Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review.

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

Practice-Oriented Research: An Introduction to New Developments and Future Directions.

Aimed at understanding and improving psychological therapies as they are conducted in clinical routine, practice-oriented research (POR) is now a well-established approach to the scientific foundations of mental health care services. Resting on the accumulation of a wide range of practice-based evidence related to treatment outcome and process, as well as factors associated with the participants of psychotherapy and its context, POR is ripe for new developments - regarding what to investigate and how to investigate it. This paper is the introduction of a series devoted to recent advances and future directions of POR as their pertained to routine outcome monitoring, technologies and artificial intelligence, the integration of constructs and methods from program evaluation and implementation science, and the investigation of populations with limited financial resources across various regions of the world. The series also includes commentaries from two leaders of POR.

Determining differences between therapists using an extended version of the facilitative interpersonal skills performance test.

OBJECTIVES: The therapist-facilitative interpersonal skills (FIS) has shown to predict therapy outcomes, demonstrating that high FIS therapists are more effective than low FIS therapists. There is a need for more insight into the variability in strengths and weaknesses in therapist skills. This study investigates whether a revised and extended FIS-scoring leads to more differentiation in measuring therapists' interpersonal skills. Furthermore, we explorative examine whether subgroups of therapists can be distinguished in terms of differences in their interpersonal responses. METHOD: Using secondary data analysis, 93 therapists were exposed to seven FIS-clips. Responses of therapists using the original and the extended FIS scoring were rated. RESULTS: Three factors were found on the extended FIS scoring distinguishing supportive, expressive, and persuasive interpersonal responses of therapists. A latent profile analysis enlightened the presence of six subgroups of therapists. CONCLUSION: Using the revised and extended FIS-scoring contributes to our understanding of the role of interpersonal skills in the therapeutic setting by unraveling the question what works for whom.

Routine Outcome Monitoring and Clinical Feedback in Psychotherapy: Recent Advances and Future Directions.

In the past decade, there has been an increase in research related to the routine collection and active use of standardized patient data in psychotherapy. Research has increasingly focused on personalization of care to patients, clinical skills and interventions that modulate treatment outcomes, and implementation strategies, all of which appear to enhance the beneficial effects of ROM and feedback. In this article, we summarize trends and recent advances in the research on this topic and identify several essential directions for the field in the short to medium term. We anticipate a broadening of research from the focus on average effects to greater specificity around what kinds of feedback, provided at what time, to which individuals, in what settings, are most beneficial. We also propose that the field needs to focus on issues of health equity, ensuring that ROM can be a vehicle for increased wellbeing for those who need it most. The complexity of mental healthcare systems means that there may be multiple viable measurement solutions with varying costs and benefits to diverse stakeholders in different treatment contexts, and research is needed to identify the most influential components in each of these contexts.

An examination of therapists' professional characteristics as moderators of the effect of feedback on psychological treatment outcomes.

Feedback-informed treatment (FIT) has been shown to reduce the gap between more and less effective therapists. This study aimed to examine therapists' professional characteristics as potential moderators of the effect of feedback on treatment outcomes.The IAPT-FIT Trial was a clinical trial where therapists were randomly assigned to a FIT group or a usual care control group. Treatment response was monitored using measures of depression (PHQ-9), anxiety (GAD-7) and functional impairment (WSAS). In a secondary analysis of this trial (n = 1,835 patients; t = 67 therapists), we used multilevel modelling to examine interactions between therapists' professional characteristics (e.g., attitude towards and self-efficacy regarding feedback utilization, decision-making style, job satisfaction, burnout, difficulties in practice, coping styles, caseload size) with random allocation (FIT vs. controls) to identify moderators of the effects of feedback.Between 9.6% and 10.8% of variability in treatment outcomes was attributable to therapist effects. Therapist-level caseload sizes and external feedback propensity (EFP) moderated the effect of feedback on depression outcomes. No statistically significant main effects were found for any of the included therapist characteristics.FIT reduced variability in outcomes between therapists and was particularly effective for therapists with high EFP and larger caseloads.

Hospital infections and health-related quality of life after cardiac surgery: a multicenter survey.

