DEVOE-1 CSE 5810 Research Topics in Computer Science and Medical Imaging Gordon Devoe - 2014.
Beth Barnet, MD 1, Adrienne Williams, PhD 1, Margo DeVoe, MS 1, Ed Pecukonis, Ph.D. 2, Melanie A....
Transcript of Beth Barnet, MD 1, Adrienne Williams, PhD 1, Margo DeVoe, MS 1, Ed Pecukonis, Ph.D. 2, Melanie A....
Beth Barnet, MD1, Adrienne Williams, PhD1, Margo DeVoe, MS1, Ed Pecukonis, Ph.D.2,
Melanie A. Gold, DO3 Anne K. Duggan, ScD4
1 University of Maryland Department of Family & Community Medicine2 University of Maryland School of Social Work
3 University of Pittsburgh Department of Pediatrics, Pittsburgh PA4 Johns Hopkins Department of Pediatrics
Motivational Intervention toMotivational Intervention toReduce Rapid Repeat Births in Reduce Rapid Repeat Births in
Adolescent Mothers: Adolescent Mothers: A Community-based Randomized TrialA Community-based Randomized Trial
Project Funding Project Funding
• Grant APRPA006010 from the Department of Health and Human Services, Office of Population Affairs, Office of Adolescent Pregnancy Programs
• Cooperative Agreement MM-0452-03/03 from the Centers for Disease Control/Association of American Medical Colleges
Teenage Births in U.S.
•Births to teens increased in 2006 & 2007
•435,436 births in 2006 to 15-19 year olds
•>1/4 have another birth within 2 years
•Adverse outcomes increase with a 2nd birth• Greater school dropout• Long term poverty, welfare dependence• Higher levels of stress & poor mental health • Cognitive and behavioral problems in the kids• Substantial public sector costs
Factors Associated with Rapid Factors Associated with Rapid Repeat Pregnancy/BirthRepeat Pregnancy/Birth
• Age (mixed findings)
• Race (African-American & Hispanic > White)
• Partner relationships– married, living with partner > non-married
• Low cognitive ability
• Type/use of contraception
• Depression?
Many well designed interventions to reduce 2nd and higher order teen births
• Settings: clinic and community
• Service providers: broad range
• Interventions: – health education– birth control– home visiting– social support, family support – service coordination– life skills– employment training – monetary incentives
modest impact
…perhaps because of insufficient attention to
motivation and support for
behavior change
Motivational Interviewing
• Empirically-validated counseling style
• Effective helping people change negative behaviors
• Employs empathy and reflection to raise awareness of discrepancies between stated goals and actual behaviors– Facilitates the individual’s own motivation
to change
Can MI be used to facilitate motivation and behavior
change for repeat pregnancy prevention in teens?
Research Question
ObjectivesObjectives
• To conduct an intervention aimed at reducing adolescent repeat birth
– Grounded in theory – Explicit focus on motivation– Address malleable proximate risk factors– Informed by our prior home visiting experience – Rigorously evaluated
• To examine effectiveness in real world setting
– Baltimore’s teen birth rates among highest in U.S.
CAMICAMIComputer Assisted Motivational InterventionIntervention
• Customized software - algorithms based on the Transtheoretical Model
• Questions measure reproductive health risks & behaviors– Computes readiness to use
contraception and condoms– Summary printout of pregnancy and
STI risk
• 20-minute stage-matched motivational interviewing– begins after delivery – repeated every 3 months until index
child turns 2 years
BRIDGES Intervention Timing and Components
• Prenatal (enrollment) through 2 years postpartum (completion)
• Biweekly to monthly home visits– Parenting curriculum with child age-&-
developmentally- specific modules
– Case management
– Teen and family support
– Outreach to fathers
• CAMI conducted every 4th home visit
Target Population
Intervention Component / Service Use Proximal Outcomes Distal Outcomes Objective
Pregnant and mothering teenage girls < 18 years at enrollment Baby’s fathers – if teen mother agrees
Computer Assisted Motivational Intervention Assess risk for repeat pregnancy & STIs Assess motivation to avoid repeat pregnancy &
STIs Assess stage of change for consistent
contraception and condom use Use MI to promote use of effective
contraception and condoms
Care Management – Teen Mother Connect teen & child to primary care medical
home Track & promote primary care appointment-
keeping Provide information to primary care provider(s)
(e.g. teen’s contraception use, depression) Coordinate the involvement with community
mental health, if needed
Social Support via a Caring Continuity Relationship
Teen Mother consistent use of
effective contraception
consistent condom use
Reduce repeat
pregnancy and
repeat birth
within 2 years of
index birth
Baby’s Father support for
partner’s contraception use
consistent condom use Baby’s Father
Increase perceived risk & costs of rapid repeat fathering
Improve communication and reduce conflict with partner
Teen Mother Improve motivation to
use contraception & condoms
Forward movement along stage of change continuum for contraception and condom us
Improve communication & reduce conflict with partner
Logic Model for CAMI Intervention
Compare 2 Interventions
CAMI-Only
CAMI+
Enhanced Home Visiting
1. Does a CAMI-only intervention or a CAMI+ intervention (enhanced home visiting) reduce repeat pregnancy in teen mothers?
