Large Differences In Estimates Research Articles

Geospatial Food Environment Exposure and Obesity among Low Income Baltimore City Children: Associations Differ by Data Source and Processing Method

ABSTRACT Due to the high prevalence of childhood obesity, it is imperative to assess the relationship children’s access to food retailers and obesity. However, the influence of methodological decisions on these associations has been understudied. We examined relationships between different measures of geospatial food environment (using 4 data sources, and 2 data processing methods), and BMI in a sample of low-income children in Baltimore, Maryland. The choice of data sources and data processing methods produced large differences in estimates of children’s exposures to certain store types, such as supermarket-like stores, but had less impact on associations with BMI z-scores.

Age-Based Anthropometric Cutoffs Provide Inconsistent Estimates of Undernutrition: Findings from a Cross-Sectional Assessment of Late-Adolescent and Young Women in Rural Pakistan.

ABSTRACTAmbiguity around age ranges for adolescence and adulthood can make the application of age-based nutrition cutoffs confusing. We examined how estimates generated using the age-based anthropometric cutoffs for adolescent girls (10 to <19 y) and women of reproductive age (15–49 y) compared between late-adolescent and young women, and determined how application of both cutoffs affected late-adolescents’ estimates. Using cross-sectional data from participants aged 15–23 y in the Pakistan-based Matiari emPowerment and Preconception Supplementation (MaPPS) Trial (n = 25,447), notably large differences in estimates were observed for stunting (30.5% and 7.9% for late-adolescent and young women, respectively; P < 0.001) and thinness (9.3% and 30.8%, respectively; P < 0.001). When both cutoffs were applied to adolescents’ data, estimate differences were maintained. With each year of age, the difference for stunting increased and thinness decreased. Given the discrepancies observed both between and within groups, clarity around application of anthropometric cutoffs for youth (aged 15–24 y) is needed.This trial was registered at clinicaltrials.gov as NCT03287882.

Snow-induced buffering in aerosol–cloud interactions

Abstract. Complex aerosol–cloud–precipitation interactions lead to large differences in estimates of aerosol impacts on climate among general circulation models (GCMs) and satellite retrievals. Typically, precipitating hydrometeors are treated diagnostically in most GCMs, and their radiative effects are ignored. Here, we quantify how the treatment of precipitation influences the simulated effective radiative forcing due to aerosol–cloud interactions (ERFaci) using a state-of-the-art GCM with a two-moment prognostic precipitation scheme that incorporates the radiative effect of precipitating particles, and we investigate how microphysical process representations are related to macroscopic climate effects. Prognostic precipitation substantially weakens the magnitude of ERFaci (by approximately 54 %) compared with the traditional diagnostic scheme, and this is the result of the increased longwave (warming) and weakened shortwave (cooling) components of ERFaci. The former is attributed to additional adjustment processes induced by falling snow, and the latter stems largely from riming of snow by collection of cloud droplets. The significant reduction in ERFaci does not occur without prognostic snow, which contributes mainly by buffering the cloud response to aerosol perturbations through depleting cloud water via collection. Prognostic precipitation also alters the regional pattern of ERFaci, particularly over northern midlatitudes where snow is abundant. The treatment of precipitation is thus a highly influential controlling factor of ERFaci, contributing more than other uncertain “tunable” processes related to aerosol–cloud–precipitation interactions. This change in ERFaci caused by the treatment of precipitation is large enough to explain the existing difference in ERFaci between GCMs and observations.

The effect of fluid compressibility and elastic rock properties on deformation of geothermal reservoirs

A geothermal reservoir deforms when the extraction of pore fluid exceeds reservoir recharge, causing a decrease in pore pressure. The magnitude of this deformation is related to the amount of pore fluid that is extracted. Assuming compressible material properties in a homogeneous reservoir, we derive an expression for the ratio of reservoir volume change per extracted fluid mass. We show that this ratio depends on a number of parameters, notably the compressibilities of reservoir rock and pore fluid. We apply the obtained relationship to three different geothermal areas (Hellisheidi, Reykjanes and The Geysers) to illustrate under which circumstances the relation between reservoir deformation and the amount of extracted fluid is able to help us learn more about reservoir conditions. We find that the fluid compressibility, depending on whether the system is single-phase or two-phase, may explain large differences in estimates of reservoir volume changes per mass of extracted fluid

