Clinician Referral Research Articles

Genetic consultation embedded in a gynecologic oncology clinic improves compliance with guideline-based care.

Analyze the impact of embedding genetic counseling services in gynecologic oncology on clinician referral and patient uptake of cancer genetics services. Data were reviewed for a total of 737 newly diagnosed epithelial ovarian cancer patients seen in gynecologic oncology at a large academic medical center including 401 from 11/2011-7/2014 (a time when cancer genetics services were provided as an off-site consultation). These data were compared to data from 8/2014-9/2016 (n=336), when the model changed to the genetics embedded model (GEM), incorporating a cancer genetic counselor on-site in the gynecologic oncology clinic. A statistically significant difference in proportion of patients referred pre- and post-GEM was observed (21% vs. 44%, p<0.0001). Pre-GEM, only 38% of referred patients were actually scheduled for genetics consultation and post-GEM 82% were scheduled (p<0.00001). The difference in the time from referral to scheduling in genetics was also statistically significant (3.92months pre-GEM vs. 0.79months post-GEM, p<0.00001) as was the time from referral to completion of genetics consultation (2.52months pre-GEM vs. 1.67months post-GEM, p<0.01). Twenty-five percent of patients referred post GEM were seen by the genetic counselor on the same day as the referral. Providing cancer genetics services on-site in gynecologic oncology and modifying the process by which patients are referred and scheduled significantly increases referral to cancer genetics and timely completion of genetics consultation, improving compliance with guideline-based care. Practice changes are critical given the impact of genetic test results on treatment and familial cancer risks.

Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test.

It is unclear whether substance use disorder (SUD) treatment is offered to, or utilized by, patients who are discontinued from long-term opioid therapy (LTOT) following aberrant urine drug tests (UDTs). To describe the proportion of patients who were referred to, and engaged in, SUD treatment following LTOT discontinuation and to examine differences in SUD treatment referral and engagement based on the substances that led to discontinuation. From a sample of 600 patients selected from a national cohort of Veterans Health Administration patients who were discontinued from LTOT, we used manual chart review to identify 169 patients who were discontinued because of a UDT that was positive for alcohol, cannabis, or other illicit or non-prescribed controlled substances. We extracted sociodemographic, clinical, and health care utilization data from patients' electronic medical records. Forty-three percent of patients (n=73) received an SUD treatment referral following LTOT discontinuation and 20% (n=34) engaged in a new episode of SUD treatment in the year following discontinuation. Logistic regression models controlling for sociodemographic and clinical variables demonstrated that patients who tested positive for cannabis were less likely than patients who tested positive for non-cannabis substances to receive referrals for SUD treatment (aOR=0.44, 95% CI=0.23-0.84, p=0.01) or engage in SUD treatment (aOR=0.42, 95% CI=0.19-0.94, p=0.04). Conversely, those who tested positive for cocaine were more likely to receive an SUD treatment referral (aOR=3.32, 95% CI=1.57-7.06, p=0.002) and engage in SUD treatment (aOR=2.44, 95% CI=1.00-5.96, p=0.05) compared to those who did not have a cocaine-positive UDT. There may be substance-specific differences in clinician referrals to, and patient engagement in, SUD treatment. This suggests a need for more standardized implementation of clinical guidelines that recommend SUD care, when appropriate, following LTOT discontinuation.

Analysis of Recruitment Strategies: Enrolling Veterans With PTSD Into a Clinical Trial

This analysis evaluated the efficacy of a variety of recruitment methods employed in a medication trial in a veteran population. Recruitment and demographic data were collected over the course of a randomized controlled trial (RCT) assessing the efficacy of an experimental medication for posttraumatic stress disorder (PTSD). Multivariate logistic regression was used to identify demographic and recruitment variables predictive of consenting to participation in the trial. Data were collected for 1,050 potential study participants. As compared with individuals contacted by mail based on chart review, potential participants who were referred by a clinician were 3 times more likely to consent to participate, and individuals who responded to an advertisement were 5 times more likely to consent to participate. Females were more likely to respond to advertisements, whereas males were more likely to be referred. Those who were referred were significantly older than potential participants identified via the directed mailing. Clinician referral was the method most likely to lead to identifying an eligible and willing participant. When designing a recruitment plan for a clinical trial, factors such as the target sample and available staff should be carefully considered.

