Quality of asynchronous webchats vs in-person consultations for postpartum depression in China:a cross-sectional, mixed methods study using standardized patients

Background: Prompt professional care for postpartum depression (PPD) is difficult to obtain in China. Though online consultations improve accessibility and reduce stigma, the quality of services compared to in-person consultations is unclear. Methods: Five trained, undisclosed “standardized patients” (SPs) made “asynchronous webchats” visits and in-person visits with psychiatrists. Visits were made to 85 psychiatrists who were based in 69 hospitals in ten provincial capital cities. The care between online and in-person consultations with the same psychiatrist was compared, including diagnosis, guideline adherence, and patient-centeredness. False discovery rate (FDR) was used to adjust p values. Third visits using asynchronous webchats were made to psychiatrists who offered discrepant diagnoses. Thematic content analysis was used for the discrepancies. Findings: The proportion of diagnostic accuracy was lower for online than in-person visits (76.5% [65/85] vs 91.8% [78/85]; pFDR = 0.0066), as were the proportions of completing questions involving clinical history (16.6% vs 42.7%; pFDR < 0.0001), and management decisions (16.2% vs 27.5%; pFDR < 0.0001) consistent with recommended guidelines. Patient-centeredness was lower online than in-person (pFDR < 0.0001). Fifteen of 16 psychiatrists completed third visits, most of them considered lack of nonverbal information online as a key barrier. Interpretation: Online consultations using asynchronous webchats were inferior to in-person consultations, with respect to diagnostic accuracy, adherence to recommended clinical guidelines, and patient-centeredness. To fully realise the potential benefits of online consultations and to prevent safety issues, there is an urgent need for major improvement in the quality and oversight of these consultations. Funding:  China Medical Board, National Natural Science Foundation of China, and Swiss Agency for Development and Cooperation Global Cooperation Department

Patient Preferences in Controlling Access to Their Electronic Health Records: a Prospective Cohort Study in Primary Care

Introduction: Previous studies have measured individuals’ willingness to share personal information stored in electronic health records (EHRs) with health care providers, but none has measured preferences among patients when they are allowed to determine the parameters of provider access. Methods: Patients were given the ability to control access by doctors, nurses, and other staff in a primary care clinic to personal information stored in an EHR. Patients could restrict access to all personal data or to specific types of sensitive information, and could restrict access for a specific time period. Patients also completed a survey regarding their understanding of and opinions regarding the process. Results: Of 139 eligible patients who were approached, 105 (75.5 %) were enrolled, and preferences were collected from all 105 (100 %). Sixty patients (57 %) did not restrict access for any providers. Of the 45 patients (43 %) who chose to limit the access of at least one provider, 36 restricted access only to all personal information in the EHR, while nine restricted access of some providers to a subset of the their personal information. Thirty-four (32.3 %) patients blocked access to all personal information by all doctors, nurses, and/or other staff, 26 (24.8 %) blocked access by all doctors and/or nurses, and five (4.8 %) denied access to all doctors, nurses, and staff. Conclusions: A significant minority of patients chose to restrict access by their primary care providers to personal information contained in an EHR, and few chose to restrict access to specific types of information. More research is needed to identify patient goals and understanding of the implications when facing decisions of this sort, and to identify the impact of patient education regarding information contained in EHRs and their use in the clinical care settin

Does Practice Make Perfect? A Randomized Control Trial of Behavioral Rehearsal on Suicide Prevention Gatekeeper Skills

Suicide is the third leading cause of death among 10-24-year-olds and the target of school-based prevention efforts. Gatekeeper training, a broadly disseminated prevention strategy, has been found to enhance participant knowledge and attitudes about intervening with distressed youth. Although the goal of training is the development of gatekeeper skills to intervene with at-risk youth, the impact on skills and use of training is less known. Brief gatekeeper training programs are largely educational and do not employ active learning strategies such as behavioral rehearsal through role play practice to assist skill development. In this study, we compare gatekeeper training as usual with training plus brief behavioral rehearsal (i.e., role play practice) on a variety of learning outcomes after training and at follow-up for 91 school staff and 56 parents in a school community. We found few differences between school staff and parent participants. Both training conditions resulted in enhanced knowledge and attitudes, and almost all participants spread gatekeeper training information to others in their network. Rigorous standardized patient and observational methods showed behavioral rehearsal with role play practice resulted in higher total gatekeeper skill scores immediately after training and at follow-up. Both conditions, however, showed decrements at follow-up. Strategies to strengthen and maintain gatekeeper skills over time are discussed

