Motivation rulers for smoking cessation: a prospective observational examination of construct and predictive validity

BACKGROUND: Although popular clinically, the psychometric properties of motivation rulers for tobacco cessation are unknown. This study examined the psychometric properties of rulers assessing importance, readiness, and confidence in tobacco cessation. METHODS: This observational study of current smokers was conducted at 10 US emergency departments (EDs). Subjects were assessed during their ED visit (baseline) and reassessed two weeks later. We examined intercorrelations between the rulers as well as their construct and predictive validity. Hierarchical multinomial logistic regressions were used to examine the rulers\u27 predictive ability after controlling for covariables. RESULTS: We enrolled 375 subjects. The correlations between the three rulers ranged from 0.50 (between Important and Confidence) to 0.70 (between Readiness and Confidence); all were significant (p \u3c 0.001). Individuals in the preparation stage displayed the highest motivation-ruler ratings (all rulers F 2, 363 \u3e/= 43; p \u3c 0.001). After adjusting for covariables, each of the rulers significantly improved prediction of smoking behavior change. The strength of their predictive ability was on par with that of stage of change. CONCLUSION: Our results provide preliminary support for the psychometric soundness of the importance, readiness, and confidence rulers

Feasibility of audit methods to study access to substance use treatment

Audit studies represent an emerging method for examining disparities in access to care, like substance use treatment, whereby fake patients (i.e., actors) attempt to procure a service with one or more characteristics isolated across condition. This allows for manipulation of variables, like insurance status, that are normally fixed or impossible to standardize with precision when studying actual patients. This pilot study explored whether these methods were feasible for the examination of community-based substance use treatment access. Masked telephone calls (n=48) were made to providers (k=8) in a single city seeking an appointment. A male and female patient made calls in three insurance status conditions: no insurance, state-funded insurance, and private insurance. All other subject characteristics were held constant. Results showed an audit design to be a feasible method for examining disparities in access and demonstrated substantial barriers to voluntary treatment. Implications and future directions are discussed

A randomized clinical trial of the Health Evaluation and Referral Assistant (HERA): Research methods

The Health Evaluation and Referral Assistant (HERA) is a web-based program designed to facilitate screening, brief intervention, and referral to treatment (SBIRT) for tobacco, alcohol, and drug abuse. After the patient completes a computerized substance abuse assessment, the HERA produces a summary report with evidence-based recommended clinical actions for the healthcare provider (the Healthcare Provider Report) and a report for the patient (the Patient Feedback Report) that provides education regarding the consequences of use, personally tailored motivational messages, and a tailored substance abuse treatment referral list. For those who provide authorization, the HERA faxes the individual\u27s contact information to a substance abuse treatment provider matched to the individual\u27s substance use severity and personal characteristics, like insurance and location of residence (dynamic referral). This paper summarizes the methods used for a randomized controlled trial to evaluate the HERA\u27s efficacy in leading to increased treatment initiation and reduced substance use. The study was performed in four emergency departments. Individual patients were randomized into one of two conditions: the HERA or assessment only. A total of 4269 patients were screened and 1006 participants enrolled. The sample was comprised of 427 tobacco users, 212 risky alcohol users, and 367 illicit drug users. Forty-two percent used more than one substance class. The enrolled sample was similar to the eligible patient population. The study should enhance understanding of whether computer-facilitated SBIRT can impact process of care variables, such as promoting substance abuse treatment initiation, as well as its effect on subsequent substance abuse and related outcomes

Preventing Skin Cancer in College Females: Heterogeneous Effects Over Time

Objectives: To evaluate the effects of an appearance-focused intervention to reduce the risk of skin cancer by decreasing indoor tanning, examine potential heterogeneity in tanning across this time, and correlate the subtypes with predictors collected at baseline. Design: Randomized controlled trial with 379 female college students measured at 6 monthly time points. Main Outcome Measure: Self-reported indoor tanning frequency. Results: The intervention was effective at decreasing tanning over the period between the fall and spring. Longitudinal latent class analysis found 3 patterns of tann1ers among the treatment individuals: abstainers, moderate tanners, and heavy tanners. These classes appeared in both the treatment and control conditions, and the intervention had a harm reduction effect by reducing levels of exposure within the moderate and heavy tanner classes. Participant age and self-reported tanning patterns were found to be predictive of class membership. Conclusions: This research suggests that brief intervention approaches can be effective at reducing risk for skin cancer and illustrates several ways in which these protective effects can be enhanced

Spatial regression analysis of MR diffusion reveals subject-specific white matter changes associated with repetitive head impacts in contact sports

