Using Mixed Methods to Examine the Role of Veterans' Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance.

BACKGROUND: Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment. OBJECTIVES: To determine whether veterans' illness perceptions of depression may be serving as barriers to guideline-concordant treatment. RESEARCH DESIGN: We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study. SUBJECTS: Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast. MEASURES: The Illness Perceptions Questionnaire-Revised, measuring patients' perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans' illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study. RESULTS: A total of 839 veterans screened positive for a new episode of depression from May 2009-June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans' illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment. CONCLUSIONS: Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans' illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

Mortality associated with lithium and valproate treatment of US Veterans Health Administration patients with mental disorders.

BackgroundThe mood stabilisers lithium and valproate might plausibly have differing associations with mortality because of differing effects on mental health and various physiological indicators.AimsTo assess associations between lithium, valproate and non-suicide mortality.MethodIntention-to-treat, propensity score-matched cohort study.ResultsLithium was associated with significantly reduced non-suicide mortality in the intent-to-treat cohort over 0-90 days (hazard ratio (HR) = 0.67, 95% CI 0.51-0.87) but not longer. In secondary analyses, a sizeable reduction in mortality was observed during active treatment with lithium across all time periods studied (for example 365-day HR = 0.62, 95% CI 0.45-0.84), but significantly increased risks were observed among patients discontinuing lithium by 180 days (HR = 1.54, 95% CI 1.01-2.37).ConclusionsPatients initiating lithium had lower non-suicide mortality over 0-90 days than patients initiating valproate and consistently lower non-suicide mortality among patients maintaining treatment, but elevated risk among patients discontinuing treatment by 180 days. Although residual confounding or selection effects cannot be excluded, this study suggests potential benefits to enhancing lithium treatment persistence and the monitoring of patients discontinuing lithium. There is a need for further research.

Suicide risk in Veterans Health Administration patients with mental health diagnoses initiating lithium or valproate: a historical prospective cohort study.

BACKGROUND: Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate. METHODS: A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008. RESULTS: Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015). CONCLUSIONS: In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.

Predictors of decline in overall mental health, PTSD and alcohol use in OEF/OIF veterans.

This study identified predictors of worsening mental health (including PTSD and alcohol use) over a 6-month period following return from deployment to Iraq (OIF) or Afghanistan (OIF). Using a national sample of 512 OEF/OIF veterans surveyed within 12 months of return from deployment (T1), and 6 months later (T2), we obtained demographic and deployment characteristics, risk and resilience factors, mental health status, PTSD and alcohol abuse. We performed logistic regression analyses to identify predictors of worse mental health, PTSD or alcohol use between T1 and T2, controlling for initial levels. Of the sample, 14-25% showed clinically worse mental health, PTSD or alcohol use. Each outcome was associated with some shared and some unique predictors. For example, younger age and recent medical care were both associated with worse alcohol use. Lack of adequate deployment training was uniquely associated with worse PTSD symptoms.

Conceptual foundation for measures of physical function and behavioral health function for Social Security work disability evaluation.

Physical and mental impairments represent the 2 largest health condition categories for which workers receive Social Security disability benefits. Comprehensive assessment of physical and mental impairments should include aspects beyond medical conditions such as a person's underlying capabilities as well as activity demands relevant to the context of work. The objective of this article is to describe the initial conceptual stages of developing new measurement instruments of behavioral health and physical functioning relevant for Social Security work disability evaluation purposes. To outline a clear conceptualization of the constructs to be measured, 2 content models were developed using structured and informal qualitative approaches. We performed a structured literature review focusing on work disability and incorporating aspects of the International Classification of Functioning, Disability and Health as a unifying taxonomy for framework development. Expert interviews provided advice and consultation to enhance face validity of the resulting content models. The content model for work-related behavioral health function identifies 5 major domains: (1) behavior control, (2) basic interactions, (3) temperament and personality, (4) adaptability, and (5) workplace behaviors. The content model describing physical functioning includes 3 domains: (1) changing and maintaining body position, (2) whole-body mobility, and (3) carrying, moving, and handling objects. These content models informed subsequent measurement properties including item development and measurement scale construction, and provided conceptual coherence guiding future empirical inquiry. The proposed measurement approaches show promise to comprehensively and systematically assess physical and behavioral health functioning relevant to work.

Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan.

