Using Outcome Data to Create Clinical Change: Foundations and Example

When we evaluate the success of a hearing aid fitting, or the effectiveness of new amplification technology, self-report data occupy a position of critical importance. Unless patients report that our efforts are helpful, it is difficult to justify a conclusion that the intervention has been successful. Although it is generally assumed that subjective reports primarily reflect the excellence of the fitted hearing aid(s) within the context of the patient's everyday circumstances, there is relatively little research that assesses the validity of this assumption. In previous work, we have reported some contributions of the service delivery setting (private practice versus public health) to self-report outcomes. The purpose of the present investigation was to assess the relative contributions of patient variables (such as personality and hearing problems) and amplification variables (such as soft sound audibility, gain and maximum output) to self-reports of hearing aid fitting outcomes. A cross-sectional survey of 205 patients was conducted with cooperation of eleven Audiology clinics. All subjects were recruited when they were seeking new hearing aids. Before the hearing aid fitting, measurements of personality and response bias were made, as well as measures of hearing problems and expectations about amplification. At the fitting, traditional verification data were measured including sound field thresholds, preferred gain for conversation, and maximum output. Six months after the fitting, a set of 12 standardized self-report outcomes was completed. Analyses concerned: (1) the associations among personality, response bias, and self-reports about hearing problems that are available before the hearing aid fitting, and (2) the associations of these precursor variables, and fitting verification data, with self-report data assessing the outcome of hearing aid provision. Self-reports of hearing problems, sound aversiveness, and hearing aid expectations obtained before the fitting were found to be more closely related to the strength of certain personality traits than to audiometric hearing loss. Response bias also was associated with personality variables. Analyses of the collection of outcome measures produced a set of three components that were interpreted as a Device component, a Success component, and an Acceptance component. The Device component was construed as reflecting characteristics of the hearing aid whereas the two other components were construed as reflecting attributes of the wearer. The Success and Acceptance components were each significantly associated with several personality traits, but the Device component was not associated with personality. Variables available before the fitting accounted for 20 to 30% of each outcome component whereas amplification variables measured to verify the fitting accounted for only 10% on only one component. As reported in previous research, personality is associated with self-report outcome data. However, if practitioners utilize existing measures of hearing problems at the prefitting stage, separate personality data will not yield additional leverage in prediction of long-term fitting outcomes. Traditional fitting verification data as measured in this study, proved minimally useful in prediction of long-term outcomes of the fitting. A large proportion of variance in self-report fitting outcomes has yet to be accounted for. Finally, it appears that certain types of questionnaires might be more appropriate for research evaluating new amplification devices, whereas a different questionnaire approach might be optimal for evaluating intervention effectiveness in a clinical context.

Study purpose: This descriptive study used a routine practice dataset to investigate whether demographic variables and intervention length were associated with outcome after brief psychological interventions in primary care. Brief description of the participants: The data are from 3687 adults with a wide range of presenting problems, from a culturally diverse inner London borough, referred to primary care psychologists and counsellors. Methodology: Demographic and service activity data were routinely collected using a local monitoring form and self-report outcome data using the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM). The paradigm of reliable and clinically significant change was used to explore individual as well as group change. The relationship between demographic variables, intervention length and outcome was investigated. Results, conclusions and implications: Sixty-six per cent of the group with complete outcome data (n = 458) showed reliable improvement and 45% also showed clinically significant improvement after the intervention. Ethnicity was not related to outcome, suggesting that the service was not culturally biased in this respect (although clients from ethnic minorities were significantly underrepresented in the sample of clients who attended). Women and employed clients were more likely to show improvement. Unemployed men had comparatively poor outcomes. There was a positive relationship between length of intervention and improvement. As is often the case, client and data attrition were high: the small sample for which complete outcome data were available reduced the representativeness and generalisability of the findings which must therefore be treated with caution. Issues of attrition must be addressed in future to ensure that data quality is sufficient to increase confidence in using it for service management, development and 'benchmarking'. However, the study adds to the growing body of 'practice-based evidence' supporting the provision of primary care psychology and counselling services. The findings suggest that the employment status and gender of clients may both need to be considered when 'benchmarking' outcomes