BACKGROUND: Recent research suggested that hospital infections are a predictive marker for physical non-recovery one year after cardiothoracic surgery. The purpose of this study was to explore whether this risk factor is etiologic. Additional, the influence of a potential effect modifying factor, diabetes mellitus, was investigated. METHODS: In this multicenter study, patients underwent elective or urgent cardiothoracic surgery between 01-01-2015 and 31-12-2019, and completed pre- and one year post-operative Short Form Health Survey 36/12 quality of life questionnaires. A binary logistic regression model, in which the inverse of the propensity score for infection risk was included as a weight variable, was used. Second, this analysis was stratified for diabetes mellitus status. RESULTS: 8577 patients were included. After weighing for the propensity score, the standardized mean differences of all variables decreased and indicated sufficient balance between the infection and non-infection groups. Hospital infections were found to be a risk factor for non-recovery after cardiothoracic surgery in the original and imputed dataset before weighting. However, after propensity score weighing, hospital infections did not remain significantly associated with recovery (OR for recovery = 0.79; 95% CI [0.60-1.03]; p = 0.077). No significant interaction between diabetes mellitus and hospital infections on recovery was found (p = 0.845). CONCLUSIONS: This study could not convincingly establish hospital infections as an etiologic risk factor for non-improvement of physical recovery in patients who underwent cardiothoracic surgery. In addition, there was no differential effect of hospital infections on non-improvement of physical recovery for patients with and without diabetes mellitus. Trial registration International Clinical Trials Registry Platform ID NL9818; date of registration, 22-10-2021 ( https://trialsearch.who.int/ ).

Renewed Feedback-Informed Group Treatment for Patients with Anxiety and Depressive Disorders.

Feedback-Informed Group Treatment (FIGT) shows promise for improving outcomes, but results are mixed. The aim was investigating the feasibility, acceptability and effects of renewed FIGT on clinical outcomes and therapy processes. In a quasi-experimental pilot study, 65 patients with anxiety or depressive disorders and 15 therapists of interpersonal psychotherapy or cognitive behavioural therapy groups using renewed FIGT were included. Renewed FIGT contained three additions compared to the previous tool: (1) personalized goals along with the Outcome Questionnaire-45 (OQ-45), (2) therapists' training, coaching and intervision, and (3) instructions to actively use feedback in the group. Data on feasibility, acceptability, outcomes and process factors were analysed and compared with those of historical cohorts using only OQ-45 feedback or no feedback, using descriptive, multilevel and covariance statistical analyses. Feasibility was mostly improved, with patients experiencing more feedback discussions and better usability compared to only OQ-45 feedback. At least two thirds of the patients and therapists give preference to using feedback in the future. At the end of the study, therapists were less convinced that the OQ-45 and goals were able to detect change. Renewed FIGT did not improve effectiveness on clinical outcomes. Compared to no feedback, patients experienced more cohesion, engagement and less avoidance, but improved less on depressive symptoms. Even when renewed FIGT is more feasible and usable than only OQ-45 feedback and associated with more cohesiveness and engagement, it may not automatically lead to improved effectiveness on clinical outcomes in short-term group therapy. Implications and future directions are described.

Effect of dietary interventions on markers of type 2 inflammation in asthma: A systematic review.

INTRODUCTION: Type 2 (T2) inflammation is a key mechanism in the pathophysiology of asthma. Diet may have immunomodulatory effects, and a role for diet in T2 inflammation has been suggested in the literature. Indeed, diet and food allergies play a role in children with atopic asthma, but less is known about diet in relation to adult asthma, which is often non-atopic. OBJECTIVE: To review the effect of dietary interventions on markers of T2 inflammation in adults with asthma. METHODS: The databases PubMed, Embase, Cochrane Library, and CINAHL were searched for eligible studies until December 2022. We included studies of all types of foods, nutrients, diets or supplements, either as an exposure or as an intervention, in adults and adolescents with asthma. Outcomes of interest included the T2 biomarkers FeNO, eosinophils, IL-4, IL-5, IL-13, eosinophil cationic protein and eosinophil peroxidase. The methodological quality of eligible studies was systematically evaluated, and the results were summarised according to dietary clusters. RESULTS: The systematic search identified studies on the dietary clusters antioxidants (n = 14), fatty acids, (n = 14), Mediterranean-style diets (n = 5), phytotherapy (n = 7), prebiotics & probiotics (n = 8), vitamin D (n = 7), and other dietary factors (n = 5). Studies within the phytotherapy and omega-3 poly-unsaturated fatty acids (PUFA) clusters showed possible improvements in T2 inflammation. Furthermore, we found little evidence for an effect of antioxidants, prebiotics & probiotics, and Mediterranean-style diets on T2 inflammation. However, heterogeneity in study protocols, methodological shortcomings and limited power of almost all studies make it difficult to fully determine the impact of different dietary approaches on T2 inflammation in asthma. CONCLUSIONS: Overall, the current evidence does not support a specific dietary intervention to improve T2 inflammation in asthma. Interventions involving phytotherapy and omega-3 PUFA currently have the best evidence and warrant further evaluation in well-designed and adequately powered studies, while taking into account T2-high phenotypes of asthma.

