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2016 NAPCRG Annual Meeting

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PR1 CASFM 2016 Methods Pre-Conference: Advancing Primary Care Research

Tyler Williamson, PhD; Christopher P. Morley, PhD; Gillian Bartlett, PhD; Chester H. Fox, MD; Lee A. Green, MD, MPH; Joseph W LeMaster, MD, MPH; Maeve O'Beirne, MD, PhD; Jon Salsberg, PhD; Hazel Tapp, PhD

11/12/16 9:00 AM - 5:00 PM Colorado A

Objectives: The mission of the Committee on Advancing the Science of Family Medicine (CASFM) is to promote and actively contribute to the the academic discipline of primary care for the betterment of patients and their communities. It will also help to assure that the development, translation, and implementation of new evidence rapidly becomes part of the fabric of what it means to be a family physician. Building on the successful 2015 pre-conference organized by the CASFM Research Methods Work Group, this submission aims to provide a breadth of introductory and advanced sessions on various aspects of research methodology. This year’s pre-conference is being organized by the CASFM Work Groups to provide a unique educational opportunity aimed at diverse audiences interested in developing a foundation, expanding, or refreshing their research skills. Content: The course will be offered through four 90-minute sessions. In the morning, two general sessions will introduce primary concepts in quantitative and qualitative research. The afternoon will offer concurrent sessions focusing on different aspects of research methodology organized by the CASFM Work Groups, as follows. Research Methods: Covariate Constrained Randomization Health IT: Attribution of Primary Care Physician or Other Healthcare Provider Practice Based Research Networks: Describing PBRNs in North America Practice Based Research Networks: Linking Research to Policy & Recruitment and Engagement Participatory Research: Photo Elicitation & Cognitive Fuzzy Mapping Participatory Research: Collaborative Coding & World Café with Vulnerable Populations Method: During all sessions participants be provided with substantive material and will actively participate in the course through engagement exercises and in-class activities. This method has been shown to promote retention of the material and minimize the time burden for the participants. The day is organized so that participants can pick and choose which two of the sessions they would like to attend. Prerequisite Knowledge: None.

PR2 Place Matters: Using Web-Based Mapping Tools to Explore the Links Between Community and Health

Jené Grandmont; Andrew Bazemore, MD, MPH; Mark Carrozza; David Grolling; Claire Meehan; Jennifer L Rankin, PhD; Michael Topmiller, PhD

11/12/16 9:00 AM - 12:00 PM Colorado B

Objectives: This preconference session will enhance participants’ understanding about the importance of geography to population health, give a practical understanding of the tools, methods, and data available to incorporate geography into research, and consider ways in which care providers can use these resources to inform their practice. Content: Place matters to personal and population health. Understanding the community context of patients has become increasingly important in the primary care research domain. In light of the growing interest in this area of research, multiple tools have been developed to help physicians use these concepts at both the research and practice level. This hands-on workshop will introduce participants to a variety of geographic information analysis and data dissemination tools, as well as discuss ways in which community-level data can help inform research and care. Participants will review the existing research highlighting the importance of Social Determinants of Health, explore ways to define the service area of a provider or practice and determine the target community, access hundreds of community-level data points, and consider how they can begin to use the combination of data and geography to positively affect health outcomes by making changes both at the community level and at the point of care. The workshop will include real-world examples of spatial primary care research and application. Method: Didactics, discussion, and hands-on computer workshop using GIS software and web-based mapping applications. We will provide sample data to use in applying concepts taught in the session and incorporate examples from a variety of primary care domains. Participants are encouraged to bring their own examples. Prerequisite Knowledge: None

PR3 Identifying Priority Regions for Primary Care: A Hands-On Introduction to Geospatial Approaches for Exploring "Hot Spots," "Cold Spots," & "Bright Spots"

Michael Topmiller, PhD; Mark Carrozza; Jené Grandmont; Andrew Bazemore, MD, MPH; David Grolling; Claire Meehan; Jennifer L Rankin, PhD

