Substantial Attrition Research Articles

Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early detection of dementia across a variety of healthcare settings.

The Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) is a structured interview based on informant responses that is used to assess for possible dementia. IQCODE has been used for retrospective or contemporaneous assessment of cognitive decline. There is considerable interest in tests that may identify those at future risk of developing dementia. Assessing a population free of dementia for the prospective development of dementia is an approach often used in studies of dementia biomarkers. In theory, questionnaire-based assessments, such as IQCODE, could be used in a similar way, assessing for dementia that is diagnosed on a later (delayed) assessment. To determine the accuracy of the informant-based questionnaire IQCODE for the early detection of dementia across a variety of health care settings. We searched these sources on 16 January 2016: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE Ovid SP, Embase Ovid SP, PsycINFO Ovid SP, BIOSIS Previews on Thomson Reuters Web of Science, Web of Science Core Collection (includes Conference Proceedings Citation Index) on Thomson Reuters Web of Science, CINAHL EBSCOhost, and LILACS BIREME. We also searched sources specific to diagnostic test accuracy: MEDION (Universities of Maastricht and Leuven); DARE (Database of Abstracts of Reviews of Effects, in the Cochrane Library); HTA Database (Health Technology Assessment Database, in the Cochrane Library), and ARIF (Birmingham University). We checked reference lists of included studies and reviews, used searches of included studies in PubMed to track related articles, and contacted research groups conducting work on IQCODE for dementia diagnosis to try to find additional studies. We developed a sensitive search strategy; search terms were designed to cover key concepts using several different approaches run in parallel, and included terms relating to cognitive tests, cognitive screening, and dementia. We used standardised database subject headings, such as MeSH terms (in MEDLINE) and other standardised headings (controlled vocabulary) in other databases, as appropriate. We selected studies that included a population free from dementia at baseline, who were assessed with the IQCODE and subsequently assessed for the development of dementia over time. The implication was that at the time of testing, the individual had a cognitive problem sufficient to result in an abnormal IQCODE score (defined by the study authors), but not yet meeting dementia diagnostic criteria. We screened all titles generated by the electronic database searches, and reviewed abstracts of all potentially relevant studies. Two assessors independently checked the full papers for eligibility and extracted data. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool, and reported quality using the STARDdem tool. From 85 papers describing IQCODE, we included three papers, representing data from 626 individuals. Of this total, 22% (N = 135/626) were excluded because of prevalent dementia. There was substantial attrition; 47% (N = 295) of the study population received reference standard assessment at first follow-up (three to six months) and 28% (N = 174) received reference standard assessment at final follow-up (one to three years). Prevalence of dementia ranged from 12% to 26% at first follow-up and 16% to 35% at final follow-up. The three studies were considered to be too heterogenous to combine, so we did not perform meta-analyses to describe summary estimates of interest. Included patients were poststroke (two papers) and hip fracture (one paper). The IQCODE was used at three thresholds of positivity (higher than 3.0, higher than 3.12 and higher than 3.3) to predict those at risk of a future diagnosis of dementia. Using a cut-off of 3.0, IQCODE had a sensitivity of 0.75 (95%CI 0.51 to 0.91) and a specificity of 0.46 (95%CI 0.34 to 0.59) at one year following stroke. Using a cut-off of 3.12, the IQCODE had a sensitivity of 0.80 (95%CI 0.44 to 0.97) and specificity of 0.53 (95C%CI 0.41 to 0.65) for the clinical diagnosis of dementia at six months after hip fracture. Using a cut-off of 3.3, the IQCODE had a sensitivity of 0.84 (95%CI 0.68 to 0.94) and a specificity of 0.87 (95%CI 0.76 to 0.94) for the clinical diagnosis of dementia at one year after stroke. In generaI, the IQCODE was sensitive for identification of those who would develop dementia, but lacked specificity. Methods for both excluding prevalent dementia at baseline and assessing for the development of dementia were varied, and had the potential to introduce bias. Included studies were heterogenous, recruited from specialist settings, and had potential biases. The studies identified did not allow us to make specific recommendations on the use of the IQCODE for the future detection of dementia in clinical practice. The included studies highlighted the challenges of delayed verification dementia research, with issues around prevalent dementia assessment, loss to follow-up over time, and test non-completion potentially limiting the studies. Future research should recognise these issues and have explicit protocols for dealing with them.

