Treatment Attrition Research Articles

Cancer care treatment attrition in adults: Measurement approaches and inequities in patient dropout rates – a rapid review

BackgroundCancer treatment attrition refers to the discontinuation of prescribed cancer therapies before completion. It can significantly impact patient outcomes and cancer survival rates making it a critical concern. There is growing evidence on inequalities in cancer care, the avoidable systematic differences in the health of different groups of people. Understanding the extent of treatment attrition, why it happens, for whom, and associated inequalities may improve cancer care delivery and patient outcomes.MethodsA rapid review was conducted to identify existing evidence on measures of cancer treatment attrition, definitions, reasons for attrition and potential inequalities. The review followed a systematic approach but with abbreviated processes to facilitate quicker evidence synthesis. Searches were restricted to MEDLINE and Embase databases from their inception dates to May 7, 2024. Additional searches were performed in PubMed, Google Scholar, and key grey literature from relevant organizations. Inclusion criteria were adults with any type of cancer undergoing treatment, with studies reporting quantitative or qualitative data on treatment attrition conducted outside of clinical trials. Exclusion criteria included studies on children or adolescents, clinical trials, non-English publications, and various non-research article types. Data extraction and quality assessment were performed using standardized tools, and studies were synthesized narratively.ResultsThe search retrieved 1,353 references, with 40 studies meeting inclusion criteria. Most studies were retrospective. Studies covered various cancer types and treatments, reporting measures of attrition and reasons for treatment drop-out. Factors influencing attrition included disease progression, death, clinical deterioration, treatment toxicity, and socioeconomic factors such as lower income or socioeconomic disadvantage.ConclusionsThis review highlights significant variability in how treatment attrition is measured and defined, and suggests potential inequalities in who discontinues treatment. Standardized measures of attrition and data collection on reasons for discontinuation are essential to improve cancer care outcomes and equity. Future research should focus on developing these standardized metrics and exploring interventions targeting identified disparities to support cancer patients to complete treatment and improve outcomes.

Genicular Artery Embolization, Radiofrequency Ablation, and Corticosteroid Therapy for Knee Osteoarthritis: A Cost-Effectiveness Analysis Using Randomized Clinical Trial Data.

Background: Many patients with symptomatic knee osteoarthritis (KOA) are refractory to traditional nonsurgical treatments such as intraarticular corticosteroid (CS) injection but are not yet eligible for or decline surgery. Genicular artery embolization (GAE) and radiofrequency ablation (RFA) are emerging adjunctive or alternative minimally invasive treatments. Objective: To perform a cost-effectiveness analysis (CEA) comparing CS, GAE, and RFA, for treatment of symptomatic KOA using a Markov model based on a de novo network meta-analysis (NMA) of randomized control trials. Methods: CEA was conducted to compare GAE and RFA to CS using a Markov cohort state-transition model from a U.S. Medicare payer's perspective over a 4-year time horizon. The model incorporated each treatment's success and attrition rates, costs, and utility benefit. Utility benefit values were derived at short-term (0.5-3 months) and long-term (6-12 months) posttreatment follow-up from NMA of published RCTs using an outcome of improved knee pain and/or function. Analyses were conducted at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). Sensitivity analyses were performed, including when simulating various cost setting scenarios (i.e., office vs hospital outpatient treatment). Results: RFA demonstrated larger treatment effect than GAE, more pronounced at short-term [standardized mean difference (SMD), -1.6688, 95% CI [-2.7806; -0.5571], p=.003] than long-term (SMD -0.3822, 95% CI [-1.9743; 1.2100], p=.64) follow-up. Across cost setting scenarios, incremental cost-effectiveness ratios relative to CS were $561-1563/QALY for GAE versus $76-429/QALY for RFA (not counting scenarios in which RFA was dominated by CS). GAE demonstrated higher cost-effectiveness probability compared to RFA (41.6-54.8% vs. 18.4-29.2%, respectively). GAE was more cost-effective than RFA when the GAE clinical success rate and post-GAE utility value exceeded 32.1-51.0% and 0.562-0.617, respectively, and when the GAE quarterly attrition rate was less than 8.8-17.4%. RFA was more cost-effective when baseline pre-treatment utility values exceeded 0.695-0.713. Neither GAE costs nor RFA costs were sensitive parameters. Conclusion: Across scenarios, GAE was consistently the most likely cost-effective treatment option compared to RFA and CS, although clinical success rates, attrition rates, and utility values impact its cost-effectiveness. Clinical Impact: GAE is likely to be more cost-effective than RFA or CS for treatment of symptomatic KOA.

