Early Attrition Research Articles

A staging system to predict prognosis among methadone maintenance patients, based on admission characteristics

As U.S. general internists play an increasing role in providing opioid maintenance therapy in practice offices, they are having to face the challenge of identifying patients who need specialized services especially at the outset of treatment. In methadone maintenance treatment, prognostic studies have failed to find robust predictors on the basis of single predictive variables. We hypothesize that a multivariable staging system will predict treatment outcome more accurately than single variables. We reviewed baseline and treatment data regarding 226 consecutive patients admitted to a methadone maintenance program in New Haven, Connecticut, from January 1, 1993 to March 28, 1994, and followed until December 1, 1996. The staging system was developed from the data on the first 112 patients, confirmed in the remaining 114 patients, and then applied to the entire cohort of 226 patients. Retention was the main outcome measure used in developing the staging system. The staging system was also validated as a predictor of illicit drug use during treatment and adverse discharge. In the staging system one point is scored for each of the following: use of more than two bags of heroin daily, previous prison term, previous period in reform school, and a history of diseases related to substance use, e.g., endocarditis, hepatitis, abscesses, and overdose. The total score classifies patients as Stage I (0 and 1 points), Stage II (2 points), or Stage III (3 and 4 points). This staging system was significantly associated with retention in a proportional‐hazards model, and no other variable added any additional predictive influence. The specific stage was also found to be a significant predictor of adverse discharge. Although additional validation is necessary in other populations, we found the staging system to be a useful and simple way of identify ing patients at risk for early attrition and adverse discharge.

Breastfeeding and employment: an assessment of employer attitudes.

Both research and anecdotal reports suggest that maternal employment is associated with failure to initiate breastfeeding and early breastfeeding attrition. The objective of this study was to describe the experience with and attitudes toward breastfeeding of a sample of employers in a small Midwestern city in the United States. Based on an analysis of 85 mail-out questionnaires, we found that less than half of the employers had personal experience with breastfeeding. A large percentage of the sample, however, indicated that they would be willing to facilitate women who wished to breastfeed or express milk in the workplace. However, these employers also stated that they saw little value to their business of supporting breastfeeding in the work environment. Thus, enhancement of breastfeeding opportunity in the work environment may come as a result of public and employer education but, more likely, will require some type of directive from official sources.

Depressive Symptomatology and Early Attrition from Intensive Outpatient Substance Use Treatment

Depressive Symptomatology and Early Attrition from Intensive Outpatient Substance Use Treatment

Predicting early breastfeeding attrition.

The Breastfeeding Attrition Prediction Tool (BAPT) is based on the theory of planned behavior, which explains behavior as a function of attitudes, subjective norm, and perceived control. The BAPT subscales are positive and negative attitudes toward breastfeeding, family and professional expectations, and perceived ability to be successful. The purpose of this study was to test the reliability and validity of the BAPT among 269 women who planned to breastfeed for at least 8 weeks. Subjects completed the BAPT in the hospital and during a telephone interview at 8 weeks. Based on factor analysis, several items were deleted. Using discriminant function analysis, the modified BAPT was an effective predictor of 78% of women who stopped breastfeeding before 8 weeks and 68% of those who were still breastfeeding. There is potential for the modified BAPT to be an adjunct for the clinician in identifying women at risk for early cessation of breastfeeding.

The Asthma Accession Standard: A Survival Analysis of Military Recruits, 1995 to 1997

Asthma has a significant impact on U.S. military expenditures and readiness. Every year approximately 1,000 recruits are discharged for asthma during their first 6 months of service. This study was done to evaluate the practice of allowing some individuals with a history of asthma to enter military service (waiving). A survival analysis was performed to compare length of time until discharge and asthma-related failure for individuals waived for asthma (cases) and individuals not disqualified for asthma (controls). Cases were 587 recruit applicants initially disqualified who received waivers for asthma and accessed in the years 1995 to 1997. Controls were 1,761 matched enlisted recruits starting basic training in those years. No significant differences were found with respect to general attrition. The statistical differences for asthma-related hospitalization or discharge did not translate into practical differences. Waiving for asthma was not a significant occupational liability in terms of asthma-related hospitalization or early military attrition.

Perceptions of pysical education beginning teachers' first year of teaching: are we doing enough to prevent early attrition?

This article examines beginning teachers' perceptions of how their school experiences during their first year of teaching had helped them to develop as teachers. Thirty-three physical education teachers responded to a questionnaire that focused on their school backgrounds, the problems and constraints encountered during the year, factors they saw as important in their development, what they saw as the value of collegial advice, their objectives and strategies, and how they would advise future teachers. There were indications that many had moved beyond the ‘survival’ stage of teaching and were actively developing their pedagogical skills and focusing on pupils' learning outcomes. However, the personal nature of the beginning teachers' experiences (e.g. school placements, personal biographies) suggests that impressions about teaching could range from those of disillusionment to those of optimism, and that the type of support provided in schools would not necessarily underpin their beliefs about teaching or extend them professionally. Although the impact of this first year of teaching on their future careers cannot be assessed at this stage, it would appear that more needs to be done in a structured way to try and address the individualised nature of those experiences, and to build on their early enthusiasm and pedagogical skills if teaching is going to viewed as a long-term commitment.