A Clinical Leadership Lens on Implementing Progress Feedback in Three Countries: Development of a Multidimensional Qualitative Coding Scheme.

BACKGROUND: Progress feedback, also known as measurement-based care (MBC), is the routine collection of patient-reported measures to monitor treatment progress and inform clinical decision-making. Although a key ingredient to improving mental health care, sustained use of progress feedback is poor. Integration into everyday workflow is challenging, impacted by a complex interrelated set of factors across patient, clinician, organizational, and health system levels. This study describes the development of a qualitative coding scheme for progress feedback implementation that accounts for the dynamic nature of barriers and facilitators across multiple levels of use in mental health settings. Such a coding scheme may help promote a common language for researchers and implementers to better identify barriers that need to be addressed, as well as facilitators that could be supported in different settings and contexts. METHODS: Clinical staff, managers, and leaders from two Dutch, three Norwegian, and four mental health organizations in the USA participated in semi-structured interviews on how intra- and extra-organizational characteristics interact to influence the use of progress feedback in clinical practice, supervision, and program improvement. Interviews were conducted in the local language, then translated to English prior to qualitative coding. RESULTS: A team-based consensus coding approach was used to refine an a priori expert-informed and literature-based qualitative scheme to incorporate new understandings and constructs as they emerged. First, this hermeneutic approach resulted in a multi-level coding scheme with nine superordinate categories and 30 subcategories. Second-order axial coding established contextually sensitive categories for barriers and facilitators. CONCLUSIONS: The primary outcome is an empirically derived multi-level qualitative coding scheme that can be used in progress feedback implementation research and development. It can be applied across contexts and settings, with expectations for ongoing refinement. Suggestions for future research and application in practice settings are provided. Supplementary materials include the coding scheme and a detailed playbook.

Dietary Inflammatory Index and Clinical Outcome Measures in Adults With Moderate-to-Severe Asthma.

BACKGROUND: Diet is increasingly recognized as a modifiable factor in lung health, predominantly due to the immunomodulatory effects of nutrients. The Dietary Inflammatory Index (DII) is a score developed to express the inflammatory potential of a diet. OBJECTIVE: We aimed to assess the association of the DII and food groups, with clinical, functional, and inflammatory asthma outcomes in adults with asthma. METHODS: Patients with moderate-to-severe asthma were included in this cross-sectional study between June 2019 and October 2021, and completed a 3-day food diary, to calculate the DII and intake of food groups (ie, fruits, whole grains, processed meats, and sugar-sweetened beverages). Functional outcomes included pulmonary function tests and the 6-minute walking distance, whereas clinical outcomes were assessed using questionnaires on asthma control, quality of life, and health care utilization. Inflammatory markers were exhaled nitric oxide and blood leukocytes, eosinophils, and IL-6. Multivariable regression analyses were used to examine the association of DII and food groups with asthma outcomes. RESULTS: A total of 109 patients participated (35% male, mean ± standard deviation age 51.8 ± 14.2 years, body mass index 27.4 ± 5.3 kg/m2). Overall, 62% had a DII score >0, indicating a proinflammatory diet, which was not related to asthma severity. A more proinflammatory diet was consistently associated with lower forced vital capacity (%pred), but inconsistent results were observed with respect to airway obstruction. Neither the DII nor food groups were associated with clinical outcomes. Except for higher levels of exhaled nitric oxide in relation to an anti-inflammatory diet, we found no associations between inflammatory markers and the DII. CONCLUSION: Results from this cross-sectional study among patients with moderate-to-severe asthma do not support the hypothesis that a proinflammatory diet is associated with worse asthma outcomes, although limitations in study design and dietary intake estimation should be considered. Future well-designed experimental studies are needed to assess whether targeting the inflammatory potential of diet could lead to better outcomes in adults with asthma.

