Understanding the characteristics of Latino individuals with first-time DUI offenses to facilitate effective interventions.

Literature shows that Latinos who drink are more likely to experience alcohol-related consequences and less likely to seek care for alcohol misuse than Whites. We aim to understand characteristics, consumption patterns, and openness to treatment among Latino first-time offenders driving under the influence. Latino participants were significantly younger (29.0 years) than non-Latinos (37.7 years). In adjusted models, Latino participants were significantly more likely than non-Latinos to binge drink, but there were no significant group differences in amount of alcohol consumed in a typical week. There was no significant difference in incidence of alcohol-related consequences, readiness to change drinking, and driving behaviors in this sample.

Appropriate analyses of bimodal substance use frequency outcomes: a mixture model approach.

Background: In addiction research, outcome measures are often characterized by bimodal distributions. One mode can be for individuals with low substance use and the other mode for individuals with high substance use. Applying standard statistical procedures to bimodal data may result in invalid inference. Mixture models are appropriate for bimodal data because they assume that the sampled population is composed of several underlying subpopulations.Objectives: To introduce a novel mixture modeling approach to analyze bimodal substance use frequency data.Methods: We reviewed existing models used to analyze substance use frequency outcomes and developed multiple alternative variants of a finite mixture model. We applied all methods to data from a randomized controlled study in which 30-day alcohol abstinence was the primary outcome. Study data included 73 individuals (38 men and 35 women). Models were implemented in the software packages SAS, Stata, and Stan.Results: Shortcomings of existing approaches include: 1) inability to model outcomes with multiple modes, 2) invalid statistical inferences, including anti-conservative p-values, 3) sensitivity of results to the arbitrary choice to model days of substance use versus days of substance abstention, and 4) generation of predictions outside the range of common substance use frequency outcomes. Our mixture model variants avoided all of these shortcomings.Conclusions: Standard models of substance use frequency outcomes can be problematic, sometimes overstating treatment effectiveness. The mixture models developed improve the analysis of bimodal substance use frequency.

Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use.

BACKGROUND: Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes. OBJECTIVES: To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior RESEARCH DESIGN: Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system. PARTICIPANTS: A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews. MAIN MEASURES: Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up. KEY RESULTS: The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated. CONCLUSIONS: This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.

Randomized Clinical Trial Examining Cognitive Behavioral Therapy for Individuals With a First-Time DUI Offense.

BACKGROUND: Driving under the influence (DUI) programs are a unique setting to reduce disparities in treatment access to those who may not otherwise access treatment. Providing evidence-based therapy in these programs may help prevent DUI recidivism. METHODS: We conducted a randomized clinical trial of 312 participants enrolled in 1 of 3 DUI programs in California. Participants were 21 and older with a first-time DUI offense who screened positive for at-risk drinking in the past year. Participants were randomly assigned to a 12-session manualized cognitive behavioral therapy (CBT) or usual care (UC) group and then surveyed 4 and 10 months later. We conducted intent-to-treat analyses to test the hypothesis that participants receiving CBT would report reduced impaired driving, alcohol consumption (drinks per week, abstinence, and binge drinking), and alcohol-related negative consequences. We also explored whether race/ethnicity and gender moderated CBT findings. RESULTS: Participants were 72.3% male and 51.7% Hispanic, with an average age of 33.2 (SD = 12.4). Relative to UC, participants receiving CBT had lower odds of driving after drinking at the 4- and 10-month follow-ups compared to participants receiving UC (odds ratio [OR] = 0.37, p = 0.032, and OR = 0.29, p = 0.065, respectively). This intervention effect was more pronounced for females at 10-month follow-up. The remaining 4 outcomes did not significantly differ between UC versus CBT at 4- and 10-month follow-ups. Participants in both UC and CBT reported significant within-group reductions in 2 of 5 outcomes, binge drinking and alcohol-related consequences, at 10-month follow-up (p < 0.001). CONCLUSIONS: In the short-term, individuals receiving CBT reported significantly lower rates of repeated DUI than individuals receiving UC, which may suggest that learning cognitive behavioral strategies to prevent impaired driving may be useful in achieving short-term reductions in impaired driving.