11/12/16 1:00 PM - 4:00 PM Broadmoor F

Objectives: At the end of this seminar, participants will be able to Describe key concepts in spatial analysis Understand how hot spots, cold spots, and bright spots are defined in the healthcare and geospatial fields. Be able to use Geoda, a free, open source GIS, to identify priority regions for primary care Content: This session will focus on key concepts in spatial analysis, including spatial autocorrelation and heterogeneity. The session will provide a description of hot spots, cold spots, and bright spots as defined in the healthcare and geospatial fields. The session will include hands-on training using Geoda, an open-source GIS, to conduct geospatial analysis to identify priority areas for primary care research. Method: Didactics and hands-on workshop using computers with GIS software. We will provide sample data to use in applying concepts taught in the session. Prerequisites: Basic/intermediate knowledge of spatial analysis. Attendees must bring their own laptop with Geoda 1.6 installed (see https://geodacenter.asu.edu/software/downloads). The instructors will schedule a one-time webinar prior to the conference to assist attendees with loading the software. Schedule: The workshop will first review key concepts in spatial analysis and describe hot spots, cold spots, and bright spots as they relate to the healthcare and geospatial fields. Next, the session will provide hands-on instruction on how to use Geoda using sample data and cases applicable to primary care research. After being introduced to the basic functions of loading data and creating simple maps, the remainder of the session will consist of step-by-step examples to conduct hot spot, cold spot, and bright spot analyses. On completion, participants will have a working knowledge of conducting geospatial analyses to identify priority areas for their own research. Why a preconference?: To sufficiently cover the material and provide the necessary experience, planners estimate the need for 4 hours. Participants will not only be introduced to GIS, but build their skills through a hands-on session with computers and GIS software, including small group teaching. This format is not compatible with regular meeting sessions.

PR4 Creating a Primary Care Research Agenda in Response to Global Climate Change

Jonathan L. Temte, MD, PhD; Bruce Barrett, MD, PhD; Rodney A Erickson, MD; David Meyers, MD

11/12/16 1:00 PM - 4:30 PM Broadmoor D

Objectives. Recognizing that climate change is already affecting the health of North Americans and is likely to create greater changes in the decades to come, this workshop will initiate a dialogue regarding a long-term, research agenda to support primary care practices in the future. Participants will develop the outline for a ‘white paper’ on developing a primary health care response to climate change with a focus on important research questions and methodologies. The group will consider developing a Climate Change in Primary Care (CCPC) Special Interest Group at NAPCRG and further work on the development of an international research agenda. Content: 3.5 hour workshop providing the following: Overview and Introductions (15m). Brief presentation on the scope of climate change and current assessments of issues relating to primary health care from perspectives of both a community physician and an academic primary care researcher. (45m). Small group work considering and prioritizing research questions and approaches (45 minutes) (40m). Group reporting process (30m). Discussion and refinement of ideas (45m). Summary, solicitation of white paper writing group, and planning to future activities (15m). Method of and extent of audience participation: This will be a highly participatory workshop. Participants will be asked to review a small set of foundational articles in advance of the workshop to provide a basis for shared discussion. After short presentations by content experts, the remainder of the workshop will consist of small group discussion and idea generation and full group reflections and prioritizing. After the workshop, participants will be invited to participate in development of a white paper, formation of a NAPCRG interest group, and possible grant application writing. Prerequisite Knowledge: While interest in primary health care delivery, climate change, and research methodology is valuable, no prerequisite knowledge is required.

P101 Iterative Usability Testing and Design of eQuit WorRx: an iPad App for Use in Primary Care Practices to Promote Smoking Cessation Shared Decision Making

Matthew Tubb, MD, PhD; Balaji Baskaran; Nandita Subramanian; Mary Beth Von der Meulen, RN, CCRC; Haley Boling; Saundra L. Regan, PhD; Shauna Acquavita, PhD; Brett Harnett; Nancy C. Elder, MD, MSPH; Harini Pallerla; Charles R. Doarn

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: One third of the world’s adult population smoke cigarettes (%gt;1.1 billion people) causing nearly 5 million deaths annually. Primary care practices are an ideal setting in which to promote smoking cessation attempts, but we are limited by time for, and comfort with, counseling and treatment methods. Objective: To develop and test a tablet-based application to assist PCPs in disseminating patient centered outcomes evidence and support shared decision making (SDM) about smoking cessation while minimizing clinical time burden. Design: The app is designed for use during the patient’s wait time at their PCP’s office. It collects demographics, household information, smoking and quitting history, assesses stage of change, nicotine dependence, triggers, roadblocks, and motivators, provides personalized feedback, allows for comparison and selection of evidence-based smoking cessation methods, and presents a summary for the PCP to foster SDM in developing a quit plan. Setting/Participants: Smoking cessation experts from our academic health center (n=9) and, from our primary care network, thus far 8 patients, 5 staff and 7 physicians/providers. Methods: Semi-structured interviews/focus groups, usability scores, and iterative app design based on feedback. Main and Secondary Outcomes: A usable iPad app to pilot test in 3 local practices. Secondary outcomes will relate to subsequent pilot trial. Results: Initial input prior to a prototype was completed and 3 versions of the app have been tested to date for usability, resulting in both minor and significant revisions in app content, appearance, and flow. Iterative versions of the app design will be shared in this presentation. Average usability score was above average (75/100). The pilot trial of the final app will begin mid-2016. Conclusions: Development of an evidence-based app that includes custom feedback and is brief enough to be practical is challenging but rewarding, especially if it is found to improve cessation attempts and success.

