and diagnostic equipment is planned during the conference, InterNetView crack serial keygen. Papers chosen by the Scientific Committees will be recommended for publishing in international and national technical journals. The conference will be held at the Wrocław University of Technology, building C-13, i.e. Integrated Students Center, Wybrzeże Wyspiańskiego 23/25 in Wrocław More information can be found on the conference website: www.imaps2010.pwr.

European Electronics Assembly

Reliability Summit The European Union continues to impose legislation on the electronics manufacturing community. REACH, RoHS and WEEE all have significant impact on the manufacturability of our board assemblies and finished goods. The Second European Electronics Assembly Reliability Summit brings together experts and provides a unique opportunity to examine, learn and debate these business-critical issues through industry discussion, technical collaboration and information sharing. The event will include a technical conference, tabletop exhiibition and networking opportunities. Join us this September. Visit the website to learn more.

September 21-23, 2010 Tallink Spa & Conference Hotel, Tallin, Estonia This conference is being held at a critical time for the electronics industry. Increasing legislation and lack of reliability in electronics assemblies and interconnections is providing many challenges for, designers, specifiers and manufacturers of printed assemblies. The rise in counterfeit components Mini tool power recovery keygen,serial,crack,generator only adding to these challenges.

September 21-23, 2010

Abstracts from the 36th Annual Meeting of the Society of General Internal Medicine



“MY CLIENTS FALL THROUGH EVERY CRACK IN THE SYSTEM”: ASSESSING THE NEED FOR GERIATRICS HEALTH TRAINING AMONG LEGAL PROFESSIONALS Tacara N. Soones1; Cyrus Ahalt2; Sarah Garrigues2; David Faigman3; Brie Williams2, InterNetView crack serial keygen. 1University of California- San Francisco, San Francisco, CA; 2University of California-San Francisco, San Francisco, CA; 3UCSF/UC Hasting Consortium on Law, Science & Health Policy, San Francisco, CA. (Tracking ID #1607152)

BACKGROUND: Older adults (age 55+) represent the fastest growing age group in jail. While attorneys, judges, and other legal professionals are not generally considered healthcare team members, InterNetView crack serial keygen, they provide front-line identification and response to age-related health conditions affecting legal outcomes. For example, cognitive impairment can affect the ability to access adequate legal representation, participate in one’s defense, or follow court orders; and physical impairment can jeopardize safety in jail. However, legal professionals’ knowledge of age-related health issues is unknown.

METHODS: This was a cross-sectional, qualitative study of legal professionals in San Francisco County’s criminal justice system, InterNetView crack serial keygen. Questionnaires included open and close-ended questions to assess demographics, attitudes towards older adults (validated Geriatrics Attitudes Scale) and self-reported knowledge of geriatrics topics relevant to legal services, including cognitive and sensory impairment, legal competency, and knowledge of community resources. Questionnaires also elicited recommendations for closing InterNetView crack serial keygen knowledge gaps. We analyzed questionnaires using standard grounded theory principles and conducted in-depth interviews with 9 participants to ensure that questionnaires were interpreted accurately.

RESULTS: Seventy-two of 83 legal professionals participated (87 % participation), including judges (6 %), District Attorneys (25 %), Public Defenders (58 %), and Pretrial Diversion case managers (11 %). Most legal professionals (73 %) worked with older adults on at least a monthly basis and 100 % had positive attitudes towards aging (Geriatrics Attitudes Scale >3). Self-reported geriatrics knowledge gaps were greatest in 3 areas: (1) General aging-related health- 14 % rated themselves as knowledgeable about age-related health issues, 74 % had never received training in aging; (2) Cognitive impairment-55 % did not feel knowledgeable at explaining how delirium, dementia and depression might affect behavior or the ability to follow instructions, and (3) Safety assessment-61 % felt unprepared to identify older adults at high safety risk and 62 % could not describe types of surrogate decision-makers, including public guardians or appointed power of attorneys. Five recommendations to close these knowledge gaps emerged: (1) educate legal professionals about aging-related health; (2) develop checklists to identify older adults at risk of health decline or poor safety; (3) train to assess older adults for cognitive and sensory impairments before legal proceedings; (4) create communication mechanisms between legal professionals, clinicians, and social services providers about client needs during and after detainment; and (5) encourage multidisciplinary research to improve health outcomes in older adults.

CONCLUSIONS: This study identifies critical gaps in the geriatrics knowledge of legal professionals in the criminal justice system and proposes recommendations to address these knowledge gaps, minimize adverse health outcomes, and improve legal outcomes for older adults.

“WHO’S ON FIRST?” IN THE CHAOS OF SHARED DECISION MAKING: A STUDY OF DOCTOR, PATIENT, AND OBJECTIVE RATINGS OF SHARED DECISION MAKING USING DIRECTLY OBSERVED ENCOUNTERS Patrick G. O’Malley1,2; Dorothy Becher1; Gretchen Rickards2,1; Janice L. Hanson3,1; Jeffrey L. Jackson4,1. 1Uniformed Services University, Bethesda, InterNetView crack serial keygen, MD; 2Walter Reed National Military Medical Center, Bethesda, MD; 3University of Colorado School of Medicine, Aurora, CO; 4Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #1639946)

BACKGROUND: Shared decision making involves complex patient-physician interaction, yet patient encounters tend to be chaotic, without coherent direction or InterNetView crack serial keygen symmetry. We sought to explore how patients and doctors perceive the degree of shared decision making in the same chronic InterNetView crack serial keygen encounters, and how well their perceptions correspond with objective assessments of the interaction.

METHODS: Prospective, observational study of audiotaped encounters, with surveys of patients and physicians before and after the encounter. We enrolled a consecutive sample of 120 participants aged 40–80 y.o. with ≥3 additional chronic medical conditions (excluding dementia), and scheduled for a routine appointment with their primary provider. Immediately after the visit, patients and doctors were independently surveyed to assess the decision making style of the encounter along a 20-point spectrum ranging from “doctor-dominant” (0–6) to “shared” (7–13) to “patient-dominant” (14–20) decision making. The scale InterNetView crack serial keygen behavioral descriptors in order to anchor one’s choice, InterNetView crack serial keygen. Three raters (PO, DB, GR) dual-rated transcriptions independently on the level of decision making complexity (low, medium, high), and the degree of shared decision making (20-item scale), blinded to the patient and doctor ratings; disagreements were reconciled through consensus. Agreement between patient, doctor, and objective ratings were measured using the intraclass correlation coefficient (ICC).

RESULTS: Of the 105 patients who completed the visit, complete data was available on 98. The demographics were as follows: 53 % F, 56 % AA, mean age: 66 yo, 88 % were on 5 or more medications, only 8 % had poor health literacy, and 30 % had a very good or excellent functional status. The physician profile (N = 11) was: 55 % F, 28 % AA, mean age: 48 yo, and mean time since graduation: 19 yrs. The level of decision making in the encounters was low in 61 %, and mod/high in 39 %. Categorical ratings of encounters (by collapsing scores into 3 groups), stratified by perspective (doctor, patient, objective), InterNetView crack serial keygen, is presented in the table (below). Immediately after the visit, there was no agreement between patients and physicians on the degree of shared decision making during the visit (ICC = 0.06, P = 0.37). By objective measurement, InterNetView crack serial keygen, 88 of the 98 encounters were dominated by the physician (ie, scores from 0 to 9), and only 27 of those could be categorized as relatively “shared” (ie, scores of 7–9). When compared to objective ratings, physicians’ ratings of shared decision making correlated more strongly (ICC = 0.55, P < 0.001) than patients’ ratings (ICC = 0.39, P = 0.01).

CONCLUSIONS: Immediately after participating in the same chronic care encounter of mostly low to moderate decision complexity, both patients and physicians uTorrent Pro 3.5.5 Build 46096 Crack Here | Tested the degree of shared decision making, and neither agreed on the degree of shared decision making of the same encounter. Interventions to improve shared decision making will need to address 1. Physician lack of awareness of their tendency to dominate encounters, and 2. both parties’ ability to engage in true shared decision making.

Shared Decision Making Spectrum

Doctor Shared Patient


Doctor 34 % 47 % 19 %

Patient 22 % 69 % 9 %

Objective 81 % 15 % 4 %

Ratings of the Same Encounter (N = 98)

(RE)TURNING THE PAGES OF RESIDENCY: THE IMPACT OF LOCALIZING RESIDENT PHYSICIANS TO HOSPITAL UNITS ON PAGING FREQUENCY Laura Fanucchi1; Lia S. Logio2. 1University of Kentucky College of Medicine, Lexington, KY; 2Weill Cornell Medical College, New York, NY. (Tracking ID #1634924)

BACKGROUND: Pagers are ubiquitous, yet fundamentally flawed, as they do not prioritize, InterNetView crack serial keygen, lead to communication errors, and interrupt patient care and educational activities. Given duty hour restrictions, there is concern that residents experience increased workload due to having fewer hours to do the same amount of work. Geographic localization of physicians to patient care units is thought InterNetView crack serial keygen improve communication and agreement on goals of care, and also to reduce workload by decreasing paging and other inefficiencies attributable to traveling throughout the hospital. We investigated whether interns on geographically localized teams received fewer pages than interns on teams that were not localized.

METHODS: We conducted a retrospective analysis of the number of pages received by interns on 5 general medicine teams from Oct, InterNetView crack serial keygen. 17–Nov. 13, InterNetView crack serial keygen, 2011 at New York Presbyterian Hospital/Weill Cornell. Two teams were in a Geographically Localized Model (GLM), two in a Partial Localization Model (PLM), and one Standard Model (SM) team admitted patients irrespective of their assigned bed location. ANOVA and standard multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team.

RESULTS: Over 28 days, 10 interns on 5 teams received 6652 pages. Eighty-five percent of patients in the GLM were on the designated unit, InterNetView crack serial keygen, compared to 45 % in the PLM, and 37 % in the SM. The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.18 in the GLM, 2.77 in the PLM, and 3.87 in the SM. All of these differences were statistically significant in the linear regression analysis (p < 0.0001). Figure 1 shows the pattern of paging for the three types of teams.

CONCLUSIONS: Geographic localization of resident teams to patient care units is associated with significantly fewer pages received by interns during the day, InterNetView crack serial keygen. Previous research suggests that geographic localization decreases perceived paging frequency. We show a statistically significant relationship with a dose–response effect. We also demonstrate that interns whose patients are scattered throughout the hospital may experience five pages per hour, or an interruption by pager every 12 min. Geographically localized patient care models may improve resident workload in part by mitigating paging. Decreased resident workload has potential to improve both clinical and educational outcomes. A working environment that facilitates in-person communication decreases not only pager interruptions, but the latent communication errors inherent in unidirectional alpha-numeric paging, which may improve InterNetView crack serial keygen safety.

Figure 1. Average number of pages per intern per hour for each care model.

24 MONTH METABOLIC BENEFITS OF A COMMUNITY-BASED TRANSLATION OF THE DIABETES PREVENTION PROGRAM Carolyn F. Pedley1; Doug Case1; InterNetView crack serial keygen Z. Vitolins1; Jeffrey A. Katula1; Caroline S. Blackwell1; Scott Isom1; David C. Goff2. 1Wake Forest University, Winston-Salem, NC; 2Colorado School of Pulbic Health, Denver, CO, InterNetView crack serial keygen. (Tracking ID #1642380)

BACKGROUND: The practice of general internal medicine involves treating a high percentage of individuals with hypertension, increased waist circumference, glucose intolerance, hypertriglyceridemia and decreased HDL cholesterol. These individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease and diabetes. Although several large-scale clinical trials have demonstrated that weight loss achieved InterNetView crack serial keygen diet and physical activity can reduce the incidence of diabetes, translating lifestyle weight loss programs to general practice has been difficult. Numerous studies have attempted to translate the Diabetes Prevention Program (DPP) to community-based and primary care settings and have documented modest success. However, no translational studies to date have documented the impact of diabetes prevention interventions on aspects of the metabolic syndrome. The Healthy Living Partnership to Prevent Diabetes study (HELP PD; NIDDK) tested the impact of a community-based translation of the DPP on fasting blood glucose in participants at high risk for diabetes. The impact of HELP PD on fasting blood glucose and waist circumference have been published previously. The purpose of the present study is to examine the HELP PD intervention on features of the metabolic syndrome.

METHODS: The study randomly assigned 301 overweight volunteers with fasting blood glucose 95–125 mg/dl and BMI 25–40 kg/m2 to two treatment groups: enhanced usual care (EUC vs DPP LWL (Lifestyle, Weight Loss) intervention. Ages ranged from 34 to 81 years with a median of 58 years; 57 % were female, 26 % minority and 73 % obese. The LWL intervention was administered through a local diabetes education program and participants met in 14 groups of 8–12 delivered by community health workers (CHW) in community locations, InterNetView crack serial keygen. CHWs were volunteers with well-controlled diabetes.

RESULTS: Duriing 24 months of follow-up there were significant between group differences in metabolic parameters: fasting blood glucose, waist circumference, HDL and DBP differed significantly between the LWL and EUC groups, all in favor of the LWL. SBP and triglycerides were lower in the LWL group but the differences were not statistically significant. Fasting blood glucose decreased by 2.2 mg/dl in the LWL group and increased by that amount in the EUC group for a difference of 4.4 mg/dl at 24 months (p = .001). Waist circumference decreased by 3.4 cm in the LWL group and remained relatively unchanged in the EUC group (0.2 cm decrease) for 3.2 cm difference at 24 weeks (p < .001). HDL increased by 0.4 mg/dl in the LWL group while decreasing by 2.7 mg/dl in the EUC group (p = .004). Diastolic blood pressure decreased by 1.6 mmHg in the LWL group and increased by 0.5 mmHg in the EUC group (p = .024) while systolic blood pressure decreased by 2.3 mmHg in the LWL group and 1.0 mmHg in the EUC group (p = .437). Triglycerides decreased by 23.4 mg/dl in the LWL group compared to the 10.8 mg/dl in the EUC group (p = .083).

CONCLUSIONS: This study demonstrates that community-based partnerships can successfully deliver effective, affordable behavioral lifestyle weight loss programs in general medical patients who have several metabolic risks for diabetes and heart disease with resultant metabolic benefits. Utilizing community-based volunteers in community settings to deliver diabetes prevention programs has the potential to reduce health disparities in accessing such care.

“AM I CUT OUT FOR THIS?” UNDERSTANDING THE EXPERIENCE OF DOUBT AMONG FIRST YEAR MEDICAL STUDENTS Rhianon Liu; Jorie Colbert-Getz; Robert Shochet. Johns Hopkins University School of Medicine, Baltimore, MD. (Tracking ID #1628595)

BACKGROUND: Research on medical student wellbeing shows high rates of distress, yet doubt as a distinct phenomenon remains poorly understood. The purpose of our study was to examine how first year medical students experience and respond to doubt, and how doubt relates to other aspects of student distress.

METHODS: We conducted a mixed methods study involving a survey and focus groups examining the phenomenon of doubt among first InterNetView crack serial keygen medical students at the Johns Hopkins University School of InterNetView crack serial keygen (JHUSOM). Students were asked to answer 14 questions about doubt embedded in an online advising program survey in June, 2012. Doubt survey items were developed and revised based on literature review, and included four questions from a validated wellbeing index. Results were analyzed by grouping students into categories of high, moderate, low, or no doubt. For each doubt item, logistic regression was used to compare the proportion of students who “agreed” among moderate/high doubters vs low/no doubters. For wellbeing questions, total doubt scores and total wellbeing scores were correlated with Spearman’s rho. In addition, four 90-min focus groups were conducted with a convenience sample of students in June–July, InterNetView crack serial keygen, 2012. Focus group questions were written by the authors, then pilot-tested and revised prior to use. Phpstorm 2019.1 Crack Archives recordings were transcribed, independently coded, and iteratively reviewed by the authors to identify major themes.

RESULTS: 114/119 (96 %) students completed the survey. 20 % had high doubt, 29 % moderate doubt, 22 % low doubt, and 29 % no doubt. Compared to those with low/no doubt, students with moderate/high doubt were 5 to 13 times as likely to question their personal purpose, to question who they were, to struggle with coping with doubt, and to perceive the JHUSOM climate as discouraging them from expressing doubt, There was moderate correlation between total doubt and wellbeing scores (spearman’s rho = 0.36). 34 students participated in the focus groups. Three major themes were identified: types of doubt, ways of coping with doubt, and impact of doubt. Types of doubt were related to two main questions: -Do I want to become a doctor? Subtheme example: the opportunity cost of pursuing medicine -Am I capable of becoming a doctor? Subtheme example: concerns about one’s ability to succeed and maintain work-life balance Ways of coping with doubt included: -Relying on supportive relationships -Maintaining perspective through a focus on long-term goals The impact of doubt included positive and negative aspects: -Positive examples: motivation and resilience in the face of uncertainty -Negative examples: burnout, stress, and poor academic performance

CONCLUSIONS: Doubt is prevalent among first-year medical students, affecting students’ sense of confidence, identity, and purpose, and has both positive and negative consequences. Students also experience other forms of distress, InterNetView crack serial keygen, which may be related to doubt. Doubt among medical students merits awareness and further study, as it may be an important mediator of students’ emerging sense of identity and personal wellbeing.

A BEFORE/AFTER TRIAL OF A DECISION AID ON MAMMOGRAPHY SCREENING FOR WOMEN AGED 75 AND OLDER Mara A. Schonberg; Mary Beth Hamel; Roger B. Davis; Edward R. Marcantonio, InterNetView crack serial keygen. Beth Israel Deaconess Medical Center, Boston, MA. (Tracking ID #1636857)

BACKGROUND: Guidelines state there is insufficient evidence to recommend mammography screening for women aged >75 years. Instead, they encourage clinicians to discuss the potential benefits and risks of screening and engage older women in shared decision-making. We aimed to design and evaluate a decision aid (DA) for women >75 years to inform their decision-making around mammography screening.

METHODS: We designed the DA based on international standards and included data from medical literature review. An expert panel reviewed iterative versions of the DA and it was then reviewed for acceptability by 15 patients and 5 of their primary care physicians (PCPs). The 10-page DA (written at a 6th grade reading level) includes information on breast cancer risk, life expectancy, competing mortality risks, likely outcomes if screened or not screened over 5 years, and a values clarification exercise. We evaluated the DA in a before/after trial at a large academic InterNetView crack serial keygen care practice in Boston. Eligible InterNetView crack serial keygen were >75 years, spoke and read English fluently, had not had a mammogram in the past 9 months but were screened in the past 3 years, did not have a history of invasive or non-invasive breast cancer or dementia, InterNetView crack serial keygen, and were scheduled for a routine visit with their PCP within 8 weeks. Participants came early to their PCP appointment to complete a “before” survey and to read the DA. After the visit, they completed an “after” survey. The surveys included 10 knowledge questions, the 16-item decisional conflict scale (DCS, 0–100, lower scores = less conflict), and a question that assessed screening intentions. Participants were followed by medical record for up to 1 year to examine whether there was a note documenting a discussion of the pros/cons of screening and to abstract receipt of mammography. We used the signed rank test and McNemar’s test to compare before/after responses. We also asked PCPs to complete a survey about using the DA in their practice.