Prevalence of Postpartum Depression Based on Diagnostic Interviews:A Systematic Review and Meta-Analysis

Background. Postpartum depression (PPD) is common after childbirth. Previous reviews on the prevalence of PPD have mainly included results that relied on screening instruments or a mixture of such instruments and diagnostic interviews. In this study, we aimed to assess the prevalence of PPD based exclusively on studies using diagnostic interviews, as they provide the most reliable and valid approach for defining “caseness.” Methods. Using PubMed, Web of Science, Cochrane Library, Embase, CNKI, WANFANG DATA, and CBM up to September 18, 2022, we searched for original articles reporting data that could be used to calculate the prevalence of PPD based on diagnostic interviews. A random-effect meta-analysis model was then used to estimate the pooled prevalence. In addition, we assessed quality, heterogeneity, and publication bias across studies. Also, we did subgroup analyses to explore the pooled prevalence at different time points and settings. This study was registered with PROSPERO, CRD42021244539. Results. Of 17,115 articles retrieved, 54 studies were included (total sample size=15,586 women). The pooled prevalence of all depression and major depression within one year postpartum was 12.1% (95% CI 10.3%-14.1%; I2=91.0%) and 7.0% (95% CI 5.7%-8.4%; I2=83.0%), respectively. The peaks of all depression occurred during the first 6 months postpartum, especially 2-3 weeks and 6-8 weeks. Subgroup analyses showed that the prevalence of major depression was associated with the income level of countries (higher in low- and middle-income countries (LMICs) than in high-income countries (HICs)) and diagnostic criteria (higher using ICD than using DSM and RDC). No evidence of publication bias was found. Conclusions. Approximately one in eight postpartum women experiences a depressive condition, with one in fifteen suffering major depression. The pooled prevalence based on diagnostic interviews was lower than the existing consensus, which was largely based on self-reported screening instruments. The higher prevalence in LMICs underlines the importance of strengthening research and service provision among these populations

Provider Responses to Patients Controlling Access to their Electronic Health Records: A Prospective Cohort Study in Primary Care

Introduction: Applying Fair Information Practice principles to electronic health records (EHRs) requires allowing patient control over who views their data. Methods: We designed a program that captures patients’ preferences for provider access to an urban health system’s EHR. Patients could allow or restrict providers’ access to all data (diagnoses, medications, test results, reports, etc.) or only highly sensitive data (sexually transmitted infections, HIV/AIDS, drugs/alcohol, mental or reproductive health). Except for information in free-text reports, we redacted EHR data shown to providers according to patients’ preferences. Providers could “Break the Glass” to display redacted information. We prospectively studied this system in one primary care clinic, noting redactions and when users “Broke the Glass,” and surveyed providers about their experiences and opinions. Results: Eight of 9 eligible clinic physicians and all 23 clinic staff participated. All 105 patients who enrolled completed the preference program.. Providers did not know which of their patients were enrolled and nor their preferences for accessing their EHRs. During the six-month prospective study, 92 study patients (88%) returned 261 times during which providers viewed their EHRs 126 times (48%). Providers “broke the glass” 102 times, 92 times for patients not in the study and 10 times for 6 returning study patients, all of whom had restricted EHR access. Providers “broke the glass” for 6 (14%) of 43 returning study patients with redacted data vs. zero among 49 study patients without redactions (p=0.01). Although 54% of providers agreed that patients should have control over who sees their EHR information, 58% believed restricting EHR access could harm provider-patient relationships and 71% felt quality of care would suffer. Conclusions: Patients frequently preferred restricting provider access to their EHRs. Providers infrequently overrode patients’ preferences to view hidden data. Providers believed restricting EHR access would adversely impact patient care. Applying Fair Information Practice principles to EHRs will require balancing patient preferences, providers’ needs, and health care quality.This study was supported in part by grant number 90HT005 from the Office of the National Coordinator for Health Information Technology (ONC) to the Indiana Health Information Technology Corporation. The opinions expressed in this work are the authors’ and do not necessarily reflect the positions of ONC, IHIT, Eskenazi Health, Indiana University, or the Regenstrief Institute, Inc