Evidence of inflated exclusive breastfeeding estimates from a clinical trial in Bangladesh

Suboptimal breastfeeding is a major cause of infant morbidity and mortality across the world. Inconsistent data has hampered quantification of this practice, however, limiting breastfeeding promotion efforts. As part of a clinical trial in Dhaka, Bangladesh, data was collected on breastfeeding patterns among 125 infants. Infants were ages 4 to 12 weeks (mean = 8.05, SD = 2.13) at the time of enrollment, and breastfeeding data were collected at 24 study visits during a twelve-week period. Breastfeeding status was assessed using the WHO-recommended “current status” (24-h recall) method. These data were used to calculate two measures: a longitudinal estimate of exclusive breastfeeding since birth and a simulated cross-sectional prevalence to approximate common data collection methods. Infants were then ranked based on their breastfeeding status at all study visits and grouped into quartiles and compared using hospitalization data recorded for all infants as part of the original study. These data showed large differences in estimates of exclusive breastfeeding behaviors when assessed longitudinally (8.8% exclusive breastfeeding) vs. calculating a cross-sectional prevalence (56.2% exclusive breastfeeding). Additionally, when infants were grouped by quartile of breastfeeding behavior and matched with hospitalization records, it was found that infants in the lowest quartile of breastfeeding behaviors were significantly more likely to be hospitalized than infants in the highest quartile. These results provide further evidence that current breastfeeding epidemiology studies may overestimate rates of exclusive breastfeeding. They also provide further evidence to support the significant infant health benefits from breastfeeding promotion.Trial registration: ClinicalTrials.gov NCT01899378. Registered July 10, 2013.

Estimating the effectiveness of a hospital's interventions in India: impact of the choice of disability weights.

ObjectiveTo calculate the effect of using two different sets of disability weights for estimates of disability-adjusted life-years (DALYs) averted by interventions delivered in one hospital in India.MethodsDALYs averted by surgical and non-surgical interventions were estimated for 3445 patients who were admitted to a 106-bed private hospital in a semi-urban area of northern India in 2012–2013. Disability weights were taken from global burden of disease (GBD) studies. We used the GBD 1990 disability weights and then repeated all of our calculations using the corresponding GBD 2010 weights. DALYs averted were estimated for surgical and non-surgical interventions using disability weight, risk of death and/or disability, and effectiveness of treatment.FindingsThe disability weights assigned in the GBD 1990 study to the sequelae of conditions such as cataract, cancer and injuries were substantially different to those assigned in the GBD 2010 study. These differences in weights led to large differences in estimates of DALYs averted. For all surgical interventions delivered to this patient cohort, 11 517 DALYs were averted if we used the GDB 1990 weights and 9401 DALYs were averted if we used the GDB 2010 disability weights. For non-surgical interventions 5168 DALYs were averted using the GDB 1990 disability weights and 5537 DALYS were averted using the GDB 2010 disability weights.ConclusionEstimates of the effectiveness of hospital interventions depend upon the disability weighting used. Researchers and resource allocators need to be very cautious when comparing results from studies that have used different sets of disability weights.

Confronting Price Endogeneity in a Duration Model of Residential Subdivision Development

Spatial equilibrium in housing markets implies that distant factors are correlated with prices in specific (focal) neighborhoods through market mechanisms. Using this logic, we develop a novel approach for handling price endogeneity in a reduced-form land use model. We combine a control function approach with a duration model of optimal land development to shed light on the role of price and supply-side factors that influence subdivision development at a micro level. We find that failure to control for endogeneity results in large differences in estimates of residential land supply price elasticities. Specifically, we find an elasticity of 2.06 compared to 0.67 in a model that ignores endogeneity.

Incidence rate of community-acquired sepsis among hospitalized acute medical patients-a population-based survey.

