Protective Associations between Supportive Environment and Suicidality among Minority and Majority Adolescents

OBJECTIVE

To examine the association between supportive environments and adolescent suicidal behavior, especially among marginalized minority groups.

METHODS

Participants included 12,196 middle and 16,981 high school students who completed the 2019 Vermont Youth Risk Behavior Survey. Multiple logistic regression models were used to assess the association between three protective factors that were part of a supportive environment (feeling like they matter to people in their community, usually eating dinner at home, having a trusted adult) and suicidality (plan or attempt), controlling for key demographics (sex, sexual orientation, gender identity, and race/ethnicity). Moderating effects of demographics were also explored.

RESULTS

All supportive environment variables were protective of making a suicide plan and making a suicide attempt (ORs < 0.75, p-values < 0.005). Students of minority identities were significantly more likely to make a suicide plan (middle school ORs: 1.34-3.51, p-values < 0.0005; high school ORs: 1.19-3.38, p-values < 0.02) and attempt suicide (middle school ORs: 1.42-3.72, p-values < 0.006; high school ORs: 1.38-3.25, p-values < 0.0005) compared to students with majority demographic characteristics. Generally, the associations between having a supportive environment and suicidality did not vary within sexual orientation, gender identify, or race/ethnicity subgroups, suggesting that these supportive environment factors were more universally protective. However, a few associations were stronger among students in the majority demographic groups.

CONCLUSIONS

These data suggest that having a supportive environment is protective of suicidality for adolescents from both majority and minority demographic groups.

Cultural contributions to adults' self-rated mental health problems and strengths: 7 culture clusters, 28 societies, 16 906 adults

BACKGROUND

It is unknown how much variation in adult mental health problems is associated with differences between societal/cultural groups, over and above differences between individuals.

METHODS

To test these relative contributions, a consortium of indigenous researchers collected Adult Self-Report (ASR) ratings from 16 906 18- to 59-year-olds in 28 societies that represented seven culture clusters identified in the Global Leadership and Organizational Behavioral Effectiveness study (e.g. Confucian, Anglo). The ASR is scored on 17 problem scales, plus a personal strengths scale. Hierarchical linear modeling estimated variance accounted for by individual differences (including measurement error), society, and culture cluster. Multi-level analyses of covariance tested age and gender effects.

RESULTS

Across the 17 problem scales, the variance accounted for by individual differences ranged from 80.3% for DSM-oriented anxiety problems to 95.2% for DSM-oriented avoidant personality (mean = 90.7%); by society: 3.2% for DSM-oriented somatic problems to 8.0% for DSM-oriented anxiety problems (mean = 6.3%); and by culture cluster: 0.0% for DSM-oriented avoidant personality to 11.6% for DSM-oriented anxiety problems (mean = 3.0%). For strengths, individual differences accounted for 80.8% of variance, societal differences 10.5%, and cultural differences 8.7%. Age and gender had very small effects.

CONCLUSIONS

Overall, adults' self-ratings of mental health problems and strengths were associated much more with individual differences than societal/cultural differences, although this varied across scales. These findings support cross-cultural use of standardized measures to assess mental health problems, but urge caution in assessment of personal strengths.

Statewide Trends in Buprenorphine Prescribing in Rural and Nonrural Vermont: Analysis of Population-based Patient Pharmacy Claims

IMPORTANCE

Opioid-related mortality rates have risen dramatically over the past decade, and office-based opioid treatment using buprenorphine offers hope for combatting this trend. Vermont's policymakers, health care systems, and treatment providers have worked to expand access to treatment throughout the rural state.

OBJECTIVE

The objective of the current study was to characterize the trends in the number of buprenorphine prescribers and the number of patients per prescriber in Vermont over the past decade (2010-2020).

METHODS

We used Vermont's all-payer claims database to identify patients with buprenorphine claims between 2010 and 2020 and their prescribers. We conducted analyses of trends in the number of prescribers treating different numbers of patients, the number of patients treated by prescribers in those categories, and the number of rural (vs nonrural) patients filling buprenorphine prescriptions. We used Z tests to determine if there were statistical differences between trends.

RESULTS

The number of buprenorphine prescribers treating 10+ patients grew more rapidly than other prescriber groups ( P < 0.001). Nearly half of Vermont patients in 2020 were treated by 33 high-volume prescribers who treated 100 or more patients with buprenorphine. The number of patients filling buprenorphine prescriptions in Vermont increased by 98% between 2010 and 2020, with greater increases seen among rural than nonrural residents (107% vs 72%; P = 0.008).

CONCLUSIONS AND RELEVANCE

Since 2010, Vermont has increased utilization of its office-based opioid treatment capacity, particularly in rural counties.

Associations Between Mental and Physical Illness Comorbidity and Hospital Utilization

OBJECTIVE

Characterize the prevalence of chronic physical illness types and mental illness and their comorbidity among adolescents and young adults (AYA) and assess the association of comorbidity on hospital utilization.

METHODS

This study features a population-level sample of 61 339 insurance-eligible AYA with an analytic sample of 49 089 AYA (aged 12-21) in Vermont's 2018 all-payer database. We used multiple logistic regressions to examine the associations between physical illness types and comorbid mental illness and emergency department (ED) use and inpatient hospitalization.

RESULTS

The analytic sample was 50% female, 63% Medicaid, and 43% had ≥1 chronic illness. Mental illness was common (31%) and highly comorbid with multiple physical illnesses. Among AYA with pulmonary illness, those with comorbid mental illness had 1.74-times greater odds (95% confidence interval [CI]: 1.49-2.05, P ≤.0005) of ED use and 2.9-times greater odds (95% CI: 2.05-4.00, P ≤.0005) of hospitalization than those without mental illness. Similarly, comorbid endocrine and mental illness had 1.84-times greater odds of ED use (95% CI: 1.39-2.44, P ≤.0005) and 2.1-times greater odds of hospitalization (95% CI: 1.28-3.46, P = .003), comorbid neurologic and mental illness had 1.36-times greater odds of ED use (95% CI: 1.18-1.56, P ≤.0005) and 2.4-times greater odds of hospitalization (95% CI: 1.73-3.29, P ≤.0005), and comorbid musculoskeletal and mental illness had 1.38-times greater odds of ED use (95% CI: 1.02-1.86, P = .04) and 2.1-times greater odds of hospitalization (95% CI: 1.20-3.52, P = .01).

CONCLUSIONS

Comorbid physical and mental illness was common. Having a comorbid mental illness was associated with greater ED and inpatient hospital utilization across multiple physical illness types.

The Association Between Type of Supplementation in the Newborn Nursery and Breastfeeding Outcomes at 2 and 6 Months of Age

BACKGROUND

Supplementation in the newborn nursery has been associated with shorter breastfeeding duration. However, supplementation may at times be necessary.

RESEARCH AIM

To determine the association between type of supplementation in the newborn nursery (mother's own milk, formula, donor human milk) and breastfeeding outcomes at 2 and 6 months of age.

METHODS

This was a prospective, longitudinal, observational multi-group cohort study. In total, 2,343 surveys were sent to parents who, prior to delivery, indicated intent to exclusively breastfeed. Participants were grouped by type of nursery supplementation. Surveys asked about breastfeeding outcomes when infants were 2 and 6 months old. Our final analytic sample included data from 1,111 healthy newborns ≥ 35 weeks. We used multiple logistic regression to compare future breastfeeding outcomes for infants who were exclusively directly breastfed or who received supplementation during their birth hospitalization.

