Michael R. Hufford

Patient compliance with paper and electronic diaries

Paper diaries are commonly used in health care and clinical research to assess patient experiences. There is concern that patients do not comply with diary protocols, possibly invalidating the benefit of diary data. Compliance with paper diaries was examined with a paper diary and with an electronic diary that incorporated compliance-enhancing features. Participants were chronic pain patients and they were assigned to use either a paper diary instrumented to track diary use or an electronic diary that time-stamped entries. Participants were instructed to make three pain entries per day at predetermined times for 21 consecutive days. Primary outcome measures were reported vs actual compliance with paper diaries and actual compliance with paper diaries (defined by comparing the written times and the electronically-recorded times of diary use). Actual compliance was recorded by the electronic diary. Participants submitted diary cards corresponding to 90% of assigned times (+/-15 min). However, electronic records indicated that actual compliance was only 11%, indicating a high level of faked compliance. On 32% of all study days the paper diary binder was not opened, yet reported compliance for these days exceeded 90%. For the electronic diary, the actual compliance rate was 94%. In summary, participants with chronic pain enrolled in a study for research were not compliant with paper diaries but were compliant with an electronic diary with enhanced compliance features. The findings call into question the use of paper diaries and suggest that electronic diaries with compliance-enhancing features are a more effective way of collecting diary information.

Alcohol and suicidal behavior

Alcohol dependence and alcohol intoxication are important risk factors for suicidal behavior. However, the mechanism for the relationship remains unclear. This review presents a conceptual framework relating alcohol to suicidal behavior. Distal risk factors create a statistical potential for suicide. Alcohol dependence, as well as associated comorbid psychopathology and negative life events, act as distal risk factors for suicidal behavior. Proximal risk factors determine the timing of suicidal behavior by translating the statistical potential of distal risk factors into action. The acute effects of alcohol intoxication act as important proximal risk factors for suicidal behavior among the alcoholic and nonalcoholic alike. Mechanisms responsible for alcohols ability to increase the proximal risk for suicidal behavior include alcohols ability to: (1) increase psychological distress, (2) increase aggressiveness, (3) propel suicidal ideation into action through suicide-specific alcohol expectancies, and (4) constrict cognition which impairs the generation and implementation of alternative coping strategies. Moreover, the proximal risk factors associated with acute intoxication are consistent with Baumeisters (1990) escape theory of suicide. Suggestions for additional research are discussed, including the possibility that a nonlinear cusp catastrophe model characterizes the relationship between alcohol intoxication and suicidal behavior.

Signaling does not adequately improve diary compliance

Hypothesis: Compliance with a paper diary protocol would be improved by using auditory signaling.Background: Prior research has demonstrated that compliance with the reporting schedule in paper diary protocols is poor.Methods: Adults with chronic pain (N = 27) were recruited from the community to participate in a 24-day experience sampling protocol of 3 pain assessments per day (10:00 a.m., 4:00p.m., 8:00p.m.). Diaries were instrumented to record openings and closings, thereby permitting determination of date and time when the participant could have made diary entries. Participants were signaled with a programmed wristwatch at the onset of each 30-min assessment window. Two compliance windows were defined: ± 15 min and ± 45 min of the targeted assessment time.Results: Self-reported compliance based on participants’ paper diaries was 85% and 91% for the 30- and 90-min windows. Verified compliance was 29% and 39% for the two windows. Signaling produced a significant increment in verified compliance when compared with an identical trial without signaling. A significant eroding of verified compliance was observed across the 3 weeks of the study.Conclusions: Self-report dating of diary entries may be misleading investigators about compliance with diary protocols. Although auditory signaling enhances compliance, the result is still unsatisfactory.