The Home Instruction Program for Preschool Youngsters (HIPPY)

The Home Instruction Program for Preschool Youngsters (HIPPY) is a two-year home-based early education intervention program designed to help parents with limited formal education prepare their four- and five-year-old children for school. This article begins with a brief overview of the HIPPY program and then presents the findings from a series of interconnected research studies, including a two-site, two-cohort evaluation in New York and Arkansas, a one-site case study, and a three-site qualitative study. With respect to program effectiveness, results varied across the New York and Arkansas sites and across participating cohorts at each site. For Cohort I, children who had been enrolled in HIPPY scored higher than children in the control/comparison groups on measures of cognitive skills (New York), classroom adaptation (New York and Arkansas), and standardized reading (New York); and more children were promoted to first grade (Arkansas). For Cohort II, comparison group children outperformed HIPPY children on school readiness and standardized achievement at posttest (Arkansas). Analyses to account for the differing results between cohorts were inconclusive. Qualitative analyses revealed considerable variation in parent involvement in HIPPY. Program staff identified four patterns of attrition from HIPPY: (1) early attrition within the first month after enrollment, (2) attrition between the program's first and second years, (3) attrition due to changes in the life circumstances of participating families, and (4) attrition due to turnover among the home visitors. Families were more likely to participate in in-home than out-of-home aspects of the program (for example, group meetings), but different family characteristics were associated with participation in the in- and out-of-home aspects of the program. The authors conclude with recommendations for future practice and research.

Strategies for preparing clients for treatment. A review.

Substantial numbers of mental health clients do not return following their initial therapy visits or drop out of treatment prematurely. Two general classes of strategies designed to reduce premature attrition and enhance treatment participation are reviewed. Research on psychotherapy preparatory techniques (role induction, vicarious therapy pretraining, and experiential pretraining) indicates that these educational techniques are effective in reducing early treatment attrition and may be especially effective with populations at high risk for dropout (e.g., lower socioeconomic groups, chronically mentally ill clients, and institutionalized juvenile delinquents). Motivational interviewing, a technique originally developed for clients with alcohol problems, is designed to reduce client ambivalence toward therapy and change and enhance commitment to and motivation for treatment. Research in the alcohol field suggests that a session of pretreatment motivational interviewing enhances treatment outcome. Both motivational interviewing and psychotherapy preparatory techniques are relatively brief and easy to incorporate into existing mental health care.

The effect of patient attrition on estimates of the frequency of dementia following stroke.

Given that prevalence surveys may underestimate the magnitude of the association between an exposure and a disease with high morbidity or mortality, we investigated the effects of patient attrition on estimates of the frequency of dementia following ischemic stroke. We examined 251 patients 3 months after stroke and diagnosed dementia in 66 (26.3%) based on the results of neuropsychological and functional assessments and modified criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Those 251 patients were drawn from a larger cohort of 297 patients, with the majority of the remaining 46 patients being unavailable for assessment due to death, severe stroke, or comorbid medical disorders. Using the coefficients in a logistic model of the clinical determinants of dementia based on the 251 patients who were examined, we calculated the probability of dementia for each of the 46 patients who were not examined. We considered a patient to have dementia when that probability was higher than the mean of the median probabilities of dementia in the groups of patients with and without dementia who completed the examinations. The sensitivity and specificity of our diagnostic method were 75.8% and 72.4%, respectively. We recognized dementia in 21 (45.7%) of the 46 unavailable patients, a significantly higher frequency than among examined patients. Additional analyses determined that the factors that increased the risk of becoming unavailable for follow-up, which included more severe stroke, left and right hemisphere infarct locations, and a history of prior stroke, are similar to the factors that increase the risk of dementia after stroke. Our findings suggest that dementia is differentially associated with early patient attrition, potentially resulting in the underestimation of its frequency and underrecognition of its importance as an outcome of ischemic stroke.

