An embedded randomised controlled retention trial of personalised text messages compared to non-personalised text messages in an orthopaedic setting

Background: Several studies have investigated whether personalising trial documentation can aid recruitment and retention. We did a 'study within a trial' (SWAT) evaluating the effectiveness of a personalised text message compared to a non-personalised text message, on the retention rate in a large orthopaedic trial. Methods: The SWAT was embedded in the Knee Replacement Bandaging Study (KReBS) trial. The primary outcome was the proportion of 12-month questionnaires returned. Secondary outcomes were the proportion of questionnaires completed and time to questionnaire return. Binary data were analysed using logistic regression and time to return using Cox proportional hazards regression.  Odds ratios (OR) and hazard ratios (HR) are presented, with associated 95% confidence intervals (CI) and p-values. Results: In total, 1465 participants were included in the SWAT. In the personalised group, 644/723 (89.1%) of participants returned a questionnaire, compared to 654/742 (88.1%) in the non-personalised group. The absolute difference in return rate was 0.9% (95% CI: -2.3% to 4.2%; p=0.57). There was no evidence of a difference between the groups in the likelihood of returning a questionnaire (OR 1.09; 95% CI: 0.79 to 1.51; p=0.61), the likelihood of returning a complete questionnaire (OR 1.11; 95% CI: 0.82 to 1.51; p=0.50) nor in time to return (HR 1.05; 95% CI: 0.94 to 1.17; p=0.40). Conclusion: This SWAT adds to the growing evidence base for whether personalised text messages are effective. Registration: ISRCTN87127065 (20/02/2017); SWAT 35 (01/12/2015).

Predictors of Engagement in a Pediatric Weight Management Clinic after Referral

Background: Little is known about factors that affect a family's ability to engage in pediatric weight management clinics (PWMCs). We aimed at comparing child and family characteristics of patients referred to a PWMC by participants' attendance at orientation, attendance at intake, or completing the program. Methods: We performed a retrospective study of patients ages 2-18 years referred to a PWMC between 2014 and 2017. We extracted data from electronic medical records and clinic databases, including age, sex, race/ethnicity, language, referral year, address, and insurance. We performed t-tests and chi-square tests to examine the association of engagement outcomes with covariates. We used separate multivariate logistic regression models to assess the predictors of engagement outcomes, including significant covariates from bivariate analyses. Results: Participants (N = 2020 referred) had a mean age of 11.5 ± 3.5 years; 72% had Medicaid, and 34% lived in city limits. Participants were 39% white, 30% black, and 27% Hispanic. Of those referred, 41% attended orientation, 14% attended intake, and 9% completed. Significant predictors of attending orientation were age [odds ratio (OR): 0.93, 95% confidence interval (CI): 0.91-0.96], male sex (OR: 0.74, 95% CI: 0.60-0.91), Hispanic ethnicity (OR: 1.69, 95% CI: 1.26-2.26), living in city limits (OR: 1.39, 95% CI: 1.11-1.75), and Medicaid (OR: 0.77, 95% CI: 0.60-0.98). Significant predictors of attending intake were age (OR: 0.93, 95% CI: 0.90-0.96), Medicaid (OR: 0.61, 95% CI: 0.46-0.81), and 2017 referral year (OR: 0.21, 95% CI: 0.12-0.35). Hispanic ethnicity was associated with twice the odds of completion (OR: 2.07, 95% CI: 1.10-3.91). Conclusions: Child and family characteristics more strongly predicted initial engagement with a PWMC than completion. Future research should examine how targeting these predictors (e.g., referring at younger age) can improve PWMC engagement.

