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AHRQ Research Studies Date
Topics
- (-) Arthritis (26)
- Back Health and Pain (1)
- Children/Adolescents (1)
- Chronic Conditions (4)
- Clinician-Patient Communication (2)
- Communication (2)
- Comparative Effectiveness (4)
- Decision Making (4)
- Elderly (1)
- Electronic Health Records (EHRs) (1)
- Evidence-Based Practice (3)
- Guidelines (1)
- Health Information Technology (HIT) (1)
- Health Literacy (3)
- Health Status (1)
- Injuries and Wounds (1)
- Medication (4)
- Mortality (1)
- Obesity (1)
- Opioids (1)
- Orthopedics (3)
- Outcomes (4)
- Pain (4)
- Patient-Centered Outcomes Research (8)
- Patient and Family Engagement (2)
- Patient Safety (1)
- Practice Patterns (1)
- Prevention (1)
- Quality of Life (1)
- Racial and Ethnic Minorities (1)
- Registries (6)
- Risk (1)
- Sexual Health (1)
- Social Determinants of Health (1)
- Surgery (7)
- Tobacco Use (1)
- Vaccination (1)
- Women (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 26 Research Studies DisplayedBarber CEH, Zell J, Yazdany J
2019 American College of Rheumatology recommended patient-reported functional status assessment measures in rheumatoid arthritis.
This study’s objective was to develop American College of Rheumatology (ACR) Functional Status Assessment Measures (FSAMs) for patient reporting in most clinic settings. The authors convened a workgroup to conduct a systematic literature review through March 2017. They focused on the following FSAMs: the Health Assessment Questionnaire (HAQ) and derived measures from the Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Out of 11,835 articles identified in the search, 56 were included in the review. A modified Delphi process identified 7 measures which fulfilled the minimum standard for regular use, and 3 measures were recommended: the PROMIS 10-item short form, the HAQ-II, and the Multidimensional HAQ.
AHRQ-funded; HS025638.
Citation: Barber CEH, Zell J, Yazdany J .
2019 American College of Rheumatology recommended patient-reported functional status assessment measures in rheumatoid arthritis.
Arthritis Care Res 2019 Dec;71(12):1531-39. doi: 10.1002/acr.24040..
Keywords: Arthritis, Health Status, Guidelines, Evidence-Based Practice
Brodney S, Fowler FJ, Barry MJ
Comparison of three measures of shared decision making: SDM Process_4, CollaboRATE, and SURE scales.
This study compared 3 different shared decision making (SDM) aids for patients facing surgery for hip or knee osteoarthritis, lumbar herniated disc or lumber spinal stenosis (backs). Patients were surveys after they used one of the following patient decision aids (PDAs): SMD Process_4, CollaboRATE, or SURE. The sample size was 649 with a mean age of 63.3 years, 51% female, and 60% were college educated. Most patients (69%) were facing hip or knee surgery. Results showed that the PDAs did aid patients – especially for hips/knees and were different for each PDA.
AHRQ-funded; HS025718.
Citation: Brodney S, Fowler FJ, Barry MJ .
Comparison of three measures of shared decision making: SDM Process_4, CollaboRATE, and SURE scales.
Med Decis Making 2019 Aug;39(6):673-80. doi: 10.1177/0272989x19855951..
Keywords: Decision Making, Surgery, Arthritis, Back Health and Pain
Birru Talabi M, Cllowse MEB, Blalock SJ
Contraception use among reproductive-age women with rheumatic diseases.
The purpose of this study was to determine contraception use among a cohort of reproductive-age women with rheumatic diseases. Women who had one of 21 possible rheumatic disease diagnoses, and had at least two outpatient rheumatology visits, were included. Findings revealed low use of prescription contraception, and the authors recommended urgent efforts to improve contraceptive care and access for some women with rheumatic diseases.
AHRQ-funded; HS022989.
Citation: Birru Talabi M, Cllowse MEB, Blalock SJ .
Contraception use among reproductive-age women with rheumatic diseases.
Arthritis Care Res 2019 Aug;71(8):1132-40. doi: 10.1002/acr.23724..
Keywords: Arthritis, Chronic Conditions, Women, Sexual Health
Kim SC, Jin Y, Lee YC
Association of preoperative opioid use with mortality and short-term safety outcomes after total knee replacement.
