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1.  The Effect of Removing Cost as a Barrier to Treatment Initiation With Outpatient Tobacco Dependence Clinics Among Emergency Department Patients 
Objectives
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1111/j.1553-2712.2011.01048.x
PMCID: PMC3777236  PMID: 21518096
2.  Trends in US Emergency Department Visits for Attempted Suicide and Self-inflicted Injury, 1993–2008 
General hospital psychiatry  2012;34(5):557-565.
Objective
To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.
Method
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.
Results
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.
Conclusions
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.
doi:10.1016/j.genhosppsych.2012.03.020
PMCID: PMC3428496  PMID: 22554432
Suicide; Emergency Departments; Public Health
3.  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.
doi:10.1016/j.drugalcdep.2008.06.015
PMCID: PMC2636871  PMID: 18775606
technology; substance abuse treatment; referrals; treatment matching; substance abuse screening; treatment initiation
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.
doi:10.1080/07347332.2010.532299
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.
doi:10.1111/j.1553-2712.2012.01291.x
PMCID: PMC3664550  PMID: 22435866
6.  Multicenter Study of Predictors of Suicide Screening in Emergency Departments 
Objectives
To provide estimates and predictors of screening for suicide in emergency departments (EDs).
Methods
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.
Results
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%).
Conclusions
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.
doi:10.1111/j.1553-2712.2011.01272.x
PMCID: PMC3664554  PMID: 22288721
7.  Intentions to Quit Smoking: Causal Attribution, Perceived Illness Severity, and Event-Related Fear During an Acute Health Event 
Background
Experiencing a serious consequence related to one’s health behavior may motivate behavior change.
Purpose
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.
Methods
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.
Results
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).
Conclusion
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.
doi:10.1007/s12160-010-9227-z
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
8.  The Computer-Assisted Brief Intervention for Tobacco (CABIT) Program: A Pilot Study 
Background
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.
Objective
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.2196/jmir.2074
PMCID: PMC3799483  PMID: 23208070
technology; tobacco use cessation; smoking cessation; referrals
9.  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.
doi:10.1155/2012/935139
PMCID: PMC3444830  PMID: 22997584
10.  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.
doi:10.1007/s13181-011-0149-3
PMCID: PMC3667954  PMID: 21455810
Technology; mHealth; Medication adherence; HIV
11.  Patient preferences for emergency department-initiated tobacco interventions: a multicenter cross-sectional study of current smokers 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1940-0640-7-4
PMCID: PMC3414814  PMID: 22966410
Smoking; Tobacco; Cigarettes; Emergency medicine; Counseling; Patient preference
12.  Motivation rulers for smoking cessation: a prospective observational examination of construct and predictive validity 
Background
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.
Methods
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.
Results
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.
Conclusion
Our results provide preliminary support for the psychometric soundness of the importance, readiness, and confidence rulers.
doi:10.1186/1940-0640-7-8
PMCID: PMC3507634  PMID: 23186265
Tobacco; Tobacco cessation; Motivation; Stage of change; Reliability; Validity
13.  The Psychiatric Emergency Research Collaboration-01: methods and results 
General hospital psychiatry  2009;31(6):515-522.
Objective
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.
Method
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.
Results
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.
Conclusion
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.
doi:10.1016/j.genhosppsych.2009.04.009
PMCID: PMC2852101  PMID: 19892209
Psychiatric emergency; Emergency medicine; Psychiatry
14.  An Evidence-Based Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Emergency Department (ED) Providers Improves Skills and Utilization 
SUMMARY
Objective
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.
Methods
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 (www.ed.bmc.org/sbirt). A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure.
Results
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.
Conclusions
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.
doi:10.1300/J465v28n04_01
PMCID: PMC3976968  PMID: 18077305
Brief intervention; alcohol screening; substance abuse; alcohol education
15.  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.
doi:10.1007/s13181-011-0149-3
PMCID: PMC3667954  PMID: 21455810
Technology; mHealth; Medication adherence; HIV

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