Risk Factors for Attrition From Pediatric Trauma-Focused Treatment

Rates of attrition from pediatric trauma-focused treatments are high, yet few studies have examined predictors of dropout. The aim of the study was to investigate whether higher levels of caregiver- and child-reported pretreatment difficulties predicted attrition from trauma-focused therapy. One hundred seventy-two children aged 6-18 (M = 10.53, SD = 3.36; 64% female, 64% Black) and their caregivers were included in the study. Two operational definitions of attrition were utilized: (1) clinician-rated dropout and (2) whether the child received an adequate dose of treatment (i.e., 12 or more sessions). Rates of clinician-rated attrition were high (76.2%); however, 73.8% received an adequate dose. Despite expectations, higher levels of rule-breaking and aggressive behavior were related to clinician-rated dropout (d = 0.59, .63, respectively) but were not significant predictors in a logistic regression model. Child-reported symptoms were unrelated to clinician-rated attrition. Higher levels of caregiver-reported anxiety/depression, somatic complaints, and trauma-related difficulties corresponded with adequate dose (ds = 0.52-1.06). Yet only caregiver-reported sexual concerns predicted adequate dose in a regression model (OR = 1.09). Caregiver- and child-reported symptoms may be unrelated to clinician-rated treatment completion and appear to play a small role in understanding whether the child received an adequate dose of treatment.

A meta-analysis of dropout rates from exposure with response prevention and pharmacological treatment for youth with obsessive compulsive disorder

OBJECTIVE

Beliefs that exposure with response prevention (ERP) is excessively distressing and will result in client dropout from treatment are commonly-cited reasons for clinicians not providing evidence-based treatment. This meta-analysis examined treatment attrition for ERP for youth with obsessive compulsive disorder (OCD) compared with other treatment modalities.

METHOD

A systematic literature search identified 11 randomized controlled trials (RCTs) comparing ERP to active or waitlist control conditions, 9 comparing pharmacotherapy to control, and 3 comparing ERP to pharmacotherapy for youth with OCD.

RESULTS

Attrition rates were low for ERP (10.24%) compared to pharmacotherapy (17.29%), active control (e.g., relaxation, metacognitive therapy; 20.63%), and pill placebo (23.49%). ERP had lower risk of attrition compared to active control conditions (RR = 0.60; p = .02), and was not significantly different to waitlist (RR = 0.80; p = .59). In head-to-head trials, there was no difference between the risk of attrition from ERP and pharmacotherapy (RR = 1.26; p = .74). Of the pharmacotherapy trials, risk of attrition from serotonin reuptake inhibitors treatment was not significantly different compared to placebo (RR = 0.94; p = .76), with no difference between antidepressants and clomipramine (p = .19). Attrition from ERP was primarily for logistical reasons, compared to lack of efficacy for relaxation and/or adverse reactions from pharmacotherapy.

CONCLUSIONS

Attrition from ERP is low, and is generally lower than non-ERP interventions. Given favorable attrition and efficacy data, there is little justification for appropriately-trained clinicians not to offer ERP as a first-line treatment for youth with OCD.

Controlling for selective dropout in longitudinal dementia data: Application to the SveDem registry

Introduction

Loss to follow‐up in dementia studies is common and related to cognition, which worsens over time. We aimed to (1) describe dropout and missing cognitive data in the Swedish dementia registry, SveDem; (2) identify factors associated with dropout; and (3) estimate propensity scores and use them to adjust for dropout.

Methods

Longitudinal cognitive data were obtained from 53,880 persons from the SveDem national quality dementia registry. Inverse probability of censoring weights (IPCWs) were estimated using a logistic regression model on dropout.

Results

The mean annualized rate of change in Mini‐Mental State Examination (MMSE) in those with a low MMSE (0 to 10) was likely underestimated in the complete case analysis (+1.5 points/year) versus the IPCW analysis (−0.3 points/year).

Discussion

Handling dropout by IPCWs resulted in plausible estimates of cognitive decline. This method is likely of value to adjust for biased dropout in longitudinal cohorts of dementia.

Athletic Trainer Burnout: A Systematic Review of the Literature

OBJECTIVE

To identify the causes, effects, and prevalence of burnout in athletic trainers (ATs) identified in the literature.

DATA SOURCES

EBSCO: SPORTDiscus and OneSearch were accessed, using the search terms athletic trainer AND burnout.

STUDY SELECTION

Studies selected for inclusion were peer reviewed, published in a journal, and written in English and investigated prevalence, causes, effects, or alleviation of AT burnout.

DATA EXTRACTION

The initial search yielded 558 articles. Articles that did not specifically involve ATs were excluded from further inspection. The remaining 83 full-text articles were reviewed. Of these 83 articles, 48 examined prevalence, causes, effects, or alleviation of AT burnout. An evaluation of the bibliographies of those 48 articles revealed 3 additional articles that were not initially identified but met the inclusion criteria. In total, 51 articles were included in data collection.

