Mining Treatment Termination Data in an Adolescent Mental Health Service

SUMMARY

This study utilizes available clinical information from client records to explore patterns of termination from mental health treatment among adolescents at an urban outpatient mental health center. The analysis focuses on how and why adolescents terminate from treatment and identifies variables associated with “acknowledged” and “unacknowledged” terminations. Findings indicate that termination was acknowledged infrequently, often a brief process that occurred almost as frequently by telephone as in the context of treatment. Contrary to “practice wisdom” concerning treatment termination, adolescents who “dropped out” without a “clinical process” reported considerably more engagement in treatment than those who acknowledged the termination of treatment. Recommendations for a more “open door” policy and a more flexible practice with adolescents are discussed.     

The comprehensive diagnostic study is suggested as a design to model the diagnostic process

ObjectivesThe classical diagnostic cross-sectional study has a focus on one disease only. Generalist clinicians, however, are confronted with a wide range of diagnoses. We propose the “comprehensive diagnostic study design” to evaluate diagnostic tests regarding more than one disease outcome.Study Design and SettingWe present the secondary analysis of a data set obtained from patients presenting with chest pain in primary care. Participating clinicians recorded 42 items of the history and physical examination. Diagnostic outcomes were reviewed by an independent panel after 6-month follow-up (n = 710 complete cases). We used Shannon entropy as a measure of uncertainty before and after testing. Four different analytical strategies modeling specific clinical ways of reasoning were evaluated.ResultsAlthough the “global entropy” strategy reduced entropy most, it is unlikely to be of clinical use because of its complexity. “Inductive” and “fixed-set” strategies turned out to be efficient requiring a small amount of data only. The “deductive” procedure resulted in the smallest reduction of entropy.ConclusionWe suggest that the comprehensive diagnostic study design is a feasible and valid option to improve our understanding of the diagnostic process. It is also promising as a justification for clinical recommendations.     

A need to expand our thinking about "repeat" abortions

BackgroundWomen who have more than one abortion are often the “targets” for social and clinical interventions geared at preventing “repeat abortions.” Such an approach ignores the unique circumstances that may surround each abortion.Study DesignWe qualitatively analyzed the history of 10 women who have had more than one abortion who were participating in a larger study of women's emotional experiences following abortion. Women were recruited following their initial contact with a postabortion support talk line and from a previously completed study.ResultsOverall, women in the sample reported that each abortion was different and some abortions were more emotionally difficult than others, suggesting that the phrase “repeat” can be a misnomer and discounts the unique circumstances surrounding each abortion.ConclusionRather than use the term “repeat abortions,” we advocate for the use of the less loaded term “multiple abortions,” in which each abortion is understood as a unique experience.     

Toward System-Wide Implementation of Patient-Reported Outcome Measures: A Framework for Countries,States, and Regions

ObjectivesThis study aimed to develop a framework facilitating (1) the maturity assessment of healthcare systems regarding patient-reported outcome measure (PROM) implementation and (2) the comparison of different healthcare systems’ PROM implementation levels to guide discussions and derive lessons for regional, state-level, and national PROM initiatives.MethodsGuided by the grounded theory methodology, a PROM healthcare system implementation framework was developed following multiple steps. Based on interviews with 28 experts from 12 countries and a literature review, a framework was drafted and refined through 29 additional validation interviews.ResultsThe resulting framework comprises 5 implementation stages along 7 dimensions. Implementation stages range from “first experimentation” to “system-wide adoption and a vibrant ecosystem.” The dimensions are grouped into patient-reported outcome (PRO) measurement and PRO utilization, the former with the dimensions “scope and condition coverage,” “metric and process standardization,” and “tools and information technology–based solutions” and the latter with “patient empowerment and clinical decision support,” “reporting and quality improvement,” and “rewarding and contracting.” The “culture and stakeholder involvement” dimension connects both groups. Although a concerted implementation approach across dimensions can be observed in advanced countries, others show a more uneven adoption.ConclusionsThe framework and its preliminary application to different healthcare systems demonstrate (1) the importance of coherent progress across complementing dimensions and (2) the relevance of PROM integration across clinical specialties and care sectors to strengthen patient-centered care. Overall, the framework can facilitate dialogues between stakeholders to analyze the current PROM implementation status and strategies to advance it.     

