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Global SMT & Packaging July 2010 US edition

www.globalsmt.net

The Global Assembly Journal for SMT and Advanced Packaging Professionals

False top coatings of a counterfeit component revealed layer by layer Wafer-level solder sphere placement and its implications Steps toward closing the software quality gap

Volume 10 Number 7 July 2010 ISSN 1474 - 0893

David David Raby Raby Interview Interview Inside Inside NEW NEW PRODUCTS PRODUCTS INDUSTRY INDUSTRY NEWS NEWS INTERNATIONAL INTERNATIONAL DIARY DIARY



Contents

Volume 10, No. 7 July 2010

Global SMT & Packaging is distributed by controlled circulation to qualified personnel. For all others, subscriptions are available at a cost of £181.50 for the current volume (twelve issues). No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without prior written consent of the publisher. No responsibility is accepted for the accuracy of information contained in the text, illustrations or advertisements. The opinions expressed in the articles are not necessarily those of the editors or publisher. ISSN No. 1474-0893 © Trafalgar Publications Ltd Designed and Published by Trafalgar Publications Ltd, Bournemouth, United Kingdom Printed by Ovid Bell, Fulton, MO, USA.

Contents 2

Foxconn and the power of tier one EMS companies Trevor Galbraith

European edition

12

Technology Focus

10 False top coatings of a counterfeit component revealed layer by layer Art Ogg, World Micro 14 Wafer-level solder sphere placement and its implications Andrew Strandjord, Thomas Oppert, Thorsten Teutsch, and Ghassem Azdasht, PacTech—Packaging Technologies, Inc.

30

26 Steps toward closing the software quality gap Frederick R. Hume, Data I/O Corporation, and Mary Beth Soloy, Ford Motor Company Special Features

52

30 Interview—David Raby, STI Electronics 32 Show report: SMT/HYBRID/PACKAGING rises above the ashes

regular columns

4

Desoldering braid/solder wick Bob Willis

20 Strong global growth throughout supply chain Walt Custer and Jon Custer-Topai Other Regular Features

6 Industry News 36 SMT Answers 38 New Products

48 Association News 50 IMAPS Europe 52 International Diary

With Inovar’s Shop Floor Tracking, products are tracked from initial kit release until the completed assembly is moved into finished goods.

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 1


Editorial

Trevor Galbraith

Editorial Offices

Europe Global SMT & Packaging Trafalgar Publications Ltd Unit 18, 2 Lansdowne Crescent Bournemouth Dorset BH1 1SA United Kingdom Tel: +44 (1202) 388997 E-mail: news@globalsmt.net Website: www.globalsmt.net United States Global SMT & Packaging PO Box 7579 Naples, FL 34102, USA Tel: +1 (239) 245-9264 Fax: (239) 236-4682 E-mail: news@globalsmt.net China Global SMT & Packaging Electronics Second Research Institute No.159, Hepin South Road Taiyuan City, PO Box 115, Shanxi, Province 030024, China Tel: +86 (351) 652 3813 Fax: +86 (351) 652 0409 Editor-in-Chief Trevor Galbraith Tel: +44 (0)20 8123 6704 (Europe) Tel: +1 (239) 245-9264 x101 (US) E-mail: editor@globalsmt.net Managing Editor Heather Lackey Tel: +1 (239) 245-9264 x105 E-mail: hglackey@globalsmt.net

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Editor-in-Chief

Foxconn and the power of tier one EMS companies There have been many column inches expounded on the recent suicides at Foxconn plants, particularly in their South China facility in Shenzhen. While these deaths are tragic, if you compare the number of suicides to the national average per capita, then the Foxconn deaths actually fall below the national average. This is not to say that working and living condition in a Foxconn plant are any great shakes, but the bigger story is the ramifications these sensationalist headlines produce. Not four months ago there was an incident in Juarez where some workers were wrongly told the bus was not available at the end of their shift to take them into town. When one suspicious worker walked outside to verify this and found they had been lied to, a small riot ensued and they started a bonfire at the end of one of the production lines. The negative press was quickly followed by an announcement from Foxconn corporate about their intention to revive attempts to build the industry’s first ‘lights-out” factory. The furor over the suicide jumpers produced another strong reaction from the world’s largest CEM. It started with announcement to double factory workers salaries to around $132 per month. This in itself was a little suspicious. According to the company, this will add 10-12% to the bottom line, but what about these razor thin profit margins of 2-3% we keep hearing about? Nevertheless, it was a generous response to a baying global public that was starting to impact on their biggest customer, Apple. Steve Jobs was duly dispatched to Shenzhen and did a less than convincing PR job. The next step by the EMS giant was more menacing—according

to recent reports, they are planning to move the majority of their manufacturing outside of China. Even to a country the size of China, this is a serious threat. 400,000 workers would be laid-off, making the difficult job the Chinese government has containing social unrest even harder. This reminded me of the time when Hungary applied for membership of the European Union. A condition of membership was to stop all the capital gains and other tax incentives they offered foreign companies for inward investment. At the time, the biggest reaction came from Flextronics who were the country’s biggest employer. They threatened to pullout if these rules were implemented and the country was forced to go back to the European Union and negotiate a more acceptable phase-out of these incentives over ten years. The power of tier one manufacturers should not be underestimated. Given the number of jobs (albeit low-paid and sometimes in less than desirable conditions), the taxes paid and the spending power of the employees back into the local economy, they make a significant contribution. Notwithstanding the strange number surrounding the recently announced wage hike in Southern China, tier one manufacturers perform a very necessary job in very demanding conditions. These conditions are not set by themselves, or even their customers, but by us, the consumer. The constant goal of smaller, faster, cheaper looks like it may finally be finding its lowest point. —Trevor Galbraith.

Correction: Dr. George Riley, author of the article “New Opportunities for Controlling Pressure in Flip Chip Assembly,” printed in our March issue, is employed by flipchips.com and not Sensor Products Inc.

2 – Global SMT & Packaging – Celebrating 10 Years – July 2010

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Henkel – Materials Partner of Choice for the Electronics Industry No matter where you are or what your process requires, you can count on Henkel’s expertise. Our unmatched portfolio of advanced materials for the semiconductor and assembly markets, all backed by the innovation, knowledge and support of Henkel’s world-class global team, ensures your success and guarantees a low-risk partnership proposition.


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Desoldering braid/solder wick

Bob Willis

Desoldering braid/ solder wick May be low tech but still vital in rework and repair areas

Figure 1. Manual desoldering using solder braid.

Solder wick or braid is supplied in two forms, tin plated or plain copper woven braid which is impregnated with flux. Today the bare copper option is the most popular and most often seen in production. The flux coating helps provide protection to the copper braid during storage and helps the solder wet the braid and capillary quickly during soldering. If is often seen in production that braid held in an operator’s toolbox does not have the same wicking or capillary action during desoldering. This is due to the copper braid ageing, so don’t lock it away or order a large stock to save money—new is best!! Also, don’t let braid supported with liquid flux become part of your standard shop floor operation!! Copper is the preferred braid as it is far easier to see soldering, or rather the desoldering action, taking place. The solder can be seen to wick up into the braid when new material is used along with the correct gauge. It also provides a simple guide to the solderability or the age of the braid being used.

Desoldering single-sided through hole joints with copper braid Solder braid is used in two main applications during assembly: • On conventional through hole boards for solder short removal and on single-sided, non-plated through hole boards for desoldering terminations. Heated vacuum desoldering systems, however, are the preferred method for professional desoldering of plated through hole boards • For the removal of solder from surface mount and area array pads after component removal or during solder short removal on SOIC or on other fine pitch components.

The basic method for using braid is as follows: Solder short removal on through hole and surface mount component terminations. Select a braid width the same size or slightly smaller than the short being removed. This allows the desoldering operation to be seen. It also reduces the heat input required to allow the solder to

4 – Global SMT & Packaging – Celebrating 10 Years – July 2010

reflow. Clean and tin the iron bit, making sure the bit is the correct size and temperature. Normally the tip temperature would be 600˚F for work on printed circuit boards. The size of the tip would be the same size as the braid width. Before desoldering, make sure the end of the braid is free from solder. The more braid and solder in contact will affect the time to reflow or the time required on the joint area for all the solder to be removed. Apply the braid onto the surface of the solder short and place the iron tip on to the braid. By tinning the bit the solder on the tip will speed up heat transfer to the braid and the whole desoldering operation. This is often where damage occurs, when operators do not tin the bit and try to speed up heat transfer by applying pressure to the braid that is not necessary. When the solder becomes a liquid, it will wet up the braid by capillary action, but also based on the type and age of the braid. After the solder short has been removed from the joint, check that the solder remaining on the adjacent joints

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Desoldering braid/solder wick

Figure 2. Avoid having excess braid when desoldering on pads with a wide tip tool.

Figure 3. Avoid braid which has become unwoven.

meets your inspection standard. If it does not, resolder the terminations to meet the standard requirements

may be removed. If all leads have been correctly desoldered, no damage can occur on the pads.

Desoldering non-plated through hole joints Select a braid width the same size or slightly smaller than the solder joint being desoldered. This allows the desoldering operation to be seen it also reduces the heat input required to allow the solder to reflow. Clean and tin the bit on the iron making sure the bit is the correct size and temperature. Normally the tip temperature would be 600F for work on printed circuit boards. The size of the tip would be the same size as the braid width. Before desoldering make sure the end of the braid is free from solder. The more braid and solder in contact will either affect the time to reflow or the time required on the joint area for all the solder to be removed. Staff are often observed on the shop floor using a solder loaded braid tail several inches long before cutting the braid tail off. Apply the braid onto the surface of the solder joint and place the iron tip on to the braid. By tinning the bit, the solder on the tip will speed up heat transfer to the braid and the whole de-soldering operation. This is often where damage occurs, when operators do not tin the bit and instead try to speed up heat transfer by applying unnecessary pressure to the braid. It is relatively simple to see solder left between surface pads, normally referred to as sweat joints. After the solder has been removed from the joint, check that the leads of the component are free from the pads and that no damage is visible on the pads. Using tweezers or snip-nose pliers should allow the leads to move freely in the hole. When all leads have been checked the component

Solder removal from surface mount pads In the first place, only remove solder from surface mount pads when it is really necessary. In most cases it is not. It is, however, for many fine pitch and all BGA applications due to the difficulty of replacing the new components or printing paste onto the repair site. Select a braid width the same size or slightly smaller than the pad being reworked. This allows the desoldering operation to be seen; it also reduces the heat input required to allow the solder to reflow. Clean and tin the bit on the iron ensuring the bit is the correct size and temperature. Normally the tip temperature would be 600˚F for work on printed circuit boards. The size of the tip would be the same as the braid width or slightly smaller. Before desoldering, ensure the end of the braid is free from solder. The more braid and solder11—Underfill in contact withreservoir the pad will affect the time to reflow or the time required on the pad area during solder removal. Try and avoid having excess braid when desoldering on pads with a wide tip tool, as shown in Figure 2. It requires more heat/time. Also avoid braid which has become unwoven as shown in Figure 3. Cut the damaged braid and start again— the capillary action will be faster during desoldering. Apply the braid onto the surface of the pad and place the iron tip on to the braid. By tinning the bit, the solder on the tip will speed up heat transfer to the braid and the whole de-soldering operation.

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This is often where damage occurs, when operators do not tin the bit and instead try to speed up heat transfer by applying unnecessary pressure to the braid. As the braid and solder are directly in contact with the pad, more care needs to be taken during this operation. It is perfectly feasible to desolder pads in this manner provided care is taken and no pressure is applied to the pads. It is not the heat which lifts or misplaces pads, it is the combination of heat and pressure. You can hold the solder on the pad in a liquid for a number of seconds without damage to the bond. If you apply pressure during this stage the pad is lifted. This is due to the bond between the copper and the laminate becoming weak. Remove the heat, and within a minute the original strength of the bond is retained. Remember not to leave pads with no or very little solder on for weeks after desoldering as the pad solderability will deteriorate. In the case of nickel gold plated boards after desoldering, the nickel could be exposed. This will become unsolderable in a matter of days. The most important things to remember: • Use the right size of braid • Use new copper braid • Don’t apply pressure with your iron • Practice makes perfect in everything you do!!!! Bob Willis is a process engineer providing engineering support in conventional and surface mount assembly processes.He runs production lines for suppliers at exhibitions and also provides seminar and workshops world wide. Bob will be presenting Master Classes at SMT Nurenberg in Germany for those engineers visiting the show. For further information on how Bob may be able to support your staff contact him via his web site, bobwillis.co.uk.

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 5


Basic printed Industry Newsboard repair and rework for copper tracks and pads, part 2

Industry News OSEO assigns € 9.9 million in support to the CUIVRE project OSEO has assigned an overall support package of € 9.9 million for the realization of a collaborative project called CUIVRE (French for copper). This three-year project will allow a simplification and shortening of the metallization steps in the microelectronics fabrication cycle whilst at the same time improving the electrical performance. The CUIVRE project, certified by the Minalogic Competitive Cluster, aims to provide the microelectronics industry with further development of an innovative process for the deposition of copper patterns on wafers (ECPR). This process, developed by Replisaurus Technologies, uses an electrochemical-based metallization technique providing a simpler way to apply copper interconnect patterns and certain types of components whilst at the same time ensuring better form factors and increased geometrical accuracy. This innovative and environmentally-friendly technology represents a direct response to changes in the semiconductor market needs thanks to the uniformity of the deposited pattern and a reduction of the costs, the number and the complexity of the traditional wafer metallization and processing steps. The goal of the research program is to demonstrate stable process performance and industrial applicability by effectively integrating it into an actual fabrication flow. Etek Europe launches second user division—Etek Used SMT

Etek Europe Ltd launched a new division to the growing business—Etek Used SMT. Etek Used SMT has been launched to provide quality, second user SMT equipment to the global electronic manufacturing industry, allowing customers the opportunity to purchase second user, but still retain the peace of mind that every piece of euipment has been serviced by an Etek engineer. Etek Used SMT also provides ex-demo equipment for sale, all of which are available with the unique Etek Warranty to give complete peace of mind, guaranteed to operate and perform consistently. www.etekusedsmt.com VERMES Technik is now VERMES Microdispensing GmbH VERMES Technik, the manufacturer of fast piezoelectric dispensing valves, has been spun out of the Woellner Group and

turned into VERMES Microdispensing GmbH. The two new stockholders are Essemtec and Promess. VERMES focuses on fast, highly accurate micro dispensing valves. VERMES’ valves for the MDS 3000 series are well known in many industries such as biology and pharmaceutics, medical technology, chemistry and food technology, mechanical construction, precision engineering automotive, and electronics. Because of its excellent properties the company is the preferred choice for LED and LCD production lines, especially in Asia. The valves can dispense all media from low to high viscosity, and are especially well suited for abrasive and filled media. www.vermes.de Juki selects Microscan’s machine vision solution for its JX series placement systems Juki Automation Systems has integrated Microscan’s Visionscape® machine vision solution into the JX-100 placement systems. Microscan’s machine vision solution, including Visionscape® software, application-specific software for part placement, NERLITE® lighting, and custom electronics and mechanics, allows the JX-100 to place BGAs, microBGAs, fine-pitch QFPs and other leaded devices down to 15 mil pitch. This, in turn, allows Juki customers to purchase a highperformance, cost effective pick-and-place machine. For more information regarding the

6 – Global SMT & Packaging – Celebrating 10 Years – July 2010

advantages of electronics manufacturing solutions, traceability and cost savings, view a recent interview with Bob Black, Microscan President Jeff Timms, and Global SMT & Packaging Magazine at http://www.microscan.com/en-us/ TrainingAndResources/Videos/ ApexExpo2010JeffTimmsInterview.aspx. Vi TECHNOLOGY welcomes Koen Gutscoven as worldwide sales VP Vi TECHNOLOGY is pleased to welcome Koen Gutscoven as worldwide sales vicepresident to head up Vi TECHNOLOGY worldwide sales activities. Koen joined ICOS Vision Systems in 1994 as sales manager Asia, and was promoted in 1999 to VP marketing & sales of automatic vision and inspection systems to the semiconductor final assembly industry, where he knows all key players. He was responsible for the Americas, South East Asia, Japan, Korea, China, Hong Kong, Taiwan, Philippines and Europe, including customer application support and internal sales administration. www.vitechnology.com GEM Expo attracts leading names in SMT industry Trafalgar Publications Ltd. announces that many of the biggest names in the SMT industry will be participating in GEM Expo 2010, scheduled to take place October 5-7, 2010 at Expo Center Norte in São Paulo, Brazil. Major companies such as FUJI, Juki, Panasonic, Asymtek, BTU International, MIRAE, Aqueous Technologies, KIC and many more have confirmed their attendance at Brazil’s first dedicated EMS manufacturing event. The show is also supported by all of the key distributors in the region including Hi-Tech, PSP, Celtra, SMA and others. The show will feature IPC Training courses, a series of workshops by international experts and a comprehensive vendor conference. www.gemexpobrazil.com Fabrico and Henkel partner to provide Loctite® bonding, joining & sealing solutions Fabrico is working with Henkel to offer custom, high-performance Loctite® solutions for liquid adhesives for a

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 7


Industry News

variety of applications, including coating, gasketing, and potting. The two companies blend Fabrico applications and converting expertise with Loctite high-value products to provide customers with exceptional bonding, joining, fastening, and assembly solutions. www.fabrico.com, www.henkel.com SEHO Academy to provides efficient training, higher knowledge, added value and reduced costs SEHO Systems GmbH introduces the SEHO Academy, an innovative, flexible training concept. By investing in the professional development of its staff, every company can achieve added value and reduce its production costs sustainably. It always is worthwhile to train employees in the professional operation of soldering systems, and the SEHO Academy was developed to help companies do this. SEHO’s training concept, designed to provide employees with required qualifications, delivers optimal performance in practice. Customers can select one or several training blocks from the existing courses to best suit their individual needs. The seminars are subdivided into three categories: REFLOW, SELECTIVE and WAVE. Each category offers both basic training courses on maintenance of soldering systems as well as optimization of processes and workflow. www.seho.de JJS Electronics extends EMS capabilities UK and Czech Republic-based JJS Electronics has extended its EMS capabilities even further with the appointment of Richard Barratt to the new post of principal NPI engineer. Joining the company as part of the ongoing expansion taking place at its state-of-theart Lutterworth facility following recent growth, the new recruit brings with him extensive new product introduction experience. www.jjselectronics.com Aqueous Technologies sells several machines during IPC APEX Expo Accurex Solutions Pvt. Ltd. of Bangalore, India has purchased the Trident III automatic defluxing and cleanliness testing system. Accurex provides complete engineering services that ensure that both system hardware and software are capable of

performing all testing functions required by customer specifications and test requirements documents. The Trident III will help Accurex evaluate its customers’ test requirements and develop efficient test strategies. Advance Circuit Technology of Rochester, NY, also purchased a Trident III. The Trident III will join contract electronics manufacturer ACT’s impressive repertoire of manufacturing solutions that work together to exceed customer requirements. Finally, Consysis of San Diego, CA, purchased a Zero-Ion g3 ionic contamination (cleanliness) tester. www.aqueoustech.com DYMAX earns export achievement certificate

DYMAX Corporation was recognized by the U.S. Department of Commerce for its innovation and exportation to foreign companies. DYMAX officers were presented the chamber’s Export Achievement Certificate at company headquarters in Torrington, CT, in April. The award recognizes companies that have shown growth in exports, remained in good financial standing, and demonstrated a willingness to talk with other businesses about expanding their export market. Foreign exports are driving DYMAX’s growth and most of the company’s manufacturing and research and development jobs are related to their exports. www.dymax.com DRAM growth approaches record territory, setting stage for best year ever How hot was the DRAM market in the first quarter? So hot that during the first three months of 2010, global DRAM sales exceeded the total for the initial six months of 2009. So hot that the first quarter delivered the third highest quarterly DRAM revenue seen during the past 11 years. So hot that DRAM pricing actually rose in the first quarter compared

8 – Global SMT & Packaging – Celebrating 10 Years – July 2010

to the fourth quarter of 2009, defying the normal double-digit seasonal decline. Worldwide DRAM revenue in the first quarter of 2010 neared $9.5 billion, up 9.7 percent from $8.7 billion from the fourth quarter of 2009, and up a stunning 181.6 percent from $3.4 billion in the first quarter of 2009. Second-half demand also promises to be even more robust than in the first half as supply growth for the year will not be able to significantly exceed the expansion in demand. www.isuppli.com Televés invests in innovative SIPLACE line The Spanish company Televés S.A., a market leader in radio and TV installation solutions, has been at the forefront of innovations since its foundation in 1958. One of Televés’ main success factors is the 25 years of close cooperation with Siemens Electronics Assembly Systems (SEAS). In order to be prepared for further innovations and growing product demands, Televés invested once again in a new SMT production line consisting of the latest SIPLACE SX2 and SIPLACE CA (chip assembly) machines. With the new SIPLACE line Televes acquired the potential to cover all future requirements with optimum flexibility combined with bare-die and classic component processing. www.siplace.com Rutronik awarded ESD and Dry Pack certifications Rutronik Elektronische Bauelemente GmbH’s systematic implementation of its quality management has currently been confirmed by a further two certificates: The Electrostatic Discharge (ESD) Protective Measure certification ensures Rutronik’s customers will not receive any components damaged in advance by electrostatic discharge. The Dry Pack Packaging System certificate confirms that Rutronik repackages all moisture-sensitive components solely in accordance with the internationally-approved standards (J-STD 033B.1, J-STD 020D and JEP 113-B). www.rutronik.com

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 9


False top coatings of a counterfeit component revealed layer by layer

False top coatings of a counterfeit component revealed layer by layer

Art Ogg, World Micro, Roswell, Georgia, USA Much has been written about the curse of counterfeit electronic components having such a compounding effect on the security and economy of the United States. This paper will demonstrate one of the techniques used by those responsible for polluting the open market inventories of the world with counterfeit components. This sample of a counterfeit component and the photos shown are examples of a real inspection rejection event that successfully detected what could have been a tragic failure in an aerospace, military or mission critical system somewhere in the world. It is the intent of this paper to share the knowledge and experience it took to detect this counterfeit component, with the hope that every organization may benefit from this information.

Introduction The general inspection processes employed to detect the fraudulent examples shown below are contained in the current IDEASTD-1010 inspection standard published by the Independent Distributors of Electronics. See their website at WWW. IDofEA.ORG. The experience of the individual quality inspector can be measurably enhanced by participating in the Professional Inspector Certification Program, also conducted by the IDEA. This effective program of training quality inspectors is known as the IDEA-ICE-3000 Exam.

The suspicious top surface topography was compared to the bottom surface. The bottom surface displayed the typical small and grainy topography of a factory fresh component (Figure 2).

Counterfeit example This is a study conducted on Maxim part number MAX154XXXX. This component is characterized as an ADC single semi flash, 400KSPS 8-bit parallel, 24 pin SOIC component.

Visual inspection #3 During the visual inspection, what appeared to be a false top coating that did not belong on this component was noted. The top and sides were observed under 40X power microscopy to confirm there was indeed a layer that did not come from the factory. In Figure 3, the false top coating is captured in the red highlighted box. The photo is taken from the side of the component looking over the top of the part.

Visual inspection #1 Using the IDEA-STD-1010 visual inspection standard, these components were subjected to the multipoint inspection process. It was immediately noticed that the top surface was very shiny and the texture was smooth. Additionally, the topography of factory fresh components has a small textured surface compared with the somewhat larger texture exhibited by these parts (Figure 1).

Visual inspection #2 As noted above, the top surface had a very smooth and shiny surface. Each of the components in this lot were inspected and found to be equally shiny and smooth. A highly reflective surface on an electronic component is not normally what an inspector would expect to see under examination.

Visual inspection #4 The leads on this component were also given a thorough visual inspection under high-powered microcopy. There were no traces of alteration or counterfeiting

Keywords: Counterfeit Detection, IDEA-STD-1010

Figure 1. Top surface of modified part.

10 – Global SMT & Packaging – Celebrating 10 Years – July 2010

Figure 2. Bottom surface of modified part.

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False top coatings of a counterfeit component revealed layer by layer

Figure 3. False top known as blacktopping.

activity detected. This will be an important data point in the conclusion of this paper. See Figure 4 to observe that there are no issues of lead coplanarity, corrosion or retinning that may have been the result if subjected to a rework process. Date code comparison Maxim components will routinely have a component date code on both the top and the bottom surfaces. Not all manufacturers take this manufacturing step, but Maxim is one. Notice in Figure 1, the last line has the date code of 9812. This tells the inspector the component was allegedly manufactured during the twelfth (12th) week of 1998. However, notice the date code on the bottom of this component in Figure 2. The bottom line has a date code of 9609. Occasionally a certified inspector will see a variation between the two date codes on a Maxim part of one or maybe even two weeks. Any variance over two weeks is a variance that needs further explanation. This is a very big “red flag” to an inspector. In this case, the markings tell us that the bottom section of this component was manufactured two years and three weeks prior to the top portion being attached. This is impossible and will never happen. The overconfident counterfeiter has made the assumption that the inspector will not compare the top and bottom date codes and reject the lot based upon the lengthy variations in dates. They will also assume that most facilities have no inspection procedure at all and the parts will be received and shipped without anyone taking a look for component flaws such as these.

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Figure 4. Component leads pass inspection.

Resistance to solvents The experienced professional inspector has learned that, in most cases, a mixture of three parts mineral spirits and one part alcohol will remove the ink from a counterfeited component. The reason this happens is the counterfeiter will seldom cure the ink like the original component manufacturer (OCM) does during their production runs. The process where this solution is used to test the ink is known as the “Marker Permanency Test” and is documented in MIL-STD-883. This solution and test procedure was administered to a sample of the components. The results were negative. This is another important data point to be discussed in the conclusion. The experienced professional inspector has also learned that pure acetone will typically remove a false top coating placed on a component. An acetone wash was administered to the top surface of this component with negative results. Component measurements The experienced inspector has been trained to download the component’s datasheet from the Internet. This document has several very important tables, drawings and explanations about the component. One of the more important data points contained in the datasheet is the measurements. In the case of this particular Maxim component, the thickness has a specification of between 1.73 mm and 1.99 mm. A random sample of five parts was taken from the lot and measured. The average thickness between these five parts was 2.36 mm. This resulted in +.63 mm above the shallowest

measurement of 1.73 mm (36%) and +.37 mm (19% out of specification) thicker than the high end of the thickness specification. These components were far above the allowable thickness of acceptability. This will weigh heavily in the preliminary conclusions and how to proceed with proving these parts to be counterfeit. Preliminary conclusions Acceptable inspection findings 1. The texture and topography of the bottom surface is consistent with a factory fresh part. 2. The component leads remain untouched and are in pristine shape. 3. The components are not affected by the normal solvents used to validate if parts are indeed counterfeit.

Unacceptable findings 1. The parts have an untypical shiny reflective top surface. 2. The top surface topography is not consistent with a factory fresh component. 3. High power microscopy shows the addition of a false top coat on the top surface. 4. There is a two-year variance between the top surface date code and the bottom surface date code. This should never happen to a part coming from the factory. 5. The thickness specification has been exceeded by 19% above the high end of the thickness specification. At this point, when the unacceptable findings of this inspection are weighed against the acceptable findings, there is more than enough evidence detected thus far to reject these components due to

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 11


False top coatings of a counterfeit component revealed layer by layer

Figure 5. Clear epoxy top coat material.

quality issues. The inspector has now applied most of the thorough inspection protocols found in the IDEA-STD-1010 inspection standard. The parts could be rightfully rejected at this point. In an attempt to learn more about the techniques being used by this counterfeiter, the decision was made to proceed further. The goal was to reconstruct the steps the

Figure 7. Original component surface.

Figure 6. Clear epoxy removed.

counterfeiter must have taken to produce the modified parts shown in this report Removal of the clear and shiny top coating The use of the solvents normally used to remove false top coats and uncured ink stampings resulted in failure. Apparently, the counterfeiter has used a process to prevent their use in testing parts for uncured ink stampings. The second attempt to remove the clear top coating also resulted in failure. A razor blade was used to scrape the coating from the top. This step caused more material to be removed than was desired. The decision was made to discontinue this procedure. A piece of the clear coating that was removed from the top appears in Figure 5. The piece, shown in this photo, is estimated to be one-fifth the size of a period used in this report. Under very high-powered

Figure 8. Layers of counterfeiting rework.

microscopy (300X), it was established that the thin clear top coating is actually just partially clear. The top layer of the false coating directly below the clear coat can be easily observed. Apparently, over time the clear epoxy coating has absorbed some quantity of the material used in the false top coat directly below it. It has become dark in color as shown in Figure 5. Small pieces of 3M 401Q Imperial™ Wetordry™ 2,000 grit sandpaper was applied to one side of the component as shown in Figure 6. ESD tape was applied to the left side of this component to protect it from the abrasive qualities of the sanding. The right side was slowly abraded until the clear top coating was removed. The sanding process continued until the part markings were still visible on the right side, but all of the highly reflective material had been removed. All that remains in this photo on the right side depicts the beginning of the false top coat. A calibrated caliper was used to measure the thickness of the component to the right of the red line. The thickness of the clear coating was determined to be .05 mm thick. The component was further abraded to remove the entire thickness of the false top coat applied to this part. The same process and sandpaper used to remove the clear epoxy was also used to remove the false top coating. Once the entire false top coating had been removed, the component thickness was once again measured with the calipers. The component was now back to its original thickness and measured 1.86 mm, placing it well within the 1.73 mm-1.99 mm specification. Figure 7 shows the original component

12 – Global SMT & Packaging – Celebrating 10 Years – July 2010

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False top coatings of a counterfeit DL Trade Ad 4_9:Layout 1 5/1/09 3:49 PM component Page 1 revealed layer by layer

surface the component would have had when it left the factory. At this point the part has had all of the material placed on it by the counterfeiters to conceal the true identity of the part. Important items to notice Figure 7 shows the original top surface and markings as it came from the factory. Notice the original P/N was MAX154ACWG and the date code was 9609, shown on the bottom line. Figure 1 shows this same part at the beginning of this investigation prior to any testing or chemical analysis being conducted. Notice the new P/N placed on the part by the counterfeiters is MAX154BEWG and the date code is 9812. The original date code on the part is two years and three weeks older than the newer date code placed on the false top coat. The original P/N has a suffix of “ACWG,” meaning it had an operating temperature of (0˚C to + 70˚C). The second P/N placed on the part has a suffix of “BEWG,” meaning it had an operating temperature of (-40˚C to +80˚C). Figure 8 illustrates the layers of rework that were done on the counterfeit component. Layer 1 is the original component measuring 1.86 mm thick with the original part number ink stamped showing MAX154ACWG. Layer 2 shows the original part number and the original date code of 9609. Layer 3 is a .45 mm thick false black topping placed on the top to hide the original P/N. It was made from a material that would not dissolve in acetone. This is very unusual since most false coatings will wash away using this solvent. Layer 4 is the new part number of MAX154BEWG and a new date code of 9812. Layer 5 is the clear coating of epoxy that is .04 mm thick. Epoxy is a material that is not affected by an acetone wash. It was placed there to prevent failure of the marker permanency test used by a certified inspector. Overall conclusions The workmanship on these parts is exceptional. The materials used, the clear epoxy top coating and the black topping placed over the original top surface were chosen to prevent detection by the usual marker permanency test and the use of acetone for testing false top coatings. An inexperienced inspector may not have detected these reworked parts. The

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THERE ARE NO SHORTCUTS TO A 5-MIL DOT Small, repeatable volumes are a challenge. But not impossible if you have been creating them as long as we have. However, to do it well, you need three things: Dispensing Expertise in a variety of applications: micro-attach, precision fill, highly-repeatable patterns; Micro Valve

Feasibility Testing and process verification based on years of product engineering, material flow testing, and software control;

Product Development for patented valves, dispensing cartridges, needles, and accessories.

HY-FLO™ Valve with Thermal Controls

For Micro Dispensing, there is one product line that is proven and trusted by manufacturers in semiconductor packaging, electronics assembly, medical device, and electro-mechanical assembly the world over. DispenseLink® for Micro Volume Dispensing R

www.dltechnology.com

DL Technology is a registered trademark of DL Technology LLC. DispenseLink is a registered trademark of DL Technology LLC. HY-FLO is a trademark of DL Technology LLC.

visual attributes that gave them away were that the top surface topography did not match the bottom surface, the clear coating was shiny and reflective, and the date code on the top did not match the one on the bottom. The ultimate proof, however, was the remarked part number that was for a part that can operate in a much wider temperature range, meaning it is more expensive, and that the original date of the part was two years younger than the remarked date code. By definition, this is a

reworked part. Art Ogg, World Micro’s director of quality, is responsible for World Micro’s quality initiatives, product quality, ISO certifications, technical documentation and quality team. Prior to joining World Micro, Mr. Ogg held senior management positions with Seagate Technology and Digital Equipment Corporation. He brings 40 years of high tech electronics experience to his position, and is noted expert and regular speaker at industry trade events.

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 13


Wafer-level solder sphere placement and its implications

Wafer-level solder sphere placement and its implications

Andrew Strandjord, Thomas Oppert, Thorsten Teutsch, and Ghassem Azdasht, PacTech—Packaging Technologies, Inc., Nauen, Germany There are three main packaging technologies used by the semiconductor industry today to create solder bumps on wafers: paste printing, electroplating, or sphere dropping1. The choice between these technologies is highly influenced by the following criteria: the bump size & pitch requirements, cost and overall yield. As the bumping industry evolves, many of the deficiencies and trade-offs associated with the three bumping technologies are no longer acceptable. As a consequence, a significant transition is occurring toward a fourth bumping alternative: solder sphere placement2. This technique offers wide flexibility in bump size (40760 µm), very high bump yields (>>99%) and low cost (sphere price dominated). Keywords: Solder Bumping, Solder Sphere, Ball Placement, Sphere Transfer, Flip Chip, WLCSP

Figure 1. Ultra-SB2™ solder sphere placement tool.

Introduction Solder bumping is often separated into several different categories: flip chip bumping (FC), wafer level chip scale packaging (WLCSP) and ball grid array (BGA). This categorization and affiliated nomenclature is partially based on the solder bump size and the type of equipment used to create the bump. Pushing the limits of each of the three traditional bumping technologies has allowed some overlap between these bumping classifications. But for the most part, volume manufacturing of flip chip, WLCSP, and BGA bumps are carried out using different processes steps on different types of equipment. Solder sphere placement is a technique that has been

shown to completely bridge this technology gap. The basic principle of this technology is to simultaneously pick up preformed solder spheres using a patterned vacuum plate and then accurately place them onto the bond pads of the wafer. The solder sphere placement technique allows a single technology to be used for an array of different bumping applications. These include: • All wafer sizes from 100 to 300 mm and fan-out substrates • All solder alloys (lead based, lead-free, polymer core) • FC, WLCSP, and BGA bump sizes (60760 μm spheres) This up-and-coming technology has been associated with several different names in the literature. These include: gang ball placement, solder ball transfer, wafer level solder sphere transfer, ultra solder ball bumping, and solder sphere placement. The versatility of this technology can be further enhanced by coupling several other technologies into the solder sphere placement system. These include adding: 2D inspection capabilities, single sphere removal and replacement capabilities (repair and rework), and in-situ solder reflow (inert atmosphere hotplate). The ultimate solder sphere placement system incorporates all of these discrete technologies into a single tool in order to increase versatility and assure high yields.

Figure 2. Solder sphere reservoir filled with solder spheres.

14 – Global SMT & Packaging – Celebrating 10 Years – July 2010

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Wafer-level solder sphere placement and its implications

allowed the technique of solder sphere placement to expand within the industry. Typical lead-free spheres (SAC alloys) range in price between $25-50 per million when purchased in volume. As the volume of sphere consumption continues to increase, the cost will continue to come down. Spheres of other alloys, including polymer core and copper core spheres, are also starting to become more prevalent within the industry as alternatives to SAC alloys. Figure 3. Sphere placement head positioned over the solder sphere reservoir.

Figure 4. Sphere placement head lowered onto sphere reservoir. Vacuum and ultrasonics applied to reservoir.

Figure 5. Shear placement head with solder spheres passing over deionizing air knife to remove any excess spheres.

Figure 6. A pre-fluxed wafer is automatically placed onto the vacuum wafer chuck.

The final configuration of the tool is often dictated by the product distribution (flip chip vs WLCSP vs BGA volumes). Wafers or substrates for WLCSP and BGA applications have relatively large solder bumps and have relatively few interconnects compared to flip chip applications. These larger spheres are placed in extremely high yields by the solder sphere placement tool and the

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added expense of incorporating inspection and rework capabilities might not be justified. High I/O flip chip applications, on the other hand, often require very high bump yields in order to achieve high die yields. In these applications, integration of all the options makes good economical and throughput sense. The recent availability of highly uniform solder spheres at lower costs has

Process flow A predetermined number of spheres are automatically dispensed into a sphere reservoir (Figure 2). The amount of spheres in this reservoir is important in order to achieve high transfer yields. This value is approximately 20-30% more than the number of I/O on the wafer. The fixture which picks up the spheres consists of two main components: a vacuum head which is mounted to a high precision x-y-z translation stage and a tooling plate which contains small holes that is mechanically mounted to the vacuum head (Figure 3). The tooling plate is patterned with openings that correspond directly with the locations of the I/O pads on the wafer. This tooling is created using similar methods to that of making a nickel-plated surface-mount stencil. There are a large number of vendors who can now manufacture these stencils using electroforming techniques. The size of openings in the tooling plate is designed to be slightly smaller than the size of spheres that will be placed onto the wafer. The sphere placement head is then lowered onto the sphere reservoir and the vacuum is applied to the vacuum port (Figure 4). The vacuum alone is not sufficient to efficiently transport and relocate the solder spheres into each opening in the stencil template. The application of ultrasonics is applied to the reservoir to aid in sphere movement. Optimization of the ultrasonic amplitude and frequency, in addition to the vacuum, is required for each spheres size and I/O density in order to maximize sphere relocation to the template. Even with this optimization, an unwanted sphere can occasionally adhere to the stencil. This is commonly a result of static electricity. Removal of these extra spheres is accomplished passing the head over a deionizing air knife (Figure 5). The placement head is then moved over to the transfer station within the tool. A prefluxed wafer has been pre-positioned from a wafer cassette onto the

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 15


Wafer-level solder sphere placement and its implications

Figure 7. Optical sensor extended between the wafer and placement head. Aligning the template to the wafer and also inspecting for missing or unwanted spheres.

Figure 8. Tooling head lowered on wafer to bring spheres into contact with the fluxed wafer pads.

Figure 9. Raise placement head and insert optical sensor over wafer.

Figure 10. SB2 repair head positioned over a pad with a missing solder bump.

vacuum chuck at this station (Figure 6). The application of tacky flux is applied in a separate tool prior to being loaded into the sphere placement tool. For WLCSP and BGA applications, screen-printing or stencil printing are used to apply this flux.

For flip chip applications, spin coating is used to apply the flux. The important criteria for all applications include flux thickness and viscosity. The solder transfer head is then moved over the wafer chuck and a bidirectional

16 – Global SMT & Packaging – Celebrating 10 Years – July 2010

optical sensor is extended in between the head and the chuck (Figure 7). This inspection system allows the spheres within the apertures of the stencil template to be aligned to the bond pads on the wafer. In addition to alignment, this sensor performs a 2D scan of the stencil template to confirm that all apertures contain a solder sphere and also inspects for unwanted stray spheres that may still be attached to the template. The tool software can then make a decision based on user criteria to continue to the transfer step, return further cleaning at the air knife station, or go completely back to the sphere pickup station to fill in empty apertures with spheres. The solder placement head is then lowered toward the wafer until the solder spheres penetrate the flux and touch the wafer bond pads (Figure 8). The mechanical downward force is adjusted to help drive the spheres onto the pads. The vacuum is then released and a N2 back pressure is applied to the placement head to assist in releasing the spheres. The head is then raised and the optical inspection sensor is reinserted over the wafer, and the wafer is scanned to quantify transfer yields (Figure 9). This scan will document the x-y coordinates of any missing or misplaced spheres that may have moved after the transfer process. For flip chip applications, where high bump yields are an absolute requirement to give high die yields, integration of rework/repair capabilities is critical. It is common for high-end applications, such as microprocessors, to have hundreds of interconnects per die. Even small bump yield losses can translate into high die yield losses. A repair head, which is based on the SB2 ™ sphere bumping process3, is used to repair any defects identified in the 2D inspection (Figure 10). For missing bumps, a sphere is dropped onto the pad where the bump is missing. This process has no mechanical contact with the wafer and solder bumps are deposited at a rate of 6-10 spheres per second. For misplaced or damaged spheres, the capillary head of the SB2 tool is lowered over the sphere, the capillary heated, and a vacuum is applied to the tube, which removes the sphere. In both cases a laser pulse can be added to help liquify the flux or melt the solder sphere. The wafer is then ready for final reflow. For most WLCSP and BGA devices the wafers are placed back into the wafer cassette. Once all 25 wafers are bumped, the cassette is moved over to a linear

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SEM

IC We ON s #91 t 1


Wafer-level solder sphere placement and its implications

conduction oven for reflow. Alternatively the wafers can be moved over to a reflow chamber located within in the tool (Figure 11). This is more common for fine pitch flip chip devices. After reflow, the wafers are placed back into the process cassette and cleaned in a batch process using a combination of ultrasonics, solvents and water rinsing (Figure 12). Conclusions The wafer level solder sphere placement tool can perform flip chip, WLCSP, and BGA bumping operations (Figure 13). The configuration of the tool is dictated by the product distribution (Tables 1 and 2). Defects in the ppm range result in die yields greater than 99%. Wafer throughputs are between 20-45 wafers per hour. Acknowledgements The authors would like to thank all the engineers and technicians of PacTech for their help in developing the solder sphere placement technology. References 1. D. S. Patterson, P. Elenius, and J. Leal, “Wafer Bumping Technologies – A comparative analysis of Solder Deposition Processes and Assembly Considerations”, EEP Vol. 19-1, Advances in Electronic Packaging, Hawaii, 1997, pp. 337-351.

M. Whitmore, M. Staddon, D. Manessis: “Development of a Low Cost Wafer-Level Bumping Technique”, International Wafer-Level Packaging Conference, 2004.

Figure 11. Solder bumps reflowed on heated vacuum chuck.

Figure 12. Bumped, reflowed and cleaned wafer.

Process Step

Equipment

Process Step

Equipment

1. Flux deposition

Stencil or screen printer

1. Fluxing

Spin coating

2. Sphere transfer

Basic solder sphere placement

2a. Sphere transfer

Integrated solder sphere placement tool

3. Reflow

Linear oven

4. Wafer clean

Solvent and/or DI water tools

d. Hot plate reflow

5. Inspection

2D scanner

3. Wafer clean

Table 1. Process steps for WLCSP and BGA applications.

b. 2D inspection c. Rework

Solvent and/or DI water

Table 2. Process steps for flip chip applications.

J. Ling, T. Strothmann, D. Stepniak, P. Elanius, “Flex-On-Cap Solder Bump for 300mm Wafer”, Semicon, Singapore, 2001. T. Flynn, C.W. Argento, and J.Obrien, “Electro-plated flip chip Wafer Bumping Interconnect Technology Solutions for the 21st Century”, Proceedings of International Symposium on Microelectronics, Chicago, Illinois, October 26-28, 1999, pp. 8-12. 2. K. Tatsumi, K. Shimokawa, E. Hashino, Y. Ohzeki, T. Nakamori, and M.Tanaka, “Micro-Ball Bumping Technology for flip chip”, The International Journal of Microcircuits and Electronic Packaging, Volume

Figure 13. SEM image of 60 μm flip chip bumps and 300 μm WLCSP solder bumps.

22, Number 2, Second Quarter 1999 (ISSN 1063-1674), pp.127-136. Andrew Strandjord, Thorsten Teutsch, Axel Scheffler, Thomas Oppert, Ghassem Azdasht, and Elke Zakel, “WLCSP Production Using Electroless Ni/Au Plating and Wafer Level Solder Sphere Transfer Technology”, IWLPC, San Jose, CA, October 14th, 2008.

18 – Global SMT & Packaging – Celebrating 10 Years – July 2010

Andrew Strandjord “Solder Ball Transfer for flip chip and WLCSP”, Advanced Packaging, March 19, 2008. 3. P . Kasulke, W. Schmidt, L. Titerle, H. Bohnaker, T. Oppert, E. Zakel, “Solder Ball Bumper SB2-A flexible manufacturing tool for 3-dimensional sensor and microsystem packages”, Proceedings of the International Continued on page 25

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Addressing package advancement challenges with innovative contactor probe technology

SEM

IC We ON #63 st 56

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 19


Integrated testing, modeling and failure Strong global growth throughout supplyanalysis chain of CSPnl for board level reliability

Walt Custer and Jon Custer-Topai

Strong global growth throughout supply chain Using global semiconductor shipments as a measure of world electronic manufacturing activity, Chart 1 shows the magnitude and timing of our most recent global recession (& recovery) relative to the “Internet Bubble” crash of 2001/2002. Recovery was much quicker in 2010, thanks to dramatically better inventory control. Ten years ago, large finished goods and electronic component stocks had to be consumed (or written off) before new purchases could resume. That is not the case today. Chart 2 is a companion to Chart 1, showing 3-month growth (rather than actual US$) of monthly world semiconductor shipments. 3/12 chip growth recently peaked (at a whopping +58%) in March. The early-2010 massive chip shipment growth rates were of course calculated relative to the deep trough of early 2009. As we look to the second half of this year, growth will slow (chip shipments will still be increasing but at a more moderate pace). 2010 should still end with almost a 20100604

25

30% semiconductor expansion compared to last year. From Chart 1 note that world April 2010 chip shipments exceeded their precrash high of 2008. The global electronics industry has quickly recovered (to pre-crash levels)! Global electronic equipment shipment growth (Chart 3) is now in positive territory (3/12 > 1.0) in all regions. Converted to monthly US dollars (Chart 4), the vast majority of the present electronic equipment production expansion is in SE Asia—but all regions are improving. Looking forward, semiconductor shipments (Chart 5) are projected to jump 28.6% in 2010 followed by an added 5.6% in 2011, with further growth until at least 2012. Semiconductor capital spending (Chart 6) is forecasted to increase 83.5% this year and then an additional 13.9% in 2011. Spending for capital equipment (Chart 7) remains highly volatile! Feast or famine is the rule! World printed circuit shipments

World Semiconductor Shipments

US$ Billions (3-month average)

20100604

3-Month Growth Rates on $ Basis

1.6

3/12 Rate of Change

1

2

1.4

8

6

3

13

10

5 4

1.2

15

End markets • Worldwide IT spending will increase by 3.8% this year at constant currency, to $1.47 trillion; hardware to grow 6.4% at constant currency; IT market will increase by 13.7% in China, and by 13.8% in India.—IDC • Digital information grew 62%y/y in 2009 to 800 billion gigabytes (0.8 Zettabytes).—EMC

Global Semiconductor Shipments

Monthly US$

20

are also strong (Chart 8) with SE Asia dominating global production. On a consolidated (world) basis PCB shipments dropped about 20% in 2009 but now appear to be on track for 28% growth this year (up from Custer Consulting Group’s +20% growth estimate made in early 2010). Most supply chain prognosticators have recently revised their 2010 forecasts upwards due to stronger than expected demand. The global recovery is certainly well underway as we move into the normal late summer/early autumn “busy season.”

7

9 11

12

1 10

0.8

2009 recession much sharper but shorter than 2001

5

0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10

SIA

Chart 1.

20 – Global SMT & Packaging – Celebrating 10 Years – July 2010

0.6 0.4 1591591591591591591591591591591591591591591591591591591591591591591591591591591 5/10 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10

Total $ Shipments from All Countries to an Area SIA website: www.sia-online.org/

Chart 2.

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Strong global growth throughout supply chain

• Chinese electronics manufacturing

export delivery value increased 24.4% y/y and 5.7% m/m to CNY 267.8 billion in April 2010.—MIIT • Global smart homes market will grow at a 16.5% CAGR from 2009 to 2014 to $13.4 billion by 2014. Computers & peripherals • Worldwide mobile PC shipments grew 43.4% y/y to 49.4 million units in 1Q10.—Gartner • Global PC shipments will rise 22% to 376.6 million units in 2010 plus an additional 10 million media tablets.— Gartner • Notebook sales rose 21% to $36.1 billion in 1Q’10. —Gartner • Worldwide media tablets shipments will reach 7.6 million in 2010.—IDC • Netbook shipments are expected to grow from 36.3 million in 2009 to 58 million in 2010.—ABI Research • Stereo 3-D PC market shipments will rise from rising from nearly one million to 75 million by 2014.—Jon

users in April 2010 reaching a total of 786.5 million.—MIIT Consumer electronics • U.S. household spent $1,380 (on an average) on consumer electronics products in the past 12 months, an increase of $151 from last year.—CEA • Global 3D TV shipments are expected to grow from 4.2 million units in 2010 to 12.9 million units in 2011, 27.4 million units in 2012 and 78.1 million units in 2015.—iSuppli • U.S. videogame hardware, software and accessories sales fell to $766.2 million in April from $1.03 billion a year earlier.—NPD Group Automotive electronic systems are expected to rise from $125 billion in 2009 to $244 billion by 2017.—Strategy Analytics Global commercial navigation system shipments will grow from 3 million units in 2010 to 7.5 million units in 2015.—ABI Research

expected to increase 4.6% y/y to $10.4 billion in 1Q10.—IDC • HDD industry will deliver more than 300,000 petabytes of storage capacity over the next five years to enterprise datacenters and clouds.—IDC • Worldwide hardcopy peripheral shipments grew 9.1% y/y to 28.7 million units in 1Q10.—IDC Mobile communications • Worldwide mobile phone sales to end users grew 17% to 314.7 million units in 1Q10.—Gartner • Worldwide converged mobile device (smartphone) market grew 56.7% y/y to 54.7 million units in 1Q10.—IDC • Handset navigation shipments will rise from 30 million units in 2010 to 181 million units in 2015.—ABI Research Forecast • Touch screen shipments expanded 29% y/y to 606 million units in 2009.—DisplaySearch 20100620

20100620

Global Electronic Equipment Shipment Growth

1.6

• China added 8.497 million phone

Peddie Research

• Worldwide server market revenue is

Converted @ Constant 2008 Exchange Rates

Taiwan/China Europe Japan USA 0

3/12 rate of growth in local currency

1.5 1.4

World Electronic Equipment Monthly Shipments

100

$ Billions

N America

Europe

Japan

SE Asia

80

1.3 1.2

60

1.1 1

40

0.9 0.8

20

0.7

Europe = Eurostat EU27 NACE C26 (computer, electronic & optical products)

0.6

1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 02 03 04 05 06 07 08 09 10 00 01

0 1 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 02 03 04 05 06 07 08 09 10 00 01

CALENDAR YEAR

Source: Custer Consulting Group

Chart 3.

Chart 4.

20100622

Worldwide Semiconductor Market by Geography WSTS Forecast 350.0

20100622

Worldwide Semiconductor Capital Spending

+28.6% +5.6% 320.0

300.0 250.0

213.1

204.4

200.0 150.0

227.4

247.7 255.6 248.6

-9%

291.0

307.4

70.0 60.0

226.3

138.9 140.8

63.4 +83.5 %

44.0

30.0

47.5

+13.9 %

54.1

58.3

51.7

49.4

-41%

25.9

20.0 10.0

50.0

Asia Pacific Japan Europe N. America

60.0

40.0

166.3

149.4

$ Billions

50.0

100.0

0.0

CALENDAR YEAR

0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 37.2 32.8 31.9 47.5

51.3 46.7 42.3 64.1

39.8 33.1 30.2 35.8

51.2 30.5 27.8 31.3

62.8 38.9 32.3 32.3

88.8 45.8 39.4 39.1

103.5 44.1 39.1 40.7

116.5 46.4 39.9 44.9

123.5 48.8 41.0 42.3

124.0 48.5 38.2 37.9

119.6 38.3 29.9 38.5

159.9 44.8 38.2 48.1

169.6 47.3 40.1 50.4

177.1 49.2 41.6 52.1

Other Capital Spending Automated Test Equip Packaging & Assembly Equip Wafer Fab Equip

WSTS 6/2010

Gartner 6/2010

Chart 5.

Chart 6.

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2006 17.9 4.1 5.4 32.5

2007 18.7 3.6 5.2 36.0

2008 13.3 2.4 4.0 24.2

2009 9.3 1.1 2.7 12.7

2010 12.1 2.7 5.5 27.2

2011 16.3 3.0 5.6 29.1

2012 17.5 2.8 5.0 33.0

2013 16.9 2.1 3.4 29.3

2014 14.8 2.3 3.9 28.4

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 21


Strong global growth throughout supply chain

20100622

Semiconductor Capital Equipment Shipments by Area 16.0

$ Billions

14.0

13.0 12.9 11.7

12.0 10.0

11.3

11.0

10.1

9.8

8.0

9.4

8.7 8.8

10.3

11.2 10.811.0 9.8

9.6 9.6

9.4 7.6

10.6

8.0 8.0

7.8

6.6

6.0

7.5 6.6

5.7

5.6 4.1 4.1

4.0

4.7

5.1

5.6 4.4

4.9

5.7

5.4 4.6

4.5 3.1

2.7

2.0 0.0 ROW China Taiwan Korea N America Japan Europe

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 01 02 03 04 05 06 07 08 09 10 00

1.1 1.5 1.7 1.6 1.2 0.3 0.8 0.4 0.4 0.7 0.9 0.5 0.8 4.4 4.9 2.3 0.8 2.4 2.2 1.4

2.5 1.2 3.2 1.8 1.5

2.5 0.9 3.5 2.6 1.7

2.0 0.9 3.9 2.6 1.9

1.1 1.0 3.0 3.4 1.6

1.0 0.5 2.2 1.8 1.0

0.7 0.3 1.7 1.5 0.7

0.4 0.4 1.4 1.0 0.6

0.5 0.3 1.5 0.9 0.4

1.1 0.4 1.3 0.8 0.5

1.1 0.5 1.6 1.1 0.5

0.8 0.6 1.6 1.0 0.6

0.5 1.1 1.4 1.3 0.5

1.2 1.0 1.1 1.5 0.7

0.3 1.9 2.0 1.5 1.2 2.2 0.8

1.5 0.9 1.7 1.1 1.4 2.0 0.9

0.7 0.5 1.9 1.2 1.4 2.1 0.9

0.7 0.4 2.2 0.9 1.7 2.0 0.9

0.7 0.3 1.4 2.3 1.6 2.1 0.9

0.7 0.2 1.6 1.2 1.4 1.6 0.8

0.7 0.4 1.3 1.0 1.4 2.5 0.7

0.7 0.4 1.4 1.3 1.3 2.0 0.9

0.8 0.4 1.6 1.8 1.8 2.3 0.9

1.0 0.6 1.8 1.5 1.8 1.9 0.9

1.0 0.9 1.9 2.0 1.8 2.7 0.9

0.9 0.5 2.1 1.8 1.9 2.3 0.9

0.8 0.7 2.0 2.5 1.8 2.3 0.8

0.6 1.2 3.2 1.8 1.5 2.1 0.6

0.8 0.5 3.2 1.6 1.7 2.6 0.8

0.8 0.5 2.3 1.6 1.6 2.4 0.7

0.7 0.8 2.4 1.7 1.8 2.4 0.7

0.8 0.5 1.5 1.4 1.3 1.9 0.5

0.8 0.4 0.8 1.2 1.1 1.7 0.6

0.4 0.2 0.4 0.5 1.4 1.1 0.6

0.1 0.1 0.3 0.3 1.1 0.8 0.4

0.2 0.1 0.7 0.4 0.7 0.3 0.2

0.5 0.4 1.4 0.8 0.7 0.5 0.2

0.6 0.3 2.0 1.1 0.9 0.6 0.3

0.8 0.4 2.2 1.9 0.9 0.9 0.3

www.semi.org, 6/2010

Chart 7.

EMS, ODM & related assembly • EMS industry had 11 merger & acquisitions in 1Q10.—Lincoln International • Solar contract manufacturing is expected to grow from 1,100 MW in 2010 to 4.1 GW in 2014.—iSuppli Ability Enterprise set up production base in eastern China for cameras, video recorders, optical lenses, digital photo frames, LCD monitors and projectors. Adeptron received a US$ 1.3 million EMS contract from a defense OEM customer and a $1.5 million assembly order for smart grid applications. Aero Stanrew obtained BE EN 9100:2003 and ISO 9001:2008 certifications. Assel added a NORDSON Asymtek SL-940 conformal coating system and a TC2600 V4 IR oven. Assembly Contracts entered a contract manufacturing partnership with Cinterion. Bogart invested in a MYDATA P&P SMT line with jet printer MY500 and vaporphase reflow soldering system. Celestica: • received a manufacturing order for LumiSmart devices from Cavet Technologies. • received an outsourcing agreement from HP Ireland that included the transfer of 140 workers. China Wireless Technologies will open a handset assembly plant in India by 2012. Compal earned US$0.064 EPS in 1Q10, becoming world‘s most profitable NB contract manufacturer. CSM added an Asymtek Century C-740

automated, conformal coating application system. Diversified Systems ended operations. Elcoteq: • Bangalore received Excellent Award from Quality Circle Forum of India. • becomes Sharp’s partner for the KIN Windows phones. • elected Jorma Vanhanen chairman and Heikki Horstia deputy chairman. • sold ZAO Elcoteq (St Petersburg, Russia) operation to Optogan CJSC. 20100620

3500

Electronqiue Lacroix Tunisia obtained EN9100 certification. Elprog added an Assembléon pick & place machine and screen printer. EPE moved to larger facility to accommodate 150% growth over past three years. EPIC Technologies received Volkswagen Group Award, 2010. Etek Europe launched used SMT division. Flextronics: • celebrated production of 25,000 Redbox DVD rental kiosks in Creedmoor, North Carolina. • expanded Citrix Systems’ partnership to include joint design of new hardware products. • was named ‘Strategic Partner of the Year’ and ‘Best-in-Class’ supplier by LSI. • expanded notebook PC capacity in China to 15 million units/ yr. • received solar panel manufacturing contract from SunPower. • added 1,500 workers at its NB PC production in Taiwan. Foxconn /Hon Hai: • installed safety nets and asked workers to sign ‘no suicide’ agreement at its Shenzhen, China plant. • employees were arrested for stealing $60,000 in processors at the Santa Teresa plant in Mexico. • received Dell enterprise notebook orders for 2011. • plans to ship 24 million 4G iPhones in 2010. Frontline India added a DEK Horizon 03iX platform.

