Hybridizing two-step growth mixture model and exploratory factor analysis to examine heterogeneity in nonlinear trajectories

Empirical researchers are usually interested in investigating the impacts of baseline covariates have when uncovering sample heterogeneity and separating samples into more homogeneous groups. However, a considerable number of studies in the structural equation modeling (SEM) framework usually start with vague hypotheses in terms of heterogeneity and possible reasons. It suggests that (1) the determination and specification of a proper model with covariates is not straightforward, and (2) the exploration process may be computational intensive given that a model in the SEM framework is usually complicated and the pool of candidate covariates is usually huge in the psychological and educational domain where the SEM framework is widely employed. Following \citet{Bakk2017two}, this article presents a two-step growth mixture model (GMM) that examines the relationship between latent classes of nonlinear trajectories and baseline characteristics. Our simulation studies demonstrate that the proposed model is capable of clustering the nonlinear change patterns, and estimating the parameters of interest unbiasedly, precisely, as well as exhibiting appropriate confidence interval coverage. Considering the pool of candidate covariates is usually huge and highly correlated, this study also proposes implementing exploratory factor analysis (EFA) to reduce the dimension of covariate space. We illustrate how to use the hybrid method, the two-step GMM and EFA, to efficiently explore the heterogeneity of nonlinear trajectories of longitudinal mathematics achievement data.Comment: Draft version 1.6, 08/08/2020. This paper has not been peer reviewed. Please do not copy or cite without author's permissio

Identifying Attrition Phases in Survey Data: Applicability and Assessment Study

Background: Although Web-based questionnaires are an efficient, increasingly popular mode of data collection, their utility is often challenged by high participant dropout. Researchers can gain insight into potential causes of high participant dropout by analyzing the dropout patterns. Objective: This study proposed the application of and assessed the use of user-specified and existing hypothesis testing methods in a novel setting—survey dropout data—to identify phases of higher or lower survey dropout. Methods: First, we proposed the application of user-specified thresholds to identify abrupt differences in the dropout rate. Second, we proposed the application of 2 existing hypothesis testing methods to detect significant differences in participant dropout. We assessed these methods through a simulation study and through application to a case study, featuring a questionnaire addressing decision-making surrounding cancer screening. Results: The user-specified method set to a low threshold performed best at accurately detecting phases of high attrition in both the simulation study and test case application, although all proposed methods were too sensitive. Conclusions: The user-specified method set to a low threshold correctly identified the attrition phases. Hypothesis testing methods, although sensitive at times, were unable to accurately identify the attrition phases. These results strengthen the case for further development of and research surrounding the science of attrition

Methods for Evaluating Respondent Attrition in Web-Based Surveys

Background: Electronic surveys are convenient, cost effective, and increasingly popular tools for collecting information. While the online platform allows researchers to recruit and enroll more participants, there is an increased risk of participant dropout in Web-based research. Often, these dropout trends are simply reported, adjusted for, or ignored altogether. Objective: To propose a conceptual framework that analyzes respondent attrition and demonstrates the utility of these methods with existing survey data. Methods: First, we suggest visualization of attrition trends using bar charts and survival curves. Next, we propose a generalized linear mixed model (GLMM) to detect or confirm significant attrition points. Finally, we suggest applications of existing statistical methods to investigate the effect of internal survey characteristics and patient characteristics on dropout. In order to apply this framework, we conducted a case study; a seventeen-item Informed Decision-Making (IDM) module addressing how and why patients make decisions about cancer screening. Results: Using the framework, we were able to find significant attrition points at Questions 4, 6, 7, and 9, and were also able to identify participant responses and characteristics associated with dropout at these points and overall. Conclusions: When these methods were applied to survey data, significant attrition trends were revealed, both visually and empirically, that can inspire researchers to investigate the factors associated with survey dropout, address whether survey completion is associated with health outcomes, and compare attrition patterns between groups. The framework can be used to extract information beyond simple responses, can be useful during survey development, and can help determine the external validity of survey results

A state-level study of opioid use disorder treatment access and neonatal abstinence syndrome

Background Adult opioid use and neonatal abstinence syndrome (NAS) are growing public health problems in the United States (U.S.). Our objective was to determine how opioid use disorder treatment access impacts the relationship between adult opioid use and NAS. Methods We conducted a cross-sectional state-level ecologic study using 36 states with available Healthcare Cost and Utilization Project State Inpatient Databases in 2014. Opioid use disorder treatment access was determined by the: 1) proportion of people needing but not receiving substance use treatment, 2) density of buprenorphine-waivered physicians, and 3) proportion of individuals in outpatient treatment programs (OTPs). The incidence of NAS was defined as ICD-9 code 779.5 (drug withdrawal syndrome in newborn) from any discharge diagnosis field per 1000 live births in that state. Results Unmet need for substance use disorder treatment correlated with NAS (r = 0.54, 95% CI: 0.26–0.73). The correlation between adult illicit drug use/dependence and NAS was higher in states with a lower density of buprenorphine-waivered physicians and individuals in OTPs. Conclusions Measures of opioid use disorder treatment access dampened the correlation between illicit drug use/dependence and NAS. Future studies using community- or individual-level data may be better poised to answer the question of whether or not opioid use disorder treatment access improves NAS relative to adult opioid use