The purpose of this study was to determine the association of preoperative opioid use among patients 65 years and older with mortality and other complications at 30 days post-total knee replacement (TKR). Findings show that continuous opioid users had a higher risk of revision operations, vertebral fractures, and opioid overdose at 30 days post-TKR but not of in-hospital or 30-day mortality, compared with opioid-naive patients. Highlights include the need for better understanding of patient characteristics associated with chronic opioid use to optimize preoperative assessment of overall risk after TKR.
AHRQ-funded; HS018910.
Citation: Kim SC, Jin Y, Lee YC .
Association of preoperative opioid use with mortality and short-term safety outcomes after total knee replacement.
JAMA Netw Open 2019 Jul 3;2(7):e198061. doi: 10.1001/jamanetworkopen.2019.8061..
Keywords: Opioids, Medication, Surgery, Orthopedics, Elderly, Patient-Centered Outcomes Research, Mortality, Outcomes, Arthritis, Evidence-Based Practice
Gandek B, Roos EM, Franklin PD
A 12-item short form of the Hip disability and Osteoarthritis Outcome Score (HOOS-12): tests of reliability, validity and responsiveness.
The goal of this study was to measure validity, reliability and responsiveness of the 12-item version of the 40-item Hip disability and Osteoarthritis Outcome Score (HOOS) surveys that measure joint-specific pain, function and quality of life (QOL) for patients. The shorter forms were given to 1,281 hip OA patients from the FORCE-TJR cohort who had previously completed the HOOS surveys before and after total joint replacement surgery. The HOOS-12 survey was compared to the full-length HOOS, HOOS-PS, and HOOS, JR surveys. Internal consistency reliability was above 0.70 for all HOOS-12 scales and above 0.90 for the Summary score. Validity and responsiveness were also found to be comparable to full-length HOOS scales.
AHRQ-funded; HS024632; HS018910.
Citation: Gandek B, Roos EM, Franklin PD .
A 12-item short form of the Hip disability and Osteoarthritis Outcome Score (HOOS-12): tests of reliability, validity and responsiveness.
Osteoarthritis Cartilage 2019 May;27(5):754-61. doi: 10.1016/j.joca.2018.09.017..
Keywords: Patient-Centered Outcomes Research, Registries, Arthritis, Orthopedics
Gandek B, Roos EM, Franklin PD
Item selection for 12-item short forms of the Knee injury and Osteoarthritis Outcome Score (KOOS-12) and Hip disability and Osteoarthritis Outcome Score (HOOS-12).
The goal of this study was to develop 12-item versions of the 42-item Knee injury and Osteoarthritis Outcome Score (KOOS) and 40-item Hip disability and Osteoarthritis Outcome Score (HOOS) surveys that measure joint-specific pain, function and quality of life (QOL) for patients. The shorter forms were given to 1,395 knee osteoarthritis (OA) and 1,281 hip OA patients from the FORCE-TJR cohort who had previously completed the KOOS and HOOS surveys before and after total joint replacement surgery. The KOOS-12 and HOOS-12 surveys were found to successfully measure pain and function items of the patients as well as the 42-item versions.
AHRQ-funded; HS024632; HS018910.
Citation: Gandek B, Roos EM, Franklin PD .
Item selection for 12-item short forms of the Knee injury and Osteoarthritis Outcome Score (KOOS-12) and Hip disability and Osteoarthritis Outcome Score (HOOS-12).
Osteoarthritis Cartilage 2019 May;27(5):746-53. doi: 10.1016/j.joca.2018.11.011..
Keywords: Patient-Centered Outcomes Research, Registries, Arthritis, Orthopedics
Gandek B, Roos EM, Franklin PD
A 12-item short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-12): tests of reliability, validity and responsiveness.
The purpose of this study was to evaluate reliability, validity and responsiveness of KOOS-12, a 12-item short form of the 42-item Knee injury and Osteoarthritis Outcome Score (KOOS) that provides Pain, Function and Quality of Life (QOL) scale scores and a summary knee impact score. Results showed that KOOS-12 was a reliable and valid alternative to KOOS in total knee replacement patients with moderate to severe knee osteoarthritis and provided three domain-specific and summary knee impact scores with substantially reduced respondent burden.
