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Developing clinical quality champions is an important strategy for improving health care quality. The NorthShore Quality and Patient Safety Fellowship was a yearlong program for practicing physicians devoting 4 hours/wk to a didactic curriculum and quality practicum. Thirty-seven clinicians completed the Fellowship from 2011 to 2018. Sixty percent of graduates reported a significant impact on their quality-related career trajectory, with 44% of early graduates and 64% of recent graduates reporting a new quality role or responsibility as a result of the Fellowship. Fifty-four percent of practicum projects were adopted or adapted by the organization. The Fellowship has been an effective framework to identify and train future quality champions and has led to further quality leadership opportunities for many graduates. Evolution of the Fellowship aligned practicum projects with organizational quality priorities. This curricular framework may be useful for other organizations that seek to develop quality champions among practicing physicians.

Objectives Identify the incidence, rate of physician recognition, diagnostic practices and cancer outcomes for unintentional weight loss (UWL). Methods We completed a secondary analysis of structured and unstructured EHR data collected from adult patients between January 1, 2020 and December 31, 2021. We used four common definitions to define UWL, excluding patients with known causes of weight loss, intentional weight loss, and pregnancy. Unstructured physicians’ notes were used to identify both intentional weight loss (e.g. dieting) as well as physician recognition of UWL. Cancer outcomes were identified within 12 months of UWL using diagnostic codes. Physician actions (lab tests, etc.) in response to UWL were identified through manual chart review. Results Among 29,494 established primary care patients with a minimum of two weight measurements in 2020 and in 2021, we identified 290 patients who met one or more criteria for UWL (1 %). UWL was recognized by physicians in only 60 (21 %). UWL was more common and more likely to be recognized among older patients. Diagnostic practices were quite variable. A complete blood count, complete metabolic profile, and thyroid stimulating hormone level were the three most common tests ordered in response to UWL. Five patients were diagnosed with cancer within 12 months of UWL (3 in whom UWL was recognized; two in whom it was not.) Conclusions Unintentional weight loss is poorly recognized across a diverse range of patients. A lack of research-informed guidance may explain both low rates of recognition and variability in diagnostic practices.

Background U.S. physicians lack training in caring for patients with obesity. For family medicine, the newly developed Obesity Medicine Education Collaborative (OMEC) competencies provide an opportunity to compare current training with widely accepted standards. We aimed to evaluate the current state of obesity training in family medicine residency programs. Methods We conducted a study consisting of a cross-sectional survey of U.S. family medicine residency program leaders. A total of 735 directors (including associate/assistant directors) from 472 family medicine residency programs identified from the American Academy of Family Physicians public directory were invited via postal mail to complete an online survey in 2018. Results Seventy-seven program leaders completed surveys (16% response rate). Sixty-four percent of programs offered training on prevention of obesity and 83% provided training on management of patients with obesity; however, 39% of programs surveyed reported not teaching an approach to obesity management that integrates clinical and community systems as partners, or doing so very little. Topics such as behavioral aspects of obesity (52%), physical activity (44%), and nutritional aspects of obesity (36%) were the most widely covered (to a great extent) by residency programs. In contrast, very few programs extensively covered pharmacological treatment of obesity (10%) and weight stigma and discrimination (14%). Most respondents perceived obesity-related training as very important; 65% of the respondents indicated that expanding obesity education was a high or medium priority for their programs. Lack of room in the curriculum and lack of faculty expertise were reported as the greatest barriers to obesity education during residency. Only 21% of the respondents perceived their residents as very prepared to manage patients with obesity at the end of the residency training. Conclusion Family medicine residency programs are currently incorporating recommended teaching to address OMEC competencies to a variable degree, with some topic areas moderately well represented and others poorly represented such as pharmacotherapy and weight stigma. Very few program directors report their family medicine residents are adequately prepared to manage patients with obesity at the completion of their training. The OMEC competencies could serve as a basis for systematic obesity training in family medicine residency programs.

Pancreatic ductal adenocarcinoma (PDAC) has the worst survival of common cancers, partly because there are no reliable early detection tests. Unintentional weight loss (≥ 5% decrease from baseline) has been linked to PDAC, but the frequency and severity of weight loss using objective measures, and its relationship to prognosis, have not been well characterized. We identified 390 patients with PDAC (all stages) and two or more prediagnosis weights in the electronic medical record. Percentage weight loss in the 365 and 180 days preceding diagnosis was calculated. Results were compared with raw weights of age- and sex-matched non-cancer controls (n = 780). Odds ratios for PDAC were calculated using conditional logistic regression. Cox proportional hazards models were used for survival. Within 1 year of diagnosis, more PDAC patients lost ≥ 5% weight relative to controls (74.9% vs. 11.2%; p

We previously found that antibiotic use at24 months of age was associated with slightly higher body weight at 5 years of age. In this study, we examine associations of early life antibiotic prescriptions with weight outcomes at 108 to 132 months of age ("10 years").We used electronic health record data from 2009 through 2016 from 10 health systems in PCORnet, a national distributed clinical research network. We examined associations of any (vs no) antibiotics at24 months of age with body mass index z-score (BMI-z) at 10 years adjusted for confounders selected a priori. We further examined dose response (number of antibiotic episodes) and antibiotic spectrum (narrow and broad).Among 56,727 included children, 57% received any antibiotics at24 months; at 10 years, mean (standard deviation) BMI-z was 0.54 (1.14), and 36% had overweight or obesity. Any versus no antibiotic use at24 months was associated with a slightly higher BMI-z at 10 years among children without a complex chronic condition (β 0.03; 95% confidence interval [CI] 0.01, 0.05) or with a complex chronic condition (β 0.09; 95% CI 0.03, 0.15). Any versus no antibiotic use was not associated with odds of overweight or obesity at 10 years among children without (odds ratio 1.02; 95% CI 0.97, 1.07) or with a complex chronic condition (odds ratio 1.07; 95% CI 0.96, 1.19).The small and likely clinically insignificant associations in this study are consistent with our previous 5-year follow-up results, suggesting that, if this relationship is indeed causal, early increases in weight are small but maintained over time.

Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid's Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio's Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

Early detection is a valued strategy to decrease cancer mortality rates; however, new strategies are needed. Unintentional weight loss (UWL) is experienced by patients across the cancer spectrum, but often goes unnoticed. Patient-centered weight tracking may be a useful early detection marker. Fifty patients were enrolled in a prospective patient-centered weight tracking trial. Patients received a scale and monetary compensation to participate. A reminder to measure and record weight was texted to participants for 26 consecutive weeks. Most patients were black (86.0%) and female (68.0%). The median age was 47 years (range: 22-84 years). Many participants had Medicaid (42.0%) and the median household income by home zip code was $31,046. After 26 weeks, 90% of patients had recorded at least one weight. Among all patients, 73.7% of all possible weights were recorded and the median response rate per patient was 92.3% (24 of 26 weights). There was no difference in the response rates during the first and second halves of the study (77.7% vs. 69.7%, P = 0.53). The range of weight change over the study period was 16.1% loss to 25.0% gain, with 56% of patients maintaining stable weight. Seven patients (14.0%) lost more than 5% weight and 11 patients (22.0%) gained over 5%. Of the seven patients with weight loss, two (4.0% of the cohort) were determined to have UWL. Patient-centered weight tracking is feasible and inexpensive, and has potential as an early detector of UWL. Further studies are needed to apply this strategy to detect underlying malignancies.

BACKGROUND Since the COVID-19 pandemic, telemedicine appointments have replaced many in-person healthcare visits [1 2]. However, older people are less likely to participate in telemedicine, preferring either in-person care or foregoing care altogether [3-6]. With a high prevalence of chronic conditions and vulnerability to COVID-19 morbidity and mortality through exposure to others in health care environments, (1-4), promoting telemedicine use should be a high priority for seniors. Seniors face significant barriers to participation in telemedicine, including lower internet and device access and skills, and visual, auditory, and tactile difficulties with telemedicine. OBJECTIVE Hoping to offer training to increase telemedicine use, we undertook a quality improvement survey to identify barriers to, and facilitators of telemedicine among seniors presenting to an outpatient family medicine teaching clinic which serves predominantly African American, economically disadvantaged adults with chronic illness in Cleveland, Ohio. METHODS Our survey, designated by the IRB as quality improvement, was designed based on a review of the literature, and input from our primary care providers and a digital equity expert (Figure 1). To minimize patient burden, the survey was limited to 10 questions. Because we were interested in technology barriers, data were collected on paper rather than a tablet or computer, with a research assistant available to read the survey questions. Patients presenting with needs that could be accomplished remotely were approached by a research assistant to complete the survey starting February 2021 until we reached the pre-determined sample size (N=30) in June 2021. Patients with known dementia, those who normally resident in a long-term care facility, and those presenting with an acute condition (e.g. fall or COPD exacerbation) were ineligible. Because of the small number of respondents, only univariate and bivariate tabulations were performed, in Excel. RESULTS 83% of respondents said they had devices that could be used for a telemedicine visit and that they went on the internet, but just 23% had had telemedicine visits. Few patients had advanced devices (iPhones, desktops, laptops or tablets); 46% had only a single device that was not IOS based mobile (Table 1). All participants with devices said they used them for “messaging on the internet,” but this was the only function used by 40%. No one used the internet for banking, shopping, and few used internet functions commonly needed for telemedicine (23.3% had email; 30% did video calling) (Table 1). 23.3% of respondents had had a telemedicine appointment. Many reported a loss of connection to their doctor as a concern. Participants who owned a computer or iPhone used their devices for a broader range of tasks, (Table 2 and 3), were aged 65-70 (Table 4), and were more likely to have had a telemedicine visit and to have more favorable views of telemedicine (Table 2). Respondents who had not had a telemedicine appointment endorsed a greater number of telemedicine disadvantages and endorsed less interest in future appointments (Table 2). Respondents who did not own an internet-capable device did not report using any internet functions and none had had a telemedicine appointment (Table 2). CONCLUSIONS This small survey revealed significant gaps in telemedicine readiness among seniors who said they had devices that could be used for telemedicine and that they went online themselves. No patients used key internet functions needed for staying safe during COVID, and few used internet applications that required skills needed for telemedicine. Few patients had devices that are optimal for seniors using telemedicine. Patients with more advanced devices used more internet functions and had more telemedicine experience and more favorable attitudes than others. Our results confirm previous studies [7-9] showing generally lower technological proficiency among older adults and some concerns about participating in telemedicine. However, our study is novel in pointing to subtle dimensions of telemedicine readiness that warrant further study—device capacity and use of internet in ways that build skills needed for telemedicine such as email and video calling. Before training seniors to use telemedicine, it’s important to ensure that they have the devices, basic digital skills and connectivity needed for telemedicine. Larger studies are needed to confirm our results and apply multivariate analysis to understand the relationships among age, device quality, internet skills and telemedicine attitudes. Development of validated scales of telemedicine readiness and telemedicine training to complement in-person care can help health systems offer precision-matched interventions to address barriers, facilitate increased adoption, and generally improve patients’ overall access to primary care and engagement with their primary care provider.