Sepsis is a frequent cause of admission, but incidence rates based on administrative data have previously produced large differences in estimates. The aim of the study was to estimate the incidence of community-acquired sepsis based on patients' symptoms and clinical findings at arrival to the hospital. Population-based survey. Medical emergency department from September 1, 2010, to August 31, 2011. All patients were manually reviewed using a structured protocol in order to identify the presence of infection. Vital signs and laboratory values were collected to define the presence of systemic inflammatory response syndrome and organ dysfunction. Incidence rate of sepsis of any severity. Among 8,358 admissions to the medical emergency department, 1,713 patients presented with an incident admission of sepsis of any severity, median age 72 years (5-95%; range, 26-91 yr), 793 (46.3%) were men, 728 (42.5%) presented with a Charlson comorbidity index greater than 2,621 (36.3%) were admitted with sepsis, 1,071 (62.5%) with severe sepsis, and 21 (1.2%) with septic shock. Incidence rate was 731/100,000 person-years at risk (95% CI, 697-767) in patients with sepsis of any severity, 265/100,000 person-years at risk (95% CI, 245-287) in patients with sepsis, 457/100,000 person-years at risk (95% CI, 430-485) in patients with severe sepsis, and 9/100,000 person-years at risk (95% CI, 6-14) in patients with septic shock. Based on symptoms and clinical findings at arrival, incidence rates of patients admitted to a medical emergency department with sepsis and severe sepsis are more frequent than previously reported based on discharge diagnoses.

Large differences in estimates of soil organic carbon turnover in density fractions by using single and repeated radiocarbon inventories

Radiocarbon measurements are frequently used to model the turnover of soil organic carbon (OC) fractions. The assumption of homogeneous turnover in these fractions is typically stated, but consequences of its violation have not been tested. We used samples of a repeated soil inventory of a German beech forest from the litter layer to 50cm depth in 2004 and 2009 to determine the suitability of short-term repeated radiocarbon inventories for estimating the turnover times of OC in soil fractions. Samples from 0–5 and 10–20cm soil depth were density separated into a free light fraction (fLF), an occluded light fraction (oLF), and a heavy, mineral-associated fraction (HF). Samples were analysed for radiocarbon (∆14C), OC, and total nitrogen (TN) contents.Similar portions of OC were stored in the HF, but contributions of fLF and oLF varied between study years, probably due to interannual variations or methodological constraints. Following declining atmospheric CO2–14C, also ∆14C values at 0–5cm depth declined significantly between 2004 and 2009. Exchange of old for new OC was largest in the fLF and smallest in the HF, which confirms slow turnover of OC associated with minerals. Model results revealed that turnover time estimates based on single-pool models were not in agreement with observed changes in any of the fractions, suggesting all of them to be mixtures, to varying degrees, of fast and slow cycling pools. While single-pool models suggest average turnover times of 115years for HF-OC at 0–5cm depth, thus being a stable fraction, fitting a two-pool model to the two-point measurements of radiocarbon suggested the presence of a fast cycling pool of 15–25years of turnover time. It was however only possible to constrain the portion of this fast pool as being between 50 and 85% of total HF-OC. Increasing ∆14C in bulk soil and density fractions between study years at 10–20cm depth suggest that OC enters deeper soil layers with a longer time lag than topsoil layers, e.g., by slow transport, and 5years was not enough to induce significant changes.Even 40years after the bomb peak, radiocarbon time series are still suitable to detect OC fractions of decadal turnover and hint at time lags and translocation processes. Nevertheless, they do not allow for fixing the portions of fast and slow cycling OC in two-pool models and their turnover times.

Interpreting Long-Term Trends in Time Series Intervention Studies of Smoke-Free Legislation and Health

Background: Numerous studies have investigated the impact of smoke-free laws on health outcomes. Large differences in estimates are in part attributable to how the long-term trend is modelled. However, the choice of appropriate trend is not always straightforward. We explore these complexities in an analysis of myocardial infarction (MI) mortality in England before and after the introduction of smoke-free legislation in July 2007. Methods: Weekly rates of MI mortality among men aged 40+ between July 2002 and December 2010 were analysed using quasi-Poisson generalised additive models. We explore two ways of modelling the long-term trend: (1) a parametric approach, where we fix the shape of the trend, and (2) a penalised spline approach, in which we allow the model to decide on the shape of the trend. Results: While both models have similar measures of fit and near identical fitted values, they have different interpretations of the legislation effect. The parametric approach estimates a significant immediate reduction in mortality rate of 13.7% (95% CI: 7.5, 19.5), whereas the penalised spline approach estimates a non-significant reduction of 2% (95% CI:-0.9, 4.8). After considering the implications of the models, evidence from sensitivity analyses and other studies, we conclude that the second model is to be preferred. Conclusions: When there is a strong long-term trend and the intervention of interest also varies over time, it is difficult for models to separate out the two components. Our recommendations will help further studies determine the best way of modelling their data.