Examining Ethnoracial Differences in Retention in Evidence-Based Treatments for Posttraumatic Stress Disorder Secondary to Military Sexual Trauma.

Improving and expanding mental health treatment for Veterans who have experienced military sexual trauma (MST) is currently a top priority in Veterans Healthcare Administration. Many of these Veterans develop posttraumatic stress disorder (PTSD), and there is increasing recognition that diversity is a core treatment consideration for Veterans who have experienced trauma. As such, more information is needed concerning the relationship between trauma-focused treatment attrition and ethnoracial identity in Veterans who have experienced MST. This article presents two studies exploring dropout from a Midwestern Department of Veterans Affairs (VA) PTSD clinic in samples of Veterans who experienced MST. These studies aim to reduce this knowledge gap by contrasting Black and White Veterans' retention in trauma-focused care. In Study 1 (n = 141), we examined ethnoracial differences in dropout in a cohort of treatment-seeking Veterans who experienced MST and engaged in cognitive processing therapy (CPT) in a VA specialty PTSD clinic. In Study 2 (n = 109), we explored the same questions related to treatment attrition in a separate cohort of treatment-seeking Veterans who experienced MST and engaged in prolonged exposure (PE) in a VA specialty PTSD clinic. Results from both studies did not indicate ethnoracial differences in attrition rate (for both total sessions and an 8-week minimally adequate care [MAC] window) across evidence-based PTSD treatment. However, it remains important to consider the impact of racial and cultural factors on retention. Future research should aim to recruit a larger racially and ethnically diverse sample to explore possible varying retention outcomes of CPT and PE for MST-related PTSD.

Exploring the Benefits of Dog-Assisted Therapy for the Treatment of Complex Trauma in Children: A Systematic Review.

The manifestation of complex trauma results from exposure to severe and repetitive stressors occurring within the caregiver system. Frequently associated with child maltreatment, complex trauma can lead to impairments in multiple domains, including attachment, affect and behavioural regulation, and cognition. Treatments, including Trauma-Focused Cognitive Behavioural Therapy, have been shown to be efficacious, but high attrition rates point to the need for complementary methods that boost client retention and treatment efficacy. This systematic review examines whether dog-assisted therapy has beneficial impacts on the treatment of complex trauma and whether it can decrease treatment attrition among children presenting with complex trauma exposure. We followed PRISMA guidelines to locate relevant research reports. Seven published research reports matched the inclusion criteria. Dog-assisted therapy may increase the efficacy of standard interventions for complex trauma, although only one study formally assessed treatment retention. Across most studies, there is an overall lack of detailed information on the nature of therapeutic activities involving the dog and how these activities may complement or enhance therapy as usual. Studies were of varying methodological quality, impacting the reliability of findings. Future studies should aim to better describe and justify dog-assisted therapy techniques and evaluate these in comparison with standard evidence-based approaches to the treatment of childhood complex trauma.

