Using short information leaflets as recruitment tools did not improve recruitment: a randomized controlled trial

ObjectiveTo assess if the type of patient information leaflet (PIL) received at an initial invitation to participate in a randomized trial influences the number of patients recruited.Study Design and SettingA randomized controlled trial was used to compare the effects of short or full PILs on recruitment in a primary care setting. Patients invited to take part in the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy study through a database mail out were randomly allocated to receive one of two types of PIL.ResultsThe type of PIL received with the initial invitation did not influence recruitment. Of those receiving the short PIL, 5.4% were recruited compared with 5.1% in the full PIL group. The difference in proportions between the groups was not statistically significant (mean difference = 0.3%; 95% confidence interval [CI] = ?1.5%, 2.2%; P = 0.75). Secondary analyses on the numbers of ineligible patients showed a statistically significant difference between the groups in favor of the full PIL group, which yielded fewer ineligible patients (P = 0.04; mean difference = 1.4%; CI = 0.03%, 2.8%).ConclusionProviding patients with shorter PILs when inviting them to participate in research does not affect the numbers who are subsequently recruited and yields more ineligible patients. Therefore, it is recommended to use the full PIL as a recruitment tool.     

Burnout among mental health professionals: A Tunisian experience

BackgroundBurnout syndrome consists in physical as well as mental exhaustion observed in professionals whose work involves continuous contact with other people. Psychiatrists and psychiatry nursing staff are considered to be vulnerable to experiencing burnout. The purposes of this study aim to investigate the prevalence of burnout syndrome in practitioners, residents and nurses working in the psychiatric hospital of Tunisia. It also aims to investigate the relationship between burnout, depression, and a variety of personal variables, including age, gender, marital, parental and personal difficulties within this population.MethodsA cross-sectional study was conducted among the nursing staff (n = 54), residents (n = 41) and practitioners (n = 11) in Razi hospital in Tunisia. The Maslach Burnout Inventory, the Beck depression inventory and a general questionnaire on demographic data were used.ResultsHigh levels of burnout were detected among nurses. This was true for the emotional tiredness sub-scale (mean score: 26.18); the depersonalization subscale (mean score: 10.20) and for the alteration of personal achievements (mean score: 32.94). High scores in emotional tiredness were correlated to depression (P = 0.000; R = 0.56) and to personal difficulties (P = 0.021; R = 0.31) in this group. Residents showed high scores in personal achievements (mean score: 32.56), and practitioners did not reach the cutoff scores on the Maslach Burnout Inventory.ConclusionOur results are somewhat comparable to those of studies in other countries. Burnout syndrome was highly prevalent among nurses and residents. This study corroborates former results of a relation between depression and burnout. A strong relationship was found between personal difficulties and burnout, but seemed to be more specific to the nursing sample.     

Temporal changes in the nature of disability: U.S. Army soldiers discharged with disability, 1981-2005

BackgroundWe sought to (1) document and describe the relative proportion of disabilities by major type over the study period, (2) describe the population at risk for different types of disability, and (3) document and describe the type of compensation (an indicator of severity) awarded for different types of disability and any temporal changes in these associations.MethodsTime-series, logistic regression analyses, and direct standardization of rates were used to study 108,119 active-duty Army soldiers discharged with permanent disability between 1981 and 2005.ResultsOf all disability, 91% is captured within the top five most prevalent types of disability: musculoskeletal (72%, n = 77,418), neurological (6%, n = 6,896), mental health (5%, n = 5,075), cardiovascular system (4%, n = 4,429), and respiratory (4%, n = 4,202). Musculoskeletal disability rates are increasing rapidly (+2.5% per year); neurological and cardiovascular disability rates are decreasing (−1.3% and −10.0% annually, respectively), and respiratory and mental health disability rates did not change significantly. Demographic risk factors vary by disability type. At greatest risk for musculoskeletal disability were female soldiers, soldiers who were between the ages of 21 and 35 years, white, in lower- to mid-level enlisted ranks with relatively short service tenure, and soldiers without a college education. Compensation awards also varied by disability type: Overall, 77% (n = 83,320) received separation with severance pay, 15% (n = 16,107) received a permanent disability retirement, and 8% (n = 8,692) received separation without benefits. Separation with severance pay was the largest and fastest growing disability disposition for all disabilities and for musculoskeletal disability specifically.ConclusionsDemographic risk factors vary by type of disability and by compensation award. Musculoskeletal disability rates are rapidly increasing as is separation with severance pay—particularly among white, young, lower ranking female soldiers.     