World PCB Monthly Shipments

Converted @ Constant 2008 Exchange Rates N America

Europe

Japan

SE Asia

3000 2500 2000 1500 1000 500 0 1 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 99 00 01 02 03 04 05 06 07 08 09 10

Source: Custer Consulting Group

CALENDAR YEAR

Chart 8.

22 – Global SMT & Packaging – Celebrating 10 Years – July 2010

www.globalsmt.net


Surface Mount Technology

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automotive

consumer computer telecom Innovative by Synapse

3DSPI

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5K

SERIES

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Strong global growth throughout supply chain 20100620

World PCB Shipments (with forecast)

Converted @ Constant 2008 Exchange Rates 60

50

$ Billion Assumptions: Europe = composite European SIA & local PCB assoc data Japan & N. America from JPCA & IPC data Taiwan/China based upon 44 rigid & flex company composite Rest of Asia growth = Taiwan/China 44 company composite Data scaled to match Henderson Ventures annual totals 2007 based upon sum of monthly totals

+28%

-20%

40

30

20

31.6 38.6 31.2 29.4 31.7 37.6

42.9 51.7 54.3 51.1 40.9 52.6

1 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 3 5 7 9111 01 02 03 04 05 06 07 08 09 10 11 99 00

CALENDAR YEAR Source: Custer Consulting Group - synthesized from Henderson Ventures annual estimates and N. American, Japanese & Taiwan/China monthly PCB shipments and SIA European chip shipments

Chart 9.

Hanza Intressenter acquired all outstanding shares of Hanza from HSF Group. Incap received a rotor component manufacturing supply contract from ABB Oy, Machines. Interphase Engineering expanded its design & contract manufacturing services. Itron added 40 new jobs and $4 million in new equipment. Jabil implemented carbon footprint, on-demand program throughout entire organization. JJS Electronics: • appointed Richard Barratt principal NPI engineer. • developed training process which promotes step-by-step analysis supported by pictorial guidance. Kimball Electronics received a manufacturing contract for Third Eye retroscopes from Avantis Medical Systems. King Jim began offering EMS services in Malaysia. Kitron received a NOK 45 million/year contract for electronics manufacturing and assembly of industrial tools from Atlas Copco Tools. LaBarge: • received ANSI/ESD S20.20 certification at its Appleton (WI), Pittsburgh (PA) and Tulsa (OK) manufacturing facilities. • received a $1.5 million electronic assemblies contract from Northrop Grumman for F-16 fighter fire control radar system. Macrotron Systems moved to 75,000 SF

manufacturing plant in Fremont, CA. Nortech Systems acquired Trivirix. PartnerTech added six Trumpf machines at its new Myslowice, Poland, plant. Plexus: • received a solar inverter EMS contract from Sustainable Energy Partners. • invested in a 1,800 SF Renewable Energy Lab. Proxy Electronics (Sweden) filed for bankruptcy protection. Sanmina-SCI Israel Medical Systems is spending $10 million to build a plant in Suzhou, China. Season Group expanded into the U.S. with the acquisition of DC Electronics and its San Antonio facility. SinoHub commenced operations at its new 77,500 SF mobile phone manufacturing facility in Shenzhen, China. SMTC began providing Kontron with PCB and module level assembly manufacturing in Chihuahua, Mexico, and Dongguan, China. Sparton received a $830,000 manufacturing contract for SP3004D digital compass for military warfare equipment. Spectrum Control received $13.1m multiyear contract for complex microwave assembly. Stadium Electronics appointed Peter O’Keeffe business improvement manager. Suntron consolidated its Manchester, NH, and Lawrence, MA, operations into a larger facility in Methuen, MA. Surface Mount Technology: • completed renovation of SMT

24 – Global SMT & Packaging – Celebrating 10 Years – July 2010

Engineering, LLC.

• will add 25,000 additional SF of manufacturing space by 4Q’10. Televés S.A. invested in a SMT production line consisting of Siplace SX2 and Siplace CA (chip assembly) machines. Vega Grieshaber KG (Schiltach, Germany) implemented Siplace Facts for its SMT production inventory management system. Victron: • opened Victron de Mexico. • passed UL DQS’ tri-annual audit of ISO14001:2004 Environmental Management System, and ISO9001:2008 and ISO13485:2003 quality systems. Videoton Electronics Assembly Services received a EMS manufacturing contract from Linak for furniture electronics. Xenterio appointed Ernst Gockel sales & marketing manager. Materials & process equipment Industrial automation electronics equipment (excluding software and services) revenue declined 14.3% y/y to $74.9 billion in 2009.—IMS Research Azuma renewed its PCB copper plating lines. 3M: • Electronic Solutions Division introduced a halogen-free embedded capacitance material. • released its material library for ANSYS simulation software. Agilent Technologies acquired Varian. AIM appointed Andy Dolan business development manager. Arlon and Rogers Corporation resolved their patent infringement litigation. BASF will expand its annual methanesulfonic acid capacity in Ludwigshafen, Germany, to 30,000 tons. Chemtura opened a Technical Center of Excellence in Nanjing, China for the AsiaPacific region. ChipChecker launched electrical inspection services. Co-Tech • is developing copper foils for electric car batteries. • will ship 15,000 tons of copper foil in 2010. CyberOptics named Daniel Good VP of corporate development and Tim Skunes VP of technology and business development. DEK expanded its presence in South America in partnership with Fuji Do Brasil. DKN Research began supplying substrates for printable electronics engineering trials. Dow Electronic Materials: • opened a new research and

www.globalsmt.net


Strong global growth throughout supply chain

• development center in Seoul, Korea. • received Excellent Supplier award from

HannStar Board. Dow Europe raised epoxy products prices in Europe. Electro Scientific Industries received Provectus Award for advanced IP processes. EMC will ramp up CCL capacity at each of its plants in Taiwan and China in 4Q. Europlacer opened 3,000 SF facility in Tampa, Florida. Fabrico and Henkel entered a partnership for Loctite bonding, joining & sealing solutions. Furukawa Electric will expand capacity for general grade copper foil for rigid PCBs to 1,200 tons/ month with construction of 2nd factory in Taiwan which is scheduled for operation at end of fiscal 2014. GCT started production at its diamond coating facility in Weingarten, Germany. GOEPEL electronic and InterElectronic Hungary entered a partnership to distribute AOI systems for electronic assemblies in Hungary and Romania. Isola received OHSAS 18001:2007 and DIN EN ISO 14001:2004 3-year recertification from TÜV Rheinland (Technical Inspection Authority). Kester appointed Michael Fullbrecht European sales manager. Laird released a low-cost high-performance thermal substrate for LED module applications. Mallinckrodt Baker: • named former Rohm & Haas CEO Raj Gupta chairman. • is expanding its solar panel and flatscreen TV businesses. Manncorp introduced two “HighThroughput Flex Lines” turnkey SMT lines, which include twin MC-385 pick and place machines and “Box Builder Line” with MC-387 placer. Nissan Chemical developed a organicinorganic hybrid polymer for optical printed circuit boards. Park Electrochemical: • elected Emily Groehl to its board of directors. • appointed Dr. Ke Wang director of research & development and W. Douglas Leys director of advanced material applications. • introduced E-710 Easycure low temperature cure epoxy prepreg. Seica named Zero Defects International its North American sales agent for bare board flying probes. Siemens Electronics Assembly Systems (SEAS) introduced capacity-on-demand business models: SIPLACE Peak Demand and SIPLACE Floating Demand. Sun Chemical named Toryon

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Technologies its national distributor for circuit product materials. Taiflex PV’s back sheet factory in China began production in July. Tamura started volume production of a flexible black light absorber for flexible circuits designed as LED module substrates. Taiwan Glass Industrial plans to raise glass fabric capacity by 20,000 tons in 2H’11. Ticona acquired Dupont LCP and PCT product lines. T-Tech introduced its Quick Circuit QCJ5 advanced prototyping system. TUC expanded its CCL front-end processing capacity to 300,000 units/ month. Unimicron began offering Shocking Technologies’ XStatic™ voltage switchable dielectric material to its customers. Vi TECHNOLOGY appointed Koen Gutscoven worldwide VP of sales. Viking: • formed an equipment supply and service division for the electronics production industry. • Test named Peter Collins sales manager Walt Custer is an independent consultant who monitors and offers a daily news service and market reports on the PCB and assembly automation and semiconductor industries. He can be contacted at walt@custerconsulting.com or visit www.custerconsulting.com. Jon Custer-Topai is vice president of Custer Consulting Group and responsible for the corporation’s market research and news analysis activities. Jon is a member of the IPC and active in the Technology Marketing Research Council. He can be contacted at jon@custerconsulting.com.

Wafer-level solder sphere placement and its implications— continued from page 18

1. Electronics Manufacturing Technology Symposium (22nd IEMT), Berlin, April 27-29, 1998. Elke Zakel, Lars Titerle, Thomas Oppert, Ronald G. Blankenhorn, “High Speed Laser Solder Jetting Technology for Optoelectronics and MEMS Packaging”, Proceedings of the International Conference on Electronics Packaging (Tokyo, Japan), Apr. 17-19, 2002. Andrew Strandjord is senior manager of advanced packaging at PacTech USA. He received his Ph.D. in organic chemistry from the University of Minnesota. strandjord@pactech-usa.com Mr. Oppert is vice president global sales & marketing at PacTech in Nauen, Germany. He earned a master’s degree in electrical engineering from the Technical University of Berlin in 1995. Thomas Oppert has co-authored more than 50 technical papers related to semiconductor packaging. oppert@pactech.de Dr. Thorsten Teutsch is president of PacTech-USA. He received his Ph.D. in physical chemistry and surface science from Fritz-Haber Institute of the Max Planck Society. Teutsch@pactech-usa.com Mr. Ghassem Azdasht is co-founder and CTO of PacTech GmbH. He studied mechanical engineering and laser technologies at the Technical University Berlin. Mr. Azdasht has authored of over 100 publications and patents related to wire bonding, flip chip, and laser assembly. azdasht@pactech.de

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 25


Steps toward closing the software quality gap

Steps toward closing the software quality gap Frederick R. Hume, Data I/O Corporation, and Mary Beth Soloy, Ford Motor Company

The production programming process of loading firmware into the semiconductor device must be controlled if the quality and integrity of the software content in the outgoing product is to be assured. Keywords: Quality, Firmware, Production Programming

A few years ago, while visiting a successful United States manufacturer of networking and communications equipment, the host provided a tour of the facility including a walk through their programming center filled with equipment from many vendors. A colleague asked, “Do you ever find circuit boards on the factory floor that contain devices mis-programmed with the wrong software?” Our host’s response was “It happens all the time.” It is surprising that a gap in quality methods of this apparent frequency was accepted as matter-of-fact. In an era when Six Sigma and statistical methods have been widely deployed to drive out process variation throughout the factory, here was an example of a leading manufacturer that seemingly had no demonstrable control of the programming process for loading firmware1 into their products. The circuit boards containing the mis-programmed devices had to be identified during test, thus reducing first-pass yield, and required rework before delivery to final assembly. While one might suspect that this firm’s experience is an anomaly, a deviation from good manufacturing practice isolated to a few firms, these gaps in quality methods are far more common than one could have expected. The sophisticated quality methods that industry has deployed have been focused primarily on hardware,

things that are visible, that are built by their factory. However, the software is generally built outside of the factory and then released to the factory electronically to be loaded into the device or product as a data file. In this way, it circumvents the normal quality control processes used with hardware production so mistakes in the loading of the data file are not found until circuit boards fail to operate correctly. In most cases, the result is scrap and/or rework in the factory, but in some cases the defect is not discovered until the product is in the field. A leading wireless handset manufacturer recently delivered 200,000 phones to a well-known Fortune 50 service provider in the US. Half of the phones operated correctly; the other 100,000 did not and had to be returned to the manufacturer. The subsequent investigation found that the phones were built on two production lines. One line was using the correct programming algorithm; the other wasn’t. The expense to identify which phone was built on which production line and then to return the incorrectly programmed phones to the factory for rework ran into the millions of dollars. This error could have been identified earlier or eliminated with the use of a simple data collection plan and a statistical test such as Chi-Square to show

Figure 1. Typical firmware supply chain. 1 The term firmware used in this article refers to the software programmed into a semiconductor device such as a microcontroller or Flash memory that contains non-volatile memory. This software often represents a firm’s most valuable intellectual property.

26 – Global SMT & Packaging – Celebrating 10 Years – July 2010

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Tsunami growth waves followed by modest swell

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 27


Steps toward closing the software quality gap

the difference in production output from the different lines. A typical firmware supply chain is shown in the flow chart in Figure 1. Many firms assume that because their software, or source code, is under revision control during development and release they have a quality process. Unfortunately, their process may fail to account for the multitude of mistakes that are possible when loading the software into a semiconductor device shown as production programming in the flow chart in Figure 1. Production programming involves selecting the appropriate data file to be loaded into the semiconductor device, selecting the appropriate algorithm for the device, actual setup of the programming equipment, physical handling of the devices during programming, and operation of the programming equipment. Mistakes in any of these may lead to defective devices on the circuit board or to devices that contain the wrong firmware. Table 1 identifies a number of the common mistakes possible at this step that lead to scrap and rework and, if not detected during test, may lead to field failures. While these fifteen are the most common mistakes, more than forty potential mistakes have been identified. Although many of the common mistakes are easily identifiable and have minor consequences, some of them are not easily detected and have severe financial consequences in terms of the scrap and rework. In cases where the mistakes are not detected until products are deployed at the customer’s location, the damage to a firm’s reputation may be more significant than the cost of the corrective action. This is an opportunity to utilize a Cause and Effects Matrix or Failure Mode Effects Analysis (FMEA) to plan for what could go wrong and put prevention in place based on the severity, occurrence and ease of detection. Figure 2 graphs the frequency and impact of the fifteen common mistakes from Table 1. While these data do not have statistical significance, since they are drawn by one programming equipment manufacturer from the experience of its customers in a variety of industries and countries, we have no reason to believe that they are not representative of many other firms’ experiences as well. As you can see from this chart, some of the frequently recurring mistakes have substantial impact (1, 7, and 10). With respect to mistakes in handling

Category

Common mistakes in:

Failure to create jobs correctly

1. Handling of data files 2. Choosing the appropriate algorithm or adapter or both 3. Identifying the device to be programmed

Failure to run the programming job correctly

4. Starting or stopping jobs

Failure to operate equipment correctly

7. Setting up the equipment

5. Acting on machine error messages 6. Setting up the job 8. Selecting package files 9. Loading software/firmware 10. Physically handling devices 11. Preventative maintenance

Failure to achieve statistical process control

12. Extracting information from equipment log files 13. Supervisory monitoring of the programming process Correlating yield statistics across equipment platforms Detecting non-conforming lots

Table 1. Common mistakes in firmware process control. Source: Data I/O Corporation.2

data files (item 1 in the chart above), an electronics manufacturing firm in China recently told us that they used more than one hundred types of data files and “sometimes the operator just programs the wrong data.” These errors tend to occur most often when the firm is using a manual process to load the firmware into the semiconductor device or circuit board. Automated methods for loading firmware can eliminate many of these mistakes and particularly the ones that have the greatest financial impact. Also, automation provides a means for closing the loop around the process achieving effective process control by generating log files that can tie revision levels of the firmware to manufacturing dates or serial numbers. This provides a high-integrity means to ensure configuration control and traceability of the finished product that extends beyond hardware to include the firmware. Yield and trend information can also be extracted from the log files. One automotive electronics manufacturer located in the Southeast of the USA uses automated equipment to load the firmware that also connects to barcode scanning equipment. This Poka-Yoke/ Mistakeproofing enables them to ensure that the algorithm and data file are the correct ones, both for the semiconductor device and for the circuit board. Automated methods for loading firmware also provide a means for remotely monitoring the programming process even when it is conducted in factories halfway

around the world. Statistical information, such as knowing the number of devices being programmed each day, enables a firm to track production levels, yield, and other vital manufacturing data including downtime to ensure effective control regardless how disintegrated the supply chain. A recent IBM survey3 of 1,130 CEOs of electronics manufacturing companies found that 43% of them were worried about counterfeiting and piracy, but it appears there is a disconnect between Mahogany Row and the factory floor as the programming process presents one of the greatest vulnerabilities with respect to the potential loss of a firm’s intellectual property. With manual programming, multiple copies of the firmware reside on multiple sets of equipment in an unprotected state and subject to theft. Using automated programming solutions, however, it is possible to encrypt data files and transmit them to remote manufacturing sites securely. Once there, the files remained stored in an encrypted state on a secure server. Access to the data files can be restricted to authorized personnel. Files remain encrypted until decrypted inside of the automated programming equipment where they are not easily accessed by operators. System level software incorporated in the automated equipment also has the means to program encrypted serial numbers that contain vital information about the manufacturing process such as when, where, who. Even if a manufacturer

Extracted from calls for assistance to the firm’s customer service organization. “The Enterprise of the Future; The Global CEO Study 2008.” IBM Institute for Business Value. May 2008

2 3

28 – Global SMT & Packaging – Celebrating 10 Years – July 2010

www.globalsmt.net


Steps toward closing the software quality gap

of software IP and injection of malware as wireless. As the electronic 3600CPH = 120 + (8mm) feeders component units SQ foot print = L (42”) x W (42”) (ECUs) within the MaX Board Size: 558.8mm (22.0”) x 609.59mm (24.0”) vehicle proliferate and the data communication 4000C = Traditional Dependability + New Technology between the vehicle and the external world increases, the exposure is magnified. There is no reason ® to assume that automotive electronics systems will not become future targets for criminal activity. The production programming process of loading firmware into the semiconductor device must be controlled if For more info visit: www.goppm.com the quality and Email: ppm@goppm.com or Call: 603.895.5112 integrity of the Windows is a registered trademark of Microsoft Corporation software content in the outgoing product is to be provides for the real-time monitoring of assured. Automation of this process, while yield and job statistics to ensure effective not a panacea, can substantially reduce process control. Security software can the potential for mistakes that result in also be added to program encrypted serial scrap and/or rework. Automation also numbers to further ensure traceability and configuration control over the firmware supply chain throughout the software life cycle.

is unable to prevent the theft of its intellectual property, it can later read back the encrypted serial number to ascertain when and where the loss occurred. This is particularly useful if a firm subcontracts production to facilities outside of its direct control. The point of production programming (deployment) is also the easiest place in the software life cycle (requirements, design, coding, testing, deployment and operations) to add malware4 without the risk of detection. Malware has become so commonplace that a recent study found that each US adult had a 66% chance of experiencing at least one data exposure in 20085. We are now beginning to see the increasing risk with wireless handsets as they begin to take over many of the functions normally performed by personal computers and store sensitive data. Rich Cannings, security leader for the Android operating system (OS), recently said, “The smartphone OS will become a major security target. Attackers can already hit millions of victims with a smartphone attack, and soon that number will be even larger. I think this will become an epiphany to malware authors.”6 The point of production programming must be protected since malware injected at this point circumvents the extensive filtering for spam and malicious content provided by the wireless carriers. Fortunately the same methods that protect the software from theft at this point also provide protection from the injection of spurious content. Automotive electronics systems share the same vulnerabilities to the theft

Severe Not Easily Detectable

Lesson 1 :

$28,750.00

5

1

7

Frederick R. Hume is president and CEO of Data I/O Corporation, Redmond, WA. Mary Beth Soloy, ASQ CQE, CRE, CSSBB, is the global product development quality functional lead with Ford Motor Company.

10

FINANCIAL IMPACT

9 15

Not Severe Easily Detectable

3

4

14

6

13

8

2

11

Seldom

Occasionally

FREQUENCY Figure 2. Frequency and impact of the fifteen common mistakes

www.globalsmt.net

12

Frequently

4 Malware, short for malicious software, is software designed to infiltrate or damage a product and may take a variety of forms such as hostile, intrusive, or annoying software. 5 Chang, Frederick R. “Is Your Computer Secure? SCIENCE, Vol. 325, p550, 31 July 2009 6 Cannings, Rich, Usenix Security Symposium, 13 August 2009

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 29


Interview

Interview—David Raby, STI Electronics David Raby is CEO of one of America’s most successful tier 3 EMS manufacturing companies. A past president of SMTA, David and his father, Jim Raby, have grown STI Electronics from a small contracting house to a multi-faceted business with a unique business model. Trevor Galbraith spoke to David about the origins and evolution of STI Electronics. David, your father, Jim Raby, founded the business. Can you tell us the origins of STI Electronics? Actually, the whole family founded the company, but it was based on Dad’s expertise. He had spent his career with NASA and the US Navy studying and testing electrical connections as well as developing manufacturing, quality and training specifications for their contractors. In 1982, we incorporated Soldering Technology International—Mom (Ellen) was the only “full time” employee—and began conducting seminars around the country teaching government contractors how to successfully and efficiently build military hardware to MIL-STD-2000. By 1984, the business had outgrown Mom & Dad’s living room in Ridgecrest, California and we opened an office in San Dimas, California. Dad left his government job and began consulting on a full time basis. I left my “real job” in early 1985 to manage the business side and hope we could all make a living for some period of time. We also soon began to do some hand solder training of companies’ operators and, because of their requests, began selling training kits very similar to the ones we still sell today. In 1993, we moved back home to Madison, Alabama, and eventually changed our name to STI Electronics. At the end of 2008, we moved about 500 yards into our current 54,000 ft2 building in Madison. The business is divided into three unique business segments. Can you explain the rationale behind this and how the three business units integrate with each other? We are unusual in the combination of businesses we operate, but we believe they

all complement each other. Our original consulting business led to what is now our Engineering Services department, which includes our Prototype and Manufacturing area, our Analytical/Failure Analysis Lab, and our Microelectronics Lab. If you are working with any of those areas, you are building (or contemplating building) a product and should be able to benefit from our Training Resources department. Training Resources consists of Training Services, which provides IPC and NASA certifications as well as customized training, and Training Materials, which provides training kits, dummy parts and other training materials and aids. If you are using either of the above departments, you are building hardware and can use our Distribution Sales department, which provides primarily benchtop equipment as well as consumable manufacturing materials (solder, flux, etc…). If you use our Distribution Sales department, obviously you are a candidate for our Engineering Services and Training Resources areas…. From the outside, they may seem like an odd combination of businesses, but the reality is that anyone who uses one probably has a need for at least one and probably both of the others. It also helps our customers tremendously

30 – Global SMT & Packaging – Celebrating 10 Years – July 2010

when they have issues arise, because of the unmatched variety of expertise we have under one roof. One of our biggest challenges through the years has been educating customers of one department on all of our capabilities in other areas. STI invented and patented embedded active die technology. Can you explain the features and benefits of this technology and the most likely applications? STI’s Imbedded Component/Die Technology (IC/DT) is helping customers

www.globalsmt.net


Interview

address size, weight, and power problems (SWAP). IC/DT is all about size reduction—utilization of the smallest form factor components and bare die available today. This reduction in component size allows STI to imbed these bare die minus their secondary packaging to achieve the lowest size and weight possible. Utilizing these small form factor devices and lowest power driven devices allows STI to meet and reduce power requirements and thus gain battery life and minimize power consumption while maximizing heat dissipation. SWAP is a major driver in military and some industrial applications. IC/DT also helps with component obsolescence because, as die size shrinks over time, the wiring out format does not change, but the package size does, which drives redesign of the printed circuit boards. Guidance systems and power supplies are great applications for IC/DT, as well as sensors and monitoring devices. You have a well-equipped failure analysis laboratory. Typically, what differentiates your lab from other facilities, and is the business US-based or further afield? The percentage of international business in our Analytical/Failure Analysis Lab is higher than in any other segment of STI. We perform analysis work from the component level through printed circuit board fabrication all the way to fully assembled system level analysis. We also perform material qualifications from the component level thru PCB fabrication and ultimately at the fully assembled state. This level of detail allows STI to differentiate ourselves from the competition because not only can we perform analytical services for customers, but with our prototype line we also have the capability to replicate the variables of their processes and truly understand the problems. The ability to use all our departments’ expertise to give solutions that are proven and correct is the main difference between our lab and other labs. STI have been involved in IPC Standards from the early days of the association. Recently, you were awarded a contract with IPC to update the existing IPC-A-610 and J-STD-001 training and certification programs from the D to the recently released E revision of the standards. Can you tell us about what was changed as part of the update? Many changes have been made to the documents as IPC’s staff and industry committee volunteers work to make sure

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the IPC-A-610 and J-STD-001 documents are in agreement with each other and contain new component package styles and technology as needed. The most notable changes in the E revision of J-STD-001 are the addition of criteria for non-collapsing solder balls to the BGA section, that materials criteria have been combined in one section, and the criteria for solder sleeves has been expanded to match IPC/WHMA-A-620. The most notable changes for IPC-A-610 include the addition and/or replacement of drawings with actual hardware photos, all damaged criteria moved to one section, and added new criteria for SMT termination style “flattened post.” In 2008 you quadrupled the size of your manufacturing plant. Have you managed to find sufficient contract work to feed this expansion, and how many lines do you have now? When we moved into the new facility in mid-December of 2008, we brought our prototype line from our previous facility and added a complete new SMT line. We’ve also added a third small but very capable SMT line inside of our cleanroom. In addition to size and SMT line capacity, we’ve added a tremendous amount to our capabilities including a high speed aqueous cleaner, a flying probe tester and a conformal coater. Of course, we had no idea what 2009 was going to be like for the industry, but we actually managed to grow our manufacturing business by more than 35% during that year and have continued at roughly the same pace in 2010. This week, we added a business development/sales manager to help guide our centralized sales force to help drive our overall sales and fill up the manufacturing area. You have extensive capabilities in your microelectronics lab and cleanroom. What kind of advanced packaging technologies can you undertake, and how does this feed into the SMT assembly side of the business? Our Microelectronics Lab operates in a 3,000 ft2 class 1,000 cleanroom. We now have the capability to build multichip modules, sensors and miniaturized hybrid packages for military and industrial customers. We are starting to acquire customers and build volume production hardware in this facility. The knowledge and experience from our manufacturing floor is definitely a plus in the cleanroom production, and, as well, the engineers

from microelectronics are always available to the manufacturing floor. Will the end of the NASA space program have a negative effect on your business? Today there are still several scenarios being discussed regarding the future of NASA, but right now I don’t expect any to have a tremendous effect on STI. Even if the manned program does end, the unmanned programs still require the engineering, workmanship and training that STI provides. Because of our history, we take a lot of pride in working with NASA, and we definitely want that to continue, but it does not make up a high percentage financially of our overall business. Your sales division stocks a large number of different solder, adhesive, encapsulants and other materials. Was this division badly affected during the downturn, and what percentage of the overall business is it? Last year was not a good year to be selling benchtop equipment and consumable supplies. I was very glad to have our diversification because this division took a pretty bad hit, but we weathered it without losing any people and have already begun to enjoy growth again. As I mentioned earlier, overall our sales were up last year, but our Distribution Sales department dropped to less than 20% of our total sales. Looking forward five years, where do you think STI Electronics will be? We will be the top training company in the world. (I wish I was smart enough to know exactly what things we will be teaching.) We will be known for our quality manufacturing and lab services. IC/DT will be an accepted technology for several applications. Our Distribution Sales will be providing the best quality materials (I don’t know whose) and outstanding service. I have no idea where we’ll be regarding sales volume or head count but I do believe we will be well known around the world because of our reputation of doing things the right way. I’ll also have a daughter headed off to her first year of college, so as a father, I’ll be terrified. David, many thanks for joining us today. Trevor Galbraith.

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 31


Show report: SMT/HYBRID/PACKAGING rises above the ashes

Show report: SMT/HYBRID/

PACKAGING rises above the ashes

After more than 20 years of travelling to Nuremberg every year for SMT/ HYBRID/PACKAGING, I have come to the conclusion that it is not only the most consistent event in the electronics calendar, but also the best organized. Perhaps that’s why it’s the most consistent! Being a non-Productronica year, European manufacturers used this platform to roll out new equipment, upgrades and improvements. Here is a selection of companies I visited during the show. NORDSON Dage probably had one of the biggest new product introductions with the 4000 Plus BondTester. Dage already own this market worldwide with over 4,500 machines in the field. This latest version is a complete redesign offering improved data integrity, accuracy, a stepback before sheer of ± 1µm, camera assisted tool alignment and improved automation.

Among the new applications the 4000 Plus offers are fatigue testing, crack initiation and growth, creep and relaxation tests. On the materials testing front, it has the option of additional Borescope for fine pitch applications and a hot bump pull test. Data I/O were celebrating their best Q2 ever and at the same time delivered

their first customized X-series Roadrunner to a Siemens customer in Hungary. Kyzen introduced Exaklean 5612 to the European market for the first time. This readyto-use stencil cleaner contains the Kyzen inhibitor package that makes it compatible with all pastes, fluxes and adhesives. The Exaklean 5612 does not need a rinse cycle, is PH neutral, fast drying and has a low odor. This makes it a more economical alternative using less waste and no need for the operator to monitor the cleaning cycle. In other news from Kyzen, they have started a contract cleaning service from their facility in Belgium. The company hopes to expand these services over the coming months. MIRTEC were fortunate to make two sales of their newly introduced SPI system on the first day of the show. The company is expanding their manufacturing facilities in Korea to meet the surge in demand for their inspection products. MIRTEC introduced a real game-changer at APEX earlier this year with their new ISIS (Infinitely Scalable Inspection Sensor), comprising a 15 megapixel camera. JUKI officially unveiled the EPV monitoring system on their FX2070 placement machine. This ultimate quality-monitoring system takes no less than five

32 – Global SMT & Packaging – Celebrating 10 Years – July 2010

photographs of every component from each nozzle. The first photo determines if the component is present after pick up. The second determines if has tombstoned or changed position. The third takes a photo of the pads on the board as a reference designator. The fourth checks the alignment during placement, and the fifth checks that the placement is still good after the nozzle has retracted. This new system is factory fitted on all new FX2070 machines and will soon be available on 2080’s. Europlacer introduced the RC5.15 software, which contains an NPI wizard that leads the operator through the setup for quick, efficient NPI programming. The company have also relocated some staff recently and added two more support staff in the United States. Viscom launched the S2088BO-II, a desktop system for automatic optical wirebond inspection. Developed to inspect medium and small product runs and reliable defect detection on die, ball-wedge, wedgewedge and security bonds, the S2088BO-II inspects everything from aluminum thick wire and aluminum or gold thin wire connections, down to diameters of 17 μm. The inspection library includes inspection patterns for die, ball-wedge, wedge-wedge and security bonds as well as for damaged and misplaced components. Another new product from Viscom was their vVision software. A new, GUI based software interface on a Windows®7 platform. It is fully touch-screen operated and simplifies the operation of Viscom

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 33


Show report: SMT/HYBRID/PACKAGING rises above the ashes

inspection equipment, while allowing access for experienced programmers to go deeper into the software to fine-tune inspection routines. Mentor Graphics’ Valor Division revealed that their MSS system has now been fully beta tested in a Chinese facility and has the unique ability to see work orders in advance and predict potential bottlenecks. This new software system can balance jobs across multiple lines, reduce the three-day inventory rule and achieve real job scheduling. The latest release of Valor V-Plan 2.1 in June 2010 can now program the entire line from end to end, producing machine code, DFM programs and documentation. Essemtec are never short of new product introductions. They kept up their blistering pace with the COBRA pick and place machine. Constructed on a composite frame, it offers better damping and stability. The COBRA has a unique v-shaped clamping system for boards, a carbon-fibre gantry on linear motors with magnesium heatsinks, all designed to reduce weight and increase speed. The COBRA boasts 240 feeders and an IPC placement speed of 15,000 cph. It is available from September 2010. The Tucano printer is high precision printer with a cycle time of 12 seconds and a price tag of €47,000. It has automatic stencil alignment and a maximum board size of 608 x 540 mm. The other big news from Essemtec was the acquisition of Vermes Microdispensing GmbH. The company currently offers two types of microdispensing valves, the MDS 3200 for high viscosity materials and the MDS 3010 for low/medium viscosity materials, capable of dispensing materials of 0-300 mpas and a droplet size of < 1 nlitre. DEK were demonstrating their dual layer stencils using their VectorGuard Platinum products. The double layer stencil is fabricated through a two-step lithography and nickel electroforming process before being mounted on the VectorGuard tensioning frame. The mesh layer of the two-

layer structure serves to hold the stencil intact while accurately controlling the flow of paste to the second layer. The circuit layer determines the thickness and shape of the print deposits to deliver high tolerance, fine dimension printing. Ideal for accuracy-critical applications such as solar cell manufacture or LTCC manufacture. DEK also introduced the Sentinel inspection system onto their Galaxy, Europa/Photon and Horizon printers. Sentinel operates concurrently with the print cycle to bring 100% inspection at line beat rates and provides full verification and traceability. Marrantz introduced a new iSpector desktop model. The iSpector Desktop offers 10 µm resolution using eight 1-megapixel cameras and one 2-megapixel centre camera, using a telecentric lens. The system uses three angled light sources and an 18-LED centre light. It has a GUI software interface and sells for €65,000. The iSpector Desktop is available from August. Assembléon is now leasing entry level machines from as little as €55 per day, plus a residual payment at the end of the lease. The new True Capacity on Demand system, where manufacturers rent heads to meet peaks in demand, is gaining popularity. Assembléon also introduced their new Twin Placement Robot. This robotic feeder picks from reels or trays and is an ideal plug-in for the DRAM or memory market. The TPR handles a maximum component size of 45 x 45 mm with a placement accuracy of ± 25 µm. The placement speed from tapes is 16,000 cph (IPC) and from the trays it is 13,000 cph (IPC). ERSA introduced the ECOCELL selective soldering system. The ECOCELL offers two integrated preheaters. Up to four boards can be processed simultaneously, and dual solder bath systems offer the possibility to efficiently process multiple panels. Both the miniwave and the multiwave baths have the possibility to use different alloys in each bath. This function, together with the possibility to perform maintenance on a multiwave bath

34 – Global SMT & Packaging – Celebrating 10 Years – July 2010

while the other bath is operating, reduces downtime to an absolute minimum. The ECOCELL has a tightly controlled spray fluxing system, and the under-board IR preheaters can be upgraded to convection systems for heavy-duty boards. SEHO won a local environmental award for a novel approach to harnessing the ambient heat that escapes from the top of their reflow oven chambers. A collector between the machine’s two outer hoods collects the wasted heat from the reflow soldering machine. In addition, this heat recovery concept also covers the exhaust system of the reflow oven, the cooling aggregate, and the cyclone unit used for process gas cleaning. This reclaimed heat can be transported to the manufacturing building either for use in a heat sink for the generation of tap water or in a preheating system for the fresh air supply. Warming of tap water in the manufacturing area is ideal because the soldering machine’s uptime is identical to the usage period of tap water, and water heating is the most efficient way to use wasted heat.

That is a short overview of some of the new products released at SMT/HYBRID/ PACKAGING 2010. This year the show attracted 555 exhibitors and 22,300 visitors. Next year, the show moves back to the May timeslot, and we can safely predict it will be another success. —Trevor Galbraith

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The 2010 GLOBAL Technology Awards The ONLY global awards program in the industry A GLOBAL Technology Award sends the message that your product or service is an innovation and quality leader in an industry crowded with competing products. Sponsored by Global SMT & Packaging magazine, the GLOBAL Technology Awards are now in their sixth year of recognizing and celebrating innovation in the electronics manufacturing industry. Entries are being accepted now through July 31st. Entries are invited from equipment, materials and EMS companies of all sizes. In addition to the award statue, winners receive publicity in a special awards issue of each of Global SMT & Packaging magazine’s five editions (US, Europe, China, Korea & South East Asia) as well as on the Global SMT & Packaging and GLOBAL Technology Award websites and in the Global SMT & Packaging email newsletters. Winners also receive a small poster for use at trade shows and an image and logo for use in advertising, websites and other promotional materials.

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 35


SMT Answers

SMT Answers SMT Answers, found online at answers.globalsmt.net, offers a place for members of the electronics manufacturing community to ask and answer questions—it’s a community-based ‘help board.’ Registration is not required for participation. Here are some recent questions and answers. Jump online any time to ask your own questions or help others out. When we solder FR1 board, we are facing problems with bubbles. What would be the possible reasons and how do we eliminate this issue?

the solder from the hole. Not all the holes were outgassing, we could test it with soldering iron. Outgassing continues when the solder remelts. The cause of the plating issue was the borehole’s surface roughness. You can test the holes like this: http:// www.youtube.com/watch?v=HCh_oyts9WE —Istvan

A: Most likley humidity. Check your screen printers humidity and temprature controls and make sure they are functioning properly. This has been the problem when we had bubbles or blow holes. This may require a solder paste brand change. —jt A: The laminate might have absorbed moisture. You could try baking it before use. A: We used to have issues with FR4 boards where the plating of the through holes

Tombstoning small parts on HASL boards—is there a solution or are we going to have to look into another kind of board? were not continuous and had a rough surface . The boards had outgassing during wave soldering what formed large boubles inside the solder joint and pushed out

36 – Global SMT & Packaging – Celebrating 10 Years – July 2010

A: No, you should not have to get new boards, although HASL finish is where I have seen all tombstoning. If you went to an ENIG board your tombstoning would

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SMT Answers

most likley go away, but that costs. Try decreasing the amount of paste being deposited onto the pad. You have enough solder that surface tension is pulling the part upright. Also, as I am sure you have done already, make sure that chip is dead center. If you have a glue machine in line you may just want to brute force it and add glue. Most glue cures at about 180˚F before solder reflows. —J Torrez, Production Manager, Transparent Technologies

This is for a Sn/Pb based material. —Dr. Brian Toleno, Director of Technical Service, Henkel

A: Have you tried an ’anti-tombstoning’ paste, available for tin/lead process, through Indium Corp? —Mark

We find it difficult to find a subcontractor to do these short run assemblies. Getting the bare PCBs made is no problem. Having SMT components properly assembled is a problem. Since we are a subcontractor we cannot promise the large board houses any future volume business if they produce the short run prototypes. So we have a “Catch-22” situation in our business. Our past designs have created product for our clients in volumes of 100K-1M PCBs. Yet we find it difficult to produce the prototypes and lead boards that ultimately produce this larger volume. We have thought of investing in table top pick & place, stencil screens and

A: LT (Low Tombstoning) versions of AIM SnPb and SAC solder pastes are available. These work well with convection reflow ovens and vapour phace. —Andrew Clarke, European Business Manager, AIM A: There are several ways to reduce tombstoning without changing the PWB finish. The two main factors are design and materials. See Toleno, B., Poole, N. “A Materials Based Solution for AntiTombstoning”, APEX 2003. In this study, on a board designed to produce tombstones, we reduced the defects from 444 to 211.

Market for short run prototypes? I run a small R&D business in which we do custom electronic and firmware (software) design. Our typical project produces 2 or 3 prototype PCBs and then 10-20 first beta product boards. From there the client usually sends the design off to a large board house for volume production.

reflow ovens. The cost of these tools are affordable; however, the cost of labor to run these tools may be far below breakeven. Has anyone out there dealt with such problem? How did you resolve it? A: I would not recommend setting up a short run facility for your designs. We explored the same situation a few years ago. Instead of producing first prototypes for clients, we now provide a paper design package which includes schematics, PCB gerbers, and component lists. The production of PCB prototypes is now the responsibility of the client company. And as you elude to above, the client does have the clout to negotiate short-run production with a promise of full production runs later. As a part of our contract, we accept built up prototype units back from the client to perform extensive testing, firmware design, and revisions as necessary. Have we lost much business with this approaoh? Not really, once the client understands the economics of this approach. Furthermore, we are preparing to exit this business in the USA as low cost labor in Asian countries will soon dominate.

These questions and answers are the opinion of the author(s). The Publisher does not accept responsibility for the accuracy or veracity of the information contained on this page.

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Global SMT & Packaging – Celebrating 10 Years – July 2010 – 37


Teaming for improved ruggedized product reliability New Products

New products Seika Machinery introduces PR1 pocket handy BGA solder ball checker Seika Machinery, Inc., introduces M.S. Engineering Co. Ltd.’s PR1 BGA solder ball checker for fast and accurate inspection of BGA soldering and QFP lead sections. The easy-to-use system is the ideal solution for checking BGA solder balls. The handheld system provides fast and accurate inspection of the soldered points and surface of BGAs, and features a conductive body for ESD. It also enables visual inspection of QFP leads as well as chip parts. As an additional benefit, the small checker (50 x 30 x 15 mm, weighing 25 g) fits in a handy pocket and comes standard with a wrist strap for convenience. www.seikausa.com Manncorp adds two higherthroughput PCB assembly systems to turnkey line-up In response to increased interest from OEMs aiming to cut costs by bringing PCB assembly in-house, Manncorp has expanded the top end of its turnkey lines. The two new systems are the “HighThroughput Flex Line” which includes twin MC-385 pick and place machines with a combined placement rate of 10,000 cph, and the “Box Builder Line” with the MC-

Nordson DAGE launch 4000Plus multi-purpose bondtester Nordson DAGE, a subsidiary of Nordson Corporation, introduces the 4000Plus multi-purpose bondtester. The 4000Plus represents the new industry standard in bond testing, providing unsurpassed data accuracy and repeatability and offering complete confidence in results. The system is able to perform a wide range of shear and pull applications as well as new push functionality up to 50kg. The 4000Plus is suitable for the full spectrum of traditional bond tests as well as meeting the requirements of emerging test applications including ribbon pull, new hot bump pull and fatigue. Ergonomically it also sets new standards with innovative user interfaces. www.nordsondage.com

387 placer that houses a huge 224-feeder capacity. The Flex Line enables assemblers to increase throughput by balancing their line and is Internet-priced at $199,995. The Box Builder Line, with its pick and place having an IPC9850-rated speed of 5,500 cph, is particularly suitable for short-run assemblers who require abundant feeder capacity. The Box Builder is Internet-priced at $139,995. www.manncorp.com Major new functionality in the vSure DFM Product Mentor Graphics Corporation announced the release of the vSure™ version 9.0 product, the successor of Valor Enterprise 3000™ Design-for-Manufacturing (DFM)

38 – Global SMT & Packaging – Celebrating 10 Years – July 2010

product. The enhancements in this release enable designers to more easily perform extensive DFM analysis during the PCB design process, thus improving their productivity, avoiding costly design re-spins, and speeding the time to target highvolume production. Electronics companies can now better meet their aggressive business goals of getting a more competitive product to market on time and at reduced manufacturing costs. go.mentor.com New upgrade possibilities make the KE-2050/60light mounters even more attractive With the 2050Light and 2060Light, JUKI offers a perfect match for current

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The Adventures of James Bondless production environments at a very affordable price. Time and again, so called “light machines” are heavily stripped down machines but this is not the case at JUKI. To keep up with new requirements JUKI adapts new market trends to these machines and is able to offer new options: • The long wide option extends the board size from 410 mm x 360 mm to 510 mm x 360 mm. • The KE-2060light now places components up to 20 mm height, and a 20 mm upgrade is available to existing 2060Light customers with 12 mm machines. • The KE-2050/60light are now available with “blue light,” which makes it easier for the operator to see the components on the board for visual checks. www.jas-smt.com

integrate its customers’ manufacturing processes. www.assembleon.com

New software for Assembléon’s A-Series cuts NPI time by 30% Royal Philips Electronics subsidiary Assembléon is cutting new product introduction (NPI) time on its A-Series pick & place equipment by 30%. The improvement is the first result of Assembléon’s strategic partnership with Valor—a division of Mentor Graphics— which brings a full suite of NPI and MES factory integration tools to automate machine-, line- and factory-level workflows and business processes. The result is a lean manufacturing operations management framework that is open, modular, and flexible. And it connects flawlessly to Assembléon’s enriched interfaces enabling performance monitoring, traceability and warehousing solutions. All that helps

Microscan announces the availability of Visionscape® 4.1. Microscan’s Visionscape® is a completely scalable, single-software package that can be used on machine vision boards, GigE solutions, and smart cameras. Visionscape®’s comprehensive machine vision toolset includes blob analysis, OCR, OCV, barcode, vector and edge algorithms, plus the industry leading pattern-matching tool, Intellifind. Visionscape® 4.1 brings additional tools such as color matching and color segmentation. Color matching can be used in high-speed applications such as sorting parts, and color segmentation enables other tools to be applied in a specific color plane. www.microscan.com

Microscan upgrades Visionscape®, the most comprehensive machine vision software for multi-platform use

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New Products

thermal conductivity adhesives from LORD Corporation, MT-815 has a modulus of <1 GPa , allowing it to be more flexible and therefore less likely to crack or delaminate under the stresses of temperature cycles. MT-815 was also formulated to achieve thermal conductivity of >10 W/m-K, creating a new class of flexible adhesives with high thermal conductivity. www.lord.com

VJ Technologies announces IR pre-heaters with advanced control VJ Technologies, Inc. updated its IR Pre-heater Series, designed to preheat assemblies that require additional heat to compliment manual soldering and desoldering of SMT, through-hole and other thermal applications. The IR Pre-heater Series is designed to work in conjunction with hand soldering and desoldering tools. IR Pre-heaters were developed for manual rework or for use with equipment, such as selective soldering systems for preheating boards to help eliminate board warping prior to rework. The pre-heaters also compliment underpowered rework systems lacking effective bottom heating. VJ Technologies’ infrared pre-heaters provide the additional heat and control required for lead-free applications, especially for multi-layer circuits. www.vjt.com LORD Corporation develops thermal conductivity adhesive LORD Corporation has announced the availability of a new low modulus, high thermal conductivity adhesive. Created in response to a market need for a more flexible, high thermal conductivity adhesive, MT-815 can be used in a variety of applications including as a thermal adhesive for large die, in die attach applications, or as a solder replacement. The first in a series of new low modulus,

Christopher Associates introduces new SPC software package for solder paste inspection Christopher Associates Inc. today introduced a powerful new yield improvement tool for the solder paste printing process. SPC+ Software, developed by Koh Young Technology, is a high-functionality statistical process control (SPC) package that can be run on the system or offline. The new software is included free of charge on all new Koh Young equipment. The software offers the ability to analyze both images and data to track performance, improve manufacturing yields and provide complete traceability under real-time conditions. Defect review, X Bars & S charts, Cp and CpK calculation, histograms, and other analytical tools can be calculated quickly and accurately with Pareto charts and the ability to drill down on specific data points. www.christopherweb.com Loctite PowerstrateXtreme Printable raises the bar on thermal management flexibility Addressing the challenges posed by traditional greases and phase-change thermal interface materials, Henkel has developed and commercialized Loctite PowerstrateXtreme

Essemtec upgrades MIS 6.6 software suite Essemtec’s Management Information System (MIS) for SMD placement machines has been enhanced with additional functions, including the support of automatic PCB identification with bar code and the splitting of production and placement data for each individual PCB. MIS is a software suite for the complete work-flow management on SMD pick-and-place machines. The system supports production planning, enables set-up optimization and control, includes a component stock management tool, and stores all production and placement data for traceability. MIS version 6.6 has been optimized for tracing both panels and PCB clusters. With the upgrade, MIS now saves production and assembly data with reference to each individual circuit. Therefore, data can be analyzed and tracked for each PCB. This is particularly important for the medical, automotive and aviation industries. www.essemtec.com

40 – Global SMT & Packaging – Celebrating 10 Years – July 2010

Printable (PSX-P), a new print-friendly thermal management product. Delivering unprecedented process flexibility, Loctite PSX-P allows for thermal management materials to be deposited using traditional screen and stencil printing methodologies and is offered in both medium dry and extended dry version to accommodate varying manufacturing conditions and requirements. The reliability and performance of PSX-P is consistent with that of Loctite PowerstrateXtreme phasechange films but its paste format enables the material thickness to be adjusted as required. www.henkel.com/electronics. SEHO adds features to GoSelective product line

SEHO Systems GmbH enhanced its GoSelective light to include additional features and capabilities. With the upgrades, the product has been renamed to communicate the new features. The GoSelective light standalone will now be referred to as the GoSelective. With its enhanced capabilities, the system is no longer considered “light”. Also, the GoSelective light inline is now called the SelectiveLine to express the systems’ inline capability and to highlight the modular concept, which allows the soldering machine to be upgraded with fluxer and preheat modules up to a complete manufacturing line. www.seho.de BPM Microsystems announces support for Exar’s PowerXR family of programmable power solutions BPM Microsystems L.P., now supports the PowerXR family of high-performance programmable power controllers from Exar Corporation on their automated and manual programmers. Exar’s PowerXR ICs, combined with BPM Microsystems’ unrivaled universal device programmers, significantly reduce development time, cost and are easily reconfigured for real-

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New Products

time design changes. BPM Microsystems supports the XRP7704 and XRP7714, a 5Amp/channel regulator, and the XRP7740, a 16 Amp/channel version, on its full line of universal device programmers. www.bpmmicro.com

from lead-free versions. In addition, Count On Tools now offers custom selective solder nozzles based on specific application requirements. This includes special wave form sizes and extended or shortened lengths. www.cotinc.com

Count On Tools introduces selective soldering nozzles for ACE equipment Count On Tools Inc. is now manufacturing ACE Bullet nozzles for the KISS range of selective soldering machines. By utilizing superior steel alloys made in the USA, along with the latest precision machining technologies, Count On Tools is able to produce selective soldering nozzles that are more durable and last longer than those from the OEM, while still maintaining all of the original design properties. The nozzles are available in all standards sizes from 3mm (0.125”) to 25mm (1.0”). Count On Tools also provides identification marks that enable customers to easily identify lead nozzles

Multitest’s MT9928 platform combines ROI and high efficiency

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has successfully passed the strict QA and production approval requirements of an international IDM. The state-of-the-art gravity feed handler offers a variety of loading and un-loading options. With a throughput of up to 14,500 uph, the bowl feed loading module is the loading option of choice for small package sizes. The bowl feed module offers the modularity and conversion of the MT9928 platform without limiting the flexibility of the base machine. The system can be combined with all types of un-loaders, further improving the return on investment. www.multitest.com MEMS cavity seal integrity As part of its bonded wafer inspection

Multitest announces that its nextgeneration MT9928 bowl feed module

Global SMT & Packaging – Celebrating 10 Years – July 2010 – 41


New Products

technology, Sonoscan has recently demonstrated acoustic imaging of defects in the seal that surrounds and protects the cavities in MEMS devices. The defects most frequently take the form of voids (Device 1 above) within the seal, which may be direct Si, metallic, glass or polymer, depending on the reliability level of hermetic seal required as per SEMI MS8-0309. In some locations on a wafer the seal may be breached (Device 2 above). Another frequent defect is delamination of the seal from one or both substrates, the result of poor wetting or contamination during fabrication. The defects are risky because thermal and mechanical stresses can cause them to grow until they cause a leak in the seal. Defects in the seal may be only a few tens of microns in diameter and of sub-micron thickness, but can be imaged by Sonoscan’s C-SAM® systems because they represent a gap that reflects >99.99% of the VHF/UHF ultrasonic pulse. In production, a percentage of MEMS devices may be imaged with C-SAM acoustic micro imaging systems in order to verify that process parameters are preventing the formation of voids. Where high reliability is essential, as in mil/aero or medical MEMS, 100% of devices may be inspected. www.sonoscan.com New radiometer ensures consistent light curing

DYMAX Corporation addresses this condition and offers accurate intensity and dosage measurements for LED curing equipment. The easy-to-operate ACCU-CAL™ 50-LED radiometer offers accurate measurement of curing energy. This radiometer can measure energy levels emitted from lightguides (3 mm, 5 mm, and 8 mm) and LED flood lamps. A specially designed photo-sensor assembly provides repeatable measurements and protection from high temperatures associated with some LED systems on the market. www.dymax.com Techcon Systems introduces updated product catalog Techcon Systems, a product group of OK International, introduces its updated product catalog.The enhanced catalog highlights the new Easy Flow Blue Piston Series, designed with close tolerances to precisely fit inside the syringe barrel. The Easy Flow Blue Series Piston requires less pressure to dispense fluids consistently and prevent air from becoming trapped during the dispensing process. Techon’s new Techkit TS 6500 Series Cartridge Mixer has also been added to the new product catalog. The catalog also features syringes, needles, cartridges, dispensing guns and accessories. www.techconsystems.com Orthodyne Electronics introduces HD series wire bonders Orthodyne Electronics’ new High Density Series wire bonders are designed to address the demand for smaller, thinner and denser discrete power semiconductor packages such as SO-8, PDFN, PQFN, DSO and DrMos. The HD Series includes the 7200HD dual-head semiconductor bonder and the 7600HD semiconductor Bonder, available in one to four head

configurations. Both systems can be equipped with large and small aluminum wire or PowerRibbon®. www.orthodyne.com New resource for electronics engineers and electronics products manufacturers

Electronics engineers and electronics products manufacturers seeking to use rapidly advancing laser die cutting technology for membrane switches, flexible circuits and other electronic component fabrication can now determine if the materials they use can be handled by modern laser die cutting technology by sending samples for engineering studies and analyses to the new Spartanics Laser Cutting Applications Laboratory for Materials Research. The Spartanics Laser Die Cutting Applications Laboratory for Materials Research provides no-cost detailed engineering analyses of maximum material thicknesses that can be handled with these different substrates, including brand name materials, correlated to laser power and other variables. To arrange for a no-cost materials analysis of suitability for finishing, marking and other detailing with laser die cutting, contact Mike Bacon, Spartanics VP, at mbacon@spartanics.com. www.spartanics.com The thinnest compliant board-to-board interposer Custom Interconnects, LLC announced the thinnest compliant board-to-board

Although many UV and visible radiometers currently available have a wide range of sensitivity in the UVA through visible portions of the spectrum, their sensitivity levels may not effectively match at the specific narrow band frequencies emitted by LED curing systems. The new ACCU-CAL™ 50-LED radiometer from

42 – Global SMT & Packaging – Celebrating 10 Years – July 2010

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Global SMT AD:Layout 1

interposer ever developed: the Thinnerposer®. The Thinnerposer® is expected to draw a great deal of interest from the RF design community. Targeted applications for the new Thinnerposer® technology include UAV/UAS, avionics, radar arrays, space probes and orbital satellites—a natural fit for the superior flexibility, impedance matching, and shock/vibration attributes of this product set. www.custominterconnects. com

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New Products

New Horizons in Bond Testing The Nordson DAGE 4000Plus is the most advanced bondtester on the market, representing the industry standard in bond testing.

Boundary scan tools keep on developing

Data Integrity Developed by the world leader in bond testing technology, the 4000Plus offers unsurpassed accuracy and repeatability of data providing complete confidence in results.

JTAG Technologies announced further advances in the boundary-scan tool arena with the latest release of its development and hardware debug tool, JTAG ProVisionT V1.8, that features on the latest tools CD (release 16 - May 2010). ProVision combines advanced automation with the level of control and precision that engineers demand when creating test programs and in-system programming (ISP) routines for PLDs, FPGAs, flash memories, serial PROMs and other devices. Enhancements to the ProVision version (V1.8) include new pin-level ActiveTest, multi-board and scan bridge support for JFT (Python) script routines, and an expanded ProVision model library covering more than 78,00 devices. www.jtag.com The stock you need, when & where you need it; Paragon VMI service cuts cost of component supply In the wake of recent economic challenges, the pressure is on manufacturers to find new ways to remain competitive. Against this backdrop, Bedford-based Paragon’s Vendor Managed Inventory (VMI) service is fast becoming the supply chain management service of choice for production environments in the UK and beyond. Part of Paragon’s Total

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Extensive Testing Capability

Intelligent Software

Load cartridges combined with standard and specialized fixtures perform shear tests up to 500kg, pull tests up to 100kg and push tests up to 50kg, covering all your test applications including new hot bump pull and fatigue applications.

The 4000Plus utilizes Nordson DAGE’s next generation Paragon™ software which boasts a highly configurable and intuitive interface as well as a wide variety of advanced functionality such as automatic GR&R calculation, built-in diagnostics, a unique database search engine wizard and superior reporting.

Ultimate Versatility A range of XY stages, with a 160mm XY stage as standard, meets a wide range of requirements. The image capture system for advanced analysis is quick to set-up and in close proximity to the test head aiding faster testing.

Learn more at www.nordsondage.com/4000Plus See the 4000Plus bondtester in action at Semicon West 2010: Booth No. 5947

www.nordsondage.com

Abstracts from the 36th Annual Meeting of the Society of General Internal Medicine

ABSTRACTS OF SUBMISSIONS

ACCEPTED FOR PRESENTATION

“MY CLIENTS FALL THROUGH EVERY CRACK IN THE SYSTEM”: ASSESSING THE NEED FOR GERIATRICS HEALTH TRAINING AMONG LEGAL PROFESSIONALS Tacara N. Soones1; Cyrus Ahalt2; Sarah Garrigues2; David Faigman3; Brie Williams2. 1University of California- San Francisco, San Francisco, CA; 2University of California-San Francisco, San Francisco, CA; 3UCSF/UC Hasting Consortium on Law, Science & Health Policy, San Francisco, CA. (Tracking ID #1607152)

BACKGROUND: Older adults (age 55+) represent the fastest growing age group in jail. While attorneys, judges, and other legal professionals are not generally considered healthcare team members, they provide front-line identification and response to age-related health conditions affecting legal outcomes. For example, cognitive impairment can affect the ability to access adequate legal representation, participate in one’s defense, or follow court orders; and physical impairment can jeopardize safety in jail. However, legal professionals’ knowledge of age-related health issues is unknown.

