Objective To assess recent temporal trends in guideline-compliant pediatric lipid testing, and to examine the influence of social determinants of health (SDoH) and provider characteristics on the likelihood of testing in youth. Study design In this observational, multiyear cross-sectional study, we calculated lipid testing prevalence by year among 268 627 12-year olds from 2015 through 2019 who were enrolled in Florida Medicaid and eligible for universal lipid screening during age 9 to 11, and 11 437 22-year olds (2017-2019) who were eligible for screening during age 17-21. We compared trends in testing prevalence by SDoH and health risk factors at two recommended ages and modeled the associations between patient characteristics and provider type on lipid testing using generalized estimating equations. Results Testing among 12-year olds remained low between 2015 through 2019 with the highest prevalence in 2015 (8.0%) and lowest in 2017 (6.7%). Screening compliance among 22-year olds was highest in 2017 (21.1%) and fell to 17.8% in 2019. Hispanics and non-Hispanic Blacks in both age groups had about 2%-3% lower testing prevalence than non-Hispanic Whites. Testing in 12-year olds was 12.3% vs 7.7% with and without obesity, and 14.4% vs 7.6% with and without antipsychotic use. Participants who saw providers who were more likely to prescribe lipid testing were more likely to receive testing (OR = 2.3, 95% CI 2.0-2.8, P < .001). Conclusions Although lipid testing prevalence was greatest among high-risk children, overall prevalence of lipid testing in youth remains very low. Provider specialty and choices by individual providers play important roles in improving guideline-compliant pediatric lipid testing.

Purpose: Within the United States, human papillomavirus (HPV) vaccination rates remain low. We examined HPV vaccine recommendation practices among Florida clinicians by assessing variability in: (1) recommendation priorities by patient characteristics and (2) concordance with best practices. Methods: In 2018 and 2019, we conducted a cross-sectional survey incorporating a discrete choice experiment among primary care clinicians (MD/DO, APRN, and PA). We used linear mixed-effects models to determine the importance of patient characteristics (age, sex, time in practice, and chronic condition) and parental concerns. We compared clinician endorsement of predetermined constructs with reported vaccine recommendation statements.Results: Among 540 surveys distributed, 272 were returned and 105 reported providing preventive care to 11-to 12-year-olds (43% response rate). Among completing clinicians, 21/99 (21%) did not offer the HPV vaccine. Among clinicians offering the vaccine (n = 78), 35%-37% of each decision to recommend the vaccine was based on the child's age (15 vs. 11 years). For closed-ended questions, most clinicians endorsed best practices including emphasizing cancer prevention (94% for girls and 85% for boys; p = .06), vaccine efficacy (60% both sexes), safety (58% girls and 56% boys), impor-tance at 11-12 years (64% both sexes), and bundling vaccines (35% girls and 31% boys). When clinicians reported their typical recommendation, fewer clinicians incorporated best practices (59% cancer prevention, 5% safety, 8% the importance at 11-12 years, and 8% bundling vaccines).Discussion: HPV vaccination recommendation strategies among Florida clinicians somewhat aligned with best practices. Alignment was higher when clinicians were explicitly asked to endorse constructs versus provide recommendations.(c) 2023 Society for Adolescent Health and Medicine. All rights reserved.

Although superficially similar to data from clinical research, data extracted from electronic health records may require fundamentally different approaches for model building and analysis. Because electronic health record data is designed for clinical, rather than scientific use, researchers must first provide clear definitions of outcome and predictor variables. Yet an iterative process of defining outcomes and predictors, assessing association, and then repeating the process may increase Type I error rates, and thus decrease the chance of replicability, defined by the National Academy of Sciences as the chance of "obtaining consistent results across studies aimed at answering the same scientific question, each of which has obtained its own data."[1] In addition, failure to account for subgroups may mask heterogeneous associations between predictor and outcome by subgroups, and decrease the generalizability of the findings. To increase chances of replicability and generalizability, we recommend using a stratified split sample approach for studies using electronic health records. A split sample approach divides the data randomly into an exploratory set for iterative variable definition, iterative analyses of association, and consideration of subgroups. The confirmatory set is used only to replicate results found in the first set. The addition of the word 'stratified' indicates that rare subgroups are oversampled randomly by including them in the exploratory sample at higher rates than appear in the population. The stratified sampling provides a sufficient sample size for assessing heterogeneity of association by testing for effect modification by group membership. An electronic health record study of the associations between socio-demographic factors and uptake of hepatic cancer screening, and potential heterogeneity of association in subgroups defined by gender, self-identified race and ethnicity, census-tract level poverty and insurance type illustrates the recommended approach.

