Here we report spectacular non-volcanic CO2 emissions and hydrothermal disturbances at the front of the Nepal Himalayas following the deadly 25 April 2015 Gorkha earthquake (moment magnitude Mw = 7.8). The data show unambiguously the appearance, after the earthquake, sometimes with a delay of several months, of CO2 emissions at several sites separated by > 10 kilometres, associated with persistent changes in hydrothermal discharges, including a complete cessation. These observations reveal that Himalayan hydrothermal systems are sensitive to co- and post- seismic deformation, leading to non-stationary release of metamorphic CO2 from active orogens. Possible pre-seismic effects need further confirmation.Fluid–earthquake interplay, as evidenced by aftershock distributions or earthquake-induced effects on near-surface aquifers, has suggested that earthquakes dynamically affect permeability of the Earth’s crust. The connection between the mid-crust and the surface was further supported by instances of carbon dioxide (CO 2 and hydrothermal disturbances triggered by the 2015 Nepal earthquake, revealing high sensitivity of Himalayan hydrothermal systems to co-, post- and possibly pre- seismic deformation.Earthquakes rarely affect hydrothermal systems in non-magmatic context. Here the authors report outbursts of CO For the last 20 years, there has been a growing number of evidence for fluid-driven earthquakes2. Deep fluids have been shown controlling aftershock distribution in the tectonic contexts of rifting5, subduction7, and reverse8 and strike-slip faulting9. Contemporaneously, numerous observations of earthquake-induced effects on near-surface aquifers have been reported10, including mainly changes in stream and spring discharge13, groundwater level15 and temperature19 in various tectonic contexts. These observations have suggested that earthquakes dynamically affect permeability of the Earth’s crust21. Carbon dioxide (CO2) emissions were observed in association with seismicity in the case of the Matsushiro swarm9 in Japan or, recently, at the Lassen volcano22  and in the Eger Rift23 (Czech Republic), which suggests connection between the mid-crust and the ground surface through gas transport. However, such examples so far were only observed in the presence of magmatic activity.Understanding fluid–earthquake interplay has long received a lot of attention24, the Main Himalayan Thrust (MHT) accommodating at 2 cm year−1 half of the shortening between the two continents25. The largest earthquake in Nepal before 2015, the 1934 Bihar-Nepal earthquake (moment magnitude Mw~ 8.2) in Eastern Nepal, which claimed >15,000 lives, ruptured the MHT up to the surface over 150 kilometres along the Main Frontal Thrust26. Inter-seismic deformation is associated with intense background seismicity27, with 4–5 events of local magnitude ML > 5 per year, concentrated between 10 and 25 kilometres depth at the foot of the Himalayan topographic rise28. This region – the Main Central Thrust (MCT) zone29 – also exhibits numerous hydrothermal systems30  events over a year. From 25 April 2015 to 31 December 2017, >10,200 (ML > 3), >1100 (ML > 4) and >135 (ML > 5) earthquakes occurred in Central Nepal  data, as well as prior data on hydrothermal systems and CO2 emissions30.The 2 and hydrothermal disturbances at several sites in Central Nepal separated by >10 kilometres that have been triggered by the 2015 Gorkha earthquake. These observations, in particular the first earthquake-induced gaseous changes in the absence of magmatic activity, reveal high sensitivity of Himalayan hydrothermal systems to co-, post- and possibly pre- seismic deformation, and non-stationary release of metamorphic CO2 from active orogens.In this paper, we report spectacular outbursts of CO2 emissions were observed after the Gorkha earthquake, sometimes spatially associated with substantial changes from the pre-existing CO2 emissions (Table 2 flux measurements (see Methods) were made before  and after the earthquake , a quantitative comparison of CO2 emissions before and after the earthquake can be undertaken in the Upper Trisuli valley. Spectacular effects were observed first in Syabru-Bensi, 56 kilometres east from the epicentre , corresponding to an increase factor of 2.1 ± 0.3  showed one-order-of-magnitude smaller CO2 emission after the earthquake  along a profile which had been measured precisely at different times before 2011 , hence of the same order as the main Syabru-Bensi discharge.Two kilometres to the west of Chilime, at the Sanjen hydropower construction site Fig. , spectac2 emissions ever reported in Central Nepal were observed in January 2017 on the partly flooded riverbank, where no phenomenon had been known to the locals before the earthquake , similar to the whole CO2 discharge observed in Syabru-Bensi. In addition to the flux from the bank, an innovative method was used to measure the CO2 flux from and through the hot water pond , such a persistent post-seismic CO2 outburst is unusual. For instance, small outbursts following the 2008 Wenchuan earthquake in China lasted only a few months46. In the Marsyandi valley, further west , while significant, are smaller than in the Upper Trisuli valley.In the Budhi Gandaki valley, 16.5 kilometres to the epicentre  and Timure  was systematically measured at all occurrences (Table n = 77) so far in a seismically active area without magmatic activity. Along the rupture zone, average δ13C values range from –6.9 ‰ to –0.1 ‰, and appear similar at the various sites of a given valley. CO2 emissions in Sanjen and Syabru-Bensi, although separated by eight kilometres, have comparable CO2 concentration (96–98%) and δ13C signature (from –0.9 ‰ to –0.7 ‰), precluding shallow sources, but instead suggesting similar CO2 source and transport from a crustal-scale reservoir. In addition, the δ13C values remain relatively stable after the earthquake  were systematically measured for all hot spring waters (Table n = 8), CDIC of the SBP0 hot spring increased by 29 ± 2% after the mainshock and, in September 2017, returned to values measured before the mainshock  concentration and isotopic ratio  or Peak Ground Velocity (PGV) values. In Lassen  for example, a 2014 volcano-seismic swarm peaking at Mw = 3.85 at 5.7 kilometres distance, corresponding to SED∼0.2 J m−3 and PGV∼0.2 cm s−1, caused an outburst of geothermal fluids, explained by a two-fold permeability increase22. In the case of the Matsushiro earthquake swarm in Japan, modelling indicates the necessity of a 2-order-of-magnitude permeability increase with a small overpressure of only a few megapascals9. In Syabru-Bensi, the Gorkha earthquake produced SED∼63 J m−3 and PGV∼26 cm s−1   Fig. , however2 emissions with similar isotopic anomaly were observed over the whole region, whenever faults, boreholes or a tunnel gave the opportunity. These observations also attest the presence of a large, relatively shallow, reservoir of CO2 in the Himalayan crust, suggesting that metamorphic CO2 produced at depth is huge, as independently shown by petrological estimates48, and unlikely sequestered. Nevertheless, as hot water could also be found when deep boreholes are available, the overwhelming presence of hot water could match the evidence of an extended CO2 reservoir, and the debate cannot be considered as closed.Strikingly, CO2 emissions appear consistent with hydrothermal outburst effects, as observed in Lassen22, suggesting that apparent two-fold permeability increases and/or changes in hydrothermal pathways for pre-existing CO2 emissions could have been major effects of the Gorkha earthquake. First-order modelling indeed confirms that at least a doubling of permeability could explain CO2 flux increases  > 2.7 years after in January 2018 of all the increased CO2 emissions and hydrothermal unrest. In Lassen22, the permeability increase was inferred to be maintained for 50–60 days. In the Napa valley13, a vertical permeability change, following diffusion of a pressure pulse, was proposed to explain post-seismic stream discharge, suggesting basin-scale fluid diffusivity of 0.1 m2 s−1. Taking this conservative value, for one-kilometre spatial scale, the timescale for fluid displacement is ~ 120 days, compatible with our six-month delay time. This suggests that the Sanjen CO2 outburst and the Chilime cessation likely result from hydrogeological fluid diffusion.Compared with reported earthquake-induced hydrological effects−1 in Syabru-Bensi increased, and a linear trend in the GPS time-series, continuing to October 2017 about 2.5 years after the mainshock, was initiated. Thus, some post-seismic CO2 emissions and hydrothermal unrest may be related to changes in the state of post-seismic relaxation. Incidentally, the time of the Sanjen outburst and the Chilime cessation coincides with renewal of aftershock activity near Syabru-Bensi in the fall of 2015 , less than 15 kilometres from Syabru-Bensi, producing PGV > 1 cm s−1  and associated aftershocks remained active several months after the mainshock. About 6 months after the mainshock, contemporaneous with the Sanjen outburst and the Chilime cessation Fig. , the num015 Fig. , includi2 may in turn play a role in the installation of the next inter-seismic regime. Alternatively, the still evolving CO2 emissions in Syabru-Bensi, Timure and Chilime may also indicate a currently unstabilized system, able to diverge unpredictably. Given the issue of a pending mega-earthquake in the region42, long-term monitoring of CO2 emissions should seriously be considered as a chance to capture possible pre-earthquake signals.The Himalayan hydrothermal systems appear highly sensitive to small deformation rates and are therefore in near-critical condition. This suggests that post-seismic relaxation of co-seismic stress may result from pore pressure changes, and that metamorphic CO2 emissions triggered by a major earthquake, demonstrating the coupling between mechanical deformation and fluid transport properties at the crustal scale, highlighting that crustal deformation dynamically affects permeability during the seismic cycle. The large post-seismic CO2 emissions observed in the Narayani basin suggest non-stationary metamorphic CO2 production, and that its current estimate32 (>1.3 × 1010 mol year−1 with >(1.0 ± 0.2) × 108 mol year−1 from direct gaseous CO2 emissions), independently confirmed by petrological studies48, may be enhanced during a significant fraction of the seismic cycle. Metamorphic CO2 and its transport therefore emerge as an essential component of mountain build-up and the associated dynamics of large earthquakes.In this paper, we have presented the first assessment of CO50 was used to measure surface CO2 flux and to quantify the total CO2 discharge of a given site and the associated uncertainties, whose assessment is based on numerous systematic tests and our 10-year experience34. The method is robust, even in remote locations51 and during the monsoon36, and allows the measurement of CO2 fluxes over more than five orders of magnitude , that are regularly inter-calibrated in the laboratory. The CO2 flux is expressed in grams per squared metre per day (g m−2 d−1). The total CO2 discharge, expressed in mol s−1 (or ton d−1), is estimated using the CO2 flux data-set by kriging and interpolation procedures34. CO2 fluxes (n = 1720) and total CO2 discharges obtained before the Gorkha earthquake (from 2006 to 2011) are published elsewhere51. Here we present for the first time CO2 fluxes (n = 