P102 African-American and African Perspectives on Mental Health: A Pilot Study of the Pre and Post Colonial and Slavery Influences and Their Implications on Mental Health

Victoria Adewale, MSc

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: African-Americans, though approximately 13% of the overall US population, make up nearly half of all the incarcerated persons (one out of the 2.3 million people), while the leading cause of incarceration is related to illicit drug use and/or possession. Substance abuse in this population has been linked to increased mental health disorders; however, most do not receive the appropriate services that they need. Objective: This study sought out to determine whether this phenomenon may be due to different mental illness perceptions among minority groups, inaccurate representation of other groups with the umbrella term ‘African-American,’ or limited access to culturally sensitive treatment in consideration of slavery and colonialism. Design: This was an ethnographic qualitative research study using semi-structured surveys. Setting: Research was done in Washington D.C/Virginia and Providence RI in community (local church and clothing closet), academic (a college), and hospital work settings (professionals in a medical setting). Participants: 31 African-Americans and 29 Nigerian-Americans were interviewed in person and over the phone. These two populations were chosen on the basis that slavery would influence African-Americans and colonialism would influence Nigerian-Americans. Results: Results show that Nigerian-Americans and Africans Americans have different viewpoints on various mental health issues such as eating and mood disorders, but also share similar viewpoints on other issues such as the negative impact of slavery and colonialism on mental health. Conclusions: While various other themes emerged (involving religion and society), the underlying conclusion is that African-American, Nigerian-American, and other derivations of Black Americans should be considered separately when understanding mental health perceptions. Furthermore, the impact of major historical events such as slavery and colonialism should be understood when assessing mental health.

P103 Barriers to Physical Activity Counseling among Rural Primary Care Physicians

Elizabeth Ann Beverly; Julie Creech

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: Current guidelines recommend that primary care physicians provide physical activity counseling as part of routine preventive healthcare. However, how often primary care physicians engage in physical activity counseling is still not clear. Thus, a better understanding of primary care physicians’ physical activity counseling behavior is needed. Objective: The purpose of this study was to assess primary care physicians’ participation in physical activity counseling. Design: Descriptive cross-sectional questionnaire study Participants: Primary care physicians practicing in rural Southeastern Ohio. Instrument: The 18-item Exercise Counseling Questionnaire, developed specifically for this mixed method study, assessed primary care physicians’ knowledge, beliefs, and attitudes about physical activity counseling during medical appointments. Main Outcome Measures: Outcome measures included: 1) awareness of physical activity recommendations; 2) physical activity counseling behaviors; and 3) barriers to physical activity counseling in practice. Results: Sixty-three physicians completed the questionnaire (age= 46.1±8.8 years, 50.8% women, 88.8% White, years in practice=18.7±9.7). All physicians (n=63) reported counseling patients on physical activity, and 92% (n=58) felt that physical activity promotion was the responsibility of the primary care physician. The overwhelming majority (85.7%; n=54) were aware of current physical activity recommendations, and 68% (n=43) felt very comfortable counseling patients on physical activity lifestyle changes. Physicians reported spending an average of four minutes (4.1±3.6) counseling patients about activity; however, they desired at least 10 minutes per visit (9.7±7.9). Physicians cited numerous barriers to physical activity counseling, including insufficient time, lack of reimbursement for time spent counseling, lack of support staff, and perceived inadequacy in evidence-based guidelines. Conclusions: Rural primary care physicians in Southeastern Ohio are aware of and utilizing established guidelines for activity counseling during medical visits. However, these physicians faced numerous barriers to physical activity counseling. Strategies to address these barriers are needed to engage physicians in regular physical activity counseling with their patients.

P104 Sexual Violence Among Women in FQHCs in California With History of Substance Use: A Study of its Prevalence and Consequences

Curtis William Bone, MD; Mani Vahidi; Ronald Max Andersen; Barbara Leake; Lillian Gelberg, MD, MSPH

