Strategies for Implementing an Electronic Patient-Reported Outcomes-Based Symptom Management Program Across Six Cancer Centers.

Background: Electronic patient-reported outcome (ePRO)-based symptom management improves cancer patients' outcomes. However, implementation of ePROs is challenging, requiring technical resources for integration into clinical systems, substantial buy-in from clinicians and patients, novel workflows to support between-visit symptom management, and institutional investment. Methods: The SIMPRO Research Consortium developed eSyM, an electronic health record-integrated, ePRO-based symptom management program for medical oncology and surgery patients and deployed it at six cancer centers between August 2019 and April 2022 in a type II hybrid effectiveness-implementation cluster randomized stepped-wedge study. Sites documented implementation strategies monthly using REDCap, itemized them using the Expert Recommendations for Implementation Change (ERIC) list and mapped their target barriers using the Consolidated Framework for Implementation Research (CFIR) to inform eSyM program enhancement, facilitate inter-consortium knowledge sharing and guide future deployment efforts. Results: We documented 226 implementation strategies: 35 'foundational' strategies were applied consortium-wide by the coordinating center and 191 other strategies were developed by individual sites. We consolidated these 191 site-developed strategies into 64 unique strategies (i.e., removed duplicates) and classified the remainder as either 'universal', consistently used by multiple sites (N=29), or 'adaptive', used only by individual sites (N=35). Universal strategies were perceived as having the highest impact; they addressed eSyM clinical preparation, training, engagement of patients/clinicians, and program evaluation. Across all documented SIMPRO strategies, 44 of the 73 ERIC strategies were addressed and all 5 CFIR barriers were addressed. Conclusion: Methodical collection of theory-based implementation strategies fostered the identification of universal, high-impact strategies that facilitated adoption of a novel care-delivery intervention by patients, clinicians, and institutions. Attention to the high-impact strategies identified in this project could support implementation of ePROs as a component of routine cancer care at other institutions.

Childhood maladaptive coping mechanisms and the subsequent development of depression.

BACKGROUND: Depression is a major source of symptoms and disability. In adults, maladaptive coping (usually characterized as personality dysfunction) has been shown to be associated with a depression diagnosis and poorer depression outcome. As adults with maladaptive coping difficulties are more prone to depression, we hypothesized that children with childhood disorders that involve poor coping would increase the risk of later developing depressive disorders. METHODS: Longitudinal studies of conduct disorder (CD), oppositional defiant disorder (ODD) and Disruptive Disorder (DD) that included a later measure of depressive disorder were reviewed. Meta-analyses of CD and ODD + DD were performed to predict increased odds of depression. RESULTS: Eight longitudinal studies were found where there was a measure of CD followed by depressive disorder assessment and nine studies for the variables ODD + DD. All of these studies showed these diagnoses were a significant risk factor for later depression. For the studies included in the meta-analysis CD predicted depression OR = 3.9 (1.6-9.3) (six studies), while ODD + DD also predicted depression OR = 5.6 (2.7-11.8) (five studies). CONCLUSIONS: Childhood disorders with maladaptive coping may increase the odds of later development of a depressive disorder diagnosis. If so, these diagnoses might also indicate an early intervention possibility to prevent depression.

Prevalence, Factor Structure, and Heritability of Avoidant Personality Disorder.

ABSTRACT: To review the community prevalence, factor structure, and heritability of avoidant personality disorder (AVPD), we reviewed the literature of empirical studies reported between years 1980 and 2020. Community point prevalence rates ranged from 0.8% to 5%, with one study of women older than 25 years finding a lifetime rate of 9.3%. A weighted point prevalence for studies involving both men and women was 3.3%. All factor analytic studies indicated a one factor solution. The themes were social inadequacy, feeling inferior, and fears of social rejection. Family studies of heritability for AVPD ranged from 0.18 to 0.56. Twin studies ranged from 0.28 to 0.71. The weighted average for heritability was 0.55. AVPD is an important clinical issue because it is prevalent in the community and has high morbidity and high heritability. Its single factor seems to suggest evaluation and treatment should be straightforward, but despite this, it tends to be underdiagnosed and undertreated.

