Assessments of infectious disease spread in hospitals seldom account for interfacility patient sharing. This is particularly important for pathogens with prolonged incubation periods or carrier ...states.
We quantified patient sharing among all 32 hospitals in Orange County (OC), California, using hospital discharge data. Same-day transfers between hospitals were considered "direct" transfers, and events in which patients were shared between hospitals after an intervening stay at home or elsewhere were considered "indirect" patient-sharing events. We assessed the frequency of readmissions to another OC hospital within various time points from discharge and examined interhospital sharing of patients with Clostridium difficile infection.
In 2005, OC hospitals had 319,918 admissions. Twenty-nine percent of patients were admitted at least twice, with a median interval between discharge and readmission of 53 days. Of the patients with 2 or more admissions, 75% were admitted to more than 1 hospital. Ninety-four percent of interhospital patient sharing occurred indirectly. When we used 10 shared patients as a measure of potential interhospital exposure, 6 (19%) of 32 hospitals "exposed" more than 50% of all OC hospitals within 6 months, and 17 (53%) exposed more than 50% within 12 months. Hospitals shared 1 or more patient with a median of 28 other hospitals. When we evaluated patients with C. difficile infection, 25% were readmitted within 12 weeks; 41% were readmitted to different hospitals, and less than 30% of these readmissions were direct transfers.
In a large metropolitan county, interhospital patient sharing was a potential avenue for transmission of infectious agents. Indirect sharing with an intervening stay at home or elsewhere composed the bulk of potential exposures and occurred unbeknownst to hospitals.
We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at ...the VA Puget Sound Health Care system from October 1996–January 1999 (
n=2,545) were invited to participate in a research interview. Participants (
n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (
n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82–0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.
Frequent symptom self-monitoring protocols have become popular tools in the addiction field. Interactive Voice Response (IVR) is a telephone monitoring system that has been shown to be feasible for ...collecting frequent self-reports from a variety of research populations. Little is known, however, about the feasibility of using IVR monitoring in clinical samples, and few controlled trials exist assessing the impact of any type of frequent self-report monitoring on the behaviors monitored. This pilot study with patients in early recovery from an alcohol use disorder (
n
=
98) evaluated compliance with two IVR monitoring protocols, subjective experiences with monitoring, and change in symptoms associated with monitoring (i.e., measurement reactivity). Participants were randomly assigned to call an IVR system daily for 28 days, once per week for 4 weeks, or only to complete 28-day follow-up assessment including retrospective drinking reports. Monitoring calls assessed alcohol craving, substance use, emotional well-being, and PTSD symptoms. Most monitoring participants completed calls on at least 75% of scheduled days (72.2% and 59.2% for daily and weekly, respectively). Including reconstructed data from follow-up of missed calls yielded 77.8% and 74.1% of maximum data points, respectively. Most monitoring participants indicated the protocol was manageable and reported positive or no effects of monitoring on urges to use alcohol, actual drinking, and PTSD symptoms. Analyses of measurement reactivity based on assessment one month after randomization found no significant group differences on drinking, craving for alcohol, or PTSD-related symptoms. Results suggest that IVR technology is feasible and appropriate for telephone symptom monitoring in similar clinical samples.
To compare self-administered versions of three questionnaires for detecting heavy and problem drinking: the CAGE, the Alcohol Use Disorders Identification Test (AUDIT), and an augmented version of ...the CAGE.
Cross-sectional surveys.
Three Department of Veterans Affairs general medical clinics.
Random sample of consenting male outpatients who consumed at least 5 drinks over the past year ("drinkers"). Heavy drinkers were oversampled.
An augmented version of the CAGE was included in a questionnaire mailed to all patients. The AUDIT was subsequently mailed to "drinkers." Comparison standards, based on the tri-level World Health Organization alcohol consumption interview and the Diagnostic Interview Schedule, included heavy drinking (>14 drinks per week typically or >/=5 drinks per day at least monthly) and active DSM-IIIR alcohol abuse or dependence (positive diagnosis and at least one alcohol-related symptom in the past year). Areas under receiver operating characteristic curves (AUROCs) were used to compare screening questionnaires.
