Key Variables for Effective eHealth Designs for Individuals With and Without Mental Health Disorders: 212-4 Fractional Factorial Experiment.

BACKGROUND: eHealth applications not only offer the potential to increase service convenience and responsiveness but also expand the ability to tailor services to improve relevance, engagement, and use. To achieve these goals, it is critical that the designs are intuitive. Limited research exists on designs that work for those with a severe mental illness (SMI), many of whom have difficulty traveling for treatments, reject or infrequently seek treatment, and tend to discontinue treatments for significant periods. OBJECTIVE: This study aims to evaluate the influence of 12 design variables (eg, navigational depth, reading level, and use of navigational lists) on the usability of eHealth application websites for those with and without SMI. METHODS: A 212-4 fractional factorial experiment was used to specify the designs of 256 eHealth websites. This approach systematically varied the 12 design variables. The final destination contents of all websites were identical, and only the designs of the navigational pages varied. The 12 design elements were manipulated systematically to allow the assessment of combinations of design elements rather than only one element at a time. Of the 256 websites, participants (n=222) sought the same information on 8 randomly selected websites. Mixed effect regressions, which accounted for the dependency of the 8 observations within participants, were used to test for main effects and interactions on the ability and time to find information. Classification and regression tree analyses were used to identify effects among the 12 variables on participants' abilities to locate information, for the sample overall and each of the 3 diagnostic groups of participants (schizophrenia spectrum disorder [SSD], other mental illnesses, and no mental illness). RESULTS: The best and worst designs were identified for each of these 4 groups. The depth of a website's navigation, that is, the number of screens users needed to navigate to find the desired content, had the greatest influence on usability (ability to find information) and efficiency (time to find information). The worst performing designs for those with SSD had a 9% success rate, and the best had a 51% success rate: the navigational designs made a 42% difference in usability. For the group with other mental illnesses, the design made a 50% difference, and for those with no mental illness, a 55% difference was observed. The designs with the highest usability had several key design similarities, as did those with the poorest usability. CONCLUSIONS: It is possible to identify evidence-based strategies for designing eHealth applications that result in significantly better performance. These improvements in design benefit all users. For those with SSD or other SMIs, there are designs that are highly effective. Both the best and worst designs have key similarities but vary in some characteristics.

Correction: Key Variables for Effective eHealth Designs for Individuals With and Without Mental Health Disorders: 212-4 Fractional Factorial Experiment.

[This corrects the article DOI: 10.2196/23137.].

Identifying the Demographic and Mental Health Factors That Influence Insomnia Treatment Recommendations Within a Veteran Population.

Objective/Background: Insomnia is a pervasive and costly disorder that is particularly prevalent within the U.S. Veteran population. Although Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for insomnia, high rates of sedative-hypnotic prescribing continue. There is little research investigating the rates and factors impacting insomnia treatment recommendations, both behavioral and pharmacological. Participants: A cohort of 5,254 Veterans referred for either CBT-I or prescribed a sedative-hypnotic medication at a single VA Medical Center composed the group of participants. Methods: The current study evaluated the rates of insomnia treatment recommendations and the extent to which demographic variables, psychiatric disorders, and sleep disorders contributed to referrals for CBT-I or prescriptions for sedative-hypnotic medications within a large administrative data set. Results: Military service-related disability, insomnia diagnosis, and having one or more psychiatric diagnoses were associated with a greater likelihood of receiving a CBT-I referral (alone or in addition to a sedative-hypnotic medication) rather than a sedative-hypnotic prescription alone. A diagnosis of posttraumatic stress disorder was associated with a greater likelihood of receiving a sedative-hypnotic medication alone versus a CBT-I referral. Conclusions: Overall, the findings suggest that sedative-hypnotic medications were overwhelmingly the primary treatment recommendation despite evidence to support CBT-I as the recommended first-line treatment. However, key factors were identified that increased the likelihood of Veterans being referred for CBT-I. Suggestions for better identifying and understanding key factors that impact treatment recommendations are discussed.

Clinical Characterization of Insomnia among Veterans with PTSD: Identifying Risk Factors for Diagnosis and Treatment with Sedative-Hypnotics.