RESULTS: Forty-nine before/after trial participants (from 26 PCPs) had median age of 79 years; 70 % were Non-Hispanic white; 63 % had attended some college; and 24 % had <7 year life expectancy. Comparison of “after” to “before” survey results found: 1) participants InterNetView crack serial keygen on average 1 more question correct (interquartile range 0–2) on the 10 item index from 6 to 7 questions correct, p < 0.001; 2) decisional conflict declined by 4.8 points (range −10.2 to +4.7 points, mean DCS scores before = 20.1, p = 0.03); and 3) fewer participants intended to be screened (59 % compared to 82 % before, p = 0.01). In the following 6 months, 61 % of participants had a PCP note documenting a discussion of the pros/cons of screening compared to 10 % in the previous 5 years, p < 0.001. While 86 % had been screened within 2 years before participating only 61 % were screened within 1 year after, p < 0.001 (a similar decline was found among women with <7 year life expectancy). Overall, 94 % reported that they would recommend the DA, 94 % found it helpful, and 78 % found the amount of information just right. PCPs (17/26) reported that using the DA would result in their patients making more informed (74 %) and value laden (79 %) decisions.

CONCLUSIONS: We developed a DA for women aged >75 years contemplating mammography screening. Our before/after trial demonstrates that this DA allows women to make more informed, preference-sensitive decisions around mammography screening. Next, we plan to test the effectiveness of the DA in a large randomized control trial.

A CENSUS OF STATE-BASED CONSUMER HEALTH CARE PRICE WEBSITES Jeffrey T. Kullgren1; Katia A. Duey2; Rachel M. Werner3. 1Ann Arbor VA Healthcare System and University of Michigan, Ann Arbor, MI; 2University of Pennsylvania, Philadelphia, PA; 3Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA, InterNetView crack serial keygen. (Tracking ID #1642367)

BACKGROUND: As Americans’ out-of-pocket health care costs continue to rise, many health plans, consumer groups, and state governments are reporting health care price information directly to patients. Though there is broad recognition that this information must be InterNetView crack serial keygen, accurate, and usable to improve the value of patients’ out-of-pocket spending, it is currently unknown what information is actually being reported to patients. The objective of this study was to describe the types of information that are currently being reported on state consumer health care price websites and identify opportunities to improve the usefulness of this information for patients.

METHODS: We conducted a systematic internet search to identify patient-oriented, state-based health care price websites that were operational in early 2012. We chose to focus on state-based websites since states are a focal point for health care price transparency initiatives and often publicly report the health care price information they collect under legislative or regulatory authority. For each website we identified, we classified the type of organization that reported the information, the kinds of health care services for which prices were reported, the type of price information that was reported (e.g., out-of-pocket cost, allowable charge, or billed charge), the patient-level factors that were incorporated in the estimate, and the presence of quality information alongside the reported price information. We then calculated frequencies for each of these characteristics.

RESULTS: We identified 62 state health care price transparency websites, most of which were provided by either a state government agency (46.8 %) or state hospital association (38.7 %). Most websites reported information on prices of inpatient care for medical conditions (72.6 %) or surgeries (71.0 %); prices for outpatient services such as diagnostic or screening procedures (37.1 %), radiology studies (22.6 %), prescription drugs (14.5 %), or laboratory tests (9.7 %) were reported less often. The reported prices usually reflected only billed charges (80.6 %). For outpatient services that commonly include both facility and professional fees (e.g., diagnostic procedures or radiology studies), the majority of InterNetView crack serial keygen estimates (66.0 %) included just facility fees. Only a small minority of prices were tailored to individual circumstances that commonly affect what a patient is truly expected to pay out-of-pocket for a service, such as their insurance status (9.7 %) or specific health plan (8.1 %). For services where price and quality information together could help patients assess value across providers (e.g., outpatient clinician services or outpatient surgeries), quality information was infrequently portrayed alongside prices (13.2 %).

CONCLUSIONS: Most states now have websites that report health care prices directly to patients. However, the information being reported on these state health care price websites is unlikely to be useful for most patients, and often fails to reflect the true prices they would actually face for services. Improvements in the relevance, accuracy, and usability of publicly reported health care prices could help this information reach its full potential to improve the value of out-of-pocket health care spending for patients.

A HIGH RISK OF HOSPITALIZATION FOLLOWING RELEASE FROM CORRECTIONAL FACILITIES AMONG MEDICARE BENEFICIARIES Emily A. Wang1; Yongfei Wang2; Harlan M. Krumholz1,2, InterNetView crack serial keygen. 1Yale School of Medicine, New Haven, CT; 2Yale-New Haven Hospital Center of Outcomes Research and Evaluation, New Haven, CT. (Tracking ID #1642216)

BACKGROUND: Healthcare is constitutionally guaranteed in correctional facilities, InterNetView crack serial keygen, but not upon release, which could increase the risk of acute events. We studied the risk for hospitalizations among former inmates soon after their release from correctional facilities.

METHODS: We conducted a retrospective cohort study using data from Medicare administrative claims for all fee-for-service beneficiaries who were released from a correctional facility from 2002 to 2010. Using McNemar’s test and condition logistic regression, we compared hospitalization rates after release among former inmates 7, 30, and 90 days after release to beneficiaries matched based on age, sex, race, Medicare status, and residential InterNetView crack serial keygen code. We also compared hospitalizations with the specified diagnosis codes between the two groups and examined whether being released from a correctional facility was associated with different risks for hospitalizations for ambulatory care-sensitive conditions compared with the matched control. We used Kaplan Meier survival analyses to compare time to the first hospitalization and death between the two matched groups after release. Data were censored at the time of death or the end of the observation period.

RESULTS: Of 110,419 released inmates, 1559 individuals (1.4 %) were hospitalized within 7 days after release; 4285 individuals (3.9 %) within 30 days; and 9196 (8.3 %) within 90 days. The odds of hospitalization was higher for released inmates compared with matched controls (within 7 days, odds ratio (OR) 2.5, 95 % confidence interval [CI] 2.3, 2.8; 30 days, OR 2.1, 95 % CI, 2.0, 2.2; and 90 days, OR 1.8, 95 % CI 1.7, 1.9). Compared with matched controls, former inmates were more likely to be hospitalized for ambulatory care-sensitive conditions (within 7 days, OR 1.7, 95 % CI 1.4, 2.1; 30-days, OR 1.6, 95 % CI 1.5, 1.8; and 90-days, OR 1.6, 95 % CI 1.5, 1.7). Mental health conditions were the most common reason for hospitalizations among former inmates 30 days post release (22.1 %). Diseases of the circulatory system (14.0 %), InterNetView crack serial keygen, injury and poison (12.7 %), and disease of the respiratory system (10.5 %) were also common reasons for hospitalization among released inmates. In event-free analyses, former inmates were more likely to be hospitalized compared with the control group within a year following release.

CONCLUSIONS: About one in 70 former inmates are hospitalized for an acute condition within 7 days of release, and one in 12 InterNetView crack serial keygen 90 days, a rate much higher than the general population, InterNetView crack serial keygen. Transitions between correctional facilities and the community are a high-risk period; correctional and community healthcare systems should collaborate to reduce morbidity for this vulnerable population.

A META-ANALYSIS OF THE RAPID ANTIGEN STREPTOCOCCUS TEST Emily Stewart; Brian Davis; Lee Clemans-Taylor; Robert M. Centor; Carlos Estrada. The University of Alabama at Birmingham, InterNetView crack serial keygen, Birmingham, AL. (Tracking ID #1624984)

BACKGROUND: Current guidelines to diagnose and treat group A streptococcal (GAS) pharyngitis do not take into account the uncertainty of rapid testing. We examined the accuracy of the rapid antigen streptococcus test (RAST) to diagnose GAS pharyngitis.

METHODS: Systematic review InterNetView crack serial keygen meta-analysis. MEDLINE search and reference lists, 2000–2012. We included clinical studies using RAST and a reference standard. We assessed quality with Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. We obtained hierarchical summary receiver operating characteristic (HSROC) curve and obtained adjusted estimates of test characteristics.

RESULTS: We included 41 of 728 studies; the overall prevalence was 28 % (13,588/48,377 patients; range 4–67 %). The setting was solely in the emergency department (27 %) or outpatient clinic (56 %); 22 % were solely in children; and 14 % were retrospective. Of 14 QUADAS criteria, eight were fulfilled by over 90 % of studies, five by 60–80 %, and one by 22 %. The Deek’s funnel plot was asymmetric (p < 0.001) suggesting InterNetView crack serial keygen presence of publication bias. Studies were heterogeneous as illustrated by a wide 95 % prediction region in the HSROC curve (Figure, dashed line) and high inconsistency estimates for sensitivity (I2 = 94.4 %) and specificity (I2 = 98.2 %). The adjusted pooled sensitivity was 88.2 % (95 % confidence interval [CI], 83.9 to InterNetView crack serial keygen range 52.6 % to 99.9 %). The pooled specificity was 98.5 % (95 % CI, 96.7 to 99.3 %; range 68.8 % to 100 %). Inconsistency between studies remained high for sensitivity and specificity in sub-group analyses for location of test performance (point-of-care, laboratory), pediatric population, setting (outpatient, emergency department), InterNetView crack serial keygen, study design (prospective, retrospective), study methodological quality (verification bias, non-differential bias, InterNetView crack serial keygen, non-incorporation bias), and funding (commercial or not)(all I2 > 80 %).

CONCLUSIONS: The RAST is moderately sensitive and highly specific to diagnose group A streptococcal pharyngitis. However, significant heterogeneity and publication bias were observed among studies. Guidelines should incorporate uncertainty in estimates for rapid tests for the diagnosis of GAS pharyngitis.

A MIXED-METHODS RANDOMIZED CONTROLLED TRIAL OF EMPLOYER MATCHING OF DEPOSIT CONTRACTS TO PROMOTE WEIGHT LOSS Jeffrey T. Kullgren1; Andrea B. Troxel2; George Loewenstein3; Laurie Norton2; InterNetView crack serial keygen Gatto2; Yuanyuan Tao2; Jingsan Zhu2; Heather Schofield4; Judy A. Shea2; David A. Asch5; Thomas Pellathy6; Jay Driggers7; Kevin G. Volpp5. 1Ann Arbor VA Healthcare System and University of Michigan, InterNetView crack serial keygen, Ann Arbor, MI; 2University of Pennsylvania, Philadelphia, InterNetView crack serial keygen, PA; 3Carnegie Mellon University, Pittsburgh, PA; 4Harvard University, Cambridge, MA; 5Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA; 6McKinsey & Company, Pittsburgh, PA; 7Horizon Healthcare Innovations, Newark, NJ. (Tracking ID #1642494)

BACKGROUND: Deposit contracts are behavioral economic devices that ask people to put money at risk that they forfeit if they do not meet a goal. While deposit contracts can effectively promote weight loss, a major challenge to wider impact of these programs is getting more people to participate. The goals of this study were to test whether matching of deposits can increase participation in deposit contracts, characterize the corresponding amount of InterNetView crack serial keygen loss, and identify factors associated with non-participation in these programs.

METHODS: We recruited 132 employees of Horizon BCBS of NJ who wanted to lose weight and had a BMI between 30 and 50. Participants were given a weight loss goal of 1 lb per week for 24 weeks and randomized to a monthly weigh-in control group or monthly opportunities to deposit $1 to $3 per day with daily feedback. Deposits were either not matched, matched 1:1, or matched 2:1 and provided back to participants at the end of the month for every day in that month that participant was at or below the goal weight for InterNetView crack serial keygen day. After the 24-week intervention period, we conducted semi-structured interviews with intervention arm participants to identify factors that influenced their participation in deposit contracts. The primary outcome was weight loss at 24 weeks. Secondary outcomes included deposit contract participation; changes in eating behaviors, physical activity, and wellness program participation at 24 weeks; and weight loss 12 weeks after the interventions ended.

RESULTS: After 24 weeks, control arm participants gained an average of 1.0 lb (SD 7.6), compared to mean weight losses of 4.3 lbs (SD 8.9; P = .03) in the no match arm, 5.3 lbs (SD 10.1; P = .005) in the 1:1 match arm, and 2.3 lbs (SD 9.8; P = .29) in the 2:1 match arm. Overall, 29.3 % of participants in a deposit contract arm made at least one deposit, and there were no significant differences in participation rates across the 3 deposit contract arms. There were also no significant differences in changes in eating behaviors, physical activity, and participation in wellness programs after InterNetView crack serial keygen. In semi-structured interviews, the main factors that limited participation in deposit contracts were a lack of confidence in meeting weight loss goals and fear of losing money. 12 weeks after the interventions ended, control arm participants gained an average of 2.1 lbs from baseline (SD 7.9), compared to mean weight losses of 5.1 lbs (SD 11.1; P = .008) in the no match arm, 3.6 lbs (SD 9.6; P = .02) in the 1:1 match arm, and 2.8 lbs (SD 10.1; P = .12) in the 2:1 match arm.

CONCLUSIONS: Relatively few study participants assigned to deposit contract conditions took up opportunities to enter into deposit contracts designed to promote weight loss, and employer matching of deposits did not increase participation. Approaches to promote confidence in losing weight or seed deposit contract accounts might be alternative ways to increase participation in these programs. Greater weight loss in deposit contract arms at 24 and 36 weeks may have been mediated by the automated daily feedback these participants received, InterNetView crack serial keygen, and this approach could be another promising tool to promote behavior change in workplace settings.

A NATIONAL ASSESSMENT ON PATIENT SAFETY EDUCATION IN UNDERGRADUATE MEDICAL EDUCATION: A SURVEY OF CLERKSHIP DIRECTORS IN INTERNAL MEDICINE C. Charles Jain1; Meenakshy K. Aiyer1; Jean C. Aldag1; Eric Alper2; Steven Durning4; Elizabeth A. Murphy2; Dario M. Torre3. 1University of Illinois College of Medicine at Peoria, Peoria, IL; 2University of Massachusetts, Worcester, MA; 3Drexel University, Philadelphia, PA; 4Uniformed Services University of the Health Sciences, Bethesda, MD. (Tracking ID #1638436)

BACKGROUND: Patient safety is an important aspect of quality patient care. For this reason, accreditation bodies emphasize educating learners on patient safety in both undergraduate and graduate medical education curricula. This study looks at the current status of patient safety curricula from the perspectives of internal medicine clerkship directors. In addition, this study compares the current status to what was found in a similar study from 20061.

METHODS: The patient safety survey was a part of the Clerkship Directors in Internal Medicine (CDIM) 2012 annual survey. Questions were identified based on literature review, then modified and edited by the CDIM research committee. 37 patient safety related questions were organized into sections including general information, curriculum content and delivery, learner assessment, and barriers to providing the curriculum. All analysis was done using SPSS with group difference tested with Chi-squares for nominal variables, InterNetView crack serial keygen. IRB approval was obtained.

RESULTS: Of the 121 clerkship directors surveyed 99 (82 %) responded. Of those responding 45.6 % (n = 41) describe having patient safety curriculum at some point during the 4 years of MAGIX Sound Forge Pro Crack [Latest] Free Download school curriculum. Patient safety curriculum was commonly taught in the third year (30.3 %) of medical school followed by the pre-clinical years (yr1 = 19.2 %, yr2 = 28.3 %). The top three content areas included in the curriculum were infection control (54.1 %), handoffs and sign outs (47.4 %), and medication safety (39.5 %). Small groups (42.4 %) followed by lectures (31.3 %), direct observation (30.3 %) and Morbidity and Mortality reports (28.3 %) were used as educational strategies. Even though strategies such as patient safety project, simulations and OSCE were used for assessment of the curricula, only 20 % of the respondents reported satisfaction with student safety competency assessment during their IM clerkship. Lack of a mandate InterNetView crack serial keygen their school’s dean’s office (38 %), lack of physician champions (43.7 %), lack of trained faculty (65.3 %), and lack of time (78.1 %) were cited as barriers to implementation. Schools with female clerkship directors were significantly more likely to have a patient safety curriculum compared to schools with male clerkship directors (p = 0.01).

CONCLUSIONS: Less than half of medical school curricula report InterNetView crack serial keygen patient safety curricula. Even though clerkship directors recognize the importance of teaching patient safety curriculum, barriers exist to implementing the curricula. National guidelines on patient safety curriculum are currently not enough and more needs to be done to bring about the desired changes. 1. Alper MD E, Rosenberg MD, MSPH, Eric I., O’Brien MD KE, Fischer MD MEd M, Durning MD SJ. Patient safety education at U.S. and Canadian medical schools: Results from the 2006 clerkship directors in internal medicine survey. Acad Med. 2009;84:1672–1676.

A NOVEL WEBSITE TO PREPARE DIVERSE OLDER ADULTS FOR DECISION MAKING AND ADVANCE CARE PLANNING: A PILOT STUDY Rebecca L. Sudore2,1; Sara J, InterNetView crack serial keygen. Knight2,5; Anita L. Stewart4; Ryan D. McMahan2,1; Mariko Feuz2,1; Yinghui Miao2,1; Deborah E. Barnes3. 1UCSF, San Francisco, CA; 2San Francisco VA Medical Center, San Francisco, CA; 3UCSF, San Francisco, CA; 4UCSF, San Francisco, CA; 5Veterans Health Administration, Washington, DC. (Tracking ID #1638672)

BACKGROUND: Advance care planning (ACP) has typically focused OmniGraffle 7.15.2 MAC Crack Archives advance directives and preferences for treatments, such as CPR. We have reconceptualized ACP as a multi-step process focused on preparing patients with skills needed for communication and in-the-moment decision making. To operationalize this paradigm, we created a new ACP website called PREPARE that is interactive, written at 5th-grade reading level, and shows people through videos and a step-by-step process how to communicate what is most important in life and how to make informed medical decisions. To assess the efficacy of PREPARE, we created and assessed the validity of a new survey that detects behavior change in ACP and then conducted a separate pre-to-post efficacy study.

METHODS: Study #1 (Survey Validation) validates the ACP Engagement Survey, which includes Process Measures of behavior change (knowledge, self-efficacy, and readiness, 5-point Likert) and Action Measures (e.g., “Did you do X?” yes/no) of multiple ACP behaviors such as choosing a surrogate, asking someone to be a surrogate, and speaking to surrogates and doctors about one’s wishes. We administered surveys at baseline and one-week later to 50 diverse, older adults from San Francisco hospitals. Internal consistency of the Process Measures was assessed using Cronbach’s alpha (only for continuous variables) and test-retest reliability for both Process and Action Measures was examined using intraclass correlations. Study #2 (PREPARE Efficacy): Using a separate cohort (n = 43) from low-income, San Francisco senior centers, InterNetView crack serial keygen, we assessed change in ACP Engagement Survey responses (Process and Action Measures) and change in percentage of participants in the lowest, “precontemplation”, behavior stage of change to higher stages (contemplation, preparation, InterNetView crack serial keygen, action, maintenance) at baseline and one-week after viewing PREPARE. We also assessed PREPARE’s ease-of-use on a 10-point scale, 10 being the easiest. To assess comparisons, we used paired t-tests and McNemar’s tests.