Feasibility of identifying out of care HIV-positive patients in a hospital setting and enrolling them in a retention intervention

Background: The hospital setting provides an opportunity to re-engage people living with HIV (PLWH) in HIV care. We developed and implemented a protocol to identify PLWH in a hospital setting. The aim of the current study was to report on our strategy to recruit hospitalized HIV patients into an intervention study, and to report on lessons learned for future studies.Methods: Our protocol was developed based on experience of our research staff in recruiting HIV patients as well as clinical input from providers and administrators on delivering care in hospitalized settings. We identified hospitalized PLWH between 2010 and 2013 who were potentially eligible for an intervention study. Patients were identified by review of electronic medical records and clinician referral, followed by in-person screening to confirm eligibility. We examined factors related to identifying and enrolling hospitalized patients, and documented lessons learned.Results: Key strategies included systematic medical record review followed by in-person screening, collaboration with staff, and flexibility in recruitment logistics. We identified 1801 PLWH hospitalized during the 3-year study period. Eighty-four percent (n = 1514) met the met the inclusion criteria based on medical record review. Of these, 48% (n = 733) were ineligible. Among eligible patients, 59% (n = 460) were enrolled. Only 3% (n = 23) of eligible patients declined; 84% (n = 321) were not enrolled because they were discharged before enrollment. Lessons learned included (1) needing to identify patients and deliver the intervention before hospital discharge, (2) limiting the complexity of the intervention, and (3) having research staff available on weekends and after hours.Conclusions: Targeted recruitment of hospitalized populations is a feasible and productive approach for finding and engaging PLWH who are newly diagnosed or out of routine care.

A Clinician Referral and 12-Week Exercise Training Program for Men With Prostate Cancer: Outcomes to 12 Months of the ENGAGE Cluster Randomized Controlled Trial.

The ENGAGE (efficacy of a referral and physical activity program for survivors of prostate cancer) study established that a clinician referral and 12-week exercise training program increased vigorous physical activity at 12 weeks among men with prostate cancer. Here, we report the 6- and 12-month outcomes. In this multicenter cluster randomized controlled trial, we compared a clinician referral and exercise training program to usual care. Discounted gym membership was offered to men in the intervention condition on completion of the 12-week exercise program. Self-reported physical activity at 6 and 12 months was the primary outcome. Quality of life, anxiety, and depressive symptoms were secondary outcomes. A total of 147 men meeting eligibility criteria agreed to participate (54 intervention, 93 control). A positive interaction effect for vigorous physical activity was observed at 6 months, but not 12 months. No significant effects for the secondary outcomes were found. A clinician referral and community-based supervised and unsupervised exercise training program, along with discounted gym membership, had a positive short-term effect on vigorous physical activity levels, but did not improve quality of life, in men with prostate cancer.

Recruitment methods in a clinical trial of provoked vulvodynia: Predictors of enrollment.

Successful recruitment in clinical trials for chronic pain conditions is challenging, especially in women with provoked vulvodynia due to reluctance in discussing pain associated with sexual intercourse. The most successful recruitment methods and the characteristics of women reached with these methods are unknown. To compare the effectiveness and efficiency of four recruitment methods and to determine socioeconomic predictors for successful enrollment in a National Institutes of Health-sponsored multicenter clinical trial evaluating a gabapentin intervention in women with provoked vulvodynia. Recruitment methods utilized mass mailing, media, clinician referrals and community outreach. Effectiveness (number of participants enrolled) and efficiency (proportion screened who enrolled) were determined. Socioeconomic variables including race, educational level, annual household income, relationship status, age, menopausal status and employment status were also evaluated regarding which recruitment strategies were best at targeting specific cohorts. Of 868 potential study participants, 219 were enrolled. The most effective recruitment method in enrolling participants was mass mailing ( p < 0.001). There were no statistically significant differences in efficiency between recruitment methods ( p = 0.11). Relative to clinician referral, black women were 13 times as likely to be enrolled through mass mailing (adjusted odds ratio 12.5, 95% confidence interval, 3.6-43.1) as white women. There were no differences in enrollment according to educational level, annual income, relationship status, age, menopausal status, or employment status and recruitment method. In this clinical trial, mass mailing was the most effective recruitment method. Race of participants enrolled in a provoked vulvodynia trial was related to the recruitment method.

Associations of objectively measured moderate-to-vigorous physical activity and sedentary behavior with quality of life and psychological well-being in prostate cancer survivors.

