Stepped Collaborative Care Targeting Posttraumatic Stress Disorder Symptoms and Comorbidity for US Trauma Care Systems: A Randomized Clinical Trial

Key Points

Question  Can a brief stepped collaborative care intervention for injured patients at a trauma center delivered by front-line clinicians reduce posttraumatic stress disorder symptoms compared with usual care?

Findings  In a randomized clinical trial with 635 injured patients from 25 US trauma centers, intervention patients demonstrated significant posttraumatic stress disorder symptom reductions compared with those who received usual care at 6 months, but not 12 months, postinjury. Subgroup analyses revealed larger posttraumatic stress disorder treatment effects at trauma centers with good or excellent protocol implementation.

Meaning  In this study, a well-implemented brief intervention for injured patients reduced posttraumatic stress disorder symptoms; policy efforts should incorporate these findings into national trauma center requirements and verification criteria.

Importance  To date, few multisite investigations have evaluated early interventions for injured patients with posttraumatic stress disorder (PTSD) symptoms.

Objective  To simultaneously assess the effectiveness and implementation of a brief stepped collaborative care intervention targeting PTSD and comorbidity.

Design, Setting, and Participants  A stepped-wedge cluster randomized clinical trial was conducted at 25 US level I trauma centers. Participants included hospitalized survivors of physical injury who underwent a 2-step evaluation for PTSD symptoms. Patients reporting high levels of distress on the PTSD Checklist (PCL-C) were randomized (N = 635) per the stepped-wedge protocol to enhanced usual care control (n = 370) or intervention (n = 265) conditions. The study was conducted from January 4, 2016, through November 2019. Data analysis was performed from November 4, 2019, to December 8, 2020.

Interventions  The Trauma Survivors Outcomes and Support collaborative care intervention included proactive injury case management that assisted patients transitioning from hospital inpatient to outpatient and community settings. The intervention also integrated evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD symptoms and comorbidity.

Main Outcomes and Measures  The primary study outcome was PTSD symptoms assessed with the PCL-C at baseline in the surgical ward and at 3, 6, and 12 months postinjury. Secondary outcomes included depressive symptoms, alcohol use, and physical function. Subgroup analyses examined the effect of baseline risk factors for enduring PTSD and quality of protocol implementation on study outcomes. Primary statistical analyses were conducted using the intent-to-treat sample.

Results  A total of 327 men (51.5%) were included in analysis; mean (SD) age was 39.0 (14.2) years. The investigation attained follow-up of 75% to 80% of the participants at 3 to 12 months. The intervention lasted a mean (SD) of 122 (132) minutes. Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with control patients at 6 months (difference, −2.57; 95% CI, −5.12 to −0.03; effect size, 0.18; P < .05) but not 12 months (difference, −1.27; 95% CI, −4.26 to 1.73; effect size, 0.08; P = .35). Subgroup analyses revealed larger PTSD treatment effects for patients with 3 or more baseline risk factors for enduring PTSD and for patients, including firearm injury survivors, treated at trauma centers with good or excellent protocol implementation. Intervention effects for secondary outcomes did not attain statistical significance.

Conclusions and Relevance  A brief stepped collaborative care intervention was associated with significant 6-month but not 12-month PTSD symptom reductions. Greater baseline PTSD risk and good or excellent trauma center protocol implementation were associated with larger PTSD treatment effects. Orchestrated efforts targeting policy and funding should systematically incorporate the study findings into national trauma center requirements and verification criteria.

Trial Registration  ClinicalTrials.gov Identifier: NCT02655354

Annually, between 2.5 million and 3.0 million individuals in the US are so severely injured that they require inpatient hospital admission.¹ The symptoms of posttraumatic stress disorder (PTSD) and related comorbidity occur frequently after traumatic physical injury.^2-6 Traumatically injured patients commonly present with associated depressive symptoms, alcohol and drug use disorders, and other comorbidities.^3,7-10 Prospective studies suggest that comorbid conditions and other factors, such as preinjury trauma exposure and intentional injury mechanisms (eg, firearm injury), may act as risk factors that contribute to an enduring course of PTSD symptoms.^11-17 After injury, PTSD and related comorbidities are associated with a broad profile of functional and health-related impairments and associated societal costs.^7,18-22