Five-Year Survival of Transcatheter Aortic Valve Implantation in High-Risk Patients

Although transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic stenosis in high-risk patients in Australia, there is still limited data on long term survival. All patients undergoing TAVI at a single tertiary institution between September 2009 and December 2015 were included. The primary outcome was survival, by linkage of patients with the National Death Index of the Australian Institute of Health and Welfare. Post-procedure data and echocardiographic measurements were retrospectively analysed for all patients. A total of 186 patients were included. It was a high-risk patient population (mean EuroSCORE 31.5±20.5, mean age 83.0±8.2 years). Valve prostheses used were Edwards SAPIEN (ES) (Edwards, Irvine, CA, USA) in 16.1%, Edwards SAPIEN XT (ESXT) in 74.2%, and Medtronic CoreValve (MCV) (Medtronic, Minneapolis, MN, USA) in 9.7%. Median survival time for the entire cohort was 68.2 months (95% Confidence Interval [CI]; Lower Limit [LL] 58.0 months, Upper Limit [UL] not defined). The 2- and 5-year estimates of survival were 85% (LL 80%, UL 90%) and 56% (LL 48%, UL 66%), respectively. There was no statistically significant difference in median survival between the ES and ESXT valves, or implantation approach. Survival was greater in patients with creatinine <200 μmol/L compared to >200 μmol/L (68.8 months [LL 61.4, UL n/a] vs 48.0 months [LL 25.5, UL n/a]). Over the study period, there was a statistically significant trend in increasing mean transvalvular gradient (ES: 1.66 mmHg/yr, p=0.0058; ESXT: 2.50 mmHg/yr, p≤0.001) and maximum velocity (ESXT: 0.16 m/s/yr, p=0.004) and decreasing valve area (ESXT: -0.07 cm2/yr, p<0.001). There was substantial attrition of patient echocardiographic follow-up (number of echocardiograms followed up at 5 years=6, number at risk=41). This study has demonstrated acceptable survival in a high-risk cohort of patients undergoing TAVI, with comparable results to larger international experiences. There was a trend for worsening haemodynamics that needs to be monitored. Future studies need to examine patient quality of life and the performance of newer generation prostheses.

Changes in Body Mass Index Associated with Antiretroviral Regimen Switch Among Treatment-Experienced, Virologically Suppressed People Living with HIV in the United States

With obesity on the rise among people living with HIV (PLWH), there is growing concern that weight gain may result as an undesired effect of antiretroviral therapy (ART). This analysis sought to assess the association between ART regimens and changes in body mass index (BMI) among ART-experienced, virologically suppressed PLWH. ART-experienced, virologically suppressed PLWH ≥18 years of age in the Observational Pharmacoepidemiology Research and Analysis (OPERA) cohort were included for analysis if prescribed a new regimen containing one of the following core agents: dolutegravir (DTG), elvitegravir/cobicistat (EVG/c), raltegravir (RAL), rilpivirine (RPV), or boosted darunavir (bDRV), for the first time between August 1, 2013 and December 31, 2017. Multivariable linear regression was used to assess the association between regimen and mean changes in BMI at 6, 12, and 24 months after switch. In unadjusted analyses, BMI increases ranged from 0.30 kg/m2 (bDRV) to 0.83 kg/m2 (RPV) at 24 months following switch, but gains were observed with every regimen. In adjusted analyses, compared to DTG, only bDRV was associated with a smaller increase in BMI at all time points, while EVG/c and RAL were associated with smaller increases in BMI at 6 months only. Overall, results were consistent in analyses stratified by baseline BMI category. BMI increases were relatively small but followed an upward trend over time in this cohort of treatment-experienced, suppressed PLWH. Gains were attenuated with a longer period of follow-up. BMI gains did not differ by regimens, except for bDRV regimens, which were consistently associated with smaller BMI increases than DTG.

