Predicting attrition in a pediatric asthma intervention study

Infant Television Watching Predicts Toddler Television Watching in a Low-Income Population

OBJECTIVE

This study examines the development of active television (TV) watching behaviors across the first 2 years of life in a racially and ethnically diverse, low-income cohort and identifies caregiver and child predictors of early TV watching.

METHODS

We used longitudinal data from infants enrolled in the active control group (N = 235; 39% Latino; 29% Black; 15% White) of Greenlight, a cluster randomized multisite trial to prevent childhood obesity. At preventive health visits from 2 months to 2 years, caregivers were asked: "How much time does [child's first name] spend watching television each day?" Proportional odds models and linear regression analyses were used to assess associations among TV introduction age, active TV watching amount at 2 years, and sociodemographic factors.

RESULTS

Sixty-eight percent of children watched TV by 6 months, and 88% by 2 years. Age of TV introduction predicted amount of daily active TV watching at 2 years, with a mean time of 93 minutes if starting at 2 months; 64 minutes if starting at 4 or 6 months; and 42 minutes if starting after 6 months. Factors predicting earlier introduction included lower income, fewer children in household, care away from home, male sex, and non-Latino ethnicity of child.

CONCLUSIONS

Many caregivers report that their infants actively watch TV in the first 6 months of life. Earlier TV watching is related to sociodemographic factors yet predicts more daily TV watching at 2 years even controlling those factors. Interventions to limit early TV watching should be initiated in infancy.

Assessment of a University-Based Outpatient Asthma Education Program for Children

INTRODUCTION

To assess the effect of a pediatric asthma intervention program on reducing asthma morbidity.

METHODS

Study eligibility criteria included aged less than 18 years and at least two office visits for asthma in the previous year. Patients were randomly assigned to either the control or intent to intervene group. The intervention included home visits and education on the basic pathophysiology of asthma, self-management techniques, modification of asthma triggers, and proper use of asthma medications by a certified nurse educator.

RESULTS

Using simple randomization, 901 eligible pediatric patients with asthma were assigned; 458 to the control and 443 to the intent to intervene group. Of the 443 patients randomized to the intent to intervene group, 271 received the asthma education intervention. Most of the remaining 172 patients in the intent to intervene group did not receive the intervention owing to not having an appointment during the study period. Only 27 families allowed a home visit. After controlling for the difference in sex, children in the intent to intervene group had significantly less total clinic visits (incidence rate ratio [IRR] = 0.53, p < .01), and steroid bursts (IRR = 0.47, p < .01) than controls.

DISCUSSION

The implementation of a pediatric asthma education program decreased both the total clinic visits and the need for steroid bursts consistent with better asthma control. We demonstrated the benefit of a dedicated asthma educator in university-based community practice and recommend this intervention be considered a standard of care for children with asthma in all health-care settings.

A proposed standardized approach to studying attrition in pediatric weight management

Pediatric obesity is a major public health issue. Lifestyle and behavioral interventions are the foundation of pediatric weight management; however, intervention effectiveness is compromised when families (children, youth, and/or parent[s]) discontinue care prematurely. Intervention attrition minimizes the potential health benefits derived from interventions, results in inefficient use of health services resources, and can magnify health disparities. Most attrition research in pediatric weight management has been descriptive, highlighting the need to advance the field, both academically and clinically. Herein, we propose a standard approach to studying attrition in pediatric weight management interventions to enhance our understanding, elevate the quality of research, enable study-to-study comparisons, and inform strategies designed to mitigate its impact. We focus on three issues. First, "Conceptualization and operationalization," whereby the processes underlying attrition from interventions should be decomposed into clinically important phases that are defined based on intervention characteristics. Relatedly, theoretically relevant variables should be identified with different mechanisms driving attrition in each phase. We propose a matrix of attrition, a tool designed to delineate the relevant stages of attrition and associated variables of analytical value. Second, "Pre-study" underscores the value of developing a plan to study attrition a priori rather than post hoc, including variable and sample size considerations, which broadens the range and quality of analysis. Finally, "Post-study" emphasizes comprehensive reporting of attrition, outlines typical comparisons of analytical interest, and statistical techniques used to handle missing data. Implications for clinical practice in pediatric weight management are discussed. Clinical Trial Registration: Not applicable.

