Karin Johnson

The Use of Dietary Supplements and Medications by Canadian Athletes at the Atlanta and Sydney Olympic Games

Objective:To learn more about the prevalence of dietary supplement and medication use by Canadian athletes in the Olympic Games in Atlanta 1996 and Sydney 2000. Setting and Participants:Data were collected from personal interviews with Canadian athletes who participated at the 1996 Atlanta and 2000 Sydney Olympic Games. The athletes were interviewed by Canadian physicians regarding the use of vitamins, minerals, nutritional supplements, and prescribed and over-the-counter medications. Of the 271 Canadian athletes who participated at the Atlanta Olympics, 257 athletes were interviewed; at the Sydney Olympics, 300 of 304 Canadian athletes were interviewed. Main Outcome Measurement:A quantitative and qualitative description of the use of dietary supplements by Canadian athletes at the Atlanta and Sydney Olympics. Results:At the Atlanta Games, 69% of the athletes used some form of dietary supplements, whereas 74% of the athletes used dietary supplements at the Sydney Games. Vitamins were taken by 59% of men and 66% of women in Atlanta, and 65% of men and 58% women in Sydney. Mineral supplements were used by 16% of men and 45% of women in Atlanta, and 30% of men and 21% of women in Sydney. Nutritional supplements were used by 35% of men and 43% of women in Atlanta, and 43% of men and 51% of women in Sydney. The most popular vitamins were multivitamins in both Olympics. The most popular mineral supplements were iron supplements. The most commonly used nutritional supplement in Atlanta was creatine (14%), but amino acids (15%) were the most commonly used nutritional supplement in Sydney. In Atlanta, 61% of the athletes were using some form of medication, 54% of the athletes were using medications in Sydney. Nonsteroidal antiinflammatory drugs (NSAIDS) were the most commonly used medications at both Olympic Games. Among all sports, the highest prevalence of vitamin use occurred in boxing (91%) in Atlanta and swimming (76%) in Sydney. Rowers (56%) and cyclists (73%) demonstrated the highest use of mineral supplements. Nutritional supplement use occurred most often in swimming (56%) and cycling (100%). The use of NSAIDs was highest in softball (60%) in Atlanta and gymnastics (100%) in Sydney. Conclusion:This review demonstrates that dietary supplement use was common among Canadian athletes at both the Atlanta and Sydney Olympic Games. There was a slight increase in total dietary supplement use at the Sydney Games. Widespread use of supplements, combined with an absence of evidence of their efficacy and a concern for the possibility of “inadvertent” doping, underscore the need for appropriately focused educational initiatives in this area.

A systematic review of validated methods for identifying atrial fibrillation using administrative data

Purpose To characterize the validity of algorithms to identify AF from electronic health data through a systematic review of the literature, and to identify gaps needing further research.The objectives of this study were to characterize the validity of algorithms to identify AF from electronic health data through a systematic review of the literature and to identify gaps needing further research.

Stepped care approach to smoking cessation in patients hospitalized for coronary artery disease.

PURPOSE Smoking cessation is an important goal for smokers with coronary artery disease (CAD) because it reduces cardiac morbidity and mortality. Effective interventions for cigarette smokers with CAD exist, but they often are considered to be intensive and expensive. Stepped-care interventions have been proposed as a promising way to allocate smoking cessation treatments in a cost-effective manner. Stepped care refers to the practice of initiating treatment with low-intensity intervention and then exposing treatment failures to successively more intense interventions. METHODS To address the efficacy of this approach, 254 cigarette smokers hospitalized with CAD were provided a brief cessation intervention. The participants then were assigned randomly to either a more intensive stepped-care treatment (counseling and nicotine patch therapy) or no additional treatment. Outcomes were point-prevalent abstinence measured 3 months and 1 year after hospital discharge. RESULTS Stepped-care treatment increased smoking cessation rates from 42% to 53% during a 3-month follow-up period (P =.05), but showed little effect at the 1-year follow-up assessment, as evidenced by a cessation rate for the minimal intervention group of 36% versus 39% for the stepped-care group (P =.36). CONCLUSIONS A stepped-care approach to smoking cessation increased short-but not long-term point-prevalent abstinence in patients with CAD. For improvement of long-term effectiveness, refinement of the timing and content of stepped-care interventions needs to occur.

A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.

Background:Effective healthcare for people with multiple chronic conditions (MCC) is a US priority, but the inherent complexity makes both research and delivery of care particularly challenging. As part of AHRQ Multiple Chronic Conditions Research Network (MCCRN) efforts, the Network developed a conceptual model to guide research in this area. Objective:To synthesize methodological and topical issues relevant to MCC patient care into a framework that can improve the delivery of care and advance future research about caring for patients with MCC. Methods:The Network synthesized essential constructs for MCC research identified from roundtable discussion, input from expert advisors, and previously published models. Results:The AHRQ MCCRN conceptual model defines complexity as the gap between patient needs and healthcare services, taking into account both the multiple considerations that affect the needs of MCC patients, as well as the contextual factors that influence service delivery. The model reframes processes and outcomes to include not only clinical care quality and experience, but also patient health, well being, and quality of life. The single-condition paradigm for treating needs one-by-one falls apart and highlights the need for care systems to address dynamic patient needs. Conclusions:Defining complexity in terms of the misalignment between patient needs and services offers new insights in how to research and develop solutions to patient care needs.