Comparison of the Growth and Fate of Fetal Spinal Iso- and Allografts in the Adult Rat Injured Spinal Cord

Most studies investigating early fetal CNS graft–host interactions and host immune responses have been performed using intracerebral transplantation paradigms. The purpose of this study was to establish the early developmental dynamics of fetal graft integration with the injured host spinal cord and to determine whether fetal allografts in this environment are subject to rejection. ACI rat fetal spinal cord (FSC) tissue was grafted into acute lesion cavities of adult WF rat spinal cords. Graft development and/or rejection was followed from 1 to 45 days posttransplantation with morphometric, histological, and immunocytochemical methods. We determined that all FSC grafts in acute resection lesions of the adult rat spinal cord undergo an early substantial cellular attrition, but following favorable attachment to healthy host tissue margins, they rebound and grow to fill the lesion cavity by approximately 45 days. We also determined that FSC allografts into nonimmunosuppressed adult recipients are consistently rejected, but only after an early period of growth and maturation. The onset of rejection is characterized by extensive cellular infiltration coincidental with graft and host MHC antigen expression. The implications of delayed graft development and graft–host integration are discussed relative to interconnectivity and long-term potential for graft-derived benefits. The observed rejection response was characteristic of first-order allograft rejection and underscores a lack of immunological privilege in the microenvironment of the injured spinal cord.

Some potential contributions of reinforcement and consumer-demand theory to reducing cocaine use

Cocaine abuse remains a daunting United States public health problem. Recreational cocaine use is decreasing, but regular use indicative of dependence is stable or increasing. Treatment interventions are often characterized by high rates of early attrition and continued drug use and involve only a small proportion of cocaine users. Hence, more effective and expanded strategies for motivating individuals to forgo or reduce cocaine use are needed. This commentary has a two-part purpose: (a) to underscore the fundamental role of reinforcement in the genesis and maintenance of cocaine use and (b) to illustrate how that knowledge in combination with consumer-demand theory might be translated into effective strategies for reducing cocaine use.

A 50-year prospective study of the psychological sequelae of World War II combat

The authors took advantage of a 50-year prospective study of World War II veterans to examine the predictors and correlates of combat exposure, symptoms of posttraumatic stress disorder (PTSD), and trait neuroticism. The subjects were 107 veterans who had been extensively studied before and immediately after serving overseas in World War II. All served as members of the study until the present time, and 91 completed questionnaires of both PTSD symptoms and neuroticism. In this study group, variables associated with positive psychosocial health in adolescence and at age 65 predicted combat exposure. Combat exposure and number of physiological symptoms during combat stress--but not during civilian stress--predicted symptoms of PTSD in 1946 and 1988. Combat exposure also predicted early death and study attrition. Psychosocial vulnerability in adolescence and at age 65 and physiological symptoms during civilian stress--but not during combat stress--predicted trait neuroticism at age 65. Combat exposure predicted symptoms of PTSD but not nonspecific measures of psychopathology. Premorbid vulnerability predicted subsequent psychopathology but not symptoms of PTSD.

Coronary artery bypass grafting with the inferior epigastric artery: Midterm clinical and angiographic results

Between December 1988 and September 1993, 157 patients (141 men, 16 women, average age 60.2 years, range 37 to 78 years) underwent a complete myocardial revascularization with 157 inferior epigastric artery grafts and 285 internal mammary artery grafts (281 in situ, 4 free grafts). A total of 543 distal arterial anastomoses (average 3.4, range two to five per patient) were constructed, 376 with the internal mammary artery and 167 with the inferior epigastric artery. The inferior epigastric artery grafts were anastomosed to two left anterior descending, 5 diagonal, 34 circumflex, and 126 right coronary arteries. The indications for the use of the inferior epigastric artery were the unavailability of conventional conduits in 56 patients and a favorable anatomy or a young age in 101 selected patients. The clinical follow-up averages 31.8 months (range 6 to 62 months). Four patients died early, and there were three perioperative nonfatal myocardial infarctions. Eight patients required early reoperation for thoracic bleeding (2) or drainage of an abdominal parietal collection (6). There were four late deaths (2 sudden deaths, 2 noncardiac causes) and one nonfatal myocardial infarction. Angina recurred in nine patients, of whom one required reoperation and three underwent successful percutaneous balloon angioplasty of a native coronary artery (2) or an old saphenous vein graft (1). An early recatheterization was obtained before discharge (average 11 days) in 135 patients: 132 of 135 inferior epigastric artery grafts were patent. Seventy-seven patients underwent a second angiographic restudy 6 to 43 months after the operation. Forty-four of the 48 inferior epigastric artery grafts restudied within the first postoperative year (average 8.5 months) were patent, but eight showed a diffuse narrowing. Twenty-eight of the 29 inferior epigastric artery grafts examined angiographically between 13 and 43 months (average 25 months) were open, and among those 29, 25 were widely patent, perfectly matching the receiving coronary artery. Most of the occluded or narrowed inferior epigastric artery grafts were grafted onto coronary arteries with mild stenosis at restudy. Five patients underwent a third angiographic reexamination up to 60 months after the operation (average 39 months). All five inferior epigastric artery grafts were widely patent. The early attrition rate of the inferior epigastric artery, as for any free arterial graft, is probably the result of both the loss of a true pedicle and the need for constructing an additional proximal anastomosis. The fact that the patency rate of the inferior epigastric artery graft seems to remain stable beyond 1 year could suggest a good durability in the future. (J T HORAC C ARDIOVASC S URG 1995; 109: 553-60)