RESULTS

Both the donor human milk and formula groups had decreased breastfeeding at 2 and 6 months compared to the exclusively directly breastfed group. Notably, for infants who received formula compared to donor human milk, the odds of breastfeeding at 2 and 6 months were 74% and 58% lower, respectively (OR = 0.26, 95% CI [0.12, 0.56] at 2 months; OR = 0.42, 95% CI [0.19, 0.94] at 6 months). The donor human milk group had lower odds of breastfeeding at both follow up times compared to the mother's own milk group.

CONCLUSION

Among those who intend to breastfeed, supplementation with donor human milk instead of formula in the newborn nursery may support longer breastfeeding.

Weekend Versus Weekday Asthma-Related Emergency Department Utilization

OBJECTIVE

To assess variation in asthma-related emergency department (ED) use between weekends and weekdays.

METHODS

Cross-sectional administrative claims-based analysis using California 2016 Medicaid data and Vermont 2016 and Massachusetts 2015 all-payer claims databases. We defined ED use as the rate of asthma-related ED visits per 100 child-years. A weekend visit was a visit on Saturday or Sunday, based on date of ED visit claim. We used negative binomial regression and robust standard errors to assess variation between weekend and weekday rates, overall and by age group.

RESULTS

We evaluated data from 398,537 patients with asthma. The asthma-related ED visit rate was slightly lower on weekends (weekend: 18.7 [95% confidence interval (CI): 18.3-19.0], weekday: 19.6 [95% CI, 19.3-19.8], P < .001). When stratifying by age group, 3- to 5-year-olds had higher rates of asthma-related ED visits on weekends than weekdays (weekend: 33.7 [95% CI, 32.6-34.7], weekday: 29.8 [95% CI, 29.1-30.5], P < .001) and 12- to 17-year-olds had lower rates of ED visits on weekends than weekdays (weekend: 13.0 [95% CI: 12.5-13.4], weekday: 16.3 [95% CI: 15.9-16.7], P < .001). In the other age groups (6-11, 18-21 years) there were not statistically significant differences between weekend and weekday rates (P > .05).

CONCLUSIONS

In this multistate analysis of children with asthma, we found limited overall variation in pediatric asthma-related ED utilization on weekends versus weekdays. These findings suggest that increasing access options during the weekend may not necessarily decrease asthma-related ED use.

Follow-Up After Asthma Emergency Department Visits and Its Relationship With Subsequent Asthma-Related Utilization

OBJECTIVE

To assess the association between follow-up after an asthma-related emergency department (ED) visit and the likelihood of subsequent asthma-related ED utilization.

METHODS

Using data from California Medicaid (2014-2016), and Vermont (2014-2016) and Massachusetts (2013-2015) all-payer claims databases, we identified asthma-related ED visits for patients ages 3 to 21. Follow-up was defined as a visit within 14 days with a primary care provider or an asthma specialist.

OUTCOME

asthma-related ED revisit after the initial ED visit. Models included logistic regression to assess the relationship between 14-day follow-up and the outcome at 60 and 365 days, and mixed-effects negative binomial regression to assess the relationship between 14-day follow-up and repeated outcome events (# ED revisits/100 child-years). All models accounted for zip-code level clustering.

RESULTS

There were 90,267 ED visits, of which 22.6% had 14-day follow-up. Patients with follow-up were younger and more likely to have commercial insurance, complex chronic conditions, and evidence of prior asthma. 14-day follow-up was associated with decreased subsequent asthma-related ED revisits at 60 days (5.7% versus 6.4%, P < .001) and at 365 days (25.0% versus 28.3%, P < 0.001). Similarly, 14-day follow-up was associated with a decrease in the rate of repeated subsequent ED revisits (66.7 versus 77.3 revisits/100 child-years; P < 0.001).

CONCLUSIONS

We found a protective association between outpatient 14-day follow-up and asthma-related ED revisits. This may reflect improved asthma control as providers follow the NHLBI guideline stepwise approach. Our findings highlight an opportunity for improvement, with only 22.6% of those with asthma-related ED visits having 14-day follow-up.

Assessing the Relationship Between Well-Care Visit and Emergency Department Utilization Among Adolescents and Young Adults

PURPOSE

To investigate the association between adolescent and young adult (AYA) well-care visits and emergency department (ED) utilization.

METHODS

Vermont's all-payer claims data were used to evaluate visits for 49,089 AYAs (aged 12-21 years) with a health-care claim from January 1 through December 31, 2018. We performed multiple logistic regression analyses to determine the association between well-care visits and ED utilization, investigating potential moderating effects of age, insurance type, and medical complexity.

RESULTS

Nearly half (49%) of AYAs who engaged with the health-care system did not attend a well-care visit in 2018. AYAs who did not attend a well-care visit had 24% greater odds (95% confidence interval [CI]: 1.19-1.30) of going to the ED at least once in 2018, controlling for age, sex, insurance type, and medical complexity. Older age, female sex, Medicaid insurance, and greater medical complexity independently predicted greater ED utilization in the adjusted model. In stratified analyses, late adolescents and young adults (aged 18-21 years) who did not attend a well-care visit had 47% greater odds (95% CI: 1.37 - 1.58) of ED visits, middle adolescents (aged 15-17 years) had 9% greater odds (95% CI: 1.01-1.18), and early adolescents (aged 12-14 years) had 16% greater odds (95% CI: 1.06 - 1.26).

CONCLUSIONS

Not attending well-care visits is associated with greater ED utilization among AYAs engaged in health care. Focus on key quality performance metrics such as well-care visit attendance, especially for 18- to 21-year-olds during their transition to adult health care, may help reduce ED utilization.

Opioid use disorder treatment in rural settings: The primary care perspective

Despite the efficacy of medications for treating opioid use disorder (OUD), they are underutilized, especially in rural areas. Our objectives were to determine the association between primary care practitioners (PCPs) rurality and concerns for patient substance use, and to identify factors associated with PCP comfort treating OUD, focusing on barriers to treatment. We developed a web-based survey completed by 116 adult-serving PCPs located in Vermont's rural and non-rural counties between April-August 2020. The instrument included PCP-identified concerns for substance use among patients, barriers to treating patients with OUD, and current level of comfort treating patients with OUD. On a scale from 0 to 10, rural PCPs reported higher concern for heroin (mean difference; Mdiff = 1.38, 95% CI: 0.13 to 2.63), fentanyl (Mdiff = 1.52, 95% CI: 0.29 to 2.74), and methamphetamine (Mdiff = 1.61, 95% CI: 0.33 to 2.90) use among patients compared to non-rural PCPs, and practitioners in both settings expressed high concern regarding their patients' use of tobacco (7.6 out of 10) and alcohol (7.0 out of 10). There was no difference in reported comfort in treating patients with OUD among rural vs. non-rural PCPs (Mdiff = 0.65, 95%CI: 0.17 to 1.46; P = 0.119), controlling for higher comfort among male PCPs and those waivered to prescribe buprenorphine (Ps < 0.05). Lack of training/experience and medication diversion were PCP-identified barriers associated with less comfort treating OUD patients, while time constraints was associated with more comfort (Ps < 0.05). Taken together, these data highlight important areas for dissemination of evidence-based training, support, and resources to expand OUD treatment capacity in rural communities.

