Mixed-effects Multinomial Regression Research Articles

'I secretly wish...' Caregivers' expression of wish for death of persons with severe dementia.

Qualitative evidence suggests that caregivers may express a wish for death of persons with severe dementia (PwSD). No study has assessed the extent to which it happens, stability of this wish over time and the factors associated with it. We examined caregivers' wish for death of PwSDs overtime and the factors associated with this wish. 215 caregivers of community dwelling PwSDs were surveyed every 4months for 2years. Using the mixed-effects multinomial regression model, we assessed the PwSD and caregiver factors associated with caregivers' wish for PwSDs' death. At baseline, 27% caregivers expressed a wish for PwSDs' life to end sooner. Overall, 43% of the caregivers expressed a wish for PwSDs' death at least once during the study period and 11% expressed it consistently. Caregivers' perception of PwSDs' lower quality of life (RRR: 1.05, 95% CI: 1.00, 1.10), higher functional dependency (RRR: 1.1, 95% CI: 1.01, 1.21), eating difficulty (RRR: 2.25, 95% CI: 1.26, 4.04) and suffering (RRR: 1.92, 95% CI: 1.05, 3.52) were associated with this wish. Caregivers who were emotionally close to PwSDs were less likely (RRR: 0.25, 95% CI: 0.11, 0.55) while those who understood that dementia is a terminal illness were more likely (RRR: 2.01, 95% CI: 1.03, 3.92) to express this wish. Caregivers' wish for PwSDs' death changed over time and was primarily driven by their perception of PwSDs' poor well-being and awareness of their illness being terminal, indicating a need for increased support in this challenging caregiving context.

The trifecta of adulthood: Housing, partnering and childbearing trajectories

Substantial changes in residential transitions and family formation patterns have been observed in Western societies, but less attention has been paid to the de-standardisation of adulthood pathways in East Asian contexts, where unique social, economic and cultural circumstances may produce diverse trajectories that are less explored in existing theoretical and empirical frameworks. Adopting a life course perspective, this study identifies the multi-trajectories of housing, partnering and childbearing across adulthood in Taiwan, a setting marked by high housing costs and low fertility rates. Data from the Taiwanese Panel Study of Family Dynamics 2000–2020 (N = 6,931) were used for group-based trajectory modelling, and mixed-effects multinomial regression was employed to examine the likelihood of group membership given early-life resources and social origin. Six common housing–partnering–childbearing trajectories were identified. The most prevalent living arrangement was living in parental homes (50.7%), followed by rental homes (25%), self-owned homes (15.5%) and dorms or other (8.8%). Union formation generally precedes childbearing, whereas housing transitions may occur at various time points. Young adults’ home-leaving and homeownership access appear to be closely related to their parental backgrounds, such as their parents’ educational attainment and occupational status. Overall, the findings are consistent with the de-standardisation of pathways to adulthood, demonstrating the diversity in adult trajectories and the lack of a single dominant pattern.

Phonological variation on Twitter: Evidence from letter repetition in three French dialects

AbstractWriting on social media often departs from prescriptive norms through the use of non-standard words, spellings and punctuation. Amongst these traits is the repetition of letters (e.g. <ouiiiii> for oui ‘yes’). In this study, we draw upon a corpus of over 65 million tweets from three dialects of French (Laurentian, Metropolitan and Midi) to test phonological motivations for the choice of repeated letter in a word with repetition. Using mixed-effects multinomial regression, we compare dialectal differences in whether repetition targets final consonants (silent or pronounced), word-final orthographic <e> corresponding to phonological schwa, and prosodically accented penults. We demonstrate that repetition covertly signals phonological properties. We conclude that prosody mediates morphological and phonological effects and that grapheme-to-phoneme correspondences vary between regions, thereby producing phonological patterns that writers likely did not intend to convey at the time of writing. We also propose that orthographic repetition on Twitter has two prosodic sources: the default pitch accent in French (shifted or not) and focus.

