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PubMed2006

A mixed effects Markov model for repeated binary outcomes with non-ignorable dropout.

In many areas of research, repeated binary measures often represent a two-state stochastic process, where individuals can transition among two states. In a behavioural or physical disability setting, individuals can flow from susceptible or subthreshold state, to an infectious or symptomatic state, and back to a subthreshold state. Quite often the transition among the states happens in continuous time but is observed at discrete, irregularly spaced timepoints which may be unique to each individual. Methods for analyses of such data are typically based on the Markov assumption. Cook (Biometrics 1999; 55:915-920) introduced a conditional Markov model that accommodates the subject-to-subject variation in the model parameters with random effects. We extend this model by adding a non-ignorable dropout component to the model. Specification of the distribution of the random effects is made to guarantee a closed form expression of the marginal likelihood. This methodology is illustrated by applications to a data set from a parasitic field infection survey, a data set from a cocaine treatment study, and a data set from an aging study. Simulations suggest that the shared parameter model is robust with respect to at least one alternative non-ignorable model.

Activities of Daily Living↗

PubMed1990

School-based prevention of teen-age pregnancy and school dropout: process evaluation of the national replication of the Teen Outreach Program.

Examined a program designed to prevent adolescent pregnancy, school failure, and dropout using a process model of evaluation to assess with which groups of participants and under what conditions the program was most effective. Students in the Teen Outreach Program of the Association of Junior Leagues and matched comparison students in 35 schools nationwide participated. Sites that highly utilized a volunteer service component, and sites that primarily served older students reported lower levels of student problem behaviors at program exit, after controlling for problem behaviors at entry. These findings occurred only for program youths and not for comparison youths. The connection of volunteer service to reductions in adolescent problem behaviors is interpreted in terms of helper-therapy and empowerment theories. Limitations of the analytic strategy used in this study, as well as techniques for addressing the limitations, are also discussed.

Adolescent↗

PubMed1979

Dropouts and terminators from a community mental health center: their use of other psyciatric services.

Differences in patterns of utilization of psychiatric services were studied in 178 adult outpatients who either had dropped out of, or had terminated from treatment with the consent of their therapists. The Monroe County Psychiatric Case Register was employed to determine the use of psychiatric services by these patients within a period of two years before and two years after their admission to a community mental health center (CMHC). Dropping out of treatment was associated with a pattern of utilization of multiple psychiatric facilities. Of those individuals who made contact with a psychiatric facility both prior to and subsequent to their admission to the CMHC, the dropout group made, on the average, approximately twice as many contacts per person as the terminator group.

Adolescent↗

PubMed1994

Inpatient PTSD treatment: a study of pretreatment measures, treatment dropout, and therapist ratings of response to treatment.

Pretreatment measures including demographic variables, adjustment index variables and psychological testing variables were studied in relationship to treatment dropout and therapist ratings of overall response to treatment among PTSD veterans in an inpatient PTSD program. Analysis comparing a group of fourteen veterans who dropped out of treatment early and a random sample of fourteen who successfully completed treatment showed no significant differences. Analysis comparing a group of 35 veterans who received the highest therapist ratings on response to treatment with a group of 35 veterans receiving the lowest ratings on response to treatment also showed no significant differences. Analysis of subgroups of patients who had completed the Millon Clinical Multiaxial Inventory (MCMI) and received high versus low therapist ratings showed one significant difference on the hypomania scale. Overall findings on the MMPI and MCMI appeared similar to other investigations of PTSD.

Adult↗

PubMed2006

Predictors of follow-up and assessment of selection bias from dropouts using inverse probability weighting in a cohort of university graduates.