Readability and Missing Data Rates in CAHPS 2.0 Medicare Survey in African American and White Medicare Respondents

PurposeTo examine associations between readability of survey items and missing data rates in a sample of white and African-American Medicare enrollees in managed care plans.MethodsConsumer Assessment of Healthcare Provider and Systems (CAHPS) 2.0 health plan survey data collected from 139,284 respondents (127,524 whites and 11,760 African Americans) in 321 health plans. Product-moment correlations were computed between Flesch-Kincaid (F-K) readability estimates and the CAHPS item-missing data rates.ResultsF-K reading levels for items ranged from 4.8 to 17.7 with a mean of 8.9 across items. Missing data rates ranged from 1% to 10%, with African Americans having significantly higher missing data rates. Correlations between missing data rates and item-level readability were statistically significant for whites (r = 0.33, P = .0515) and African Americans (r = 0.37, P = .0284).ConclusionsThe significant associations between missing data rates and item-level readability estimates indicate that the completion of survey items varies by their readability. Enhancing the readability of survey items can improve the inclusion of survey data collected from different respondents.     

An assessment of the effectiveness of growth monitoring and promotion practices in the Lusaka district of Zambia

ObjectiveWe evaluated the effectiveness of the growth monitoring and promotion (GMP) program in Zambia.MethodsA 3-mo prospective study of growth outcomes was undertaken at randomly selected health facilities and community posts within the Lusaka district. Children <2 y old (n = 698) were purposively sampled from three health facilities (n = 459) and four community posts (n = 77) where health workers had undergone training in GMP and three health facilities where staff had not received training (n = 162). Qualitative data on knowledge, attitudes, and practices of GMP were collected from health facility managers (n = 6), health workers (n = 35), and mothers whose children attended all follow-up visits (n = 27).ResultsAnthropometric status of children in all groups deteriorated, with children at community posts having the worst outcomes (change in weight-for-age Z-score ?0.8 ± 0.7), followed by trained (?0.5 ± 0.6) and untrained (–0.3 ± 0.47; P < 0.05) health facilities. A similar trend was seen for weight for length. The overall dropout rate was 74.1%. Weight-for-age Z-scores were higher at 1- and 2-mo follow-up visits for children who did not complete the study at trained health facilities and community posts compared with those who remained in the study. Mothers/caregivers identified GMP as important in attending the under-five clinic, associated their child's weight with overall health status, and expressed a willingness to comply with health workers' advice. However, health care providers were poorly motivated, inadequately supervised, and demonstrated poor practices.ConclusionsThe GMP program in Lusaka is functioning suboptimally, even in facilities with trained staff.     

The HIV epidemic among industrial male miners in Guinea: prevalence, associated factors and trends from 2001 to 2007

BackgroundTo estimate HIV prevalence, associated factors and trends from 2001 to 2007 among male miners in Guinea.MethodsTwo hundred and eighty-six male miners in 2001 and 579 in 2007 were tested for HIV and interviewed about their lifestyles and sexual practices. Investigations were conducted in the five mining companies operating in the country. A standard questionnaire was used for collecting data and SAS Windows 9.2 version (SAS Institute, Cary, North Carolina, USA) for statistical analysis.ResultsMedian age was 45 years in 2001 and 39 years in 2007 (P = 0.001). HIV prevalence was 4.5% (95% Confidence Interval [95% CI]: 2.1–7.0) in 2001 and 6.4% (95% CI: 4.4–8.4) in 2007. In multivariate analysis, HIV prevalence was associated with history of sexually transmitted infections (STIs) (Prevalence Ratio [PR] = 2.21; P = 0.03), and with paying for sex (PR = 6.01; P = 0.04), whereas it was significantly higher in divorced, separated or widowed men. HIV prevalence increased but not significantly between 2001 and 2007, whereas casual sex (P = 0.03) and counseling activities against HIV (P < 0.0007) decreased.ConclusionHIV prevalence is high in this population and, although not statistically significant, the increase observed between 2001 and 2007 is worrying in a context where the population of miners became younger over time. Prevention of HIV/AIDS has to be reinforced among miners in Guinea.     