Insomnia is prevalent among Veterans with post-traumatic stress disorder (PTSD), it exacerbates PTSD symptoms, and it contributes to impaired functioning and quality of life. To improve treatment outcomes, it is important to identify risk factors for insomnia and sedative-hypnotic use. Classification and regression trees and logistic regression models were used to identify variables associated with insomnia or sedative-hypnotic use. Key findings include low insomnia diagnosis rates (3.5-5.6%) and high rates of sedative-hypnotics (44.2-49.0%). Younger Veterans and those without a breathing-related sleep disorder (BRSD) were more likely to receive an insomnia diagnosis. Veterans with greater service connection and those with an alcohol/substance use disorder were more likely to be prescribed sedative-hypnotics. Interaction terms may have identified potential groups at risk of being under-diagnosed with insomnia (i.e. non-black Veterans with psychiatric co-morbidity, black Veterans without psychiatric co-morbidity) as well as groups at risk for sedative-hypnotic use (i.e. younger Veterans without BRSD). In sum, Veterans with PTSD have high rates of sedative-hypnotic use despite minimal evidence they are effective. This is counter to recommendations indicating behavioral interventions are the first-line treatment. Policy changes are needed to reduce use of sedative-hypnotics and increase access to behavioral insomnia interventions.

Do surgeons and patients discuss what they document on consent forms?

BACKGROUND: Previous studies of surgeon behavior report that surgeons rarely meet basic standards of informed consent, raising concerns that current practice requires urgent remediation. We wondered if the Veterans Affairs Healthcare System's recent implementation of standardized, procedure-specific consent forms might produce a better practice of informed consent than has been reported previously. Our goal was to determine how the discussions shared between surgeons and patients correspond to the VA's standardized consent forms. METHODS: We enrolled a prospective cohort of patients presenting for possible cholecystectomy or inguinal herniorrhaphy and the surgical providers for those patients. Audio recordings captured the clinical encounter(s) culminating in a decision to have surgery. Each patient's informed consent was documented using a standardized, computer-generated form. We abstracted and compared the information documented with the information discussed. RESULTS: Of 75 consecutively enrolled patients, 37 eventually decided to have surgery and signed the standardized consent form. Patients and providers discussed 37% (95% confidence interval, 0.07-0.67) and 33% (95% confidence interval, 0.21-0.43) of the information found on the cholecystectomy and herniorrhaphy consent forms, respectively. However, the patient-provider discussions frequently included relevant details nowhere documented on the standardized forms, culminating in discussions that included a median 27.5 information items for cholecystectomy and 20 items for herniorrhaphy. Fully, 80% of cholecystectomy discussions and 76% of herniorrhaphy discussions mentioned at least one risk, benefit or alternative, indication for, and description of the procedure. CONCLUSIONS: The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need.

Willingness and access to joint replacement among African American patients with knee osteoarthritis: a randomized, controlled intervention.

OBJECTIVE: African American patients are significantly less likely to undergo knee replacement for the management of knee osteoarthritis (OA). Racial difference in preference (willingness) has emerged as a key factor. This study was undertaken to examine the efficacy of a patient-centered educational intervention on patient willingness and the likelihood of receiving a referral to an orthopedic clinic. METHODS: A total of 639 African American patients with moderate-to-severe knee OA from 3 Veterans Affairs primary care clinics were enrolled in a randomized, controlled trial with a 2 × 2 factorial design. Patients were shown a knee OA decision-aid video with or without brief counseling. The main outcome measures were change in patient willingness and receipt of a referral to an orthopedic clinic. Also assessed were whether patients discussed knee pain with their primary care provider or saw an orthopedic surgeon within 12 months of the intervention. RESULTS: At baseline, 67% of the participants were definitely/probably willing to consider knee replacement, with no difference among the groups. The intervention increased patient willingness (75%) in all groups at 1 month. For those who received the decision aid intervention alone, the gains were sustained for up to 3 months. By 12 months postintervention, patients who received any intervention were more likely to report engaging their provider in a discussion about knee pain (92% versus 85%), to receive a referral to an orthopedic surgeon (18% versus 13%), and for those with a referral, to attend an orthopedic consult (61% versus 50%). CONCLUSION: An educational intervention significantly increased the willingness of African American patients to consider knee replacement. It also improved the likelihood of patient-provider discussion about knee pain and access to surgical evaluation.

Hospitalized patients' acceptability of nurse-delivered screening, brief intervention, and referral to treatment.