1668) and total discharges obtained after the earthquake in the Marsyandi, Budhi Gandaki and Upper Trisuli valleys relying on seven measurement campaigns carried out in November 2015, in January, May and November 2016, in January and September 2017, and in January 2018. Pre-earthquake and post-earthquake campaigns were performed outside the monsoon periods to reduce the meteorological effects on CO2 flux data. Every uncertainty is given around one-sigma standard deviation (68% confidence level) and averages are arithmetic means except otherwise stated. Data are summarised in Table The accumulation chamber method2 flux from or through water was measured at the new degassing site of Machhakhola  in the following manner. A collecting container was installed upside down on the water with a pipe leading to an accumulation chamber installed on the ground nearby , was measured after off-line purification by mass spectrometry on a Finnigan™ MAT-253 mass spectrometer  in CRPG 34. External repeatability of a given sample was ±0.1 ‰. The twenty δ13C values measured before the Gorkha earthquake are published elsewhere52. Fifty-seven measurements were carried out after the earthquake from January 2016 to January 2018. Data are summarised in Table We sampled gas in the field using evacuated glass tubes. CO−3 °C) and high-sensitivity (10−4 °C) thermometers . Due to the time response of the instruments, several minutes are needed to measure temperature. Experimental uncertainty of a given measurement was ±0.1 °C. The pH of the water in thermal springs was measured with various pH metres , systematically recalibrated in the field using buffer solutions. Experimental uncertainty of a given measurement was ±0.1. The flow rate of thermal springs was determined using stopwatch and measured cylinders or buckets and was repeated at least three times. Data are summarised in Table To measure water temperature of springs, we used thermometers  regularly inter-calibrated in the laboratory with a reference thermometer not currently used in the field , and compared with high-precision (10CDIC = [H2CO3] + [HCO3–] + [CO32–]) and its isotopic composition (δ13CDIC), expressed in mmol L−1 and in per mil relative to V-PDB, respectively, were determined using a gas chromatograph coupled to an isotope ratio mass spectrometer  in IPGP . The whole procedure is described elsewhere53. The relative experimental uncertainty of CDIC was 1–2% and the experimental uncertainty of a given δ13CDIC measurement was ±0.1‰. For a given sample, final values correspond to weighted arithmetic averages of two to three measurements. The CDIC and δ13CDIC values measured before the Gorkha earthquake are published elsewhere33. A total of 71 measurements were carried out after the earthquake from January 2016 to January 2018. Data are summarised in Table We sampled every water in the field using two to three glass screw cap vials of 12 millilitres volume each. DIC concentration , surface temperature anomalies, occurrence of water bubbles, presence of cavities, occurrence of inactive or active travertine deposits, and discussion with local people, or a combination of the above51. In remote places, the detection of previously unknown thermal springs relied on the use of hand-held thermal infrared cameras51 .The CO2 emissions and hot springs, we calculated SED56 and vertical PGV57 produced by the Gorkha earthquake and its main aftershocks. Empirical equations are used to estimate SED56 and PGV58. Peak Dynamic Stress (PDS) is estimated using: PGV × shear modulus (3 × 1010 Pa) / shear wave velocity (3500 km s−1). For the mainshock and six main aftershocks, values of SED, PGV and PDS at eight hydrothermal sites are gathered in Supplementary Table At the sites which experienced the most significant post-seismic changes in COML) given by the catalogue into moment magnitude (Mw), using the following linear calibration: Mw = 1.109 ML – 0.626. The seismic moment was obtained using the classical relationship: log(M0) = 1.5Mw + 9.1. The SMRR, expressed in N.m per 20 days, was calculated for all seismic events around Syabru-Bensi and is shown in Fig. We calculated the Seismic Moment Release Rate (SMRR) produced by the aftershocks of the Gorkha earthquake using the NSC earthquake catalogue from 25 April 2015 to 31 December 2017. We converted local magnitude  surrounded by two media (a and b) transports the gaseous CO2 to the surface by advection. Each medium is characterised by connected porosity (ε) and permeability (k). A pressure source is fixed at depth. Darcy’s law is defined according to a pressure distribution (p) that follows Δp2 = 0 (ref.59). An example calculation is shown in Supplementary Fig. To study the effect of permeability changes on CO37, to the calculation of water flow rate. We consider a vertical fault (f) driving the water flow to the surface, surrounded by two media (a and b). Each medium is characterised by permeability (k). Pressure source is fixed at depth. Solutions of the pressure distribution are expressed as a sum of exponential terms on horizontal axis, modulated by a sinusoidal signal along vertical axis37. An example of calculation is shown in Supplementary Fig. To study the effect of permeability changes on spring water flow rate at the surface, we adapted the 2-D fault model described above60  to the surface (z = 0), with flow rate Q, density ρ and specific heat CP. Temperature at depth h is defined by T(h) = βh + T(0), where β is the thermal gradient, which is poorly constrained in this hydrothermal region61 and taken equal to 55–75 °C km−1. We consider a quasi-static state having characteristic length λT and we define θ = T–T(0) and α = ρCPQλT/(pKTh). Using the initial conditions, the differential equation αh(dθ/dz) + θ = –βz has the following solution: θ = αhβ(1–e–1/α). Examples of calculation of the water temperature as a function of water flow rate, for two values of the thermal gradient, are shown in Supplementary Fig. To study the effect of water flow rate changes on hot spring exit temperature, we relied on an analytical first-order modelThe data that support the findings of this study are available in the article, in Supplementary Information, and from the corresponding author upon request (girault@ipgp.fr).Supplementary InformationPeer Review FileDescription of Additional Supplementary FilesSupplementary Movie 1Supplementary Movie 2


N = 6670) examining the effectiveness of parent training programs for preventing or reducing child maltreatment. From these studies, 185 effect sizes were extracted and more than 40 program components and techniques were coded. A significant and small overall effect size was found , p < 0.001). No significant moderating effects were found for contextual factors and structural elements . Further, no significant moderating effects were found for most of the coded program components and techniques, indicating that these components are about equally effective. Only a few program components and techniques moderated program effectiveness, however these effects were negative. These results indicated that improving parental personal skills, improving problem solving skills, and stimulating children’s prosocial behavior should not be the main focus of parental training programs for preventing and reducing child maltreatment. This also holds for practicing new skills by rehearsal and giving direct feedback in program sessions. Further clinical implications and directions for future research are discussed.This is the first meta-analytic review investigating what components and techniques of parent training programs for preventing or reducing child maltreatment are associated with program effectiveness. A literature search yielded 51 studies ( Child maltreatment is a major problem that affects many children around the world and has serious consequences for individual victims and society. A review of a series of meta-analyses on the prevalence of child maltreatment showed that prevalences varied from 12.7% to 36.3% for self-report studies and from 0.3% to 0.4% for multi-informant studies ,6,7,8, tWorldwide, many programs have been designed to prevent child maltreatment. These programs are usually based on etiological models for child abuse and neglect. Generally, it is assumed that child maltreatment is caused by a complex interaction between multiple risk factors, rather than the presence of only a single risk factor ,11. BelsAn important question is how parent programs must be shaped in such a way, so that child maltreatment is prevented or reduced effectively. Currently available parent training programs with this aim generally focus on improving child-rearing skills and parenting practices, and on modifying parental attitudes towards harsh parenting. In many of these programs, individual or group-based parenting support is offered. Components and techniques that are commonly found in these programs are: stimulating a positive parent-child interaction, increasing parental knowledge of child development, improving discipline strategies and behavior management, and improving parental attitudes towards their child and/or parenting in general. Most programs also comprise components aimed at enhancing the emotional well-being of parents, for instance by learning parents how to control their anger and stress . reduce the incidence of child maltreatment in physically abusive parents is Parent–child Interaction Therapy (PCIT). PCIT is a protocolled program focusing on the interaction between the parent and the child as well as the child’s behavior [Most parent training programs are targeted at a clearly defined population. Programs aimed at preventing the occurrence of child maltreatment in at-risk, but non-maltreating families can be distinguished from programs aimed at reducing (episodes of) child maltreatment in maltreating families. The ACT-Parents Raising Safe Kids program (ACT-PRSK)  is an exbehavior . In livebehavior . A diffebehavior .d = 0.13) of parent training programs aimed at preventing or reducing child maltreatment, which even became non-significant after controlling for publication bias. Pinquart and Teubert [d = 0.30) of parent training programs on substantiated and self-reported child maltreatment reports and child maltreatment potential. Finally, Lundahl et al. [d = 0.45) of parent training programs on child maltreatment. However, these authors only included three studies that reported on actual child maltreatment. In only a few of these meta-analyses, potential moderators of program effects were examined. It was found that the effectiveness of parent training programs could vary by several study and program characteristics, like sample type  [A number of meta-analyses have synthesized results on the degree to which parenting training programs reduce (the parents’ risk of) child maltreatment ,18,25,26samples) , the delpractice elements for discrete clinical techniques or strategies used as part of a larger intervention plan . They used the term common elements for practice elements that are commonly found in different effective treatments. Another term for intervention components is active ingredients. Barth and Liggett-Creel [core components, which they define as “the essential functions or principles, and associated elements and intervention activities, that are judged necessary to produce desired outcomes”. They argue that these core components refer to program characteristics, like contextual aspects , structural elements , and specific