Background Older adults are a high priority for telemedicine given their elevated COVID-19 risk and need for frequent provider contact to manage chronic illnesses. It seems that many older adults now use smartphones but few studies have examined their overall readiness for telemedicine. Objective The aim of this study is to survey older primary care patients about their telemedicine preparedness, including internet usage, internet-capable devices, telemedicine experiences and concerns, and perceived barriers. Results were used to inform a telemedicine preparedness training program. Methods Community-dwelling older adult patients (aged 65-81 years; N=30) with a chronic health condition that could be managed remotely who were present at a family medicine clinic that primarily serves an urban African American population for a prescheduled in-person appointment were asked to complete a brief survey written for this study. Data were collected February-June 2021 at a large, urban, Midwestern hospital. To minimize patient burden, the survey was limited to 10 questions, focused on the most critical topics. Results Most participants (21/30, 70%) reported having a device that could be used for telemedicine and using the internet. However, about half had only a single connected device, and messaging and video calling were the most commonly used applications. Few used email and none used online shopping or banking. Only 7 patients had had telemedicine appointments. Telemedicine users were younger than nonusers and used more internet functions than nonusers. Only 2 people reported problems with their telemedicine visits (technology and privacy). Nearly all respondents recognized avoiding travel and COVID-19 exposure as telemedicine benefits. The most common concerns were loss of the doctor-patient connection and inability to be examined. Conclusions Most older adults reported having devices that could be used for telemedicine, but their internet use patterns did not confirm the adequacy of their devices or skills for telemedicine. Doctor-patient conversations could be helpful in addressing telemedicine concerns but device and skill gaps must be addressed as well.

Adult cardiovascular disease has its roots in childhood and adolescence. Risks for pediatric hypertension include obesity, male sex, and minority race. We identified risk factors associated with hypertension specifically among African American adolescents ages 13-18.We analyzed data from the US National Health and Nutrition Examination Surveys from 2011 to 2018, defining BP consistent with hypertension as average systolic or diastolic BP ≥ 130/80 mmHg or taking medication for a clinical diagnosis of hypertension. Univariate analyses compared characteristics of adolescents with and without hypertensive-level BP. Logistic regression was completed to more precisely identify risk factors.Among 838 African American adolescents, 48 met criteria for hypertensive-level BP, for a population prevalence of 5.8%. Due to low rates of hypertensive-level BP in girls (2.7%), our analysis focused on the subset of boys, who had an 8.9% prevalence rate, increasing to 26.1% for boys with obesity and 35.3% for boys with severe obesity. Boys with hypertensive-level BP had significantly lower family incomes, higher rates of being in single-parent families, more frequent consumption of fast food, were more likely to be taking prescription medications for psychiatric diagnoses, and had higher A1c and cholesterol values.Our study confirms the much higher risk for hypertensive-level BP in African American boys and emphasizes the important role of social determinants of health in this common illness.

Objective measures of post-pancreatectomy weight change for pancreatic ductal adenocarcinoma (PDAC) have not been extensively studied for long-term outcomes. We used weight measurements in our institutional medical record to analyze trends in post-pancreatectomy weight and determine the association with disease status.Pancreatectomies for PDAC (n = 315) and benign indications (n = 111) were identified. Preoperative baseline, minimum postoperative (Min #1), and subsequent postoperative maximum (Max) weights were abstracted. Multivariable Cox hazards regression was conducted to analyze the association between weight change and survival.Median weight loss postoperatively in each group was 20 lbs. PDAC patients gained 10 lbs after Min #1 compared to 15 lbs in the benign cohort (p 0.001). Few patients returned to their preoperative weight (29.8% PDAC vs. 40.5% benign, p = 0.04). Patients with early PDAC recurrence ( 13 months) lost more weight (18.0% vs. 13.3% vs. 10.9%, p 0.001) and gained less weight (2.1% vs. 12.0% vs. 7.9%, p 0.001) compared with those with late cancer recurrence (≥ 13 months) or no evidence of active disease, respectively. PDAC patients lost 11.2 lbs in the year preceding recurrence diagnosis. Weight loss was not associated with survival; however, weight gain was associated with improved survival.Resections for PDAC are complicated by a similar degree of weight loss as patients with benign disease, and there is no association with survival. However, failure to gain weight is especially ominous. Weight loss after weight recovery foreshadows disease recurrence. These data suggest that rigorous weight tracking is an untapped surveillance strategy in patients with PDAC.

BACKGROUND Privacy-protecting analytic approaches without centralized pooling of individual-level data, such as distributed regression, are particularly important for vulnerable populations, such as children, but these methods have not yet been tested in multi-center pediatric studies. METHODS Using the electronic health data from 34 healthcare institutions in the National Patient-Centered Clinical Research Network (PCORnet), we fit 12 multivariable-adjusted linear regression models to assess the associations of antibiotic use

CONTEXT Health benefits of yogurt are well documented in adults and older children, but less is known about the effects of yogurt in infants and toddlers (aged 4 to 24 months). OBJECTIVE The aim of this qualitative systematic review was to assess the effects of yogurt and fermented milk products on the health of infants and toddlers. DATA SOURCES PubMed was searched for English-language papers. No date restrictions were applied. STUDY SELECTION Randomized controlled trials, observational studies, and prospective cohort studies were included. Systematic or narrative reviews, conference abstracts, and dissertations were excluded. In total, 1624 abstracts were screened, of which 1614 were excluded. DATA EXTRACTION Full texts of the remaining 10 abstracts were independently reviewed by both authors, who reached consensus about relevance, methods, findings, quality, and conclusions of the included studies. RESULTS The included studies (published between 1987 and 2017) were heterogeneous with respect to sample size, study population, and type of yogurt used. Five of six studies showed a positive effect of yogurt consumption on infectious diarrhea. Two studies reported a positive effect on gut microbiota composition. Two cohort studies reported a positive effect on reducing the incidence of atopic dermatitis, one of which also reported a positive impact on food sensitivity. CONCLUSIONS Published evidence, much of it decades old, supports a health benefit of yogurt consumption in infants and children. New short- and long-term studies are needed to better evaluate the impact of yogurt consumption in contemporary settings.