Although superficially similar to data from clinical research, data extracted from electronic health records (EHRs) may require fundamentally different approaches to analysis and model building. Some outcome and predictor variables may not be well-defined at the start of the study. Selecting specific definitions requires exploratory data analysis. Specifying the rules for computing a new variable inevitably leads to exploratory analyses. Achieving replicability, i.e., a high probability that a similar future study will reach the same conclusions, requires special approaches. We recommend a study design strategy based on stratified sample splitting for studies using EHRs. The split-sample design ensures meeting the goal of replicability. Stratified sampling of EHRs increases generalizability by allowing heterogeneity between subgroups to be tested appropriately with good statistical power. Building a model from EHR data to predict uptake of hepatic cancer screening illustrates the recommended approach.

Relative to other racial/ethnic groups in the United States, Hispanic American (HA) youth have higher rates of overweight and obesity. Previous work suggests that low perceived social status (SS) promotes excess caloric intake and, thereby, development of obesity. Psychological resilience may play a role in reducing adverse eating behaviors and risk for obesity. The objective of this study was to investigate whether resilience (as measured by the Connor Davidson Resilience Scale) interacts with experimentally manipulated SS to affect dietary intake among HA adolescents (n = 132). Using a rigged game of Monopoly (Hasbro, Inc.), participants were randomized to a high or low SS condition. Following the Monopoly game, participants consumed an ad libitum lunch and their dietary intake was assessed. There was a significant interaction between resilience and experimentally manipulated SS for total energy intake (p = 0.006), percent energy needs consumed (p = 0.005), and sugar intake (p = 0.004). For the high SS condition, for each increase in resilience score, total energy intake decreased by 7.165 ± 2.866 kcal (p = 0.014) and percent energy needs consumed decreased by 0.394 ± 0.153 (p = 0.011). In the low SS condition, sugar intake increased by 0.621 ± 0.240 g for each increase in resilience score (p = 0.011). After correction for multiple comparisons, the aforementioned interactions, but not simple slopes, were statistically significant.

ObjectiveWe sought to examine the extent to which body mass index (BMI) was available in electronic health records for Florida Medicaid recipients aged 5 to 18 years taking Second-Generation Antipsychotics (SGAP). We also sought to illustrate how clinical data can be used to identify children most at-risk for SGAP-induced weight gain, which cannot be done using process-focused measures.MethodsElectronic health record (EHR) data and Medicaid claims were linked from 2013 to 2019. We quantified sociodemographic differences between children with and without pre- and post-BMI values. We developed a linear regression model of post-BMI to examine pre-post changes in BMI among 4 groups: 1) BH/SGAP+ children had behavioral health conditions and were taking SGAP; 2) BH/SGAP- children had behavioral health conditions without taking SGAP; 3) children with asthma; and 4) healthy children.ResultsOf 363,360 EHR-Medicaid linked children, 18,726 were BH/SGAP+. Roughly 4% of linked children and 8% of BH/SGAP+ children had both pre and post values of BMI required to assess quality of SGAP monitoring. The percentage varied with gender and race-ethnicity. The R2 for the regression model with all predictors was 0.865. Pre-post change in BMI differed significantly (P < .0001) among the groups, with more BMI gain among those taking SGAP, particularly those with higher baseline BMI.ConclusionMeeting the 2030 Centers for Medicare and Medicaid Services goal of digital monitoring of quality of care will require continuing expansion of clinical encounter data capture to provide the data needed for digital quality monitoring. Using linked EHR and claims data allows identifying children at higher risk for SGAP-induced weight gain.

