An evaluation of collaborative interventions to improve chronic illness care. Framework and study design

The author's dual-purpose evaluation assesses the effectiveness of formal collaboratives in stimulating organizational changes to improve chronic illness care (the chronic care model or CCM). Intervention and comparison sites are compared before and after introduction of the CCM. Multiple data sources are used to measure the degree of implementation, patient-level processes and outcomes, and organizational and team factors associated with success. Despite challenges in timely recruitment of sites and patients, data collection on 37 participating organizations, 22 control sites, and more than 4,000 patients with diabetes, congestive heart failure, asthma, or depression is nearing completion. When analyzed, these data will shed new light on the effectiveness of collaborative improvement methods and the CCM.     

Comparisons of Test Statistics Arising from Marginal Analyses of Multivariate Survival Data

We investigate the properties of several statistical tests for comparing treatment groups with respect to multivariate survival data, based on the marginal analysis approach introduced by Wei, Lin and Weissfeld [Regression Analysis of multivariate incomplete failure time data by modelling marginal distributians, JASA vol. 84 pp. 1065–1073]. We consider two types of directional tests, based on a constrained maximization and on linear combinations of the unconstrained maximizer of the working likelihood function, and the omnibus test arising from the same working likelihood. The directional tests are members of a larger class of tests, from which an asymptotically optimal test can be found. We compare the asymptotic powers of the tests under general contiguous alternatives for a variety of settings, and also consider the choice of the number of survival times to include in the multivariate outcome. We illustrate the results with simulations and with the results from a clinical trial examining recurring opportunistic infections in persons with HIV.     

Comparative Potency Method for Cancer Risk Assessment: Application to Diesel Particulate Emissions1

An estimation of the human lung cancer “unit risk” from diesel engine particulate emissions has been made using a comparative potency approach. This approach involves evaluating the tumorigenic and mutagenic potencies of the particulates from four diesel and one gasoline engine in relation to other combustion and pyrolysis products (coke oven, roofing tar, and cigarette smoke) that cause lung cancer in humans. The unit cancer risk is predicated on the linear nonthreshold extrapolation model and is the individual lifetime excess lung cancer risk from continuous exposure to 1 μg carcinogen per m³ inhaled air. The human lung cancer unit risks obtained from the epidemiologic data for coke oven workers, roofing tar applicators, and cigarette smokers were, respectively, 9.3 × 10^?4, 3.6 × 10^?4, and 2.2 × 10^?6 per μg particulate organics per m³ air. The comparative potencies of these three materials and the diesel and gasoline engine exhaust particulates (as organic extracts) were evaluated by in vivo tumorigenicity bioassays involving skin initiation and skin carcinogenicity in SENCAR mice and by the in vitro bioassays that proved suitable for this analysis: Ames Salmonella microsome bioassay, L5178Y mouse lymphoma cell mutagenesis bioassay, and sister chromatid exchange bioassay in Chinese hamster ovary cells. The relative potencies of the coke oven, roofing tar, and cigarette smoke emissions, as determined by the mouse skin initiation assay, were within a factor of 2 of those determined using the epidemiologic data. The relative potencies, from the in vitro bioassays as compared to the human data, were similar for coke oven and roofing tar, but for the cigarette smoke condensate the in vitro tests predicted a higher relative potency. The mouse skin initiation bioassay was used to determine the unit lung cancer risk for the most potent of the diesel emissions. Based on comparisons with coke oven, roofing tar, and cigarette smoke, the unit cancer risk averaged 4.4 × 10^?4. The unit lung cancer risks for the other, less potent motor-vehicle emissions were determined from their comparative potencies relative to the most potent diesel using three in vitro bioassays. There was a high correlation between the in vitro and in vivo bioassays in their responses to the engine exhaust particulate extracts. The unit lung cancer risk per μg particulates per m³ for the automotive diesel and gasoline exhaust particulates ranged from 0.20 × 10^?4 to 0.60 × 10^?4; that for the heavy-duty diesel engine was 0.02 × 10^?4. These unit risks provide the basis for a future assessment of human lung cancer risks when combined with human population exposure to automotive emissions.     