OBJECTIVES: We examined (1) mental and physical health symptoms and functioning in US veterans within 1 year of returning from deployment, and (2) differences by gender, service component (Active, National Guard, other Reserve), service branch (Army, Navy, Air Force, Marines), and deployment operation (Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF]). METHODS: We surveyed a national sample of 596 OEF/OIF veterans, oversampling women to make up 50% of the total, and National Guard and Reserve components to each make up 25%. Weights were applied to account for stratification and nonresponse bias. RESULTS: Mental health functioning was significantly worse compared with the general population; 13.9% screened positive for probable posttraumatic stress disorder, 39% for probable alcohol abuse, and 3% for probable drug abuse. Men reported more alcohol and drug use than did women, but there were no gender differences in posttraumatic stress disorder or other mental health domains. OIF veterans reported more depression or functioning problems and alcohol and drug use than did OEF veterans. Army and Marine veterans reported worse mental and physical health than did Air Force or Navy veterans. CONCLUSIONS: Continuing identification of veterans at risk for mental health and substance use problems is important for evidence-based interventions intended to increase resilience and enhance treatment.

Is DSM-IV criterion A2 associated with PTSD diagnosis and symptom severity?

The diagnostic criteria for posttraumatic stress disorder (PTSD) have received significant scrutiny. Several studies have investigated the utility of Criterion A2, the subjective emotional response to a traumatic event. The American Psychiatric Association (APA) has proposed elimination of A2 from the PTSD diagnostic criteria for DSM-5; however, there is mixed support for this recommendation and few studies have examined A2 in samples at high risk for PTSD such as veterans. In the current study of 908 veterans who screened positive for a traumatic event, A2 was not significantly associated with having been told by a doctor that the veteran had PTSD. Those who endorsed A2, however, reported greater PTSD symptom severity in the 3 DSM-IV symptom clusters of reexperiencing (d = 0.45), avoidance (d = 0.61), and hyperarousal (d = 0.44), and A2 was significantly associated with PTSD symptom severity for all 3 clusters (R(2) = .25, .25, and .27, respectively) even with trauma exposure in the model. Thus, although A2 may not be a necessary criterion for PTSD diagnosis, its association with PTSD symptom severity warrants further exploration of its utility.

Enhancing self-report assessment of PTSD: development of an item bank.

The authors report results of work to enhance self-report posttraumatic stress disorder (PTSD) assessment by developing an item bank for use in a computer-adapted test. Computer-adapted tests have great potential to decrease the burden of PTSD assessment and outcomes monitoring. The authors conducted a systematic literature review of PTSD instruments, created a database of items, performed qualitative review and readability analysis, and conducted cognitive interviews with veterans diagnosed with PTSD. The systematic review yielded 480 studies in which 41 PTSD instruments comprising 993 items met inclusion criteria. The final PTSD item bank includes 104 items representing each of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994), PTSD symptom clusters (reexperiencing, avoidance, and hyperarousal), and 3 additional subdomains (depersonalization, guilt, and sexual problems) that expanded the assessment item pool.

Describing depression: congruence between patient experiences and clinical assessments.

OBJECTIVES: Efforts to describe depression have relied on top-down methods in which theory and clinical experience define depression but may not reflect the individuals' experiences with depression. We assessed the degree of overlap between academic descriptions of depression and patient-reported symptoms as conceptualized in the Patient-Reported Outcomes Measurement Information System(®) (PROMIS(®)). By extension, this work assesses the degree of overlap between current clinical descriptions of depression and patient-reported symptoms. DESIGN: In this content analysis study, four focus groups were conducted across two sites to elicit symptoms and the experience of depression from depressed and medically ill patients. METHODS: Depressed and medically ill patients were asked to describe symptoms that characterize depression. Data were transcribed and then coded using an a priori list of 43 facets of depression derived from extant depression measures. RESULTS: Participants described 93% of the symptoms from the a priori list, supporting the validity of current depression measures. Interpersonal difficulties were underscored as was anger. In general, results from the focus groups did not require the generation of new items for depression and supported the content validity of the PROMIS hierarchical framework and item pool created originally. CONCLUSIONS: This work supports the validity of current depression assessment, but suggests further investigation of interpersonal functioning and anger may add to the depth and breadth of depression assessment.

An illness perception model of primary care patients' help seeking for depression.

