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Screening programs based on fecal blood testing have been shown in randomized controlled trials to reduce colorectal cancer incidence and mortality. Professional organizations highly recommend screening average-risk patients with fecal immunochemical testing (FIT). Many patients find these stool tests more acceptable than colonoscopy and stool testing may be the preferred option for areas with limited endoscopic resources. However, the diagnostic performance of FIT testing, particularly for CLIA-waived point-of-care (POC) tests, has not been well studied. Purpose: We are comparing the diagnostic accuracy of 4 FIT tests, one automated (AUTO) and 3 POC, for detecting advanced neoplasia (advanced adenomas and carcinomas) using colonoscopy as a gold standard. Methods. We are enrolling subjects ages 50 to 85 at 3 academic medical centers in Iowa, Texas, and North Carolina who were scheduled for a screening or surveillance colonoscopy. Each subject completed 4 different FIT tests on a single stool specimen. Based on colonoscopy results, we calculated sensitivity, specificity, and predictive values. We used PROC GLIMMIX models in SAS to compare sensitivity and specificity across the different tests, accounting for the within-patient correlation. Results: We currently have 641 subjects who completed FIT and colonoscopy. Mean age is 61.2 (±7.5) years, 63% women, 63% non-Hispanic white, and 31% Hispanic. We found advanced neoplasia, including 5 carcinomas, in 68 subjects. The sensitivities for detecting these neoplasia were 3%, 22%, 28%, and 16% (AUTO), respectively. Corresponding positive predictive values were 18%, 21%, 33%, and 24% (AUTO). Specificities were 97%, 89%, 90%, and 94% (AUTO), respectively, and corresponding negative predictive values were 89%, 91%, 92%, and 90% (AUTO). We found statistically significant differences in sensitivity (P < 0.01) and specificity (P < 0.01) across tests. Conclusions: Early data suggest that FIT products may vary in their sensitivity and specificity for detecting advanced colorectal neoplasia. This variability could have important impacts on the effectiveness of efforts to limit the burden of colorectal cancer by increasing population-based screening rates through fecal blood testing.

Introduction Practice-based research networks (PBRNs) conduct research in community settings, which poses quality control challenges to the integrity of research, such as study implementation and data collection. A foundation for improving research processes within PBRNs is needed to ensure research integrity. Methods Network directors and coordinators from seven U.S.-based PBRNs worked with a professional team facilitator during semiannual in-person meetings and monthly conference calls to produce content for a compendium of recommended research practices specific to the context of PBRNs. Participants were assigned to contribute content congruent with their expertise. Feedback on the draft document was obtained from attendees at the preconference workshop at the annual PBRN meeting in 2013. A revised document was circulated to additional PBRN peers prior to finalization. Results The PBRN Research Good Practices (PRGPs) document is organized into four chapters: (1) Building PBRN Infrastructure; (2) Study Development and Implementation; (3) Data Management, and (4) Dissemination Policies. Each chapter contains an introduction, detailed procedures for each section, and example resources with information links. Conclusion The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings.

Introduction: In the United States, many fecal occult blood tests are mailed by patients to a laboratory for analysis. Hemoglobin is not stable in feces and can be affected by the heat. Effects of season and ambient temperature on fecal immunochemical tests (FITs) have demonstrated a decrease in positivity rates during the hottest season. Objective: To investigate the potential effect of the average of 4-day ambient maximum temperature variations on the positivity of a single sample, one-time Clinical Laboratory Improvement Amendments (CLIA)–waived FIT. Setting: Midwestern tertiary care hospital. Methods: Individuals scheduled for a colonoscopy were invited to complete a qualitative FIT prior to their colonoscopy in 2010 and 2011. FITs were read as positive or negative. Results: Valid FITs were received from 1026 individuals over 25 months. The positivity rate was 10.9%. The mean 4-day average of daily maximum ambient temperatures was calculated including the day of receipt for each sample. Fahrenheit temperatures ranged from 16.0 to 96.8. Based on the odds ratio of 1.04 with a confidence interval of 0.94 to 1.14 for a 10°F increase in temperature, there was no statistically significant evidence of an effect of the preceding maximum average 4-day ambient temperature on FIT positivity. Conclusion: No evidence was found that ambient temperature had an effect on positivity rate over a 25-month period using 4 different qualitative FIT products. Further analysis on effect of ambient temperatures is warranted for the automated FITs and CLIA-waived FITs, including liquid-vial and dry-slide FITs. Primary care providers need to be aware of potential adverse effects of FITs.

Colorectal cancer (CRC) is the second leading cause of cancer death. CRC screening with a fecal immunochemical test (FIT) is important as occult blood may be detected. To offer Iowa Research Network members in family physician offices the opportunity to provide FITs at no charge to patients in need and determine how many of the tests would be handed out to patients and how many would be returned to the office. Eight family physician offices agreed to participate and 50 two-day FITs were provided, potentially providing 400 patients a CRC screening test. One hundred and eighty (45 %) of the 400 FITs were handed out to patients. Of the 92 (51 %) patients who returned at least one card, 77 (84 %) had negative results, 13 (14 %) were positive, and 2 (2 %) were indeterminate. Of 13 patients with a positive result, 11 (85 %) had a follow-up colonoscopy. Providing 400 FITs at no charge to the offices was an expensive endeavor. Implementing this forced a change in office routine and the type of fecal occult blood test used. Less than half of the FITs were given out to patients and of those given out, about half of the patients returned a FIT. For those who returned FITs and had positive findings, 85 % followed-up with a colonoscopy. Office nurses implementing the CRC screening need to be included in the planning of the type of fecal occult blood test used and receptive to the project.