Predictors of successful telephone follow-up in a multicenter study of infants with severe bronchiolitis

PURPOSE

To identify the characteristics that predict successful telephone follow-up with parents of infants with severe bronchiolitis.

METHODS

We analyzed data from a 17-center, prospective cohort study of infants (age <1 year) hospitalized with bronchiolitis during three consecutive fall/winter seasons. Participant contact information and clinical data were collected during the index hospitalization. Parents were called at 6-month intervals (based on the child's age) after discharge to assess respiratory problems. The primary outcome was age 12-month telephone interview status. Participants were classified as unreachable after 28 days of unsuccessful attempts.

RESULTS

798 of 916 children (87%) completed the age 12-month telephone interview. In unadjusted analyses, factors associated with successful follow-up included: private health insurance, annual household income $60,000 or more, and residing in the Northeast, Midwest, or West. Follow-up was less common among non-Hispanic blacks, Hispanics, and households with 3 or more children. In multivariable analyses, follow-up was more likely among parents of females, and, compared with the South, in the Northeast and Midwest (all P < .05). Compared with non-Hispanic whites, non-Hispanic blacks and Hispanics remained less likely to complete the interview as did households with 3 or more children (all P < .05).

CONCLUSION

Sociodemographic and geographic factors predict successful telephone follow-up, even among parents of infants with severe illness.

Identifying the participant characteristics that predict recruitment and retention of participants to randomised controlled trials involving children: a systematic review

Background

Randomised controlled trials (RCTs) are recommended as the ‘gold standard’ in evaluating health care interventions. The conduct of RCTs is often impacted by difficulties surrounding recruitment and retention of participants in both adult and child populations. Factors influencing recruitment and retention of children to RCTs can be more complex than in adults. There is little synthesised evidence of what influences participation in research involving parents and children.

Aim

To identify predictors of recruitment and retention in RCTs involving children.

Methods

A systematic review of RCTs was conducted to synthesise the available evidence. An electronic search strategy was applied to four databases and restricted to English language publications. Quantitative studies reporting participant predictors of recruitment and retention in RCTs involving children aged 0–12 were identified. Data was extracted and synthesised narratively. Quality assessment of articles was conducted using a structured tool developed from two existing quality evaluation checklists.

Results

Twenty-eight studies were included in the review. Of the 154 participant factors reported, 66 were found to be significant predictors of recruitment and retention in at least one study. These were classified as parent, child, family and neighbourhood characteristics. Parent characteristics (e.g. ethnicity, age, education, socioeconomic status (SES)) were the most commonly reported predictors of participation for both recruitment and retention. Being young, less educated, of an ethnic minority and having low SES appear to be barriers to participation in RCTs although there was little agreement between studies. When analysed according to setting and severity of the child’s illness there appeared to be little variation between groups. The quality of the studies varied. Articles adhered well to reporting guidelines around provision of a scientific rationale for the study and background information as well as displaying good internal consistency of results. However, few studies discussed the external validity of the results or provided recommendations for future research.

Conclusion

Parent characteristics may predict participation of children and their families to RCTs; however, there was a lack of consensus. Whilst sociodemographic variables may be useful in identifying which groups are least likely to participate they do not provide insight into the processes and barriers to participation for children and families. Further studies that explore variables that can be influenced are warranted. Reporting of studies in this field need greater clarity as well as agreed definitions of what is meant by retention.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1415-0) contains supplementary material, which is available to authorized users.

Factors influencing attrition in a multisite, randomized, clinical trial following traumatic brain injury in adolescence

BACKGROUND

Attrition in longitudinal research negatively affects statistical power, disrupts statistical stability, and can produce unwanted bias.

OBJECTIVE

To investigate factors associated with shorter length of study participation and lower rates of study completion (ie, attrition) in a large, multisite, longitudinal, randomized, clinical trial examining the efficacy of a Web-based family problem-solving treatment following traumatic brain injury (TBI) in adolescence.

SETTING

Five major trauma centers in the central and western regions of the United States.

PARTICIPANTS

Children (N = 132) aged 12 to 17 years hospitalized for complicated mild to severe TBI within the previous 6 months.