Measures of success of computerized clinical decision support systems: An overview of systematic reviews

IntroductionAlthough increasing number of clinical decision support systems (CDSSs) were introduced, a lack of rigorous evaluations of information systems (IS) success limits these systems’ usage and diffusion. The purpose of this overview is to identify specific features which are critical to information system success based on the updated DeLone & McLean IS Success Model from published systematic reviews (SRs) over the last 10 years.MethodsThis systematic review was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.ResultsThere were 39 measures were synthesized from 45 SRs published during 2009–2020 and were classified into 16 categories and 6 dimensions. The most frequently displayed dimension was “net benefit”, which was divided into four categories: “process of care”, “professional competency”, “patient outcomes” and “cost-effectiveness”. Very limited publications summarized evaluation metrics under the remaining five dimensions, excepted “validity” in “system performance” category and “acceptance” in “use behavior” category.ConclusionThe findings of this overview may have meaningful and useful implications to the evaluation of CDSSs. Future research needs to focus on developing a comprehensive evaluation framework through summarizing evaluation metrics on the base of theoretical model, which is critical to CDSSs development, utilization and research. Furthermore, multi-centered, large sample size and long-term follow up studies are required to ensure more reliable evidence on patient outcomes of CDSSs usage.     

Profiles of Met and Unmet Needs in People with Dementia According to Caregivers’ Perspective: Results from a European Multicenter Study

ObjectivesThis exploratory study aimed at investigating profiles of care needs in people with mild to moderate dementia and examined variables associated with these profiles.DesignA longitudinal international cohort study.Setting and ParticipantsThe baseline data of 447 community-dwelling dyads of people with dementia and their caregivers from the Access to Timely Formal Care (Actifcare) Study were included for analysis.MethodsA latent class analysis was applied to identify profiles of needs, measured with the Camberwell Assessment of Need for the Elderly as rated by the caregiver. We examined sociodemographic (eg, relative stress scale) and clinical characteristics (eg, neuropsychiatric inventory) associated with these profiles.ResultsFour distinct need profiles were identified through latent class analysis. These comprised a “no need” profile (41% of the sample), a “met psychological needs” profile (25%), a “met social needs” profile (19%), and an “unmet social needs” profile (15%). A larger impact of caregiving on the caregiver's life as indicated by a higher relative stress scale score was associated with the “unmet social needs” profile.Conclusions and ImplicationsIn this large European sample, there was a subgroup of persons with dementia with high “unmet social needs” whose caregivers simultaneously perceived high stress in their caregiving tasks. Identification of these profiles may help provision of appropriate support for these people.     

Equidad y autonomía del paciente en las estrategias de atención a personas con enfermedades crónicas en los servicios de salud de España

ObjectiveTo examine the chronic care models of the different Spanish health services and to discuss the ethical questions derived from implementing some of their components.MethodNarrative review of care strategies and programmes for chronic patients in the different Autonomous Communities, searching in official health departments’ web pages, using the terms “Programmes”, “Strategies”, “Chronic patients”, and “Chronicity”.Results15 programmes were found. Most of them include all components of the chronic care model, “decision-making support” being under-represented. The main conflicts in the autonomy of patients arise from the use of big data to stratify the population and from telemonitoring. The stratification of population does not consider the social factors that accompany the disease.ConclusionsChronic care strategies should consider the autonomy and privacy of patients in the use of clinical data and telemonitoring. In order to be equitable, they would have to provide an integrated health care system, incorporating measures to reduce the inequalities due to the social determinants that accompany the disease.     

Development,validation and transfer to clinical practice of a mobile application for the treatment of smoking

ObjectiveThe main objective is to transfer to clinical practice a new smoking cessation application (“Vive sin Tabaco” a) in all health centers of the public Basque Health Service.DesignAn implementation study of a smoking cessation program previously validated. After implementation, a retrospective study has been carried out to evaluate its use under normal conditions.SiteThe process of transfer to clinical practice has been held in several phases; first a pilotage in four health centers of Alava and subsequently, when all reported incidents were resolved, it was extended to all health centers of the Basque Health Service.Intervention and main measurementDevelopment of “Vive sin Tabaco”; a corporate tool for smoking cessation, and its transfer to clinical practice. All interested health care workers received training on how to use the application. User manuals for both patients and professionals were developed. Smoking cessation rates at 12 months during implementation were also collected.ResultsThe percentage of patients of post pilot phase who quit smoking at 12 months was 14.1%.ConclusionsThe conception of “Vive sin tabaco” as a corporate tool for smoking cessation, available in all health centers of Basque Health Service, has been long and arduous, and has required the participation of health professionals and patients as end-users in order to obtain a tool that adapts to their expectations and guarantees greater usability and satisfaction. This application is being effective as an adjuvant tool to health advice.     