RESULTS: Study #1 (Survey Validation): Mean age InterNetView crack serial keygen 69.3 (SD 10.5) and 42 % were non-White. The internal consistency of the Process Measures was 0.94. Intraclass correlations were 0.70 for the Process Measures and 0.86 for the Action Measures. Study #2 (PREPARE Efficacy): Mean age was 68.4 (SD 6.6) and 65 % were non-White, and 33 % had limited health literacy. Behavioral change Process Measure average Likert scores increased from 3.1 (SD 0.9) to 3.7 (SD 0.7), p < .001. Action Measures did not change significantly in 1 week. However, precontemplation significantly decreased for most ACP actions including asking someone to be a surrogate 39.5 % vs. 23.3 %, p < .04; talking to the doctor about the surrogate, 62.8 % vs. 30.2 %, P.001; talking with the surrogate and doctor about medical wishes, 46 % vs. 28 %, InterNetView crack serial keygen, p = .02 and 61 % vs. 35 %, P = .003, respectively. PREPARE was rated 9 out of 10 (SD 1.9) for ease-of-use.

CONCLUSIONS: A new patient-centered ACP website prepares people for ACP communication and medical decision making and is easy-to-use among older adults from diverse backgrounds. The new ACP Engagement Survey that measures both ACP behavior change and ACP actions demonstrated good reliability and validity. And, the PREPARE website significantly improves individuals’ behavior change and engagement in ACP. The website is available at and a clinical trial is underway.

A PEER-LED INTERVENTION IMPROVES STROKE SURVIVORS’ BLOOD PRESSURE CONTROL Carol Horowitz1; Kezhen Fei1; Ian M. Kronish2,1; Stanley Tuhrim1; Rennie Negron1. 1Mount Sinai School of Medicine, New York, NY; 2NY Presbyterian, New York, NY. (Tracking ID #1641866)

BACKGROUND: Hypertension is a major risk factor for stroke recurrence but it is poorly controlled among stroke survivors, particularly from minority groups. The Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial tests whether a community-based, peer-led InterNetView crack serial keygen education intervention improves stroke risk factors, primarily blood pressure control.

METHODS: Using community-based participatory research, clinicians, educators and stroke survivors developed a six-session peer-led workshop to help stroke survivors understand their illness, and identify and manage their recurrent risks, particularly hypertension. We recruited 600 individuals with a history of stroke or TIA within the past 5 years who were randomized to the intervention or a wait-list control group. At baseline, 6 and 12 months, we measured participants’ blood pressures, socio-demographics, beliefs and behaviors.

RESULTS: Participants have a mean of 63 years, the majority are female (60 %), Black InterNetView crack serial keygen Latino (81 %) and live in poverty (56 %). At baseline, 31 % in both groups had uncontrolled blood pressure (<140/90 mmHg). At 6 months, the intervention group demonstrated better blood pressure control when compared to the control group, 76 % vs. 65 % (p = 0.01). The intervention group also had a significant blood pressure reduction of 3.6/2.0 mmHg (p = 0.005/p = 0.04) compared to the control group (+0.5/−0.5 mmHg).

CONCLUSIONS: A peer-led educational program developed through a community-academic partnership was successful in improving blood pressure control at 6 months. While 12-month data will confirm the longevity of this impact, PRAISE is simple, culturally appropriate and inexpensive, and may represent an important and sustainable secondary stroke prevention strategy.

A PILOT STUDY OF A COMPUTER-BASED RELATIONAL AGENT TO SCREEN FOR SUBSTANCE-USE PROBLEMS IN PRIMARY CARE Steven R. Simon1,5; Kyle Checchi1,2; Sarah S. McNair1,2; Amy Rubin3,4; Thomas Marcello1,5; Timothy Bickmore6. 1VA Boston, Boston, MA; 2Harvard Medical School, Boston, MA; 3Boston University, Boston, MA; 4VA Boston Healthcare System, Boston, MA; 5Brigham and Women’s Hospital, Boston, MA; 6Northeastern University, Boston, MA. (Tracking ID #1638383)

BACKGROUND: Because of time constraints in delivering office-based primary care, interventions are needed to offload some tasks from primary care clinicians. Relational Agents - computer characters that simulate face-to-face conversation using voice, hand gesture, InterNetView crack serial keygen, gaze cues and other nonverbal behavior, InterNetView crack serial keygen, and that use simulated social behaviors to establish trust and therapeutic alliance - can provide education and counseling. Patients may find this type of computerized system suitable for “discussing” sensitive topics, although empirical data are lacking. We therefore conducted a pilot study - the first in the Veterans Health Administration (VA) - to test the feasibility of using this technology to screen for substance use problems in primary care.

METHODS: We recruited 24 male Veterans from VA Boston. Each participant completed the National Institute on Drug Abuse-Modified Alcohol, Smoking and Substance Involvement Screening Test (NM-ASSIST), administered once by a InterNetView crack serial keygen assistant and once by the Relational Agent, with the order randomly counter-balanced. Following both screenings, the research assistant conducted a semi-structured interview that solicited the Veteran’s perspectives of the Relational Agent for screening, strengths and weaknesses of the Relational Agent compared with live interaction, suggestions for improving the Relational Agent, and potential applications in primary care. We conducted a content analysis of transcribed interview notes, employing standard qualitative research techniques to identify dominant themes.

RESULTS: Among the 24 participants, 19 (79 %) expressed positive impressions of answering the NM-ASSIST with a Relational Agent, InterNetView crack serial keygen, while 3 (13 %) were neutral and 2 (8 %) were negative. A total of 14 (58 %) reported being comfortable completing the NM-ASSIST with the Relational Agent. Only 6 participants (25 %) indicated that they preferred the Relational Agent over a live interviewer, while 11 (46 %) preferred the live interviewer and 7 (29 %) were indifferent. Live interviewer was generally preferred because of greater depth of interaction, InterNetView crack serial keygen, ability to clarify questions Defraggler Professional v2.22.995 key Archives responses or unease with technology. In contrast, participants who favored the Relational Agent appreciated its ease and efficiency of use, privacy and lack of judgmentalism, and clear answer choices. Among 18 Veterans expressing InterNetView crack serial keygen opinion, similar percentages favored the use of Relational Agents to ask questions about benign (diet and exercise [16/18, 89 %], family history [15/18, 83 %]), and sensitive (sexual history [15/18, 83 %]) topics. Participants offered constructive feedback on the Relational Agent’s behavior, particularly her eye movements; speech, InterNetView crack serial keygen, being unnatural and computerized; and relatively unsophisticated graphics. Veterans generally favored the Relational Agent’s appearance (attractive woman dressed casually but modestly) and did not express a preference for other characteristics. Veterans frequently voiced concerns about how the Relational Agent would maintain confidentiality of their responses.

CONCLUSIONS: Although participants preferred a live interview to interaction with a computerized Relational InterNetView crack serial keygen, a majority of Veterans were comfortable with the Relational Agent and would be willing to engage with it for counseling and screening for sensitive topics such as substance use and sexual history. Future randomized trials will test the effectiveness of Relational Agents in both screening and brief intervention for substance use problems.

A RANDOMIZED CONTROLLED TRIAL OF AN EVIDENCE-BASED TOOLBOX AND GUIDE TO INCREASE PRIMARY CARE CLINICIANS’ RATES OF COLORECTAL CANCER SCREENING IN DIPLOMATES OF THE ABIM Lorna A. Lynn2; Carmen E. Guerra1; Kathryn M. Ross2; Eric Holmboe2; Kaitlin Woo1; Daniel InterNetView crack serial keygen. Heitjan1; Debbie Kirkland3; Durado Brooks3. 1Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 2American Board of Internal Medicine, Phiadelphia, PA; 3American Cancer Society, Atlanta, GA. (Tracking ID #1642572)

BACKGROUND: Colorectal cancer screening (CRCS) is effective, cost-effective and consistently recommended by clinical guidelines, yet only 64.5 % of Americans aged 50–75 years have been screened, InterNetView crack serial keygen. Recommendation from a physician is the most influential factor in determining whether a patient is screened for CRC. This study was undertaken to determine whether the Evidence-Based Toolbox and Guide to Increase Primary Care Clinicians’ Rates of CRCS, developed by the Centers for Disease Control and American Cancer Society, could help diplomates of the American Board of Internal Medicine (ABIM) recertifying for the Internal Medicine boards increase their practice rates of CRCS. The main study aim was to compare practice rates of CRCS in the the control (PIM only) and study (PIM + toolbox) arms.

METHODS: In this randomized controlled trial diplomates who are primary care providers for patients over age 50 and who were enrolled in ABIM’s Maintenance of Certification program were invited to participate. Participants had to enroll in the Cancer Screening Practice Improvement Module (PIM), which requires physician-directed measurement of their performance and design of a quality improvement plan. Diplomates were randomized to InterNetView crack serial keygen PIM or the PIM + toolbox arm. The toolbox InterNetView crack serial keygen of four essential sections and evidence-based tools: Your Recommendation, An Office-based Policy, a Reminder System and an Effective Communication System. Analysis was based on the intention-to-treat principle. An external auditor determined the validity of self-reported CRCS rates in a random sample of 20 % of the participants.

RESULTS: A total of 2288 recruitment emails were sent to ABIM diplomates who met the inclusion/exclusion criteria of whom 160 diplomates expressed interest in participation and 144 enrolled in the study. Of these, 79 diplomates completed the study. The CRCS rates declined in 17 of the InterNetView crack serial keygen, but improved in the remaining 62. We conducted an analysis of covariance, a GEE and mixed logistic regression models. All final CRCS were adjusted for the baseline performance and all results showed a non-significant treatment effect. In the final mixed logistic regression model adjusted for the baseline performance rate and treatment group of the physician and shown in Table 1, we determined the strength of various physician characteristics in predicting the probability of a successful screening that was performed post-treatment. Medical school country was the only predictor of improved screening rates post-treatment.

CONCLUSIONS: These results InterNetView crack serial keygen that while most diplomates improved their CRCS rates from baseline during the study, the improvement was not significantly different in the control arm (PIM only) compared to the study arm (PIM plus toolbox), InterNetView crack serial keygen. Medical school country was the only predictor of success rate, with those physicians who attended medical school abroad having an odds ratio of 4.32 (95 % CI: 1.75–10.65) of performing a successful screening than those physicians who attended medical school in the U.S.

Odds ratio estimates and 95 % confidence intervals

Effect Odds Ratio Estimate 95 % CI

Baseline Performance Rate 1,010 (1.00, 1.03)

Treatment vs. Control Arm 1.680 (0.88, 3.19)

Solo vs. Group Practice 1.463 (0.57, 3.76)

Female vs. Male 1.263 (0.65, 2.44)

Foreign vs. U.S. Medical School 4.318 (1.75, 10.65)

Age 0.950 (0.90, 1.01)

Years until MOC Expiration 0.990 (0.77, 1.28)

A RANDOMIZED TRIAL OF TWO APPROACHES TO TRAINING VETERANS AFFAIRS (VA) MEDICAL HOME HEALTHCARE PROVIDERS ON MOTIVATIONAL INTERVIEWING FOR TOBACCO CESSATION Steven Fu1,2; Craig Roth2; Catherine Battaglia4; David Nelson1; Melissa Farmer5; Tam Do1; Michael Goldstein6; Rahul Kavathekar2; Rachel InterNetView crack serial keygen Hildi Hagedorne1; Alan Zillich3. 1Minneapolis VA Health Care System, Minneapolis, MN; 2Minneapolis VA Health Care System, InterNetView crack serial keygen, Minneapolis, MN; 3Roudebush VA Medical Center, Indianapolis, IN; 4VA Eastern Colorado Health Care System, Denver, CO; 5VA Greater Los Angeles Health Care System, Los Angeles, CA; 6VHA National Center for Health Promotion and Disease Prevention, Durham, InterNetView crack serial keygen, NC. (Tracking ID #1638026)

BACKGROUND: Tobacco cessation counseling from a clinician doubles a patient’s odds of quitting. Motivational interviewing (MI) is an effective communication skill in tobacco cessation counseling, but strategies to train providers on MI are needed. This study evaluated a high-intensity versus moderate-intensity MI training program to improve delivery of tobacco cessation care.

METHODS: VA Patient Aligned Care Team (PACT) members at 2 VA facilities were randomized to moderate- or high-intensity MI training. Both training models included the following 3 components: 1) 3-day intensive MI training for site-based MI clinical champions and a site-based MI expert consultant, 2) Half day on-site training workshop for PACT members, and 3) self-study materials. The high-intensity model added 6 booster sessions coached by champions. Three booster sessions used telephone interactions with simulated patients and occurred at 4, 8, and 12 weeks after the initial training. Three additional booster sessions (at 2, 6, and 10 weeks) used small group coaching facilitated by the champions. Each 1-h booster session focused on specific MI skills. To evaluate the 2 training models, a structured clinical evaluation (OSCE) was conducted with providers in each group before and 12 weeks after the onsite training. The OSCEs assessed provider competence with and acquisition of MI and tobacco cessation skills through interaction with a simulated patient. A trained, InterNetView crack serial keygen, blinded rater assessed the provision of MI skills by listening to the audio-recorded OSCEs. The primary outcome was the Motivational Interviewing Treatment Integrity (MITI) scale scores, a validated assessment of MI skills. Hierarchical models compared the average changes in MITI scale scores from the pre-training OSCE to the 12 week InterNetView crack serial keygen OSCE for the moderate intensity and the high intensity groups. The models incorporated random effects for study site and participant and fixed effects for simulated patient and pre-training OSCE MITI scores.

RESULTS: Thirty-five PACT members were enrolled in the study and 18 members were randomly assigned to the high intensity group. Compared to the moderate intensity group, the high intensity group scored significantly higher for 5 of the 10 MITI scales (Table 1). For 3 of the other 5 MITI scales, a non-significant improvement was seen in the high intensity versus the moderate intensity group.

CONCLUSIONS: A training model using several booster sessions incorporating telephone interactions with simulated patients, in addition to MI champions, expert consultant, ½ day training and study materials,was effective for sustaining and enhancing providers’ MI skills in the delivery of tobacco cessation care.

Table 1

MITI Scales InterNetView crack serial keygen Group Pre-MITI Score (SD) Post-MITI Score (SD) Model Estimated Change (SE) p-value

Global Spirit High Intensity 2.89 (0.61) 3.20 InterNetView crack serial keygen 0.31 (0.20)

Moderate Intensity 2.67 (0.81) 2.50 (0.72) −0.26 (0.21)

Difference 0.57 (0.20) 0.0091

Percent Open Questions High Intensity 0.32 (0.21) 0.48 (0.23) 0.17 (0.04)

Moderate Intensity 0.27 (0.18) 0.32 (0.24) 0.03 (0.05)

Difference 0.14 (0.06) 0.0336

Percent MI Adherence High Intensity 0.50 (0.37) 0.90 (0.19) 0.31 (0.11)

Moderate Intensity 0.62 (0.38) 0.57 (0.39) −0.00 (0.12)

Difference 0.32 (0.10) 0.0047

Evocation High Intensity 2.75 (0.88) 3.00 (1.22) 0.33 (0.22)

Moderate Intensity 2.40 (1.05) 2.00 (0.87) −0.54 (0.27)

Difference 0.87 (0.35) 0.0211

Collaboration High Intensity 2.69 (0.93) 3.16 (1.02) 0.38 (0.33)

Moderate Intensity 2.68 (1.13) 2.32 (1.04) −0.43 (0.35)

Difference 0.81 (0.28) 0.0083

A STRATEGY TO ENGAGE COMMUNITY BASED ORGANIZATIONS IN BUILDING RESEARCH CAPACITY Crispin N. Goytia1; Barbara Brenner2; Peggy M. Shepard3; Lea Rivera-Todaro1; Carol Horowitz1. 1Mount InterNetView crack serial keygen School of Medicine, New York, NY; 2Mount Sinai School of Medicine, New York, NY; 3WE ACT for Environmental Justice, New York, NY. (Tracking ID #1642376)

BACKGROUND: Building and sustaining community-academic research partnerships is a challenge for both academic institutions and for community based organizations (CBOs). Each partner comes to the relationship with differing expertise and gaps in knowledge. Many Clinical and Translational Science Award (CTSA) sites are working to build CBO capacity to engage in research, but information about needs and goals of CBO’s in this regard is lacking. Therefore, our CTSA’s community and academic partners aimed to conduct a community research needs assessment.

METHODS: Based on literature review, informal interviews with research-interested CBOs locally InterNetView crack serial keygen nationally, and with community-engaged research groups from other CTSAs, we developed a needs assessment survey. Key domains of this survey included experience and interest in research collaboration, skill development and program evaluation. The team identified a preliminary list of 80 eligible CBOs through network analysis and a list from the Foundation Center’s Directory of New York City organizations that received grants in 2009–2010 in health services or research. We trained Community Health Workers (CHWs) to recruit a senior leader from each site and the CHW’s encouraged them via mail, email and telephone over a 90-day period to complete the survey.

RESULTS: Fully 76 % (61) CBOs completed the needs assessment. Most (69 %) umt box crack Archives involvement with research or evaluation in the last 2 years, 42 % were currently involved in research or program evaluation and 33 % had some funding for research. Fully 75 % had collaborated with academic institutions in the past. Most were interested in collaborating or working as partners on research, with a mean score of 6 on a scale of 1 = not interested, to 8 = the most interested. The average experience with collaboration in research was unimpressive: “good” on a scale of “poor, fair, good, very good, excellent”. The four areas of greatest interest were program evaluation, developing a needs assessment, statistical analysis and survey development. There was less interest in how to establish a research collaboration with academics. Respondents preferred a hybrid format of online and in- person workshops to other options to either format on its own.

CONCLUSIONS: A formal needs assessment of the research training and education needs of CBO’s in New York City revealed that, despite underwhelming experiences with collaboration, most had significant interest in future collaboration and learning about research. CBO leaders were particularly interested in learning about how to conduct research and evaluation, and less interested in learning how to partner with academics to collaborate on research. Community representatives from the CTSA will use these findings to: develop a research capacity building course, InterNetView crack serial keygen. Other partnerships should consider building or making use of such assessments to transform the capacity of community organizations to be active research partners and leaders.

