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1.  The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): Method and Design Considerations 
Contemporary clinical trials  2013;36(1):14-24.
Due to the concentration of individuals at-risk for suicide, an emergency department visit represents an opportune time for suicide risk screening and intervention.
The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) uses a quasi-experimental, interrupted time series design to evaluate whether (1) a practical approach to universally screening ED patients for suicide risk leads to improved detection of suicide risk and (2) a multi-component intervention delivered during and after the ED visit improves suicide-related outcomes.
This paper summarizes the ED-SAFE’s study design and methods within the context of considerations relevant to effectiveness research in suicide prevention and pertinent human participants concerns. 1,440 suicidal individuals, from 8 general ED’s nationally will be enrolled during three sequential phases of data collection (480 individuals/phase): (1) Treatment as Usual; (2) Universal Screening; and (3) Intervention. Data from the three phases will inform two separate evaluations: Screening Outcome (Phases 1 and 2) and Intervention (Phases 2 and 3). Individuals will be followed for 12 months. The primary study outcome is a composite reflecting completed suicide, attempted suicide, aborted or interrupted attempts, and implementation of rescue procedures during an outcome assessment.
While ‘classic’ randomized control trials (RCT) are typically selected over quasi-experimental designs, ethical and methodological issues may make an RCT a poor fit for complex interventions in an applied setting, such as the ED. ED-SAFE represents an innovative approach to examining the complex public health issue of suicide prevention through a multiphase, quasi-experimental design embedded in ‘real world’ clinical settings.
PMCID: PMC3979300  PMID: 23707435
suicide; research methods; mental health; emergency department
2.  A Randomized Clinical Trial of the Health Evaluation and Referral Assistant (HERA): Research Methods 
Contemporary clinical trials  2013;35(2):87-96.
The Health Evaluation and Referral Assistant (HERA) is a web-based program designed to facilitate screening, brief intervention, and referral to treatment (SBIRT) for tobacco, alcohol, and drug abuse. After the patient completes a computerized substance abuse assessment, the HERA produces a summary report with evidence-based recommended clinical actions for the healthcare provider (the Healthcare Provider Report) and a report for the patient (the Patient Feedback Report) that provides education regarding the consequences of use, personally tailored motivational messages, and a tailored substance abuse treatment referral list. For those who provide authorization, the HERA faxes the individual’s contact information to a substance abuse treatment provider matched to the individual’s substance use severity and personal characteristics, like insurance and location of residence (dynamic referral). This paper summarizes the methods used for a randomized controlled trial to evaluate the HERA’s efficacy in leading to increased treatment initiation and reduced substance use. The study was performed in four emergency departments. Individual patients were randomized into one of two conditions: the HERA or assessment only. A total of 4,269 patients were screened and 1,006 participants enrolled. The sample was comprised of 427 tobacco users, 212 risky alcohol users, and 367 illicit drug users. Fourty-two percent used more than one substance class. The enrolled sample was similar to the eligible patient population. The study should enhance understanding of whether computer-facilitated SBIRT can impact process of care variables, such as promoting substance abuse treatment initiation, as well as its effect on subsequent substance abuse and related outcomes.
PMCID: PMC3979303  PMID: 23665335
substance abuse treatment; brief intervention; referral; treatment matching; substance abuse screening; e-health
3.  The Effect of Removing Cost as a Barrier to Treatment Initiation With Outpatient Tobacco Dependence Clinics Among Emergency Department Patients 
The campaign against tobacco addiction and smoking continues to play an important role in public health. However, referrals to outpatient tobacco cessation programs by emergency physicians are rarely pursued by patients following discharge. This study explored cost as a barrier to follow-up.
The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a “Stop Smoking Clinic” affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee), $20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject.
The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p > 0.05). Two-hundred forty-seven (43%) participants reported “very much” interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic.
Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation.
PMCID: PMC3777236  PMID: 21518096
4.  Initial Development of the Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) 
Journal of psychosocial oncology  2011;29(1):83-102.