Real-world treatment patterns and outcomes in relapsed/refractory multiple myeloma (1-3 prior lines): Flatiron database

AbstractIn the context of multiple myeloma (MM), early use of the immunomodulatory drug lenalidomide has led to an increased population of patients with lenalidomide-refractory MM in early-line settings, but their outcomes are not well characterized. Herein, we report treatment patterns, survival outcomes, prognostic variables, and attrition rates for patients with proteasome inhibitor–exposed, lenalidomide-refractory MM, treated with 1 to 3 prior lines of therapy (LOT). From 12 767 patients with MM in the Flatiron Health database between January 2016 and April 2022, 1455 met the inclusion criteria. The most common subsequent treatments were triplet combinations (41.6% of patients); daratumumab/pomalidomide/dexamethasone was the most common treatment regimen (13.2%). Median real-world progression-free survival (RW-PFS) and overall survival (OS) were 6.5 months and 44.4 months, respectively. RW-PFS was similar in patients with 1, 2, or 3 prior LOT. International Staging System stage III, Eastern Cooperative Oncology Group performance status of 1, hemoglobin <12 g/dL, high-risk cytogenetics, and refractoriness to anti-CD38 antibody at baseline were associated with worse RW-PFS and OS. Outcomes remained similar for patients who received National Comprehensive Cancer Network–preferred treatments and those who received treatments after 2020. In 561 patients with 1 prior LOT at inclusion, the cumulative attrition rate from LOT 2 to 5 was 85%, which included 25% patients who died and 60% with no further treatment. Patients with lenalidomide-refractory MM who have received 1 to 3 prior LOT have poor outcomes and progress rapidly through available therapies, highlighting the need for more effective treatments early in the disease course, before patients are lost to attrition.

Predictability of buprenorphine-naloxone treatment retention: A multi-site analysis combining electronic health records and machine learning.

Opioid use disorder (OUD) and opioid dependence lead to significant morbidity and mortality, yet treatment retention, crucial for the effectiveness of medications like buprenorphine-naloxone, remains unpredictable. Our objective was to determine the predictability of 6-month retention in buprenorphine-naloxone treatment using electronic health record (EHR) data from diverse clinical settings and to identify key predictors. This retrospective observational study developed and validated machine learning-based clinical risk prediction models using EHR data. Data were sourced from Stanford University's healthcare system and Holmusk's NeuroBlu database, reflecting a wide range of healthcare settings. The study analyzed 1800 Stanford and 7957 NeuroBlu treatment encounters from 2008 to 2023 and from 2003 to 2023, respectively. Predict continuous prescription of buprenorphine-naloxone for at least 6months, without a gap of more than 30 days. The performance of machine learning prediction models was assessed by area under receiver operating characteristic (ROC-AUC) analysis as well as precision, recall and calibration. To further validate our approach's clinical applicability, we conducted two secondary analyses: a time-to-event analysis on a single site to estimate the duration of buprenorphine-naloxone treatment continuity evaluated by the C-index and a comparative evaluation against predictions made by three human clinical experts. Attrition rates at 6months were 58% (NeuroBlu) and 61% (Stanford). Prediction models trained and internally validated on NeuroBlu data achieved ROC-AUCs up to 75.8 (95% confidence interval [CI] = 73.6-78.0). Addiction medicine specialists' predictions show a ROC-AUC of 67.8 (95% CI = 50.4-85.2). Time-to-event analysis on Stanford data indicated a median treatment retention time of 65 days, with random survival forest model achieving an average C-index of 65.9. The top predictor of treatment retention identified included the diagnosis of opioid dependence. US patients with opioid use disorder or opioid dependence treated with buprenorphine-naloxone prescriptions appear to have a high (∼60%) treatment attrition by 6months. Machine learning models trained on diverse electronic health record datasets appear to be able to predict treatment continuity with accuracy comparable to that of clinical experts.

Opportunities lost? Rates and predictors of attrition in an eating disorders outpatient service

ObjectiveTo examine rates and predictors of attrition from referral through to treatment completion in an outpatient public psychology service's eating disorder program in Perth, Western Australia. MethodThe proportion (number) of clients (N = 671; mean age = 23.8 years) transitioning between stages of pre-treatment and treatment was identified. Associations between demographic, treatment and clinical variables and attrition were investigated using logistic regression. ResultsOnly 34% (n = 230) of referred patients started treatment and 16% (n = 107) completed treatment. Referral acceptance was correlated with provisional diagnoses that meet the service's inclusion criteria, and attendance at an initial assessment was correlated with younger age. Treatment commencement was correlated with the presence of a co-occurring depressive or anxiety disorder, and no previous suicide attempts. Completing a full course of treatment was correlated with no previous hospitalisation for psychiatric issues, no previous suicide attempts, a history of psychiatric medication use, and treatment with family-based therapy. DiscussionHigh rates of attrition were found from referral to treatment completion. A suggested framework for defining the different stages of attrition is proposed to allow for consistency of attrition reporting across the mental health field. Future studies are needed to identify why clients disengage following referral, assessment, and treatment commencement, to inform strategies to engage and sustain engagement and to optimise outcomes.