METHODS: This was a cross-sectional, qualitative study of legal professionals in San Francisco County’s criminal justice system. Questionnaires included open and close-ended questions to assess demographics, attitudes towards older adults (validated Geriatrics Attitudes Scale) and self-reported knowledge of geriatrics topics relevant to legal services, including cognitive and sensory impairment, legal competency, and knowledge of community resources. Questionnaires also elicited recommendations for closing geriatrics knowledge gaps. We analyzed questionnaires using standard grounded theory principles and conducted in-depth interviews with 9 participants to ensure that questionnaires were interpreted accurately.

RESULTS: Seventy-two of 83 legal professionals participated (87 % participation), including judges (6 %), District Attorneys (25 %), Public Defenders (58 %), and Pretrial Diversion case managers (11 %). Most legal professionals (73 %) worked with older adults on at least a monthly basis and 100 % had positive attitudes towards aging (Geriatrics Attitudes Scale >3). Self-reported geriatrics knowledge gaps were greatest in 3 areas: (1) General aging-related health- 14 % rated themselves as knowledgeable about age-related health issues, 74 % had never received training in aging; (2) Cognitive impairment-55 % did not feel knowledgeable at explaining how delirium, dementia and depression might affect behavior or the ability to follow instructions, and (3) Safety assessment-61 % felt unprepared to identify older adults at high safety risk and 62 % could not describe types of surrogate decision-makers, including public guardians or appointed power of attorneys. Five recommendations to close these knowledge gaps emerged: (1) educate legal professionals about aging-related health; (2) develop checklists to identify older adults at risk of health decline or poor safety; (3) train to assess older adults for cognitive and sensory impairments before legal proceedings; (4) create communication mechanisms between legal professionals, clinicians, and social services providers about client needs during and after detainment; and (5) encourage multidisciplinary research to improve health outcomes in older adults.

CONCLUSIONS: This study identifies critical gaps in the geriatrics knowledge of legal professionals in the criminal justice system and proposes recommendations to address these knowledge gaps, minimize adverse health outcomes, and improve legal outcomes for older adults.

“WHO’S ON FIRST?” IN THE CHAOS OF SHARED DECISION MAKING: A STUDY OF DOCTOR, PATIENT, AND OBJECTIVE RATINGS OF SHARED DECISION MAKING USING DIRECTLY OBSERVED ENCOUNTERS Patrick G. O’Malley1,2; Dorothy Becher1; Gretchen Rickards2,1; Janice L. Hanson3,1; Jeffrey L. Jackson4,1. 1Uniformed Services University, Bethesda, MD; 2Walter Reed National Military Medical Center, Bethesda, MD; 3University of Colorado School of Medicine, Aurora, CO; 4Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #1639946)

BACKGROUND: Shared decision making involves complex patient-physician interaction, yet patient encounters tend to be chaotic, without coherent direction or dyad symmetry. We sought to explore how patients and doctors perceive the degree of shared decision making in the same chronic care encounters, and how well their perceptions correspond with objective assessments of the interaction.

METHODS: Prospective, observational study of audiotaped encounters, with surveys of patients and physicians before and after the encounter. We enrolled a consecutive sample of 120 participants aged 40–80 y.o. with ≥3 additional chronic medical conditions (excluding dementia), and scheduled for a routine appointment with their primary provider. Immediately after the visit, patients and doctors were independently surveyed to assess the decision making style of the encounter along a 20-point spectrum ranging from “doctor-dominant” (0–6) to “shared” (7–13) to “patient-dominant” (14–20) decision making. The scale included behavioral descriptors in order to anchor one’s choice. Three raters (PO, DB, GR) dual-rated transcriptions independently on the level of decision making complexity (low, medium, high), and the degree of shared decision making (20-item scale), blinded to the patient and doctor ratings; disagreements were reconciled through consensus. Agreement between patient, doctor, and objective ratings were measured using the intraclass correlation coefficient (ICC).

RESULTS: Of the 105 patients who completed the visit, complete data was available on 98. The demographics were as follows: 53 % F, 56 % AA, mean age: 66 yo, 88 % were on 5 or more medications, only 8 % had poor health literacy, and 30 % had a very good or excellent functional status. The physician profile (N = 11) was: 55 % F, 28 % AA, mean age: 48 yo, and mean time since graduation: 19 yrs. The level of decision making in the encounters was low in 61 %, and mod/high in 39 %. Categorical ratings of encounters (by collapsing scores into 3 groups), stratified by perspective (doctor, patient, objective), is presented in the table (below). Immediately after the visit, there was no agreement between patients and physicians on the degree of shared decision making during the visit (ICC = 0.06, P = 0.37). By objective measurement, 88 of the 98 encounters were dominated by the physician (ie, scores from 0 to 9), and only 27 of those could be categorized as relatively “shared” (ie, scores of 7–9). When compared to objective ratings, physicians’ ratings of shared decision making correlated more strongly (ICC = 0.55, P < 0.001) than patients’ ratings (ICC = 0.39, P = 0.01).

CONCLUSIONS: Immediately after participating in the same chronic care encounter of mostly low to moderate decision complexity, both patients and physicians overestimated the degree of shared decision making, and neither agreed on the degree of shared decision making of the same encounter. Interventions to improve shared decision making will need to address 1. Physician lack of awareness of their tendency to dominate encounters, and 2. both parties’ ability to engage in true shared decision making.

Shared Decision Making Spectrum

Doctor Shared Patient

Perspective

Doctor 34 % 47 % 19 %

Patient 22 % 69 % 9 %

Objective 81 % 15 % 4 %

Ratings of the Same Encounter (N = 98)

(RE)TURNING THE PAGES OF RESIDENCY: THE IMPACT OF LOCALIZING RESIDENT PHYSICIANS TO HOSPITAL UNITS ON PAGING FREQUENCY Laura Fanucchi1; Lia S. Logio2. 1University of Kentucky College of Medicine, Lexington, KY; 2Weill Cornell Medical College, New York, NY. (Tracking ID #1634924)

BACKGROUND: Pagers are ubiquitous, yet fundamentally flawed, as they do not prioritize, lead to communication errors, and interrupt patient care and educational activities. Given duty hour restrictions, there is concern that residents experience increased workload due to having fewer hours to do the same amount of work. Geographic localization of physicians to patient care units is thought to improve communication and agreement on goals of care, and also to reduce workload by decreasing paging and other inefficiencies attributable to traveling throughout the hospital. We investigated whether interns on geographically localized teams received fewer pages than interns on teams that were not localized.

METHODS: We conducted a retrospective analysis of the number of pages received by interns on 5 general medicine teams from Oct. 17–Nov. 13, 2011 at New York Presbyterian Hospital/Weill Cornell. Two teams were in a Geographically Localized Model (GLM), two in a Partial Localization Model (PLM), and one Standard Model (SM) team admitted patients irrespective of their assigned bed location. ANOVA and standard multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team.

RESULTS: Over 28 days, 10 interns on 5 teams received 6652 pages. Eighty-five percent of patients in the GLM were on the designated unit, compared to 45 % in the PLM, and 37 % in the SM. The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.18 in the GLM, 2.77 in the PLM, and 3.87 in the SM. All of these differences were statistically significant in the linear regression analysis (p < 0.0001). Figure 1 shows the pattern of paging for the three types of teams.

CONCLUSIONS: Geographic localization of resident teams to patient care units is associated with significantly fewer pages received by interns during the day. Previous research suggests that geographic localization decreases perceived paging frequency. We show a statistically significant relationship with a dose–response effect. We also demonstrate that interns whose patients are scattered throughout the hospital may experience five pages per hour, or an interruption by pager every 12 min. Geographically localized patient care models may improve resident workload in part by mitigating paging. Decreased resident workload has potential to improve both clinical and educational outcomes. A working environment that facilitates in-person communication decreases not only pager interruptions, but the latent communication errors inherent in unidirectional alpha-numeric paging, which may improve patient safety.

Figure 1. Average number of pages per intern per hour for each care model.

24 MONTH METABOLIC BENEFITS OF A COMMUNITY-BASED TRANSLATION OF THE DIABETES PREVENTION PROGRAM Carolyn F. Pedley1; Doug Case1; Mara Z. Vitolins1; Jeffrey A. Katula1; Caroline S. Blackwell1; Scott Isom1; David C. Goff2. 1Wake Forest University, Winston-Salem, NC; 2Colorado School of Pulbic Health, Denver, CO. (Tracking ID #1642380)

BACKGROUND: The practice of general internal medicine involves treating a high percentage of individuals with hypertension, increased waist circumference, glucose intolerance, hypertriglyceridemia and decreased HDL cholesterol. These individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease and diabetes. Although several large-scale clinical trials have demonstrated that weight loss achieved through diet and physical activity can reduce the incidence of diabetes, translating lifestyle weight loss programs to general practice has been difficult. Numerous studies have attempted to translate the Diabetes Prevention Program (DPP) to community-based and primary care settings and have documented modest success. However, no translational studies to date have documented the impact of diabetes prevention interventions on aspects of the metabolic syndrome. The Healthy Living Partnership to Prevent Diabetes study (HELP PD; NIDDK) tested the impact of a community-based translation of the DPP on fasting blood glucose in participants at high risk for diabetes. The impact of HELP PD on fasting blood glucose and waist circumference have been published previously. The purpose of the present study is to examine the HELP PD intervention on features of the metabolic syndrome.

METHODS: The study randomly assigned 301 overweight volunteers with fasting blood glucose 95–125 mg/dl and BMI 25–40 kg/m2 to two treatment groups: enhanced usual care (EUC vs DPP LWL (Lifestyle, Weight Loss) intervention. Ages ranged from 34 to 81 years with a median of 58 years; 57 % were female, 26 % minority and 73 % obese. The LWL intervention was administered through a local diabetes education program and participants met in 14 groups of 8–12 delivered by community health workers (CHW) in community locations. CHWs were volunteers with well-controlled diabetes.

RESULTS: Duriing 24 months of follow-up there were significant between group differences in metabolic parameters: fasting blood glucose, waist circumference, HDL and DBP differed significantly between the LWL and EUC groups, all in favor of the LWL. SBP and triglycerides were lower in the LWL group but the differences were not statistically significant. Fasting blood glucose decreased by 2.2 mg/dl in the LWL group and increased by that amount in the EUC group for a difference of 4.4 mg/dl at 24 months (p = .001). Waist circumference decreased by 3.4 cm in the LWL group and remained relatively unchanged in the EUC group (0.2 cm decrease) for 3.2 cm difference at 24 weeks (p < .001). HDL increased by 0.4 mg/dl in the LWL group while decreasing by 2.7 mg/dl in the EUC group (p = .004). Diastolic blood pressure decreased by 1.6 mmHg in the LWL group and increased by 0.5 mmHg in the EUC group (p = .024) while systolic blood pressure decreased by 2.3 mmHg in the LWL group and 1.0 mmHg in the EUC group (p = .437). Triglycerides decreased by 23.4 mg/dl in the LWL group compared to the 10.8 mg/dl in the EUC group (p = .083).

CONCLUSIONS: This study demonstrates that community-based partnerships can successfully deliver effective, affordable behavioral lifestyle weight loss programs in general medical patients who have several metabolic risks for diabetes and heart disease with resultant metabolic benefits. Utilizing community-based volunteers in community settings to deliver diabetes prevention programs has the potential to reduce health disparities in accessing such care.

“AM I CUT OUT FOR THIS?” UNDERSTANDING THE EXPERIENCE OF DOUBT AMONG FIRST YEAR MEDICAL STUDENTS Rhianon Liu; Jorie Colbert-Getz; Robert Shochet. Johns Hopkins University School of Medicine, Baltimore, MD. (Tracking ID #1628595)

BACKGROUND: Research on medical student wellbeing shows high rates of distress, yet doubt as a distinct phenomenon remains poorly understood. The purpose of our study was to examine how first year medical students experience and respond to doubt, and how doubt relates to other aspects of student distress.

METHODS: We conducted a mixed methods study involving a survey and focus groups examining the phenomenon of doubt among first year medical students at the Johns Hopkins University School of Medicine (JHUSOM). Students were asked to answer 14 questions about doubt embedded in an online advising program survey in June, 2012. Doubt survey items were developed and revised based on literature review, and included four questions from a validated wellbeing index. Results were analyzed by grouping students into categories of high, moderate, low, or no doubt. For each doubt item, logistic regression was used to compare the proportion of students who “agreed” among moderate/high doubters vs low/no doubters. For wellbeing questions, total doubt scores and total wellbeing scores were correlated with Spearman’s rho. In addition, four 90-min focus groups were conducted with a convenience sample of students in June–July, 2012. Focus group questions were written by the authors, then pilot-tested and revised prior to use. Digital recordings were transcribed, independently coded, and iteratively reviewed by the authors to identify major themes.

RESULTS: 114/119 (96 %) students completed the survey. 20 % had high doubt, 29 % moderate doubt, 22 % low doubt, and 29 % no doubt. Compared to those with low/no doubt, students with moderate/high doubt were 5 to 13 times as likely to question their personal purpose, to question who they were, to struggle with coping with doubt, and to perceive the JHUSOM climate as discouraging them from expressing doubt, There was moderate correlation between total doubt and wellbeing scores (spearman’s rho = 0.36). 34 students participated in the focus groups. Three major themes were identified: types of doubt, ways of coping with doubt, and impact of doubt. Types of doubt were related to two main questions: -Do I want to become a doctor? Subtheme example: the opportunity cost of pursuing medicine -Am I capable of becoming a doctor? Subtheme example: concerns about one’s ability to succeed and maintain work-life balance Ways of coping with doubt included: -Relying on supportive relationships -Maintaining perspective through a focus on long-term goals The impact of doubt included positive and negative aspects: -Positive examples: motivation and resilience in the face of uncertainty -Negative examples: burnout, stress, and poor academic performance

CONCLUSIONS: Doubt is prevalent among first-year medical students, affecting students’ sense of confidence, identity, and purpose, and has both positive and negative consequences. Students also experience other forms of distress, which may be related to doubt. Doubt among medical students merits awareness and further study, as it may be an important mediator of students’ emerging sense of identity and personal wellbeing.

A BEFORE/AFTER TRIAL OF A DECISION AID ON MAMMOGRAPHY SCREENING FOR WOMEN AGED 75 AND OLDER Mara A. Schonberg; Mary Beth Hamel; Roger B. Davis; Edward R. Marcantonio. Beth Israel Deaconess Medical Center, Boston, MA. (Tracking ID #1636857)

BACKGROUND: Guidelines state there is insufficient evidence to recommend mammography screening for women aged >75 years. Instead, they encourage clinicians to discuss the potential benefits and risks of screening and engage older women in shared decision-making. We aimed to design and evaluate a decision aid (DA) for women >75 years to inform their decision-making around mammography screening.

METHODS: We designed the DA based on international standards and included data from medical literature review. An expert panel reviewed iterative versions of the DA and it was then reviewed for acceptability by 15 patients and 5 of their primary care physicians (PCPs). The 10-page DA (written at a 6th grade reading level) includes information on breast cancer risk, life expectancy, competing mortality risks, likely outcomes if screened or not screened over 5 years, and a values clarification exercise. We evaluated the DA in a before/after trial at a large academic primary care practice in Boston. Eligible women were >75 years, spoke and read English fluently, had not had a mammogram in the past 9 months but were screened in the past 3 years, did not have a history of invasive or non-invasive breast cancer or dementia, and were scheduled for a routine visit with their PCP within 8 weeks. Participants came early to their PCP appointment to complete a “before” survey and to read the DA. After the visit, they completed an “after” survey. The surveys included 10 knowledge questions, the 16-item decisional conflict scale (DCS, 0–100, lower scores = less conflict), and a question that assessed screening intentions. Participants were followed by medical record for up to 1 year to examine whether there was a note documenting a discussion of the pros/cons of screening and to abstract receipt of mammography. We used the signed rank test and McNemar’s test to compare before/after responses. We also asked PCPs to complete a survey about using the DA in their practice.

RESULTS: Forty-nine before/after trial participants (from 26 PCPs) had median age of 79 years; 70 % were Non-Hispanic white; 63 % had attended some college; and 24 % had <7 year life expectancy. Comparison of “after” to “before” survey results found: 1) participants answered on average 1 more question correct (interquartile range 0–2) on the 10 item index from 6 to 7 questions correct, p < 0.001; 2) decisional conflict declined by 4.8 points (range −10.2 to +4.7 points, mean DCS scores before = 20.1, p = 0.03); and 3) fewer participants intended to be screened (59 % compared to 82 % before, p = 0.01). In the following 6 months, 61 % of participants had a PCP note documenting a discussion of the pros/cons of screening compared to 10 % in the previous 5 years, p < 0.001. While 86 % had been screened within 2 years before participating only 61 % were screened within 1 year after, p < 0.001 (a similar decline was found among women with <7 year life expectancy). Overall, 94 % reported that they would recommend the DA, 94 % found it helpful, and 78 % found the amount of information just right. PCPs (17/26) reported that using the DA would result in their patients making more informed (74 %) and value laden (79 %) decisions.

CONCLUSIONS: We developed a DA for women aged >75 years contemplating mammography screening. Our before/after trial demonstrates that this DA allows women to make more informed, preference-sensitive decisions around mammography screening. Next, we plan to test the effectiveness of the DA in a large randomized control trial.

A CENSUS OF STATE-BASED CONSUMER HEALTH CARE PRICE WEBSITES Jeffrey T. Kullgren1; Katia A. Duey2; Rachel M. Werner3. 1Ann Arbor VA Healthcare System and University of Michigan, Ann Arbor, MI; 2University of Pennsylvania, Philadelphia, PA; 3Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA. (Tracking ID #1642367)

BACKGROUND: As Americans’ out-of-pocket health care costs continue to rise, many health plans, consumer groups, and state governments are reporting health care price information directly to patients. Though there is broad recognition that this information must be relevant, accurate, and usable to improve the value of patients’ out-of-pocket spending, it is currently unknown what information is actually being reported to patients. The objective of this study was to describe the types of information that are currently being reported on state consumer health care price websites and identify opportunities to improve the usefulness of this information for patients.

METHODS: We conducted a systematic internet search to identify patient-oriented, state-based health care price websites that were operational in early 2012. We chose to focus on state-based websites since states are a focal point for health care price transparency initiatives and often publicly report the health care price information they collect under legislative or regulatory authority. For each website we identified, we classified the type of organization that reported the information, the kinds of health care services for which prices were reported, the type of price information that was reported (e.g., out-of-pocket cost, allowable charge, or billed charge), the patient-level factors that were incorporated in the estimate, and the presence of quality information alongside the reported price information. We then calculated frequencies for each of these characteristics.

RESULTS: We identified 62 state health care price transparency websites, most of which were provided by either a state government agency (46.8 %) or state hospital association (38.7 %). Most websites reported information on prices of inpatient care for medical conditions (72.6 %) or surgeries (71.0 %); prices for outpatient services such as diagnostic or screening procedures (37.1 %), radiology studies (22.6 %), prescription drugs (14.5 %), or laboratory tests (9.7 %) were reported less often. The reported prices usually reflected only billed charges (80.6 %). For outpatient services that commonly include both facility and professional fees (e.g., diagnostic procedures or radiology studies), the majority of price estimates (66.0 %) included just facility fees. Only a small minority of prices were tailored to individual circumstances that commonly affect what a patient is truly expected to pay out-of-pocket for a service, such as their insurance status (9.7 %) or specific health plan (8.1 %). For services where price and quality information together could help patients assess value across providers (e.g., outpatient clinician services or outpatient surgeries), quality information was infrequently portrayed alongside prices (13.2 %).

CONCLUSIONS: Most states now have websites that report health care prices directly to patients. However, the information being reported on these state health care price websites is unlikely to be useful for most patients, and often fails to reflect the true prices they would actually face for services. Improvements in the relevance, accuracy, and usability of publicly reported health care prices could help this information reach its full potential to improve the value of out-of-pocket health care spending for patients.

A HIGH RISK OF HOSPITALIZATION FOLLOWING RELEASE FROM CORRECTIONAL FACILITIES AMONG MEDICARE BENEFICIARIES Emily A. Wang1; Yongfei Wang2; Harlan M. Krumholz1,2. 1Yale School of Medicine, New Haven, CT; 2Yale-New Haven Hospital Center of Outcomes Research and Evaluation, New Haven, CT. (Tracking ID #1642216)

BACKGROUND: Healthcare is constitutionally guaranteed in correctional facilities, but not upon release, which could increase the risk of acute events. We studied the risk for hospitalizations among former inmates soon after their release from correctional facilities.

METHODS: We conducted a retrospective cohort study using data from Medicare administrative claims for all fee-for-service beneficiaries who were released from a correctional facility from 2002 to 2010. Using McNemar’s test and condition logistic regression, we compared hospitalization rates after release among former inmates 7, 30, and 90 days after release to beneficiaries matched based on age, sex, race, Medicare status, and residential zip code. We also compared hospitalizations with the specified diagnosis codes between the two groups and examined whether being released from a correctional facility was associated with different risks for hospitalizations for ambulatory care-sensitive conditions compared with the matched control. We used Kaplan Meier survival analyses to compare time to the first hospitalization and death between the two matched groups after release. Data were censored at the time of death or the end of the observation period.

RESULTS: Of 110,419 released inmates, 1559 individuals (1.4 %) were hospitalized within 7 days after release; 4285 individuals (3.9 %) within 30 days; and 9196 (8.3 %) within 90 days. The odds of hospitalization was higher for released inmates compared with matched controls (within 7 days, odds ratio (OR) 2.5, 95 % confidence interval [CI] 2.3, 2.8; 30 days, OR 2.1, 95 % CI, 2.0, 2.2; and 90 days, OR 1.8, 95 % CI 1.7, 1.9). Compared with matched controls, former inmates were more likely to be hospitalized for ambulatory care-sensitive conditions (within 7 days, OR 1.7, 95 % CI 1.4, 2.1; 30-days, OR 1.6, 95 % CI 1.5, 1.8; and 90-days, OR 1.6, 95 % CI 1.5, 1.7). Mental health conditions were the most common reason for hospitalizations among former inmates 30 days post release (22.1 %). Diseases of the circulatory system (14.0 %), injury and poison (12.7 %), and disease of the respiratory system (10.5 %) were also common reasons for hospitalization among released inmates. In event-free analyses, former inmates were more likely to be hospitalized compared with the control group within a year following release.

CONCLUSIONS: About one in 70 former inmates are hospitalized for an acute condition within 7 days of release, and one in 12 by 90 days, a rate much higher than the general population. Transitions between correctional facilities and the community are a high-risk period; correctional and community healthcare systems should collaborate to reduce morbidity for this vulnerable population.

A META-ANALYSIS OF THE RAPID ANTIGEN STREPTOCOCCUS TEST Emily Stewart; Brian Davis; Lee Clemans-Taylor; Robert M. Centor; Carlos Estrada. The University of Alabama at Birmingham, Birmingham, AL. (Tracking ID #1624984)

BACKGROUND: Current guidelines to diagnose and treat group A streptococcal (GAS) pharyngitis do not take into account the uncertainty of rapid testing. We examined the accuracy of the rapid antigen streptococcus test (RAST) to diagnose GAS pharyngitis.

METHODS: Systematic review and meta-analysis. MEDLINE search and reference lists, 2000–2012. We included clinical studies using RAST and a reference standard. We assessed quality with Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. We obtained hierarchical summary receiver operating characteristic (HSROC) curve and obtained adjusted estimates of test characteristics.

RESULTS: We included 41 of 728 studies; the overall prevalence was 28 % (13,588/48,377 patients; range 4–67 %). The setting was solely in the emergency department (27 %) or outpatient clinic (56 %); 22 % were solely in children; and 14 % were retrospective. Of 14 QUADAS criteria, eight were fulfilled by over 90 % of studies, five by 60–80 %, and one by 22 %. The Deek’s funnel plot was asymmetric (p < 0.001) suggesting the presence of publication bias. Studies were heterogeneous as illustrated by a wide 95 % prediction region in the HSROC curve (Figure, dashed line) and high inconsistency estimates for sensitivity (I2 = 94.4 %) and specificity (I2 = 98.2 %). The adjusted pooled sensitivity was 88.2 % (95 % confidence interval [CI], 83.9 to 91.4 %; range 52.6 % to 99.9 %). The pooled specificity was 98.5 % (95 % CI, 96.7 to 99.3 %; range 68.8 % to 100 %). Inconsistency between studies remained high for sensitivity and specificity in sub-group analyses for location of test performance (point-of-care, laboratory), pediatric population, setting (outpatient, emergency department), study design (prospective, retrospective), study methodological quality (verification bias, non-differential bias, non-incorporation bias), and funding (commercial or not)(all I2 > 80 %).

CONCLUSIONS: The RAST is moderately sensitive and highly specific to diagnose group A streptococcal pharyngitis. However, significant heterogeneity and publication bias were observed among studies. Guidelines should incorporate uncertainty in estimates for rapid tests for the diagnosis of GAS pharyngitis.

A MIXED-METHODS RANDOMIZED CONTROLLED TRIAL OF EMPLOYER MATCHING OF DEPOSIT CONTRACTS TO PROMOTE WEIGHT LOSS Jeffrey T. Kullgren1; Andrea B. Troxel2; George Loewenstein3; Laurie Norton2; Dana Gatto2; Yuanyuan Tao2; Jingsan Zhu2; Heather Schofield4; Judy A. Shea2; David A. Asch5; Thomas Pellathy6; Jay Driggers7; Kevin G. Volpp5. 1Ann Arbor VA Healthcare System and University of Michigan, Ann Arbor, MI; 2University of Pennsylvania, Philadelphia, PA; 3Carnegie Mellon University, Pittsburgh, PA; 4Harvard University, Cambridge, MA; 5Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA; 6McKinsey & Company, Pittsburgh, PA; 7Horizon Healthcare Innovations, Newark, NJ. (Tracking ID #1642494)

BACKGROUND: Deposit contracts are behavioral economic devices that ask people to put money at risk that they forfeit if they do not meet a goal. While deposit contracts can effectively promote weight loss, a major challenge to wider impact of these programs is getting more people to participate. The goals of this study were to test whether matching of deposits can increase participation in deposit contracts, characterize the corresponding amount of weight loss, and identify factors associated with non-participation in these programs.

METHODS: We recruited 132 employees of Horizon BCBS of NJ who wanted to lose weight and had a BMI between 30 and 50. Participants were given a weight loss goal of 1 lb per week for 24 weeks and randomized to a monthly weigh-in control group or monthly opportunities to deposit $1 to $3 per day with daily feedback. Deposits were either not matched, matched 1:1, or matched 2:1 and provided back to participants at the end of the month for every day in that month that participant was at or below the goal weight for that day. After the 24-week intervention period, we conducted semi-structured interviews with intervention arm participants to identify factors that influenced their participation in deposit contracts. The primary outcome was weight loss at 24 weeks. Secondary outcomes included deposit contract participation; changes in eating behaviors, physical activity, and wellness program participation at 24 weeks; and weight loss 12 weeks after the interventions ended.

RESULTS: After 24 weeks, control arm participants gained an average of 1.0 lb (SD 7.6), compared to mean weight losses of 4.3 lbs (SD 8.9; P = .03) in the no match arm, 5.3 lbs (SD 10.1; P = .005) in the 1:1 match arm, and 2.3 lbs (SD 9.8; P = .29) in the 2:1 match arm. Overall, 29.3 % of participants in a deposit contract arm made at least one deposit, and there were no significant differences in participation rates across the 3 deposit contract arms. There were also no significant differences in changes in eating behaviors, physical activity, and participation in wellness programs after 24 weeks. In semi-structured interviews, the main factors that limited participation in deposit contracts were a lack of confidence in meeting weight loss goals and fear of losing money. 12 weeks after the interventions ended, control arm participants gained an average of 2.1 lbs from baseline (SD 7.9), compared to mean weight losses of 5.1 lbs (SD 11.1; P = .008) in the no match arm, 3.6 lbs (SD 9.6; P = .02) in the 1:1 match arm, and 2.8 lbs (SD 10.1; P = .12) in the 2:1 match arm.

CONCLUSIONS: Relatively few study participants assigned to deposit contract conditions took up opportunities to enter into deposit contracts designed to promote weight loss, and employer matching of deposits did not increase participation. Approaches to promote confidence in losing weight or seed deposit contract accounts might be alternative ways to increase participation in these programs. Greater weight loss in deposit contract arms at 24 and 36 weeks may have been mediated by the automated daily feedback these participants received, and this approach could be another promising tool to promote behavior change in workplace settings.

A NATIONAL ASSESSMENT ON PATIENT SAFETY EDUCATION IN UNDERGRADUATE MEDICAL EDUCATION: A SURVEY OF CLERKSHIP DIRECTORS IN INTERNAL MEDICINE C. Charles Jain1; Meenakshy K. Aiyer1; Jean C. Aldag1; Eric Alper2; Steven Durning4; Elizabeth A. Murphy2; Dario M. Torre3. 1University of Illinois College of Medicine at Peoria, Peoria, IL; 2University of Massachusetts, Worcester, MA; 3Drexel University, Philadelphia, PA; 4Uniformed Services University of the Health Sciences, Bethesda, MD. (Tracking ID #1638436)

BACKGROUND: Patient safety is an important aspect of quality patient care. For this reason, accreditation bodies emphasize educating learners on patient safety in both undergraduate and graduate medical education curricula. This study looks at the current status of patient safety curricula from the perspectives of internal medicine clerkship directors. In addition, this study compares the current status to what was found in a similar study from 20061.

METHODS: The patient safety survey was a part of the Clerkship Directors in Internal Medicine (CDIM) 2012 annual survey. Questions were identified based on literature review, then modified and edited by the CDIM research committee. 37 patient safety related questions were organized into sections including general information, curriculum content and delivery, learner assessment, and barriers to providing the curriculum. All analysis was done using SPSS with group difference tested with Chi-squares for nominal variables. IRB approval was obtained.

RESULTS: Of the 121 clerkship directors surveyed 99 (82 %) responded. Of those responding 45.6 % (n = 41) describe having patient safety curriculum at some point during the 4 years of medical school curriculum. Patient safety curriculum was commonly taught in the third year (30.3 %) of medical school followed by the pre-clinical years (yr1 = 19.2 %, yr2 = 28.3 %). The top three content areas included in the curriculum were infection control (54.1 %), handoffs and sign outs (47.4 %), and medication safety (39.5 %). Small groups (42.4 %) followed by lectures (31.3 %), direct observation (30.3 %) and Morbidity and Mortality reports (28.3 %) were used as educational strategies. Even though strategies such as patient safety project, simulations and OSCE were used for assessment of the curricula, only 20 % of the respondents reported satisfaction with student safety competency assessment during their IM clerkship. Lack of a mandate from their school’s dean’s office (38 %), lack of physician champions (43.7 %), lack of trained faculty (65.3 %), and lack of time (78.1 %) were cited as barriers to implementation. Schools with female clerkship directors were significantly more likely to have a patient safety curriculum compared to schools with male clerkship directors (p = 0.01).

CONCLUSIONS: Less than half of medical school curricula report having patient safety curricula. Even though clerkship directors recognize the importance of teaching patient safety curriculum, barriers exist to implementing the curricula. National guidelines on patient safety curriculum are currently not enough and more needs to be done to bring about the desired changes. 1. Alper MD E, Rosenberg MD, MSPH, Eric I., O’Brien MD KE, Fischer MD MEd M, Durning MD SJ. Patient safety education at U.S. and Canadian medical schools: Results from the 2006 clerkship directors in internal medicine survey. Acad Med. 2009;84:1672–1676.

A NOVEL WEBSITE TO PREPARE DIVERSE OLDER ADULTS FOR DECISION MAKING AND ADVANCE CARE PLANNING: A PILOT STUDY Rebecca L. Sudore2,1; Sara J. Knight2,5; Anita L. Stewart4; Ryan D. McMahan2,1; Mariko Feuz2,1; Yinghui Miao2,1; Deborah E. Barnes3. 1UCSF, San Francisco, CA; 2San Francisco VA Medical Center, San Francisco, CA; 3UCSF, San Francisco, CA; 4UCSF, San Francisco, CA; 5Veterans Health Administration, Washington, DC. (Tracking ID #1638672)

BACKGROUND: Advance care planning (ACP) has typically focused on advance directives and preferences for treatments, such as CPR. We have reconceptualized ACP as a multi-step process focused on preparing patients with skills needed for communication and in-the-moment decision making. To operationalize this paradigm, we created a new ACP website called PREPARE that is interactive, written at 5th-grade reading level, and shows people through videos and a step-by-step process how to communicate what is most important in life and how to make informed medical decisions. To assess the efficacy of PREPARE, we created and assessed the validity of a new survey that detects behavior change in ACP and then conducted a separate pre-to-post efficacy study.

METHODS: Study #1 (Survey Validation) validates the ACP Engagement Survey, which includes Process Measures of behavior change (knowledge, self-efficacy, and readiness, 5-point Likert) and Action Measures (e.g., “Did you do X?” yes/no) of multiple ACP behaviors such as choosing a surrogate, asking someone to be a surrogate, and speaking to surrogates and doctors about one’s wishes. We administered surveys at baseline and one-week later to 50 diverse, older adults from San Francisco hospitals. Internal consistency of the Process Measures was assessed using Cronbach’s alpha (only for continuous variables) and test-retest reliability for both Process and Action Measures was examined using intraclass correlations. Study #2 (PREPARE Efficacy): Using a separate cohort (n = 43) from low-income, San Francisco senior centers, we assessed change in ACP Engagement Survey responses (Process and Action Measures) and change in percentage of participants in the lowest, “precontemplation”, behavior stage of change to higher stages (contemplation, preparation, action, maintenance) at baseline and one-week after viewing PREPARE. We also assessed PREPARE’s ease-of-use on a 10-point scale, 10 being the easiest. To assess comparisons, we used paired t-tests and McNemar’s tests.

RESULTS: Study #1 (Survey Validation): Mean age was 69.3 (SD 10.5) and 42 % were non-White. The internal consistency of the Process Measures was 0.94. Intraclass correlations were 0.70 for the Process Measures and 0.86 for the Action Measures. Study #2 (PREPARE Efficacy): Mean age was 68.4 (SD 6.6) and 65 % were non-White, and 33 % had limited health literacy. Behavioral change Process Measure average Likert scores increased from 3.1 (SD 0.9) to 3.7 (SD 0.7), p < .001. Action Measures did not change significantly in 1 week. However, precontemplation significantly decreased for most ACP actions including asking someone to be a surrogate 39.5 % vs. 23.3 %, p < .04; talking to the doctor about the surrogate, 62.8 % vs. 30.2 %, P,.001; talking with the surrogate and doctor about medical wishes, 46 % vs. 28 %, p = .02 and 61 % vs. 35 %, P = .003, respectively. PREPARE was rated 9 out of 10 (SD 1.9) for ease-of-use.

CONCLUSIONS: A new patient-centered ACP website prepares people for ACP communication and medical decision making and is easy-to-use among older adults from diverse backgrounds. The new ACP Engagement Survey that measures both ACP behavior change and ACP actions demonstrated good reliability and validity. And, the PREPARE website significantly improves individuals’ behavior change and engagement in ACP. The website is available at www.prepareforyourcare.org and a clinical trial is underway.

A PEER-LED INTERVENTION IMPROVES STROKE SURVIVORS’ BLOOD PRESSURE CONTROL Carol Horowitz1; Kezhen Fei1; Ian M. Kronish2,1; Stanley Tuhrim1; Rennie Negron1. 1Mount Sinai School of Medicine, New York, NY; 2NY Presbyterian, New York, NY. (Tracking ID #1641866)

BACKGROUND: Hypertension is a major risk factor for stroke recurrence but it is poorly controlled among stroke survivors, particularly from minority groups. The Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial tests whether a community-based, peer-led stroke education intervention improves stroke risk factors, primarily blood pressure control.

METHODS: Using community-based participatory research, clinicians, educators and stroke survivors developed a six-session peer-led workshop to help stroke survivors understand their illness, and identify and manage their recurrent risks, particularly hypertension. We recruited 600 individuals with a history of stroke or TIA within the past 5 years who were randomized to the intervention or a wait-list control group. At baseline, 6 and 12 months, we measured participants’ blood pressures, socio-demographics, beliefs and behaviors.

RESULTS: Participants have a mean of 63 years, the majority are female (60 %), Black or Latino (81 %) and live in poverty (56 %). At baseline, 31 % in both groups had uncontrolled blood pressure (<140/90 mmHg). At 6 months, the intervention group demonstrated better blood pressure control when compared to the control group, 76 % vs. 65 % (p = 0.01). The intervention group also had a significant blood pressure reduction of 3.6/2.0 mmHg (p = 0.005/p = 0.04) compared to the control group (+0.5/−0.5 mmHg).

CONCLUSIONS: A peer-led educational program developed through a community-academic partnership was successful in improving blood pressure control at 6 months. While 12-month data will confirm the longevity of this impact, PRAISE is simple, culturally appropriate and inexpensive, and may represent an important and sustainable secondary stroke prevention strategy.

A PILOT STUDY OF A COMPUTER-BASED RELATIONAL AGENT TO SCREEN FOR SUBSTANCE-USE PROBLEMS IN PRIMARY CARE Steven R. Simon1,5; Kyle Checchi1,2; Sarah S. McNair1,2; Amy Rubin3,4; Thomas Marcello1,5; Timothy Bickmore6. 1VA Boston, Boston, MA; 2Harvard Medical School, Boston, MA; 3Boston University, Boston, MA; 4VA Boston Healthcare System, Boston, MA; 5Brigham and Women’s Hospital, Boston, MA; 6Northeastern University, Boston, MA. (Tracking ID #1638383)

BACKGROUND: Because of time constraints in delivering office-based primary care, interventions are needed to offload some tasks from primary care clinicians. Relational Agents - computer characters that simulate face-to-face conversation using voice, hand gesture, gaze cues and other nonverbal behavior, and that use simulated social behaviors to establish trust and therapeutic alliance - can provide education and counseling. Patients may find this type of computerized system suitable for “discussing” sensitive topics, although empirical data are lacking. We therefore conducted a pilot study - the first in the Veterans Health Administration (VA) - to test the feasibility of using this technology to screen for substance use problems in primary care.

METHODS: We recruited 24 male Veterans from VA Boston. Each participant completed the National Institute on Drug Abuse-Modified Alcohol, Smoking and Substance Involvement Screening Test (NM-ASSIST), administered once by a research assistant and once by the Relational Agent, with the order randomly counter-balanced. Following both screenings, the research assistant conducted a semi-structured interview that solicited the Veteran’s perspectives of the Relational Agent for screening, strengths and weaknesses of the Relational Agent compared with live interaction, suggestions for improving the Relational Agent, and potential applications in primary care. We conducted a content analysis of transcribed interview notes, employing standard qualitative research techniques to identify dominant themes.

RESULTS: Among the 24 participants, 19 (79 %) expressed positive impressions of answering the NM-ASSIST with a Relational Agent, while 3 (13 %) were neutral and 2 (8 %) were negative. A total of 14 (58 %) reported being comfortable completing the NM-ASSIST with the Relational Agent. Only 6 participants (25 %) indicated that they preferred the Relational Agent over a live interviewer, while 11 (46 %) preferred the live interviewer and 7 (29 %) were indifferent. Live interviewer was generally preferred because of greater depth of interaction, ability to clarify questions and responses or unease with technology. In contrast, participants who favored the Relational Agent appreciated its ease and efficiency of use, privacy and lack of judgmentalism, and clear answer choices. Among 18 Veterans expressing an opinion, similar percentages favored the use of Relational Agents to ask questions about benign (diet and exercise [16/18, 89 %], family history [15/18, 83 %]), and sensitive (sexual history [15/18, 83 %]) topics. Participants offered constructive feedback on the Relational Agent’s behavior, particularly her eye movements; speech, being unnatural and computerized; and relatively unsophisticated graphics. Veterans generally favored the Relational Agent’s appearance (attractive woman dressed casually but modestly) and did not express a preference for other characteristics. Veterans frequently voiced concerns about how the Relational Agent would maintain confidentiality of their responses.

CONCLUSIONS: Although participants preferred a live interview to interaction with a computerized Relational Agent, a majority of Veterans were comfortable with the Relational Agent and would be willing to engage with it for counseling and screening for sensitive topics such as substance use and sexual history. Future randomized trials will test the effectiveness of Relational Agents in both screening and brief intervention for substance use problems.

A RANDOMIZED CONTROLLED TRIAL OF AN EVIDENCE-BASED TOOLBOX AND GUIDE TO INCREASE PRIMARY CARE CLINICIANS’ RATES OF COLORECTAL CANCER SCREENING IN DIPLOMATES OF THE ABIM Lorna A. Lynn2; Carmen E. Guerra1; Kathryn M. Ross2; Eric Holmboe2; Kaitlin Woo1; Daniel F. Heitjan1; Debbie Kirkland3; Durado Brooks3. 1Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 2American Board of Internal Medicine, Phiadelphia, PA; 3American Cancer Society, Atlanta, GA. (Tracking ID #1642572)

BACKGROUND: Colorectal cancer screening (CRCS) is effective, cost-effective and consistently recommended by clinical guidelines, yet only 64.5 % of Americans aged 50–75 years have been screened. Recommendation from a physician is the most influential factor in determining whether a patient is screened for CRC. This study was undertaken to determine whether the Evidence-Based Toolbox and Guide to Increase Primary Care Clinicians’ Rates of CRCS, developed by the Centers for Disease Control and American Cancer Society, could help diplomates of the American Board of Internal Medicine (ABIM) recertifying for the Internal Medicine boards increase their practice rates of CRCS. The main study aim was to compare practice rates of CRCS in the the control (PIM only) and study (PIM + toolbox) arms.

METHODS: In this randomized controlled trial diplomates who are primary care providers for patients over age 50 and who were enrolled in ABIM’s Maintenance of Certification program were invited to participate. Participants had to enroll in the Cancer Screening Practice Improvement Module (PIM), which requires physician-directed measurement of their performance and design of a quality improvement plan. Diplomates were randomized to the PIM or the PIM + toolbox arm. The toolbox consists of four essential sections and evidence-based tools: Your Recommendation, An Office-based Policy, a Reminder System and an Effective Communication System. Analysis was based on the intention-to-treat principle. An external auditor determined the validity of self-reported CRCS rates in a random sample of 20 % of the participants.

RESULTS: A total of 2288 recruitment emails were sent to ABIM diplomates who met the inclusion/exclusion criteria of whom 160 diplomates expressed interest in participation and 144 enrolled in the study. Of these, 79 diplomates completed the study. The CRCS rates declined in 17 of the 79, but improved in the remaining 62. We conducted an analysis of covariance, a GEE and mixed logistic regression models. All final CRCS were adjusted for the baseline performance and all results showed a non-significant treatment effect. In the final mixed logistic regression model adjusted for the baseline performance rate and treatment group of the physician and shown in Table 1, we determined the strength of various physician characteristics in predicting the probability of a successful screening that was performed post-treatment. Medical school country was the only predictor of improved screening rates post-treatment.

CONCLUSIONS: These results demonstrated that while most diplomates improved their CRCS rates from baseline during the study, the improvement was not significantly different in the control arm (PIM only) compared to the study arm (PIM plus toolbox). Medical school country was the only predictor of success rate, with those physicians who attended medical school abroad having an odds ratio of 4.32 (95 % CI: 1.75–10.65) of performing a successful screening than those physicians who attended medical school in the U.S.

Odds ratio estimates and 95 % confidence intervals

Effect Odds Ratio Estimate 95 % CI

Baseline Performance Rate 1,010 (1.00, 1.03)

Treatment vs. Control Arm 1.680 (0.88, 3.19)

Solo vs. Group Practice 1.463 (0.57, 3.76)

Female vs. Male 1.263 (0.65, 2.44)

Foreign vs. U.S. Medical School 4.318 (1.75, 10.65)

Age 0.950 (0.90, 1.01)

Years until MOC Expiration 0.990 (0.77, 1.28)

A RANDOMIZED TRIAL OF TWO APPROACHES TO TRAINING VETERANS AFFAIRS (VA) MEDICAL HOME HEALTHCARE PROVIDERS ON MOTIVATIONAL INTERVIEWING FOR TOBACCO CESSATION Steven Fu1,2; Craig Roth2; Catherine Battaglia4; David Nelson1; Melissa Farmer5; Tam Do1; Michael Goldstein6; Rahul Kavathekar2; Rachel Widome1; Hildi Hagedorne1; Alan Zillich3. 1Minneapolis VA Health Care System, Minneapolis, MN; 2Minneapolis VA Health Care System, Minneapolis, MN; 3Roudebush VA Medical Center, Indianapolis, IN; 4VA Eastern Colorado Health Care System, Denver, CO; 5VA Greater Los Angeles Health Care System, Los Angeles, CA; 6VHA National Center for Health Promotion and Disease Prevention, Durham, NC. (Tracking ID #1638026)

BACKGROUND: Tobacco cessation counseling from a clinician doubles a patient’s odds of quitting. Motivational interviewing (MI) is an effective communication skill in tobacco cessation counseling, but strategies to train providers on MI are needed. This study evaluated a high-intensity versus moderate-intensity MI training program to improve delivery of tobacco cessation care.

METHODS: VA Patient Aligned Care Team (PACT) members at 2 VA facilities were randomized to moderate- or high-intensity MI training. Both training models included the following 3 components: 1) 3-day intensive MI training for site-based MI clinical champions and a site-based MI expert consultant, 2) Half day on-site training workshop for PACT members, and 3) self-study materials. The high-intensity model added 6 booster sessions coached by champions. Three booster sessions used telephone interactions with simulated patients and occurred at 4, 8, and 12 weeks after the initial training. Three additional booster sessions (at 2, 6, and 10 weeks) used small group coaching facilitated by the champions. Each 1-h booster session focused on specific MI skills. To evaluate the 2 training models, a structured clinical evaluation (OSCE) was conducted with providers in each group before and 12 weeks after the onsite training. The OSCEs assessed provider competence with and acquisition of MI and tobacco cessation skills through interaction with a simulated patient. A trained, blinded rater assessed the provision of MI skills by listening to the audio-recorded OSCEs. The primary outcome was the Motivational Interviewing Treatment Integrity (MITI) scale scores, a validated assessment of MI skills. Hierarchical models compared the average changes in MITI scale scores from the pre-training OSCE to the 12 week post-training OSCE for the moderate intensity and the high intensity groups. The models incorporated random effects for study site and participant and fixed effects for simulated patient and pre-training OSCE MITI scores.

RESULTS: Thirty-five PACT members were enrolled in the study and 18 members were randomly assigned to the high intensity group. Compared to the moderate intensity group, the high intensity group scored significantly higher for 5 of the 10 MITI scales (Table 1). For 3 of the other 5 MITI scales, a non-significant improvement was seen in the high intensity versus the moderate intensity group.

CONCLUSIONS: A training model using several booster sessions incorporating telephone interactions with simulated patients, in addition to MI champions, expert consultant, ½ day training and study materials,was effective for sustaining and enhancing providers’ MI skills in the delivery of tobacco cessation care.

Table 1

MITI Scales Training Group Pre-MITI Score (SD) Post-MITI Score (SD) Model Estimated Change (SE) p-value

Global Spirit High Intensity 2.89 (0.61) 3.20 (0.77) 0.31 (0.20)

Moderate Intensity 2.67 (0.81) 2.50 (0.72) −0.26 (0.21)

Difference 0.57 (0.20) 0.0091

Percent Open Questions High Intensity 0.32 (0.21) 0.48 (0.23) 0.17 (0.04)

Moderate Intensity 0.27 (0.18) 0.32 (0.24) 0.03 (0.05)

Difference 0.14 (0.06) 0.0336

Percent MI Adherence High Intensity 0.50 (0.37) 0.90 (0.19) 0.31 (0.11)

Moderate Intensity 0.62 (0.38) 0.57 (0.39) −0.00 (0.12)

Difference 0.32 (0.10) 0.0047

Evocation High Intensity 2.75 (0.88) 3.00 (1.22) 0.33 (0.22)

Moderate Intensity 2.40 (1.05) 2.00 (0.87) −0.54 (0.27)

Difference 0.87 (0.35) 0.0211

Collaboration High Intensity 2.69 (0.93) 3.16 (1.02) 0.38 (0.33)

Moderate Intensity 2.68 (1.13) 2.32 (1.04) −0.43 (0.35)

Difference 0.81 (0.28) 0.0083

A STRATEGY TO ENGAGE COMMUNITY BASED ORGANIZATIONS IN BUILDING RESEARCH CAPACITY Crispin N. Goytia1; Barbara Brenner2; Peggy M. Shepard3; Lea Rivera-Todaro1; Carol Horowitz1. 1Mount Sinai School of Medicine, New York, NY; 2Mount Sinai School of Medicine, New York, NY; 3WE ACT for Environmental Justice, New York, NY. (Tracking ID #1642376)

BACKGROUND: Building and sustaining community-academic research partnerships is a challenge for both academic institutions and for community based organizations (CBOs). Each partner comes to the relationship with differing expertise and gaps in knowledge. Many Clinical and Translational Science Award (CTSA) sites are working to build CBO capacity to engage in research, but information about needs and goals of CBO’s in this regard is lacking. Therefore, our CTSA’s community and academic partners aimed to conduct a community research needs assessment.

METHODS: Based on literature review, informal interviews with research-interested CBOs locally and nationally, and with community-engaged research groups from other CTSAs, we developed a needs assessment survey. Key domains of this survey included experience and interest in research collaboration, skill development and program evaluation. The team identified a preliminary list of 80 eligible CBOs through network analysis and a list from the Foundation Center’s Directory of New York City organizations that received grants in 2009–2010 in health services or research. We trained Community Health Workers (CHWs) to recruit a senior leader from each site and the CHW’s encouraged them via mail, email and telephone over a 90-day period to complete the survey.

RESULTS: Fully 76 % (61) CBOs completed the needs assessment. Most (69 %) reported involvement with research or evaluation in the last 2 years, 42 % were currently involved in research or program evaluation and 33 % had some funding for research. Fully 75 % had collaborated with academic institutions in the past. Most were interested in collaborating or working as partners on research, with a mean score of 6 on a scale of 1 = not interested, to 8 = the most interested. The average experience with collaboration in research was unimpressive: “good” on a scale of “poor, fair, good, very good, excellent”. The four areas of greatest interest were program evaluation, developing a needs assessment, statistical analysis and survey development. There was less interest in how to establish a research collaboration with academics. Respondents preferred a hybrid format of online and in- person workshops to other options to either format on its own.

CONCLUSIONS: A formal needs assessment of the research training and education needs of CBO’s in New York City revealed that, despite underwhelming experiences with collaboration, most had significant interest in future collaboration and learning about research. CBO leaders were particularly interested in learning about how to conduct research and evaluation, and less interested in learning how to partner with academics to collaborate on research. Community representatives from the CTSA will use these findings to: develop a research capacity building course. Other partnerships should consider building or making use of such assessments to transform the capacity of community organizations to be active research partners and leaders.

A SUCCESSFUL COMMUNITY PARTNERSHIP MODEL FOR RECRUITING PUBLIC HOUSING RESIDENTS INTO RESEARCH Tracy A. Battaglia1; Jo-Anna L. Rorie2; Sarah W. Primeau1; Sarah E. Caron1; Sarah G. Bhosrekar2; Bing L. Chen1; Sharon Bak1; Gerry Thomas3; Rachel Goodman5; Eugenia Smith4; Deborah J. Bowen2. 1Boston University School of Medicine, Boston, MA; 2Boston University School of Public Health, Boston, MA; 3The Boston Public Health Commission, Boston, MA; 4The Community Committee for Health Promotion, Boston, MA; 5The Boston Housing Authority, Boston, MA. (Tracking ID #1612855)

BACKGROUND: The Boston University Partners in Health and Housing Prevention Research Center (PHH-PRC), a partnership between the School of Public Health, Community Committee for Health Promotion, Boston Housing Authority and Boston Public Health Commission, aims to improve the health of Boston’s Public Housing residents through research. This study aims to demonstrate the Center’s ability to recruit and retain a representative sample of residents in the community setting to participate in a research study.

METHODS: An ongoing community engagement activity of the PHH-PRC is the conduct of monthly, on-site educational health screenings conducted in collaboration with housing development residents and research center staff. We conducted a descriptive analysis of enrollment outcomes from these community-based health screenings held across 6 housing developments from April 2011 through June 2012. The outcome of interest was enrollment into Project HHEART (Heart Health Equality Among ResidenTs), a patient navigation intervention study designed to improve clinical and community program participation among housing development residents at risk for cardiovascular disease. All those attending the health screenings completed a survey, underwent an evaluation for cardiovascular risk factors and received written educational materials. Those eligible for enrollment into Project HHEART were ≥18 years of age, spoke English or Spanish, resided in the respective housing development and screened positive for ≥1 risk factor (overweight/obese, hypertension, hypercholesterolemia, diabetes, tobacco use). We compared socio-demographic and risk factor characteristics of those eligible vs. ineligible for Project HHEART enrollment. Among those eligible, we compared characteristics of those who enrolled vs. declined.

RESULTS: 610 residents participated in screenings April 2011–June 2012. Most were female (74 %), non-White (30 % Black, 44 % Hispanic, 15 % other), had public (84 %) or no health insurance (10 %), reported a clinical visit with a primary care provider in the past 3 months (62 %) and screened positive for >1 risk factor (92 %). About half spoke a language other than English (50 %), were foreign-born (49 %), and had less than high school education (45 %). Overall, 451 (74 %) of participants were eligible for enrollment. Reasons for ineligibility included: not living on site (n = 106), no positive screens for risk factors (n = 32) and significant language barriers (did not speak English or Spanish) (n = 21). Compared to those ineligible for Project HHEART, eligible participants were more likely to be older (mean age 50 v. 49 years, p < 0.01), Hispanic (48 % v. 33 %, p < 0.01), and have public or no health insurance (93 % v. 86 %, p = 0.05). Of the 451 eligible participants, 326 (72 %) agreed to participate and were enrolled into Project HHEART. Compared to those who declined to participate, enrolled subjects were slightly younger (mean age 50 v. 53, p < 0.01), but did not differ in any other socio-demographic or health risk factor status. Of those enrolled (n = 326), 80 % completed 3-month follow-up surveys.

CONCLUSIONS: Socio-demographic differences in eligibility reflect the study design. Among those eligible, we enrolled and retained a representative sample of public housing residents and engaged them into prevention research. This program serves as one viable model to engage a diverse population in research.

A TECHNOLOGY-BASED APPROACH TO IDENTIFYING UNDIAGNOSED HYPERTENSION Christopher Masi1; Michael Rakotz1,2; Ruth Ross1; Ari Robicsek1; Chad Konchak1; Bernard Ewigman2. 1NorthShore University HealthSystem, Evanston, IL; 2NorthShore University HealthSystem, Evanston, IL. (Tracking ID #1633262)

BACKGROUND: Affecting 30 % of all U.S. adults 18 years and older, hypertension is the leading modifiable risk factor for coronary artery disease, stroke, and congestive heart failure. According to the 2008 National Health and Nutrition Examination Survey, approximately 19 % of U.S. adults with hypertension are unaware of their diagnosis. Our goal was to identify primary care patients with suspected but undiagnosed hypertension and then clarify their status using an automated office blood pressure (AOBP) device.

METHODS: We queried the electronic health records (EHR’s) of patients who receive care at one of twenty-three health system-affiliated primary care clinics to identify adults aged 18 to 79 years who had at least one primary care office visit within 12 months of the query, had elevated blood pressure readings as identified by at least one of five hypertension screening algorithms, and did not have a diagnosis of hypertension recorded in the EHR. Individuals who met these criteria were considered at-risk for undiagnosed hypertension and were invited to complete a clinic-based AOBP measurement using a BpTRU device which averages five readings over a five-minute period. Since each patient had one or more previously documented elevated blood pressure readings, we classified patients based upon their AOBP mean: hypertension if BP ≥ 140/90 mmHg; prehypertension if BP ≥ 120/80 mmHg and <140/90 mmHg; and white coat hypertension if BP < 120/80 mmHg. The positive predictive value (PPV) of the hypertension screening algorithms was calculated by dividing the number of individuals with an AOBP mean in the prehypertension or hypertension ranges (true positives) by the number of individuals identified by at least one of the hypertension screening algorithms (all positives).

RESULTS: Of the 139,666 adults who receive care at one of the participating clinics, 1,586 met our inclusion criteria. After confirming the appropriateness of study participation with each patient’s primary care physician, attempts were made to recruit 1,432 patients. 475 of these patients agreed to participate in the study and undergo a clinic-based AOBP measurement. Among participants, the median age was 54.4 years, the mean BP recorded in the EHR was 136/82 mmHg, and the mean BMI was 29.6 kg/m2. Fifty-two percent of participants were male. Participants identified themselves as Caucasian (70.9 %), African American (6.1 %), Hispanic/Latino (3.4 %), Asian (2.7 %), or other (16.8 %). Comparing the 475 participants to the 957 non-participants revealed the participants were older (54.4 vs. 50.0 years, p < 0.001) but were similar in all other respects, including distribution of ethnicities, and prevalence of co-morbidities, including diabetes, congestive heart failure, and COPD. Based upon AOBP means among participants, 183 (39 %) had hypertension, 196 (41 %) had prehypertension, and 96 (20 %) had white coat hypertension. The positive predictive value for detecting prehypertension or hypertension using our technology-based approach was 80 %.

CONCLUSIONS: Essential elements of our approach included an EHR, computer-based screening algorithms, and an established AOBP protocol. Results from this study confirm the notion that technology-based strategies have significant potential to detect undiagnosed chronic disease - a critical first step toward enhancing chronic disease management.

