A case control study of the implementation of change model versus passive dissemination of practice guidelines for compliance in monitoring for metabolic syndrome.

We developed an intervention to improve compliance with guidelines for monitoring metabolic syndrome and compared compliance prior to intervention and three times post-intervention at three community mental health clinics in Texas. One test clinic received intervention and two other clinics served as controls. Fifty random charts were reviewed from each clinic for three specific, 1-2 weeks periods over the course of 18 months. There were significant improvements in the ordering of labs, the presence of lab results in the chart, and documentation of blood pressure, body mass index and waist circumference in the intervention clinic over time in comparison to the control clinics. Documented evidence of physician action with respect to out of range values remained low. Metabolic monitoring is a multi-step process. Removing barriers, creating specific procedures, and dedicating staff resources can improve compliance with monitoring.

Interrater reliability of using brief standardized outcome measures in a community mental health setting.

OBJECTIVE: Given psychiatry's need to implement measurement-based care, the study examined whether direct-care staff could reliably administer brief positive and negative symptom instruments to track symptom changes and inform clinical decision making. METHODS: Raters (82 case managers) were assessed at baseline. Training was provided for individuals not meeting reliability criteria. These individuals were reassessed to determine the effect of training. In addition, rater drift was assessed for raters judged to be reliable at baseline. RESULTS: Seventy-seven percent of direct-care staff met criteria for reliability either at baseline or after they received additional training. CONCLUSIONS: A majority of direct-care staff can be trained to reliability on brief scales of positive and negative symptoms that can be used to guide clinical decision making.

Public-academic partnerships: tools for mental health agencies to evaluate research protocols.

Research involving community mental health center clients, resources, or both can affect clinical care, administrative processes, and costs. To help agencies identify and quantify these effects, a stakeholder group examined and discussed a range of protocols and then developed questionnaires and rating scales for agency use. The purpose of these materials is to make explicit the risks, costs, and benefits of a research protocol so an agency can make informed decisions about protocol approval and implementation. The goal of this work was to promote the conduct of appropriate research in community mental health settings while reducing risks to the agency and its clientele.

Bioética desde una perspectiva odontológica / Bioethics from an odontological perspective

La bioética es el estudio sistemático y profundo de la conducta humana en el campo de las ciencias de la vida y de la salud, a la luz de los valores y de los principios morales. La reflexión bioética es de suma importancia en la formación del odontólgo, tanto en la apropiación de valores como en crear conciencia sobre la aplicación de normas de bioseguridad. En Colombia, en el año 1989 se crea el Código de Ética del Odontólogo decretado bajo la Ley 35; en donde se establecen normas, principios y deberes éticos que deben regir la vida profesional del odontólogo. En la praxis odontológica, existe una alta posibilidad de contagio. Porque la boca es el hábitat normal de 300 especies distintas de microorganismos que están presentes cuando el odontólogo realiza sus tratamientos. La odontología no es un medio es un fin. Esto quiere decir, que ayudamos a la realización del otro; a través de una correcta o adecuada sonrisa y al escuchar y orientar a nuestros pacientes. El valor trascendente de la profesión de odontología está en comprender que cada persona tiene un proyecto de vida único y particular. Nuestra responsabilidad es contribuir a través del desempeño clínico y cuidado de la Salud Bucal con ese proyecto y lograr una vida feliz. También sirve de ayuda para crecer, porque se enriquece la persona con sus experiencias. La bioética permite tener conciencia que toda praxis odontológica puede repercutir positiva o negativamente en el paciente.

Bioethics is the systematic and extensive study of human behavior in the field of life and health sciences, in view of the values and moral principles. Bioethical reflexion has a great importance in the formation of the dentist, both in the appropriation of values and in creating consciousness on the implementation of biosafety standards. In Colombia, in 1989 a Code of Ethics was created and ruled for dental profession by Law 35, which established standards, principles and ethical obligations to govern the professional exercise for dentists. In dental practice, there is a high possibility of infection because the mouth is the normal habitat of numerous different species of microorganisms that are present when the dentists carry out their treatments. Dentistry is not a medium, but it is a goal. This means that we help to the realization of the other, by reestablishing a proper smile and listening and guiding our patients. The transcendent value of the profession of dentistry is to understand that each person has a single and particular project of life. Our responsibility is to contribute with this project giving an adequate Oral Health Care and helping our patients to achieve a happy life. Bioethics is useful to create consciousness that any dental practice can positively or negatively affect the patient.