PurposeAlthough evidence is building on the positive effects of physical activity for prostate cancer survivors, less is known about the possible independent effects of sedentary behavior on quality of life and psychological well-being in this population. We determined the extent to which objectively measured moderate-to-vigorous physical activity (MVPA) and sedentary behavior were independently associated with quality of life, anxiety, and depressive symptoms in prostate cancer survivors.MethodsAn exploratory cross-sectional analysis was undertaken on baseline data from a multicenter, cluster randomized controlled trial on the efficacy of a clinician referral and 12-week exercise program for men who had completed active treatment for prostate cancer. Multiple regression analyses were performed using data from 98 prostate cancer survivors who wore hip-mounted accelerometers (time spent sedentary defined as <100 counts per minute [CPM]; MVPA defined as >1,951 CPM) and completed self-report instruments on their quality of life, anxiety, and depressive symptoms. Results were compared with minimal clinically important differences for the quality of life scales.ResultsIndependent of sedentary behavior, increases in MVPA of between 15 and 33 min/day were associated with clinically important (but not statistically significant) improvements in three quality of life scales (insomnia, diarrhea, and financial difficulties). Independent of MVPA, decreases in sedentary behavior of 119 and 107 min/day were associated with clinically important (but not statistically significant) improvements in physical functioning and role functioning, respectively.ConclusionWithin our exploratory study, modest increases in MVPA and more substantive decreases in sedentary behavior were independently associated with clinically important improvements in several quality of life scales. Further research, including prospective studies, is required to understand sedentary behavior across larger and more representative samples (in terms of their physical, psychological, and social functioning and their engagement in physical activity) of prostate cancer survivors.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000609055

Fitness outcomes from a randomised controlled trial of exercise training for men with prostate cancer: the ENGAGE study.

PurposeThe main purpose of this study was to investigate the effects of a 12-week, clinician-referred, community-based exercise training program with supervised and unsupervised sessions for men with prostate cancer. The secondary purpose was to determine whether androgen deprivation therapy (ADT) modified responses to exercise training.MethodsSecondary analysis was undertaken on data from a multicentre cluster randomised controlled trial in which 15 clinicians were randomly assigned to refer eligible patients to an exercise training intervention (n = 8) or to provide usual care (n = 7). Data from 119 patients (intervention n = 53, control n = 66) were available for this analysis. Outcome measures included fitness and physical function, anthropometrics, resting heart rate, and blood pressure.ResultsCompared to the control condition, men in the intervention significantly improved their 6-min walk distance (M diff = 49.98 m, p adj = 0.001), leg strength (M diff = 21.82 kg, p adj = 0.001), chest strength (M diff = 6.91 kg, p adj = 0.001), 30-s sit-to-stand result (M diff = 3.38 reps, p adj = 0.001), and reach distance (M diff = 4.8 cm, p adj = 0.024). A significant difference (unadjusted for multiplicity) in favour of men in the intervention was also found for resting heart rate (M diff = −3.76 beats/min, p = 0.034). ADT did not modify responses to exercise training.ConclusionsMen with prostate cancer who act upon clinician referrals to community-based exercise training programs can improve their strength, physical functioning, and, potentially, cardiovascular health, irrespective of whether or not they are treated with ADT.Implications for Cancer SurvivorsClinicians should inform men with prostate cancer about the benefits of exercise and refer them to appropriately qualified exercise practitioners and suitable community-based programs.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000609055

Prevalence of and treatment outcomes for patients with obstructive sleep apnoea identified by preoperative screening compared with clinician referrals.

Obstructive sleep apnoea (OSA) has implications perioperatively. We compared the prevalence of OSA and outcome with continuous positive airway pressure (CPAP) in patients diagnosed through preoperative screening and following referrals from other clinicians.Among 1412 patients (62% males) the prevalence of OSA, Epworth Sleepiness Score (ESS), the number referred for CPAP, and short and longer term use of CPAP were compared between the two groups.The prevalence of OSA was similar (62% versus 58%). There were differences in mean±sd age (61±16 versus 55±13 years; p<0.0001), ESS (11±6 versus 8±5; p<0.0001) and oxygen desaturation index (22±20 versus 19±17; p=0.039). Clinician-referred patients were more likely to be offered CPAP (p<0.0001; OR 2.84). Pre-assessment patients with mild OSA were less likely to continue CPAP long term (p=0.002; OR 6.8). No difference was seen between moderate and severe OSA patients.The prevalence of OSA was similar in both groups but pre-assessment patients were younger and less symptomatic. Preoperative screening of patients is worthwhile, independent of any effect of CPAP upon surgical outcomes; younger and less symptomatic patients are identified earlier. Pre-assessment patients with mild OSA were less likely to use CPAP; this should be considered when offering CPAP to these patients prior to surgery.