A VALID MEASURE OF HEALTH-RELATED TRUST FOR USE IN DIVERSE POPULATIONS Rebecca J. Schwei1; Paul Rathouz2; Seung W. Choi3; Elizabeth A. Jacobs1. 1University of Wisconsin School of Medicine and Public Health, Madison, WI; 2University of Wisconsin School of Medicine and Public Health, Madison, WI; 3McGraw-Hill Education, Monteray, CA. (Tracking ID #1640804)

BACKGROUND: Varying levels of distrust in health care among racial/ethnic groups are hypothesized to contribute to health disparities in the US. However, few measures of trust and distrust have been developed and validated for use across racial/ethnic groups to allow adequate exploration of this hypothesis. The objective of the study was to develop a measure of health-related trust in the 3 major racial/ethnic groups in the US: African Americans, Hispanic-Mexicans, and non-Hispanic whites.

METHODS: We developed candidate items through extensive qualitative work, cognitive testing, piloting, and rigorous translation into Spanish. We administered the 81 candidate items to a convenience sample of African American (n = 142), Hispanic-Mexican (n = 143), and non-Hispanic white (n = 155) individuals at Chicago-area supermarkets. Participants responded using a 5-item Likert response scale: never true, a little true, half the time true, mostly true, always true. We conducted exploratory and confirmatory factor analyses using Mplus. We also asked “In the past 5 years, have you had a negative health care experience you considered to be bad or negative?” (Y/N).

RESULTS: The final instrument contained 36 items and 7 factors: Discrimination (3 items), Equity (6 items), Hidden Agenda (4 items), Insurance (3 items), Negative Physician Perceptions (5 items), Positive Physician Perceptions (12 items) and System Welcoming (3 items). A higher trust score indicated increased trust. The instrument (α = .94) and individual factors performed well overall and in each racial/ethnic group (α = .61 to .94) The 7-factor CFA model provided reasonable fit statistics (CFI = .964, TLI = .961, RMSEA = .055) and evidence for construct validity. Across all racial/ethnic groups individuals reporting a negative health care experience had lower levels of institutional trust.

CONCLUSIONS: Our measure of health-related trust performed well across racial/ethnic groups while including constructs that may vary considerably across groups (e.g., Discrimination). There was increased trust in groups without a reported previous negative health care experience. We found trust in health care to be multi-faceted, incorporating perceptions about physicians, health care systems, and insurance. This measure has the potential to advance the field studying how health-related trust contributes to health disparities in the US.

A CASE METHOD EDUCATION ON MANAGEMENT OF DISCHARGE PLANNING FOR HEALTHCARE PROFESSIONALS Yukio Tsugihashi1,2; Noriko Kawai2; Hitoshi Ishii2. 1Tenri Hospital, Tenri, Japan; 2Tenri Hospital, Tenri, Japan. (Tracking ID #1627411)

BACKGROUND: In collaborative healthcare systems, reducing length of stay has been a priority for general hospitals. There is concern that the reduction may provide low-quality transitional care for the patients and the families. In order to secure the quality for the patients and the families, hospital workers should effectively acquire a management skill for discharge planning. A case method is a teaching method that is widely used in business schools. Students can enhance their leadership and management skills through discussion about a teaching case. The case is a document that objectively illustrates business cases to be solved and includes information for classroom discussion. Both business and discharge planning, there are no simple solutions. We hypothesized that the case method could be adjusted into education in discharge planning. Therefore, we developed a novel educational program for the discharge planning using a case method education. The purpose of this study was to (1) develop educational strategies and (2) assess the learning outcomes of this program.

METHODS: This study was conducted from April 2012 to July 2012 at one general hospital in Japan (Tenri Hospital, Tenri City, Nara, Japan). Cornerstones of the program are provided in Table 1. The Participants were provided with a case method education consisting of following three steps: 1) Preparing their opinions for teaching cases before the classes. 2) Discussing with other participants in small groups and a classroom, 3) A short lecture summarizing key points in the cases. A medical doctor and a registered nurse specialized in care transition prepared four cases based on actual care transition in Tenri Hospital. In order to evaluate learning outcomes of the program, we performed questionnaire surveys after each lecture, including descriptive analyses about participants’ satisfaction and qualitative content analysis focused on their self-awareness through the program.

RESULTS: This study enrolled 57 healthcare providers working in Tenri Hospital and affiliated care institutions. With regard to the occupation, 31(54 %) were registered nurses, 7 (12 %) were medical social workers, and 19 (38 %) were other occupations including physical therapists, long-term care support specialists, medical doctors, pharmacists, certified care workers, medical college teachers and medical secretary. Over 90 % of the participants were satisfied with the program. The participants’ self-awareness was identified to the following three categories: acquiring core competencies for discharge planning, problem extraction through active interaction among the participants, and precious opportunities for inter-professional communications in the related institutions.

CONCLUSIONS: A case method by the discussion-based education using actual cases successfully contributed to enhance the participants’ awareness for management of discharge planning in addition to obtaining the core competency. Furthermore, the program itself could promote inter-professional communications among the hospital workers.

Table 1. Cornerstones of a case method education on management of discharge planning

Teaching method A case method education with 3 h session per a month (Small group discussion: 60 min, Classroom discussion: 60 min, Short lecture: 30 min)

Duration/Frequency 4 months/One Saturday afternoon per month

Titles of teaching cases Case 1. An elderly woman emergently admitted to a hospital with acute pyelonephritis

Case 2. An elderly patient with advanced dementia and bilateral leg gangrenes

Case 3. A patients who can’t eat by mouth because of severe neurological disease

Case 4. Tohoku earthquake. Effort of medical support teams from Nara prefecture

Learning outcomes Satisfaction level (descriptive analysis)/Self-awareness (qualitative analysis)

A MULTI-INSTITUTION RETROSPECTIVE STUDY ON CAUSATIVE DISEASES AND DIAGNOSTIC METHODS FOR FEVERS OF UNKNOWN ORIGIN IN JAPAN: A PROJECT OF THE JAPANESE SOCIETY OF GENERAL HOSPITAL MEDICINE

Toshio Naito1; Fujiko Mitsumoto2; Hiroyuki Morita3; Masafumi Mizooka4; Shiro Oono5; Akira Ukimura6; Keito Torikai7; Kenji Kanazawa8; Masashi Yamanouchi1; Susumu Tazuma4; Jun Hayashi2. 1Juntendo University School of Medicine, Tokyo, Japan; 2Kyushu University Hospital, Fukuoka, Japan; 3Gifu University Graduate School of Medicine, Gifu, Japan; 4Hiroshima University Hospital, Hiroshima, Japan; 5Nara Medical University, Nara, Japan; 6Osaka Medical College, Osaka, Japan; 7St. Marianna University School of Medicine, Tokyo, Japan; 8Kobe Universtiy Hospital, Kobe, Japan. (Tracking ID #1634255)

BACKGROUND: Fevers of unknown origin (FUO) are caused by a wide range of diseases, and they occur in a variety of regions and age groups. In Japan, research on the topic has been limited to single facilities/regions, and no national surveys have been conducted. Analysis is important, as causes may differ with race, region and era. Further, few studies have evaluated the usefulness of diagnostic exams, and FUO is diagnosed according to guidelines specific to each facility. In particular, there has been very little research on the efficacy of recently developed diagnostic methods, such as blood procalcitonin analysis and positron emission tomography (PET). Here, we conducted a national survey at facilities belonging to the Japanese Society of General Hospital Medicine, to clarify what exams are useful and what diseases deserve attention in the differential diagnosis and treatment of FUO.

METHODS: Seventeen facilities were surveyed nationwide from January to December 2011. The subjects were patients who were 18 years or older and diagnosed with “classical FUO (a fever with an axillary temperature of 38 °C or higher and measured 2 times or more in a period of 3 weeks or longer, and where the cause was unclear after 3 outpatient visits or a 3-day hospital stay).” Subject data were recorded in a common case report form and tallied using FAX.

RESULTS: A total of 121 FUO cases were recorded, with a median age of 59 years (19–94 years). The causative disease was infection in 28 cases (23.1 %), noninfectious inflammatory disease in 37 cases (30.6 %), malignant tumor in 13 cases (10.7 %), something else in 15 cases (12.4 %), and unknown in 28 cases (23.1 %). “Something else” included causes such as drug-induced fevers. The median number of days from fever onset to first examination was 28 days. A case of familial Mediterranean fever took the longest days to be diagnosed. Blood cultures were performed at 86.8 %, blood procalcitonin values measured at 43.8 %, and PET performed at 29.8 %.

CONCLUSIONS: With the increased use of computed tomography, FUO due to deep abscesses or solid tumors have declined markedly. The causative disease with the largest proportion was polymyalgia rheumatica (9 cases), reflecting the aging of the society. The relatively small number of cases due to an unknown cause was possibly attributable to the bias of the retrospective study. HIV/AIDS caused 4 FUO cases, showing that this has become an important cause of FUO in Japan. This study clarified diseases that deserve attention when differentiating FUO. We have a plan to analyze the usefulness of exams and create guidelines for diagnosing FUO.

A NATIONAL STUDY OF INTERNISTS’ POINT OF CARE LEARNING Michael Green1; Siddharta Reddy2; Eric Holmboe2. 1Yale School of Medicine, New Haven, CT; 2American Board of Internal Medicine, Philadelphia, PA. (Tracking ID #1639990)

BACKGROUND: Physicians frequently encounter clinical questions at the point of care (POC), which represent opportunities for learning, immediate application of new knowledge, and longer term performance improvement. An understanding of these POC learning episodes would inform continuing medical education programs, electronic information resources, evidence-based practice training, and reflective practice. Previous studies of POC learning have been confined to small numbers of physicians in limited geographic areas.

METHODS: We studied internists enrolled in the ABIM Maintenance of Certification (MOC) program who registered for and entered at least one question in the ABIM Point-of-Care Clinical Question Module between November 2010 and December 2012. To complete this web-based module, internists documented the characteristics, information seeking, learning, practice impact, and barriers of at least 20 point of care clinical questions. We compiled descriptive statistics for the module data.

RESULTS: Four-hundred-seventy-two internists entered at least one clinical question (224 completed the module, 188 are currently working on it, and 60 cancelled). Among those who completed the module, 197 (88 %) spent more than 30 h per week in patient care activities, 66 (28 %) were generalists, and 108 (48 %) worked in academic settings. The internists documented 5187 POC learning episodes over periods ranging from 1 to 19 months. The episodes most commonly were stimulated by direct patient care in the ambulatory setting, with or without a trainee (57 %); involved cardiovascular disease (21 %) or gastroenterology (14 %) content; represented foreground questions (58 %); and concerned therapy (55 %) or diagnosis (14 %) questions. The internists spent a median of 30 min looking up medical information, most often some time after the clinical encounter (61 %); using a median of 2 resources; and most commonly consulting UpToDate® (25 %) and articles retrieved via PubMed (17 %). The internists planned to change their practice based on 40 % of the point of care learning episodes. Among the remainder, they reported that the information supported their current practice (47 %), they required more information before making a change (9 %), or the practice change was not feasible (3 %). Internists encountered barriers during 11 % of the learning episodes, including limited access to information resources (17 %), uncertainty about the sufficiency of the information initially obtained (13 %), difficulty searching information resources (11 %), and difficulty appraising the validity or usefulness of the information (8 %).

CONCLUSIONS: Using a novel web-based portfolio for MOC, internists’ report POC learning episodes that most commonly occur in the ambulatory setting, involve cardiovascular disease or gastroenterology content, and concern questions of therapy and diagnosis. They consult an average of two information resources per episode, most commonly UpToDate and PubMed. Forty percent of POC learning episodes result in a planned practice change.

A PREDICTION RULE FOR MORTALITY FOR INPATIENTS WITH STAPHYLOCOCCUS AUREUS BACTEREMIA: A CLASSIFICATION AND REGRESSION TREE (CART) ANALYSIS Daiki Kobayashi1,2; Kyoko Yokota4; Osamu Takahashi2,3; Hiroko Arioka2; Tsuguya Fukui2; Christina C. Wee1. 1Beth Israel Deaconess Medical Center, Boston, MA; 2St Luke’s International Hospital, Tokyo, Japan; 3St Luke’s Life Science Institute, Tokyo, Japan; 4Kagawa University, Takamatsu, Japan. (Tracking ID #1641328)

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is one of the most common types of bacteremia in both community and healthcare settings. Previous studies suggest that the mortality associated with SAB is significant rangeing from 20 to 40 %. Although mortality is high, the risk factors for mortality among patients with SAB have not been sufficiently evaluated.

METHODS: This was a retrospective cohort study of all adult patients with SAB at a large community hospital in Tokyo, Japan, from April 1, 2004 to March 31, 2011. All patients with fever and afebrile patients who were suspected of having a bacterial infection had 2 sets of blood cultures sent at the time of admission. SAB was determined based on at least one positive blood culture. The primary outcome was death within 90 days. Baseline data and clinically relevant factors were collected from the electronic chart. All candidate predictors were included in a Classification and Regression Trees (CART) analysis to create a prediction rule to identify risk factors of mortality among patients with SAB. A receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was obtained.

RESULTS: 340 patients had SAB during the study period. Of these, 121 (36 %) patients died within 90 days. Among 41 potential variables examined, the CART analysis revealed that underlying malignancy, serum blood glucose level, methicillin resistance, and low serum albumin were predictors of mortality. Our results suggest that patients can be categorized in 3 risk groups: low (< 30 % mortality), medium (40–60 %), and high (> 60 %) (see fig). For patients without underlying malignancy, the next best predictor was serum blood glucose level, where patients with a blood glucose level >167 mg/dl had higher risk of mortality (see fig). Methicillin resistance predicted mortality risk only among patients who had a glucose level higher than 167 mg/dl. For patients with malignancy, serum albumin was the most important predictor; patients with <3.25 mg/dl albumin were placed in the high risk group. The AUC was 0.76 (95 %CI: 0.70–0.81).

CONCLUSIONS: We propose a prediction model for mortality of patients with SAB consisting of 4 predictors: underlying malignancy, low serum albumin, high glucose, and methicillin resistance. This model, if validated in other populations, may facilitate appropriate preventative management for patients with SAB who are at high risk of mortality.

Decision tree for 90 Day Mortality (95 % Confidence Interval) Among Patients with Staphylococcus aureus Bacteremia. Results are derived from CART Analysis. Low risk = <30 % mortality, medium risk = 40–50 %, high risk = > 60 % MSSA* refers to Methicillin-sensitive Staphylococcus aureus, MRSA† refers to Methicillin-resistant Staphylococcus aureus

A RANDOMIZED CONTROLLED TRIAL OF A COMMUNITY HEALTH WORKER POST-HOSPITAL CARE TRANSITIONS INTERVENTION FOR LOW SOCIOECONOMIC STATUS PATIENTS

Shreya Kangovi1,6; David Grande2,3; Nandita Mitra4; Jeffrey Sellman1; Mary L. White6; Sharon McCollum6; Richard Shannon2; Judith A. Long5,2. 1Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 3University of Pennsylvania, Philadelphia, PA; 4University of Pennsylvania, Philadelphia, PA; 5Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; 6Spectrum Health Services, Inc., Philadelphia, PA. (Tracking ID #1631341)

BACKGROUND: The post-hospital transition is a focus of national policy attention. Low socioeconomic status (SES) patients are more likely to report poor quality of discharge planning, lack of social support during recovery and inability to access outpatient follow-up after hospitalization. Low-SES patients have an elevated risk of all-cause readmission and post-hospital death. Existing post-hospital transition interventions often employ clinical personnel and neglect socioeconomic factors that are important to low-SES patients. To address these issues, we performed a randomized controlled trial comparing a community health worker (CHWs) intervention (IMPaCT-Individualized Management towards Patient-Centered Targets) to usual discharge care.

METHODS: Participants were recruited from two academically affiliated hospitals in Philadelphia, PA. Eligible patients were:1)admitted to the General Medicine service; 2)uninsured or insured by Medicaid; 3)18–64 years old and 4)residents of low-income ZIP codes. Eligible patients were randomized to receive usual discharge care or IMPaCT. Patients randomized to IMPaCT received structured CHW social support, advocacy and health system navigation from the time of hospitalization until post-hospital primary care follow-up. CHWs were recruited through a network of community-based organizations, underwent a month-long training and were paid $15 per hour. The primary outcome of the trial was the proportion of patients who completed primary care follow-up within 2 weeks of hospital discharge. Secondary outcomes, which each ranged from 0 to 100, were: self-rated health (SF-12), quality of discharge communication (Consumer Hospital Consumer Assessment of Healthcare Providers and Systems-HCAHPS- discharge communication items), patient activation (Patient Activation Measure score) and readmission rate at 14,30,60 and 90 days. Patient-reported outcomes were measured by a blinded assessor 2 weeks after index discharge. We compared outcomes between control and intervention groups using an intention to treat analysis.

RESULTS: 442 patients were enrolled from May 15th, 2011 to December 1st, 2012. 86.6 % of participants completed the trial. The intervention group had a higher proportion of patients who engaged in post-hospital primary care than the control group (59.4 % vs. 48.4 %, p = 0.03). Patients in the intervention group had higher self-rated health mental component summary scores (49.2 vs. 46.3, p = 0.02), were more likely to report high-quality discharge communication (91.3 % vs. 78.3 %, p = 0.002) and had higher levels of patient activation (64.0 vs. 60.3, p = 0.04). At 14 days readmission rates were not different between groups (9.9 % vs. 7.2 %, p = 0.60). 30, 60 and 90-day readmission rates are pending.

CONCLUSIONS: A brief transitions intervention performed by CHWs can improve a variety of post-hospital outcomes for low-SES patients. 14-day rates of readmission are low and not different between groups. CHWs, who are inexpensive and rapidly trained, are well-suited to provide post-hospital support to a high-risk, underserved population.

Secondary Patient-Reported Outcomes*

Control (n = 221) Intervention (n = 221) P Value

Self-rated health

Mental Component Summary 46.3 ± 12.9 49.2 ± 12.4 0.02

Physical Component Summary 38.2 ± 11.8 38.4 ± 11.1 0.89

HCAHPS high-quality discharge communication 78.3 % 91.3 % 0.002

Patient Activation Measure 60.3 ± 15.9 64.0 ± 17.4 0.04

14-d Readmission 7.2 % 9.9 % 0.60

*Values are expressed as percentage or mean ± SD

A RANDOMIZED CONTROLLED TRIAL OF PRIMARY CARE BASED PHARMACIST-PHYSICIAN COLLABORATIVE MEDICATION THERAPY MANAGEMENT FOR HYPERTENSION Jan D. Hirsch1; Neil Steers2; David S. Adler1; Grace M. Kuo1,4; Candis M. Morello1; Megan Lang6; Renu F. Singh1; Yelena Wood3; Robert M. Kaplan5; Carol Mangione2. 1University of California San Diego, La Jolla, CA; 2University of California Los Angeles, Los Angeles, CA; 3University of California San Diego, San Diego, CA; 4University of California San Diego, La Jolla, CA; 5University of California Los Angeles, Los Angeles, CA; 6University of California San Diego, San Diego, CA. (Tracking ID #1634599)

BACKGROUND: Managing patients with chronic diseases to achieve therapeutic goals such as blood pressure (BP) control is challenging for busy primary care physicians. Collaborative care models that fully integrate pharmacists within the primary care team may help address this problem by giving patients better access to highly trained provider teams. We conducted a randomized controlled trial (RCT) evaluating BP control for hypertensive patients collaboratively managed by a pharmacist-primary care physician team versus those who were solely managed by their primary care physician (PCP).

METHODS: Patients with BP > 140/90 mmHg or BP > 130/80 mmHg with a diagnosis of diabetes mellitus were randomized to treatment by a pharmacist under a collaborative pharmacist-physician medication therapy management (MTM) protocol versus usual care in an academic General Internal Medicine practice. Patients were scheduled for pharmacist appointments independent of physician visits. Pharmacist actions included drug therapy monitoring, physical assessment, laboratory test review and order, medication adjustments (dosage change, initiation, discontinuation), and patient education. The primary outcome was mean change in systolic blood pressure (SBP) at 6 and 9 months after initial visit. Secondary outcomes were percent achieving BP goal, mean change in diastolic blood pressure (DBP), LDL and HDL cholesterol.

RESULTS: At baseline the MTM group (n = 76) was similar to the Usual Care group (n = 91) for all eight measured clinical markers; however MTM patients were slightly younger 65.4 (13.0) vs. 69.6 (11.4) years, had lower Charlson Comorbidity Index 3.1 (1.9) vs. 4.1 (2.6), and had more men (53.3 % vs. 31.9 %). Mean change in SBP in the MTM group was significantly greater at 6 months −7.1 (19.4) vs. +1.6 (21.0) mm Hg, (p = 0.008) but the difference was no longer statistically significant at 9 months −5.2 (16.9) vs. −1.7 (17.7) mmHg, (p = 0.22). The mean change in SBP from initial visit to 9 months for patients who had returned to their PCP after 6 months was +1.9 (13.8) compared to −7.8 (17.3) for those who continued to see the MTM pharmacist through the 9-month visit (p = 0.03). Compared to Usual Care patients, a greater percentage of MTM patients were at goal at 6 months (81 % vs. 44 %, p < 0.001) and 9 months (70 % vs. 52 %, p = 0.02). No significant difference in change in LDL or HDL was detected at 6 or 9 months between groups.

CONCLUSIONS: A pharmacist-physician collaborative medication therapy management service was more effective in lowering blood pressure than usual care at 6 months and at 9 months for patients who continued to see the pharmacist. Given the shortages of PCPs and the aging population, incorporating pharmacists in the primary care team can be a successful strategy for managing medication therapy, improving patient outcomes and extending primary care capacity.

A RANDOMIZED TRIAL OF A COMMUNITY HEALTH WORKER LED INTERVENTION USING HPV SELF-SAMPLING TO INCREASE CERVICAL CANCER SCREENING AMONG MINORITY WOMEN: PRELIMINARY FINDINGS Olveen Carrasquillo; Brendaly Rodriguez; Erin N. Kobetz-Kerman. University of Miami, Miami, FL. (Tracking ID #1642511)

BACKGROUND: Cervical cancer disproportionately affects minority and immigrant women. Among this population, there are multiple barriers to Pap smear screening including knowledge, limited access to care and cultural norms. In 2012, the USPSTF noted that self sampling for the human papilloma virus (HPV) holds great promise as a screening strategy among hard to reach populations. We present preliminary findings from our ongoing randomized trial testing this approach in three minority communities in Miami.

METHODS: The South Florida Center for Reduction of Cancer Disparities is a comprehensive NCI initiative aimed at reducing cervical cancer disparities in South Florida through community based participatory research. Using community health workers (CHWs) our community partners are recruiting 600 minority women ages 30–65 who had not had a Pap smear in the last three years into the study. Following a baseline intake, women are randomized into one of three arms. Group one receives culturally tailored cervical cancer education materials. Groups 2 and 3 receive a 1 hour CHW home health education session. CHWs subsequently refer and navigate women in group 2 to Pap smear screening at community based facilities that perform free or low cost testing. Women in group 3 have the option of Pap smear or doing HPV self sampling after a brief CHW instruction session. A research assistant blinded to study allocation performs a 6 month follow-up visit to assess screening status. A formal interim analysis was not part of the study design. However, we are able to present preliminary baseline data as well as follow-up status in Groups 2 and 3 based on CHWs logs. We do not include any hypothesis testing.

RESULTS: To date, using various community outreach strategies, CHWs have assessed 2,601 women for study inclusion. Of these 515 are study eligible; most ineligibles are due to being screened already or age exclusion. Less than 5 % of eligible women have declined to participate. Among the 280 women we have already randomized, 51 % are Hispanic, 39 % Haitian, and 11 % African American. Over half are uninsured. Among the 70 women randomized to group 2 and having already received the educational session, 48 % have obtained a subsequent Pap smear. Among the 64 women randomized to Group 3 who have received the education, 95 % have been screened. Of these 69 % preferred to have the HPV self-sampling at time of CHW session over being referred for a Pap smear. In Little Haiti, 10 of 21 (48 %) HPV samples have been positive for high risk HPV versus 18 % in the other two communities.

CONCLUSIONS: Using the CBPR framework, in a 14 month period we have been able to recruit and randomize almost half of our planned 600 “hard to reach” study population with almost no women refusing to participate. Our rates of Pap smear completion among women in group 2 compares very favorably with data from other similar CHW led programs. Our preliminary data also makes an extremely strong case for HPV self-sampling as a strategy for cervical cancer screening among unscreened minority women.

A RANDOMIZED TRIAL OF A WEB-BASED VERSUS COUNSELOR-BASED INTERVENTION TO REDUCE CHD RISK Stacey L. Sheridan; Thomas C. Keyserling; Lindy B. Draeger. University of North Carolina at Chapel Hill, Chapel Hill, NC. (Tracking ID #1642611)

BACKGROUND: Coronary heart disease (CHD) is the leading cause of death in the United States and effective interventions are available to reduce CHD risk. However, the best way to implement risk reduction strategies is yet to be determined.

METHODS: We developed two versions of a combined lifestyle and medication intervention (counselor intevention (CI) and web intervention (WI)) to reduce CHD risk and compared their effects in a randomized trial conducted at five socioeconomically diverse clinics in a practice-based research network. Both interventions were tailored to participants’ baseline risk factors and treatment preferences and included similar content: a web-based decision aid, 4 monthly contacts during an intensive intervention phase (4 months) and 3 brief contacts at 2 month intervals during a maintenance phase (8 months). The primary outcome was within group change in 10 year predicted risk by Framingham score at 4 month follow-up. Secondary outcomes included between group difference in predicted CHD risk and within group changes in CHD risk factors, lifestyle behaviors, and medication adherence. Cost-effectiveness from a societal perspective was also assessed.

RESULTS: We randomized 389 participants with no known CHD and 10-year Framingham CHD risk > or =10 % to either the CI (n = 195) or the WI (n = 194). Mean age was 63. 49 % were female, 25 % were African-American and 75 % white. Mean 10-year predicted CHD risk was 16.9 %. 14 % read at less than a 7–8th grade reading level. 88 % had health insurance. At 4 month follow-up, the CI reduced CHD risk by 2.2 percentage points (p < .0001) and the WI by 1.4 percentage points (p < 0.001; adjusted mean difference between groups: 0.8 percentage points, p 0.04). These changes resulted from small changes in systolic blood pressure (CI: −2.85 mmHg; WI −1.1 mmHg), total cholesterol (CI: −8.4 mg/dL; WI −3.8 mg/dL), HDL cholesterol (CI: +1.4 mg/dL; WI: +1.8 mg/dL), smoking cessation (CI: −3 %; WI −2 %) and aspirin use (CI: +10 %; WI: +11 %). Small statistically significant changes were also noted in self-reported fruit and vegetable intake (CI: +0.4 servings/day; WI: +0.2 servings/day), walking (CI: +54 min/week; WI: +30 min/week), and adherence (% with high adherence in CI: +14 %; WI: +18 %). The incremental cost-effectiveness ratio for a 1 percentage point reduction in CHD risk was $129 for the WI compared with usual care, and $159 for the CI compared with the WI.

CONCLUSIONS: Both counselor and web interventions reduced CHD risk compared to baseline. The counselor intervention was somewhat more effective than the web intervention, but the web intervention was incrementally more cost-effective.

A RANDOMIZED, CONTROLLED TRIAL OF ALTERNATIVE FORMS OF FEEDBACK ON GLYCEMIC CONTROL IN PATIENTS WITH POORLY CONTROLLED DIABETES Anjali Gopalan1,3; Emin Tahirovic2; Haley Moss2; Andrea B. Troxel2; Jingsan Zhu2; Kevin G. Volpp1,2. 1Philadelphia VA Medical Center, Philadelphia, PA; 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 3Robert Wood Johnson Clinical Scholars Program, Philadelphia, PA. (Tracking ID #1633742)

BACKGROUND: Prior work has indicated that understanding of the hemoglobin A1c (A1c) among diabetic patients is low. A 2008 study in the British Medical Journal by Parkes et al. showed the potential effectiveness of translating poorly understood medical values into more universally understood forms. This study expressed FEV1 in terms of “lung age” to active tobacco users. Patients given their “lung age” in place of their FEV1 value had significantly higher rates of smoking cessation at study completion. This approach may hold promise for improving feedback for diabetic patients on glycemic control.

METHODS: We randomly assigned 177 poorly controlled diabetics seen at University of Pennsylvania outpatient practices to receive a “diabetes report card” with individualized information about glycemic control in one of three study arms: (1) letter grades ranging from A-F (grade arm); (2) faces whose emotion reflected current glycemic control (face arm) or (3) actual A1c value (control arm) (Figure 1). The primary study outcome was change in A1c values between baseline and 6 months. Secondary outcomes were changes in participant perceptions of their current diabetes control, disease severity, and future risk of associated complications.

RESULTS: The average A1c for enrolled participants was 9.9 ± 1.7 % and did not differ significantly between study arms. The pre-intervention survey confirmed high levels of misunderstanding of current glycemic control, with the majority (63 %) of participants describing their control as ‘moderate’ or ‘good’/‘excellent’ in spite of an average A1c of 9.8 % and 10.2 %, respectively. We noted no significant differences in change in A1c at 6 months between the control arm and the experimental arms. Using multiple imputation to handle missing A1c values, the change in A1c for the grade, face, and control arms was −0.55 ± 0.3 %, −0.89 ± 0.3 %, and −0.74 ± 0.37 %, respectively (p = 0.67 for grade vs. control, p = 0.76 for face vs. control). We found no significant differences between study arms for the changes in perceptions of current diabetes control, severity, and future complication risk.

CONCLUSIONS: Letter grades and faces did not differentially affect A1c at 6 months or participant perceptions of current control in this population of poorly controlled diabetics. This may reflect the particular alternatives tested in this study, without invalidation of the concepts that improving communication and patient understanding of disease management targets could significantly improve diabetes outcomes.

A SYSTEMATIC REVIEW OF INTERVENTIONS TO IMPROVE PALLIATIVE CARE REFERRAL Irene Kirolos1; Leonardo Tamariz1; Barbara A. Wood2; Ana M. Palacio1. 1University of Miami-Miller School of Medicine, Miami, FL; 2University of Miami-Miller School of Medicine, Miami, FL. (Tracking ID #1642043)

BACKGROUND: Palliative care is underutilized among patients at the end of their lives despite evidence that it improves patient satisfaction and that it reduces costs. The purpose of this study is to synthesize the evidence regarding interventions to increase palliative care usage.

METHODS: We performed a MEDLINE database search (1979 to November 2012) supplemented by manual searches of bibliographies of key relevant articles. We selected all studies in which an intervention was used in palliative care or hospice. Study design, quality criteria, population, interventions and outcomes for each study were extracted. The main outcome evaluated was increase in hospice/palliative care referral.

RESULTS: Our search strategy yielded 412 studies, of which only five met our eligibility criteria (table). Three studies included nursing home populations and only one study reported on heart failure patients. Three studies had a cohort design, one had a pre-post design and only one study had a randomized design. The specific intervention differed in each study. The cohort studies that implemented a palliative care program that ranged from a facilitator to a comprehensive program had a median increase in referrals of 14 %. The randomized study that included a triage system to identify patients’ needs and preferences increased referral by 19 %. Similar trends were seen in the pre-post design.

CONCLUSIONS: Interventions of different levels of complexity can improve the use of palliative and hospice services among subjects with high mortality risk, particularly nursing home patients. More data is needed on the impact of interventions targeting high risk groups in other clinical environments.

Study design Number of studies Population Intervention % Referral to palliative care in intervention group % Referral to palliative care in control group

Cohort 3 At risk of death Palliative care program 47(31–56) 33(7–37)

Pre-post 1 Nursing home Educational 7 4

Randomized 1 Nursing home Triage system 20 1

A WEB-BASED LIFESTYLE INTERVENTION TO DECREASE POSTPARTUM WEIGHT RETENTION IN WOMEN WITH RECENT GESTATIONAL DIABETES MELLITUS: THE BALANCE AFTER BABY PILOT RCT Jacinda M. Nicklas1,2; Chloe A. Zera3; Bernard A. Rosner4,5; Sue E. Levkoff6,7; Ellen W. Seely2. 1University of Colorado School of Medicine, Aurora, CO; 2Brigham and Women’s Hospital, Boston, MA; 3Brigham and Women’s Hospital, Boston, MA; 4Harvard Medical School, Boston, MA; 5Harvard School of Public Health, Boston, MA; 6Brigham and Women’s Hospital, Boston, MA; 7University of South Carolina, Columbia, SC. (Tracking ID #1631193)

BACKGROUND: Women with a history of gestational diabetes mellitus (GDM) have a 7-fold increased risk for developing type 2 diabetes (T2DM). A post-hoc analysis of women with self-reported history of GDM in the Diabetes Prevention Program (DPP) demonstrated that an intensive face-to-face lifestyle intervention focused on weight loss significantly decreased the incidence of T2DM by 53 % over 3 years. However, face-to-face weight loss interventions in postpartum women in general have demonstrated poor adherence and efficacy. We sought to develop and test a postpartum lifestyle intervention based on the DPP and modified for women with recent GDM.

METHODS: After conducting focus groups and informant interviews with women with prior GDM, we developed a web-based program named Balance after Baby. Key modifications from the DPP included web-delivery to allow 24-h access, lifestyle coaching by phone/email, and content tailored for the postpartum period. Women with GDM in their most recent pregnancy were recruited during pregnancy or early postpartum and randomized into the Balance after Baby program or enhanced control arm (glucose tolerance tests) 4–12 weeks postpartum. Pre-pregnancy weight was self-reported at recruitment; gestational weight gain and insulin use were extracted from medical records. We administered demographic questionnaires and measured height, weight, and response to a 2 h 75 g oral glucose tolerance test, at 6 weeks, 6 months, and 12 months postpartum. We compared mean weight changes using an intent-to-treat model by t-tests and by estimating a mixed-effects regression model using a random intercept and an unstructured covariance matrix. We conducted structured exit interviews with women completing the program.

RESULTS: 75 women with recent GDM were randomized (mean age 33.4 ±5.4 years; BMI 31.4 (±5.6) kg/m2; 57 % White, 29 % African-American, 15 % Asian, with 20 % Hispanic; 34 % low-income). There were no significant differences between groups at baseline for age, race, education, income, weight, BMI, pre-pregnancy weight, gestational weight gain, insulin use in pregnancy, breastfeeding, or glucose tolerance. Clinically determined weights were collected 12 months postpartum for 95 % of eligible participants. Women assigned to the Balance after Baby arm lost a mean 5.0 (±13.5) lbs compared to women in the control arm who gained 1.3 lbs (±9.8) (p = .0223) between 6 weeks and 12 months postpartum. Women in the Balance after Baby arm were at their pre-pregnancy weight (mean −0.2 ± 15.4 lbs) at 12 months postpartum vs. the control arm (+7.9 ± 15.3 lbs) (p = 0.025). In a longitudinal mixed model controlling for pre-pregnancy weight, assignment to the Balance after Baby arm resulted in greater loss at 6 (mean 8.5 lbs, SE 2.7, p = 0.002) and 12 months (mean 7.0 lbs, SE 2.9, p = 0.0175) compared to women in the control arm. While there were no significant group differences in glucose tolerance at 12 months, 3 women in the control group developed T2DM compared to none in the intervention group. Women randomized to the Balance after Baby program expressed a high degree of satisfaction with the program.

CONCLUSIONS: The web-based Balance after Baby program is feasible, acceptable, and resulted in greater postpartum weight loss in women with recent GDM. If confirmed and found cost-effective in a longer study, the Balance after Baby program could be used at the population level to increase postpartum weight loss and potentially delay or prevent development of T2DM in women with recent GDM.

ACADEMIC DETAILING TO TEACH AGING AND GERIATRICS Cathryn Caton; Ashley Duckett; Theresa Cuoco; Pamela Pride; Patty J. Iverson; William P. Moran. Medical University of South Carolina, Charleston, SC. (Tracking ID #1643098)

BACKGROUND: Detailing has been employed by the pharmaceutical sales industry to increase physician knowledge about new medications. Work hour rules have challenged residency training programs to develop and utilize efficient and effective teaching methods. We chose to employ academic detailing as a teaching intervention in our residents’ clinic and on the general medicine inpatient wards to improve clinical knowledge and skills in geriatric care.

METHODS: Aging Q3 - Quality Education, Quality Care and Quality of Life- is a longitudinal curriculum focusing on improving geriatric knowledge in the residency program at the Medical University of South Carolina. Sixteen geriatric topics were chosen based on the Assessing Care of Vulnerable Elder (ACOVE) paradigm and each topic was delivered over 3 months. For each ACOVE, faculty workgroups of 6 members identified key educational messages and skill instruction to teach residents over a three-month intervention period. Each workgroup created one page academic detailing sheets with specific knowledge and skills to be reviewed. Residents were detailed at the time of encounters with geriatric patients with key messages of the current ACOVE by faculty using the provided detailing sheets. By design, the one-on-one detailing process took about 5 min, thereby ensuring that residents were not significantly delayed on rounds or in their clinics.

RESULTS: Over three years noon conference attendance for Aging Q3 topics ranged from 20 % to 51 %, while the percentage of residents detailed by faculty ranged from 61 % to 93 %. ACOVEs with the highest rates of resident detailing had statistically significant increases in medical knowledge, as measured by pre-test/post-test. For ACOVEs with the highest resident detailing rates, general medicine faculty participation in the detailing process ranged from 60 % to 86 %. In some instances, despite good detailing rates and improvement in self-efficacy, there was not a statistically significant improvement in medical knowledge.

CONCLUSIONS: We found that academic detailing is an efficient way of reaching a high percentage of residents and increasing knowledge in aging and geriatrics. Topics with a narrow focus are best taught in this format.

ACOVE Detailing Rates and Resident Knowledge

ACOVE Detailing Rates (%) Pre-test (%) Post-test (%) p-value

Pressure Ulcers/Malnutrition 93 6 41 <0.0001

Falls 86 16 49 <0.0001

Osteoporosis 85 29 62 <0.0001

Screening & Prevention 78 16 40 <0.0001

Continuity of Care 88 46 31 0.0419

Vision 84 63 71 0.2489

Dementia 82 41 32 0.2558

Pain Management 80 1 15 0.1579

End of LIfe Care 78 55 51 0.6907

Hospital Care & Transitions 73 38 57 0.0163

Medication Use & Safety 61 28 36 0.5174

ACOVE Detailing Rates and Resident Self Efficacy

ACOVE Detailing Rates (%) Pre-test Mean Confidence Score Post-test Mean Confidence Score Paired t-test on mean change in reported confidence p value

Continuity of Care 88 - - - n/a

Dementia 82 - - - n/a

End of Life Care 78 8.72 9.55 0.83 0.0013

Falls 86 9.71 11.08 1.37 <0.0001

Hospital Care & Transitions 73 11.25 11.98 0.73 0.0056

Medication Use & Safety 61 - - - n/a

Osteoporosis 85 2.45 3.83 1.38 <0.0001

Pain Management 80 9.87 10.48 0.61 0.0039

Pressure Ulcer/Malnutrition 93 2.82 3.6 0.7765 <0.0001

Screening & Prevention 78 2.72 2.4 0.3167 0.0106

Vision - - - - n/a

ACCESS TO SUBSPECIALTY CARE FOR PATIENTS WITH MOBILITY IMPAIRMENT Tara Lagu1,2; Nicholas S. Hannon1; MIchael B. Rothberg8; Annalee S. Wells9; K. Laurie Green3,4; McAllister O. Windom5; Katherine R. Dempsey1; Penelope S. Pekow1,6; Jill S. Avrunin1; Aaron Chen7; Peter K. Lindenauer1,2. 1Baystate Medical Center, Springfield, MA; 2Tufts University School of Medicine, Boston, MA; 3Baystate Medical Center, Springfield, MA; 4Baystate Medical Center, Springfield, MA; 5Duke University School of Medicine, Durham, NC; 6University of Massachusetts-Amherst, Amherst, MA; 7University of New England College of Osteopathic Medicine, Biddeford, ME; 8Cleveland Clinic, Cleveland, OH; 9Dorchester House, Dorchester, MA. (Tracking ID #1615945)

BACKGROUND: The Americans with Disabilities Act (ADA) states that all medical practitioners are required to provide “full and equal access to their health care services and facilities,” yet adults who use wheelchairs have difficulty accessing physicians and receive less preventive care than their able-bodied counterparts. We aimed to describe access to medical and surgical subspecialists for patients with mobility impairment.

METHODS: Using a standardized script, we called subspecialty (endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology, psychiatry) practices in four metropolitan areas in the United States and attempted to make an appointment for a fictional patient who used a wheelchair and was unable to transfer from chair to exam table. If a practice reported that they were able to make an appointment for the patient, the investigator would then probe to clarify that both the building and office were accessible and to determine the method by which the practice planned to transfer the patient from the wheelchair to the exam table. If the practice was unable to accommodate the patient, the investigator responded with the question, “Can you please explain why you are unable to accommodate this patient?” We calculated summary statistics and conducted a qualitative analysis of the responses.

RESULTS: Of 256 practices, 56 (22 %) reported they could not accommodate our fictional patient. Only nine of these reported that the building was inaccessible. The remaining 47 reported that they were unable to transfer a patient from a wheelchair to an exam table. Reasons for the inability to transfer the patient included a lack of staff who could perform the transfer (37 practices), a concern about liability (five practices), or that the “patient was too heavy” (five practices). Inaccessibility varied by subspecialty: only 6 % of psychiatry practices were inaccessible, while gynecology was the subspecialty with the highest rate (44 %) of inaccessible practices. The other subspecialties had proportions of inaccessible practices ranging from 13 to 28 %. Of 200 accessible practices, 67 (33 %) reported they had equipment that could adjust to the patient while sitting in the wheelchair (e.g., otolaryngology, ophthalmology) or, in the case of psychiatry, that they did not need to move the patient for an exam. 103 practices (51 %) reported they planned to “manually transfer” the patient from her wheelchair to a non-accessible high table without the use of a lift. Only 22 practices (11 %) reported the use of accessible tables or use of a lift for transfer.

CONCLUSIONS: More than 20 years after the passage of the ADA, many subspecialty practices were unable to accommodate a patient with mobility impairment. This was rarely due to building inaccessibility. More frequently, practices were inaccessible because they were unable to transfer the patient to perform an exam. A minority of accessible of practices possessed equipment that would facilitate the safe transfer (from chair to table) of our fictional patient. Instead, a majority of accessible practices reported transfer methods that have been deemed to be unsafe by disability experts. These results provide one possible explanation for the health care disparities observed in this population and identify the need for better awareness among physicians about the requirements of the ADA and the standards of care for patients with mobility impairment.

ACCULTURATION AND RISK FACTORS FOR HYPERTENSION AMONG A HETEROGENEOUS POPULATION OF BLACK MEN Candace Tannis; Jessica M. Forsyth; Joseph Ravenell. NYU School of Medicine, New York, NY. (Tracking ID #1638147)

BACKGROUND: Black men are at increased risk for developing hypertension and consequent morbidity compared to other racial/ethnic groups. The composition of the Black population in the United States is diversifying rapidly, with many implications for the prevention and management of hypertension. This study seeks to examine the role of acculturation on engagement in therapeutic lifestyle changes (TLCs; healthy diet, physical activity, smoking and alcohol consumption, and medication adherence) to lower blood pressure (BP).

METHODS: Participants were recruited during health screening events for a larger clinical trial at barbershops and churches. All adult men who self-identified as Black were eligible. Acculturation, the main predictor variable, was measured using a single item regarding place of birth and a 10-item questionnaire adapted from two measures: the Cultural Lifestyle Inventory (CLSI); and the Measures of Acculturation Strategies for People of African Descent (MASPAD). Items taken from the CLSI and MASPAD were measured on 5-point and 6-point Likert scales respectively with items summed to create scale scores. Outcome variables included 1) diet, measured using the National Cancer Institute fat screener and a 2-item modified Food Frequency Questionnaire measuring daily fruit and vegetable consumption; 2) physical activity, measured with the shortened International Physical Activity Questionnaire; 3) medication adherence, measured with the 4-item Morisky scale; and 4) smoking and alcohol consumption, measured using items adapted from the Behavioral Risk Factor Surveillance Survey. BP was measured using an automated BP cuff, and co-morbidity was measured using the Charlson Co-morbidity Index. We utilized ANCOVA to test group differences in outcome variables between foreign-born and US-born at baseline, and linear regression to examine relationships between acculturation and outcome variables at baseline. All analyses controlled for age, income, employment status and education level.

RESULTS: 171 men completed the survey. 26 % were foreign-born. The mean age of participants was 53.6 years (SD = 10.24) and the median annual income was $11,400. Twenty-seven percent of men in the study reported having less than a high school education, and 75 % of the men were currently unemployed. Foreign-born participants had lower percentage of fat in their diets (p = 0.003). There were no differences between foreign-born and US-born men in mean BP, presence of co-morbidity, and lifestyle behaviors other than fat consumption. However, among participants who reported taking BP medication, foreign-born blacks had poorer adherence (p = 0.028). Medication non-adherence was also associated with the “traditionalist” MASPAD dimension (p = 0.015, R2adj .333), as well as positively with the individual item corresponding to ethnic pride (p = 0.021) and negatively with maintenance of cultural practices (p = .035). There was no relationship between acculturation and the TLCs other than medication adherence or measured BP.

CONCLUSIONS: This study provides evidence that nativity and acculturation among Black men may play a role in engagement in certain TLCs to lower BP. More research is needed to determine how best to tailor TLC interventions to control hypertension for the rapidly diversifying population of Black men, the highest risk group in the United States.

ACCURACY OF RACE/ETHNICITY AND LANGUAGE PREFERENCE IN AN ELECTRONIC HEALTH RECORD Sara V. Carlini1; Elissa Klinger1; Irina Gonzalez1; Jeffrey A. Linder1; Elyse R. Park2; Emily Kontos3; Nancy A. Rigotti2; Jennifer Haas1,3. 1Brigham and Women’s Hospital, Boston, MA; 2Massachusetts General Hospital, Boston, MA; 3Harvard School of Public Health, Boston, MA. (Tracking ID #1634097)

BACKGROUND: Eliminating health care disparities requires accurate data on race/ethnicity and language preference. Health care organizations that receive federal funds are required to record information about patient race/ethnicity and language preference, yet little is known about the accuracy of these electronic health record (EHR) data.

METHODS: We compared the accuracy of race/ethnicity and language preference data recorded in an EHR, compared to self-reported race/ethnicity and language preference (English, Spanish) from an Interactive Voice Recognition (IVR) survey as part of a randomized controlled trial of a telephone-based tobacco treatment program. Using IVR, we called 6,771 low-income (by zip code) white, black, or Latino smokers who were listed in the EHR as English or Spanish-speaking and had made a primary care visit in the preceding 60 days; 2,189 (32 %) answered the phone and selected a language preference, and 434 (6 %) enrolled and provided information about race/ethnicity.

RESULTS: Median age was 51 years; 53 % self-reported race/ethnicity as white, 26 % as African-American, and 21 % as Hispanic; and 10 % reported that they were Spanish-speaking. Overall agreement between EHR-recorded and self-reported race/ethnicity information was excellent (Kappa 0.84; p < 0.001). However, the sensitivity and positive predictive value (PPV) for EHR-recorded race/ethnicity compared to self-report varied by race/ethnicity: 82 % and 97 % for Hispanics, 78 % and 95 % for African-Americans, and 100 % and 87 % for whites, suggesting that for both Hispanics and African-Americans, some individuals are misclassified in the EHR as white. For language preference, EHR-documentation and self-report showed good overall agreement (Kappa 0.74, p < 0.001), but the PPV for an EHR-documented language preference of Spanish was only 68 % with a sensitivity of 86 %. While only 1.2 % of EHR-documented English speakers elected to hear the IVR call in Spanish, 31.9 % of EHR-documented Spanish speakers elected to hear the call in English.

CONCLUSIONS: We demonstrate strong agreement between EHR-recorded and self-reported race/ethnicity and language preference. However, there were inaccuracies that indicate the need to investigate how EHR data are obtained and perhaps systems to improve EHR documentation. The results also demonstrate the importance of offering services that respond to multilingual patients, who may have differing preferences based on the specific content and method of contact.

ACCURATE DISEASE ATTRIBUTION IS A HURDLE FOR DEVELOPMENT OF A PAY FOR PERFORMANCE REIMBURSEMENT MODEL Jennifer Zreloff; Jillian Gaumond; Jason Higdon. Emory University, Atlanta, GA. (Tracking ID #1642285)

BACKGROUND: With medical reimbursement shifting away from fee for service and toward quality incentives, it is important to understand the accuracy of data being used by insurance companies and clinics for quality incentive payouts.

METHODS: In the setting of a university-based and NCQA recognized Patient-Centered Medical Home with a single payer, we sought to reconcile quality reports generated by our payer versus by our clinic’s data warehouse. Lists of patients were generated with diabetes, CHF, and COPD. Our private payer generated its list based on their methods that utilize billing data.. Lists generated by the PCMH were generated by diagnoses on the “problem list” in the EMR and diagnosis billing data specific to that clinic. The two lists were compared and evaluated by chart review when they were discordant. Chart review included all data available such as labs, echo, radiology, specialty clinic notes, and PCP notes. Patients were then divided into groups of inclusion error by insurance, inclusion error by PCP, exclusion error by insurance, and exclusion error by PCP

RESULTS: Percentage of times that the Private Payer and the PCMH agreed varied by disease state. Based on the total number of patients included in a disease group by either the insurance company or the PCMH, 61.2 % of the patients on the diabetes list, 32.1 % of those on the CHF list, and 21.2 % of those on the COPD list, were agreed upon by both the insurance company and the clinic. There were both errors of omission and inclusion by the insurance company. Errors of inclusion (those attributed to have the disease that did not actually have it) occurred for diabetes in 16.9 % of the total attributed patients, 32.1 % for CHF, and 78.8 % for COPD. Errors of exclusion (those that had the disease but were not listed by the insurance company) occurred for 21.9 % of diabetics, 35.7 % of patients with heart failure, and 0 % with COPD. A small percentage of errors of exclusion occurred with the PCMH. There were no errors of inclusion by the PCMH. Looking at only the data generated by the insurance company, 21.7 % of insurance-attributed diabetic patients were incorrect, and 26.3 % of the patients on the final, verified diabetic list were missing. For CHF, 50 % of insurance-attributed patients were incorrect, and 52.6 % of patients on the verified CHF list were missing. COPD had the worst data accuracy with 78.8 % of insurance-attributed patients being incorrect, and with no missing patients.

CONCLUSIONS: When entering the world of pay for performance, it is important to recognize the inherent inaccuracies of data based primarily on claims data. This clinic had the added luxury of a separate attribution process which allowed both sides to agree on the total pool of patients. For most clinic sites the quality data would be expected to have more errors due to discrepancies of attribution to PCP. For these reasons, it is important for clinics to have opportunities to collect their own quality data specific to disease attribution, and have a reconciliation process with payers participating in pay for performance initiatives.

ACETAMINOPHEN RECEIPT AMONG HIV-INFECTED PATIENTS WITH ADVANCED HEPATIC FIBROSIS E. J. Edelman1; Kirsha S. Gordon2; Vincent Lo Re3; Melissa Skanderson4; David A. Fiellin1; Amy C. Justice2,1. 1Yale University, New Haven, CT; 2VA Connecticut Healthcare System, West Haven, CT; 3University of Pennsylvania, Philadelphia, PA; 4VA Pittsburgh Healthcare System, Pittsburgh, PA. (Tracking ID #1642388)

BACKGROUND: HIV-infected (HIV+) patients may be at particular risk for acetaminophen-induced hepatotoxicity given their underlying risk of liver disease, high prevalence of hepatitis C virus (HCV) coinfection, differences in acetaminophen metabolism, and exposure to antiretroviral therapy. However, acetaminophen overuse (greater than 2 g per day) in the context of liver injury has been incompletely examined among HIV+ patients. Among a cohort of HIV+ patients, our aims were to: 1) describe the patterns of acetaminophen receipt; 2) assess the cross-sectional association between acetaminophen receipt and advanced hepatic fibrosis; and 3) determine whether factors associated with acetaminophen overuse varied by HCV status.

METHODS: We performed a cross-sectional analysis of the Veterans Aging Cohort Study-Virtual Cohort. We excluded patients who had a cancer diagnosis other than non-epithelial skin cancers; no inpatient or outpatient visit in FY2006; or missing laboratory or pharmacy data. Outpatient acetaminophen receipt among HIV+ patients in the cohort was categorized as: 1) no acetaminophen use, 2) appropriate use (<2 g/day); or 3) overuse (> 2 g/day). The primary independent variable was advanced hepatic fibrosis, defined as a FIB-4 > 3.25. The FIB-4 score is a validated non-invasive index that identifies advanced fibrosis/cirrhosis using age, alanine aminotransferase, aspartate aminotransferase, and platelet count. We evaluated acetaminophen daily dosage stratified by FIB-4 status. We then performed multivariable ordered polytomous logistic regression to determine adjusted odds ratios (AOR) for acetaminophen daily dosage, classified as a three level outcome variable. The final model included patients characteristics that were clinically relevant or significant at the p < 0.05 level. Results were stratified by HCV status.

RESULTS: Our sample included 14,885 HIV+ patients, 4,592 (31 %) of whom received at least one acetaminophen prescription and 1,885 (41 %) of whom were HIV/HCV-coinfected. Among those receiving acetaminophen, 1,442 (31 %) patients were identified with acetaminophen overuse, with no differences observed between HIV-monoinfected and HIV/HCV-coinfected patients (846 [31 %] vs. 596 [32 %], p = 0.59). Among HIV-monoinfected patients, the average daily acetaminophen dose was not significantly different between those with a FIB-4 < 3.25 and those with a FIB-4 > 3.25 (1.50 vs. 1.20 g/day, p = 0.08); results were similar for HIV/HCV-coinfected patients (p = 0.14). After adjusting for age, gender, race/ethnicity, HCV status, alcohol use disorders, and pain-related diagnoses, FIB-4 was associated with a decreased odds of acetaminophen overuse (AOR [95 % CI] = 0.80 [0.65, 1.00]). After stratifying by HCV status, HIV+ patients with advanced hepatic fibrosis were equally likely to receive acetaminophen. Further, HIV-monoinfected patients with an alcohol use disorder were more likely to have acetaminophen overuse (AOR [95 % CI] = 1.56 [1.21, 2.02]).

CONCLUSIONS: Acetaminophen overuse was common in this sample of HIV+ patients. Strategies to minimize acetaminophen exposure in HIV+ patients are warranted.

ACHIEVING COMMUNICATION BETWEEN PRIMARY CARE AND MENTAL HEALTH: WHY IS IT SO DIFFICULT, EVEN IN THE VA? A QUALITY IMPROVEMENT APPROACH Evelyn Chang1; Kenneth B. Wells5,4; Alexander S. Young3,2; Susan E. Stockdale3; Jacqueline Fickel3; Megan Johnson2,3; Kevin Jou2; Lisa V. Rubenstein3,4. 1VA- Greater Los Angeles, Los Angeles, CA; 2VA- Greater Los Angeles, North Hills, CA; 3VA- Greater Los Angeles, North Hills, CA; 4RAND, Santa Monica, CA; 5UCLA, Los Angeles, CA. (Tracking ID #1624000)

BACKGROUND: Research shows that bi-directional communication between mental health (MH) and primary care (PC) clinicians is critical for improving patient outcomes, yet achieving this in health care organizations is challenging. In the Veterans Administration (VA), the high prevalence of co-occurring physical and mental illnesses can make PC-MH collaboration essential for providing effective care. Despite extensive national VA efforts to integrate PC and MH, however, local settings continue to experience barriers to effective communication and collaboration.

METHODS: We proposed a project to the local VA site’s quality improvement (QI) council directed at improving communication between PC and MH providers. We used QI diagnostic tools to understand barriers to PC/MH communication and to initiate a change strategy in a multi-specialty academic community-based outpatient clinic serving 16,000 veterans in Los Angeles. The clinic has two PC teams with five to six teamlets each using the patient-centered medical home model. We recruited 11 on-site PC and MH clinical providers, administrators, and researchers for our workgroup, which held 4 monthly meetings. The workgroup constructed fishbone diagrams of causes of poor communication and mapped communication flow among providers for emergent and non-urgent situations for the VA site. We performed chart reviews on patients with established PC and MH providers to assess documentation of communication. We conducted a rapid literature review of interventions for improving PC/MH communication and identified potentially feasible evidence-based interventions to address the problems we found.

RESULTS: PC providers were frustrated by inconsistent access to psychiatrists for emergent and routine situations. MH providers did not respect PC management of uncomplicated depression. Key communication barriers included geographic distance, cultural differences, and lack of standardized communication processes. A key facilitator was personal relationships across disciplines. Chart review confirmed considerable between-provider variation in documenting MH and medical problems and in communication strategies. Literature review, combined with the workgroup’s assessments, identified joint care planning and joint case conferences as two feasible interventions. While these interventions were developed, the site began to collocate MH specialists to PC.

CONCLUSIONS: QI tools suggested that there were procedural, cultural, and structural factors affecting communication and respect. Clarifying these factors helped to initiate an ongoing change strategy. A locally tailored QI process focusing on communication helped initiate change strategies that had not originated from policy or health information systems.

ADEQUACY AND CORRECTION OF MEDICAL RECORD DOCUMENTATION IN PATIENTS WITH A PRIOR ADMISSION FOR ACE-INHIBITOR ANGIOEDEMA IN AN URBAN ACADEMIC MEDICAL CENTER: A PATIENT SAFETY INTERVENTION Andrew M. Davis1; Eric R. Yoo3; Cheryl Nocon2; Jacquelynne P. Corey2. 1University of Chicago, Chicago, IL; 2University of Chicago, Chicago, IL; 3University of Illinois College of Medicine, Chicago, IL. (Tracking ID #1626449)

BACKGROUND: Angiotensin-converting enzyme inhibitor (ACEI) induced angioedema affecting the upper airway is a potentially life-threatening condition, occurring in 0.1 to 2.2 % of recipients, with a higher incidence in African-American patients. Over 40 million patients in the U.S. currently take a medication in this class. Recurrent ACEI-induced angioedema is readily preventable, but requires proper allergy documentation in the medical record after the first event. Our institution’s transition from Oacis to an Epic Electronic Medical Record (EMR) in 2008 improved clinician training and engagement with the EMR. This transition provided an opportunity to assess allergy documentation following episodes of ACEI-induced angioedema requiring inpatient admission, and to correct deficits in EMR allergy documentation in our urban academic medical center.