Using the RE-AIM Framework in Formative Evaluation and Program Planning for a Nutrition Intervention in the Lower Mississippi Delta

ObjectiveIdentification of prominent themes to be considered when planning a nutrition intervention using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.DesignQualitative formative research.SettingWomen's social and civic organizations in the Lower Mississippi Delta.ParticipantsThirty-seven (5 white and 32 black) women with a college degree or higher.Phenomenon of InterestImpact of dietary and contextual factors related to the Lower Mississippi Delta culture on intervention planning.AnalysisCase analysis strategy using question-by-question coding.ResultsMajor themes that emerged were “healthy eating focus” and “promoting a healthy lifestyle” when recruiting organizations (Reach); “positive health changes” as a result of the intervention (Effectiveness); “logistics: time commitment, location, and schedule” to initiate a program (Adoption); “expense of healthy foods” and “cooking and meal planning” as barriers to participation (Implementation); and “resources and training” and “motivation” as necessary for program continuation (Maintenance). The “health of the Delta” theme was found across all dimensions, which reflected participants' compassion for their community.Conclusions and ImplicationsResults were used to develop an implementation plan promoting optimal reach, effectiveness, adoption, implementation, and maintenance of a nutrition intervention. This research emphasizes the benefits of formative research using a systematic process at organizational and individual levels.     

Consequences of Screening in Lung Cancer: Development and Dimensionality of a Questionnaire

ObjectiveThe objective of this study was to extend the Consequences of Screening (COS) Questionnaire for use in a lung cancer screening by testing for comprehension, content coverage, dimensionality, and reliability.MethodsIn interviews, the suitability, content coverage, and relevance of the COS were tested on participants in a lung cancer screening program. The results were thematically analyzed to identify the key consequences of abnormal and false-positive screening results. Item Response Theory and Classical Test Theory were used to analyze data. Dimensionality, objectivity, and reliability were established by item analysis, examining the fit between item responses and Rasch models.ResultsEight themes specifically relevant for participants in lung cancer screening results were identified: “self-blame,” “focus on symptoms,” “stigmatization,” “introvert,” “harm of smoking,” “impulsivity,” “empathy,” and “regretful of still smoking.” Altogether, 26 new items for part I and 16 new items for part II were generated.These themes were confirmed to fit a partial-credit Rasch model measuring different constructs including several of the new items.ConclusionIn conclusion, the reliability and the dimensionality of a condition-specific measure with high content validity for persons having abnormal or false-positive lung cancer screening results have been demonstrated. This new questionnaire called Consequences of Screening in Lung Cancer (COS-LC) covers in two parts the psychosocial experience in lung cancer screening. Part I: “anxiety,” “behavior,” “dejection,” “sleep,” “self-blame,” “focus on airway symptoms,” “stigmatization,” “introvert,” and “harm of smoking.” Part II: “calm/relax,” “social network,” “existential values,” “impulsivity,” “empathy,” and “regretful of still smoking.”     

Homicide,schizophrénie et abus de substances : des liaisons dangereuses ?

Background and aimThe prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia.MethodsA systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms “schizophrenia”, “psychotic disorders”, “homicide”, “violence”, “substance use disorder”, and the TIAB term “alcohol”. Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively.ResultsOf the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into “early-starters” and “late-starters” according to the age of onset of their antisocial and violent behavior. The violence of the “early-starters” is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the “late-starters”, the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not.ConclusionDefining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.     

Linking measurement error to minimal important change of patient-reported outcomes

ObjectiveTo provide a practical example showing how to relate measurement error to minimal important change (MIC) to estimate sample sizes required for detecting important changes in research, and to determine the usefulness of patient-reported outcomes (PROs) in daily clinical practice.Study Design and SettingThe standard error of measurement (SEM) can be calculated as a parameter of measurement error. MIC can be determined by taking the mean change in score on the questionnaire in the subgroup of patients that reported to be “a little better” or “better” on a global rating scale minus the mean change in score in the subgroup of patients that reported to be “not changed.” Based on SEM and MIC, formulas are presented that can be used to estimate sample sizes and to determine whether the questionnaire can be used to monitor changes in individual patients in daily clinical practice.ResultsA fully worked-out example is presented, using Western Ontario and McMaster University Osteoarthritis Index data from a cohort of patients undergoing hip or knee replacement.ConclusionWe strongly recommend investigators to present the SEM and MIC of PROs and use these to estimate sample sizes for research and to determine the usefulness of these outcomes in daily clinical practice.     