Guideline-concordant weight-loss programs in an urban area are uncommon and difficult to identify through the internet.

To determine the reliability of Internet-based information on community-based weight-loss programs and grade their degree of concordance with 2013 American Heart Association, American College of Cardiology, and The Obesity Society weight-management guidelines. An online search was conducted for weight-loss programs in the Maryland-Washington, DC-Virginia corridor. Content analysis was performed to abstract program components from their websites, and then 80 programs were randomly selected for a telephone survey to verify this information. Reliability of Internet information was determined in comparison with telephone interview responses. Of the 191 programs, 1% were graded as high, 8% as moderate, and 91% as low with respect to guideline concordance based on website content. Fifty-two programs participated in the telephone survey (65% response rate). Program intensity, diet, physical activity, and use of behavioral strategies were underreported on websites as compared to description of these activities during the phone interview. Within the subsample, 6% of programs were graded as high based on website information, whereas 19% were graded as high after the telephone interview. Most weight-loss programs in an urban, mid-Atlantic region do not currently offer guideline-concordant practices and fail to disclose key information online, which may make clinician referrals challenging.

Primary brain tumor patients' supportive care needs and multidisciplinary rehabilitation, community and psychosocial support services: awareness, referral and utilization.

Primary brain tumors are associated with significant physical, cognitive and psychosocial changes. Although treatment guidelines recommend offering multidisciplinary rehabilitation and support services to address patients' residual deficits, the extent to which patients access such services is unclear. This study aimed to assess patients' supportive care needs early after diagnosis, and quantify service awareness, referral and utilization. A population-based sample of 40 adults recently diagnosed with primary brain tumors was recruited through the Queensland Cancer Registry, representing 18.9% of the eligible population of 203 patients. Patients or carer proxies completed surveys of supportive care needs at baseline (approximately 3months after diagnosis) and 3months later. Descriptive statistics summarized needs and service utilization, and linear regression identified predictors of service use. Unmet supportive care needs were highest at baseline for all domains, and highest for the physical and psychological needs domains at each time point. At follow-up, participants reported awareness of, referral to, and use of 32 informational, support, health professional or practical services. All or almost all participants were aware of at least one informational (100%), health professional (100%), support (97%) or practical service (94%). Participants were most commonly aware of speech therapists (97%), physiotherapists (94%) and diagnostic information from the internet (88%). Clinician referrals were most commonly made to physiotherapists (53%), speech therapists (50%) and diagnostic information booklets (44%), and accordingly, participants most commonly used physiotherapists (56%), diagnostic information booklets (47%), diagnostic information from the internet (47%), and speech therapists (43%). Comparatively low referral to and use of psychosocial services may limit patients' abilities to cope with their condition and the changes they experience.

A Randomized Controlled Trial of Individual Family Psychoeducational Psychotherapy and Omega-3 Fatty Acids in Youth with Subsyndromal Bipolar Disorder.

This pilot study evaluates efficacy of omega-3 fatty acid supplementation (Ω3), individual family psychoeducational psychotherapy (IF-PEP), and their combination in youth with subsyndromal bipolar disorders (bipolar disorder not otherwise specified [BP-NOS], cyclothymic disorder [CYC]). This study was a 12 week, randomized trial of Ω3 versus placebo and IF-PEP versus active monitoring (AM) using a 2 × 2 design (Ω3 + PEP: n = 5; Ω3 + AM: n = 5; placebo + PEP: n = 7; placebo + AM: n = 6). Twenty-three youth ages 7-14 with BP-NOS or CYC were recruited via community advertisements and clinician referrals. Participants could be taking stable medication for attention-deficit/hyperactivity disorder and sleep aids, but no other psychotropics. Independent evaluators assessed participants at screen, baseline, and 2, 4, 6, 9, and 12 weeks. Primary outcome measures were the Kiddie Schedule for Affective Disorders (K-SADS) Depression (KDRS) and Mania (KMRS) Rating Scales, Children's Depression Rating Scale-Revised (CDRS-R), and Young Mania Rating Scale (YMRS). Ω3/placebo conditions were double-blind; independent evaluators were blind to psychotherapy condition. Most participants (83%) completed the 12 week trial. Side effects were uncommon and mild. Intent-to-treat analyses indicated significant improvement in depressive symptoms (KDRS) for combined treatment relative to placebo and AM (p = 0.01, d = 1.70). Across groups, manic symptoms improved over time without significant treatment effects. Effect of IF-PEP on child depression compared with AM was medium (d = 0.63, CDRS-R) to large (d = 1.24, KDRS). Effect of Ω3 on depression was medium (d = 0.48, KDRS). IF-PEP and Ω3 are well tolerated and associated with improved mood symptoms among youth with BP-NOS and CYC. Clinicaltrials.gov Identifier: NCT01507753.