Alcohol Policy, Social Context, and Infant Health: The Impact of Minimum Legal Drinking Age

Objective: The minimum legal drinking age (MLDA) was increased in the U.S. in the late 1980s in an effort to reduce intoxication-associated injuries, especially those related to motor vehicle accidents. This paper explores distal (secondary) effects of changing MLDA on indices of infant health, and whether changes in drinking behaviors or birth composition contributed to these effects. Methods: State- and year-fixed-effects models are used to analyze the relationship between MLDA, drinking behaviors, and birth outcomes. We studied the effects of different MLDA (age 18, 19, 20, or 21 years) when potential mothers were 14 years old by merging two population-based datasets, the Natality Detailed Files and the Behavioral Risk Factor Surveillance System between 1985 and 2002. Results: A MLDA of 18 years old (when potential mothers were 14 years old) increased the prevalence of low birth weight, low Apgar scores, and premature births. Effects were stronger among children born to black women compared with white women. Moreover, a younger MLDA was associated with an increasing proportion of very young and high school dropouts for black women. Furthermore, older MLDA laws at age 14 years decreased the prevalence of binge drinking among black women. Conclusions: Increasing the MLDA had longer term, distal impacts beyond the initially intended outcomes, specifically on birth outcomes (particularly among infants born to black women) as well as school drop-outs and binge drinking patterns among black young females. The older MLDA, intended initially to reduce problematic drinking behaviors, appeared to alter broader social contexts that influenced young women during their early childbearing years

Testimony on Pennsylvania SB1306: No Additional Protections for Religious Freedom

On behalf of the Public Rights/Private Conscience Project (PRPCP) at Columbia Law School I offer the following legal analysis of Senate Bill 1306. Overall, the current version of the bill promises to modernize Pennsylvania’s Human Relations Act by expanding antidiscrimination protections in employment to include sexual orientation and gender identity-based discrimination. Were the Pennsylvania legislature to pass SB 1306, the Commonwealth would join twenty-two states that include sexual orientation and nineteen states that include gender identity in their laws assuring equal employment opportunities for their citizens

Discerning suicide in drug intoxication deaths: Paucity and primacy of suicide notes and psychiatric history

Objective A paucity of corroborative psychological and psychiatric evidence may be inhibiting detection of drug intoxication suicides in the United States. We evaluated the relative importance of suicide notes and psychiatric history in the classification of suicide by drug intoxication versus firearm (gunshot wound) plus hanging/suffocation—the other two major, but overtly violent methods. Methods This observational multilevel (individual/county), multivariable study employed a generalized linear mixed model (GLMM) to analyze pooled suicides and undetermined intent deaths, as possible suicides, among the population aged 15 years and older in the 17 states participating in the National Violent Death Reporting System throughout 2011–2013. The outcome measure was relative odds of suicide versus undetermined classification, adjusted for demographics, precipitating circumstances, and investigation characteristics. Results A suicide note, prior suicide attempt, or affective disorder was documented in less than one-third of suicides and one-quarter of undetermined deaths. The prevalence gaps were larger among drug intoxication cases than gunshot/hanging cases. The latter were more likely than intoxication cases to be classified as suicide versus undetermined manner of death (adjusted odds ratio [OR], 41.14; 95% CI, 34.43–49.15), as were cases documenting a suicide note (OR, 33.90; 95% CI, 26.11–44.05), prior suicide attempt (OR, 2.42; 95% CI, 2.11–2.77), or depression (OR, 1.61; 95% CI, 1.38 to 1.88), or bipolar disorder (OR, 1.41; 95% CI, 1.10–1.81). Stratification by mechanism/cause intensified the association between a note and suicide classification for intoxication cases (OR, 45.43; 95% CI, 31.06–66.58). Prior suicide attempt (OR, 2.64; 95% CI, 2.19–3.18) and depression (OR, 1.48; 95% CI, 1.17–1.87) were associated with suicide classification in intoxication but not gunshot/hanging cases. Conclusions Without psychological/psychiatric evidence contributing to manner of death classification, suicide by drug intoxication in the US is likely profoundly under-reported. Findings harbor adverse implications for surveillance, etiologic understanding, and prevention of suicides and drug deaths