Beyond the \u201cSTEM Pipeline\u201d: Expertise, Careers, and Lifelong Learning

Studies of education and careers in science, technology, engineering, and math (STEM) commonly use a pipeline metaphor to conceptualize forward movement and persistence. However, the “STEM pipeline” carries implicit assumptions regarding length (i.e. that it “starts” and “stops” at specific stages in one’s education or career), contents (i.e. that some occupational fields are “in” the pipeline while others are not), and perceived purpose (i.e. that “leakage,” or leaving STEM, constitutes failure). Using the National Survey of College Graduates, we empirically measure each of these dimensions. First, we show that a majority of STEM workers report skills training throughout their careers, suggesting no clear demarcation between education and work. Second, we show that using on-the-job expertise requirements (rather than occupational titles) paints a very different portrait of the STEM workforce—and persistence in it (where substantial attrition remains evident, especially among women and African Americans). Third, we show that STEM-educated workers are well-prepared for but dissatisfied with non-STEM jobs, complicating our understanding of leaving. Collectively, these results recommend expanded conceptions of STEM education and careers and contribute to studies of science and engineering workforce transitions and diversity.

Kinematic Alignment Technique for TKA on Degenerative Knees with Severe Bone Loss: A Report of 3 Cases

A severely degenerative knee joint with substantial bone attrition poses a significant challenge when performing Total Knee Arthroplasty (TKA) using the Kinematic Alignment (KA) technique. In order to restore the pre-arthritic knee anatomy, the surgeon has the task of estimating quantity and location of bone loss. We present three such cases and describe the key steps to safely perform KATKA in these complex situations.

What can the African diaspora contribute to innovation and knowledge creation? The case study of Zimbabwean innovators

The importance of diaspora and transnational knowledge production, innovation, and development is of growing interest, particularly in the developing world. The phenomenal increase in high human capital migration from poor to rich countries has historically led to what is commonly known as brain drain, which has negatively impacted the capacity of such countries to innovate. Yet more recently the emergence of the phenomenon of transnationalism has demonstrated the potential to transform brain drain into brain circulation, for the mutual benefit of both sending and receiving contexts. This article uses the case of Zimbabwe to explore the role of diasporan professionals, scholars, and entrepreneurs in contributing to knowledge production, innovation, and development initiatives in their countries of origin. Zimbabwe is an example of many African countries that have experienced substantial attrition of highly qualified knowledge workers for various reasons. A qualitative approach, involving interviews and documentary evidence, enabled the researchers to engage with the Zimbabwean diaspora to capture their narratives regarding the challenges and opportunities, which were then used to develop successful transnational knowledge production initiatives.

The effects of financial incentives on diabetes prevention program attendance and weight loss among low-income patients: the We Can Prevent Diabetes cluster-randomized controlled trial

BackgroundPenetration and participation of real life implementation of lifestyle change programs to prevent type 2 diabetes has been challenging. This is particularly so among low income individuals in the United States. The purpose of this study is to examine the effectiveness of financial incentives on attendance and weight loss among Medicaid beneficiaries participating in the 12-month Diabetes Prevention Program (DPP).MethodsThis is a cluster-randomized controlled trial with two financial incentive study arms and an attention control study arm. Medicaid beneficiaries with prediabetes from 13 primary care clinics were randomly assigned to individually earned incentives (IND; 33 groups; n = 309), a hybrid of individual- and group-earned incentives (GRP; 30 groups; n = 259), and an attention control (AC; 30 groups; n = 279). Up to $520 in incentives could be earned for attaining attendance and weight loss goals over 12 months. Outcomes are percent weight loss from baseline, achieving 5% weight loss from baseline, and attending 75% of core and 75% of maintenance DPP sessions. Linear mixed models were used to examine weight change and attendance rates over the 16 weeks and 12 months.ResultsThe percent weight change at 16 weeks for the IND, GRP, and AC participants were similar, at − 2.6, − 3.1%, and − 3.4%, respectively. However, participants achieving 5% weight loss in the IND, GRP, and AC groups was 21.5, 24.0% (GRP vs AC, P < 0.05), and 15.2%. Attendance at 75% of the DPP core sessions was significantly higher among IND (60.8%, P < 0.001) and GRP (64.0%, P < 0.001) participants than among AC (38.6%) participants. Despite substantial attrition over time, attendance at 75% of the DPP maintenance sessions was also significantly higher among IND (23.0%, P < 0.001) and GRP (26.1%, P < 0.001) participants than among AC (11.0%) participants.ConclusionsFinancial incentives can improve the proportion of Medicaid beneficiaries attending the 12-month DPP and achieving at least 5% weight loss.Trial registrationClinicalTrials.govNCT02422420; retrospectively registered April 21, 2015.

