Electronic Health Records: An Unfulfilled Promise and a Call to Action

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Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy: A Randomized Trial: Annals of Internal Medicine: Vol 166, No 8

Background: Active discopathy is associated with a specific phenotype of chronic low back pain (LBP). Local inflammation has a role in active discopathy–associated symptoms. Objective: To assess the efficacy of a single glucocorticoid intradiscal injection (GC IDI) in patients with chronic LBP with active discopathy. Design: Prospective, parallel-group, double-blind, randomized, controlled study. (ClinicalTrials.gov: NCT00804531) Setting: 3 tertiary care centers in France. Patients: 135 patients with chronic LBP with active discopathy on magnetic resonance imaging (MRI). Intervention: A single GC IDI (25 mg prednisolone acetate) during discography (n = 67) or discography alone (n = 68). Measurements: The primary outcome was the percentage of patients with LBP intensity less than 40 on an 11-point numerical rating scale (0 [no pain] to 100 [maximum pain] in 10-point increments) in the previous 48 hours at 1 month after the intervention. The main secondary outcomes were LBP intensity and persistent active discopathy on MRI at 12 months and spine-specific limitations in activities, health-related quality of life, anxiety and depression, employment status, and use of analgesics and nonsteroidal anti-inflammatory drugs at 1 and 12 months. Results: All randomly assigned patients were included in the primary efficacy analysis. At 1 month after the intervention, the percentage of responders (LBP intensity <40) was higher in the GC IDI group (36 of 65 [55.4%]) than the control group (21 of 63 [33.3%]) (absolute risk difference, 22.1 percentage points [95% CI, 5.5 to 38.7 percentage points]; P = 0.009). The groups did not differ in LBP intensity at 12 months and in most secondary outcomes at 1 and 12 months. Limitation: Tertiary care setting. Conclusion: In chronic LBP associated with active discopathy, a single GC IDI reduces LBP at 1 month but not at 12 months. Primary Funding Source: French Ministry of Health.

The Relationships Among Exposure to Violence, Psychological Distress, and Gun Carrying Among Male Adolescents Found Guilty of Serious Legal Offenses: A Longitudinal Cohort Study: Annals of Internal Medicine: Vol 166, No 6

Background: Gun violence and psychological problems are often conflated in public discourse on gun safety. However, few studies have empirically assessed the effect of exposure to violence when exploring the association between gun carrying and psychological distress. Objective: To examine the potential effect of exposure to violence on the associations between gun carrying and psychological distress among vulnerable adolescents. Design: Longitudinal cohort study. Setting: The Pathways to Desistance study, a study of youths found guilty of a serious criminal offense in Philadelphia County, Pennsylvania, or Maricopa County, Arizona. Participants: 1170 male youths aged 14 to 19 years who had been found guilty of a serious criminal offense. Measurements: Youths were assessed at baseline and at four 6-month intervals with regard to gun carrying (“Have you carried a gun?”), psychological distress (Global Severity Index), and exposure to violence (modified version of the Exposure to Violence Inventory). Results: At the bivariate level, gun carrying was consistently associated with higher levels of psychological distress. However, the association between psychological distress and gun carrying diminished or disappeared when exposure to violence was considered. Exposure to violence (as either a victim or a witness) was significantly related to gun carrying at all follow-up assessments, with increased odds of gun carrying ranging from 1.43 to 1.87 with each additional report of exposure to violence. Limitations: The study sample was limited to justice-involved male youths. Precarrying distress and exposure to violence could not be fully captured because many participants had initiated gun carrying before baseline. Conclusion: In male youths involved in the criminal justice system, the relationship between psychological distress and gun carrying seems to be influenced by exposure to violence (either experiencing or witnessing it). Further study is warranted to explore whether interventions after exposure to violence could reduce gun carrying in this population. Primary Funding Source: None.