Dropouts in cohort studies can introduce selection bias. In this paper, we aimed (i) to assess predictors of retention in a cohort study (the SUN Project) where participants are followed-up through biennial mailed questionnaires, and (ii) to evaluate whether differential follow-up introduced selection bias in rate ratio (RR) estimates. The SUN Study recruited 9907 participants from December 1999 to January 2002. Among them, 8647 (87%) participants answered the 2-year follow-up questionnaire. The presence of missing information in key variables at baseline, being younger, smoker, a marital status different of married, being obese/overweight and a history of motor vehicle injury were associated with being lost to follow-up, while a self-reported history of cardiovascular disease predicted a higher retention proportion. To assess whether differential follow-up affected RR estimates, we studied the association between body mass index and the risk of hypertension, using inverse probability weighting (IPW) to adjust for confounding and selection bias. Obese individuals had a higher crude rate of hypertension compared with normoweight participants (RR=6.4, 95% confidence interval (CI): 3.9-10.5). Adjustment for confounding using IPW attenuated the risk of hypertension associated to obesity (RR=2.4, 95% CI: 1.1-5.3). Additional adjustment for selection bias did not modify the estimations. In conclusion, we show that the follow-up through mailed questionnaires of a geographically disperse cohort in Spain is possible. Furthermore, we show that despite existing differences between retained or lost to follow-up participants this may not necessarily have an important impact on the RR estimates of hypertension associated to obesity.

Adult↗

PubMed2006

Participation in occupational health longitudinal studies: predictors of missed visits and dropouts.

PURPOSE: The purpose of this study is to determine whether demographics, health, and job factors influence continued participation of employed persons in a longitudinal intervention study of tertiary prevention for work-related low-back disorders (WR-LBDs). METHODS: Four hundred fifty-four actively employed persons had enrolled in an intervention study of back supports and education to promote recovery from a WR-LBD. Baseline values were examined according to whether individuals continued in the study, missed a visit, or dropped out; frequency of missed visits; and early or late dropouts at follow-up intervals of 1, 2, 6, and 12 months. RESULTS: Workers who did not complete all study visits were significantly more likely to be younger and have poorer self-reported health. Individuals with a greater percentage of body fat dropped out early. Significantly more missed visits were observed among those who had arthritis and longer duration of low-back pain symptoms. Job factors did not influence study participation. CONCLUSIONS: Continued participation in a longitudinal study of working adults was influenced by age, health status, and factors related to the primary condition targeted by the intervention study. Strategies aimed at those who report lower levels of health and symptoms related to the condition under study may promote follow-up participation in longitudinal studies. Thus, even among actively employed persons, one should not assume that all workers are "healthy."

Adiposity↗

PubMed2005

The role of the early therapeutic alliance in predicting drug treatment dropout.

BACKGROUND: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment. METHODS: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention. RESULTS: Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological well-being, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer. CONCLUSIONS: The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors' alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention.

Adaptation, Psychological↗

PubMed2004

Survival analysis of dropout patterns in dieting clinical trials.

Subjects who withdraw from diet clinical trials are a drain on limited resources and reduce statistical power. Dropout pattern data, collected during a clinical trial for which the primary findings compared weight loss from three dieting protocols, are examined using survival analysis and found to be exponentially distributed. The predicted probability of remaining in the study is 83% for 30 days and 60% for 84 days. Survival analysis methods consider subjects who did not return after the initial visit and others who may have continued dieting beyond study termination. When applied to clinical trials, this type of analysis provides valuable information for planning and budgeting of future trials. Inclusion of a 1- to 2-week run-in period at the beginning of the study may improve retention. Otherwise, the diet researcher should consider increasing initial randomized sample size by approximately 10% to 25% as an allowance for early withdrawals.

Body Mass Index↗

PubMedDate not supplied

Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity.

BACKGROUND: Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves outcomes and postoperative compliance. We compared outcomes of GBP patients undergoing a mandatory 13 weeks of PDC (n = 72) to a contemporaneous group of patients with no such requirement (no-PDC; n = 252) who underwent operation between January 2000 and December 2002. METHODS: The PDC and no-PDC groups were characterized by similar male:female ratios (1:4 vs 1:4.6), mean age (42 years), mean body weight (324 lb vs 309 lb), and mean body mass index (BMI) (52 kg/m2 vs 50 kg/m2). The PDC group had a higher incidence of obstructive sleep apnea compared with the no-PDC group (41% vs 28%; P < .04) but otherwise the two groups had similar incidences of obesity-related comorbidities. The presurgery dropout rate was 50% higher in the PDC group than in the no-PDC group (28% vs 19%; P < .05). RESULTS: At 1 year follow-up, the no-PDC patients had a statistically greater percentage excess weight loss (67% vs 60%; P < .0001), lower BMI (32 vs 35; P < .015), and lower body weight (197 vs 218; P < .01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups. CONCLUSIONS: The data demonstrate that insurance-mandated PDC is an obstacle to patient access for surgical treatment of severe obesity and has no impact on weight loss outcome or postsurgical compliance. PDC should be abandoned by the insurance industry.