Description of collective team behaviours and team performance analysis of elite rugby competition via cooperative network analysis

ABSTRACT This study investigated cooperative passing interactions in elite rugby match play. Associations between team network metrics and match outcomes were also investigated. A cross-sectional approach was adopted, using data from four Australian Super Rugby teams, across five seasons. 44,178 passing actions were included across 321 team-fixture observations. Network metrics were calculated for each positional group within each match, and two statistical models were developed; First: a mixed-effects multinomial regression to identify differences between positional groups; and second: a mixed-effects binomial logistic regression to determine the association between team-level network metrics and match outcomes. Differences were identified between positional groups e.g. Halves had the highest out-degree centrality and betweenness, while Centres had higher eigenvector centrality than all other positions. Within the Forwards pack, the Back Row had greater in-degree, out-degree, and betweenness than the Tight Five. Regarding match outcomes, the model explained only 6.9% of variance, although greater in-degree centralisation (OR = 1.847 [1.241–2.749], p = 0.002) and lower eigenvector centralisation (OR = 0.655 [0.440–0.975]; p = 0.037) were associated with successful outcomes. Cooperative passing networks in rugby union may provide useful information to describe how various positions interact, and some behaviours may contribute towards successful team performance.

Speech production factors and verbal working memory in children and adults with developmental language disorder.

Verbal working memory (VWM) deficits are common in individuals with developmental language disorder (DLD) but are not well understood. This study evaluated how both memory and language production factors influence VWM performance in children and adults with DLD, focusing on the influence of serial position, phonological activation (PA), and lexical frequency. Participants were 30 children with DLD and 26 with typical language (TL), and 21 adults with DLD and 23 with TL. The participants completed a listening span task in which they were asked to recall the final words of sentences in sets of increasing size. Responses (dependent variable) were coded as correct, incorrect, or no response. Final words were coded for frequency, serial position within the set, and PA (number of occurrences of the initial phoneme, vowel, and whole word in the task). These variables, along with age and language status, were entered as predictors in mixed-effects multinomial regression models. Extreme serial position, greater PA, and higher frequency reduced incorrect and no responses. These effects were attenuated for the DLD group, and the effect of greater PA varied with set size. The findings suggest that for individuals with DLD, VWM performance is affected by more limited effective language experience and by the dynamic task demands.

Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study

SummaryTraumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER‐TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed‐effects multinomial regression to quantify the effects on pre‐hospital or in‐hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre‐hospital and 483 (13%) in‐hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre‐hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1–4.3) for pre‐hospital intubation, and 2.7 (95%CI 1.9–3.5) for in‐hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre‐hospital intubation (OR 2.9, 95%CI 1.3–6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between‐centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.

Inattention in boys from low-income backgrounds predicts welfare receipt: a 30-year prospective study.

Childhood disruptive behaviors are highly prevalent and associated with adverse long-term social and economic outcomes. Trajectories of welfare receipt in early adulthood and the association of childhood behaviors with high welfare receipt trajectories have not been examined. Boys (n = 1000) from low socioeconomic backgrounds were assessed by kindergarten teachers for inattention, hyperactivity, aggression, opposition, and prosociality, and prospectively followed up for 30 years. We used group-base trajectory modeling to estimate trajectories of welfare receipt from age 19-36 years using government tax return records, then examined the association between teacher-rated behaviors and trajectory group membership using mixed effects multinomial regression models. Three trajectories of welfare receipt were identified: low (70.8%), declining (19.9%), and chronic (9.3%). The mean annual personal employment earnings (US$) for the three groups at age 35/36 years was $36 500 (s.d. = $24 000), $15 600 (s.d. = $16 275), and $1700 (s.d. = $4800), respectively. Relative to the low welfare receipt group, a unit increase in inattention (mean = 2.64; s.d. = 2.32, range = 0-8) at age 6 was associated with an increased risk of being in the chronic group (relative risk ratio; RRR = 1.16, 95% CI 1.03-1.31) and in the declining group (RRR = 1.13, 95% CI 1.03-1.23), after adjustment for child IQ and family adversity, and independent of other behaviors. Family adversity was more strongly associated with trajectories of welfare receipt than any behavior. Boys from disadvantaged backgrounds exhibiting high inattention in kindergarten are at elevated risk of chronic welfare receipt during adulthood. Screening and support for inattentive behaviors beginning in kindergarten could have long-term social and economic benefits for individuals and society.

Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR).

Shared decision making has been advocated as a means to improve patient-orientation and quality of health care. There is a lack of knowledge on clinical decision making and its relation to outcome in the routine treatment of people with severe mental illness. This study examined preferred and experienced clinical decision making from the perspectives of patients and staff, and how these affect treatment outcome. "Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness" (CEDAR; ISRCTN75841675) is a naturalistic prospective observational study with bimonthly assessments during a 12-month observation period. Between November 2009 and December 2010, adults with severe mental illness were consecutively recruited from caseloads of community mental health services at the six study sites (Ulm, Germany; London, UK; Naples, Italy; Debrecen, Hungary; Aalborg, Denmark; and Zurich, Switzerland). Clinical decision making was assessed using two instruments which both have parallel patient and staff versions: (a) The Clinical Decision Making Style Scale (CDMS) measured preferences for decision making at baseline; and (b) the Clinical Decision Making Involvement and Satisfaction Scale (CDIS) measured involvement and satisfaction with a specific decision at all time points. Primary outcome was patient-rated unmet needs measured with the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Mixed-effects multinomial regression was used to examine differences and course over time in involvement in and satisfaction with actual decision making. The effect of clinical decision making on the primary outcome was examined using hierarchical linear modelling controlling for covariates (study centre, patient age, duration of illness, and diagnosis). Analysis were also controlled for nesting of patients within staff. Of 708 individuals approached, 588 adults with severe mental illness (52% female, mean age=41.7) gave informed consent. Paired staff participants (N=213) were 61.8% female and 46.0 years old on average. Shared decision making was preferred by patients (χ 2=135.08; p<0.001) and staff (χ 2=368.17; p<0.001). Decision making style of staff significantly affected unmet needs over time, with unmet needs decreasing more in patients whose clinicians preferred active to passive (-0.406 unmet needs per two months, p=0.007) or shared (-0.303 unmet needs per two months, p=0.015) decision making. Decision making style of staff is a prime candidate for the development of targeted intervention. If proven effective in future trials, this would pave the ground for a shift from shared to active involvement of patients including changes to professional socialization through training in principles of active decision making.

Patterns of sex and racial/ethnic differences in patient health care experiences in US Veterans Affairs hospitals.

Few studies have assessed sex or racial/ethnic differences in inpatient experiences in the Veterans Affairs (VA) Healthcare System. This study aimed to compare inpatient experiences by sex and race/ethnicity within and between VA hospitals. We used mixed-effects multinomial regression to assess within-facility and between-facility sex and racial/ethnic differences in the 2010 VA Survey of Healthcare Experiences of Patients. 50,471 respondents from 144 VA hospitals (4.5% female; 75.4% non-Hispanic white, 14.7% non-Hispanic black, 5.4% Hispanic, and 4.4% other race/ethnicity). Negative and positive patient-reported experiences in 13 health care domains were included. Adjusted within-facility sex differences indicated that women reported more negative and less positive experiences than men in 4 domains, and less negative and more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics reported less negative and/or more positive experiences than whites within the same facility, although patients at facilities with more black and Hispanic patients reported more negative and less positive experiences overall. There were few and inconsistent within-facility differences between other racial/ethnic patients and whites. Patients at facilities with more other racial/ethnic patients reported slightly less negative and more positive experiences. Male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities. However, less positive experiences are reported by patients overall in hospitals that serve larger populations of women and racial/ethnic minorities.