A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Comparison of Children's Double Dichotic Digits and SCAN-3 Competing Words Free Recall Scores.

BACKGROUND: Practice guidelines do not specify which test recordings are best for assessing dichotic deficit or interaural asymmetry. Dichotic Digits and SCAN-3 Competing Words Free Recall are among the most widely used dichotic tests, but it is not known if the choice of test results in important differences in the identification of children with deficits or if they can be used interchangeably. PURPOSE: To determine whether two commonly used dichotic tests, SCAN-3 Competing Words Free Recall (CW) and Musiek's Dichotic Digits (DD), agree on interaural asymmetry and dichotic deficit in children. RESEARCH DESIGN: CW and DD tests were administered to all participants. Each participant had a single study visit. STUDY SAMPLE: Sixty volunteers aged 7-14 years with normal hearing sensitivity participated in the study. DATA COLLECTION AND ANALYSIS: Hearing sensitivity, CW, and DD performance were measured at a single study visit. We used Spearman's rho (ρ) to assess associations between rank ordering of participants by each test and the kappa statistic (κ) to assess decision consistency between tests. RESULTS: Participants were rank-ordered similarly by CW and DD for the right ear (ρ = 0.58), left ear (ρ = 0.51), and total (ρ = 0.73) scores, but not for interaural asymmetry (ρ =0.18). They agreed no better than chance on direction of ear advantage (κ = 0.01, p = 0.93) and had poor agreement on which children scored below cut-scores (κ = 0.22, p < 0.01). DD identified significantly more participants with deficits (n = 18) than CW (n = 3) (p < 0.001). CONCLUSIONS: Although children with high scores on one test tend to have high scores on the other, CW and DD do not agree on ear advantage or the presence of deficit. They are not interchangeable for clinical use. Additional research is needed to determine whether either is appropriate for identifying children who would benefit from treatment for dichotic listening deficits.

Dichotic Listening Test-Retest Reliability in Children.

Purpose The objective of the study was to compare test-retest reliability of three dichotic listening tests: SCAN-3 Competing Words Test (Words; Keith, 2009a , 2009b ), Double Dichotic Digits Test (Digits; Musiek, 1983a ), and Bergen Dichotic Listening Test With Consonant-Vowel Syllables (Syllables; Hugdahl & Hammar, 1997 ). Method Sixty English-speaking children, 7-14 years old with normal hearing, had a single study visit during which each test was administered twice. Changes on retest were summarized by within-subject standard deviation ( S w), compared among tests, and compared with binomial model predictions. Correlates of variance were explored. Results Scores based on 40 items were more precise ( S w = 5%) than those based on 20-30 items ( S w = 6%-8%). All 3 tests had reliability within bounds predicted by binomial model. Changes on retest for Words and Digits Test were weakly associated with age, but this is confounded by the trend for older children to have higher Words and Digits scores. Conclusions Digits Right, Digits Left, and Words Total scores-each based on 40 items-had the best reliability among the clinically used scores. Scores based on fewer items were less precise. Poor precision may contribute to misdiagnosis in clinic and to nondifferential misclassification in research. More precise estimates of dichotic listening ability require longer tests.

Structured Review of Dichotic Tests of Binaural Integration: Clinical Performance in Children.

PURPOSE: The aim of the study was to evaluate the evidence of clinical utility for dichotic speech tests of binaural integration used to assess auditory processing in English-speaking children 6-14 years old. METHOD: Dichotic speech test recordings and pertinent research studies were identified from iterative searches of the Internet and bibliographic databases, as well as communication with colleagues and test publishers. Test documentation and peer-reviewed literature were evaluated for evidence of reliability, accuracy, usefulness, and value. RESULTS: Eleven dichotic tests of binaural integration were identified for children. Evidence of test-retest reliability was found for 5 tests and demonstrated moderate to good correlation between results on repeated administration (r = .59-.92). Evidence of accuracy was identified for 5 tests but was either inconsistent with accurate performance or was not generalizable due to significant limitations in study design. No evidence was found to either support or dispute claims of usefulness or value. CONCLUSIONS: A medical diagnostic framework is useful for evaluating dichotic tests. Although dichotic procedures show moderate reliability, the absence of a widely accepted gold standard reference test limits our ability to assess their value. Overall, the data available at the time of this review do not support the routine use of dichotic tests of binaural integration for clinical evaluation of children.

Inter-rater reliability for scoring children's dichotic words test responses.

OBJECTIVE: To determine whether rater agreement is randomly distributed or varies importantly with test-taker characteristics, test words, or rater experience with the dichotic words test (DWT). DESIGN: DWT was administered to 34 children in 1st-4th grade and responses scored by two raters. The proportion of rater agreement was calculated for each child and for each word. Correlates of inter-rater agreement were explored. STUDY SAMPLE: Two raters judged 6686 total responses from 34 children. RESULTS: Overall agreement between the two raters was 0.97. Test-taker scores ranged from 35%-91% (mean = 81%). Agreement was associated with score but not with test-taker age or sex. Test words spanned the full range of difficulty (pass proportion 0.06-1.00). Rater agreement was not randomly distributed among the words. Inter-rater agreement for test words ranged from 0.82-1.00 and was associated with pass proportion (Spearman's ρ = 0.28; p < 0.0001). However, there were words at all pass proportions with perfect or near-perfect agreement. Rater agreement improved from 0.94 on the first day of data collection to 0.98 on the fifth day (p = 0.026). CONCLUSIONS: Inter-rater reliability should be considered along with test item difficulty when developing speech audiometry materials, scoring protocols, and rater training.