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states. Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC. Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01). Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.

Evaluate retention efforts in an ongoing longitudinal multi-site study to develop a self-administered, simple-to-score caries risk tool to identify young children at risk of developing dental caries through medical settings. Preliminary study data had suggested that expected retention rates within a year of follow up, without any intermediate contact, would be approx. 75% in the target population. 1,326 primary caregiver/infant (1 year ± 3 months) pairs were enrolled at baseline across three study sites (Duke University, Indiana University, University of Iowa). Children were …

Background: In most states, health care providers are required to report abuse. Some states provide investigation feedback/findings to the reporter. The reporters rarely know if the perpetrator is convicted. The purposes of this study are to determine the incidence of Iowa dependent adult abuse prosecutions from 2006 through 2015, the incidence of convictions, and the association between dependent adult abuse prosecutions with county census and government characteristics. Design and Methods: Through the Iowa Court Information Systems, dependent adult abuse prosecution data were purchased for a 10-year time period. County demographics were obtained through the US Census and government data were Iowa State Association of Counties and the US Department of Agriculture. Results: During 2006-2015, there were 368 dependent adult abuse prosecution cases accounting for 482 original charges. Exploitation greater than $100 was the dependent adult abuse charge most frequently cited. Within the 10 years, it accounted for 60% of the original charges. Of the 482 disposed charges, 251 (52%) of the charges were dismissed. A total of 122 (14%) counts resulted in probation, 73 resulted in prison, and 37 in jail. Conclusions: For the first time, information about dependent adult abuse prosecutions in Iowa is available. The latter 5 years, 2011 to 2015, of dependent adult abuse prosecutions are significantly higher than the first 5 years, 2006 to 2010. This project encourages health care providers to report dependent adult abuse to law enforcement if appropriate as well as adult protective services.

A description of long term care settings and the history of their development are provided. Federal and state legislation pertinent to nursing homes and assisted living facilities is described with emphasis on the Omnibus Budget Reconciliation Act of 1987. Prevalence of abuse, neglect, and exploitation in long term care settings is explored through research with employees, family members, and other relatives, reports from adult protective services programs, Medicaid Fraud Control Unit reports, the National Ombudsman Reporting System, the On-line Survey and Certification and Reporting System, agencies responsible for Licensure and Re-certification, and the Long Term Care Minimum Data Set. Research on resident-to-resident aggression, resident-to-staff aggression, sexual abuse/resident-to-resident sexual aggression, exploitation/nursing home theft, education to prevent abuse, and pressure ulcers is summarized.

Background Faecal occult blood tests are often the initial test in population-based screening. We aimed to: 1) compare the results of single sample faecal immunochemical tests (FITs) with colonoscopy, and 2) calculate the sensitivity for proximal vs. distal adenomatous polyps or cancer. Methods Individuals scheduled for a colonoscopy were invited to complete a FIT prior to their colonoscopy preparation. FIT results were classified as positive, negative, or invalid. Colonoscopy reports were reviewed and abstracted. Because of product issues, four different FIT manufacturers were used. The test characteristics for each FIT manufacturer were calculated for advanced adenomatous polyps or cancer according to broad reason for colonoscopy (screening or surveillance/diagnostic). Results Of those invited, 1,026 individuals (43.9%) completed their colonoscopy and had a valid FIT result. The overall sensitivity of the FITs (95% confidence intervals) was 0.18 (0.10 to 0.28) and specificity was 0.90 (0.87 to 0.91) for advanced adenomas or cancer. The sensitivity for distal lesions was 0.23 (0.11 to 0.38) and for proximal lesions was 0.09 (0.02 to 0.25). The odds ratio of an individual with a distal advanced adenoma or cancer testing positive was 2.68 (1.20 to 5.99). The two individuals with colorectal cancer tested negative, as did one individual with high-grade dysplasia. Conclusions The sensitivity of a single-sample FIT for advanced adenomas or cancer was low. Individuals with distal adenomas had a higher odds of testing positive than those with proximal lesions or no lesions.

Introduction: In this 3-year longitudinal study, parent/child attended 3 dental visits and in between, parents were called every 4 months and asked if their child had visited the dentist and if fluoride varnish had been applied. Methods: Objectives were to assess changes in parents’ perceptions of how well they do in taking care of their children’s teeth and/or gums across these 3 time points (at age 1, 2.5, and 4 years), assess differences in parents’ perceptions of how well they do taking care of their children’s teeth and/or gums versus taking care of their children’s medical health, and determine factors associated with parental perceptions of how well they do in taking care of the children’s teeth and/or gums longitudinally. Results: Participant pairs (1325) were enrolled and over time there was a significant improvement in parental perceptions of their job taking care of their children’s teeth and/or gums, increasing from 86% perceiving it to be excellent/very good/good at their child’s 1 year of age to 92% at child’s age 4 years. The estimated odds of parents perceiving they provided excellent/very good/good versus fair/poor care for the children’s teeth and/or gums were higher for those who cleaned and checked inside the children’s mouth and/or gums daily (odds ratio 4.74) or took their children to the dentist yearly or twice yearly (odds ratio; 2.73). Conclusions: Parents’ perceptions of the care of their children’s teeth and/or gums improved over time. Parents consistently perceived that they provided better medical care than dental care for their child.