DATA SYNTHESIS

Articles were categorized based on investigation of prevalence, causes, effects, or alleviation of burnout. Articles were also categorized based on which subset of the athletic training population they observed (ie, athletic training students, certified graduate assistants, high school or collegiate staff members, academic faculty).

CONCLUSIONS

Burnout was observed in all studied subsets of the population (ie, students, graduate assistants, staff, faculty), and multiple causes of burnout were reported. Suggested causes of burnout in ATs included work-life conflict and organizational factors such as poor salaries, long hours, and difficulties dealing with the "politics and bureaucracy" of athletics. Effects of burnout in ATs included physical, emotional, and behavioral concerns (eg, intention to leave the job or profession).

The cluster randomized crossover trial: The effects of attrition in the AB/BA design and how to account for it in sample size calculations

Background/Aims:

This article studies the effect of attrition in the cluster randomized crossover trial. The focus is on the two-treatment two-period AB/BA design where attrition occurs during the washout period. Attrition may occur at either the subject level or the cluster level. In the latter case, clusters drop out entirely and provide no measurements in the second period. Subject attrition can only occur in the cohort design, where each subject receives both treatments. Cluster attrition can also occur in the cross-sectional design, where different subjects are measured in the two time periods. Furthermore, this article explores two different strategies to account for potential levels of attrition: increasing sample size and replacing those subjects who drop out by others.

Methods:

The statistical model that takes into account the nesting of subjects within clusters, and the nesting of repeated measurements within subjects is presented. The effect of attrition is evaluated on the basis of the efficiency of the treatment effect estimator. Matrix algebra is used to derive the relation between efficiency, the degree of attrition, cluster size and the intraclass correlations: the within-cluster within-period correlation, the within-cluster between-period correlation and (in the case of a cohort design) the within-subject correlation. The methodology is implemented in two Shiny Apps.

Results:

Attrition in a cluster randomized crossover trial implies a loss of efficiency. Efficiency decreases with an increase of the attrition rate. The loss of efficiency due to attrition of subjects in a cohort design is largest for small number of subjects per cluster-period, but it may be repaired to a large degree by increasing the number of subjects per cluster-period or by replacing those subjects who drop out by others. Attrition of clusters results in a larger loss of efficiency, but this loss does not depend on the number of subjects per cluster-period. Repairing for this loss requires a large increase in the number of subjects per cluster-period. The methodology of this article is illustrated by an example on the effect of lavender scent on dental patients’ anxiety.

Conclusion:

This article provides the methodology of exploring the effect of attrition in cluster randomized crossover trials, and to repair for attrition. As such, it helps researchers plan their trial in an appropriate way and avoid underpowered trials. To use the methodology, prior estimates of the degree of attrition and intraclass correlation coefficients are needed. It is advocated that researchers clearly report the estimates of these quantities to help facilitate planning future trials.

Sociocognitive factors associated with lifestyle intervention attrition after successful weight loss among participants with prediabetes-The PREVIEW study

INTRODUCTION

Major risk factors for type 2 diabetes are lifestyle choices such as lack of physical activity (PA) and poor diet. Many individuals either do not take part or struggle to complete interventions supporting lifestyle changes. Demographic and theory-based sociocognitive factors associated with PREVIEW intervention attrition after successful weight loss were examined.

METHODS

Participants (1,856) who started the weight maintenance phase after completion of low-energy diet were retrospectively divided into three clusters depending on the point they left the trial. Discriminant analysis examined which demographic and theory-based sociocognitive variables were associated with cluster membership.

RESULTS

Most of the participants were women and well-educated. Two discriminant functions were calculated (χ² (24) = 247.0, p ≥ .05, d = 0.78). The demographic variables, such as age and ethnicity, and the social cognitive variable outcome expectancies on the other side were associated with cluster membership. Older age, Caucasian ethnicity, and fewer expected disadvantages of PA were associated with high success.

DISCUSSION

The discriminant model gave insight into some factors associated with early attrition. For practitioners planning interventions it underlines the necessity to take extra attention to younger participants and to those being afraid that being physically active causes unpleasant ramifications.