AHRQ-funded; HS024632; HS018910.
Citation: Gandek B, Roos EM, Franklin PD .
A 12-item short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-12): tests of reliability, validity and responsiveness.
Osteoarthritis Cartilage 2019 May;27(5):762-70. doi: 10.1016/j.joca.2019.01.011..
Keywords: Arthritis, Evidence-Based Practice, Injuries and Wounds, Outcomes, Pain, Patient-Centered Outcomes Research, Quality of Life
Hirsh J, Wood P, Keniston A
Limited health literacy and patient confusion about rheumatoid arthritis patient global assessments and model disease states.
The objective of this study was to understand the perspectives of vulnerable patients regarding patient global assessment visual analog scales (PGA-VAS) and model disease states. The investigators found that vulnerable patients perceived difficulty with PGA-VAS and did not reliably rate a model disease state VAS. The authors suggest that these patients are potentially at risk for disease activity misclassification because of literacy and other barriers in completing VAS.
AHRQ-funded.
Citation: Hirsh J, Wood P, Keniston A .
Limited health literacy and patient confusion about rheumatoid arthritis patient global assessments and model disease states.
Arthritis Care Res 2019 May;71(5):611-19. doi: 10.1002/acr.23692..
Keywords: Arthritis, Health Literacy
Gianfrancesco MA, Trupin L, Shiboski S
Smoking is associated with higher disease activity in rheumatoid arthritis: a longitudinal study controlling for time-varying covariates.
Prior studies around the relationship between smoking and rheumatoid arthritis (RA) disease activity have reported inconsistent findings, which may be ascribed to heterogeneous study designs or biases in statistical analyses. In this study, the investigators examined the association between smoking and RA outcomes using statistical methods that account for time-varying confounding and loss to followup. They found that smoking was associated with higher levels of disease activity in RA.
AHRQ-funded; HS024412.
Citation: Gianfrancesco MA, Trupin L, Shiboski S .
Smoking is associated with higher disease activity in rheumatoid arthritis: a longitudinal study controlling for time-varying covariates.
J Rheumatol 2019 Apr;46(4):370-75. doi: 10.3899/jrheum.180262..
Keywords: Arthritis, Tobacco Use
Dannecker EA, Warne-Griggs MD, Royse LA
Listening to patients' voices: workarounds patients use to construct pain intensity ratings.
This study analyzed patients’ perspectives on constructing pain intensity ratings and workarounds used. Focus groups were conducted with thirty-one patients with osteoarthritis. Three emerging themes were found: 1) many factors affected patients’ perceptions and ratings of intensity, 2) patients used different approaches to evaluate pain, and 3) patients interpreted maximal response anchors differently. Activity items also helped patients to remember pain.
AHRQ-funded; HS022140.
Citation: Dannecker EA, Warne-Griggs MD, Royse LA .
Listening to patients' voices: workarounds patients use to construct pain intensity ratings.
Qual Health Res 2019 Mar 1;29(4):484-97. doi: 10.1177/1049732318773714..
Keywords: Pain, Arthritis
Norgeot B, Glicksberg BS, Trupin L
Assessment of a deep learning model based on electronic health record data to forecast clinical outcomes in patients with rheumatoid arthritis.
This study researched the use of artificial intelligence learning models to predict clinical outcomes in patients with rheumatoid arthritis (RA). Patients from a university hospital (UH) and a public safety-net hospital (SNH). The populations were quite different from each other. A total of 578 UH patients and 242 SNH patients were included in the study. Patients at the UH were seen more frequently than the SNH patients and were often prescribed high-class medications (63% vs. 28.9%). The model that was used showed a statistically random performance based on each patients’ most recent disease activity score.
AHRQ-funded; HS024412.
Citation: Norgeot B, Glicksberg BS, Trupin L .
Assessment of a deep learning model based on electronic health record data to forecast clinical outcomes in patients with rheumatoid arthritis.
JAMA Netw Open 2019 Mar;2(3):e190606. doi: 10.1001/jamanetworkopen.2019.0606..
Keywords: Arthritis, Electronic Health Records (EHRs), Health Information Technology (HIT), Outcomes
Curtis JR, Xie F, Yang S
Uptake and clinical utility of multibiomarker disease activity testing in the United States.