Exploring Side Effects of Sublingual Immunotherapy: A Systemic Review and Meta-Analysis.

Objective: Sublingual immunotherapy (SLIT) has emerged as a potentially safe and convenient option for allergen immunotherapy for patients with inhalant allergy. Larger studies on the overall side effects and severe reactions anaphylaxis are still lacking. Study Design: Systematic review and meta-analysis. Setting: Author's review was completed in the University of Texas Medical Branch. Methods: A systematic review and meta-analysis of prospective clinical trials focusing on SLIT safety published from January 1, 2001, to December 31, 2021, was conducted. Results: Twenty-six studies were included with analysis of 7827 patients, representing over 2.7 million SLIT doses. All studies focused on single-antigen immunotherapy. The mean duration of treatment was 11.54 months. Local side effects were present in 40.83% of patients [95% confidence interval (CI) 24.78-57.96]. Systemic side effects were encountered in 1.09% of SLIT patients (95% CI 0.57-1.78). Anaphylaxis was reported in 0.13% of patients (95% CI 0.06-0.22). Discontinuation rates due to side effects were low, at 4.32% of patients (95% CI 3.28-5.49). Conclusion: This meta-analysis shows that single-antigen SLIT is well-tolerated, with overall low rates of systemic side effects including anaphylaxis. Although there is a high rate of minor local side effect, the treatment attrition during the first year is low. With growing allergy burden worldwide, SLIT is a convenient and economically feasible option for immunotherapy. Further work is needed to evaluate long-term safety and efficacy of single as well as multi-antigen SLIT, including quality of life assessments.

Changes in treatment (Rx) patterns and attrition rates in patients (pts) with metastatic clear cell renal cell carcinoma (mccRCC).

Changes in treatment (Rx) patterns and attrition rates in patients (pts) with metastatic clear cell renal cell carcinoma (mccRCC).

Treatment Patterns and Attrition With Lines of Therapy for Advanced Urothelial Carcinoma in the US

The treatment paradigm for advanced urothelial carcinoma (aUC) has undergone substantial transformation due to the introduction of effective, novel therapeutic agents. However, outcomes remain poor, and little is known about current treatment approaches and attrition rates for patients with aUC. To delineate evolving treatment patterns and attrition rates in patients with aUC using a US-based patient-level sample. This retrospective cohort study used patient-level data from the nationwide deidentified electronic health record database Flatiron Health, originating from approximately 280 oncology clinics across the US. Patients included in the analysis received treatment for metastatic or local aUC at a participating site from January 1, 2011, to January 31, 2023. Patients receiving treatment for 2 or more different types of cancer or participating in clinical trials were excluded from the analysis. Frequencies and percentages were used to summarize the (1) treatment received in each line (cisplatin-based regimens, carboplatin-based regimens, programmed cell death 1 and/or programmed cell death ligand 1 [PD-1/PD-L1] inhibitors, single-agent nonplatinum chemotherapy, enfortumab vedotin, erdafitinib, sacituzumab govitecan, or others) and (2) attrition of patients with each line of therapy, defined as the percentage of patients not progressing to the next line. Of the 12 157 patients within the dataset, 7260 met the eligibility criteria and were included in the analysis (5364 [73.9%] men; median age at the start of first-line treatment, 73 [IQR, 66-80] years). All patients commenced first-line treatment; of these, only 2714 (37.4%) progressed to receive second-line treatment, and 857 (11.8%) advanced to third-line treatment. The primary regimens used as first-line treatment contained carboplatin (2241 [30.9%]), followed by PD-1/PD-L1 inhibitors (2174 [29.9%]). The PD-1/PD-L1 inhibitors emerged as the predominant choice in the second- and third-line (1412 of 2714 [52.0%] and 258 of 857 [30.1%], respectively) treatments. From 2019 onward, novel therapeutic agents were increasingly used in second- and third-line treatments, including enfortumab vedotin (219 of 2714 [8.1%] and 159 of 857 [18.6%], respectively), erdafitinib (39 of 2714 [1.4%] and 28 of 857 [3.3%], respectively), and sacituzumab govitecan (14 of 2714 [0.5%] and 34 of 857 [4.0%], respectively). The findings of this cohort study suggest that approximately two-thirds of patients with aUC did not receive second-line treatment. Most first-line treatments do not include cisplatin-based regimens and instead incorporate carboplatin- or PD-1/PD-L1 inhibitor-based therapies. These data warrant the provision of more effective and tolerable first-line treatments for patients with aUC.