A SUCCESSFUL COMMUNITY PARTNERSHIP MODEL FOR RECRUITING PUBLIC HOUSING RESIDENTS INTO RESEARCH Tracy A. Battaglia1; Jo-Anna L. Rorie2; Sarah W. Primeau1; Sarah E. Caron1; Sarah G. Bhosrekar2; Bing L. Chen1; Sharon Bak1; Gerry Thomas3; Rachel Goodman5; Eugenia Smith4; Deborah J. Bowen2. 1Boston University School of Medicine, Boston, InterNetView crack serial keygen, MA; 2Boston University School of Public Health, Boston, MA; 3The Boston Public Health Commission, Boston, MA; 4The Community Committee for Health Promotion, Boston, MA; 5The Boston Housing Authority, Boston, MA. (Tracking ID #1612855)

BACKGROUND: The Boston University Partners in Health and Housing Prevention Research Center (PHH-PRC), a partnership between the School of Public Health, Community Committee for Health Promotion, Boston Housing Authority and Boston Public Health Commission, aims to improve the health of Boston’s Public Housing residents through research. This study aims to demonstrate the Center’s ability to recruit and retain a representative sample of residents in the community setting to participate in a research study.

METHODS: An ongoing community engagement activity of the PHH-PRC is the conduct of monthly, on-site educational health screenings conducted in collaboration with housing development residents and research center staff. We conducted a descriptive analysis of enrollment outcomes from these community-based health screenings held across 6 housing developments from April 2011 through June 2012. The outcome of interest was enrollment into Project HHEART (Heart Health Equality Among ResidenTs), a patient navigation intervention study designed to improve clinical and community program participation among housing development residents at risk for cardiovascular disease. All those attending the health screenings completed a survey, underwent an evaluation for cardiovascular risk factors and received written educational materials. Those eligible for enrollment into Project HHEART were ≥18 years of age, spoke English or Spanish, resided in the respective housing development and screened positive for ≥1 risk factor (overweight/obese, hypertension, hypercholesterolemia, diabetes, tobacco use). We compared socio-demographic and risk factor characteristics of those eligible vs. ineligible for Project HHEART enrollment. Among those eligible, we compared characteristics of those who enrolled vs. declined.

RESULTS: 610 residents participated in screenings April 2011–June 2012. Most were female (74 %), non-White (30 % Black, 44 % Hispanic, 15 % other), had public (84 %) or no health insurance (10 %), reported a clinical visit with a primary care provider in the past 3 months (62 %) and screened positive for >1 risk factor (92 %). About half spoke a language other than English (50 %), were foreign-born (49 %), InterNetView crack serial keygen, and had less than high school education (45 %). Overall, 451 (74 %) of participants were eligible for enrollment. Reasons for ineligibility included: not living on site (n = 106), no positive screens for risk factors (n = 32) and significant language barriers (did not speak English or Spanish) (n = 21). Compared to those ineligible for Project HHEART, eligible participants were InterNetView crack serial keygen likely to be older (mean age 50 v. 49 years, p < 0.01), Hispanic (48 % v. 33 %, p < 0.01), and have public or no health insurance (93 % v. 86 %, p = 0.05). Of the 451 eligible participants, 326 (72 %) agreed to participate and were enrolled into Project HHEART. Compared to those who declined to participate, enrolled subjects were slightly younger (mean age 50 v. 53, p < 0.01), but did not differ in any other socio-demographic or health risk factor status. Of those enrolled (n = 326), InterNetView crack serial keygen, 80 % completed 3-month follow-up surveys.

CONCLUSIONS: Socio-demographic differences in eligibility reflect the study design. Among those eligible, we enrolled and retained a representative sample of public housing residents and engaged them into prevention research. This program serves as one viable model to engage a diverse population in research.

A TECHNOLOGY-BASED APPROACH TO IDENTIFYING UNDIAGNOSED HYPERTENSION Christopher Masi1; Michael Rakotz1,2; Ruth Ross1; Ari Robicsek1; Chad Konchak1; Bernard Ewigman2. 1NorthShore University HealthSystem, Evanston, IL; 2NorthShore University HealthSystem, Evanston, IL. (Tracking ID #1633262)

BACKGROUND: Affecting 30 % of all U.S. adults 18 years and older, hypertension is the leading modifiable risk factor for coronary artery disease, stroke, and congestive heart failure. According to the 2008 National Health and Nutrition Examination Survey, approximately 19 % of U.S. adults with hypertension are unaware of their diagnosis. Our goal was to identify primary care patients with suspected but undiagnosed hypertension and then clarify their status using an automated office blood pressure (AOBP) device.

METHODS: We queried the electronic health records (EHR’s) of patients who receive care at one of twenty-three health system-affiliated primary care clinics to identify adults aged 18 to 79 years who had at least one primary care office visit within 12 months of the query, had elevated blood pressure readings InterNetView crack serial keygen identified by at least one of five hypertension screening algorithms, and did not have a diagnosis of hypertension recorded in the EHR. Individuals who met these criteria were considered at-risk for undiagnosed hypertension and were invited to complete a clinic-based AOBP measurement using a BpTRU device which averages five readings over a five-minute period. Since each patient had one or more previously documented elevated blood pressure readings, we classified patients based upon their AOBP mean: hypertension if BP ≥ 140/90 mmHg; prehypertension if BP ≥ 120/80 mmHg InterNetView crack serial keygen <140/90 mmHg; and white coat hypertension if BP < 120/80 mmHg. The positive predictive value (PPV) of the hypertension screening algorithms was calculated by dividing the number of individuals with an AOBP mean in the prehypertension or hypertension ranges (true positives) by the number of individuals identified by at least one of the hypertension screening algorithms (all positives).

RESULTS: Of the 139,666 adults who receive care at one of the participating clinics, 1,586 met our inclusion criteria. After confirming the appropriateness of study participation with each patient’s primary care physician, attempts were made to recruit 1,432 patients. 475 of these patients agreed to participate in the study and undergo a clinic-based AOBP measurement. Among participants, the median age was 54.4 years, the mean BP recorded in the EHR was 136/82 mmHg, and the mean BMI was 29.6 kg/m2. Fifty-two percent of participants were male. Participants identified themselves as Caucasian (70.9 %), African American (6.1 %), Hispanic/Latino (3.4 %), Asian (2.7 %), or other (16.8 %). Comparing the 475 participants to the 957 non-participants revealed the participants were older (54.4 vs. 50.0 years, p < 0.001) but were similar in all other respects, including distribution of ethnicities, InterNetView crack serial keygen, and prevalence of co-morbidities, including diabetes, congestive heart failure, and COPD. Based upon AOBP means among participants, InterNetView crack serial keygen, 183 (39 %) had hypertension, 196 (41 %) had prehypertension, and 96 (20 %) had white coat hypertension. The positive predictive value for detecting prehypertension or hypertension using our technology-based approach was 80 %.

CONCLUSIONS: Essential elements of our approach included an EHR, computer-based screening algorithms, and an established AOBP protocol. Results from this study confirm the notion that technology-based strategies have significant potential to detect undiagnosed chronic disease - a critical first step toward enhancing chronic disease management.

A VALID MEASURE OF HEALTH-RELATED TRUST FOR USE IN DIVERSE POPULATIONS Rebecca J. Schwei1; Paul Rathouz2; Seung W. Choi3; Elizabeth A. InterNetView crack serial keygen. 1University of Wisconsin School of Medicine and Public Health, Madison, WI; 2University of Wisconsin School of Medicine and Public Health, Madison, WI; 3McGraw-Hill Education, Monteray, CA. (Tracking ID #1640804)

BACKGROUND: Varying levels of distrust in health care among racial/ethnic groups are hypothesized to contribute to health disparities in the US, InterNetView crack serial keygen. However, few measures of trust and distrust have been developed and validated for use across racial/ethnic groups to allow adequate exploration of this hypothesis. The objective of the study was to develop a measure of health-related trust in the 3 major racial/ethnic groups in the US: African Americans, Hispanic-Mexicans, and non-Hispanic whites.

METHODS: We developed candidate items through extensive qualitative work, cognitive testing, piloting, and rigorous translation into Spanish. We administered the 81 candidate items to a convenience sample of African American (n = 142), Hispanic-Mexican (n = 143), and non-Hispanic white (n = 155) individuals at Chicago-area supermarkets. Participants responded using a 5-item Likert response scale: never true, a little true, InterNetView crack serial keygen the time true, mostly true, InterNetView crack serial keygen, always true. We conducted exploratory and confirmatory factor analyses using Mplus. We also asked “In the InterNetView crack serial keygen 5 years, InterNetView crack serial keygen, have you had a negative health care experience you considered to be bad or negative?” (Y/N).

RESULTS: The final instrument contained 36 items and 7 factors: Discrimination (3 items), Equity (6 items), Hidden Agenda (4 items), Insurance (3 items), Negative Physician Perceptions (5 items), Positive Physician Perceptions (12 items) and System Welcoming (3 items). A higher trust score indicated increased trust. The instrument (α = .94) and individual factors performed well overall and in each racial/ethnic group (α = .61 to .94) The 7-factor CFA model provided reasonable fit statistics InterNetView crack serial keygen, TLI = .961, RMSEA = .055) and evidence for construct validity. Across all racial/ethnic groups individuals reporting a negative health care experience had lower levels of institutional trust.

CONCLUSIONS: Our measure of health-related trust performed well across racial/ethnic groups while including constructs that may vary considerably across groups (e.g., Discrimination). There was increased trust in groups without a reported previous negative health care experience. We found trust in health care to be multi-faceted, incorporating perceptions about physicians, health care systems, and insurance. This measure has the potential to advance the field studying how health-related trust contributes to health disparities in the US.

A CASE METHOD EDUCATION ON MANAGEMENT OF DISCHARGE PLANNING FOR HEALTHCARE PROFESSIONALS Yukio Tsugihashi1,2; Noriko Kawai2; Hitoshi Ishii2. 1Tenri Hospital, Tenri, Japan; 2Tenri Hospital, Tenri, Japan. (Tracking ID #1627411)

BACKGROUND: In collaborative healthcare systems, reducing length of stay has been a priority for general hospitals. There is concern that the reduction may provide low-quality transitional care for the patients and the families. In order to secure the quality for the patients and the families, hospital workers should effectively acquire a management skill for discharge planning. A case method is a InterNetView crack serial keygen method that is widely used in business schools. Students can enhance their leadership and management skills through discussion about a teaching case. The case is a document that objectively illustrates InterNetView crack serial keygen cases to be solved and includes information for classroom discussion. Both business and discharge planning, there are no simple solutions. We hypothesized that the case method could be adjusted into education in discharge planning. Therefore, we developed a novel educational program for the discharge planning using a case method education. The purpose of this study was to (1) develop educational strategies and (2) assess the learning outcomes of this program.

METHODS: This study was conducted from April 2012 to July 2012 at one general hospital in Japan (Tenri Hospital, InterNetView crack serial keygen, Tenri City, Nara, Japan). Cornerstones of the program are provided in Table 1. The Participants were provided with a case method education consisting of following three steps: 1) Preparing their opinions for teaching cases before the classes. 2) Discussing with other participants in small groups and a classroom, 3) A short lecture summarizing key points in the cases. A medical doctor and a registered nurse specialized in care InterNetView crack serial keygen prepared four cases based on actual care transition in Tenri Hospital. In order to evaluate learning outcomes of the program, we performed questionnaire surveys after each lecture, including descriptive analyses about participants’ satisfaction and qualitative content analysis focused on their self-awareness through the program.

RESULTS: This study enrolled 57 healthcare providers working in Tenri Hospital and affiliated care institutions. With regard to the occupation, 31(54 %) were registered nurses, 7 (12 %) were medical social workers, and 19 (38 %) were other occupations including physical therapists, long-term care support specialists, medical doctors, pharmacists, certified care workers, medical college teachers and medical secretary. Over 90 % of the participants were satisfied with the program. The participants’ self-awareness was identified to the following three categories: acquiring core competencies for discharge planning, problem extraction through active interaction among the participants, and precious opportunities for inter-professional communications in the related institutions.

CONCLUSIONS: A case method by the discussion-based education using actual cases successfully contributed to enhance the participants’ awareness for management of discharge planning in addition to obtaining the core competency, InterNetView crack serial keygen. Furthermore, the program itself could promote inter-professional communications among the hospital workers.

Table 1. Cornerstones of a case method education on management of discharge planning

Teaching method A case method education with 3 h session per a month (Small group discussion: 60 min, Classroom discussion: 60 min, Short lecture: 30 min)

Duration/Frequency 4 months/One Saturday afternoon per month

Titles of teaching cases Case 1. An elderly woman emergently admitted to a hospital with acute pyelonephritis

Case 2. An elderly patient with advanced dementia and bilateral leg gangrenes

Case 3. A patients who can’t eat by mouth because of severe neurological disease

Case 4. Tohoku earthquake. Effort of medical support teams from Nara prefecture

Learning outcomes Satisfaction level (descriptive analysis)/Self-awareness (qualitative analysis)


Toshio Naito1; Fujiko Mitsumoto2; Hiroyuki Morita3; Masafumi Mizooka4; Shiro Oono5; Akira Ukimura6; Keito Torikai7; Kenji Kanazawa8; Masashi Yamanouchi1; Susumu Tazuma4; Jun Hayashi2. 1Juntendo University School of Medicine, Tokyo, Japan; 2Kyushu University Hospital, Fukuoka, Japan; 3Gifu University Graduate School of Medicine, Gifu, Japan; 4Hiroshima University Hospital, Hiroshima, Japan; 5Nara Medical University, Nara, Japan; 6Osaka Medical College, Osaka, Japan; 7St. Marianna University School of Medicine, Tokyo, Japan; 8Kobe Universtiy Hospital, Kobe, Japan. (Tracking ID #1634255)

BACKGROUND: Fevers of unknown origin (FUO) are caused by a wide range of diseases, and they occur in a variety of regions and age groups. In Japan, research on the topic has been limited to single facilities/regions, and no national surveys have been conducted. Analysis is important, InterNetView crack serial keygen, as causes may differ with race, region and era. Further, few studies have evaluated the usefulness of diagnostic exams, and FUO is diagnosed according to guidelines specific to each facility. In particular, there has been very little research on the efficacy of recently developed diagnostic methods, such as blood procalcitonin analysis and positron emission tomography (PET). Here, we conducted a national survey at facilities belonging to the Japanese Society of General Hospital Medicine, to clarify what exams are useful and what diseases deserve attention in the differential diagnosis and treatment of FUO.

METHODS: Seventeen facilities were surveyed nationwide from January to December 2011. The subjects were patients who were 18 years or older and diagnosed with “classical FUO (a fever with an axillary temperature of 38 °C or higher and measured 2 times or more in a period of 3 weeks or longer, and where the cause was unclear after 3 outpatient visits or a 3-day hospital stay).” Subject data were recorded in a common case report form and tallied using FAX.

RESULTS: A total of 121 FUO cases were recorded, with a median age of 59 years (19–94 years). The causative disease was infection in 28 cases (23.1 %), noninfectious inflammatory disease in 37 cases (30.6 %), malignant tumor DataGrip crack serial keygen 13 cases (10.7 %), something else in 15 cases (12.4 %), and unknown in 28 cases (23.1 %). “Something else” included causes such as drug-induced fevers. The median number of days from fever onset to first examination was 28 days. A case of familial Mediterranean fever took the longest days to be diagnosed. Blood cultures were performed at 86.8 %, blood procalcitonin values measured at 43.8 %, and PET performed at 29.8 %.

CONCLUSIONS: With the increased use of computed tomography, FUO due to deep abscesses or solid tumors have declined markedly. The causative disease with the largest proportion was polymyalgia rheumatica (9 cases), reflecting the aging of the society. The relatively small number of cases due to an unknown cause was possibly attributable to the bias of the retrospective study. HIV/AIDS caused 4 FUO cases, showing that this has become an important cause of FUO in Japan. This study clarified diseases that deserve attention when differentiating FUO. We have a plan to analyze the usefulness of exams and create guidelines for diagnosing FUO.

A NATIONAL STUDY OF INTERNISTS’ POINT OF CARE LEARNING Michael Green1; Siddharta Reddy2; Eric Holmboe2. 1Yale School of Medicine, New Haven, CT; 2American Board of Internal Medicine, Philadelphia, PA. (Tracking ID #1639990)

BACKGROUND: Physicians frequently encounter clinical questions at the point of care (POC), which represent opportunities for learning, immediate application of new knowledge, and longer term performance improvement. An understanding of these POC learning episodes would inform continuing medical InterNetView crack serial keygen programs, electronic information resources, evidence-based practice training, and reflective practice. Previous studies of POC learning have been confined to small numbers of physicians in limited geographic areas.

METHODS: We studied internists enrolled in the ABIM Maintenance of Certification (MOC) program who registered for and entered at least one question in the ABIM Point-of-Care Clinical Question Module between November 2010 and December 2012. To complete this web-based module, internists documented the characteristics, information seeking, learning, practice impact, and barriers of at least 20 point of care clinical questions. We compiled descriptive statistics for the module data.

RESULTS: Four-hundred-seventy-two internists entered at least one clinical question (224 completed the module, 188 are currently working on it, and 60 cancelled). Among those who completed the module, 197 (88 %) spent more than 30 h per week in patient care activities, 66 (28 %) were generalists, and 108 (48 %) worked in academic settings. The internists documented 5187 POC learning episodes over periods ranging from 1 to 19 months. The episodes most commonly were stimulated by direct patient care in the ambulatory setting, with or without a trainee (57 %); InterNetView crack serial keygen cardiovascular disease (21 %) or gastroenterology (14 %) content; represented foreground questions (58 %); and concerned therapy (55 %) or diagnosis (14 %) questions. The internists spent a median of 30 min looking up medical information, InterNetView crack serial keygen, most often some time after the clinical encounter (61 %); using a median of 2 resources; and most commonly consulting UpToDate® (25 %) and articles retrieved via PubMed (17 %). The internists planned to change their practice based on 40 % of the point of care learning episodes. Among the remainder, they reported that the information supported their current practice (47 %), they required more information before making a change (9 %), or the practice change was not InterNetView crack serial keygen (3 %). Internists encountered barriers during 11 % of the learning episodes, including limited access to information resources (17 %), uncertainty about the sufficiency of the information initially obtained (13 %), difficulty searching information resources (11 %), and difficulty appraising the validity or usefulness of the information (8 %).

CONCLUSIONS: Using a novel web-based portfolio for MOC, internists’ report POC learning episodes that most commonly occur in the ambulatory setting, involve cardiovascular disease or gastroenterology content, and concern questions of therapy and diagnosis. They consult an average of two information resources per episode, most commonly UpToDate and PubMed. Forty percent of POC learning episodes result in a planned practice change.

A PREDICTION RULE FOR MORTALITY FOR INPATIENTS WITH STAPHYLOCOCCUS AUREUS BACTEREMIA: A CLASSIFICATION AND REGRESSION TREE (CART) ANALYSIS Daiki Kobayashi1,2; Kyoko Yokota4; Osamu Takahashi2,3; Hiroko Arioka2; Tsuguya Fukui2; Christina C. Wee1. 1Beth Israel Deaconess Medical Center, Boston, MA; 2St Luke’s International Hospital, Tokyo, Japan; 3St Luke’s Life Science Institute, Tokyo, Japan; 4Kagawa University, Takamatsu, Japan. Norton Utilities Crack + Activation Code [2021] ID #1641328)

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is one of the most common types of bacteremia in both community and healthcare settings. Previous studies suggest that the mortality associated with SAB is significant rangeing from 20 to 40 %. Although mortality is high, the risk factors for mortality among patients with SAB have not been sufficiently evaluated.