METHODS: We reviewed charts of patients with inpatient encounter codes for “angioneurotic edema, NOS” (ICD 995.1), hereditary angioedema (277.6), anaphylactic shock (995.0), anaphylactic shock due to food reaction (995.6), or anaphylactic shock due to serum (995.4). Cases with clear corroboration of ACEI-induced angioedema in the clinical notes were split by admit dates: 2000–2007 (n = 372 total, 82 ACEI related) and 2008–2011 (n = 139 total, 37 ACEI related). We also reviewed a random sample of 30 ED cases (2008–2011) with ACEI-related angioedema not requiring admission. The current Epic allergy and problem lists were examined for each case; elements abstracted included documentation of the ACEI allergy, the severity of reaction, and presence of the name of the specific causative agent. As a patient safety intervention, incomplete allergy documentation in the EMR was corrected.

RESULTS: Overall 95 % of the admitted patients were African American and 66 % were female; the median age was 64. The severity of angioedema in admitted patients was quite high, with 43 % requiring intubation in 2000–2007, and 59 % during the 2008–2011 period. Before current EMR implementation in 2008, 60 (73.2 %) of charts for admitted patients were completely missing ACEI-allergy documentation and 17 (20.7 %) had incomplete allergy lists. After transition to the current EMR, inpatient charts (2008–2011) markedly improved in ACEI allergy documentation (p < .001), though 5 (13.5 %) of the 2008–20011 admitted patients were completely missing data, and 29 (78.4 %) had incomplete allergy lists, lacking the specific agent or reaction severity. Patients treated and released from the ED were more likely to have absent documentation (23.3 %). In several instances, the ACEI remained on patient medication list, but review of recent notes found that ACEI had actually been discontinued, and that the medication list was in error.

CONCLUSIONS: ACEI-allergy documentation markedly improved following transition to a newer EMR; however, an unacceptably high number of patients with an admission for ACEI angioedema continued to have no documentation of this reaction on their current allergy list, and missing agent or severity data remained common. Urban medical centers should regularly review ACEI allergy angioedema events, and establish a redundant patient safety process to confirm event documentation in the EMR allergy list.

Admitted 2000–2007 (n = 82) Admitted 2008–2011 (n = 37) ED only 2008–2011 (n = 30)

Category n % n % n %

Full data at baseline 5 6.0 % 3 8.1 % 5 16.7 %

Partial data 17 20.7 % 29 78.4 % 18 60.0 %

No mention of ACEI allergy 60 73.2 % 5 13.5 % 7 23.3 %

ADHERENCE TO PRESCRIPTION OPIOID MONITORING GUIDELINES AMONG RESIDENTS AND ATTENDING PHYSICIANS IN THE PRIMARY CARE SETTING Laila Khalid; Jane M. Liebschutz; Christopher W. Shanahan; Shernaz Dossabhoy; Yoona R. Kim; Karen E. Lasser. Boston Medical Center, Boston, MA. (Tracking ID #1636318)

BACKGROUND: Prescription opioid misuse is a significant public health problem, with primary care providers being the principal prescribers of opioids for chronic non-cancer pain. While one study showed that residents provide higher quality primary care than attendings, opioid prescribing practices have not been compared between resident and attending physicians. We compared adherence to opioid prescribing guidelines as well as evidence for potential patient misuse of prescribed opioid medications between resident and attending physician.

METHODS: We conducted a retrospective cross-sectional study at a primary care practice of a large Northeastern safety-net hospital using data abstracted from the electronic medical record through the institution’s clinical data warehouse. Patients included were 18–89 years old, who had at least one visit to primary care and were prescribed long-term opioid treatment (3 or more opioid prescriptions written at least 21 days apart within 6 months) for chronic non-cancer pain from 8/31/11 to 9/1/12. The primary outcome was adherence to any one of two key American Pain Society Guidelines; 1) documentation of at least one opioid agreement (contract) ever, and 2) any urine drug testing in the past year; and evidence of potential prescription misuse with 1, 2 or more than 2 early refills. Early refill was a prescription written 7–25 days after the previous prescription of the same drug. Patients were classified as a resident patient if they received 2, or more prescriptions from a resident physician. Statistical analysis was performed using chi-square tests.

RESULTS: 96 residents prescribed opioid prescriptions to 136 patients, while 49 attendings prescribed to 609 patients. The results are summarized below.

CONCLUSIONS: Despite the low numbers of contract documentation in resident and attending patients, the majority of the patients did receive urine drug testing. It is not clear whether the documentation of a contract indicates guideline adherence. Evidence for potential misuse of prescription opioids, indicated by two or more early refills, was significantly higher in resident patients relative to attending patients. Features of a resident-based practice that may be associated with prescription opioid misuse need to be explored.

ADMISSION TO TEACHING HOSPITALS AND WEEKDAY DISCHARGES ARE ASSOCIATED WITH BETTER OUTCOMES IN HEART FAILURE PATIENTS Anita G. Au; Raj S. Padwal; Erik Youngson; Sumit R. Majumdar; Finlay A. McAlister. University of Alberta, Edmonton, AB, Canada. (Tracking ID #1635314)

BACKGROUND: It is unclear whether hospital teaching status or the day of discharge influences post-discharge outcomes for patients hospitalized with heart failure (HF).

METHODS: We linked four population-based databases in Alberta, Canada to identify adults hospitalized for HF who were discharged alive between 1999 and 2009. We conducted a retrospective cohort study comparing outcomes between patients discharged from teaching versus non-teaching hospitals and on weekends versus weekdays. The primary outcome was the composite of death or non-elective readmission 30-days post-discharge.

RESULTS: Over 10 years, 12,216 HF patients were discharged from teaching hospitals and 12,157 from non-teaching hospitals; 21,001 (86 %) discharges occurred on weekdays. Although they had greater comorbidity and used more health care resources in the year prior to HF hospitalization, patients discharged from teaching hospitals exhibited significantly lower rates of 30-day death or readmission than those discharged from non-teaching hospitals (17.4 % vs. 22.1 %, aHR 0.83, 95 % CI 0.77–0.89). Patients discharged on weekdays were older and had greater comorbidity, yet exhibited significantly lower rates of death or readmission at 30-days than those discharged on weekends (19.5 % vs. 21.1 %, adjusted hazard ratio [aHR] 0.87, 95 % CI 0.80–0.94). Compared to weekend discharge from a non-teaching hospital (reference), the 30-day risk of death or readmission was lower for weekday discharge from a non-teaching hospital (aHR: 0.85, 95 %CI 0.77–0.94), weekend discharge from a teaching hospital (aHR: 0.79, 95 %CI 0.69–0.92), and weekday discharge from a teaching hospital (aHR: 0.71, 95 %CI 0.63–0.79, with p < 0.001 for trend).

CONCLUSIONS: Patients discharged from non-teaching hospitals or on weekends exhibited poorer risk-adjusted outcomes than those discharged from teaching hospitals or on weekdays. The structures and processes which may have yielded better outcomes for those admitted to teaching hospitals and those discharged on weekdays should be studied and possibly emulated in order to optimize heart failure related outcomes.

ADVERSE OUTCOMES OF POLYSEDATIVE USE IN VETERANS WITH PTSD Brian C. Lund1,2; Stephen L. Hillis1; Elizabeth A. Chrischilles2. 1Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA; 2University of Iowa College of Public Health, Iowa City, IA. (Tracking ID #1628276)

BACKGROUND: While department of Veterans Affairs (VA) clinical practice guidelines recommend against their use, benzodiazepines are prescribed to 30–40 % of veterans with posttraumatic stress disorder (PTSD). Nationally, opioid abuse has been labeled as epidemic, and inpatient chemical dependency admissions involving the combination of opioids and benzodiazepines have risen more than 500 % in the last decade. Therefore, our objective was to determine whether benzodiazepines, opioids, and other sedatives - particularly in combination - are associated with adverse events in veterans with PTSD.

METHODS: National VA administrative data were used to identify veterans with PTSD. Among these patients, new benzodiazepine starters during FY04-09 (N = 66,406) were matched to nonusers (N = 128,062) using high dimensional propensity scores. Adverse events were based on prior work involving sedative use in veterans and included emergency visits and hospitalizations for wounds/injuries, drug-related accidents/overdoses, and self-inflicted injuries identified by ICD-9 coding. One year adverse event risk was determined using a stratified Cox proportional hazards model. Exposure to opioids and other sedatives was modeled with time-dependent covariates. Prazosin use was included as a control exposure because it is prescribed in PTSD for the treatment of nightmares and other sleep disturbances but does not have significant sedating properties.

RESULTS: Adverse events occurred within 1 year in 2,926 (1.5 %) patients. Hazard ratios (95 % C.I.) for adverse events were: benzodiazepines, 1.8 (1.6–2.0); opioids, 1.4 (1.2–1.7); atypical antipsychotics, 1.9 (1.7–2.1); and hypnotics, 1.4 (1.1–1.8). In addition, the benzodiazepine-opioid interaction was significant (p < .001), indicating a multiplicative effect where the hazard ratio for this combination was 3.8 compared to nonusers of both. Among dual users of benzodiazepines and opioids, 78 % were prescribed by different providers. Prazosin exposure and other interaction terms were not significantly associated with adverse events.

CONCLUSIONS: Polysedative use in veterans with PTSD leads to incremental risk for serious adverse events. The combination of benzodiazepines and opioids is particularly troublesome given the synergistic interaction and the tendency toward being prescribed by different providers. The clinical complexity of caring for veterans with PTSD creates an environment that, without careful coordination of care, can lead to high-risk polysedative use.

AFTER THE FACT: EDUCATING WOMEN INCARCERATED IN JAIL ON THE USE OF MEDICAL THERAPIES TO PREVENT HIV ACQUISITION FOLLOWING A RISKY EXPOSURE Neha Gupta3; Heidi Schmidt3; Timothy Buisker2; Mi-Suk Kang Dufour2; Janet Myers2; Jacqueline P. Tulsky1. 1University of California San Francisco, San Francisco, CA; 2University of California San Francisco, San Francisco, CA; 3University of California San Francisco, San Francisco, CA. (Tracking ID #1634988)

BACKGROUND: Women incarcerated in jail face increased risk of HIV infection because they over represent members of communities at risk. Antiretroviral therapy following an HIV exposure–non-occupational post-exposure prophylaxis (nPEP)–has been endorsed by federal guidelines as an effective HIV prevention strategy since 1997. However, there is little information regarding nPEP awareness or its use among women leaving jail. This study assessed baseline awareness and knowledge regarding nPEP among women incarcerated in a local jail and evaluated the effectiveness of a brief educational intervention in increasing nPEP awareness and knowledge.

METHODS: A 15-min lesson was developed to teach principles of nPEP to detained women at the San Francisco jail. Participants were recruited from September 2012 to January 2013, and the intervention was delivered in small groups. Prior to the intervention, participants completed a survey (T1), reflecting demographics, HIV risk factors and nPEP awareness, knowledge and attitudes. The nPEP section was repeated immediately after the program (T2) and at one week (T3). Knowledge scores were calculated and assessed in 2 domains: risky behaviors and nPEP logistics (initiation timeframe, duration of use, side effects). Baseline knowledge scores and awareness were compared to answers at T2 and T3 using paired t-tests. Linear regression analysis was used to identify predictors of baseline awareness, baseline knowledge and improvement in knowledge scores.

RESULTS: Of 62 women enrolled, 53 completed T1, 48 completed both T1 and T2, and 34 completed both T2 and T3. 43 % identified themselves as black or African American, 21 % as white, 13 % as Hispanic, and 23 % as other. The mean age was 34 years, and mean total time incarcerated was 5.8 years. 32 % of the women had less than a high school education. 83 % of women were tested for HIV in the past year. 82 % reported sex-related HIV exposures in the past year, yet only 38 % perceived themselves at risk. Similarly, 28 % reported drug-related HIV exposures, while only 10 % perceived themselves as at risk. Baseline awareness of nPEP’s existence was 55 %. Increased education was associated with improved risk knowledge and overall knowledge (β = 0.252, p = 0.015 and β = 0.291, p = 0.011). Additionally, while knowledge scores increased in both domains after the intervention (see Table 1), the increase in nPEP logistics knowledge was greater than the increase in behavioral knowledge (p < 0.001). The percent of participants who would “definitely seek out nPEP after a risky exposure” was high at baseline (77 %), and remained high at T2 and T3 (83 % and 95 %, respectively), despite possible side effects and the need to take medications for 4 weeks.

CONCLUSIONS: Despite the high rates of recent HIV testing and engagement in high-risk behaviors, awareness of individuals’ own risk and the existence of nPEP as an HIV prevention strategy was low among women in this study. A 15-min educational intervention is an effective means of delivering HIV prevention information to women in jail, but may be more useful for teaching basic information about taking nPEP than changing knowledge about risk behaviors.

Table 1

Knowledge Domain Average Knowledge Score (%)

N = 48 N = 34

T1 T2 P value T2 T3 P value

Risky behaviors 46.6 74.0 < 0.001 80.5 66.2 < 0.001

nPEP logistics 27.5 81.5 < 0.001 79.4 74.7 = 0.230

Overall 41.4 76.0 < 0.001 80.2 68.5 < 0.001

AGING, CHRONIC HEALTH CONDITIONS, AND SEXUAL FUNCTION IN WOMEN Ayesha A. Appa1; Jennifer Creasman1; Jeanette S. Brown1; David Thom1; Stephen K. Van Den Eeden2; Leslee L. Subak1; Alison J. Huang1. 1University of California, San Francisco, San Francisco, CA; 2Kaiser Permanente Division of Research, Oakland, CA. (Tracking ID #1633496)

BACKGROUND: Sexual function in women is thought to decline with age, yet some women report preserved sexual function in older age. Changes in health, such as the development of chronic health conditions, may play an important role in determining whether sexual desire, activity, or satisfaction decrease in women in middle and older age.

METHODS: Sexual function was evaluated prospectively in a multiethnic, population-based cohort of 2,270 women aged 45 to 80 years randomly selected from age and race/ethnicity strata from an integrated healthcare delivery system in California. Using structured-item, self-administered questionnaires, women described their level of sexual desire, frequency of sexual activity, and overall sexual satisfaction at baseline and after 5 years. Additional questionnaires assessed participants’ detailed medical histories, medication use, and health-related behaviors, including diagnosed chronic conditions such as cancer and cardiometabolic, colorectal, neuropsychiatric, respiratory, and urogynecological disorders. Repeated measures multivariable models were developed to assess the relationship of age and chronic conditions to self-reported sexual desire, activity, and satisfaction, adjusting for race/ethnicity and relationship status.

RESULTS: Of the 2,270 participants (1007 White, 443 Black, 419 Latina, and 401 Asian), 54 % reported low sexual desire, 50 % reported less than monthly sexual activity, and 46 % reported low sexual satisfaction at baseline. Over 5 years of follow-up (N = 1,395), 34 %, 26 %, and 38 % of women reported decrease in sexual desire, frequency of sexual activity, and sexual satisfaction, respectively. In repeated measures analyses using data from all study visits and controlling for age, race/ethnicity, and relationship status, greater number of chronic conditions was independently associated with low sexual desire (OR 1.14 [1.09–1.19] per condition), less than monthly sexual activity (OR 1.14 [1.09–1.19] per condition), and low overall sexual satisfaction (OR 1.13 [1.08–1.18] per condition). Women with neuropsychiatric conditions in particular (stroke, dementia, Parkinson’s disease, depression) were more likely to report low sexual desire (OR 1.55 [1.31–1.83]), less than monthly sexual activity (OR1.41 [1.18–1.68]), and low sexual satisfaction (OR 1.44 [1.21–1.71]), independent of other types of chronic conditions. Age persisted as a significant predictor of low desire, lower frequency of sexual activity, and low overall sexual satisfaction even after adjustment for number and types of chronic conditions (P < 0.001 for all).

CONCLUSIONS: Decline in sexual desire, activity, and satisfaction appear common but not inevitable as women age. Sexual function may decrease as women acquire chronic conditions, although differences in the number and type of conditions do not fully explain differences in sexual function with aging. Clinicians caring for female patients across the aging spectrum should consider the specific impact of chronic conditions, particularly neuropsychiatric conditions, on women’s interest in and ability to enjoy sexual activity.

AMBULATORY RESIDENT PRACTICE REDESIGN: THE CREATION OF PRACTICE TEAMS WITHIN A 6 + 2 MODEL Christina Harris; Lauren Acinapura; Johanna Martinez; Judy Tung; Cathy Jalali. Weill Cornell Medical College, New York, NY. (Tracking ID #1642447)

BACKGROUND: Calls for Internal Medicine residency redesign have emphasized the strengthening of ambulatory education with the IM Residency Review Committee specifically mandating that programs “develop models and schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities”. In response, in 2011 we restructured our residency program away from traditional block time with weekly half day continuity clinics to a model where inpatient and outpatient time were independent of each other in a 6 + 2 model (6 weeks inpatient followed by 2 weeks of ambulatory practice) and created resident teams (“pods”) of four residents each.

METHODS: We implemented a 6 + 2 scheduling template at the start of the 2011–2012 academic year for all 130 residents across 3 continuity practices. In order to ensure adequate coverage of patient care matters during the 6 weeks away from practice, we created pods of four residents who hand off to each other every 2 weeks. The resident on ambulatory block functions as the “pod leader” and is responsible for ensuring that all direct and indirect patent care needs of the pod are met. Resident surveys were administered prior to the block restructuring and 1 year after implementation. Residents were asked to rate their satisfaction in four main areas including clinical and learning environment, personal experience and satisfaction with ambulatory preceptors using a 5-point rating scale. In addition, individual resident visit volume and patient continuity data were obtained for the main resident practice.

RESULTS: The survey data, analyzed using Wilcoxon Signed Rank Test, revealed that the scheduling template and creation of resident teams significantly improved resident satisfaction with their overall clinical environment (3.33 vs 4.13; p < .005) and learning environment (3.55 vs 4.16; p = .002), as well as personal reward (3.68 vs 4.11;p = .041) from their ambulatory practice. Residents reported improved satisfaction with their ability to focus while on the wards (2.68 vs 4.33; p < .005) and as well while on outpatient rotation (3.65 vs 4.51; p < .005). The repetitive nature of the schedule resulted in residents feeling significantly more connected to each other (3.81 vs 4.43, p = .003), however, without a similar increase in satisfaction in the exposure to their assigned continuity preceptor (4.13 vs 4.21; p = .732). With the creation of coverage pods, there was in improvement in resident satisfaction in how patient calls were answered (3.21 vs 3.82; p = .006), as well as with how patients results were managed (3.54 vs 4.08; p = .009) for the resident practice. The patient volume lost by the elimination of weekly afternoon continuity clinics was offset almost exactly with the increase in ambulatory block from 8 to 12 weeks per year (15,822 vs 15,972 resident visits/year). Despite an increase in satisfaction with the sense of patient ownership (4.17 vs 4.47; p = .029) individual resident-patient continuity remained unchanged (47 % vs 46 %). No change in resident reported spectrum of type patient care issues was seen.

CONCLUSIONS: Utilizing a 4 resident pod team approach, our residency program was able to effectively decouple the inpatient and outpatient residency experience in a way that improved the residents’ perceived ambulatory experience without negatively impacting patient volume or continuity of care. Future efforts to improve resident-patient continuity both within their individual panel and within the pod are underway.

AN EHR-BASED INTERVENTION TO PROACTIVELY IDENTIFY AND MITIGATE DELAYS IN CANCER DIAGNOSIS: A RANDOMIZED CLINICAL TRIAL Daniel R. Murphy2,1; Louis Wu2,1; Archana Laxmisan2,1; Eric J. Thomas3; Samuel N. Forjuoh4; Hardeep Singh2,1. 1Baylor College of Medicine, Houston, TX; 2Michael E. DeBakey VA Medical Center, Houston, TX; 3University of Texas Houston Medical School and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX; 4Scott & White Healthcare, Texas A&M Health Science Center, Houston, TX. (Tracking ID #1642092)

BACKGROUND: Delays in cancer diagnosis can results in poor patient outcomes and increased malpractice litigation. Many of these delays are related to “missed” follow-up of non-life threatening abnormal clinical findings such as positive cancer screens (i.e. red flags). Methods to identify patients at risk for delayed diagnosis due to missed follow-up are in their infancy and have not been evaluated thus far.

METHODS: We conducted a randomized clinical trial to test the effectiveness of an intervention using EHR-based triggers (i.e., specific set of data signals that prompt record review) to improve follow-up of red flags related to colorectal, breast, and prostate cancer. The two-part intervention included: (1) using an electronic trigger to identify high-risk patients with missed red flags suggestive of the cancer, and (2) communication of information about high-risk patients to primary care providers (PCPs). Study settings included a large urban VA facility and a large private health system. PCPs were the unit of randomization and were randomly assigned to intervention or controls using a randomized block design. Triggers identified patient records with red flags that had no EHR evidence of follow-up action. Red flags included a positive fecal occult blood test (FOBT), labs consistent with iron deficiency anemia, new diagnosis of hematochezia, imaging study with a lung mass, and an elevated prostate specific antigen. Triggers were prospectively applied every 2 weeks to EHR data of all patients assigned to an intervention provider. Each triggered chart was manually reviewed initially to determine whether follow-up was truly delayed per a priori definitions (e.g. no colonoscopy within 60 days of positive FOBT). If so, the respective provider was contacted by secure email. One week later, if no action was taken, the provider was called. The primary outcome was a documented follow-up action in response to the red flag, which was determined through blinded final reviews performed 7 months after the date of red flag. A chi-squared analysis was performed to test if the intervention improved follow-up.

RESULTS: A total of 72 PCPs participated in the study, and 36 were randomly assigned to each group. Seven PCPs left their facility during the study period. The intervention was applied to all patients seen at the study sites for 15 months from April 20, 2011 to July 19, 2012 and identified a total of 1257 high-risk patients. After initial review, 376 (29.9 %, 210 intervention and 166 control) records were excluded because they did not meet study criteria (e.g., patient declined follow-up or pursued outside care), leaving 881 patients with confirmed delays. Patients assigned to an intervention provider were more likely to receive subsequent follow-up (RR:1.22; 95 % CI:1.002,1.485; p = 0.047).

CONCLUSIONS: A proactive EHR-based intervention to identify patients at risk for delays in cancer diagnosis has potential to improve their follow-up. Similar EHR-based interventions could be applied to other conditions where delays in diagnosis and/or follow-up are a problem.

AN ITERATIVE, COMMUNITY FEEDBACK-DRIVEN APPROACH TO HOUSEHOLD SURVEY DESIGN Lujia Zhang1; Dennishia Banner2; Rachelle Bross5; Nell Forge4; Felica U. Jones2; Loretta Jones2,4; Katherine L. Kahn1; Roberto Vargas1; Keyonna M. King1; Aziza L. Wright2,4; Sigrid K. Madrigal2; D’Ann M. Morris3; Keith C. Norris4; Orwilda L. Pitts4; Ibrahima Sankare1; Arleen Brown1. 1UCLA, Los Angeles, CA; 2Healthy African American Families, Los Angeles, CA; 3Los Angeles Urban League, Los Angeles, CA; 4Charles Drew University, Los Angeles, CA; 5Los Angeles Biomed, Los Angeles, CA. (Tracking ID #1641961)

BACKGROUND: While household surveys are common in epidemiologic research, few studies have employed community partnered participatory research (CPPR) in the research design phase. The Healthy Community Neighborhood Initiative (HCNI) is a collaborative effort between the Los Angeles Urban League, and Healthy African American Families (HAAF), Charles Drew University, and University of California in Los Angeles (UCLA) to improve health and health care in a South Los Angeles community disproportionately affected by preventable chronic conditions. Community-academic input informed survey development and study design to build capacity for community engaged research to reduce health disparities.

METHODS: HCNI members identified key topics for the interview and examination and then iteratively ranked items, refined and piloted elements of the survey and clinical examination; obtained community input on the informed consent form, the survey, and the clinical and laboratory data collection protocols; and piloted household surveys. After each household visit, observer and participant recommendations were incorporated into the protocol for the next visit.

RESULTS: Over six household visits (n = 11), changes to the data collection instruments and protocols enhanced participant understanding of the informed consent form (ICF) and survey questions, reduced time spent “in-home” by 30 min, and streamlined the protocol to facilitate fewer surveyors in the household.

CONCLUSIONS: An iterative, community-academic feedback-driven revision process resulted in substantive changes to the ICFs, surveys, and data collection protocols that reflected the unique characteristics of the community and its residents. By emphasizing community engagement early in the study design phase, we established bidirectional knowledge exchange between researchers and the community.

AN UNDER-APPRECIATED ETHICAL PROBLEM: DELAYS IN DEATH CERTIFICATE COMPLETION Philip C. Carullo1; Daniel Sulmasy2. 1University of Chicago, Chicago, IL; 2University of Chicago, Chicago, IL. (Tracking ID #1627627)

BACKGROUND: Death certificates are legal documents that permit families to finalize a multitude of end-of-life tasks. Physicians play a key role in generating these documents, in partnership with hospital staff, funeral directors, and state health departments. While delays and errors in the completion of a death certificates increase waiting times for families and, anecdotally, have been reported to cause great anguish, there have been no systematic studies of delays in death certificate completion by physicians, especially the impact of such delays on families. The purpose of this study was to gain broad insight into the phenomenon of delayed death certificate completion by physicians, especially the impact of such delays on families.

METHODS: The authors selected 12 academic medical centers dispersed throughout the US and interviewed 30 participants, including hospital staff dedicated to death certificate paperwork, and local funeral parlor and medical examiner office personnel to understand the phenomenon and the impact of delays in death certificate completion by physicians. They used a phenomenological, qualitative approach; 2 independent coders analyzed the interview data and jointly resolved coding disagreements; no more interviews were conducted once thematic saturation was reached.

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Component Management™ (TCM™) solution, the company’s VMI service is central to its belief that OEMs can gain substantial benefits by outsourcing procurement, supply chain management and logistics to a specialist company. With their VMI service, Paragon establishes line side stores at customer premises, enabling instant access to high volumes of parts, onsite. Available as ‘consigned stock’, these parts are only invoiced for when used, reducing customer risk and streamlining supply. Not only does VMI significantly improve cash flow and improve stock

availability, but it reduces acquisition costs through reduced material handling and eliminating the need for multiple purchase transactions and processing multiple invoices. www.paragon-kitting.com Single component snap cure epoxy has outstanding electrical properties and chemical resistance Master Bond EP17HT-3 is a one part epoxy that sets

Global SMT &amp; Packaging – Celebrating 10 Years – July 2010 – 43


New Products

up in 20 to 30 seconds and snap cures in only 2 to 3 minutes at 250°F-300ºF. As a one-part system, no mixing is required and the epoxy can be cured in sections up to ¼-inch thick. Moreover, its working life is indefinite as it will not gel until heated above 200ºF. With a volume resistivity of greater than 1014 ohm-cm, EP17HT-3 has excellent electrical insulation and chemical resistance characteristics. It also has superior temperature resistance with a service operating temperature range of -60ºF to +400ºF. It is 100% reactive and contains no solvents or diluents. www.masterbond.com

Shine™ glass and surface cleaner and EcoShower™ cleaner and degreaser. Both are effective, safe and eco-friendly, and feature the following advantages: Non-flammable; biodegradable; low VOC, zero GWP; non-ozone depleting. The benefits of the Renew product line include low ecological impact, low VOCs and no global warming, sustainable and biodegradable, recycled/ recyclable packaging and regulatory compliance—they fully meet European REACH and WEEE requirements. www.intertronics.co.uk Verigy announces mixed-signal testing capability for V101 platform

Intertronics unveils “GREEN” Techspray Renew™ cleaners

Intertronics announced a new range of environmentally friendly Techspray Renew products. Two innovative products are designed specifically for a range of industrial applications from engineering to electronics and laboratories to offices: Eco-

44 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

Verigy has enhanced its V101 platform by adding new capability for testing mixedsignal semiconductor devices. The versatile V101 platform, designed for high-volume testing of cost-sensitive ICs at both the wafer sort and final test production steps, now delivers mixed-signal capability designed for testing devices with audio and video signals. The V101’s mixedsignal capability is enabled by a plugand-play module that can be quickly and easily installed into the V101 for testing mixed-signal ICs used in applications such as automotive, communications, data processing, and audio and video consumer electronics. The zero-footprint V101 platform can cost-effectively test microcontrollers and other low-pin-count, low-cost ICs in the high-mix manufacturing environments where these devices are typically produced. www.verigy.com Absolute Turnkey introduces Absolute Advantage program to the OEM and EMS marketplace Absolute Turnkey announces the Absolute Advantage program for OEMs and the EMS marketplace. The Absolute Advantage program was developed to provide customers with the ultimate in flexibility, while getting their products

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to market with speed. The combination of flexibility and speed is what sets the Absolute Advantage apart from other EMS providers.The Absolute Advantage helps customers to rapidly introduce innovative technology, which provides a speed-tomarket solution for OEM customers. The complete solution also provides speed in getting OEM customers’ products to market quickly. The end-to-end solution is ideal for engineering services, prototypes, pilots and production. www.AbsoluteTurnkey.com Multi-Seals now offers epoxy preforms with low outgassing properties Multi-Seals Inc. introduces a line of Uniform epoxy preforms with low outgassing properties. Unlike many adhesives, these highly cross-linked pre-shaped thermoplastics release minimal amounts of trapped gasses or condensable material under vacuum conditions and elevated heat.

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Low outgassing properties are essential for aerospace applications, particularly in vacuum environments where volatiles from other adhesives often condense on optics and electronics, adversely affecting their function. With a typical total mass loss of 0.35% and typical collected volatile condensable materials of 0.03% (tested per ASTM-E-595-93), these low-outgassing epoxies meet NASA requirements for most spacecraft materials. www.multi-seals.com Guide to Understanding Electrical Test and Measurement

Keithley Instruments, Inc. released a tutorial CD that offers practical and helpful techniques for obtaining the most accurate and precise measurements

possible. Keithley’s “A Guide to Understanding Electrical Test and Measurement” CD is the most in-depth knowledge center that Keithley has ever created, and covers all aspects of measurement performance, including how to troubleshoot, how to connect, how to select instruments and much more. The CD contains a large number of application notes, white papers and webcasts on a wide variety of test and measurement topics. To receive your free copy of Keithley’s A Guide to Understanding Electrical Test and Measurement CD, visit www.keithley.info/tmcdfy10 For beautiful marking results—fast TRUMPF introduces two new marking lasers—the TruMark 6030 and TruMark 6140—to its TruMark Series 6000. Users can now choose from six high performance machines that are available in any wavelength needed for surface processing. The TruMark 6030 and 6140 lasers feature considerably shorter marking times when compared to other products in the TruMark Series 6000. TRUMPF has increased the output of these new marking lasers by about 35 percent. www.trumpf.com

Global SMT &amp; Packaging – Celebrating 10 Years – July 2010 – 45


Case Study: High qualityA manufacturing need not mean highgrid production costs history of the development of ball array (BGA) and column grid array (CGA) components

Werner Engelmaier “BGAs and CGAs came about, because the solder attachments of leadless ceramic chip carriers (LLCCCs) on FR-4 PCBs could not meet reliability requirements.”

A history of the development of ball grid array (BGA) and column grid array (CGA) components While purely technical treatments of reliability issues are important, it also is important to understand why some of the developments impacting our industry came about. The development of ball grid array (BGA) components as well as column grid array (CGA) components is such a case.

BGAs and CGAs came about because the solder attachments of leadless ceramic chip carriers (LLCCCs) on FR-4 PCBs could not meet reliability requirements. The first large surface mount (SMT) component was the leadless ceramic chip carrier (LLCCC), with solder joints

Figure 1. Fatigued solder joints of leadless ceramic chip carrier on FR-4 (Courtesy of Dave Hillman, Rockwell Collins, USA).

Figure 2. Fatigued ‘ bulbous’ solder joints of leadless ceramic chip carrier on FR-4 (Courtesy of Gail Love, Martin-Marietta, Florida USA).

46 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

formed by bottom soldering pads and soldering areas in ‘castellations’ along the sides. These castellations were the result of the postage-stamp-like perforations of the ceramic in its green stage prior to separation by breaking. As all components in that time frame, it was made of ceramic to be soldered to hybrid substrates, also made of ceramic. That, of course, did not last, and LLCCCs were placed on FR-4 PCBs as well, with the in hindsight fully understandable problem with inadequate solder joint reliability1 as can be seen in Figure 1. Lots of effort went into trying to improve the solder joint reliability of this combination2, see Figure 2. However, for leadless solder joints, there are only four primary parameters determining solder joint reliability: 1. component size, DNP (distance from neutral point) 2. the mismatch in coefficients of thermal expansion, ∆CTE; 3. the cyclic thermal excursion, ∆T; and 4. the solder joint height, h. For ceramic components on FR-4, the ∆CTE is essentially fixed; the component size determining the DNP is a function of functionality, as is ∆T—that leaves only h. Everything else being equal, the cycles-tofailure increase roughly with the power-oftwo of the solder joint height, h. Thus, at Bell Laboratories, both solder balls and solder columns were utilized to increase h; mind you those initial components had only peripheral rows of

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A history of the development of ball grid array (BGA) and column grid array (CGA) components

Figure 4. Fatigued solder columns from a ceramic CGA on FR-4 (Source: Werner Engelmaier, Bell Laboratories, USA).

Forgotten Lessons,” Global SMT &amp; Packaging, Vol. 3, No. 2, March 2003, pp. 42-43. Hall, P. M., “Forces, Moments, and Displacements During Thermal Chamber Cycling of Leadless Ceramic Chip Carriers Soldered to Printed Boards,” IEEE Trans. Components, Hybrids, and Manufacturing Technology, Vol. CHMT-7, No. 4, December 1984, p. 314. Fisher, J. R., “Cast Solder Leads for Leadless Semiconductor Circuits,” U.S. Patent 4,412,642, November 1, 1983. Fisher, J. R., “Cast Leads for Surface Attachment,” Proc. 44th Electronic Components Conf., New Orleans, LA, May 1984, pp. 487-497; also in IEEE Trans. Components, Hybrids, and Manufacturing Technology, Vol. CHMT-7, No. 4, December 1984, pp. 306-313 LoVasco, F., and M. A. Oien, “A New Soldering Technology for SurfaceMounting Pad Grid Arrays,” Proc. Int. Electronics Packaging Conf. (IEPS), November 1988. Engelmaier, W., “BGA and CGA Solder Attachments: Results of Low-Acceleration Test and Analysis,” Proc. Surface Mount International Conf., San Jose, CA, August 1995, pp. 344-358; also in Proc. Int. Electronics Packaging Conf. (IEPS), San Diego, September 1995, pp. 758-774; also in Proc. NEPCON West ‘96, Anaheim, CA, February 1996, pp. 385-395. Engelmaier, W., “Achieving Solder Joint Reliability in a Lead-Free World, Part 2,” Global SMT &amp; Packaging, Vol. 7, No. 7, July 2007 [EU-edition], pp. 48-50; No. 8, August 2007 [USedition], pp. 44-46.

Figure 3. Fatigued solder ball from a ceramic BGA on FR-4 (Source: Werner Engelmaier, Bell Laboratories, USA).

soldering pads since they were LLCCCs3-6. Only somewhat later a second row was added. We certainly did not call them the ‘array-anything’ initially, because at that stage they were not arrays. The results of exhausting reliability testing were published rather late because of misplaced management competitive concerns7. Figures 3 and 4 show the first fatigued solder balls and solder columns. Because of the origin as LLCCCs, the initial soldering pads, both on the components and the PCBs, were not circular, but rectangular or square. Circular pads were only introduced because of the solder columns. Results from accelerated tests show that the solder joint geometries produced by rectangular soldering pads result in slightly higher fatigue lives than those from circular pads7. The insights gained led to the commercialization of BGAs and CGAs; it also led to the development of highmelting 90Pb10Sn solder balls which would not melt and collapse during reflow soldering, thus maintaining the ball diameter as the solder joint height, h. With the soldering temperatures for the Pb-free solders, this technology is no longer available, however, and an alternate technology8 works at least as well. References: 1. Engelmaier, W., “Effects of Power Cycling on Leadless Chip Carrier Mounting Reliability and Technology,” Proc. Int. Electronics Packaging Conf. (IEPS), San Diego, CA, November 1982, p. 15. 2. Engelmaier, W., “Of Ceramic Components: Failed Solder Joints, LLCCCs, ‘Bulbous’ Solder Joints, ‘Super-Compliant’ Leads, and

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3.

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5.

6.

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Werner Engelmaier will be giving some of his reliability workshops at Conferences in Tallinn, Estonia, September 21-23, 2010 and GEM Expo Brazil 2010 in Sao Paolo, Brazil, October 5-7, 2010. He will be available for in-house workshops and consulting in both English and German in Europe in the June timeframe; for details of the workshops go to www.engelmaier. com; for more information about the workshops and consulting contact engelmaier@aol.com. Werner Engelmaier has over 44 years experience in electronic packaging and interconnection technology and has published over 200 papers, columns, book chapters and White Papers. Known as ‘Mr. Reliability’ in the industry, he is the president of Engelmaier Associates, L.C., a firm providing consulting services on reliability, manufacturing and processing aspects of electronic packaging and interconnection technology. He is the chairman of the IPC Main Committee on Product Reliability. The TGM-Exner Medal was bestowed on him in 2009 in Vienna, Austria, he was elected into the IPC Hall of Fame 2003, and was awarded the IPC President’s Award in 1996 and the IEPS Electronic Packaging Achievement Award in 1987. He also was named a Bell Telephone Laboratories Distinguished Member of Technical Staff in 1986 and an IMAPS Fellow in 1996. More information is available at www.engelmaier. com, and he can be reached at engelmaier@ aol.com.

Global SMT &amp; Packaging – Celebrating 10 Years – July 2010 – 47


Case Study:&amp;High qualitynews manufacturing need not mean high production costs Association institutes

Association &amp; institutes news SMART Group announce 26th Birthday Conference Following our successful two-day conference last year that celebrated 25 years of the SMART Group’s existence, SMART Group proudly announces that after a busy year of events, they will celebrate their 26th anniversary with an equally exciting twoday event. The aim and thrust of this year’s conference is to address many of the issues facing our industry today. Despite some of the pessimism, the electronics industry here has much still to offer our global customers. As an example, SMART Group’s vice chair, Graham Naisbitt, quoted a recent statement issued by the Chinese government that they were concerned that their industry has a poor reputation for quality and reliability. “They sponsored a delegation to come to the UK, through ITRI, International Tin Research Institute in St Albans,” Naisbitt said, “where a number of persons would make presentations to them on this topic. In particular I was thankful that they consider the UK is still the centre to develop products that have high quality and high reliability. “Shame only that we no longer seemingly have the capacity to produce in large quantities, perhaps that will change.” This year’s conference will look at the supply chain, inform about the latest research projects and explore whether manufacturing standards make things better. Other topics cover production control, the importance of chemistry, what’s happening with RoHS and REACH, why do we clean when we have no clean and what are tin whiskers—all will be explained. The sessions will also cover component tinning and re-tinning good practice, silver vs sulphur—can conformal coating help? We are lining up an eminent worldclass team for this event to be held on 6th &amp; 7th of October. The venue is again The Oxfordshire GC Business Centre.

The full programme of presentations will be announced shortly with a list of exhibitors. For more information contact: Tony Gordon, SMART Group Secretary, Tel: +44 (0)1494 465217 Email: info@ smartgroup.org or Mike Judd, SMART Group PR Director, Tel: +44 (0)118 978 4589 Email: mjudd@mjm-marketing.com.

European Parliament Environment Committee vote puts TBBPA on priority assessment list IPC—Association Connecting Electronics Industries® expressed disappointment in the vote by the European Parliament’s Environment Committee to include broad families of chemicals, such as organobromines, in Annex III for priority assessment. While an outright ban of these chemicals has been averted in this vote, the committee’s decision falls far short of supporting a rigorous scientific assessment that would ensure protection of the environment and human health. IPC is concerned that the process outlined in the amendments approved today does not define a rigorous scientific methodology. The proposed process “lacks a rigorous scientific methodology and could therefore lead to additional substance restrictions that provide neither environmental nor human health benefits,” says Fern Abrams, IPC director of environmental policy and government relations. The inclusion of broad families of chemicals, such as all organobromines, for priority assessment under Annex III is impractical and unscientific. While some organobromines, such as polybrominated biphenyls (PBBs), have been identified as toxic, restricted under the RoHS Directive and voluntarily withdrawn from the market, other organobromines, such as TBBPA, have been found to be safe for human health and the environment by both the World Health Organization and the European Commission Scientific Committee on Health and Environmental Risks (SCHER).

48 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

In direct lobbying efforts over the past year, IPC has urged the European Union to amend the RoHS Directive to introduce rigorous scientific methodology aligned with the comprehensive chemicals evaluations under the REACH (Registration, Evaluation, Authorisation and Restriction of Chemicals) regulation. IPC continues to lobby to ensure the RoHS revision’s process reflects sound scientific methodology. IPC’s white paper, “Recasting the RoHS Directive: An Opportunity to Solidify its Scientific Basis in Support of Comprehensive Environmental Regulation,” advocates for a revised RoHS to be based on sound science and fully aligned with the REACH methodology for substance restrictions. The European Parliament is currently scheduled to vote in July on the Environment Committee’s recommendations for recasting the RoHS Directive. The Environment Committee is also scheduled to vote on the related Waste Electrical and Electronic Equipment (WEEE) Directive later this month, with a plenary vote to take place in July. www.IPC.org IPC-2152-DE—Standard for determining current-carrying capacity in printed board design now available in German IPC - Association Connecting Electronics Industries® announced the German language release of IPC-2152-DE, Designrichtlinie für die Bestimmung der Stromtragfähigkeit von Leiterplatten. This document is the translation of IPC-2152, Standard for Determining Current-Carrying Capacity in Printed Board Design, which was released in English in August of 2009. The 97-page document sets the sole industry standard for determining the appropriate sizes of internal and external conductors as a function of the current-carrying capacity required and the acceptable conductor temperature rise. IPC members may request a free, single-user download of IPC-2152-DE by e-mailing MemberTechRequests@ipc. org within 90 days of its release; after 90 days, the price for members is $50. The nonmember price of IPC-2152-DE is $100. Visit www.ipc.org/2152-DE for details and to purchase.

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Global SMT &amp; Packaging – Celebrating 10 Years – July 2010 – 49


IMAPS news

IMAPS Europe news

News from IMAPS Italy On the 20th of May, IMAPS Italy held a workshop on cleaning technologies for electronic assembly at the Crown Plaza hotel San Donato Milan. The event was held in association with Assodel, the Italian electronic suppliers association, and sponsored by AMES, the microelectronic and semiconductor section of the Italian Electronic and Electrical Association. Over 60 participants attended from 46 technical institutions and companies representing a cross section of companies involved in electronic component and system manufacture. Presentations were given on the potential hazards caused by contaminants in microlectronic assemblies and the identification of associated failure mechanisms, cleaning methods including new developments solvents and plasma cleaning. A particularly interesting problem was outlined by L. Ferruccci of Nokia Siemens Networks showing how miniscule flux residues can vary RF performance.

News from IMAPS Nordic IMAPS Nordic has an old tradition to hold their yearly conference alternating in each of the four Nordic countries. This year Sweden was in tour and Gothenburg on the west coast was chosen as a lot of electronics industry and research is located here. The programme was very rich, with both local speakers and invitees from other regions. Among the best was Jean-Marc Yannou’s presentation on 3D packaging and IPDs. The ELC President Nihal Sinnadurai brought us both technical information and news about the organisational situation within Europe and globally. The event was finished with a visit to IMEGO Institute where applied research and new electronics products are pre-developed in close cooperation with both industry and other R&amp;D institutes. Unfortunately the participation in the conference was lower than ever. This could be due to the fact that this was the first time it was held in June, not September. Perhaps the organisers were not alert to market the event early enough, or is June not a good time for the participants? Next year we will try June again, this time in Finland.

Conference building (C-13) at Wrocław University of Technology . (Source: Maciek Krol) News from IMAPS Poland The 34th IMAPS-CPMT Poland 2010 International Conference organized by Wroclaw University of Technology (Faculty of Microsystem Electronics and Photonics) will be held in Wroclaw on 22-25 September, 2010. This year our conference is organized together with 10th Electron Technology ELTE 2010 Conference (Polish conference organized every three years and devoted to electronic materials, micro- and nanoelectronics, photonics and microsystems). It will be a good opportunity to exchange the scientific results between wide range of scientists and specialists from electronic industry. The conference presentations will be divided into plenary sessions, section sessions and poster sessions. The main topics include: • Thin- and thick-film technologies; • Thin- and thick-film sensors; • Modelling, design and simulation of film structures, components and circuits; • Modern technologies and applications of multichip modules; • Electrical, optical, mechanical and thermal characterization of film structures, components and circuits; • Packaging in electronics, photonics and microsystems; • Quality and reliability of film structures and packaging processes.

50 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

The exhibition of technological and diagnostic equipment is planned during the conferences. Papers chosen by scientific committees will be recommended for publishing in international and national technical journals. The conference presentations will be divided into plenary sessions, section sessions and poster sessions. Presentations/ posters for IMAPS/CPMT will be prepared in English abstracts, and full texts of papers will be prepared in English. Students, PhD students and young researchers (below 32 years old) can participate in contests for best papers in particular thematic sections. Exhibition of technological and diagnostic equipment is planned during the conference. Papers chosen by the Scientific Committees will be recommended for publishing in international and national technical journals. The conference will be held at the Wrocław University of Technology, building C-13, i.e. Integrated Students Center, Wybrzeże Wyspiańskiego 23/25 in Wrocław More information can be found on the conference website: www.imaps2010.pwr. wroc.pl.

www.globalsmt.net


European Electronics Assembly

Reliability Summit The European Union continues to impose legislation on the electronics manufacturing community. REACH, RoHS and WEEE all have significant impact on the manufacturability of our board assemblies and finished goods. The Second European Electronics Assembly Reliability Summit brings together experts and provides a unique opportunity to examine, learn and debate these business-critical issues through industry discussion, technical collaboration and information sharing. The event will include a technical conference, tabletop exhiibition and networking opportunities. Join us this September. Visit the website to learn more.

September 21-23, 2010 Tallink Spa &amp; Conference Hotel, Tallin, Estonia This conference is being held at a critical time for the electronics industry. Increasing legislation and lack of reliability in electronics assemblies and interconnections is providing many challenges for, designers, specifiers and manufacturers of printed assemblies. The rise in counterfeit components is only adding to these challenges.

September 21-23, 2010

Bourdain is dead. I’m devastated.

There is no death closer to home for me. For some it was Robin Williams that left them gasping, but this is the one by which all others will measure.

If you’re new to me, I’ve been travelling the world alone for nearly three years now. 22 countries. I’m a journalist and writer by trade.

I find my life experiences through words, food, and places, like Bourdain. I feel injustices deeply and rage against the storm. I’ve spoken truth to power and shouted with futility into the wind.

All these things are evocative of the path Bourdain has blazed before me, and his death fucking rocks me to core. And I’m over 10,000 kilometres from nearly everyone I love and I feel so goddamned alone after this news.

Today, I acknowledge I’ve been suicidal before and there are no guarantees I won’t feel that way again one day. This is not that day.

Still. I just discovered this horrific news while walking along the Sava River in Belgrade, Serbia to reach a Latin gastropub in the sweltering sun. The first song playing here is some electronic dance number that keeps repeating the phrase “Keep yourself together. Keep yourself together.”

Fitting, that. I’m trying, song. I’m trying.

I woke this morning in a foul mood, and I shouldn’t have. Yesterday was a good news day. A free trip to Poland is coming my way: Great! I couldn’t fathom why I woke so foul. I woke and the world felt wrong to me.

It was one of those Things Don’t Feel Right mornings where the mood’s oppressive and non-explanatory. The heat is choking Belgrade today. Feels like 102 F, and I hate it. I do badly in this heat at the best of times.

But this news explains why I woke feeling like there was a disturbance in the Force.

Understanding What We Don’t Understand

I can’t understand what drove Bourdain to his death. I understand depression. I understand, too, the futility that must come from so long of travelling.

Jaded. Jaded as fuck, is what I can describe my worldview as, some days.

There are times when I feel like history tempers all things and despite every obstacle we face, humans rumble on. The world just keeps moving. We survive, we persist. The bastards die and new bastards are born. The heroes die and new heroes are born.

Then there are times when I rage against the world, angered that someone like Trump can be in power, that we can be so blind to hate and fear and injustice and corruption. I travel through places where corruption is as much a part of the fabric of life as the air we breathe, and people shrug in the face of it. I see poverty that makes me wonder how life is such a lottery of luck, and how that can be okay in the scheme of things.

I see enough to convince me that I don’t think there’s a god. Not in the benevolent way we dream, anyhow. Delusional is what I feel most faith today is. I think of the Cambodian man with arms blown off and no eyes, thanks to an American landmine, and I question that there’s a god. I see a child beggar bawling in hopelessness and I think there must be no god, because how could there be?

But some people seem like they’re the guard on the wall, the check to the power, the shouter in the storm, and Bourdain was that guy for me.

And it’s frustrating to me because I understand depression. I do. Deeply. So deeply.

I understand the futility of sanity and how it can slip away so goddamned fast. I understand that suicide and depression are often a chemistry question that can’t be solved.

Eenie-Meenie Miney-Mo

Sometimes I wonder what the variant is. Is there a variant? Why him? Why not me? Is it just a matter of time? I have to believe there’s something in the cosmic mix that distinguishes us. Like, I’ve never done heroin or cocaine or any kind of hard drug. I never will. Bourdain has, and so have many of those who’ve killed themselves in the public circle of late.

Maybe drugs affect our mind more. Who knows. I remember a guy told me, when I was 21, that the secret to surviving drug use was to never take anything not grown by a Grateful Dead fan. I’m 45 in September and that has served me well, yet I cowered in the corner in August, 2006 as I called a therapist to say I feared I would kill myself that day, and I meant every word of it.

The thing about Bourdain that makes me think today is that he seemed to talk about so much, about everything, except about mental health. I’ve never really seen him talking about depression or anxiety — just misery and mood. There’s a big difference between being a curmudgeonly person and owning your depression. They’re arguably both caused by the same thing — mental health — but one involves ignoring the overall roots and implications. The other involves understanding that the mindset can sometimes be bigger than you are, a problem of chemistry, a defect of cells, a matter of interrupted neurons.

Standing in the Picture

And that’s somewhere Bourdain and I have always differed. I think about the internal factor. I put myself in the picture and I think about how it all impacts me — how it will always impact me, especially in travel. I filter the world through my eyes, because what the fuck else have I got?

There’s a mentality growing in travel writing today about trying to erase colour lines and shunning the colonial perspective of the Great White Traveller, but I’m not going to go that way.

It’d be nice to pretend I can, but the reality is, I am white. I am fish-belly white. I’m so white, I make white look tan. I am the Great White Traveller.

Then there’s my Vancouver-Canada birth thing. I go into these countries from the perspective of someone who’s life has been shaped by one of the most peaceful countries in the world, born in a city with only 130 years of history. To pretend I’m anything other than white and privileged is ridiculous. To pretend I somehow have a collective, all-encompassing view on the places I’ve been, that’s moronic.

All I can offer the world is my experience, and I’m not going to apologize for it. But should people look for more than just my white perspective? Goddamned right. Celebrate writers for who they are, the variety they bring to the experiences. Read writers from other cultures too.

Did Bourdain do enough of that? Putting himself in the picture? Accepting that he could be relevant to the story too? Did he forget who he was in the process? Did his celebrity make him feel he had lost the ability to be vulnerable? Did we hold him up as the answer to injustice, to be the keeper at the gate, and was that pressure too great for him?

There Ain’t No Saviors, No How

I’m thinking a lot right now of a woman I told off a few months ago. Bourdain had come up in conversation and she railed against him because he didn’t “do enough” about the situations he saw in the world.

Really? And how does one “do enough”? How does one shine the spotlight on all things while trying to fix them too? It’s impossible. Some of us are meant to hold the mirror, and others are meant to get in there and tinker. Bourdain was a mirror-holder. He did it so well. So many of us learned more about the world around us, and shattered our illusions, thanks to mirrors held by the likes of Bourdain.

I’m a mirror-holder. It’s hard work enough. I can’t tell you how much some of the shit I’ve seen while travelling weighs on me. A friend of mine did a whirlwind trip through troubled countries and now is in counselling because he feels he’s suffered PTSD from all the terrible things he’s learned about what’s possible for humans to do to others. “Man’s inhumanity against man,” and all that.

We can question morality forever and I don’t think we’ll ever understand the conflict of good and evil, or the way in which we reconcile the two existing in the same space.

My heart goes through the ground every time I see a child on the streets, begging. And I don’t mean just sitting there, asking for money — I mean the child who epitomizes, in a single glance, all the horrors that exist in humanity. Rage explodes within me when I know it’s someone exploiting that child and forcing them to be that way. Helplessness roars when I know it’s a no-win situation; I can’t contribute to them or I’m making exploitation pay. I can’t report them, because the system already knows, and the child just keeps falling through the cracks. I walk away. There’s nothing I can do. And I fucking hate myself every time, but that’s all a traveller can do, sometimes.

Yet someone like that woman can’t understand that the best someone like me or Bourdain can do is to keep pointing out how this situation hasn’t improved with modernity, it’s still there, it needs fixing.

And maybe, in the end, what got Bourdain is the futility of repeating the message. The fatigue of being demanded to do more, and the hopelessness of knowing he couldn’t. Perhaps it’s the uneasy burden of machismo and the inability to be vulnerable in a sea of scrutiny and hero-worship.

Talk, Talk, Talk

And so today I’m doing the only thing I know how to do to keep me from being in that situation:

I’m talking about it.

I’m flawed. Moods get the better of me. But I know how to fight them. I own them. I accept them. I don’t apologize for them. I speak to them. I blow off steam. I call out bullshit when I see it. I say fuck off to people who expect me to be more even-keeled or together. I let my vulnerabilities show — probably not as much as I should, but enough that they drown out the mental noise of anger and depression.

I understand that not all depression responds to these efforts. That’s the problem. Sometimes it’s not enough. And that’s why I know I need to do this when I’m cognizant of where I’m at, because there’s only so much I can do and for so long. One day, maybe I hit that point that Bourdain hit yesterday, and I hope if I do, this groundwork I’ve lain will help me rise against it.

So, today, I’ve talked about it. I’ve written about it. I’ve tried to understand why it’s devastating me that this moody fucking light I loved so much has been snuffed out in France. And maybe I don’t understand it a lot better, but I understand it a little better, and I’ve put a name to it and I’ve owned it and I’ve shared it.

Life will always be daunting and scary and lonely, especially for someone like me who’s travelling alone and challenging the night in so many unfamiliar, unsettling ways day after day after day.

But hopefully sharing my vulnerabilities and failings will keep me from ever feeling the kind of pressure someone like Bourdain does.

Fuck Your Hero Worship

You know, I don’t talk about things with my stalling writing career a lot. In some ways, I find my vulnerability is my saving grace, but it’s also my burden, because it makes people feel more entitled to my personal space and my mental real estate. (Newsflash, you’re not entitled to shit.)

I get flak from some people for not having released my ebook on my travels yet. I get flak from others for not trying to promote myself more because they think I should be more successful than I am.

But my past is weird. It’s a long story, but in 2005/2006, I had between 5,000 and 10,000 readers a day on my original blog. I remember the pressures that came with it. Becoming suicidal in 2006 put an end to that popularity and freed me from those pressures.

Still, I know what it’s like to get angry as fuck about injustice, like in the Jian Ghomeshi assault case in Canada, where 300,000 people turned to my words on my blog in three days, and then wrote to me about all matter of injustices they wanted me to speak about, like I was somehow the only person who could carry the cross and fight the fight.

I’m just a girl with words, man. That’s all it is. I got my words. You got words too. Use yours, don’t demand mine.

I’ve never wanted to be anyone’s hero, and yet I’ve had people say that’s what I am. What the fuck? I’m so imperfect, it’s crazy. Aim higher, people. The only heroes out there are the ones on the page of Marvel and DC Comics, man.

Everyone else is a mistake on legs.

But Bourdain was hero to so many. They expected so much of him, wrongly.

Maybe that’s why I keep treading water as a writer — because I like not having to be more than what I am.

But Bourdain lived with those pressures for the last 17 years. I can’t imagine that. I never want his life. There’s only so much any of us owes anyone else, and maybe Bourdain just stopped feeling like he had that in him to give.

Never forget that your heroes have flaws. They have weaknesses and stupidities and imperfections. You aren’t your ideal self every day, and you sure as hell have no right to demand it of them.

Celebrity today means living under a magnifying glass, being inescapably under scrutiny by people who couldn’t live under the same judgment for a week, let alone a year or a decade. The hypocrisy is legion, and yet the public demands perfection of its idols.

Someone like Bourdain, well… I’m just some blogger girl with barely an audience and I can’t tell you how often someone tells me off for disappointing them because I’m imperfect and normal. What the hell did he have to endure?

Accept Imperfection — Your‘s and Others’

Live your own life. Stop expecting your idols and celebrities to be the crutch that props you up through it all. Their humanity will surely have you falling down, because there’s no way that crutch doesn’t one day break.

I’m sorry that one of my perfectly imperfect heroes didn’t have it in him to get through the struggles of life, but I can’t say I’m unable to imagine why, either. I’m just sorry, is all.

I hope his pain is over. I hope his family finds a way to carry on. I hope you do too. I hope you speak your truths, however uncomfortable they are, because it helps.