Prescription opioid policies and associations with opioid overdose and related adverse effects

BACKGROUND

United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state policies in Vermont (July 2017) and Maine (July 2016) on opioid overdoses and opioid-related adverse effects.

METHODS

Study population included patients 15 years and older in all-payer claims of Vermont (N = 597,683; Jan.2016-Dec.2018) and Maine (N = 1,370,960; Oct.2015-Dec.2017). We used interrupted time series analyses to assess the impact of opioid prescribing policies on monthly opioid overdose rate and opioid-related adverse effects rate. We used the International Classification of Disease-10-CM to identify overdoses (T40.0 × 1-T40.4 × 4, T40.601-T40.604, T40.691-T40.694) and adverse effects (T40.0 × 5, T40.2 × 5-T40.4 × 5, T40.605, T40.695).

RESULTS

Immediately after the policy, the level of Vermont's opioid overdose rate increased by 34% (95% confidence interval, CI: 1.09, 1.65) while the level of opioid-related adverse effects rate decreased by 29% (95% CI: 0.58, 0.87). In Maine, there was no level change in opioid overdose rate, but the slope of the adverse effects rate after the policy decreased by 3.5% (95% CI: 0.94, 0.99). These results varied within age and rurality subgroups in both states.

CONCLUSION

While the decrease in rate of adverse effects following the policy changes is promising, the increase in Vermont's opioid overdose rate may suggest there is an association between policy implementation and short-term risk to public health.

Influence of Opioid Prescription Policy on Overdoses and Related Adverse Effects in a Primary Care Population

BACKGROUND

In response to the opioid epidemic, many states have enacted policies limiting opioid prescriptions. There is a paucity of evidence of the impact of opioid prescribing interventions in primary care populations, including whether unintended consequences arise from limiting the availability of prescribed opioids.

OBJECTIVE

Our aim was to compare changes in opioid overdose and related adverse effects rate among primary care patients following the implementation of state-level prescribing policies.

DESIGN

A cohort of primary care patients within an interrupted time series model.

PARTICIPANTS

Electronic medical record data for 62,776 adult (18+ years) primary care patients from a major medical center in Vermont from January 1, 2016, to June 30, 2018.

INTERVENTIONS

State-level opioid prescription policy changes limiting dose and duration.

MAIN MEASURES

Changes in (1) opioid overdose rate and (2) opioid-related adverse effects rate per 100,000 person-months following the July 1, 2017, prescription policy change.

KEY RESULTS

Among primary care patients, there was no change in opioid overdose rate following implementation of the prescribing policy (incidence rate ratio; IRR: 0.64, 95% confidence interval; CI: 0.22-1.88). There was a 78% decrease in the opioid-related adverse effects rate following the prescribing policy (IRR: 0.22, 95%CI: 0.09-0.51). This association was moderated by opioid prescription history, with decreases observed among opioid-naïve patients (IRR: 0.18, 95%CI: 0.06-0.59) and among patients receiving chronic opioid prescriptions (IRR: 0.17, 95%CI: 0.03-0.99), but not among those with intermittent opioid prescriptions (IRR: 0.51, 95%CI: 0.09-2.82).

CONCLUSIONS

Limiting prescription opioids did not change the opioid overdose rate among primary care patients, but it reduced the rate of opioid-related adverse effects in the year following the state-level policy change, particularly among patients with chronic opioid prescription history and opioid-naïve patients. Limiting the quantity and duration of opioid prescriptions may have beneficial effects among primary care patients.

Statewide Asthma Learning Collaborative Participation and Asthma-Related Emergency Department Use

BACKGROUND

Quality improvement (QI) efforts can improve guideline-recommended asthma care processes in the pediatric office setting. We sought to assess whether practice participation in an asthma QI collaborative was associated with decreased asthma-related emergency department (ED) visits.

METHODS

A statewide network of practices participated in a pediatric asthma QI collaborative from 2015 to 2016. We evaluated asthma-related ED visit rates per 100 child-years for children ages 3 to 21 years with asthma, using the state's all-payer claims database. We used a difference-in-differences approach, with mixed-effects negative binomial regression models to control for practice and patient covariates. Our main analysis measured the outcome before (2014) and after (2017) the QI collaborative at fully participating and control practices. Additional analyses assessed (1) associations during the intervention period (2016) and (2) associations including practices partially participating in QI collaborative activities.

RESULTS

In the postintervention year (2017), participating practices' (n = 20) asthma-related ED visit rate decreased by 5.8 per 100 child-years, compared to an increase of 1.8 per 100 child-years for control practices (n = 15; difference in differences = -7.3; P = .002). Within the intervention year (2016), we found no statistically significant differences in asthma-related ED visit rates compared to controls (difference in differences = -4.3; P = .17). The analysis including partially participating practices yielded similar results and inferences to our main analysis.

CONCLUSIONS

Participation in an asthma-focused QI collaborative was associated with decreased asthma-related ED visit rates. For those considering implementing this type of QI collaborative, our findings indicate that it takes time to see measurable improvements in ED visit rates. Further study is warranted regarding QI elements contributing to success for partial participants.

The Strengths and Difficulties Questionnaire as a Mental Health Screening Tool for Newly Arrived Pediatric Refugees

Many refugee children have exposure to trauma prior to arrival and during resettlement. Mental health screening in primary care among resettled refugee children is needed. The Strengths and Difficulties Questionnaire (SDQ) was used to screen refugee children age 4-18 years at their Domestic Medical Examination and three other primary care visits in their first year of resettlement. We tested the association between time and SDQ score or intervention/referral, and differences based on geographic origin. SDQ scores were highest upon arrival (Ps < .0005). Referrals were most common at the six-month visit compared to arrival and one month (Ps < .01). Iraqi children had higher SDQ scores at all visits (Ps < .03). The SDQ can be used in primary care to screen newly arrived refugee children. Practitioners should screen at arrival to identify difficulties. Those with difficulties continuing at six months may need an intervention or referral.

A randomized clinical trial of mobile phone motivational interviewing for alcohol use problems in Kenya

AIM

To test the effectiveness of a motivational interviewing (MI) intervention using the mobile phone among adults with alcohol use problems.

DESIGN

A randomized clinical trial of mobile MI and standard in-person MI with 1- and 6-month follow-up, including a 1-month waitlist control followed by mobile MI.

SETTING

A primary health center in rural Kenya.

PARTICIPANTS

Three hundred adults screening positive for alcohol use problems were randomized and received immediate mobile MI (n = 89), in-person MI (n = 65) or delayed mobile MI (n = 76) for waiting-list controls 1 month after no treatment, with 70 unable to be reached for intervention.

INTERVENTION AND COMPARATOR

One MI session was provided either immediately by mobile phone, in-person at the health center or delayed by 1 month and then provided by mobile phone.

MEASUREMENTS

Alcohol use problems were repeatedly assessed using the Alcohol Use Disorder Identification Test (AUDIT) and the shorter AUDIT-C. The primary outcome was difference in alcohol score 1 month after no intervention for waiting-list control versus 1 month after MI for mobile MI. The secondary outcomes were difference in alcohol score for in-person MI versus mobile MI one and 6 months after MI.