Many people with depression recognize their symptoms as depression, but fail to seek treatment for a number of years. We aimed to explore the reasons for this. Thirty primary care patients who screened positive for depression participated in semistructured, face-to-face interviews. Transcripts were analyzed using grounded thematic analysis. Patients who sought depression treatment emphasized their understanding of depression, their belief that treatment would work, and the negative consequences that would ensue if they did not seek treatment. Patients who did not seek treatment emphasized that treatment would not be effective, thought that depression would not last very long, and believed that depression did not affect their everyday lives. Patients' illness perceptions of depression were represented by and organized using the framework of the Self-Regulation Model of Illness Behavior. This model might be useful for planning patient activation intervention studies to increase the uptake of depression treatment in primary care.

Routine outcomes monitoring to support improving care for schizophrenia: report from the VA Mental Health QUERI.

In schizophrenia, treatments that improve outcomes have not been reliably disseminated. A major barrier to improving care has been a lack of routinely collected outcomes data that identify patients who are failing to improve or not receiving effective treatments. To support high quality care, the VA Mental Health QUERI used literature review, expert interviews, and a national panel process to increase consensus regarding outcomes monitoring instruments and strategies that support quality improvement. There was very good consensus in the domains of psychotic symptoms, side-effects, drugs and alcohol, depression, caregivers, vocational functioning, and community tenure. There are validated instruments and assessment strategies that are feasible for quality improvement in routine practice.

Predisposing characteristics, enabling resources and need as predictors of utilization and clinical outcomes for veterans receiving mental health services.

BACKGROUND: Though demand for mental health services (MHS) among US veterans is increasing, MHS utilization per veteran is decreasing. With health and social service needs competing for limited resources, it is important to understand the association between patient factors, MHS utilization, and clinical outcomes. OBJECTIVES: We use a framework based on Andersen's behavioral model of health service utilization to examine predisposing characteristics, enabling resources, and clinical need as predictors of MHS utilization and clinical outcomes. METHODS: This was a prospective observational study of veterans receiving inpatient or outpatient MHS through Veterans Administration programs. Clinician ratings (Global Assessment of Functioning [GAF]) and self-report assessments (Behavior and Symptom Identification Scale-24) were completed for 421 veterans at enrollment and 3 months later. Linear and logistic regression analyses were conducted to examine: (1) predisposing characteristics, enabling resources, and need as predictors of MHS inpatient, residential, and outpatient utilization and (2) the association between individual characteristics, utilization, and clinical outcomes. RESULTS: Being older, female, having greater clinical need, lack of enabling resources (employment, stable housing, and social support), and easy access to treatment significantly predicted greater MHS utilization at 3-month follow-up. Less clinical need and no inpatient psychiatric hospitalization predicted better GAF and Behavior and Symptom Identification Scale-24 scores. White race and residential treatment also predicted better GAF scores. Neither enabling resources, nor number of outpatient mental health visits predicted clinical outcomes. CONCLUSIONS: This application of Andersen's behavioral model of health service utilization confirmed associations between some predisposing characteristics, need, and enabling resources on MHS utilization but only predisposing characteristics, need, and utilization were associated with clinical outcomes.

Measuring social health in the patient-reported outcomes measurement information system (PROMIS): item bank development and testing.

PURPOSE: To develop a social health measurement framework, to test items in diverse populations and to develop item response theory (IRT) item banks. METHODS: A literature review guided framework development of Social Function and Social Relationships sub-domains. Items were revised based on patient feedback, and Social Function items were field-tested. Analyses included exploratory factor analysis (EFA), confirmatory factor analysis (CFA), two-parameter IRT modeling and evaluation of differential item functioning (DIF). RESULTS: The analytic sample included 956 general population respondents who answered 56 Ability to Participate and 56 Satisfaction with Participation items. EFA and CFA identified three Ability to Participate sub-domains. However, because of positive and negative wording, and content redundancy, many items did not fit the IRT model, so item banks do not yet exist. EFA, CFA and IRT identified two preliminary Satisfaction item banks. One item exhibited trivial age DIF. CONCLUSION: After extensive item preparation and review, EFA-, CFA- and IRT-guided item banks help provide increased measurement precision and flexibility. Two Satisfaction short forms are available for use in research and clinical practice. This initial validation study resulted in revised item pools that are currently undergoing testing in new clinical samples and populations.

The Essential Properties of Yoga Questionnaire (EPYQ): Psychometric Properties.