The purpose of this study was to examine the clinical utility of the multibiomarker disease activity (MBDA) test for rheumatoid arthritis management (RA) in routine care in the United States. Using Medicare data for 2011-15, researchers linked each patient with RA to their MBDA test result. Initiation of a biologic or Janus kinase inhibitor during the 6 months after MBDA testing was described. The researchers found that the MBDA score was associated with both biologic and Janus kinase inhibitor medication addition/switching and subsequent treatment outcomes.
AHRQ-funded; HS013852.
Citation: Curtis JR, Xie F, Yang S .
Uptake and clinical utility of multibiomarker disease activity testing in the United States.
J Rheumatol 2019 Mar;46(3):237-44. doi: 10.3899/jrheum.180071..
Keywords: Arthritis
Mehta B, Szymonifka J, Dey S
Living in immigrant communities does not impact total knee arthroplasty outcomes: experience from a high-volume center in the United States.
The objective of this study was to assess the relationship of neighborhood immigrant proportion (IP) to preoperative and 2-year postoperative pain and function after elective total knee arthroplasty (TKA) using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Patients in a high-volume institutional TKA registry were analyzed retrospectively, and demographics, pre-op and 2-year post-op WOMAC pain and function scores, and addresses obtained. Patient-level variables were linked to Census Bureau tract data. Researchers conclude that patients living in high IP neighborhoods do not have worse pre-op or 2-year post-op pain and function outcomes after TKA compared to those living in lower IP neighborhoods.
AHRQ-funded; HS016075.
Citation: Mehta B, Szymonifka J, Dey S .
Living in immigrant communities does not impact total knee arthroplasty outcomes: experience from a high-volume center in the United States.
BMC Musculoskelet Disord 2019 Feb 9;20(1):67. doi: 10.1186/s12891-019-2446-y..
Keywords: Arthritis, Outcomes, Patient-Centered Outcomes Research, Racial and Ethnic Minorities, Social Determinants of Health, Surgery
Pinto D, Bockenholt U, Lee J
Preferences for physical activity: a conjoint analysis involving people with chronic knee pain.
The goals of this study were to investigate individual preferences for physical activity attributes in adults with chronic knee pain, to identify clusters of individuals with similar preferences, and to identify whether these individuals differ by demographic or health characteristics. Researchers conducted an adaptive conjoint analysis (ACA) using the Potentially All Pairwise RanKings of all possible Alternatives (PAPRIKA) method to determine preference weights representing the relative importance of six physical activity attributes: health benefit, enjoyment, convenience, financial cost, effort, and time cost. The study sample included 146 participants. The authors conclude that patients with chronic knee pain have preferences for physical activities which are effectively distinguished by using ACA methods, and that adults with chronic knee pain, as clustered by their preferences, share distinguishing characteristics.
AHRQ-funded; HS023011.
Citation: Pinto D, Bockenholt U, Lee J .
Preferences for physical activity: a conjoint analysis involving people with chronic knee pain.
Osteoarthritis Cartilage 2019 Feb;27(2):240-47. doi: 10.1016/j.joca.2018.10.002..
Keywords: Arthritis, Chronic Conditions, Pain
Singh JA, Lewallen DG
Increasing obesity and comorbidity in patients undergoing primary total hip arthroplasty in the U.S.: a 13-year study of time trends.
The researchers examined the time-trends in key demographic and clinical characteristics of patients undergoing primary total hip arthroplasty (THA). They found that obesity, medical and psychological comorbidity increased and the underlying diagnosis of RA/inflammatory arthritis decreased rapidly in primary THA patients over 13-years.
AHRQ-funded; HS021110.
Citation: Singh JA, Lewallen DG .
Increasing obesity and comorbidity in patients undergoing primary total hip arthroplasty in the U.S.: a 13-year study of time trends.
BMC Musculoskelet Disord 2014 Dec 17;15:441. doi: 10.1186/1471-2474-15-441..
Keywords: Surgery, Obesity, Risk, Registries, Arthritis
Curtis JR, Chen L, Bharat A
Linkage of a de-identified United States rheumatoid arthritis registry with administrative data to facilitate comparative effectiveness research.
