Effects of a clinical feedback system on client and therapist outcomes in a rural community mental health center

This study was undertaken following the advent of managed care. Clinicians have been critical of managed care\u27s use of utilization review and arbitrary session limits, claiming these restrictions have not allowed them to provide needed care to some clients;The study evaluated the Outcomes Questionnaire ( OQ), a monitoring system that measures mental health symptoms and functioning (Lambert et al., 1996). Using this system, clients are assessed at multiple time points over the course of psychotherapy and compared to community samples; when clients are not improving or are deteriorating, adjustments in the treatment regimen can be made;The study was conducted in a community mental health center in a rural midwestern state with 127 clients measured at the initial time point, 77 at time 2, and 59 at time 3. Clinicians were randomly assigned to two conditions: (1) a feedback condition, where clients were assessed at each therapy session, the results graphed, and feedback given to the therapist; (2) a no feedback condition, where clients were assessed at each session, but no feedback given; and (3) a control condition, where clients received treatment as usual. All participating clients were assessed with multiple instruments at the initial session, after two months of therapy, and after four months of therapy;The results demonstrated the efficacy of providing mental health services by showing positive results on several measures of quality of life, including mental health symptoms, physical health symptoms, self-esteem, perceived stress, service utilization and work-related measures. The study sample was generally satisfied with the services, although level of satisfaction was unrelated to progress in therapy. Although therapists generally disliked managed care, the managed care clients did no worse than the non-managed care clients, and there were indications that managed care clients did somewhat better. The provision of outcome feedback to clinicians on client progress was generally well accepted by this group of 11 clinicians, although no indication of differences in improvement over time for the clients whose therapists received outcome feedback was detected. Study limitations may be responsible for the lack of outcome feedback effects

Effects of parent-child affective quality during high school years on subsequent substance use

The literature indicates that the quality of affective relationships between youth and parents is associated with lower levels of a range of problem behaviors during childhood, early and late adolescence. While the protective effect of parental monitoring on substance use in the high school and post high school years has been demonstrated, there is a knowledge gap concerning effects of parent-child affective quality (PCAQ) during the same periods. We tested a conceptual theoretical model to examine the effects of PCAQ on substance use following high school. The sample was from a RCT that assessed adolescents in rural Iowa from the seventh grade through two years after high school (N=456). We specified direct effects of PCAQ in 12th grade on drunkenness, smoking and illicit drug use during the two years immediately following high school graduation. We also specified the effects of early substance use initiation (alcohol, tobacco and marijuana use reported at baseline) on later use. The direct effect of PCAQ in 12th grade on substance use was significant for all substances during at least one of the two years past graduation (ypg). Results were: drunkenness 1 ypg, β=-.126, p<.05; smoking 1 ypg, β=-.119, p<.05; 2 ypg, β=-.146, p<.05; illicit drug use 2 ypg, β=-.165, p<.05. Some significant indirect effects of PCAQ at baseline, via PCAQ at 12th grade, were found. Results also indicated significant direct effects of early initiation on two of the three substances, albeit with a different pattern of effects over time for each substance by years post high school. Importantly, while early initiation remains the strongest predictor of long-term tobacco and illicit drug use, results show how PCAQ might reduce its harmful effects.peer-reviewe

Délocalisation outre frontière de l'emploi : mise à jour sur l'activité législative aux États-Unis

This note updates and completes a first note published in June 2004 by Linda Lee on recent legislative reactions at the state level to offshore outsourcing. It paints a picture of the recent evolution of this phenomenon and completes the list of bills under consideration in the U.S. Congress and state legislatures, and provides additional details on laws and executive orders that have been put into effect since this first publication.Cette note complète et met à jour une note publiée en juin 2004 par Linda Lee au sujet des réactions législatives récentes des États américains face au phénomène de la délocalisation outre frontière de l'emploi. Elle décrit sommairement l'évolution de ce débat au cours des dernières années et complète le tableau détaillé des projets de lois en y ajoutant des détails sur lois et les décrets adoptés dans les États depuis la parution de la première not