The Overtraining Syndrome in Soldiers: Insights from the Sports Domain

INTRODUCTION

Soldiers are exposed to extreme training regimens in order to optimally prepare for real battle. High attrition rates are a known issue during training courses, especially for elite troops. An underlying factor might be the disbalance between stress/strain and recovery. The aim of this review is to give insight in the current knowledge about functional overreaching (FOR), non-FOR (NFOR), and the overtraining syndrome (OTS) in the military.

MATERIALS AND METHODS

A systematic literature review was conducted. PubMed, IngentaConnect, Science Direct, and Web of Science were screened for the following keywords and combinations of search terms; military, personnel, OT, soldier.

RESULTS

Seven studies investigating the effects of OT during training courses were selected. The definitions used for OT varied widely and there is no systematic use of markers to determine FOR, NFOR, or the OTS in the military.

CONCLUSIONS

Much research on NFOR/OTS has been conducted in the sports domain and the military could make use of these insights to promote a more efficient balance between training load and recovery. It is suggested to regularly test soldiers on physical performance, psychomotor speed and mood using ideally a military-specific test or the 1.5-mile run, psychomotor vigilance test and Profile of Mood States. The two-bout exercise test can be used as a specific test if previous testing indicates the development of NFOR/OTS and can be combined with metabolic and immunological testing to exclude pathological causes.

A New Pathway to University Retention? Identity Fusion With University Predicts Retention Independently of Grades

Individuals who are "strongly fused" with a group view the group as self-defining. As such, they should be particularly reluctant to leave it. For the first time, we investigate the implications of identity fusion for university retention. We found that students who were strongly fused with their university (+1 SD) were 7-9% points more likely than weakly fused students (-1SD) to remain in school up to a year later. Fusion with university predicted subsequent retention in four samples (N = 3,193) and held while controlling for demographics, personality, prior academic performance, and belonging uncertainty. Interestingly, fusion with university was largely unrelated to grades, suggesting that identity fusion provides a novel pathway to retention independent of established pathways like academic performance. We discuss the theoretical and practical implications of these findings.

Dropout rates of in-person psychosocial substance use disorder treatments: a systematic review and meta-analysis

BACKGROUND AND AIMS

Relapse rates for psychosocial substance use disorder (SUD) treatments are high, and dropout is a robust predictor of relapse. This study aimed to estimate average dropout rates of in-person psychosocial SUD treatments and to assess predictors of dropout.

DESIGN

A comprehensive meta-analysis of dropout rates of studies of in-person psychosocial SUD treatment. Studies included randomized controlled trials (RCTs) and cohort studies.

SETTING

Studies conducted anywhere in the world that examined SUD treatment and were published from 1965 to 2016, inclusive.

PARTICIPANTS/CASES

One hundred and fifty-one studies, 338 study arms and 299 dropout rates including 26 243 participants.

MEASUREMENTS

Databases were searched for studies of SUD treatment that included an in-person psychosocial component. Meta-analyses and meta-regressions were conducted to estimate dropout rates and identify predictors of dropout, including participant characteristics, facilitator characteristics and treatment characteristics. Pooled estimates were calculated with random-effects analyses accounting for the hierarchical structure of study arms nested within studies.

FINDINGS

The average dropout rate across all studies and study arms was 30.4% [95% confidence interval (CI) = 27.2-33.8 and 95% prediction interval (PI) = 6.25-74.15], with substantial heterogeneity (I²  = 93.7%, P < 0.0001). Studies including a higher percentage of African Americans and lower-income individuals were associated with higher dropout rates. At intake, more cigarettes/day and a greater percentage of heroin use days were associated with lower dropout rates, whereas heavier cocaine use was associated with higher dropout rates. Dropout rates were highest for studies targeting cocaine, methamphetamines and major stimulants (broadly defined) and lowest for studies targeting alcohol, tobacco and heroin, although there were few studies on methamphetamines, major stimulants and heroin. Programs characterized by more treatment sessions and greater average session length were associated with higher dropout rates. Facilitator characteristics were not significantly associated with dropout.

CONCLUSIONS

On average, approximately 30% of participants drop out of in-person psychosocial SUD treatment studies, but there is wide variability. Drop-out rates vary with the treated population, the substance being targeted, and the characteristics of the treatment.