intervention practices . To better understand why parent training programs are effective, it is important to examine how specific intervention components, such as different types of program content, techniques, or strategies, influence intervention effectiveness. In previous literature, various terms were used for these intervention components. Chorpita et al.  used thett-Creel  (pp. 7) tt-Creel , pp. 3) Van der Put et al.  investigStudies were selected if they met the following three inclusion criteria. First, studies had to report on the effect of at least one parent training program for preventing or reducing child maltreatment. These programs had to be aimed at improving parenting skills, either in an individual or group setting. However, home visitation programs, which include prenatal and early-childhood home visits as preventive services to families in need of support , were noTo select relevant studies for this meta-analysis, multiple searches were conducted. First, we screened the full reference list of Van der Put et al. , who aimA detailed coding scheme was designed according to the guidelines of Lipsey and Wilson  to code The program characteristics were divided into contextual factors, structural elements, program components, and delivery techniques. As for the contextual factors, we coded the general aim of the study (reduction of (re-)abuse or prevention), delivery location , and delivery setting . The coded structural elements were the program duration , minimum and maximum program duration (in weeks), average number of program sessions (attended by the participants), and the interval between program sessions . The coded program components and delivery techniques are described in In the first coding round, the first and the last author of this study independently coded five randomly selected studies that were eligible for inclusion . These independent codings were compared, and percentages of agreement were calculated. For the study characteristics, the contextual factors, and the structural elements, the interrater agreement was 85%. The agreement was 80% for the double-coded program components and delivery techniques, and 75% for the double-coded effect sizes. All inconsistencies in the independent codings were discussed and resolved until the authors fully agreed on all final coding decisions. In general, minor coding errors caused the disagreement in the double-coded study characteristics, contextual factors, structural elements, and effect sizes. The discrepancies in the coded program components and techniques were mostly due to different coding styles. Some codings could be based on rather elaborate information about the parent training programs as described in the studies or factsheets, whereas other codings could only be based on a rather narrow definition of a program. Prior to coding the remaining studies, the coding sheet was modified where necessary. In a second coding round, it was decided to code the remaining 46 studies according to a more strictly coding style to reduce subjectivity in coding as much as possible. This coding round was performed by the first author of this study. Whenever the first author doubted about the presence of a certain component or technique, the other two authors were consulted.d. Most studies reported on means and standard deviations, proportions, and odd ratios. These outcomes were transformed into Cohen’s d values using formulas of Ferguson [d value indicated that lower levels of child maltreatment  were found in the intervention group than in the control group, whereas a negative d value indicated that higher levels of child maltreatment were found in the intervention group than in the control group. If results in primary studies were described as non-significant without any statistical information, a d value of zero was coded [The outcomes of the primary studies were transformed into the standardized difference between two means, also referred to as Cohen’s Ferguson , Lipsey Ferguson , and RosFerguson . As for as coded . This prAll coded variables and calculated effect sizes were entered in SPSS version 24 . Next, continuous variables were centered on their mean, and categorical variables were recoded into dummy variables.To estimate the overall effect of parent training programs on child maltreatment and to examine which study or program characteristics moderated this effect, a three-level meta-analysis was conducted. Because most studies reported on multiple relevant effect sizes, a traditional random effects model was extended to a three-level random effects model so that effect size dependency is accounted for . As a reA common problem in conducting a meta-analysis is that studies with non-significant or negative results are less likely to be published than studies with positive and significant results. The effect sizes extracted from the primary studies included in the current meta-analysis may therefore not be an adequate representation of the actual effect of parent training programs on child maltreatment. This phenomenon is called publication bias and is often referred to as the ‘file drawer problem’ . FurtherAs one of the included studies provided 56 effect sizes , which wk = 50 non-overlapping samples), reporting on 185 effect sizes and a total of N = 6670 participants, of whom n = 3340 participated in a parent training program and n = 3330 participated in a control group. The sample sizes of the included studies varied between n = 18 and n = 918. The studies were published between 1985 and 2018, and were conducted in the USA (k = 26), Europe (k = 8), Canada (k = 3), Australia or New Zealand (k = 6), and in various other non-western countries (k = 7).The current meta-analysis consisted of 51 studies , t (184) = 9.977, p < 0.001. According to the guidelines formulated by Cohen [d = 0.20 considered small, d = 0.50 medium, and d = 0.80 large, this effect is small. The results of the two log-likelihood ratio tests showed that significant variance was present both at level 2 (2χ (1) = 17.611, p < 0.001; one-sided) and level 3 (2χ (1) = 3.712, p = 0.027; one-sided) of the meta-analytic model.by Cohen  to intert (128) = 8.976, p < 0.001 (see d = 0.009). Therefore, it could be assumed that the effect sizes reported in study of Kolko [Of the total variance, 33.2%, 39.3% and 27.4% was distributed at levels 1, 2 and 3, respectively. As these results indicated substantial heterogeneity in effect sizes, we could test study design and intervention characteristics as potential moderators of the overall effect of the parent training programsNext, we performed a sensitivity analysis, as the study of Kolko  produced.001 see . This ovof Kolko  did not Finally, the trim and fill analysis showed that the distribution of effect sizes was symmetrical , in comparison with RCTs (d = 0.358). A significant moderating effect was also found for the study quality index, indicating that effect sizes decreased as the quality of studies increased.As for the study design characteristics, we found a significant moderating effect of the study’s sample size . Further, a significant moderating effect of the type of research design was found. Larger effect sizes were found in studies with a quasi-experimental design, in which no matching was used to assign participants to either the intervention or control group , improving parental problem solving (d = 0.363 versus d = 0.512 for programs without this component), and stimulating prosocial behavior/discourage antisocial behavior of children (d = 0.361 versus d = 0.527 for programs without this component).Several program components significantly moderated the overall effect. Notably, the presence of these components reduced program effects. In specific, smaller effect sizes were found for programs with a focus on improving personal skills of parents (d = 0.329 versus d = 0.512 for programs not using this technique).As for the delivery techniques, we also found a negative moderating effect. Specifically smaller effects were found for programs using practice and rehearsal as a delivery technique  of RCTs on interventions for preventing or reducing child maltreatment. Pinquart and Teubert [d = 0.13) of RCTs on parenting interventions for families with newborns. Generally, the effect of interventions can best be determined in RCTs, as random assignment of participants to an experimental and a control group  equalizes both groups on all other variables. Therefore, RCT’s are considered to be the most powerful study design in intervention research [Further, larger effect sizes were found in studies with quasi-experimental designs using non-matched intervention and control groups relative to RCTs. This was in line with previous literature, as meta-analyses on the effect of interventions on child maltreatment outcomes that included only RCTs generally showed smaller effect sizes than meta-analyses including both RCTs and quasi-experimental designs. For example, Euser et al.  found a  Teubert  found a research ,60. On tresearch  noted thFinally, we found that studies with a lower study quality index showed larger effects than high-quality studies. This index was determined for each study and was based on three aspects of a primary study’s design: the research design of the study , whether or not the study used an ‘intent-to-treat’ design, and whether or not the study included a 12 month (or longer) follow-up assessment of the child maltreatment outcomes. Out of these three variables, the research design was the only variable with a significant moderating effect, indicating that the significant moderating effect of the study quality index was largely explained by this variable.Our findings indicate that the contextual factors and structural elements that we investigated, were not associated with the effectiveness of parent training programs for preventing or reducing child maltreatment. Therefore, it is not expected that programs that differ on these characteristics will also differ in their effectiveness. This is not in line with the findings of Van der Put and colleagues  who founFurthermore, we found no significant moderating effects for most of the program components and delivery techniques. This suggests that the different program components and techniques used in parent training programs are about equally effective in preventing or reducing child maltreatment. Previous meta-analyses did find moderating effects of program components and techniques for other types of interventions aimed at preventing or reducing child maltreatment, such as family programs, or substance abuse interventions ,34. GeneFor three program components and one program technique, a negative moderating effect was found. Parent training programs targeting the personal and problem-solving skills of parents showed significant smaller effects on child maltreatment compared with programs not targeting these skills. Several review studies showed that personal problems of parents, such as stress, anger and health problems, are important risk factors for child maltreatment ,16,17. TA negative moderating effect was also found for the component regarding the encouragement of the child’s pro-social behavior . This means that parent training programs promoting parents to stimulate more pro-social or less anti-social behavior of their child have smaller effects than programs not stimulating this child behavior. This result also corresponds with the findings of Kaminski et al. , as theyFinally, we found a negative