RESULTS

Completers had a higher primary caregiver education and higher family income than noncompleters, whereas ethnicity, latency to baseline assessment, and intervention group were not significantly associated with study completion.

CONCLUSION

This is the first study that has specifically examined factors of attrition in a pediatric TBI population. The results suggest that research on pediatric TBI populations may be biased toward higher-income families and highlights the importance of designing studies with increased awareness of the impact of participant demographic factors.

An Electronic Asthma Self-Management Intervention for Young African American Adults

BACKGROUND

Health disparities are seen in many chronic conditions including asthma. Young African American adults represent a population at high risk for poor asthma outcomes due to both their minority status and the difficult transition from adolescence to adulthood. Recruitment and retention has been challenging in this demographic stratum, and traditional asthma education is often not feasible.

OBJECTIVE

The objective of this study was to develop and assess the feasibility of an electronic asthma self-management program for young African American adults.

METHODS

A total of 44 African American adults (age 18-30 years) with uncontrolled persistent asthma were enrolled in an asthma self-management program. The 6-week Breathe Michigan program (predicated on the social cognitive theory) was tailored specifically to the concerns and preferences of young African American adults. The entire program was completed electronically, without any specialized human support. At 2 weeks and 3 months after program completion, participants were contacted for follow-up.

RESULTS

A total of 89% of enrolled subjects completed the 6-week intervention, and 77% were available for evaluation at 3 months. All subjects completing the 2-week postprogram survey reported that the program was helpful, and 97% would recommend it to others. Asthma control as measured by the Asthma Control Test improved from 16.1 to 19.3 (P < .01), and asthma quality of life as measured by the Mini Asthma Quality of Life Questionnaire improved from 4.0 to 5.1 (P < .01).

CONCLUSIONS

The Breathe Michigan program is feasible for recruitment and retention, and demonstrated an improvement in asthma control and quality of life for young African American adults.

Improving retention of very old participants in longitudinal research: experiences from the Newcastle 85+ study

Background

People aged 85 and over are often excluded from research on the grounds of being difficult to recruit and problematic to retain. The Newcastle 85+ study successfully recruited a cohort of 854 85-year-olds to detailed health assessment at baseline and followed them up over 3 phases spanning 5 years. This paper describes the effectiveness of its retention strategies.

Methods

Primary retention strategies involved meticulous management of contact information and active maintenance of contact with participants between research visits and between phases of the study. For statistical analysis, data on post-inclusion attrition over the 3 follow-up phases was separated into ‘death’ and ‘withdrawal’ categories, with sub-categories ‘health’ and ‘non-health’ reasons created for ‘withdrawal’. Multinomial logistic regression was used to determine if particular socio-demographic and health characteristics were associated with post-inclusion attrition due to withdrawal at each of the 3 phase-to-phase transition points.

Results

For both sexes, at successive follow-up phases there was a decrease in attrition due to withdrawal and an increase due to death. Withdrawal was most prevalent between baseline and phase 2. Across the 5 years of the study total post-inclusion (post-baseline) attrition due to death accounted for a 40% (344/854) loss to cohort and total post-inclusion attrition due to withdraw a 19% (166/854) loss to cohort, with health reasons for withdrawal becoming more dominant over time. Adjusting for sex, parsimonious modelling showed only occupational class (National Statistics Socio-economic Classification) to be associated with withdrawal and only between baseline and phase 2 (routine/manual compared to managerial (OR 3.41; 95% CI [1.23 to 9.44]).

Conclusion

Following successful recruitment, we retained a high proportion of participants from a very old age group over 5 years of longitudinal research. No strong predictors of post-inclusion attrition due to withdrawal were found, suggesting the general effectiveness of our retention strategies.

Intervention completion rates among African Americans in a randomized effectiveness trial for diet and physical activity changes

BACKGROUND

The intervention completion rate is an important metric in behavioral and intervention research; trials with limited intervention completion rates may have reduced internal validity. We examined intervention completion rates among 530 African Americans who had been randomized to an integrated (INT) or disease-specific (DSE) risk education protocol as part of a comparative effectiveness trial from September 2009 to August 2012.

METHODS

The interventions were developed by an academic-community partnership using community-based participatory research. Intervention completion rates were determined based on attendance at all four intervention sessions. Intervention completers were participants who completed all four sessions and noncompleters were those who did not complete any session or only completed one to three sessions following randomization.