Introduction: To direct interventions, the Florida counties with the greatest risk of current and future human papillomavirus-associated cancers were identified by estimating county level (1) percentages of adolescents aged 13-17 years who initiated (>= 1 dose) and were up to date (2-3 doses) for the human papillomavirus vaccine and (2) human papillomavirus-associ-ated cancer incidence rates. Methods: Records were obtained for human papillomavirus vaccinations from the Florida immunization registry (2006-2019), incident cancer cases from the Florida registry (2013-2017), and annual population counts from the Florida Department of Health (2006-2019). In 2020, annual county-level human papillomavirus vaccine initiation, human papillomavirus vaccine up-to-date, and age-adjusted human papillomavirus-associated cancer incidence rates were estimated. Results: Among adolescents aged 13-17 years, average 2018-2019 county-specific human papillomavirus vaccine initiation ranged from 38% to 100% for females and from 34% to 96% for males. Up-to-date estimates ranged from 20% to 72% for females and from 24% to 77% for males. The majority (78%) of counties with initiation and up-to-date estimates within the lowest tercile were located in Northern Florida. County-specific 2013-2017 annualized, adjusted human papillomavirus-associated cancer incidence rates ranged from 0 to 29.8 per 100,000 among females and from 5.4 to 24.1 per 100,000 among males. Counties within the highest tercile for human papillomavirus-associated cancers were primarily (90% for females and 77% for males) located in Northern Florida. Conclusions: Human papillomavirus-associated cancer risk varies widely across Florida counties, with particularly high risk within Northern Florida. Targeting interventions toward counties with low vaccination and high cancer rates may reduce human papillomavirus-associated cancers. (C) 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Abstract Hepatitis C virus (HCV) infection is a leading risk factor for hepatocellular carcinoma. We employed a retrospective cohort study design and analyzed 2012–2018 Medicaid claims linked with electronic health records data from the OneFlorida Data Trust, a statewide data repository containing electronic health records data for 15.07 million Floridians from 11 health care systems. Only adult patients at high-risk for HCV (n = 30,113), defined by diagnosis of: HIV/AIDS (20%), substance use disorder (64%), or sexually transmitted infections (22%) were included. Logistic regression examined factors associated with meeting the recommended sequence of HCV testing. Overall, 44.1% received an HCV test. The odds of receiving an initial test were significantly higher for pregnant females (odds ratio [OR]1.99; 95% confidence interval [CI] 1.86–2.12; P < .001) and increased with age (OR 1.01; 95% CI 1.00–1.01; P < .001).Among patients with low Charlson comorbidity index (CCI = 1), non-Hispanic (NH) black patients (OR 0.86; 95% CI 0.81–0.9; P < .001) had lower odds of getting an HCV test; however, NH black patients with CCI = 10 had higher odds (OR 1.41; 95% CI 1.21–1.66; P < .001) of receiving a test. Of those who tested negative during initial testing, 17% received a second recommended test after 6 to 24 months. Medicaid-Medicare dual eligible patients, those with high CCI (OR 1.14; 95% CI 1.11–1.17; P < .001), NH blacks (OR 1.93; 95% CI 1.61–2.32; P < .001), and Hispanics (OR 1.49; 95% CI 1.08–2.06; P = .02) were significantly more likely to have received a second HCV test, while pregnant females (OR 0.71; 95% CI 0.57–0.89; P = .003), had lower odds of receiving it. The majority of patients who tested positive during the initial test (97%) received subsequent testing. We observed suboptimal adherence to the recommended HCV testing among high-risk patients underscoring the need for tailored interventions aimed at successfully navigating high-risk individuals through the HCV screening process. Future interventional studies targeting multilevel factors, including patients, clinicians and health systems are needed to increase HCV screening rates for high-risk populations.