Of 393 eligible patients, 261 (66%) returned the AUDIT and completed interviews. For detection of active alcohol abuse or dependence, the CAGE augmented with three more questions (AUROC 0.871) performed better than either the CAGE alone or AUDIT (AUROCs 0.820 and 0.777, respectively). For identification of heavy-drinking patients, however, the AUDIT performed best (AUROC 0.870). To identify both heavy drinking and active alcohol abuse or dependence, the augmented CAGE and AUDIT both performed well, but the AUDIT was superior (AUROC 0.861).
For identification of patients with heavy drinking or active alcohol abuse or dependence, the self-administered AUDIT was superior to the CAGE in this population.
Most studies comparing frequent self‐monitoring protocols and retrospective assessments of alcohol use find good correspondence, but have excluded participants with significant comorbidity and/or ...social instability, and some have included abstainers. We evaluated the correspondence between measures of alcohol use based on daily interactive voice response (IVR) telephone monitoring and a 28‐day modification of the Form‐90 (Form‐28). Participants were 25 outpatients with alcohol use disorder and significant PTSD symptomatology
. Overall correlations between the IVR and Form‐28 on days drinking and total standard drink units (SDUs) were strong for the entire sample and the subsample of drinkers (n = 7). Day‐to‐day correspondence between IVR and Form‐28 was modest, but much stronger for the most recent week assessed than for the prior 3 weeks. Finally, the drinkers reported significantly greater total SDUs and heavy drinking days on the Form‐28 than via IVR. The results indicate a need for further refinement of IVR methodology for treatment seeking populations as well as caution when retrospectively assessing drinking over time periods longer than a week among these individuals. (Am J Addict 2010;00:1–6)
Background: Recently attention has focused on the assessment of functional health status in substance-dependent individuals. The addiction severity index (ASI) is a widely used assessment instrument ...that includes scales to reflect current medical and psychiatric status. This study examines the concurrent validity of these ASI composite scores in relation to the short form 36-item health survey (SF-36), a well-established measure of health-related quality of life/functional health status.
Methods: Veterans (
n = 674) were assessed at admission to substance dependence treatment. Correlations were performed between ASI composite scores and SF-36 scales and the physical and mental summary components (PSC and MSC, respectively). Areas under receiver operating characteristic (ROC) curves determined the descriminative ability of the ASI composites to ascertain impairment.
Results: The ASI medical composite score demonstrated robust correlations with the four SF-36 scales that relate to physical health and with the PCS. The ASI psychiatric composite score had robust correlations with the four SF-36 scales related to mental health and with the mental component summary (MCS). ROC curves indicated that the ASI medical (AUC = 0.83) and psychiatric composites (AUC = 0.90) accurately detected subjects with impairment.
Conclusions: ASI medical and psychiatric composite scores provide effective initial screening for patients with impaired functional status as measured by the corresponding SF-36 component summary scores.
This study of women Veterans Affairs (VA) health care patients screened for the prevalence of past-year smoking, hazardous and problem drinking, other drug abuse, and psychiatric disorders.
A survey ...was mailed to women veterans who had received care from VA Puget Sound Health Care System between October 1, 1996, and January 1, 1998. Screening measures included questions about cigarettes; questions from the Alcohol Use Disorders Identification Test about consumption (hazardous drinking); the TWEAK test (problem drinking); a drug abuse screen; the Patient Health Questionnaire (psychiatric conditions); and the PTSD (posttraumatic stress disorder) Checklist.