Although the fecal immunochemical test (FIT) has recently emerged as an effective and affordable colorectal cancer screening option, many family physician offices continue to use guaiac-based tests. The purpose of this study was to assess the use of FITs in the Iowa Research Network and to assess physicians' knowledge about FITs. A cover letter and questionnaire were faxed twice to the 291 physician members followed up by a mailing. One hundred and seven (37%) questionnaires were returned. Participants' mean age was 55 years with 78 male responders. Fifty-two (49%) of the physician's offices were in a nonmetro area. Fifty-one (49%) reported using guaiac-based tests and 39 (39%) reported using FITs. Many physicians were unsure of the answers for the FIT knowledge questions. FIT use is not widespread in Iowa Research Network physician offices, and not all physicians are aware of the type of fecal occult blood test being conducted in their office.

Background: More than half of eligible individuals are not up-to-date with colon cancer screening. Purpose: To assess the characteristics of those who received a colonoscopy screening recommendation and those who followed the physician recommendation. Methods: Patient self-administered questionnaire and medical record review in 16 private family physician practices. Results: From 8372 patients invited to participate, 685 were enrolled and had a medical record review; 219 (32%) had a colonoscopy recommendation and 86 (39%) received a colonoscopy. Independent factors associated with having a recommendation for colonoscopy were significantly younger in age (odds ratios [OR] = 1.6), higher incomes (annual income ≥$40 000 vs

To explore through interviews of critical care nurses their perspectives on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process.In 44 states and the District of Columbia health care providers are required by law to report elder abuse but the patient, patient's family and health care providers all have barriers to reporting allegations of elder abuse.This study design is qualitative.Through a mailed survey, critical care nurses were invited to participate in a taped in-depth qualitative interview.Ten nurses were interviewed. A thematic analysis was used to describe the following core themes: types of elder abuse, suspicions of elder abuse, reporting of elder abuse, barriers to reporting elder abuse, legislation and improvement in practice.Critical care nurses are aware of elder abuse and somewhat systematically evaluate for abuse at admission to their unit. They recognize signs and symptoms of abuse and are suspicious when it is warranted. They are aware of why an older person does not want to report abuse and take this into consideration when soliciting information. Facts, values and experience influence personally defining abuse, suspicion and dependence for each individual health care professional.Critical care unit protocols and/or policies and procedure for reporting elder abuse are needed in critical care settings and are warranted for providing quality of care.

The purpose of this study was to explore through interviews of healthcare professionals their perspectives on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process. Through a mailed survey, nurses, physicians, and social workers were invited to participate in an interview. Nine nurses, 8 physicians, and 6 social workers were interviewed and thematic analysis was used to identify the following core themes: professional orientation, assessment, interpretation, systems, and knowledge and education. The impact by healthcare professionals in recognizing and reporting elder abuse and obtaining resources for those mistreated can be profound. Nurses tended to perceive elder abuse as uncommon and generally did not feel it was their role nor did they have time to assess patients for potential abuse. Physicians felt that other patient care issues, time limitations and maintaining trust in the clinician-patient relationship outweighed the importance of detecting and pursuing suspected cases of elder abuse. Social workers, although having the most knowledge and experience related to elder abuse, relied on nurses and physicians to detect potential abusive situations and to work with them in making appropriate referrals. The three disciplines acknowledged the need for more and better education about elder abuse detection and reporting. Participants suggested a reorganization of the external reporting system. More frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse.

Only about half of all eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to test whether mailed educational materials and a fecal immunochemical test (FIT), with or without a scripted telephone reminder, led to FIT testing. In addition, we compared changes in attitudes toward, readiness for, and barriers to screening from baseline to follow-up after education about screening.Subjects due for CRC screening were recruited from 16 Iowa Research Network family physician offices. Half of the subjects were randomized to receive mailed written and DVD educational materials, along with a FIT, either with or without a telephone call designed to encourage screening and address barriers. Subjects completed surveys regarding their attitudes and readiness for CRC screening at baseline and after education about screening. The main outcome was whether the subject completed FIT testing.A total of 373 individuals received educational materials (including a FIT) and 231 (62%) returned a posteducation survey. The mean age was 61.2 years; 52% were women, 99% were white, 39% had a high school education or less, 39% had a total family income of less than $40,000, and 7% had no insurance. The written materials were read by 82%, understood by 91% (of those who read them), and 82% felt their knowledge was increased. The DVD was viewed by 67%, understood by 94% of those who viewed it, and 86% felt the DVD increased their knowledge. Compared with baseline, individuals reported being significantly more likely to bring up CRC screening at their next doctor's visit (P.0001) and being more likely to be tested for CRC in the next 6 months (P.0001). Comparing baseline with follow-up, summary attitude scores improved (P.0001), readiness scores improved (P.0001), and there were fewer barriers (P = .034, Wilcoxon signed rank). The FIT return rate increased from 0% to 45.2% in the education alone group and from 0% to 48.7% for the group receiving education plus the telephone call (P.0001 for each group individually and overall when compared with Medicare beneficiaries in Iowa).Mailing FIT kits with easy-to-understand educational materials improved attitudes toward screening and dramatically increased CRC screening rates among patients who were due for screening in a practice-based research network. A telephone call addressing barriers to screening did not result in increased FIT testing compared with mailed education alone.

Objective: A diabetes management program was implemented in a rural primary care office for those who did not choose to consult a multidisciplinary specialty care. The purposes of this study were to describe the current practices and health care provider management of patients with diabetes in a rural primary care office and determine differences between Hispanic and non-Hispanic persons concerning diabetes self-care behaviors, barriers to self-care, and their association with glycosylated hemoglobin level. Methods: A retrospective medical record review of diabetes-related medical information was completed. Results: Sixty-one (74%) of the 83 patients with diabetes completed the questionnaire and had the diabetes management program implemented (problem summary and clinical summary generated). Medical record review was completed for 83 (100%) subjects. Glycosylated hemoglobin was significantly higher for the younger group and women. Hispanic women and married persons had significantly higher glycosylated hemoglobin than did non-Hispanic and unmarried persons. Hispanic persons who were obese had significantly higher glycosylated hemoglobin. Self-care behaviors for managing diabetes were different by group. Non-Hispanic subjects reported taking their diabetes medications 99% of the time and Hispanic subjects 50% of the time. Discussion: It was feasible to implement a diabetes management program in a rural primary care setting, and its implementation highlighted the ethnic differences for Hispanics and non-Hispanics in diabetes self-care behavior, barriers to self-care, and family support for diabetes management. The implementation of the diabetes management program, though, was time-consuming and costly and was facilitated outside of the usual realm of practice.