Food patterns of Australian children ages 9 to 13 y in relation to ω-3 long chain polyunsaturated intake

ObjectiveThe aim of this study was to examine food patterns of Australian children ages 9 to 13 y in relation to ω-3 long-chain polyunsaturated fatty acid (ω-3 LCPUFA) intake.MethodsSecondary analysis was conducted on nationally representative food data of 1110 Australian children ages 9 to 13 y (525 boys and 585 girls) that was obtained using two 24-h recalls. Principle component factor analysis was used to identify food patterns. Discriminant function analysis was used to identify the relationship between the food patterns and total ω-3 LCPUFA intake.ResultsFour major food patterns emerged for each sex. For boys these were labeled: “snack foods,” “soft drinks,” “vegetables,” and “pork and meat chops, steak, and mince.” For girls they were labeled: “vegetables,” “take-away,” “tea, coffee, iced coffee drinks” and “canned meals and soup.” Fish consumption bought from take-away outlets was more frequently consumed in the “soft drink” (r = 0.577) and take-away (r = 0.485) food pattern in boys and girls, respectively. In contrast, fish prepared at home was more often consumed in “vegetables” in both boys (r = 0.018) and girls (r = 0.106), as well as in the “pork and meat chops, steak and mince” food pattern in boys (r = 0.060). There was a trend that in boys, the “vegetables” group discriminated children who consumed ω-3 LCPUFA levels similar to adequate intakes (AI) (P = 0.067), whereas in girls, the take-away food pattern discriminated for being a fish consumer (P = 0.060).ConclusionsDietary patterns associated with a high consumption of vegetables and “take-aways” food that include meat and fish are likely to positively influence dietary ω-3 LCPUFA intake in Australian children.     

Meaning of the Terms “Overweight” and “Obese” Among Low-Income Women

ObjectiveTo determine how low-income, US women understand the meanings of the terms “overweight” and “obese.”MethodsLow-income women (n = 145; 72% white, 12% black, and 8% Hispanic; 59% obese and 21% overweight) each participated in an individual semi-structured interview during which they were asked to explain what the terms “overweight” and “obese” mean to them. Responses were transcribed and the constant comparative method was used to identify themes.ResultsThree themes emerged: (1) The terms are offensive and describe people who are unmotivated and depressed and do not care about themselves; (2) obese is an extreme weight (eg, 500 lb and being immobile); (3) being overweight is a matter of opinion; if a woman is “comfortable in her own skin” and “feels healthy,” she is not overweight.Conclusions and ImplicationsHealth education focused on obesity should consider that vulnerable populations might consider the terms “overweight” and “obese” offensive and stigmatizing.     

Using an analytical hierarchy process (AHP) for weighting items of a measurement scale: A pilot study

BackgroundMany clinical scales contain items that are scored separately prior to being compiled into a single score. However, if the items have different degrees of importance, they should be weighted differently before being compiled. The principal aims of this study were to show how the “analytic hierarchy process” (AHP), which has never been used for this purpose, can be applied to weighting the six items of the “London handicap scale”, and to compare the AHP to the “conjoint analysis” (CA), which was previously implemented by Harwood et al. (1994) [1].DesignIn order to assess the relative importance of the six items, we submitted AHP and CA to a group of 10 physiatrists. We compared the methods in terms of item ranking according to importance, assessment of fictitious patients based on weights determined by each method, and perceived difficulty by the physiatrist.ResultsFor both techniques, “Physical independence” (PHY) was the best-weighted item, but other ranks varied depending on the technique. AHP was better than CA in terms of accuracy (global assessment of the clinical status) and perceived difficulty.ConclusionAHP may be used to reveal the importance that experts assign to the items of a multidimensional scale, and to calculate the appropriate weights for specific items. For this purpose, AHP seems to be more accurate than CA.     