In order to address a gap in linkage methodology, the researchers sought to link a large, de-identified outpatient registry of patients with rheumatoid arthritis with national Medicare administrative claims data. The purpose of their report was to describe the methods and validity of this linkage.
AHRQ-funded; HS018517
Citation: Curtis JR, Chen L, Bharat A .
Linkage of a de-identified United States rheumatoid arthritis registry with administrative data to facilitate comparative effectiveness research.
Arthritis Care Res. 2014 Dec;66(12):1790-8. doi: 10.1002/acr.22377..
Keywords: Arthritis, Registries, Comparative Effectiveness
Ghomrawi HM, Alexiades M, Pavlov H
Evaluation of two appropriateness criteria for total knee replacement.
The researchers evaluated the performance of 2 sets of non-U.S. appropriateness criteria (one from Spain and the other from Canada) for total knee replacement (TKR) in a group of 508 TKR patients. Although only 4.7 percent were classified as inappropriate by both sets of criteria, there was little agreement between the two.
AHRQ-funded; HS016075
Citation: Ghomrawi HM, Alexiades M, Pavlov H .
Evaluation of two appropriateness criteria for total knee replacement.
Arthritis Care Res. 2014 Nov;66(11):1749-53. doi: 10.1002/acr.22390..
Keywords: Surgery, Arthritis, Decision Making
Baddley JW, Winthrop KL, Chen L
Non-viral opportunistic infections in new users of tumour necrosis factor inhibitor therapy: results of the SAfety Assessment of Biologic ThERapy (SABER) study.
The purpose of this paper was to determine, among patients with autoimmune diseases in the USA, whether the risk of non-viral opportunistic infections (OI) was increased among new users of tumour necrosis factor alpha inhibitors (TNFI), when compared to users of non-biological agents used for active disease. The investigators concluded that in the USA, the rate of non-viral OI was higher among new users of TNFI with autoimmune diseases compared to non-biological disease-modifying antirheumatic drugs users.
AHRQ-funded; HS017552; HS018517; HS017919.
Citation: Baddley JW, Winthrop KL, Chen L .
Non-viral opportunistic infections in new users of tumour necrosis factor inhibitor therapy: results of the SAfety Assessment of Biologic ThERapy (SABER) study.
Ann Rheum Dis 2014 Nov;73(11):1942-8. doi: 10.1136/annrheumdis-2013-203407..
Keywords: Arthritis, Comparative Effectiveness, Medication, Patient Safety
Curtis JR, Zhang J, Xie F
Use of oral and subcutaneous methotrexate in rheumatoid arthritis patients in the United States.
The researchers aimed to examine the epidemiology of methotrexate (MTX) use among rheumatoid arthritis patients initiating MTX, including dosing, method of administration (oral versus subcutaneous (SC)) , and persistence. They also compare the effectiveness of 2 strategies in regard to delaying or avoiding use of biologic agents: switching to SC MTX or adding another nonbiologic disease-modifying antirheumatic drug.
AHRQ-funded; HS018517
Citation: Curtis JR, Zhang J, Xie F .
Use of oral and subcutaneous methotrexate in rheumatoid arthritis patients in the United States.
Arthritis Care Res. 2014 Nov;66(11):1604-11. doi: 10.1002/acr.22383..
Keywords: Arthritis, Comparative Effectiveness, Medication
Goode AP, Shi XA, Gracely RH
Associations between pressure-pain threshold, symptoms, and radiographic knee and hip osteoarthritis.
The researchers sought to determine the association between generalized evoked pressure pain sensitivity with distal pressure–pain threshold and the presence, severity, or number of involved knee/hip joints with radiographic osteoarthritis or related symptoms. They found that as a participant’s sensitivity for pressure pain decreased, there were several significant associations with presence, severity, and number of joints with symptoms, regardless of the knee or hip joint.
AHRQ-funded; HS019479
Citation: Goode AP, Shi XA, Gracely RH .
Associations between pressure-pain threshold, symptoms, and radiographic knee and hip osteoarthritis.
Arthritis Care Res. 2014 Oct;66(10):1513-9. doi: 10.1002/acr.22321.