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Background: Background: Sexual violence (SV) is common in the United States. Approximately 15% of women are victims of SV at some point in their lifetime. A large degree of heterogeneity exists among victims of SV in regards to ethnicity, socioeconomic (SES), education, and substance use history with the number of sexual assaults they have experienced. The Affordable Care Act (ACA) was designed to make primary care available to millions of Americans from diverse ethnic, education and SES backgrounds. FQHCs are an increasingly important access point for beneficiaries of the ACA who have recently entered the health care system. Substance use is a known risk factor for SV. Still little is known regarding SV among female patients of FQHCs who have risky drug use. The aim of this study is to describe the SV history of women of FQHCs in California that self-identify as risky drug users and to assess associations of repeated SV with health status. Methods: 334 patients in FQCH waiting rooms were classified as risky drug users with the ASSIST screening tool and were enrolled in the study. 124 (37%) of those participants were women and were included in the analysis. Descriptive statistics were utilized to characterize study participants and logistic regression was utilized to assess for associations between repeated history of SV and perceived health status (SF-12). Results: Among the 124 participants included in the study, 61 (49%) of the women reported a history of SV. There were 51 of 124 (41%) participants who experienced SV before age 18, 43 of 124 (35%) experienced SV after age 18 and 33 of 124(27%) experienced SV both before and after 18 years of age. 33 of 51(64%) of the women who experienced SV prior to 18 years of age experienced multiple assaults. Victims of repeat SV had increased odds of feeling limited in their accomplishments (OR 5.7) and unable to work because of their emotions (OR 3.8), but had lower odds of feel limited by their physical health (OR 0.57). Conclusions: Primary care and addiction medicine physicians working in FQHCs should be aware that women who are identified as risky drug users are far more likely to have a history of SV than the general population (49% vs 15%). Women with SV may experience significant negative health consequences from these events. Strong pathways between FQHCs, mental health and substance use treatment services may be important for comprehensive care of this vulnerable patient population.

P105 Does Integration Change Primary Care Practice and Patient Utilization of Services?

Shandra Brown Levey, PhD; Gerald Pulver, PhD, MPH; Wilson Douglas Pace, MD, FAAFP

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: This study reviewed an existing database of health care records to determine if providing behavioral health services in a primary care medical setting had an impact on clinical behaviors and outcomes through examination and measurement of diagnosed mental health conditions by PCPs both within an integrated care practice as compared to a matched control practice. Objective: This study helps determine the cost effectiveness of behavioral health providers in primary care and examines the value-added of including behavioral health services. Design: An exploratory study of our existing database of health care records was conducted. De-identified data was obtained from the Department of Family Medicine’s Clinical Data Repository (CDR), a data mart of University of Colorado Health’s EPIC Electronic Health Record system. There was no sampling done, as data derived from the records of all patients meeting criteria were included in the study. Setting: University Hospital Internal Medicine and Family Medicine practices. Participants: Pre-existing adult patient de-identified data were used. As only de-identified data previously obtained for clinical purposes was used, and there was no recruitment needed for the project, the Colorado Multi Institutional Review Board determined this to be not human subject research. The subject cohorts were adult patients seen at free-standing outpatient primary care clinics of the Department of Family Medicine and the Division of Internal Medicine during the study period of 12/2012 to 12/2015. The former site being intervention; the latter: control. Annually, approximately 12,100 adult patients are seen in the Family Medicine Clinic and 9,800 are seen at the Internal Medicine Clinic. Main and Secondary Outcome Measures: Initial outcomes include service use and its impact on broader medical utilization. Current costs and utilization data will be presented to help inform long-term sustainability of integrated behavioral health services and implications for health care funders. Conclusions: Lessons learned on behavioral integration impact on PCP clinical behaviors, cost effectiveness of behavioral health providers in primary care, value-added of including behavioral health services in primary care, and future implications for health care funders.

P106 Provider Knowledge, Attitudes and Practice Patterns Related to ADHD Pharmacotherapy and Non-Medical Use of Stimulants in Young Adults

Natalia Loskutova, MD, PhD; Emily M Bullard, MPH, CHES; Joel Shields MA; Jason A. Waterman DO, FAAP, FACOP, DO

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: A growing body of research demonstrates the non-medical use, abuse, and misuse of prescription stimulants among college age teenagers and young adults is rising, but the role of primary care providers in ADHD medication use and misuse in this population is unclear. Objective: To investigate: 1.) Current care practices, concerns, needs, beliefs, barriers and facilitators to appropriate pharmacological treatment, 2.) Prevention of stimulant misuse of young adults aged 17 - 26 with ADHD. Design: Cross-sectional survey. Methods: The study was conducted between October 2015 and January 2016.The 42 item survey, developed by the project team and other experts, was mailed with a formal American Academy of Family Physicians cover letter, a pre-paid return envelope and a 2-dollar bill. Participants and Setting: A random sample of 2000 AAFP members and a census of 573 American College Health Association eligible members were invited to participate. Results: Surveys were returned at a rate of 28.7%, n=739. Respondents estimated that ADHD prevalence is slightly higher in young adults than in adults overall. The majority of respondents agree: that untreated ADHD affects quality of life (n=533, 88.8%); that diversion or abuse is a problem (n=490, 81.7%) and 473 (78.9%) have concerns with ADHD medication diversion but only 58.8% use state medication registries for treatment compliance monitoring. Referral out for ADHD diagnosis is common (n=298, 49.7%). Respondents find discussions about pharmacotherapy or behavioral therapy choices and stimulant misuse challenging. Conclusion: The results are an important step toward documenting knowledge about pharmacotherapy and non-medical use of stimulants in young adults in family medicine and college health clinics. Additional research, education and quality improvement interventions are needed to address identified gaps in misuse reduction and to ensure safe and appropriate use of stimulants.