moderating effect of the delivery technique practice and rehearsal. This finding suggests that parent training programs, in which certain skills are practiced in the program sessions by rehearsal and direct feedback of the trainer, are less effective than programs in which this technique is not applied. This is not in line with findings of Kaminski et al. , who repAlthough no specific contextual factors, structural elements or program components were found that significantly contributed to the overall effect of parent training programs, there are a number of common factors that all interventions need in order to be effective, regardless of the target group and the type of intervention. For example, programs should have a clear structure and a clear goal ,65. FurtSeveral limitations of the present meta-analysis should be discussed. First, the results of the current study do not permit conclusions about causality because of the non-experimental nature of this review. We investigated whether the presence or absence of individual program components or techniques were associated with the program effectiveness  of parent training programs in reducing or preventing child maltreatment. Our findings indicate that none of the components or techniques significantly moderated the overall effect of parent training programs. However, it remains unclear whether the components or techniques were effective on itself. This should be investigated in future experimental research by assigning participants to either a group receiving an intervention with a certain component or a group receiving an intervention without this component. The second limitation is related to the outcomes that are measured in the included primary studies. Primary studies reported on outcome measures such as official reports, investigations, or a recurrence in child protection, as it was assumed that these measures were indicative of child maltreatment. However, previous literature suggested that a large proportion of maltreatment is not reported to the child protection authorities ,72,73. TThe third limitation is related to the sex of the parents who participated in the included primary studies. Most of these studies mainly recruited mothers, and some studies focused even solely on mothers in examining the effects of a parent training program. This is despite the fact that previous literature revealed that targeting fathers in parent training programs enhances child behavior and parent practices ,79,80. TFinally, shortcomings regarding the coding of the program components and delivery techniques should be mentioned here. First, the information about the specific content of the parent training programs reported in the primary studies or the online factsheets and protocols was sometimes limited. Therefore, it was difficult to determine whether a program focused on a specific component or used a certain delivery technique or not. In addition, the way in which a parent training program was offered to participants of a study may differ from the implementation procedures that are described in the factsheets, manuals, and/or protocols that were found online. The scarcity of information on a program’s content may have caused incorrect codings of components and techniques. These shortcomings were noticed in the first coding round, in which some studies were double-coded . It was decided that, in order to reduce subjectivity in the coding process, components were coded rather strictly. This means that a component or technique was only coded as present if the text clearly stated that the component or technique was part of the program content.Despite these limitations, our study provides important knowledge for clinical practice and suggestions for future research. Parent training programs have a significant effect on child maltreatment. Therefore, parent training programs should be taken into account by clinical professionals and policy makers in choosing an appropriate intervention to prevent or reduce child maltreatment, especially because most program components and delivery techniques used in these programs seem equally effective. However, improving parental personal skills, problem solving skills, and stimulating children’s prosocial behavior should not be the main focus of these programs, just as practicing new skills by rehearsal and giving direct feedback in program sessions. As our findings indicate that all program components and delivery techniques are about equally effective in preventing or reducing child maltreatment, it can be argued to combine components when treating high-risk or maltreating parents in parent training programs. The program components and techniques were only tested in bivariate models in this study. Therefore, no conclusions can be drawn about the interactions between components, and the effects of these interactions on child maltreatment. This should be examined in future research. Furthermore, it is very important that future intervention research gives a more specific and elaborate description of the intervention content, as this will greatly improve the quality of future component research.The results of this meta-analysis showed a significant and small effect of parent training programs on child maltreatment. We found that the overall effect was moderated by several study characteristics , and a larger study quality index yielded smaller effect sizes). No significant moderating effects were found for contextual factors and structural elements . Notably, most of the program components and techniques that we investigated were not significantly associated with the effectiveness of parent training programs for preventing or reducing child maltreatment. Therefore, our findings indicate that most components are about equally effective and that none of the currently examined components or techniques are individually associated with the effectiveness of parent training programs.


Interprofessional education (IPE) has been shown to improve health outcomes and patient satisfaction. IPE is now represented in the Accreditation Council for Graduate Medical Education’s emergency medicine (EM) milestones given the team-based nature of EM. The Highland Allied Health Rotation Program (H-AHRP) was developed by residents to enhance and standardize IPE for EM residents in a single hospital setting. H-AHRP was incorporated into the orientation month for interns starting in the summer of 2016. EM interns were paired with emergency department preceptors in registered nursing (RN), respiratory therapy (RT), pharmacy (PH), laboratory (LAB), and social work (SW) in either a four-hour shadowing experience  or lecture-based overview . We conducted a survey before and after the program. Overall, the EM interns reported an improved understanding of the scope of practice and day-to-day logistics after working with the preceptors. They found the program helpful to their future as physicians and would recommend it to other residencies. The H-AHRP program allows for the early incorporation of IPE into EM training, enhances interns’ understanding of both the scope and logistics of their colleagues, and is a well-received effort at improving team-based care. Almost 20 years ago, the Institute of Medicine  issued a report drawing attention to the high rate of preventable healthcare errors, many of which may have been influenced by ineffective teamwork.2Interprofessional education (IPE) is now represented in the competencies for emergency medicine (EM) training.The program’s objectives for first-year residents were threefold: 1) better understand the roles of their fellow health professionals (scope); 2) learn to perform a number of procedures and actions common to these roles (logistics); and 3) develop skills of interprofessional communication and teamwork while getting to know these team members. The desired outcome was a resident physician who understands the contributions of other healthcare professionals, integrates skill sets effectively, and champions an interdisciplinary approach to patient care.At Highland Hospital the first month of intern year serves as an orientation to the emergency department (ED) during which interns participate in ED shifts, lectures, and workshops. The H-AHRP program was initially created in 2016 to purposefully introduce IPE into the curriculum. After significant modifications and a pilot year, the program was studied in 2018.At the beginning of orientation month, an introductory presentation and syllabus were provided to outline the expectations and objectives for the program. EM interns were assigned sessions with registered nursing (RN), respiratory therapy (RT), pharmacy (PH), laboratory (LAB), and social work (SW). The RN, RT, and PH shifts were one-on-one sessions lasting four hours, during which the intern participated in the activities of his or her preceptor with the guidance of syllabus objectives. These sessions allowed the interns to experience the real-time responsibilities of each allied health professional. In addition, SW and LAB learning objectives were introduced through a group-based tour and discussion, with the respective experts, the ED medical social worker and the director of the clinical laboratory, guiding the session.To evaluate the interns’ understanding, we administered pre- and post-program surveys using a five-point modified Likert scale with responses from −2 (strongly disagree) to +2 (strongly agree). The numerical responses were averaged for each question and these values were aggregated based on the professional it referenced and question type. The five sections that followed asked questions about the role of each professional represented in the program. We subdivided these questions into “scope”-type questions or “logistic”-type questions. “Scope” referred to questions related to the intern’s understanding of the general role or scope of practice of that profession, whereas “logistic” referred to specific procedures or actions of that profession. In the post-program survey, there were 10 additional questions aimed at collecting general program feedback and perceived utility of the session.H-AHRP was designed and implemented to fill a need for improved IPE early on in EM training. After participating in this program, interns showed an overall trend toward increased understanding of the scope of practice and logistics for each professional group. During the initial orientation lecture, all 12 interns (100%) completed the pre-program survey, and 11 of 12 (92%) completed the similar post-program survey at the end of the month. All responses to the seven general interprofessional questions demonstrated a better appreciation of IPE after the intervention, from agree (+1.0) to closer to strongly agree (+1.7).Overall, interns reported an improved understanding of both scope and logistics of each profession after the program . For exaAlthough limited in time and scope, as well as by its small studied sample size, this IPE initiative serves as a framework for EM residencies to introduce the basic roles and skills of non-physician team members in the ED. We recognize the limitations of survey data and self-report; therefore, future studies should aim to objectively evaluate the impact of IPE on physician behavior and patient care over time.Excellent teamwork is predicated on an understanding of the skills and knowledge of teammates. As Wilbur describes in a 2014 call to action, EM is the best-qualified specialty to lead an emphasis on IPE.