Caregiver Satisfaction with a Video Telehealth Home Safety Evaluation for Dementia

Family caregivers are vital to telehealth-delivered dementia care. The objective of this mixed methods descriptive study conducted in the VA Bedford Healthcare System was to examine caregiver satisfaction with a video telehealth dementia home safety occupational therapy evaluation. Ten caregivers of Veterans with dementia participated. Ratings of caregiver satisfaction, measured by nine Likert scale items including ability to see and hear, were examined in relation to person and visit-related contextual factors extracted from RA field notes, to develop an in-depth understanding of caregiver experience. Person factors included caregiver age and gender and Veteran cognitive status. Visit-related contextual factors included occurrence  of technical glitches. Caregiver visit satisfaction was overall positive, with exceptions related to technological glitches and the presence of the person with dementia during the visit. Veteran cognitive status appeared to influence caregiver satisfaction. Implications of the study are that proactively addressing technical glitches and incorporating dementia stage-specific approaches may optimize caregivers’ telehealth experience.

Real world costs and cost-effectiveness of Rituximab for diffuse large B-cell lymphoma patients: a population-based analysis.

BackgroundCurrent treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice.MethodsWe performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG).ResultsRituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of$61,984 (95% CI $34,087-$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60-79 years old and$110,100/LYG for patients ≥ 80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age.ConclusionsOur results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients &lt;60 years old. However, cost-effectiveness decreased significantly with age, suggesting that rituximab may be not as economically attractive in the very elderly on average. This has important clinical implications regarding age-related use and funding decisions on this drug

Community-based screening and triage connecting First Nations children and youth to local supports: a cross-sectional study

BACKGROUND: First Nations children in Canada experience health inequities. We aimed to determine whether a self-report health app identified children's needs for support earlier in their illness than would typically occur. METHODS: Children (aged 8 to 18 yr) were recruited from a rural First Nation community. Children completed the Aaniish Naa Gegii: the Children's Health and Well-being Measure (ACHWM) and then met with a local mental health worker who determined their risk status. ACHWM Emotional Quadrant Scores (EQS) were compared between 3 groups of children: healthy peers (HP) who were not at risk, those with newly identified needs (NIN) who were at risk and not previously identified, and a typical treatment (TT) group who were at risk and already receiving support. RESULTS: We included 227 children (57.1% girls), and the mean age was 12.9 (standard deviation [SD] 2.9) years. The 134 children in the HP group had a mean EQS of 80.1 (SD 11.25), the 35 children in the NIN group had a mean EQS of 67.2 (SD 13.27) and the 58 children in the TT group had a mean EQS of 66.2 (SD 16.30). The HP group had significantly better EQS than the NIN and TT groups (p < 0.001). The EQS did not differ between the NIN and TT groups (p = 0.8). INTERPRETATION: The ACHWM screening process identified needs for support among 35 children, and the associated triage process connected them to local services; the similarity of EQS in the NIN and TT groups highlights the value of community screening to optimize access to services. Future research will examine the impact of this process over the subsequent year in these groups

Barriers and facilitators to implementing community outreach work, and inter-professional collaboration with regional partners

Abstract : Objective. Community outreach workers support individuals in accessing the health and community services they require through various forms of proximity approaches. Even though community outreach has been available in the province of Quebec (Canada) for the past 40 years, it is still difficult to implement and sustain, especially with families of young children. The aim of this study was to document barriers and facilitators to implementing community outreach practices, and to describe how such workers collaborate with sectoral (e.g. health care) and inter-sectoral (e.g. municipalities, community organizations, schools) partners. Methodology. We performed a content analysis on 55 scientific and grey literature documents, and transcriptions of 24 individual interviews and 3 focus groups with stakeholders including parents, community outreach workers, health care employees, and inter-sectoral partners. Results. This study reveals four categories of barriers and facilitators to the implementation of community outreach work (i.e. organizational factors, nature of the work and worker-related factors, family-related factors, external factors). With regards to collaboration, community outreach workers deal with various partners. Good inter-professional collaboration is achieved through positive interactions and communication, shared or co-developed activities for the families, co-intervention with families, and strategies to enhance role awareness and inter-sectoral meetings. Conclusion. Results highlighted that many factors interact and can either influence, positively or negatively, the opportunity to implement community outreach work. The collaborative practices identified may help to maximize facilitators and overcome barriers. Advocacy and a better understanding of how to integrate community outreach work within health services while maintaining the workers’ flexibility are needed to sustain this practice