Abstract Repetitive head impacts (RHI) are a growing concern due to their possible neurocognitive effects, with research showing a season of RHI produce white matter (WM) changes seen on neuroimaging. We conducted a secondary analysis of diffusion tensor imaging (DTI) data for 28 contact athletes to compare WM changes. We collected pre-season and post-season DTI scans for each subject, approximately 3 months apart. We collected helmet data for the athletes, which we correlated with DTI data. We adapted the SPatial REgression Analysis of DTI (SPREAD) algorithm to conduct subject-specific longitudinal DTI analysis, and developed global inferential tools using functional norms and a novel robust p value combination test. At the individual level, most detected injured regions (93.3%) were associated with decreased FA values. Using meta-analysis techniques to combine injured regions across subjects, we found the combined injured region at the group level occupied the entire WM skeleton, suggesting the WM damage location is subject-specific. Several subject-specific functional summaries of SPREAD-detected WM change, e.g., the $${L}^{\infty }$$ L ∞ norm, significantly correlated with helmet impact measures, e.g. cumulative unweighted rotational acceleration (adjusted p = 0.0049), time between hits rotational acceleration (adjusted p value 0.0101), and time until DTI rotational acceleration (adjusted p = 0.0084), suggesting RHIs lead to WM changes

The effect of removing cost as a barrier to treatment initiation with outpatient tobacco dependence clinics among emergency department patients

Objectives: The campaign against tobacco addiction and smoking continues to play an important role in public health. However, referrals to outpatient tobacco cessation programs by emergency physicians are rarely pursued by patients following discharge. This study explored cost as a barrier to follow-up. Methods: The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a Stop Smoking Clinic affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee),$20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject. Results: The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p \u3e 0.05). Two-hundred forty-seven (43%) participants reported very much interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic. Conclusions: Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation. (c) 2011 by the Society for Academic Emergency Medicin

Screening for Suicidal Ideation and Attempts Among Emergency Department Medical Patients: Instrument and Results from the Psychiatric Emergency Research Collaboration

Joint Commission National Patient Safety Goal 15 calls for organizations to identify patients at risk for suicide. Overt suicidal behavior accounts for 0.6% of emergency department (ED) visits, but incidental suicidal ideation is found in 3%-11.6%. This is the first multicenter study of suicide screening in EDs. Of 2,243 patients in six diverse emergency settings, 1,068 (47.7%) were screened with a brief instrument. Depression was endorsed by 369 (34.5%); passive suicidal ideation by 79 (7.3%); and active suicidal ideation by 24 (2.3%). One hundred thirty-seven (12.8%) reported prior attempts, including 35 (3.3%) with current suicidal ideation. Almost half of those with current ideation had a prior attempt (43.8%) versus those without current ideation, 10.3%, chi(2) (1) = 75.59, p \u3c .001. Twenty cases (25%) were admitted to medical services, but only 10 (12.5%) received mental health assessment; none were admitted directly to a psychiatry service. The prevalence of suicidal ideation here is similar to previous studies but the frequency of prior attempts has not been reported. The 35 cases with current ideation and prior attempt are at risk. As they did not present psychiatrically, they would likely have gone undetected. Despite reporting these cases to clinical staff, few received risk assessment

Promoting tobacco cessation utilizing pre-health professional students as research associates in the emergency department

OBJECTIVE: The objective of this study was to investigate the extent to which volunteer research associates (RAs) can be utilized to screen emergency department patients and their visitors for tobacco use and effectively refer tobacco users requesting help to state Tobacco Quitlines. METHODS: A sample of 19,149 individuals in 10 emergency departments around the country was enrolled into a prospective, interventional study on tobacco cessation by pre-health professional RAs. Participants who screened positive for tobacco use were provided a brief description of Tobacco Quitline programs and then offered a faxed referral to their respective state Quitline. RESULTS: A total of 10,303 (54%) participants reported tobacco use for more than one month during their lives, with 3861 (20%) currently using every day and an additional 1340 using on some days (7%). Most importantly, 2151 participants requested a faxed Tobacco Quitline referral (36% of individuals who used tobacco in the past month). DISCUSSION: Pre-health professional RAs were shown to be an effective and cost-efficient resource for providing a strongly recommended service in the emergency department. Patient care (and the care of their visitors) was supplemented, emergency department personnel were not provided with additional burden, and RAs were provided with valuable experience for their futures in the health professions

Cognitive and affective predictors of smoking after a sentinel health event

Objective: This study examined how smoking-related causal attributions, perceived illness severity, and event-related emotions relate to both intentions to quit and subsequent smoking behavior after an acute medical problem (sentinel event). Methods: Three hundred and seventy-five patients were enrolled from 10 emergency departments (EDs) across the USA and followed for six months. Two saturated, manifest structural equation models were performed: one predicting quit attempts and the other predicting seven-day point prevalence abstinence at 14 days, three months, and six months after the index ED visit. Stage of change was regressed onto each of the other predictor variables (causal attribution, perceived illness severity, event-related emotions) and covariates, and tobacco cessation outcomes were regressed on all of the predictor variables and covariates. Results: Non-White race, baseline stage of change, and an interaction between causal attribution and event-related fear were the strongest predictors of quit attempt. In contrast, abstinence at six months was most strongly predicted by baseline stage of change and nicotine dependence. Conclusion: Predictors of smoking behavior after an acute medical illness are complex and dynamic. The relations vary depending on the outcome examined (quit attempts vs. abstinence), differ based on the time that has progressed since the event, and include significant interactions