The association between health literacy and health care costs, particularly for hospitalizations and emergency room services, has been previously observed. Health information interventions aimed at addressing the negative impacts of inadequate health literacy are needed. The MedEncentive Mutual Accountability and Information Therapy (MAIT) Program is a Web-based system designed to improve health and lower costs by aligning patient-doctor incentives.In this mixed methods study of a Web-based patient-doctor aligned-incentive, information therapy program conducted in an 1800-member employee health plan, we aimed to (1) determine the program’s quantitative impact on hospitalization and emergency room utilization and costs, and (2) assess survey responses about the program’s perceived value.We used a mixed methods, single within-group, pre-post, descriptive study design. We analyzed quantitative data using pre-post mean utilization and cost differences and summarized the data using descriptive statistics. We used open-ended electronic survey items to collect descriptive data and analyzed them using thematic content analysis.P<.05). Qualitative findings suggested that respondents valued the program, benefiting from its educational and motivational aspects to better self-manage their health.Hospitalizations and emergency room visits per 1000 decreased 32% (26.5/82.4) and 14% (31.3/219.9), respectively, after we implemented the program in 2015-2017, relative to 2013-2014. Correspondingly, the plan’s annual per capita expenditures declined US $675 (95% CI US $470-865), or 10.8% ($675/$6260), after program implementation in 2015-2017 (US $5585 in 2013-2014 dollars), relative to the baseline years of 2013-2014 (US $6260; Analyses suggested that the reported reductions in hospitalizations, emergency room visits, and costs were associated with the program. Qualitative findings indicated that targeted users perceived value in participating in the MAIT Program. Further research with controls is needed to confirm these outcomes and more completely understand the health improvement and cost-containment capabilities of this Web-based health information, patient-doctor, aligned-incentive program. Health literacy is defined as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”  and “theFor decades, financial incentives to improve health care and health behaviors have been directed toward physicians and patients separately, with marginal success ,13. A reInformation therapy is a term for “supplying patients with health information, enabling them to make informed decisions about their health and care, participate in their own well-being, and thus decrease the utilization of healthcare resources” [sources” . It is fsources” . Compenssources” . Incentisources” ,18.Prior research suggests that the majority of the general population have inadequate or marginal health literacy, requiring remediation when accessing the health care system . InformaThe purpose of this study was to evaluate the outcomes of an employee health plan over a 5-year period, before and after the introduction of a Web-based information therapy, patient-doctor, aligned-incentive program. More specifically we aimed to (1) determine the impact (quantitatively) of the program on inpatient and emergency room utilization and costs, which also are proxies for overall health status, before and after implementation; and (2) evaluate participants’ experiences using the program in correlation with the quantitative results.plan) as an additional benefit to the plan’s members (beneficiaries). In the case of self-insured employers, the plan’s summary plan description is modified to recognize the program as a benefit. As part of the service agreement, the plan sponsor directs its plan administrator (third-party administrator) to electronically transmit plan-member demographic enrollment and claims files to MedEncentive’s computer system, and receive reward files for payment to doctors and patients who participate in the program. These electronic data exchanges employ industry-standard transmission protocols and data formats, so that they are secure, automated, and maintenance-free.The MedEncentive Mutual Accountability and Information Therapy (MAIT) Program is a Web-based, mobile-enabled, information therapy, patient-doctor aligned-incentive program that promotes patient education and personal accountability, and supports health care cost containment ,18. MedEopportunity, for both doctors and patients, is initiated when doctors access the program’s website, or as a result of MedEncentive’s receipt of a claim associated with a covered service. Covered services include any visit, consultation, or preventive examination rendered in-office to a covered member, by physicians  of any medical specialty, or by licensed physician extenders , for any medical condition or wellness examination.The MAIT Program uses plan sponsor-supplied member enrollment data to send orientation letters and personalized membership identification cards to all adult plan members. A program MedEncentive uses the diagnosis from the transmitted office visit claim to notify physicians of program opportunities via fax and email. These notices direct physicians to the MedEncentive website, where they may elect to participate in the program in 2 ways: (1) on a point-of-service (POS)-initiated basis, or (2) on a claims-initiated basis. The POS-initiated version is typically accomplished when practice personnel assign an identifier in their in-office computer system to patients covered by the program. These systems automatically notify doctors to access the program’s website during or shortly after a covered office visit, to initiate an opportunity by entering the patient’s diagnosis see . The MAIThe claims-initiated version serves as a safety net in case a POS-initiated opportunity is missed. In the claims-initiated version, the MedEncentive system monitors incoming insurance claims to see whether physicians have previously used the POS-initiated version of the program. If not, then the system uses claim information to preload the patient’s diagnosis and send the doctor the fax or email opportunity notice. When doctors choose to participate via the POS- or claims-initiated version, they access the program’s website to complete 2 tasks: (1) consider evidence-based medicine treatment guidelines, and (2) select a patient educational article that the program’s computer system lists in relevancy order to the patient’s diagnosis see . The POSWhen physicians do not participate within 4 days of a claims-initiated notification, patients select their own articles from the list in conjunction with their program opportunity. As a result of this accommodation, both doctors and patients can earn the program’s financial rewards independently of the other party’s participation.success. When an opportunity expires without completion, this is referred to as a miss. Once a quarter, patients are given a second chance to complete the misses that occurred during the previous 90 days.Patient opportunities are initiated as a result of doctor participation, or as a result of office visit claims processing. Patients are notified of their opportunities to participate, by email notices or letters sent to their home, after each office visit see . PatientWhile the program can be adapted to most Web-based educational content, MedEncentive used Healthwise articles in this implementation. Healthwise, Incorporated  is a conflict-free, nonprofit organization, nationally recognized for providing evidence-based, easy-to-understand health education at the fifth-grade reading level. They supply technology solutions that integrate with complex health information technology systems, with expert guidance on behavior change and shared decision making within the field of health care.This study used a mixed methods, single within-group, pre-post, descriptive study design to evaluate the MedEncentive MAIT Program. We used open-ended electronic survey items to collect descriptive data. The study involved the employee health plan of a not-for-profit, acute-care general hospital  located in a semirural community in the south-central United States. The hospital is staffed by more than 1400 employees, with more than 100 physicians representing more than 30 specialties.The study sample comprised the plan sponsor’s employees and their covered dependents, to include spouses and children. The employees in the health plan were hospital and clinic personnel, including doctors, nurses, and other medical professionals, as well as administrative and support staff. No person in the covered population was excluded from this study or its analyses. We did not adjust to account for new hires or terminations.The analysis of the program implementation relied on multiple sources of data and related background information. The health plan sponsor, its third-party administrator, and its pharmacy benefits manager were the primary sources of plan-member enrollment, medical claims, and pharmacy expenditure data, from 2013 through 2017. We compiled the provider and patient program activity data and survey responses from MedEncentive’s computer system.Quantifying the impact of the MAIT Program involved a careful, step-by-step process of compiling and evaluating doctor and patient participation rates; the health plan’s 2013-2017 hospitalizations, emergency room visits, and total expenditures; and other demographic and comorbid condition variables, before and after the program was implemented.success rate. This metric is derived by dividing the number of program successes (successfully completed information therapy sessions) by the total number of opportunities (office visits) incurred by all covered plan members. While patients need to know their doctors have an opportunity to participate—thus making physician inclusion in the program essential—patient success rate is the metric most aligned with reductions in hospitalizations and per capita expenditures at a group level.The MedEncentive computer system automatically calculates doctor and patient participation using a unit of measure called Detailed claims data for medical services, excluding pharmacy, were transmitted to MedEncentive on a monthly basis by the plan sponsor and its third-party administrator. Each claim contained more than 200 data elements, such as type of service, diagnosis, rendering provider, service location, gross charges, and net payments. The claims data included physician compensation and patient rewards associated with the program.We sorted these data by date of service (end date) to organize the medical activity into the year services were rendered, from 2013 through 2017. We observed a typical 90-day run-out period for each year to capture the incurred charges in the year they occurred. We removed dental and optometry claims, since these services are not covered or directly affected by the program. To account for total expenditures, we added the plan members’ direct out-of-pocket payments  to the amount paid by the plan sponsor. The clinical and economic analyses included all health plan enrollees, before and after implementation, regardless of program participation status.We collected descriptive data about users’ experiences with the MAIT Program through open- and closed-item electronic surveys. Administered at the conclusion of every information therapy session, for both doctors and patients, the surveys were voluntary and had no effect on the participants’ financial rewards associated with the program. The open-ended items asked physicians and patients about their experience with the program and for their suggestions for improvement. Closed-ended survey items asked patients about (1) how helpful the educational article was for managing their diagnosis or in maintaining their health (2) how closely they were following the health recommendations contained in this article, (3) how much physician access to the program’s survey responses motivated them to improve their health literacy and health behaviors, (4) the importance of their physician’s awareness regarding the patient’s capacity for self-management, and (5) the importance of their physician’s awareness of the patient’s intention