Benchmarking the Incidence and Mortality of Severe Sepsis in the United States*

In 1992, the first consensus definition of severe sepsis was published. Subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis produced large differences in estimates. We seek to describe the variations in incidence and mortality of severe sepsis in the United States using four methods of database abstraction. We hypothesized that different methodologies of capturing cases of severe sepsis would result in disparate estimates of incidence and mortality. Using a nationally representative sample, four previously published methods (Angus et al, Martin et al, Dombrovskiy et al, and Wang et al) were used to gather cases of severe sepsis over a 6-year period (2004-2009). In addition, the use of new International Statistical Classification of Diseases, 9th Edition (ICD-9), sepsis codes was compared with previous methods. Annual national incidence and in-hospital mortality of severe sepsis. The average annual incidence varied by as much as 3.5-fold depending on method used and ranged from 894,013 (300/100,000 population) to 3,110,630 (1,031/100,000) using the methods of Dombrovskiy et al and Wang et al, respectively. Average annual increase in the incidence of severe sepsis was similar (13.0% to 13.3%) across all methods. In-hospital mortality ranged from 14.7% to 29.9% using abstraction methods of Wang et al and Dombrovskiy et al. Using all methods, there was a decrease in in-hospital mortality across the 6-year period (35.2% to 25.6% [Dombrovskiy et al] and 17.8% to 12.1% [Wang et al]). Use of ICD-9 sepsis codes more than doubled over the 6-year period (158,722 - 489,632 [995.92 severe sepsis], 131,719 - 303,615 [785.52 septic shock]). There is substantial variability in incidence and mortality of severe sepsis depending on the method of database abstraction used. A uniform, consistent method is needed for use in national registries to facilitate accurate assessment of clinical interventions and outcome comparisons between hospitals and regions.

Real-time Feedback and Electricity Consumption: A Field Experiment Assessing the Potential for Savings and Persistence

Real-time information feedback delivered via technology has been reported to produce up to 20 percent declines in residential energy consumption. There are however large differences in estimates of the effect of real-time feedback technologies on energy use. In this study, we conduct a field experiment to obtain an estimate of the impact of a real-time feedback technology. Access to feedback leads to an average reduction in household electricity consumption of 5.7percent. Significant declines persist for up to four weeks. In examining time of day reduction effects, we find that the largest reductions were observed initially at all times of the day but as time passes, morning and evening intervals show larger reductions. We find no convincing evidence that household characteristics explain heterogeneity in our treatment effects; we examine demographics, housing characteristics and psychological variables.

Modeling the spatial and temporal heterogeneity of deforestation‐driven carbon emissions: the INPE‐EM framework applied to the Brazilian Amazon

AbstractWe present a generic spatially explicit modeling framework to estimate carbon emissions from deforestation (INPE‐EM). The framework incorporates the temporal dynamics related to the deforestation process and accounts for the biophysical and socioeconomic heterogeneity of the region under study. We build an emission model for the Brazilian Amazon combining annual maps of new clearings, four maps of biomass, and a set of alternative parameters based on the recent literature. The most important results are as follows: (a) Using different biomass maps leads to large differences in estimates of emission; for the entire region of the Brazilian Amazon in the last decade, emission estimates of primary forest deforestation range from 0.21 to 0.26 Pg C yr−1. (b) Secondary vegetation growth presents a small impact on emission balance because of the short duration of secondary vegetation. In average, the balance is only 5% smaller than the primary forest deforestation emissions. (c) Deforestation rates decreased significantly in the Brazilian Amazon in recent years, from 27 Mkm2 in 2004 to 7 Mkm2 in 2010. INPE‐EM process‐based estimates reflect this decrease even though the agricultural frontier is moving to areas of higher biomass. The decrease is slower than a non‐process instantaneous model would estimate as it considers residual emissions (slash, wood products, and secondary vegetation). The average balance, considering all biomass, decreases from 0.28 in 2004 to 0.15 Pg C yr−1 in 2009; the non‐process model estimates a decrease from 0.33 to 0.10 Pg C yr−1. We conclude that the INPE‐EM is a powerful tool for representing deforestation‐driven carbon emissions. Biomass estimates are still the largest source of uncertainty in the effective use of this type of model for informing mechanisms such as REDD+. The results also indicate that efforts to reduce emissions should focus not only on controlling primary forest deforestation but also on creating incentives for the restoration of secondary forests.