Yoga interventions are heterogeneous and vary along multiple dimensions. These dimensions may affect mental and physical health outcomes in different ways or through different mechanisms. However, most studies of the effects of yoga on health do not adequately describe or quantify the components of the interventions being implemented. This lack of detail prevents researchers from making comparisons across studies and limits our understanding of the relative effects of different aspects of yoga interventions. To address this problem, we developed the Essential Properties of Yoga Questionnaire (EPYQ), which allows researchers to objectively characterize their interventions. We present here the reliability and validity data from the final phases of this measure-development project. Analyses identified fourteen key dimensions of yoga interventions measured by the EPYQ: acceptance/compassion, bandhas, body awareness, breathwork, instructor mention of health benefits, individual attention, meditation and mindfulness, mental and emotional awareness, physicality, active postures, restorative postures, social aspects, spirituality, and yoga philosophy. The EPYQ demonstrated good reliability, as assessed by internal consistency and test-retest reliability analysis, and evidence suggests that the EPYQ is a valid measure of multiple dimensions of yoga. The measure is ready for use by clinicians and researchers. Results indicate that, currently, trained objective raters should score interventions to avoid reference frame errors and potential rating bias, but alternative approaches may be developed. The EPYQ will allow researchers to link specific yoga dimensions to identifiable health outcomes and optimize the design of yoga interventions for specific conditions.

Measuring clinically meaningful change following mental health treatment.

Assessment of clinically meaningful change is useful for treatment planning, monitoring progress, and evaluating treatment response. Outcome studies often assess statistically significant change, which may not be clinically meaningful. Study objectives are to: (1) evaluate responsiveness of the BASIS-24 using three methods for determining clinically meaningful change: reliable change index (RCI), effect size (ES), and standard error of measurement (SEM); and (2) determine which method provides an estimate of clinically meaningful change most concordant with other change measures. BASIS-24 assessments were obtained at two time points for 1,397 inpatients and 850 outpatients. The proportion showing clinically meaningful change using each method was compared to the proportion showing change in global mental health, retrospectively reported change, and clinician-assessed change. BASIS-24 demonstrated responsiveness at both aggregate and individual levels. Regarding clinically meaningful improvement and decline, SEM was most concordant with all three outcome measures; regarding no change, RCI was most concordant with all three measures.

Mental Health Providers' Decision-Making Around the Implementation of Evidence-Based Treatment for PTSD.

It is estimated that <15% of veterans with posttraumatic stress disorder (PTSD) have engaged in two evidence-based psychotherapies highly recommended by VA-cognitive processing therapy (CPT) and prolonged exposure (PE). CPT and PE guidelines specify which patients are appropriate, but research suggests that providers may be more selective than the guidelines. In addition, PTSD clinical guidelines encourage "shared decision-making," but there is little research on what processes providers use to make decisions about CPT/PE. Sixteen licensed psychologists and social workers from two VA medical centers working with ≥1 patient with PTSD were interviewed about patient factors considered and decision-making processes for CPT/PE use. Qualitative analyses revealed that patient readiness and comorbid conditions influenced decisions to use or refer patients with PTSD for CPT/PE. Providers reported mentally derived and instances of patient-involved decision-making around CPT/PE use. Continued efforts to assist providers in making informed and collaborative decisions about CPT/PE use are discussed.

Reliability and validity of the BASIS-24 Mental Health Survey for Whites, African-Americans, and Latinos.

Increasing racial and ethnic diversity calls for mental health assessment instruments that are appropriate, reliable, and valid for the wide range of cultures that comprise the current US population. However, most assessment instruments have not been tested on diverse samples. This study assessed psychometric properties and sensitivity to change of the revised Behavior and Symptom Identification Scale (BASIS-24) among the three largest race/ethnicity groups in the USA: Whites, African-Americans, and Latinos. BASIS-24 assessments were obtained for 2436 inpatients and 2975 outpatients treated at one of 27 mental health and/or substance abuse programs. Confirmatory factor analysis and several psychometric tests supported the factor structure, reliability, concurrent validity, and sensitivity of the instrument within each race/ethnicity group, although discriminant validity may be weaker for African-Americans and Latinos than for Whites. Further research is needed to test and validate assessment instruments with other race/ethnicity groups.

Job satisfaction of Department of Veterans Affairs peer mental health providers.