to accomplish health objectives.Since voluntary participation in the program by doctors and patients can be associated with the intended clinical and economic outcomes, we began our quantitative analysis by examining the standard doctor and patient success rate reports generated by the MedEncentive computer system. We were particularly interested in determining whether we had achieved the 55% patient success rate threshold, since it is predictive of the clinical and economic group-level effectiveness of the program.We analyzed clinical and economic outcomes by comparing annual hospitalizations per 1000 enrollees, emergency room visits per 1000 enrollees, total expenditures per capita, and other variables for 2015-2017 (the implementation period) versus the baseline years (2013-2014), prior to implementing the program. We conducted pre-post analysis of mean cost differences, with confidence intervals, for emergency room, hospitalization, and total care costs -22.Since the program was designed to motivate adherence to recommended treatments and mitigate the effects of inadequate health literacy, which are associated in the literature with hospitalizations, emergency room visits, and total expenditures, these measures were the most effective means to measure program effectiveness -26. To cStructured, open-ended survey-item data were deidentified and cleaned, and prepared for analysis. We managed qualitative survey data responses using thematic content analysis, based on the topic addressed in the structured items and the response . We analyzed data in 2 stages to identify domains and taxonomies related to participant experiences . The firUltimately, we sorted open-ended survey data into program, provider (doctor), health status, and other categories. Comments pertaining to the program were coded as testimonials, suggestions and service requests, and complaints. Comments pertaining to providers were coded as testimonials and complaints. Comments related to the patient’s health status were coded as general medical condition, improving medical condition, and worsening medical condition. Other comments included insurance complaints.Patient participation exceeded the targeted 55% success rate threshold in the first year, reaching 68.67% (4245/6182) at the end of 2015. Patient success rate continued to climb to 74.23% (5108/6881) in the first quarter of 2018 see 0. This lAs The overall annual provider success rate started at 30.62% (1890/6173) at the end of 2015 and climbed to 45.41% (2619/5768) by the end of 2016 see 0. The prP<.05). On average, this represents a 32% (26.5/82.4) decrease in admissions per 1000, relative to the baseline year of 2014. Emergency room visits per 1000 in 2013 and 2014 were 251.8 and 219.9, respectively, whereas in 2015, 2016, and 2017, emergency room visits per 1000 plan members decreased to 191.3, 187.5, and 187.3, respectively (P<.05). In summary, hospitalizations and emergency room visit rates per 1000 decreased 32% (26.5/82.4) and 14% (31.3/219.9), respectively, in 2015-2017 after implementation of the program, relative to 2013-2014, prior to program implementation, inclusive of all enrollees (participants and nonparticipants).Program effectiveness can, in part, be measured by an improvement in clinical outcomes, including overall hospitalization and emergency room visit rates. We compiled the total hospitalizations and emergency room visits from the claims data for the 2 years prior to program implementation (2013-2014), and the 3 years after deployment (2015-2017), as P<.05), inclusive of all enrollees (participants and nonparticipants) (see As nts) see .During 2015-2017, the participating health plan members rated the helpfulness of the program’s educational content at 4.40 out of 5 (with 5 being most helpful), representing 15,260 responses. These ratings indicated there was a strong consensus among patients that the program’s educational content was helpful in managing their disease or condition, or in maintaining good health.When patients were asked to report (to their doctors) their level of adherence with the health recommendations contained in the program’s educational content, on a scale of 1 to 5, with 1 meaning “not following recommendations” and 5 meaning “following recommendations closely,” the mean response was 4.70  over the 2015-2017 time period. These self-assessments indicated a strong consensus among patients that they were, or intended to be, compliant with recommended treatments. The survey item reflecting physician influence on the patient’s motivation to gain health knowledge and improve health behaviors had a mean score of 8.80 out of 10, representing 13,401 responses, indicating a strong consensus that physicians positively influenced patients to improve their health literacy and health behaviors. When asked whether it was important for his or her physician to know of the patient’s competency to self-manage, patient responses had a mean score of 9.24 out of 10, representing 13,401 responses. This indicated that the majority of patients thought it important that their doctor was aware that they understood how to manage their health. Finally, when asked whether it was important that their physicians knew that they were accomplishing health objectives, patient responses had a mean score of 9.26 out of 10, representing 13,401 responses. This indicated that the majority of patients thought it important that their doctor was aware that they were trying to accomplish health objectives. During 2016-2017, patients posted 555 comments, with 323 (58.2%) pertaining to the program, 183 (33.0%) pertaining to their provider, 31 (5.6%) pertaining to health-related topics, and 18 (3.2%) pertaining to other general topics. Of the program-related comments, the majority  were testimonials, 33.4% (n=108) were suggestions or requests to improve the program, and 1.6% (n=5) were complaints. The MedEncentive MAIT Program is, to our knowledge, one of the first population-level solutions to use a Web-based approach, combining doctor and patient aligned incentives and information therapy, aimed at improving health and lower costs. Our analysis suggests that the MedEncentive MAIT Program was associated with meaningful reductions in health care utilization that were sustained into the third year of program implementation, through reductions in per capita expenditures and hospitalizations and emergency room use. These findings are in line with previous research on aligned-incentive program expenditure outcomes .Our quantitative analysis found that, from 2015 through 2017, after the program was introduced, hospitalizations and emergency room visits per 1000 plan members, and per capita expenditures, declined relative to the 2013-2014 preimplementation period, by 32.1%, 14.2%, and 10.8%, respectively. Correspondingly, the qualitative survey items suggested that the majority of respondents found the program’s educational content to be very helpful in managing their disease or condition, and maintaining good health. Since patient adherence is such an important predictor of health status, service utilization, and costs , it is cThese findings indicated that it was important to patients for their doctor to be aware that they (1) understand how to self-manage their health, and (2) are trying to accomplish health objectives. These reported attitudes help explain the quantitative outcomes and set the stage for aligned-incentive programs to leverage information therapy as a means to mitigate the impact of inadequate health literacy. It is notable that other health improvement initiatives were launched by the plan sponsor, principally in the 2016-2017 time frame. However, the most significant improvement in hospitalizations and emergency room rates was temporally associated with the introduction of the program in 2015.Program adoption and retention are predicated on its ease of implementation and maintenance. Over the test period, the plan sponsor experienced continuous program access 99.8% of the time, with no reports of degradation in the program’s website performance due to scaling or spikes in activity. The plan sponsor integrated the program with its clinic electronic health record system to streamline the provider experience. This integration functioned without difficulty throughout program implementation.The effectiveness of any wellness, prevention, or managed-care program relies on high levels of patient and medical provider engagement in aspects of the program designed to improve health and health care. As the program participation statistics indicate, this goal was achieved and sustained, aided by the collaborative efforts of the plan sponsor and MedEncentive.Study limitations should be considered when interpreting our findings. First, though these findings are compelling, they can only be generalized to not-for-profit, acute-care, general-hospital employee health plans, located in the south-central United States. Second, the primary limitation is the internal nature of the evaluation. Future research should focus on external review and validation. Third, while this study offers associated confirmation of the program’s effectiveness, it is not a randomized control trial and, therefore, falls short of the gold standard for determining causation; hence, further research is needed. Fourth, the conservative analysis may be considered a limitation, compared with more complex analyses ; however, this was prohibited so as to remain compliant with institutional review board standards. Fifth, this evaluation did not control for individual health literacy, but we contend that, statistically, the majority of the general population have inadequate or marginal health literacy and require health information support, such as information therapy; therefore, this program supports health literacy needs at the universal level and measures relevant and meaningful associated outcomes. Future research should control for health literacy. Sixth, we made adjustments to normalize postimplementation expenditures to baseline levels in consultation with the plan sponsor. These adjustments reflect known variances in medical services coding, pricing, charge capture, and benefit design. The precision of these adjustments is difficult to judge, which is further justification to test the program’s capabilities by means of randomized control trials. Finally, although this was an opt-in study design, loss to follow-up can be an issue in cohort studies. Our study, however, included patients who used care throughout the study time frame.P<.05). Our qualitative analysis of participant survey responses corroborated these findings. Therefore, it is reasonable to conclude that the effectiveness of the program was evident in this study. Findings warrant investment in larger, longer-running randomized control trials to further examine and validate these results.Use of the Web-based MedEncentive MAIT Program was associated with a reduction in hospitalizations  and emergency room visits  per 1000 members. The plan’s annual per capita expenditures declined US $675 (95% CI US $470-865), or 10.8% ($675/$6260), after program implementation in 2015-2017 (US $5585 in 2013-2014 dollars), relative to the baseline year of 2014 (US $6260;