Prehabilitation: The underutilised weapon for chronic pain management.

Prehabilitation encompasses preparatory clinical intervention(s) delivered during the period between diagnosis and treatment commencement. Despite widespread successful usage preoperatively, psychological prehabilitation is neglected in outpatient chronic pain management. Although pain management waitlists are associated with treatment attrition and psychological and physical decline, this time window is underutilised in preventing escalation. Waitlists present an under-explored opportunity to 'prehabilitate' patients waiting for treatment. This topical review aimed to: (1) examine the effectiveness of psychological prehabilitation for pain services; (2) evaluate the psychological and physical decline associated with waiting for pain management; (3) highlight key psychological prehabilitative targets for increasing treatment engagement; (4) promote pain management psychological prehabilitation within personalised pain medicine, building recommendations for future interventions. Studies regarding the impact of waitlists and prehabilitation for chronic pain were reviewed. Findings demonstrated that the psychological constructs of patient expectations, health locus of control, self-efficacy and pain catastrophizing dynamically influence attrition, treatment engagement and outcomes while waiting. These constructs are amenable to change, emphasising their potential utility within a targeted waitlist intervention. Prehabilitating chronic pain patients towards treatment engagement could circumvent cycles of failed treatment seeking, preventing psychological and physical decline, and reducing healthcare utilisation. Utilising the waitlist to identify psychosocial risk factors (external health locus of control, low self-efficacy and high pain catastrophizing) would identify who requires additional support to prevent increased risk of treatment failure, enhancing personalised care before prescribed treatment is accessed. This review cements the urgent need for pain services to engage proactively with prehabilitation innovation.

Maternal executive function and stress and children's behavior problem treatment outcomes.

This prospective, observational study was designed to investigate the relationship of mothers' executive function capacities and parenting stress to early dropout, appointment attendance, and outcomes of in-clinic delivery of parent management training to address children's behavior problems. We hypothesized that mothers' executive functions (EFs) would be prospectively and positively associated with adherence to children's behavioral treatment appointments and reduction in children's behavior problems and that mothers' stress levels would be inversely related to these outcomes. Mothers (n = 288) completed the Behavior Rating Inventory of Executive Function for Adults (EF) and Parenting Stress Index at the beginning of treatment. Children were 2-12 years old. Regression models evaluated the extent to which deficits in maternal EF and clinical levels of parenting stress contributed to the three outcomes. The 11% of mothers with clinically significant deficits in executive functioning were significantly (3 times) more likely to drop out early compared to mothers in the normal range. Almost one third of mothers reported clinically significant parenting stress. Their children were half as likely to achieve a positive behavior outcome, although stress was not significantly associated with attendance. Remaining in treatment is fundamental to being able to learn and practice the parenting skills necessary to manage young children's age-inappropriate behavior in positive ways. Clinical consideration of mothers' EF challenges may help prevent early treatment attrition and clinical management of parenting stress may further help improve children's treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact of trial attrition rates on treatment effect estimates in chronic inflammatory diseases: A meta-epidemiological study.