Suicide et technique thérapeutique de résolution de problèmes

Background/Aim: Numerous studies have shown associations between exposure to traffic noise and hypertension but most were cross-sectional and based on self-reported outcome data. Aim of this cohort study was to investigate the relationship between traffic noise from various sources and incidence of hypertension. Methods: We assessed individual long-term exposure to noise from road traffic, railways and aircraft based on residential histories in a cohort of 4913 men and women from Stockholm County, free of hypertension at recruitment. Noise levels were estimated at the most exposed façade of each dwelling based on a modification of the Nordic prediction method. Hypertension incidence was assessed during an average follow-up period of 8.9 years based on doctor diagnosis or blood pressure measurements. Extensive information on potential confounders was available from repeated questionnaires and registers. We used Cox proportional hazards regression models with age as the time scale and estimated hazard ratios (HR) adjusted for age, sex, smoking, body mass index at recruitment and socioeconomic status. Results A total of 1357 (27%) subjects were diagnosed with hypertension during follow-up. A 10 dB Lden increase in estimated noise levels during 5 years preceeding the event was associated with a 9% increased risk of hypertension due to aircraft noise (HR1.09, 95% confidence interval 1.05 to 1.15). However, no clear association was observed for road or railway traffic noise, with HRs of 0.97 (95%CI 0.92 to 1.03) and 0.96 (95%CI 0.90 to 1.02), respectively, per 10 dB Lden. The association for aircraft noise appeared particularly high in men (HR 1.15, 95%CI 1.08 to 1.23 per 10 dB Lden) compared to women (HR 1.05, 95%CI 0.98 to 1.12 per 10 dB Lden). Conclusions: Our results provide further evidence linking environmental noise exposure to development of hypertension, particularly from aircraft.

Abstract: Background: Perceived scarcity shows promise as an indicator of physical and mental health and a possible predictor of health disparities; however, a systematic investigation of how perceived scarcity is experienced across racial and ethnic, gender, and socioeconomic groups is imperative. Moreover, it is necessary to unpack the unique predictive power of each scarcity domain. Aims: First, differences in the experience of perceived scarcity by various sociodemographic groups in overall perceived scarcity and each of its three dimensions were explored using a cross-sectional sample. Next, using self-reported health outcome data collected from participants at a second time point, the direct and mediating role of perceived scarcity in the relationship between sociodemographic indicators and self-reported health was examined. Method: Participants included a racially and socioeconomically diverse online sample. One-way analyses of variance (ANOVAs) and t-tests were used to assess whether perceived scarcity, overall and by domain, varied by sociodemographic factors. PROCESS macro for SPSS v 3.5 was used to analyze the proposed direct effects and mediations. Results: Results indicate that sociodemographic differences do exist in perceived scarcity and in a variety of ways that may not be reflected when solely examining overall perceived scarcity. Dimensions of perceived scarcity were found to mediate the relationship between some sociodemographic factors and self-reported health. Limitations: Future research should address the limitations of the current study’s sample insofar as recruiting a wider sample of participants to include those experiencing the most extreme forms of scarcity. Conclusion: Findings support the importance of considering the unique experience of perceived scarcity by domain across sociodemographic groups when using it as a predictor or mediator of health.

6584 Background: Continued smoking in cancer patients receiving treatment results in decreased efficacy, reduced survival, amd increased risk of recurrence. Despite ASCO and AACR policy statements, routine tobacco use screening and provision of smoking cessation treatment has not been widely implemented in the cancer setting. A paper-based tobacco use screening and clinician-dependent referral program for new ambulatory cancer patients was initiated at Princess Margaret Cancer Centre in 2013 resulting in moderate screen rates but low referral rates. In response, we developed and implemented a tailored patient directed electronic smoking cessation platform (CEASE) which included three elements:1) tobacco use assessment tool; 2) patient education on benefits of cessation; 3) a patient directed automatic referral system to smoking cessation programs. Methods: Interrupted time series design to examine the impact of CEASE on process of care (screening rates, referrals offered and accepted) and patient reported (quit attempts, smoking status, uptake of cessation programs) outcomes. Included 20 monthly intervals: 6 pre implementation (Apr-Sept 2015) (PRE), 8 gradual implementation across all tumour sites (Oct 2015-May 2016), and 6 postb implementation (Jun 2016-Nov 2016) (POST). A time series segmented linear regression was conducted to evaluate changes in process of care outcomes (excluding the implementation period). Pre-post self-report patient outcome data was also compared. Results: We assessed data from n = 3785 (PRE) and n = 4726 (POST) new patients. Screening rates increased from 44% using the paper-based approach to 65% with CEASE (p = 0.0019). Referrals offered to smokers who were willing to quit increased from 24% to 100% (p < 0.0001). Accepted referrals decreased from 45% to 26%; though the overall referral rate increased from 11% to 26% (p = 0.0001). The proportion of those using tobacco or attempting to quit did not differ at 3-months. However, engagement with the referral source increased from 4% to 62.5% (p < 0.001). Conclusions: CEASE was successfully implemented across all clinics and resulted in improvements in overall screening and referral rates and engagement with referral services.