Best first-line therapy for people with advanced non-small cell lung cancer, performance status 2 without a targetable mutation or with an unknown mutation status.

BACKGROUND: Most people who are newly diagnosed with non-small cell lung cancer (NSCLC) have advanced disease. For these people, survival is determined by various patient- and tumor-related factors, of which the performance status (PS) is the most important prognostic factor. People with PS 0 or 1 are usually treated with systemic therapies, whereas people with PS 3 or 4 most often receive supportive care. However, treatment for people with PS 2 without a targetable mutation remains unclear. Historically, people with a PS 2 cancer are frequently excluded from (important) clinical trials because of poorer outcomes and increased toxicity. We aim to address this knowledge gap, as this group of people represents a significant proportion (20% to 30%) of the total population with newly diagnosed lung cancer. OBJECTIVES: To identify the best first-line therapy for advanced lung cancer in people with performance status 2 without a targetable mutation or with an unknown mutation status. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 17 June 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared different chemotherapy (with or without angiogenesis inhibitor) or immunotherapy regimens, specifically designed for people with PS 2 only or studies including a subgroup of these people. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. overall survival (OS), 2. health-related quality of life (HRQoL), and 3. toxicity/adverse events. Our secondary outcomes were 4. tumor response rate, 5. progression-free survival, and 6. survival rates at six and 12 months' treatment. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS: We included 22 trials in this review and identified one ongoing trial. Twenty studies compared chemotherapy with different regimens, of which 11 compared non-platinum therapy (monotherapy or doublet) versus platinum doublet. We found no studies comparing best supportive care with chemotherapy and only two abstracts analyzing chemotherapy versus immunotherapy. We found that platinum doublet therapy showed superior OS compared to non-platinum therapy (hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.57 to 0.78; 7 trials, 697 participants; moderate-certainty evidence). There were no differences in six-month survival rates (risk ratio [RR] 1.00, 95% CI 0.72 to 1.41; 6 trials, 632 participants; moderate-certainty evidence), whereas 12-month survival rates were improved for treatment with platinum doublet therapy (RR 0.92, 95% CI 0.87 to 0.97; 11 trials, 1567 participants; moderate-certainty evidence). PFS and tumor response rate were also better for people treated with platinum doublet therapy, with moderate-certainty evidence (PFS: HR 0.57, 95% CI 0.42 to 0.77; 5 trials, 487 participants; tumor response rate: RR 2.25, 95% CI 1.67 to 3.05; 9 trials, 964 participants). When analyzing toxicity rates, we found that platinum doublet therapy increased grade 3 to 5 hematologic toxicities, all with low-certainty evidence (anemia: RR 1.98, 95% CI 1.00 to 3.92; neutropenia: RR 2.75, 95% CI 1.30 to 5.82; thrombocytopenia: RR 3.96, 95% CI 1.73 to 9.06; all 8 trials, 935 participants). Only four trials reported HRQoL data; however, the methodology was different per trial and we were unable to perform a meta-analysis. Although evidence is limited, there were no differences in 12-month survival rates or tumor response rates between carboplatin and cisplatin regimens. With an indirect comparison, carboplatin seemed to have better 12-month survival rates than cisplatin compared to non-platinum therapy. The assessment of the efficacy of immunotherapy in people with PS 2 was limited. There might be a place for single-agent immunotherapy, but the data provided by the included studies did not encourage the use of double-agent immunotherapy. AUTHORS' CONCLUSIONS: This review showed that as a first-line treatment for people with PS 2 with advanced NSCLC, platinum doublet therapy seems to be preferred over non-platinum therapy, with a higher response rate, PFS, and OS. Although the risk for grade 3 to 5 hematologic toxicity is higher, these events are often relatively mild and easy to treat. Since trials using checkpoint inhibitors in people with PS 2 are scarce, we identified an important knowledge gap regarding their role in people with advanced NSCLC and PS 2.

Long-Term Weight Changes After Starting Anti-IL-5/5Ra Biologics in Severe Asthma: The Role of Oral Corticosteroids.