P107 Feasibility of Including Couples in Studies of Intimate Partner Violence

Sandra K. Burge, PhD; Johanna Becho, BA; Robert Wood, DrPH; David A. Katerndahl, MD; Robert L. Ferrer, MD, MPH

11/13/16 10:15 AM - 11:15 AM Broadmoor A

CONTEXT: Our research team seeks to understand interpersonal dynamics in violent relationships. In this exploratory study, we included men to gain both partners’ perspectives, and assessed the feasibility of studying couples. Findings will inform a larger study of the dynamics of violence and alcohol use. OBJECTIVE: This analysis reports on retention, missing data, and data validity. DESIGN: Time series study, collecting daily reports of male and female aggression over 8 weeks. SETTING: County-funded family medicine clinic PATIENTS: Heterosexual couples with a history of husband-to-wife aggression in the past 30 days. OUTCOME MEASURES: Both partners reported self and partner aggression daily. RESULTS: 20 couples were enrolled in the study; 15 (75%) completed daily reports and end-of-study interviews. Missing data from daily reports were minimal; husbands completed surveys on 94% of days, and wives completed surveys on 93% of days. Wives reported husband-to-wife aggression on 24% of days, with verbal abuse on in 22% days; moderate physical abuse on 4% of days; severe physical abuse on 1.5% of days. Husbands reported wife-to-husband aggression on 21% of days, with verbal abuse on 17% days, moderate physical abuse on 7% of days, severe physical abuse on 4% of days. For every aggressive behavior, the ‘aggressor’ reported less frequent personal violence than the partner, but not significantly so. To further assess data validity, investigators correlated summaries of daily aggressive behaviors with social desirability scores and found few significant correlations (p%gt;.10). One exception was wives’ reports of husbands’ stalking (r =-.641, p=.010). CONCLUSIONS: Participants’ adherence to the study protocol was remarkably high, turning in 93% of daily reports; partners may have encouraged each other to complete the surveys each day. Husbands’ and wives’ reports of aggressive behaviors were similar, and not correlated with social desirability. However, the small sample size may have precluded statistical significance.

P108 Associations Between Provider Personality and Provider and Patient Language During Clinical Visits

Robert Keeley, MD; David Brody; Margaret "Peggy" Driscoll, MSM

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: Little is known regarding effects of the primary care provider’s (PCP’s) personality on quality measures of clinical discourse. Objective: To explore whether the PCPs’ 5-Factor personality attributes (Extraversion, Openness, Agreeableness, Conscientiousness, and Neuroticism) are associated with measures of PCP and patient language related in the literature to important health behavior-related outcomes. Design: Secondary analysis of a cluster randomized trial of Motivational Interviewing (MI) for depression. Setting: Seven Federally Qualified Urban Health Clinics. Participants: Twenty PCPs and 158 patients with newly diagnosed depression. Intervention: MI training for PCPs randomized to intervention. Outcomes: PCPs completed the Big-5 Personality Inventory. First visits for depression were audio-recorded to evaluate PCP and patient language. PCPs’ MI-concordant language (empathy, reflective statements) and patients’ "change talk," both associated with healthful behavior change, as well as PCPs’ MI-nonadherent statements (MINAs- e.g. confronting) and patients’ "sustain talk" that predict poor outcomes, were assessed. Results: Across all patients, in adjusted analyses the PCPs’ endorsing Openness were rated as less empathetic (Est.=-0.70, p=.002). Increasing Extraversion was associated with more MINAs (Est.=1.28, p=.001) and patient sustain talk (Est.=0.4, p=.02). Correlations in the intervention subgroup replicated negative results from the complete population. Additionally, Neuroticism was associated with fewer MINAs, a positive finding. Within the control group, Extraversion and Agreeableness were associated with less empathy and fewer reflective statements: Neuroticism was associated with increased empathy and more reflections (all Spearman rhos %gt; 0.20, ps < .02). Conclusions: That Extraversion, Openness, and Agreeableness were associated with measures of PCP and patient language considered to have a negative effect on health-related behaviors, while Neuroticism predicted positive language expression, was counterintuitive and worthy of further study. That MI training did not appear to mitigate these findings raises the question of whether language training for clinicians should be tailored to personality. Limitations include the small n.

