Development of a Short Trauma Screening Tool (STST) to Measure Child Trauma Symptoms: Establishing Content Validity

Purpose: The purpose of the study was to identify major symptom domain variables common to child trauma and create a prototype short trauma symptom screening tool (STST) intended for use in pediatric medical settings. Methods: This manuscript describes the first two phases of an on-going prospective mixed-method instrument development study. Phase 1 exploratory factor analysis was conducted with an archived LONGSCAN CBCL dataset to: (1) identify behavioral symptoms endorsed by children with known trauma exposure; and (2) generate a preliminary STST item pool. During Phase 2, researchers convened an expert panel (N = 10) and conducted Content Validity Index (CVI) procedures with the 20-item preliminary STST item pool, to further inform item retention, elimination and modification for an updated prototype STST. Findings: Expert quantitative scores yielded a CVI of 0.90 for the overall preliminary STST. The first two phases of this study assisted researchers with identifying 12 items that represent nine child trauma symptom domain variables, which include: (1) aggression/anger; (2) anxiety/fear; (3) sexual concerns; (4) elimination concerns; (5) somatic concerns; (6) depression; (7) dissociation; (8) physical acting out; and (9) dysregulation. Conclusions: The first two phases of STST development resulted in development of a brief, empirically-derived prototype screening tool that features 12 items operationalizing nine domains of child trauma symptoms. Developers can now advance to the next phase of STST development; feasibility assessment and psychometric testing

Using Mindfulness for Increasing Provider Capacity to Support Inner City Survivors of Violence [English and Spanish versions]

A Spanish translation of this publication is available to download under Additional Files below. Mindfulness is recognized as an evidence-based practice that can improve a person’s physical and emotional health and well-being. This research project examined the cultural relevance and potential acceptability of mindfulness practices by front-line providers working with a low-income community of color affected by gun homicide

Overcoming Barriers to Perinatal Depression Treatment

Background Untreated perinatal depression is common and has deleterious effects on mother, fetus/child and family Despite effective evidence-based treatment for perinatal depression, most women do not get treatment Obstetricians have not traditionally identified and/or responded to the mental health needs of perinatal women Caring and committed providers are frustrated and confused5 and mothers do not feel seen, heard or understood by their providers Implementing supports for perinatal women within the traditional medical model poses many challenges to mental health and obstetric providers MotherWoman is a community-based grassroots organization dedicated to preventing and treating perinatal depression through an innovative organizational change approach, the Community-Based Perinatal Support Model (CPSM). This model includes: Peer-led support groups for perinatal women Organizational change interventions that include structured screening and referral, health care provider trainings and networks, and resource and referral guides Methods Participants Four focus groups with MotherWoman clients, 3 months – 3 years postpartum who self-identified as having experienced perinatal depression or emotional crisis Data collection Focus group probes targeted perceptions of the best practices to engage perinatal women in depression treatment and potential strategies for change Investigators met after each group to record observations and review verbatim notes Participants received gift cards for their participation Data analysis Transcripts were reviewed, segmented, and coded by investigators using an iterative, constant-comparative process to identify emerging themes and recurrent patterns Inter-rater reliability of more than 90% was achieved by two investigators comparing randomly selected coded pages from focus group notes Discussion Despite barriers, numerous facilitators to treatment were identified Supporting women’s mental health during the perinatal time period should ideally be done in both the medical setting and community Supporting the mental health of perinatal women is a fundamental challenge with multiple opportunities for intervention and education Strategies to address perinatal depression include: Offer training to OB/Gyn and mental health providers in the detection and screening of perinatal depression Prepare women for the postpartum period through psychoeducation and peer-support Create flexible treatment options that go beyond medication management and emphasize transition to motherhood Results will Contribute to understanding the barriers and facilitators perinatal women experience when trying to access depression treatment Provide preliminary guidelines for the development of strategies to engage perinatal women in depression treatment Inform the development of interventions that aim to integrate the treatment of perinatal depression into medical setting

Psychometric Evaluation of the Care Transition Measures in a Sample of ACS Patients: Results from Transitions, Risks, and Actions in Coronary Events – Center for Outcomes Research and Education (TRACE-CORE)