Adult↗

PubMedDate not supplied

A comparison of three "interventions" on pretreatment dropout rates in an outpatient substance abuse clinic.

Studies examining pretreatment dropout in outpatient substance abuse clinics have consistently demonstrated that fewer days between phone contact and scheduled intake appointment result in higher client show rates. To compare time to intake with two other interventions hypothesized to increase show rates, individuals (N = 128) seeking treatment were randomly assigned to one of four groups. Individuals in Group 1 were scheduled within 48 hours of the telephone intake. Individuals in Groups 2, 3, and 4 were scheduled 48 hours or more after the telephone intake and received either a reminder call 24 hours prior to their appointment (Group 2), an appointment card and clinic brochure in the mail (Group 3), or no intervention (Group 4). The results show that Group 1 had a higher show rate as compared to the other three groups, and receiving a reminder call or an appointment card did not improve show rates beyond that of the no-contact control group. Implications for intake procedures are discussed.

Adult↗

PubMed2001

Drug use, HIV-related risk behaviors and dropout status of new admissions and re-admissions to methadone treatment.

New entrants to methadone maintenance treatment programs (MMTP) have been reported to have different drug use patterns than re-admissions. This study assesses differences between 211 re-admissions and 128 new admissions to a NYC MMTP. Those new to MMTP were found to be less likely to have ever injected drugs, have used more types of drugs, and used heroin at higher frequencies in the 30 days prior to admission. Within the first three months of treatment, new admissions dropped out at a higher rate than the re-admissions (31% vs. 20%, p < 0.05). The most frequent reasons for dropout, for both groups, included "lost to contact" and incarceration. Further research on strategies to address polydrug use of MMTP admissions is needed. Efforts to identify concerns of new admissions early in treatment, and programs to continue drug treatment services to incarcerated clients, are indicated.

Adult↗

PubMed2005

Risk and protective factors for substance use among African American high school dropouts.

Risk and protective factors that predict substance use were investigated with 318 African American high school dropout youths who completed the 1992 follow-up of the National Educational Longitudinal Study of 1988. A conceptual model linking positive family relationships and religious involvement to youths' substance use and conventional peer affiliations through a positive life orientation was examined with structural equation modeling. Positive life orientation, which included optimism and conventional goals for the future, fully mediated the influence of family relationships on conventional peer affiliations. Religious involvement directly predicted conventional peer affiliations and positive life orientation. Conventional peer affiliations mediated the other variables' influence on substance use.

Black or African American↗

PubMed1985

Characteristics of dropouts, remainers, and refusers at a psychosocial rehabilitation program for the chronically mentally disabled.

Thirty-eight chronically mentally disabled patients who were invited to join a newly established, vocationally oriented, day treatment program in Raleigh, North Carolina, served as subjects. We attempted to determine whether demographic and psychosocial characteristics significantly differed among groups of clients who dropped out of, remained in, or refused membership in this community-support program. A variety of demographic, expectancy, psychological, and psychosocial measures were administered to each subject. Most significant was the finding that the subjects' perceived level of help and support from friends was a significant determinant of the level of program participation. Those subjects who refused to participate (refusers) perceived themselves as receiving proportionately less support than did members of the other two groups (dropouts and remainers).

Adult↗

PubMed2003

HIV-related mental health care: factors influencing dropout among low-income, HIV-positive individuals.