Screening for depression in an elderly population living at home. Interest of the Mini-Geriatric Depression Scale

BackgroundDepression is the most usual mental disorder in the elderly, but underdiagnosed and undertreated. Its prevalence is variable. Symptoms of depression present in the elderly can be masked and difficult to recognize. The purpose of this study was to examine prevalence and risk factors for depression in elderly living in their home.MethodsA cross-sectional study of randomly selected homes in randomly selected geographical islets was carried out Monastir City (Tunisia). Questionnaire-based interviews were conducted among the elderly aged more than 65 years living in their home. Depression symptoms were assessed using a Mini-Geriatric Depression Scale. The relationship between the risk of depression and sociodemographic and health-related variables was studied using logistic regression.ResultsOut of 598 (female 66 %, mean (SD) age 72.3 (7.4) years) elderly persons interviewed, 136 (22.7 %) were screened to have a Mini-Geriatric Depression Scale more than or equal to 1. Multiple logistic regression analysis revealed that the following were significant (P < 0.01) independent predictors of risk of depression: female sex (OR = 2.36 [95 % CI = 1.43–3.94]), having a low level of education (OR = 4.02 [95 % CI = 1.38–11.65]), disability (OR = 3.50 [95 % CI = 1.94–6.46]), a history of stroke (OR = 2.90 [95 % CI = 1.20–7.72]) and the use of hypnotic medications (OR = 2.47 [95 % CI = 1.38–4.42]).ConclusionThis study suggests that the risk of depression is a common psychiatric disorder in elderly living in their home, and underlines the usefulness of the Mini-Geriatric Depression Scale to detect the risk of depression in the elderly. This clinical approach should be encouraged in all medical practices to improve the prognosis of depression in the elderly.     

HIV-1 test acceptance within the prevention of mother-to-child HIV-1 transmission program in Democratic Republic of Congo

BackgroundHIV-1 testing and counselling are essential activities that must be integrated into mother-to-child HIV transmission prevention programs (PMTCT) in order to identify women who can benefit from the treatment, immediately or later and from interventions that can prevent HIV in their infants. The aim of this study was to describe how women's attitudes influence acceptance of HIV-1 testing in the context of antenatal care.MethodsFour hundred and thirty-nine women attending antenatal care clinics offering HIV-1 testing in the health district of Lubumbashi in Democratic Republic of Congo were included in the study. Data were collected through interviewer-administered questionnaire. Women were asked to give their consent for a home visit and interview of their partners; 143 agreed to participate. Statistical analyses were carried out using Chi-square test and logistic regression.ResultsThe proportion of pregnant women who declared that they would accept HIV testing was 76.5%. Non-married women (p = 0.046), women who had never carried out a former HIV test (p < 0.001), who had mentioned that they would wish to share the results of the test with their partner or would wish to be accompanied at least once by their partner at the antenatal clinic (p < 0.001), those whose partner agreed to participate in the study (p = 0.010) and those who knew at least one mode of HIV transmission (p = 0.025) were more likely to accept the HIV testing.ConclusionImproving counselling and a policy of HIV counselling and testing integrating a couple components could help to overcome obstacles to the integration of the women within PMTCT programs and help improve acceptance of HIV testing.     

Lower utilization of cervical cancer screening by nurses in Taiwan: a nationwide population-based study

ObjectiveUsing a nationwide population-based database in Taiwan, this study compares use of Pap smear testing by nurses and the general population.MethodWe compared 1093 practicing female nurses and 5465 randomly selected female patients from the 2006 National Health Insurance (NHI) database to evaluate the likelihood of receiving at least one Pap smear during a three-year period.ResultsWe found that 48.9% of the nurses and 56.2% of comparison subjects received a Pap test from 2004 to 2006 in Taiwan. Regression analysis showed that practicing female nurses were less likely to receive a Pap smear compared with the general population (OR = 0.42, 95% CI = 0.35–0.50, p < 0.001), after adjusting for monthly incomes, number of ob/gyn ambulatory care visits, urbanization level and the geographic location of the communities where subjects resided.ConclusionNurses were less likely to undergo cervical screening than the general population, despite ease of access and a national health insurance system providing universal coverage to residents of Taiwan. Efforts to raise the Pap screening rate among nurses may require addressing unique cultural and occupational concerns.     