Background: Quality of transitional care is associated with important health outcomes such as rehospitalization and costs. A widely used measure of the construct, the Care Transitions Measure (CTM-15), was developed with classical test theory approach. Its short version (CTM-3) was included in the CAHPS® Hospital Survey. Methods: As part of TRACE-CORE 1545 participants were interviewed during hospitalization for ACS providing information on general health status (SF-36). At 1 month post-discharge, patients completed CTM-15, health utilization and care process questions. We evaluated the psychometric properties of the CTM using classical and item response theory analyses. We compared the measurement precision of CTM-15, CTM-3, and a CTM-IRT based score using relative validity (RV). Results: Participants were 79% non-Hispanic white, 67% male, 27% with a college education or higher (27%) and average age of 62 years. The CTM scale had good internal consistency (Cronbach’s alpha=0.95), but demonstrated strong acquiescence bias (8.7% participants responded “Strongly agree”, 19% “Agree” to all 15 items) and limited score variability. IRT based item parameters were estimated for all items. The CTM-15 differentiated between groups of patients defined by self-reported health status, health care utilization, and care transition process indicators. Differences between groups were small (2-3 points). There was no gain in measurement precision for the scale from IRT scoring. The CTM-3 was not significantly lower for patients reporting rehospitalization or emergency department visits. Conclusion: We identified psychometric challenges of the CTM, which may limit its value in research and practice. The strong acquiescence bias in the measure leads to highly skewed, clustered scores with restricted score variance. In the absence of guidelines on meaningfully important differences, it is hard to determine whether detected statistically significant differences in CTM are important. These results are in line with emerging evidence of gaps in the validity of the measure

Addressing Bias in LGBTQIA+ Undergraduate Medical Education: An Innovative and Community Based Approach to Curriculum Reform

Background: Individuals who are LGBTQIA+ or gender nonconforming have specific health needs and face health disparities that are exacerbated by a lack of training and cultural sensitivity among health professionals. This study was initiated by a second year University of Massachusetts School of Medicine student in response to the lack of LGBTQIA+ health content in the first year Doctoring & Clinical Skills (DCS1) course. The DCS1 session on collecting a sexual history was selected as the primary focus for revision. Community-Based Participatory Research, because of its emphasis on joining with a community of interest as full and equal partners in all phases of the research process, served as an ideal model for the novel application to curriculum development to address this gap in training in undergraduate medical education. Methods: A sample of 13 LGBTQIA+ community members from Worcester were recruited to form a curriculum advisory committee. The committee convened for two focus-group style meetings where they reviewed the curriculum and had the opportunity to provide their feedback, which was used to rewrite the session. Additionally, the community members had the opportunity to participate in a storytelling video where they discussed their experiences in healthcare as LGBTQIA+ patients. A pre-test post-test design was used to survey the UMMS SOM students in order to evaluate the new version of the DCS1 session. Results: The percentage of M1 students reporting they had the necessary skills to treat LGBTQIA+ patients increased from pre-session to post-session (26.2% (n=130), 63.2% (n=76), p = \u3c 0.001). Compared to current M2 students who completed the course last year (n=65), more MS1 students (n=76) rated the overall quality of the DCS1 session as excellent or good (23.1%, 77.6%, p= \u3c 0.0001. Conclusion: CBPR serves as an efficacious model for the creation of curriculum inclusive of LGBTQIA+ health

Sustained Use of Patient Portal Features and Improvements in Diabetes Physiological Measures

BACKGROUND: Personal health records (PHRs) have the potential to improve patient self-management for chronic conditions such as diabetes. However, evidence is mixed as to whether there is an association between PHR use and improved health outcomes. OBJECTIVE: The aim of this study was to evaluate the association between sustained use of specific patient portal features (Web-based prescription refill and secure messaging-SM) and physiological measures important for the management of type 2 diabetes. METHODS: Using a retrospective cohort design, including Veterans with diabetes registered for the My Health e Vet patient portal who had not yet used the Web-based refill or SM features and who had at least one physiological measure (HbA1c, low-density lipoprotein (LDL) cholesterol, blood pressure) in 2009-2010 (baseline) that was above guideline recommendations (N=111,686), we assessed portal use between 2010 and 2014. We calculated the odds of achieving control of each measure by 2013 to 2014 (follow-up) by years of using each portal feature, adjusting for demographic and clinical characteristics associated with portal use. RESULTS: By 2013 to 2014, 34.13% (38,113/111,686) of the cohort was using Web-based refills, and 15.75% (17,592/111,686) of the cohort was using SM. Users were slightly younger (P \u3c .001), less likely to be eligible for free care based on economic means (P \u3c .001), and more likely to be women (P \u3c .001). In models adjusting for both features, patients with uncontrolled HbA1c at baseline who used SM were significantly more likely than nonusers to achieve glycemic control by follow-up if they used SM for 2 years (odds ratio-OR=1.24, CI: 1.14-1.34) or 3 or more years (OR=1.28, CI: 1.12-1.45). However, there was no significant association between Web-based refill use and glycemic control. Those with uncontrolled blood pressure at baseline who used Web-based refills were significantly more likely than nonusers to achieve control at follow-up with 2 (OR=1.07, CI: 1.01-1.13) or 3 (OR=1.08, CI: 1.02-1.14) more years of Web-based refill use. Both features were significantly associated with improvements in LDL cholesterol levels at follow-up. CONCLUSIONS: Although rates of use of the refill function were higher within the population, sustained SM use had a greater impact on HbA1c. Evaluations of patient portals should consider that individual components may have differential effects on health improvements