Using test station and on-farm data for the genetic evaluation of Piétrain boars used on Landrace sows for growth performance1

The aim of this study was to develop a new genetic evaluation model to estimate the genetic merit of boars for growth based on 1) performance of their crossbred progeny fattened in the test station and 2) their own performance or those of relatives from the on-farm testing system. The model was a bivariate random regression animal model with linear splines and was applied to Piétrain boars from the Walloon Region of Belgium mated with Landrace sows. Data contained 1) 12,610 BW records from the test station collected on 1,435 crossbred pigs from Piétrain boars and Landrace sows, and 2) 52,993 BW records from the on-farm testing system collected on 50,670 pigs with a breed composition of at least 40% Piétrain or Landrace. Since 2007, 56 Piétrain boars have been tested in the station. Data used to estimate variance components and breeding values were standardized for the age to take into account heterogeneity of variances and then pre-adjusted at 210 d of age to put all records on the same scale. Body weight records from the test station and from the on-farm testing system were considered as 2 different traits. The heterosis effect was modeled as fixed regression on the heterozygosity coefficient. As all test station animals were similarly crossbred, smaller variation in heterozygosity caused the sampling error of the regression estimate at 210 d to be larger in the test station than in on-farm data with estimates of 28.35 ± 14.55 kg and 9.02 ± 0.67 kg, respectively. Therefore, the most likely reason for the large differences in estimates was sampling. Heritability estimates ranged from 0.37 to 0.60 at 210 and 75 d, respectively, for test station BW and from 0.42 to 0.60 at 210 d and 175 d, respectively, for on-farm BW. Genetic correlation decreased when the age interval between records increased, and were greater between ages for test station than for on-farm data. Genetic correlations between test station and on-farm BW at the same age were high: 0.90 at 175 d and 0.85 at 210 d. For the 56 boars tested in the station, the average reliability of their EBV for ADG between 100 and 210 d was improved from 0.60 using only test station data to 0.69 using jointly test station and on-farm data. Based on these results, the new model developed was considered as a good method of detection of differences in growth potential of Piétrain boars based on test station and on-farm data.

Red Snapper in the Gulf of Mexico and U.S. South Atlantic: Data, Doubt, and Debate

AbstractStock assessments provide fisheries managers with information that is used in the regulation of a fish stock. Assessments often rely upon a wide array of biological and fisheries data of varying quantity and quality, making the assessment process data hungry, complex, and uncertain. Assessment scientists face the difficulty of estimating numbers of individuals (among other biological benchmarks) of a population of widely distributed, often mobile, fishes for which direct measurement of almost everything is impossible. Consequently, stock assessment scientists are forced to use tools designed to assemble a variety of indirect measures into a statistical model capable of producing predictions to inform fisheries management about stock status and the consequences of past, current and future fishing practices. Despite large differences in estimates of the status of red snapper stocks in the Gulf of Mexico (U.S.) and south Atlantic Ocean (U.S.), and the management conclusions and decision drawn from these assessments, there are more similarities than differences in the basic data being used to inform assessment models, as well as in model outcomes concerning trends in biomass, catch‐at‐age and stock productivity. There are key differences in some of these data, and in how historical landings and uncertainty is handled in the assessment process, that result in large differences between the two management regions in beliefs about current and future productivity of red snapper stocks, and regulatory measures necessary for reaching management goals.

Linguistic Minorities in a Health Survey

Survey interview languages not only determine who is eligible to participate in certain surveys but may also influence survey estimates. We examined potential biases arising from the exclusion of linguistic minorities using the 2003 California Health Interview Sur vey (CHIS), a multilingual survey. Although 88.3 percent of the inter views were conducted in English, results show that surveys using only English are likely to produce large differences in estimates. When survey interviews are conducted in English and Spanish, the overall difference may disappear, but the survey results for Asians remain unchanged. This implies that surveys conducted only in English may not adequately rep resent the general population and differences in estimates for Asians may exist even if English and Spanish are used.

