Laura Raaen

Safety of Vaccines Used for Routine Immunization of US Children: A Systematic Review

BACKGROUND: Concerns about vaccine safety have led some parents to decline recommended vaccination of their children, leading to the resurgence of diseases. Reassurance of vaccine safety remains critical for population health. This study systematically reviewed the literature on the safety of routine vaccines recommended for children in the United States. METHODS: Data sources included PubMed, Advisory Committee on Immunization Practices statements, package inserts, existing reviews, manufacturer information packets, and the 2011 Institute of Medicine consensus report on vaccine safety. We augmented the Institute of Medicine report with more recent studies and increased the scope to include more vaccines. Only studies that used active surveillance and had a control mechanism were included. Formulations not used in the United States were excluded. Adverse events and patient and vaccine characteristics were abstracted. Adverse event collection and reporting was evaluated by using the McHarm scale. We were unable to pool results. Strength of evidence was rated as high, moderate, low, or insufficient. RESULTS: Of 20 478 titles identified, 67 were included. Strength of evidence was high for measles/mumps/rubella (MMR) vaccine and febrile seizures; the varicella vaccine was associated with complications in immunodeficient individuals. There is strong evidence that MMR vaccine is not associated with autism. There is moderate evidence that rotavirus vaccines are associated with intussusception. Limitations of the study include that the majority of studies did not investigate or identify risk factors for AEs; and the severity of AEs was inconsistently reported. CONCLUSIONS: We found evidence that some vaccines are associated with serious AEs; however, these events are extremely rare and must be weighed against the protective benefits that vaccines provide.

Surgery for Degenerative Lumbar Scoliosis: The Development of Appropriateness Criteria.

Study Design. The RAND/UCLA Appropriateness Method is a well-established means of developing criteria for assessing the appropriateness of surgery in specific subpopulations. It involves a systematic review of the literature and ratings by a multidisciplinary panel of national experts. Objective. To evaluate the appropriateness of surgical interventions for degenerative lumbar scoliosis (DLS), including identifying clinical characteristics that influence when surgery is inappropriate, appropriate, or necessary, and which procedures are preferable. Summary of Background Data. DLS presents with diverse clinical symptoms and radiographic findings. Variability exists in both nonoperative and operative management. The appropriateness of surgery, and of specific surgical procedures, has not been defined for this important pathology of the aging spine. Methods. We selected a panel of 11 experts, including surgical specialists from multiple disciplines. Next, we systematically reviewed relevant literature. Finally, in a three-round, modified-Delphi process, panelists rated the appropriateness and necessity of five different surgical procedures (dependent variables) on a nine-point scale for 260 different clinical scenarios that stratified patients according to age, medical comorbidities, symptoms, signs, and radiographic variables (independent variables). Results. The 59 eligible studies identified via the systematic review were generally small or used weak designs. Panelists judged that surgery was generally appropriate for patients with at least moderate symptoms and larger or progressive deformities, moderate spinal or foraminal stenosis, or sagittal plane imbalance. Surgery was generally inappropriate for mild symptoms and smaller stable deformities, without sagittal imbalance or moderate stenosis, particularly among patients with advanced age and multiple comorbidities. For patients with larger or progressive deformities, imbalance, or severe multilevel stenosis, more extensive fusion and deformity correction procedures were generally preferred. Conclusion. Defining the appropriateness of surgery for patients with DLS will be useful to improve evidence-based clinical decision making as well as the consistency and quality of care for patients with DLS. Level of Evidence: 3

Effects of Health Care Payment Models on Physician Practice in the United States

The project reported here, sponsored by the American Medical Association (AMA), aimed to describe the effects that alternative health care payment models (i.e., models other than fee-for-service payment) have on physicians and physician practices in the United States. These payment models included capitation, episode-based and bundled payment, shared savings, pay for performance, and retainer-based practice. Accountable care organizations and medical homes, which are two recently expanding practice and organizational models that frequently participate in one or more of these alternative payment models, were also included. Project findings are intended to help guide efforts by the AMA and other stakeholders to make improvements to current and future alternative payment programs and help physician practices succeed in these new payment models-i.e., to help practices simultaneously improve patient care, preserve or enhance physician professional satisfaction, satisfy multiple external stakeholders, and maintain economic viability as businesses. The article provides both findings and recommendations.

The Paradox of Parks in Low-Income Areas Park Use and Perceived Threats

Concerns about safety and perceived threats have been considered responsible for lower use of parks in high-poverty neighborhoods. To quantify the role of perceived threats on park use, we systematically observed 48 parks and surveyed park users and household residents in low-income neighborhoods in the City of Los Angeles. Across all parks, the majority of both park users and local residents perceived parks as safe or very safe. We noted apparently homeless individuals during nearly half of all observations, but very few instances of fighting, intimidating groups, smoking, and intoxication. The presence of homeless individuals was associated with higher numbers of park users while the presence of intoxicated persons was associated with lower numbers. Overall, the strongest predictors of increased park use were the presence of organized and supervised activities. Therefore, to increase park use, focusing resources on programming may be more fruitful than targeting perceived threats.