Efficacy and effectiveness spectrum investigations have documented that early psychotherapeutic and psychopharmacologic interventions targeting the symptoms of PTSD can be effective.^6,17,23-29 Some acute care medical investigations that have tested broad reach interventions with more generalizable samples have yielded mixed results.^30-35 Comprehensive disease management strategies, such as collaborative care, that combine proactive case management, pharmacotherapy targeting PTSD, and behavioral intervention elements embedded within injury care management have demonstrated effectiveness in reducing PTSD symptoms while also broadening intervention reach.^25,36-38

Pragmatic clinical trials aim to recruit generalizable samples of patients in real-world settings to influence policy decisions regarding the adoption of health care practices.^39-41 Over the past decade, the Trauma Survivors Outcomes and Support team has established a stakeholder partnership with the American College of Surgeons Committee on Trauma (ACS/COT), allowing the results of pragmatic comparative effectiveness trials to be directly translated into policy for US trauma care systems.^42-46 Previous investigations suggest that less than 10% of US level I and II trauma centers routinely provide postinjury screening or integrated treatment targeting PTSD.⁴⁷ The 2014 ACS/COT guidelines suggest PTSD screening, intervention, and referral as a best practice, but unlike mandates for alcohol, do not require that trauma centers implement these practices as part of verification criteria.⁴³

By necessity, pragmatic clinical trials may incorporate methods derived from implementation science approaches to both advance the sustainable delivery of screening and intervention procedures and document shifting health care system contexts.^48-52 The events of 2020, including the coronavirus disease 2019 pandemic^53-55 and increases in firearm sales and firearm injuries,^56-61 provide examples of the shifting context of life-threatening exposures for US patient populations. The effect of these developments on patients reinforces the need to improve screening and intervention procedures targeting PTSD and related conditions for patients presenting to acute care medical settings.

This pragmatic comparative effectiveness trial hypothesized that injured patients receiving a brief stepped collaborative care intervention would demonstrate significant reductions in PTSD symptoms compared with control patients receiving enhanced usual care. A secondary hypothesis was that the intervention could effectively reduce depressive symptoms, alcohol use, and postinjury functional impairments. An additional issue was whether baseline surgical ward risk factors for enduring PTSD symptoms affected intervention treatment effects. Individual sites’ ability to initiate the intervention protocol was evaluated via an implementation process assessment, and the investigation explored whether the quality of protocol implementation affected any observed PTSD treatment effects.

The Trauma Survivors Outcomes and Support pragmatic trial orchestration was carried out at University of Washington’s Harborview Medical Center, in close collaboration with the National Institutes of Health Care Systems Research Collaboratory.⁶² The Western Institutional Review Board approved the protocol before study initiation.⁶³ All patients provided written informed consent prior to protocol participation and received financial compensation.⁵⁰ This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline for randomized clinical trials.

Investigative procedures are detailed in the study protocol (Supplement 1) and are briefly described here. Sites recruited into the study constituted a representative subsample of all US level I trauma centers.⁵⁰ The investigation used a stepped-wedge cluster randomized design, and sample size estimates that include adjustments for the clustering of individual observations within sites have been previously described (Supplement 1).⁵⁰ All sites began the protocol recruiting control patients and were randomized sequentially to initiate the intervention. Patients were assessed at baseline in the surgical ward as trauma inpatients and again 3, 6, and 12 months after the injury. Recruitment for the trial began January 4, 2016, and 12-month patient study follow-up ended November 2019. Data analysis was performed from November 4, 2019, to December 8, 2020.

Injured patients aged 18 years or older were included in the trial. To ensure adequate follow-up rates, patients were required to provide 2 sets of contact information.

The study team had previously developed a 10-domain electronic health record screen to detect patients with a high likelihood of PTSD distress as hospitalized inpatients (Supplement 1).⁶⁴ Patients identified by the screen as likely to have high levels of distress, indicated by a score of 3 or more positive electronic health record domains, were then formally screened for study entry with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)⁶⁵ PTSD Checklist (PCL-C), anchored to the acute injury event.^37,38,66 Patients with high levels of distress, as indicated by a score 35 or higher on the PCL-C, were randomized into the trial (Figure 1).

Before patient recruitment, each of the 25 sites was randomized electronically by a study biostatistician to 1 of 4 waves in the stepped-wedge design. Recruiters at the 25 sites were aware of each patient’s intervention or control group status at the time of the baseline surgical ward interview but were instructed not to inform patients of their status until after completion of the baseline interview. All follow-up interviewers were blinded to patient intervention or control group status.