Violence Perpetration Among Patients Hospitalized for Unintentional and Assault-Related Firearm Injury: A Case–Control Study and a Cohort Study: Annals of Internal Medicine: Vol 165, No 12

Background: Hospital-based violence intervention programs typically focus on patients whose firearm injury occurred through interpersonal violence (assault). Knowledge of violence perpetration by victims of unintentional (accidental) firearm injury is limited. Objective: To examine violence perpetration before and after a patient becomes hospitalized for firearm injury according to injury intent (intentional [assault] or unintentional [accidental]). Design: A case–control study and a retrospective cohort study. Setting: Hospitals in Washington. Patients: Persons aged 15 years or older hospitalized for a firearm injury, other injuries, or a noninjury reason from 2006 to 2007. Measurements: In the case–control study, the odds of violence-related arrest from 2001 through hospitalization by injury intent among 3 groups were compared. In the cohort study, the rates of violence-related arrest from hospitalization through 2011 by injury intent among 3 groups were compared. Results: Patients with unintentional firearm injuries (n = 180) were more likely than those with other unintentional injuries (n = 62 795; odds ratio [OR], 2.01 [95% CI, 1.31 to 3.09]) and no injuries (n = 172 830; OR, 3.43 [CI, 2.22 to 5.32]) to have been arrested for a violent crime before hospitalization. Prior violence-related arrest did not differ between patients with assault-related firearm injuries (n = 339) and those with other assault-related injuries (n = 2342; OR, 1.10 [CI, 0.84 to 1.46]). During follow-up, the cumulative incidence of violence-related arrest for patients with unintentional and assault-related firearm injuries was 10% and 15% (subhazard ratio, 1.88 [CI, 1.11 to 3.17] and 1.61 [CI, 1.08 to 2.44]), respectively, compared with 1% for those without injuries. Limitation: Exclusion of self-inflicted injuries, misclassification of intent, and ascertainment bias. Conclusion: Some firearm injuries classified as accidental may indicate involvement in the cycle of violence and present an opportunity for intervention. Primary Funding Source: City of Seattle and the University of Washington Royalty Research Fund.

Firearm Acquisition Without Background Checks: Results of a National Survey: Annals of Internal Medicine: Vol 166, No 4

Background: In 1994, 40% of U.S. gun owners who had recently acquired a firearm did so without a background check. No contemporary estimates exist. Objective: To estimate the proportion of current U.S. gun owners who acquired their most recent firearm without a background check, by time since and manner of acquisition, for the nation as a whole and separately in states with and without legislation regulating private sales. Design: Probability-based online survey. Setting: United States, 2015. Participants: 1613 adult gun owners. Measurements: Current gun owners were asked where and when they acquired their last firearm; if they purchased the firearm; and whether, as part of that acquisition, they had a background check (or were asked to show a firearm license or permit). Results: 22% (95% CI, 16% to 27%) of gun owners who reported obtaining their most recent firearm within the previous 2 years reported doing so without a background check. For firearms purchased privately within the previous 2 years (that is, other than from a store or pawnshop, including sales between individuals in person, online, or at gun shows), 50% (CI, 35% to 65%) were obtained without a background check. This percentage was 26% (CI, 5% to 47%) for owners residing in states regulating private firearm sales and 57% (CI, 40% to 75%) for those living in states without regulations on private firearm sales. Limitation: Potential inaccuracies due to recall and social desirability bias. Conclusion: 22% of current U.S. gun owners who acquired a firearm within the past 2 years did so without a background check. Although this represents a smaller proportion of gun owners obtaining firearms without background checks than in the past, millions of U.S. adults continue to acquire guns without background checks, especially in states that do not regulate private firearm sales. Primary Funding Source: Fund for a Safer Future and the Joyce Foundation.