METHODS: This was a retrospective cohort study of all adult patients with SAB at a large community hospital in Tokyo, Japan, from April 1, 2004 to March 31, 2011. All patients with fever and afebrile patients who were suspected of having a bacterial infection had 2 sets of blood cultures sent at the time of admission. SAB was determined based on at least one positive blood culture. The primary outcome was death within 90 days. Baseline data and clinically relevant factors were collected from the electronic chart. All candidate predictors were included in a Classification and Regression Trees (CART) analysis to create a prediction rule to identify risk factors of mortality among patients with SAB. A receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was obtained.

RESULTS: 340 patients had SAB during the study period. Of these, 121 (36 %) patients died within 90 days. Among 41 potential variables examined, InterNetView crack serial keygen CART analysis revealed that underlying malignancy, serum blood glucose level, methicillin resistance, and low serum albumin were predictors of mortality. Our results suggest that patients can be categorized in 3 risk groups: low (< 30 % mortality), medium (40–60 %), and high (> 60 %) (see fig). For patients without underlying malignancy, the next best predictor was serum blood glucose level, where patients with a blood glucose level >167 mg/dl had higher risk of mortality (see fig). Methicillin resistance predicted mortality risk only among patients who had a glucose level higher than 167 mg/dl. For patients with malignancy, serum albumin was the most important predictor; patients with <3.25 mg/dl albumin were placed in the high risk group. The AUC was 0.76 (95 %CI: 0.70–0.81).

CONCLUSIONS: We propose a prediction model for mortality of patients with SAB consisting of 4 predictors: underlying malignancy, low serum albumin, high glucose, and methicillin resistance. This model, if validated in other populations, may facilitate appropriate preventative management for patients with SAB who are at high risk of mortality.

Decision tree for 90 Day Mortality (95 % Confidence Interval) Among Patients with Staphylococcus aureus Bacteremia. Results are derived from CART Analysis. Low risk = <30 % mortality, medium risk = 40–50 %, high risk = > 60 % MSSA* refers to Methicillin-sensitive Staphylococcus aureus, MRSA† refers to Methicillin-resistant Staphylococcus aureus


Shreya Kangovi1,6; David Grande2,3; Nandita Mitra4; Jeffrey Sellman1; Mary L. White6; Sharon McCollum6; Richard Shannon2; Judith A. Long5,2. 1Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 3University of Pennsylvania, Philadelphia, PA; 4University of Pennsylvania, Philadelphia, PA; 5Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; 6Spectrum Health Services, Inc., Philadelphia, InterNetView crack serial keygen, PA. (Tracking ID #1631341)

BACKGROUND: The post-hospital transition is a focus of national policy attention, InterNetView crack serial keygen. Low socioeconomic status (SES) patients are more likely to report poor quality of discharge planning, lack of social support during recovery and inability to access outpatient follow-up after hospitalization. Low-SES patients have an elevated risk of all-cause readmission and post-hospital death. Existing post-hospital transition interventions often employ clinical personnel and neglect socioeconomic factors that are important to low-SES patients. To address these issues, we performed a randomized controlled trial comparing a community health worker (CHWs) intervention (IMPaCT-Individualized Management towards Patient-Centered Targets) to usual discharge care.

METHODS: Participants were recruited from two academically affiliated hospitals in Philadelphia, PA. Eligible patients were:1)admitted to the General Medicine service; 2)uninsured or insured by Medicaid; 3)18–64 years old and 4)residents of low-income ZIP codes. Eligible patients were randomized to receive usual discharge care or InterNetView crack serial keygen. Patients randomized to IMPaCT received structured CHW social support, InterNetView crack serial keygen, advocacy and health system navigation from the time of hospitalization until post-hospital primary care follow-up. CHWs were recruited through a network of community-based organizations, underwent a month-long training and were paid $15 per hour. The primary outcome of the trial was the proportion of patients who completed primary care follow-up within 2 weeks of hospital discharge. Secondary outcomes, InterNetView crack serial keygen, which each ranged from 0 to 100, were: self-rated health (SF-12), quality of discharge communication (Consumer Hospital Consumer Assessment of Healthcare Providers and Systems-HCAHPS- discharge communication items), patient activation (Patient Activation Measure score) and readmission rate at 14,30,60 and 90 days. Patient-reported outcomes were measured by a blinded assessor 2 weeks after index discharge. We compared outcomes between control and intervention groups using an intention to treat analysis.

RESULTS: 442 patients were enrolled from May 15th, 2011 to December 1st, 2012. 86.6 % of participants completed the trial. The intervention group had a higher proportion of patients who engaged in post-hospital primary care than the control group (59.4 % vs. 48.4 %, p = 0.03). Patients in the intervention group had higher self-rated health mental component summary scores (49.2 vs. 46.3, p = 0.02), were more likely to report high-quality discharge communication (91.3 % vs, InterNetView crack serial keygen. 78.3 %, p = 0.002) and had higher levels of patient activation (64.0 vs. 60.3, p = 0.04). At 14 days readmission rates were not different between groups (9.9 % vs. 7.2 %, p = 0.60). 30, 60 and 90-day readmission rates are pending.

CONCLUSIONS: A brief transitions intervention performed by CHWs can improve a variety of post-hospital outcomes for low-SES patients. 14-day rates of readmission are low and not different between groups. CHWs, who are inexpensive and rapidly trained, are well-suited to provide post-hospital support to a high-risk, underserved population.

Secondary Patient-Reported Outcomes*

Control (n = 221) Intervention (n = 221) P Value

Self-rated health

Mental Component Summary 46.3 ± 12.9 49.2 ± 12.4 0.02

Physical Component Summary 38.2 ± 11.8 38.4 ± 11.1 0.89

HCAHPS high-quality discharge communication 78.3 % 91.3 % 0.002

Patient Activation Measure 60.3 ± 15.9 64.0 ± 17.4 0.04

14-d Readmission 7.2 % 9.9 % 0.60

*Values are expressed as percentage or mean ± SD

A RANDOMIZED CONTROLLED TRIAL OF PRIMARY CARE BASED PHARMACIST-PHYSICIAN COLLABORATIVE MEDICATION THERAPY MANAGEMENT FOR HYPERTENSION Jan D. Hirsch1; Neil Steers2; David S. Adler1; Grace M. Kuo1,4; Candis M. Morello1; Megan Lang6; Renu F. Singh1; Yelena Wood3; Robert M. Kaplan5; Carol Mangione2. 1University of California San Diego, La Jolla, CA; 2University of California Los Angeles, Los Angeles, CA; 3University of California San Diego, San Diego, CA; 4University of California San Diego, La Jolla, CA; 5University of California Los Angeles, Los Angeles, CA; 6University of California San Diego, San Diego, CA. (Tracking ID #1634599)

BACKGROUND: Managing patients with chronic diseases to achieve therapeutic goals such as blood pressure (BP) control is challenging for busy primary care physicians. Collaborative care models that fully integrate pharmacists within the primary care team may help address this problem by giving patients better access to highly trained provider teams, InterNetView crack serial keygen. We conducted a randomized controlled trial (RCT) evaluating BP control for hypertensive patients collaboratively managed by a pharmacist-primary care physician team versus those who were solely managed by their primary care physician (PCP).

METHODS: Patients with BP > 140/90 mmHg or BP > 130/80 mmHg with a diagnosis of diabetes mellitus were randomized to treatment by a pharmacist under a collaborative pharmacist-physician medication therapy management (MTM) protocol versus usual care in an academic General Internal Medicine practice. Patients were scheduled for pharmacist appointments independent of physician visits, InterNetView crack serial keygen. Pharmacist actions included drug therapy monitoring, InterNetView crack serial keygen, physical assessment, laboratory test review and order, medication adjustments (dosage change, initiation, discontinuation), and patient education. The primary outcome was mean change in systolic blood pressure (SBP) at 6 and 9 months after initial visit, InterNetView crack serial keygen. Secondary outcomes were percent achieving BP goal, mean change in diastolic blood pressure (DBP), LDL and HDL cholesterol.

RESULTS: At baseline the MTM group (n = 76) was similar to the Usual Care group (n = 91) for all eight measured clinical markers; however MTM patients were slightly younger 65.4 (13.0) vs. 69.6 (11.4) years, had lower Charlson Comorbidity Index 3.1 (1.9) vs. 4.1 (2.6), and had more men (53.3 % vs. 31.9 %). Mean change in SBP in the InterNetView crack serial keygen group was significantly greater at 6 months −7.1 (19.4) vs, InterNetView crack serial keygen. +1.6 (21.0) mm Hg, (p = 0.008) but the difference was no longer statistically significant at 9 months −5.2 (16.9) vs. −1.7 (17.7) mmHg, (p = 0.22). The mean change in SBP from initial visit to 9 months for patients who had returned to their PCP after 6 months was +1.9 (13.8) compared to −7.8 (17.3) for those who continued to see the MTM pharmacist through the 9-month visit (p = 0.03). Compared to Usual Care patients, a greater percentage of MTM patients were at goal at 6 months (81 % vs. 44 %, p < 0.001) and 9 months (70 % vs. 52 %, p = 0.02). No significant difference in change in LDL or HDL was detected at 6 or 9 months between groups.

CONCLUSIONS: A pharmacist-physician collaborative medication therapy management service was more effective in lowering blood pressure than usual care at 6 months and at 9 months for patients who continued to see the pharmacist. Given the shortages of PCPs and the aging population, incorporating pharmacists in the primary care team can be a successful strategy for managing medication therapy, improving patient outcomes and extending primary care capacity.


BACKGROUND: Cervical cancer disproportionately affects minority and immigrant women. Among this population, there are multiple barriers to Pap smear screening including knowledge, InterNetView crack serial keygen, limited access to care and cultural norms. In 2012, the USPSTF noted that self sampling for the human papilloma virus (HPV) holds great promise as a screening strategy among hard to reach populations. We present preliminary findings from our ongoing randomized trial testing this approach in three minority communities in Miami.

METHODS: The South Florida Center for Reduction of Cancer Disparities is a comprehensive NCI initiative aimed at reducing cervical cancer disparities in South Florida through community based participatory research. Using community health workers (CHWs) our community partners are recruiting 600 minority women ages 30–65 who had not had a Pap smear in the last three years into the study. Following a baseline intake, women are randomized into one of three arms. Group one receives culturally tailored cervical cancer education materials. Groups 2 and 3 receive a 1 hour CHW home health education session. CHWs subsequently refer and navigate women in group 2 to Pap smear screening at community based facilities that perform free or low cost testing. Women in group 3 have the option of Pap smear or doing HPV self sampling after a brief CHW instruction session. A research assistant blinded to study allocation performs a 6 month follow-up visit to assess screening status. A formal interim analysis was not part of the study design. However, we are able to present preliminary baseline data as well as follow-up status in Groups 2 and 3 based on CHWs logs. We do not include any hypothesis testing.

RESULTS: To date, using various community outreach strategies, CHWs have assessed 2,601 women for study inclusion. Of these 515 are study eligible; most ineligibles are due to being screened already or age exclusion. Less than 5 % of eligible women have declined to participate. Among the 280 women we have already randomized, 51 % are Hispanic, 39 % Haitian, and 11 % African American. Over half are uninsured. Among the 70 women randomized to group 2 and having already received the educational session, 48 % have obtained a subsequent Pap smear. Among the 64 women randomized to Group 3 who have received the education, 95 % have been screened, InterNetView crack serial keygen. Of these 69 % preferred to have the HPV self-sampling at time of CHW session over being referred for a Pap smear. In Little Haiti, 10 of 21 (48 %) HPV samples have been positive for high risk HPV versus 18 % in the other two communities.

CONCLUSIONS: Using the CBPR framework, in a 14 month period we have been able to recruit and randomize almost half of our planned 600 “hard to reach” study population with almost no women refusing to participate. Our rates of Pap smear completion among women in group 2 compares very favorably with data from other similar CHW led programs. Our preliminary data also makes an extremely strong case for HPV self-sampling as a strategy for cervical cancer screening among unscreened minority women.

A RANDOMIZED TRIAL OF A WEB-BASED VERSUS COUNSELOR-BASED INTERVENTION TO REDUCE CHD RISK Stacey L. Sheridan; Thomas C. Keyserling; Lindy B. Draeger. University of North Carolina at Chapel Hill, Chapel Hill, NC. (Tracking ID #1642611)

BACKGROUND: Coronary heart disease (CHD) is the leading InterNetView crack serial keygen of death in the United States and effective interventions are available to reduce CHD risk. However, the best way to implement risk InterNetView crack serial keygen strategies is yet to be determined.

METHODS: We developed two versions of a combined lifestyle and medication intervention (counselor intevention (CI) and web intervention (WI)) to reduce CHD risk and compared their effects in a randomized trial conducted at five socioeconomically diverse clinics in a practice-based research network. Both interventions were tailored to participants’ baseline risk factors and InterNetView crack serial keygen preferences and included similar content: a web-based decision aid, 4 monthly contacts during an intensive intervention phase (4 months) and 3 brief contacts at 2 month intervals during a maintenance phase (8 months). The primary outcome was within group change in 10 year predicted risk by Framingham score at 4 month follow-up. Secondary outcomes included between group difference in predicted CHD risk and within group changes in CHD risk factors, lifestyle behaviors, and medication adherence. Cost-effectiveness from a societal perspective was also assessed.

RESULTS: We randomized 389 participants with no known CHD and 10-year Framingham CHD risk > or =10 % to either the CI (n = 195) or the WI (n = 194). Mean age was 63. 49 % were female, InterNetView crack serial keygen, 25 % were African-American and 75 % white. Mean 10-year predicted CHD risk was 16.9 %. 14 % read at less than a 7–8th grade reading level. 88 % had health insurance, InterNetView crack serial keygen. At 4 month follow-up, the CI reduced CHD risk by 2.2 percentage points (p < .0001) and the WI by 1.4 percentage points (p < 0.001; adjusted mean difference between groups: 0.8 percentage points, p 0.04). These changes resulted from small changes in systolic blood pressure (CI: −2.85 mmHg; WI −1.1 mmHg), total cholesterol (CI: −8.4 mg/dL; WI −3.8 mg/dL), HDL cholesterol (CI: +1.4 mg/dL; WI: +1.8 mg/dL), smoking cessation (CI: −3 %; WI −2 %) and aspirin use (CI: +10 %; WI: +11 %). Small statistically significant changes were also noted in self-reported fruit and vegetable intake (CI: +0.4 servings/day; WI: +0.2 servings/day), walking (CI: +54 min/week; WI: +30 min/week), and adherence (% with high adherence in CI: +14 %; WI: +18 %). The incremental cost-effectiveness ratio for a 1 percentage point reduction in CHD risk was $129 for the WI compared with usual care, and $159 for the CI compared with the WI.

CONCLUSIONS: Both counselor and web interventions reduced CHD risk compared to baseline. The counselor intervention was somewhat more effective than the web intervention, but the web intervention was incrementally more cost-effective.

A RANDOMIZED, CONTROLLED TRIAL OF ALTERNATIVE FORMS OF FEEDBACK ON GLYCEMIC CONTROL IN PATIENTS WITH POORLY CONTROLLED DIABETES Anjali Gopalan1,3; Emin Tahirovic2; Haley Moss2; Andrea B. Troxel2; Jingsan Zhu2; Kevin G. Volpp1,2. 1Philadelphia VA Medical Center, Philadelphia, PA; 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 3Robert Wood Johnson Clinical Scholars Program, Philadelphia, PA. (Tracking ID #1633742)

BACKGROUND: Prior work has indicated that understanding of the hemoglobin A1c (A1c) among diabetic patients is low. A 2008 study in the British Medical Journal by Parkes et al. showed the potential effectiveness of translating poorly understood medical values into more universally understood forms. This study expressed FEV1 in terms of “lung age” to active tobacco users. Patients given their “lung age” in place of their FEV1 value had significantly higher rates of smoking cessation at study completion. This approach may hold promise for improving feedback for diabetic patients on glycemic control.

METHODS: We randomly assigned 177 poorly controlled diabetics seen at University of Pennsylvania outpatient practices to receive a “diabetes report card” with individualized information about glycemic control in one of InterNetView crack serial keygen study arms: (1) letter grades ranging from A-F (grade arm); (2) faces whose emotion reflected current glycemic control (face arm) or (3) actual A1c value (control arm) (Figure 1). The primary study outcome was change in A1c values between baseline and 6 months. Secondary outcomes were changes in participant perceptions of their current diabetes control, disease severity, and future risk of associated complications.

RESULTS: The average A1c for enrolled participants was 9.9 ± 1.7 % and did not differ significantly between study arms. The pre-intervention survey confirmed high levels of misunderstanding of current glycemic control, with the majority (63 %) of participants describing their control as ‘moderate’ or ‘good’/‘excellent’ in spite of an average A1c of 9.8 % and 10.2 %, respectively. We noted no significant differences in change in A1c at 6 months between the control arm and the experimental arms. Using multiple imputation to handle missing A1c values, the change in A1c for the grade, face, InterNetView crack serial keygen, and control arms was −0.55 ± 0.3 %, −0.89 ± 0.3 %, and −0.74 ± 0.37 %, respectively (p = 0.67 for grade vs. control, p = 0.76 for face vs. control). We found no significant differences between study arms for the changes in perceptions of current diabetes control, severity, and future complication risk.

CONCLUSIONS: Letter grades and faces did not differentially affect A1c at 6 months or participant perceptions of current control in this population of poorly controlled diabetics. This may reflect the particular alternatives tested in this study, without invalidation of the concepts that improving communication and patient understanding InterNetView crack serial keygen disease management targets could significantly improve diabetes outcomes.

A SYSTEMATIC REVIEW OF INTERVENTIONS TO IMPROVE PALLIATIVE CARE REFERRAL Irene Kirolos1; Leonardo Tamariz1; Barbara A. Wood2; Ana M. Palacio1. 1University of Miami-Miller School of Medicine, Miami, FL; 2University of Miami-Miller School of Medicine, Miami, FL. (Tracking ID #1642043)

BACKGROUND: Palliative care is underutilized among patients at the end of their lives despite evidence that it improves patient satisfaction and that it reduces costs. The purpose of this study is to synthesize the evidence regarding interventions to increase palliative care usage.

METHODS: We performed a MEDLINE database search (1979 to November InterNetView crack serial keygen supplemented by manual searches of bibliographies of key relevant articles. We selected all studies in which an intervention was used in palliative care or hospice, InterNetView crack serial keygen. Study design, quality criteria, population, interventions and outcomes for each study were extracted. The main InterNetView crack serial keygen evaluated was increase in hospice/palliative care referral.