The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a program that conducts a computerized assessment of physical, psychological and social functioning related to oncology treatment, prints personalized summary reports for both the patient and the provider, and for those who provide consent, faxes a referral and assessment summary report to a matched mental health treatment provider (i.e., dynamic referral). The functionality, feasibility, and end user satisfaction of the Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) were tested in a comprehensive care center. Of the 101 subjects enrolled, 61 (60%) exhibited elevated distress on at least one of the mental health indices, and, of these, 12 (20%) chose a dynamic referral for mental health services. Patients and health care providers exhibited high levels of satisfaction with the program. The MHADRO has potential for assisting in meeting the psychosocial needs faced by individuals with cancer and should be tested further for its facilitation of mental health treatment initiation.
PMCID: PMC3664548  PMID: 21240727
psychological distress; cancer; computerized; mental health treatment; dynamic referrals
5.  When an Event Sparks Behavior Change: An Introduction to the Sentinel Event Method of Dynamic Model Building and Its Application to Emergency Medicine 
Experiencing a negative consequence related to one’s health behavior, like a medical problem leading to an emergency department visit, can promote behavior change, giving rise to the popular concept of the “teachable moment.” However, the mechanisms of action underlying this process of change have received scant attention. In particular, most existing health behavior theories are limited in explaining why such events can inspire short-term change in some, and long-term change in others. Expanding on recommendations published in the 2009 Academic Emergency Medicine consensus conference on public health in emergency medicine, we propose a new method for developing conceptual models that explain how negative events, like medical emergencies, influence behavior change, called the Sentinel Event Method. The method itself is atheoretical; instead, it defines steps to guide investigations that seek to relate specific consequences or events to specific health behaviors. This method can be used to adapt existing health behavior theories to study the event-behavior change relationship, or to guide formulation of completely new conceptual models. This paper presents the tenets underlying the Sentinel Event Method, describes the steps comprising the process, and illustrates its application to emergency medicine through an example of a cardiac-related emergency department visit and tobacco use.
PMCID: PMC3664550  PMID: 22435866
6.  Multicenter Study of Predictors of Suicide Screening in Emergency Departments 
To provide estimates and predictors of screening for suicide in emergency departments (EDs).
Eight geographically diverse U.S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening.
The cohort of 800 patients had a median age of 41 years (interquartile range 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%), or intentional illegal or prescription drug misuse (36%).
The presence of known psychiatric problems and substance use had the strongest associations with suicide screening; yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.
PMCID: PMC3664554  PMID: 22288721
7.  The Computer-Assisted Brief Intervention for Tobacco (CABIT) Program: A Pilot Study 
Health care providers do not routinely carry out brief counseling for tobacco cessation despite the evidence for its effectiveness. For this intervention to be routinely used, it must be brief, be convenient, require little investment of resources, require little specialized training, and be perceived as efficacious by providers. Technological advances hold much potential for addressing the barriers preventing the integration of brief interventions for tobacco cessation into the health care setting.
This paper describes the development and initial evaluation of the Computer-Assisted Brief Intervention for Tobacco (CABIT) program, a web-based, multimedia tobacco intervention for use in opportunistic settings.
The CABIT uses a self-administered, computerized assessment to produce personalized health care provider and patient reports, and cue a stage-matched video intervention. Respondents interested in changing their tobacco use are offered a faxed referral to a “best matched” tobacco treatment provider (ie, dynamic referral). During 2008, the CABIT program was evaluated in an emergency department, an employee assistance program, and a tobacco dependence program in New Jersey. Participants and health care providers completed semistructured interviews and satisfaction ratings of the assessment, reports, video intervention, and referrals using a 5-point scale.
Mean patient satisfaction scores (n = 67) for all domains ranged from 4.00 (Good) to 5.00 (Excellent; Mean = 4.48). Health care providers completed satisfaction forms for 39 patients. Of these 39 patients, 34 (87%) received tobacco resources and referrals they would not have received under standard care. Of the 45 participants offered a dynamic referral, 28 (62%) accepted.
The CABIT program provided a user-friendly, desirable service for tobacco users and their health care providers. Further development and clinical trial testing is warranted to establish its effectiveness in promoting treatment engagement and tobacco cessation.