RESULTS

Seventy-three percent of participants were intervention completers and 27% were noncompleters. There were no differences in intervention completion based on randomization to INT (72%) or DSE (75%), sociodemographic factors, or body mass index (BMI) in the total sample. Different factors were associated significantly with intervention completion within study groups. Among participants randomized to INT, the odds of intervention completion were greater with higher levels of intrinsic motivation, less exposure to information about diet and cardiovascular disease, and greater BMI. Among participants randomized to DSE, the odds of completing the intervention were associated significantly with older age and greater dietary self-efficacy.

CONCLUSIONS

Many African Americans are likely to complete risk education interventions.

IMPACT

Psychologic characteristics should be considered when determining intervention completion rates following randomization in behavioral and intervention trials.

Factors associated with recruitment and retention of diverse children with asthma

This study examines factors associated with recruitment and retention of Latino, Dominican (DR) and mainland Puerto Rican (PR), and non-Latino white (NLW) families into a pediatric asthma study. Over eleven hundred (n=1185) families were screened, and 489 (n= 174 NLW, n= 160 DR, n= 155 PR) were enrolled. Rates of recruitment by source of recruitment and rates of retention differed by ethnic group. Families whose caregiver had never married had lower odds of completing the study. The findings highlight the need for further study to examine the effectiveness of specific recruitment and retention strategies with Latino and non-Latino white families.

Predictors of attendance in a practical clinical trial of two pediatric weight management interventions

The objective of this study was to evaluate demographic and psychosocial predictors of attendance in a family-based behavioral weight management clinical trial. Ninety-three children and adolescents aged 7-17 (Mean age = 11.59, s.d. = 2.6) who were either overweight or obese (Mean BMI percentile = 98.2) and their parents received either a 10-session behavioral treatment or a three-session brief family intervention in the context of a randomized clinical trial (10). Psychosocial and anthropometric measures were obtained before enrollment and at the end of 10 weeks for both treatment groups. Univariate linear regression and hierarchical multiple regression analyses were used to identify predictors of attendance to treatment from an a priori set of hypothesized predictors. Three variables demonstrated significant associations with the dependent variable, percent of treatment sessions attended. Specifically, distance from participant's home to treatment site, lower gross family income, and youth self-report of depressive symptoms were each associated with lower percent attendance (all Ps < 0.05). These results corroborate (i.e., income, depressive symptoms) and expand (i.e., distance from treatment site) previous reports in the literature of potential barriers to effective treatment for pediatric obesity, and suggest the need for research on treatment delivery methods that could increase participation among low-income families (e.g., eHealth, mHealth options). Depressive symptoms could represent an additional barrier to treatment attendance, suggesting that assessment and treatment for these symptoms may be appropriate before commencing weight management treatment.

Differences in recruitment and early retention among ethnic minority participants in a large pediatric cohort: the TEDDY Study

OBJECTIVE

The TEDDY Study is an international, multi-center prospective study designed to identify the environmental triggers of type 1 diabetes (T1D) in genetically at-risk children. This report investigates ethnic minority (EM) differences in patterns of enrollment and retention in the US centers.

METHODS

As of June 2009, 267,739 newborns had been screened at birth for high risk T1D genotypes. Data collected at the time of screening, enrollment and at the baseline visit were used. Descriptive and multiple-logistic regression analyses assessed differences between EM groups regarding exclusion, enrollment and early withdrawal.

RESULTS

Of the 10,975 eligible subjects, 6,912 (67%) were invited to participate. EM subjects were more likely to be excluded because of an inability to contact. Of those invited 3,265 (47%) enrolled by the age of 4.5 months. Adjusted analyses showed that except for those classified as other EM, the odds of enrolling were similar across groups. EM subjects had elevated early withdrawal rates. Adjusted models demonstrated that this was significantly more likely among Hispanic subjects.

CONCLUSION

Understanding patterns associated with EM participation in research extends our ability to make more accurate inferences and permits assessment of strategies that promote inclusion of EM to better address health disparities.