A guide to research partnerships for pragmatic clinical trials

#### Summary points Pragmatic clinical trials are comparative effectiveness studies conducted in real-world settings to answer questions relevant to patients, clinicians, and healthcare decision makers. In contrast, explanatory clinical trials study how treatments or interventions work in carefully controlled settings and study populations, often to investigate a biological hypothesis or test a drug or device to meet regulatory requirements. The pragmatic approach requires unique methods to achieve the goal of identifying sustainable, generalizable, evidence based ways to improve healthcare.1 2 3 4 5 While previous authors addressed statistical considerations,6 little guidance is available on the methods for establishing partnerships between researchers and the people and processes in usual care settings that are necessary to conduct a pragmatic clinical trial. Based on insights from an initiative to accelerate pragmatic research,7 this article summarizes best practices for researchers and partners in healthcare systems as they establish collaborative relationships, develop research questions, and implement sustainable pragmatic clinical trials. A recent example …

Validation of an Algorithm to Estimate Gestational Age in Electronic Health Plan Databases

To validate an algorithm that uses delivery date and diagnosis codes to define gestational age at birth in electronic health plan databases.

Identifying atrial fibrillation from electronic medical data: a systematic review

Purpose To characterize the validity of algorithms to identify AF from electronic health data through a systematic review of the literature, and to identify gaps needing further research.The objectives of this study were to characterize the validity of algorithms to identify AF from electronic health data through a systematic review of the literature and to identify gaps needing further research.

Retention of J-1 visa waiver program physicians in Washington state's health professional shortage areas

Purpose To determine whether the Conrad Program, which allows states to recruit 30 foreign-trained physicians per year to work in underserved settings, is meeting its goal of increasing the number of physicians in Washington States underserved areas. Participating physicians have completed their residency training in, and want to continue residing in, the United States. Method The authors identified all J-1 visa waiver physicians assigned to employers in Washington between 1995 and 2003, tracked them (whenever possible) through public databases to their current locations, and surveyed them about their experiences in, and subsequent to, the program. Results The authors tracked 141 of 155 physicians (91%). Of those 141, 77 (55%) responded to the survey. These respondents reported that they remained with their J-1 waiver employers a median of 23 (range: 0–120) months longer than their required commitment periods and that they remained in practices serving primarily underserved populations for, on average, 34 (0–120) consecutive months after fulfilling their commitments. After leaving J-1 waiver employers, 35 of 47 physicians (74%) who served in rural areas moved toward more urban areas, and 57% (80/141) still live in the state. Whereas most expressed satisfaction with the program, 29/77 (38%) felt employers should have shown them more respect. Conclusions In Washington State, the Conrad Program has increased the number of physicians in underserved areas who frequently stay beyond their obligations. The significant movement away from rural areas for postobligation employment, however, highlights the long-term need to continue state efforts to recruit physicians to these areas.

Use of PRECIS ratings in the National Institutes of Health (NIH) Health Care Systems Research Collaboratory

BackgroundThe National Institutes of Health (NIH) Health Care Systems Research Collaboratory (NIH Collaboratory) seeks to produce generalizable knowledge about the conduct of pragmatic research in health systems. This analysis applied the PRECIS-2 pragmatic trial criteria to five NIH Collaboratory pragmatic trials to better understand 1) the pragmatic aspects of the design and implementation of treatments delivered in real world settings and 2) the usability of the PRECIS-2 criteria for assessing pragmatic features across studies and across time.Methods/DesignUsing the PRECIS-2 criteria, five pragmatic trials were each rated by eight raters. For each trial, we reviewed the original grant application and a required progress report written at the end of a 1-year planning period that included changes to the protocol or implementation approach. We calculated median scores and interrater reliability for each PRECIS domain and for the overall trial at both time points, as well as the differences in scores between the two time points. We also reviewed the rater comments associated with the scores.ResultsAll five trials were rated to be more pragmatic than explanatory, with comments indicating that raters generally perceived them to closely mirror routine clinical care across multiple domains. The PRECIS-2 domains for which the trials were, on average, rated as most pragmatic on the 1 to 5 scale at the conclusion of the planning period included primary analysis (mean = 4.7 (range = 4.5 to 4.9)), recruitment (4.3 (3.6 to 4.8)), eligibility (4.1 (3.4 to 4.8)), setting (4.1 (4.0 to 4.4)), follow-up (4.1 (3.4 to 4.9)), and primary outcome (4.1 (3.5 to 4.9)). On average, the less pragmatic domains were organization (3.3 (2.6 to 4.4)), flexibility of intervention delivery (3.5 (2.1-4.5)), and flexibility of intervention adherence (3.8 (2.8-4.5)). Interrater agreement was modest but statistically significant for four trials (Gwet’s AC1 statistic range 0.23 to 0.40) and the intraclass correlation coefficient ranged from 0.05 to 0.31. Rating challenges included assigning a single score for domains that may relate to both patients and care settings (that is, eligibility or recruitment) and determining to what extent aspects of complex research interventions differ from usual care.ConclusionsThese five trials in diverse healthcare settings were rated as highly pragmatic using the PRECIS-2 criteria. Applying the tool generated insightful discussion about real-world design decisions but also highlighted challenges using the tool. PRECIS-2 raters would benefit from additional guidance about how to rate the interwoven patient and practice-level considerations that arise in pragmatic trials.Trial registrationsClinicaltrials.gov trial registrations: NCT02019225, NCT01742065, NCT02015455, NCT02113592, NCT02063867.

Methods of linking mothers and infants using health plan data for studies of pregnancy outcomes

Research on medication safety in pregnancy often utilizes health plan and birth certificate records. This study discusses methods used to link mothers with infants, a crucial step in such research.