Empirical evidence of the effect of personality pathology on the outcome of panic disorder.

BACKGROUND: Treatment resistant disorders are a significant clinical problem. Impediments to good outcome need to be identified and addressed. Personality pathology has been hypothesized to be one such factor in panic disorder. There is no consensus as to the effects of personality pathology on the outcome of panic disorder. This study examined empirical evidence. The hypothesis was that personality pathology would cause poorer outcome of panic disorder. METHODS: A literature search was conducted that winnowed 2627 articles down to 27 based on 1) longitudinal design; 2) validated measures of personality; 3) validated outcome measures; and 4) the presence of effect size or data to calculate effect size. All effect sizes were translated into odds ratios (ORs) for ease of comparison. RESULTS: An overall median OR of 2.7 was found, indicating personality pathology negatively affected outcome. This finding persisted even when adjusted for baseline severity of illness. The effects were found for both clinical outcomes (OR = 2.7) and for social adjustment (OR = 2.9). There was a tendency for more dropouts in the personality pathology group. More highly structured drug therapy regimens and highly structured psychotherapy seemed to partially mitigate this outcome. CONCLUSION: The negative effect of personality pathology was confirmed in well-designed longitudinal studies. This was not related to initial clinical severity. Clinical implications are that patients with personality pathology require the therapist to stick more closely to treatment protocols and to mitigate the tendency of these patients to drop out of treatment.

Empirical findings of fitness-for-duty evaluations.

This article was migrated. The article was marked as recommended. Background:The ability of physicians to practice appropriately is often evaluated by a fitness for duty exam. This report reviews the empirical literature on fitness for duty evaluations. Methods: A literature review was performed on PubMed using the terms physician, impairment, burnout, fitness to practice and fitness for duty. Results: At least one percent of physicians are referred each year for possibly serious difficulties. Surgery and its subspecialties and psychiatry may be at higher risk. Variables associated with fitness for duty evaluations include educational, personality, culture and emotional illness. Conclusions: Risk factors appear to vary between modifiable (training, culture and treatable emotional illness), less modifiable (personality) and likely unmodifiable (specialty).  Fitness for duty should be part of the training of all psychiatrists.

An empirical data comparison of regulatory agency and malpractice legal problems for psychiatrists.

BACKGROUND: Our objective is to compare legal difficulties that psychiatrists encounter in regulatory agency and malpractice (insurance) settings. METHODS: Data sources included a literature search of malpractice and medical board discipline from 1990 to 2009 (rates and types of discipline); publicly available insurance data (malpractice frequency and type); and data from the National Practitioner Data Bank (NPDB) (required reports of malpractice settlements and hospital discipline). RESULTS: Medical board discipline findings indicate that psychiatrists are at increased risk of disciplinary action compared with other specialties. NPDB data indicated relatively infrequent problems for psychiatrists. In malpractice, psychiatry accounted for a small percentage of overall claims and settlements. Overall, more years in practice and a lack of board certification increased the risk of legal difficulties. CONCLUSIONS: There are shared and separate risk factors in the malpractice and regulatory agency areas, but there is evidence that these 2 legal areas are distinct from each other.

Empirical findings on legal difficulties among practicing psychiatrists.

BACKGROUND: This article reviews the published literature on areas of legal difficulty among practicing psychiatrists. METHODS: A literature search using PubMed identified studies of malpractice lawsuits or medical board discipline of psychiatrists between 1990 and 2009. Eight studies of physician discipline in the United States and one from the United Kingdom were identified. Information from 3 insurance companies and 3 sets of aggregated insurance company data also were available. One follow-up study of hospitalized psychiatric patients also was reviewed. RESULTS: Studies of medical board discipline indicate that, compared with other specialties, psychiatrists are at an increased risk of disciplinary action. Psychiatrists who were female, board certified, and in practice for a short period of time had a lower chance of medical board discipline. Psychiatry claims accounted for a very small proportion of overall malpractice claims and settlements. The amount of patient disability secondary to alleged malpractice was the most important variable predicting insurance payout. CONCLUSIONS: Psychiatrists appear to be disciplined by medical boards at an above-average frequency compared with other medical specialties. However, few malpractice suits reach the courts, and psychiatry represents a very small proportion of overall physician malpractice claims and dollars of settlement.