Think Before You Administer: Is Routine Benzodiazepine Premedication Before Endoscopy in Adults Necessary?

Think Before You Administer: Is Routine Benzodiazepine Premedication Before Endoscopy in Adults Necessary?

Persistent Challenges in the Hepatitis C Virus Care Continuum for Patients in a Central Texas Public Health System.

BackgroundDirect-acting antiviral treatment regimens cure >95% of chronic hepatitis C virus (HCV) infections, but recent studies indicate that <25% of patients in the United States receive treatment. Patients need to overcome barriers on the steps of the care continuum in order to be prescribed treatment. We aimed to examine the steps of the HCV care continuum up to prescription of HCV therapy among patients receiving care within a large safety net health care system in Houston, Texas.MethodsWe used electronic medical records to identify patients with positive screening tests for HCV antibodies between July 1, 2017, and June 30, 2018, and abstracted data on their advancement through the care continuum for HCV. We used logistic regression to identify factors associated with patient navigation through the continuum.ResultsOf the 2450 patients screening positive for HCV antibodies, 2016 (82.3%) received quantitative RNA testing, of whom 1081 (53.6%) exhibited chronic infection. Providers referred 915 (84.6%) to specialty care for evaluation, 540 of these patients (50.0%) received their specialist evaluation, and 299 (27.7%) received a prescription for treatment. Patients with history of substance use were less likely to be prescribed treatment (adjusted odds ratio, 0.66; 95% CI, 0.49–0.88).ConclusionsWe found substantial attrition at each stage of the HCV care continuum. In particular, history of substance abuse was a predictor of nonprescription. Challenges in the care continuum motivate increased provider education as well as the adoption of recent innovations in patient care.

Indicators of retention in remote digital health studies: a cross-study evaluation of 100,000 participants

Digital technologies such as smartphones are transforming the way scientists conduct biomedical research. Several remotely conducted studies have recruited thousands of participants over a span of a few months allowing researchers to collect real-world data at scale and at a fraction of the cost of traditional research. Unfortunately, remote studies have been hampered by substantial participant attrition, calling into question the representativeness of the collected data including generalizability of outcomes. We report the findings regarding recruitment and retention from eight remote digital health studies conducted between 2014–2019 that provided individual-level study-app usage data from more than 100,000 participants completing nearly 3.5 million remote health evaluations over cumulative participation of 850,000 days. Median participant retention across eight studies varied widely from 2–26 days (median across all studies = 5.5 days). Survival analysis revealed several factors significantly associated with increase in participant retention time, including (i) referral by a clinician to the study (increase of 40 days in median retention time); (ii) compensation for participation (increase of 22 days, 1 study); (iii) having the clinical condition of interest in the study (increase of 7 days compared with controls); and (iv) older age (increase of 4 days). Additionally, four distinct patterns of daily app usage behavior were identified by unsupervised clustering, which were also associated with participant demographics. Most studies were not able to recruit a sample that was representative of the race/ethnicity or geographical diversity of the US. Together these findings can help inform recruitment and retention strategies to enable equitable participation of populations in future digital health research.