Sarcopenic Obesity Predicts Early Attrition in Treatment-Seeking Patients with Obesity: A Longitudinal Pilot Study

Attrition is a major cause of failure in obesity treatment, which is still not fully understood. The identification of factors related to this outcome is of clinical relevance. We aimed to assess the relationship between sarcopenic obesity (SO) and early attrition. Early attrition was assessed at six months, and two groups of patients were selected from a large cohort of participants with overweight or obesity enrolled at the Outpatient Clinic of the Department of Nutrition and Dietetics at Beirut Arab University (Lebanon). Body composition was measured using a bioimpedance analyser (Tanita BC-418) and participants at baseline were categorized as having or not having SO. The “dropout group” included 72 participants (cases) compared to 31 participants (controls) in the “completer group”, with the former displaying a higher prevalence of SO than the latter (51.0% vs. 25.8%; p = 0.016). In the same direction, Poisson regression analysis showed that SO increased the relative risk of dropout by nearly 150% (RR = 1.45; 95% CI = 1.10–1.89; p = 0.007) after adjustment for age, gender, body mass index (BMI), age at first dieting, sedentary habits and weight-loss expectation. In conclusion, in a “real-world” outpatient clinical setting, the presence of SO at baseline increases the risk of dropout at six months. New directions of future research should be focused on identifying new strategies to reduce the attrition rate in this population.

Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.

METHODS

A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.

RESULTS

One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations.

CONCLUSION

Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.

College Students' Reasons for Leaving Biomedical Fields: Disenchantment with Biomedicine or Attraction to Other Fields?

This study examined whether students who left biomedical fields of study during college did so primarily because they became disenchanted with those fields or because they felt attracted to alternative fields of study. We identified 1193 students intending to pursue biomedical fields of study early in college, collected data about their beliefs and performance throughout college, and interviewed them near graduation about their future plans. Descriptively, we examined the topics students discussed as affecting their attrition decisions. Predictive research aims were to determine how academic performance, interest, and demographic factors predicted students' likelihood of overall attrition and likelihood of reporting distinct reasons for attrition. Among the 192 students who left biomedical fields, 62.5% described leaving only in terms of feeling disenchanted, whereas 37.4% expressed that they left at least in part due to feeling attracted towards non-biomedical fields. Most students who left biomedical fields expressed changing plans for reasons related to interest; this was especially prevalent among students who reported leaving due to attraction towards non-biomedical fields. Predictive analyses showed that interest in biology and grades at the end of an introductory biology course predicted the likelihood of overall attrition and likelihood of leaving due to feeling disenchantment, whereas underrepresented ethnic minority status predicted these outcomes positively. Interest and course grades also predicted the likelihood of students leaving due to feeling attraction towards other fields, but interest was a stronger predictor relative to grades. Results highlight distinct types of attrition that may have implications for policies to promote STEM retention.

Should I stay or must I go? Predictors of dropout in an internet-based psychotherapy programme for posttraumatic stress disorder in Arabic

Background: Dropout from psychotherapy has negative impacts on clients, therapists, and health-care agencies. Research has identified a variety of variables as predictors of dropout, which can be grouped in three domains: socio-demographic, psychological, and treatment-related variables. Objective: In order to further clarify the question of predictors of dropout, an exploratory research design was applied to a large sample, testing 25 different variables from the three domains as possible predictors. Method: The sample included 386 adults who started an internet-based cognitive-behavioural treatment approach for posttraumatic stress disorder (PTSD) in Arabic. As the participants had different countries of origin and of current residence, multilevel analyses were performed. For the selection of predictor variables, the Least Absolute Shrinkage and Selection Operator was used. Results: Dropout rates did not vary significantly between participants from different countries of origin or from different countries of residence. Likewise, dropout did not vary significantly between clusters of individuals with the same country of origin and the same country of residence, i.e. the same migration path. Three of the 25 variables were identified as significant predictors for dropout: marital status (divorced participants' probability to drop out was higher compared to non-divorced, i.e. single, married, or widowed, clients), treatment credibility scores (higher dropout probability of participants with lower treatment credibility), and the participants' year of registration for the treatment (earlier years of registration predicted lower dropout probability). The overall ability of the three-factor-model to discriminate between dropout and completion was poor (AUC = 0.652, with low sensitivity and acceptable specificity). Conclusions: The predictors belong to the treatment-related domain (credibility, year of registration) or are specific to the target group (marital status). However, the results show that predicting treatment dropout continues to be a very challenging endeavour and indicate that it is important to look at each intervention individually.