How to weight chronic diseases in multimorbidity indices? Development of a new method on the basis of individual data from five population-based studies

ObjectiveIn multimorbidity indices, chronic conditions are often weighted according to their severity or their impact on different outcomes. These weights are mostly developed on the basis of only one study population by using very specific study participants, such as hospital patients. To overcome the limited validity of the indices, mean weights across five population-based studies were calculated according to the impact of diseases on self-reported health status.Study Design and SettingIndividual data was provided from the National Health Interview and Examination Survey (n = 1,010), Dortmund Health Study (n = 281), Memory and Morbidity in Augsburg Elderly Study (n = 385), Survey of Health, Aging and Retirement in Europe Study (n = 1,278), and Study of Health in Pomerania Study (n = 962). By using logistic regression analysis, odds ratios (ORs) were calculated for reporting a fair or poor health status resulting from one of 10 different chronic conditions compared with a reference group without the specific disease, controlling for age and sex. If the results were homogenous across studies (I² < 40%), significant pooled ORs were considered valid weights for a multimorbidity index.ResultsMyocardial infarction has the highest impact on self-reported health status across studies with a pooled OR of 3.9, followed by chronic obstructive pulmonary disease (pooled OR: 3.1). A medium impact was observed for arthrosis, asthma, diabetes mellitus, and osteoporosis.ConclusionThis method provided valid weights for seven chronic conditions.     

Correlates of moderate-to-vigorous physical activity among preschoolers during unstructured outdoor play periods

ObjectiveQuantify moderate-to-vigorous physical activity (MVPA) and its correlates in preschool children during outdoor unstructured play periods using direct observation.MethodsCross-sectional data consisting of 204 observation periods collected from 51 four- and five-year-old children using the Observation System for Recording Physical Activity in Children — Preschool (OSRAC-P) at a preschool in southern California, autumn and spring 2009–2010. Gender and BMI classification and OSRAC-P environmental codes were related to observed MVPA in multiple logistic regression models.ResultsLess than 21% of intervals were spent in MVPA overall. Boys and normal weight children engaged in higher intensity levels than their respective counterparts. More MVPA was associated with normal weight (OR = 2.49–3.25, R² = 3%), location (grass, playground, looping cycle path; OR = 3.21–4.90, R² = 4–12%), play context (ball/objects, wheel, open space; OR = 2.78–8.51, R² = 9%), and group composition (solitary, one-on-one; OR = 1.34–2.08, R² = 1%).ConclusionOpen spaces located in playgrounds and grass fields, and activity-genic portable equipment, manipulative objects, and riding vehicles are some design and equipment features that appear to foster MVPA. Lowering play space density and engaging children through teacher prompts and teacher-arranged activities may further increase MVPA on playgrounds.     

Nonalcoholic fatty liver disease is associated with insulin resistance in a young Hispanic population

ObjectiveTo investigate whether nonalcoholic fatty liver disease (NAFLD) is associated with insulin resistance (IR) in a young Hispanic population.MethodsA cross-sectional study was performed in Bogotá, Colombia, during 2006 in 263 males from the Colombian Air Force (age range 29–54 years). Anthropometric measurements and biochemical determinations (glycemia, lipid profile, insulin, and HOMA-IR) were obtained in order to determine the presence of metabolic syndrome (MS) criteria and insulin resistance in this population. In addition, ultrasound studies were performed to evaluate the presence of NAFLD.ResultsNAFLD was detected in 26.6% (n = 70) of the subjects. Thirty four individuals had complete MS criteria (48.5%). The presence of NAFLD was associated with higher insulin levels (11.0 ± 5.1 vs. 6.6 ± 3.6, p = 0.001), and its prevalence increased from 11% (n = 8), to 24% (n = 17) to 64% (n = 45) from the lowest to the highest HOMA-IR tertile. Body mass index, triglycerides and subcutaneous and visceral fat were found to be independent predictors of NAFLD.ConclusionsThese results suggest that NAFLD is associated with insulin resistance and extrahepatic adiposity in nondiabetic young Hispanic population.     