The objective of this meta-epidemiological study was to explore the impact of attrition rates on treatment effect estimates in randomised trials of chronic inflammatory diseases (CID) treated with biological and targeted synthetic disease-modifying drugs. We sampled trials from Cochrane reviews. Attrition rates and primary endpoint results were retrieved from trial publications; Odds ratios (ORs) were calculated from the odds of withdrawing in the experimental intervention compared to the control comparison groups (i.e., differential attrition), as well as the odds of achieving a clinical response (i.e., the trial outcome). Trials were combined using random effects restricted maximum likelihood meta-regression models and associations between estimates of treatment effects and attrition rates were analysed. From 37 meta-analyses, 179 trials were included, and 163 were analysed (301 randomised comparisons; n = 62,220 patients). Overall, the odds of withdrawal were lower in the experimental compared to control groups (random effects summary OR = 0.45, 95% CI, 0.41-0.50). The corresponding overall treatment effects were large (random effects summary OR = 4.43, 95% CI 3.92-4.99) with considerable heterogeneity across interventions and clinical specialties (I2 = 85.7%). The ORs estimating treatment effect showed larger treatment benefits when the differential attrition was more prominent with more attrition in the control group (OR = 0.73, 95% CI 0.55-0.96). Higher attrition rates from the control arm are associated with larger estimated benefits of treatments with biological or targeted synthetic disease-modifying drugs in CID trials; differential attrition may affect estimates of treatment benefit in randomised trials.

Trauma-focused therapy retention among military sexual trauma survivors: relationship with veterans’ sexual or gender minority identification

ABSTRACT Military servicemembers identifying as sexual and gender minorities (SGM) are at increased risk for military sexual trauma (MST) exposure and Post-traumatic Stress Disorder (PTSD). Although evidence-based treatments can reduce symptoms of PTSD, treatment attrition is concerning. Unfortunately, evaluations of such approaches with veterans identifying as SGM are currently restricted to case studies offering limited information regarding treatment completion. Both historic and current contextual factors related to military and mental health practices may uniquely influence minority veterans’ treatment engagement in veteran healthcare settings. We explored associations between SGM identification and treatment of MST-focused therapy completion patterns (finishing the full protocol [FP] or receiving minimally adequate care [MAC; defined as attending eight or more sessions]). Veterans (N = 271, 12.5% SGM) enrolled in individual Prolonged Exposure or Cognitive Processing Therapies at a Midwestern veterans hospital system. Those identifying as SGM were more likely than non-identifying peers to complete FP treatment and, even when attrition occurred, they were retained longer. For MAC, the SGM group was as likely as non-SGM peers to be retained. This research suggests SGM veterans represent a notable minority of those seeking treatment in association with MST and do not appear at greater risk for discontinuation from trauma-focused treatment.

Treatment (Rx) trends and attrition with lines of therapy in patients (pts) with advanced urothelial carcinoma (aUC).

Treatment (Rx) trends and attrition with lines of therapy in patients (pts) with advanced urothelial carcinoma (aUC).

Real-world (rw) treatment patterns, sequencing, and outcomes in patients (pts) with locally advanced or metastatic urothelial carcinoma (la/mUC) receiving avelumab first-line maintenance (1LM) in the US.