PMCID: PMC3799483  PMID: 23208070
technology; tobacco use cessation; smoking cessation; referrals
8.  Smoking, Cardiac Symptoms, and an Emergency Care Visit: A Mixed Methods Exploration of Cognitive and Emotional Reactions 
Emergency departments and hospitals are being urged to implement onsite interventions to promote smoking cessation, yet little is known about the theoretical underpinnings of behavior change after a healthcare visit. This observational pilot study evaluated three factors that may predict smoking cessation after an acute health emergency: perceived illness severity, event-related emotions, and causal attribution. Fifty smokers who presented to a hospital because of suspected cardiac symptoms were interviewed, either in the emergency department (ED) or, for those who were admitted, on the cardiac inpatient units. Their data were analyzed using both qualitative and quantitative methodologies to capture the individual, first-hand experience and to evaluate trends over the illness chronology. Reported perceptions of the event during semistructured interview varied widely and related to the individual's intentions regarding smoking cessation. No significant differences were found between those interviewed in the ED versus the inpatient unit. Although the typical profile was characterized by a peak in perceived illness severity and negative emotions at the time the patient presented in the ED, considerable pattern variation occurred. Our results suggest that future studies of event-related perceptions and emotional reactions should consider using multi-item and multidimensional assessment methods rated serially over the event chronology.
PMCID: PMC3444830  PMID: 22997584
9.  The Dynamic Assessment and Referral System for Substance Abuse (DARSSA): Development, Functionality, and End-user Satisfaction 
Drug and alcohol dependence  2008;99(1-3):37-46.
The Dynamic Assessment and Referral System for Substance Abuse (DARSSA) conducts a computerized substance abuse assessment; prints personalized summary reports that include tailored substance abuse treatment referral lists; and, for individuals who provide authorization, automatically faxes their contact information to a “best match” substance abuse treatment provider (dynamic referral). After piloting the program and resolving problems that were noted, we enrolled a sample of 85 medical patients. The DARSSA identified 48 (56%) participants who were risky substance users, many of whom had not been identified during their routine medical assessment. Mean satisfaction scores for all domains ranged between “Good” to “Excellent” across patients, nurses, doctors, and substance abuse treatment providers The median completion time was 13 minutes. Of the 48 risky substance using participants, 20 (42%) chose to receive a dynamic referral. The DARSSA provides a user-friendly, desirable service for patients and providers. It has the potential to improve identification of substance abuse in medical settings and to provide referrals that would not routinely be provided. Future studies are planned to establish its efficacy at promoting treatment initiation and abstinence.
PMCID: PMC2636871  PMID: 18775606
technology; substance abuse treatment; referrals; treatment matching; substance abuse screening; treatment initiation
10.  Evaluating and selecting mobile health apps: strategies for healthcare providers and healthcare organizations 
Mobile applications (apps) to improve health are proliferating, but before healthcare providers or organizations can recommend an app to the patients they serve, they need to be confident the app will be user-friendly and helpful for the target disease or behavior. This paper summarizes seven strategies for evaluating and selecting health-related apps: (1) Review the scientific literature, (2) Search app clearinghouse websites, (3) Search app stores, (4) Review app descriptions, user ratings, and reviews, (5) Conduct a social media query within professional and, if available, patient networks, (6) Pilot the apps, and (7) Elicit feedback from patients. The paper concludes with an illustrative case example. Because of the enormous range of quality among apps, strategies for evaluating them will be necessary for adoption to occur in a way that aligns with core values in healthcare, such as the Hippocratic principles of nonmaleficence and beneficence.
PMCID: PMC4286553  PMID: 25584085
Mobile health; e-health; Application; Health promotion; Health behavior
11.  Measuring Cognitive and Affective Constructs in the Context of an Acute Health Event 
Psychology, health & medicine  2012;18(4):398-411.
The latest recommendations for building dynamic health behavior theories emphasize that cognitions, emotions, and behaviors – and the nature of their inter-relationships -- can change over time. This paper describes the development and psychometric validation of four scales created to measure smoking-related causal attributions, perceived illness severity, event-related emotions, and intention to quit smoking among patients experiencing acute cardiac symptoms. After completing qualitative work with a sample of 50 cardiac patients, we administered the scales to 300 patients presenting to the emergency department for cardiac-related symptoms. Factor analyses, alpha coefficients, ANOVAS, and Pearson correlation coefficients were used to establish the scales' reliability and validity. Factor analyses revealed a stable factor structures for each of the four constructs. The scales were internally consistent, with the majority having an alpha of >0.80 (range: 0.57 to 0.89). Mean differences in ratings of the perceived illness severity and event-related emotions were noted across the three time anchors. Significant increases in intention to quit at the time of enrollment, compared to retrospective ratings of intention to quit before the event, provide preliminary support for the sensitivity of this measure to the motivating impact of the event. Finally, smoking-related causal attributions, perceived illness severity, and event-related emotions correlated in the expected directions with intention to quit smoking, providing preliminary support for construct validity.