FINDINGS

For our primary outcome, average AUDIT-C scores were nearly three points higher (difference = 2.88, 95% confidence interval = 2.11, 3.66) for waiting-list controls after 1 month of no intervention versus mobile MI 1 month after intervention. Results for secondary outcomes supported the null hypothesis of no difference between in-person and mobile MI at 1 month (Bayes factor = 0.22), but were inconclusive at 6 months (Bayes factor = 0.41).

CONCLUSION

Mobile phone-based motivational interviewing may be an effective treatment for alcohol use problems among adults visiting primary care in Kenya. Providing mobile motivational interviewing may help clinicians in rural areas to reach patients needing treatment for alcohol use problems.

Trauma among Kenyan School Children in Urban and Rural Settings: PTSD Prevalence and Correlates

This study estimated the prevalence and correlates of PTSD in Kenyan school children during a period of widespread post-election violence. The UCLA PTSD Reaction Index was administered to 2482 primary and secondary school students ages 11-17 from rural and urban communities. A high proportion of school children had witnessed people being shot at, beat up or killed (46.9%) or had heard about the violent death or serious injury of a loved one (42.0%). Over one quarter (26.8%, 95% CI = 25.1% - 28.7%) met criteria for PTSD. Correlates of PTSD included living in a rural (vs urban) area (AOR = 1.72, 95% CI = 1.41-2.11), attending primary (vs secondary) school (AOR = 2.25, 95% CI = 1.67-3.04) and being a girl (with girl as referent AOR = .70, 95% CI = .57-.86). We recommend training Kenyan teachers to recognize signs of emotional distress in school children and psychosocial counselors to adapt empirically-supported mental health interventions for delivery in primary and secondary school settings.

A primary care learning collaborative to improve office systems and clinical management of pediatric asthma

OBJECTIVE

Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled.

METHODS

The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven.

RESULTS

This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures.

CONCLUSIONS

A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.

Improving Adolescent Depression Screening in Pediatric Primary Care

OBJECTIVE

Depression among adolescents is a leading public health problem. Although screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care.

METHODS

Seventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over 7 months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices.

RESULTS

As practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over 7 months. Adolescents at participating practices had 3.5 times greater odds (95% confidence interval [CI], 1.14-10.98, P = .03) of being screened for depression and 37.5 times greater odds (95% CI, 7.67-183.48, P < .0005) of being screened with a validated tool than adolescents at control practices, accounting for patient characteristics.

CONCLUSIONS

There were significant within practice increases in adolescent depression screening after a QI learning collaborative, as well as in comparison with control practices 1 year later.

Change in Site of Children's Primary Care: A Longitudinal Population-Based Analysis

PURPOSE

Evidence that fewer children are being seen at family physician (FP) practices has not been confirmed using population-level data. This study examines the proportion of children seen at FP and pediatrician practices over time and the influence of patient demographics and rurality on this trend.

METHODS

We conducted a retrospective longitudinal analysis of Vermont all-payer claims (2009-2016) for children aged 0 to 21 years. The sample included 184,794 children with 2 or more claims over 8 years. Generalized estimating equations modeled the outcome of child attribution to a FP practice annually, with covariates for calendar year, child age, sex, insurance, and child Rural Urban Commuting Area (RUCA) category.

RESULTS

Over time, controlling for other covariates, children were 5% less likely to be attributed to a FP practice (P <.001). Children had greater odds of attribution to a FP practice as they aged (odds ratio (OR) = 1.11, 95% CI, 1.10-1.11), if they were female (OR = 1.05, 95% CI, 1.03-1.07) or had Medicaid (OR = 1.09, 95% CI, 1.07-1.10). Compared with urban children, those from large rural cities (OR = 1.54, 95% CI, 1.51-1.57), small rural towns (OR = 1.45, 95% CI, 1.42-1.48), or isolated/small rural towns (OR = 1.96, 95% CI, 1.93-2.00) had greater odds of FP attribution. When stratified by RUCA, however, children had 3% lower odds of attending a FP practice in urban areas and 8% lower odds in isolated/small rural towns.

CONCLUSIONS

The declining proportion of children attending FP practices, confirmed in this population-based analysis and more pronounced in rural areas, represents a continuing challenge.

Utilization Outcomes of a Pilot Primary Care Team Redesign

Objectives:

To evaluate the effect of a team-based primary care redesign on primary care, emergency department (ED) and urgent care (UC) utilization, and new patient access to primary care.

Study Design:

A retrospective pre–post difference-in-differences analysis of utilization outcomes for patients on a redesigned primary care team compared to a standard primary care group.

Methods:

Within a patient-centered medical home, a pilot team was developed comprising 2 colocated “teamlets” of 1 physician, 1 nurse practitioner (NP), 1 registered nurse (RN), and 2 licensed practical nurses (LPNs). The redesigned team utilized physician–NP comanagement, expanded roles for RNs and LPNs, and dedicated provider time for telephone and e-mail medicine. We compared changes in number of office, ED, and UC visits during the implementation year for patients on the redesigned team compared to patients receiving the standard of care in the same clinic. Proportion of new patient visits was also compared between the pilot and the control groups.

Results:

There were no differences between the redesign group and control group in per-patient mean change in office visits (Δ = −0.04 visits vs Δ = −0.07; P = .98), ED visits (Δ = 0.00 vs Δ = 0.01; P = .25), or UC visits (Δ = 0.00 vs Δ = 0.05; P = .08). Proportion of new patient visits was higher in the pilot group during the intervention year compared to the control group (6.6% vs 3.9%; P < .0001).

Conclusions:

The redesign did not significantly impact ED, UC, or primary care utilization within 1 year of follow-up. It did improve access for new patients.

Quality Improvement to Immunization Coverage in Primary Care Measured in Medical Record and Population-Based Registry Data

OBJECTIVES

Despite the proven benefits of immunizations, coverage remains low in many states, including Vermont. This study measured the impact of a quality improvement (QI) project on immunization coverage in childhood, school-age, and adolescent groups.

METHODS

In 2013, a total of 20 primary care practices completed a 7-month QI project aimed to increase immunization coverage among early childhood (29-33 months), school-age (6 years), and adolescent (13 years) age groups. For this study, we examined random cross-sectional medical record reviews from 12 of the 20 practices within each age group in 2012, 2013, and 2014 to measure improvement in immunization coverage over time using chi-squared tests. We repeated these analyses on population-level data from Vermont's immunization registry for the 12 practices in each age group each year. We used difference-in-differences regressions in the immunization registry data to compare improvements over time between the 12 practices and those not participating in QI.

RESULTS

Immunization coverage increased over 3 years for all ages and all immunization series (P ≤ .009) except one, as measured by medical record review. Registry results aligned partially with medical record review with increases in early childhood and adolescent series over time (P ≤ .012). Notably, the adolescent immunization series completion, including human papillomavirus, increased more than in the comparison practices (P = .037).

CONCLUSIONS

Medical record review indicated that QI efforts led to increases in immunization coverage in pediatric primary care. Results were partially validated in the immunization registry particularly among early childhood and adolescent groups, with a population-level impact of the intervention among adolescents.

