Faculty Bibliography

The Society for Academic Emergency Medicine (SAEM) consensus conference provided many platforms for patient advocates to share their experiences and demonstrate the powerful contribution they have to offer to the decision-making process. One such platform was the presentation of a film 'The Faces of Medical Error: From Tears to Transparency' shared by Patty and David Skolnik. In this article the Skolniks build on their story shared at the SAEM consensus conference and the panel discussion. They provide further insight drawn from nine years of experiences as advocates for patient safety, including their reflections on working with, training and educating medical professionals, lawmakers, and consumers in shared decision-making and informed consent

As part of the 2016 Academic Emergency Medicine consensus conference, 'Shared Decision Making in the Emergency Department: Development of a Policy-Relevant Patient-Centered Research Agenda,' a panel of representatives from the Office of Emergency Care Research, the Patient Centered Outcomes Research Institute, the American Heart Association, the John A. Hartford Foundation, and the Emergency Care Coordination Center were assembled to discuss funding opportunities for future research in this field. This article summarizes their discussion of funding priorities and examples of successfully funded projects related to shared decision making in emergency medicine

For many people the Emergency Department (ED) is the first point of access to healthcare for acute needs, and a recurring location for many with chronic healthcare needs. While the ED is well placed to identify unmet needs it can also be a net that people slip through when faced with uncoordinated and expensive healthcare challenges. Thus the ED has a responsibility to set patients on a safe and meaningful care trajectory which can only be done in consultation and partnership with the patients themselves. The purpose of this article is to present crucial aspects of patient engagement that are essential for future research to foster an environment of co-learning and respect that encourages ongoing involvement by patients, families, and staff

BACKGROUND: Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE: To convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS: Participants were identified based on expertise in emergency, palliative, or geriatrics care, policy, or patient-advocacy and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION: Key research questions identified by the group related to which ED patients are likely to benefit from palliative care, what interventions can most effectively promote palliative care in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness

Although the Patient Protection and Affordable Care Act and other laws have promoted the use of shared decision making (SDM) in recent years, few specific policies have addressed the opportunities and challenges of utilizing SDM in the emergency department (ED). Policies relating to physician payment, quality measurement, and medical-legal risks each present unique challenges to adoption of SDM in the ED. This article summarizes findings from a health policy breakout session of the 2016 Academic Emergency Medicine consensus conference 'Shared Decision Making in the Emergency Department: Development of a Policy-Relevant, Patient-Centered Research Agenda.' The objectives were to (1) describe federal and state policies that influence utilization or assessment of SDM; (2) identify policies and policy-focused knowledge gaps that serve as barriers to adoption of emergency department SDM; and (3) to define a consensus-based, policy-focused research agenda to support adoption of SDM in emergency care

The emergency department (ED) occupies a unique position within the healthcare system, serving as a safety net for vulnerable patients, regardless of their race, ethnicity, religion, country of origin, sexual orientation, socioeconomic status, or medical diagnosis. Shared decision making (SDM) presents special challenges when used with vulnerable population groups. The differing circumstances, needs, and perspectives of vulnerable groups invoke issues of provider bias, disrespect, judgmental attitudes, and lack of cultural competence, as well as patient mistrust and the consequences of their social and economic disenfranchisement. A research agenda that includes community-engaged approaches, mixed-methods studies, and cost-effectiveness analyses is proposed to address the following questions: 1) What are the best processes/formats for SDM among racial, ethnic, cultural, religious, linguistic, social, or otherwise vulnerable groups who experience disadvantage in the healthcare system? 2) What organizational or systemic changes are needed to support SDM in the ED whenever appropriate? 3) What competencies are needed to enable emergency providers to consider patients' situation/context in an unbiased way? 4) How do we teach these competencies to students and residents? 5) How do we cultivate these competencies in practicing emergency physicians, nurses, and other clinical providers who lack them? The authors also identify the importance of using accurate, group-specific data to inform risk estimates for SDM decision aids for vulnerable populations and the need for increased ED-based care coordination and transitional care management capabilities to create additional care options that align with the needs and preferences of vulnerable populations.

Asian Americans have lower levels of physical activity (PA) compared to other racial/ethnic groups; however, there is little understanding of the social and cultural determinants of PA in this population. Few analyses describe specific PA domains (occupation-, transportation-, recreation-related), focus on one Asian subgroup, or use validated scales. The study objective was to assess the association between acculturation and activity behaviors (meeting 2008 PA guidelines, activity minutes by PA domain, sitting time) in a cross-sectional sample of urban-dwelling, Chinese American immigrants. Data were from the Chinese American Cardiovascular Health Assessment (CHA CHA) 2010-11 among participants with valid reports of PA minutes, assessed by the WHO Global Physical Activity Questionnaire (n = 1772). Acculturation was assessed using the Stephenson Multigroup Acculturation Scale, a 32-item instrument which characterizes two acculturative dimensions: ethnic society (Chinese) immersion and dominant society (American) immersion (maximum possible scores = 4). Multivariable models regressing activity behaviors on acculturation were run, adjusting for age, sex, household income, education, and age at immigration. Ethnic society immersion was high (mean = 3.64) while dominant society immersion was moderate (mean = 2.23). Higher ethnic society immersion was associated with less recreation-related PA (- 40.7 min/week); higher dominant society immersion was associated with a higher odds of meeting PA guidelines (OR: 1.66 (1.25, 2.20), p < 0.001) and more recreation-related PA (+ 36.5 min/week). Given low PA levels in Chinese adults in China, results suggest that PA for leisure may increase and become a more normative behavior among Chinese American immigrants with acculturation. Understanding acculturation level may inform strategies to increase PA in Chinese Americans.