Background: Funded by the Ohio Department of Medicaid, the Ohio Cardiovascular and Diabetes Health Collaborative (Cardi-OH) unites the 7 medical schools in Ohio to improve outcomes and reduce disparities in hypertension and type 2 diabetes (T2D). The purpose of this needs assessment was to identify high priority educational topics for the dissemination of evidenced-based best practices. Methods: Questions surveyed collaborative members’ familiarity with guidelines, educational topics, and barriers to care. Results: A total of 111 out of 123 members completed the needs assessment (90.2% response rate). Half (49.5%, n=55) were familiar with the 2017 ACC/AHA guidelines for hypertension, whereas only 36.9% (n=41) were familiar with the 2020 ADA guidelines. The 3 topics of most interest were: 1) social determinants of health (SDOH, 55.9%, n=62), 2) lifestyle approaches to T2D (40.5%, n=45), and 3) new therapies for T2D (32.4%, n=36). Fifty-nine members (53.2%) provided direct clinical care; the others worked in research and public health. Providers estimated 25% of their T2D patients had A1C values >9.0%. Providers listed the 3 most common patient self-care barriers as: 1) lack of patient motivation (65.5%, n=38), 2) lack of patient education (60.3%, n=35), and 3) limited formularies and prior authorizations (41.4%, n=24). The 3 most common reasons for clinical inertia were: 1) lack of patient education (50.0%, n=29), 2) competing priorities (46.6%, n=27), and 3) lack of patient motivation (44.8%, n=26). Providers felt payers could help them with: 1) transportation (61.0%, n=68), 2) coverage of diabetes self-management education and support (DSMES, 59.4%, n=66), and 3) obtaining glucose monitors (45.9%, n=51). Conclusions: Top priorities for future evidence-based best practices are SDOH, patient engagement, and addressing complexity of care. Payers should prioritize increased coverage for DSMES and simplification of ordering monitoring supplies. Disclosure E. A. Beverly: None. G. D. Solomon: None. M. B. Holliday: None. J. Lewis: None. A. Nevar: None. S. M. Swiatkowski: None. M. W. Konstan: None. S. D. Bolen: None. K. M. Dungan: Advisory Panel; Self; Eli Lilly and Company, Tolerion, Inc., Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Elsevier, Novo Nordisk, Other Relationship; Self; UpToDate, Research Support; Self; Abbott, Sanofi-Aventis, Viacyte, Inc. J. T. Wright: None. A. Caron: None. M. Clemons: None. S. Aldrich renner: None. K. Gawlik: None. M. Sajatovic: Consultant; Self; Alkermes, Janssen Pharmaceuticals, Inc., Otsuka America Pharmaceutical, Inc., Other Relationship; Self; Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate, Research Support; Self; Alkermes, Nuromate, Otsuka America Pharmaceutical, Inc. G. Rao: None. Funding Ohio Medicaid Technical Assistance and Policy Program (G-2021-05-0069)

The incidence of type 2 diabetes in children and adolescents in the United States rose at an annual rate of 4.8% between 2002-2003 and 2014-2015. Type 2 diabetes progresses more aggressively to complications than type 1 diabetes. For example, in one large epidemiological study, proliferative retinopathy affected 5.6% and 9.1% of children with type 1 and type 2 diabetes, respectively. Screening begins at age 10 or at onset of puberty, and is recommended among children with a BMI% ≥85 with risk factors such as a family history and belonging to a high risk racial or ethnic or racial group. HbA1C% is preferred for screening as it does not require fasting. As distinguishing between type 1 and type 2 diabetes is not straightforward, all children with new onset disease should undergo autoantibody testing. Results of lifestyle interventions for control of type 2 diabetes have been disappointing, but are still recommended for their educational value and the potential impact upon some participants. There is limited evidence for the benefit of newer mediations. Liraglutide, a GLP-1 agonist, however, has been shown to significantly reduce HbA1C% in one study and is now approved for children. Liraglutide should be considered as second line therapy.

Pancreatic ductal adenocarcinoma (PDAC) has the worst survival of common cancers, partly because there are no reliable early detection tests. Unintentional weight loss (≥ 5% decrease from baseline) has been linked to PDAC, but the frequency and severity of weight loss using objective measures, and its relationship to prognosis, have not been well characterized.We identified 390 patients with PDAC (all stages) and two or more prediagnosis weights in the electronic medical record. Percentage weight loss in the 365 and 180 days preceding diagnosis was calculated. Results were compared with raw weights of age- and sex-matched non-cancer controls (n = 780). Odds ratios for PDAC were calculated using conditional logistic regression. Cox proportional hazards models were used for survival.Within 1 year of diagnosis, more PDAC patients lost ≥ 5% weight relative to controls (74.9% vs. 11.2%; p 0.001), with a median weight loss of 14.2 versus 2.9 lbs. The odds ratio for PDAC comparing weight loss within 1 year of 5 to 10% was 10.30 (p 0.001) and 77.82 for ≥ 10% (p 0.001), compared with stable weight. Weight loss prior to diagnosis was also associated with early-stage PDAC. PDAC cases with ≥ 10% prediagnosis weight loss had worse survival compared with stable weights (hazard ratio [HR] 1.60; p = 0.01). Greater prediagnosis weight loss was associated with poor survival after pancreatectomy (5 to 10% vs. 5%, HR 2.40, p = 0.03; ≥ 10% vs. 5%, HR 2.59, p = 0.03).Diagnosis of PDAC is preceded by unintentional weight loss in the majority of patients, even at an early stage. Greater prediagnosis weight loss severity is also associated with poor postoperative survival.