Of eligible patients, 1,257 (65 percent) returned surveys with complete substance use data. Patients reported a relatively high rate of past-year smoking (29.1 percent) and hazardous drinking, problem drinking, or both (31.1 percent). The rate of past-year drug use was much lower (4.9 percent). Younger age was strongly associated with greater substance abuse: 59 percent of women under age 35 screened positive for smoking, hazardous or problem drinking, or drug abuse. Screening positive for a psychiatric condition (N=504) was also associated with substance abuse: The rate of past-year drug abuse among women screening positive for a psychiatric condition (9.7 percent) was double the rate for the entire sample. Of the women who screened positive for depression, PTSD, eating disorders, or panic disorders, 57 percent screened positive for substance abuse (including smoking).
Substance abuse is common among women VA patients and is associated with younger age and with screening positive for other psychiatric conditions. Providers are expected to follow up on positive screening tests, and these data indicate substantial provider burden.
Background: Several variations on the CAGE alcohol screening questionnaire have been recommended. This report evaluates modifications and additions to the CAGE.
Methods: Alcohol screening ...questionnaires were evaluated in male VA general medicine patients (n= 227; mean age, 65.8). Mailed questionnaires included two scoring options for the CAGE (standard and last‐year time frames), questions about quantity and frequency of drinking, two questions about episodic heavy drinking, and the question “Have you ever had a drinking problem?” Main analyses compared alcohol screening questions, at various cut‐points, to a gold standard of hazardous drinking during the past year (≥14 drinks/week or ≥5 drinks on an occasion) and/or DSM‐III‐R alcohol abuse or dependence, based on standardized interviews.
Results: The CAGE questionnaire with a past‐year time frame was much less sensitive (0.57 vs. 0.77) but more specific (0.82 vs. 0.59) than the standard CAGE for detecting hazardous drinking during the past year and/or DSM‐III‐R alcohol abuse or dependence. An eight‐item questionnaire that included the standard CAGE was most sensitive (0.92) but had low specificity (0.50). A single question about the frequency of drinking ≥6 drinks on an occasion, included in the eight‐item questionnaire, was both relatively sensitive (0.77) and specific (0.83).
Conclusion: The CAGE questionnaire with a past‐year time frame was an insensitive alcohol‐screening test. An eight‐item augmented version of the standard CAGE was the most sensitive. A question about the frequency of drinking ≥6 drinks on an occasion performed better than the standard CAGE, which made it the optimal brief screening test for at‐risk drinking.
Methamphetamine-dependent inpatients (N = 51) were screened for childhood attention deficit hyperactivity disorder (ADHD) using the Wender Utah Rating Scale upon admission to 30-day inpatient ...treatment. Baseline assessments included neuropsychological tests of executive function, memory, information processing, verbal fluency, attention, motor skills, and the Brief Symptom Inventory (BSI), a measure of psychiatric symptomatology. The thirty-six participants (70.6%) screening positive for ADHD reported significantly more frequent methamphetamine use prior to baseline. Baseline cognitive functioning was similar between groups, but the presumptive ADHD participants exhibited significantly worse psychiatric symptomatology. At three-week follow-up, 41 participants (80.4%) repeated the neuropsychological battery and BSI. All 10 non-completers screened positive for ADHD. The entire sample improved with abstinence in most neuropsychological domains except memory. The presumptive ADHD group failed to improve on tests of attention. All participants demonstrated significant reductions in psychiatric symptoms with abstinence. Methamphetamine-dependent individuals with ADHD symptoms are common and pose a significant treatment challenge.
OBJECTIVE: This study describes primary care discussions with patients who screened positive for at‐risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a ...provider‐prompting intervention, are compared.
DESIGN: Cross‐sectional analyses of audiotaped appointments collected over 6 months.
PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at‐risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients (N = 47) and providers (N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus.
INTERVENTION: Intervention providers received patient‐specific results of positive alcohol‐screening tests at each visit.
MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol‐related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol‐related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P = .026).
CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol‐related advice. Discussions about alcohol occurred more often when providers were prompted.
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