2. Do they differ in effectiveness?
Secondary Objective
• To investigate risk factors along the causal pathway to adolescent repeat pregnancy – i.e. - is depression is a risk factor?
Intervention Staff & CAMI Training
• African American women from local communities
• Equivalent caseloads for CAMI+ and CAMI-only home visitors
• 2 ½ days initial interactive training– Motivational interviewing– Use of CAMI program
• Rating of videotaped CAMI session with standardized patient
• Proficiency maintenance - audio-taped sessions
Participants and Setting
• Eligibility– Pregnant teen, > 24 wks, < 18 years– Informed consent from teen and parent/guardian– Teen completed baseline assessment– Random assignment
• Recruitment – from 5 Baltimore clinics providing prenatal
care to low income women
• Home & community-based intervention
Design & Study FlowRecruitment between February 2003 and April 2005
Intervention Phase completed October, 2007
Outcome MeasurementTiming and Sources
• Data collected at 1-and-2 years postpartum
• Two data sources:– Structured interview assessing rpt preg. & birth – Birth certificates (baseline consent from teen)
• Successful match for entire cohort of 235
• Main Outcome – % with a repeat birth by 24 months
• Overall and by group– Cox proportional hazards ratios for time (months) to repeat birth
AnalysisAnalysis
• Intention to Treat (ITT)
• Complier Average Causal Effect (CACE )– Most interventions do not achieve full participant
adherence
– With variable adherence, ITT may produce biased estimates of intervention causal effects
•Adherence is measured only in the intervention group
•Control group participants who would have adheredwho would have adhered if assigned to the experimental group are not identified
•As a result, treatment effects are under-estimated
CACE AnalysisCACE Analysis2-step iterative procedure
1. Define intervention adherence “receipt > 2 CAMIs”
• Identify baseline characteristics of intervention adherers and assign a weight of 1
• Use these adherence characteristics to compute the probability of adherence for individuals in the control group
2. Outcomes for adherers in the intervention group are compared with outcomes for the weighted controls “supposed adherers”
CACE models enable comparison of outcomes between actual intervention adherers and the subpopulation of
controls who meet criterion for adherence
Baseline Assessment
Overall CAMI+ CAMI-Only UCC p valuen=235 n=80 n=87 n=68
Maternal age (12-19), mean years (SD)
17.0(1.2)
17.2 (1.1)
17.0 (1.2)
16.9 (1.4)
.24
African American, % 97 99 95 99 .39
Medicaid insurance, % 86 80 89 90 .18
Continuous health insurance, past 12 months, %
61 53 66 63 .25
Dropped out of school, % 42 39 43 46 .69
Married (n=2), living together, going with baby’s father, %
74 78 72 72 .66
Age of baby’s father (14-39), mean years (SD)
19.8 (3.2)
20.4 (3.4)
19.3 (2.6)
19.7 (3.6)
.11
Characteristics of Adolescent Mothers at Baseline
Teen Mothers’ Pregnancy History at Baseline, by group
38
1614 14
30
5
18
12
24
13
710
0
5
10
15
20
25
30
35
40
PriorPregnancy
Prior Birth Prior Abortion PriorMiscarriage
Per
cent
CAMI+ CAMI-Only Usual Care Control
p=.19
p=.04p=.14
p=.85
Teen Mothers’ Contraceptive & Condom Practices, Plans, and STI History at Baseline,
by Groupp=.76
p=.76
p=.14
p=.003
p=.02
p=.54
Results
Follow-up Outcome Data
• DHMH Vital Statistics Administration matched 100% of our index birth cohort followed by search for subsequent birth records
• 80% of cohort completed a 2-year follow-up interview– 85% CAMI+– 77% CAMI-Only– 79% usual care control
% of Teens with a Repeat Birth by Groupn=235
25
1714
0
5
10
15
20
25
30
Control CAMI-only CAMI+
Re
pea
t B
irth
, %
p=.08
CAMI=Computer Assisted Motivational Intervention
Results
Months between index birth and repeat birth
Cu
mu
lati
ve H
azar
d o
f R
epea
t B
irth
252015105
0.20
0.15
0.10
0.05
0.00
Control
CAMI-only
CAMI+