Influence of clinician referral on Nebraska women’s decision-to-abortion time

ObjectiveTo assess the association of clinician referral with decision-to-abortion time. Study designWe conducted a cross-sectional survey of women seeking abortion at all three Nebraska abortion clinics. We defined referral as direct (information for an abortion clinic), inappropriate (information for a clinic that does not provide abortions) or no referral. Women reported when they recognized their pregnancy, decided to seek abortion and contacted a clinician. The primary outcome — decision-to-abortion time — was time from certain decision to abortion. We used multivariate linear regression analysis, controlling for potential confounders. ResultsParticipants (n=356) were a mean of 26.8±5.3years old, primarily white (62%), unmarried (88%) and urban (87%), with a mean gestational duration of 82/7weeks (S.D.±20days). Forty-six percent (164) had contacted a clinician and 30% (104) had discussed abortion with one before their abortion. Of those, 30% received a direct referral, 6% received an inappropriate referral and 64% received no referral. Decision-to-abortion time did not vary by referral type [mean difference compared with direct referral: inappropriate referral, 1.1days, 95% confidence interval (CI) −13.4 to 15.6, p=.88; no referral, −0.4days, 95% CI −7.0 to 6.3]. The most common reasons cited for delay in obtaining an abortion were an inability to get an earlier appointment (105/263, 40%) and time needed to raise money to pay for the abortion (73/263, 28%). ConclusionWhile neither occurrence of referral nor type was associated with decision-to-abortion times, women in Nebraska continue to face barriers to timely abortion care. ImplicationsAdditional research is needed to explore whether quality clinician referral improves abortion access and whether increased resources should be dedicated to improving referral patterns.

Projection of participant recruitment to primary care research: a qualitative study.

BackgroundRecruitment to clinical trials remains a challenge, particularly in primary care settings. Initial projections of participant recruitment need to be as accurate as possible in order to avoid the financial, clinical and ethical costs of trial extensions or failures. However, estimation of recruitment rates is challenging and often poorly executed, if attempted at all. We used qualitative methods to explore the experiences and views of researchers on the planning of recruitment in this setting.MethodsParticipants had registered accrual to a UK-based primary care research study between April 2009 and March 2012. We conducted nine interviews with chief investigators or study managers, using a semi-structured topic guide. Analysis was conducted using the framework approach.ResultsThree themes are presented: 1) the factors affecting recruitment rates, 2) the use of planning techniques, and 3) influences on poor estimation. 1) A large number of factors affecting recruitment rates were discussed, including those relating to the study protocol, the clinical setting and the research setting. Use of targeted mail-outs to invite apparently eligible individuals to participate was preferred in order to eliminate some of the uncertainty in the recruitment rate associated with opportunistic clinician referrals. 2) The importance of pilot work was stressed. We identified significant uncertainty as to how best to schedule trial timelines to maximise efficiency. 3) Several potential sources of bias involved in the estimation of recruitment rates were explored and framed as technological, psychological or political factors.ConclusionsWe found a large number of factors that interviewees felt impact recruitment rates to primary care research and highlighted the complexity of realistic estimation. Suitable early planning of the recruitment process is essential, and there may be potential to improve the projection of trial timelines by reducing biases involved in the process. Further research is needed to develop formal approaches that would be suitable for use in this setting.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-1002-9) contains supplementary material, which is available to authorized users.