Patients in the control group underwent informed consent, both PTSD screenings, baseline surgical ward evaluation, and follow-up interviews. The enhanced aspect of usual care consisted of nurse notification of each patient whose score was 35 or higher on the PCL-C. Previous investigation suggests that, after hospital discharge, usual posttraumatic care includes routine surgical, primary care, and emergency department visits, as well as some mental health specialty appointments.^36-38

Acute care medical stepped collaborative care protocols targeting PTSD and related comorbidity have been described previously (Supplement 1).^36-38 Briefly, stepped collaborative care treatments bring together evidence-based medication and psychotherapeutic intervention elements with proactive case management strategies that aim to reduce care fragmentation for injured patients. Patients who demonstrate enduring PTSD symptoms after initial treatment receive stepped-up care that can include medication adjustments or the addition of new psychotherapeutic elements.

After completion of the usual care control phase of recruitment, the principal investigator (D.Z.) visited each trauma center in order to train front-line social workers, nurses, physicians, and other health care professionals via a 1-day, onsite intervention workshop.^50,67 The workshop provided an overview of the core case management, psychopharmacology, and motivational interviewing and cognitive behavioral therapy elements of the stepped collaborative care intervention. After the 1-day workshop, the study team initiated regular site supervisory calls in which the site interventionists presented cases to supervising psychiatric, research coordinator, and other study team members. The supervisory calls also addressed protocol issues related to recruitment, regulatory compliance, and staff turnover. The 25 sites’ intervention and staffing activities were documented in the REDCap database.⁶⁸

The PCL-C was used to assess the symptoms of PTSD. At baseline in the surgical ward, patients were asked to rate their symptoms since the injury event; the 3-, 6- and 12-month interviews queried patients about their symptoms over the month prior to the interview. Prior investigations, including studies by the research team with injured patients, have established the psychometric equivalence of the DSM-IV and DSM-5 versions of the PCL.^65,69-73 Because the study team had validated the 10-domain EHR screen with the PCL-C for DSM-IV and DSM-IV CAPS,⁶⁴ all primary surgical ward and follow-up assessments were performed with the DSM-IV version of the PCL (PCL-C).^69,74

With regard to secondary outcomes, the 9-item Patient Health Questionnaire (PHQ-9) brief depression severity measure was used to assess depressive symptoms.⁷⁵ The Alcohol Use Disorder Identification Test 3-item version (AUDIT-C) was used to assess alcohol use problems before and after the injury hospitalization.^37,76,77 The investigation used the Medical Outcomes Study Short Form Physical Components Summary Score (MOS SF PCS) SF-12 at baseline in the surgical ward to assess physical function in the month before the injury admission, and the SF-36 at 3-, 6-, and 12-month follow-up to assess postinjury physical function.^37,78,79

Medical record data from the 25 sites’ trauma registries were used to derive injury severity scores and injury mechanisms.^80-83 Laboratory toxicologic test results, insurance status, length of hospital and intensive care unit stays, and other clinical characteristics were obtained from trauma registries.

Over the course of the multiyear study, the Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) approach was used to assess the processes of protocol implementation.^44,50 RAPICE used data from multiple sources, including study team intervention documentation, and recruitment, regulatory, and other clinical trial logs. The RAPICE approach also embedded participant observation within clinician investigators immersed in the pragmatic trial implementation coupled with regular mixed method consultation.⁴⁴

Over the course of the trial, 4 core domains of the implementation process were identified: site attainment of recruitment milestones, quality of intervention implementation, leadership stability and turnover, and regulatory adherence. A coding framework was developed, and sites were grouped by fair or poor vs good or excellent implementation status based on their scores across the four domains (eTable 1 in Supplement 2).

All primary statistical analyses were conducted using the intent-to-treat sample. The first goal of the statistical analysis was to examine and compare patterns over time in the symptoms of PTSD. To determine whether patients in the intervention and control groups manifested different patterns of change in PTSD symptoms over the year after injury, the study team used mixed-effects regression models.^84-86 Mixed-effects regression was used to account for both repeated measures for individuals over time (ie, baseline, 3-month, 6-month, and 12-month time points) and site-level cluster randomization. This analytic approach was replicated for all secondary outcomes, including the PHQ-9, AUDIT, and SF MOS PCS scores. For all dependent variables, models were fit containing time categories, intervention, and intervention by time interactions, as well as stepped-wedge period and site. Baseline characteristics identified to be significantly different across the 2 groups were included as design variables in regression analyses. In addition, to better understand clinically relevant PTSD symptom reductions over time, the study team compared intervention and control group 10-point PCL-C symptom reductions.³⁸ The study team conducted sensitivity analyses to assess the impact of removing baseline covariates, as well as including the DSM-5 version of the PCL as the dependent variable.