RESULTS: Our search strategy yielded 412 studies, InterNetView crack serial keygen, of which only five met our eligibility criteria (table). Three studies included nursing home populations and only one study reported on heart failure patients. Three studies had a cohort design, InterNetView crack serial keygen, one had a pre-post design and only one study had a randomized design. The specific intervention differed in each study. The cohort studies that implemented a palliative care program that ranged from a facilitator to a comprehensive program had a median increase in referrals of 14 %, InterNetView crack serial keygen. The randomized study that included a triage system to identify patients’ needs and preferences increased referral by 19 %. Similar trends were seen in the pre-post design.

CONCLUSIONS: Interventions of different levels of complexity can improve the use of palliative and hospice services among subjects with high mortality risk, particularly nursing home patients. More data is needed on the impact of interventions targeting high risk groups in other clinical environments.

Study design Number of studies Population InterNetView crack serial keygen % Referral to palliative care in intervention group % Referral to palliative care in control group

Cohort 3 At risk of death InterNetView crack serial keygen care program 47(31–56) 33(7–37)

Pre-post 1 Nursing home Educational 7 4

Randomized 1 Nursing home Triage system 20 1

A WEB-BASED LIFESTYLE INTERVENTION TO DECREASE POSTPARTUM WEIGHT RETENTION IN WOMEN WITH RECENT GESTATIONAL DIABETES MELLITUS: THE BALANCE AFTER BABY PILOT RCT Jacinda M. Nicklas1,2; Chloe A. Zera3; Bernard A. Rosner4,5; Sue E. Levkoff6,7; Ellen W. Seely2. 1University of Colorado School of Medicine, Aurora, CO; 2Brigham and Women’s Hospital, Boston, MA; 3Brigham and Women’s Hospital, Boston, MA; 4Harvard Medical School, Boston, MA; 5Harvard School of Public Health, Boston, MA; 6Brigham and Women’s Hospital, Boston, MA; 7University of South Carolina, Columbia, SC. (Tracking ID #1631193)

BACKGROUND: Women with a history of gestational diabetes mellitus (GDM) have a 7-fold increased risk for developing type 2 diabetes (T2DM). A post-hoc analysis of women with self-reported history of GDM in the Diabetes Prevention Program (DPP) demonstrated that an intensive face-to-face lifestyle intervention focused on weight loss significantly decreased the incidence of T2DM by 53 % over 3 years. However, face-to-face weight loss interventions in postpartum women in general have demonstrated poor adherence and efficacy. We sought to develop and test a postpartum lifestyle intervention based on the DPP and modified for women with recent GDM.

METHODS: After conducting focus groups and informant interviews with women with prior GDM, we developed a web-based program named Balance after Baby. Key modifications from the DPP included web-delivery to allow 24-h access, lifestyle coaching by phone/email, and content tailored for the postpartum period. Women with GDM in their most recent pregnancy were recruited during pregnancy or early postpartum and randomized into the Balance after Baby program or enhanced control arm (glucose tolerance tests) 4–12 weeks postpartum. Pre-pregnancy weight was self-reported at recruitment; gestational weight gain and insulin use were extracted from medical records. We administered demographic questionnaires and measured height, weight, and response to a 2 h 75 g oral glucose tolerance test, at 6 weeks, 6 months, and 12 months postpartum. We compared mean weight changes using an intent-to-treat model by t-tests and by estimating a mixed-effects regression model using a random intercept and an unstructured covariance matrix. We conducted structured exit interviews with women completing the program.

RESULTS: 75 women with recent GDM were randomized (mean age 33.4 ±5.4 years; BMI 31.4 (±5.6) kg/m2; 57 % White, 29 % African-American, InterNetView crack serial keygen, 15 % Asian, with 20 % Hispanic; 34 % low-income). There were no significant differences between groups at baseline for age, race, education, income, InterNetView crack serial keygen, weight, BMI, pre-pregnancy weight, gestational weight gain, insulin use in pregnancy, breastfeeding, or glucose tolerance, InterNetView crack serial keygen. Clinically determined weights were collected 12 months postpartum for 95 % of eligible participants. Women assigned to the Balance after Baby arm lost a mean 5.0 (±13.5) lbs compared to women in the control arm who gained 1.3 lbs (±9.8) (p = .0223) between 6 weeks and 12 months postpartum. Women in the Balance after Baby arm were at their pre-pregnancy weight (mean −0.2 ± 15.4 lbs) at 12 months postpartum vs. the control arm (+7.9 ± 15.3 lbs) (p = 0.025). In a longitudinal mixed model controlling for pre-pregnancy weight, assignment to the Balance after Baby arm resulted in greater loss at 6 (mean 8.5 lbs, SE 2.7, p = 0.002) and 12 months (mean 7.0 lbs, SE 2.9, p = 0.0175) compared to women in InterNetView crack serial keygen control arm. While there were no significant group differences in glucose tolerance at 12 months, 3 women in the control group developed T2DM compared to none in the intervention group. Women randomized to the Balance after Baby InterNetView crack serial keygen expressed a high degree of satisfaction with the program.

CONCLUSIONS: The web-based Balance after Baby program is feasible, acceptable, and resulted in greater postpartum weight loss in women with recent GDM. If confirmed and found cost-effective in a longer study, the Balance after Baby program could be used at the population level to increase postpartum weight loss and potentially delay or prevent development of T2DM in women with recent GDM.

ACADEMIC DETAILING TO TEACH AGING AND GERIATRICS Cathryn Caton; Ashley Duckett; Theresa Cuoco; Pamela Pride; Patty J. Iverson; William P. Moran. Medical University of South Carolina, Charleston, SC. (Tracking ID #1643098)

BACKGROUND: Detailing has been employed by the pharmaceutical sales industry to increase physician knowledge about new medications. Work hour rules have challenged residency training programs to develop and utilize efficient and effective teaching methods. We chose to employ academic detailing as a teaching intervention in our residents’ clinic and on the general medicine inpatient wards to improve clinical knowledge and skills in geriatric care.

METHODS: Aging Q3 - Quality InterNetView crack serial keygen, Quality Care and Quality of Life- is a longitudinal curriculum focusing on improving geriatric knowledge in the residency program at the Medical University of South Carolina. Sixteen geriatric topics were chosen based on the Assessing Care of Vulnerable Elder (ACOVE) paradigm and each topic was delivered over 3 months. For each ACOVE, faculty workgroups of 6 members identified key educational messages and skill instruction to teach residents over a three-month intervention period. Each workgroup created one page academic detailing sheets with specific knowledge and skills to be reviewed. Residents were detailed at the time of encounters with geriatric patients with key messages of the current ACOVE by faculty using the provided detailing sheets. By design, the one-on-one detailing process took about 5 min, thereby ensuring that residents were not significantly delayed on rounds or in their clinics.

RESULTS: Over three years noon conference attendance for Aging Q3 topics ranged from 20 % to 51 %, while the percentage of residents detailed by faculty ranged from 61 % to 93 %. ACOVEs with the highest rates of resident detailing had statistically significant increases in medical knowledge, as measured by pre-test/post-test. For ACOVEs with the highest resident detailing rates, general medicine faculty participation in the detailing process ranged from 60 % to 86 %. In some instances, despite good detailing rates and improvement in self-efficacy, there was not a statistically significant improvement in medical knowledge.

CONCLUSIONS: We found that academic detailing is an efficient way of reaching a high percentage of residents and increasing knowledge in aging and geriatrics. Topics with a narrow focus are best InterNetView crack serial keygen in this format.

ACOVE Detailing Rates and Resident Knowledge

ACOVE Detailing Rates (%) Pre-test (%) Post-test (%) p-value

Pressure Ulcers/Malnutrition 93 6 41 <0.0001

Falls 86 16 49 <0.0001

Osteoporosis 85 29 62 <0.0001

Screening & Prevention 78 16 40 <0.0001

Continuity of Care 88 46 31 0.0419

Vision 84 63 71 0.2489

Dementia 82 41 32 0.2558

Pain Management 80 1 15 0.1579

End of LIfe Care 78 55 51 0.6907

Hospital Care & Transitions 73 38 57 0.0163

Medication Use & Safety 61 28 36 0.5174

ACOVE Detailing Rates and Resident Self Efficacy

ACOVE Detailing Rates (%) Pre-test Mean Confidence Score Post-test Mean Confidence Score Paired t-test on mean change in reported confidence p value

Continuity of Care 88 - - - n/a

Dementia 82 - - - n/a

End of Life Care 78 8.72 9.55 0.83 0.0013

Falls 86 9.71 11.08 1.37 <0.0001

Hospital Care & Transitions 73 11.25 11.98 0.73 0.0056

Medication Use & Safety 61 - - - n/a

Osteoporosis 85 2.45 3.83 1.38 <0.0001

Pain Management 80 9.87 10.48 0.61 0.0039

Pressure Ulcer/Malnutrition 93 2.82 3.6 0.7765 <0.0001

Screening & Prevention 78 2.72 2.4 0.3167 0.0106

Vision - - - - n/a

ACCESS TO SUBSPECIALTY CARE FOR PATIENTS WITH MOBILITY IMPAIRMENT Tara Lagu1,2; Nicholas S. Hannon1; MIchael B. Rothberg8; Annalee S. Wells9; K. Laurie Green3,4; McAllister O. Windom5; Katherine R. Dempsey1; Penelope S. Pekow1,6; Jill S. Avrunin1; Aaron Chen7; Peter K. Lindenauer1,2. 1Baystate Medical Center, Springfield, MA; 2Tufts University School of Medicine, Boston, MA; 3Baystate Medical Center, Springfield, MA; 4Baystate Medical Center, Springfield, MA; 5Duke University School of Medicine, Durham, NC; 6University of Massachusetts-Amherst, Amherst, MA; 7University of New England College of Osteopathic Medicine, Biddeford, ME; 8Cleveland Clinic, Cleveland, OH; 9Dorchester House, Dorchester, InterNetView crack serial keygen, MA. (Tracking ID #1615945)

BACKGROUND: The Americans with Disabilities Act (ADA) states that all medical practitioners are required to provide “full and equal access to their health care services and facilities,” yet adults who use wheelchairs have difficulty accessing physicians and receive less preventive care than their able-bodied counterparts. We aimed to describe access to medical and surgical subspecialists for patients with mobility impairment.

METHODS: Using a standardized script, we called subspecialty (endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology, psychiatry) practices in four metropolitan areas in the United States and attempted to make an appointment for a fictional patient who used a wheelchair and was unable to transfer from chair to exam table. If a practice reported that they were able to make an appointment for the patient, the investigator would then probe to clarify that both the building and office were accessible and to determine the method by which the practice planned to transfer the patient from the wheelchair to the exam table. If the practice was unable to accommodate the patient, the investigator responded with the question, “Can you please explain why you are unable to accommodate this patient?” We calculated summary statistics and conducted a qualitative analysis of the responses.

RESULTS: Of 256 practices, 56 (22 %) reported they could not accommodate our fictional patient. Only nine of these reported that the building was inaccessible. The remaining 47 reported that they were unable to transfer a patient from a wheelchair to an exam table. Reasons for the inability to transfer the patient included a lack of staff who could perform the transfer (37 practices), a concern about liability (five practices), or that the “patient was too heavy” (five practices). Inaccessibility varied by subspecialty: only 6 % of psychiatry practices were inaccessible, while gynecology was the subspecialty with the highest rate (44 %) of inaccessible practices. The other subspecialties had proportions of inaccessible practices ranging from 13 to 28 %. Of 200 accessible practices, 67 (33 %) reported they had equipment that could adjust to the patient while sitting in the wheelchair (e.g., otolaryngology, InterNetView crack serial keygen, ophthalmology) or, in the case of psychiatry, that they did not need to move the patient for an exam. 103 practices (51 %) reported they planned to “manually transfer” the patient from her wheelchair to a non-accessible high table without the use of a lift. Only 22 practices (11 %) reported the use of accessible tables or use of a lift for transfer.

CONCLUSIONS: More than 20 years after the passage of the ADA, many subspecialty practices were unable to accommodate a patient with mobility impairment. This was rarely due to building inaccessibility. More frequently, practices were inaccessible because they were unable to transfer the patient to perform an exam. A minority of accessible of practices possessed equipment that would facilitate the safe transfer (from chair to table) of our fictional patient. Instead, a majority of accessible practices reported transfer methods that have been deemed to be unsafe by disability experts. These results provide one possible explanation for the health care disparities observed in this population and identify the need for better awareness among physicians about the requirements of the ADA and the standards of care for patients with mobility impairment.

ACCULTURATION AND RISK FACTORS FOR HYPERTENSION AMONG A HETEROGENEOUS POPULATION OF BLACK MEN Candace Tannis; Jessica M, InterNetView crack serial keygen. Forsyth; Joseph Ravenell. NYU School of Medicine, New York, NY. (Tracking ID #1638147)

BACKGROUND: Black men are at increased risk for developing hypertension and consequent morbidity compared to other racial/ethnic groups. The composition of the Black population in the United States is diversifying rapidly, with many implications for the prevention and management of hypertension. InterNetView crack serial keygen study seeks to examine the role of acculturation on engagement in therapeutic lifestyle changes (TLCs; healthy diet, physical activity, smoking and alcohol consumption, and medication adherence) to lower blood pressure (BP).

METHODS: Participants were recruited during health screening events for a larger clinical trial at barbershops and churches. All adult men who self-identified as Black were eligible. Acculturation, the main predictor variable, was measured using a single item regarding place of birth and a 10-item questionnaire adapted from two measures: the Cultural Lifestyle Inventory (CLSI); and the Measures of Acculturation Strategies for People of African Descent (MASPAD). Items taken from the CLSI and MASPAD were measured on 5-point and 6-point Likert scales respectively with items summed to create scale scores. Outcome variables included 1) diet, measured using the National Cancer Institute fat screener and a 2-item modified Food Frequency Questionnaire measuring daily fruit and vegetable consumption; 2) physical activity, measured with the shortened International Physical Activity Questionnaire; 3) medication adherence, measured with the 4-item Morisky scale; and 4) smoking and alcohol consumption, measured using items adapted from the Behavioral Risk Factor Surveillance Survey. BP was measured using an automated BP cuff, InterNetView crack serial keygen, and co-morbidity was measured InterNetView crack serial keygen the Charlson Co-morbidity Index. We utilized ANCOVA to test group differences in outcome variables between foreign-born and US-born at baseline, and linear regression to examine relationships between acculturation and outcome variables at baseline. All analyses controlled for age, income, employment status and education level.

RESULTS: 171 men completed the survey. 26 % were foreign-born. The mean age of participants was 53.6 years (SD = 10.24) and the median annual income was $11,400. Twenty-seven percent of men in the study reported having less than a high school education, and 75 % of the men were currently unemployed. Foreign-born participants had lower percentage of fat in their diets InterNetView crack serial keygen. There were no differences between foreign-born and US-born men in mean BP, presence of co-morbidity, and lifestyle behaviors other than fat consumption. However, InterNetView crack serial keygen, among participants who reported taking BP medication, foreign-born blacks had poorer adherence (p = 0.028). Medication non-adherence was also associated with the “traditionalist” MASPAD dimension (p = 0.015, R2adj .333), as well as positively with the individual item corresponding to ethnic pride (p = 0.021) and negatively with maintenance of cultural practices (p = .035). There was no relationship between acculturation and the TLCs other than medication adherence or measured BP.

CONCLUSIONS: This study provides evidence that nativity and acculturation among Black men may play a role in engagement in certain TLCs to lower BP. More research is needed to determine how best to tailor TLC interventions to control hypertension for the rapidly diversifying population of Black men, the highest risk group in the United States.

ACCURACY OF RACE/ETHNICITY AND LANGUAGE PREFERENCE IN AN ELECTRONIC HEALTH RECORD Sara V. Carlini1; Elissa Klinger1; Irina Gonzalez1; Jeffrey A. Linder1; Elyse R. Park2; Emily Kontos3; Nancy A. Rigotti2; Jennifer Haas1,3, InterNetView crack serial keygen. 1Brigham and Women’s Hospital, Boston, MA; 2Massachusetts General Hospital, Boston, MA; 3Harvard School of Public Health, Boston, MA. (Tracking ID #1634097)

BACKGROUND: Eliminating health care disparities requires accurate data on race/ethnicity and language preference. Health care organizations that receive federal funds are required to record information about patient race/ethnicity and language preference, yet little is known about the accuracy of these electronic health record (EHR) data.

METHODS: We compared the accuracy of race/ethnicity and language preference data recorded in an EHR, compared to self-reported race/ethnicity and language preference (English, Spanish) from an Interactive Voice Recognition (IVR) survey as part of a randomized controlled trial of a telephone-based tobacco treatment program. Using IVR, we called 6,771 low-income (by zip code) white, InterNetView crack serial keygen, black, or Latino smokers who were listed in the EHR as English or Spanish-speaking and had made a primary care visit in the preceding 60 days; 2,189 (32 %) answered the phone InterNetView crack serial keygen selected a language preference, and 434 (6 %) enrolled and provided information about race/ethnicity.

RESULTS: Median age was 51 years; 53 % self-reported race/ethnicity as white, 26 % as African-American, and 21 % as Hispanic; and 10 % reported that they were Spanish-speaking. Overall agreement between EHR-recorded and self-reported race/ethnicity information was excellent (Kappa 0.84; p < 0.001). However, the sensitivity and positive predictive value (PPV) for EHR-recorded race/ethnicity compared to self-report varied by InterNetView crack serial keygen 82 % and 97 % for Hispanics, 78 % and 95 % for African-Americans, and 100 % and 87 % for whites, suggesting InterNetView crack serial keygen for both Hispanics and African-Americans, some individuals are misclassified in the EHR as white. For language preference, EHR-documentation and self-report showed good overall agreement (Kappa 0.74, p < 0.001), but the PPV for an EHR-documented language preference of Spanish was only 68 % with a sensitivity of 86 %. While only 1.2 % of EHR-documented English speakers elected to InterNetView crack serial keygen the IVR call in Spanish, 31.9 % of EHR-documented Spanish speakers elected to hear the call in English.

CONCLUSIONS: We demonstrate strong agreement between EHR-recorded and self-reported race/ethnicity and language preference. However, there were inaccuracies that indicate the need to investigate how EHR data are obtained and perhaps systems to improve EHR documentation. The results also demonstrate the InterNetView crack serial keygen of offering services that respond to multilingual patients, who may have differing preferences based on the specific content and method of contact.

ACCURATE DISEASE ATTRIBUTION IS A HURDLE FOR DEVELOPMENT OF A PAY FOR PERFORMANCE REIMBURSEMENT MODEL Jennifer Zreloff; Jillian Gaumond; Jason Higdon, InterNetView crack serial keygen. Emory University, Atlanta, GA. (Tracking ID #1642285)

BACKGROUND: With medical reimbursement shifting away from fee for service and toward quality incentives, it is important to understand the accuracy of data being used by insurance companies and clinics for quality incentive payouts.