BACKGROUND:Low objective socioeconomic status (SES) and subjective social status (SSS), one's perceived social rank, are associated with obesity. This association may be due, in part, to social status-related differences in energy expenditure. Experimental studies are needed to assess the extent to which SES and SSS relate to energy expenditure. OBJECTIVE:Assess the effects of experimentally manipulated social status and SSS on moderate-to-vigorous physical activity (MVPA) and sedentary behaviour. METHODS:One hundred thirty-three Hispanic adolescents aged 15-21 were randomized to a high or low social status position, facilitated through a rigged game of Monopoly™. SSS was assessed with MacArthur Scales. Post-manipulation 24-h MVPA and sedentary behaviour were assessed via accelerometry. Analyses were conducted with general linear regression models. RESULTS:Experimentally manipulated social status did not significantly affect the total time spent in MVPA or sedentary behaviour; however, identifying as low SSS was significantly associated with less MVPA (p = 0.0060; 18.76 min less). CONCLUSIONS:Tewnty-four-hour MVPA and sedentary behaviour are not affected by an acute experimental manipulation of social status. However, low SSS, independent of SES, was associated with clinically significant differences in MVPA. SSS may be a better predictor of MVPA than SES among Hispanic adolescents, potentially influencing obesity, and other health-related outcomes.

BACKGROUND AND OBJECTIVE:First-line, nonpharmacological therapy is recommended for many pediatric mental health (MH) conditions prior to initiating antipsychotic prescription therapies. Many children do not receive these recommended services, despite the known association between antipsychotic medications and metabolic dysfunction. The main objective of this study was to quantify the association among children's MH diagnosis categories, sociodemographic characteristics and receipt of first-line psychosocial care among children in Florida Medicaid METHODS: Florida Medicaid enrollment, healthcare and pharmacy claims were used for this multivariate analysis. Children were assigned to condition clusters wherein related diagnoses were grouped into clinically relevant categories. A total of 7704 children were included in the final analysis.RESULTS:Twenty-four percent of children in Florida Medicaid do not receive first-line, nonpharmacological psychosocial care. Age was significantly associated with not receiving psychosocial services, with older children less likely to receive. Non-Hispanic White children as well as those living in rural areas had lower odds of receiving behavioral intervention prior to initiating antipsychotics. Children with mood-disorders, behavior problems, anxiety and stress related disorders were more likely to receive first-line psychosocial care.CONCLUSIONS:This study provides an important understanding of the variability in receipt of first-line psychosocial care before antipsychotic medication initiation among children in Medicaid based on sociodemographic and MH health characteristics. These analyses can be used to develop quality improvement initiatives targeted toward children that are most vulnerable for not receiving recommended care.

Objective This randomized trial experimentally manipulated social status to assess effects on acute eating behavior and 24-hour energy balance. Methods Participants (n = 133 Hispanics; age 15-21 years; 60.2% females) were randomized to low social status ("LOW") or high social status ("HIGH") conditions in a rigged game of Monopoly (Hasbro, Inc.). Acute energy intake in a lunchtime meal was measured by food scales. Twenty-four-hour energy balance was assessed via summation of resting metabolic rate (metabolic cart), physical activity energy expenditure (accelerometer), thermic effect of food, and subtraction of twenty-four-hour energy intake (food diary). Results In the total sample, no significant differences were observed by study condition at lunchtime. LOW females consumed a greater percent of lunchtime daily energy needs (37.5%) relative to HIGH females (34.3%); however, this difference was not statistically significant (P = 0.291). In males, however, LOW consumed significantly less (36.5%) of their daily energy needs relative to HIGH males (45.8%; P = 0.001). For 24-hour energy balance, sex differences were nearly significant (P = 0.057; LOW females: surplus +200 kcal; HIGH males: surplus +445 kcal). Food-insecure individuals consumed a nearly significant greater lunchtime percent daily energy than those with food security (40.7% vs. 36.3%; P = 0.0797). Conclusions The data demonstrate differential acute and 24-hour eating behavior responses between Hispanic male and female adolescents in experimentally manipulated conditions of low social status.