P109 Taking Action Against Intimate Partner Violence: Qualitative Findings

Maria P Montanez Villacampa, MD; Sandra K. Burge, PhD; Johanna Becho, BA; Robert L. Ferrer, MD, MPH; Robert Wood, DrPH; David A. Katerndahl, MD

11/13/16 10:15 AM - 11:15 AM Broadmoor A

CONTEXT: In longitudinal studies of intimate partner violence, our research team observed women’s efforts to take action against the violence in their relationships: seeking counseling, legal action, or separation from the relationship. We implemented a follow-up investigation to examine the influences on need-for-action from day-to-day in the context of living with a violent partner. Qualitative interviews at end-of-study provided detailed information about women’s context, coping strategies, and decision-making about taking action. OBJECTIVE: Qualitatively explore the decision-making process used by women in violent relationships, as well as its context and triggers. DESIGN: Qualitative interviews, following 8 weeks of daily telephone surveys. SETTING: Five family medicine clinics PATIENTS: Women with a history of husband-to-wife aggression in the past 30 days. OUTCOME MEASURES: Narrative descriptions of women’s relationships, decision-making processes, and experiences on the study. RESULTS: 105 women completed the 8-week longitudinal study, and 29 took action during the study. Investigators interviewed 33 women at end-of-study: 13 took action; 20 did not. Women’s narratives revealed several broad themes: partners’ violent and controlling behaviors; participants’ personal histories and current living situations; methods of coping with violence; decisions about taking action; and experiences on the study. Women described how their relationships developed and evolved into one filled with conflict and aggression. Coping strategies included preventing escalation, withdrawal, fighting back, and seeking informal supports; these strategies merged into action-taking for some women: seeking formal counseling, legal intervention or separation. Women also reported how study participation affected them, prompting self-reflection, behavior change, and decision-making. CONCLUSIONS: Most women in violent relationships are not ready "today" to take legal action against their partner or to separate from the relationship. Their narratives revealed many efforts to manage or prevent abuse, short of these larger interventions. Over 8 weeks, we observed the decision-making processes that led several women to take more decisive action.

P110 Launching a Website of U.S. Patient Experiences With a Module About Young Adults With Depression

Nancy Pandhi, MD, PhD; Margaret Wise PhD; Mark Schlesinger PhD; Natalie Wietfeldt BS; Lane Hanson MSW; Rachel Grob MA PhD

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: There is growing awareness of the importance of internet-based patient experience information in shaping treatment decisions. Young adults, in particular, are likely to search for online health information and ~10% have depression. Healthtalk.org is a collection of evidence-based patient experience websites based in the UK and received ~2 million visits from the U.S. in 2015, but experiences between the UK and the US may differ. Objectives: (1) Understand young adults’ experiences with depression in the U.S. (2) Develop the first healthtalk.org module in the U.S. context. Design: In-depth audio or video-recorded semi-structured qualitative interviews were conducted using maximum variation sampling. Participants were interviewed in their homes or other preferred setting. Analysis occurred by a multidisciplinary research team using a grounded theory-based approach. Topic summaries summarizing key themes are also illustrated on the web platform by video, audio and text clips from the interviews. Data interpretation, topic summaries and selection of clips was guided by a stakeholder advisory board. Setting: General community Participants: 38 young adults (ages 18-29) with self-identified depression provided 40 interviews. Participants varied in geographical location, race/ethnicity, gender, sexual identity, relationship status, parental status, living situation and education level Results: 35 topic summaries were developed in five categories: (1) First experiences with depression; (2) Living with depression; (3) Getting help: seeking assistance and treatment; (4) Helping yourself: support, self-care, and feeling better; and (5) Messages to others. ~350 video, audio and text clips illustrate these summaries. The module containing these summaries will be available both at www.healthtalk.org and HealthExperiencesUSA.org. Conclusions: There is great demand for internet-based patient experience information. This project launches the use of a rigorous qualitative approach for developing and disseminating this information in the U.S. context. It is anticipated that the information presented will be a resource for numerous stakeholders interested in patient experience.

P111 Efficiency of Systemic Family Therapy in the Treatment of Older Adults With Depression

Claudia Elsa Perez Ruiz, MD

11/13/16 10:15 AM - 11:15 AM Broadmoor A

INTRODUCTION: Depression is one of the most common, disabling and is associated with high mortality conditions. Ageing (global aging) is a serious problem worldwide as it implies increased demand for health services. You need to find suitable alternatives for management. MATERIALS AND METHODS: A pre-experimental study was conducted pretest - posttest with a group of 15 patients aged 70-85 years diagnosed as depressed by the Geriatric Depression Scale Yesavage (EDG) short questionnaire of 15 items, to which they He gave a session monthly systemic family therapy for 6 months after the conclusion of the 6 sessions the scale was applied again to get results. RESULTS: Before the intervention, 15 (100%) patients had depression; of these 12 (80%) were established and 3 depression (20%) mild depression, the end of the intervention only 1 (6.6%) patient had mild depression (p <0.05). The median depression Yesavage scale before surgery was 10 (range 8-13) and after the intervention of 3 (range 3-6). (P <0.05). CONCLUSIONS: Systemic family therapy is effective in reducing the frequency and degree of depression in older adults.