Assessing factors associated with discharge from opioid agonist therapy due to incarceration in the United States

The following study investigates factors associated with discharge from OAT due to incarceration in a sample of 64,331 discharges in the United States. Multinomial regression investigated the association between demographic factors, prior arrest, referral source (i.e criminal justice agency) intravenous drug use, types of drug used, length of prior treatment and discharge due to incarceration compared to completing treatment or discharge due to other reasons. African Americans, Latinx, and Native Americans were at greater risk of discharge due to incarceration compared to whites. Referral to OAT from criminal justice agencies and self-referral was associated with increased risk of discharge from OAT due to incarceration compared to referral from a health care provider. Substance use of heroin, benzodiazepines, synthetic opioids, cocaine and non-prescription use of methadone were associated with discharge due to incarceration. Risk of discharge due to incarceration was higher for patients who reported intravenous drug use and who reported a co-morbid psychiatric problem. These findings enrich a nascent body of literature on mechanisms associated with attrition from OAT due to incarceration and emphasize the need for programs to divert people with OUD from incarceration to increase engagement and retention in OAT.

HIV Care Cascade among Prisoners of the Mandalay Central Prison in Myanmar: 2011-2018

Prisoners have a higher HIV prevalence and higher rates of attrition from care as compared with the general population. There is no published evidence on this issue from Myanmar. We assessed (1) HIV test uptake, HIV positivity, and enrollment in care among newly admitted prisoners between 2017 and 18 (2) Treatment outcomes among HIV-positive prisoners enrolled in care between 2011 and 18. This was a cohort study involving secondary analysis of program data. Among 26,767 prisoners admitted to the Mandalay Central Prison between 2017 and 2018, 10,421 (39%) were HIV-tested, 547 (5%) were HIV-positive, and 376 (69%) were enrolled in care. Among the 1288 HIV-positive prisoners enrolled in care between 2011 and 2018, 1178 (92%) were started on antiretroviral therapy. A total of 883 (69%) were transferred out (post-release) to other health facilities, and among these, only 369 (42%) reached their destination health facilities. The final outcomes (censored on 30 June 2019) included the following: (i) Alive and in care 495 (38%), (ii) death 138 (11%), (iii) loss to follow-up 596 (46%), and (iv) transferred out after reaching the health facilities 59 (5%). We found major gaps at every step of the HIV care cascade among prisoners, both inside and outside the prison. Future research should focus on understanding the reasons for these gaps and designing appropriate interventions to fill these gaps.

Diagnosing Covariate Balance Across Levels of Right-Censoring Before and After Application of Inverse-Probability-of-Censoring Weights

Covariate balance is a central concept in the potential outcomes literature. With selected populations or missing data, balance across treatment groups can be insufficient for estimating marginal treatment effects. Recently, a framework for using covariate balance to describe measured confounding and selection bias for time-varying and other multivariate exposures in the presence of right-censoring has been proposed. Here, we revisit this framework to consider balance across levels of right-censoring over time in more depth. Specifically, we develop measures of covariate balance that can describe what is known as "dependent censoring" in the literature, along with its associated selection bias, under multiple mechanisms for right censoring. Such measures are interesting because they substantively describe the evolution of dependent censoring mechanisms. Furthermore, we provide weighted versions that can depict how well such dependent censoring has been eliminated when inverse-probability-of-censoring weights are applied. These results provide a conceptually grounded way to inspect covariate balance across levels of right-censoring as a validity check. As a motivating example, we applied these measures to a study of hypothetical "static" and "dynamic" treatment protocols in a sequential multiple-assignment randomized trial of antipsychotics with high dropout rates.

Mental disorders, attrition at follow-up, and questionnaire non-completion in epidemiologic research. Illustrations from the CoLaus|PsyCoLaus study

OBJECTIVE

This study aimed to investigate the associations between mental disorders recorded at baseline and participation in the subsequent follow-up interview (vs. attrition) or baseline questionnaire completion (vs. non-response) within the psychiatric arm of a population-based study.