IntroductionCardiac rehabilitation (CR) is offered to reduce the risk of further cardiac events and to improve patients’ health and quality of life following a cardiac event. Psychological care is a...

Self-report questionnaires are a frequently used method of evaluating hearing aid outcomes. Studies have shown that personality can account for 5-20% of the variance in response to self-report measures. As a result, these influences can impact results and limit their generalizability when the purpose of the study is to examine the technological merit of hearing aids. To reduce personality influences on self-report outcome data, the Device-Oriented Subjective Outcome (DOSO) was developed. The DOSO is meant to demonstrate outcomes of the amplification device relatively independent of the individual's personality. Still, it is unknown if the DOSO achieves its original goal. The purpose of this study was to examine the relationship between personality and the DOSO. The relationship between personality and several widely used hearing-related questionnaires was also examined. This is a nonexperimental study using a correlational design. A total of 119 adult hearing aid wearers participated in the study. The NEO Five-Factor Inventory was used to measure five personality traits (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness). The initial (unaided) hearing disablement, residual (aided) hearing disablement, and hearing aid benefit and satisfaction was measured using the DOSO, Hearing Handicap Inventory for the Elderly/Adult, Abbreviated Profile of Hearing Aid Benefit, and Satisfaction with Amplification in Daily Life. The relationship between personality and each questionnaire was examined using a correlation analysis. All of the DOSO subscales were found to be significantly correlated to personality, regardless of whether age and better-ear hearing thresholds were controlled. Individuals who reported poorer hearing aid outcomes tended to have higher Neuroticism scores, while those who scored higher in Extraversion, Openness, and Agreeableness were more likely to report better outcomes. Across DOSO subscales, the maximum variance explained by personality traits ranged from 6% to 11%. Consistent with the literature, ∼3-18% of the variance of other hearing-related questionnaires was attributable to personality. The degree to which personality affects the DOSO is similar to other hearing-related questionnaires. Although the variance accounted for by personality is not large, researchers and clinicians should not assume that the results of the DOSO are independent of personality.

Introduction Advances in telehealth and technology have created opportunities for a more comprehensive care approach for patients with OSA. However, it is unclear if these comprehensive care models translate to improved treatment adherence and patient satisfaction compared to their traditional sleep clinic counterparts. This study aims to evaluate self-reported patient experience and treatment outcome data between a traditional sleep care approach and a clinically integrated, comprehensive sleep care program. Methods To better understand the patient experience within these models of care, this study compares outcomes between a traditional sleep care approach and a clinically integrated, comprehensive sleep care program. The study analyzed survey responses from 206 patients with sleep apnea (n=102, traditional care model and n=104, comprehensive care model) with items evaluating patient satisfaction, CPAP adoption and adherence, and quality of life, with descriptive statistics, chi-square analyses, and t-tests conducted to compare outcomes between the two groups. Results A significantly higher proportion of patients (p<.05) in the comprehensive model (85%) were satisfied at all measured points along the patient’s journey compared to the traditional care model (51%). Notably, significantly more patients in the comprehensive model were very satisfied with the ease of navigating the testing process (83% vs. 38%, p<.05), time between diagnosis and CPAP adoption (91% vs. 49%, p<.05), and availability and level of ongoing CPAP support (79% vs. 39%, p<.05). Comprehensive care patients experienced significantly fewer work disruptions due to sleep apnea, with 7% missing work in the past 3 months compared to 58% in the traditional model (p<.05). Conclusion The findings underscore the advantages of a comprehensive care model that improves patient satisfaction, streamlines the sleep apnea treatment journey, and enhances quality of life. These results, paired with prior evidence from the same model, highlight the benefits of removing obstacles to care, which increases patient satisfaction, improves adherence to therapy, and reduces overall healthcare costs, warranting further investigation into these relationships. Support (if any) Funding for this study was provided by Nox Health, Inc. Data gathering and analysis performed by CE Outcomes, Inc.

