A framework for understanding and designing partnerships in emergency preparedness and response

Thesis (S.M.)--Massachusetts Institute of Technology, Engineering Systems Division, Technology and Policy Program, 2007.This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.Includes bibliographical references.Using partnerships between the public and private sectors to provide emergency preparedness and response (EPER) functions has become a useful and necessary tool for improving overall emergency management in the United States. Privatization has been studied comprehensively in many areas that are ripe for partnerships, but not in the field of emergency preparedness and response. Thus, this research fills that gap and advises both the architects of EPER partnerships and the policy makers that influence them, how to design partnerships based on the experience of former and existing EPER partnerships. In order to learn from existing partnerships, this research uses a case study method. After identifying and interviewing representatives from 16 EPER partnerships, this research classifies those partnerships based on several attributes. There are three general categories for those descriptive attributes: structural, functional and event. The structural attributes represent characteristics of a partnership that an architect has decision making power over. Functional and event attributes, on the other hand, are dependent on the EPER function being provided and are thus largely pre-defined for an architect.(cont.) This research identifies links between the independent variables -- the functional and event attributes -- and the dependent variables -- the structural attributes -- that will guide architects and policy makers in their decision making processes. In general, this research found that there are several event and functional attributes of successful past EPER partnerships that can inform the structural decisions of the architect. Also, this research finds that there are several lessons the policy maker can take from past EPER partnerships, including the importance of allowing and encouraging flexibility in the partnership design process.by Jennifer L. Gustetic.S.M

Universal screening for depression in cancer patients and its impact on management patterns.

232 Background: Screening for distress in cancer patients (pts) is recommended by several national guidelines. High distress scores are associated with increased depression. We established universal depression screening and investigated its impact on cancer patient management. Methods: Patient Health Questionnaire (PHQ9) was administered to newly diagnosed cancer patients prior to receiving their first non-oral antineoplastic agent. Patient demographics, disease characteristics, chronic medication load, antidepressant use, treatment interruptions, weight change, referral and adherence to psychiatry were recorded. Pts with high (&gt; 9) and low (&lt; 4) PHQ9 scores were compared using Chi-square and Wilcoxon rank-sum tests. Results: Screening was performed in 1,190 consecutive pts over an 18 month period at Mayo Clinic. Responses were received from 1055 (89%) pts, of which 144 had high score (PHQ-H). These were compared with 99 randomly selected low score (PHQ-L) pts. The 243 pts (median age 65; range 18-92 years) in the final analysis included: 53.5% females, 90% Caucasians, 74% married and 77% living with others. Diagnosis was solid organ cancer in 81% and metastatic disease in 54% patients, and 13% were on antidepressants for preexisting depression. PHQ-H were more likely to be on antidepressants than PHQ-L (19% vs. 3%; p = 0.0002), be referred to psychiatry (69% vs. 12%; p &lt; 0.0001), attend psychiatry appointment (45% vs. 12%; p &lt; 0.0001) and require behavioral therapy (50% vs 8%; p = 0.0065). PHQ-H did not have a significantly increased antidepressant use, treatment interruptions (p = 0.5) or weight change (p = 0.4). Race, gender, chronic medication load, marital status, living situation, metastatic disease and type of cancer were not significantly different between PHQ-H and PHQ-L. Conclusions: We implemented a universal depression screening and management plan for cancer pts and noted that previously being on antidepressants was associated with higher patient distress. Higher score led to more frequent behavioral therapy, possibly preventing non-compliance or need for increased psychotropic medications. Our model identifies cancer pts with depression and implements an effective management plan for their care. </jats:p

Socio-Demographic Parameters Including Race, As Predictors of Depression in Patients with Hematologic Malignancies

Abstract Background: Cancer diagnosis and treatment are important risk factors for developing clinical depression. Validated tools for screening distress and depression, such as Cancer Distress Thermometer (DT) and PHQ9 (Patient Health Questionnaire), are underutilized, despite endorsement by NCCN and Institute of Medicine. We investigated patient and treatment characteristics as well as patient endorsement of depression or anhedonia to predict those at risk of having depression. Methods: The PHQ9 and/or DT were administered prospectively to patients with hematologic malignancies (HM) before they started antineoplastic therapy at Mayo Clinic in Florida. Patient endorsement of depression or anhedonia was collected from the current visit information survey. Patient demographics, disease and treatment characteristics, chronic medication burden, Charlson comorbidity index, living situation, clinic/hospital visit burden in the month prior to screening and number of psychiatric medications for every patient were recorded. Intergroup comparison of categorical and continuous variables was done by Chi-square and Wilcoxon rank-sum tests, respectively. Linear or logistic regression models were used to compare PHQ9 score with DT (continuous) or endorsing depression or anhedonia (categorical) respectively. Multivariate models were constructed using the stepwise selection technique using all potential variables in the models. All analyses were completed using SAS v9.3. Results: Final analysis included 246 patients with a median age at diagnosis 64.5 (range: 18-94) years, diagnosed between 6/30/93-10/9/14 and screened between 1/13/11-2/13/15. PHQ9 score of ≥9 and DT score ≥5 suggested a high risk of depression and distress, respectively, as per published literature. Patient characteristics at time of survey and analysis are noted in table 1. PHQ9, DT and answers to two questions about depression and anhedonia were available on 129, 129 and 246 patients, respectively. 63% of patients were chemotherapy naïve. In multivariate analysis, PHQ9 score ≥9 was associated with living alone (p=0.003) (Fig.1a) and non-White race (p=0.043) (Fig.1b), while a DT score ≥5 was associated with being currently married (p=0.048) and female gender (p=0.02). The only characteristic significant on univariate but not on multivariate analysis being chemotherapy naive, associated with a DT score ≥5 (p=0.049). Answering "no" to both the questions regarding depression or anhedonia was significantly associated with a low score on PHQ9 (p=0.007). Age at diagnosis, Charlson comorbidity score, chronic medication or visit burden, daily psychiatric medication use or type of malignancy were not associated with scores on any screen. Conclusions: Causes of depression in patients with HM have not been fully explored. We validated previously known risk factors for depression, such as living alone. We also reported for the first time that non-White race independently predicts depression in these patients. Female patients and those currently married are at a higher risk of psychological distress, possibly due to fear of abandoning family. We also found that simply asking a patient two questions about feelings of depression or anhedonia significantly correlates with the well-established PHQ9. Our analysis provides simple tools and reveals at-risk patient subgroups with HM where depression and distress screening should be aggressively instituted for better resource utilization and survivorship. Table 1. Patient Characteristic N % Gender Male Female 146 100 59.4 40.6 Race White Non-White 216 30 87.8 12.2 Marital Status Married Not married* 180 66 73.2 26.8 Living Situation Alone With others 37 209 15 85 Type of Malignancy Aggressive lymphoid Indolent lymphoid Aggressive myeloid Indolent myeloid 124 94 25 3 50.4 38.2 10.2 1.2 Prior Cancer Treatment Yes No 91 155 37 63 Daily Psych Meds Yes No 52 194 21.1 78.9 Patient Status Alive Dead 191 55 77.6 22.4 *Not currently married=single, divorced, widowed or unknown Disclosures No relevant conflicts of interest to declare. </jats:sec