Risk of Subsequent Birth, by groupIntent to Treat Model
Hazard Ratio 0.45
p<.05
Results
Proportion of Teen Mothers Reporting a Repeat Pregnancy Between Index Birth and 2 Years Postpartum
Interview Data n=190
53
55
49
56
44
46
48
50
52
54
56
58
Per
cent
p=.74
Overall CAMI + Home
Visiting
CAMI -Only
Usual Care
Control
Proportion of Teen Mothers Reporting they Had an Abortion Between Index Birth and 2 Years Postpartum
Interview Data n=190
21 2119
24
0
5
10
15
20
25
30
Per
cent
p=.81
Usual Care
Control
CAMI -Only
CAMI + Home
Visiting
Overall
Process Data Collected by CAMI Counselors
• Session attempts
• Completed sessions
• Content of sessions
Variation in CAMI Session Adherence among Intervention Participants
Total Possible = 7 CAMI sessions
CAMI Sessions Completed
CAMI + CAMI-Only
Mean # (SD) 4.3 (3.6) 2.2 (2.6)
7 39% 11%
> 5 50% 32%
> 2 66% 41%
0 25% 49%
Differences Between CAMI Adherers and Non-adherers
No Differences• School dropout• Depressive symptoms• Substance use• Household violence• Prior birth• Condom use• Intention to use
contraception after delivery
Adherer Differences
• Younger
• Insured by Medicaid
• Greater social support
• Less likely to have been diagnosed with STI
GroupHazard Ratio
95% Confidence Interval
Control ref --
CAMI + 0.40‡ 0.16-0.98
CAMI-Only 0.19‡ 0.05-0.69
CACE Model* of the Risk of Subsequent Birth, by Group
‡p<.05 *compares outcomes between actual intervention adherers (received > 2 CAMIs) and
the subpopulation of controls who meet criterion for adherence
(i.e. who would have received > 2 CAMIs if they had been assigned to the intervention group)
Conclusions
• Receipt of > 2 CAMI sessions, either alone or in the context of a multi-component home-based intervention, reduced the risk of rapid repeat birth to adolescent mothers
• Earlier and more frequent contact in the CAMI + group facilitated participant engagement
Limitations
• Lack of follow-up interview data for the entire sample– Reduces ability to examine intervention impact on
behavioral mediators (e.g. use of contraception)
• MI quality ratings not systematically collected – Not able to determine moderating effects of quality
on outcomes
• 2-year follow-up observation period– Do reductions in repeat birth continue throughout
the teen’s adolescence?
Implications
• Findings support the use of motivational interviewing paired with interactive behavior change technology to reduce rapid subsequent birth in adolescent mothers
• A CAMI initiative within or closely linked with primary care might have broader reach to impact unintended and teen pregnancy
• Evaluation of CAMI in primary care settings should be considered
Secondary Findings
Months Between Index Birth & 1 stRepeat Pregnancy
25.020.015.010.05.00.0
Cu
mu
lati
ve H
azar
d o
f
Rep
eat
Pre
gn
ancy
1.0
0.8
0.6
0.4
0.2
0.0
Depressive Symptoms
No Depressive Symptoms
Risk of Repeat Pregnancy among those with and without Preceding Depressive Symptoms
p<.05
Months Between Index Birth & 1st Repeat Pregnancy
25.020.015.010.05.00.0
Cu
mu
lati
ve H
azar
d o
f
Rep
eat
Pre
gn
ancy
1.0
0.8
0.6
0.4
0.2
0.0
Depressive Symptoms
No Depressive Symptoms
Risk of Repeat Pregnancy among those with and without Preceding Depressive Symptoms
p<.05
Barnet et. al., Archives of Pediatrics and Adolescent Medicine, 2008.
Cost Effectiveness Analysis
Costs of Computer Assisted Motivational Intervention With and Without Enhanced Home Visiting, 2009 US$
CAMI+ CAMI-Only
Average cost per teenager $2,735 $1,449
Cost per prevented repeat birth, (95% Confidence Intervals)
$19,247(15,085-26,072)
$15,078(11,546-21,092)
Lessons Learned
• Need functional, user-friendly data management system
• Weekly review of process data– Individual participants– Summary views– Feedback to front line staff
• Measure intervention progress by predetermined benchmarks…
• …but be flexible - listen to staff input
• Quality control systems to increase fidelity