PMCID: PMC3979315  PMID: 22970703
12.  Evaluating Current Patterns of Assessment for Self-Harm in Emergency Departments, A Multicenter Study 
To describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed.
This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt, suicidal ideation, or non-suicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity.
Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age ≥ 65 years (0.56, 95% CI = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males <65 years of age being more likely to be assessed (aRR 1.14, 95% CI = 1.02 to 1.37).
Emergency department assessment of self-harm was highly variable among institutions. Presence of specific assessment policies was associated with higher assessment rates. Assessment varied based upon patient characteristics. The identification of self-harm in 2.7% of ED patients indicates that a substantial proportion of current risk of self-harm may go unidentified, particularly in certain patient groups.
PMCID: PMC3775284  PMID: 24033624
13.  Randomized Control Trial to Test a Computerized Psychosocial Cancer Assessment and Referral Program: Methods and Research Design 
Contemporary clinical trials  2013;35(1):15-24.
The National Cancer Coalition Network, National Cancer Institute, and American College of Surgeons all emphasize the need for oncology providers to identify, address, and monitor psychosocial needs of their patients. The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a patient-driven, computerized, psychosocial assessment that identifies, addresses, and monitors physical, psychological, and social issues faced by oncology patients. This paper presents the methodology of a randomized controlled trial (RCT) that tested the impact of the MHADRO on patient outcomes at 2, 6, and 12 months. Patient outcomes including overall psychological distress, depression, anxiety, functional disability, and use of psychosocial resources will be presented in future publications after all follow–up data is gathered. Eight hundred and thirty six cancer patients with heterogeneous diagnoses, across three comprehensive cancer centers in different parts of the United States, were randomized to the MHADRO (intervention) or an assessment-only control group. Patients in the intervention group were provided detailed, personalized reports and, when needed, referrals to mental health services; their oncology provider received detailed reports designed to foster clinical decision making. Those patients who demonstrated high levels of psychosocial problems were given the option to authorize that a copy of their report be sent electronically to a “best match” mental health professional. Demographic and patient cancer-related data as well as comparisons between patients who were enrolled and those who declined enrollment are presented. Challenges encountered during the RCT and strategies used to address them are discussed.
PMCID: PMC3665365  PMID: 23395772
computer-based intervention; cancer; psychological distress; mental health treatment; facilitated referral
14.  An Evidence-Based Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Emergency Department (ED) Providers Improves Skills and Utilization 
Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices.
ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program ( A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure.
Among 402 ED providers, 74% reported < 10 hours of prior professional alcohol-related education and 78% had < 2 hours exposure in the previous year. At 3-month follow-up, scores for self-reported confidence in ability, responsibility to intervene, and actual utilization of SBIRT skills all improved significantly over baseline. Gains decreased somewhat at 12 months, but remained above baseline. Length of time in practice was positively associated with SBIRT utilization, controlling for gender, race and type of profession. Persistent barriers included time limitations and lack of referral resources.
ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.
PMCID: PMC3976968  PMID: 18077305
Brief intervention; alcohol screening; substance abuse; alcohol education
15.  Trends in US Emergency Department Visits for Attempted Suicide and Self-inflicted Injury, 1993–2008 
General hospital psychiatry  2012;34(5):557-565.
To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.
Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950–E959) during 1993–2008.
Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury (1.50 [95% confidence interval (CI) 1.33–1.67] visits per 1,000 US population) and the average annual number for these ED visits more than doubled from 244,000 in 1993–1996 to 538,000 in 2005–2008. During the same timeframe, ED visits for these injuries per 1,000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82), and blacks (1.14 to 2.10). Visits were most common among ages 15–19 and the number of visits coded as urgent/emergent decreased.
ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.
PMCID: PMC3428496  PMID: 22554432
Suicide; Emergency Departments; Public Health
16.  Designing Interventions to Overcome Poor Numeracy and Improve Medication Adherence in Chronic Illness, Including HIV/Aids 
Numeracy is an element of health literacy that refers to the ability to understand numerically related information. When applied to health behaviors, it describes the degree to which individuals have the capacity to access, process, interpret, and act on graphical and probabilistic health information. As a cognitive and functional skill, low numeracy correlates with poor outcomes in the management of chronic diseases; numeracy is therefore an essential component of patients’ capacity to adhere to medication regimens. In this manuscript, we describe novel visual interventions to improve medication adherence in difficult, chronically ill populations. We have used personalized graphical representations of plasma medication concentration and dynamic disease state simulation to overcome poor numeracy. These methods incorporate efficient, precise, and clear graphical data; cartographical techniques focused on judicious use of color intensities; and animation that increases engagement and accentuates information transfer.
PMCID: PMC3667954  PMID: 21455810
Technology; mHealth; Medication adherence; HIV
17.  Predictors of Successful Telephone Contact After Emergency Department-based Recruitment into a Multicenter Smoking Cessation Cohort Study 
Emergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.
This study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.
Of 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99–1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04–2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2–4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03–3.8]) and Medicare (AOR 5.7 [95%CI, 1.5–22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6–6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00–1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01–1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07–1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.
Successful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations.
PMCID: PMC4323181
18.  Intentions to Quit Smoking: Causal Attribution, Perceived Illness Severity, and Event-Related Fear During an Acute Health Event 
Experiencing a serious consequence related to one’s health behavior may motivate behavior change.
This study sought to examine how causal attribution, perceived illness severity, and fear secondary to an acute health event relate to intentions to quit smoking.
Using a cross-sectional survey design, adult emergency department patients who smoked provided demographic data and ratings of nicotine dependence, causal attribution, perceived illness severity, event-related fear, and intentions to quit smoking.
A linear regression analysis was used to examine the relations between the independent variables and quit intentions. We enrolled 186 participants. After adjusting for nicotine dependence, smoking-related causal attribution and event-related fear were associated with intentions to quit (β=0.26, p<0.01 and β=0.21, p<0.01, respectively). Perceived illness severity was correlated with event-related fear (r=0.46, p<0.001) but was not associated with intentions to quit (β=−0.08, p=0.32).
While causal attribution and event-related fear were modestly associated with quit intentions, perceived illness severity was not. Longitudinal studies are needed to better explicate the relation between these variables and behavior change milestones.
PMCID: PMC3532886  PMID: 20827518
Smoking cessation; Causal attribution; Perceived illness severity; Fear; Acute health event; Smoking; Readiness to quit; Stage of change; Affect; Illness severity; Emergency medicine
19.  Designing Interventions to Overcome Poor Numeracy and Improve Medication Adherence in Chronic Illness, Including HIV/Aids 
Journal of Medical Toxicology  2011;7(2):133-138.
Numeracy is an element of health literacy that refers to the ability to understand numerically related information. When applied to health behaviors, it describes the degree to which individuals have the capacity to access, process, interpret, and act on graphical and probabilistic health information. As a cognitive and functional skill, low numeracy correlates with poor outcomes in the management of chronic diseases; numeracy is therefore an essential component of patients’ capacity to adhere to medication regimens. In this manuscript, we describe novel visual interventions to improve medication adherence in difficult, chronically ill populations. We have used personalized graphical representations of plasma medication concentration and dynamic disease state simulation to overcome poor numeracy. These methods incorporate efficient, precise, and clear graphical data; cartographical techniques focused on judicious use of color intensities; and animation that increases engagement and accentuates information transfer.
PMCID: PMC3667954  PMID: 21455810
Technology; mHealth; Medication adherence; HIV
20.  Patient preferences for emergency department-initiated tobacco interventions: a multicenter cross-sectional study of current smokers 
The emergency department (ED) visit provides a great opportunity to initiate interventions for smoking cessation. However, little is known about ED patient preferences for receiving smoking cessation interventions or correlates of interest in tobacco counseling.