BACKGROUND: Inpatient healthcare providers in the United States may soon be required to offer alcohol screening, brief intervention, and referral to treatment (SBIRT) for hospital accreditation, but little is known about inpatient acceptability for SBIRT, particularly when performed by nonphysician providers such as nurses. The purpose of this study was to assess patient acceptability for and comfort with nurse-delivered SBIRT care among hospitalized patients and to identify factors associated with SBIRT acceptability. METHODS: We conducted a cross-sectional survey of 370 hospitalized medical-surgical patients at a large university-affiliated medical center, which is part of the U.S. Department of Veterans Affairs. RESULTS: Patient acceptability for 8 of 10 individual nurse-delivered SBIRT tasks was >84%. Patients were more accepting of SBIRT tasks if they felt able to determine their alcohol risk, able to reduce alcohol-related health risks, and expressed some degree of concern about their own use of alcohol. Approximately 20% of patients reported some degree of personal discomfort with alcohol-related discussions. Patients who were less comfortable with these discussions had lower perceived ability to reduce alcohol-related health risk, were >60 years old, had a positive AUDIT-C screening, and were of nonblack race. CONCLUSIONS: Among hospitalized patients, patient acceptability for nurse-delivered SBIRT is high, and alcohol-related risk perceptions appear to be important factors associated with acceptability for SBIRT tasks. Providers can proceed with greater confidence in SBIRT-related discussions with most hospitalized patients but may need particular sensitivity and skill addressing alcohol with patient subgroups such as older patients and those with positive alcohol screenings.

The impact of iMedConsent on patient decision-making regarding cholecystectomy and inguinal herniorrhaphy.

BACKGROUND: The Veterans Affairs Healthcare System implemented a computer-based tool (iMedConsent) to improve the quality of informed consent in 2004. The impact of this tool on the process of informed consent remains unknown. Our aim was to determine the impact of iMedConsent on patient information preference, anxiety, trust in the surgeon, ambivalence about the surgical decision, and comprehension of procedure-specific risk, benefits, and alternatives. MATERIALS AND METHODS: We prospectively enrolled a consecutive cohort of patients presenting to a general surgery clinic for possible cholecystectomy or inguinal herniorrhaphy from October 2009 to August 2010. We administered questionnaires before and after the clinic visit. RESULTS: Seventy-five patients completed pre-visit questionnaires. After evaluation by the surgeon, 42 patients were offered surgery and documented their informed consent using iMedConsent, of whom 38 (90%) also completed a post-visit questionnaire. Among the participants who completed both pre- and post-visit questionnaires, participant comprehension of procedure-specific risks benefits and alternatives improved from 50% at baseline to 60% after the clinic visit (P < 0.001). No differences were noted in ambivalence, trust, or anxiety. After the clinic visit, significantly more patients expressed a preference for participating in decision making with their surgeon (98% versus 71%, P = 0.008). However, significantly fewer expressed a preference for knowing all possible details about their illness (25% to 83%, P ≤ 0.001). CONCLUSIONS: The informed consent process using iMedConsent improves patient comprehension of procedure-specific risks, benefits, and alternatives. It also increases patient preferences for participating more actively in the decision-making process. However, the process may provide more detail than patients want regarding their illness.

A pilot study of the nutritional status of opiate-using pregnant women on methadone maintenance therapy.

Pregnant women in methadone maintenance therapy may have poor nutrition during pregnancy. In 2006-2008, methadone-treated pregnant women (n = 22) were recruited at an urban academic medical center and compared with nondrug-using pregnant women (n = 119) at 20-35 weeks' gestation. We measured adiposity using prepregnancy body mass index (BMI), dietary intake using a food frequency questionnaire, and micronutrient and essential fatty acid status using biomarkers. Methadone-treated women had lower BMI, consumed more calories, had lower serum carotenoid concentrations, and higher plasma homocysteine concentrations than controls. The study's limitations and implications for future research are discussed.

Teaching the teachers: faculty preparedness and evaluation of a retreat in screening, brief intervention, and referral to treatment.

Effective clinical faculty are essential for disseminating substance abuse screening, brief intervention, and referral to treatment (SBIRT). The authors developed an 8-hour SBIRT training for internal medicine faculty preceptors. Trainers conducted SBIRT lectures and small-group communication practice sessions. The authors assessed participants' (n = 27) knowledge, skills, and attitudes using an enhanced Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ). Participants self-assessed their changes in SBIRT competence and comfort. Faculty trainees did not feel competent in SBIRT, particularly in intervention and referral to treatment. AAPPQ subscale scores were highest in Role Legitimacy and Motivation and lowest in Role Adequacy and Satisfaction. After training, faculty members reported greater likelihood of performing and teaching SBIRT. In some topic areas, faculty attending an SBIRT training reported limited knowledge and competence for treating drinkers; however, their interest and motivation for doing so was high. Ongoing faculty and organizational development efforts may help close these gaps.