A systematic review of elder abuse research has not been conducted across disciplines. The purpose of this research was to provide a systematic review of and assign an evidence grade to the research articles on elder abuse. Sixteen healthcare and criminal justice literature databases were searched. The literature review was of English-language publications reporting research on abuse of people aged 55 years and older, from any country. Titles, abstracts, and publications were retrieved from 16 databases and were reviewed by at least 2 independent readers who graded each from A (evidence of well-designed meta-analysis) to D (evidence from expert opinion or multiple case reports) on the quality of the evidence gained from the research. Of 6,676 titles identified in the search, 1,700 publications met inclusion criteria. Omitting duplicates from the 1,700 publications, 590 publications were annotated and graded. No elder abuse research publication was given an A grade. Fourteen publications were given a B grade (controlled trials), 483 were given a C grade (observational studies), and 93 were given a D grade (opinion or multiple case reports). Of the 590 publications, 492 were quantitative studies, 78 were qualitative studies, and 20 were case studies. Little evidence is available that supports any intervention to prevent elder abuse. Financial support for elder abuse research is needed along with more rigorous research trials.

Context: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a major pathogen among skin and soft tissue infections (SSTIs). Most CA-MRSA infections are managed initially on an outpatient basis. It is critical that primary care clinicians recognize and appropriately treat patients suspected of having such infections. Objective: To identify and evaluate best methods and procedures for primary care clinicians to manage skin and soft tissue infections. Design, Setting, and Patients: Preintervention/postintervention study in eight Iowa Research Network offices conducted between October 2007 and August 2010. We reviewed medical records of 216 patients with SSTI before a set of interventions (preintervention) and 118 patients after the intervention (postintervention). Interventions: Included a focus group meeting at each office, distribution of a modified Centers for Disease Control and Prevention (CDC) algorithm, “Outpatient Management of MRSA Skin and Soft Tissue Infections,” education handouts, and an office policy for patients with skin infections. Main Outcome Measures: Proportion of subjects who were prescribed an antibiotic that would cover MRSA at the initial visit and proportion who were prescribed an antibiotic that would cover MRSA at any time. Results: Three hundred sixty-eight forms (244 preintervention and 124 postintervention) were returned; 216 (89%) preintervention forms and 118 (95%) postintervention forms were usable. Multivariable logistic regression models found statistically significant and independent factors associated with MRSA coverage at the initial visit included being in the postintervention rather than the preintervention group, having an abscess component compared with cellulitis alone, having a culture sent, being prescribed two or fewer antibiotics, and not being hospitalized. Conclusions: The CDC algorithm was feasible for offices to use. Following a discussion of SSTI management in the outpatient setting, use of MRSA coverage increased both initially and overall. Thus, involving clinicians in a discussion about guidelines rather than simply providing guidelines or a didactic session may be a useful way to change physician practices. (J Am Board Fam Med 2011;24:524‐533.)

Most states' adult or elder protective services and aging agency personnel prepare annual reports about their protective services. These reports vary by state and have different terms for the reporter of abuse. Reviewing annual reports from 46 states and the District of Columbia, 248 different terms were used for the reporter of abuse. To develop essential data elements for reporters of abuse, a literature search, a compilation of state elder abuse annual report list of abuse reporters, and a sorting exercise were conducted. Eleven terms were recommended for the different reporters of abuse, encouraging all state administrators and caseworkers to reach consensus to standardize the language.

Objective: This study examined retrospectively the relationship between premenstrual symptoms and health anxiety. Methods: Premenstrual symptoms of nursing school graduates were assessed in 1985 and again in 1991 using the Premenstrual Assessment Form (PAF). A total of 571 women completed the survey in 1991, along with items relating to their physical and mental health. The latter included depression, anxiety, and panic attacks. Health anxiety was also assessed using the Whiteley Index (WI). After women who were amenorrheic for any reason were excluded, a final sample of 410 women aged 25 to 52 years was obtained. Factor analyses yielded 57 items that were useful for calculating a total PAF score. A stepwise multivariate linear regression model was used to find the association of PAF scores with various participant characteristics. Results: Thirty-kone of the 410 (7.6%) women had WI scores of ≥5 and were considered to have significant health-related anxiety. The PAF score had statistically significant associations with health anxiety, as well as depression and anxiety. Conclusions: Our results suggest that the premenstrual symptoms often coexist with health anxiety as well as other psychological symptoms. Clinicians should be alert to the fact that PMS may be associated with treatable psychiatric conditions.