BACKGROUND: Many patients with severe asthma are overweight or obese, often attributed to unintentional weight gain as a side effect of oral corticosteroids (OCSs). Anti-IL-5/5Ra biologics significantly reduce OCS use, but their long-term effects on weight are unknown. OBJECTIVES: To examine (1) weight change up to 2 years after anti-IL-5/5Ra initiation in subgroups on the basis of maintenance OCS use at start of treatment and (2) whether cumulative OCS exposure before or changes in OCS exposure during treatment are related to weight change. METHODS: Real-world data on weight and cumulative OCS dose from adults included in the Dutch Registry of Adult Patients with Severe asthma for Optimal DIsease management before and at least 2 years after starting anti-IL-5/5Ra were analyzed using linear mixed models and linear regression analyses. RESULTS: For the included 389 patients (55% female; mean body mass index, 28 ± 5 kg/m2; 58% maintenance OCS), mean weight decreased -0.27 kg/y (95% CI, -0.51 to -0.03; P = .03), with more weight loss in patients with maintenance OCS use than in those without maintenance OCS use (-0.87 kg/y [95% CI, -1.21 to -0.52; P < .001] vs +0.54 kg/y [0.26 to 0.82; P < .001]). Greater weight loss at 2 years was associated with higher cumulative OCS dose in the 2 years before anti-IL-5/5Ra initiation (ß = -0.24 kg/g; 95% CI, -0.38 to -0.10; P < .001) and, independently, greater reduction in cumulative OCS dose during follow-up (ß = 0.27 kg/g; 95% CI, 0.11 to 0.43; P < .001). CONCLUSIONS: Anti-IL-5/5Ra therapy is associated with long-term weight reduction, especially in patients with higher OCS exposure before treatment and those able to reduce OCS use during treatment. However, the effect is small and does not apply to all patients, and so additional interventions seem necessary if weight change is desired.

The effect of therapist characteristics on the use and outcome of systematic client feedback in outpatient mental healthcare.

OBJECTIVE: Therapist characteristics are known to affect treatment outcome in general and could also influence the use of systematic client feedback (SCF). The current study explores the effect of feedback orientation, regulatory focus, self-efficacy, attitude towards feedback resources and perceived feedback validity on the use and outcome of SCF in outpatient mental healthcare. METHOD: The data of therapists (n = 12) and patients (n = 504) of two outpatient centres offering brief psychological treatment were analysed when SCF, based on the Partners for Change Outcome Management System (PCOMS), was added to treatment as usual. The data of therapists were obtained through a therapist questionnaire composed of relevant characteristics from feedback studies in social and organizational psychology. The effect on the use of SCF was analysed using logistic regression; whereas, the effect on outcome was assessed using a two-level multilevel analysis. Regular use of SCF and the Outcome Questionnaire (OQ-45) were used as outcome variables. DSM-classification, sex and age of each patient were included as covariates. RESULTS: High perceived feedback validity significantly increased the use of SCF. No significant therapist characteristics effects were found on outcome, but high promotion focus was associated with treating more complex patients. CONCLUSIONS: The perceived feedback validity of SCF is likely to have an influence on its use and is probably affected by the changes in the organizational climate.

Treatment Course Comparison Between Anxiety-Related Disorders in Adult Outpatients: A Leiden Routine Outcome Monitoring Study.

ABSTRACT: Anxiety-related disorders constitute the leading prevalent mental disorders, with major burden on patients, their relatives, and society. Moreover, there is considerable treatment nonadherence/nonresponse. We used routine outcome monitoring (ROM) data from outpatients covering four anxiety-related disorders ( DSM-IV-R , N = 470) to examine their 6-month treatment course and its predictors: generalized anxiety disorder, panic disorder with agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Measures included Mini-International Neuropsychiatric Interview Plus, Brief Symptom Inventory (BSI), Montgomery-Åsberg Depression Rating Scale (MADRS), Brief Anxiety Scale (BAS), and Short Form Health Survey 36 (SF-36). On the clinician-rated instruments (MADRS/BAS), all anxiety-related disorder groups showed a significant albeit modest improvement after treatment. On the BSI self-rating, only generalized anxiety disorder and posttraumatic stress disorder showed a significant modest improvement. No anxiety-related disorder groups improved significantly regarding SF-36 physical functioning. For BSI symptom course, significant predictors were comorbid somatoform/total disorders, SF-36 physical functioning/general health, and MADRS score. Clinical implications and future research recommendations are discussed.

Clinical response to benralizumab can be predicted by combining clinical outcomes at 3†months with baseline characteristics.