Successful Integration of Pediatrics Into State Health Care Reform Efforts

Health care reform in Vermont promotes patient-centered medical homes (PCMH) and multi-disciplinary community health teams to support population health. This qualitative study describes the expansion of Vermont's health care reform efforts, initially focused on adult primary care, to pediatrics through interviews with project managers and facilitators, CHT members, pediatric practitioners and care coordinators, and community-based providers. Analyses used grounded theory, identifying themes confirmed by repeat occurrence across respondents. Respondents believed that PCMH recognition and financial and community supports would improve care for pediatric patients and families. Respondents shared three main challenges with health care reform efforts: achieving PCMH recognition, adapting community health teams for pediatric patients and families, and defining roles for care coordinators. For health care reform efforts to support pediatric patients and be family-centered, states may need additional resources to understand how pediatric and adult primary care differ and how best to support pediatrics during health care reform efforts.

Pediatric-Informed Facilitation of Patient-Centered Medical Home Transformation

Patient-centered medical home (PCMH) transformation has been challenging for pediatric practices, in part because of the National Committee for Quality Assurance (NCQA) PCMH focus on conditions and processes specific to adult patients. Realizing the potential challenges faced by pediatric practices, Vermont supported pediatric-informed facilitators to help practices during PCMH transformation. This study characterizes the impact of pediatric-informed facilitators; provides benchmark data on NCQA scores, number of facilitation meetings, and the time between facilitation start and end; and compares pediatric- and adult-serving practices. We found no difference between pediatric and matched adult-serving practices in NCQA score, number of facilitation meetings, or weeks to NCQA scoring. These results suggest that pediatric-informed facilitators can help pediatric practices achieve NCQA PCMH recognition on par with practices serving adult patients. Supporting primary care practices with specialty-informed facilitators can assist integration into health care reform efforts.

Increasing Immunization Compliance by Reducing Provisional Admittance

Students in Vermont with incomplete or undocumented immunization status are provisionally admitted to schools and historically had a calendar year to resolve their immunization status. The process of resolving these students’ immunization status was challenging for school nurses. We conducted a school-based quality improvement effort to increase student compliance with Vermont immunization regulations using a collaborative learning approach with public health school liaisons and school nurses from public schools to reduce provisional admittance in 2011–2012. Strategies included using a tracking system, accessing the immunization registry, promoting immunization importance, tracking immunization plans, and working with medical homes to update records. Participating school nurses observed decreases in the number of provisionally admitted students, although this reduction was not significantly different than matched comparison schools. We also found the number of provisionally admitted students fluctuated throughout the year and resolving the immunization status of New Americans and exchange students required special attention. Our approach supports the coordinated school health model and demonstrates the critical role school nurses play in improving population health outcomes.

Problems and Adaptive Functioning Reported by Adults in 17 Societies

This study tested for similarities and differences across societies in self-ratings of problems, personal strengths, and aspects of adaptive functioning on the Adult Self-Report (ASR) for nonclinical samples of adults ages 18 to 59 in 17 societies ( N = 10,197). Results indicated considerable consistency across societies regarding mean ratings on the ASR problem items. Most effect sizes (ESs) for societal differences in problem scales were small (2–5%). Hierarchical linear modeling (HLM) analyses indicated that culture clusters and society accounted for small percentages of variance in Internalizing, Externalizing, and Total Problems scores, with most of the variation accounted for by individual differences within societies. In contrast to the small effects of society on problem scores, for the ASR Personal Strengths scale the societal ES was 34% and culture cluster accounted for 12% of the variance. Worse reported relations with spouse/partner were associated with higher problem scores. Overall, findings indicated considerable similarity but also some important differences in self-reported problems and adaptive functioning across 17 societies.

Child Temperament, Maternal Parenting Behavior, and Child Social Functioning

We examined child temperament, maternal parenting, and the effects of their interactions with each other on child social functioning. A total of 355 children aged 5-18 years old (54% male; mean age=10.8) were evaluated. Regression equations were used to test models of the main and interactive effects of temperament and maternal parenting behavior on the Social Problems and Social Competence Subscales of the Child Behavior Checklist (CBCL), a questionnaire assessing internalizing and externalizing behavior problems in children ages 4 to 18. Higher levels of child Novelty Seeking and Harm Avoidance and lower levels of Persistence were significantly associated with poorer social functioning. When accounting for child temperament, neither maternal parenting nor the interaction between maternal parenting and child temperament were significantly associated with social functioning. However, the interaction between maternal positive involvement and harm avoidance trended toward significance, such that at higher levels of harm avoidance, more extreme levels of maternal positive involvement were related to lower levels of social functioning. Further research on the interplay between child temperament and parenting across different stages of development is warranted.

Connecting Cultures: A training model promoting evidence-based psychological services for refugees

Training clinical psychology graduate students in providing effective psychological services to refugees can be extremely complex. The training approach requires a culturally sensitive framework, potential modification of empirically validated techniques, and flexibility on the part of trainees and supervisors. Connecting Cultures is a program that creates a culturally sensitive context from which trainees can learn to effectively work with refugees within a social justice framework and the ecological model of human development. Connecting Cultures graduate students provide both community-based outreach and direct clinical services to meet the mental health needs of refugees in the Northeast region of the United States. The primary aim of this manuscript is to provide an overview of Connecting Cultures' training and supervision model, highlight the importance of working with cultural consultants, interpreters, and community elders, and discuss the impact this work has on clinical psychology graduate students. A secondary aim is to describe our method for evidence-based psychological assessment and to present preliminary outcome data from our graduate students. Strengths of the Connecting Cultures program include its clinical and research efforts with refugees from over 20 countries, and its ability to flexibly incorporate alternative therapeutic frameworks such as Acceptance and Commitment Therapy. Finally, the manuscript concludes by providing the implications of our work in attempting to meet the mental health needs of refugees after resettlement.

Syndromes of Self-Reported Psychopathology for Ages 18-59 in 29 Societies

This study tested the multi-society generalizability of an eight-syndrome assessment model derived from factor analyses of American adults' self-ratings of 120 behavioral, emotional, and social problems. The Adult Self-Report (ASR; Achenbach and Rescorla 2003) was completed by 17,152 18-59-year-olds in 29 societies. Confirmatory factor analyses tested the fit of self-ratings in each sample to the eight-syndrome model. The primary model fit index (Root Mean Square Error of Approximation) showed good model fit for all samples, while secondary indices showed acceptable to good fit. Only 5 (0.06%) of the 8,598 estimated parameters were outside the admissible parameter space. Confidence intervals indicated that sampling fluctuations could account for the deviant parameters. Results thus supported the tested model in societies differing widely in social, political, and economic systems, languages, ethnicities, religions, and geographical regions. Although other items, societies, and analytic methods might yield different results, the findings indicate that adults in very diverse societies were willing and able to rate themselves on the same standardized set of 120 problem items. Moreover, their self-ratings fit an eight-syndrome model previously derived from self-ratings by American adults. The support for the statistically derived syndrome model is consistent with previous findings for parent, teacher, and self-ratings of 1½-18-year-olds in many societies. The ASR and its parallel collateral-report instrument, the Adult Behavior Checklist (ABCL), may offer mental health professionals practical tools for the multi-informant assessment of clinical constructs of adult psychopathology that appear to be meaningful across diverse societies.