Keywords: Arthritis, Pain, Comparative Effectiveness
Mannion ML, Xie F, Curtis JR
Recent trends in medication usage for the treatment of juvenile idiopathic arthritis and the influence of tumor necrosis factor inhibitors.
The researchers investigated temporal trends in medication use among children diagnosed with juvenile idiopathic arthritis (JIA). They found that the use of tumor necrosis factor inhibitors (TNFi) in the treatment of JIA increased 2- to 3-fold from 2005 to 2012. New TNFi use was associated with decreased NSAID and oral glucocorticoids use. TNFi may be replacing, rather than complementing, methotrexate in the treatment of many patients.
AHRQ-funded; HS018517.
Citation: Mannion ML, Xie F, Curtis JR .
Recent trends in medication usage for the treatment of juvenile idiopathic arthritis and the influence of tumor necrosis factor inhibitors.
J Rheumatol 2014 Oct;41(10):2078-84. doi: 10.3899/jrheum.140012.
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Keywords: Children/Adolescents, Medication, Patient-Centered Outcomes Research, Practice Patterns, Arthritis
Ayers DC, Franklin PD
Joint replacement registries in the United States: a new paradigm.
This commentary serves as an introduction to an upcoming series of articles about orthopaedic registries, in general, with an emphasis on lessons learned from the evolving U.S. and international total joint replacement registries. Specifically, this paper provides an overview of total joint replacement registries and the current expansion of data collection beyond implant attributes and survival to include postoperative complications and patient-reported outcomes.
AHRQ-funded; HS018910.
Citation: Ayers DC, Franklin PD .
Joint replacement registries in the United States: a new paradigm.
J Bone Joint Surg Am 2014 Sep 17;96(18):1567-9. doi: 10.2106/jbjs.n.00641.
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Keywords: Arthritis, Chronic Conditions, Patient-Centered Outcomes Research, Registries, Surgery
Ayers DC, Franklin PD
Joint replacement registries in the United States: a new paradigm.
This commentary serves as an introduction to an upcoming series of articles about orthopaedic registries, in general, with an emphasis on lessons learned from the evolving U.S. and international total joint replacement registries. Specifically, this paper provides an overview of total joint replacement registries and the current expansion of data collection beyond implant attributes and survival to include postoperative complications and patient-reported outcomes.
AHRQ-funded; HS018910.
Citation: Ayers DC, Franklin PD .
Joint replacement registries in the United States: a new paradigm.
J Bone Joint Surg Am 2014 Sep 17;96(18):1567-9. doi: 10.2106/jbjs.n.00641..
Keywords: Arthritis, Chronic Conditions, Patient-Centered Outcomes Research, Registries, Surgery
Perry LM, Winthrop KL, Curtis JR
Vaccinations for rheumatoid arthritis.
The goal of this paper is to highlight the most recent literature on the key vaccines and the specific considerations for the rheumatologist and their rheumatoid arthritis (RA) patients, with a particular focus on influenza, pneumococcal, and herpes zoster vaccines. It is important for rheumatologists to understand which vaccines are live and what potential contraindications exist for giving vaccines to RA patients.
AHRQ-funded; HS018517
Citation: Perry LM, Winthrop KL, Curtis JR .
Vaccinations for rheumatoid arthritis.
Curr Rheumatol Rep. 2014 Aug;16(8):431. doi: 10.1007/s11926-014-0431-x..
Keywords: Arthritis, Vaccination, Prevention
Barton JL, Trupin L, Tonner C
English language proficiency, health literacy, and trust in physician are associated with shared decision making in rheumatoid arthritis.
The objective of this study was to examine patterns of perceived communication around decision making in 2 cohorts of adults with rheumatoid arthritis (RA). The investigators found that nearly one-third of subjects reported suboptimal shared decision making communication (SDM) with their clinicians, regardless of cohort. Lower trust in physician was independently associated with suboptimal SDM communication in both cohorts.
AHRQ-funded; HS019209.
Citation: Barton JL, Trupin L, Tonner C .
English language proficiency, health literacy, and trust in physician are associated with shared decision making in rheumatoid arthritis.
J Rheumatol 2014 Jul;41(7):1290-7. doi: 10.3899/jrheum.131350..
Keywords: Arthritis, Clinician-Patient Communication, Communication, Decision Making, Health Literacy, Patient and Family Engagement