The maximum adsorption capacities, evaluated using the Langmuir isotherm equation, were 36.53 mg/g and 40.37 mg/g for As (III) and As (V), respectively. The pseudo-second-order model fitted the kinetic data better, with R2 more than 0.99 for both As (III) and As (V). The removal of As (V) decreased with the increase in pH, especially when the pH was above 9, whereas for As (III), the removal effectiveness almost remained constant at both acidic and neutral pHs. H2PO4− and SiO32− could strongly inhibit arsenic adsorption onto the WTRs, and the effect of other ions was little.Water treatment residuals (WTRs), obtained from a groundwater treatment plant for biological iron and manganese removal, were investigated and used as adsorbents for arsenic removal. The surface morphology and structural features of the WTRs were characterized by scanning electron microscopy (SEM), transmission electron microscopy (TEM), X-ray diffraction (XRD), and Brunauner–Emmett–Teller analysis (BET). Laboratory experiments were also carried out to test the adsorption capability and adaptability of WTRs on both As (III) and As (V) removal from the water. The results showed that the WTRs were mainly amorphous and had a large specific surface area of 253.152 m Arsenic pollution in water is a global concern due to its toxicity and chronic effects on human health. Long-term exposure to arsenic-contaminated water increases the risk of the development of cardiovascular and hematological diseases, and cancers of the liver, lung, and skin . The souVarious arsenic-removal techniques have been developed, including precipitation, coagulation, membrane separation, ion exchange, lime softening and adsorption. Among these methods, adsorption and coagulation are the most promising and are widely used in the developing world , but theCompared with the three aforementioned wastes, Water Treatment Residuals (WTRs)—which are produced during the backwashing process from biofilters for iron and manganese removal in groundwater treatment plants—are the most promising, since they are not hazardous waste. At present, there are many biological iron and manganese removal water treatment plants in China, so large quantities of WTRs must be produced annually, and their treatment, disposal, and application need further research .This study aimed to examine the adsorption behaviors of WTRs from waterworks for iron and manganese removal. More attention was paid to the characteristics of WTRs, and batch experiments were conducted to investigate the kinetics and isotherm characteristics of As (III) and As (V) adsorption onto WTRs.2+ and 0.8–1 mg/L for Mn2+, and 0.2 mg/L for TFe, 0.01 mg/L for Fe2+ and 0.02 mg/L for Mn2+. The backwashing water was collected and settled for several days, then thickened in the bottom, filtered with filter paper, and finally air-dried naturally. After that, it was crushed and sieved with 100 mesh screens to obtain a particle size under 147 um, then stored in a desiccator with blue silica gel particles for further analysis and experiments.WTRs  were tak2HAsO4·7H2O and sodium arsenite NaAsO2. The working solutions were prepared by diluting stock solutions with deionized water before use. NaOH and HCl with concentrations of 0.01 M, 0.1 M, and 1 M were used to adjust solution pH. Reaction vessels were cleaned with 1% HNO3 and rinsed several times with deionized water before use. Potassium borohydride and thiourea were of guarantee grade and solutions were prepared before use.All chemicals used in this work were above analytical grade and purchased from Beijing Chemical Co. All solutions were prepared with deionized water. As (V) and As (III) stock solutions were prepared with disodium hydrogen arsenate Naα radiation (l = 1.79026 A) at a 2θ range of 0–90°, and the operated current and voltage were 40 mA and 40 kV, respectively. The specific surface area of the WTRs was determined through nitrogen adsorption–desorption measurements . Chemical bond and functional group information was analyzed using a Fourier transform infrared spectrometer . The zero-charge point (pHpzc) was determined using the drift method [3 solutions (100 mL) with different initial pH values (4.0–10.0) and reacted for 24 h, and the final pH values of solutions were tested. Then a curve correlated with the ΔpH and initial pH was plotted and the point where the curve crossed the axis determined the pHpzc of the WTRs.The samples of WTRs were characterized using the following method: microscopic examinations were conducted using a HITACHI S-4700 scanning electron microscope (SEM) with an Energy Dispersive Spectrometer (EDS) and a transmission electron microscope (TEM) . The X-ray diffraction (XRD) pattern was recorded on a diffractometer , using Co Kt method . A samplTo measure adsorption kinetics, 0.1 g of WTRs was added into polyethylene vessels containing 1000 mL solutions with 1 mg/L of initial arsenic (III) and arsenic (V) concentrations. The experiments were conducted at 25 °C on a mechanical orbit shaker at 100 rpm for 48 h. Samples were taken from the mixture at different time intervals.t is the contact time of the adsorption test (h), qe (mg/g) and qt (mg/g) are the adsorption capacity at equilibrium status and at any time t, respectively, and k1 (1/h) and k2 (g/(mg·h)) are the rate constants of the two models, respectively. In order to get more information about the kinetic characteristics of WTRs for adsorbing As (III) and As (V), to further understand the mechanism of the adsorption process, the research data were respectively fitted using the pseudo-first-order kinetic model and pseudo-second-order kinetic model given in Equation (1) and Equation (2).3. The samples were taken after 12 h of contact on a mechanical orbit shaker at 100 rpm for 12 h at 25 °C. To measure the adsorption isotherms, 0.1 g of WTRs was added into stopper glass bottles containing 1000 mL As (V) solution and 500 mL As (III) solution, with different initial concentrations (from 0.1 mg/L to 50 mg/L) and a constant ionic strength of 0.01 M NaNOqe (mg/g) is the As concentration adsorbed on the WTRs, qm (mg/g) is the maximum adsorption capacity of WTRs, ce (mg/L) is the equilibrium As concentration in solution, KL (L/mg) is a constant related to the affinity of binding sites, KF (mg/g) is a rough indicator of the adsorption capacity, and 1/n is a heterogeneity factor.To further understand the interaction between arsenic and WTRs, the data for the isotherm adsorption for As (III) and As (V) were fitted using the isotherm models of Langmuir and Freundlich given in Equation (3) and Equation (4).To measure the influence of the initial solution pH, a series of stoppered conical flasks containing 1000 mL of 1mg/L As (V) solution were prepared and 0.1 g of WTRs was added into every flask. Also, flasks containing 500 mL of 2 mg/L As (III) were prepared and 0.2 g of WTRs was added. The initial pH was adjusted in the range of 3.0–11.0 by adding solutions of NaOH or HCl. The samples were taken after 12 h of contact on a mechanical orbit shaker at 100 rpm for 12 h at 25 °C. 42−, HCO3−, SiO32− and H2PO4−) were also tested. A series of stoppered conical flasks containing 1000 mL of 1 mg/L As (V) solution was prepared and 0.5 g of WTRs was added into every flask. Also, flasks containing 500 mL of 2 mg/L As (III) were prepared and 0.5 g of WTRs was added. The specified concentrations of each coexisting ion were controlled at 0.1, 1, and 10 mmol/L. The samples were taken after 12 h of contact on a mechanical orbit shaker at 100 rpm for 12 h at 25 °C. All water samples were filtered using a 0.45 um membrane before test. Three parallel tests were conducted for each test, and the average value was taken for analysis.The effects of common coexisting anions . Three parallel aqueous samples were prepared and an average of these three measured Arsenic concentration values was used for analysis.2/g according to the Brunauner–Emmett–Teller (BET) analysis model, and such a large specific surface area is particularly conducive to adsorption. On the basis of International Union of Pure and Applied Chemistry (IUPAC) classification, the adsorption isotherm of WTRs was almost type Ⅳ with hysteresis loop type H3, having adsorption curve characteristics of typical mesoporous materials. The BJH desorption cumulative volume of pores between 1 nm and 300 nm diameter was 0.2199 cm3/g, and the BJH desorption average pore diameter was 3.6914 nm. The specific surface area of WTRs was determined using the nitrogen adsorption method a,b. It w2+ in natural water [The previous research showed that iron oxides are easy to form by the oxidation of Feal water , but othal water . The resSEM was an efficient method to check the surface morphology of WTRs. It can be seen in pzc of the WTRs was 6.7, so the surface of WTRs could exhibit a positive or a negative charge. When the pH of the solution was below or above 6.7, it greatly influenced the reaction between WTRs and arsenic [Experiments showed that the pH arsenic .As we know, there are usually three stages during the adsorption process for the porous adsorbent , and thiIt can be seen from 2 0.992 and 0.998 compared with 0.985 and 0.887, respectively. The results indicate that there was a chemical mechanism between arsenic and the WTRs during the adsorption process.The adsorption data of both As (III) and As (V) were fitted better b using a2 of the Langmuir model was 0.982 and 0.994 for As (III) and As (V), respectively, compared with results of 0.974 and 0.973 in the Freundlich model for As (III) and As (V), respectively. Actually, the value of R2 for both models was high. The adsorption could be fitted by both models. As can be seen from The maximum adsorption capacities calculated by the Langmuir model were 36.53 mg/g and 40.37 mg/g for As (III) and As (V), respectively. This revealed that the studied WTRs showed very high maximum adsorption capacities compared with other iron and manganese oxide adsorbents . The As 2AsO4− to HAsO42− and AsO43−, which made the electrostatic repulsion between arsenate and WTRs (negative charge under the condition of pH > 6.7) bigger. However, for arsenite, the influence was little, not only in the acidic and neutral environments, but also in the alkaline environment, and it remained at about 60% during the whole experiment. Firstly, in the acidic condition, due to the form of undissociated H3AsO3, the adsorption of arsenite on iron oxides did not change a lot and it was ineffective compared with arsenate. Secondly, in the alkaline environment, the reason why the removal rate did not decrease a lot like arsenate was that there might be some manganese dioxide in the WTRs, so it could oxidize As (III) to As (V) and result in the release of Mn2+ cations, which then could be adsorbed on the WTRs, give a positive charge and benefit the adsorption of arsenic [pH is important in the adsorption process, and the results about the effect of initial solution pH on arsenic removal are as follows : for ars arsenic .42−, HCO3−, SiO32− and H2PO4− often coexist with arsenic. Furthermore, the effect of these anions was as follows: the removal rate was more or less not affected by SO42−. For SiO32− and H2PO4−, they caused a big drop of 7.1% and 11.4% for As (III), and 27.4% and 32.1% for As (V) during the range of anion concentration from 0.1 mmol/L to 1 mmol/L, because these two anions could form an inner-sphere complex with iron oxide, and compete with arsenic anions. In particular, the molecular structure of H2PO4− was very similar with arsenate and arsenite, because As and P elements are in the same main group in the periodic table. However, for HCO3−, though it could form an inner complex with iron oxide, and the increase in pH value caused by HCO3− in the water could enhance the electrostatic repulsion between As anions and WTRs, the removal rate did not decrease so much, ranging from 91% to 79%, then 58% for As (III), and from 73% to 63%, then 55% for As (V), with the concentration of HCO3− ranging from 0.1 mmol/L to 1 mmol/L, then 10 mmol/L. The main reason is that the shared charge of As was smaller than that of HCO3−, which made the WTRs have a stronger affinity with As over HCO3− [In the natural water environment, many anions such as SOer HCO3− .It can be seen from FTIR  that WTRUp to now, it was thought that this arsenic adsorption by WTRs included two mechanisms: physical adsorption and chemical specific adsorption. Their large specific surface area and large amount of –OH are the most important reasons for the strong arsenic adsorption capacity of WTRs.WTRs—by products of the groundwater treatment plant for biological iron and manganese removal—were used as arsenic adsorbents from a water solution. The characterization of WTRs was conducted and laboratory experiments were also carried out to evaluate their arsenic adsorption behaviors. With maximum adsorptions of 36.53 mg/g and 40.37 mg/g for As (III) and As (V), respectively, WTRs should be considered as a promising low-cost adsorbent for the purification of arsenic-containing water solutions, and this would also provide a novel and feasible solution for the treatment and disposal of backwashing sludge wastes from groundwater treatment plants for iron and manganese removal.