Purpose of Review Rapid economic growth in the Gulf Cooperation Council (GCC) states over the last half-century has been associated with a rise in obesity and cardiovascular morbidity and mortality. In this review, we shed some light on the factors driving the obesity epidemic, promising interventions to overcome this public health crisis, and challenges precluding a successful public health impact. Recent Findings Overweight and obesity rates have nearly tripled in the GCC countries over the past four decades. Cardiovascular morbidity and mortality have been rising in parallel. Several sociodemographic, environmental, and behavioral factors have been correlated with sedentary lifestyle and unhealthy diet habits, and ultimately the rise in overweight and obesity rates. Numerous studies have documented factors unique to the population of the Arab Gulf states, but high-quality data is scarce. Despite the growing awareness of the extent of the problem, several barriers to weight loss and physical activity need to be addressed. A few interventions to combat obesity at different levels have been reported with some promising outcomes. Using the social-ecological model (SEM), we review recently published interventions and discuss some challenges to overcome in order to make progress in fighting the obesity epidemic in the GCC. Summary Obesity prevalence has been mounting worldwide, and the Arab Gulf states are no exception. This public health crisis is drawing the attention of policymakers and several stakeholders. However, a lot needs to be done to reduce the burden of obesity and improve cardiovascular risks in the Arab Gulf states.

Clinical practice guidelines for diagnosis and management of pediatric hypertension have been available for decades. Yet, most cases of hypertension in children are undiagnosed. Provider and system-based factors, such as the complexity of diagnostic standards, and a failure among physicians to recognize the importance of hypertension in children, play a role in underdiagnosis. It is unclear, however, how patient and family behaviors impact the diagnosis and treatment of pediatric hypertension. We aimed to explore the perspectives of parents whose children have had multiple high blood pressure readings or have been diagnosed with hypertension to inform clinicians with areas for practice improvement. In a 2 site qualitative study, we interviewed parents of 15 children diagnosed with hypertension. Results from semi-structured interviews with parents revealed barriers to the diagnosis of pediatric hypertension, including uncertainty about the diagnosis and concerns around the accuracy of blood pressure measurements. Delay in diagnosis and lack of child engagement emerged as obstacles to the treatment of pediatric hypertension.

Intensive lifestyle interventions targeting diet and physical activity are recommended for reducing atherosclerotic cardiovascular disease (ASCVD) risk in adults. However, existing interventions often do not reach immigrant populations because of a mismatch between the social, cultural, and environmental context of immigrants and Western bio behavioral models which underpin evidence-based lifestyle interventions. The South Asian Healthy Lifestyle Intervention (SAHELI) study is a type 1 hybrid design randomized controlled trial aimed at reducing ASCVD risk in South Asian Americans, a group at higher ASCVD risk than whites and other Asian Americans. The objective is to evaluate the clinical effectiveness and implementation potential of a community-based, culturally-adapted lifestyle intervention for South Asian adults. Participants (n = 550) will be randomized to printed healthy lifestyle education materials or SAHELI, a group-based lifestyle change program that includes weekly classes for 16 weeks and 4 booster classes though month 11. SAHELI integrates evidence-based behavior change strategies with culturally-adapted strategies and group motivational interviewing to improve diet, physical activity, and stress management. Follow-up assessments will occur at 6 and 12 months. We hypothesize that the SAHELI intervention group will have greater improvements in clinical ASCVD risk factors (weight, blood pressure, glycated hemoglobin, and lipids), physical activity, and psychosocial outcomes than the print material group at 6- and 12- months. We will use mixed-methods to examine SAHELI's potential for reach, adoption, implementation, and maintenance from the perspective of multiple stakeholders. This study offers the potential to increase the reach and effectiveness of evidence-based lifestyle interventions for South Asian adults at increased risk for ASCVD.

OBJECTIVES: The National Patient-Centered Clinical Research Network (PCORnet) supports observational and clinical research using healthcare data. The PCORnet Antibiotics and Childhood Growth Study is one of PCORnet’s inaugural observational studies. The objectives of this manuscript are to describe (1) the processes used to integrate and analyze data from children across 36 participating institutions and (2) the cohort characteristics and prevalence of antibiotic use. METHODS: We included children in the cohort if they had at least one same-day height and weight measured in each of three age periods: 1) before 12 months, 2) 12 to 30 months, and 3) after 24 months. We distributed statistical queries that each institution ran on its local version of the PCORnet Common Data Model, with aggregate data returned for analysis. We defined overweight or obesity as age-sex-specific body mass index ≥ 85(th), obesity ≥95(th) percentile, and severe obesity ≥120% of the 95(th) percentile. RESULTS: 681,739 children met the cohort inclusion criteria and were racially/ethnically diverse (24.9% black, 17.5% Hispanic). Before 24 months, 55.2% of children received at least one antibiotic prescription; 21.3% received a single antibiotic prescription, 14.3% received four or more, and 33.3% received a broad spectrum antibiotic. Overweight and obesity prevalence was 27.6% at 4 to

Diagnostic error is a serious public health problem to which knowledge gaps and associated cognitive error contribute significantly. Identifying diagnostic approaches to common problems in ambulatory care associated with more timely and accurate diagnosis and lower cost and harm associated with diagnostic evaluation is an important priority for health care systems, clinicians, and of course patients. Unfortunately, guidance on how best to approach diagnosis in patients with common presenting complaints such as abdominal pain, dizziness, and fatigue is lacking. Exploring diagnostic practice variation and patterns of diagnostic evaluation is a potentially valuable approach to identifying best current diagnostic practices. A “diagnostic path” is the sequence of actions taken to evaluate a new complaint from first presentation until a diagnosis is established, or the evaluation ends for other reasons. A “big data” approach to identifying diagnostic paths from electronic health records can be used to identify practice variation and best practices from a large number of patients. Limitations of this approach include incompleteness and inaccuracy of electronic medical record data, the fact that diagnostic paths may not represent clinician thinking, and the fact that diagnostic paths may be used to identify best current practices, rather than optimal practices.