Both a priori and exploratory secondary analyses were performed. Baseline surgical ward risk factors were identified that were associated with higher levels of enduring PTSD symptoms; a priori secondary analyses stratified the intent-to-treat sample to identify risk groups that manifested differential treatment effects. Post hoc exploratory analyses examined the influence of quality of implementation and firearm injury on observed treatment effects. Statistical significance was set at 2-sided P < .05. The study team used SAS, version 9.4 (SAS Institute Inc) and SPSS version 25 (SPSS Software IBM) for all analyses.

The 635 injured participants recruited and randomized into the investigation were diverse patients with substantial histories of preinjury trauma (Table 1). The population included 308 women (48.5%) and 327 men (51.5%). Mean (SD) age was 39.0 (14.2) years. Three patient characteristics across the usual care (n = 370) vs intervention (n = 265) groups were observed to be significantly different at baseline across the 2 groups: age (mean [SD], 39.9 [14.8] vs 37.6 [13.4] years; P = .047), sex (female, 161 [43.5%] vs 147 [55.5%]; P = .003), and electronic health record PTSD diagnosis (55 [14.9%] vs 60 [22.6%]; P = .01) .

The investigation attained follow-up rates of 80.2% at 3 months, 77.3% at 6 months, and 75.1% at 12 months (Figure 1). Follow-up rates did not substantially differ for patients assigned to the control and intervention groups over the course of 12 months.

Site intervention teams spent a mean (SD) of 122 (132) minutes (median, 81 minutes; range, 3-890 minutes; interquartile range, 45-147.5 minutes) with each patient over the course of the year after injury. Approximately 70% of intervention activity occurred during the first 3 months postinjury, 20% occurred between months 3 and 6, and 10% occurred between months 6 and 12.

Overall, at the 3-, 6-, and 12-month outcome assessment points, a greater percentage of intervention patients compared with control patients reported receiving antidepressant medication, stepped adjustments to medication dosages, and/or counseling visits (Table 2). These comparisons, however, did not achieve statistical significance. Equivalent numbers of intervention and control patients were treated at fair or poor vs good or excellent implementation sites. Additional care processes for the intervention group are described in eTable 2 in Supplement 2.

The study sites received a mean (SD) of 27 (11) supervisory sessions during the course of the intervention implementation. Sites randomized to earlier stepped-wedge intervention waves were significantly more likely to receive more supervisory sessions (F_3,543 = 8.0; P < .001). There were no significant differences in the number of supervisory sessions received by sites with fair or poor vs good or excellent implementation (F_1,17 = 0.9; P < .36).

Mixed model regression analyses revealed statistically significant changes in PCL-C scores for intervention patients compared with controls at 6 months, but not 3 or 12 months, after the index injury admission (Table 3, Figure 2A). Compared with control patients, intervention patients demonstrated approximately 5% greater 10-point PCL-C reductions at each follow-up time point (eTable 3 in Supplement 2). Patients with 3 or more baseline PTSD risk factors for higher levels of enduring PTSD symptoms manifested larger treatment effects (Table 3, Figure 2B). Patients treated at sites with good or excellent implementation also demonstrated larger treatment effects (Table 3, Figure 2C). There were no significant baseline PCL-C differences for intervention and control group patients treated at sites with good or excellent protocol implementation (net difference mean, 3.34; 95% CI, −1.39 to 8.07; P = .15) (Figure 2C).

Patients with firearm injuries treated at good or excellent implementation sites had among the largest 6-month (net difference mean, −7.81; 95% CI, −15.61 to 0.00; effect size, 0.52) and 12-month (net difference mean, −10.37; 95% CI, −19.16 to −1.59; effect size, 0.61) treatment effects (eFigure in Supplement 2). The PHQ-9, AUDIT-C, and SF-36 PCS outcome comparisons did not attain statistical significance. Sensitivity analyses that included the DSM-5 PCL and removed baseline covariates did not substantially alter the magnitude, pattern, or directionality of the observed treatment effects.