An estimated 95,000 people developed methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005 of which 14% were community-associated and 85% were hospital or other health setting associated, and 19,000 Americans died from these infections that year. Purpose: To explore health care providers’ perspectives on management of skin and soft tissue infections to gain a better understanding of the problems faced by busy providers in primary care settings. Methods: Focus group meetings were held at 9 family physician offices in the Iowa Research Network. Seventy-eight clinicians including physicians, nurses, nurse practitioners, and house officers attended. Meeting audiotapes were transcribed and coded by 3 investigators, and a MRSA-management taxonomy was developed. Findings: The main themes that emerged from the focus groups included epidemiology, diagnosis, treatment, management, prevention, special populations, and public relations. The incidence of MRSA infections was perceived to have increased over the past decade. However, diagnosis and treatment protocols for physicians in the outpatient setting have lagged behind, and no well-accepted diagnostic or treatment algorithms were used by physicians attending the focus groups. Conclusion: The clinicians in this study noted considerable confusion and inconsistency in the management of skin and soft tissue infections, particularly those due to MRSA.

(a) To identify reliable and valid questions that identify elder abuse, (b) to assess the reliability and validity of extant self-reported elder abuse screens in a high-risk elderly population, and (c) to describe difficulties of completing and interpreting screens in a high-need elderly population.All elders referred to research-trained social workers in a community service agency were asked to participate. Of the 70 elders asked, 49 participated, 44 completed the first questionnaire, and 32 completed the duplicate second questionnaire. A research assistant administered the telephone questionnaires.Twenty-nine (42%) persons were judged abused, 12 (17%) had abuse reported, and 4 (6%) had abuse substantiated. The elder abuse screen instruments were not found to be predictive of assessed abuse or as predictors of reported abuse; the measures tended toward being inversely predictive. Two questions regarding harm and taking of belongings were significantly different for the assessed abused group.In this small group of high-need community-dwelling elders, the screens were not effective in discriminating between abused and nonabused groups. Better instruments are needed to assess for elder abuse.

Background A federal complaint/incident system was implemented in 2004 with the stated purpose of promoting and protecting the health, safety, and the welfare of residents receiving health care services. This system provided the first national database of mistreatment in the nursing home setting. Methods The purpose of this research was to identify state and nursing home characteristics associated with the rates of nursing home resident mistreatment. Outcomes were incident reports filed by nursing home staff and complaints filed by persons other than service providers obtained from the federal complaints/incidents tracking system. Predictor variables used in the analysis of the reporting system included state legislation, census demographic data, and characteristics of the nursing home including aggregate characteristics of the residents. Results In 2004, based on complaint and incident reports, 1.6% of the nursing home population was reported to be mistreated. The average rates per 1000 residents were 16 reports, 14 investigations, and 4 substantiations. Incident report rates per 1000 ranged from 0.04 in Virginia to 46 in Alabama. Complaint report rates ranged from 0.42 in Hawaii to 52 in New Mexico. Incident outcomes were significantly lower in states that had nursing home statutes that require the facility, rather than the individual, to report mistreatment or in states that defined mistreatment in the nursing home differently from the definitions used by adult protective service statutes. Higher complaint outcomes were associated with lower levels of staffing. After controlling for resident characteristics, mistreatment measures remained associated with nursing home staffing levels but not with elements of statutes. Conclusions Documentation of nursing home mistreatment shows substantial differences in report rates across states. These differences cannot be explained by variations in the laws.

Background: Fewer than half of Americans have been screened for colorectal cancer (CRC), a largely preventable disease. Methods: All physician members (n = 1030) of the Iowa Academy of Family Physicians were mailed a 3-page investigator-developed survey about their attitudes, barriers, and practices regarding CRC screening. Results: The usable response rate was 29%. Forty-three percent practiced in rural settings. Ninety-five percent felt that they were well informed about American Cancer Society guidelines and 90% tried to follow the guidelines. Most doctors (88%) disagreed with the statement that there was "no time to adequately discuss screening," but they would like more time to discuss screening. Only 40% felt their medical records were organized to easily determine screening status, 40% encouraged office staff to participate in screening, and 16% had a written policy regarding CRC screening. Physicians estimated that they recommend screening to 78% of their patients and that 54% of their patients were actually up-to-date. Discussion of CRC screening was strongly dependent on visit type, with physicians estimating that CRC screening is discussed at 11% of acute visits, 42% of chronic visits, and 87% of health maintenance visits. Several office system factors were associated with a recommendation for screening in a multivariable linear regression model (R 2 = 0.33). Conclusions: Although nearly all physicians felt that they were well informed about American Cancer Society guidelines and tried to follow guidelines for CRC screening, few had office systems to facilitate screening. Physicians would like more time to discuss screening. Office systems likely have the most potential to improve CRC screening among patients attending primary care practices.

This study evaluated on a county level the association of Iowa's domestic dependent-adult abuse investigations with the location of adult protective services (APS) offices, rurality, government resources, felony charges and prosecutions, child abuse reports, and census demographics. In 2003, the rate of dependent-adult abuse investigations for Iowa was 0.70 per 1,000 population age 18 and older. Higher rates of child abuse investigations, felony prosecutions, sheriff's annual salary, and lower rates of child abuse substantiations are associated with higher rates of dependent-adult abuse investigations and substantiations.

Compared with urban settings, much less is known about the prevalence and correlates of elder abuse in rural areas. The purposes of this study were to: (1) examine the prevalence of elder domestic part ner violence and (2) estimate the prevalence of elder abuse reported and inflicted by men and women and to identify factors associated with elder domestic partner violence. A secondary data analyses was completed for 362 cohabitating partners who were participants in a population-based, prospective study. Based on results of the Conflict Tactics Scale, 32% of the cohabiting participants reported emotional abuse and 2% reported physical abuse. Significant risk factors of reported emotional abuse were having depressive symptoms, higher antisocial personality score, and not living in a town.