Impact of perceived discrimination in healthcare on patient-provider communication.

BACKGROUND: The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown. OBJECTIVE: To examine association of past perceived discrimination with subsequent patient-provider communication. RESEARCH DESIGN: Observational cross-sectional study. SUBJECTS: African-American (N=100) and white (N=253) patients treated for osteoarthritis by orthopedic surgeons (N=63) in 2 Veterans Affairs facilities. MEASURES: Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes. RESULTS: Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [ß=-0.41, 95% confidence interval (CI)=-0.73 to -0.09] and providers (ß=-0.34, 95% CI=-0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR)=0.19, 95% CI=0.05-0.72] and ease of communication (OR=0.22, 95% CI=0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (ß=-4.18, 95% CI=-7.68 to -0.68), and with low patient ratings of visit informativeness (OR=0.40, 95% CI=0.23-0.71) and ease of communication (OR=0.43, 95% CI=0.20-0.89). Perceived classism yielded similar results. CONCLUSIONS: Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting.

BACKGROUND: The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored. OBJECTIVE: To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment. DESIGN: Prospective, observational study. PARTICIPANTS: African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics. MAIN MEASURES: Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons' notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment. RESULTS: Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26-0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36-1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16-1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21-1.54, P = 0.27). CONCLUSIONS: In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.

Perceived racial discrimination in health care and its association with patients' healthcare experiences: does the measure matter?

OBJECTIVES: Examine whether three measures of perceived racial discrimination in health care detect similar rates of discrimination and show similar associations with patients' healthcare experiences. DESIGN: Cross-sectional observational study involving telephone surveys and medical record reviews. SETTING: Veterans Affairs Pittsburgh Healthcare System. PARTICIPANTS: 50 White and 50 African American veterans with diabetes. MAIN OUTCOME MEASURES: Three types of measures of perceived racial discrimination in health care were compared: single-item and multi-item measures assessing personal experiences of discrimination in healthcare settings, and a measure assessing general racism in the healthcare system. Associations of each measure with patient-reported problems with their medical care and receipt of recommended preventive screenings were also explored. RESULTS: More African American than White veterans reported perceived discrimination on all measures (personal discrimination, single-item: 42% vs 6%, P<.001; personal discrimination, multi-item: 42% vs 18%, P=.01; general racism: 74% vs 40%, P=.001). In the total sample, discrimination was more likely to be reported on the general racism measure than on the single-item (OR=36.53, 95% CI=7.95-167.89) or multi-item measures (OR=20.28, 95% CI=5.12-80.34) of personal discrimination. The multi-item measure of personal discrimination (OR=3.96, 95% CI=1.29-12.18) and general racism measure (OR=3.61, 95% CI=1.34-9.71) were significantly associated with patient-reported problems with their care. Receipt of recommended screenings was not associated with any of the discrimination measures. CONCLUSIONS: Different measures of perceived racial discrimination in healthcare settings yield different rates of discrimination and show variable associations with patients' perceptions of care.

Sleep complaints in late pregnancy and the recurrence of postpartum depression.

This study evaluated the relationship between sleep quality in late pregnancy and recurrence of postpartum major depression (PPMD) through 28 weeks postpartum. The Pittsburgh Sleep Quality Index (PSQI) at 36 weeks gestation was assessed in 51 non-depressed women with a history of PPMD; recurrence was determined by the 21-item Hamilton Rating Scale for Depression and the Schedule for Affective Disorders and Schizophrenia. Sleep quality in late pregnancy was not related to recurrence per se, but it was related to timing of recurrence (Kruskal-Wallace = 9.78, p = .008). Rapid recurrence (within 4 weeks post delivery) was preceded by fewer sleep complaints (mean PSQI for early recurrers = 4.8 vs. 7.3 for non-recurrers, p = .09). Recurrence after 4 weeks postpartum was preceded by more sleep complaints in late pregnancy (mean PSQI for late recurrers = 9.9 vs. 7.3 for non-recurrers, p = .02). Sleep quality in late pregnancy may help in identifying women at risk for a PPMD recurrence.

Residents' perceptions of a night float system.