Objectives: Promoting patient involvement in managing co-occurring physical and mental health conditions is increasingly recognized as critical to improving outcomes and controlling costs in this growing chronically ill population. The main objective of this study was to conduct an economic evaluation of the Wellness Incentives and Navigation (WIN) intervention as part of a longitudinal randomized pragmatic clinical trial for chronically ill Texas Medicaid enrollees with co-occurring physical and mental health conditions. Methods: The WIN intervention used a personal navigator, motivational interviewing, and a flexible wellness expense account to increase patient activation, that is, the patient's knowledge, skills, and confidence in managing their self-care and co-occurring physical and mental health conditions. Regression models were fit to both participant-level quality-adjusted life years (QALYs) and total costs of care (including the intervention) controlling for demographics, health status, poverty, Medicaid managed care plan, intervention group, and baseline health utility and costs. Incremental costs and QALYs were calculated based on the difference in predicted costs and QALYs under intervention versus usual care and were used to calculate the incremental cost-effectiveness ratios (ICERs). Confidence intervals were calculated using Fieller's method, and sensitivity analyses were performed. Results: The mean ICER for the intervention compared with usual care was $12 511 (95% CI $8971-$16 842), with a sizable majority of participants (70%) having ICERs below $40 000. The WIN intervention also produced higher QALY increases for participants who were sicker at baseline compared to those who were healthier at baseline. Conclusion: The WIN intervention shows considerable promise as a cost-effective intervention in this challenging chronically ill population.

AbstractObjectiveTo examine whether the Wellness Incentive and Navigation (WIN) intervention can improve health‐related quality of life (HRQOL) among Medicaid enrollees with co‐occurring physical and behavioral health conditions.Data SourcesAnnual telephone survey data from 2013 to 2016, linked with claims data.Study DesignWe recruited 1259 participants from the Texas STAR + PLUS managed care program and randomized them into an intervention group that received flexible wellness accounts and navigator services or a control group that received standard care. We conducted 4 waves of telephone surveys to collect data on HRQOL, patient activation, and other participant demographic and clinical characteristics.Data Collection/Extraction MethodsThe 3M Clinical Risk Grouping Software was used to extract variables from claims data and group participants based on disease severity.Principal FindingsOur results showed that the WIN intervention was effective in increasing patient activation and HRQOL among Medicaid enrollees with co‐occurring physical and behavioral health conditions. Furthermore, we found that this intervention effect on HRQOL was partially mediated by patient activation.ConclusionsProviding navigator support with wellness account is effective in improving HRQOL among Medicaid enrollees. The pragmatic nature of the trial maximizes the chance of successfully implementing it in state Medicaid programs.

Patient activation, the perceived capacity to manage one’s health, is positively associated with better health outcomes and lower costs. Underlying characteristics influencing patient activation are not completely understood leading to gaps in intervention strategies designed to improve patient activation. We suggest that variability in executive functioning influences patient activation and ultimately has an impact on health outcomes. To examine this hypothesis, 440 chronically ill Medicaid enrollees completed measures of executive functioning, patient activation, and health-related quality of life. Mediation analyses revealed that executive functioning: (a) directly affected patient activation and mental health-related quality of life, (b) indirectly affected mental health-related quality of life through patient activation, and (c) was unrelated to physical health-related quality of life. These data indicate that further study of the relationships among neurocognitive processes, patient activation, and health-related quality of life is needed and reinforces previous work demonstrating the association between patient activation and self-reported outcomes.