Dropout from computer-based interventions for children and adolescents with chronic health conditions

Dropout is a frequent problem in face-to-face psychological interventions. However, little is known regarding dropout in computer-based interventions (CBIs). It is important to understand the extent to which children and adolescents drop out of CBIs, so we can ensure that more people complete the programmes to gain maximum benefit. A systematic review of current research on dropout from CBIs identified 15 studies. Dropout rate ranged from 0 per cent to 54 per cent with a median of 15 per cent. There is a need for more rigorous investigation of the extent of, and reasons for, dropout from CBIs with children and adolescents with chronic health conditions.

The Environmental Determinants of Diabetes in the Young (TEDDY) study: predictors of early study withdrawal among participants with no family history of type 1 diabetes

OBJECTIVE

The Environmental Determinants of Diabetes in the Young (TEDDY) study seeks to identify environmental triggers of autoimmunity and type 1 diabetes mellitus (T1DM) in children at increased human-leukocyte-antigen conferred genetic risk for this disease. The objective of this study was to identify predictors of early withdrawal from TEDDY among families with no immediate family history of T1DM.

METHOD

Logistic multiple regression was used to discriminate 2994 (83%) families currently active in the TEDDY study for ≥1 yr from 763 (17%) families who withdrew in the first year. Data collected on the screening form at the time of the child's birth and from interview and questionnaire data obtained at the baby's first study visit (at ≤4.5 months of age) were used.

RESULTS

Significant and independent predictors of early withdrawal included country of residence, young maternal age, no father participation, and female gender of the study participant. Mothers of children who withdrew were more likely to report smoking during pregnancy, abstaining from alcohol, and reducing their work hours or not working at all during pregnancy. Mothers who withdrew were also more likely to underestimate their child's risk for T1DM and fail to respond to multiple items on the enrollment questionnaires or interview. Among mothers with accurate risk perceptions, those experiencing high anxiety about their child's risk were more likely to be early withdrawals.

CONCLUSIONS

Identifying families at high risk for study withdrawal at the time of enrollment allows for targeting these families with individually tailored plans to help maintain their participation in the study.

Publishing pilot intervention work

Pilot intervention studies can be viewed as rehearsals for subsequent full-scale trials. They can help investigators fine-tune later larger studies as well as explore issues related to project management and budget. Pilot studies permit testing of sampling strategies, participant recruitment, intervention content, delivery methods, data collection, and analysis. They also allow researchers to experience the more practical aspects of implementing a study, such as determining the number of study staff members needed to handle recruitment and data collection or identifying special equipment needs. Because pilot study findings may be generalizable, publication is encouraged as long as the preliminary nature of the work is clearly indicated in both the abstract and the article. The present article provides an overview of the types of information that can be gleaned from pilot intervention studies that are suitable for publication.

Adherence to pediatric asthma treatment in economically disadvantaged African-American children and adolescents: an application of growth curve analysis

OBJECTIVES

The primary aims of the study were to: (a) describe the trajectories of adherence to daily inhaled corticosteroid (ICS) medication for a year in economically disadvantaged, African-American youth with asthma based on growth curve modeling; and (b) test the relationship of treatment adherence to symptom control, quick-relief medication, and healthcare utilization.

METHODS

This prospective study measured adherence to daily ICS treatment using electronic monitoring in 92 children and adolescents with moderate to severe asthma for 9-12 months and assessed clinical outcomes, including asthma-related symptoms, quick-relief medication, and healthcare utilization.

RESULTS

Youth showed a decrement in treatment adherence to less than half of prescribed corticosteroid treatment over the course of the study, which related to increased healthcare utilization (p < .04), but not to asthma symptoms or albuterol use.

CONCLUSION

Economically disadvantaged youth with asthma demonstrate high rates of chronic nonadherence that warrant identification and intervention to reduce asthma-related healthcare utilization.

Adherence to combined montelukast and fluticasone treatment in economically disadvantaged african american youth with asthma

High rates of asthma treatment nonadherence have been reported, particularly in economically disadvantaged African American youth. The relationship between adherence to combined medication treatment and asthma outcomes has potential clinical significance but is not well understood. Using electronic monitoring, we describe the pattern of adherence to daily corticosteroid (fluticasone) and leukotriene receptor antagonist (montelukast) medication over the course of 1 year in a population of African American youth with moderate to severe asthma. On average, adherence to montelukast was higher than adherence to fluticasone (p < 0.01); however, for both medications, adherence rates significantly declined over the course of the study. After 1 year, participants took only 31% of prescribed doses of montelukast and 23% of prescribed doses of fluticasone. The decline in adherence to both fluticasone (p < 0.05) and montelukast (p < 0.001) was related to increased healthcare utilization. Furthermore, asthma symptom ratings were related montelukast (p < 0.001), but not fluticasone adherence. These results suggest that adherence promotion intervention strategies are warranted to improve health-related outcomes in families who are at-risk for treatment nonadherence.