What Role Does Efficiency Play in Understanding the Relationship Between Cost and Quality in Physician Organizations?

BACKGROUND: The belief that there is inefficiency, or the potential to improve patient health at current levels of spending, is driving the push for greater value in health care. Previous studies demonstrate overuse of a narrow set of services, suggesting provider inefficiency, but existing studies neither quantify inefficiency more broadly nor assess its variation across physician organizations (POs). DATA AND METHODS: We used data on quality of care and total cost of care from 129 California POs participating in a statewide value-based pay-for-performance program. We estimated a production function with quality as the output and cost as the input, using a stochastic frontier model, to develop a measure of relative efficiency for each PO. To validate the efficiency measure, we examined correlations of PO efficiency estimates with indicators representing overuse of services. RESULTS: The estimated production function showed that PO quality was positively associated with costs, although there were diminishing marginal returns to spending. A certain minimum level of spending was associated with high quality even among efficient POs. Most strikingly, however, POs had substantial variation in efficiency, producing widely differing levels of quality for the same cost. CONCLUSIONS: Differences among POs in the efficiency with which they produce quality suggest opportunities for improvements in care delivery that increase quality without increasing spending.

Bayesian restricted spatial regression for examining session features and patient outcomes in open-enrollment group therapy studies.

Group-based interventions have been developed for treating patients across a range of health conditions. Enrollment into such groups often occurs on an open (or rolling) basis. Conditional autoregression modeling of random session effects has been proposed to account for the expected correlation in session effects associated with the overlap in patient participation session to session. However, when the analytic objective is to examine the relationship between a fixed-effect session feature and a patient outcome using conditional autoregression, confounding might arise if the fixed session feature of interest and the random session effects vary across sessions in similar ways, resulting in bias and inflated standard errors of a fixed-effect session feature of interest. Motivated by the goal of examining the relationships between outcomes and the session features of leader and session module theme, we applied restricted spatial regression to the analysis of patient outcomes collected from 132 participants in an open-enrollment group for treating depression among patients of a residential alcohol and other drug treatment program, adapting the approach to the multilevel data structure of open-enrollment group data. As compared with standard conditional autoregression, the restricted regression approach resulted in more precise estimates of regression coefficients of the module theme and leader predictor variables. The restricted regression approach provides an important analytic tool for group therapy researchers who are investigating the relationship between key components of open-enrollment group therapy interventions and patient outcomes.

Bayesian Semi- and Non-parametric Models for Longitudinal Data with Multiple Membership Effects in R.

We introduce growcurves for R that performs analysis of repeated measures multiple membership (MM) data. This data structure arises in studies under which an intervention is delivered to each subject through the subject's participation in a set of multiple elements that characterize the intervention. In our motivating study design under which subjects receive a group cognitive behavioral therapy (CBT) treatment, an element is a group CBT session and each subject attends multiple sessions that, together, comprise the treatment. The sets of elements, or group CBT sessions, attended by subjects will partly overlap with some of those from other subjects to induce a dependence in their responses. The growcurves package offers two alternative sets of hierarchical models: 1. Separate terms are specified for multivariate subject and MM element random effects, where the subject effects are modeled under a Dirichlet process prior to produce a semi-parametric construction; 2. A single term is employed to model joint subject-by-MM effects. A fully non-parametric dependent Dirichlet process formulation allows exploration of differences in subject responses across different MM elements. This model allows for borrowing information among subjects who express similar longitudinal trajectories for flexible estimation. growcurves deploys "estimation" functions to perform posterior sampling under a suite of prior options. An accompanying set of "plot" functions allow the user to readily extract by-subject growth curves. The design approach intends to anticipate inferential goals with tools that fully extract information from repeated measures data. Computational efficiency is achieved by performing the sampling for estimation functions using compiled C++.

Evaluating the impact of getting to outcomes-underage drinking on prevention capacity and alcohol merchant attitudes and selling behaviors.