Intake of n-3 polyunsaturated fatty acids (PUFAs) has been reported to provide various benefits for patients with metabolic syndrome (MetS), such as reducing blood pressure and improving blood lipids, but results are inconsistent. This study aimed to investigate the effect of n-3 PUFA intake on components of MetS. We searched PubMed, Scopus, Web of Sciences, and Cochrane databases up to June 2018 for randomized trials at least 30 days long comparing n-3 PUFAs with a control in patients diagnosed with MetS (PROSPERO registration ID: CRD42017072332). The outcomes include body mass index, systolic and diastolic blood pressure, triglyceride, high-density lipoprotein cholesterol, and fasting blood glucose. Mean differences post-intervention or mean change from baseline were combined using random-effects models; confirmation of within-study effect sizes is ongoing. A total of 14 trials were identified. The pooled results showed n-3 PUFA intake reduced systolic blood pressure by 3.92 mmHg (95%CI: –6.89, –0.96, P-value = 0.009, I2 = 34%, 9 trials) and diastolic blood pressure by 2.81 mmHg (95%CI: –4.26, –1.36, P-value = 0.0001, I2 = 15%, 8 trials). Body mass index was lower in the n-3 PUFA group by 3.19 kg/m2 (95%CI: –6.16, –0.22, P-value = 0.04, I2 = 97%, 7 trials) compared to the control group. Triglyceride levels in n-3 PUFA groups were significantly lower than the control when pooling trials with post intervention data only (–33.13 mg/dL, 95%CI: –49.44, –16.81, P-value < 0.0001, I2 = 71%, 6 trials), but the overall effect was non-significant when including studies with pre-post data (P-value = 0.08). The n-3 PUFA intake did not significantly alter high-density lipoprotein cholesterol (P-value = 0.71) or fasting glucose (P-value = 0.36). Our preliminary results provide evidence for beneficial effects of n-3 PUFAs on reducing blood pressure and improving weight control in patients with MetS, with less certain results for triglycerides. Sensitivity and confirmatory analyses are in progress to test the robustness of results under different effect-size assumptions and to investigate sources of heterogeneity. Most of the included trials had small sample sizes. Randomized trials with higher quality and larger scale are needed to confirm the findings. The authors received no funding for this specific work. Other funding support includes: AWB: NIH R25DK099080, R25HL124208.

Objectives Subjective and objective social status is associated with weight status, but this relationship differs by sex and the mechanisms remain unclear. Methods This randomized study in Hispanic adolescents investigated the effects of experimentally manipulated social status on ad libitum acute and 24-hour dietary intakes and stress-related outcomes as potential mechanisms through which social status affects weight. Participants (n = 133; ages 15-21; 60.2% girls; BMI ≥18.5 and ≤40 kg/m2; 23.4% food insecure) consumed a standardized breakfast and then were randomized to a low (LOW) or high social status position (HIGH) in a rigged game of Monopoly™, in which the rules differed substantially by social status position. Following the game, the participants consumed an ad libitum lunchtime meal. Energy intake was assessed by pre- and post- food weighing. Stress-related markers were measured at baseline, before Monopoly™, after Monopoly™, and after lunch, with the exception of cortisol (measured before and after Monopoly™). Results There was a significant interaction between sex and experimentally manipulated social status (P = 0.0087), such that girls randomized to LOW consumed significantly more of their daily energy needs at the ad libitum lunchtime meal relative to those randomized to HIGH (37.5% vs. 34.3%, respectively). Individuals with food insecurity consumed a greater % of their daily energy needs at the lunchtime meal than those with food security, although the result was not quite statistically significant (40.7% vs. 36.3%, respectively; P = 0.08). In LOW, participants report decreased feelings of powerfulness following Monopoly™ (P = 0.0006). There were no significant differences between HIGH and LOW following Monopoly™ regarding perceived stress, cortisol, heart rate, or blood pressure. Social status condition was not related to 24-hour % of daily energy needs consumed. Conclusions Our data suggest a causal link between experimentally manipulated low social status and increased acute energy intakes among Hispanic girls, potentially influenced by decreased feelings of powerfulness, which is independent of stress. Low social status may play a causal role in the development of obesity by promoting excess calorie consumption. Further research is needed to identify the biobehavioral mechanisms contributing to this phenomenon. Funding Sources NIH. Supporting Tables Images and/or Graphs