The relative ability of three obesity indices to predict hypertension (HTN) and diabetes (DM) and the validity of using Asian-specific thresholds of these indices were examined in Filipino-American women (FAW). Filipino-American women (n = 382), 40–65 years of age were screened for hypertension (HTN) and diabetes (DM) in four major US cities. Body mass index (BMI), waist circumference (WC) and waist circumference to height ratio (WHtR) were measured. ROC analyses determined that the three obesity measurements were similar in predicting HTN and DM (AUC: 0.6–0.7). The universal WC threshold of ≥ 35 in. missed 13% of the hypertensive patients and 12% of the diabetic patients. The Asian WC threshold of ≥ 31.5 in. increased detection of HTN and DM but with a high rate of false positives. The traditional BMI ≥ 25 kg/m2 threshold missed 35% of those with hypertension and 24% of those with diabetes. The Asian BMI threshold improved detection but resulted in a high rate of false positives. The suggested WHtR cut-off of ≥ 0.5 missed only 1% of those with HTN and 0% of those with DM. The three obesity measurements had similar but modest ability to predict HTN and DM in FAW. Using Asian-specific thresholds increased accuracy but with a high rate of false positives. Whether FAW, especially at older ages, should be encouraged to reach these lower thresholds needs further investigation because of the high false positive rates., Highlights • WC, BMI and WHtR measurements cutoff points were higher in middle aged FAW. • WC, BMI and WHtR measurements had similar ability to predict HTN and DM in FAW. • Need to tailor thresholds of obesity measurements for specific Asian subgroups.

In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-post designs, in favor of stepped wedge and interrupted time series; (6) Leverage best practices for patient safety research and engage experts from relevant domains; and (7) Consider sources of bias and design studies and their analyses to minimize selection and information bias and control for confounding. Areas of diagnostic error mitigation research identified for further attention include: role of competing diagnoses, understanding the impacts of organizational culture, timing of diagnosis, and sequencing of research studies. Future research will likely require novel clinical, health services, and qualitative research methods to address the age-old problem of arriving at an accurate diagnosis.

“Eat a variety of foods,” or dietary diversity, is a widely accepted recommendation to promote a healthy, nutritionally adequate diet and to reduce the risk of major chronic diseases. However, recent evidence from observational studies suggests that greater dietary diversity is associated with suboptimal eating patterns, that is, higher intakes of processed foods, refined grains, and sugar-sweetened beverages and lower intakes of minimally processed foods, such as fish, fruits, and vegetables, and may be associated with weight gain and obesity in adult populations. This American Heart Association science advisory summarizes definitions for dietary diversity and reviews current evidence on its relationship with obesity outcomes, eating behavior, and food-based diet quality measures. Current data do not support greater dietary diversity as an effective strategy to promote healthy eating patterns and healthy body weight. Given the current state of the science on dietary diversity and the insufficient data to inform recommendations on specific aspects of dietary diversity that may be beneficial or detrimental to healthy weight, it is appropriate to promote a healthy eating pattern that emphasizes adequate intake of plant foods, protein sources, low-fat dairy products, vegetable oils, and nuts and limits consumption of sweets, sugar-sweetened beverages, and red meats.

OBJECTIVES: To determine the association of antibiotic use with weight outcomes in a large cohort of children. METHODS: Health care data were available from 2009 to 2016 for 35 institutions participating in the National Patient-Centered Clinical Research Network. Participant inclusion required same-day height and weight measurements at 0 to RESULTS: Among 1 792 849 children with a same-day height and weight measurement at CONCLUSIONS: Antibiotic use at

The diagnostic process is a complex, uncertain, and highly variable process which is under-studied and lacks evidence from randomized clinical trials. This study used a novel visual analytics method to identify and visualize diagnostic paths for undifferentiated abdominal pain, by leveraging electronic health record (EHR) data of 501 patients in the ambulatory setting of a single institution. A total of 63 patients reached diagnoses in the study sample. We illustrate steps in identifying diagnostic paths of the study patients, both individually and collectively, and visually present the diversity in their diagnostic processes. Patients in whom diagnoses were obtained generally had more clinical encounters and health services utilization, although their diagnostic paths were more variable than those of the undiagnosed group. The capability of identifying diagnostic paths demonstrated from this study allows us to study larger data sets to determine diagnostic paths associated with more timely, accurate, and cost-efficient diagnosis processes.

Obesity, defined as excess fat (adipose) tissue accumulation that may impair health,1 is a highly prevalent and serious public health problem. Roughly 35.7% of American adults are obese.2 High rates of obesity are not limited to the United States or even to other highly developed countries. The prevalence of obesity in Mexico, for example, is comparable to that in the United States.3 Not surprisingly, rates of obesity-related illnesses including cardiovascular disease (CVD) are rising quickly worldwide. More than 25 million American adults have been diagnosed with diabetes mellitus.4 India is projected to have >100 million diabetic people by the year 2030.5 CVD is the number 1 cause of death worldwide.6 These grim statistics highlight the need for accurate identification of overweight and obese adults who are at high risk for obesity-related illnesses. Accurate identification of such people allows healthcare professionals, policymakers, and others to target prevention and treatment programs to those at the highest risk of morbidity and mortality. Unfortunately, the tools and measures currently available to identify obesity and associated risks are either impractical, inaccurate, or both. For example, the body mass index (BMI) is easy to calculate, and established cutoffs that define overweight (25 kg/m2) and obesity (30 kg/m2) are readily available and well known. The application of such cutoffs to a diverse population, as will be discussed, however, leads to misclassification of a large number of people. Many people with a normal BMI have high levels of adiposity and also are at high risk for obesity-related illness. Others with a high BMI have relatively normal levels of adiposity and are metabolically healthy. The problem of misclassification is especially important for racial and ethnic minorities, who make up nearly 40% of the American population today and will make up more …