But I hope you find a light in the darkness too. I know I often do, and expect I’ll continue to, because where there’s evil, there’s good. Where there’s pain, there’s often joy too. It’s a complicated life of contradictions, and sometimes I find the best thing for my mental health is to remember how chaotically contrasting life has always been and always will be.

But ultimately, I try to remember that it’s okay to be vulnerable — not just for me, but for my heroes too.

Stop expecting perfection from people. Stop expecting them to somehow have it more together than you do. Nobody does. We’re all fucked up. We’re all trying to navigate a life that’s often hard and unthinkably cruel. Understanding that is what can get us through it together.

Talk about it. End the stigma.

I’m fucked up. I bet you are too. And that’s okay. Just own it.

(If this resonated for you, please “clap” for it so it gets a wider audience. Stigma’s easier fought with a megaphone. Thanks.)


The Burden of Being Bourdain was originally published in Noteworthy - The Journal Blog on Medium, where people are continuing the conversation by highlighting and responding to this story.

Источник: [https://torrent-igruha.org/3551-portal.html]
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Case Study: High qualityA manufacturing need not mean highgrid production costs history of the development of ball array (BGA) and column grid array (CGA) components

Werner Engelmaier “BGAs and CGAs came about, because the solder attachments of leadless ceramic chip carriers (LLCCCs) on FR-4 PCBs could not meet reliability requirements.”

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BGAs and CGAs came about because the solder attachments of leadless ceramic chip carriers (LLCCCs) on FR-4 PCBs could not meet reliability requirements. The first large surface mount (SMT) component was the leadless ceramic chip carrier (LLCCC), with solder joints

Figure 1. Fatigued solder InterNetView 2.0.1.8 crack serial keygen of leadless ceramic chip carrier InterNetView 2.0.1.8 crack serial keygen FR-4 (Courtesy of Dave Hillman, Rockwell Collins, USA).

Figure 2. Fatigued ‘ bulbous’ solder joints of leadless ceramic chip carrier on FR-4 (Courtesy of Gail Love, Martin-Marietta, Florida USA).

46 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

formed by bottom soldering pads and soldering areas in ‘castellations’ along the sides. These castellations were the result of the postage-stamp-like perforations of the ceramic in its green stage prior to separation by breaking. As all components in that time frame, it was made of ceramic to be soldered to hybrid substrates, InterNetView 2.0.1.8 crack serial keygen, also made of ceramic. That, of course, did not last, and LLCCCs were placed on FR-4 PCBs as InterNetView 2.0.1.8 crack serial keygen, with the in hindsight fully understandable problem with inadequate solder joint reliability1 as can be seen in Figure 1. Lots of effort went into trying to improve the solder joint reliability of this combination2, see Figure 2. However, for leadless solder joints, there are only four primary parameters determining solder joint reliability: 1. component size, DNP (distance from neutral point) 2. the mismatch in coefficients of thermal expansion, ∆CTE; 3. the cyclic thermal excursion, ∆T; and 4. the solder joint height, h. For ceramic components on FR-4, the ∆CTE is essentially fixed; the component size determining the DNP is a function of functionality, as is ∆T—that leaves only h. Everything else being equal, the cycles-tofailure increase roughly with the power-oftwo of the solder joint height, h. Thus, at Bell Laboratories, both solder balls and solder columns were utilized to increase h; mind you those initial components had only peripheral rows of

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Figure 4, InterNetView 2.0.1.8 crack serial keygen. Fatigued solder columns from a ceramic CGA on FR-4 (Source: Werner Engelmaier, Bell Laboratories, USA).

Forgotten Lessons,” Global SMT &amp; Packaging, Vol. 3, No. 2, March 2003, pp. 42-43. Hall, P. M., “Forces, Moments, and Displacements During Thermal Chamber Cycling of Leadless Ceramic Chip Carriers Soldered to Printed Boards,” IEEE Trans. Components, Hybrids, and Manufacturing Technology, Vol. CHMT-7, No. 4, December 1984, p. 314. Fisher, J. R., “Cast Solder Leads for Leadless Semiconductor Circuits,” U.S. Patent 4,412,642, November 1, InterNetView 2.0.1.8 crack serial keygen, 1983. Fisher, J. R., “Cast Leads for Surface Attachment,” Proc. 44th Electronic Components Conf., New Orleans, LA, May 1984, pp. 487-497; also in IEEE Trans. Components, Hybrids, and Manufacturing Technology, Vol. CHMT-7, No. 4, December 1984, pp. 306-313 LoVasco, F., and M. A. Oien, “A New Soldering Technology for SurfaceMounting Pad Grid Arrays,” Proc. Int, InterNetView 2.0.1.8 crack serial keygen. Electronics Packaging Conf, InterNetView 2.0.1.8 crack serial keygen. (IEPS), November 1988. Engelmaier, W., “BGA and CGA Solder Attachments: Results of Low-Acceleration Test and Analysis,” Proc. Surface Mount International Conf., InterNetView 2.0.1.8 crack serial keygen, San Jose, CA, August 1995, pp. 344-358; also in Proc. Int. Electronics Packaging Conf. (IEPS), San Diego, September 1995, pp. 758-774; also in Proc. NEPCON West ‘96, Anaheim, CA, February 1996, pp. 385-395. Engelmaier, W., “Achieving Solder Joint Reliability in a Lead-Free World, Part 2,” Global SMT &amp; Packaging, Vol. 7, No. 7, July InterNetView 2.0.1.8 crack serial keygen [EU-edition], pp. 48-50; No. 8, August 2007 [USedition], pp. 44-46.

Figure 3. Fatigued solder ball from a ceramic BGA on FR-4 (Source: InterNetView 2.0.1.8 crack serial keygen Engelmaier, Bell Laboratories, USA).

soldering pads since they were LLCCCs3-6. Only somewhat later a second row was added. We certainly did not call them the ‘array-anything’ initially, because at that stage they were not arrays. The results of exhausting reliability testing were published rather late because of misplaced management competitive concerns7. Figures 3 and 4 show the first fatigued solder balls and solder columns. Because of the origin as LLCCCs, the initial soldering pads, both on the components and the PCBs, were not circular, but rectangular or square. Circular pads were only introduced because of the solder columns. Results from accelerated tests show that the solder joint geometries produced by rectangular soldering pads result in slightly higher fatigue lives than those from circular pads7. The insights gained led to the commercialization of BGAs and CGAs; it also led to the development of highmelting 90Pb10Sn solder balls which would not melt and collapse during reflow soldering, thus maintaining the ball diameter as the solder joint height, h. With the soldering temperatures for the Pb-free solders, this technology is no longer available, however, InterNetView 2.0.1.8 crack serial keygen, and an alternate technology8 works at least as well. References: 1. Engelmaier, W., “Effects of Power Cycling on Leadless Chip Carrier Mounting Reliability and Technology,” Proc. Int. Electronics Packaging Conf. (IEPS), San Diego, CA, November 1982, p. 15. 2. Engelmaier, W., “Of Ceramic Components: Failed Solder Joints, LLCCCs, ‘Bulbous’ Solder Joints, ‘Super-Compliant’ Leads, and

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Werner Engelmaier will be giving some of his reliability workshops at Conferences in Tallinn, Estonia, September 21-23, 2010 and GEM Expo Brazil 2010 in Sao Paolo, Brazil, October 5-7, 2010. He will be available for in-house workshops and consulting in both English and German in Europe in the June timeframe; for details of the workshops go to www.engelmaier, InterNetView 2.0.1.8 crack serial keygen. com; for more information about the workshops and consulting contact engelmaier@aol.com. Werner Engelmaier has InterNetView 2.0.1.8 crack serial keygen 44 years experience in electronic packaging and interconnection technology and has published over 200 papers, InterNetView 2.0.1.8 crack serial keygen, columns, book chapters and White Papers. Known as ‘Mr. Reliability’ in the industry, he is the president of Engelmaier Associates, L.C., a firm providing consulting services on InterNetView 2.0.1.8 crack serial keygen, manufacturing and DriverMax Pro 12.15.0.15 Crack Full Version Download aspects of electronic packaging and interconnection technology. He is the chairman of the IPC Main Committee on Product Reliability. The TGM-Exner Medal was bestowed on him in 2009 in Vienna, Austria, he was elected into the IPC Hall of Fame 2003, and was awarded the IPC President’s Award in 1996 and the IEPS Electronic Packaging Achievement Award in 1987. He also was named a Bell Telephone Laboratories Distinguished Member of Technical Staff in 1986 and an IMAPS Fellow in 1996, InterNetView 2.0.1.8 crack serial keygen. More information is available at www.engelmaier. com, InterNetView 2.0.1.8 crack serial keygen, and he can be reached at engelmaier@ aol.com.

Global SMT &amp; Packaging – Celebrating 10 Years – July InterNetView 2.0.1.8 crack serial keygen – 47


Case Study:&amp;High qualitynews manufacturing need not mean high production costs Association institutes

Association &amp; institutes news SMART Group announce 26th Birthday Conference Following our successful two-day conference last year that celebrated 25 years of the SMART Group’s existence, SMART Group proudly announces that after a busy year of events, they will celebrate their 26th anniversary with an equally exciting twoday event, InterNetView 2.0.1.8 crack serial keygen. The aim and thrust of this year’s conference is to address many of the issues facing our industry today. Despite some of the pessimism, the electronics industry here has much still to offer our global customers. As an example, SMART Group’s vice chair, Graham Naisbitt, quoted a recent statement issued by the InterNetView 2.0.1.8 crack serial keygen government that they were concerned that their industry has a poor reputation for quality and reliability. “They sponsored a delegation to come to the UK, through ITRI, International Tin Research Institute in St Albans,” Naisbitt said, “where a number of persons would make presentations to them on this topic. In particular I was thankful that they consider the UK is still the centre to develop products that have high quality and high reliability. “Shame only that we no longer seemingly have the capacity to produce in large quantities, perhaps that will change.” This year’s conference will look at the supply chain, inform about the latest research projects and explore whether manufacturing standards make things better. Other topics cover production control, the importance of chemistry, what’s happening with InterNetView 2.0.1.8 crack serial keygen and REACH, why do we clean when we have no clean and what are tin whiskers—all will be explained. The sessions will also cover component tinning and re-tinning good practice, silver vs sulphur—can conformal coating help? We are lining up an eminent worldclass team for this event to be held on 6th &amp; 7th of October. The venue is again The Oxfordshire GC Business Centre.

The full programme of presentations will be announced shortly with a list of exhibitors. For more information contact: Tony Gordon, SMART Group Secretary, Tel: +44 (0)1494 465217 Email: info@ smartgroup.org or Mike Judd, SMART Group PR Director, Tel: +44 (0)118 978 4589 Email: mjudd@mjm-marketing.com.

European Parliament Environment Committee vote puts TBBPA on priority assessment list IPC—Association Connecting Electronics Industries® expressed disappointment in the vote by the European Parliament’s Environment Committee InterNetView 2.0.1.8 crack serial keygen include broad families of chemicals, such as organobromines, in Annex III for priority assessment. While an outright ban of these chemicals has been averted in this vote, the committee’s decision falls far short of supporting a rigorous scientific assessment that would ensure protection of the environment and human health. IPC is concerned that the process outlined in the amendments approved today does not define a rigorous scientific methodology. The proposed process “lacks a rigorous scientific methodology and could therefore lead to additional substance restrictions that provide neither environmental nor human health benefits,” says Fern Abrams, IPC director of environmental policy and government relations. The inclusion of broad families of chemicals, such as all organobromines, for priority assessment under Annex III is impractical and unscientific. While some organobromines, such as polybrominated biphenyls (PBBs), have been identified as toxic, restricted under the RoHS Directive and voluntarily withdrawn from the market, other organobromines, such as TBBPA, have been found to be safe for human health and the environment by both the World Health Organization and the European Commission Scientific Committee on Health and Environmental Risks (SCHER).

48 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

In direct lobbying efforts over the past year, IPC has urged the European Union to amend the RoHS Directive to introduce rigorous scientific methodology aligned with the comprehensive chemicals evaluations under the REACH (Registration, Evaluation, InterNetView 2.0.1.8 crack serial keygen, Authorisation and Restriction of Chemicals) regulation. IPC continues to lobby to ensure the RoHS revision’s process reflects sound scientific methodology, InterNetView 2.0.1.8 crack serial keygen. IPC’s white paper, “Recasting the RoHS Directive: An Opportunity to Solidify its Scientific Basis in Support of Comprehensive Environmental Regulation,” advocates for a revised RoHS to be based on sound science and fully aligned with the REACH methodology for substance restrictions. The European Parliament is currently scheduled to vote in July on the Environment Committee’s recommendations for recasting the RoHS Directive. The Environment Committee is also scheduled to vote on the related Waste Electrical and Electronic Equipment (WEEE) Directive later this month, with a plenary vote to take place in July. www.IPC.org IPC-2152-DE—Standard for determining current-carrying capacity in printed board design now available in German IPC - Association Connecting Electronics Industries® announced the German language release of InterNetView 2.0.1.8 crack serial keygen, Designrichtlinie für die Bestimmung der Stromtragfähigkeit von Leiterplatten. This document is the translation of IPC-2152, Standard for Determining Current-Carrying Capacity in Printed Board Design, which was released in English in August of 2009. The 97-page document sets the sole industry standard for determining the appropriate sizes of internal and external conductors as a function of the current-carrying capacity required and the acceptable conductor temperature rise. IPC members may request a free, single-user download of IPC-2152-DE by e-mailing MemberTechRequests@ipc. org within 90 days of its release; after 90 days, the price for members is $50. The nonmember price of IPC-2152-DE is $100. Visit www.ipc.org/2152-DE for details and to purchase.

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Global SMT &amp; Packaging – Celebrating 10 Years – July 2010 – 49


IMAPS news

IMAPS Europe news

News from IMAPS Italy On the 20th of May, IMAPS Italy held a workshop on cleaning technologies for electronic assembly at the Crown Plaza hotel San Donato Milan. The event was held in association InterNetView 2.0.1.8 crack serial keygen Assodel, the Italian electronic suppliers association, and sponsored by AMES, the microelectronic and semiconductor section of the Italian Electronic and Electrical Association. Over 60 participants attended from 46 technical institutions and companies representing a cross section of companies involved in electronic component and system manufacture. Presentations were given on the potential hazards caused by contaminants in microlectronic assemblies and the identification of associated failure mechanisms, cleaning methods including new developments solvents and plasma cleaning. A particularly interesting problem was outlined by L. Ferruccci of Nokia Siemens Networks showing how miniscule flux residues can vary RF performance.

News from IMAPS Nordic IMAPS Nordic has an old tradition to hold their yearly conference alternating in each of the four Nordic countries. This year Sweden was in tour and Gothenburg on the west coast was chosen as a lot of electronics industry and research is located here. The programme was very rich, with both local speakers and invitees from other regions. Among the best was Jean-Marc Yannou’s presentation on 3D packaging and IPDs, InterNetView 2.0.1.8 crack serial keygen. The ELC President Nihal Sinnadurai brought us both technical information and news about the organisational situation within Europe and globally. The event was finished with a visit to IMEGO Institute where applied research and new electronics products are pre-developed in close cooperation with both industry and other R&amp;D institutes. Unfortunately the participation in the conference was lower than ever, InterNetView 2.0.1.8 crack serial keygen. This could be due to the fact that this was the first time it was held in June, not September. Perhaps the organisers were not alert to market the event early enough, or is June not a good time for the participants? Next year we will try June again, this time in Finland.

Conference building (C-13) at Wrocław University of Technology. InterNetView 2.0.1.8 crack serial keygen Maciek Krol) News from IMAPS Poland The 34th IMAPS-CPMT Poland 2010 International Conference organized by Wroclaw University of Technology (Faculty of Microsystem Electronics and Photonics) will be held in Wroclaw on 22-25 September, 2010. This year our conference is organized together with 10th Electron Technology ELTE 2010 Conference (Polish conference organized every three years and devoted to electronic materials, micro- and nanoelectronics, photonics InterNetView 2.0.1.8 crack serial keygen microsystems). It will be a good opportunity to exchange the scientific results between wide range of scientists and specialists from electronic industry. The conference presentations will be divided into plenary sessions, section sessions and poster sessions, InterNetView 2.0.1.8 crack serial keygen. The main topics include: • Thin- and thick-film technologies; • Thin- and thick-film sensors; • Modelling, design and simulation of film structures, components and circuits; • Modern technologies and applications of multichip modules; • Electrical, InterNetView 2.0.1.8 crack serial keygen, optical, mechanical and thermal characterization of film structures, components and circuits; • Packaging in electronics, photonics and microsystems; • Quality and reliability of film structures InterNetView 2.0.1.8 crack serial keygen packaging processes.

50 – Global SMT &amp; Packaging – Celebrating 10 Years – July 2010

The exhibition of technological and diagnostic equipment is planned during the conferences. Papers chosen by scientific committees will be recommended for publishing in international and national technical journals. The conference presentations will be divided into plenary sessions, section sessions and poster sessions. Presentations/ posters for IMAPS/CPMT will be prepared in English abstracts, InterNetView 2.0.1.8 crack serial keygen, and full texts of papers will be prepared in English. Students, PhD students and young researchers (below 32 years old) can participate in contests for best papers in particular thematic sections. Exhibition of technological and diagnostic equipment is planned during the conference. Papers chosen by the Scientific Committees will be recommended for publishing in international and national technical journals. The conference will be held at the Wrocław University of Technology, building C-13, i.e. Integrated Students Center, Wybrzeże InterNetView 2.0.1.8 crack serial keygen 23/25 in Wrocław More information can InterNetView 2.0.1.8 crack serial keygen found on the conference website: www.imaps2010.pwr. wroc.pl.

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European Electronics Assembly

Reliability Summit The European Union continues to impose legislation on the electronics manufacturing community. REACH, RoHS and WEEE all have significant impact on the manufacturability of our board assemblies and finished goods. The Second European Electronics Assembly Reliability Summit brings together InterNetView 2.0.1.8 crack serial keygen and provides a unique opportunity to examine, learn and debate these business-critical issues through industry discussion, technical collaboration and information sharing. The event will include a technical conference, tabletop exhiibition and networking opportunities. Join us this September. Visit the website to learn more.

September 21-23, 2010 Tallink Spa &amp; Conference Hotel, Tallin, Estonia This conference is being held at a critical time for the electronics industry. Increasing legislation and lack of reliability in electronics assemblies and interconnections is providing many challenges for, designers, specifiers and manufacturers of printed assemblies. The rise in counterfeit components is only adding to these InterNetView 2.0.1.8 crack serial keygen 21-23, 2010

Abstracts from the 36th Annual Meeting of the Society of General Internal Medicine

ABSTRACTS OF SUBMISSIONS

ACCEPTED FOR PRESENTATION

“MY CLIENTS FALL THROUGH EVERY CRACK IN THE SYSTEM”: ASSESSING THE NEED FOR GERIATRICS HEALTH TRAINING AMONG LEGAL PROFESSIONALS Tacara N. Soones1; Cyrus Ahalt2; Sarah Garrigues2; David Faigman3; Brie Williams2. 1University of California- San Francisco, San Francisco, CA; 2University of California-San Francisco, InterNetView 2.0.1.8 crack serial keygen, San Francisco, CA; 3UCSF/UC Hasting Consortium on Law, Science & Health Policy, San Francisco, CA, InterNetView 2.0.1.8 crack serial keygen. (Tracking ID #1607152)

BACKGROUND: Older adults (age 55+) represent the fastest growing age group in jail. While attorneys, judges, and other legal professionals are not generally considered healthcare team members, InterNetView 2.0.1.8 crack serial keygen, they provide front-line identification and response InterNetView 2.0.1.8 crack serial keygen age-related health conditions affecting legal outcomes. For example, cognitive impairment can affect the ability to access adequate legal representation, participate in one’s defense, or follow court orders; and physical impairment can jeopardize safety in jail. However, legal professionals’ knowledge of age-related health issues is unknown.

METHODS: This was a cross-sectional, qualitative study of legal professionals in San Francisco County’s criminal justice system. Questionnaires included open and close-ended questions to assess demographics, attitudes towards older adults (validated Geriatrics Attitudes Scale) and self-reported knowledge of geriatrics topics relevant to legal services, including cognitive and sensory impairment, InterNetView 2.0.1.8 crack serial keygen, legal competency, and knowledge of community resources. Questionnaires also elicited recommendations for closing geriatrics knowledge gaps. We analyzed questionnaires using standard grounded theory principles and conducted in-depth interviews with 9 participants to ensure that questionnaires were interpreted accurately.

RESULTS: Seventy-two of 83 legal professionals participated (87 % participation), including judges (6 %), District Attorneys (25 %), Public Defenders (58 %), and Pretrial Diversion case managers (11 %). Most legal professionals (73 %) worked with older adults on at least a monthly basis and 100 % had positive attitudes towards aging (Geriatrics Attitudes Scale >3). Self-reported geriatrics knowledge gaps were greatest in 3 areas: (1) General aging-related health- 14 % rated themselves as knowledgeable about age-related health issues, 74 % had never received training in aging; (2) Cognitive impairment-55 % did not feel knowledgeable at explaining how delirium, dementia and depression might affect behavior or the ability to follow instructions, and (3) Safety assessment-61 % felt unprepared to identify older adults at high safety risk and 62 % could not describe types of surrogate decision-makers, including public guardians or appointed power of attorneys. Five recommendations to close these knowledge gaps emerged: (1) educate legal professionals about aging-related health; (2) develop checklists to identify older adults at risk of health decline or poor safety; (3) train to assess older adults for cognitive and sensory impairments before legal proceedings; (4) create communication mechanisms between legal professionals, clinicians, and social services providers about client needs during and after detainment; and (5) encourage multidisciplinary research to improve health outcomes in older adults.

CONCLUSIONS: This study identifies critical gaps in the geriatrics knowledge of legal professionals in the criminal justice system and proposes recommendations to address these knowledge gaps, minimize adverse health outcomes, and improve legal outcomes for older adults.

“WHO’S ON FIRST?” IN THE CHAOS OF SHARED DECISION MAKING: A STUDY OF DOCTOR, PATIENT, AND OBJECTIVE RATINGS OF SHARED DECISION MAKING USING DIRECTLY OBSERVED ENCOUNTERS Patrick G. O’Malley1,2; Dorothy Becher1; Gretchen Rickards2,1; Janice L. Hanson3,1; Jeffrey L. Jackson4,1, InterNetView 2.0.1.8 crack serial keygen. 1Uniformed Services University, Bethesda, MD; 2Walter Reed National Military Medical Center, Bethesda, InterNetView 2.0.1.8 crack serial keygen, MD; 3University of Colorado School of Medicine, Aurora, InterNetView 2.0.1.8 crack serial keygen, CO; 4Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #1639946)

BACKGROUND: Shared decision making involves complex patient-physician interaction, yet patient encounters tend to be chaotic, without coherent direction or dyad symmetry. We sought to explore how patients and doctors perceive the degree of shared decision making in the same chronic care encounters, and how InterNetView 2.0.1.8 crack serial keygen their perceptions correspond with objective assessments of the interaction.

METHODS: Prospective, observational study of audiotaped InterNetView 2.0.1.8 crack serial keygen, with surveys of patients and physicians before and after the encounter. We enrolled a consecutive sample of 120 participants aged 40–80 y.o. with ≥3 additional chronic medical conditions (excluding dementia), and scheduled for a routine appointment with their primary provider. Immediately after InterNetView 2.0.1.8 crack serial keygen visit, patients and doctors were independently surveyed to assess the decision making style of the encounter along a 20-point spectrum ranging from “doctor-dominant” (0–6) to “shared” (7–13) to “patient-dominant” (14–20) decision making. The scale included behavioral descriptors in order to anchor one’s choice. Three raters (PO, DB, GR) dual-rated transcriptions independently on the level of decision making complexity (low, medium, high), and the degree of shared decision making (20-item scale), blinded to the patient and doctor ratings; disagreements were reconciled through consensus. Agreement between patient, doctor, and objective ratings Media-Comm Multi-App v2.0 for Win98 crack serial keygen measured using the intraclass correlation coefficient (ICC).

RESULTS: Of the 105 patients who completed the visit, complete data was available on 98. The demographics were as follows: 53 % F, 56 % AA, mean age: 66 yo, 88 % were on 5 or more medications, only 8 % had poor health literacy, and 30 % had a very good or excellent functional status. The physician profile (N = 11) was: 55 % F, 28 % AA, mean age: 48 yo, and mean time since graduation: 19 yrs. The level of decision making in the encounters was low in 61 %, and mod/high in 39 %. Categorical ratings of encounters (by collapsing scores into 3 groups), stratified by perspective (doctor, patient, objective), is presented in the table (below). Immediately after the visit, InterNetView 2.0.1.8 crack serial keygen, there was no agreement between patients and physicians on the degree of shared decision making during the visit (ICC = 0.06, P = 0.37). By InterNetView 2.0.1.8 crack serial keygen measurement, 88 of the 98 encounters were dominated by the physician (ie, scores from 0 to 9), and only 27 of those could be categorized as relatively “shared” (ie, scores of 7–9). When compared to objective ratings, physicians’ ratings of shared decision making correlated more strongly (ICC = 0.55, P < 0.001) than patients’ ratings (ICC = 0.39, P = 0.01).

CONCLUSIONS: Immediately after participating in the same chronic care encounter of mostly low to moderate decision complexity, both patients and physicians overestimated the degree of shared decision making, and neither agreed on the degree of shared decision making of the same encounter, InterNetView 2.0.1.8 crack serial keygen. Interventions to improve shared decision making will need to address 1. Physician lack of awareness of their tendency to dominate encounters, and 2. both parties’ ability to engage in true shared InterNetView 2.0.1.8 crack serial keygen making.

Shared Decision Making Spectrum

Doctor Shared Patient

Perspective

Doctor 34 % 47 % 19 %

Patient 22 % 69 % 9 %

Objective 81 % 15 % 4 %

Ratings of the Same Encounter (N = 98)

(RE)TURNING THE PAGES OF RESIDENCY: THE IMPACT OF LOCALIZING RESIDENT PHYSICIANS TO HOSPITAL UNITS ON PAGING FREQUENCY Laura Fanucchi1; Lia S, InterNetView 2.0.1.8 crack serial keygen. Logio2. 1University of Kentucky College of Medicine, Lexington, KY; 2Weill Cornell Medical College, New York, NY. (Tracking ID #1634924)

BACKGROUND: Pagers are ubiquitous, yet fundamentally flawed, as they do not prioritize, lead to communication errors, and interrupt patient care and educational activities. Given duty hour restrictions, there is concern that residents experience increased workload due to having fewer hours to do the same amount of work. Geographic localization of physicians to patient care units is thought to improve communication and agreement on goals of care, and also to reduce workload by decreasing paging and other inefficiencies attributable to traveling throughout the hospital. We investigated whether interns on geographically localized teams received fewer pages than interns on teams that were not localized.

METHODS: We conducted a retrospective analysis of the number of pages received by interns on 5 general medicine teams from Oct. 17–Nov. 13, 2011 at New York Presbyterian Hospital/Weill Cornell. Two teams were in a Geographically Localized Model (GLM), two in a Partial Localization Model (PLM), and one Standard Model (SM) team admitted patients irrespective of their assigned bed location. ANOVA and standard multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team.

RESULTS: Over 28 days, 10 interns on 5 teams received 6652 pages. Eighty-five percent of patients in the GLM were on the designated unit, compared to 45 % in the PLM, and 37 % in the SM. The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.18 in the GLM, 2.77 in the PLM, and 3.87 in the SM. All of these differences were statistically significant in the linear regression analysis (p < 0.0001). Figure 1 shows the pattern of paging for the three types of teams.

CONCLUSIONS: Geographic localization of resident teams to patient care units is associated with significantly fewer pages received by interns during the day. Previous research suggests that geographic localization decreases perceived paging frequency. We show a statistically significant relationship with a dose–response effect. We also demonstrate that interns whose patients are scattered throughout the hospital may experience five pages per hour, or an interruption by pager every 12 min. Geographically localized patient care models may improve resident workload in part by mitigating paging. Decreased resident workload has potential to improve both clinical and educational outcomes. A working environment that facilitates in-person communication decreases not only pager interruptions, but the latent communication errors inherent in unidirectional alpha-numeric paging, which may improve patient safety.

Figure 1. Average number of pages per intern per hour for each care model.

24 MONTH METABOLIC BENEFITS OF A COMMUNITY-BASED TRANSLATION OF THE DIABETES PREVENTION PROGRAM Carolyn F. Pedley1; Doug Case1; Mara Z. Vitolins1; Jeffrey A. Katula1; Caroline S. Blackwell1; Scott Isom1; David C. Goff2. 1Wake Forest University, Winston-Salem, NC; 2Colorado School of Pulbic Health, Denver, CO, InterNetView 2.0.1.8 crack serial keygen. (Tracking ID #1642380)

BACKGROUND: The practice of general internal medicine involves treating a high percentage of individuals with hypertension, increased waist circumference, glucose intolerance, hypertriglyceridemia and InterNetView 2.0.1.8 crack serial keygen HDL cholesterol. These individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease and diabetes. Although several large-scale clinical trials have demonstrated that weight loss achieved through diet and physical activity can reduce the incidence of diabetes, translating lifestyle weight loss programs to general practice has been difficult. Numerous studies have attempted to translate the Diabetes Prevention Program (DPP) to community-based and primary care settings and have documented modest success. However, no translational studies to date have documented the impact of diabetes prevention interventions on aspects of the metabolic syndrome. The Healthy Living Partnership to Prevent Diabetes study (HELP PD; NIDDK) tested the impact of a community-based translation of the DPP on fasting blood glucose in participants at high risk for diabetes. The impact of HELP PD on fasting blood glucose and waist circumference have been published previously. The purpose of the present study is to examine the HELP PD intervention on features of the metabolic syndrome.

METHODS: The study randomly assigned 301 overweight volunteers with fasting blood glucose 95–125 mg/dl and BMI 25–40 kg/m2 to two treatment groups: enhanced usual care (EUC vs DPP LWL (Lifestyle, Weight Loss) intervention. Ages ranged from 34 to 81 years with a median of 58 years; 57 % were female, 26 % minority and 73 % obese. The LWL intervention was administered through a local diabetes education program and participants met in 14 groups of 8–12 delivered by community health workers (CHW) in community locations. CHWs were volunteers InterNetView 2.0.1.8 crack serial keygen well-controlled diabetes.

RESULTS: Duriing 24 months of follow-up there were significant between group differences in metabolic parameters: fasting blood glucose, waist circumference, HDL and DBP differed significantly between the LWL and EUC groups, all in favor of the LWL. SBP and triglycerides were lower in the LWL group but the differences were not statistically significant. Fasting blood glucose decreased by 2.2 mg/dl in the LWL group and increased by that amount in the EUC group for a difference of 4.4 mg/dl at 24 months (p = .001). Waist circumference decreased by 3.4 cm in the LWL group and remained relatively unchanged in the EUC group (0.2 cm decrease) for 3.2 cm difference at 24 weeks (p < .001). HDL increased by 0.4 mg/dl in the LWL group while decreasing by 2.7 mg/dl in the EUC group (p = .004). Diastolic blood pressure decreased by 1.6 mmHg in the LWL group and increased by 0.5 mmHg in the EUC group (p = .024) while systolic blood pressure decreased by 2.3 mmHg in the LWL group and 1.0 mmHg in the EUC group (p = .437). Triglycerides decreased by 23.4 mg/dl in the LWL group compared to the 10.8 mg/dl in the EUC group (p = .083).

CONCLUSIONS: This study demonstrates that community-based partnerships can successfully deliver effective, affordable behavioral lifestyle weight loss programs in general medical patients who have several metabolic risks for diabetes and heart disease with resultant metabolic benefits. Utilizing community-based volunteers in community settings to deliver diabetes prevention programs has the potential to reduce health disparities in accessing such care.

“AM I CUT OUT FOR THIS?” UNDERSTANDING THE EXPERIENCE OF DOUBT AMONG FIRST YEAR MEDICAL STUDENTS Rhianon Liu; Jorie Colbert-Getz; Robert Shochet. Johns Hopkins University School of Medicine, Baltimore, MD. (Tracking ID #1628595)

BACKGROUND: Research on medical student wellbeing shows high rates of distress, yet doubt as a distinct phenomenon remains poorly understood. The purpose of our study was to examine how first year medical students experience and respond to doubt, and how doubt relates to other aspects of student distress.

METHODS: We InterNetView 2.0.1.8 crack serial keygen a mixed methods study involving a survey and focus groups examining the phenomenon of doubt among first year medical students at the Johns Hopkins University School of Medicine (JHUSOM). Students were asked to answer 14 questions about doubt embedded in an online advising program InterNetView 2.0.1.8 crack serial keygen in June, 2012. Doubt survey items were developed and revised based on literature review, and included four questions from a validated wellbeing index. Results were analyzed by grouping students into categories of high, moderate, low, InterNetView 2.0.1.8 crack serial keygen, or no doubt. For each doubt item, logistic regression was used to compare the proportion of students who “agreed” among moderate/high doubters vs low/no doubters. For wellbeing questions, total doubt scores and total wellbeing scores were correlated with Spearman’s rho. InterNetView 2.0.1.8 crack serial keygen addition, four InterNetView 2.0.1.8 crack serial keygen focus groups were conducted with a convenience sample of students in June–July, 2012. Focus group questions were written by the authors, then pilot-tested and revised prior to use. Digital recordings were transcribed, independently coded, and iteratively reviewed by the authors to identify major themes.

RESULTS: 114/119 (96 %) students completed the survey. 20 % had high doubt, 29 % moderate doubt, 22 % low doubt, and 29 % no doubt. Compared to those with low/no doubt, students with moderate/high doubt were 5 to 13 times as likely to question their personal purpose, to question who they were, to struggle with coping with doubt, and to perceive the JHUSOM climate as discouraging them from expressing doubt, There was moderate correlation between total doubt and wellbeing scores (spearman’s rho = 0.36). 34 students participated in the focus groups, InterNetView 2.0.1.8 crack serial keygen. Three major themes were identified: types of doubt, ways of coping with doubt, and impact of doubt. Types of doubt were related to two main questions: -Do I want to become a doctor? Subtheme example: the opportunity cost of pursuing medicine -Am I capable of becoming a doctor? Subtheme example: concerns about one’s ability to succeed and maintain work-life balance Ways of coping with doubt included: -Relying on supportive relationships -Maintaining perspective through a focus on long-term goals The impact of doubt included positive and negative aspects: -Positive examples: motivation and resilience in the face of uncertainty -Negative examples: burnout, stress, and poor academic performance

CONCLUSIONS: Doubt is prevalent among first-year medical students, affecting students’ sense of confidence, identity, and purpose, and has both positive and negative consequences. Students also experience other forms of distress, which may be related to doubt, InterNetView 2.0.1.8 crack serial keygen. Doubt among medical students merits awareness and further study, as it may be an important mediator of students’ emerging sense of identity and personal wellbeing.

A BEFORE/AFTER TRIAL OF A DECISION AID ON MAMMOGRAPHY SCREENING FOR WOMEN AGED 75 AND OLDER Mara A. Schonberg; Mary Beth Hamel; Roger B. Davis; Edward R. Marcantonio. Beth Israel Deaconess Medical Center, Boston, MA. (Tracking ID #1636857)

BACKGROUND: Guidelines state there is insufficient evidence to recommend mammography screening for women aged >75 years. Instead, they encourage clinicians to discuss the potential benefits and risks of screening and engage older women in shared decision-making. We aimed to design and evaluate a decision aid (DA) for women >75 years to inform their decision-making around mammography screening.

METHODS: We designed the DA based on international standards and included data from medical literature review. An expert panel reviewed iterative versions of the DA and it was then reviewed for acceptability by 15 patients and 5 of their primary care physicians (PCPs). The 10-page DA (written at a 6th grade reading level) includes information on breast cancer risk, life expectancy, competing mortality risks, likely outcomes if screened or not screened over 5 years, and a values clarification exercise. We evaluated the DA in a before/after trial at a large academic primary care practice in Boston. Eligible women were >75 years, spoke and read English fluently, had not had a mammogram in the past 9 months but InterNetView 2.0.1.8 crack serial keygen screened in the past 3 years, did not have a history of invasive or non-invasive breast cancer or dementia, and were scheduled for a routine visit with their PCP within 8 weeks. Participants came early to their PCP appointment to complete a “before” survey and to read the DA. After the visit, InterNetView 2.0.1.8 crack serial keygen, they completed an “after” survey. The surveys included 10 knowledge questions, the 16-item decisional conflict scale (DCS, 0–100, lower scores = less conflict), and a question that assessed screening intentions. Participants were followed by medical record for up to 1 year to examine whether there was a note documenting a discussion of the pros/cons of screening and to abstract receipt of mammography. We used the signed rank test and McNemar’s test to compare before/after responses. We also asked PCPs to complete a survey about using InterNetView 2.0.1.8 crack serial keygen DA in their practice.

RESULTS: Forty-nine before/after trial participants (from 26 PCPs) had median age of 79 years; 70 % were Non-Hispanic white; 63 % had attended some college; and 24 % had <7 year life expectancy. Comparison of “after” to “before” survey results found: 1) participants answered on average 1 more question correct (interquartile range 0–2) on the 10 item index from 6 to 7 questions correct, p < 0.001; 2) decisional conflict declined by 4.8 points (range −10.2 to +4.7 points, mean DCS scores before = 20.1, p = 0.03); and 3) fewer participants intended to be InterNetView 2.0.1.8 crack serial keygen (59 % compared to 82 % before, p = 0.01). In the following 6 months, 61 % of participants had a PCP note documenting a discussion of the pros/cons of screening compared to 10 % in the previous 5 years, p < 0.001. While 86 % had been screened within 2 years before participating only 61 % were screened within 1 year after, p < 0.001 (a similar decline was found among women with <7 year life expectancy). Overall, 94 % reported that they would recommend the DA, 94 % found it helpful, and 78 % found the amount of information just right, InterNetView 2.0.1.8 crack serial keygen. PCPs (17/26) reported that using the DA would result in their patients making more informed (74 %) and value laden (79 %) decisions.

CONCLUSIONS: We developed a DA for women aged >75 years contemplating mammography screening. Our before/after trial demonstrates that this DA allows women to make more informed, preference-sensitive decisions around mammography screening. Next, we plan to test the effectiveness of the DA in a large randomized control trial.

A CENSUS OF STATE-BASED CONSUMER HEALTH CARE PRICE WEBSITES Jeffrey T. Kullgren1; Katia A. Duey2; Rachel M. Werner3, InterNetView 2.0.1.8 crack serial keygen. 1Ann Arbor VA Healthcare System and University of Michigan, Ann Arbor, MI; 2University of Pennsylvania, Philadelphia, PA; 3Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA. (Tracking ID #1642367)

BACKGROUND: As Americans’ out-of-pocket health care costs continue to rise, many health plans, consumer groups, and state governments are reporting health care price information directly to patients. Though there is broad recognition that this information must be relevant, accurate, and usable to improve the value InterNetView 2.0.1.8 crack serial keygen patients’ out-of-pocket spending, it is currently unknown what information is actually being reported to patients. The objective of this study was to describe the types of information that are currently being reported on state consumer health care price websites and identify opportunities to improve the usefulness of this information for patients.

METHODS: We conducted a systematic internet search to identify patient-oriented, state-based health care price websites that were operational in early 2012. We chose to focus on state-based websites since states are a focal point for health care price transparency initiatives and often publicly report the health care price information they collect under legislative or regulatory authority. For each website we identified, we classified the type of organization that reported the information, the kinds of health care services for which prices were reported, the type of price information that was reported (e.g., out-of-pocket cost, allowable charge, or billed charge), InterNetView 2.0.1.8 crack serial keygen, the patient-level factors that were incorporated in the estimate, and the presence of quality information alongside the reported price information. We then calculated frequencies for each of these characteristics.

RESULTS: We identified 62 state health care price transparency websites, most of which were provided by either a state government agency (46.8 %) InterNetView 2.0.1.8 crack serial keygen state hospital association (38.7 %). Most websites reported information on prices of inpatient care for medical conditions (72.6 %) or surgeries (71.0 %); prices for outpatient services such as diagnostic or screening procedures (37.1 %), radiology studies (22.6 %), prescription drugs (14.5 %), InterNetView 2.0.1.8 crack serial keygen, or laboratory tests (9.7 %) were reported less often. The reported prices usually reflected only billed charges (80.6 %). For outpatient services that commonly include both facility and professional fees (e.g., diagnostic procedures or radiology studies), the majority of price estimates (66.0 %) included just facility fees. Only a small minority of prices were tailored to individual circumstances that commonly affect what a patient is truly expected to pay out-of-pocket for a service, such as their insurance status (9.7 %) or specific health plan (8.1 %), InterNetView 2.0.1.8 crack serial keygen. For services where price and quality information together could help patients assess value across providers (e.g., outpatient clinician services or outpatient surgeries), quality information was infrequently portrayed alongside prices (13.2 %).

CONCLUSIONS: Most states now have websites that report health care prices directly to patients. However, the information being reported on these state health care price websites is unlikely to be useful for most patients, and often fails to reflect the true prices they would actually face for services. Improvements in the relevance, accuracy, and usability of publicly reported health care prices could help this information reach its full potential to improve the value of out-of-pocket health care spending for patients.

A HIGH RISK OF HOSPITALIZATION FOLLOWING RELEASE FROM CORRECTIONAL FACILITIES AMONG MEDICARE BENEFICIARIES Emily A. Wang1; Yongfei Wang2; Harlan M. Krumholz1,2. 1Yale School of Medicine, New Haven, CT; 2Yale-New Haven Hospital Center of Outcomes Research InterNetView 2.0.1.8 crack serial keygen Evaluation, New Haven, CT. (Tracking ID #1642216)

BACKGROUND: Healthcare is constitutionally guaranteed in correctional facilities, but not upon release, which could increase the risk of acute events. We studied the risk for hospitalizations among former inmates soon after their release from correctional facilities.

METHODS: We conducted a retrospective cohort study using data from Medicare administrative claims for all fee-for-service beneficiaries who were released from a correctional facility from 2002 to 2010. Using McNemar’s test and condition logistic regression, we compared hospitalization rates after release among former inmates 7, 30, and 90 days after release to beneficiaries matched based on age, sex, race, Medicare status, and residential zip code. We also compared hospitalizations with the specified diagnosis codes between the two groups and examined whether being released from a correctional facility was associated with different risks for hospitalizations for ambulatory care-sensitive conditions compared with the matched control. We used Kaplan Meier survival analyses to compare time to the first hospitalization and death between the two matched groups after release. Data were censored at the time of death or the end of the observation period.

RESULTS: Of 110,419 released inmates, 1559 individuals (1.4 %) were hospitalized within 7 days after release; 4285 individuals (3.9 %) within 30 days; and 9196 (8.3 %) within 90 days. The odds of hospitalization was higher for released inmates compared with matched controls (within 7 days, odds ratio (OR) 2.5, 95 % confidence interval [CI] 2.3, 2.8; 30 days, OR 2.1, 95 % CI, 2.0, 2.2; and 90 days, OR 1.8, 95 % CI 1.7, 1.9). Compared with matched controls, former inmates were more likely to be hospitalized for ambulatory care-sensitive conditions (within 7 days, OR 1.7, 95 % CI 1.4, 2.1; 30-days, OR 1.6, 95 % CI 1.5, 1.8; and 90-days, OR 1.6, 95 % CI 1.5, 1.7). Mental health conditions were the most common reason for hospitalizations among former inmates 30 days post release (22.1 %). Diseases of the circulatory system (14.0 %), injury and poison (12.7 %), and disease of the respiratory system (10.5 %) were also common reasons for hospitalization among released inmates. In event-free analyses, former inmates were more likely to be hospitalized compared with the control group within a year following release.

CONCLUSIONS: About one in 70 former inmates are hospitalized for an acute condition within 7 days of release, and one in 12 by 90 days, a rate much higher than the general population, InterNetView 2.0.1.8 crack serial keygen. Transitions between correctional facilities and the community are a high-risk period; correctional and community healthcare systems should collaborate to reduce morbidity for this vulnerable population.

A META-ANALYSIS OF THE RAPID ANTIGEN STREPTOCOCCUS TEST Emily Stewart; Brian Davis; Lee Clemans-Taylor; Robert M. Centor; Carlos Estrada. The University of Alabama at Birmingham, Birmingham, AL. (Tracking ID #1624984)

BACKGROUND: Current guidelines to diagnose and treat group A streptococcal (GAS) pharyngitis do not take into account the uncertainty of rapid testing. We examined the accuracy of the rapid antigen streptococcus test (RAST) to diagnose GAS pharyngitis.

METHODS: Systematic review and meta-analysis. MEDLINE search and reference lists, 2000–2012. We included clinical studies using RAST and a reference standard. We assessed quality with Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. We obtained hierarchical summary receiver operating characteristic (HSROC) curve and obtained adjusted estimates of test characteristics.

RESULTS: We included 41 of 728 studies; the overall K.I.S.S. (Keep It Simple Spreadsheet) 1.0 crack serial keygen was 28 % (13,588/48,377 patients; range 4–67 %). The setting was solely in the emergency department (27 %) or outpatient clinic (56 %); 22 % were solely in children; and 14 % were retrospective. Of 14 QUADAS criteria, eight were fulfilled by over 90 % of studies, five by 60–80 %, and one by 22 %. The Deek’s funnel plot was asymmetric (p < 0.001) suggesting the presence of publication bias. Studies were heterogeneous as illustrated by a wide 95 % prediction region in the HSROC curve (Figure, dashed line) and high inconsistency estimates for sensitivity (I2 = 94.4 %) and specificity (I2 = 98.2 %). The adjusted pooled sensitivity was 88.2 % (95 % confidence interval [CI], 83.9 to 91.4 %; range 52.6 % to 99.9 %). The pooled specificity was 98.5 % (95 % CI, 96.7 to 99.3 %; range 68.8 % to 100 %). Inconsistency between studies remained high for sensitivity and specificity in sub-group analyses for location of test performance (point-of-care, laboratory), InterNetView 2.0.1.8 crack serial keygen, pediatric population, setting (outpatient, emergency department), study design (prospective, retrospective), study methodological quality (verification bias, non-differential bias, non-incorporation bias), and funding (commercial or not)(all I2 > 80 %).

CONCLUSIONS: The RAST is moderately sensitive and highly specific to diagnose group A streptococcal pharyngitis. However, significant heterogeneity and publication bias were observed among studies. Guidelines should incorporate uncertainty in estimates for rapid tests for the diagnosis of GAS pharyngitis.

A MIXED-METHODS RANDOMIZED CONTROLLED TRIAL OF EMPLOYER MATCHING OF DEPOSIT CONTRACTS TO PROMOTE WEIGHT LOSS Jeffrey T. Kullgren1; Andrea B. Troxel2; George Loewenstein3; Laurie Norton2; Dana Gatto2; Yuanyuan Tao2; Jingsan Zhu2; Heather Schofield4; Judy A, InterNetView 2.0.1.8 crack serial keygen. Shea2; David A. Asch5; Thomas Pellathy6; Jay Driggers7; Kevin G. Volpp5. 1Ann Arbor VA Healthcare System and University of Michigan, InterNetView 2.0.1.8 crack serial keygen, Ann Arbor, MI; 2University of Pennsylvania, Philadelphia, PA; 3Carnegie Mellon University, Pittsburgh, PA; 4Harvard University, Cambridge, MA; 5Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, PA; 6McKinsey & Company, Pittsburgh, PA; 7Horizon Healthcare Innovations, Newark, NJ. (Tracking ID #1642494)

BACKGROUND: InterNetView 2.0.1.8 crack serial keygen contracts are behavioral economic devices that ask people to put money at risk that they forfeit if they do not meet a goal. While deposit contracts can effectively promote weight loss, InterNetView 2.0.1.8 crack serial keygen, a major challenge to wider impact of these programs is getting more people to participate. The goals of this study were to test whether matching of deposits can increase participation in deposit contracts, characterize the corresponding amount of weight loss, and identify factors associated with non-participation in these programs.

METHODS: We recruited 132 employees of Horizon BCBS of NJ who wanted to lose weight and had a BMI between 30 and 50. Participants were given a weight loss goal of 1 lb per week for 24 weeks and randomized to a monthly weigh-in control group or monthly opportunities to deposit $1 to $3 per day with daily feedback. Deposits were either not matched, matched 1:1, or Jogos de Social Deduction de Graça para Baixar 2:1 and provided back to participants at the end of the month for every day in that month that participant was at or below the goal weight for that day. After the 24-week intervention period, we conducted semi-structured interviews with intervention arm participants to identify factors that influenced their participation in deposit contracts. The primary outcome was weight loss at 24 weeks. Secondary outcomes included deposit contract participation; changes in eating behaviors, physical activity, and wellness program participation at 24 weeks; and weight loss 12 weeks after the interventions ended.

RESULTS: After 24 weeks, control arm participants gained an average of 1.0 lb (SD 7.6), compared to mean weight losses of 4.3 lbs (SD 8.9; P = .03) in the no match arm, 5.3 lbs (SD 10.1; P = .005) in the 1:1 match arm, InterNetView 2.0.1.8 crack serial keygen, and 2.3 lbs (SD 9.8; P = .29) in the 2:1 match arm. Overall, 29.3 % of participants in a deposit contract arm made at least one deposit, and there were no significant differences in participation rates across the 3 deposit contract arms. There were also no significant differences in InterNetView 2.0.1.8 crack serial keygen in eating behaviors, physical activity, and participation in wellness programs after 24 weeks. In semi-structured interviews, the main factors that limited participation in deposit contracts were a lack of confidence in meeting weight loss goals and fear of losing money. 12 weeks after the interventions ended, control arm participants gained an average of 2.1 lbs from baseline (SD 7.9), InterNetView 2.0.1.8 crack serial keygen, compared to mean weight losses of 5.1 lbs (SD 11.1; P = .008) in the no match arm, 3.6 lbs (SD 9.6; P = .02) in the 1:1 InterNetView 2.0.1.8 crack serial keygen arm, and 2.8 lbs (SD 10.1; P = .12) in the 2:1 match arm.

CONCLUSIONS: Relatively few study participants assigned to deposit contract conditions took up opportunities to enter into deposit contracts designed to promote weight loss, and employer matching of deposits did not increase participation. Approaches to promote confidence in losing weight or seed deposit contract accounts might be alternative ways to increase participation in these programs. Greater weight loss in deposit contract arms at 24 and 36 weeks may have been mediated by the automated daily feedback these participants received, and this approach could be another promising tool to promote behavior change in workplace settings.

A NATIONAL ASSESSMENT ON PATIENT SAFETY EDUCATION IN UNDERGRADUATE MEDICAL EDUCATION: A SURVEY OF CLERKSHIP DIRECTORS IN INTERNAL MEDICINE C. Charles Jain1; Meenakshy K. Aiyer1; Jean C. Aldag1; Eric Alper2; Steven Durning4; Elizabeth A. Murphy2; Dario M. Torre3. 1University of Illinois College of Medicine at Peoria, Peoria, IL; 2University of Massachusetts, Worcester, MA; 3Drexel University, Philadelphia, PA; 4Uniformed Services University of the Health Sciences, Bethesda, MD. (Tracking ID #1638436)

BACKGROUND: Patient safety is an important aspect of quality patient care. For this reason, accreditation bodies emphasize octane 4 cracked Archives learners on patient safety in both undergraduate and graduate medical education curricula. This study looks at the current status of patient safety curricula from the perspectives of internal medicine clerkship directors. In addition, this study compares InterNetView 2.0.1.8 crack serial keygen current status to what was found in a similar InterNetView 2.0.1.8 crack serial keygen from 20061.

METHODS: The patient safety survey was a part of the Clerkship Directors in Internal Medicine (CDIM) 2012 annual survey, InterNetView 2.0.1.8 crack serial keygen. Questions were identified based on literature review, then modified and edited by the CDIM research committee. 37 patient safety related questions were organized into sections including general information, curriculum content and delivery, learner assessment, and barriers to providing the curriculum. All analysis was done using SPSS with group difference tested with Chi-squares for nominal variables. IRB approval was obtained.

RESULTS: Of the 121 clerkship directors surveyed 99 (82 %) responded. Of those responding 45.6 % (n = 41) describe having patient safety curriculum at some point during the 4 years of medical school curriculum. Patient safety curriculum was commonly taught in the third year (30.3 %) of medical school followed by the pre-clinical years (yr1 = 19.2 %, yr2 = 28.3 %). The top three content areas included in the curriculum were infection control (54.1 %), handoffs and sign outs (47.4 %), and medication safety (39.5 %), InterNetView 2.0.1.8 crack serial keygen. Small groups (42.4 %) followed by lectures InterNetView 2.0.1.8 crack serial keygen, direct observation (30.3 %) and Morbidity and Mortality reports (28.3 %) were used as educational strategies. Even though strategies such as patient safety project, simulations and OSCE were used for assessment of the curricula, only 20 % of the respondents reported satisfaction with student safety competency assessment during their IM clerkship. Lack of a mandate from their school’s dean’s office (38 %), lack of physician champions (43.7 %), lack of trained faculty (65.3 %), and lack of time (78.1 %) were cited as barriers to implementation. Schools with female clerkship directors were significantly more likely to have a patient safety curriculum compared to schools with male clerkship directors (p = 0.01).

CONCLUSIONS: Less than half of medical school curricula report having patient safety curricula. Even though clerkship directors recognize the importance of teaching patient safety curriculum, barriers exist to implementing the curricula. National guidelines on patient safety curriculum are currently not enough and more needs to be done to bring about the desired changes. 1. Alper MD E, Rosenberg MD, MSPH, Eric I., O’Brien MD KE, Fischer MD MEd M, InterNetView 2.0.1.8 crack serial keygen, Durning MD SJ. Patient safety education at U.S. and Canadian medical schools: Results from the 2006 clerkship directors in internal medicine survey. Acad Med. 2009;84:1672–1676.

A NOVEL WEBSITE TO PREPARE DIVERSE OLDER ADULTS FOR DECISION MAKING AND ADVANCE CARE PLANNING: A PILOT STUDY Rebecca L. Sudore2,1; Sara J. Knight2,5; Anita L. Stewart4; Ryan D, InterNetView 2.0.1.8 crack serial keygen. McMahan2,1; Mariko Feuz2,1; Yinghui Miao2,1; Deborah E. Barnes3. 1UCSF, San Francisco, CA; 2San Francisco VA Medical Center, San Francisco, CA; 3UCSF, San Francisco, CA; 4UCSF, San Francisco, CA; 5Veterans Health Administration, Washington, DC. (Tracking ID #1638672)

BACKGROUND: Advance care planning (ACP) has typically focused on advance directives and preferences for treatments, such as CPR. We have reconceptualized ACP as a multi-step process focused on preparing patients with skills needed for communication and in-the-moment decision making. To operationalize this paradigm, InterNetView 2.0.1.8 crack serial keygen, we created a new ACP website called PREPARE that is interactive, written at 5th-grade reading level, InterNetView 2.0.1.8 crack serial keygen, and shows people through videos and a step-by-step process how to communicate what is most important in life and how to make informed medical decisions. To assess the efficacy of PREPARE, we created and assessed the validity of a new survey that detects behavior change in ACP and then conducted a separate pre-to-post efficacy study.

METHODS: Study #1 (Survey Validation) validates the ACP Engagement Survey, which includes Process Measures of behavior change (knowledge, self-efficacy, and readiness, 5-point Likert) and Action Measures (e.g., “Did you do X?” yes/no) of multiple ACP behaviors such as choosing a surrogate, asking someone to be a surrogate, and speaking to surrogates and doctors about one’s wishes. We administered surveys at baseline and one-week later to 50 diverse, older adults from San Francisco hospitals. Internal consistency of the Process Measures was assessed using Cronbach’s alpha (only for continuous variables) and test-retest reliability for both Process and Action Measures was examined using intraclass correlations. Study #2 (PREPARE Efficacy): Using a separate cohort (n = 43) from low-income, San Francisco senior centers, we assessed change in ACP Engagement Survey responses (Process and Action Measures) and change in percentage of participants in the lowest, “precontemplation”, behavior stage of change to higher stages (contemplation, preparation, action, maintenance) at baseline and one-week after viewing PREPARE. We also assessed PREPARE’s ease-of-use on a 10-point scale, 10 being the easiest. To assess comparisons, we used paired t-tests and McNemar’s tests.

RESULTS: Study #1 (Survey Validation): Mean age was 69.3 (SD 10.5) and 42 % were non-White. The internal consistency of the Process Measures was 0.94. Intraclass correlations were 0.70 for the Process Measures and 0.86 for the Action Measures. Study #2 (PREPARE Efficacy): Mean age was 68.4 (SD 6.6) and 65 % were non-White, and 33 % had limited health literacy. Behavioral change Process Measure average Likert scores increased from 3.1 (SD 0.9) to 3.7 (SD 0.7), p < .001. Action Measures did not change significantly in 1 week, InterNetView 2.0.1.8 crack serial keygen. However, precontemplation significantly decreased for most ACP actions including asking someone to be a surrogate 39.5 % vs. 23.3 %, p < .04; talking to the doctor about the surrogate, 62.8 % vs. 30.2 %, P.001; talking with the surrogate and doctor about medical wishes, 46 % vs. 28 %, p = .02 and 61 % vs. 35 %, P = .003, respectively. PREPARE was rated 9 out of 10 (SD 1.9) for ease-of-use.

CONCLUSIONS: A new patient-centered ACP website prepares people for ACP communication and medical decision making and is easy-to-use among older adults from diverse backgrounds. The new ACP Engagement Survey that measures both ACP behavior change and ACP actions demonstrated good reliability and validity. And, the PREPARE website significantly improves individuals’ behavior change and engagement in ACP. The website is available at www.prepareforyourcare.org and a clinical trial is underway.