Background: Benralizumab is highly effective in many, but not all, patients with severe asthma. Baseline characteristics alone are insufficient to predict an individual's probability of long-term benralizumab response. The objectives of the present study were to: 1) study whether parameters at 3 months, in addition to baseline characteristics, contribute to the prediction of benralizumab response at 1 year; and 2) develop an easy-to-use prediction tool to assess an individual's probability of long-term response. Methods: We assessed the effect of benralizumab treatment in 192 patients from the Dutch severe asthma registry (RAPSODI). To investigate predictors of long-term benralizumab response (≥50% reduction in maintenance oral corticosteroid (OCS) dose or annual exacerbation frequency) we used logistic regression, including baseline characteristics and 3-month Asthma Control Questionnaire (ACQ-6) score and maintenance OCS dose. Results: Benralizumab treatment significantly improved several clinical outcomes, and 144 (75%) patients were classified as long-term responders. Response prediction improved significantly when 3-month outcomes were added to a predictive model with baseline characteristics only (area under the receiver-operating characteristic (AUROC) 0.85 versus 0.72, p=0.001). Based on this model, a prediction tool using sex, prior biologic use, baseline blood eosinophils, forced expiratory volume in 1 s, and at 3 months OCS dose and ACQ-6 was developed which classified patients into three categories with increasing probability of long-term response (95% CI): 25% (3-65%), 67% (57-77%) and 97% (91-99%), respectively. Conclusion: In addition to baseline characteristics, treatment outcomes at 3 months contribute to the prediction of benralizumab response at 1 year in patients with severe eosinophilic asthma. Prediction tools as proposed in this study may help physicians optimise the use of costly biologics.

Routine Outcome Monitoring (ROM) and Feedback: Research Review and Recommendations.

OBJECTIVE: To provide a research review of the components and outcomes of routine outcome monitoring (ROM) and recommendations for research and therapeutic practice. METHOD: A narrative review of the three phases of ROM - data collection, feeding back data, and adapting therapy - and an overview of patient outcomes from 11 meta-analytic studies. RESULTS: Patients support ROM when its purpose is clear and integrated within therapy. Greater frequency of data collection is more important for shorter-term therapies, and use of graphs, greater specificity of feedback, and alerts are helpful. Overall effects on patient outcomes are statistically significant (g ≈ 0.15) and increase when clinical support tools (CSTs) are used for not-on-track cases (g ≈ 0.36-0.53). Effects are additive to standard effects of psychological therapies. Organizational, personnel, and resource issues remain the greatest obstacles to the successful adoption of ROM. CONCLUSION: ROM offers a low-cost method for enhancing patient outcomes, on average resulting in an ≈ 8% advantage (success rate difference; SRD) over standard care. CSTs are particularly effective for not-on-track patients (SRD between ≈ 20% and 29%), but ROM does not work for all patients and successful implementation is a major challenge, along with securing appropriate cultural adaptations.

Diet quality, food intake and incident adult-onset asthma: a Lifelines Cohort Study.

PURPOSE: Dietary factors have been suggested as drivers of the rising prevalence of adult-onset asthma, but evidence is inconclusive, possibly due to the complex interrelation with obesity. We aim to explore the relation of diet quality and food intake with incident adult-onset asthma in normal weight and overweight adults of the prospective population-based Lifelines Cohort Study. METHODS: Incident adult-onset asthma was defined as self-reported asthma at ± 4-year follow-up, in adults free of airway disease at baseline. Diet quality scores and food group intake were assessed at baseline. Log-binomial regression analyses were used to estimate adjusted relative risks (RR) between dietary intake (per portion) and incident adult-onset asthma, in categories of BMI (cutoff: 25 kg/m2). RESULTS: 477 incident asthma cases (75% female, 62% overweight) and 34,698 controls (60% female, 53% overweight) were identified. Diet quality-assessed by the Lifelines Diet Score and Mediterranean Diet Score-was not associated with incident adult-onset asthma in the two BMI groups. Although the dietary intake of several food groups differed between cases and controls, after adjustment for confounders only few remained associated with adult-onset asthma, including red and processed meat (RR: 0.93 per 15 g intake; 95% CI 0.86-0.99) in the normal weight group and intake of cheese (RR 1.09 per 20 g intake; 95% CI 1.00-1.17) and vegetables (RR 1.10 per 50 g intake; 95% CI 1.00-1.21) in the overweight group. CONCLUSION: The results of this study question the role of food as a 'simple' predictor of adult-onset asthma and call for an integrative approach, including a range of modifiable lifestyle factors and further asthma phenotyping.