Purpose This study compared in one data set the relative importance of most previously examined risk factors for different symptoms of insomnia. Methods Data were obtained from personal interviews of 1588 adults in a rural area. Statistical methods evaluated the association of 42 risk factors with any insomnia and each of four insomnia subtypes: difficulty with initiating sleep (DIS), difficulty maintaining sleep (DMS), early morning awakening (EMA), and restless sleep (RS). Results Insomnia rates were greater in this rural population than most U.S. studies and greater in the United States than other countries. The correlations between insomnia subtype and energy level was highest for RS, –0.29, and lowest for EMA, –0.11. All sleep disturbances increased monotonically with depressive symptoms, but the increase was greatest for RS (r = 0.57) and weakest for EMA (r = 0.24). Anxiety and pain also were independently associated with each insomnia subtype. Insomnia problems of spouses were uncorrelated. Other risk factors were independently associated with some insomnia subtypes but not others. For example, the association of age with difficulty maintaining sleep was independent of health measures. Conclusion The results suggest that different insomnias have different rates and risk factors and therefore possibly different etiologies and management strategies.

Unexplained chronic fatigue (UCF) is a poorly understood condition with little known about its etiology and treatment. A wide range of health care providers, including physicians, nurse practitioners, and complementary and alternative medical practitioners, offer services for persons with UCF. This study explored perspectives of family medicine physicians and licensed acupuncture clinicians with experience in treating patients with UCF, regarding their treatment regimens and perceived success at improving their patients' energy and coping with symptoms. A sample of 141 family medicine physicians and licensed acupuncturists was surveyed via a questionnaire; 48 returned the completed questionnaire. Clinicians reported treating from 3 to 375 patients with UCF. Family physicians provided more conventional methods, and licensed acupuncturists provided alternative treatments. The reported success of the licensed acupuncturists at improving energy and stamina and helping patients cope with fatigue was significantly higher than that of the family physicians. Implications for future research are discussed.

The goal of this project was to establish the feasibility of linking a practice-based research network of Adult Protective Service (APS) workers to an academic institution. To determine whether this newly formed APS research network was feasible, a qualitative research project was attempted with network members who had e-mail. An e-mailed single case study with three questions sent to the 356 network members yielded a 31% return rate. APS workers suggested 73 different ideal and actual services for the case study abuse victim. Half of the respondents were unable to implement the ideal service. Barriers were predominantly financial, victim and daughter cooperation, and availability of resources. It is realistic and feasible to establish an adult protective service research network with an interdisciplinary academic research team.

Using peer learning strategies, seven experienced PBRNs working in collaborative teams articulated procedures for PBRN Research Good Practices (PRGPs). The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings. This paper describes the team science processes which culminated in the PRGPs. Skilled facilitators used team science strategies and methods from the Technology of Participation (ToP®), and the Consensus Workshop Method to support teams to codify diverse research expertise in practice-based research. The participatory nature of "sense-making" moved through identifiable stages. Lessons learned include (1) team input into the scope of the final outcome proved vital to project relevance; (2) PBRNs with diverse domains of research expertise contributed broad knowledge on each topic; and (3) ToP® structured facilitation techniques were critical for establishing trust and clarifying the "sense-making" process.

Objective: Iowa has the highest average radon concentrations in the nation, with an estimated 400 radon-induced lung cancer deaths each year. Radon is the second leading cause of lung cancer death overall. The objectives of this study were (1) to educate the population attending a family medicine office about the dangers of radon, (2) to encourage homeowners to test for radon, (3) to work with the community to identify resources for mitigation, and (4) to assess the utility of working with a local family medicine office as a model that could be adopted for other communities with high home radon concentrations. Methods: Participants obtained a US Environmental Protection Agency‐certified activated charcoal short-term radon kit through their primary care office or by attending a seminar held by their medical office. Participants completed a short investigator-developed questionnaire about their home, heating, and demographics. Results: Of 746 radon kits handed out, 378 valid results (51%) were received, of which 351 questionnaires could be matched to the kit results. The mean radon result was 10.0 pCi/L (standard deviation, 8.5 pCi/L). A radon result of 4 pCi/L or higher, the Environmental Protection Agency action level for mitigation, was found in 81% of homes (n 285). Conclusions: Four of 5 homes tested had elevated radon levels. This family medicine office/university collaborative educational model could be useful for educating patients about other environmental dangers. (J Am Board Fam Med 2015;28:617‐623.)

Background: Through a cancer research infrastructure building grant, iPads were given to health care providers in family physician offices. The purpose of this study was to determine the use and application of iPads in the Iowa Research Network. Methods: A Qualtrics survey was sent to 81 iPad recipients after institutional review board approval. Results: Fifty-nine percent responded and 85% reported they have used the iPad. The main reason for use of the iPad was browsing the World Wide Web for health care information. Open-ended comments supported use of the iPad for photographic documentation of wound and other skin lesions for insertion into the medical record and it helped improve clinic flow by making it easier to put orders in the system through the iPad. Conclusions: Tablet uses are variable in physician offices with provider’s gathering health care information from the Internet and securing education material for patients as the frequent usages.