METHODS

Participants of a physical health survey were initially invited to also participate in a semi-structured interview covering mental disorders and were reassessed approximately 5.5 years later. They were also asked to complete self-rating questionnaires at baseline. Associations between the presence of lifetime mental disorders assessed at baseline and attrition at follow-up as well as non-completion of self-rating questionnaires at baseline were established.

RESULTS

After controlling for sociodemographic variables, a significant negative association was found between anxiety disorders at baseline and attrition at follow-up (Adjusted odds ratio (AOR) = 0.84; 95% confidence interval (CI) = 0.71-1.00) and a positive association between major depressive disorders (MDD) and non-response to the self-rating questionnaires at baseline (AOR = 1.24; 95% CI = 1.05-1.45).

CONCLUSIONS

The associations of anxiety disorders during lifetime with a higher participation rate in interviews at follow-up and of MDD during lifetime with the non-completion of self-rating questionnaires are potential sources of bias and should be taken into account in future longitudinal research.

Baseline Psychosocial and Demographic Factors Associated with Study Attrition and 12-Month Weight Gain in the DIETFITS Trial

OBJECTIVE

The purpose of this study was to examine correlates of failure-trial attrition and weight gain-in a randomized clinical weight-loss trial.

METHODS

The Diet Intervention Examining The Factors Interacting with Treatment Success (DIETFITS) trial included 609 adults (18-50 years; BMI 28-40). Participants were randomized to a 12-month healthy low-fat or healthy low-carbohydrate diet for weight loss. At baseline, participants completed psychosocial, demographic, and anthropometric measures. Stepwise logistic regressions identified baseline factors associated with (1) study attrition and (2) among trial completers, weight gain at 12 months.

RESULTS

Having higher baseline food addiction and self-efficacy was linked to treatment failure. Being younger, not having a college education, having higher outcome expectations and quality of life, and having lower social functioning and self-control increased the odds of trial attrition. Identifying as other than non-Hispanic white; not being married or cohabitating; having higher cognitive restraint and self-control; and having lower amotivation, family encouragement, and physical limitations increased the odds of gaining weight by treatment's end.

CONCLUSIONS

Participants' baseline psychosocial and demographic factors may support or impede successful weight loss. Trialists should attend to these factors when designing treatments in order to promote participants' likelihood of completing the trial and achieving their weight-loss goals.

Attrition of HIV-positive children from HIV services in low and middle-income countries

INTRODUCTION

Identification and retention of HIV-positive children in HIV services is essential to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition [loss to follow-up (LTFU) and death) of HIV-positive children from HIV services in low and middle-income countries (LMICs).

METHODS

We performed a comprehensive multidatabase search of original studies reporting retention/attrition data for HIV-positive children in LMICs through April 2016. Outcomes included LTFU, death, and overall attrition (LTFU + death) at intervals up to 60 months of follow-up. At least two authors determined study eligibility, performed data extraction, and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses.

RESULTS

We identified 3040 unique studies; 91 met eligibility criteria and were included in the analysis. This represents 147 129 HIV-positive children; most were from Africa (83%). LTFU definitions varied widely, with significant variability in outcomes across studies. Most attrition occurred in the first 6 months of follow-up, increasing to 23% by 36 months. HIV-positive children receiving antiretroviral therapy (ART) had significantly better retention in care than those not on ART. Studies that performed case-finding/tracing for those LTFU had better retention in care up to 24 months of follow-up.

CONCLUSIONS

These findings underscore the high attrition of children from HIV services in LMICs. Early ART initiation and decentralized patient support services (e.g. tracing for those LTFU) have potential to improve retention in care. Implementation research and resources are urgently needed to improve retention among this vulnerable population.

PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique

OBJECTIVE

To evaluate the effectiveness of the prevention of mother-to-child transmission (PMTCT) Option B+ programme in two provinces with high human immunodeficiency virus (HIV) burden in Mozambique over the first four years of programme implementation.

METHODS

We assessed the PMTCT cascade in antenatal care (ANC) from July 2013 to December 2017 using facility-level data and performed a retrospective cohort analysis with patient-level data. We compared the 12-month antiretroviral therapy (ART) retention rates between women with HIV infection who initiated ART under Option B+ ('B+ pregnant') and those who initiated ART for their own health ('own health').