Feasibility and utility of a clinician dashboard from wearable and mobile application Parkinson\u2019s disease data

Mobile and wearable device-captured data have the potential to inform Parkinson’s disease (PD) care. The objective of the Clinician Input Study was to assess the feasibility and clinical utility of data obtained using a mobile health technology from PD patients. In this observational, exploratory study, PD participants wore a smartwatch and used the Fox Wearable Companion mobile phone app to stream movement data and report symptom severity and medication intake for 6 months. Data were analyzed using the Intel® Pharma Analytics Platform. Clinicians reviewed participants’ data in a dashboard during in-office visits at 2 weeks, 1, 3, and 6 months. Clinicians provided feedback in focus groups leading to dashboard updates. Between June and August 2017, 51 PD patients were recruited at four US sites, and 39 (76%) completed the 6-month study. Patients streamed 83,432 h of movement data from their smartwatches (91% of expected). Reporting of symptoms and medication intake using the app was lower than expected, 44% and 60%, respectively, but did not differ according to baseline characteristics. Clinicians’ feedback resulted in ten updates to the dashboard during the study period. Clinicians reported that medications and patient reported outcomes were generally discernable in the dashboard and complementary to clinical assessments. Movement, symptoms, and medication intake data were feasibly translated from the app into a clinician dashboard but there was substantial attrition rate over 6 months. Further enhancements are needed to ensure long-term patient adherence to portable technologies and optimal digital data transfer to clinicians caring for PD patients.

The changing career trajectories of new parents in STEM

The gender imbalance in science, technology, engineering, and math (STEM) fields has remained constant for decades and increases the farther up the STEM career pipeline one looks. Why does the underrepresentation of women endure? This study investigated the role of parenthood as a mechanism of gender-differentiated attrition from STEM employment. Using a nationally representative 8-year longitudinal sample of US STEM professionals, we examined the career trajectories of new parents after the birth or adoption of their first child. We found substantial attrition of new mothers: 43% of women leave full-time STEM employment after their first child. New mothers are more likely than new fathers to leave STEM, to switch to part-time work, and to exit the labor force. These gender differences hold irrespective of variation by discipline, race, and other demographic factors. However, parenthood is not just a "mother's problem"; 23% of new fathers also leave STEM after their first child. Suggesting the difficulty of combining STEM work with caregiving responsibilities generally, new parents are more likely to leave full-time STEM jobs than otherwise similar childless peers and even new parents who remain employed full time are more likely than their childless peers to exit STEM for work elsewhere. These results have implications for policymakers and STEM workforce scholars; whereas parenthood is an important mechanism of women's attrition, both women and men leave at surprisingly high rates after having children. Given that most people become parents during their working lives, STEM fields must do more to retain professionals with children.

Neurodevelopment of children born very preterm and/or with a very low birth weight: 8-Year follow-up of a nutritional RCT

Children born very preterm are at risk for cognitive deficits and motor impairment. Enhanced protein intake immediately after very preterm birth has been associated with favorable growth and improved neurodevelopment. It is unknown whether increased protein intake after discharge from the hospital affects long-term neurodevelopment. The primary objective was to assess neurodevelopment from infancy to 8 years in preterm-born children who received either protein-enriched formula (PDF), standard term formula (TF), or human milk (HM) after discharge. The secondary objective was to assess the correlation between outcomes obtained at 24 months corrected age (CA) and at 8 years. This RCT included 152 children born very preterm (gestational age ≤32 weeks) and/or with a very low birth weight (≤1500g) of whom 102 were randomly assigned to receive PDF (n=54) or TF (n=48) from term age to 6 months CA. A control group of infants fed HM (n=50) was also included. Neurodevelopmental outcomes were assessed at 24 months CA (cognitive and motor functioning; n=123) and at 8 years (estimated Full Scale Intelligence Quotient, visual-motor skills, verbal memory, attention, and motor functioning; n=76). The PDF and TF groups were not significantly different in neurodevelopmental outcomes. The HM group had a better cognitive score compared with the PDF group: at 24 months CA 92.9±12.5 vs. 105.2±18.6, P<0.001 and at 8 years 98.1±11.3 vs. 105.8±9.1, P=0.017 (P=0.002 and P=0.080, respectively, after adjustment for parental educational level). Correlations between outcomes at 24 months CA and 8 years were weak: r=0.35 and r=0.37 for cognitive and motor outcomes, respectively. PDF did not improve long-term neurodevelopmental outcomes as compared with TF. However, these results should be interpreted with caution considering the substantial attrition at follow-up. Furthermore, the correlation between outcomes at different ages was weak, emphasizing the need for long-term follow-up of nutritional intervention studies in preterm-born children.