Diet Quality among the Brazilian Population and Associated Socioeconomic and Demographic Factors: Analysis from the National Dietary Survey 2008-2009

BackgroundEvaluating diet quality is a way to monitor a population’s adherence to dietary guidelines.ObjectiveTo adapt the Healthy Eating Index-2015 (HEI-2015) to the Brazilian population, to evaluate the validity and reliability of the adapted HEI-2015, and to assess diet quality of Brazilian adults as well as socioeconomic and demographic factors associated with diet quality.DesignIn this cross-sectional study, two dietary records from nonconsecutive days were used to obtain food intake information. The collected socioeconomic and demographic data included sex, age, education, per capita income, and residence area.Participants/settingA representative sample (n=27,760) of the Brazilian adult population participated in the Nutrition Dietary Survey 2008-2009.Main outcome measuresTotal and component scores for the adapted HEI-2015. The validity and reliability of the index were tested.Statistical analysis performedMean total and component scores were estimated for the adapted HEI-2015. Also, the proportion of subjects that achieved the maximum score for each component was calculated. Regarding validity and reliability analysis, principal components analysis examined the number of dimensions; Pearson correlations were estimated between total score, components, and energy, and Cronbach’s coefficient α was estimated. Diet quality was compared among socioeconomic and demographic categories.ResultsThe mean total score for the adapted HEI-2015 was 45.7 (95% CI: 45.4 to 46.0). Women had higher diet quality scores (46.4; 95% CI: 46.1 to 46.7) than men (44.9; 95% CI: 44.6 to 45.3). Age, education, and per capita income were directly associated with the adapted HEI-2015 total score. Greater than or equal to 50% of subjects received the maximum adapted HEI-2015 component scores for “total protein foods,” “seafood and plant proteins,” “fatty acids,” and “sodium.” In contrast, less than 30% of subjects received the maximum component scores for “total vegetables,” “dairy,” and “saturated fats.” Higher percentages of women received the maximum component scores for “total fruits,” “whole fruits,” “total vegetables,” “greens,” “dairy,” and “sodium,” whereas higher percentages of men received the maximum component scores for “total protein foods,” “seafood and plant proteins,” “fatty acids,” “added sugars,” and “saturated fats” components. Finally, validity analysis revealed weak correlations between component scores and energy and weak to moderate correlations with total scores; six dimensions were responsible for the total variance in diet quality and the standardized Cronbach’s coefficient α was .65 (unstandardized=.64).ConclusionsBrazilian adults have suboptimal diet quality as assessed by the adapted HEI-2015. Diet quality varied by socioeconomic and demographic factors. Results support the validity and the reliability of the index.     

Effect of glycemic index and glycemic load on energy intake in children

ObjectiveSeveral studies assessed the effect of glycemic index (GI) and glycemic load (GL) on energy intake in children but findings are not consistent in this regard. The aim of this study is to summarize and assess the evidence for the effect of GI and GL on energy intake by conducting a meta-analysis on published randomized clinical trials.MethodOur search process was conducted in PUBMED, Web of Science, and Google Scholar databases. The following keywords were searched in any part of published articles: “glycemic index” OR “glycaemic index” OR “glycemic load” OR “glycaemic load” OR “energy intake” AND “child” OR “children” OR “adolescent” OR “youth.”ResultsWe gathered 5099 articles. Non-clinical trial studies that did not intervene by GI or GL or those not assessing energy intake as a dependent variable and those that were conducted on patients over age 18 y were excluded. Each included study was evaluated three times and the exclusion criteria was checked. Eventually, six studies from 1999 to 2012 met the criteria (213 participants ages 4–17.5 y). There is heterogeneity in the study’s participants in the present paper. Children with type 2 diabetes, obesity, or normal-weight children were recruited in different studies. Overall effect of consuming low GI (LGI) and low GL (LGL) meals on energy intake was not significant. Subgroup analysis showed that LGI (not LGL) meals decreased subsequent energy intake, whereas heterogeneity was significant in the LGI group of studies. Although a slight asymmetry was shown by Begg’s funnel plot, the Egger’s asymmetry was not significant. We did not find any evidence of publication bias for studies assessing the effect of low GI or GL meals on energy intake.ConclusionConsuming LGI diet (not LGL) has favorable effect on reducing energy intake and obesity, subsequently.     

Cercarial Dermatitis

Cercarial dermatitis or “swimmers’ itch” is a maculopapular skin eruption associated with the penetration of the skin by cercaria of certain species of nonhuman schistosomes. It is globally distributed and affects those who work or play in fresh and salt water.

The etiology and epidemiology of the disease are similar to that of human schistosomiasis (bilharziasis). The trematode parasite passes through a life cycle that involves both warm-blooded and molluscan hosts.

The clinical manifestations of “swimmers’ itch” are principally associated with an intensely pruritic dermatitis that lasts five to ten days and becomes more severe with subsequent exposure. Prevention is directed toward control of the molluscan hosts and their supporting environment. Treatment is symptomatic.