BACKGROUND. Only about half of eligible individuals undergo colon cancer screening. We have limited knowledge about the patient beliefs that adversely affect screening decisions and about which beliefs might be amenable to change through education. METHODS. As part of a clinical trial, 641 rural Iowans, aged 52 to 79 years, reported their beliefs about colon cancer screening in response to a mailed questionnaire. Consenting subjects were randomized into 4 groups, which were distinguished by 4 levels of increasingly intensive efforts to promote screening. Two of the groups received mailed educational materials and completed a follow-up questionnaire, which allowed us to determine whether their beliefs about screening changed following the education. We also completed a factor analysis to identify underlying (latent) factors that might explain the responses to 33 questions about readiness, attitudes and perceived barriers related to colon cancer screening. RESULTS. The strongest predictors of a patient’s stated readiness to be screened were a physician’s recommendation to be screened (1-point difference on 10-point Likert scale, 95% confidence interval[CI], 0.5 to 1.6 point difference), a family history of colon cancer (0.85-point Likert-scale difference, 95% CI, 0.1 to 1.6), and a belief that health care decisions should be mostly left to physicians rather than patients (Spearman correlation coefficient 0.21, P

Objective Assess reasons for improved control for patients with initially poorly controlled diabetes. Research design and methods Patients in seven practices with type 2 diabetes were selected if within a 6-month period they had two glycosylated hemoglobin (HbA1c) levels of at least 8.0%. Patient factors that may influence control were compared for patients grouped according to their last two HbA1c levels. Results Review of 643 medical records of diabetic patients treated by 29 clinicians identified 69 study patients. After at least 1 year of follow-up 26 patients became well controlled, 14 had intermediate control, and 29 remained in poor control. Becoming controlled was not significantly associated with gender, age, duration of diabetes, BMI, or HbA1c levels prior to baseline. It was inversely associated with greater use of medications ( P = 0.04), and positively associated with understanding of diabetes ( P = 0.03), adherence to recommendations for meal plan ( P = 0.001), and glucose monitoring ( P = 0.02). Thirty-one percent of patients who became controlled had a change in life circumstances. Reasons for not advancing medications were probably justified for 69% of patients who remained uncontrolled. Conclusion Improved control depends largely on patient self-care behaviors.

Objective To evaluate the association of nursing home abuse reported by employees in Iowa licensed nursing homes with nursing home characteristics, inspection results, nursing staff hours, and census demographics. Design Mailed survey. Setting Iowa's 409 Medicare-certified stand-alone nursing homes. Participants Administrators and directors of nursing. Results The annual rate of abusive events was 20.7 per 1000 nursing home residents, with a rate of 18.4 reported events and 5.2 substantiated events. A higher number of residents and a higher number of certified beds were significantly associated with higher incident, report, and substantiation rates. Higher incident and report rates were associated with nursing homes in metropolitan areas. Higher substantiation rates were associated with for-profit nursing homes. Conclusion Recognized abuse in nursing homes is not uncommon. Approximately 90% of events are reported to the state authorities with 29% of those being substantiated. Differences associated with nursing facility abuse rates are metropolitan area, ownership, occupancy rate, and number of residents and certified beds.

The purpose of this research is to determine if there is an association between ombudsman report rates of abuse, gross neglect, and exploitation from 1997 through 2002 and ombudsmen's public and staff education, investigative process, program expenditures, and census demographics. Data were obtained from the National Ombudsman Reporting System. Ombudsman annual reports of nursing home abuse, neglect, and exploitation are representative of that state's individual program. These reports should not be construed to represent all abuse in nursing homes. Physical abuse and resident-to-resident abuse were the highest rates of abuse reported. Census demographics and ombudsman program characteristics were associated with rates of abuse.

The purpose of this paper is to evaluate the relationship of required educational background of APS workers to the 1999 rates of domestic elder abuse. Data were obtained from APS related statutes and regulations and questions to the National Center for Elder Abuse list serve. Descriptive statistics and independent sample t-tests were used for analyses. Those states whose legislations required a social work degree for APS caseworkers did have higher elder abuse investigation rates. A lower substantiation ratio was found for those states requiring a social work degree or license. These findings suggest that social work education may lead to an emphasis on investigation and interventions and de-emphasis on the criminal aspects of elder abuse evaluation substantiations.

Instruments designed to measure specific types of elder mistreatment are not available, but they may be warranted after an initial screen indicates abuse or risk for abuse. The purpose of this study was to evaluate definitions for different types of elder mistreatment and validate the indicators as perceived by adult protective services (APS) caseworkers' opinions. Through 351 APS research network participants, a Delphi survey was completed. A 45% return rate was achieved for round one and 40% for round two with 70 same respondents from both rounds. These types of abuse, emotional abuse, exploitation of finances and/or property, neglect, physical abuse, and sexual abuse, have some similar and some extremely different indicators that singly and together expand their definition. Instruments to measure five different types of abuse are offered for caseworker or prevalence study use.

Adult Protective Services statutes designate penalties for those who inflict abuse on elders. These penalties are either civil or criminal, with criminal penalties delineated as misdemeanors or felonies. The purpose of this study is to evaluate the relationship of criminal penalties for the infliction of abuse on the rates of reported, investigated, and substantiated domestic elder abuse for all states. The District of Columbia and forty-three states’ APS-related statutes make elder abuse crimes felonies while thirty provide misdemeanors for some or all aspects of elder abuse. After taking into account demographic factors that influence investigation rates, states were found to have higher investigation rates if their statute made abuse a felony, had longer prison terms, tracked reports of abuse allegations, required reporting by professionals, and had more words in the definitions of abuse. After taking into account demographic factors that influence substantiation rates, states were found to ha...

Objectives: To evaluate the association between state-defined elder abuse investigation systems and rates of reported, investigated and substantiated domestic elder abuse. Methods: A mailed survey was administered to 1,763 adult protective service (APS) office investigators in 44 states and the District of Columbia. Information about investigative structures and investigations was obtained from 1,409 of the APS investigators, an 80% return rate. County/district domestic elder abuse report, investigation, and substantiation numbers for each state for 1999 was obtained for APS state administrators. Results: Elder abuse reports to APS offices ranged from 0 to 191.7 per 1,000 elder population. Investigation and substantiation rates ranged from 0 to a high of 150.0 and 116.7, respectively. Investigation rates were higher in counties having investigators only evaluating elder abuse cases, having a social work educational background and feeling that the elders were usually better off after investigation...