Underage drinking is a significant problem facing US communities. Several environmental alcohol prevention (EAP) strategies (laws, regulations, responsible beverage service training and practices) successfully address underage drinking. Communities, however, face challenges carrying out these EAP strategies effectively. This small-scale, 3-year, randomized controlled trial assessed whether providing prevention coalitions with Getting To Outcomes-Underage Drinking (GTO-UD), a tool kit and implementation support intervention, helped improve implementation of two common EAP strategies, responsible beverage service training (RBS) and compliance checks. Three coalitions in South Carolina and their RBS and compliance check programs received the 16-month GTO-UD intervention, including the GTO-UD manual, training, and onsite technical assistance, while another three in South Carolina maintained routine operations. The measures, collected at baseline and after the intervention, were a structured interview assessing how well coalitions carried out their work and a survey of merchant attitudes and practices in the six counties served by the participating coalitions. Over time, the quality of some RBS and compliance check activities improved more in GTO-UD coalitions than in the control sites. No changes in merchant practices or attitudes significantly differed between the GTO-UD and control groups, although merchants in the GTO-UD counties did significantly improve on refusing sales to minors while control merchants did not.

The quality of mental health care for veterans of Operation Enduring Freedom/Operation Iraqi Freedom.

BACKGROUND: Some Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans experience serious mental health (MH) problems. As OEF/OIF soldiers leave active military duty, their growing numbers pose a challenge to the Department of Veterans Affairs (VA) in delivering high-quality mental health/substance-use disorder (MH/SUD) care. OBJECTIVE: To determine whether the quality of MH/SUD care provided by the VA differs by OEF/OIF veteran status. METHODS: Veterans with selected MH/SUDs were identified from administrative records using diagnostic codes. OEF/OIF service was determined based on Defense Manpower Data Center separation files. Eleven processes of care and 7 utilization performance indicators were examined. Regression analyses were adjusted for veteran demographic and clinical characteristics to test for differences in care by OEF/OIF status. RESULTS: Of the 836,699 veterans with selected diagnoses who received MH/SUD treatment in FY2007, 52,870 (6.3%) were OEF/OIF veterans. In unadjusted analyses, OEF/OIF veterans were more likely to receive evidence-based care processes captured by 6 of the 11 dichotomous performance indicators examined; however, among those receiving psychotherapy encounters, OEF/OIF veterans received significantly fewer visits (6.9 vs. 9.7, P<0.0001). In adjusted analyses, only postdischarge follow-up remained meaningfully higher for OEF/OIF veterans. CONCLUSIONS: Efforts to maintain and/or increase OEF/OIF veteran participation in VA MH/SUD services should be informed by their characteristics, such as younger age and better physical health relative to other veterans.

Intervening with practitioners to improve the quality of prevention: one-year findings from a randomized trial of assets-getting to outcomes.

There continues to be a gap in prevention outcomes achieved in research trials versus those achieved in "real-world" practice. This article reports interim findings from a randomized controlled trial evaluating Assets-Getting To Outcomes (AGTO), a two-year intervention designed to build prevention practitioners' capacity to implement positive youth development-oriented practices in 12 community coalitions in Maine. A survey of coalition members was used to assess change on individual practitioners' prevention capacity between baseline and one year later. Structured interviews with 32 program directors (16 in the intervention group and 16 in the control group) were used to assess changes in programs' prevention practices during the same time period. Change in prevention capacity over time did not differ significantly between the intervention and control groups. However, in secondary analyses of only those assigned to the AGTO intervention, users showed greater improvement in their self-efficacy to conduct Assets-based programming and increases in the frequency with which they engaged in AGTO behaviors, whereas among non-users, self-efficacy to conduct Assets-based programming declined. Interview ratings showed improvement in several key areas of performance among intervention programs. Improvement was associated with the number of technical assistance hours received. These results suggest that, after one year, AGTO is beginning to improve the capacity of community practitioners who make use of it.

Causal inference under interference with prognostic scores for dynamic group therapy studies.