Background: Accumulating evidence implicates diet quality in childhood as playing a significant role in adult cardiometabolic health. Polyunsaturated fatty acids (PUFAs) of the n-6 (omega-6) and n-3 (omega-3) series contribute unique protective effects against cardiometabolic disease. As such, the ratio between n-6 and n-3 PUFAs is a dietary metric of interest in the early life span, although an optimum intake ratio has yet to be determined. Objective: This cross-sectional study assesses relations between the ratio of total n-6:n-3 PUFA intake and cardiometabolic risk factors in a racially diverse sample of children (n = 191) from the Admixture Mapping of Ethnic and Racial Insulin Complex Outcomes (AMERICO) study. Methods: Outcome measures included waist circumference, lipid concentrations, fasting glucose, and two 24-h dietary recalls from boys and girls aged 7-12 y who self-reported as European American (n = 81), African American (n = 55), or Hispanic American (n = 55). Linear regression analyses were used to assess associations between predictors of interest and outcomes after adjusting for covariates. Results: PUFA intake reflected in the n-6: n-3 ratio was inversely associated with concentrations of total and LDL cholesterol [beta +/- SE: -0.359 +/- 0.107 (P = 0.001) and -0.189 +/- 0.069 (P = 0.007), respectively]. Exploratory analyses showed that the intake of total n-6 PUFAs was not significantly predictive of any cardiometabolic risk factor assessed, whereas total n-3 PUFA intake was positively associated with concentrations of HDL cholesterol (beta +/- SE: 0.114 +/- 0.042; P = 0.007). Conclusions: Results suggest that the effect of n-6 and n-3 PUFA intake reflected in the ratio may be largely driven by n-3 PUFAs in reducing 2 lipid cardiometabolic risk factors among this multiethnic cohort of children. Until an ideal intake ratio is determined, nutritional counseling should focus on meeting recommended levels of both n-3 and n-6 PUFAs in order to establish beneficial childhood dietary patterns that may positively influence adult cardiometabolic health.

Although Short Form (SF)-12 × 2® has been extensively studied and used as a valid measure of health-related quality of life in a variety of population groups, no systematic studies have described the reliability of the measure in patients with behavioral conditions or serious mental illness (SMI).

Appropriate use criteria (AUC) have been developed for a variety of cardiovascular tests and services. AUC are based on the best available evidence with the goal of identifying which clinical scenarios are likely to result in net patient benefit or harm. Little is known about how well physicians on

Background: Despite efforts by professional societies to reduce low value care, many reports indicate that unnecessary tests, such as nuclear myocardial perfusion imaging (MPI), are commonly used in contemporary practice. The degree to which lack of awareness and professional liability concerns drive these behaviors warrants further study. We sought to investigate patient and provider perceptions about MPI in asymptomatic patients, the Choosing Wisely (CW) campaign, and professional liability concerns.Methods: We administered an anonymous, paper-based survey with both discrete and open-response queries to subjects in multiple outpatient settings at our facilities. The survey was completed by 456 respondents including 342 patients and 114 physicians and advanced practice providers between May and August 2014. Our outcome was to compare patient and provider perceptions about MPI in asymptomatic patients and related factors.Results: Patients were more likely than providers to report that MPI was justified for asymptomatic patients (e.g. asymptomatic with family history of heart disease 75% versus 9.2%, p < 0.0001). In free responses to the question "What would be an inappropriate reason for MPI?" many responses echoed the goals of CW (for example, "If you don't have symptoms", "If the test is too risky", "For screening or in asymptomatic patients"). A minority of providers were aware of CW while even fewer patients were aware (37.2% versus 2.7%, p < 0.0001). Over one third of providers (38.9%) admitted to ordering MPI out of concern for professional liability including 48.3% of VA affiliated providers.Conclusions: While some patients and providers are aware of the low value of MPI in patients without symptoms, others are enthusiastic to use it for a variety of scenarios. Concerns about professional liability likely contribute, even in the VA setting. Awareness of the Choosing Wisely campaign is low in both groups.