Predictors of non-participation in a randomized intervention trial to reduce environmental tobacco smoke (ETS) exposure in pediatric cancer patients

BACKGROUND

Exposure to environmental tobacco smoke (ETS) is associated with the development of serious health consequences in children with cancer due to preexisting disease and treatment-related vulnerabilities. The purpose of the current investigation was to identify predictors of non-participation in a randomized intervention trial to reduce ETS exposure among pediatric cancer patients.

METHODS

One hundred fifty-three families of pediatric cancer patients met study eligibility criteria. Parents of 117 (76%) patients agreed to study participation, whereas 36 (24%) parents declined (non-participants). Data were collected with respect to participant sociodemographic, medical, and treatment-related characteristics.

RESULTS

Univariate analyses indicated that families whose primary caregivers were females or smokers were more likely to be non-participants in the ETS reduction trial (P = 0.045 and P = 0.009, respectively). Medical features that significantly associated with study non-participation included CNS tumor diagnosis (P = 0.030), no history of chemotherapy (P = 0.012), history of surgery prior to study recruitment (P = 0.036), and having future radiation therapy planned post study recruitment (P = 0.009). Multivariable logistic regression modeling revealed that study non-participation was associated with the primary caregiver being a smoker (OR = 6.48, P = 0.002) or female (OR = 8.56, P = 0.023), and patient CNS tumor diagnosis (OR = 4.63, P = 0.021).

CONCLUSIONS

Although a large percentage of eligible participants enrolled in the ETS reduction trial, findings suggest that future recruitment strategies of families should be tailored to parental smoking status and gender, as well as child diagnosis and treatment.

Interventions for educating children who are at risk of asthma-related emergency department attendance

BACKGROUND

Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

OBJECTIVES

To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

SELECTION CRITERIA

We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

MAIN RESULTS

A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

AUTHORS' CONCLUSIONS

Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

Predictors of study completion and withdrawal in a randomized clinical trial of a pediatric diabetes adherence intervention

PURPOSE

Loss of participants in randomized clinical trials threatens the validity of study findings. The purpose of this study was to determine pre-randomization predictors of study completion status throughout the course of a randomized clinical trial involving young children with type 1 diabetes and their primary caregivers.

METHODS

An intervention to improve adherence to the diabetes treatment regimen was delivered as part of the child's regular 3-month diabetes clinic visit. The study protocol involved 7 clinic visits across 18 months for the Immediate Treatment group and 9 clinic visits across 24 months for the Delayed Treatment group. Among those who completed the study and regardless of treatment group, participants were categorized into two groups: On-Time Completers (n=41) and Late Completers (n=39). Demographic, disease, and psychosocial characteristics of children and their primary caregivers measured prior to study randomization were tested for their association with the participants' completion status (i.e., On-Time Completers, Late Completers, or Withdrawals).

RESULTS

Of the 108 participants, 28 (25.9%) withdrew and 80 (74.1%) completed the study. On-Time Completers (i.e., study completed within 4 months of expected date) were more likely to have private insurance and primary caregivers with some college education. Late Completers (i.e., study completion took longer than 4 months) were more likely to be boys and to have primary caregivers who reported mild to moderate levels of depression. Children who subsequently withdrew from the study reported poorer diabetes-related quality of life and poorer school-related quality of life at study inception and were more likely to have primary caregivers who did not work outside the home.

CONCLUSIONS

Pre-randomization screening of participants on both demographic and psychological variables may help identify those at greatest risk for study withdrawal or poor study protocol adherence, permitting the investigators to develop retention strategies aimed at this high-risk group.

Attrition in randomized controlled trials for pediatric chronic conditions

OBJECTIVE

To examine attrition variables in randomized controlled trials of cognitive behavioral interventions for children with chronic illnesses.