P112 Ethical Dilemmas and Research

Hector R. Riquelme- Heras, MD, FP; Celina Gomez-Gomez, MD, PhD; Rosalva Gonzalez-Melendez; Raul Fernando Gutierrez- Herrera, MD, FP; Eduardo Mendez-Espinosa; Irasema Rodriguez-Rodriguez, MD, FP

11/13/16 10:15 AM - 11:15 AM Broadmoor A

ABSTRACT: The practice of medicine, especially research, continuously confronts the doctor with ethical dilemmas, where many conflicting alternatives force physicians to make value judgments choosing a path that based on medical indications will lead to respect the patients’ preferences in their environment and also respect them. In the practice of medicine it common to find patients whose alternative of diagnosis and/or treatment or even research, present an ethical dilemma. In this report, we propose a simple classification of the dilemmas related to clinical research and practice. Clinical. It is a term used in the doctor-patient encounter when a physician is caring for an individual patient. Such patient care is the essence of a physician’s work, as are the relationships with family, other health professionals and medical institutions, including insurance companies, given the economic, administrative and legal influence, play an important role in the patient environment for decisions making. Investigation. Dilemmas in research have emerged and continue to emerge as science advances and appearance of new scientific and technological inventions. The discoveries of DNA, antibodies, in vitro fertilization, transplantation techniques, etc. continue to present medical dilemmas in the research process in patients. TYPES OF DILEMMAS 1. Case analysis or closed case dilemma. 2. Solution cases or open cases dilemma. 3. Hypothetical cases dilemma. 4. Real Dilemma. 5. Complete dilemma. 6. Incomplete dilemma. Conclusion Ethical dilemmas are an inevitable feature of life. They are also an inescapable part of medicine because ethical dilemmas force us to make a choice between damages and results.

P113 Perspectives on Monitoring Youth With Ongoing Mental Health Problems in Primary Health Care: Family Physicians Are "Out of the Loop"

Kyleigh Schraeder, MSc; Judith Belle Brown, PhD; Graham J. Reid, PhD

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: Youth often experience mental health (MH) problems that recur after periods of remission. Following treatment, youth may require monitoring and follow-up. For these youth, Primary Health Care (PHC) is highly relevant as family physicians (FPs) are the only professionals who follow patients across the lifespan. Collaborative MH care into young adulthood requires exploration. Objective: To gain multiple perspectives from youth (ages 12-15), their caregivers and MH providers, and FPs about: (1) the role of FPs in caring for youth with ongoing and recurring MH problems, and (2) incorporating routine MH monitoring into PHC. Design: Grounded Theory; theoretical sampling. Settings: Two publicly-funded children’s MH agencies; PHC. Participants: Interviews conducted with: (a) 10 youth patients (8 male) receiving specialized MH services for at least one year; (b) their caregivers (n=10; all female); (c) their MH providers (n=10); (d) their FPs (n=3). Altogether, 33 individual interviews were transcribed verbatim. Results: A pervasive theme expressed by youth and their caregivers was that FPs were "out of the loop" of their MH care. This stemmed from prior experiences receiving help, including: having inadequate time to discuss MH problems with FPs, perceiving a focus on the medical model within PHC, and believing FPs lacked knowledge and/or expertise to provide MH care. MH providers and FPs unanimously described a lack of collaboration with each other, which was linked to agency and system-level factors. Need for monitoring MH problems was acknowledged but views were mixed about whether FPs were the most appropriate professional. Conclusion: Improved collaboration between MH providers and FPs is needed before integrated, comprehensive models of caring for youth with ongoing MH problems can be achieved. Provider collaboration is especially necessary to counter perceptions that MH and PHC operate independently. This research has implications for training FPs and building collaborative partnerships between MH and PHC.

P114 Barriers and Facilitators of Collaborative Mental Health Care in Ontario Family Health Teams

Wayne Ambrose-Miller, PhD; Colleen McMillan

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: We are interested in exploring the nature of collaborative mental health care in Family Health Teams (FHTs) in Ontario. There have been many suggestions for effective collaboration in this area, but whether or not individual FHTs have taken up these "best practices" remains to be seen. Objective: We investigated the barriers and facilitators of collaborative mental health care within Family Health Teams. We have shown that collaborative care in mental health is impacted by organizational structure and policy (human resources, policies supportive of collaboration among providers), providers’ previous experiences with Interprofessional collaboration, and power dynamics within the Family Health Team. Design: This study utilized a qualitative methodology, relying on semi-structured interviews with stakeholders and an analysis of FHT documentation that pertains to collaborative processes within the FHT. Analysis was conducted using discourse analysis in order to identify links between structure, processes, and power. Setting: The study population included providers of mental health services within FHTs. This included family physicians, mental health workers (including social workers, mental health counselors, addictions counselors, and psychologists) and the psychiatrists that consult with these teams. Executive Directors of Family Health Teams were interviewed in an effort to better understand how the administrative and reporting organization of the agency has an impact on collaboration. Sample size was approximately 25 individuals. Study procedures: a) Compiling background information about FHT structure and processes b) Purposive sampling for participants and conducting semi-structured interviews with key stakeholders c) Data analysis using a discourse analysis protocol d) Production of a report The primary outcome of the study is an exploration of the factors that support and limit collaboration among mental health care providers on family health teams.