605 Background: Avelumab 1LM is recommended in international guidelines for pts with la/mUC and disease control after 1L platinum-based chemotherapy (PBC). This study describes the treatment landscape after FDA approval of avelumab in June 2020 by examining pt characteristics, treatment patterns and sequencing, and rw outcomes in pts treated with avelumab 1LM. Methods: This noninterventional retrospective study identified pts with la/mUC who received avelumab 1LM in the US using data from Flatiron Health’s electronic health record database. Pts aged ≥18 y with ≥2 visits on/after Jan 1, 2011, diagnosed with la/mUC from Jan 1, 2019 - Dec 31, 2022, treated with 1L PBC followed by avelumab 1LM on/after Jul 1, 2020, ≤90 d after 1L PBC discontinuation, and with no disease progression ≤14 wk after 1L PBC were included. Treatment patterns in 1LM, second line (2L), and third line (3L) were assessed. Clinical outcomes, including rw progression-free survival (rwPFS), rw overall survival (rwOS), time to treatment discontinuation (TTD), and time to next treatment (TTNT) from 1LM or 2L initiation, were assessed using Kaplan-Meier methods. Results: 214 avelumab 1LM-treated pts met eligibility criteria. Median age was 70 y; most pts were male (77%), White (66%), and had an ECOG of 0-1 (77%). Median follow-up from 1LM was 8.7 mo. Of 96 (45%) pts who received 2L treatment post avelumab 1LM, enfortumab vedotin (EV) monotherapy (55%) was most common, followed by carboplatin-based therapy (11%). Of 40 (42%) pts who received 3L treatment, EV monotherapy was most common (25%), followed by sacituzumab govitecan (20%). Median PFS and OS from start of avelumab 1LM was 5.1 (95% CI 4.1-7.0) and 23.8 (95% CI 18.2-NE) mo. Median TTNT from avelumab 1LM initiation was 7.0 (95% CI 5.6-8.6) mo. Of pts who received 2L EV, median rwPFS and rwOS from 2L initiation were 4.9 (95% CI 3.9-8.8) and 11.2 (95% CI 6.8-NE) mo. Further rw outcomes are presented in the Table. Conclusions: Clinical outcomes in this study are aligned with those of the JAVELIN Bladder 100 trial (NCT02603432), further supporting avelumab 1LM as a standard of care. With each additional line of therapy, substantial treatment attrition and less favorable clinical outcomes were observed. This study provides insights into the sequencing of treatments and management of pts with la/mUC after disease progression with avelumab 1LM in this rapidly evolving therapeutic landscape. The use of more effective upfront therapies may decrease the attrition rates. [Table: see text]

Online Compassion Focused Therapy for overeating: Feasibility and acceptability pilot study.

This pilot study aims to investigate the feasibility, acceptability, and potential effectiveness of online Compassion Focused Therapy for overeating (CFT-OE). Eighteen Portuguese women seeking treatment for overeating were enrolled in this study, and 15 participants completed the CFT-OE. This was a single-arm study. Participants were assessed at pre- and post-intervention and 3-month follow-up. All participants completed measures assessing binge eating, cognitive restraint, uncontrolled eating, emotional eating, general eating psychopathology, general and body shame, self-criticism, self-compassion, and fears of self-compassion. The treatment attrition rate was 16.7%, which is relatively low compared to other similar online interventions. Participants gave positive feedback on the program and indicated they would recommend it to people with similar difficulties. CFT-OE improved self-compassion and reduced eating psychopathology symptoms, general and body shame, self-criticism, and fears of self-compassion. Clinical significance analysis showed that the majority of participants were classified as in recovery in all measures at post-intervention and 3-month follow-up. Preliminary results suggest that the online CFT-OE program is an acceptable and feasible intervention. Results also suggest that CFT-OE is beneficial for the treatment of women with difficulties with overeating. A future randomized controlled trial is necessary to establish the effectiveness of the CFT-OE. This study indicates that online CFT-OE is a feasible and adequate intervention for women who struggle with overeating. This therapy showed promising results in reducing eating disorder symptoms, shame, and self-criticism and improving self-compassion. As an online intervention, CFT-OE may be more accessible and offer an alternative to in-person therapy.