A prospective design was used to collect data from 132 HIV-positive individuals presenting for mental health care at an inner-city HIV-related mental health clinic located in a large metropolitan area of the Southeastern USA. Data were analyzed to assess associations between study variables and whether participants returned for care following an initial mental health assessment. Hierarchical logistic regression analyses were conducted to determine the extent to which the addition of measures of health beliefs and HIV-related stigma would enhance the predictive capacity of a dropout model that included demographics and health status measures. As health beliefs and HIV-related stigma were added to the model, the predictive capacity increased significantly (R(2)=0.29 to R(2)=0.63, p<0.05). Those who did not return for care had higher levels of perceived barriers to mental health care, higher levels of HIV-related stigma, were more likely to be of non-white ethnicity and had lower T-cell counts. These findings indicate that mental health providers may need to ensure care systems are responsive to the social and cultural characteristics of clients, and the HIV epidemic itself, in order to effectively engage clients into care.

Adult↗

PubMed1999

Health risk behaviors of Texas students attending dropout prevention/recovery schools in 1997.

This study determined prevalence of health risk behaviors of 9th through 12th grade students attending dropout prevention/recovery alternative schools in Texas in 1997. Participants were 470 youth whose health risk behaviors were assessed using the Youth Risk Behavior Survey in an anonymous, self-administered format. Behaviors measured included frequency of weapon-carrying and fighting, suicide-related behaviors, substance use, and sexual behaviors. A substantial percentage of alternative school students reported participating in behaviors that placed them at acute or chronic health risk. Differences in the prevalence of risk behaviors were noted by gender, racial/ethnic, and age subgroups. In addition, alternative school students frequently engaged in multiple risk behaviors. These findings suggest a need for comprehensive school-based health education/intervention programs to reduce the prevalence of risk behaviors in populations of alternative school students.

Adolescent↗

PubMedDate not supplied

Dropout from brief psychotherapy within a combination treatment in bulimia nervosa: role of personality and anger.

BACKGROUND: To explore the personality, psychopathology, and clinical features of bulimic patients who do not complete psychotherapy, within a combined treatment. METHODS: 86 patients with bulimia nervosa (BN; DSM-IV) were evaluated before beginning treatment. The Eating Disorder Inventory II (EDI-II), State-Trait Anger Expression Inventory (STAXI), and the Temperament and Character Inventory (TCI) were administered to all patients. RESULTS: 3 subjects failed to engage in psychotherapy. Comparing patients who dropped out (n = 28) with those who did not drop out from psychotherapy (n = 55), significant differences were found in some psychopathologic (EDI-II, STAXI) and personality (TCI) variables. In particular, patients who dropped out from the treatment were more impulsive and more likely to feel anger; they were also less cooperative and less self-directive. No significant differences in sociodemographic, clinical variables and in response to fluoxetine were found between the two groups (dropout and completers). CONCLUSIONS: We found a characteristic profile in the bulimic patients who dropped out from brief psychotherapy, i.e., they are less cooperative and more predisposed to anger. These data suggest that dropping out in a subgroup of BN patients could be related to borderline personality traits and to difficulties in making and maintaining a therapeutic relationship. Implications for treatment are discussed.

Adult↗

PubMed1985

Early dropouts in brief dynamic psychotherapy.

Brief dynamic psychotherapy at the Psychiatric Clinic of Athens University follows the approach of Malan and Sifneos and the selection criteria proposed by Davanloo. The early dropout phenomenon was studied in 24 therapies, in relation to variables included in the selection criteria. The statistical analysis was based on discriminant analysis. A high final score, early transference confrontation, circumscribed problem of the patient, high motivation for treatment and existence of crisis were strongly associated with continuation of brief psychotherapy.

Adolescent↗

PubMed1997

Pretreatment dropouts: characteristics and outcomes.

The characteristics and outcome results of 123 cocaine dependent patients who dropped out following intake without returning for even one treatment visit were compared with those of 324 who did return and received at least one treatment service and 118 who remained on the program for two months or more. The pre-treatment dropouts were more often positive for cocaine on admission drug screens and less often employed. They reported fewer psychological symptoms on the scales of the SCL-90 and received lower scores on the medical problem severity scale of the ASI. At 9-month follow-up they were found to have less often attended self-help meetings or continued in outpatient treatment, more often to have been admitted for inpatient treatment or been in jail, less often returned to school and were more often using cocaine. Clearly, clinicians and researchers need a better understanding of these patients who account for significant attrition, have distinguishing characteristics, and do much more poorly than those who remain in treatment.

Adult↗