A PEER-LED INTERVENTION IMPROVES STROKE SURVIVORS’ BLOOD PRESSURE CONTROL Carol Horowitz1; Kezhen Fei1; Ian M. Kronish2,1; Stanley Tuhrim1; Rennie Negron1. 1Mount Sinai School of Medicine, New York, NY; 2NY Presbyterian, New York, NY. (Tracking ID #1641866)

BACKGROUND: Hypertension is a major risk factor for stroke recurrence but it is InterNetView 2.0.1.8 crack serial keygen controlled among stroke survivors, particularly from minority groups. The Prevent Recurrence of All Inner-city Strokes through Education (PRAISE) trial InterNetView 2.0.1.8 crack serial keygen whether a community-based, peer-led stroke education intervention improves stroke risk factors, primarily blood pressure control.

METHODS: Using community-based participatory research, clinicians, educators and stroke survivors developed a six-session peer-led workshop to help stroke survivors understand their illness, and identify and manage their recurrent risks, particularly hypertension. We recruited 600 individuals with a history of stroke or TIA within the past 5 years who were randomized to the intervention or a wait-list control group, InterNetView 2.0.1.8 crack serial keygen. At baseline, 6 and 12 months, we measured participants’ blood pressures, socio-demographics, beliefs and behaviors.

RESULTS: Participants have a mean of 63 years, the majority are female (60 %), Black or Latino (81 %) and live in poverty (56 %). At baseline, 31 % in both groups had uncontrolled blood pressure (<140/90 mmHg). At 6 months, the intervention group demonstrated InterNetView 2.0.1.8 crack serial keygen blood pressure control when compared to the control group, 76 % vs, InterNetView 2.0.1.8 crack serial keygen. 65 % (p = 0.01). The intervention group also had a significant blood pressure reduction of 3.6/2.0 mmHg (p = 0.005/p = 0.04) compared to the control group (+0.5/−0.5 mmHg).

CONCLUSIONS: A peer-led educational program developed through a community-academic partnership was successful in improving blood pressure control at 6 months. While 12-month data will confirm the longevity of this impact, PRAISE is simple, culturally appropriate and inexpensive, and may represent an important and sustainable secondary stroke prevention strategy.

A PILOT STUDY OF A COMPUTER-BASED RELATIONAL InterNetView 2.0.1.8 crack serial keygen TO SCREEN FOR SUBSTANCE-USE PROBLEMS IN PRIMARY CARE Steven R. Simon1,5; Kyle Checchi1,2; Sarah S. McNair1,2; Amy Rubin3,4; Thomas Marcello1,5; Timothy Bickmore6. 1VA Boston, Boston, MA; 2Harvard Medical School, Boston, MA; 3Boston University, Boston, MA; 4VA Boston Healthcare System, Boston, MA; 5Brigham and Women’s Hospital, Boston, MA; 6Northeastern University, Boston, MA. (Tracking ID #1638383)

BACKGROUND: Because of time constraints in delivering office-based primary care, interventions are needed to offload some tasks from primary care clinicians. Relational Agents - computer characters that simulate face-to-face conversation using voice, hand gesture, gaze cues and other nonverbal behavior, and that use simulated social behaviors to establish trust and therapeutic alliance - can provide education and counseling. Patients may find this type of computerized system suitable for “discussing” InterNetView 2.0.1.8 crack serial keygen topics, although empirical data are lacking. We therefore conducted a pilot study - the first in the Veterans Health Administration (VA) - to test the feasibility of using this technology to screen for substance use problems in primary care.

METHODS: We recruited 24 male Veterans from VA Boston. Each participant completed the National Institute on Drug Abuse-Modified Alcohol, Smoking and Substance Involvement Screening Test (NM-ASSIST), administered once by a research assistant and once by the Relational Agent, with the order randomly counter-balanced. Following both screenings, InterNetView 2.0.1.8 crack serial keygen, the research assistant conducted a semi-structured interview that solicited the Veteran’s perspectives of the Relational Agent for screening, strengths and weaknesses of the Relational Agent compared with live interaction, suggestions for improving the Relational Agent, and potential applications in primary care. We conducted a content analysis of transcribed interview notes, employing standard qualitative research techniques to identify dominant themes.

RESULTS: Among the 24 participants, 19 (79 %) expressed positive impressions of answering the NM-ASSIST with a Relational Agent, while 3 (13 %) were neutral and 2 (8 %) were negative. A total of 14 (58 %) reported being comfortable completing the NM-ASSIST with the Relational Agent. Only 6 participants (25 %) indicated that they preferred the Relational Agent over a live interviewer, while 11 (46 %) preferred the live interviewer and 7 (29 %) were indifferent. Live interviewer was generally preferred InterNetView 2.0.1.8 crack serial keygen of greater depth of interaction, ability to clarify questions and responses or unease with technology. In contrast, participants who favored the Relational Agent appreciated its ease and efficiency of use, privacy and lack of judgmentalism, and clear answer choices. Among 18 Veterans expressing an opinion, similar percentages favored the use of Relational Agents to ask questions about benign (diet and exercise [16/18, 89 %], family history [15/18, 83 %]), and sensitive (sexual history [15/18, 83 %]) topics. Participants offered constructive feedback on the Relational Agent’s behavior, particularly her eye movements; speech, being unnatural and computerized; and relatively unsophisticated graphics, InterNetView 2.0.1.8 crack serial keygen. Veterans generally favored the Relational Agent’s appearance (attractive woman dressed casually but modestly) and did not express a preference for other characteristics. Veterans frequently voiced concerns about how the Relational Agent would maintain confidentiality of their responses.

CONCLUSIONS: Although participants preferred a live interview to interaction with a computerized Relational Agent, a majority of Veterans were comfortable with the Relational Agent and would be willing to engage with it for counseling and screening for sensitive topics such as substance use and sexual history. Future randomized trials will test the effectiveness of Relational Agents in both screening and brief intervention for substance use problems.

A RANDOMIZED CONTROLLED TRIAL OF AN EVIDENCE-BASED TOOLBOX AND GUIDE TO INCREASE PRIMARY CARE CLINICIANS’ RATES OF COLORECTAL CANCER SCREENING IN DIPLOMATES OF THE ABIM Lorna A. Lynn2; Carmen E. Guerra1; Kathryn M. Ross2; Eric Holmboe2; Kaitlin Woo1; Daniel F. Heitjan1; Debbie Kirkland3; Durado Brooks3. 1Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 2American Board of Internal Medicine, Phiadelphia, PA; 3American Cancer Society, Atlanta, GA. (Tracking ID #1642572)

BACKGROUND: Colorectal cancer screening (CRCS) is effective, cost-effective and consistently recommended by clinical guidelines, yet only 64.5 % of Americans aged 50–75 years have been screened. Recommendation from a physician is the most influential factor in determining whether a patient is screened for CRC. This study was undertaken to determine whether the Evidence-Based Toolbox and Guide to Increase Primary Care Clinicians’ Rates of CRCS, developed by the Centers for Disease Control and American Cancer Society, could help diplomates of the American Board of Internal Medicine (ABIM) recertifying for the Internal Medicine boards increase their practice rates of CRCS. The main study aim was to compare practice rates of CRCS in the the control (PIM only) and study (PIM + toolbox) arms.

METHODS: In this randomized controlled trial diplomates who are primary care providers for patients over age 50 and who InterNetView 2.0.1.8 crack serial keygen enrolled in ABIM’s Maintenance of Certification program were invited to participate. Participants had to enroll in the Cancer Screening Practice Improvement Module (PIM), which requires physician-directed measurement of their performance and design of a quality improvement plan. Diplomates were randomized to the PIM or the PIM + toolbox arm. The toolbox consists of four essential sections and evidence-based tools: Your Recommendation, An Office-based Policy, a Reminder System and an Effective Communication System. Analysis was based on the intention-to-treat principle. An external auditor determined the validity of self-reported CRCS rates in a random sample of 20 % of the participants.

RESULTS: A total of 2288 recruitment emails were sent to ABIM diplomates who met the inclusion/exclusion criteria of whom 160 diplomates expressed interest in participation and 144 enrolled in the study. Of these, 79 diplomates completed the study. The CRCS rates declined in 17 of the 79, InterNetView 2.0.1.8 crack serial keygen, but improved in the remaining 62. We conducted an analysis of covariance, a GEE and mixed logistic regression models. All final CRCS were adjusted for the baseline performance and all results showed a non-significant treatment effect. In the final mixed logistic regression model adjusted for the baseline performance rate and treatment group of the physician and shown in Table 1, we determined the strength of various physician characteristics in predicting the probability of a successful screening that was performed post-treatment. Medical school country was the only predictor of improved screening rates post-treatment.

CONCLUSIONS: These results demonstrated that while most diplomates improved their CRCS rates from baseline during the study, the improvement was not significantly different in the control arm (PIM only) compared to the study arm (PIM plus toolbox). Medical school country was the only predictor of success rate, with those physicians who attended medical school abroad having an odds ratio of 4.32 (95 % CI: 1.75–10.65) of performing a successful screening than those physicians who attended medical school in the U.S.

Odds ratio estimates and 95 % confidence intervals

Effect Odds Ratio Estimate 95 % CI

Baseline Performance Rate 1,010 (1.00, 1.03)

Treatment vs. Control Arm 1.680 (0.88, 3.19)

Solo vs. Group Practice 1.463 (0.57, 3.76)

Female vs. Male 1.263 (0.65, 2.44)

Foreign vs. U.S. Medical School 4.318 (1.75, 10.65)

Age 0.950 (0.90, 1.01)

Years until MOC Expiration 0.990 (0.77, 1.28)

A RANDOMIZED TRIAL OF TWO APPROACHES TO TRAINING VETERANS AFFAIRS (VA) MEDICAL HOME HEALTHCARE PROVIDERS ON MOTIVATIONAL INTERVIEWING FOR TOBACCO CESSATION Steven Fu1,2; Craig Roth2; Catherine Battaglia4; David Nelson1; Melissa Farmer5; Tam Do1; Michael Goldstein6; Rahul Kavathekar2; Rachel Widome1; Hildi Hagedorne1; Alan Zillich3. 1Minneapolis VA Health Care System, Minneapolis, MN; 2Minneapolis VA Health Care System, Minneapolis, MN; 3Roudebush VA Medical Center, InterNetView 2.0.1.8 crack serial keygen, Indianapolis, IN; 4VA Eastern Colorado Health Care System, Denver, CO; 5VA Greater Los Angeles Health Care System, Los Angeles, CA; 6VHA National Center for Health Promotion and Disease Prevention, Durham, NC. (Tracking ID #1638026)

BACKGROUND: Tobacco cessation counseling from a clinician doubles a patient’s odds of quitting. Motivational interviewing (MI) is an effective communication skill in tobacco cessation counseling, but strategies to train providers on MI are needed. This study evaluated a high-intensity versus moderate-intensity MI training program to improve delivery of tobacco cessation care.

METHODS: VA Patient Aligned Care Team (PACT) members at 2 VA facilities were randomized to moderate- or high-intensity MI training. Both training models included the following 3 components: 1) 3-day intensive MI training for site-based MI clinical champions and a site-based MI expert consultant, 2) Half day on-site training workshop for PACT members, and 3) self-study materials. The high-intensity model added 6 booster sessions coached by champions. Three booster sessions used InterNetView 2.0.1.8 crack serial keygen interactions with simulated patients and occurred at 4, 8, and 12 weeks after the initial training. Three additional booster sessions (at 2, 6, and 10 weeks) used small group coaching facilitated by the champions. Each 1-h booster session focused on specific MI skills. To evaluate the 2 training models, a structured clinical evaluation (OSCE) was conducted with providers in each group before and 12 weeks after the onsite training. The OSCEs assessed provider competence with and acquisition of MI and tobacco cessation skills through interaction with a simulated patient. A trained, blinded rater assessed the provision of MI skills by listening to the audio-recorded OSCEs. The primary outcome was the Motivational Interviewing Treatment Integrity (MITI) scale scores, a validated assessment of MI skills. Hierarchical models compared the average changes in MITI scale scores from the pre-training OSCE to the 12 week post-training OSCE for the moderate intensity and the high intensity groups. The models incorporated random effects for study site and participant and fixed effects for simulated patient and pre-training OSCE MITI scores.

RESULTS: Thirty-five PACT members were enrolled in the study and 18 members were randomly assigned to the high intensity group. Compared to the moderate intensity group, the high intensity group scored significantly higher for 5 of the 10 MITI scales (Table 1). For 3 of the other 5 MITI scales, a non-significant improvement was seen in the high intensity versus the moderate intensity group.

CONCLUSIONS: A training model using several booster sessions incorporating telephone interactions with simulated patients, in addition to MI champions, expert consultant, ½ day training and study materials,was effective for sustaining and enhancing providers’ MI skills in the delivery of tobacco cessation care.

Table 1

MITI Scales Training Group Pre-MITI Score (SD) Post-MITI Score (SD) Model Estimated Change (SE) p-value

Global Spirit High Intensity 2.89 (0.61) 3.20 (0.77) 0.31 (0.20)

Moderate Intensity 2.67 (0.81) 2.50 (0.72) −0.26 (0.21)

Difference 0.57 (0.20) 0.0091

Percent Open Questions High Intensity 0.32 (0.21) 0.48 (0.23) 0.17 (0.04)

Moderate Intensity 0.27 (0.18) 0.32 (0.24) 0.03 (0.05)

Difference 0.14 (0.06) 0.0336

Percent MI Adherence High Intensity 0.50 (0.37) 0.90 (0.19) 0.31 (0.11)

Moderate Intensity 0.62 (0.38) 0.57 (0.39) −0.00 (0.12)

Difference 0.32 (0.10) 0.0047

Evocation High Intensity 2.75 (0.88) 3.00 (1.22) 0.33 (0.22)

Moderate Intensity 2.40 (1.05) 2.00 (0.87) −0.54 (0.27)

Difference 0.87 (0.35) 0.0211

Collaboration High Intensity 2.69 (0.93) 3.16 (1.02) 0.38 (0.33)

Moderate Intensity 2.68 (1.13) 2.32 (1.04) −0.43 (0.35)

Difference 0.81 (0.28) 0.0083

A STRATEGY TO ENGAGE COMMUNITY BASED ORGANIZATIONS IN BUILDING RESEARCH CAPACITY Crispin N, InterNetView 2.0.1.8 crack serial keygen. Goytia1; Barbara Brenner2; Peggy M. Shepard3; Lea Rivera-Todaro1; Carol Horowitz1. 1Mount Sinai School of Medicine, New York, NY; 2Mount Sinai School of Medicine, New York, NY; 3WE ACT for Environmental Justice, InterNetView 2.0.1.8 crack serial keygen, New York, NY. (Tracking ID #1642376)

BACKGROUND: Building and sustaining community-academic research partnerships is a challenge for both academic institutions and for community based organizations (CBOs), InterNetView 2.0.1.8 crack serial keygen. Each partner comes to the relationship with differing expertise and gaps in knowledge. Many Clinical InterNetView 2.0.1.8 crack serial keygen Translational Science Award (CTSA) sites are working to build CBO capacity to engage in research, but information about needs and goals of CBO’s in this regard is lacking. Therefore, our CTSA’s community and academic partners aimed to conduct a community research needs assessment.

METHODS: Based on literature review, informal interviews with research-interested CBOs locally and nationally, and with community-engaged research groups from other CTSAs, we developed a needs assessment survey. Key domains of this survey included experience and interest in research collaboration, skill development and program evaluation. The team identified a preliminary list of 80 eligible CBOs through network analysis and a list from the Foundation Center’s Directory of New York City organizations that received grants in 2009–2010 in health services or research, InterNetView 2.0.1.8 crack serial keygen. We trained Community Health Workers (CHWs) to recruit a senior leader from each site and the CHW’s encouraged them via mail, email and telephone over a 90-day period to complete the survey.

RESULTS: Fully 76 % (61) CBOs completed the needs assessment. Most (69 %) reported involvement with research or evaluation in the last 2 years, 42 % were currently involved in research or program evaluation and 33 % had some funding for research. Fully 75 % had collaborated with academic institutions in the past. Most were interested in collaborating or working as partners on research, with a mean score of 6 on a scale of 1 = not interested, to 8 = the most interested. The average experience with collaboration in research was unimpressive: “good” on a scale of “poor, fair, good, very good, InterNetView 2.0.1.8 crack serial keygen, excellent”. The four areas of greatest interest were program evaluation, developing a needs assessment, statistical analysis and survey development. There was less interest in how to establish a research collaboration with academics. Respondents preferred a hybrid format of online and InterNetView 2.0.1.8 crack serial keygen person workshops to other options to either format on its own.

CONCLUSIONS: A formal needs assessment of the research training and education needs of CBO’s in New York City revealed that, despite underwhelming experiences with collaboration, most had significant interest in future collaboration and learning about InterNetView 2.0.1.8 crack serial keygen. CBO leaders were particularly interested in learning about how to conduct research and evaluation, and less interested in learning how to partner with academics to collaborate on research. Community representatives from the CTSA will use these findings to: develop a research capacity building course. Other InterNetView 2.0.1.8 crack serial keygen should consider building or making use of such assessments to transform the capacity of community organizations to be active research partners and leaders.

A SUCCESSFUL COMMUNITY PARTNERSHIP MODEL FOR RECRUITING PUBLIC HOUSING RESIDENTS INTO RESEARCH Tracy A. Battaglia1; Jo-Anna L. Rorie2; Sarah W. Primeau1; Sarah E. Caron1; Sarah G. Bhosrekar2; Bing L. Chen1; Sharon Bak1; Gerry Thomas3; Rachel Goodman5; Eugenia Smith4; Deborah J. Bowen2. 1Boston University School of Medicine, Boston, MA; 2Boston University School of Public Health, Boston, MA; 3The Boston Public Health Commission, Boston, MA; 4The Community Committee for Health Promotion, Boston, MA; 5The Boston Housing Authority, Boston, MA. (Tracking InterNetView 2.0.1.8 crack serial keygen #1612855)

BACKGROUND: The Boston University Partners in Health and Housing Prevention Research Center (PHH-PRC), a partnership between the School of Public Health, Community Committee for Health Promotion, Boston Housing Authority and Boston Public Health Commission, aims to improve the health of Boston’s Public Housing residents through research. This study aims to demonstrate the Center’s ability to recruit and retain a representative sample of residents in the community setting to participate in a research study.

METHODS: An ongoing community engagement activity of the PHH-PRC is the conduct of monthly, on-site educational health screenings conducted in collaboration with housing development residents and research center staff. We conducted a descriptive analysis of enrollment outcomes from these community-based health screenings held across 6 housing developments from April 2011 through June 2012. The outcome of interest was enrollment into Project HHEART (Heart Health Equality Among ResidenTs), a patient navigation intervention study designed to improve clinical and community program participation among housing development residents at risk for cardiovascular disease. All those attending the health screenings completed a survey, underwent an evaluation for cardiovascular risk factors and received written educational materials. Those eligible for enrollment into Project HHEART were ≥18 years of age, spoke English or Spanish, resided in the respective housing development and screened positive for ≥1 risk factor (overweight/obese, hypertension, hypercholesterolemia, diabetes, tobacco use). We compared socio-demographic and risk factor characteristics of those eligible vs. ineligible for Project HHEART enrollment. Among those eligible, we compared characteristics of those who enrolled vs. declined.

RESULTS: 610 residents participated in screenings April 2011–June 2012. Most were female (74 %), non-White (30 % Black, 44 % Hispanic, 15 % other), had public (84 %) or no health insurance (10 %), reported a clinical visit with a primary care provider in the past 3 months (62 %) and screened positive for >1 risk factor (92 %). About half spoke a language other than English (50 %), InterNetView 2.0.1.8 crack serial keygen, were foreign-born (49 %), and had less than high school education (45 %). Overall, 451 (74 %) of participants were eligible for enrollment. Reasons for ineligibility included: not living on site (n = 106), no positive screens for risk factors (n = 32) and significant language barriers (did not speak English or Spanish) (n = 21). Compared InterNetView 2.0.1.8 crack serial keygen those ineligible for Project HHEART, eligible participants were more likely to be older (mean age 50 v. 49 years, p < 0.01), Hispanic (48 % v. 33 %, p < 0.01), and have public or no health insurance (93 % v. 86 %, p = 0.05). Of the 451 eligible participants, 326 (72 %) agreed to participate and were enrolled into Project HHEART. Compared to those who declined to participate, enrolled subjects were slightly younger (mean age 50 v. 53, p < 0.01), but did not differ in any other socio-demographic or health risk factor status. Of those enrolled (n = 326), 80 % completed 3-month follow-up surveys.

CONCLUSIONS: Socio-demographic differences in eligibility reflect the study design, InterNetView 2.0.1.8 crack serial keygen. Among those eligible, we enrolled and retained a representative sample of public housing residents and engaged them into prevention research. This program serves as one viable model to engage a diverse population in research.

A TECHNOLOGY-BASED APPROACH TO IDENTIFYING UNDIAGNOSED HYPERTENSION Christopher Masi1; Michael Rakotz1,2; Ruth Ross1; Ari Robicsek1; Chad Konchak1; Bernard Ewigman2. 1NorthShore University HealthSystem, InterNetView 2.0.1.8 crack serial keygen, Evanston, IL; 2NorthShore University HealthSystem, Evanston, IL. (Tracking ID #1633262)

BACKGROUND: Affecting 30 % of all U.S. adults 18 years and older, InterNetView 2.0.1.8 crack serial keygen, hypertension is the leading modifiable risk factor for coronary artery disease, stroke, and congestive heart failure. According to the 2008 National Health and Nutrition Examination Survey, approximately 19 % of U.S. adults with hypertension are unaware of their diagnosis. Our goal was to identify primary care patients with suspected but undiagnosed hypertension and then clarify their status using an automated office blood pressure (AOBP) device.

METHODS: We queried the electronic health records (EHR’s) of patients who receive care at one of twenty-three health system-affiliated primary care clinics to identify adults aged 18 to 79 years who had at least one primary care office visit within 12 months of the query, had elevated blood pressure readings as identified by at least one of five hypertension screening algorithms, and did not have a diagnosis of hypertension recorded in the EHR. Individuals who met these criteria were considered at-risk for undiagnosed hypertension and were invited to complete a clinic-based AOBP measurement using a InterNetView 2.0.1.8 crack serial keygen device which averages five readings over a five-minute period. Since each patient had one or more previously documented elevated blood pressure readings, we classified patients based upon their AOBP mean: hypertension if BP ≥ 140/90 mmHg; prehypertension if BP ≥ 120/80 mmHg and <140/90 mmHg; and white coat hypertension if BP < 120/80 mmHg. The positive predictive value (PPV) of the hypertension screening algorithms was calculated by dividing the number of individuals with an AOBP mean in the prehypertension or hypertension ranges (true positives) by the number of individuals identified by at least one of the hypertension screening algorithms (all positives).

RESULTS: Of the 139,666 adults who receive care at one of the participating clinics, 1,586 met our inclusion criteria. After confirming the appropriateness of study participation with each patient’s primary care physician, attempts were made to recruit 1,432 patients. 475 of these patients agreed to participate in the study and undergo a clinic-based AOBP measurement. Among participants, the median age was 54.4 years, the mean BP recorded in the EHR was 136/82 mmHg, and the mean BMI was 29.6 kg/m2. Fifty-two percent of participants were male. Participants identified themselves as Caucasian (70.9 %), African American (6.1 %), InterNetView 2.0.1.8 crack serial keygen, Hispanic/Latino (3.4 %), Asian (2.7 %), or other (16.8 %). Comparing the 475 participants to the 957 non-participants revealed the participants were older (54.4 vs. 50.0 years, p < 0.001) but were similar in all other respects, including distribution of ethnicities, and prevalence of co-morbidities, including diabetes, congestive heart failure, and COPD. Based upon AOBP means among participants, 183 (39 %) had hypertension, InterNetView 2.0.1.8 crack serial keygen, 196 (41 %) had prehypertension, and 96 (20 %) had white coat hypertension. The positive predictive value for detecting prehypertension or hypertension using our technology-based approach was 80 %.

CONCLUSIONS: Essential elements of our approach included an EHR, computer-based screening algorithms, and an established AOBP protocol. Results from this study confirm the notion that technology-based strategies have significant potential to detect undiagnosed chronic disease - a critical first step toward enhancing chronic disease management.

A VALID MEASURE OF HEALTH-RELATED TRUST FOR USE IN DIVERSE POPULATIONS Rebecca J, InterNetView 2.0.1.8 crack serial keygen. Schwei1; Paul Rathouz2; Seung W. Choi3; Elizabeth A. Jacobs1. 1University of Wisconsin School of Medicine and Public Health, Madison, WI; 2University of Wisconsin School of Medicine and Public Health, Madison, WI; 3McGraw-Hill Education, Monteray, CA. (Tracking ID #1640804)

BACKGROUND: Varying levels of distrust in health care among racial/ethnic groups are hypothesized to contribute to health disparities in the US. However, few measures of trust and distrust have been developed and validated Apple MainStage 3.5.3 Crack 2021 + Serial Key Full Free Download use across racial/ethnic groups to allow adequate exploration of this hypothesis. The objective of the study was to develop a measure of health-related trust in the 3 major racial/ethnic groups in the US: African Americans, Hispanic-Mexicans, and non-Hispanic whites.

METHODS: We developed candidate items through extensive qualitative work, cognitive testing, piloting, and rigorous translation into Spanish. We administered the 81 candidate items to a convenience sample of African American (n = 142), Hispanic-Mexican (n = 143), and non-Hispanic white (n = 155) individuals at Chicago-area supermarkets. Participants responded using a 5-item Likert response scale: never true, a little true, half the time true, InterNetView 2.0.1.8 crack serial keygen, mostly true, always true. We conducted exploratory and confirmatory factor analyses using Mplus. We also asked “In the past 5 years, have you had a negative health care experience you considered to be bad or negative?” (Y/N).

RESULTS: The final instrument contained 36 items and 7 factors: Discrimination (3 items), Equity (6 items), Hidden Agenda (4 items), Insurance (3 items), Negative Physician Perceptions (5 items), Positive Physician Perceptions (12 items) and System Welcoming (3 items). A higher trust score indicated increased trust. The instrument (α = .94) and individual factors performed well overall and in each racial/ethnic group (α = .61 to .94) The 7-factor CFA model provided reasonable fit statistics (CFI = .964, TLI = .961, RMSEA = .055) and evidence for construct validity. Across all racial/ethnic groups individuals reporting a negative health care InterNetView 2.0.1.8 crack serial keygen had lower levels of institutional trust.

CONCLUSIONS: Our measure of health-related trust performed well across racial/ethnic groups while including constructs that may vary considerably across groups (e.g., Discrimination). InterNetView 2.0.1.8 crack serial keygen was increased trust in groups without a reported previous negative health care experience. We found trust in health care to be multi-faceted, incorporating perceptions about physicians, health care systems, and insurance. This measure has the potential to advance the field studying how health-related trust contributes to health disparities in the US.

A CASE METHOD EDUCATION ON MANAGEMENT OF DISCHARGE PLANNING FOR HEALTHCARE PROFESSIONALS Yukio Tsugihashi1,2; Noriko Kawai2; Hitoshi Ishii2. 1Tenri Hospital, Tenri, InterNetView 2.0.1.8 crack serial keygen 2Tenri Hospital, Tenri, Japan. (Tracking ID #1627411)

BACKGROUND: In collaborative healthcare systems, reducing length of stay has been a priority for general hospitals. There is concern that the reduction may provide low-quality transitional care for the patients and the families. In order to secure the quality for the patients and the families, hospital workers should effectively acquire a management skill for discharge planning. A case method is a teaching method that is widely used in business schools. Students can enhance their leadership and management skills through discussion about a teaching case. The case is a document that objectively illustrates Xforce autodesk 3ds max keygen,serial,crack,generator cases to be solved and includes information for classroom discussion. Both business and discharge planning, there are no simple solutions. We hypothesized that the case method could be adjusted into education in discharge planning. Therefore, we developed a InterNetView 2.0.1.8 crack serial keygen educational program for the discharge planning using a case method education. The purpose of this study was to (1) develop educational strategies and (2) assess the learning outcomes of this program.

METHODS: This study was conducted from April 2012 to July 2012 at one general hospital in Japan (Tenri Hospital, Tenri City, Nara, Japan). Cornerstones of the program are provided in Table 1. The Participants were provided with InterNetView 2.0.1.8 crack serial keygen case method education consisting of following three steps: 1) Preparing their opinions for teaching cases before the classes. 2) Discussing with other participants in small groups and a classroom, 3) A short lecture summarizing key points in the cases. A medical doctor and a registered nurse specialized in care transition prepared four cases based on actual care transition in Tenri Hospital. In order to evaluate learning outcomes of the program, we performed questionnaire surveys after each lecture, including descriptive analyses about participants’ satisfaction and qualitative content analysis focused on their self-awareness through the program.

RESULTS: This study enrolled 57 healthcare providers working in Tenri Hospital and affiliated care institutions. With regard to the occupation, 31(54 %) were registered nurses, InterNetView 2.0.1.8 crack serial keygen, 7 (12 %) were medical social workers, and 19 (38 %) were other occupations including physical therapists, long-term care support specialists, medical doctors, pharmacists, certified care workers, medical college teachers and medical secretary. Over 90 % of the participants were satisfied with the program. The participants’ self-awareness was identified Advanced Installer license key Archives the following three categories: acquiring core competencies for discharge planning, problem extraction through active interaction among the participants, InterNetView 2.0.1.8 crack serial keygen, and precious opportunities for inter-professional communications in the related institutions.

CONCLUSIONS: A case method by the discussion-based education using actual cases successfully contributed to enhance the participants’ awareness for management of discharge planning in addition to obtaining the core competency. Furthermore, InterNetView 2.0.1.8 crack serial keygen, the program itself could promote inter-professional communications among the hospital workers.

Table 1. Cornerstones of a case method education on management of discharge planning

Teaching method A case method education with 3 h session per a month (Small group discussion: 60 min, Classroom discussion: 60 min, Short lecture: 30 min)

Duration/Frequency 4 months/One Saturday afternoon per month

Titles of teaching cases Case 1. An elderly woman emergently admitted InterNetView 2.0.1.8 crack serial keygen a hospital with acute pyelonephritis

Case 2. An elderly patient with advanced dementia and bilateral leg gangrenes

Case 3. A patients who can’t eat by mouth because of severe neurological InterNetView 2.0.1.8 crack serial keygen 4. Tohoku earthquake. Effort of medical support teams from Nara prefecture

Learning outcomes Satisfaction level (descriptive analysis)/Self-awareness (qualitative analysis)

A MULTI-INSTITUTION RETROSPECTIVE STUDY ON CAUSATIVE DISEASES AND DIAGNOSTIC METHODS FOR FEVERS OF UNKNOWN ORIGIN IN JAPAN: A PROJECT OF THE JAPANESE SOCIETY OF GENERAL HOSPITAL MEDICINE

Toshio Naito1; Fujiko Mitsumoto2; Hiroyuki Morita3; Masafumi Mizooka4; Shiro Oono5; Akira Ukimura6; Keito Torikai7; Kenji Kanazawa8; Masashi Yamanouchi1; Susumu Tazuma4; Jun Hayashi2. 1Juntendo University School of Medicine, Tokyo, Japan; 2Kyushu University Hospital, Fukuoka, Japan; 3Gifu University Graduate School of Medicine, Gifu, Japan; 4Hiroshima University Hospital, Hiroshima, Japan; 5Nara Medical University, Nara, Japan; 6Osaka Medical College, Osaka, Japan; 7St. Marianna University School of Medicine, Tokyo, Japan; 8Kobe Universtiy Hospital, Kobe, Japan. (Tracking ID #1634255)

BACKGROUND: Fevers of unknown origin (FUO) are caused by a wide range of diseases, InterNetView 2.0.1.8 crack serial keygen, and they occur in a variety of regions and age groups, InterNetView 2.0.1.8 crack serial keygen. In Japan, research on the topic has been limited to single facilities/regions, and no national surveys have been conducted. Analysis is important, as causes may differ with race, region and era, InterNetView 2.0.1.8 crack serial keygen. Further, few studies have evaluated the usefulness of diagnostic exams, and FUO is diagnosed according to guidelines specific to InterNetView 2.0.1.8 crack serial keygen facility. In particular, there has been very little research on the efficacy of recently developed diagnostic methods, such as blood procalcitonin analysis and positron emission tomography (PET). Here, we conducted a national survey at facilities belonging InterNetView 2.0.1.8 crack serial keygen the Japanese Society of General Hospital Medicine, to clarify what exams are useful and what diseases deserve attention in the differential diagnosis and treatment of FUO.

METHODS: Seventeen facilities were surveyed nationwide from January to December 2011. The subjects were patients who were 18 years or older and diagnosed with “classical FUO (a fever with an axillary temperature of 38 °C or higher and measured 2 times or more in a period of 3 weeks or longer, and where the cause was unclear after 3 outpatient visits or a 3-day hospital stay).” InterNetView 2.0.1.8 crack serial keygen data were recorded in a common case report form and tallied using FAX.

RESULTS: A total of 121 FUO cases were recorded, with a median age of 59 years (19–94 years). The causative disease was infection in 28 cases (23.1 %), noninfectious inflammatory disease in 37 cases (30.6 %), malignant tumor in 13 cases (10.7 %), something else in 15 cases (12.4 %), and unknown in 28 cases (23.1 %). “Something else” included causes such as drug-induced fevers. The median number of days from fever onset to first examination was 28 days. A case of familial Mediterranean fever took the longest days to be diagnosed. Blood cultures were performed at 86.8 %, blood procalcitonin values measured at 43.8 %, and PET performed at 29.8 %.

CONCLUSIONS: With the increased use of computed tomography, FUO due to deep abscesses or solid tumors have declined markedly. The causative disease with the largest proportion was polymyalgia rheumatica (9 cases), reflecting the aging of the society. The relatively small number of cases due to an unknown cause was possibly attributable to the bias of the retrospective study, InterNetView 2.0.1.8 crack serial keygen. HIV/AIDS caused 4 FUO cases, InterNetView 2.0.1.8 crack serial keygen, showing that this has become an important cause of FUO in Japan. This study clarified diseases that deserve attention when differentiating FUO. We have a plan to analyze the usefulness of exams and create guidelines for diagnosing InterNetView 2.0.1.8 crack serial keygen NATIONAL STUDY OF INTERNISTS’ POINT OF CARE LEARNING Michael Green1; Siddharta Reddy2; Eric Holmboe2. 1Yale School of Medicine, New Haven, CT; 2American Board of Internal Medicine, Philadelphia, PA. (Tracking ID #1639990)

BACKGROUND: Physicians frequently encounter clinical questions at the point of care (POC), which represent opportunities for learning, immediate application of new knowledge, and longer term performance improvement. An understanding of these POC learning episodes would inform continuing medical education programs, electronic information resources, evidence-based practice training, and reflective practice. InterNetView 2.0.1.8 crack serial keygen studies of POC learning have been confined to small numbers of physicians in limited geographic areas.

METHODS: We studied internists enrolled in the ABIM Maintenance of Certification (MOC) program who registered for and entered at least one question in the ABIM Point-of-Care Clinical Question Module between November 2010 and December 2012. To complete this web-based module, internists documented the characteristics, information seeking, learning, practice impact, and barriers of at least 20 point of care clinical questions. We compiled descriptive statistics for the module data.

RESULTS: Four-hundred-seventy-two internists entered at least one clinical question (224 completed the module, 188 are currently working on it, and 60 cancelled). Among those who completed the module, 197 (88 %) spent more than 30 h per week in patient care activities, 66 (28 %) were generalists, and 108 (48 %) worked in academic settings. The internists documented 5187 POC learning episodes over periods ranging from 1 to 19 months. The episodes most commonly were stimulated by direct patient care in the ambulatory setting, with or without a trainee (57 %); involved cardiovascular disease (21 %) or gastroenterology (14 %) content; represented foreground questions (58 %); and concerned therapy (55 %) or diagnosis (14 %) questions. The internists spent a median of 30 min looking up medical information, most often some time after the clinical encounter (61 %); using a median of 2 resources; and most commonly consulting UpToDate® (25 %) and articles retrieved via PubMed (17 %). The internists planned to change their practice based on 40 % of the point of care InterNetView 2.0.1.8 crack serial keygen episodes. Among the remainder, they reported that the information supported their current practice (47 %), they required more information before making a change (9 %), or the practice change was not feasible (3 %). Internists encountered barriers during 11 % of the learning episodes, including limited access to information resources (17 %), uncertainty about the sufficiency of the information initially obtained (13 %), difficulty searching information resources (11 %), and difficulty appraising the validity or usefulness of the information (8 %).

CONCLUSIONS: Using a novel web-based portfolio for MOC, internists’ report POC learning episodes that most commonly occur in the ambulatory setting, involve cardiovascular disease or gastroenterology content, and concern questions of therapy and diagnosis. They consult an average of two information resources per episode, most commonly UpToDate and PubMed. Forty percent of POC learning episodes result in a planned practice change.

A PREDICTION RULE FOR MORTALITY FOR INPATIENTS WITH STAPHYLOCOCCUS AUREUS BACTEREMIA: A CLASSIFICATION AND REGRESSION TREE (CART) ANALYSIS Daiki Kobayashi1,2; Kyoko Yokota4; Osamu Takahashi2,3; Hiroko Arioka2; Tsuguya Fukui2; Christina C. Wee1. 1Beth Israel Deaconess Medical Center, Boston, MA; 2St Luke’s International Hospital, Tokyo, Japan; 3St Luke’s Life Science Institute, Tokyo, Japan; 4Kagawa University, Takamatsu, Japan. (Tracking ID #1641328)

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is one of the most common types of bacteremia in both community and healthcare settings. Previous studies suggest that the mortality associated with SAB is significant rangeing from 20 to 40 %. Although mortality is high, the risk factors for mortality among patients with SAB have not been sufficiently evaluated.

METHODS: This was a retrospective cohort study of all adult patients with SAB at a large community hospital in Tokyo, InterNetView 2.0.1.8 crack serial keygen, Japan, from April 1, 2004 to March 31, 2011. All patients with fever and afebrile patients who were suspected of having a bacterial infection had 2 sets of blood cultures sent at the time of admission. SAB was determined based on InterNetView 2.0.1.8 crack serial keygen least one positive blood culture. The primary outcome was death within 90 days. Baseline data and clinically relevant factors were collected from the electronic chart. All candidate predictors were included in a Classification and Regression Trees (CART) analysis to create a prediction rule to identify risk factors of mortality InterNetView 2.0.1.8 crack serial keygen patients with SAB. A receiver operating characteristic (ROC) curve was drawn, and the area under the curve (AUC) was obtained.

RESULTS: 340 patients InterNetView 2.0.1.8 crack serial keygen SAB during the study period. Of these, 121 (36 %) patients died within 90 days. Among 41 potential variables examined, the CART analysis revealed that underlying malignancy, serum blood glucose level, methicillin resistance, and low serum albumin were predictors of mortality. Our results suggest that patients can be categorized in 3 risk groups: low (< 30 % mortality), medium (40–60 %), and high (> 60 %) (see fig). For patients without underlying malignancy, the next best predictor was serum blood glucose level, where patients with a blood glucose level >167 mg/dl had higher risk of mortality (see fig). Methicillin resistance predicted mortality risk only among patients who had a glucose level higher than 167 mg/dl. For patients with malignancy, serum albumin was the most InterNetView 2.0.1.8 crack serial keygen predictor; patients with <3.25 mg/dl albumin were placed in the high risk group. The AUC was 0.76 (95 %CI: 0.70–0.81).

CONCLUSIONS: We propose a prediction model for mortality of patients with SAB consisting of 4 predictors: underlying malignancy, low serum albumin, high glucose, and methicillin resistance. This model, if validated in other populations, may facilitate appropriate preventative management for patients with SAB who are at high risk of mortality.

Decision tree for 90 Day Mortality (95 % Confidence Interval) Among Patients with Staphylococcus aureus Bacteremia. Results are derived from CART Analysis. Low risk = <30 % mortality, medium risk = 40–50 %, high risk = > 60 % MSSA* refers to Methicillin-sensitive Staphylococcus aureus, MRSA† refers to Methicillin-resistant Staphylococcus aureus

A RANDOMIZED CONTROLLED TRIAL OF A COMMUNITY HEALTH WORKER POST-HOSPITAL CARE TRANSITIONS INTERVENTION FOR LOW SOCIOECONOMIC STATUS PATIENTS

Shreya Kangovi1,6; David Grande2,3; Nandita Mitra4; Jeffrey Sellman1; Mary L. White6; Sharon McCollum6; Richard Shannon2; Judith A. Long5,2. 1Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 3University of Pennsylvania, Philadelphia, PA; 4University of Pennsylvania, Philadelphia, PA; 5Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; 6Spectrum Health Services, Inc., Philadelphia, PA. (Tracking ID #1631341)

BACKGROUND: The post-hospital transition is a focus of national policy attention. Low socioeconomic status (SES) patients are more likely to report poor quality of discharge planning, lack of social support during InterNetView 2.0.1.8 crack serial keygen and inability to access outpatient follow-up after hospitalization, InterNetView 2.0.1.8 crack serial keygen. Low-SES patients have an elevated risk of all-cause readmission and post-hospital death. Existing post-hospital transition interventions often employ clinical personnel and neglect socioeconomic factors that are important to low-SES patients. To address these issues, we performed a randomized controlled trial comparing a community health worker (CHWs) intervention (IMPaCT-Individualized Management towards Patient-Centered Targets) to usual discharge care.

METHODS: Participants were recruited from two academically affiliated hospitals in Philadelphia, PA. Eligible patients were:1)admitted to the General Medicine service; 2)uninsured or insured by Medicaid; 3)18–64 years old and 4)residents of low-income ZIP codes. Eligible patients were randomized to receive usual discharge care or IMPaCT. Patients randomized to IMPaCT received structured CHW social support, advocacy and health system navigation from the time of hospitalization until post-hospital primary care follow-up. CHWs were recruited through a network of community-based organizations, underwent a month-long training and were paid $15 per hour. The primary outcome of the trial was the proportion of patients who completed primary care follow-up within 2 weeks of hospital discharge. Secondary outcomes, which each ranged from 0 to 100, were: self-rated health (SF-12), quality of discharge communication (Consumer Hospital Consumer Assessment of Healthcare Providers and Systems-HCAHPS- discharge communication items), patient activation (Patient Activation Measure score) and readmission rate at 14,30,60 and 90 days. Patient-reported outcomes were measured by a blinded assessor 2 weeks after index discharge. We compared outcomes between control and intervention groups using an InterNetView 2.0.1.8 crack serial keygen to treat analysis.

RESULTS: 442 patients were enrolled from May 15th, 2011 to December 1st, 2012. 86.6 % of participants completed the trial. The intervention group had a higher proportion of patients who engaged in InterNetView 2.0.1.8 crack serial keygen primary care than the control group (59.4 % vs. 48.4 %, p = 0.03). Patients in the intervention group had higher self-rated health mental component summary scores (49.2 vs. 46.3, p = 0.02), were more likely to report high-quality discharge communication (91.3 % vs. 78.3 %, p = 0.002) and had higher levels of patient activation (64.0 vs, InterNetView 2.0.1.8 crack serial keygen. 60.3, p = 0.04). At 14 days readmission rates were not different between groups (9.9 % vs. 7.2 %, p = 0.60). 30, 60 and 90-day readmission InterNetView 2.0.1.8 crack serial keygen are pending.

CONCLUSIONS: A brief transitions intervention performed by CHWs can improve a variety of post-hospital outcomes for low-SES patients. 14-day rates of readmission are low and not different between groups. CHWs, who are inexpensive and rapidly trained, are well-suited to provide post-hospital support to a high-risk, underserved population.

Secondary Patient-Reported Outcomes*

Control (n = 221) Intervention (n = 221) P Value

Self-rated health

Mental Component Summary 46.3 ± 12.9 49.2 ± 12.4 0.02

Physical Component Summary 38.2 ± 11.8 38.4 ± 11.1 0.89

HCAHPS high-quality discharge communication 78.3 % 91.3 % 0.002

Patient Activation Measure 60.3 ± 15.9 64.0 ± 17.4 0.04

14-d Readmission 7.2 % 9.9 % 0.60

*Values are expressed as percentage or mean ± SD

A RANDOMIZED CONTROLLED TRIAL OF PRIMARY CARE InterNetView 2.0.1.8 crack serial keygen PHARMACIST-PHYSICIAN COLLABORATIVE MEDICATION THERAPY MANAGEMENT FOR HYPERTENSION Jan D. Hirsch1; Neil Steers2; David S. Adler1; Grace M. Kuo1,4; Candis M. Morello1; Megan Lang6; Renu F. Singh1; Yelena Wood3; Robert M. Kaplan5; Carol Mangione2. 1University of California San Diego, La Jolla, CA; 2University of California Los Angeles, Los Angeles, CA; 3University of California San Diego, San Diego, CA; 4University of California San Diego, La Jolla, CA; 5University of California Los Angeles, Los Angeles, CA; InterNetView 2.0.1.8 crack serial keygen of California San Diego, San Diego, InterNetView 2.0.1.8 crack serial keygen, CA. (Tracking ID #1634599)

BACKGROUND: Managing patients with chronic diseases to achieve therapeutic goals such as blood pressure (BP) control is challenging for busy primary care physicians. Collaborative care InterNetView 2.0.1.8 crack serial keygen that fully integrate pharmacists within the primary care team may help address this problem by giving patients better access to highly trained provider teams. We conducted a randomized controlled trial (RCT) evaluating BP control for hypertensive patients collaboratively managed by a pharmacist-primary care physician team versus those who were solely managed by their primary care physician (PCP).

METHODS: Patients with BP > 140/90 mmHg or BP > 130/80 mmHg with a diagnosis of diabetes mellitus were randomized to treatment by a pharmacist under a collaborative pharmacist-physician medication therapy management (MTM) protocol versus usual care in an academic General Internal Medicine practice. Patients were scheduled for pharmacist appointments independent of physician visits. Pharmacist actions included drug therapy monitoring, physical assessment, InterNetView 2.0.1.8 crack serial keygen, laboratory test review and order, medication adjustments (dosage change, InterNetView 2.0.1.8 crack serial keygen, initiation, discontinuation), InterNetView 2.0.1.8 crack serial keygen, and patient education. The primary outcome was mean change in systolic blood pressure (SBP) at 6 and 9 months after initial visit. Secondary outcomes were percent achieving BP goal, mean change in diastolic blood pressure InterNetView 2.0.1.8 crack serial keygen, LDL and HDL cholesterol.

RESULTS: At baseline the MTM group (n = 76) was similar to the Usual Care group (n = 91) for all eight measured clinical markers; however MTM patients were slightly younger 65.4 (13.0) vs. 69.6 (11.4) years, had lower Charlson Comorbidity Index 3.1 (1.9) vs. 4.1 (2.6), and had more men (53.3 % vs. 31.9 %), InterNetView 2.0.1.8 crack serial keygen. Mean change in SBP in the MTM group was significantly greater at 6 months −7.1 (19.4) vs. +1.6 (21.0) mm Hg, (p = 0.008) but the difference was no longer statistically significant at 9 months −5.2 (16.9) vs. −1.7 (17.7) mmHg, (p = 0.22). The mean change in SBP from initial visit to 9 months for patients who had returned to their PCP after 6 months was +1.9 (13.8) compared to −7.8 (17.3) for those who continued to see the MTM pharmacist through the 9-month visit (p = 0.03). Compared to Usual Care patients, a greater percentage of MTM patients were at goal at 6 months (81 % vs. 44 %, p < 0.001) and 9 months (70 % vs. 52 %, p = 0.02). No significant difference in change in LDL or HDL was detected at 6 or 9 months between groups.

CONCLUSIONS: A pharmacist-physician collaborative medication therapy management service was more effective in lowering blood pressure than usual care at 6 months and at 9 months for patients who continued to see the pharmacist. Given the shortages of PCPs and the aging population, incorporating pharmacists in the primary care team can be a successful strategy for managing medication therapy, improving patient outcomes and extending primary care capacity.

A RANDOMIZED TRIAL OF A COMMUNITY HEALTH WORKER LED INTERVENTION USING InterNetView 2.0.1.8 crack serial keygen SELF-SAMPLING TO INCREASE CERVICAL CANCER SCREENING AMONG MINORITY WOMEN: PRELIMINARY FINDINGS Olveen Carrasquillo; Brendaly Rodriguez; Erin N. Kobetz-Kerman. University of Miami, Miami, FL. (Tracking ID #1642511)

BACKGROUND: Cervical cancer disproportionately affects minority and immigrant women, InterNetView 2.0.1.8 crack serial keygen. Among this population, there are multiple barriers to Pap smear screening including knowledge, limited access to care and cultural norms. In 2012, the USPSTF noted that self sampling for the human papilloma virus (HPV) holds great promise as a screening strategy among hard to reach populations. We present preliminary findings from our ongoing randomized trial testing this approach in three minority communities in Miami.

METHODS: The South Florida Center for Reduction of Cancer Disparities is a comprehensive NCI initiative aimed at reducing cervical cancer disparities in South Florida through community based participatory research. Using community health workers (CHWs) our community partners are recruiting 600 minority women ages 30–65 who had not had a Pap smear in the last three years into the study. Following a baseline intake, women are randomized into one of three arms. Group one receives culturally tailored cervical cancer education materials. Groups 2 and 3 receive a 1 hour CHW home health education session. CHWs subsequently refer and navigate women in group 2 to Pap smear screening at community based facilities that perform free or low cost testing. Women in group 3 have the option of Pap smear or doing HPV self sampling after a brief CHW instruction session. A research assistant blinded to study allocation performs a 6 month follow-up visit to assess screening status. A formal interim analysis was not part of the study design. However, we are able to present preliminary baseline data as well as follow-up status in Groups 2 and 3 based on CHWs logs. We do not include any hypothesis testing.

RESULTS: To date, using various community outreach strategies, CHWs have assessed 2,601 women for study inclusion. Of these 515 are study eligible; most ineligibles are due to being screened already InterNetView 2.0.1.8 crack serial keygen age exclusion. Less than 5 % of eligible women have declined to participate, InterNetView 2.0.1.8 crack serial keygen. Among the 280 women we have already randomized, 51 % are Hispanic, 39 % Haitian, and 11 % African American. Over half are uninsured. Among the 70 women randomized to group 2 and having already received the educational session, 48 % have obtained a subsequent Pap smear. Among the 64 women randomized to Group 3 who have received the education, 95 % have been screened. InterNetView 2.0.1.8 crack serial keygen these 69 % preferred to have the HPV self-sampling at time of CHW session over being referred for a Pap smear. In Little Haiti, 10 of 21 (48 %) HPV samples have been positive for high risk HPV versus 18 % in the other two communities.

CONCLUSIONS: Using the CBPR framework, in a 14 month period we have been able to recruit and randomize almost half of our planned 600 “hard to reach” study population with almost no women refusing to participate. Our rates of Pap smear completion among women in group 2 compares very favorably with data from other similar CHW led programs. Our preliminary data also makes an extremely strong case for HPV self-sampling as a strategy for cervical cancer screening among unscreened minority women.

A RANDOMIZED TRIAL OF A WEB-BASED VERSUS COUNSELOR-BASED INTERVENTION TO REDUCE CHD RISK Stacey L. Sheridan; Thomas C, InterNetView 2.0.1.8 crack serial keygen. Keyserling; Lindy B. Draeger. University of North Carolina at Chapel Hill, Chapel Hill, NC. (Tracking ID #1642611)

BACKGROUND: Coronary heart disease (CHD) is the leading cause of death in the United States and effective interventions are available to reduce CHD risk, InterNetView 2.0.1.8 crack serial keygen. However, the best way to implement risk reduction strategies is yet to be determined.

METHODS: We developed two versions of a combined lifestyle and medication intervention (counselor intevention (CI) and web intervention (WI)) to reduce CHD risk and compared their effects in a randomized trial conducted at five socioeconomically diverse clinics in a practice-based research network. Both interventions were tailored to participants’ baseline risk factors and treatment preferences and included similar content: a web-based decision aid, 4 monthly contacts during an intensive intervention phase (4 months) and 3 brief contacts at 2 month intervals during a maintenance phase (8 months). The primary outcome was within group change in 10 year predicted risk by Framingham score at 4 month follow-up. Secondary outcomes included between group difference in predicted CHD risk and within group changes in CHD risk factors, lifestyle behaviors, and medication adherence. Cost-effectiveness from a societal perspective was also assessed.

RESULTS: We randomized 389 participants with no known CHD and 10-year Framingham CHD risk > or =10 % to either the CI (n = 195) or the WI (n = 194). Mean age was 63. 49 % were female, 25 % were African-American and 75 % white. Mean 10-year predicted CHD risk was 16.9 %. 14 % read at less than a 7–8th grade reading level, InterNetView 2.0.1.8 crack serial keygen. 88 % had health insurance. At 4 month follow-up, the CI reduced CHD risk by 2.2 percentage points (p < .0001) and the WI by 1.4 percentage points (p < 0.001; adjusted mean difference between groups: 0.8 percentage points, p 0.04). These changes resulted from small changes in systolic blood pressure (CI: −2.85 mmHg; WI −1.1 mmHg), total cholesterol (CI: −8.4 mg/dL; WI −3.8 mg/dL), HDL cholesterol (CI: +1.4 mg/dL; WI: +1.8 mg/dL), smoking cessation (CI: −3 %; WI −2 %) and aspirin use (CI: +10 %; WI: +11 %). Small statistically significant changes were also noted in self-reported fruit and vegetable intake (CI: +0.4 servings/day; WI: +0.2 servings/day), walking (CI: +54 min/week; WI: +30 min/week), and adherence (% with high adherence in CI: +14 %; WI: +18 %). The InterNetView 2.0.1.8 crack serial keygen cost-effectiveness ratio for a 1 percentage point reduction in CHD risk was $129 for the WI compared with usual care, and $159 for the CI compared with the WI.

CONCLUSIONS: Both counselor and web interventions reduced CHD risk compared to baseline. The counselor intervention was somewhat more effective than the web intervention, but the web intervention was incrementally more cost-effective.

A RANDOMIZED, CONTROLLED TRIAL OF ALTERNATIVE FORMS OF FEEDBACK ON GLYCEMIC CONTROL IN PATIENTS WITH POORLY CONTROLLED DIABETES Anjali Gopalan1,3; Emin Tahirovic2; Haley Moss2; Andrea B. Troxel2; Jingsan Zhu2; Kevin G. Volpp1,2. 1Philadelphia VA Medical Center, Philadelphia, PA; 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 3Robert Wood Johnson Clinical Scholars Program, Philadelphia, PA. (Tracking InterNetView 2.0.1.8 crack serial keygen #1633742)

BACKGROUND: Prior work has indicated that understanding of the hemoglobin A1c (A1c) among diabetic patients is low. A 2008 study in the British Medical Journal by Parkes et al. showed the potential effectiveness of translating poorly understood medical values into more universally understood forms. This study expressed FEV1 in terms of “lung age” to active tobacco users. Patients given their “lung age” in place of their FEV1 value had significantly higher rates of smoking cessation at study completion, InterNetView 2.0.1.8 crack serial keygen. This approach may hold promise for improving feedback for diabetic patients on glycemic control.

METHODS: We randomly assigned 177 poorly controlled diabetics seen at University of Pennsylvania outpatient practices to receive a “diabetes report card” with individualized information about glycemic control in one of three study arms: (1) letter grades ranging from A-F (grade arm); (2) faces whose emotion reflected current glycemic control (face arm) or (3) actual A1c value (control arm) (Figure 1), InterNetView 2.0.1.8 crack serial keygen. The primary study outcome was change in A1c values between baseline and 6 months. Secondary outcomes were changes in participant perceptions of their current diabetes control, disease severity, and future risk of associated complications.

RESULTS: The average A1c for enrolled participants was 9.9 ± 1.7 % and did not differ significantly between study arms. The pre-intervention survey confirmed high levels of misunderstanding of current glycemic control, with the majority (63 %) of participants describing their control as ‘moderate’ or ‘good’/‘excellent’ in spite of an average A1c of 9.8 % and 10.2 %, respectively. We noted no significant differences in change in A1c at 6 months between the control arm and the experimental arms. Using multiple imputation to handle missing A1c values, the change in A1c for the grade, face, and control arms was −0.55 ± 0.3 %, −0.89 ± 0.3 %, InterNetView 2.0.1.8 crack serial keygen, and −0.74 ± 0.37 %, InterNetView 2.0.1.8 crack serial keygen, respectively (p = 0.67 for grade vs. control, p = 0.76 for face vs. control). We found no significant differences between study arms for the changes in perceptions of current diabetes control, severity, and future complication risk.

CONCLUSIONS: Letter grades and faces did not differentially affect A1c at 6 months or participant perceptions of current control in this population of poorly controlled diabetics. This may reflect the particular alternatives tested in this study, without invalidation of the concepts that improving communication and patient understanding of disease management targets could significantly improve diabetes outcomes.

A SYSTEMATIC REVIEW OF INTERVENTIONS TO IMPROVE PALLIATIVE CARE REFERRAL Irene Kirolos1; Leonardo Tamariz1; Barbara A. Wood2; Ana M. Palacio1. 1University of Miami-Miller School of Medicine, Miami, FL; 2University of Miami-Miller School of Medicine, Miami, FL. (Tracking ID #1642043)

BACKGROUND: Palliative care is underutilized among patients at the end of their lives despite evidence that it improves patient satisfaction and that it reduces costs. The purpose of this study is to synthesize the evidence regarding interventions to increase palliative care usage.

METHODS: We performed a MEDLINE database search (1979 to November 2012) supplemented by manual searches of bibliographies of key relevant articles. We selected all studies in which an intervention was used in palliative care or hospice. Study design, quality criteria, InterNetView 2.0.1.8 crack serial keygen, population, interventions and outcomes for each study were extracted. The main outcome evaluated was increase in hospice/palliative care referral.