The effect of a smoke-free campus policy on college students' smoking behaviors and attitudes

ObjectiveTo evaluate the impact of a smoke-free campus policy on college students' smoking behaviors and attitudes.MethodsThe current study utilized repeated cross-sectional surveys with a nested 4-wave longitudinal cohort design. Data were collected from undergraduate students at two large matched public universities in Indiana before and after one of the campuses went smoke-free in January 2008. Baseline data were collected in fall 2007 (n = 3266) and follow-up data were collected in fall 2009 (n = 3207). In addition, volunteers provided longitudinal follow-up data at four different time points.ResultsIn the cross-sectional analyses, students exposed to the smoke-free campus policy demonstrated significant favorable changes in smoking behavior (16.5% to 12.8%, p < 0.001), perceptions of peer tobacco use (73.6% to 66.8%, p < 0.001), and smoking norms (45.5% to 40.4%, p < 0.001) compared to students on the control campus. In the longitudinal analyses, students exposed to the smoke-free campus policy demonstrated these changes plus significant favorable changes in attitudes toward regulation of tobacco (83.2% to 89.9%, p < 0.01).ConclusionsThe implementation of a smoke-free campus policy may be an effective intervention for reducing tobacco use among college students.     

Evolution of cardiovascular diseases' admissions in cardiology departments of Lomé hospitals: a cross-sectional study on 7959 patients from June 2004 to May 2009

BackgroundTo determine the frequency of cardiovascular diseases, their risk factors as well as their evolution in two cardiology departments of Lomé.MethodsThis cross-sectional study was carried out among patients attending two cardiology departments of Lomé, from June 2004 to May 2009, who had a diagnosis of cardiovascular disease.ResultsA total of 7959 patients were included. Female gender predominated. The mean age was of 49.5 ± 17.2 years. The number of admissions increased from 958 in 2004 to 2399 in 2009. Arterial hypertension (62.7%) and ischemic heart diseases (10.6%) were the most frequent diagnoses. Among patients with a diagnosis of heart failure, the etiology was not recorded for 12.2%. Overweight and dyslipidemia were significantly more frequent in women (P < 0.001), while smoking and physical inactivity were significantly more frequent in men (P < 0.001). During the period, there was a moderate rise of the prevalence of overweight, dyslipidemia, and physical inactivity, whereas the prevalence of diabetes and smoking remained almost unchanged.ConclusionAdmissions for cardiovascular diseases increased from 2004 to 2009. This epidemiological transition may be related to poor awareness of cardiovascular disease among the low-income population and the financial burden of health care.     

Empatía médica en residentes y tutores de medicina familiar y comunitaria. La visión del profesional y del paciente

AimTo determine the degree of clinical empathy among family medicine residents and tutors. To gauge whether there is a relationship between physicians’ self-perceived empathy levels and their patients’ assessments.Study designObservational, cross-sectional survey.LocationPrimary Care Teaching Unit. Madrid.ParticipantsA survey was sent by email to all the Teaching Unit's family medicine tutors and residents. Responses were received from 50 residents (39.4%) and 41 tutors (45%). In addition, 428 patients were opportunistically recruited at a healthcare centre and their doctors were also interviewed.Primary measurement instrumentsEmpathy was measured using the Jefferson Scale of Empathy and the Jefferson Scale of Patient Perceptions of Physician Empathy.ResultsThe tutors scored 2.53 points higher for cognitive empathy than the residents (P = .04). Emotional empathy scores declined among older tutors (r =  −0.32; P = .05). The Spanish students (82% of the total) without previous work experience scored higher for overall empathy (P = .02). Final-year residents recorded significantly worse empathy assessments than the other residents. A positive correlation (r = 0.72; P = .01) was observed between physicians’ self-perceived empathy and their patients’ perceptions.ConclusionsResidents with previous work experience, final-year residents and those of Latin American origin score lower for empathy. There is a strong relationship between physicians’ self-perceived empathy and their patients’ views of their empathy levels.     

The effect of two types of sms-texts on the uptake of screening mammogram: a randomized controlled trial

ObjectiveTo compare the effect of two different types of short text message service (SMS-text) reminders on the uptake of screening mammogram.MethodsA randomized controlled trial was conducted in 2010 among females aged between 40 and 75, benefiting from the Health Insurance Plan at the American University of Beirut, whose cell phone numbers were available in their electronic medical records, and who did not do a mammogram in the past 2 years. The sample (n = 385) was randomly divided into two subgroups. The first subgroup (n1 = 192) received a general SMS-text inviting its members to do a mammogram while the second subgroup (n2 = 193) received an additional informative SMS-text informing them about the benefits of mammogram screening.Results30.7% (59) of subgroup 1 and 31.6% (61) of subgroup 2 underwent a mammogram screening test during the 6 months follow up interval post-intervention (Chi-square test, p-value ≥ 0.05). There was no difference between the response rates in the two subgroups.ConclusionA brief invitation SMS-text message for screening mammogram was found to be as effective as a detailed informative one.     