Treatment Recruitment and Retention of Geriatric Participants With Hoarding Disorder

This study describes the initial contact of 255 potential participants, recruitment of 63 participants, and retention of 57 participants from three geriatric Hoarding Disorder (HD) studies. Patients with HD were easily recruited from the community, primarily through the use of clinician referrals and posted flyers, as evidenced by steady patient flow despite lack of compensation for participation. Contrary to treatment outcomes of late life mood and anxiety disorders, geriatric HD patients are largely retained in clinical research treatment studies. Results demonstrate that older adults with HD can be engaged in treatment. Participants often needed the study staff to provide substantial support, including informal motivational interviewing and problem solving, in scheduling and attending the initial visit.

Effects of a clinician referral and exercise program for men who have completed active treatment for prostate cancer: A multicenter cluster randomized controlled trial (ENGAGE).

BACKGROUNDThe purpose of this study was to determine the efficacy of a clinician referral and exercise program in improving exercise levels and quality of life for men with prostate cancer.METHODSThis was a multicenter cluster randomized controlled trial in Melbourne, Australia comprising 15 clinicians: 8 clinicians were randomized to refer eligible participants (n = 54) to a 12-week exercise program comprising 2 supervised gym sessions and 1 home-based session per week, and 7 clinicians were randomized to follow usual care (n = 93). The primary outcome was self-reported physical activity; the secondary outcomes were quality of life, anxiety, and symptoms of depression.RESULTSA significant intervention effect was observed for vigorous-intensity exercise (effect size: Cohen's d, 0.46; 95% confidence interval [CI], 0.09-0.82; P = .010) but not for combined moderate and vigorous exercise levels (effect size: d, 0.08; 95% CI, −0.28 to 0.45; P = .48). Significant intervention effects were also observed for meeting exercise guidelines (≥150 min/wk; odds ratio, 3.9; 95% CI, 1.9-7.8; P = .002); positive intervention effects were observed in the intervention group for cognitive functioning (effect size: d, 0.34; 95% CI, −0.02 to 0.70; P = .06) and depression symptoms (effect size: d, −0.35; 95% CI, −0.71 to 0.02; P = .06). Eighty percent of participants reported that the clinician's referral influenced their decision to participate in the exercise program.CONCLUSIONSThe clinician referral and 12-week exercise program significantly improved vigorous exercise levels and had a positive impact on mental health outcomes for men living with prostate cancer. Further research is needed to determine the sustainability of the exercise program and its generalizability to other cancer populations. Cancer 2015;121:2646–2654. © 2015 American Cancer Society.

Uptake and population-level impact of expedited partner therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: the Washington State community-level randomized trial of EPT.

BackgroundExpedited partner therapy (EPT), the practice of treating the sex partners of persons with sexually transmitted infections without their medical evaluation, increases partner treatment and decreases gonorrhea and chlamydia reinfection rates. We conducted a stepped-wedge, community-level randomized trial to determine whether a public health intervention promoting EPT could increase its use and decrease chlamydia test positivity and gonorrhea incidence in women.Methods and FindingsThe trial randomly assigned local health jurisdictions (LHJs) in Washington State, US, into four study waves. Waves instituted the intervention in randomly assigned order at intervals of 6–8 mo. Of the state’s 25 LHJs, 24 were eligible and 23 participated. Heterosexual individuals with gonorrhea or chlamydial infection were eligible for the intervention. The study made free patient-delivered partner therapy (PDPT) available to clinicians, and provided public health partner services based on clinician referral. The main study outcomes were chlamydia test positivity among women ages 14–25 y in 219 sentinel clinics, and incidence of reported gonorrhea in women, both measured at the community level. Receipt of PDPT from clinicians was evaluated among randomly selected patients. 23 and 22 LHJs provided data on gonorrhea and chlamydia outcomes, respectively. The intervention increased the percentage of persons receiving PDPT from clinicians (from 18% to 34%, p < 0.001) and the percentage receiving partner services (from 25% to 45%, p < 0.001). Chlamydia test positivity and gonorrhea incidence in women decreased over the study period, from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000, respectively. After adjusting for temporal trends, the intervention was associated with an approximately 10% reduction in both chlamydia positivity and gonorrhea incidence, though the confidence bounds on these outcomes both crossed one (chlamydia positivity prevalence ratio = 0.89, 95% CI 0.77–1.04, p = 0.15; gonorrhea incidence rate ratio = 0.91, 95% CI .71–1.16, p = 0.45). Study findings were potentially limited by inadequate statistical power, by the institution of some aspects of the study intervention outside of the research randomization sequence, and by the fact that LHJs did not constitute truly isolated sexual networks.ConclusionsA public health intervention promoting the use of free PDPT substantially increased its use and may have resulted in decreased chlamydial and gonococcal infections at the population level.Trial RegistrationClinicalTrials.gov NCT01665690

Clinician referrals for stress echocardiography: are we compliant with the NICE guidelines?