RESULTS: Our search strategy yielded 412 studies, of which only five met our eligibility criteria (table). Three studies included nursing home populations and only one study reported on heart failure patients. Three studies had a cohort design, one had a pre-post design and only one study had a randomized design. The specific intervention differed in each InterNetView 2.0.1.8 crack serial keygen. The cohort studies that implemented a palliative care program that ranged from a facilitator to a comprehensive program had a median increase in referrals of 14 %. The randomized study that included a triage system to identify patients’ needs and preferences increased referral by 19 %. Similar trends were seen in the pre-post design.

CONCLUSIONS: Interventions of different levels of complexity can improve the use of palliative and hospice services among subjects with high mortality risk, particularly nursing home patients. More data is needed on the impact of interventions targeting high risk groups in other clinical environments.

Study design Number of studies Population Intervention % Referral to palliative care in intervention group % Referral to palliative care in control group

Cohort 3 At risk of death Palliative care program 47(31–56) 33(7–37)

Pre-post 1 Nursing home Educational 7 4

Randomized 1 Nursing home Triage system 20 1

A WEB-BASED LIFESTYLE INTERVENTION TO DECREASE POSTPARTUM WEIGHT RETENTION IN WOMEN WITH RECENT GESTATIONAL DIABETES MELLITUS: THE BALANCE AFTER BABY PILOT RCT Jacinda M. Nicklas1,2; Chloe A. Zera3; Bernard A. Rosner4,5; Sue E, InterNetView 2.0.1.8 crack serial keygen. Levkoff6,7; Ellen W. Seely2. 1University of Colorado School of Medicine, Aurora, CO; 2Brigham and Women’s Hospital, Boston, MA; 3Brigham and Women’s Hospital, Boston, MA; 4Harvard Medical School, Boston, MA; 5Harvard School of Public Health, Boston, MA; 6Brigham and Women’s InterNetView 2.0.1.8 crack serial keygen, Boston, MA; 7University of South Carolina, Columbia, SC. (Tracking ID #1631193)

BACKGROUND: Women with a history of gestational diabetes mellitus (GDM) have a 7-fold increased risk for developing type 2 diabetes (T2DM). A post-hoc analysis of women with self-reported history of GDM in the Diabetes Prevention Program (DPP) demonstrated that an intensive face-to-face lifestyle intervention focused on weight loss significantly decreased the incidence of T2DM by 53 % over 3 years. However, face-to-face weight loss interventions in postpartum women in general have demonstrated poor adherence and efficacy. We sought to develop and test a postpartum lifestyle intervention based on the DPP and modified for women with recent GDM.

METHODS: After conducting focus groups and informant interviews with women with prior GDM, we developed a web-based program named Balance after Baby, InterNetView 2.0.1.8 crack serial keygen. Key modifications from the DPP included web-delivery to allow 24-h access, lifestyle coaching by phone/email, and content tailored for the postpartum period. Women with GDM in their most recent pregnancy were recruited during pregnancy or early postpartum and randomized into the Balance after Baby program or enhanced control arm (glucose tolerance tests) 4–12 weeks postpartum. Pre-pregnancy weight was self-reported at recruitment; gestational weight gain and insulin use were extracted from medical records. We administered demographic questionnaires and measured height, weight, and response to a 2 h 75 g oral glucose tolerance test, at 6 weeks, 6 months, and 12 months postpartum. We compared mean weight changes using an intent-to-treat model by t-tests and by estimating a mixed-effects regression model using a random intercept and an unstructured covariance matrix. We conducted structured exit interviews with women completing the program.

RESULTS: 75 women with recent GDM were randomized (mean age 33.4 ±5.4 years; BMI 31.4 (±5.6) kg/m2; 57 % White, 29 % African-American, 15 % Asian, InterNetView 2.0.1.8 crack serial keygen, with 20 % Hispanic; 34 % low-income). There were no significant differences between groups at baseline for age, race, education, income, weight, InterNetView 2.0.1.8 crack serial keygen, BMI, pre-pregnancy weight, gestational weight gain, insulin use in pregnancy, breastfeeding, or glucose tolerance. Clinically determined weights were collected 12 months postpartum for 95 % of eligible participants. Women assigned to the Balance after Baby arm lost a mean 5.0 (±13.5) lbs compared to women in the control arm who gained 1.3 lbs (±9.8) (p = .0223) between 6 weeks and 12 months postpartum. Women in the Balance after Baby arm were at their pre-pregnancy weight (mean −0.2 ± 15.4 lbs) at 12 months postpartum vs. the control arm (+7.9 ± 15.3 lbs) (p = 0.025). In a longitudinal mixed model controlling for pre-pregnancy weight, assignment to the Balance after Baby arm resulted in greater loss at 6 InterNetView 2.0.1.8 crack serial keygen 8.5 lbs, SE 2.7, p = 0.002) and 12 months (mean 7.0 lbs, SE 2.9, p = 0.0175) compared to women in the control arm. InterNetView 2.0.1.8 crack serial keygen there were no significant group differences InterNetView 2.0.1.8 crack serial keygen glucose tolerance at 12 months, InterNetView 2.0.1.8 crack serial keygen women in the control group developed T2DM compared to none in the intervention group. Women randomized to the Balance after Baby program expressed a high degree of satisfaction with the program.

CONCLUSIONS: The web-based Balance after Baby program is feasible, acceptable, and resulted in greater postpartum weight loss in women with recent GDM. If confirmed and found cost-effective in a longer study, the Balance after Baby program could be used at the population level to increase postpartum weight loss and potentially delay or prevent development of T2DM in women with recent GDM.

ACADEMIC DETAILING TO TEACH AGING AND GERIATRICS Cathryn Caton; Ashley Duckett; Theresa Cuoco; Pamela Pride; Patty J. Iverson; William P. Moran, InterNetView 2.0.1.8 crack serial keygen. Medical University of South Carolina, Charleston, SC. (Tracking ID #1643098)

BACKGROUND: Detailing has been employed by the pharmaceutical sales industry to increase physician knowledge about new medications. Work hour rules have challenged residency training programs to develop and utilize efficient and effective teaching methods. We chose to employ academic detailing as a teaching intervention in our residents’ clinic and on the general medicine inpatient wards to improve clinical knowledge and skills in geriatric care.

METHODS: Aging Q3 - Quality Education, Quality Care and Quality of Life- is a longitudinal curriculum focusing on improving geriatric knowledge in the residency program at the Medical University of South Carolina, InterNetView 2.0.1.8 crack serial keygen. Sixteen geriatric topics were chosen based on the Assessing Care of Vulnerable Elder (ACOVE) paradigm and each topic was delivered over 3 months. For each ACOVE, faculty workgroups of 6 members identified key educational messages and skill instruction to teach residents over a three-month intervention period. Each workgroup created one page academic detailing sheets with specific knowledge and skills to be reviewed. Residents were detailed at the time of encounters with geriatric patients with key messages of the current ACOVE by faculty using the provided detailing sheets. By design, the one-on-one detailing process took about 5 min, thereby ensuring that residents were not significantly delayed on rounds or in their clinics.

RESULTS: InterNetView 2.0.1.8 crack serial keygen three years noon conference attendance for Aging Q3 topics ranged from 20 % to 51 %, while the percentage of residents detailed by faculty ranged from 61 % to 93 %. ACOVEs with the highest rates of resident detailing had statistically significant increases in medical knowledge, as measured by pre-test/post-test. For ACOVEs with the highest resident detailing rates, general medicine faculty participation in the detailing process ranged from 60 % to 86 %. In some instances, despite good detailing rates and improvement in self-efficacy, InterNetView 2.0.1.8 crack serial keygen, there was not a statistically significant improvement in medical knowledge.

CONCLUSIONS: We found that academic detailing is an efficient way of reaching a high percentage of residents and increasing knowledge in aging and geriatrics. Topics with a narrow focus are best taught in this format.

ACOVE Detailing Rates and Resident Knowledge

ACOVE Detailing Rates (%) Pre-test (%) Post-test (%) p-value

Pressure Ulcers/Malnutrition 93 6 41 <0.0001

Falls 86 16 49 <0.0001

Osteoporosis 85 29 62 <0.0001

Screening & Prevention 78 16 40 <0.0001

Continuity InterNetView 2.0.1.8 crack serial keygen Care 88 46 31 0.0419

Vision 84 63 71 0.2489

Dementia 82 41 32 0.2558

Pain Management 80 1 15 0.1579

End of LIfe Care 78 55 51 0.6907

Hospital Care & Transitions 73 38 57 0.0163

Medication Use & Safety 61 28 36 0.5174

ACOVE Detailing Rates and Resident Self Efficacy

ACOVE Detailing Rates (%) Pre-test Mean Confidence Score Post-test Mean Confidence Score Paired t-test on mean change in reported confidence p value

Continuity of Care 88 - - - n/a

Dementia 82 - - - n/a

End of Life Care 78 8.72 9.55 0.83 0.0013

Falls 86 9.71 11.08 1.37 <0.0001

Hospital Care & Transitions 73 11.25 11.98 0.73 0.0056

Medication Use & Safety 61 - - - n/a

Osteoporosis 85 2.45 3.83 1.38 <0.0001

Pain Management 80 9.87 10.48 0.61 0.0039

Pressure Ulcer/Malnutrition 93 2.82 3.6 0.7765 <0.0001

Screening & Prevention 78 2.72 2.4 0.3167 0.0106

Vision - - - - n/a

ACCESS TO SUBSPECIALTY CARE FOR PATIENTS WITH MOBILITY IMPAIRMENT Tara Lagu1,2; Nicholas S. Hannon1; MIchael B. Rothberg8; Annalee S. Wells9; K, InterNetView 2.0.1.8 crack serial keygen. Laurie Green3,4; McAllister O. Windom5; Katherine R. Dempsey1; Penelope S, InterNetView 2.0.1.8 crack serial keygen. Pekow1,6; Jill S. Avrunin1; Aaron Chen7; Peter K. Lindenauer1,2. 1Baystate Medical Center, Springfield, MA; 2Tufts University School of Medicine, Boston, MA; 3Baystate Medical Center, Springfield, MA; 4Baystate Medical Center, Springfield, MA; 5Duke University School of Medicine, Durham, NC; 6University of Massachusetts-Amherst, Amherst, MA; 7University of New England College of Osteopathic Medicine, InterNetView 2.0.1.8 crack serial keygen, Biddeford, ME; 8Cleveland Clinic, InterNetView 2.0.1.8 crack serial keygen, Cleveland, OH; 9Dorchester House, Dorchester, MA. (Tracking ID #1615945)

BACKGROUND: The Americans with Disabilities Act (ADA) states that all medical practitioners are required to provide “full and equal access to their health care services and facilities,” yet adults who use wheelchairs have difficulty accessing physicians and receive less preventive care than their able-bodied counterparts. We aimed to describe access to medical and surgical subspecialists for patients with mobility impairment.

METHODS: Using a standardized script, InterNetView 2.0.1.8 crack serial keygen, we called subspecialty (endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology, psychiatry) practices in four InterNetView 2.0.1.8 crack serial keygen areas in the United States and attempted to make an appointment for a fictional patient InterNetView 2.0.1.8 crack serial keygen used a wheelchair and was unable to transfer from chair to exam table. If a practice reported that they were able to make an appointment for the patient, InterNetView 2.0.1.8 crack serial keygen, the investigator would then probe to clarify that both the building and office were accessible and to determine the method by which the practice planned to transfer the patient from the wheelchair to the exam table. If the practice was unable to accommodate the patient, the investigator responded with the question, “Can you please explain why you are unable to accommodate this patient?” We calculated summary statistics and conducted a qualitative analysis of the responses.

RESULTS: Of 256 practices, 56 (22 %) reported they could not accommodate our fictional patient. Only nine of these reported that the building was inaccessible. The remaining 47 reported that they were unable to transfer a patient from a wheelchair to an exam table. Reasons for the inability to transfer the patient included a lack of staff who could perform the transfer (37 practices), a concern about liability (five practices), or that the “patient was too heavy” (five practices). Inaccessibility varied by subspecialty: only 6 % of psychiatry practices were inaccessible, InterNetView 2.0.1.8 crack serial keygen, while gynecology was the subspecialty with the highest rate (44 %) of inaccessible practices. The other subspecialties had proportions of inaccessible practices ranging from 13 to 28 %. Of 200 accessible practices, 67 (33 %) reported they had equipment that could adjust to the patient while sitting in the wheelchair (e.g., otolaryngology, ophthalmology) or, in the case of psychiatry, that they did not need to InterNetView 2.0.1.8 crack serial keygen the patient for an exam. 103 practices (51 %) reported they planned to “manually transfer” the patient from her wheelchair to a non-accessible high table without the use of a lift. Only 22 practices (11 %) reported the use of accessible tables or use of a lift for transfer.

CONCLUSIONS: More than 20 years after the passage of the ADA, many subspecialty practices were unable to accommodate a patient with mobility impairment. This was rarely due to building inaccessibility. More frequently, practices were inaccessible because they InterNetView 2.0.1.8 crack serial keygen unable to transfer the patient to perform an exam. InterNetView 2.0.1.8 crack serial keygen minority of accessible of practices possessed equipment that would facilitate the safe transfer (from chair to table) of our fictional patient. Instead, a majority of accessible practices reported transfer methods that have InterNetView 2.0.1.8 crack serial keygen deemed to be unsafe by disability experts. These results provide one possible explanation for the health care disparities observed in this population and Nero Buring Rom Crack the need for better awareness among physicians about the requirements of the ADA and the standards of care for patients with mobility impairment.

ACCULTURATION AND RISK FACTORS FOR HYPERTENSION AMONG A HETEROGENEOUS POPULATION OF BLACK MEN Candace Tannis; Jessica M. Forsyth; Joseph Ravenell. NYU School of Medicine, New York, NY. (Tracking ID #1638147)

BACKGROUND: Black men are at increased risk for developing hypertension and consequent morbidity compared to other racial/ethnic groups. The composition of the Black population in the United States is diversifying rapidly, with many implications for the prevention and management of hypertension. This study seeks to examine the role of acculturation on engagement in therapeutic lifestyle changes (TLCs; healthy diet, physical activity, smoking and alcohol consumption, and medication adherence) to lower blood pressure (BP).

METHODS: Participants were recruited during health screening events for a larger clinical trial at barbershops and churches. All adult men who self-identified as Black were eligible. Acculturation, the main predictor variable, InterNetView 2.0.1.8 crack serial keygen, was measured using a single item regarding place of birth and a 10-item questionnaire adapted from two measures: the Cultural Lifestyle Inventory (CLSI); and the Measures of Acculturation Strategies for People of African Descent (MASPAD). Items taken from the CLSI and MASPAD were measured on 5-point and 6-point Likert scales respectively with items summed to create scale scores. Outcome variables included 1) diet, measured using the National Cancer Institute fat screener and a 2-item modified Food Frequency Questionnaire measuring daily fruit and vegetable consumption; 2) physical activity, measured with the shortened International Physical Activity Questionnaire; 3) medication adherence, measured with the 4-item Morisky scale; and 4) smoking and alcohol consumption, measured using items adapted InterNetView 2.0.1.8 crack serial keygen the Behavioral Risk Factor Surveillance Survey. InterNetView 2.0.1.8 crack serial keygen was measured using an automated BP cuff, and co-morbidity was measured using the Charlson Co-morbidity Index. We utilized ANCOVA to test group differences in outcome variables between foreign-born and US-born at baseline, and linear regression to examine relationships between acculturation and outcome variables at baseline. All analyses controlled for age, income, employment status and education level.

RESULTS: 171 men completed the survey. 26 % were foreign-born, InterNetView 2.0.1.8 crack serial keygen. The mean age of participants was 53.6 years (SD = 10.24) and the median annual income was $11,400. Twenty-seven percent of men in the study reported having less than a high school education, and 75 % of the men were currently unemployed. Foreign-born participants had lower percentage of fat in their diets (p = 0.003). There were no differences between foreign-born and US-born men in mean BP, presence of co-morbidity, and lifestyle behaviors other than fat consumption. However, among participants who reported taking BP medication, foreign-born blacks had poorer adherence (p = 0.028). Medication non-adherence was also associated with the “traditionalist” MASPAD dimension (p = 0.015, R2adj .333), as well as positively with the individual item corresponding to ethnic pride (p = 0.021) and negatively with maintenance of cultural practices (p = .035). There was no relationship between acculturation and the TLCs other than medication adherence or measured BP.

CONCLUSIONS: This study provides evidence that nativity and acculturation among Black men may play a role in engagement in certain TLCs to lower BP. More research is needed to determine how best to tailor TLC interventions to control hypertension for the rapidly diversifying population of Black men, the highest risk group in the United States.

ACCURACY OF RACE/ETHNICITY AND LANGUAGE PREFERENCE IN AN ELECTRONIC HEALTH RECORD Sara V. Carlini1; Elissa Klinger1; Irina Gonzalez1; Jeffrey A, InterNetView 2.0.1.8 crack serial keygen. Linder1; Elyse R. Park2; Emily Kontos3; Nancy A. Rigotti2; Jennifer Haas1,3. 1Brigham and Women’s Hospital, Boston, MA; 2Massachusetts General Hospital, Boston, MA; 3Harvard School of Public Health, Boston, MA. (Tracking ID #1634097)

BACKGROUND: Eliminating health care disparities requires accurate data on race/ethnicity and language preference. Health care organizations that receive federal funds are required to record information about patient race/ethnicity and language IOBIT Driver Booster Crack v8.6.0.522 + Key [2021], yet little is known about the accuracy of these electronic health record (EHR) data.

METHODS: We compared the accuracy of race/ethnicity and language preference data recorded in an EHR, compared to self-reported race/ethnicity and language preference (English, Spanish) from an Interactive Voice Recognition (IVR) survey as part of a randomized controlled trial of a telephone-based tobacco treatment program. Using IVR, we called 6,771 low-income (by zip code) white, black, or Latino smokers who were listed in the EHR as English or Spanish-speaking and had made a primary care visit in the preceding 60 days; 2,189 (32 %) answered the phone and selected a language preference, and 434 (6 %) enrolled and provided information about race/ethnicity.

RESULTS: Median age was 51 years; 53 % self-reported race/ethnicity as white, 26 % as African-American, and 21 % as Hispanic; and 10 % reported that they were Spanish-speaking. Overall agreement between EHR-recorded and self-reported race/ethnicity information was excellent (Kappa 0.84; p < 0.001). However, the sensitivity and positive predictive value (PPV) for EHR-recorded race/ethnicity compared to self-report varied by race/ethnicity: 82 % and 97 % for Hispanics, 78 % and 95 % for African-Americans, and 100 % and 87 % for whites, suggesting that for both Hispanics and African-Americans, InterNetView 2.0.1.8 crack serial keygen, some individuals are misclassified in the EHR as white. For language preference, InterNetView 2.0.1.8 crack serial keygen, EHR-documentation and self-report showed good overall agreement (Kappa 0.74, p < 0.001), but the PPV for an EHR-documented language preference of Spanish was only 68 % with a sensitivity of 86 %. While only 1.2 % of EHR-documented English speakers elected to hear the IVR call in Spanish, 31.9 % of EHR-documented Spanish speakers elected to InterNetView 2.0.1.8 crack serial keygen the call in English.

CONCLUSIONS: We demonstrate strong agreement between EHR-recorded and self-reported race/ethnicity and language preference. However, there were inaccuracies that indicate the need to investigate how EHR data are obtained and perhaps systems to improve EHR documentation, InterNetView 2.0.1.8 crack serial keygen. The results also demonstrate the importance of offering services that respond to multilingual patients, who may have differing preferences based on the specific content and method of contact.

ACCURATE DISEASE ATTRIBUTION IS A HURDLE FOR DEVELOPMENT OF A PAY FOR PERFORMANCE REIMBURSEMENT MODEL Jennifer Zreloff; Jillian Gaumond; Jason Higdon. Emory University, Atlanta, GA. (Tracking ID #1642285)

BACKGROUND: With medical reimbursement shifting away from fee for service and toward quality incentives, it is important to understand the accuracy of data being used by insurance companies and clinics for quality incentive payouts.

METHODS: In the setting of a university-based and NCQA recognized Patient-Centered Medical Home with a single payer, we sought to reconcile quality reports generated by our payer versus by our clinic’s data warehouse. Lists of patients were generated with diabetes, CHF, and COPD. Our private payer generated its list based on their methods that utilize billing data. Lists generated by the PCMH were generated by diagnoses on the “problem list” in the EMR and diagnosis billing data specific to that clinic. The two lists were compared and evaluated by chart review when they were discordant. Chart review included all data available such as labs, echo, radiology, specialty clinic notes, and PCP notes. Patients were then divided into groups of inclusion error by insurance, inclusion error by PCP, exclusion error by insurance, and exclusion error by PCP

RESULTS: Percentage of times that the Private Payer and the PCMH agreed varied by disease state. Based on the total number of patients included in a disease group by either the insurance company or the PCMH, 61.2 % of the patients on the diabetes list, InterNetView 2.0.1.8 crack serial keygen, 32.1 % of those on the CHF list, and 21.2 % of those on the COPD list, were agreed upon by both the insurance company and the clinic. There were both errors of omission and inclusion by the insurance company. Errors of inclusion (those attributed to have the disease that did not actually have it) occurred for diabetes in 16.9 % of the total attributed patients, 32.1 % for CHF, and 78.8 % for COPD. Errors of exclusion (those that had the disease but were not listed by the insurance company) occurred for 21.9 % of diabetics, 35.7 % of patients with heart failure, and 0 % with COPD. A small percentage of errors of exclusion occurred with the PCMH. There were no errors of inclusion by the PCMH. Looking at only the data generated by the insurance company, 21.7 % of insurance-attributed diabetic patients were incorrect, InterNetView 2.0.1.8 crack serial keygen, and 26.3 % of the patients on the final, verified diabetic list were missing. For CHF, 50 % of insurance-attributed patients were incorrect, and 52.6 % of patients on the verified CHF list were missing. COPD had the worst data accuracy with 78.8 % of insurance-attributed patients being incorrect, and with no missing patients.

CONCLUSIONS: When entering the world of pay for performance, it is important to recognize the inherent inaccuracies of data based primarily on claims data. This clinic had the added luxury of a separate attribution process which allowed both sides to agree on the total pool of patients. For most clinic sites the quality data would be expected to have more errors due to discrepancies of attribution to PCP. For these reasons, it is important for clinics to have opportunities to collect their own quality data specific InterNetView 2.0.1.8 crack serial keygen disease attribution, and have a reconciliation process with payers participating in pay for performance initiatives.

ACETAMINOPHEN RECEIPT AMONG HIV-INFECTED PATIENTS WITH ADVANCED HEPATIC FIBROSIS E. J. Edelman1; Kirsha S. Gordon2; Vincent Lo Re3; Melissa Skanderson4; David A. Fiellin1; Amy C. Justice2,1. 1Yale University, New Haven, CT; 2VA Connecticut Healthcare System, West Haven, CT; 3University of Pennsylvania, Philadelphia, PA; 4VA Pittsburgh Healthcare System, Pittsburgh, PA. (Tracking ID #1642388)

BACKGROUND: HIV-infected (HIV+) patients may be at particular risk for acetaminophen-induced hepatotoxicity given their underlying risk of liver disease, high prevalence of hepatitis C virus (HCV) coinfection, differences in acetaminophen metabolism, and exposure to antiretroviral therapy. However, acetaminophen overuse (greater than 2 g per day) in the context of liver injury has been incompletely examined among HIV+ patients. Among a cohort of HIV+ patients, our aims were to: 1) describe the patterns of acetaminophen receipt; 2) assess the cross-sectional association between acetaminophen receipt and advanced hepatic fibrosis; and 3) determine whether factors associated with acetaminophen overuse varied by HCV status.

METHODS: We performed a cross-sectional analysis of the Veterans Aging Cohort Study-Virtual Cohort. We excluded patients who had a cancer diagnosis InterNetView 2.0.1.8 crack serial keygen than non-epithelial skin cancers; no inpatient or outpatient visit in FY2006; or missing laboratory or pharmacy data. Outpatient acetaminophen receipt among HIV+ patients in the cohort was categorized as: 1) no acetaminophen use, 2) appropriate use (<2 g/day); or 3) overuse (> 2 g/day). The primary independent variable was advanced hepatic fibrosis, defined as a FIB-4 > 3.25. The FIB-4 score is a validated non-invasive index that identifies advanced fibrosis/cirrhosis using age, alanine aminotransferase, aspartate aminotransferase, and platelet count. We evaluated acetaminophen daily dosage stratified by FIB-4 status. We then performed multivariable ordered polytomous logistic regression to determine adjusted odds ratios InterNetView 2.0.1.8 crack serial keygen for acetaminophen daily dosage, classified as a three level outcome variable. The final model included patients characteristics that were clinically relevant or significant at the p < 0.05 level. Results were stratified by HCV status.

RESULTS: Our sample included 14,885 HIV+ patients, 4,592 (31 %) of whom received at least one acetaminophen prescription and 1,885 (41 %) of whom were HIV/HCV-coinfected. Among those receiving acetaminophen, 1,442 (31 %) patients were identified with acetaminophen overuse, with no differences observed between HIV-monoinfected and HIV/HCV-coinfected patients (846 [31 %] vs. 596 [32 %], p = 0.59). Among HIV-monoinfected patients, the average daily acetaminophen dose was not significantly different between those with a FIB-4 < 3.25 and those with a FIB-4 > 3.25 (1.50 vs. 1.20 g/day, p = 0.08); results were similar for HIV/HCV-coinfected patients (p = 0.14). After adjusting for age, gender, race/ethnicity, HCV status, alcohol use disorders, and pain-related diagnoses, FIB-4 was associated with a decreased odds of acetaminophen overuse (AOR [95 % CI] = 0.80 [0.65, 1.00]). After stratifying by HCV status, HIV+ patients with advanced hepatic fibrosis were equally likely to receive acetaminophen. Further, HIV-monoinfected patients with an alcohol use disorder were more likely to have acetaminophen overuse (AOR [95 % CI] = 1.56 [1.21, 2.02]).

CONCLUSIONS: Acetaminophen overuse was common in this sample of HIV+ patients. Strategies to minimize acetaminophen exposure in HIV+ patients InterNetView 2.0.1.8 crack serial keygen warranted.

ACHIEVING COMMUNICATION BETWEEN PRIMARY CARE AND MENTAL HEALTH: WHY IS IT SO DIFFICULT, EVEN IN THE VA? A QUALITY IMPROVEMENT APPROACH Evelyn Chang1; Kenneth B. Wells5,4; Alexander S. Young3,2; Susan E. Stockdale3; Jacqueline Fickel3; Megan Johnson2,3; Kevin Jou2; Lisa V. Rubenstein3,4. 1VA- Greater Los Angeles, Los Angeles, InterNetView 2.0.1.8 crack serial keygen, CA; 2VA- Greater Los Angeles, North Hills, CA; 3VA- Greater Los Angeles, North Hills, CA; 4RAND, Santa Monica, CA; 5UCLA, Los Angeles, CA. (Tracking ID #1624000)

BACKGROUND: Research shows that bi-directional communication between mental health (MH) and primary care (PC) clinicians is critical for improving patient outcomes, yet achieving this in health care organizations is challenging. In the Veterans Administration (VA), the high prevalence of co-occurring physical and mental illnesses can make PC-MH collaboration essential for providing effective care. Despite extensive national VA efforts to integrate PC and MH, however, local settings continue to experience barriers to effective communication and collaboration.

METHODS: We proposed a project to the local InterNetView 2.0.1.8 crack serial keygen site’s quality improvement (QI) council directed at improving communication between PC and MH providers. We used QI diagnostic tools to understand barriers to PC/MH communication and to initiate a change strategy in a multi-specialty academic community-based outpatient clinic serving 16,000 veterans in Los Angeles. The clinic has two PC teams with five to six teamlets each using the patient-centered medical home model. We recruited 11 on-site PC and MH clinical providers, administrators, and researchers for our workgroup, which held 4 monthly meetings. The workgroup constructed fishbone diagrams of causes of poor communication and mapped communication flow among providers for emergent and non-urgent situations for the VA site. We performed chart reviews on patients with established PC and MH providers to assess documentation of communication. We conducted a rapid literature review of interventions for improving PC/MH communication and identified potentially feasible evidence-based interventions to address the problems we found.

RESULTS: PC providers were frustrated by inconsistent access to psychiatrists for emergent and routine situations. MH providers did not respect PC management of uncomplicated depression, InterNetView 2.0.1.8 crack serial keygen. Key communication barriers InterNetView 2.0.1.8 crack serial keygen geographic distance, cultural differences, and lack of standardized communication processes. A key facilitator was personal relationships across disciplines. Chart review confirmed considerable between-provider variation in documenting MH and medical problems and in communication strategies, InterNetView 2.0.1.8 crack serial keygen. Literature review, combined with the workgroup’s assessments, identified joint care planning and joint case conferences as two feasible interventions. While these interventions were developed, the site began to collocate MH specialists to PC.

CONCLUSIONS: QI tools suggested that there were procedural, cultural, InterNetView 2.0.1.8 crack serial keygen, and structural factors affecting communication and respect. Clarifying these factors helped to initiate an ongoing change strategy. A locally tailored QI process focusing on communication helped initiate change strategies that had not originated from policy or health information systems.

ADEQUACY AND CORRECTION OF MEDICAL RECORD DOCUMENTATION IN PATIENTS WITH A PRIOR ADMISSION FOR ACE-INHIBITOR ANGIOEDEMA IN AN URBAN ACADEMIC MEDICAL CENTER: A PATIENT SAFETY INTERVENTION Andrew M. Davis1; Eric R. Yoo3; Cheryl Nocon2; Jacquelynne P. Corey2, InterNetView 2.0.1.8 crack serial keygen. 1University of Chicago, Chicago, IL; 2University of Chicago, Chicago, InterNetView 2.0.1.8 crack serial keygen, IL; 3University of Illinois College of Medicine, Chicago, IL. (Tracking ID #1626449)

BACKGROUND: Angiotensin-converting enzyme inhibitor (ACEI) induced angioedema affecting the upper airway is a potentially life-threatening condition, occurring in 0.1 to 2.2 % of recipients, with a higher incidence in African-American patients. Over 40 million patients in the U.S. currently take a medication in this class. Recurrent ACEI-induced angioedema is readily preventable, but requires proper allergy documentation in the medical record after the first event. Our institution’s transition from Oacis to an Epic Electronic Medical Record (EMR) in 2008 improved clinician training and engagement with the EMR, InterNetView 2.0.1.8 crack serial keygen. This transition provided an opportunity to assess allergy documentation following episodes of ACEI-induced angioedema requiring inpatient admission, and to correct deficits in EMR allergy documentation in our urban academic medical center.

METHODS: We reviewed charts of patients with inpatient encounter codes for “angioneurotic edema, NOS” (ICD 995.1), hereditary angioedema (277.6), anaphylactic shock (995.0), anaphylactic shock due to food reaction (995.6), or anaphylactic shock due to serum (995.4). Cases with clear corroboration of ACEI-induced angioedema in the clinical notes were split by admit dates: 2000–2007 (n = 372 total, 82 ACEI related) and 2008–2011 (n = 139 total, InterNetView 2.0.1.8 crack serial keygen, 37 ACEI related). We also reviewed a random sample of 30 ED cases (2008–2011) InterNetView 2.0.1.8 crack serial keygen ACEI-related angioedema not requiring admission. The current Epic allergy and problem lists were examined for each case; elements abstracted included documentation of the ACEI allergy, the severity of reaction, and presence of the name of the specific causative agent. As a patient safety intervention, incomplete allergy documentation in the EMR was corrected.

RESULTS: Overall 95 % of the admitted patients were African American and 66 % were female; the median age was 64. The severity of angioedema in admitted patients was quite high, with 43 % requiring intubation in 2000–2007, and 59 % during the 2008–2011 period. Before current EMR implementation in 2008, 60 (73.2 %) of charts for InterNetView 2.0.1.8 crack serial keygen patients were completely missing ACEI-allergy documentation and 17 (20.7 %) had incomplete allergy lists. After transition to the current EMR, inpatient charts (2008–2011) markedly improved in ACEI allergy documentation (p < .001), though 5 (13.5 %) of the 2008–20011 admitted patients were completely missing data, and 29 (78.4 %) had incomplete allergy lists, lacking the specific agent or reaction severity. Patients treated and released from the ED were more likely to have absent documentation (23.3 %). In several instances, the ACEI remained on patient medication list, but review of recent notes found that ACEI had actually been discontinued, and that the medication list was in error.

CONCLUSIONS: ACEI-allergy documentation markedly improved following transition to a newer EMR; however, an unacceptably high number of patients with an admission for ACEI angioedema continued to have no documentation of this reaction on their current allergy list, and missing agent or severity data remained common. Urban medical centers should regularly review ACEI allergy angioedema events, and establish a redundant patient safety process to confirm event documentation in the EMR allergy list.

Admitted 2000–2007 (n = 82) Admitted 2008–2011 (n = 37) ED only 2008–2011 (n = 30)

Category n % n % n %

Full data at baseline 5 6.0 % 3 8.1 % 5 16.7 %

Partial data 17 20.7 % 29 78.4 % 18 60.0 %

No mention of ACEI allergy 60 73.2 % 5 13.5 % 7 23.3 %

ADHERENCE TO PRESCRIPTION OPIOID MONITORING GUIDELINES AMONG RESIDENTS AND ATTENDING PHYSICIANS IN THE PRIMARY CARE SETTING Laila Khalid; Jane M. Liebschutz; Christopher W. Shanahan; Shernaz Dossabhoy; Yoona R. Kim; Karen E. Lasser. Boston Medical Center, Boston, MA. (Tracking ID #1636318)

BACKGROUND: Prescription opioid misuse is a significant public health problem, with primary care providers being the principal prescribers of opioids for chronic non-cancer pain. While one study showed that residents provide higher quality primary care than attendings, opioid prescribing practices have not been compared between resident and attending physicians. We compared adherence to opioid prescribing guidelines as well as evidence for potential patient misuse of prescribed opioid medications between resident and attending physician.

METHODS: We conducted a retrospective cross-sectional study at a primary care practice of a large Northeastern safety-net hospital using data abstracted from the electronic medical record through the institution’s clinical data warehouse. Patients included were 18–89 years old, who had at least one visit to primary care and were prescribed long-term opioid treatment (3 or more opioid prescriptions written at least 21 days apart within 6 months) for chronic non-cancer pain from 8/31/11 to 9/1/12, InterNetView 2.0.1.8 crack serial keygen. The primary outcome was adherence to any one of two key American Pain Society Guidelines; 1) documentation of at least one opioid agreement (contract) ever, and 2) any urine drug testing in the past year; and evidence of potential prescription misuse with 1, 2 or more than 2 early refills. Early refill was a prescription written 7–25 days after the previous prescription of the same drug. Patients were classified as a resident patient if they received 2, or more prescriptions from a resident physician. Statistical analysis was performed using chi-square tests.

RESULTS: 96 residents prescribed opioid prescriptions to 136 patients, while 49 attendings prescribed to 609 patients. The results are summarized below.

CONCLUSIONS: Despite the low numbers of contract documentation in resident and attending patients, the majority of the patients did receive urine drug testing. It is not clear whether the documentation of a contract indicates guideline adherence. Evidence for potential misuse of prescription opioids, indicated by two or more early refills, was InterNetView 2.0.1.8 crack serial keygen higher in resident patients relative to attending patients. Features of a resident-based practice that may be associated with prescription opioid misuse need to be explored.

ADMISSION TO TEACHING HOSPITALS AND WEEKDAY DISCHARGES ARE ASSOCIATED WITH BETTER OUTCOMES IN HEART FAILURE PATIENTS Anita Nik Collection by DxO 4.0.8.0 Crack Full Version Download. Au; Raj S. Padwal; Erik Youngson; Sumit R. Majumdar; Finlay A. McAlister. University of Alberta, Edmonton, AB, Canada. (Tracking ID #1635314)

BACKGROUND: It is unclear whether hospital teaching status or the day of discharge influences post-discharge outcomes for patients hospitalized with heart failure (HF).

METHODS: We linked four population-based databases in Alberta, Canada to identify adults hospitalized for HF who were discharged alive between 1999 and 2009. We conducted a retrospective cohort study comparing outcomes between patients discharged from teaching versus non-teaching hospitals and on weekends versus weekdays. The primary outcome was the composite of death or non-elective readmission 30-days post-discharge.

RESULTS: Over 10 years, 12,216 HF patients were discharged from teaching hospitals and 12,157 from non-teaching hospitals; 21,001 (86 %) discharges occurred on weekdays. Although they had greater comorbidity and used more health care resources in the year prior to HF hospitalization, patients discharged from teaching hospitals exhibited significantly lower rates of 30-day death or readmission than those discharged from non-teaching hospitals (17.4 % vs. 22.1 %, aHR fabfilter pro l2 free download Archives, 95 % CI 0.77–0.89), InterNetView 2.0.1.8 crack serial keygen. Patients discharged on weekdays were older and had greater comorbidity, yet exhibited significantly lower rates of death or readmission at 30-days than those discharged on weekends (19.5 % vs. 21.1 %, adjusted hazard ratio [aHR] 0.87, 95 % CI 0.80–0.94). Compared to weekend discharge from a non-teaching hospital (reference), the 30-day risk of death or readmission was lower for weekday discharge from a non-teaching hospital (aHR: 0.85, 95 %CI 0.77–0.94), weekend discharge from a teaching hospital (aHR: 0.79, 95 %CI 0.69–0.92), and weekday discharge from a teaching hospital (aHR: 0.71, 95 %CI 0.63–0.79, with p < 0.001 for trend).

CONCLUSIONS: Patients discharged from non-teaching hospitals or on weekends exhibited poorer risk-adjusted outcomes than those discharged from teaching hospitals or on weekdays. The structures and processes which may have yielded better outcomes for those admitted to teaching hospitals and those discharged on weekdays should be studied and possibly emulated in order to optimize heart failure related outcomes.

ADVERSE OUTCOMES OF POLYSEDATIVE USE IN VETERANS WITH PTSD Brian C. Lund1,2; Stephen L. Hillis1; Elizabeth A. Chrischilles2. 1Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA; 2University of Iowa College of Public Health, Iowa City, IA. (Tracking ID #1628276)

BACKGROUND: While department of Veterans Affairs (VA) clinical practice guidelines recommend against their use, benzodiazepines are InterNetView 2.0.1.8 crack serial keygen to 30–40 % of veterans with posttraumatic stress disorder InterNetView 2.0.1.8 crack serial keygen. Nationally, opioid abuse has been labeled as epidemic, and inpatient chemical dependency admissions involving the combination of opioids and benzodiazepines have risen more than 500 % in the last decade. Therefore, our objective was to determine whether benzodiazepines, opioids, and other sedatives - particularly in combination - are associated with adverse events in veterans with PTSD.

METHODS: National VA administrative data were used to identify veterans with PTSD. Among these patients, new benzodiazepine starters during FY04-09 (N = 66,406) were matched to nonusers (N = 128,062) using high dimensional propensity scores. Adverse events were based on prior work involving sedative use in veterans and included emergency visits and hospitalizations for wounds/injuries, drug-related accidents/overdoses, and self-inflicted injuries identified by ICD-9 coding. One year adverse event risk was determined using a stratified Cox proportional hazards model. Exposure to opioids and other sedatives was modeled with time-dependent covariates. Prazosin use was included as a control exposure because it is prescribed in PTSD for the treatment of nightmares and other sleep disturbances but does not have significant sedating properties.

RESULTS: Adverse events occurred within 1 year in 2,926 (1.5 %) patients. Hazard ratios (95 % C.I.) for adverse events were: benzodiazepines, 1.8 (1.6–2.0); opioids, 1.4 (1.2–1.7); atypical antipsychotics, 1.9 (1.7–2.1); and hypnotics, 1.4 (1.1–1.8). In addition, the benzodiazepine-opioid interaction was significant (p < .001), indicating a multiplicative effect where the hazard ratio for this combination was 3.8 compared to nonusers of both. Among dual users of benzodiazepines and opioids, 78 % were prescribed by different providers. Prazosin exposure and other interaction terms were not significantly associated with adverse events.

CONCLUSIONS: Polysedative use in veterans with PTSD leads to incremental risk for serious adverse events. The combination of benzodiazepines and opioids is particularly troublesome given the synergistic interaction and the tendency toward being prescribed by different providers. The clinical complexity of caring for veterans with PTSD creates an environment that, without careful coordination of care, can lead to high-risk polysedative use.

AFTER THE FACT: EDUCATING WOMEN INCARCERATED IN JAIL ON THE USE OF MEDICAL THERAPIES TO PREVENT HIV ACQUISITION FOLLOWING A RISKY EXPOSURE Neha Gupta3; Heidi Schmidt3; Timothy Buisker2; Mi-Suk Kang Dufour2; Janet Myers2; Jacqueline P. Tulsky1. 1University of California San Francisco, San Francisco, CA; 2University of California San Francisco, San Francisco, CA; 3University of California San Francisco, San Francisco, CA. (Tracking ID #1634988)

BACKGROUND: Women incarcerated in jail face increased risk of HIV infection because they over represent members of communities at risk. Antiretroviral therapy following an HIV exposure–non-occupational post-exposure prophylaxis (nPEP)–has been endorsed by federal guidelines as an effective HIV prevention strategy since 1997. However, there is little information regarding nPEP awareness or its use among women leaving jail. This study assessed baseline awareness and knowledge regarding nPEP among women incarcerated in a local jail and evaluated the effectiveness of a brief educational intervention in increasing nPEP awareness and knowledge.

METHODS: A 15-min lesson was developed to teach principles of nPEP to detained women at the San Francisco jail. Participants were recruited from September 2012 to January 2013, and the intervention was delivered in small groups. Prior to the intervention, participants completed a survey (T1), reflecting demographics, HIV risk factors and nPEP awareness, knowledge and attitudes. The nPEP section was repeated immediately after the program (T2) and at one week (T3). Knowledge scores were calculated and assessed in 2 domains: risky behaviors and nPEP logistics (initiation timeframe, duration of use, side effects). Baseline knowledge scores and awareness were compared to answers at T2 and T3 using paired t-tests. Linear regression analysis was used to identify predictors of baseline awareness, baseline knowledge and improvement in knowledge scores.

RESULTS: Of 62 women enrolled, 53 completed T1, 48 completed both T1 and T2, and 34 completed both T2 and T3. 43 % identified themselves as black or African American, 21 % as white, 13 % as Hispanic, and 23 % as other. The mean age was 34 years, and mean total time incarcerated was 5.8 years. 32 % of the women had less than a high school education. 83 % of women were tested for HIV in the past year. 82 % reported sex-related HIV exposures in the past year, InterNetView 2.0.1.8 crack serial keygen, yet only 38 % perceived themselves at risk. Similarly, 28 % reported drug-related HIV exposures, while only 10 % perceived themselves as at risk. Baseline awareness of nPEP’s existence was 55 %. Increased education was associated with improved risk knowledge InterNetView 2.0.1.8 crack serial keygen overall knowledge (β = 0.252, p = 0.015 and β = 0.291, p = 0.011). Additionally, while knowledge scores increased in both domains after the intervention (see Table 1), the increase in nPEP logistics knowledge was greater than the increase in behavioral knowledge (p < 0.001). The percent of participants who would “definitely seek out nPEP after a risky InterNetView 2.0.1.8 crack serial keygen was high at baseline (77 %), and remained high at T2 and T3 (83 % and 95 %, respectively), despite possible side effects and the need to take medications for 4 weeks.

CONCLUSIONS: Despite the high rates of recent HIV testing and engagement in high-risk behaviors, InterNetView 2.0.1.8 crack serial keygen of individuals’ own risk and the existence of nPEP as an HIV prevention strategy was low among women in this study, InterNetView 2.0.1.8 crack serial keygen. A 15-min educational intervention is an effective means of delivering HIV prevention information to women in jail, but may be more useful for teaching basic information about taking nPEP than changing knowledge about risk behaviors.

Table 1

Knowledge Domain Average Knowledge Score (%)

N = 48 N = 34

T1 T2 P value T2 T3 P value

Risky behaviors 46.6 74.0 < 0.001 80.5 66.2 < 0.001

nPEP logistics 27.5 81.5 < 0.001 79.4 74.7 = 0.230

Overall InterNetView 2.0.1.8 crack serial keygen 76.0 < 0.001 80.2 68.5 < 0.001

AGING, CHRONIC HEALTH CONDITIONS, AND SEXUAL FUNCTION IN WOMEN Ayesha A. Appa1; Jennifer Creasman1; Jeanette S. Brown1; David Thom1; Stephen K. Van Den Eeden2; Leslee L. Subak1; Alison J. Huang1. 1University of California, San Francisco, San Francisco, CA; 2Kaiser Permanente Division of Research, Oakland, CA. (Tracking ID #1633496)

BACKGROUND: Sexual function in women is thought to decline with age, yet some women report preserved sexual function in older age, InterNetView 2.0.1.8 crack serial keygen. Changes in health, such as the development of chronic health conditions, may play an important role in determining whether sexual desire, activity, InterNetView 2.0.1.8 crack serial keygen, or satisfaction decrease in women in middle and older age.

METHODS: Sexual function was evaluated prospectively in a multiethnic, population-based cohort of 2,270 women aged 45 to 80 years randomly selected from age and race/ethnicity strata from an integrated healthcare delivery system in California. Using structured-item, self-administered questionnaires, women described their level of sexual desire, frequency of sexual activity, and overall sexual satisfaction at baseline and after 5 years. Additional questionnaires assessed participants’ detailed medical histories, medication use, and health-related behaviors, including diagnosed chronic conditions such as cancer and cardiometabolic, colorectal, neuropsychiatric, respiratory, and urogynecological disorders. Repeated measures multivariable models were developed to assess the relationship of age and chronic conditions to self-reported sexual desire, activity, and satisfaction, adjusting for race/ethnicity and relationship status.

RESULTS: Of the 2,270 participants (1007 White, 443 Black, 419 Latina, and 401 Asian), 54 % reported low sexual desire, 50 % reported less than monthly sexual activity, and 46 % reported low sexual satisfaction at baseline. Over 5 years of follow-up (N = 1,395), 34 %, InterNetView 2.0.1.8 crack serial keygen, 26 %, and 38 % of women reported decrease in sexual desire, frequency of sexual activity, and sexual satisfaction, respectively. In repeated measures analyses using data from all study visits and controlling for age, race/ethnicity, and relationship status, greater number of chronic conditions was independently associated with low sexual desire (OR 1.14 [1.09–1.19] per condition), less than monthly sexual activity (OR 1.14 [1.09–1.19] per condition), and low overall sexual satisfaction (OR 1.13 [1.08–1.18] per condition). Women with neuropsychiatric conditions InterNetView 2.0.1.8 crack serial keygen particular (stroke, dementia, Parkinson’s disease, depression) were more likely to report low sexual desire (OR 1.55 [1.31–1.83]), less than monthly sexual activity (OR1.41 [1.18–1.68]), and low sexual satisfaction (OR 1.44 [1.21–1.71]), independent of other types of chronic conditions. Age persisted as a significant predictor of low desire, lower frequency of sexual activity, and low overall sexual satisfaction even after adjustment for number and types of chronic conditions (P < 0.001 for all).

CONCLUSIONS: Decline in sexual desire, activity, InterNetView 2.0.1.8 crack serial keygen, and satisfaction appear common but not inevitable as women age. Sexual function may decrease as women InterNetView 2.0.1.8 crack serial keygen chronic conditions, although differences in the number and type of conditions do not fully explain differences in sexual function with aging. Clinicians caring for female patients across the aging spectrum should consider the specific impact of chronic conditions, particularly neuropsychiatric conditions, on women’s interest in and ability to InterNetView 2.0.1.8 crack serial keygen sexual activity.

AMBULATORY RESIDENT PRACTICE REDESIGN: THE CREATION OF PRACTICE TEAMS WITHIN InterNetView 2.0.1.8 crack serial keygen 6 + 2 MODEL Christina Harris; Lauren Acinapura; Johanna Martinez; Judy Tung; Cathy Jalali. Weill Cornell Medical College, New York, NY. (Tracking ID #1642447)

BACKGROUND: Calls for Internal Medicine residency redesign have emphasized the strengthening of ambulatory education with the IM Residency Review Committee specifically mandating that programs “develop models and schedules for ambulatory training that minimize conflicting inpatient and outpatient responsibilities”. In response, in 2011 we restructured our residency program Adobe Lightroom Classic CC 2021 Crack (10.1) Version Free Download from traditional block time with weekly half day continuity clinics to a model where inpatient and outpatient time were independent of each other in a 6 + 2 model (6 weeks inpatient followed by 2 weeks of ambulatory practice) and created resident teams (“pods”) of four residents each.

METHODS: We implemented a 6 + 2 scheduling template at the start of the 2011–2012 academic year for all 130 residents across 3 continuity practices. In order to ensure adequate coverage of patient care matters during the 6 weeks away from practice, we created pods of four residents who hand off to each other every 2 weeks. The resident on ambulatory block functions as the “pod leader” and is responsible for ensuring that all direct and indirect patent care needs of the pod are met. Resident surveys were administered prior to the block restructuring and 1 year after implementation. Residents were asked to rate their satisfaction in four main areas including clinical and learning environment, personal experience and satisfaction with ambulatory preceptors using a 5-point rating scale. In addition, individual resident visit volume and patient continuity data were obtained for the main resident practice.

RESULTS: The survey data, analyzed using Wilcoxon Signed Rank Test, revealed that the scheduling template and creation of resident teams significantly improved resident satisfaction with their overall clinical environment (3.33 vs 4.13; p < .005) and learning environment (3.55 vs 4.16; p = .002), as well as personal reward (3.68 vs 4.11;p = .041) from their ambulatory practice. Residents reported improved satisfaction with their ability to focus while on the wards (2.68 vs 4.33; p < .005) and as well while on outpatient rotation (3.65 vs 4.51; p < .005). The repetitive nature of the schedule resulted in residents feeling significantly more connected to each other (3.81 vs 4.43, p = .003), however, InterNetView 2.0.1.8 crack serial keygen, without a similar increase in satisfaction in the exposure to their assigned continuity preceptor (4.13 vs 4.21; p = .732). With the creation of coverage pods, there was in improvement in resident satisfaction in how patient calls were answered (3.21 vs 3.82; p = .006), as well as with how patients results were managed (3.54 vs 4.08; p = .009) for the resident practice. The patient volume lost by the elimination of weekly afternoon continuity clinics was offset almost exactly with the increase in ambulatory block from 8 to 12 weeks per year (15,822 vs 15,972 resident visits/year). Despite an increase in satisfaction with the sense of patient ownership (4.17 vs 4.47; p = .029) individual resident-patient continuity remained unchanged (47 % vs 46 %). No change in resident reported spectrum of type patient care issues was seen.

CONCLUSIONS: Utilizing a 4 resident pod team approach, our residency program was able to effectively decouple the inpatient and outpatient residency experience in a way that improved the residents’ perceived ambulatory experience without negatively impacting patient volume or continuity of care. Future efforts to improve resident-patient continuity both within their individual panel and within the pod are underway.

AN EHR-BASED INTERVENTION TO PROACTIVELY IDENTIFY AND MITIGATE DELAYS IN CANCER DIAGNOSIS: A RANDOMIZED CLINICAL TRIAL Daniel R. Murphy2,1; Louis Wu2,1; Archana Laxmisan2,1; Eric J. Thomas3; Samuel N. Forjuoh4; Hardeep Singh2,1. 1Baylor College of Medicine, Houston, TX; 2Michael E. DeBakey VA Medical Center, Houston, TX; 3University of Texas Houston Medical School and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX; 4Scott & White Healthcare, Texas A&M Health Science Center, Houston, TX. (Tracking ID #1642092)

BACKGROUND: Delays in cancer diagnosis can results in poor patient outcomes and increased malpractice litigation. Many of these delays are related to “missed” follow-up of non-life threatening abnormal clinical findings such as positive cancer screens (i.e. red flags). Methods to identify patients at risk for delayed diagnosis due to missed follow-up are in their infancy and have not been evaluated thus far.

METHODS: We conducted a randomized clinical trial to test the effectiveness of an intervention using EHR-based triggers (i.e., specific set of data signals that prompt record review) to improve follow-up of red flags related to colorectal, breast, and prostate cancer. The two-part intervention included: (1) using an electronic trigger to identify high-risk patients with missed red flags suggestive of the cancer, and (2) communication of information about high-risk patients to primary care providers (PCPs). Study settings included a large urban VA facility and a InterNetView 2.0.1.8 crack serial keygen private health system. PCPs were the unit of randomization and were randomly assigned to intervention or controls using a randomized block design. Triggers identified patient records with red flags that had no EHR evidence of follow-up action. Red flags included a positive fecal occult blood test (FOBT), labs consistent with iron deficiency anemia, new diagnosis of hematochezia, imaging study with a lung mass, and an elevated prostate specific antigen. Triggers were prospectively applied every 2 weeks to EHR data of all patients assigned to an intervention provider. Each triggered chart was manually reviewed initially to determine whether follow-up was truly delayed per a priori definitions (e.g. no colonoscopy within 60 days of positive FOBT). If so, the respective provider was contacted by secure email. One week later, if no action was taken, the provider was called. The primary outcome was a documented follow-up action in response to the red flag, which was determined through blinded final reviews performed 7 months after the date of red flag. A chi-squared analysis InterNetView 2.0.1.8 crack serial keygen performed to test if the intervention improved follow-up.

RESULTS: A total of 72 PCPs participated in the study, and 36 were randomly assigned to each group. Seven PCPs left their facility during the study period. The intervention was applied to all patients seen at the study sites for 15 months from April 20, 2011 to July 19, 2012 and identified a total of 1257 high-risk patients. After initial review, 376 (29.9 %, 210 intervention and 166 control) records were excluded because they did not meet study criteria (e.g., patient declined follow-up or pursued outside care), leaving 881 patients with confirmed delays. Patients assigned to an intervention provider were more likely to receive subsequent follow-up (RR:1.22; 95 % CI:1.002,1.485; p = 0.047).

CONCLUSIONS: A proactive EHR-based intervention to identify patients at risk for delays in cancer diagnosis has potential to improve their follow-up. Similar EHR-based interventions could be applied to other conditions where delays in diagnosis and/or follow-up are a problem.

AN ITERATIVE, COMMUNITY FEEDBACK-DRIVEN APPROACH TO HOUSEHOLD SURVEY DESIGN Lujia Zhang1; Dennishia Banner2; Rachelle Bross5; Nell Forge4; Felica U. Jones2; Loretta Jones2,4; Katherine L. Kahn1; Roberto Vargas1; Keyonna M. King1; Aziza L. Wright2,4; Sigrid K. Madrigal2; D’Ann M. Morris3; Keith C. Norris4; Orwilda L. Pitts4; Ibrahima Sankare1; Arleen Brown1. 1UCLA, Los Angeles, CA; 2Healthy African American Families, Los Angeles, CA; 3Los Angeles Urban League, Los Angeles, CA; 4Charles Drew University, Los Angeles, CA; 5Los Angeles Biomed, Los Angeles, CA. (Tracking ID #1641961)

BACKGROUND: While household surveys are common in epidemiologic research, InterNetView 2.0.1.8 crack serial keygen, few studies have InterNetView 2.0.1.8 crack serial keygen community partnered participatory research (CPPR) in the research design phase, InterNetView 2.0.1.8 crack serial keygen. The Healthy Community Neighborhood Initiative (HCNI) is a collaborative effort between the Los Angeles Urban League, and Healthy African American Families (HAAF), Charles Drew University, and University of California in Los Angeles (UCLA) to improve health and health care in a South Los Angeles community disproportionately affected by preventable chronic conditions. Community-academic input InterNetView 2.0.1.8 crack serial keygen survey development and study design to build capacity for community engaged research to reduce health disparities.

METHODS: HCNI members identified key topics for the interview and examination and then iteratively ranked items, InterNetView 2.0.1.8 crack serial keygen, refined and piloted elements of the survey and clinical examination; obtained community input on the informed consent form, the survey, and the clinical and laboratory data collection protocols; and piloted household surveys. After each household visit, observer and participant recommendations were incorporated into the protocol for the next visit.

RESULTS: Over six household visits (n = 11), changes to the data collection instruments and protocols enhanced participant understanding of the informed consent form (ICF) and survey questions, reduced time spent “in-home” by 30 min, and streamlined the protocol to facilitate fewer surveyors in the household.

CONCLUSIONS: An iterative, community-academic feedback-driven revision process resulted in substantive changes to the ICFs, surveys, and data collection protocols that reflected the unique characteristics of the community and its residents. By emphasizing community engagement early in the study design phase, we established bidirectional knowledge exchange between researchers and the community.

AN UNDER-APPRECIATED ETHICAL PROBLEM: DELAYS IN DEATH CERTIFICATE COMPLETION Philip C. Carullo1; Daniel Sulmasy2. 1University of Chicago, Chicago, IL; 2University of Chicago, Chicago, IL. (Tracking ID #1627627)

BACKGROUND: Death certificates are legal documents that permit families to finalize a multitude of end-of-life tasks. Physicians play a key role in generating these documents, in partnership with hospital staff, funeral directors, and state health departments. While delays and errors in the completion of a death certificates increase waiting InterNetView 2.0.1.8 crack serial keygen for families and, anecdotally, have been reported to cause great anguish, there have been no systematic studies of delays in death certificate completion by physicians, especially the impact of such delays on families. The purpose of this study was to gain broad insight into the phenomenon of delayed InterNetView 2.0.1.8 crack serial keygen certificate completion by physicians, especially the impact of such delays on families.

METHODS: The authors selected 12 academic medical centers dispersed throughout the US and interviewed 30 participants, including hospital staff dedicated to death certificate paperwork, and local funeral parlor and medical examiner office personnel to understand the phenomenon and the impact of delays in death certificate completion by physicians. They used a phenomenological, qualitative approach; 2 independent coders analyzed the interview data and jointly resolved coding disagreements; no more interviews were conducted once thematic saturation was reached.

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