METHODS

We examined attrition rates reported on 40 randomized cognitive behavioral interventions published in six pediatric research journals, during the years 2002-2007. Intervention focus was limited to children with a chronic medical condition, such as asthma, obesity, arthritis, diabetes, cancer, sickle cell disease, and cystic fibrosis.

RESULTS

Mean rate of enrollment refusal was 37% (range 0-75%). Mean attrition rate was 20% (range 0-54%) for initial follow-up and 32% (range 0-59%) for extended follow-up. Of the reviewed articles, 40% included a CONSORT diagram.

CONCLUSIONS

Strategies that can be used to limit attrition include tailoring recruitment to the study population, providing personalized feedback, maintaining consistent study procedures, providing incentives, and using intensive tracking measures. There is a need for standardized definitions and reporting of attrition rates in randomized cognitive behavioral intervention studies.

Retention of survivors of acute lymphoblastic leukemia in a longitudinal study of bone mineral density

Attrition in longitudinal studies of survivors of childhood cancer reduces these studies' statistical power, introduces bias and threatens internal and external validity. This study investigated the variables associated with dropout of survivors of acute lymphoblastic leukemia in a trial investigating the effect of vitamin D and calcium supplementation and nutritional counseling on bone mineral density (BMD). Twenty-five participants withdrew from the study. Common reasons given for withdrawing were intolerance of the study drug, family hardship and schedule conflicts. Few statistically and clinically significant differences identified participants who completed the study. Nurses need to be aware of the reasons that participants withdraw from clinical trials, as they are in a strategic position to encourage patients to participate in health promotion studies.

An interdisciplinary intervention for undertreated pediatric asthma

STUDY OBJECTIVES

To examine the effectiveness of an interdisciplinary intervention for pediatric asthma.

DESIGN

Randomized, controlled study.

SETTING

Urban tertiary-referral pediatric hospital.

PARTICIPANTS

One hundred seventy-five patients with asthma lacking written treatment plans and presenting with asthma-related emergency department visits (two or more) and/or hospitalizations (one or more) in the past year were randomized to a comparison group receiving medical care alone (n = 86) or to an interdisciplinary intervention group receiving medical care, asthma education, and problem-solving therapy (n = 89)

INTERVENTION

All participants received written asthma management plans, peak flow meters, and spacer devices. The intervention group also received asthma education, an asthma risk profile assessment, brief problem-solving therapy, and access to a 24-h nurse advice line. The primary outcome measure was change in asthma symptoms, and secondary outcomes included health-care utilization and asthma-related quality of life.

RESULTS

Both groups demonstrated significant reductions in asthma symptoms and improvements in quality of life without any between-group differences identified over the course of follow-up. In contrast, the intervention group demonstrated less frequent health-care utilization than the comparison group, with 28% of the intervention group requiring emergency department or inpatient services for asthma compared to 41% of the comparison group (adjusted odds ratio, 1.92; 95% confidence interval, 1.00 to 3.69) over the 12-month follow-up period.

CONCLUSIONS

This study examined the effectiveness of an interdisciplinary intervention for undertreated asthma. The intervention did not result in improvements in asthma symptoms, but accomplished modest reductions in the utilization of acute medical care.

Development and evaluation of a cognitive-behavioral intervention for juvenile fibromyalgia

OBJECTIVE

To describe the development and test the efficacy of a cognitive-behavioral intervention (CBT) for juvenile fibromyalgia.

METHOD

Sixty-seven children with fibromyalgia and their parents were recruited to participate in an 8-week intervention that included modules of pain management, psychoeducation, sleep hygiene, and activities of daily living. Children were taught techniques of cognitive restructuring, thought stopping, distraction, relaxation, and self-reward. Additionally, they kept daily pain and sleep diaries. Children completed questionnaires of pre- and post-treatment measuring physical status and psychological functioning.

RESULTS

Following CBT, children reported significant reductions (p < .006) in pain, somatic symptoms, anxiety, and fatigue, as well as improvements in sleep quality. Additionally, children reported improved functional ability and had fewer school absences.

CONCLUSION

Children with fibromyalgia can be taught CBT strategies that help them effectively manage this chronic and disabling musculoskeletal pain disorder.