Personality traits and medical outcome of cardiac illness.

OBJECTIVE: Our goal was to examine the empirical literature on the effect of personality traits on the medical outcome of cardiac illness. METHOD: Pub Med and Psychological Abstracts were searched for the years 1990 to September 2009 using the terms personality, personality traits, personality disorder, health, recovery from illness, cardiac illness and surgical recovery. Articles were then selected that were prospective, had a peer review published measure of personality, a standardized measure of outcome of physical illness and at least one year follow up. RESULTS: Seven articles were identified that met our criteria. All seven had a significant finding that personality traits predicted medical outcomes. Of these seven articles six had similar enough measures of personality to be included in a meta analysis. (All used Type D personality.) Meta analysis found an odds ratio of 3.76 for Type D personality traits predicting poorer medical outcome. This indicated that patients with Type D personality had a 276% increase in the odds of a poor medical outcome compared to patients without Type D personality. CONCLUSIONS: These findings indicate that personality traits are a strong predictor of medical outcome of cardiac disease.

Avoidant personality disorder and its relationship to social phobia.

This review summarizes past and recent findings in the empiric literature and the evolution of the concepts of avoidant personality disorder (APD) and social phobia (SP). APD is an internally consistent dimensional personality pathology that causes dysfunction that appears to be dimensional rather than a sudden jump in impairment after a certain number of criteria have been met. It has state and trait personality components. Evidence indicates that symptoms are at least partially treatable with psychological or pharmacologic interventions. APD and SP have similar symptoms and treatment response and identical genetics. We can conclude from the empiric evidence that no dividing line exists between APD and SP, with APD merely being the more severe form of the disorder. The best conceptualization is that APD is a dimensional personality pathology that in its attenuated form (SP) resembles an anxiety disorder.

State and trait in personality disorders.

BACKGROUND: The current definitions of personality disorder indicate early onset, long duration and disorders of relatively stable severity. It has been noticed by a number of authors and researchers that at times personality pathology can be quite variable and not fit that model. METHODS: This report examines the possibility that there is a valid psychiatric disorder whose key feature is episodic personality dysfunction. The disorder would be designated State personality disorder (State PD) to separate it from Trait personality disorder (Trait PD), which is the non episodic form, and from no personality disorder (No PD). This report examines what criteria might be necessary to validate such a diagnosis. RESULTS: It finds that State personality disorder has been identified in two distinct populations and in both it can be distinguished from its near neighbor disorders of Trait PD and No PD. The family history method of personality clusters distinguishes State PD from its near neighbors and provides a possible biological marker for the disorder. In two separate populations the disorder is related to an independent measure of the hypothesized underlying personality construct. Although the two populations in which the phenomenon has been clinically identified are very different and cannot be directly compared, in both it appears that clinical variables may distinguish State PD from its near neighbor diagnoses. State PD appears to have a negative relationship to suicidal ideation and might affect the course of treatment of comorbid Axis I disorders. CONCLUSIONS: It is concluded that State PD represents a valid diagnostic entity.

State personality disorder in social phobia.