BACKGROUND: A Night Float (NF) system has been implemented by many institutions to address increasing concerns about residents' work hours. The purpose of our study was to examine the perceptions of residents towards a NF system. METHODS: A 115-item questionnaire was developed to assess residents' perceptions of the NF rotation as compared with a regular call month. The categories included patient care, education, medical errors, and overall satisfaction. Internal Medicine housestaff (post-graduate years 1-3) from three hospital settings at the University of Pittsburgh completed the questionnaire. RESULTS: The response rate was 90% (n = 149). Of these, 74 had completed the NF rotation. The housestaff felt that the quality of patient care was improved because of NF (41% agreed and 18% disagreed). A majority also felt that better care was provided by a rested physician in spite of being less familiar with the patient (46% agreed and 21% disagreed). Most felt that there was less emphasis on education (65%) and more emphasis on service (52%) during NF. Overall, the residents felt more rested during their call months (83%) and strongly supported the 80-hour workweek requirement (77%). CONCLUSION: Housestaff felt that the overall quality of patient care was improved by a NF system. The perceived improved quality of care by a rested physician coupled with a perceived decrease in the emphasis on education may have significant implications in housestaff training.

Screening for depression in the postpartum period: a comparison of three instruments.

OBJECTIVES: Postpartum depression, the most prevalent complication of childbirth, is often unrecognized. Our objective was to compare the effectiveness of three screening instruments--Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire (PHQ-9), and the 7-item screen of the Postpartum Depression Screening Scale (PDSS)--for identifying women with postpartum depression in the first 6 months after delivery. METHODS: We administered the three instruments via telephone to women who were > or =18 years and had delivered infants 6-8 weeks earlier. We arranged home interviews to confirm DSM-IV criteria current major depressive disorder (MDD) in women who had an above-threshold score on any of the instruments. For women who screened negative on the 6-8 week call, we repeated the screening at 3 months and 6 months to identify emergent symptoms. The primary outcome measures were the screening scores and DSM-IV diagnoses. RESULTS: Of 135 women reached, 123 (91%) were screened, 29 (24%) had home visits, and 13 (11%) had an MDD within 6 months of delivery. Analyses of the scores at 6-8 weeks postpartum and the DSM-IV diagnoses indicated the EPDS at a cutoff point of > or =10 identified 8 (62%) of cases, the PHQ-9 at a cutoff point of > or =10 identified 4 (31%), and the PDSS 7-item Short Form (PDSS_SF) at a cutoff point of > or =14 identified 12 (92%). However, 15 of 16 (94%) women without current MDD screened positive on the PDSS_SF. The EPDS was significantly more accurate (p = 0.01) than the PDSS_SF and PHQ-9 with the cutoff points used. After correcting for verification bias, we found the EPDS and the PDSS_SF were significantly more accurate than the PHQ-9 (p < 0.03). CONCLUSIONS: Administering the EPDS by phone at 6-8 weeks postpartum is an efficient and accurate way to identify women at high risk for postpartum depression within the first 6 months after delivery.

Randomized Clinical Trial of Standard- Versus High-Calorie Formula for Methadone-Exposed Infants: A Feasibility Study.

BACKGROUND: Newborns who are prenatally exposed to methadone are at risk for neonatal abstinence syndrome and the associated excess weight loss and poor weight gain. This pilot feasibility study aimed to evaluate early caloric enhancement on weight patterns among infants born to women receiving methadone maintenance therapy while pregnant. METHODS: In this double-blind pilot feasibility study, we randomly assigned infants with fetal methadone exposure to 24 or 20 kcal/oz formula from days 3 to 21. Randomization was stratified by any breastfeeding, sex of the infant, and gestational age. Eligible infants were ≥35 weeks' gestation and weighed ≥2200 g. Outcomes were days to weight nadir, maximum percent weight loss, days to birth weight, percentage weight change per day, and feasibility. RESULTS: A total of 49 infants were randomly assigned (22 to standard- and 27 to high-calorie formula); groups had comparable demographic characteristics. Main outcomes comparing standard- to high-calorie formula groups were not significant (days to weight nadir, 5.0 vs 4.4 days; P = .20; maximum percent weight loss, -9.4% vs -8.6%; P = .15; days to birth weight, 14.7 vs 13.6 days; P = .07); however, in longitudinal analyses (days 4 to 21), the high-calorie group had a higher percent weight gained per day compared with the standard-calorie group (P <.001). There were high levels of protocol adherence, and no adverse effects were observed. CONCLUSIONS: Study findings suggest that early initiation of high-calorie formula for infants with prenatal methadone exposure may be beneficial for weight gain; evaluation in a larger study is warranted.