A Systematic Review of Peer-Supported Interventions for Health Promotion and Disease Prevention

Prior research has examined peer programs with respect to specific peer roles (e.g.; peer support) or specific health/wellness domains (e.g.; exercise/diet), or have aggregated effects across roles and domains. We sought to conduct a systematic review that categorizes and assesses the effects of peer interventions to promote health and wellness by peer role, intervention type, and outcomes. We use evidence mapping to visually catalog and synthesize the existing research. We searched PubMed and WorldCat databases (2005 to 2015) and New York Academy of Medicine Grey Literature Report (1999 to 2016) for English-language randomized control trials. We extracted study design, study participants, type of intervention(s), peer role(s), outcomes assessed and measures used, and effects from 116 randomized controlled trials. Maps were created to provide a visual display of the evidence by intervention type, peer role, outcome type, and significant vs null or negative effects. There are more null than positive effects across peer interventions, with notable exceptions: group-based interventions that use peers as educators or group facilitators commonly improve knowledge, attitudes, beliefs, and perceptions; peer educators also commonly improved social health/connectedness and engagement. Dyadic peer support influenced behavior change and peer counseling shows promising effects on physical health outcomes. Programs seeking to use peers in public health campaigns can use evidence maps to identify interventions that have previously demonstrated beneficial effects. Those seeking to produce health outcomes may benefit from identifying the mechanisms by which they expect their program to produce these effects and associated proximal outcomes for future evaluations. PROSPERO REGISTRATION NUMBER Although we attempted to register our protocol with PROSPERO, we did not meet eligibility criteria because we were past the data collection phase. The full PROSPERO-aligned protocol is available from the authors.

Promoting physical activity in high-poverty neighborhood parks: A cluster randomized controlled trial

Although physical activity can help mitigate or prevent multiple chronic diseases, most people in the U.S., especially high-poverty minority groups, engage in insufficient levels of physical activity. To test ways to promote more physical activity in high-poverty area public parks we conducted a randomized controlled intervention trial. After completing baseline measures of park-based physical activity using systematic direct observation three times/day each month for six months and assessing preferences for park programming among 1445 residents living within 1 mile of study parks, we randomized 48 parks in high poverty neighborhoods in the City of Los Angeles, California during 2013-2014 to four study arms: 1) free physical activity classes over a 6-month period, 2) a frequent user program where participants could win prizes based upon the number of visits they made to the park, 3) both the programs, and 4) neither one (control condition). We re-measured park use in 2014-2015 using the same methods during the six months the intervention programs were in operation. A total of 2047 free park classes were offered attracting 16,718 participants. The frequent user programs enrolled 1452 individuals and prizes were awarded to 830. Residents in the two study arms with free classes were more likely to report being aware of and participating in park-based physical activity programs; however, overall observed park-based physical activity increased similarly across all study arms. The process evaluation uncovered several barriers to program implementation, including inconsistent scheduling of classes, partly due to safety concerns among instructors. Multiple social factors interfere with leisure time physical activity among low-income populations, suggesting modest interventions may be insufficient to overcome these issues. Although new park programs can attract users, new programs alone may be insufficient to increase overall park use in low-income neighborhoods at times when the programs are not taking place.

The Use of Technology in the Clinical Care of Depression: An Evidence Map

OBJECTIVE Depression is a highly prevalent clinical condition. The use of technologies in the clinical care of depressive disorders may increase the reach of clinical services for these disorders and support more comprehensive treatment. The objective of this evidence map is to provide an overview of the use of technology in the clinical care of depression. DATA SOURCES We searched PubMed, PsycINFO, and the Web of Science from inception to June 2017 to identify published randomized controlled trials (RCTs). STUDY SELECTION Two reviewers used predetermined eligibility criteria to review 4,062 records and include 161 RCTs that met our inclusion criteria. We include studies evaluating any type of treatment-related technology in the clinical care of depression. DATA EXTRACTION We extracted data on sample sizes, the type of technology examined, the function of that technology, the effectiveness of the technology, and publication year. RESULTS Out of 161 RCTs, we found the greatest amount of research for psychotherapy by computer (51 RCTs). The majority of studies were published after 2012 (94 RCTs; 58%). Few published studies involved videoconferences or smartphones, or provider feedback or auto-reminders. 145 studies (90%) reported that the intervention had a positive outcome of symptom improvement compared to baseline. CONCLUSIONS This evidence map provides a broad overview of the existing research evaluating technology in depression care. Computer applications are still most common. Almost all applications yield symptom improvement. More information is needed to evaluate the role of technology in clinical care.

The Effects of Alternative Payment Models on Physician Practices: Follow-Up Study

The American Medical Association asked RAND Corporation researchers to examine how alternative payment models (APMs)—payment models other than fee for service—have affected physician practices. Researchers interviewed and surveyed physicians and other staff in 31 practices in six markets, including a variety of practice sizes, specialties, and ownership models. The work was a follow-up to a 2014 study that also examined APMs’ effects on physician practices.

City of Los Angeles Neighborhood Parks: Research Findings and Policy Implications (2003--2015)

This study summarizes more than a decade of research on how well neighborhood parks in Los Angeles support physical activity. Between 2003 and 2015, researchers at the RAND Corporation studied 83 parks in the city of Los Angeles, conducting thousands of observations and fielding nearly 28,000 surveys of park users and local residents. About half of all residents said that they used their neighborhood parks, most of them routinely. Parks are also the top venue that people choose for engaging in routine exercise. The majority of residents, including residents of low-income, high-crime neighborhoods, consider their neighborhood parks safe or very safe. We also found that parks get more use when they are larger, when they have more facilities, when they offer more planned activities and events, and when their services and activities are marketed to the public. While there is frequent activity in city parks, there is room for improvement. Parks are underutilized by girls and teenage girls, and they are especially underutilized by seniors. Overall, nearly half of all Los Angeles city residents living within 1 mile of a park did not use that park. Most did not know about the activities that were offered, and the majority of residents and more than a third of park users did not know the parks staff. Recommendations include devoting more resources to outreach and marketing. Los Angeles should also devote a larger proportion of its budget to city parks: Park spending per capita in Los Angeles is currently less than half of the per capita amounts that are spent by New York, Seattle, and San Francisco.