THE THERAPEUTIC ALLIANCE IN HOME‐BASED FAMILY THERAPY: IS IT PREDICTIVE OF OUTCOME?

This study examined the association between the therapeutic alliance in family therapy and changes in symptom distress, interpersonal relationships, and family coping. The participants (N = 81) were members of low socioeconomic status families referred to a university clinic for in-home family therapy. Participants completed the Outcome Questionnaire, Family Crisis Oriented Personal Evaluation, and the Family Therapy Alliance questionnaires. Regression analyses revealed that the therapeutic alliance explained 19% of the variance in symptom distress changes for mother, 55% for fathers, and 39% for adolescents. The implications of these findings for practicing and researching family therapy are presented.     

"Languaging" factors affecting clients' acceptance of forgiveness intervention in marital therapy

Forgiveness is a significant intervention for healing interpersonal injury. Yet therapists do not often use forgiveness intervention. Employing a semantic perspective and a survey design (n = 307), this study investigated whether the language used to rationalize forgiveness intervention (set at five levels: personal growth, relationship reconciliation, spiritual issue, others' growth, and pardoning/condoning) may affect its acceptability. Gender, problem type, and choice were also included in the analyses. Overall, forgiveness was found to be an acceptable intervention. A pardoning/condoning rationale led to significantly lower acceptability ratings. Other results are discussed. We conclude that therapists should be less apprehensive about using forgiveness, but need to inform themselves better concerning its purpose, process, and articulation.     

Why mentoring in the workplace works

Workplaces are ideal contexts for mentoring relationships between adults and older youth. To teach the competencies required in contemporary workplaces (many of which are equally useful in other settings), mentors need to use sophisticated teaching behaviors, which the authors characterize as reflective questioning and problem solving.     

An Empirical Test of the Relative Validity of Expert and Lay Judgments of Risk

This article investigates how accurately experts (underwriters) and lay persons (university students) judge the risks posed by life-threatening events Only one prior study (Slovic, Fischhoff, & Lichtenstein, 1985) has previously investigated the veracity of expert versus lay judgments of the magnitude of risk. In that study, a heterogeneous grouping of 15 experts was found to judge, using marginal estimations, a variety of risks as closer to the true annual frequencies of death than convenience samples of the lay population. In this study, we use a larger, homogenous sample of experts performing an ecologically valid task. We also ask our respondents to assess frequencies and relative frequencies directly, rather than ask for a "risk" estimate--a response mode subject to possible qualitative attributions-as was done in the Slovic et al. study. Although we find that the experts outperformed lay persons on a number of measures, the differences are small, and both groups showed similar global biases in terms of: (1) overestimating the likelihood of dying from a condition (marginal probability) and of dying from a condition given that it happens to you (conditional probability), and (2) underestimating the ratios of marginal and conditional likelihoods between pairs of potentially lethal events. In spite of these scaling problems, both groups showed quite good performance in ordering the lethal events in terms of marginal and conditional likelihoods. We discuss the nature of expertise using a framework developed by Bolger and Wright (1994), and consider whether the commonsense assumption of the superiority of expert risk assessors in making magnitude judgments of risk is, in fact, sensible.     

The impact of touch-tone data entry on reports of HIV and STD risk behaviors in telephone interviews

Respondents concerns about privacy can decrease reporting of HIV and STD risk behaviors in general population telephone surveys. The purpose of this paper is to describe the results of an experimental study evaluating whether one method for increasing privacy, touch-tone data entry (TTDE), is effective in increasing estimates of sexual behaviors from a population-based survey. We conducted a random-digit-dial telephone survey of adults in New Jersey (n = 405), with half the respondents using TTDE for answering sexual behavior questions. TTDE led to increased reports of same-sex sexual behavior, certain HIV and STD risk factors, and concern about one s risk for HIV and STD transmission. TTDE also narrowed the difference between men s and women s reports of the number of different sexual partners over the past 10 years. The feasibility and limitations of TTDE are discussed, as well as possible alternative interpretations that consider the impact of TTDE on the dynamics of the interaction between the respondent and the interviewer.