Background/UNASSIGNED:children in low-income countries (LICs). Currently, there is little information available on the use of brief screening instruments Increased attention is being paid to identifying and responding to the social-emotional and behavioral needs of in LICs. The lack of psychometrically sound brief assessment tools creates a challenge in determining the population prevalence of child social-emotional and behavioral risk burden in Sub-Saharan African (SSA) country contexts. This study sought to determine the reliability and validity of three brief parent-rated screening tools-the Social Competence Scale (SCS), Pictorial Pediatric Symptom Checklist (PPSC), and the Strengths and Difficulties Questionnaire (SDQ)-in Uganda. These tools consider both strength- and pathology-based dimensions of child outcomes. Methods/UNASSIGNED:Parents of 154 Ugandan 5-9 year-old children who were enrolled in Nursery to Primary 3 in Kampala (the capital city of Uganda) and part of a school-based mental health intervention trial were recruited and interviewed. About 54% of parents had educational attainment of primary school level or less. One hundred and one of these parents were interviewed a second time, about 5 months after the first/baseline assessment. Data from both time points were utilized to assess reliability and validity. Results/UNASSIGNED:Inspection of psychometric properties supports the utility of these three brief screening measures to assess children's social-emotional and behavioral functioning as demonstrated by adequate internal consistency, temporal stability, discriminant validity, concurrent validity, and predictive validity. Subscales from three screening measures were inter-related and associated with family characteristics, such as parental depression and food insecurity, in the expected directions. Conclusion/UNASSIGNED:This study provides evidence supporting the appropriateness of using three tools and applying the developmental and behavioral constructs measured in each assessment in a low-income African setting.

OBJECTIVES: To assess the utility of a long-term physical activity (PA) intervention for reducing resting pulse rate (RPR) in older persons. DESIGN: Community. SETTING: Lifestyle Interventions and Independence for Elders Study. PARTICIPANTS: Individuals aged 70 to 89 (N = 1,635, 67.2% women) were randomized to a moderate-intensity PA intervention (n = 818) or a health education-based successful aging (SA) intervention (n = 817). MEASUREMENTS: RPR was recorded at baseline and 6, 18, and 30 months. Longitudinal changes in RPR of intervention groups were compared using a mixed-effects analysis of covariance model for repeated-measure outcomes, generating least squares means with standard errors (SEs) or 95% confidence intervals (CIs). RESULTS: Mean duration of the study was 2.6 years (median 2.7 years, interquartile range 2.3-3.1 years). The average effect of the PA intervention on RPR over the course of the study period was statistically significant but clinically small (average intervention difference = 0.84 beats/min; 95% CI = 0.17-1.51; Paverage = .01), with the most pronounced effect observed at 18 months (PA, 66.5 beats/min (SE 0.32 beats/min); SA, 67.8 beats/min (SE 0.32 beats/min); difference = 1.37 beats/min, 95% CI = 0.48-2.26 beats/min). The relationship became somewhat weaker and was not statistically significant at 30 months. There were no significant differences between several prespecified subgroups. CONCLUSION: A long-term moderate-intensity PA program was associated with a small and clinically insignificant slowing of RPR in older persons. Whether PA can deliver a beneficial reduction in RPR requires further examination in older adults.

OBJECTIVE: Adults with serious psychological distress have a high likelihood of mental health problems severe enough to cause serious impairment in social and occupational functioning requiring treatment. These adults visit doctors frequently yet have poor health compared to adults without serious psychological distress. This study examined associations between emotional states of serious psychological distress in relationship to healthcare utilization indicators. A guiding hypothesis was that somatization underlying emotional states contributes to excessive healthcare seeking among adults with serious psychological distress. METHODS: Using 2006-2014 National Health Interview Survey, in adults with serious psychological distress (n=9271), the six states: unable to make efforts, nervousness, hopelessness, sadness, worthlessness and restlessness were assessed in multivariate models in relation to four healthcare utilization indicators: change in the usual place of healthcare, change due to insurance, having seen a healthcare provider in the last 6months and having 10 or more doctor visits in the last 12months. Models were adjusted for sociodemographic variables, having seen a mental health provider, and health conditions. RESULTS: Adults feeling unable to make efforts were more likely to seek healthcare in the last 6months and at least ten times in the last twelve months. Adults feeling hopeless were less likely to be heavy healthcare utilizers. CONCLUSIONS: Predisposing medical conditions do not fully explain healthcare utilization in adults with serious psychological distress. Educating healthcare providers about the emotional states motivating healthcare seeking, and integrating mental healthcare into primary care, may improve the health of adults with serious psychological distress.