The pragmatic trial described herein documents the effectiveness of a brief stepped collaborative care intervention, delivered by front-line trauma center clinicians, in reducing PTSD symptoms at 6 months, but not 12 months, postinjury. This pattern of treatment response can be explained in part by the observation that approximately 90% of intervention activity occurred in the first 6 months after the injury. Larger PTSD treatment effects were observed for the subgroups of injured patients with 3 or more baseline risk factors for higher levels of enduring PTSD symptoms and for the subgroup of patients who were treated at trauma center sites with good or excellent protocol implementation. Firearm injury survivors treated at trauma centers with good or excellent protocol implementation also demonstrated significant PTSD treatment effects at the 6- and 12-month postinjury time points.

The results of this 25-site pragmatic trial corroborate and extend previous reports demonstrating that stepped collaborative care may be an optimal intervention approach for injury survivors treated at trauma centers.^{6,25,26,36-38} Collaborative care broadens the reach of mental health treatment for injury survivors by combining evidence-based PTSD pharmacotherapy and behavioral intervention elements with proactive injury case management. A recent meta-analysis²⁵ identified stepped care collaborative care interventions as the optimal treatment approach for injured trauma survivors compared with cognitive behavioral therapy alone,⁸⁷ because stepped care approaches combine effective evidence-based interventions with expanded breadth of applicability, resulting in greater overall population impact.^88-90 The present trial extends these earlier observations by demonstrating that a brief collaborative care intervention can be feasibly delivered by front-line trauma center clinicians and is effective when well implemented. Two recent investigations that used brief session–based cognitive behavioral therapy delivered by mental health specialty³⁵ and front-line acute care³⁰ clinicians found no PTSD treatment effects. The PTSD treatment effects observed in the present investigation were toward the middle to lower end of the continuum reported for more time-intensive multisession early cognitive behavioral therapy interventions delivered to select, disproportionately noninjured patient samples by mental health specialty clinicians.²⁴ A meta-analysis of 37 primary care intervention trials reported comparable collaborative care treatment effects for depression (standardized mean difference, 0.25; 95% CI, 0.18-0.31)⁹¹ as were observed for PTSD in the present trial.

This investigation has limitations. An important consideration is that intervention patients had higher baseline PTSD symptom levels compared with controls, and therefore regression to the mean could explain observed treatment effects. However, regression to the mean is unlikely to comprehensively explain observed treatment effects in the present trial, because, when the protocol was well implemented, significant baseline differences between the intervention and control groups were minimized and treatment effects were enhanced. In addition, subgroup analyses stratified by baseline risk for enduring PTSD symptoms demonstrated that control patients had significantly higher symptoms from baseline to 3 months relative to intervention patients. The data on study exclusions, presented in Figure 1, are subject to error derived from site variability in reporting practices and lapses in hospital internet connectivity/software malfunction. In addition, more supervision was associated with randomization to an earlier stepped-wedge wave; however, the amount of supervision was not associated with the quality of protocol implementation.⁹² As another limitation, we acknowledge that in this injured patient population with multiple recurrent traumatic life events, many participants experienced enduring PTSD symptoms even after receiving the brief collaborative care intervention.

Results of this randomized clinical trial contribute to an evolving literature on early interventions for patients who experience life-threatening injuries and are at risk for the development of PTSD. A series of recent US events, including the coronavirus disease 2019 pandemic and increasing firearm violence, highlight the need for feasibly delivered hospital-based interventions that can effectively target PTSD symptoms.^53-60 The observation that, when properly implemented, a brief collaborative care intervention can reduce PTSD symptoms suggests the possibility that broad-reach preventive interventions for life-threatening exposures can be developed and implemented across acute care medical settings.

The ACS/COT has demonstrated the ability to mandate screening and intervention procedures to address alcohol use problems at US trauma centers based on the results of pragmatic comparative effectiveness trials.^42,43,46 A key observation is that the previous ACS/COT alcohol policy mandate has resulted in variable quality of implementation across US trauma center sites.⁴⁴ Orchestrated efforts targeting policy and funding should systematically incorporate the findings of the present study into national trauma center requirements and verification criteria to ensure the sustainable implementation of high-quality screening and intervention procedures for PTSD and related comorbid conditions.

Accepted for Publication: December 17, 2020.