Regular yogurt consumption has been associated with significant health benefits, including reducing weight gain and preventing obesity, prevention of diabetes, and improved overall diet quality. While yogurt has been aggressively marketed in recent years and consumption has increased, little is known about consumers of yogurt, including their health characteristics and nutrition attitudes and related behaviors. Our purpose was to summarize clinical studies on the health benefits of yogurt and also to report the results of an analysis of market research data on patterns and trends in consumption. A number of observational studies have reported associations of higher yogurt consumption with lower rates of obesity, weight gain, and diabetes. We analyzed detailed dietary intake surveys for 9560 adults and children. Women are more likely to be yogurt consumers than men (49.3 vs. 29.6%). Compared with non-consumers, consumers are more affluent and highly educated. 28.9% of yogurt consumers were obese, compared to 34.7% of non-consumers (p = 0.014). Consumers were more likely to be dieting at the time of the survey (22.9 vs. 17.7%, p = 0.02). There were substantial differences in nutrition attitudes, beliefs, and behaviors between consumers and non-consumers. Compared with non-consumers, yogurt consumers reported being more knowledgeable about nutrition (3.69 vs. 3.29, 5-point scale, p

Meta-analyses are becoming increasingly popular, especially in the fields of cardiovascular disease prevention and treatment. They are often considered to be a reliable source of evidence for making healthcare decisions. Unfortunately, problems among meta-analyses such as the misapplication and misinterpretation of statistical methods and tests are long-standing and widespread. The purposes of this statement are to review key steps in the development of a meta-analysis and to provide recommendations that will be useful for carrying out meta-analyses and for readers and journal editors, who must interpret the findings and gauge methodological quality. To make the statement practical and accessible, detailed descriptions of statistical methods have been omitted. Based on a survey of cardiovascular meta-analyses, published literature on methodology, expert consultation, and consensus among the writing group, key recommendations are provided. Recommendations reinforce several current practices, including protocol registration; comprehensive search strategies; methods for data extraction and abstraction; methods for identifying, measuring, and dealing with heterogeneity; and statistical methods for pooling results. Other practices should be discontinued, including the use of levels of evidence and evidence hierarchies to gauge the value and impact of different study designs (including meta-analyses) and the use of structured tools to assess the quality of studies to be included in a meta-analysis. We also recommend choosing a pooling model for conventional meta-analyses (fixed effect or random effects) on the basis of clinical and methodological similarities among studies to be included, rather than the results of a test for statistical heterogeneity.

Pediatric hypertension is a risk for adult cardiovascular disease, making early detection important. The prevalence of pediatric essential hypertension is rising due to the increased prevalence of obesity. Though guidelines for screening, diagnosis, evaluation, and management are available, there are barriers to accurate diagnosis of pediatric hypertension, including lack of knowledge and complexity of blood pressure standards. We aimed to gain insights into reasons for low rates of diagnosis and treatment from primary care providers. As part of a multisite randomized controlled trial, we interviewed 8 providers in a community health center network. We used a grounded theoretical approach to analyze transcripts. Providers reflected on numerous barriers to diagnosis, management, and follow-up; recommendations for educational content; and how community health center systems can be improved. Findings informed development of a multifaceted intervention. Despite lack of training on essential hypertension, providers were comfortable recommending lifestyle changes to promote healthier weight and reduced blood pressure.

643 Background: Pancreatic cancer has the worst survival of common cancers and there are no reliable early detection tests. While prior reports link unintentional weight loss (>5% decrease from baseline) to pancreatic cancer, there has never been a study documenting the frequency of this presenting sign using raw patient weight data. Methods: Patients at our institution with a pancreatic neoplasm (n=288) were queried using ICD-9 code 157.9 and ICD-10 code C25.9. Retrospective review identified 95 patients with pancreatic ductal adenocarcinoma and two or more prediagnosis weights (>7 days apart). Date of diagnosis was defined by the date of positive biopsy or encounter with surgical or medical oncology. Standard statistical analysis was performed. Results: Among the 95 patients, there was a slight preponderance of female (65.3%) and Caucasian (54.7%) patients. The median age at diagnosis was 71 (range: 41-90) and the median BMI was 25.6 kg/m2 (range: 15.4-49.5). 9.5% presented with clinical stage I disease, 27.3% with stage II, 9.5% with stage III, and 53.7% with stage IV. Within 1 year of diagnosis (range: 9-365 days), median weight loss was 7.1% of body weight (range: 0.2-34.5%). In this period, 71.6% of patients lost greater than 5% body weight and 32.6% lost over 10% (Table). In the 6 months before diagnosis (range: 9-180 days), median weight loss was 6.4% (range: 0.2-24.2%). A subgroup analysis of early (I, II) and late stage (III, IV) patients showed that those with late stage at presentation lost significantly more prediagnosis weight compared to the early stage patients (median 8.2% vs 5.6%, p=0.02) in a median of 175 days. Prior to diagnosis of late stage patients, 80.0% lost over 5% body weight and 38.3% lost over 10%. Conclusions: Diagnosis of pancreatic cancer is preceded by weight loss in the majority of cases, even at an early stage. Monitoring unintentional weight loss in otherwise asymptomatic patients may be an inexpensive and practical way to detect pancreatic cancer. [Table: see text]