To examine the effects of state on personality disorder characteristics, we compared individuals with social phobia before and after psychological intervention. Administration of the Personality Disorder Questionnaire (PDQ-4) before and after treatment allowed for the identification of three groups of patients: (1) individuals who showed elevated PDQ-4 scores but little changes from intake to post treatment (Trait PD group; n = 28); (2) individuals who showed a decrease in PDQ-4 scores from intake to post treatment (State group; n = 33); and (3) a group with no significant personality disorder characteristics at pre or post-treatment (No PD group; n = 32). There were trend differences between the Trait, State and No PD groups for being single, never married (81.5%, 44.4%, and 56.3%, p < .05) and a significant difference for having the generalized form of Social Phobia (96.4%, 88.9%, and 59.4%, p < .0001). The groups also differed in their level of trait anxiety (61.6, 51.2, 44.5, p < .001). Groups also differed in level of the personality measure Harm Avoidance (26.3, 23.3, 19.8, p < .0002). The reduction of personality disorder traits in the State PD groups from intake to post-treatment was not specific to any particular personality disorder or personality disorder cluster. Trait personality appeared to have a higher risk for suicide compared to the other two groups. A State Personality group was identified in individuals with social phobia by following changes in personality pathology from before and after a psychological intervention.

The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: a review.

Psychiatric and other clinicians have often speculated on whether the presence of a personality disorder would indicate a poorer course of treatment for an Axis I disorder. Starting around 1990, the standardized criteria of the DSM increased interest in examining this area empirically. This report updates my previous reviews and examines other writing in this area. There is still a considerable body of evidence indicating that personality may cause a poorer treatment outcome of an Axis I disorder; however, there are also intriguing new developments. The introduction of new drug treatments that may be helpful with some dysfunctional personality traits changes some of the findings and may suggest that there may be preferential treatments for some Axis I patients with certain comorbid personality traits. (In certain cases this may apply to some specific psychotherapy techniques as well.) In addition, at times, personality traits may predict a positive outcome to treatment. This review is an attempt to bring together this diverse area and suggest where fruitful areas of research and intervention may possibly be found.

Predictors of alkalosis after liver transplantation.

BACKGROUND: Metabolic alkalosis (MA) is common after orthotopic liver transplantation (OLT). METHODS: The study was conducted to identify factors associated with MA after 285 OLTs. MA, defined as total carbon dioxide content of 30 mEq/L or greater, developed in 115 patients (40%) within the first 3 postoperative days. RESULTS: By univariate analysis, patients with MA had a greater preoperative carbon dioxide content (24.4 +/- 3 versus 22.9 +/- 2.9 mEq/L; P < 0.0001) and hematocrit (35% +/- 5% versus 33% +/- 6%; P < 0.02), but lower creatinine (0.9 +/- 0.5 versus 1.2 +/- 1.2 mg/dL; P < 0.001) and blood urea nitrogen levels (15 +/- 12 versus 19 +/- 17 mg/dL; P < 0.001) compared with controls. Patients with MA were administered more citrate intraoperatively compared with controls (6.2 +/- 5.2 versus 4.5 +/- 3.6 mEq/kg of body weight; P < 0.02). Patients with MA had a lower postoperative potassium level (3.7 +/- 0.4 versus 4 +/- 0.5 mEq/L; P < 0.0001) and cumulative fluid balance (-0.66 +/- 1.87 versus +0.003 +/- 3.9 L; P < 0.007) compared with controls. By multivariate analysis, preoperative carbon dioxide content (odds ratio, 1.19; 95% confidence interval [CI], 1.08 to 1.31 per mEq/L), creatinine level (odds ratio, 0.61; 95% CI, 0.39 to 0.96 per mg/dL), intraoperative administered citrate (odds ratio, 3.35; 95% CI, 1.71 to 6.53 per 10 mEq/kg body weight), and postoperative potassium level (odds ratio, 0.32; 95% CI, 0.18 to 0.57 per mEq/L) were independently associated with MA. MA was not associated with increased hospital mortality (7.8% versus 8.2%, MA versus controls). However, patients with MA spent more time on mechanical ventilation than controls (5 +/- 0.8 versus 3 +/- 0.6 days; P < or = 0.03). CONCLUSION: Preoperative total carbon dioxide content, renal function, intraoperative administered citrate, and postoperative potassium level are independently associated with MA after primary OLT.