Feasibility, acceptability, and preliminary efficacy of an internet-based CBT intervention for loneliness in older adults: A pilot RCT

BackgroundOlder adults are an important target group for loneliness interventions. However, most existing interventions aimed at older individuals do not focus on the strategy that has proven most effective (i.e., modifying maladaptive social cognition). Additionally, given the low mental health service use in this population, innovative treatment approaches are needed in order to provide support to this age cohort. The aim of the current study was to investigate the feasibility, acceptability, and preliminary efficacy of a newly developed internet-based cognitive behavioral therapy intervention for loneliness in older individuals using a pilot randomized controlled trial (RCT). MethodsIn the current study N = 36 older adults aged between 65 and 87 years were randomly assigned to either a 7-week internet-based intervention or a wait-list condition. Treatment satisfaction, usability, attrition, and adherence were assessed as indicators for feasibility and acceptability. To investigate preliminary treatment effects, measures on loneliness, depression, anxiety, self-efficacy, and life-satisfaction were administered. ResultsOverall, the intervention program was found to be acceptable and feasible. No significant difference between conditions on loneliness were observed; however, results indicated a trend towards lower reported loneliness levels in the treatment compared to the control group. Regarding secondary outcomes, results pointed at age-specific treatment effects, such that improvements on depression, anxiety, and life satisfaction were observed in the young-old, but not old-old adults in our sample. LimitationsThe sample was small and no follow-up assessment was included. ConclusionsAn internet-based CBT intervention for loneliness seems to be feasible and acceptable in older individuals.

Predicting attrition of men with a history of violence from randomised clinical trials

Preventing dropout (attrition) from clinical trials is vital for improving study validity. Dropout is particularly important in justice-involved populations as they can be very challenging to engage and recruit in the first instance. This study identifies factors associated with dropout in a double-blind, placebo-controlled randomised control trial of a selective serotonin reuptake inhibitor (SSRI) aimed at reducing reoffending in highly impulsive men with histories of violent offending. Age, education, social support, psychiatric history, and length of previous incarceration were identified as factors that predict attrition. These findings are consistent with previous research examining variables associated with attrition in clinical trials for community and offender populations. We also explored referral source and treatment allocation as attrition predictors. Although neither significantly predicted attrition, we identified that there are discernible differences in the median time to attrition among the referral source subgroups. Understanding factors that predict treatment completion and attrition will allow researchers to identify participants for whom additional provisions may optimise retention and inform development of targeted interventions.

COVID-19-related flexibility in methadone take-home doses associated with decreased attrition: Report from an opioid treatment program in central Pennsylvania

IntroductionPennsylvania saw a dramatic increase in take-home doses of methadone after the COVID-19 pandemic-related relaxation in regulations. We evaluated whether pandemic-initiated relaxation in take-home methadone dose regulations was associated with changes in attrition and urine drug test (UDT) results at one outpatient opioid treatment program (OTP) among adult patients treated with methadone for opioid use disorder (OUD). MethodsWe analyzed aggregated, retrospective clinical practice data, using data abstracted from the OTP's electronic health record (EHR) on the number of patients treated with methadone, those allowed take-home doses, the number of take-home methadone doses dispensed, and the number and type of patient discharge (“attrition”) from treatments for 12 months before (March 2019–February 2020; “pre-pandemic”) and 12 months after (March 2020–February 2021; “pandemic”) the regulatory changes took place. We also examined monthly aggregate data on the number of urine samples testing positive for amphetamines, cocaine, benzodiazepines or illicit opioids, and compared these findings between the pre-pandemic and pandemic periods. ResultsPre-pandemic, 229 patients were treated with methadone, compared to 278 patients during the pandemic period. They received 11,047 and 28,563 take-home daily-doses of methadone (p < 0.0001) during each assessment period, respectively. All-cause treatment attrition (discharge from the program for any reason) decreased from 27.1 % in the pre-pandemic to 15.5 % in the pandemic period (p < 0.001). Compared to pre-pandemic, during the pandemic period the urine toxicology testing showed reduced positivity rates for cocaine (26.4 % vs 18.9 %, p < 0.001), and oxycodone and morphine (1.8 % vs 1.1 %, p < 0.019), and increased for fentanyl (24.0 % vs 30.5 %, p < 0.007), without statistically significant changes for benzodiazepines or amphetamines. ConclusionsThe relaxation of regulations guiding take-home methadone doses accompanied reduced treatment attrition and favorable changes in urine toxicology results in one OTP. Allowing OTPs to apply flexible decisions regarding take-home methadone doses could improve treatment retention, outcomes, and, in turn, save lives.