Associations between Childhood Body Size, Composition, Blood Pressure and Adult Cardiac Structure: The Fels Longitudinal Study

Objectives To determine whether childhood body size, composition and blood pressure are associated with adult cardiac structure by estimating childhood “age of divergence.” Methods 385 female and 312 male participants in the Fels Longitudinal Study had echocardiographic measurements of left ventricular mass, relative wall thickness, and interventricular septal thickness. Also available were anthropometric measurements of body mass index, waist circumference, percentage body fat, fat free mass, total body fat, and systolic and diastolic blood pressures, taken in both childhood and adulthood. The age of divergence is estimated as the lowest age at which childhood measurements are significantly different between patients with low and high measurements of adult cardiac structure. Results Childhood body mass index is significantly associated with adult left ventricular mass (indexed by height) in men and women (ages of divergence: 7.5 years and 11.5 years, respectively), and with adult interventricular septal thickness in boys (age of divergence: 9 years). Childhood waist circumference indexed by height is associated with left ventricular mass (indexed by height) in boys (age of divergence: 8 years). Cardiac structure was in general not associated with childhood body composition and blood pressure. Conclusions Though results are affected by adult body size, composition and blood pressure, some aspects of adult cardiac structure may have their genesis in childhood body size

Obtaining interpretable parameters from reparameterizing longitudinal models: transformation matrices between growth factors in two parameter-spaces

The linear spline growth model (LSGM), which approximates complex patterns using at least two linear segments, is a popular tool for examining nonlinear change patterns. Among such models, the linear-linear piecewise change pattern is the most straightforward one. An earlier study has proved that other than the intercept and slopes, the knot (or change-point), at which two linear segments join together, can be estimated as a growth factor in a reparameterized longitudinal model in the latent growth curve modeling framework. However, the reparameterized coefficients were no longer directly related to the underlying developmental process and therefore lacked meaningful, substantive interpretation, although they were simple functions of the original parameters. This study proposes transformation matrices between parameters in the original and reparameterized models so that the interpretable coefficients directly related to the underlying change pattern can be derived from reparameterized ones. Additionally, the study extends the existing linear-linear piecewise model to allow for individual measurement occasions, and investigates predictors for the individual-differences in change patterns. We present the proposed methods with simulation studies and a real-world data analysis. Our simulation studies demonstrate that the proposed method can generally provide an unbiased and consistent estimation of model parameters of interest and confidence intervals with satisfactory coverage probabilities. An empirical example using longitudinal mathematics achievement scores shows that the model can estimate the growth factor coefficients and path coefficients directly related to the underlying developmental process, thereby providing meaningful interpretation. For easier implementation, we also provide the corresponding code for the proposed models.Comment: Draft version 1.6, 07/28/2020. This paper has not been peer reviewed. Please do not copy or cite without author's permissio

Harnessing Information Technology to Inform Patients Facing Routine Decisions: Cancer Screening as a Test Case

PURPOSE Technology could transform routine decision making by anticipating patients’ information needs, assessing where patients are with decisions and preferences, personalizing educational experiences, facilitating patient-clinician information exchange, and supporting follow-up. This study evaluated whether patients and clinicians will use such a decision module and its impact on care, using 3 cancer screening decisions as test cases. METHODS Twelve practices with 55,453 patients using a patient portal participated in this prospective observational cohort study. Participation was open to patients who might face a cancer screening decision: women aged 40 to 49 who had not had a mammogram in 2 years, men aged 55 to 69 who had not had a prostate-specific antigen test in 2 years, and adults aged 50 to 74 overdue for colorectal cancer screening. Data sources included module responses, electronic health record data, and a postencounter survey. RESULTS In 1 year, one-fifth of the portal users (11,458 patients) faced a potential cancer screening decision. Among these patients, 20.6% started and 7.9% completed the decision module. Fully 47.2% of module completers shared responses with their clinician. After their next office visit, 57.8% of those surveyed thought their clinician had seen their responses, and many reported the module made their appointment more productive (40.7%), helped engage them in the decision (47.7%), broadened their knowledge (48.1%), and improved communication (37.5%). CONCLUSIONS Many patients face decisions that can be anticipated and proactively facilitated through technology. Although use of technology has the potential to make visits more efficient and effective, cultural, workflow, and technical changes are needed before it could be widely disseminated

Stem Cell Transplantation As A Dynamical System: Are Clinical Outcomes Deterministic?

Outcomes in stem cell transplantation (SCT) are modeled using probability theory. However the clinical course following SCT appears to demonstrate many characteristics of dynamical systems, especially when outcomes are considered in the context of immune reconstitution. Dynamical systems tend to evolve over time according to mathematically determined rules. Characteristically, the future states of the system are predicated on the states preceding them, and there is sensitivity to initial conditions. In SCT, the interaction between donor T cells and the recipient may be considered as such a system in which, graft source, conditioning and early immunosuppression profoundly influence immune reconstitution over time. This eventually determines clinical outcomes, either the emergence of tolerance or the development of graft versus host disease. In this paper parallels between SCT and dynamical systems are explored and a conceptual framework for developing mathematical models to understand disparate transplant outcomes is proposed.Comment: 23 pages, 4 figures. Updated version with additional data, 2 new figures and editorial revisions. New authors adde

Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial

Background: Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry. Methods: SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices. Discussion: Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care