Background: A systematic bias leading to the underreporting of carotid endarterectomy (CEA) complications has been suggested in published reports. The possibility of an evidence-practice gap in conjunction with uncertainties regarding operator and institutional performance impede clinical decisions by practitioners for carotid revascularization. Methods: A prospective, independent monitoring system was implemented alongside an ongoing retrospective, self-reported quality assurance (QA) system for CEA at a major metropolitan tertiary care academic medical center. Independent, trained monitors from the neurology department examined all patients undergoing CEA both preoperatively and postoperatively at 24 hours and 30 days. Data was collected on patient demographics, medical history, and procedural and anatomical variables. Outcome data from the independent QA system was compared against self-reported data for the same cohort of patients, excluding CEA performed concurrently with another procedure (typically cardiac surgeries) or non-vascular surgeons. Results: From July 2008 through June 2010 vascular surgeons performed 462 isolated CEA at the institution. Stroke and death was detected at greater frequency by the independent QA system than was self-reported by the surgical staff (3.7% versus 1.7%, p=0.05). Self-reported outcomes from the study cohort matched those previously published in a peer-reviewed journal using the same self-reporting system (1.7% versus 1.4%, p=0.52). Conclusions: In the same cohort of patients, the reported periprocedural stroke and death rate for CEA is higher comparing prospective, independent, trained monitors to surgeon self-reporting. As public health policy mandates rigorous assessment of outcome, and ultimately, performance-based reimbursement, the validity of QA systems merits heightened attention.

This article presents a summary of audiological, general health, and hearing aid (HA) outcome data in a large sample of U.S. Veterans receiving HAs. The current article also provides the foundation for a series of papers that will explore relationships between a wide range of factors and HA outcomes. The patient sample is all (n = 731,213) patients for whom HAs were ordered between April 2012 and October 2014 through the U.S. Veterans Health Administration Remote Order Entry System. For these patients, Veterans Affairs electronic health records (EHRs) stored in various databases provided data on demographics, received diagnostic and procedure codes (2007 to 2017), audiometry, self-reported outcomes up to 6 months postfitting, and HA battery orders (to 2017). Data cleaning and preparation was carried out and is discussed with reference to insights that provide potential value to other researchers pursuing similar studies. HA battery order data over time was used to derive a measure of long-term HA use persistence. Descriptive statistics were used to characterize the sample, comparative analyses against other data supported basic validity assessment, and bivariate analyses probed novel associations between patient characteristics and HA use persistence at 2 years postfitting. Following extensive cleaning and data preparation, the data show plausible characteristics on diverse metrics and exhibit adequate validity based on comparisons with other published data. Further, rates of HA use persistence are favorable when compared against therapy persistence data for other major chronic conditions. The data also show that the presence of certain comorbid conditions (Parkinson's disease, diabetes, arthritis, and visual impairment) are associated with significantly lower HA use persistence, as are prior inpatient admissions (especially among new HA recipients), and that increasing levels of multimorbidity, in general, are associated with decreasing HA use persistence. This is all despite the fact that deriving relevant audiological care-process variables from the available records was not straightforward, especially concerning the definition of the date of HA fitting, and the use of battery ordering data to determine long-term HA use persistence. We have shown that utilizing EHRs in audiology has the potential to provide novel insights into clinical practice patterns, audiologic outcomes, and relations between factors pertaining to hearing and to other health conditions in clinical populations, despite the potential pitfalls regarding the lack of control over the variables available and limitations on how the data are entered. We thus conclude that research using EHRs has the potential to be an integral supplement to population-based and epidemiologic research in the field of audiology.