Purpose: To determine family practice physician's knowledge of state laws regarding elder abuse, perceived barriers to reporting suspected cases of elder abuse, and factors associated with reporting elder abuse in practice. Methods: Mailed questionnaire to 1,030 Iowa Academy of Family Practice Physicians with 378 (37%) returned. Chi-square tests modified for trend and stepwise logistic regression were used to determine influences on whether physicians saw a case of elder abuse in the past year, and whether physicians chose to report those cases. Results: A strong predictor for number of cases seen and if cases had been reported, was the physician asking the elderly patient direct questions about elder mistreatment. Other positive associations were if the physician's office had a protocol for reporting elder abuse, and if physicians lived in the most rural areas. Conclusion: Knowledge of elder abuse legislation increases physician likelihood of reporting elder abuse, but not of seeing cases of eld...

Forty-four states and the District of Columbia have laws providing that individuals who assume the care or custody of the elderly are considered mandatory reporters and must report suspected abuse. A mandatory reporter is a person required by law to report allegations and/or suspicions of abuse. Thirty-eight state statutes specify a penalty for mandatory reporters who do not report when they should. The purpose of this study is to evaluate the relationship of state adult protective service wording of mandatory reporting on the rates of reported, investigated and substantiated domestic elder abuse. Higher investigation rates were associated with a mandatory reporting requirement. Description of mandatory reporter, penalty for failure to report abuse allegations, and time to report an abuse allegation did not result in a significant difference in report, investigation, and substantiation rates. Legislation is associated with aspects of adult protective service practice. The requirement that mandato...

Elder abuse is a societal problem that influences all members of the community. By 1993 each state had enacted laws addressing elder abuse in domestic and institutional settings (Tatara, 1995). These laws take many different forms, and in 44 states and the District of Columbia, contain sections regarding the designation of mandatory reporters of elder abuse and neglect. Health care professionals and law enforcement personnel frequently are listed as mandatory reporters. Iowa is the only state that requires education for its mandatory reporters. The purpose of this paper is to compare the investigation and substantiation rates for elder abuse allegations before and after July 1988 when Iowa statute (§ 235B. 1 IA CO) was revised to ensure training of mandatory reporters. The investigation and substantiation rates were analyzed using two-sample t-tests for comparisons of four time periods and compared to investigation rates for Texas and Wisconsin. There were no significant differences in investigat...

New fecal occult blood tests have a higher sensitivity and specificity for detection of adenomas and cancer than guaiac-based tests.

ORGANIZATIONAL PROCESSES AND EFFECT ON PATIENT OUTCOMES ABSTRACT The purpose of this study was to determine how use of a standardized nomenclature for nursing diagnosis and intervention statements on the computerized nursing care plan in a long-term care (LTC) facility would affect patient outcomes, as well as organizational processes and outcomes. An experimental design was used to compare the effects of two methods of documentation: Computer care plan and paper care plan. Twenty participants (10 in each group) were randomly assigned to either group. No statistically significant differences were found by group for demographic data. Repeated measures ANOVA was computed for each of the study variables with type of care plan, written or computerized, as the independent variable. There were no statistically significant differences between participants, group (care plan), within subjects (across time), or interaction (group and time) effects for the dependent variables: Level of care, activities of daily living, perception of pain, cognitive abilities, number of medications, number of bowel medications, number of constipation episodes, weight, percent of meals eaten, and incidence of alteration in skin integrity. There were significantly more nursing interventions and activities on the computerized care plan, although this care plan took longer to develop at each of the three time periods. Results from this study suggest that use of a computerized plan of care increases the number of documented nursing activities and interventions, but further research is warranted to determine if this potential advantage can be translated into improved patient and organizational outcomes in the long-term care setting.

An estimated 50% of nursing home residents have a dementia diagnosis. The purpose of this research was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with Behavioral and Psychological Symptoms of Dementia. DON responses were linked to Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (OSCAR/CASPER) data to examine how facility characteristics may be associated with use of and confidence in non-drug management strategies. From 431 questionnaires mailed to DONs, 160 (37%) were returned. Regression analysis showed that those who were more confident in managing challenging behavior were more likely to have satisfaction with current training on managing challenging behaviors and had a psychiatrist available to visit the facility. Facilities with a larger proportion of patients with challenging behaviors being treated with non-drug approaches instead of antipsychotics had DONs who were more likely to be confident in non-drug management strategies and have knowledge about the FDA antipsychotic medications risks.

Providing a model of a colon segment with an adenomatous polyp and cancer can help to educate patients about the adenoma to carcinoma sequence and how this sequence can be interrupted with appropriate testing. The purpose of this study was to assess the use of a three-dimensional colon model with polyps and cancer provided to family physicians or nurses in some Iowa Research Network family physician offices. Colon models were provided to 117 family medicine healthcare providers interested in colorectal cancer screening. Using a mailed survey and follow-up telephone calls to non-responders, 81 (69 %) questionnaires were returned. Thirty-six (44 %) of the respondents reported they had used the model, 33 (41 %) reported they used the model for a mean 16 % of their patients in a month’s time, 31 (38 %) reported using the model to teach patients about the colon and polyps prior to a colonoscopy. Other model use described by respondents included educating staff to promote patient willingness for colonoscopies, demonstrating the need for colon cancer screening, and teaching patients about annual fecal occult blood tests. Respondents agreed that anatomical models are helpful for patient education, the design of the colon model was good, and that it facilitated demonstration of colon polyps. Possible recommendations for an office-wide adoption of an anatomical model would be an in-service for all employees and a standard location for finding the model.