Group therapy is a common treatment modality for behavioral health conditions. Patients often enter and exit groups on an ongoing basis, leading to dynamic therapy groups. Examining the effect of high versus low session attendance on patient outcomes is a research question of interest. However, there are several challenges to identifying causal effects in this setting, including the lack of randomization, interference among patients, and the interrelatedness of patient participation. Dynamic therapy groups motivate a unique causal inference scenario, as the treatment statuses are completely defined by the patient attendance record for the therapy session, which is also the structure inducing interference. We adopt the Rubin causal model framework to define the causal effect of high versus low session attendance of group therapy at both the individual patient and peer levels. We propose a strategy to identify individual, peer, and total effects of high attendance versus low attendance on patient outcomes by the prognostic score stratification. We examine performance of our approach via simulation and apply it to data from a group cognitive behavioral therapy trial for treating depression among patients in a substance use disorders treatment setting.

The premises is the premise: understanding off- and on-premises alcohol sales outlets to improve environmental alcohol prevention strategies.

Environmental strategies to prevent the misuse of alcohol among youth--e.g., use of public policies to restrict minors' access to alcohol--have been shown to reduce underage drinking. However, implementation of policy changes often requires public and private partnerships. One way to support these partnerships is to better understand the target of many of the environmental strategies, which is the alcohol sales outlet. Knowing more about how off-premises outlets (e.g., liquor and convenience stores) and on-premises outlets (e.g., bars and restaurants) are alike and different could help community-based organizations better tailor, plan, and implement their environmental strategies and strengthen partnerships between the public and commercial sectors. We conducted a survey of managerial or supervisory staff and/or owners of 336 off- and on-premises alcohol outlets in six counties in South Carolina, comparing these two outlet types on their preferences regarding certain alcohol sales practices, beliefs toward underage drinking, alcohol sales practices, and outcomes. Multilevel logistic regression showed that while off- and on-premises outlets did have many similarities, off-premises outlets appear to engage in more practices designed to prevent sales of alcohol to minors than on-premises outlets. The relationship between certain Responsible Beverage Service (RBS) practices and outcomes varied by outlet type. This study furthers the understanding of the differences between off- and on-premises alcohol sales outlets and offers options for increasing and tailoring environmental prevention efforts to specific settings.

Training addiction counselors to implement CBT for depression.

Many clients in publicly funded substance abuse treatment programs suffer from depression yet lack access to effective mental health treatment. This study sought to examine whether addiction counselors could be effectively trained to deliver group CBT for depression and to ascertain client perceptions of the treatment. Five counselors were trained in the therapy and treated 113 clients with depression symptoms. Counselors demonstrated high fidelity to the therapy and client perceptions of the therapy were positive. Our results suggest that training addiction counselors to deliver group CBT for depression is a promising integrated treatment approach for co-occurring depression and substance disorders.

Longitudinal effects of social network changes on drinking outcomes for individuals with a first-time DUI.

BACKGROUND: Social networks are important predictors of alcohol-related outcomes, especially among those with a DUI where riskier social networks are associated with increased risk of drinking and driving. Social networks are increasingly a target for intervention; however, no studies have examined and measured whether longitudinal changes in social networks are associated with reductions in impaired driving. OBJECTIVE: The current study first examines longitudinal changes in social networks among participants receiving services following a first-time DUI, and then examines the association between network change and drinking outcomes at 4- and 10-month follow-up. METHODS: The study surveyed a subsample of participants (N = 94) enrolled in a clinical trial of individuals randomized to cognitive behavioral therapy (CBT) or usual care (UC) on an iPad using EgoWeb 2.0-an egocentric social network data collection software-about pre-DUI and post-DUI networks and their short- and long-term drinking behaviors. RESULTS: Participants were 65% male, 48% Hispanic, and an average of 32.5 years old. Overall, participants significantly reduced the proportion of network members with whom they drank from 0.41 to 0.30 (p = .001) and with whom they drank more alcohol than they wanted to from 0.15 to 0.07 (p = .0001) from two weeks prior to the DUI (measured at baseline) to 4-month follow-up. Furthermore, decreases in proportion of drinking partners over time were associated with reduced drinks per week, self-reported driving after drinking, and intentions to drive after drinking at 4-month follow-up. Participants who reported decreases in proportion of drinking partners also reported significantly less binge drinking at 10-month follow-up. Finally, increases in emotional support were associated with decreases in binge drinking at 4-month follow-up. The study found no differences in the changes in composition of networks between CBT and UC groups. CONCLUSIONS: These results suggest that individuals receiving services in DUI programs significantly reduced risky network members over time and that these social network changes were associated with reduced drinking and other indicators of risk for DUI recidivism. Clinical interventions that target reductions in risky network members may improve outcomes for those enrolled in a DUI program.