METHODS: In the setting of a university-based and NCQA recognized InterNetView crack serial keygen Medical Home with a single payer, we sought to reconcile quality reports generated InterNetView crack serial keygen our payer versus by our clinic’s data warehouse. Lists of patients were generated with diabetes, CHF, and COPD. Our private payer generated its list based on their methods InterNetView crack serial keygen utilize billing data. Lists generated by the PCMH were generated InterNetView crack serial keygen diagnoses on the “problem list” in the EMR and diagnosis billing data specific to that clinic. The two lists were compared and evaluated by chart review when they were discordant. Chart review included all data available such as labs, echo, radiology, specialty clinic notes, and PCP notes. Patients were then divided into groups of inclusion error by insurance, inclusion error by PCP, InterNetView crack serial keygen, exclusion error by insurance, and exclusion error by PCP

RESULTS: Percentage of times that the Private Payer and the PCMH agreed varied by disease state, InterNetView crack serial keygen. Based on the total number of patients included in a disease group by either the insurance company or the PCMH, 61.2 % of the patients on the diabetes list, InterNetView crack serial keygen, 32.1 % of those on the CHF list, and 21.2 % of those on the COPD list, were agreed upon by both the insurance company and the clinic. There were both errors of omission and inclusion by the insurance company. Errors of inclusion (those attributed to have the disease that did not actually have it) occurred for diabetes in 16.9 % of the total attributed patients, 32.1 % for CHF, and 78.8 % for InterNetView crack serial keygen. Errors of exclusion (those that had the disease but were not InterNetView crack serial keygen by the insurance company) occurred for 21.9 % of diabetics, 35.7 % of patients with heart failure, and 0 % with COPD. A small percentage of errors of exclusion occurred with the PCMH. There were no errors of inclusion by the PCMH. Looking at only the data generated by the insurance company, 21.7 % of insurance-attributed diabetic patients were incorrect, and 26.3 % of the patients on the final, verified diabetic list were missing. For CHF, 50 % of insurance-attributed patients were incorrect, and 52.6 % of patients on the InterNetView crack serial keygen CHF list were missing, InterNetView crack serial keygen. COPD had the worst data accuracy with 78.8 % of insurance-attributed patients being incorrect, InterNetView crack serial keygen, and with no missing patients.

CONCLUSIONS: When entering the world of pay for performance, it is important to recognize the inherent inaccuracies of data based primarily on claims data. This clinic had the added luxury of a separate attribution process which allowed both sides to agree on the total pool of patients. For most clinic sites the quality data would be expected to have more errors due to discrepancies of attribution to PCP. For these reasons, it is important for clinics to have opportunities to collect their own quality data specific to disease attribution, and have a reconciliation process with payers participating in pay for performance initiatives.

ACETAMINOPHEN RECEIPT AMONG HIV-INFECTED PATIENTS WITH ADVANCED HEPATIC FIBROSIS E. J. Edelman1; Kirsha S. Gordon2; Vincent Lo Re3; Melissa Skanderson4; David A. Fiellin1; Amy C. Justice2,1. 1Yale University, New Haven, CT; 2VA Connecticut Healthcare System, West Haven, CT; 3University of Pennsylvania, Philadelphia, PA; 4VA Pittsburgh Healthcare System, Pittsburgh, PA. (Tracking ID #1642388)

BACKGROUND: HIV-infected (HIV+) patients may be at particular risk for acetaminophen-induced hepatotoxicity given their underlying risk of liver disease, high prevalence of hepatitis C virus (HCV) coinfection, differences in acetaminophen metabolism, and exposure to antiretroviral therapy. However, acetaminophen overuse (greater than 2 g per day) in the context of liver injury has been incompletely examined among HIV+ patients. Among a cohort of HIV+ patients, our aims were to: 1) describe the patterns of acetaminophen receipt; 2) assess the cross-sectional association between acetaminophen receipt and advanced hepatic fibrosis; and 3) determine whether factors associated with acetaminophen overuse varied by HCV status.

METHODS: We performed a cross-sectional analysis of the Veterans Aging Cohort Study-Virtual Cohort. We excluded patients who had a cancer diagnosis other than non-epithelial skin cancers; no inpatient or outpatient visit in FY2006; or missing laboratory or pharmacy data. Outpatient acetaminophen receipt among HIV+ patients in the cohort was categorized as: 1) no acetaminophen use, InterNetView crack serial keygen, 2) appropriate use (<2 g/day); or 3) overuse (> 2 g/day). The primary independent variable was advanced hepatic fibrosis, defined as a FIB-4 > 3.25. The FIB-4 score is a validated non-invasive index that identifies advanced fibrosis/cirrhosis using age, alanine aminotransferase, aspartate aminotransferase, and platelet count. We evaluated acetaminophen daily dosage stratified by FIB-4 status. We then performed multivariable ordered polytomous logistic regression to determine adjusted odds ratios (AOR) for acetaminophen daily dosage, classified as a three level outcome variable. The final model included patients characteristics that were clinically relevant or significant at the p < 0.05 level. Results were stratified by BB FlashBack Pro Crack Full Version Download status.

RESULTS: Our sample included 14,885 HIV+ patients, 4,592 (31 %) of whom received at least one acetaminophen prescription and 1,885 (41 %) of whom were HIV/HCV-coinfected. Among those receiving acetaminophen, 1,442 (31 %) patients were identified with acetaminophen overuse, with no differences observed between HIV-monoinfected and HIV/HCV-coinfected patients (846 [31 %] InterNetView crack serial keygen. 596 [32 %], p = 0.59). Among HIV-monoinfected patients, the average daily acetaminophen dose was not significantly different between those with a FIB-4 < 3.25 and those with a FIB-4 > 3.25 (1.50 vs. 1.20 g/day, p = 0.08); results were similar for HIV/HCV-coinfected patients (p = 0.14). After adjusting for age, gender, race/ethnicity, HCV status, alcohol use disorders, and pain-related diagnoses, FIB-4 was associated with a decreased odds of acetaminophen overuse (AOR [95 % CI] = 0.80 [0.65, 1.00]). After stratifying by HCV status, HIV+ patients with advanced hepatic fibrosis were equally likely to receive acetaminophen. Further, HIV-monoinfected patients with an alcohol use disorder were more likely to have acetaminophen overuse (AOR [95 % CI] = 1.56 [1.21, 2.02]).

CONCLUSIONS: Acetaminophen overuse was common in this sample of HIV+ patients. Strategies to minimize acetaminophen exposure in HIV+ patients are warranted.

ACHIEVING COMMUNICATION BETWEEN PRIMARY CARE AND MENTAL HEALTH: WHY IS IT SO DIFFICULT, EVEN IN THE VA? A QUALITY IMPROVEMENT APPROACH Evelyn Chang1; Kenneth B. Wells5,4; Alexander S. Young3,2; Susan E. Stockdale3; Jacqueline Fickel3; Megan Johnson2,3; Kevin Jou2; Lisa V. Rubenstein3,4. 1VA- Greater Los Angeles, Los Angeles, InterNetView crack serial keygen 2VA- Greater Los Angeles, North Hills, CA; 3VA- Greater Los Angeles, North Hills, CA; 4RAND, Santa Monica, CA; 5UCLA, Los Angeles, CA. (Tracking ID #1624000)

BACKGROUND: Research shows that bi-directional communication between mental health (MH) and primary care (PC) clinicians is critical for improving patient outcomes, yet achieving this in health care organizations is challenging. In the Veterans Administration (VA), the high prevalence of co-occurring physical and mental illnesses can make PC-MH collaboration essential for providing effective care. Despite extensive national VA efforts to integrate PC and MH, however, local settings continue to experience barriers to effective communication and collaboration.

METHODS: We proposed a project to the local VA site’s quality improvement (QI) council directed at improving communication between PC and MH providers. We used QI diagnostic tools InterNetView crack serial keygen understand barriers to PC/MH communication and to initiate a change strategy in a multi-specialty academic community-based outpatient clinic serving 16,000 veterans in Los Angeles. The clinic has two PC teams with five to six teamlets each using the patient-centered medical home model. We recruited 11 on-site PC and MH clinical providers, administrators, and researchers for our workgroup, which held 4 monthly meetings. The workgroup constructed fishbone diagrams of causes of poor communication and mapped communication flow among providers for emergent and non-urgent situations for the VA site. We performed chart reviews on patients with established PC and MH providers to assess documentation of communication. We conducted a rapid literature review of interventions for improving PC/MH communication and identified potentially feasible evidence-based interventions to address the problems we found.

RESULTS: PC providers were frustrated by inconsistent access to psychiatrists for emergent and routine situations. MH providers did not respect PC management of uncomplicated depression. Key communication barriers included geographic distance, cultural differences, and lack of standardized communication processes. A key facilitator was personal relationships across disciplines. Chart review confirmed considerable between-provider variation in documenting MH and medical problems and in communication strategies. Literature review, combined with the workgroup’s assessments, identified joint care planning and joint case conferences as two feasible interventions. While these interventions were developed, the site began to collocate MH specialists to PC.

CONCLUSIONS: QI tools suggested that there were procedural, cultural, and structural factors affecting communication and respect. Clarifying these factors helped to initiate InterNetView crack serial keygen ongoing change strategy. A locally tailored QI process focusing on communication helped initiate change strategies that had not originated from policy or health information systems.

ADEQUACY AND CORRECTION OF MEDICAL RECORD DOCUMENTATION IN PATIENTS WITH A PRIOR ADMISSION FOR ACE-INHIBITOR ANGIOEDEMA IN AN URBAN ACADEMIC MEDICAL CENTER: A PATIENT SAFETY INTERVENTION Andrew M, InterNetView crack serial keygen. Davis1; Eric R. Yoo3; Cheryl Nocon2; Jacquelynne P. Corey2. 1University of Chicago, Chicago, IL; 2University of Chicago, Chicago, IL; 3University of Illinois College of Medicine, Chicago, IL. (Tracking ID #1626449)

BACKGROUND: Angiotensin-converting enzyme inhibitor (ACEI) induced angioedema affecting the upper airway is a potentially life-threatening condition, InterNetView crack serial keygen, occurring in 0.1 to 2.2 % of recipients, with a higher incidence in African-American patients. Over 40 million patients in the Xilisoft Movie Maker 6.6.0 crack serial keygen. currently take a medication in this class. Recurrent ACEI-induced angioedema is readily preventable, but requires proper allergy documentation in the medical record after the first event. Our institution’s transition from Oacis to an Epic Electronic Medical Record (EMR) InterNetView crack serial keygen 2008 improved clinician training and engagement with the EMR, InterNetView crack serial keygen. This transition InterNetView crack serial keygen an opportunity to assess allergy documentation following episodes of ACEI-induced angioedema requiring inpatient admission, and to correct deficits in EMR allergy documentation in our urban academic medical center.

METHODS: We reviewed charts of patients with inpatient encounter codes for “angioneurotic edema, NOS” (ICD 995.1), hereditary angioedema (277.6), anaphylactic shock (995.0), anaphylactic shock due to food reaction (995.6), or anaphylactic shock due to serum (995.4). Cases with clear corroboration of ACEI-induced angioedema in the clinical notes were split by admit dates: 2000–2007 (n = 372 total, 82 ACEI related) and 2008–2011 (n = 139 total, 37 ACEI related). We also reviewed a random sample of 30 ED cases (2008–2011) with ACEI-related angioedema not requiring admission. The current Epic allergy and problem lists were examined for each case; elements abstracted included documentation of the ACEI allergy, the severity of reaction, and presence of the name of the specific causative agent. As a patient safety intervention, incomplete allergy documentation in the EMR was corrected.

RESULTS: Overall 95 % of the admitted patients were African American and 66 % were female; the median age was 64. The severity of angioedema in admitted patients was quite high, with 43 % requiring intubation in 2000–2007, and 59 % during the 2008–2011 period. Before current EMR implementation in 2008, 60 (73.2 %) of charts for admitted patients were completely missing ACEI-allergy documentation and 17 (20.7 %) had incomplete allergy lists. After transition to the current EMR, inpatient charts (2008–2011) markedly improved in ACEI allergy documentation (p < .001), though 5 (13.5 %) of the 2008–20011 admitted patients were completely missing data, and 29 (78.4 %) had incomplete allergy lists, lacking the specific agent or reaction severity. Patients treated and released from the ED were more likely to have absent documentation (23.3 %). In several instances, the ACEI remained on patient medication list, but review of recent notes found that ACEI had actually been discontinued, and that the medication list was in error.

CONCLUSIONS: ACEI-allergy documentation markedly improved following transition to a newer EMR; however, an unacceptably high number of patients with an admission for ACEI angioedema continued to have no documentation of this reaction on their current allergy list, and missing agent or severity data remained common. Urban medical centers InterNetView crack serial keygen regularly review ACEI allergy angioedema events, and establish a redundant patient safety process to confirm event documentation in the EMR allergy list.

Admitted 2000–2007 (n = 82) Admitted 2008–2011 (n = 37) ED only InterNetView crack serial keygen (n = 30)

Category n % n % n %

Full data at baseline 5 6.0 % 3 8.1 % 5 16.7 %

Partial data 17 20.7 % 29 78.4 % 18 60.0 %

No mention of ACEI allergy 60 73.2 % 5 13.5 % 7 23.3 %

ADHERENCE TO PRESCRIPTION OPIOID MONITORING GUIDELINES AMONG RESIDENTS AND ATTENDING PHYSICIANS IN THE PRIMARY CARE SETTING Laila Khalid; Jane M. Liebschutz; Christopher W. Shanahan; Shernaz Dossabhoy; Yoona R. Kim; Karen E. Lasser. Boston Medical Center, Boston, MA, InterNetView crack serial keygen. (Tracking ID #1636318)

BACKGROUND: Prescription opioid misuse is a significant public health problem, with primary care providers being the principal prescribers of opioids for chronic non-cancer pain, InterNetView crack serial keygen. While one study showed that residents provide higher quality primary care than attendings, opioid prescribing practices have not been compared between resident and attending physicians. We compared adherence to opioid prescribing guidelines as well as evidence for potential InterNetView crack serial keygen misuse of prescribed opioid medications between resident and attending physician.

METHODS: We InterNetView crack serial keygen a retrospective cross-sectional study at a primary care practice of a large Northeastern safety-net hospital using data abstracted from the electronic medical record through the institution’s clinical data warehouse. Patients included were 18–89 years old, who had at least one visit to primary care and were prescribed long-term opioid treatment (3 or more opioid prescriptions written at least 21 days apart within 6 months) for chronic non-cancer pain from 8/31/11 to 9/1/12. The primary outcome was adherence to any one of two key American InterNetView crack serial keygen Society Guidelines; 1) documentation of at least one opioid agreement (contract) ever, and 2) any urine drug testing in the past year; and evidence of potential prescription misuse with 1, 2 or more than 2 early refills. Early refill was a prescription written 7–25 days after InterNetView crack serial keygen previous prescription of the same drug. Patients were classified as a resident patient if they received 2, or more InterNetView crack serial keygen from a resident physician. Statistical analysis was performed using chi-square tests.

RESULTS: 96 residents prescribed opioid prescriptions to 136 patients, while 49 attendings prescribed to 609 patients. The results are summarized below.

CONCLUSIONS: Despite the low numbers of contract documentation in resident and attending patients, the majority of the patients did receive urine drug testing. It is not clear whether the documentation of a contract indicates guideline adherence. Evidence for potential misuse of prescription opioids, indicated by two or more early refills, was significantly higher in resident patients relative to attending patients. Features of a resident-based practice that may be associated with prescription opioid misuse need to be explored.

ADMISSION TO TEACHING HOSPITALS AND WEEKDAY DISCHARGES ARE ASSOCIATED WITH BETTER OUTCOMES IN HEART FAILURE PATIENTS Anita G. Au; Raj S. Padwal; Erik Youngson; Sumit R. Majumdar; Finlay A. McAlister. University of Alberta, Edmonton, AB, Canada. (Tracking ID #1635314)

BACKGROUND: It is unclear whether hospital teaching status or the day of discharge influences post-discharge outcomes for patients hospitalized with heart failure (HF).

METHODS: We linked four population-based databases in Alberta, Canada to identify adults hospitalized for HF who were discharged alive between 1999 and 2009. We conducted a retrospective cohort study comparing outcomes between patients discharged from teaching versus non-teaching hospitals and on weekends versus weekdays. The primary outcome was the composite of death or non-elective readmission 30-days post-discharge.

RESULTS: Over 10 years, 12,216 HF patients were discharged from teaching hospitals and 12,157 from non-teaching hospitals; 21,001 (86 %) discharges occurred on weekdays. Although they had greater comorbidity and used more health care resources in the year prior to HF hospitalization, patients discharged from teaching hospitals exhibited significantly lower rates of 30-day death or readmission than those discharged from non-teaching hospitals (17.4 % vs. 22.1 %, aHR 0.83, 95 % CI 0.77–0.89). Patients discharged on weekdays were older and had greater comorbidity, yet exhibited significantly lower rates of death or readmission at 30-days than those discharged on weekends (19.5 % vs. 21.1 %, adjusted hazard ratio [aHR] 0.87, 95 % CI 0.80–0.94). Compared to weekend discharge from a non-teaching hospital (reference), the 30-day risk of death or readmission was lower for weekday discharge from a non-teaching hospital (aHR: 0.85, 95 %CI 0.77–0.94), weekend discharge from a teaching hospital (aHR: 0.79, 95 %CI 0.69–0.92), and weekday discharge from a teaching hospital (aHR: 0.71, 95 %CI 0.63–0.79, with p < 0.001 for trend).

CONCLUSIONS: Patients discharged from non-teaching hospitals or on weekends exhibited poorer risk-adjusted outcomes than those discharged from teaching hospitals or on weekdays. The structures and processes which may have yielded better outcomes for those admitted to teaching hospitals and those discharged on weekdays should be studied and possibly emulated in order to optimize heart failure related outcomes.

ADVERSE OUTCOMES OF POLYSEDATIVE USE IN VETERANS WITH PTSD Brian C. Lund1,2; Stephen L, InterNetView crack serial keygen. Hillis1; Elizabeth A. Chrischilles2, InterNetView crack serial keygen. 1Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA; 2University of Iowa College of Public Health, Iowa City, IA. (Tracking ID #1628276)

BACKGROUND: While department of Veterans Affairs (VA) clinical practice guidelines recommend against their use, benzodiazepines are prescribed to 30–40 % of veterans with posttraumatic stress disorder (PTSD). Nationally, opioid abuse has been labeled as epidemic, and inpatient chemical dependency admissions involving the combination of opioids and benzodiazepines have risen more than 500 % in the last decade. Therefore, our objective was to determine whether benzodiazepines, opioids, and other sedatives - particularly in combination - are associated with adverse events in veterans with PTSD.

METHODS: National VA administrative data were used to identify veterans with PTSD. Among these patients, new benzodiazepine starters during FY04-09 (N = 66,406) were matched to nonusers (N = 128,062) using high dimensional propensity scores. Adverse events were based on prior work involving sedative use in veterans and included emergency visits and hospitalizations for wounds/injuries, drug-related accidents/overdoses, and self-inflicted injuries identified by ICD-9 coding. One year adverse event risk was determined using a stratified Cox proportional hazards model. Exposure to opioids and other sedatives was modeled with time-dependent covariates. Prazosin use was included as a control exposure because InterNetView crack serial keygen is prescribed in PTSD for the treatment of nightmares and other sleep disturbances but does not have significant sedating properties.