ED patients at 10 US medical centers were surveyed about preferences for hypothetical smoking cessation interventions and specific counseling styles. Multivariable linear regression determined correlates of receptivity to bedside counseling.
Three hundred seventy-five patients were enrolled; 46% smoked at least one pack of cigarettes per day, and 11% had a smoking-related diagnosis. Most participants (75%) reported interest in at least one intervention. Medications were the most popular (e.g., nicotine replacement therapy, 54%), followed by linkages to hotlines or other outpatient counseling (33-42%), then counseling during the ED visit (33%). Counseling styles rated most favorably involved individualized feedback (54%), avoidance skill-building (53%), and emphasis on autonomy (53%). In univariable analysis, age (r = 0.09), gender (average Likert score = 2.75 for men, 2.42 for women), education (average Likert score = 2.92 for non-high school graduates, 2.44 for high school graduates), and presence of smoking-related symptoms (r = 0.10) were significant at the p < 0.10 level and thus were retained for the final model. In multivariable linear regression, male gender, lower education, and smoking-related symptoms were independent correlates of increased receptivity to ED-based smoking counseling.
In this multicenter study, smokers reported receptivity to ED-initiated interventions. However, there was variability in individual preferences for intervention type and counseling styles. To be effective in reducing smoking among its patients, the ED should offer a range of tobacco intervention options.
PMCID: PMC3414814  PMID: 22966410
Smoking; Tobacco; Cigarettes; Emergency medicine; Counseling; Patient preference
21.  Motivation rulers for smoking cessation: a prospective observational examination of construct and predictive validity 
Although popular clinically, the psychometric properties of motivation rulers for tobacco cessation are unknown. This study examined the psychometric properties of rulers assessing importance, readiness, and confidence in tobacco cessation.
This observational study of current smokers was conducted at 10 US emergency departments (EDs). Subjects were assessed during their ED visit (baseline) and reassessed two weeks later. We examined intercorrelations between the rulers as well as their construct and predictive validity. Hierarchical multinomial logistic regressions were used to examine the rulers’ predictive ability after controlling for covariables.
We enrolled 375 subjects. The correlations between the three rulers ranged from 0.50 (between Important and Confidence) to 0.70 (between Readiness and Confidence); all were significant (p < 0.001). Individuals in the preparation stage displayed the highest motivation-ruler ratings (all rulers F 2, 363 ≥ 43; p < 0.001). After adjusting for covariables, each of the rulers significantly improved prediction of smoking behavior change. The strength of their predictive ability was on par with that of stage of change.
Our results provide preliminary support for the psychometric soundness of the importance, readiness, and confidence rulers.
PMCID: PMC3507634  PMID: 23186265
Tobacco; Tobacco cessation; Motivation; Stage of change; Reliability; Validity
22.  The Psychiatric Emergency Research Collaboration-01: methods and results 
General hospital psychiatry  2009;31(6):515-522.
To describe the Psychiatric Emergency Research Collaboration (PERC), the methods used to create a structured chart review tool and the results of our multicenter study.
Members of the PERC Steering Committee created a structured chart review tool designed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients. Ten primary indicators were chosen based on the Steering Committee’s professional experience, the published literature and existing consensus panel guidelines. Eight emergency departments completed data abstraction of 50 randomly selected emergency psychiatric patients, with seven providing data from two independent raters. Inter-rater reliability (Kappas) and descriptive statistics were computed.
Four hundred patient charts were abstracted. Initial concordance between raters was variable, with some sites achieving high agreement and others not. Reconciliation of discordant ratings through re-review of the original source documentation was necessary for four of the sites. Two hundred eighty-five (71%) subjects had some form of laboratory test performed, including 212 (53%) who had urine toxicology screening and 163 (41%) who had blood alcohol levels drawn. Agitation was present in 220 (52%), with 98 (25%) receiving a medication to reduce agitation and 22 (6%) being physically restrained. Self-harm ideation was present in 226 (55%), while other-harm ideation was present in 82 (20%). One hundred seventy-nine (45%) were admitted to an inpatient or observation unit.
Creating a common standard for documenting, abstracting and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions.
PMCID: PMC2852101  PMID: 19892209
Psychiatric emergency; Emergency medicine; Psychiatry

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