Randomized Controlled Trial of a Collaborative Care Intervention for Mood Disorders by a National Commercial Health Plan.

Few individuals with mood disorders have access to evidence-based collaborative chronic care models (CCMs) because most patients are seen in small-group practices (<20 providers) with limited capacity to deliver CCMs. In this single-blind randomized controlled trial, we determined whether a CCM delivered nationally in a U.S. health plan improved 12-month outcomes among enrollees with mood disorders compared with usual care. Aetna insurance enrollees (N=238), mostly females (66.1%) with a mean age of 41.1 years, who were recently hospitalized for unipolar major depression or bipolar disorder provided informed consent, completed baseline assessments, and were randomly assigned to usual care or CCM. The CCM included 10 sessions of the Life Goals self-management program and brief contacts by phone by a care manager to determine symptom status. Primary outcomes were changes over 12 months in depression symptoms (nine-item Patient Health Questionnaire [PHQ-9]) and mental health-related quality of life (Short Form-12). Adjusted mean PHQ-9 scores were lower by 2.34 points (95% confidence level [CL]=-4.18 to -0.50, p=0.01), indicating improved symptoms, and adjusted mean SF-12 mental health scores were higher by 3.21 points (CL=-.97 to 7.38, p=0.10), indicating better quality of life, among participants receiving CCM versus usual care. Individuals receiving CCM compared with usual care had improved clinical outcomes, although substantial attrition may limit the impact of health plan-level delivery of CCMs. Further research on the use of health plan-level interventions, such as CCMs, as alternatives to practice-based models is warranted.

Gonadal shield: Is it the Albatross hanging around the neck of developmental dysplasia of the hip research?

PurposeProspective randomized controlled trials and long-term studies are essential future directions for building ­evidence-based practices in developmental dysplasia of the hip (DDH), however, sufficient attrition in data (> 20%) can introduce bias deteriorating research quality. Pelvic radiography is synonymous with DDH assessment and so are ­Gonadal Shield (GS) recommendations with pelvic radiography. ­Nonetheless, losses to diagnostic information and inadequate protection have been increasingly implicated to GS usage, with significantly worse implications in female patients. Understandably for DDH, a disease with 80% female prevalence, the impact of GS usage on quality of radiographs and readability of radiological data may be drastic. This study aims to objectively define the implications of GS recommendations in DDH patients.MethodsPelvis radiographs of all DDH patients under the hip surveillance programme at a tertiary care hospital with a written protocol for GS usage were evaluated. Images were reviewed for gender, GS presence, adequate gonadal protection and obstruction of essential anatomical landmarks for pelvic indices.ResultsIn all, 131 pelvis radiographs with DDH diagnoses (age: 1.25 to 6 years; 107 female, 24 male pelvises) were reviewed. Only 42.67% (56) of pelvis radiographs used GS despite the presence of a clear protocol. Useful anatomical landmarks were obstructed in 58.9% of radiographs with GS present. Lost diagnostic information was more common in female patients than male patients (68.1% versus 11.1%, p < 0.01). GS was ineffective at gonadal protection in 73.2% (41) of the pelvises with worse protection in female patients (78.7% vs 44.4%; p = 0.03).ConclusionsIronically, essential anatomy was obstructed in all the adequately protected female pelvises. Routine GS usage results in substantial attrition of radiographic data in DDH patients.Level of EvidenceIII

Users' Intrinsic Goals Linked to Alcohol Dependence Risk Level and Engagement With a Health Promotion Website (Hello Sunday Morning): Observational Study.