Group Cohesion and Climate in Cognitive Behavioral Therapy for Individuals with a First-Time DUI.

Few studies have examined group cohesion and climate in the substance use disorder treatment literature. We examined whether group cohesion and climate are associated with increased self-efficacy outcomes and reduced drinks per week, binge drinking and DUI behaviors, in a sample of individuals with a first-time DUI receiving either cognitive behavioral therapy (CBT) or usual care. Additionally, we examined whether CBT moderates these relationships. Group measures and drinking outcomes were not significantly associated. This study is the first to provide an in-depth analysis on group processes in DUI settings, and as such, provides important insights into how group processes may differ in a mandated DUI context.

Social Networks of Clients in First-Time DUI Programs.

OBJECTIVE: Social networks play an important role in the development of and recovery from problem drinking behaviors; however, few studies have measured the social networks of individuals convicted of driving under the influence (DUI) or assessed the relationship between social network characteristics and risk for DUI relapse and recidivism. The goal of this study is to describe the social network characteristics of a first-time DUI population in the 2 weeks before the DUI incident; examine demographic differences in social network characteristics by age, ethnicity, and gender; and assess the relationship between social network characteristics and risk factors for DUI. METHOD: We collected personal (egocentric) social network survey data from 94 participants (65% male) enrolled in a randomized clinical trial comparing the effects of cognitive behavioral therapy with usual care for individuals convicted of a first-time DUI. Multivariate models were used to assess the relationship between pre-DUI personal network characteristics and risk factors for DUI measured at baseline interview. RESULTS: Results indicate that the proportion of drinking partners in one's personal network was positively associated with drinks per week, binge drinking, alcohol use, marijuana use, and alcohol-related consequences. Several dimensions of personal network support were inversely associated with risk factors for DUI. CONCLUSIONS: The pre-DUI composition of personal networks has a strong relationship to baseline risk factors for DUI; networks composed of more risky individuals (e.g., drinking partners) were associated with greater substance use and drinking and driving behaviors. Networks with greater levels of social support were associated with lower likelihood of self-reported driving after drinking and intentions to drive after drinking. Interventions that target positive and negative aspects of personal networks may enhance clinical treatments.

Shifting From Passive Quality Reporting to Active Nudging to Influence Consumer Choice of Health Plan.

Comparative quality information on health plan and provider performance is increasingly available in the form of quality report cards, but consumers rarely make use of these passively provided decision support tools. In 2012-2013, the Centers for Medicare & Medicaid Services (CMS) initiated quality-based nudges designed to encourage beneficiaries to move into higher quality Medicare Advantage (MA) plans. We assess the impacts of CMS' targeted quality-based nudges with longitudinal analysis of 2009-2014 MA plan enrollment trends. Nudges are associated with 17% reductions in enrollment in the lowest-performing plans and 3% increases in enrollment in the highest performing plans (annually, p < .01 for both), occurring at the time of nudge implementation and relative to trends for plans with moderate performance that were not targeted by nudges. These findings suggest that quality-based nudges can successfully steer consumers into higher quality plans and provide opportunities for purchasers and payers to increase consumers' use of quality information.

Study design to evaluate a group-based therapy for support persons of adults on buprenorphine/naloxone.