Patient- and Hospital-level Predictors of 30-day Readmission after Acute Coronary Syndrome: A Systematic Review

Background: Readmissions following acute myocardial infarction (AMI) are costly and may be partly due to poor care. A previous systematic review examined the literature through 2007. Since then, health policy has changed and additional articles examining predictors of readmission have appeared. We sought to conduct a systematic review of the literature after 2007 regarding socio-demographic, clinical, psychosocial, and hospital level predictors of 30-day readmissions after acute coronary syndrome. Methods: A systematic search of the literature using Pubmed, OVID, ISI web of science, CINAHL, ACP and the Cochrane Library was conducted, including a quality assessment using Downs and Black criteria. Articles reporting on 30-day readmission rate and examining at least one patient-level predictor of readmission at 30 days were included; articles examining interventions to reduce readmissions were excluded. Results: Twenty-two studies were included in this review from which more than 60 predictors of 30-day readmission were identified. Age, co-morbidity, COPD, diabetes, hypertension and having had a previous AMI were all consistently associated with higher risk of readmission. However, no studies reported psychosocial factors as predictors of readmission at 30 days. Conclusion: Studies of readmission should adjust for age and co-morbidity, consistent predictors of readmission at 30-days. Patients with these risk factors for readmission should be targeted for more-intensive follow-up after discharge. Psychosocial predictors of readmission remains a relatively unexplored area of research

The art and science of searching MEDLINE to answer clinical questions. Finding the right number of articles

The current medical environment makes information retrieval a matter of practical importance for clinicians. Many avenues present themselves to the clinician, but here we focus on MEDLINE by summarizing the current state of the art and providing an innovative approach for skill enhancement. Because new search engines appear rapidly, we focus on generic principles that can be easily adapted to various systems, even those not yet available. We propose an idealized classification system for the results of a MEDLINE search. Type A searches produce a few articles of high quality that are directly focused on the immediate question. Type B searches yield a large number of articles, some more relevant than others. Type C searches produce few or no articles, and those that are located are not germane. Providing that relevant, high-quality articles do exist, type B and C searches may often be improved with attention to search technique. Problems stem from poor recall and poor precision. The most daunting task lies in achieving the balance between too few and too many articles. By providing a theoretical framework and several practical examples, we prepare the searcher to overcome the following barriers: a) failure to begin with a well-built question; b) failure to use the Medical Subject Headings; c) failure to leverage the relationship between recall and precision; and d) failure to apply proper limits to the search. Thought and practice will increase the utility and enjoyment of searching MEDLINE

Using the bootstrap to establish statistical significance for relative validity comparisons among patient-reported outcome measures

BACKGROUND: Relative validity (RV), a ratio of ANOVA F-statistics, is often used to compare the validity of patient-reported outcome (PRO) measures. We used the bootstrap to establish the statistical significance of the RV and to identify key factors affecting its significance. METHODS: Based on responses from 453 chronic kidney disease (CKD) patients to 16 CKD-specific and generic PRO measures, RVs were computed to determine how well each measure discriminated across clinically-defined groups of patients compared to the most discriminating (reference) measure. Statistical significance of RV was quantified by the 95% bootstrap confidence interval. Simulations examined the effects of sample size, denominator F-statistic, correlation between comparator and reference measures, and number of bootstrap replicates. RESULTS: The statistical significance of the RV increased as the magnitude of denominator F-statistic increased or as the correlation between comparator and reference measures increased. A denominator F-statistic of 57 conveyed sufficient power (80%) to detect an RV of 0.6 for two measures correlated at r = 0.7. Larger denominator F-statistics or higher correlations provided greater power. Larger sample size with a fixed denominator F-statistic or more bootstrap replicates (beyond 500) had minimal impact. CONCLUSIONS: The bootstrap is valuable for establishing the statistical significance of RV estimates. A reasonably large denominator F-statistic (F \u3e 57) is required for adequate power when using the RV to compare the validity of measures with small or moderate correlations (r \u3c 0.7). Substantially greater power can be achieved when comparing measures of a very high correlation (r \u3e 0.9)