The Endogeneity of Advance Notice and Fear of Destructive Attrition

This study simultaneously estimates the likelihoods that a worker receives advance notice of a plant closing and that a notified worker quits the job before its scheduled end. The author finds that fear of early attrition is a significant determinant of a firm's decision to provide advance notice. Explicit consideration of employer's concerns may significantly improve prediction of advance notice. Copyright 1994 by MIT Press.

Inpatient vs outpatient treatment for substance dependence revisited

Miller and Hester's 1986 review of inpatient versus outpatient alcohol treatment studies concluded with no "justification" for inpatient treatment. Further examination of these studies revealed shortcomings such as the use of random assignment designs which excluded psychiatrically-complicated patients. Carrier Foundation's inpatient/outpatient study of private psychiatric patients with alcohol and/or cocaine dependence includes a patient-treatment matching design to address weaknesses in the existing literature. Patients with high psychiatric severity and/or a poor social support system are predicted to have a better outcome in inpatient treatment, while patients with low psychiatric severity and/or a good social support system may do well as outpatients without incurring the higher costs of inpatient treatment. Preliminary results from 183 inpatients and 120 outpatients indicated outpatients, regardless of level of psychiatric severity, were 4 times more likely to be early treatment failures (chi-square = 41.2, df = 1, p < .01). While the determination of long-term follow-up status of early treatment failures is currently underway, this finding underscores the potential risk of early treatment failure in outpatient compared to inpatient substance abuse treatment programs and the importance of addressing the issue of early attrition in conducting outcome analyses.

Teacher Mentoring and Teacher Retention

Four years after their initial, mentored teaching year, two cohorts of beginning teachers (N= 160) were surveyed to determine whether they had remained in teaching and their retrospective attitudes about mentoring. Approximately 96% of those located were still teaching. Of the different types of support they received from their mentors, they most valued emotional support. It is suggested that teacher mentoring may reduce the early attrition of beginning teachers.

Dropping out of substance abuse treatment: A clinically oriented review

Early attrition from substance abuse treatment is very high, although rates do not differ dramatically from those found in medical and psychiatric treatments. The consequences of substance abuse treatment dropout are severe, however, with early dropouts having the same outcome as untreated clients. Evidence is considered regarding the impact of demographic and social variables on continuation in treatment. The effects of client motivation, substance use, criminality and legal pressure, prior treatment history, and psychopathology are also examined. An analysis of treatment factors and procedures used to enhance retention indicates that more conveniently located, smaller, decentralized clinics, with higher clinical staff ratios and more per capita expenditures, have lower attrition rates. Clients are also likely to continue in treatment longer when they receive rapid initial response and individual attention, and when they are seen in smaller groups in friendly, comfortable environments. Inexpensive techniques such as reminder phone calls and personal letters can be employed in the absence of resources needed to mount more extensive attrition prevention interventions.

Patient Factors Related to Early Attrition from an Outpatient Cocaine Research Clinic: A Preliminary Report

Of 60 cocaine misusers seeking outpatient treatment, 33 (55%) dropped out by 4 weeks. Dropouts were more likely to be male, Black or Hispanic, or with no history of primary depression. Completers were more likely to be White, female, or depressed. The implications of these findings and possible strategies for reducing the dropout rate are discussed.

“Hello, May We Help You?” A Study of Attrition Prevention at the Time of the First Phone Contact with Substance-Abusing Clients

The problem of early attrition from treatment is pervasive throughout community mental health and is particularly high for substance-abusing clients. In spite of the severity of this problem and the potential for successful interventions, there have not been many studies that attempt to reduce the dropout rate of drug abusers. The purpose of this research was to test the effectiveness of attrition prevention procedures at the time of the client's first phone contact with the clinic. Callers were either given an appointment or told to come to the clinic the same day. A second variable was the presence or absence of an experimenter-initiated dialogue designed to help subjects predict possible obstacles to attendance and to generate potential solutions to those barriers. Subjects in the same day conditions showed at a higher rate than those given appointments, but the addition of the dialogue had no effect on client behavior. The results are discussed in terms of how mental health professionals can find cost effective interventions that prevent drug abuse treatment dropout.

Prediction of early attrition from couple therapy.

This study explored prediction of early attrition from couple therapy at a community agency. Using 16 therapist-derived predictors of failure to engage in therapy, multiple regression analysis suggested that common-law relationships and low nonmortgage debt predicted dropout among 45 couples. The results are discussed with reference to the literature on early termination.