Nonnormality and Divergence in Posttreatment Alcohol Use: Reexamining the Project MATCH Data “Another Way”

Alcohol lapses are the modal outcome following treatment for alcohol use disorders, yet many alcohol researchers have encountered limited success in the prediction and prevention of relapse. One hypothesis is that lapses are unpredictable, but another possibility is the complexity of the relapse process is not captured by traditional statistical methods. Data from Project Matching Alcohol Treatments to Client Heterogeneity (Project MATCH), a multisite alcohol treatment study, were reanalyzed with 2 statistical methodologies: catastrophe and 2-part growth mixture modeling. Drawing on previous investigations of self-efficacy as a dynamic predictor of relapse, the current study revisits the self-efficacy matching hypothesis, which was not statistically supported in Project MATCH. Results from both the catastrophe and growth mixture analyses demonstrated a dynamic relationship between self-efficacy and drinking outcomes. The growth mixture analyses provided evidence in support of the original matching hypothesis: Individuals with lower self-efficacy who received cognitive behavior therapy drank far less frequently than did those with low self-efficacy who received motivational therapy. These results highlight the dynamical nature of the relapse process and the importance of the use of methodologies that accommodate this complexity when evaluating treatment outcomes.

Assessment Methods for Patient-Reported Outcomes

The methods used to collect information on patient-reported outcomes (PROs) can affect the validity, reliability and sensitivity of the data. This review examines the influence of a variety of methodological issues that occur. In particular, when patients are asked to rely on their memory to aggregate and summarize their experience, a variety of inaccuracies and biases can affect the data. As the extent and magnitude of recall bias have become more well-known, researchers have increasingly turned toward collecting data in the field, closer in time to events and experiences of interest. Diary methods require patients to self-monitor their experiences, disease episodes and healthcare utilization over time. The collection of diary data from patients places a premium on adherence to the data collection protocol. Recent evidence suggests that patients routinely fail to adhere to diary protocols, thus introducing retrospective error and biases into the data. Reasons for patients’ non-adherence to data collection protocols include their desire to appear to be ‘good’ patients which can result in back-filling PRO entries before a site visit, simply forgetting, and data collection methods that fail to help patients be adherent to the data collection protocol. Principles that can be used to enhance patient adherence to PRO data collection methods include good patient training, creating simple and intuitive user interfaces for PRO assessments, and actively driving the protocol by helping patients remember to complete PRO measures as required by the protocol.

Methodological issues affecting the value of patient-reported outcomes data.

The validity and value of patient-reported outcomes data are heavily dependent on the methods used to collect the data. This review examines the impact of a variety of methodological issues on the value of patient-reported outcome data. In particular, when patients are asked to self-monitor their experiences, disease episodes and healthcare utilization over time, a variety of methodological issues must be addressed if the data are to be considered a reliable and valid reflection of their daily lives. Ecological momentary assessment, a set of methods for collecting real-time data from patients in their natural environments, holds considerable promise as a way to enhance the value of certain types of patient-reported outcome data.

Assessing Motivation to Change Among Problem Drinkers with and without Co-occurring Major Depression

Abstract The University of Rhode Island Change Assessment Scale (URICA) is a widely used measure of readiness to change. To evaluate the URICAs ability to discriminate among alcohol abusers with and without co-occurring major depression, the authors administered it to 193 outpatients court-referred for alcohol treatment. Estimates of internal consistency suggest that scoring the URICA using its traditional factors, as well as using the newer Readiness to Change index, produced variable yet adequately reliable scores. Further, the URICA detected statistically significant differences in motivation to change an alcohol problem between an alcohol use disorder group (AD; n = 131) and an alcohol use disorder with co-occurring depression group (AD/D; n = 62) with the AD/D group showing greater readiness to change. For the AD/D group, separate URICAs were given for alcohol use and depressed mood. Confirming previous findings, results suggest the URICA may lack sensitivity to discriminate among two simultaneously occurring psychological disorders.

Development of a Brief Measure of Semantic Priming

Neuropsychologists use a variety of stimuli to investigate semantic memory functioning. Methodological concerns limit interpretation of performance differences between patients and nonpatient controls. The present study describes the development of a brief measure of semantic memory. Results indicate that this measure of semantic priming provides a brief, yet sensitive, measure of semantic memory. It may prove useful for researchers interested in examining semantic memory processes in cognitively impaired individuals.