Examining vulnerability to smokeless tobacco use among adolescents and adults meeting diagnostic criteria for major depressive disorder

Smoking prevalence is unevenly distributed in the U.S. population, with those with mental illness, other substance use disorders, and lower socioeconomic status being especially vulnerable. Less research has been conducted on the association between these same vulnerabilities and smokeless tobacco (ST) use. The present study examined cigarette and ST use among adolescents and adults who met diagnostic criteria for major depressive disorder in the National Survey on Drug Use and Health (NSDUH). Utilizing the most recent (2011) NSDUH, we compared odds for current cigarette smoking and ST use among adolescents and adults meeting criteria for past-year major depressive disorder to the general population, after adjusting for potential confounding influences of sociodemographic and other substance use characteristics. Analyses were conducted to examine sex as a moderator of the relation between major depressive disorder and tobacco use. Odds for current cigarette smoking among those classified with major depressive disorder were increased among adolescents (OR = 1.33, 95% CI [1.05, 1.69], p = .021) and adults (OR = 1.70, 95% CI [1.47, 1.97], p < .0005), and odds for current ST use did not differ among adolescents (OR = 0.90, 95% CI [0.54, 1.49], p = .678) and were lower among adults (OR = 0.68, 95% CI [0.51, 0.91], p = .010). Sex was not a significant moderator in adolescents or adults. Major depressive disorder is associated with increased risk for smoking but not ST use among adolescents and adults further demonstrating heterogeneity in predictors of vulnerability to use of different tobacco products.

Emotional and Behavioral Problems among Impoverished Kenyan Youth: Factor Structure and Sex-Differences

Data on youth emotional and behavioral problems from societies in Sub-Saharan Africa are lacking. This may be due to the fact that few youth mental health assessments have been tested for construct validity of syndrome structure across multicultural societies that include developing countries, and almost none have been tested in Sub-Saharan Africa. The Youth Self-Report (YSR), for example, has shown great consistency of its syndrome structure across many cultures, yet data from only one developing country in Sub-Saharan Africa have been included. In this study, we test the factor structure of YSR syndromes among Kenyan youth ages 11-18 years from an informal settlement in Nairobi, Kenya and examine sex-differences in levels of emotional and behavioral problems. We find the eight syndrome structure of the YSR to fit these data well (Root Mean Square Error of Approximation=.049). While Kenyan girls have significantly higher internalizing (Anxious/Depressed, Withdrawn/Depressed, Somatic) problem scores than boys, these differences are of similar magnitude to published multicultural findings. The results support the generalizability of the YSR syndrome structure to Kenyan youth and are in line with multicultural findings supporting the YSR as an assessment of emotional and behavioral problems in diverse societies.

Vulnerability to smokeless tobacco use among those dependent on alcohol or illicit drugs

INTRODUCTION

Individuals dependent on alcohol or illicit drugs are vulnerable to cigarette smoking and related adverse health outcomes. Less research has been conducted regarding whether these same groups are vulnerable to smokeless tobacco (ST) use. The goal of this study is to examine vulnerability to ST use among individuals with other drug dependence.

METHODS

Utilizing the most recent (2011) National Survey on Drug Use and Health (NDSUH), we determined odds ratios (ORs) for current cigarette smoking and ST use among those with current alcohol, cocaine, heroin, and marijuana dependence, adjusting for relevant sociodemographic characteristics. Vulnerability to cigarette smoking was assessed to confirm that alcohol and illicit drug dependence were associated with increased smoking in these data sets, as shown in prior studies. Identical analyses were completed in the 2009 and 2010 NSDUH to assess generality.

RESULTS

Odds for current cigarette smoking were increased for each category of dependence (p < .0005): alcohol (OR with 99% CI = 3.30 [2.58, 4.21]), cocaine (OR = 4.50 [1.53, 13.20]), heroin (OR = 7.84 [1.92, 32.03]), and marijuana (OR = 3.55 [2.59, 4.88]). Odds for current ST use were also increased among those with alcohol dependence (OR = 1.56 [1.06, 2.30], p = .003) but not illicit drug dependence. Generality of the findings was confirmed in the 2009 and 2010 NSDUH.

CONCLUSIONS

Consistent with earlier reports, alcohol and illicit drug dependence are associated with robust increases in risk for cigarette smoking. In the case of alcohol dependence, but not illicit drug dependence, this vulnerability also extends to ST use.

A daily process examination of the bidirectional relationship between craving and alcohol consumption as measured via interactive voice response

BACKGROUND

Craving is a central component to alcohol use disorders, although there are contradictory findings in the literature regarding the importance of craving in alcohol use. The study goal was to examine the bidirectional relationship between craving and alcohol consumption in heavy drinkers.

METHODS

Participants received brief alcohol interventions from their primary care physicians and then were asked to make daily reports of craving and alcohol consumption to an interactive voice response (IVR) telephone system for 180 days. The study sample included 246 participants (166 men) with mean age of 46. Ninety-seven percent were Caucasian and 66% met criteria for alcohol dependence. Analysis used generalized estimating equations (GEE) to evaluate whether craving intensity predicted next day alcohol consumption and whether alcohol consumption predicted next day craving intensity. Significant interactions with gender led to stratified analyses.

RESULTS

GEE analyses revealed a significant bidirectional relationship between craving and drinking, where craving intensity predicted next day total drinks consumed (p = 0.001), and total drinks predicted next day craving intensity (p = 0.02). Exploratory analysis found that gender significantly moderated the craving-drinking relationship (p = 0.002) with men increasing next day alcohol use more (b = 0.19) than women (b = 0.08).

CONCLUSIONS

Findings suggest a bidirectional relationship between craving and drinking may contribute to the development or maintenance of heavy drinking, particularly for men. Based on our findings, we recommend that during brief interventions, physicians address both drinking and craving and provide advice for coping with craving.

Alcohol, moods and male-female differences: daily interactive voice response over 6 months

AIMS

The goal of this study was to better understand the predictive relationship in both directions between negative (anger, sadness) and positive (happiness) moods and alcohol consumption using daily process data among heavy drinkers.

METHODS

Longitudinal daily reports of moods, alcohol use and other covariates such as level of stress were assessed over 180 days using interactive voice response telephone technology. Participants were heavy drinkers (majority meeting criteria for alcohol dependence at baseline) recruited through their primary care provider. The sample included 246 (166 men, 80 women) mostly Caucasian adults. Longitudinal statistical models were used to explore the varying associations between number of alcoholic drinks and mood scores the next day and vice versa with gender as a moderator.

RESULTS

Increased alcohol use significantly predicted decreased happiness the next day (P < 0.005), more strongly for females than males. Increased anger predicted higher average alcohol use the next day for males only (P < 0.005).

CONCLUSION

This daily process study challenges the notion that alcohol use enhances positive mood for both males and females. Our findings also suggest a strong association between anger and alcohol use that is specific to males. Thus, discussions about the effects of drinking on one's feeling of happiness may be beneficial for males and females as well as anger interventions may be especially beneficial for heavy-drinking males.

Lifetime mental disorders and suicidal behaviour in South Africa

OBJECTIVE

There is relatively little data on the relationship between lifetime mental disorders and suicidal behaviour in low and middle income countries. This study examines the relationship between lifetime mental disorders, and subsequent suicide ideation, plans, and suicide attempts in South Africa.

METHOD

A national survey of 4185 South African adults was conducted using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate psychiatric diagnoses and suicidal behaviour. Bivariate, multivariate and discrete-time survival analyses were employed to investigate the associations between mental disorders and subsequent suicide ideation, plans, and attempts.