Objective Physicians face barriers to incorporating recommended contraceptive and preconception health services, including reproductive life plans (RLPs), into primary care. With promising findings from early studies of RLPs, we examined the impact of a novel reproductive health self-assessment tool (RH-SAT) on reproductive health counseling. Methods We created the RH-SAT for an urban community health center population and trained providers on preconception and contraceptive guidelines. Semi-structured interviews were conducted to assess perceptions of the tool with 22 patients and with all 15 providers at the clinic. Transcripts were thematically analyzed using a grounded theoretical approach. Results Patients and providers reported the RH-SAT presented new and thought-provoking material that promoted patient participation and facilitated counseling. Conclusion This RH-SAT is acceptable and useful to patients and providers in an underserved urban health center. In accordance with Medical Communication Alignment Theory (MCAT), increased patient participation in reproductive health discussions may alert providers to patient interest in these topics. Practice implications This study provides preliminary evidence that the RH-SAT can help overcome barriers to reproductive health counseling in primary care. Providers may wish to incorporate tools into their practice to improve communication with patients about their reproductive health goals.

Severe obesity afflicts between 4% and 6% of all youth in the United States, and the prevalence is increasing. Despite the serious immediate and long-term cardiovascular, metabolic, and other health consequences of severe pediatric obesity, current treatments are limited in effectiveness and lack widespread availability. Lifestyle modification/behavior-based treatment interventions in youth with severe obesity have demonstrated modest improvement in body mass index status, but participants have generally remained severely obese and often regained weight after the conclusion of the treatment programs. The role of medical management is minimal, because only 1 medication is currently approved for the treatment of obesity in adolescents. Bariatric surgery has generally been effective in reducing body mass index and improving cardiovascular and metabolic risk factors; however, reports of long-term outcomes are few, many youth with severe obesity do not qualify for surgery, and access is limited by lack of insurance coverage. To begin to address these challenges, the purposes of this scientific statement are to (1) provide justification for and recommend a standardized definition of severe obesity in children and adolescents; (2) raise awareness of this serious and growing problem by summarizing the current literature in this area in terms of the epidemiology and trends, associated health risks (immediate and long-term), and challenges and shortcomings of currently available treatment options; and (3) highlight areas in need of future research. Innovative behavior-based treatment, minimally invasive procedures, and medications currently under development all need to be evaluated for their efficacy and safety in this group of patients with high medical and psychosocial risks.

Hypertension in children is a common and serious problem associated with target organ damage including left ventricular hypertrophy (LVH), increased carotid intima-media thickness (CIMT), and microalbuminuria. Unfortunately, there is ample evidence that the problem goes unrecognized in clinical practice. There are multiple reasons for this including the complexity of blood pressure standards in children, a lack of knowledge among clinicians, skepticism about the importance of hypertension in children, conflicting screening recommendations, and discomfort among clinicians, patients, and families with pharmacotherapy. Strategies to improve rates of diagnosis include clinical decision support systems, educational programs, and incorporating diagnosis and management of hypertension into a broader strategy to address weight and lifestyle among overweight and obese children. Furthermore, evidence about the long-term impact of hypertension in children is emerging and should motivate improved screening, diagnosis, and management according to established guidelines.

National guidelines for the diagnosis and management of hypertension in children have been available for nearly 40 years. Unfortunately, knowledge and recognition of the problem by clinicians remain poor. Prevalence estimates are highly variable because of differing standards, populations, and blood pressure (BP) measurement techniques. Estimates in the United States range from 0.3% to 4.5%. Risk factors for primary hypertension include overweight and obesity, male sex, older age, high sodium intake, and African American or Latino ancestry. Data relating hypertension in childhood to later cardiovascular events is currently lacking. It is known that BP in childhood is highly predictive of BP in adulthood. Compelling data about target organ damage is available, including the association of hypertension with left ventricular hypertrophy, carotid-intima media thickness, and microalbuminuria. Guidelines from both the United States and Europe include detailed recommendations for diagnosis and management. Diagnostic standards are based on clinic readings, ambulatory BP monitoring is useful in confirming diagnosis of hypertension and identifying white-coat hypertension, masked hypertension, and secondary hypertension, as well as monitoring response to therapy. Research priorities include the need for reliable prevalence estimates based on diverse populations and data about the long-term impact of childhood hypertension on cardiovascular morbidity and mortality. Priorities to improve clinical practice include more education among clinicians about diagnosis and management, clinical decision support to aid in diagnosis, and routine use of ambulatory BP monitoring to aid in diagnosis and to monitor response to treatment.

Obesity remains a serious public health problem. The purpose of this study was to identify the current attitudes and practices of primary care physicians (PCPs) with respect to obesity.A survey was systematically developed and administered electronically to PCPs, who received a small honorarium for their time. Results were analyzed to identify specific attitudes and practices and their associations with each other and with demographic and other variables.Physicians expressed little confidence in their ability to manage obesity. In general, however, they believed that obesity could be successfully managed. Lifestyle changes were perceived to be the most effective available method for patients to lose weight, and respondents were more likely to recommend this approach over pharmacotherapy or bariatric surgery. Respondents perceive the greatest barrier to managing obese patients to be a lack of patient motivation. Physicians were significantly more likely to initiate discussions with obese patients about their weight if they believed they had positive attitudes about and knowledge of weight management, and adequate resources to manage the problem.Physicians report a lack of confidence in managing obesity. Lack of patient motivation is perceived to be the greatest barrier. Physicians with greater knowledge, more positive attitudes toward obesity management, and access to more resources are more likely to provide weight management in primary care settings.