RESULTS: Adverse events occurred within 1 year in 2,926 (1.5 %) patients. Hazard ratios (95 % C.I.) for adverse events were: benzodiazepines, InterNetView crack serial keygen, 1.8 (1.6–2.0); opioids, 1.4 (1.2–1.7); atypical antipsychotics, 1.9 (1.7–2.1); and hypnotics, 1.4 (1.1–1.8). In addition, the benzodiazepine-opioid interaction was significant (p < .001), indicating a multiplicative effect where the hazard ratio for this combination was 3.8 compared to nonusers of both. Among dual users of benzodiazepines and opioids, 78 % were prescribed by different providers. Prazosin exposure and other interaction terms were not significantly associated with adverse events.

CONCLUSIONS: Polysedative use in veterans with PTSD leads to incremental risk for serious adverse events. The combination of benzodiazepines and opioids is particularly troublesome given the synergistic interaction and the tendency toward being prescribed by different providers. The clinical complexity of caring for veterans with PTSD creates an environment that, without careful coordination of care, can lead to high-risk polysedative use.

AFTER THE FACT: EDUCATING WOMEN INCARCERATED IN JAIL ON THE USE OF MEDICAL THERAPIES TO PREVENT HIV ACQUISITION FOLLOWING A RISKY EXPOSURE Neha Gupta3; Heidi Schmidt3; Timothy Buisker2; Mi-Suk Kang Dufour2; Janet Myers2; Jacqueline P. Tulsky1. 1University of California San Francisco, San Francisco, CA; 2University of California San Francisco, San Francisco, CA; 3University of California San Francisco, San Francisco, CA. (Tracking ID #1634988)

BACKGROUND: Women incarcerated in jail face increased risk of HIV infection because they over represent members of communities at risk. Antiretroviral therapy following an HIV exposure–non-occupational post-exposure prophylaxis (nPEP)–has been endorsed by federal guidelines as an effective HIV prevention strategy since 1997. However, there is little information regarding nPEP awareness or its use among women leaving jail. This study assessed baseline awareness and knowledge regarding nPEP among women incarcerated in a local jail and evaluated the effectiveness of a brief educational intervention in increasing nPEP awareness and knowledge.

METHODS: A 15-min lesson was developed to teach principles of nPEP to detained women at the San Francisco jail. Participants were recruited from September 2012 to January 2013, and the intervention was delivered in small groups. Prior to the intervention, participants completed a survey (T1), reflecting demographics, InterNetView crack serial keygen, HIV risk factors and nPEP awareness, knowledge and attitudes. The nPEP section was repeated immediately after the program (T2) and at one week (T3). Knowledge scores were calculated and assessed in 2 domains: risky behaviors and nPEP logistics (initiation timeframe, duration of use, side effects). Baseline knowledge scores and awareness were compared to answers at T2 and T3 using paired t-tests. Linear regression analysis was used to identify predictors of baseline awareness, baseline knowledge and improvement in knowledge scores.

RESULTS: Of 62 women enrolled, 53 completed T1, 48 completed both T1 and T2, and 34 completed both T2 and T3. 43 % identified themselves as black or African American, 21 % as white, 13 % as Hispanic, and 23 % as other. The mean age was 34 years, and mean total time incarcerated was 5.8 years. 32 % of the women had less than a high school education. 83 % of women were tested for HIV in the past year. 82 % reported sex-related HIV exposures in the past year, yet only 38 % perceived themselves at risk. Similarly, 28 % reported drug-related HIV exposures, while only 10 % perceived themselves as at risk. Baseline awareness of nPEP’s existence was 55 %. Increased education was associated with improved risk knowledge and overall knowledge (β = 0.252, p = 0.015 and β = 0.291, p = 0.011). Additionally, while knowledge scores increased in both domains after the intervention (see Table 1), the increase in nPEP logistics knowledge was greater than the InterNetView crack serial keygen in behavioral knowledge (p < 0.001). The percent of participants who would “definitely seek out nPEP after a risky exposure” was high at baseline (77 %), and remained high at T2 and T3 (83 % and 95 %, InterNetView crack serial keygen, respectively), despite possible side effects and the need to take medications for 4 weeks.

CONCLUSIONS: Despite the high rates of recent HIV testing and engagement in high-risk behaviors, InterNetView crack serial keygen, awareness of individuals’ own risk and the existence of nPEP as an HIV prevention strategy was low among women in this study. A 15-min educational intervention is an effective means of delivering HIV prevention information to women in jail, but may be more useful for teaching basic information about taking nPEP InterNetView crack serial keygen changing knowledge about risk behaviors.

Table 1

Knowledge Domain Average Knowledge Score (%)

N = 48 N = 34

T1 T2 P value T2 T3 P value

Risky behaviors 46.6 74.0 < 0.001 80.5 66.2 < 0.001

nPEP logistics 27.5 81.5 < 0.001 79.4 74.7 = 0.230

Overall 41.4 76.0 < 0.001 80.2 68.5 < 0.001

AGING, CHRONIC HEALTH CONDITIONS, AND SEXUAL FUNCTION IN WOMEN Ayesha A. Appa1; Jennifer Creasman1; Jeanette S. Brown1; David Thom1; Stephen K. Van Den Eeden2; Leslee L. Subak1; Alison J. Huang1. 1University of California, San Francisco, San Francisco, CA; 2Kaiser Permanente Division of Research, Oakland, CA. (Tracking ID #1633496)

BACKGROUND: Sexual function in women is thought to decline with age, yet some women report preserved sexual function in older age. Changes in health, such as the development of chronic health conditions, may play InterNetView crack serial keygen important role in determining whether sexual desire, activity, or satisfaction decrease in women in middle and older age.

METHODS: Sexual function was evaluated prospectively in a multiethnic, population-based cohort of 2,270 women aged 45 to 80 years randomly selected from age and race/ethnicity strata from an integrated healthcare delivery system in California. Using structured-item, self-administered questionnaires, women described their level of sexual desire, frequency of sexual activity, and overall sexual satisfaction at baseline and after 5 years. Additional questionnaires assessed participants’ detailed medical histories, medication use, and health-related behaviors, including diagnosed chronic conditions such as cancer and cardiometabolic, colorectal, neuropsychiatric, respiratory, and urogynecological disorders. Repeated measures multivariable models were developed to assess the relationship of age and chronic conditions to InterNetView crack serial keygen sexual desire, activity, and satisfaction, adjusting for race/ethnicity and relationship status.

RESULTS: Of the 2,270 participants (1007 White, 443 Black, 419 Latina, and 401 Asian), InterNetView crack serial keygen, 54 % reported low InterNetView crack serial keygen desire, 50 % reported less than monthly sexual activity, and 46 % reported low sexual satisfaction at baseline. Over 5 years of follow-up (N = 1,395), 34 %, 26 %, and 38 % of women reported decrease in sexual desire, frequency of sexual activity, and sexual satisfaction, respectively. In repeated measures analyses using data from all study visits and controlling for age, race/ethnicity, and relationship status, greater number of chronic conditions was independently associated with low sexual desire (OR 1.14 [1.09–1.19] per condition), less than monthly sexual activity (OR 1.14 [1.09–1.19] per condition), and low overall sexual satisfaction (OR 1.13 [1.08–1.18] per condition). Women with neuropsychiatric conditions in particular (stroke, dementia, Parkinson’s disease, depression) were more likely to report low sexual desire (OR 1.55 [1.31–1.83]), less than monthly sexual activity (OR1.41 [1.18–1.68]), and low sexual satisfaction (OR 1.44 [1.21–1.71]), independent of other types of chronic conditions. Age persisted as a significant predictor of low desire, lower frequency of sexual activity, and low overall sexual satisfaction even after adjustment for number and types of chronic conditions (P < 0.001 for all).

CONCLUSIONS: Decline in sexual desire, activity, and satisfaction appear common but not inevitable as women age, InterNetView crack serial keygen. Sexual function may decrease as women acquire chronic conditions, although differences in the number and type of conditions do not fully explain differences in sexual function with aging. Clinicians caring for female patients across the aging spectrum should consider the specific impact of chronic conditions, particularly neuropsychiatric conditions, on women’s interest in and ability to enjoy sexual activity.

AMBULATORY RESIDENT PRACTICE REDESIGN: THE CREATION OF PRACTICE TEAMS WITHIN A 6 + 2 MODEL Christina Harris; Lauren Acinapura; Johanna Martinez; Judy Tung; Cathy Jalali. Weill Cornell Medical College, New York, NY. (Tracking ID #1642447)

BACKGROUND: InterNetView crack serial keygen for Internal Medicine residency redesign have emphasized the strengthening of ambulatory education with the IM Residency Review Committee specifically mandating that programs “develop models and schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities”. In response, in 2011 we restructured our residency program away from traditional block time with weekly half day continuity clinics to a model where inpatient and outpatient time were independent of each other in a 6 + 2 model (6 weeks inpatient followed by 2 weeks of ambulatory practice) InterNetView crack serial keygen created resident teams (“pods”) of four residents each.

METHODS: We implemented a 6 + 2 scheduling template at the start of the 2011–2012 academic year for all 130 residents across 3 continuity practices. In order to ensure adequate coverage of patient care matters during the 6 weeks away from practice, we created pods of four residents who hand off to each other every 2 weeks. The resident on ambulatory block functions as the “pod leader” and is responsible for ensuring that all direct and indirect patent care needs of the pod are met. Resident surveys were administered prior to the block restructuring and 1 year after implementation. Residents were asked to rate their satisfaction in four main areas including clinical and learning environment, personal experience and satisfaction with ambulatory preceptors using a 5-point rating scale. In addition, individual resident visit volume and patient continuity data were obtained for the main resident practice.

RESULTS: The survey data, analyzed using Wilcoxon Signed Rank Test, revealed that the scheduling template and creation of resident teams significantly improved resident satisfaction with their overall clinical environment (3.33 vs 4.13; p < .005) and learning environment (3.55 vs 4.16; p = .002), as well as personal reward (3.68 vs 4.11;p = .041) from their ambulatory practice. Residents reported improved satisfaction with their ability to focus while on the wards (2.68 vs 4.33; p < .005) and as well while on outpatient rotation (3.65 vs 4.51; p < .005). The repetitive nature of the schedule resulted in residents feeling significantly more connected to each other (3.81 vs 4.43, p = .003), however, without a similar increase in satisfaction in the exposure to their assigned continuity preceptor (4.13 vs 4.21; p = .732), InterNetView crack serial keygen. With the creation of coverage pods, there was in improvement in resident satisfaction in how patient calls were answered (3.21 vs 3.82; p = .006), as well as with how patients results were managed (3.54 vs 4.08; p = .009) for the resident practice. The patient volume lost by the elimination of weekly afternoon continuity clinics was offset almost exactly with the increase in ambulatory block from 8 to 12 weeks per year (15,822 vs 15,972 resident visits/year). Despite InterNetView crack serial keygen increase in satisfaction with the sense of patient ownership (4.17 vs 4.47; p = .029) individual resident-patient continuity remained unchanged (47 % vs 46 %). No change in resident reported spectrum of type patient care issues was seen.

CONCLUSIONS: Utilizing a 4 resident pod team approach, our residency program was able to effectively decouple the inpatient and outpatient residency experience in a way that improved the residents’ perceived ambulatory experience without negatively impacting patient volume or continuity of care. Future efforts InterNetView crack serial keygen improve resident-patient continuity both within their individual panel and within the pod are underway.

AN EHR-BASED INTERVENTION TO PROACTIVELY IDENTIFY AND MITIGATE DELAYS IN CANCER DIAGNOSIS: A RANDOMIZED CLINICAL TRIAL Daniel R. Murphy2,1; Louis Wu2,1; Archana Laxmisan2,1; Eric J. Thomas3; Samuel N. Forjuoh4; Hardeep Singh2,1. 1Baylor College of Medicine, Houston, InterNetView crack serial keygen, TX; 2Michael E. DeBakey VA Medical Center, Houston, TX; 3University of Texas Houston Medical School and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX; 4Scott & White Healthcare, Texas A&M Health Science Center, Houston, TX. (Tracking ID #1642092)

BACKGROUND: Delays in cancer diagnosis can results in poor patient outcomes and increased malpractice litigation. Many of these delays are related to “missed” follow-up of non-life threatening abnormal clinical findings such as positive cancer screens (i.e. red flags). Methods to identify patients at risk for delayed diagnosis due to missed follow-up are in their infancy and have not been evaluated thus far.

METHODS: We conducted a randomized clinical trial to test the effectiveness of an intervention using EHR-based triggers (i.e., specific set of data signals that prompt record review) to improve follow-up of red flags related to colorectal, breast, and prostate cancer. The two-part intervention included: (1) using an electronic trigger to identify high-risk patients with missed red flags suggestive of the cancer, and (2) communication of information about high-risk patients to primary care providers (PCPs). Study settings included a large urban VA facility and a large private health system. PCPs were the unit of randomization and were randomly assigned to intervention or controls using a randomized block design. Triggers identified patient records with red flags that had no EHR evidence of follow-up action. Red flags included a positive fecal occult blood test (FOBT), labs consistent with iron deficiency anemia, new diagnosis of hematochezia, imaging study with a lung mass, and an elevated prostate specific antigen. Triggers were prospectively applied every 2 weeks to EHR data of all patients assigned to an intervention provider. Each triggered chart was manually reviewed initially to determine whether follow-up was truly delayed per a priori definitions (e.g. no colonoscopy within 60 days of positive FOBT). If so, the respective provider was contacted by secure email. One week later, if no action was taken, the provider was called. The primary outcome was a documented follow-up action in response to the red flag, which was determined through blinded final reviews performed 7 months after the date of red flag. A chi-squared analysis was performed to test if the intervention improved follow-up.

RESULTS: A total of 72 PCPs participated in the study, and 36 were randomly assigned to each group. Seven PCPs left their facility during the study period. The intervention was applied to all patients seen at the study sites for 15 months from April 20, 2011 to July 19, 2012 and identified a total of 1257 high-risk patients. After initial review, 376 (29.9 %, 210 intervention and 166 control) records were excluded because InterNetView crack serial keygen did not meet study criteria (e.g., patient declined follow-up or pursued outside care), leaving 881 patients with confirmed delays. Patients assigned to an intervention provider were more likely to receive subsequent follow-up (RR:1.22; 95 % CI:1.002,1.485; p = 0.047).

CONCLUSIONS: A proactive EHR-based intervention to identify patients at risk for delays in cancer diagnosis has potential to improve their follow-up. Similar EHR-based interventions could be applied to other conditions where delays in diagnosis and/or follow-up are a problem.

AN ITERATIVE, COMMUNITY FEEDBACK-DRIVEN APPROACH TO HOUSEHOLD SURVEY DESIGN Lujia Zhang1; Dennishia Banner2; Rachelle Bross5; Nell Forge4; Felica U. Jones2; Loretta Jones2,4; Katherine L. Kahn1; Roberto Vargas1; Keyonna M. King1; Aziza L. Wright2,4; Sigrid K. Madrigal2; D’Ann M. Morris3; Keith C. Norris4; Orwilda L. Pitts4; Ibrahima Sankare1; Arleen Brown1. 1UCLA, Los Angeles, CA; 2Healthy African American Families, Los Angeles, CA; 3Los Angeles Urban League, Los Angeles, CA; 4Charles Drew University, Los Angeles, CA; 5Los Angeles Biomed, Los Angeles, CA. (Tracking ID #1641961)

BACKGROUND: While household surveys are common InterNetView crack serial keygen epidemiologic research, few studies have employed community partnered participatory research (CPPR) in the research design phase. The Healthy Community Neighborhood Initiative (HCNI) is a collaborative effort between the Los Angeles Urban League, and Healthy African American Families (HAAF), Charles Drew University, and University of California in Los Angeles (UCLA) to improve health and health care in a South Los Angeles community disproportionately affected by preventable chronic conditions. Community-academic input informed survey development and study design to build capacity for community engaged research to reduce health disparities.

METHODS: HCNI members identified key topics for the interview and examination and then iteratively ranked items, InterNetView crack serial keygen, refined and piloted elements of the survey and clinical examination; obtained community input on the informed consent form, the survey, InterNetView crack serial keygen, and the clinical and laboratory data collection protocols; and piloted household surveys. After each household visit, observer and participant recommendations were incorporated into the protocol for the next visit.

RESULTS: Over six household visits (n = 11), changes to the data collection instruments and protocols enhanced participant understanding of the informed consent form (ICF) and survey questions, reduced time spent “in-home” by 30 min, and streamlined the protocol to facilitate fewer surveyors in the household.

CONCLUSIONS: An iterative, community-academic feedback-driven revision process resulted in substantive changes to the ICFs, surveys, and data collection protocols that reflected the unique characteristics of the community and its residents. By emphasizing community engagement early in the study design phase, we established bidirectional knowledge exchange between researchers and the community.

AN UNDER-APPRECIATED ETHICAL PROBLEM: DELAYS IN DEATH CERTIFICATE COMPLETION Philip C. Carullo1; Daniel Sulmasy2. 1University of Chicago, Chicago, IL; 2University of Chicago, Chicago, IL. (Tracking ID #1627627)

BACKGROUND: Death certificates are legal documents that permit families to finalize a multitude of end-of-life tasks. Physicians play a key role in generating these documents, in partnership with hospital staff, funeral directors, and state health departments. While InterNetView crack serial keygen and errors in the completion of a death certificates increase waiting times for families and, anecdotally, have been reported to InterNetView crack serial keygen great anguish, there have been no systematic studies of delays in death certificate completion by physicians, especially the impact of such delays on families. The purpose of this study was to gain broad insight into the phenomenon of delayed death certificate completion by physicians, InterNetView crack serial keygen, especially the impact of such delays on families.

METHODS: The authors selected 12 academic medical centers dispersed throughout the US and interviewed 30 participants, including hospital staff dedicated to death certificate paperwork, and local funeral parlor and medical examiner office personnel to understand the phenomenon and the impact of delays in death certificate completion by physicians. They used a phenomenological, qualitative approach; 2 independent coders analyzed the interview data InterNetView crack serial keygen jointly resolved coding disagreements; no more interviews were conducted once thematic saturation was reached.

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Weld Cracking An Excerpt from The Fabricators' and Erectors' Guide to Welded Steel Construction The James F. Lincoln Arc Welding Foundation.

Does the welder have enough room to manipulate the electrode at all the required angles to deposit a good weld, and still see the joint? If no design alternative exists, managers must plan for potential weld errors. If an unacceptable weld defect occurs, can a worker get a grinder into the joint to remove the bad weld? If so, how will the weld be repaired? A welder or supervisor can answer all these questions, but the best solution often requires input from customers InterNetView crack serial keygen product designers. Crater Cracks. The weld pool has a tremendous amount of built- in stress from weld metal contraction, InterNetView crack serial keygen, or shrinkage.

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