Athletic identity, affect, and peer relations in youth athletes with physical disabilities

BackgroundTheory-based investigations of the psychosocial aspects of youth participation in disability sport are underresearched, suggesting a need for more scholarly inquiry in this area. We sought to examine athletic identity, affect, and peer relations of youth athletes with physical disabilities and selected relationships among these variables.MethodsParticipants (N = 36) completed the Private-Public Athletic Identity Scale, the Positive and Negative Affect Schedule, and the Peer Relations Scale.ResultsParticipants reported stronger private athletic identity individual item scores (mean ≈ 4.0) compared with a public (mean = 2.4) athletic identity and expressed much positive (mean = 4.4) affect and low negative affect (mean = 1.7). They also expressed strong peer relations (mean = 5.0). A significant relationship (r = 0.34, p < .05) between positive affect and peer relations existed.ConclusionsFriendships in and outside of disability sport may contribute to quality of life by promoting positive affective states such as feelings of joy, satisfaction, inspiration, excitement, and enthusiasm. In general, our results supported the potentially positive role that adapted sport can have on the well-being of youth with physical disabilities.     

Author's specialty and conflicts of interest contribute to conflicting guidelines for screening mammography

ObjectiveTo examine the relationship between guideline panel members’ conflicts of interest and guideline recommendations on screening mammography in asymptomatic, average-risk women aged 40–49 years.Study Design and SettingWe searched the National Guideline Clearinghouse and MEDLINE for relevant guidelines published between January 2005 and June 2011. We examined the disclosures and specialties of the lead and secondary authors of these guidelines, as well as the publications of the lead authors.ResultsTwelve guidelines were identified with a total of 178 physician authors from a broad range of specialties. Of the four guidelines not recommending routine screening, none had a radiologist member, whereas of the eight guidelines recommending routine screening, five had a radiologist member (comparison of the proportions, P = 0.05). A guideline with radiologist authors was more likely to recommend routine screening (odds ratio = 6.05, 95% confidence interval = 0.57–∞, P = 0.14). The proportion of primary care physicians on guideline panels recommending routine vs. nonroutine screening was significantly different (38% vs. 90% of authors; P = 0.01). The odds of a recommendation in favor of routine screening were related to the number of recent publications on breast disease diagnosis and treatment by the lead guideline author (P = 0.02).ConclusionRecommendations regarding mammography screening in this target population may reflect the specialty and intellectual interests of the guideline authors.     

An evaluation of patient-reported outcomes found computerized adaptive testing was efficient in assessing stress perception

ObjectivesThis study aimed to develop and evaluate a first computerized adaptive test (CAT) for the measurement of stress perception (Stress-CAT), in terms of the two dimensions: exposure to stress and stress reaction.Study Design and SettingItem response theory modeling was performed using a two-parameter model (Generalized Partial Credit Model). The evaluation of the Stress-CAT comprised a simulation study and real clinical application. A total of 1,092 psychosomatic patients (N1) were studied. Two hundred simulees (N2) were generated for a simulated response data set. Then the Stress-CAT was given to n = 116 inpatients, (N3) together with established stress questionnaires as validity criteria.ResultsThe final banks included n = 38 stress exposure items and n = 31 stress reaction items. In the first simulation study, CAT scores could be estimated with a high measurement precision (SE < 0.32; ρ > 0.90) using 7.0 ± 2.3 (M ± SD) stress reaction items and 11.6 ± 1.7 stress exposure items. The second simulation study reanalyzed real patients data (N1) and showed an average use of items of 5.6 ± 2.1 for the dimension stress reaction and 10.0 ± 4.9 for the dimension stress exposure. Convergent validity showed significantly high correlations.ConclusionsThe Stress-CAT is short and precise, potentially lowering the response burden of patients in clinical decision making.