RESULTS

Sixty-one percent of people who seriously considered killing themselves at some point in their lifetime reported having a prior DSM-IV disorder. Mental disorders predict the onset of suicidal ideation, but have weaker effects in predicting suicide plans or attempts. After controlling for comorbid mental disorders, PTSD was the strongest predictor of suicidal ideation and attempts. There is a relationship between number of mental disorders and suicidal behaviour, with comorbidity having significantly sub-additive effects.

CONCLUSION

Consistent with data from the developed world, mental disorders are strong predictors of suicidal behaviour, and these associations are more often explained by the prediction of ideation, rather than the prediction of attempts amongst ideators. This suggests some universality of the relevant mechanisms underlying the genesis of suicidal thoughts, and the progression to suicide attempts.

Multiple traumas, postelection violence, and posttraumatic stress among impoverished Kenyan youth

Research on posttraumatic stress disorder (PTSD) among youth has focused on specific subgroups from developed countries. Most of the world's youth and war-like violence, however, is concentrated in developing countries, yet there is limited mental health data within affected countries. This study focused on a random community-based sample of 552 impoverished youth ages 6-18 within an informal settlement in Nairobi, Kenya, which experienced war-like violence for a month following the contested presidential election of 2007. Six months after the violence ended, 99 (18%) had PTSD according to the UCLA PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004), and an additional 18 (3%) were found to have partial PTSD due to high overall scores. Kenyan psychologists conducted diagnostic interviews and found the positive predictive value of the assessment tool to be 72% in this sample; the confirmed prevalence was 12%. Similar to other studies worldwide, Criterion C (avoidance) was the limiting factor for diagnosing PTSD according to the DSM-IV-TR, and parent-child agreement was at best fair. The number of traumatic experiences was strongly associated with PTSD outcomes. Differences due to age or sex were not found. The findings indicate the need for universal mental health services for trauma-exposed youth and their families in the impoverished informal settlements of Nairobi, Kenya.

International comparisons of behavioral and emotional problems in preschool children: parents' reports from 24 societies

International comparisons were conducted of preschool children's behavioral and emotional problems as reported on the Child Behavior Checklist for Ages 1½-5 by parents in 24 societies (N = 19,850). Item ratings were aggregated into scores on syndromes; Diagnostic and Statistical Manual of Mental Disorders-oriented scales; a Stress Problems scale; and Internalizing, Externalizing, and Total Problems scales. Effect sizes for scale score differences among the 24 societies ranged from small to medium (3-12%). Although societies differed greatly in language, culture, and other characteristics, Total Problems scores for 18 of the 24 societies were within 7.1 points of the omnicultural mean of 33.3 (on a scale of 0-198). Gender and age differences, as well as gender and age interactions with society, were all very small (effect sizes < 1%). Across all pairs of societies, correlations between mean item ratings averaged .78, and correlations between internal consistency alphas for the scales averaged .92, indicating that the rank orders of mean item ratings and internal consistencies of scales were very similar across diverse societies.

Propensity score techniques and the assessment of measured covariate balance to test causal associations in psychological research

There is considerable interest in using propensity score (PS) statistical techniques to address questions of causal inference in psychological research. Many PS techniques exist, yet few guidelines are available to aid applied researchers in their understanding, use, and evaluation. In this study, the authors give an overview of available techniques for PS estimation and PS application. They also provide a way to help compare PS techniques, using the resulting measured covariate balance as the criterion for selecting between techniques. The empirical example for this study involves the potential causal relationship linking early-onset cannabis problems and subsequent negative mental health outcomes and uses data from a prospective cohort study. PS techniques are described and evaluated on the basis of their ability to balance the distributions of measured potentially confounding covariates for individuals with and without early-onset cannabis problems. This article identifies the PS techniques that yield good statistical balance of the chosen measured covariates within the context of this particular research question and cohort.

Preschool psychopathology reported by parents in 23 societies: testing the seven-syndrome model of the child behavior checklist for ages 1.5-5

OBJECTIVE

To test the fit of a seven-syndrome model to ratings of preschoolers' problems by parents in very diverse societies.

METHOD

Parents of 19,106 children 18 to 71 months of age from 23 societies in Asia, Australasia, Europe, the Middle East, and South America completed the Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5). Confirmatory factor analyses were used to test the seven-syndrome model separately for each society.

RESULTS

The primary model fit index, the root mean square error of approximation (RMSEA), indicated acceptable to good fit for each society. Although a six-syndrome model combining the Emotionally Reactive and Anxious/Depressed syndromes also fit the data for nine societies, it fit less well than the seven-syndrome model for seven of the nine societies. Other fit indices yielded less consistent results than the RMSEA.

CONCLUSIONS

The seven-syndrome model provides one way to capture patterns of children's problems that are manifested in ratings by parents from many societies. Clinicians working with preschoolers from these societies can thus assess and describe parents' ratings of behavioral, emotional, and social problems in terms of the seven syndromes. The results illustrate possibilities for culture-general taxonomic constructs of preschool psychopathology. Problems not captured by the CBCL/1.5-5 may form additional syndromes, and other syndrome models may also fit the data.

Incremental validity of test session and classroom observations in a multimethod assessment of attention deficit/hyperactivity disorder

This study tested the incremental validity of behavioral observations, over and above parent and teacher reports, for assessing symptoms of Attention Deficit/Hyperactivity Disorder (ADHD) in children ages 6 to 12, using the Test Observation Form (TOF) and Direct Observation Form (DOF) from the Achenbach System of Empirically Based Assessment. The TOF Attention Problems and DOF Intrusive scales contributed significant unique variance, over and above parent and teacher ratings, to predicting parent and teacher ratings of hyperactivity and impulsivity and predicting categorical diagnoses of ADHD-Combined type versus Non-ADHD and ADHD-Combined type versus ADHD-Predominantly Inattentive type. The TOF Oppositional and Attention Deficit/Hyperactivity Problems scales contributed unique variance to predicting parent ratings of hyperactivity and impulsivity and the DOF Oppositional and Attention Deficit/Hyperactivity Problems scales contributed unique variance to predicting teacher ratings of hyperactivity and impulsivity.

COMT Val158Met genotype as a risk factor for problem behaviors in youth

OBJECTIVE

To test the association between the catechol-O-methyltransferase (COMT) Val158Met polymorphism and both aggressive behavior and attention problems in youth. We hypothesized that youth carrying a Met allele would have greater average aggressive behavior scores, and that youth exhibiting Val-homozygosity would have greater average attention problems scores.

METHOD

Complete data on maternally rated Child Behavior Checklist (CBCL) measures of aggressive behavior (AGG) and attention problems (AP), COMT polymorphism data, demographics, and maternal parenting quality were available for 149 youth (6 to 18 years old). Multivariable linear regression models were used to test the degree to which youth COMT Val158Met genotype was associated with AGG and AP while statistically controlling for age, gender, parental socioeconomic status (SES), and maternal parenting quality from the Alabama Parenting Questionnaire.

RESULTS

Mothers of Met-carriers rated their children higher on average AGG scores when compared with mothers of Val-homozygotes (p = .016). Further analyses revealed that this association was even more robust for maternal ratings of direct aggression (p = .007). The hypothesized association between Val-homozygosity and higher average AP scores relative to average AP scores of Met-carriers did not quite reach statistical significance (p = .062).

CONCLUSIONS

After controlling for demographics, SES, and maternal parenting quality as confounders, there remains a strong association between youth carrying a Met allele and higher average AGG scores relative to Val-homozygotes.