National Institutes of Health Pathways to Prevention Workshop: Advancing Research to Prevent Youth Suicide

The National Institutes of Health (NIH) Pathways to Prevention Workshop “Advancing Research to Prevent Youth Suicide” was cosponsored by the NIH Office of Disease Prevention, National Institute of Mental Health, National Institute on Drug Abuse, and National Center for Complementary and Integrative Health. A multidisciplinary working group developed the agenda, and an evidence-based practice center prepared an evidence report that addressed data systems relevant to suicide prevention efforts through a contract with the Agency for Healthcare Research and Quality. During the workshop, experts discussed the evidence and participants commented during open forums. After considering the data from the evidence report, expert presentations, and public comments, an independent panel prepared a draft report that was posted on the NIH Office of Disease Prevention Web site for 5 weeks for public comment. This abridged version of the final report provides a road map for optimizing youth suicide prevention efforts by highlighting strategies for guiding the next decade of research in this area. These strategies include recommendations for improving data systems, enhancing data collection and analysis methods, and strengthening the research and practice community.

Binge-Eating Disorder Comes of Age

Data Linkage Strategies to Advance Youth Suicide Prevention: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Background: Linking national, state, and community data systems to data from prevention programs could allow for longer-term assessment of outcomes and evaluation of interventions to prevent suicide. Purpose: To identify and describe data systems that can be linked to data from prevention studies to advance youth suicide prevention research. Data Sources: A systematic review, an environmental scan, and a targeted search were conducted to identify prevention studies and potentially linkable external data systems with suicide outcomes from January 1990 through December 2015. Study Selection: Studies and data systems had to be U.S.-based and include persons aged 25 years or younger. Data systems also had to include data on suicide, suicide attempt, or suicidal ideation. Data Extraction: Information about participants, intervention type, suicide outcomes, primary analytic method used for linkage, statistical approach, analyses performed, and characteristics of data systems was abstracted by 2 reviewers. Data Synthesis: Of 47 studies (described in 59 articles) identified in the systematic review, only 6 were already linked to data systems. A total of 153 unique and potentially linkable data systems were identified, but only 66 were classified as “fairly accessible” and had data dictionaries available. Of the data systems identified, 19% were established primarily for research, 11% for clinical care or operations, 29% for administrative services (such as billing), and 52% for surveillance. About one third (37%) provided national data, 12% provided regional data, 63% provided state data, and 41% provided data below the state level (some provided coverage for >1 geographic unit). Limitation: Only U.S.-based studies published in English were included. Conclusion: There is untapped potential to evaluate and enhance suicide prevention efforts by linking suicide prevention data with existing data systems. However, sparse availability of data dictionaries and lack of adherence to standard data elements limit this potential. Primary Funding Source: Agency for Healthcare Research and Quality.

Coverage and Access for Americans With Chronic Disease Under the Affordable Care Act: A Quasi-Experimental Study: Annals of Internal Medicine: Vol 166, No 7

Background: Half of Americans have at least 1 chronic disease. Many in this group, particularly racial/ethnic minorities, lacked insurance coverage and access to care before the Patient Protection and Affordable Care Act (ACA) was enacted. Objective: To determine whether the ACA has had an effect on insurance coverage, access to care, and racial/ethnic disparities among adults with chronic disease. Design: Quasi-experimental policy intervention. Setting: Nationally representative, noninstitutionalized sample in the United States. Patients: 606 277 adults aged 18 to 64 years with a chronic disease. Intervention: Implementation of ACA provisions on 1 January 2014. Measurements: Self-reported insurance coverage, having a checkup, having a personal physician, and not having to forgo a needed physician visit because of cost. Results: After the ACA was implemented, insurance coverage increased by 4.9 percentage points (95% CI, 4.4 to 5.4), not having to forgo a physician visit increased by 2.4 percentage points (CI, 1.9 to 2.9), and having a checkup increased by 2.7 percentage points (CI, 2.2 to 3.4). Having a personal physician did not change (0.3 percentage points [CI, −0.2 to 0.8]). All outcomes varied considerably by state, and coverage increased more in states that expanded Medicaid. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 1 in 5 black and 1 in 3 Hispanic persons with a chronic disease continued to lack coverage and access to care after ACA implementation. Limitation: The study examined data from only the first year of the ACA's major coverage expansion provisions. Conclusion: Although the ACA increased coverage and access for persons with chronic disease, substantial gaps remain, particularly for minorities and those in Medicaid nonexpansion states. Primary Funding Source: None.