Effects of a clinical feedback system on client and therapist outcomes in a rural community mental health center

This study was undertaken following the advent of managed care. Clinicians have been critical of managed care's use of utilization review and arbitrary session limits, claiming these restrictions have not allowed them to provide needed care to some clients;The study evaluated the Outcomes Questionnaire ( OQ), a monitoring system that measures mental health symptoms and functioning (Lambert et al., 1996). Using this system, clients are assessed at multiple time points over the course of psychotherapy and compared to community samples; when clients are not improving or are deteriorating, adjustments in the treatment regimen can be made;The study was conducted in a community mental health center in a rural midwestern state with 127 clients measured at the initial time point, 77 at time 2, and 59 at time 3. Clinicians were randomly assigned to two conditions: (1) a feedback condition, where clients were assessed at each therapy session, the results graphed, and feedback given to the therapist; (2) a no feedback condition, where clients were assessed at each session, but no feedback given; and (3) a control condition, where clients received treatment as usual. All participating clients were assessed with multiple instruments at the initial session, after two months of therapy, and after four months of therapy;The results demonstrated the efficacy of providing mental health services by showing positive results on several measures of quality of life, including mental health symptoms, physical health symptoms, self-esteem, perceived stress, service utilization and work-related measures. The study sample was generally satisfied with the services, although level of satisfaction was unrelated to progress in therapy. Although therapists generally disliked managed care, the managed care clients did no worse than the non-managed care clients, and there were indications that managed care clients did somewhat better. The provision of outcome feedback to clinicians on client progress was generally well accepted by this group of 11 clinicians, although no indication of differences in improvement over time for the clients whose therapists received outcome feedback was detected. Study limitations may be responsible for the lack of outcome feedback effects.</p

Long-term effects of universal preventive interventions on methamphetamine use among adolescents. Arch Pediatr Adolesc Med

ABSTRACT Background This is a supplemental report on tests of the long-term effects of universal preventive interventions conducted during middle school on 17-21-year-olds&apos; prescription drug misuse. Design/setting/participants Two randomized controlled prevention trials were conducted in public schools in the rural midwestern United States. Study 1 began in 1993, with 667 6th-graders; follow-ups with 12th-graders and 21-year-olds included 457 and 483 participants, respectively. Study 2 began in 1998 with 7th-graders (total sample across waves 2127); follow-ups with 11th-and 12th-graders included 1443 and 1212 participants, respectively. Interventions In study 1, schools were assigned to the Iowa Strengthening Families Program (ISFP), Preparing for the Drug Free Years, or a control condition. In study 2, schools were assigned to the school-based Life Skills Training (LST) plus a revised ISFP, called SFP 10-14 (LST + SFP 10-14), LST-only, or a control condition. Measurements Self reports of lifetime and past-year prescription drug misuse. Findings In study 1, ISFP 12th-graders&apos; past year narcotic misuse was significantly less than controls, as were ISFP 21-year-olds&apos; life-time narcotic and barbiturate misuse rates. In study 2, LST + SFP 10-14 showed significant effects on life-time prescription drug misuse at the 11th-grade follow-up, while effects at the 12th-grade follow-up were marginally significant. Conclusions Consistent with intervention effects on other substance use outcomes reported earlier, results suggest that universal interventions have potential for pubic health impact by reducing some types of prescription drug misuse among adolescents and young adults