The use of individually tailored environmental supports to improve medication adherence and outcomes in schizophrenia.

Cognitive adaptation training (CAT) is a psychosocial treatment that uses environmental supports such as signs, checklists, alarms, and the organization of belongings to cue and sequence adaptive behaviors in the home. Ninety-five outpatients with schizophrenia (structured clinical interview for diagnosis, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) were randomly assigned to (1) Full-CAT (CAT focused on many aspects of community adaptation including grooming, care of living quarters, leisure skills, social and role performance, and medication adherence), (2) Pharm-CAT (CAT focused only on medication and appointment adherence), or (3) treatment as usual (TAU). Treatment lasted for 9 months, and patients were followed for 6 months after the withdrawal of home visits. Medication adherence (assessed during unannounced, in-home pill counts) and functional outcomes were assessed at 3-month intervals. Results of mixed-effects regression models indicated that both CAT and Pharm-CAT treatments were superior to TAU for improving adherence to prescribed medication (P < .0001). Effects on medication adherence remained significant when home visits were withdrawn. Full-CAT treatment improved functional outcome relative to Pharm-CAT and TAU (P < .0001). However, differences for functional outcome across groups decreased following the withdrawal of home visits and were no longer statistically significant at the 6-month follow-up. Survival time to relapse or significant exacerbation was significantly longer in both CAT and Pharm-CAT in comparison to TAU (.004). Findings indicate that supports targeting medication adherence can improve and maintain this behavior. Comprehensive supports targeting multiple domains of functioning are necessary to improve functional outcomes. Maintenance of gains in functional outcome may require some form of continued intervention.

Relationships among subjective and objective measures of adherence to oral antipsychotic medications.

OBJECTIVE: The most common ways of assessing adherence to oral antipsychotic medications in research and in clinical practice are self-report and physician report. This prospective study examined the agreement among measures of adherence to oral antipsychotic medications among 52 outpatients with schizophrenia. METHODS: Participants were assessed at baseline during a visit to their outpatient clinic and followed for 12 weeks. Adherence was assessed by using subjective measures (self-report and physician report) and objective measures (pill counts conducted in the home, electronic monitoring, and blood plasma concentrations). Electronic monitoring was used as an imperfect standard against which other methods were judged. RESULTS: Data from pill counts and from electronic monitoring were strongly correlated (r(k)=.61). Self-report and physicians' ratings of compliance were weakly correlated with pill count and electronic monitoring when compliance scores were examined with rank-order correlations (r(k)=.18-.32). When the sample was dichotomized into adherent and nonadherent groups on the basis of electronic monitoring or pill count (at least 80% adherent), neither physicians nor patients identified adherent behavior (kappa

The reliability and validity of the Test of Adaptive Behavior in Schizophrenia (TABS).

Performance-based tests of functional capacity are important to utilize in schizophrenia where global measures may underestimate community functioning in the context of impoverished environments and disincentives to return to work. The Test of Adaptive Behavior in Schizophrenia (TABS) is a performance-based measure of adaptive functioning designed to address limitations of other available measures including limited assessment of the ability to initiate and of the ability to identify problems that occur in the course of performing functional activities. The TABS and a variety of symptom, functional outcome, and cognitive measures were administered to 264 outpatients with schizophrenia/schizoaffective disorders at an initial assessment. At 3 months, 110 subjects received a follow-up assessment. Results indicated that the TABS had very good test-retest reliability (0.80) and inter-item consistency (0.84). Moreover, TABS scores were moderately to strongly correlated with other measures of functional outcome, negative symptoms and neuropsychological test scores (convergent validity). Measures of positive symptoms were not found to be related to TABS performance (discriminate validity). The data provide preliminary evidence for the reliability and validity of the TABS. Further studies of the psychometric properties of the TABS including those examining the sensitivity of the TABS to treatments with different pharmacological agents or psychosocial treatments are encouraged.