Published Online: March 10, 2021. doi:10.1001/jamasurg.2021.0131

Correction: This article was corrected on March 31, 2021, to fix an error in an author affiliation, and on December 8, 2021, to fix a repeated date error in the Abstract and the Methods.

Corresponding Author: Douglas Zatzick, MD, Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Ave, PO Box 359911, Seattle, WA 98104 (dzatzick@uw.edu).

Author Contributions: Dr Zatzick had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zatzick, Jurkovich, Heagerty, Darnell, Moodliar, Bulger, Palinkas.

Acquisition, analysis, or interpretation of data: Zatzick, Jurkovich, Heagerty, Russo, Darnell, Parker, Roberts, Moodliar, Engstrom, Wang, Whiteside, Nehra, Palinkas, Moloney, Maier.

Drafting of the manuscript: Zatzick, Jurkovich, Russo, Engstrom, Wang, Moloney.

Critical revision of the manuscript for important intellectual content: Zatzick, Jurkovich, Heagerty, Darnell, Parker, Roberts, Moodliar, Bulger, Whiteside, Nehra, Palinkas, Moloney, Maier.

Statistical analysis: Zatzick, Heagerty, Russo, Parker, Roberts, Wang, Whiteside, Palinkas.

Obtained funding: Zatzick.

Administrative, technical, or material support: Zatzick, Jurkovich, Darnell, Parker, Roberts, Moodliar, Engstrom, Bulger, Whiteside, Moloney.

Supervision: Zatzick, Jurkovich, Heagerty, Darnell, Roberts, Nehra, Maier.

Other: Darnell.

Conflict of Interest Disclosures: Dr Zatzick has provided forensic expert consultation/testimony related to posttraumatic stress disorder for the Washington State Attorney General, the City of Seattle, and other agencies/firms. No other disclosures were reported.

Funding/Support: This research was supported within the National Institutes of Health (NIH) Health Care Systems Research Collaboratory by cooperative agreement 1UH2MH106338-01/4UH3MH106338-02 from the NIH Common Fund and by UH3 MH 106338-05S1 from the National Institute for Mental Health (NIMH). Support was also provided by the NIH Common Fund through cooperative agreement U24AT009676 from the Office of Strategic Coordination within the Office of the NIH director.

Role of the Funder/Sponsor: The NIH Health Care Systems Research Collaboratory/NIMH assisted in the design and conduct of the study but had no role in the collection, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Participating trauma centers and site champions included Baylor University Medical Center (Michael Foreman, MD, Ann Marie Warren, PhD, and Mark Powers, PhD); Cedars-Sinai Medical Center (Heidi Hotz, RN, and Dan Margulies, MD); Eskenazi Health (Gerardo Gomez, MD, and Michelle Laughlin, MD); Augusta University (Steven Holsten, MD); Harbor University of California Los Angeles Medical Center (Dennis Kim, MD, and Dorit Saberi, PhD); Hartford Hospital (Jonathan Gates, MD); Honor Health (Melanie Brewer, DNSc, RN); Inova Fairfax Hospital (Maggie Griffen, MD, and Anna Newcomb, PhD); Jacobi Medical Center (Noe Romo, MD, and Sheldon Teperman, MD); Louisiana State University (Erich Conrad, MD, and Alan Marr, MD); North Memorial Medical Center (Greg Beilman, MD, and Michaela West, MD, PhD); Ohio State University Wexner Medical Center (Steven Steinberg, MD); Regions Hospital (Michael McGonigal, MD, and Keith Moench, MD); Santa Clara Valley Medical Center (John Sherck, MD, and Adella Garland, MD); University of California Davis Medical Center (Joseph Galante, MD); University of Cincinnati (Jason Schrager, MD); University of Iowa (Gerald Kealey, MD, and Dionne Skeete, MD); University of Kentucky Chandler Medical Center (Andrew Bernard, MD); University of Rochester Medical Center (Julius Cheng, MD, and Michael Rotondo, MD); University of Texas Medical Branch at Galveston (Bill Mileski, MD); University of Texas Southwestern Medical Center (Joseph Minei, MD); University of Utah (Giavonni Lewis, MD, and Ram Nirula, MD); University of Vermont Medical Center (Bill Cheresh, MD, Ajai Malhotra, MD, and Matthew Price, PhD); University of Wisconsin Madison (Amy Liepert, MD); and Wake Forest University Health Sciences (Preston Miller, MD, and Laura Veach, PhD).