Calibration of Serum Creatinine in the National Health and Nutrition Examination Surveys (NHANES) 1988-1994, 1999-2004

The calibration of serum creatinine values to standardized creatinine and the commutability of serum creatinine across surveys are essential to the correct use of National Health and Nutrition Examination Survey (NHANES) data for kidney function and for generating estimates of the burden of kidney disease in the United States. Calibration study of serum creatinine in NHANES III (1988-1994) and NHANES 1999-2000, 2001-2002, and 2003-2004 to directly compare creatinine measurements from the original surveys with standard creatinine measured using an assay traceable to known gold-standard methods. We also assessed predictors of differences between methods (potential interferences) in this general population. The NHANES are ongoing cross-sectional surveys of the civilian noninstitutionalized population of the United States. We selected random samples of approximately 200 stored specimens from persons aged 60 years or older from each survey (NHANES III, 1999-2000, 2001-2002, and 2003-2004). Stored serum specimens from the 4 NHANES surveys were analyzed for serum creatinine by using a Roche enzymatic assay implemented at the Cleveland Clinic Research Laboratory (CCRL). The Roche assay is traceable to gold-standard reference methods. The original NHANES serum creatinine values were obtained using the Jaffé method (kinetic alkaline picrate) implemented in several different laboratories. Overall agreement between the original NHANES values (Jaffé method) and CCRL measurements (Roche enzymatic) was high, but substantial biases were observed in NHANES III and 1999-2000. No bias was observed in NHANES 2001-2002 and 2003-2004. Final calibration equations to correct serum creatinine values in the relevant surveys are provided. Assay differences were independent of sex, race/ethnicity, and bilirubin and triglyceride levels, but weakly related to age and glucose concentration. We were not able to examine drift in measurements over time within each survey or directly evaluate freeze-thaw effects. The magnitude of differences in serum creatinine measurements in NHANES III and 1999-2000 from standard creatinine would result in large differences in estimates of kidney function (10% to 20%). Thus, correction of original creatinine values in NHANES III and 1999-2000 is essential, but no correction is needed for NHANES 2001-2002 or 2003-2004.

Steady state assumptions in DALYs: effect on estimates of HIV impact.

OBJECTIVE: The disability adjusted life year (DALY) and the healthy life year (HeaLY) are both composite indicators of disease burden in a population, which combine healthy life lost from mortality...

Dilution of 15N in Dunaliella tertiolecta by uptake of an unidentified compound following nitrate exhaustion

Nitrate (about 20 μM) was added as 15NO 3 to a nitrate-limited continuous culture of Dunaliella tertiolecta at steady-state. Nitrate uptake was then estimated from the decrease in nitrate in the medium, the incorporation of 15N into cells, and the increase in cellular nitrogen. Although the overall nitrogen budget over 5 h was balanced, there were large differences in estimates (up to a factor of five) of nitrate assimilation by the three methods on shorter time scale. After nitrate was exhausted from the medium, cellular nitrogen continued to increase while the 15N content of the particulate matter decreased over the next 1.5 h. This indicated that an unidentified, unlabelled nitrogen form, which was neither nitrite, ammonium nor dissolved free amino acids, was being taken up by the cells, at rates comparable to those of nitrate. This phenomenon leads to an underestimation of new biomass production when assessed through 15N incorporation into cells.

Estimating psychiatric manpower requirements based on patients' needs.

To provide a better understanding of the complexities of estimating psychiatric manpower requirements, the authors describe several approaches to estimation and present a method based on patients' needs. A five-step method for psychiatric manpower estimation is used, with estimates of data pertinent to each step, to calculate the total psychiatric manpower requirements for the United States. The method is also used to estimate the hours of psychiatric service per patient per year that might be available under current psychiatric practice and under a managed care scenario. Depending on assumptions about data at each step in the method, the total psychiatric manpower requirements for the U.S. population range from 2,989 to 358,696 full-time-equivalent psychiatrists. The number of available hours of psychiatric service per patient per year is 14.1 hours under current psychiatric practice and 2.8 hours under the managed care scenario. The key to psychiatric manpower estimation lies in clarifying the assumptions that underlie the specific method used. Even small differences in assumptions mean large differences in estimates. Any credible manpower estimation process must include discussions and negotiations between psychiatrists, other clinicians, administrators, and patients and families to clarify the treatment needs of patients and the roles, responsibilities, and job description of psychiatrists.