Clinical validation of a novel web-application for remote assessment of distance visual acuity.

BACKGROUND/OBJECTIVES: Ophthalmic disorders cause 8% of hospital clinic attendances, the highest of any specialty. The fundamental need for a distance visual acuity (VA) measurement constrains remote consultation. A web-application, DigiVis, facilitates self-assessment of VA using two internet-connected devices. This prospective validation study aimed to establish its accuracy, reliability, usability and acceptability. SUBJECTS/METHODS: In total, 120 patients aged 5-87 years (median = 27) self-tested their vision twice using DigiVis in addition to their standard clinical assessment. Eyes with VA worse than +0.80 logMAR were excluded. Accuracy and test-retest (TRT) variability were compared using Bland-Altman analysis and intraclass correlation coefficients (ICC). Patient feedback was analysed. RESULTS: Bias between VA tests was insignificant at -0.001 (95% CI -0.017 to 0.015) logMAR. The upper limit of agreement (LOA) was 0.173 (95% CI 0.146 to 0.201) and the lower LOA -0.175 (95% CI -0.202 to -0.147) logMAR. The ICC was 0.818 (95% CI 0.748 to 0.869). DigiVis TRT mean bias was similarly insignificant, at 0.001 (95% CI -0.011 to 0.013) logMAR, the upper LOA was 0.124 (95% CI 0.103 to 0.144) and the lower LOA -0.121 (95% CI -0.142 to -0.101) logMAR. The ICC was 0.922 (95% CI 0.887 to 0.946). 95% of subjects were willing to use DigiVis to monitor vision at home. CONCLUSIONS: Self-tested distance VA using DigiVis is accurate, reliable and well accepted by patients. The app has potential to facilitate home monitoring, triage and remote consultation but widescale implementation will require integration with NHS databases and secure patient data storage.

Shared decision making in mental health treatment: qualitative findings from stakeholder focus groups.

PURPOSE: This article reports on findings from seven stakeholder focus groups conducted in exploring shared decision making (SDM) between provider and consumer in mental health (MH) treatment in public MH. BASIC PROCEDURES: Seven focus groups were conducted with stakeholders-consumers, family members, prescribers, MH clinicians, and rural providers. Each of the focus groups was recorded digitally, transcribed into text, and analyzed qualitatively for recurring themes. MAIN FINDINGS: Provider barriers to SDM include history of the medical model, MH crises, lack of system support, and time. Consumer-related barriers included consumer competency, fears, insight, literacy, and trauma from past experiences. Information-exchange issues include consumer passivity, whether consumers could be viewed as experts, and importance of adequate history information. New skills needed to practice SDM included provider's knowledge about alternative treatments, mastery of person-first language, and listening skills; consumer's ability to articulate their expert information; and computer skills for both providers and consumers. Outcomes expected from practice of SDM include greater sharing of power between provider and consumer, greater follow-through with treatment plans, greater self-management on the part of consumers, and improved therapeutic alliances. PRINCIPAL CONCLUSIONS: Implementing SDM in public MH will impact consumers and their families, providers, prescribers, and administrators. More SDM trials in public MH are needed to answer some of the many questions that remain.

Early childhood mental health: services that can save a life.

The Give a Kid a Chance Omnibus Mental Health Services Act of 2003 (H.R.81) is a worthwhile proposal that endorses mental health services for children, adolescents, and their families. House Representative Sheila Jackson-Lee of Texas, who is the author of H.R. 81, provides a convincing argument about the need for mental health specialty services for children, adolescents, and their families (Thomas.loc.gov, 2003). Currently, a substantial portion of the pre-adult population has some sort of mental/emotional problem and would benefit by having access to mental health services. She proposes that early intervention for childhood mental disorders will result in optimal psychosocial outcomes during the teenage years and into adulthood. H.R. 81 will be examined using a policy analysis approach. The analysis will explore the description of the problem, significance of the problem situation, assessment and outcomes of prior efforts, need for analysis, major stakeholders, goals and objectives, measures of effectiveness, potential solutions, alternatives, future consequences, spillovers and externalities, constraints and political feasibility, and policy recommendations.

Technology and rural mental health.

In addition to the specific and pervasive rural issues of isolation and suitability of services, the rural mental health system faces many of the same problems as the health system in general: access and increasing costs. The introduction of technology adds the unknown dimensions of acceptability and feasibility. Technology has the potential to decrease the gap in services and improve education, support, and connectedness between the client and the provider. As an alternative to traditional face-to-face contact for those in rural and geographically dispersed areas, the Internet potentially can bridge the disparities in health care access for rural mental health services. With an improved understanding based on research, demonstration studies of model applications, and evidence of outcomes, the emerging technologies can serve as tools to achieve the major goals of preventing, assessment, and treating serious mental illnesses in the rural communities with less barriers and stigma.