BackgroundHello Sunday Morning (HSM) is a self-guided health promotion website with the aim to improve drinking culture. Members are encouraged to sign up for a 3-month period of alcohol abstention and record and track their progress and goals.ObjectiveThis study used self-determination theory (SDT) to examine the nature of goals subscribed by HSM users to test the extent to which intrinsic goal pursuit was linked to lower alcohol dependency risk and higher engagement with the HSM website.MethodsHSM users (N=2216; 59.75%, 1324/2216, females; aged 18-79 years) completed the World Health Organization’s Alcohol Use Disorders Identification Test (WHO-AUDIT, which measures alcohol dependence risk level) at sign-up and at 4 and 6 months after sign-up. In addition, the website had a goals-subscription feature that allowed participants to share their goals. Two independent raters classified the goals according to a coding system we devised based on SDT, which proposes that intrinsic goals (eg, growth, relationships, community, and health) better promote positive outcomes than extrinsic goals (eg, wealth, fame, and image).ResultsAlthough there was substantial (1016/2216, 45.84%) attrition of HSM users from sign-up to 6 months, the attrition rate could not be attributed to alcohol dependency risk because people in different WHO-AUDIT risk zones were equally likely to be missing at 4 and 6 months after sign-up. The SDT-driven coding of goals yielded the following categories: wealth and image (extrinsic goals); relationships, personal growth, community engagement, and physical health (intrinsic goals); and alcohol use-related goals (which were hard to classify as either extrinsic or intrinsic). Alcohol dependence risk level correlated positively with goals related to money (r=.16), personal growth (r=.17), relationships (r=.10), and alcohol use (r=.25). Website engagement correlated negatively with alcohol dependence risk level (r=.10) and positively with relationship (r=.10) and community goals (r=.12).ConclusionsHSM users with higher alcohol dependence risk tended to engage with the website less, but to the extent that they did, they tended to subscribe to goals related to alcohol use and improving their personal growth, relationships, and finances. In line with SDT, engagement with goals—particularly the intrinsic goals of connecting with close-others and the broader community—related to increased website engagement. Web-based tools intended to promote healthy behaviors in users may be effective in engaging their users if the users’ experience on the website supports the pursuit of intrinsic goals.

Attrition Across the HIV Cascade of Care Among a Diverse Cohort of Women Living With HIV in Canada.

In North America, women have lower engagement across the HIV cascade of care compared with men. Among women living with HIV (WLWH) in Canada, we measured the prevalence and correlates of attrition across cascade stages overall, and by key subpopulations. We analyzed baseline survey data regarding 6 nested stages of the HIV cascade among 1424 WLWH enrolled in the Canadian HIV Sexual and Reproductive Health Cohort Study (CHIWOS), including: linked to care, retained in care, initiated antiretroviral therapy (ART), current ART use, ART adherence (≥90%), and viral suppression (<50 copies/mL). Logistic regression identified factors associated with attrition at each stage. Overall, 98% of WLWH were linked to care; 96% retained; 88% initiated ART; 83% were currently on ART; and, among those on ART, 68% were adherent and 72% were virally suppressed, with substantial variability by subpopulation (49%-84%).The largest attrition occurred between current ART use and adherence (-17%), with the greatest losses among indigenous women (-25%), women who use illicit drugs (-32%), and women incarcerated in the past year (-45%). Substantial attrition also occurred between linkage to care and ART initiation (-11%), with the greatest losses among women 16-29 years (-20%) and with unstable housing (-27%). Factors independently associated with attrition at viral suppression included household annual income, racial discrimination, incarceration history, age, and resilience. Overall, 28% of WLWH were lost across the HIV care cascade, with significant differences by stage, subpopulation, and social inequities. Targeted interventions are needed to improve women's retention across the cascade.