BackgroundSmoking continues to be a leading risk factor for several diseases globally. We hypothesised that an intervention delivered via text messages could help individuals who were looking to quit.MethodsA two-arm, parallel-groups, randomised controlled trial was employed. Both groups received treatment as usual, with the intervention group also receiving a 12-week text messaging intervention. Participants were adult, weekly or more frequent smokers, recruited online and in primary health care centres. Research personnel were blinded, while participants were not. Primary outcomes were prolonged abstinence and point prevalence of abstinence, 3 and 6 months post-randomisation. All randomised participants were included in analyses.ResultsBetween 18 September 2020 and 16 June 2022, we randomised 1012 participants (intervention: 505, control: 507). Outcome data was available for 67% (n = 682) of participants at 3 months and 64% (n = 643) at 6 months. At 3 months, the odds ratio (OR) of prolonged abstinence was 2.15 (95% compatibility interval [CoI] = 1.51; 3.06, probability of effect [POE] > 99.9%, p < 0.0001), and for point prevalence of abstinence, it was 1.70 (95% CoI = 1.18; 2.44, POE = 99.8%, p = 0.0034) in favour of the text messaging intervention. At 6 months, the OR of prolonged abstinence was 2.38 (95% CoI = 1.62; 3.57, POE > 99.9%, p = < 0.0001), and for point prevalence, it was 1.49 (95% CoI = 1.03; 2.14, POE = 98.3%, p = 0.0349) in favour of the text messaging intervention. Analyses with imputed data were not markedly different.ConclusionsAmongst general population help-seekers—who on average had smoked for 25 years—access to a 12-week text messaging intervention produced higher rates of self-reported smoking abstinence in comparison to treatment as usual only. The intervention could be part of the societal response to the burden which smoking causes; however, findings are limited by risk of bias due to attrition, self-reported outcomes, and lack of blinding.Trial registrationThe trial was preregistered in the ISRCTN registry on 27/07/2020 (ISRCTN13455271).

BackgroundBicycling, despite its health and other benefits, raises safety concerns for many people. However, reliable information on bicycle crash injury is scarce as current statistics rely on a single official database of limited quality. This paper evaluated the completeness and accuracy of crash data collected from multiple sources in a prospective cohort study involving cyclists.MethodsThe study recruited 2438 adult cyclists from New Zealand’s largest mass cycling event in November 2006 and another 190 in 2008, and obtained data regarding bicycle crashes that were attended by medical personnel or the police and occurred between the date of recruitment and 30 June 2011, through linkage to insurance claims, hospital discharges, mortality records and police reports. The quality of the linked data was assessed by capture-recapture methods and by comparison with self-reported injury data collected in a follow-up survey.ResultsOf the 2590 cyclists who were resident in New Zealand at recruitment, 855 experienced 1336 crashes, of which 755 occurred on public roads and 120 involved a collision with a motor vehicle, during a median follow-up of 4.6 years. Log-linear models estimated that the linked data were 73.7% (95% CI: 68.0%-78.7%) complete with negligible differences between on- and off-road crashes. The data were 83.3% (95% CI: 78.9%-87.6%) complete for collisions. Agreement with the self-reported data was moderate (kappa: 0.55) and varied by personal factors, cycling exposure and confidence in recalling crash events. If self-reports were considered as the gold standard, the linked data had 63.1% sensitivity and 93.5% specificity for all crashes and 40.0% sensitivity and 99.9% specificity for collisions.ConclusionsRoutinely collected databases substantially underestimate the frequency of bicycle crashes. Self-reported crash data are also incomplete and inconsistent. It is necessary to improve the quality of individual data sources as well as record linkage techniques so that all available data sources can be used reliably.

Firm, clear, and consistent consequences, such as termination from employment or suspension from athletic participation, enhance the preventive effects of drug tests, since outcome expectations and perceived self-efficacy influence people’s actions and behaviors. The drug-testing programs of the U.S. military services illustrate the dramatic effects that can be achieved by use of random drug testing based on standardized testing procedures and backed by strict disciplinary consequences. These findings from two decades of experience are ripe for study in prevention research. While drug-testing programs have also reduced illicit drug use in many arenas, including the workplace, the criminal justice system, and athletic competitions, broader and more consistent efforts are needed in prevention research. Based on these results, it appears that model drug-testing programs in prevention research need to be developed to advance the use of reliable and cost-effective drug-testing programs. More study is also needed on the preventive effects of drug testing on adolescents and young adults. Random drug testing has been implemented in several U.S. school districts, including Dade County, Florida, but the practice is uncommon, and outcome data are unavailable. Research is needed on the results of these pioneering programs. Overall, drug testing provides valuable information to researchers on preventing drug use and extends the information provided by self-reported data on drug use.

Development of National Research and Clinical Agendas for Patient-Reported Outcomes in IR: Proceedings from a Multidisciplinary Consensus Panel