OBJECTIVES: Department of Veterans Affairs (VA) peer specialists and vocational rehabilitation specialists are Veterans employed in mental health services to help other Veterans with similar histories and experiences. Study objectives were to (a) examine job satisfaction among these employees, (b) compare them to other VA mental health workers, and (c) identify factors associated with job satisfaction across the 3 cohorts. METHODS: The study sample included 152 VA-employed peer specialists and 222 vocational rehabilitation specialists. A comparison group included 460 VA employees from the same job categories. All participants completed the Job Satisfaction Index (11 aspects and overall satisfaction ratings). Linear regression was used to compare job satisfaction and identify its predictors among the 3 cohorts. RESULTS: Job satisfaction was fairly high, averaging "somewhat satisfied" to "very satisfied" in 6 (peer specialists) and 9 (vocational rehabilitation specialists) of the 11 aspects and overall job ratings. Adjusting for length of employment, age and gender resulted in no significant group differences with 2 exceptions: White peer specialists were less satisfied with pay and promotion opportunities than vocational rehabilitation specialists and comparison-group employees. Across all cohorts, shorter length of time employed in the job was associated with higher job satisfaction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The high job satisfaction levels among the 2 peer cohorts suggest support for the policy of hiring peer specialists in the VA. Furthermore, the results are consistent with those of the nonveteran samples, indicating that integrating peer providers into mental health care is possible in VA and non-VA settings.

Predictors of Employment Burnout Among VHA Peer Support Specialists.

OBJECTIVE: This study evaluated three domains of job burnout (emotional exhaustion, depersonalization, and personal accomplishment) and factors associated with burnout in a national sample of peer specialists (PSs) employed at 138 Veterans Health Administration (VHA) health care systems in 49 states. METHODS: Data were drawn from an observational study in which participants (N=152) completed online, self-report surveys about their mental health recovery, quality of life, and employment experiences at baseline, six months, and 12 months. Levels of burnout were analyzed at each time point, and regression analyses that controlled for baseline levels identified potential predictors of burnout (demographic, clinical, and employment characteristics) at six and 12 months. RESULTS: Compared with previously published burnout levels of other mental health workers in the VHA, PSs reported similar levels of emotional exhaustion, depersonalization, and personal accomplishment. At baseline, increased burnout was correlated with white race, fewer hours providing direct services, greater psychiatric symptoms, and lower self-efficacy. However, analyses did not reveal strong predictors of burnout scores at six or 12 months. CONCLUSIONS: In the first study to prospectively examine job burnout among PSs employed by the VHA, results illustrate the nuanced experience of burnout over a 12-month period and suggest the need for replication and further research on employment experiences of this emerging workforce.

Development and Validation of a Computerized-Adaptive Test for PTSD (P-CAT).

OBJECTIVE: The primary purpose was to develop, field test, and validate a computerized-adaptive test (CAT) for posttraumatic stress disorder (PTSD) to enhance PTSD assessment and decrease the burden of symptom monitoring. METHODS: Data sources included self-report and interviewer-administered diagnostic interviews. The sample included 1,288 veterans. In phase 1, 89 items from a previously developed PTSD item pool were administered to a national sample of 1,085 veterans. A multidimensional graded-response item response theory model was used to calibrate items for incorporation into a CAT for PTSD (P-CAT). In phase 2, in a separate sample of 203 veterans, the P-CAT was validated against three other self-report measures (PTSD Checklist, Civilian Version; Mississippi Scale for Combat-Related PTSD; and Primary Care PTSD Screen) and the PTSD module of the Structured Clinical Interview for DSM-IV. RESULTS: A bifactor model with one general PTSD factor and four subfactors consistent with DSM-5 (reexperiencing, avoidance, negative mood-cognitions, and arousal), yielded good fit. The P-CAT discriminated veterans with PTSD from those with other mental health conditions and those with no mental health conditions (Cohen's d effect sizes >.90). The P-CAT also discriminated those with and without a PTSD diagnosis and those who screened positive versus negative for PTSD. Concurrent validity was supported by high correlations (r=.85-.89) with the validation measures. CONCLUSIONS: The P-CAT appears to be a promising tool for efficient and accurate assessment of PTSD symptomatology. Further testing is needed to evaluate its responsiveness to change. With increasing availability of computers and other technologies, CAT may be a viable and efficient assessment method.