RESULTS

A total of 916 280 pregnant women enrolled in ANC. The proportion of women with a documented HIV status increased from 93% in 2013 to 96% in 2017. The proportion of those tested HIV-positive decreased from 8% to 6% while that of those HIV-positive on ART increased from 42% to 95%. Of the 44 377 HIV-positive women included in the analysis, 35% were lost to care. 'B+ pregnant' women initiating ART in 2015 were less likely to have no follow-up (NFU) compared with 'own health' women starting ART during the same period (adjusted odds ratio: 0.77, 95% confidence interval [CI]: 0.64-0.94, P = 0.01). There was no statistical difference between the two groups during the other years in which ART was initiated. Of those returning for care after their first visit (N = 39 801), the 'B+ pregnant' women showed a higher risk of non-retention than the other group (adjusted hazard ratio: 1.14, 95% CI: 1.03-1.25) when ART was initiated in 2013. The risk decreased during the subsequent years, with no difference observed between the groups.

CONCLUSION

PMTCT Option B+ programme scale-up has yielded positive results, including the maintenance of high HIV testing and ART initiation rates in ANC. Challenges still remain, however, in improving immediate engagement in care and long-term retention. Seeking alternative service delivery models to support existing health systems and prevent defaulters is required to achieve the UNAIDS 95-95-95 targets for PMTCT in Mozambique.

Effectiveness of a Psycho-Social Intervention Aimed at Reducing Attrition at Methadone Maintenance Treatment Clinics: A Propensity Score Matching Analysis

Methadone maintenance treatment (MMT) is an important approach to address opioid dependence. However, MMT clinics usually report high attrition rates. Our previous randomized controlled trial demonstrated additional psycho-social services delivered by social workers could reduce attrition rates compared to MMT alone. This study aimed to evaluate the effectiveness of psycho-social service in a real-world context. A quasi-experimental design and propensity score matching was adopted. 359 clients were recruited from five MMT clinics in Guangzhou from July 2013 to April 2015. One 20-minute counseling session was offered to the control group after enrolment. The intervention group received six sessions of psycho-social services. The baseline characteristics were unbalanced between two arms in the original sample. After propensity score matching, 248 participants remained in the analysis. At month six, the intervention group had a lower attrition rate [intervention (39.5%) versus control (52.4%), P = 0.041], higher monthly income [monthly income of 1000 CNY or higher: intervention (55.9%) versus control (39.0%), P = 0.028)], higher detoxification intention score [full intention score: intervention (51.6%) versus control (32.5%), P = 0.012)], higher family support in MMT participation [intervention (77.9%) versus control (61.4%), P = 0.049)]. This study demonstrated that psycho-social services delivered by social workers can reduce MMT clients’ attrition and improve their well-being in real-world settings.

Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs

INTRODUCTION

The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME.

METHODS

Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs.

RESULTS

One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047).

CONCLUSIONS

Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.

Intersession Remediation to Minimize Attrition in a Three-Year Pharmacy Program

Objective. To describe an intersession remediation process in an accelerated three-year Doctor of Pharmacy (PharmD) program and to determine if the remediation process reduced attrition rates, including program withdrawals, progression to advanced pharmacy practice experiences (APPEs), and on-time graduation rates. Methods. Attrition was defined as dismissal, withdrawal, leave of absence, and/or change in graduation date. Progression data from students who matriculated between 2008 to 2016, with data available through spring 2017, were analyzed for number of course failures and successful intersession remediation. Other factors such as pharmacy year (first or second year), course subject, and course repeats were evaluated to characterize successful remediation attempts and identify elements that foster student success. Results. Of the 812 matriculated students across the time period analyzed, 18% (n=146) failed at least one didactic course (defined as course average <69.5%). Overall, 74.7% (n=109) of the students who failed a course remediated, with 75.2% (n=82) of those able to remediate being successful, remaining on-time for graduation. If students who remediated were instead required to repeat coursework, the college attrition rate would have averaged over 10 percentage points higher for the time period analyzed than the actual rate of 13.4%. Conclusion. Our study demonstrated that the majority of students who qualified for remediation were successful and graduated on time. Further studies in this area are needed to fully elucidate the effect of remediation processes on learning and retention of knowledge and skills.