BACKGROUND: Opioid use disorders (OUDs) have devastating effects on individuals, families, and communities. While medication treatments for OUD save lives and are increasingly utilized, rates of treatment dropout are very high. In addition, most existing medication treatments for OUD may often neglect the impact of untreated OUD on relationships and ignore the potential role support persons (SPs) could have on encouraging long-term recovery, which can also impact patient treatment retention. METHODS/DESIGN: The current study adapts Community Reinforcement and Family Training (CRAFT) for use with SPs (family member, spouse or friend) of patients using buprenorphine/naloxone (buprenorphine) in an outpatient community clinic setting. The study will evaluate whether the adapted intervention, also known as integrating support persons into recovery (INSPIRE), is effective in increasing patient retention on buprenorphine when compared to usual care. We will utilize a two-group randomized design where patients starting or restarting buprenorphine will be screened for support person status and recruited with their support person if eligible. Support persons will be randomly assigned to the INSPIRE intervention, which will consist of 10 rolling group sessions led by two facilitators. Patients and SPs will each be assessed at baseline, 3 months post-baseline, and 12 months post-baseline. Patient electronic medical record data will be collected at six and 12 months post-baseline. We will examine mechanisms of intervention effectiveness and also conduct pre/post-implementation surveys with clinic staff to assess issues that would affect sustainability. DISCUSSION: Incorporating the patient's support system may be an important way to improve treatment retention in medication treatments for OUD. If SPs can serve to support patient retention, this study would significantly advance work to help support the delivery of effective treatments that prevent the devastating consequences associated with OUD. Trial registration This study was registered with ClinicalTrials.gov, NCT04239235. Registered 27 January 2020, https://clinicaltrials.gov/ct2/show/NCT04239235 .

Perceived barriers to treatment for adolescent depression.

BACKGROUND AND OBJECTIVE: Adolescent depression is common, disabling, and is associated with academic, social, behavioral, and health consequences. Despite the availability of evidence-based depression care, few teens receive it, even when recognized by primary care clinicians. Perceived barriers such as teen worry about what others think or parent concerns about cost and access to care may contribute to low rates of care. We sought to better understand perceived barriers and their impact on service use. DESIGN: After completing an eligibility and diagnostic telephone interview, all depressed teens and a matched sample of nondepressed teens recruited from 7 primary care practices were enrolled and completed telephone interviews at baseline and 6 months (August 2005-September 2006). PARTICIPANTS: Three hundred sixty-eight adolescent patients aged 13 to 17 (184 depressed and 184 nondepressed) and 338 of their parents. MEASURES: Perceived barriers to depression care and use of services for depression (psychotherapy and antidepressant medication). RESULTS: Teens with depression were significantly more likely to perceive barriers to care compared with nondepressed teens. Parents were less likely to report barriers than their teens; perceived stigma and concern about family member response were among the significant teen barriers. Teen perceived barriers scores were negatively associated with any use of antidepressants (P < 0.01), use of antidepressants for at least 1 month (P < 0.001), and any psychotherapy or antidepressant use (P < 0.05) at 6 months. CONCLUSIONS: To improve treatment for adolescent depression, interventions should address both teen and parent perceived barriers and primary care clinicians should elicit information from both adolescents and their parents.

Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals.

BACKGROUND: The debate over whether patient safety efforts should focus on adverse events or errors logically extends to voluntary incident reporting in hospitals. Reports emphasizing adverse events take an outcome-oriented approach to improving quality, whereas those emphasizing errors take a process-oriented approach. These approaches were compared in an analysis of 2,228 paper incident reports for 16,575 randomly selected inpatients at an academic hospital and a community hospital in the United States in 2001. METHODS: Measures were developed for process orientation (care varying from the norm) and outcome orientation (physical or nonphysical patient harms, regardless of cause); preventability; and any patient, system, and provider factors contributing to the incidents. RESULTS: Fifty percent of the reports were only process-oriented, 35% only outcome-oriented, and 10% both. Exclusively process-oriented reports were better than exclusively outcome-oriented reports for ascertaining preventability (as determined from 96% versus 25% of reports, respectively), system factors (described in 49% versus 5%), and provider factors (37% versus 4%) but were worse for identifying patient factors (5% versus 63%), all atp < .01. DISCUSSION: Many incident reports contain process information or outcome information but not both. Outcome-oriented reports lack the information needed to assess risk and formulate safety improvements; therefore, follow-up investigations are required. Because process-oriented reports include the necessary information more often, they are more directly useful for improving patient safety. Hospitals should focus voluntary incident reporting systems on capturing process-oriented reports and should train staff to describe contributing factors. This focus should not only improve the quality of the information in the reports but is consistent with efforts to promote a blame-free reporting culture.