Combining cross-sectoral, prospective data linkage with other data sources to examine health outcomes for socially excluded populations: A case study from Australia

IntroductionStudies of the health of prisoners have proliferated in the past decade. However, relatively few studies have examined health outcomes after release from custody. As such, although &gt;30 million people are released from prison globally each year, the health and health service experiences of this population remain poorly understood.&#x0D; Objectives and ApproachWell-powered longitudinal studies are essential for answering these questions but are expensive and difficult to conduct. Internationally, few such studies have been undertaken, and most suffer from either substantial and biased attrition, or recruitment bias. Cross-sectoral linkage of health and justice data circumvents some of these problems but presents its own ethical and methodological challenges. Large longitudinal studies, combining rich survey and clinical data with prospective data linkage, provide unique opportunities to examine and understand health outcomes for these highly marginalised individuals.&#x0D; ResultsThis presentation will describe the process and challenges of establishing the world’s largest (N=2,702) prospective study of adults released from prison: the Health After Release from Prison (HARP) cohort study. The cohort spans two Australian states and includes 538 women and 1,002 Indigenous Australians. An overview of the data collected through face-to-face surveys, medical record review, and prospective linkage with State-based health and correctional records, national Medicare and pharmaceutical records, and the National Death Index, will be provided. Some examples of how these data have been used to answer novel public health questions will be presented. The strengths and limitations of the cohort, and the applicability of this research design for other inclusion health populations, will be discussed.&#x0D; Conclusion/ImplicationsGiven their extreme vulnerability, understanding the health of people who cycle through prisons is important to addressing health inequalities at the population level. Novel research designs that combine prospective data linkage with other data sources provide new opportunities to examine the health of socially excluded populations.

Does Sample Attrition Affect the Assessment of Frailty Trajectories Among Older Adults? A Joint Model Approach

Background: Frailty constitutes an important risk factor for adverse outcomes among older adults. In longitudinal studies on frailty, selective sample attrition may threaten the validity of results. Objective: To assess the impact of sample attrition on frailty index trajectories and gaps related to socio-economic status (education) therein among older adults in Europe. Methods: A total of 64,143 observations from 21,044 respondents (50+) from the Survey of Health, Ageing and Retirement in Europe across 12 years of follow-up (2004–2015) and subject to substantial sample attrition (59%) were analysed. We compared results of a standard linear mixed model assuming missing at random (MAR) sample attrition with a joint model assuming missing not at random sample attrition. Results: Estimated frailty trajectories of both the mixed and joint models were identical up to an age of 80 years, above which modest underestimation occurred when a standard linear mixed model was used rather than a joint model. The latter effect was larger for men than women. Substantial education-based inequality in frailty continued throughout old age in both the mixed and joint models. Conclusion: Linear mixed models assuming MAR sample attrition provided good estimates of frailty trajectories up until high age. Thus, the validity of existing studies estimating frailty trajectories based on standard linear mixed models seems not threatened by substantial sample attrition.

The Human Immunodeficiency Virus Care Continuum in China: 1985-2015.

Human immunodeficiency virus (HIV) care continuum attrition is a major global public health challenge. Few studies have examined this problem in resource-limited settings. We aimed to assess cumulative, current, and historical achievement along China's HIV continuum of care. A nationwide, serial cross-sectional study of all individuals with HIV infection diagnosed in China between 1 January 1985 and 31 December 2015 was conducted using data from China's HIV/AIDS information systems. Biennial estimates of the number of persons living with HIV were also used. We defined 7 steps in HIV care continuum as infected (estimated), diagnosed, linked, retained, enrolled, receiving antiretroviral therapy (ART), and virally suppressed. Cumulative, 30-year performance, and biennial performance during the most recent 10 years were examined. A total of 573529 persons diagnosed with HIV infection were included. Cumulatively, 94% were linked, 88% were retained, 73% were enrolled, 67% were receiving ART, and 44% were suppressed. Greatest attrition was observed for adolescents, minorities, and those who reported injecting drug use as their route of infection. Improvement was observed from 2005 to 2015. As of the end of 2015, 68% among those infected were diagnosed, 67% among diagnosed were receiving ART, and 65% among those receiving ART were virally suppressed. After adjusting for those without viral load testing, the proportion suppressed increased to 89%. Despite dramatic improvements, China faces serious challenges in achieving the Joint United Nations Programme on HIV/AIDS 90-90-90 targets, because of substantial attrition along its continuum of HIV care.