Adolescent cannabis problems and young adult depression: male-female stratified propensity score analyses

Cannabis use and depression are two of the most prevalent conditions worldwide. Adolescent cannabis use is linked to depression in many studies, but the effects of adolescent cannabis involvement on young adult depression remain unclear and may differ for males versus females. In this cohort study of youth from a mid-Atlantic metropolitan area of the United States, repeated assessments from 1985 (at age 6 years) through 2002 (at age 21 years) were made for 1,494 individuals (55% female). Measured covariate differences between individuals with and without cannabis problems were controlled via propensity score techniques. The estimated risk of young adult depression for adolescents with cannabis problems was not significantly different from that for comparison adolescents for either females (odds ratio = 0.7, 95% confidence interval: 0.2, 2.3) or males (odds ratio = 1.7, 95% confidence interval: 0.8, 3.6). The evidence does not support a causal association linking adolescent-onset cannabis problems with young adult depression.

Cocaine use and educational achievement: understanding a changing association over the past 2 decades

Trends in cocaine use over the past 2 decades were compared across levels of education in a population-based US sample of adults. Significant inverse associations between educational achievement and cocaine use after 1990 were driven by dramatic decreases in persistent cocaine use among more highly educated adults, whereas persistent cocaine use remained relatively unchanged among those who did not finish high school. This emerging health disparity highlights the need for improved interventions that target persistent cocaine users with low educational achievement.

Marijuana use and depression among adults: Testing for causal associations

AIM

To determine whether marijuana use predicts later development of depression after accounting for differences between users and non-users of marijuana.

DESIGN

An ongoing longitudinal survey of 12 686 men and women beginning in 1979.

SETTING

The National Longitudinal Survey of Youth of 1979, a nationally representative sample from the United States.

PARTICIPANTS

A total of 8759 adults (age range 29-37 years) interviewed in 1994 had complete data on past-year marijuana use and current depression.

MEASUREMENTS

Self-reported past-year marijuana use was tested as an independent predictor of later adult depression using the Center for Epidemiologic Studies-Depression questionnaire. Individual's propensity to use marijuana was calculated using over 50 baseline covariates.

FINDINGS

Before adjusting for group differences, the odds of current depression among past-year marijuana users is 1.4 times higher (95% CI: 1.1, 1.9) than the odds of depression among the non-using comparison group. After adjustment, the odds of current depression among past-year marijuana users is only 1.1 times higher than the comparison group (95% CI: 0.8, 1.7). Similarly, adjustment eliminates significant associations between marijuana use and depression in four additional analyses: heavy marijuana use as the risk factor, stratifying by either gender or age, and using a 4-year lag-time between marijuana use and depression.

CONCLUSIONS

After adjusting for differences in baseline risk factors of marijuana use and depression, past-year marijuana use does not significantly predict later development of depression. These findings are discussed in terms of their relevance for understanding possible causal effects of marijuana use on depression.

Complications of endoscopic and open carpal tunnel release

PURPOSE

To compile the major complications of carpal tunnel surgery and compare reported complications for open and endoscopic techniques.

METHODS

A literature assessment was performed for published complications of open and endoscopic carpal tunnel release procedures; 80 publications, representing a period from 1966 through 2001, were reviewed. Complications were identified as neurapraxia; nerve, tendon, or artery injury; and wound infection or dehiscence that required antibiotics or additional operative care. Differences in the proportions of complications between carpal tunnel release procedures were explored with the use of Fisher exact tests.

RESULTS

The literature review yielded 22,327 cases of endoscopic carpal tunnel release and 5,669 cases of open carpal tunnel release. For structural damage to nerves, arteries, or tendons, the incidence for open carpal tunnel release is 0.49% and for endoscopic methods (transbursal and extra-bursal), 0.19%. This difference is statistically significant (P < .005; 2-tailed Fisher exact test) and suggests that the overall proportion of structural complications for open carpal tunnel release according to our complication selection criteria is greater than the overall proportion of complications for endoscopic carpal tunnel release.

CONCLUSIONS

The proportion of complications for carpal tunnel release, performed through an endoscopic or open approach, is very low. Selection of an open versus an endoscopic approach on the basis of structural complications for nerve, arteries, or tendons is not supported by statistical analysis of published complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic study.

The increase in the association of education and cocaine use over the 1980s and 1990s: evidence for a 'historical period' effect

During the 1980s the social distribution of adult cocaine use in the US changed, according to qualitative analyses, and its use became more prevalent in the lower as compared to the upper social strata. In this paper, we use national data to investigate the association of education and adult cocaine use to test whether this trend represents either a 'historical period' process that occurred concurrently across adults of all age groups or a cohort process that started with younger cohorts and only extended to older age groups as these younger cohorts aged. We also estimate the extent to which the emergence of crack cocaine use accounts for trends in the socioeconomic distribution of cocaine use over historical time. To address these questions we analyze data from each survey of the National Household Survey on Drug Abuse from 1979 to 1998 inclusive. The results point to a "historical period" process that is explained in large part--but not entirely--by the emergence of crack cocaine. Important differences are apparent across racial and ethnic groups, as well as age groups. Cocaine use joins a growing list of potentially addictive drugs that have become more prevalent in the lower as compared to the upper social strata over historical time.

Effects of sterilization on the Tekscan digital pressure sensor

Investigations into the effects of sterilization on a new biomechanical pressure sensor are necessary before contemplating in vivo use. Ten, designated Experimental, "K-Scan" digital pressure sensor arrays were sterilized with ethylene oxide gas (EtO), and their ability to accurately and reproducibly measure an applied load of 2225 N (500 lb) was assessed. Simultaneously, 10 un-sterilized sensor arrays, designated Control, were assessed. Each array was loaded 10 times inside a two-dimensional curved surface, and all arrays exhibited high reproducibility (coefficients of variation<2.0%). Following sterilization, the Experimental sensors showed a 22.2% average decrease in recorded force, a statistically significant difference from the pre-sterile data (p<0.002). However, when the Experimental sensors were re-calibrated post-sterilization, they showed only a 0.1% average decrease in recorded force, not a statistically significant difference (p>0.05, beta<0.05). Following 1-week storage, trial 2 data of the Control sensors showed a less dramatic yet significant 3.4% average decrease in recorded force when compared to trial 1 data (p<0.02). Control trial 2, once re-calibrated, showed a 0.5% average decrease in recorded force, not a statistically significant difference (p>0.05, beta<0.05). Results suggest that, following EtO sterilization, accurate and reproducible pressure measurements can be obtained from K-Scan sensors when calibration is performed at time of use.

Early failure of a proximally cemented, distally uncemented total hip arthroplasty

This investigation prospectively studied a consecutive series of 22 proximally cemented, distal cementless, femoral components with a minimum follow-up time of 24 months. The prosthesis was a titanium, proximally cemented, femoral component with a distal press-fit fluted design. Five hips (23%) developed aseptic mechanical loosening at an average of 46.2 months and required revision. The technique required excessive removal of cancellous bone leading to a suboptimal bone-cement interface. The early failure rates of this prosthesis are unacceptably high for a contemporary hip design. To the best of our knowledge, no clinical studies have reported on the stability and longevity of this new proximal cementing technique incorporated with a distal press-fit femoral design.