Accurate diagnosis of stable angina is of paramount importance, and where possible, this should be based on clinical history. In cases of uncertainty, the National Institute for Health and Care Excellence (NICE) provides a framework for assisting diagnosis based on pre-test likelihood (PTL) of coronary artery disease. Functional testing such as stress echocardiography (SE) is recommended as a first-line investigation in patients with PTL of 30–60%. This study evaluated hospital clinicians' adherence to this recommendation. A prospective analysis of patients referred for SE at a district general hospital between March and May 2013 was performed. Data were extracted from an electronic database of SE reports and medical notes. A total of 193 patients were assessed. The most common PTL was 61–90%, accounting for 40% of the cohort. Of them, 14% had a PTL of 30–60%. Of these, 15% had positive SE; 57% described non-anginal pain, as defined by NICE, of whom only nine cases had SE positivity. None of these patients required revascularisation. Findings suggest that SE is being used in a much broader selection group than advocated by NICE. This may often be for its exclusion value rather than to stratify risk. Although utility may be justified in high-risk patients to avoid proceeding directly to invasive angiography, SE appears to add little in those with non-anginal pain and with low PTL. Greater focus should be directed towards characterisation of symptoms, which may negate the need for subsequent investigation.

Acceptance and Compassion-Based Group Therapy to Reduce HIV Stigma

Interventions that target the burden of HIV-related stigma among gay and bisexual men with HIV could yield a broad array of benefits to HIV-positive individuals. In particular, recent research suggests that reducing HIV-related stigma might increase contact with medical professionals, adherence to medication, disclosure to sexual partners, and enhance the ability of persons with HIV to build necessary support networks. In this clinical pilot, we examined the feasibility, acceptability, and usefulness of delivering an HIV-related stigma-reducing group intervention in a community mental health setting to gay and bisexual men living with HIV who are currently connected with care but reporting ongoing difficulties due to HIV-related stigma. The basis of this intervention, acceptance and commitment therapy (ACT), has been found to be effective in reducing the experience of self-stigma among persons with substance abuse histories, and a recent pilot suggests it is helpful for gay and lesbian persons experiencing internalized homophobia. Along with ACT, we have incorporated ideas and exercises from compassion-focused therapy (CFT), an intervention designed to increase compassion while decreasing shame, an affective state close to self-stigma. We hypothesized that this integrated approach would be effective for those experiencing HIV-related stigma. Eight clients currently receiving mental health treatment at the UCSF Alliance Health Project (AHP) Services Center were recruited via clinician referral for an eight-session group, and five completed the group. Follow-up measures of psychological flexibility and HIV-related stigma were completed by three participants, whose data is presented here.

Coping in Parents and Caregivers of Children with Autism Spectrum Disorders (ASD): a Review

Parents and caregivers of children with ASD have reported significant stress and challenges in caregiving. However, stress coping research in parents and caregivers of children remains limited. This review attempted to close this gap. For this review, 37 studies investigating the (1) underlying themes, (2) contributing factors, and (3) psychological outcomes of ASD-related parental and caregiver coping, were selected from the literature. Results revealed that the two most useful coping resources, i.e., problem-focused coping (45.9 %) and social support (37.8 %), were supported by parental stress coping studies. Parents’ and caregivers’ use of coping strategies was also influenced by (1) demographical characteristics (i.e., gender, age, education, income, language) and psychological attributes (i.e., personality, cultural values, optimism, sense of coherence, benefit-finding and sense-making abilities, emotional health, coping styles), (2) child characteristics (i.e., age, gender, medical conditions, cognitive and adaptive functioning abilities, language difficulties, and behavior problems) and (2) situational variables (i.e., treatment availability, family function, and clinician referrals to support resources). Finally, methodological limitations in past studies were discussed. This review emphasized the importance of further examination on the coping mechanisms of parents/caregivers of children with ASD.