HIV-infected African Americans are willing to participate in HIV treatment trials.

BACKGROUND: Despite the high prevalence rates of HIV infection in the African-American community, African Americans remain underrepresented in HIV treatment trials. OBJECTIVE: (1) To develop a questionnaire that measures attitudes and concerns about HIV treatment trials among HIV-infected African Americans at a university-based clinic. (2) To determine actual participation rates and willingness to participate in future HIV treatment trials among HIV-infected African Americans at a university-based clinic. DESIGN: Questionnaire development and cross-sectional survey. SETTING, PARTICIPANTS, AND MEASUREMENTS: In a sample of 200 HIV-infected African-American adults receiving medical care at the Pittsburgh AIDS Center for Treatment (a university-based ambulatory clinic), we assessed research participation rates and willingness to participate in future HIV treatment trials, trust in the medical profession, sociodemographic characteristics, attitudes, and concerns about HIV treatment trials. MAIN OUTCOME MEASURES: Research participation rates and willingness to participate in future HIV treatment trials. RESULTS: Only 57% of survey respondents had ever been asked to participate in an HIV treatment trial but 86% of those asked said yes. Prior research participation was significantly related to willingness to participate in future HIV treatment trials (P = .001). Contrary to previous studies, neither trust/distrust in the medical profession nor beliefs about the dishonesty of researchers was associated with research participation rates or willingness to participate in future HIV treatment trials. CONCLUSIONS: Having never been asked to participate in research is a major barrier to the participation of HIV-infected African Americans in HIV treatment trials. African Americans who seek medical care for HIV infection should be asked to participate in HIV treatment trials.

Where do people go when they first become homeless? A survey of homeless adults in the USA.

The longer a person is homeless, the more likely he or she is to experience poor health and be placed at higher risk for premature death. This makes interventions early in one's homelessness an important prevention strategy. However, little is known about where someone goes for help when they first become homeless and how well those sites are prepared to address the multitude of issues facing a homeless person. In order to address this question, we conducted a cross-sectional community-based survey in two US cities in 1997 using population proportionate sampling of homeless persons identified at 91 sites to identify 'first-stop' access sites and reasons for seeking help at those sites. A total of 230 persons participated in the face-to-face interview (93% response rate). From a list of 20 possible 'first-stop' sites, 105 (45.7%) reported going to a soup kitchen, 71 (30.9%) went to a welfare office, 64 (27.8%) sought admission to a detoxification centre, 60 (26.1%) met with a homeless outreach team, 57 (24.8%) went to a family member, and 54 (23.5%) went to an emergency room. Individuals with a chronic medical or mental health condition were significantly more likely to access a healthcare site (medical: 62.6% vs. 47.6%, P = 0.02; mental health: 62.4% vs. 38.8%, P < 0.01) or social service agency (medical: 64.0% vs. 43.3%, P = 0.02; mental health: 59.1% vs. 40.7%, P < 0.01). Those persons reporting a need for alcohol treatment were significantly more likely to first go to a healthcare site (46.4% vs. 29.1%, P < 0.01) and those with alcohol abuse/dependence were less likely to seek help from family or friends (66.7% vs. 81.9%, P < 0.01). Most respondents sought assistance for concerns directly associated with an immediate need as opposed to seeking care for issues causing their actual homelessness. These findings suggest the need to expand and integrate the availability of services at 'first-stop' access sites that facilitate early exits from homelessness.

Mood Disorders in Middle-Aged and Older Veterans With Multimorbidity.

OBJECTIVE: This study identified the prevalence of and relationship between mood disorders and multimorbidity in middle-aged and older veterans. METHOD: Cross-sectional data were obtained from veterans who received primary care services at VA Pittsburgh Healthcare System from January 2007 to December 2011 ( n = 34,786). RESULTS: Most veterans had three or more organ systems with chronic disease (95.3%), of which 4.1% had a depressive disorder, 2.5% had an anxiety disorder, and 0.7% had co-occurring depression and anxiety. The odds of having a mood disorder increased with each additional organ system with chronic disease, with odds being the greatest in those with 10 to 13 organ systems with chronic disease. Younger age, female gender, non-married marital status, and having a service connected disability were also significant predictors of having a mood disorder. DISCUSSION: These findings suggest a need to integrate mental health assessment and treatment in chronic health care management for veterans.