Of 37 pediatric rheumatology fellowship training programs in the United States, many have three or fewer fellows at a given time, making large-scale assessment of fellow performance difficult. An objective structured clinical examination (OSCE) is a scenario-based simulation method that assesses individual performance, thus indirectly measuring training program effectiveness. This study describes the development and implementation of two national pediatric rheumatology OSCEs and methods used for programmatic improvement.OSCEs for pediatric rheumatology fellows were held in 2009 and 2011 during national rheumatology meetings using scenarios and assessment forms originally developed by a fellowship program director. The seven scenarios tested medical knowledge, physical exam and interpersonal skills. Pediatric rheumatologist evaluators assessed fellows’ performance using checklists and gave immediate feedback. Program directors were sent summaries of their fellows’ performances. Fellows evaluated the OSCE, providing organizational and scenario improvement suggestions. Programmatic changes to the 2011 OSCE were based on 2009 performance data and program evaluation feedback.Twenty-two fellows participated in 2009 and 19 in 2011. Performance scores in similar scenarios did not change considerably over the two iterations. In 2009, 85.7% of participants reported desire to change clinical behavior. Assessors’ 2009 program evaluation data prompted changes in rating scales and removal of invalid or unreliable assessments. Negative evaluation data about individual stations decreased from 60% in 2009 to 15.4% in 2011. Fellows’ ratings of the experience’s overall value were similar in 2009 and 2011. The average experience ratings were lower among fellows who proposed scenario-specific improvements and higher among those who recommended organizational improvements.The 2011 examination exhibited programmatic improvement via reduction in fellows’ scenario-specific negative feedback. Fellows’ overall satisfaction did not change. Further work in scenario selection, assessment validation and inter-rater reliability will improve future pediatric rheumatology OSCEs. Pediatric rheumatology is a small subspecialty in the U.S. with only 37 accredited three-year fellowship programs in 2018 and 90 active trainees in 2016  from other institutions (networking).” Nine reported that the best parts of the experience were receiving immediate feedback and the opportunity to get perspectives from attending physicians outside their own fellowship program.For both years, fellows comments were coded as positive or negative and as scenario-specific or organizational. Many of the 2009 organizational comments, such as the time of day of the PROSCE, were difficult to change, though in response to a complaint about the time allotted between scenarios, two breaks were added in 2011. Some 2009 scenario-specific complaints suggested concrete improvements and were rectified for 2011. The proportion of scenario-specific improvement suggestions decreased from 60% in 2009 to 15.4% in 2011. 35% of all 2009 program complaints were related specifically to the joint injection station compared to 3.6% of 2011 program complaints. Therefore, revising individual stations per 2009 evaluation data decreased scenario-specific suggestions for 2011, which was one of our improvement goals.Fellows rated the overall value of the PROSCE experience as 75.9 in 2009 and 75.5 in 2011 on a VAS scale of 100, so our goal to improve this rating was not met. However, both groups rated the PROSCE highly and recognized valuable aspects of the experience. One 2011 fellow gave a negative evaluation about the general process and an overall experience rating much lower than others (21 on VAS) bringing the 2011 average down considerably. The average PROSCE experience ratings were lower among fellows giving scenario-specific improvement suggestions and higher among fellows offering suggestions relating to overall organization.Our experience shows that running a national OSCE starting as a “homegrown effort” using scenarios and checklists developed by one expert and local volunteers is feasible. However, the time and effort required to plan an OSCE should not be underestimated. Financial support for administrative staff and for organizing physicians, some protection from clinical responsibilities during planning months was necessary.While many OSCEs use standardized patients, our PROSCE used real patients for various roles. Past studies have suggested that volunteer patients perform well in simulated encounters and that children participating in these types of examinations have a good sense of interpersonal dynamics and can provide effective feedback, but ethical implications exist –21. MoreThe PROSCEs were the first opportunity to compare clinical skills of pediatric rheumatology fellows across institutions and provide feedback to program directors. Although differences in training affected assessment results, almost all fellows agreed that the experience was valuable. We removed ranking as a performance measure in 2011: checklists and global rating scales are chief OSCE scoring rubrics, not comparison of fellow performance .Fellow performance data beyond what is reported in Table Program directors appreciated the data received from this novel assessment method, particularly about the ACGME competencies. The Pediatric Milestones Project , a jointThe next PROSCE is tentatively planned to be held in conjunction with the ACR’s Pediatric Rheumatology Symposium in 2020. The planning committee includes pediatric rheumatologists with formal training in medical education, fellowship directors and fellows from across the country. This committee’s work will be informed by medical education literature about performance based assessments and standardized patients , 22–26.Revisions will allow future performance data to be interpreted more meaningfully. Validation of scenarios and checklists will improve content, construct and face validity and ensure that stations test skills generally enforced across all programs. We will calculate psychometric statistics on previous performance data and develop more stringent guidelines to minimize bias and improve inter-rater reliability. Prior to the PROSCE, we will ask assessors to rate videos of fellows at various skill levels performing scenarios and provide scores from expert assessors to improve reliability. New content, including a scenario testing a fellow’s ability to accurately collect a patient’s history of joint pain will be added and fellows will be provided scenario information ahead of time. Checklist items will be mapped to specific competencies and milestones, keeping the novice-to-expert assessment scale. These changes will further assist program directors and clinical competency committees with global assessment and ACGME milestone reporting.In this report, we discuss the development of two iterations of a pediatric rheumatology OSCE in which fellows practiced skills and received immediate formative feedback. The PROSCE is invaluable for small fellowship programs that cannot organize an objective assessment on such a scale. Other subspecialties interested in designing a similar assessment can emulate this process. Although formal OSCE reliability and validity methods were not used, scenario content validity was increased in 2011 by modifications based on participant feedback. Improvement in scoring reliability was challenging to prove, but rater training was improved in 2011. The experience provided important practice and feedback for fellows and program directors while gathering suggestions for future iterations. We assert that improvement of scenario simulation exercises can occur in real time using plan-do-study-act cycles. Our long-term goal is to administer the PROSCE more frequently with ongoing programmatic improvement to further benefit pediatric rheumatology fellowship education as a whole.


Whether the final properties of large earthquakes can be inferred from initial observations of rupture (deterministic rupture) is valuable for understanding earthquake source processes and is critical for operational earthquake and tsunami early warning. Initial (P‐wave) characteristics of small to moderate earthquakes scale with magnitude, yet observations of large to great earthquakes saturate, resulting in magnitude underestimation. Whether saturation is inherent to earthquake dynamics or rather is due to unreliable observation of long‐period signals with inertial seismic instrumentation is unclear. Seismogeodetic methods are better suited for broadband observation of large events in the near‐field. In this study, we investigate the deterministic potential of seismogeodetically derived P‐wave amplitude using a dataset of 14 medium‐to‐great earthquakes around Japan. Our results indicate that seismogeodetic P‐wave amplitude is not a reliable predictor of magnitude, opposing the notion of strong determinism in the first few seconds of rupture. Seismogeodesy provides a more accurate P‐wave amplitude than high‐pass filtered seismic‐only methods due to its broadband sensitivity.Magnitude saturation from P‐wave characteristics is inherent to large earthquake dynamics and not due to instrumental limitations.P‐wave amplitude measurements are not predictive of final magnitude for medium‐to‐large magnitude earthquakes. Earthquake magnitude is of first order importance in ground motion prediction, thus, reliable characterization of magnitude in the early seconds of observation is a major target for EEW. The timeliness of source size estimates for EEW is particularly important for large continental earthquakes, where major faults coincide with population centers  and warning lead times are especially short.deterministic of final properties). One possibility is that the dynamic stress drop at rupture initiation, or initial rupture surface area, is proportional to the energy flow that advances rupture, and therefore initial rupture observations are indicative of the probability of rupture extent  in Japan, each observed by at least 22 collocated GNSS and accelerometer seismic stations  KiK‐net and K‐NET datasets. GNSS data were retrieved from the Geospatial Information Authority (http://www.gsi.go.jp), which operates the GNSS Earth Observation Network System (GEONET). We consider strong‐motion accelerometer and GNSS station pairs to be collocated if they are within 2 km of one another. In Japan, more than 300 such station pairs exist. This inter‐instrument distance is a conservative criterion based upon previous work demonstrating agreement between instrument pairs with up to 4 km separation . The P‐wave arrival times were selected manually from the vertical acceleration waveforms at each site. The accelerometer stations are operated in triggered‐mode, sometimes resulting in late triggers such that the records at some stations begin after the first P‐wave arrivals. If a record appears to begin after the P‐wave arrival, the station pair is eliminated from the analysis. As a result, the number of collocated stations used to study each earthquake is reduced to between 22 and 84 sites per event (Table The high‐rate 1 Hz) GEONET observations were processed using precise point positioning , E(t), and U(t) are the north‐south, east‐west, and up‐down component displacement waveforms, respectively. An example of the maximum P‐wave amplitude selection for two example station pairs during the 2011 Mw9.1 Tohoku‐oki mainshock can be found in Figure PV and a 3‐s observation period in the main text, with remaining results available in the Supporting Information. A fixed time window is important for potential operational utilities , however we note that this choice results in sampling a different portion of the source process for earthquakes of different magnitude. For example, a fixed window of 5 s may sample the full duration of a Mw6 event, but only the initial moment release of an Mw7 (rupture duration ~30 s).We consider observation periods of 3 and 5 s after P‐wave arrival time following Crowell et al. , and evaTo investigate whether magnitude saturation is due to the loss of the long‐period band as a result of typical high‐pass filtering practices of integrated inertial seismic observations, we compare the broadband, unfiltered seismogeodetic combination to the same waveforms filtered with a corner period of 13 s, as is typical of seismic‐only analyses  determined by previous studies . The observations of earthquakes of large magnitude overlap, and no clear pattern is visible. For example, the observations for the M9 Tohoku‐oki earthquake overlap with earthquakes as small as M7.5. This result is in contrast with the previous study by Crowell et al.  measured in either the first 3 or 5 s after the P‐wave arrival for any component considered, whether filtered or unfiltered  values to estimate Mw would be poorly constrained given the overlap of log (Pd) values across many magnitudes  appear indistinguishable this early  in the rupture process, which is consistent with the magnitude saturation typical of seismic‐only observations and previous work describing the expected behavior of P‐wave amplitudes at these observation windows  thresholds. The subject of MMI‐style warning times derived from earthquake source estimates has been previously investigated assuming the case where final earthquake properties are known instantaneously  began markedly differently, with slow rupture and little slip for nearly a minute prior to ramping up to become a great, long‐duration earthquake  earthquakes that have been recorded with collocated seismic and GNSS instrumentation. Presently, the M6Previous study of a limited, global dataset suggested that magnitude saturation is not inherent to large earthquake dynamics, but rather is due to unreliable observation of long‐period signals using inertial seismic instrumentation. Seismogeodetic methods allow full spectral fidelity in the observation of large magnitude events, providing a broadband dataset with which to evaluate whether P‐wave amplitude is indicative of final earthquake magnitude. Using a larger dataset of medium‐to‐great earthquakes, and limiting our study area to reduce regional effects, we have shown that seismogeodetically derived P‐wave amplitude is not a reliable predictor of magnitude, opposing the notion of strong determinism in the first few seconds of rupture. Instead, we find that magnitude saturation from P‐wave metrics measured in the first few seconds is inherent to large earthquake dynamics, and is not a consequence of instrumental limitations.Supporting Information S1Click here for additional data file.