P115 Late Life Depression and Poetry Recidation: The He.S.I.O.D Study (Hexameter Study in Older Depressed)

Klea D. Bertakis, MD, MPH; Mario Amore; Rabih Chattat; Lorenzo Chiari; Allesandro Cremonini; Martino Belvederi Murri, MD; Erika Nerozzi; Francesca Neviani; Carlo Tacconi; Abebaw Yohannes; Stamatula Zanetidou

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: Late life Major Depression (LLMD) is usually treated within Primary Care, but is still associated with unsatisfactory outcomes and significant residual symptoms. Moreover, LLMD increases somatic and psychological symptoms of anxiety, dyspnea, fear of falling (FOF), and risk of falls. These features worsen patient prognosis, and have limited responsiveness to antidepressant drugs. Evidence from non-depressed patients suggests the efficacy of breathing and postural exercises; in particular, rhythmic breathing during the poetry recitation was shown to improve cardio-respiratory synchronization. However, these techniques have not been tested in LLMD. Objective: To test the efficacy of antidepressants plus breathing and postural exercises to improve patients’ anxiety mood, dyspnea, FOF, and postural stability. Design: Pilot comparing two study groups: 1) antidepressant drugs plus weekly sessions of breathing/postural exercises based on the rhythmic recitation of hexameter poetry (intervention); 2) antidepressant drugs plus weekly sessions of group reading (control). Setting: Recruitment is based on a Psychiatric Consultation-Liaison Program for Primary Care. Participants: Patients aged 65+, with non-psychotic recurrent LLMD without significant cognitive impairment. Outcome Measures: Main outcome is change in Montgomery-Asberg Depression Rating Scale (MADRS) factor scores at 12 and 24 weeks. Secondary outcomes include accelerometer-based measures of postural stability; patient-rated dyspnea, and FOF. Anticipated Results: Patients receiving breathing and postural exercises are expected to display greater improvements of MADRS scores (particularly in the anxiety domain), better postural stability and reduced levels of FOF, and less dyspnea compared to the control group. Effects are expected to be in the small-medium range, and will allow scaling of a randomized trial. Conclusions: The experimental intervention involving breathing and postural exercises may exert significant clinical advantage when added to the standard antidepressant drug therapy for LLMD. This study might prompt further research on innovative treatment strategies to improve the outcomes of late life depression in Primary Care.

P116 Determining Predictors of Relapse in Opioid Addiction: A Retrospective Chart Analysis of Patients in a Primary Care Buprenorphine Treatment Program

Jessica L. Bloom-Foster, MD

11/13/16 10:15 AM - 11:15 AM Broadmoor A

Context: Opioid addiction is an epidemic in the US and particularly in Maine. Each day 46 people die of a prescription painkiller overdose. Addiction is a chronic, relapsing condition where predictors of relapse during recovery need additional research. Primary care physicians may offer office-based Medication Assisted Treatment (MAT) for opiate addiction with buprenorphine, and the need for access to these services is great, particularly in rural areas. Data describing characteristics of this population will inform future research into effective relapse prevention strategies to accompany primary care addiction treatment and improve long term success. Objectives: Primary: To evaluate whether any demographic or historical factors are associated with relapse within the first 6 months of MAT. Secondary: Establishing baseline relapse rate data for our treatment program; testing the feasibility and utility of a scoring system for at-risk behaviors that may predict relapse and that could be used in future research. Design: Retrospective cohort comparison between patients that relapse and patients that remain in treatment after 6 months of MAT. Setting: Family Medicine residency program ambulatory clinic site. Patients: Charts selected through EHR query of all patients inducted into MAT on site in calendar year 2014 will be reviewed; estimated total N=60. Outcomes: Rate of "relapse" defined as MAT failure; analysis of whether clinical or psychosocial factors are associated with likelihood of "relapse" or "no relapse" grouping; whether same factors affect time to relapse within relapse group; whether a "relapse behaviors score" threshold predicts relapse. Results: Preliminary analysis of the first 31 charts suggests a relapse rate of 32%; possible trends toward bipolar disorder, ADHD, and benzodiazepine abuse increasing relapse risk. Extensive further descriptive analysis planned. Conclusions: We anticipate this analysis to yield new information to guide further research into targeted and effective relapse prevention strategies for patients in MAT for opioid addiction.