Biomedical subjects

Thomas R Belin

Publications and source records attributed to Thomas R Belin.

At least 19 recordsLinked to original sources

PubMed2007

Robustness of a multivariate normal approximation for imputation of incomplete binary data.

Multiple imputation has become easier to perform with the advent of several software packages that provide imputations under a multivariate normal model, but imputation of missing binary data remains an important practical problem. Here, we explore three alternative methods for converting a multivariate normal imputed value into a binary imputed value: (1) simple rounding of the imputed value to the nearer of 0 or 1, (2) a Bernoulli draw based on a 'coin flip' where an imputed value between 0 and 1 is treated as the probability of drawing a 1, and (3) an adaptive rounding scheme where the cut-off value for determining whether to round to 0 or 1 is based on a normal approximation to the binomial distribution, making use of the marginal proportions of 0's and 1's on the variable. We perform simulation studies on a data set of 206,802 respondents to the California Healthy Kids Survey, where the fully observed data on 198,262 individuals defines the population, from which we repeatedly draw samples with missing data, impute, calculate statistics and confidence intervals, and compare bias and coverage against the true values. Frequently, we found satisfactory bias and coverage properties, suggesting that approaches such as these that are based on statistical approximations are preferable in applied research to either avoiding settings where missing data occur or relying on complete-case analyses. Considering both the occurrence and extent of deficits in coverage, we found that adaptive rounding provided the best performance.

Adolescent↗

PubMed2006

Fatigue in long-term breast carcinoma survivors: a longitudinal investigation.

BACKGROUND: A longitudinal study was designed to evaluate the prevalence, persistence, and predictors of posttreatment fatigue in breast carcinoma survivors. METHODS: A sample of 763 breast carcinoma survivors completed questionnaires at 1-5 and 5-10 years after diagnosis, including the RAND 36-item Health Survey, Center for Epidemiological Studies - Depression scale (CES-D), Breast Cancer Prevention Trial Symptom Checklist, and demographic and treatment-related measures. RESULTS: Approximately 34% of study participants reported significant fatigue at 5-10 years after diagnosis, which is consistent with prevalence estimates obtained at 1-5 years after diagnosis. Approximately 21% reported fatigue at both assessment points, indicating a more persistent symptom profile. Longitudinal predictors of fatigue included depression, cardiovascular problems, and type of treatment received. Women treated with either radiation or chemotherapy alone showed a small improvement in fatigue compared with those treated with both radiation and chemotherapy. CONCLUSIONS: Fatigue continues to be a problem for breast carcinoma survivors many years after cancer diagnosis, with 21% reporting persistent problems with fatigue. Several factors that may contribute to long-term fatigue are amenable to intervention, including depression and comorbid medical conditions.

Aged↗

PubMed2006

Psychosocial impacts of a camping experience for children with cancer and their siblings.

BACKGROUND: We conducted a prospective two-group evaluation of pediatric cancer patients and their siblings regarding experiences and affective changes resulting from a 1-week summer camp experience. METHODS: The patients and siblings were assessed prior to camp (Baseline), at the end of camp (Follow-up 1), and again 4-6 months later (Follow-up 2). Assessments included standardized tests for depressive affects, social competency, and a measure of pleasure and participation in camp activities. RESULTS: Sixty-six children were assessed, including 31 (47%) patients and 35 (53%) siblings. Ages ranged from 7 to 17 years. Of the patient campers 19 (61%) had leukemia or lymphoma and 12 (39%) had solid tumors. Results showed marked changes in affective symptoms for patient campers over time (improvements), not shown by sibling campers. For patient campers these affective changes were not present immediately after camp, but were quite significant when measured 4-6 months later. Both patient and sibling campers reflected the same positive memories and pleasure in camp activities over time. For neither group did memories or pleasure fade over time. The camping experience did not have differential impacts on first time versus returning campers. Twelve campers (18% of sample) indicated suicidal ideation on the measure of depressive affects. They did well at camp and presented no special management issues. CONCLUSION: Expectations appear substantially different for patient versus sibling campers. The camping experience appeared to impact these groups differently, with patient campers impacted in ways not experienced by sibling campers.

Adolescent↗

PubMed2006

Using patient self-report data to evaluate orofacial surgical outcomes.

OBJECTIVES: This study analyzes results of 336 patients treated for mandible fractures at King/Drew Medical Center in South Central Los Angeles, California from August 1996 to December 2001. Subjects were enrolled in a prospective study to evaluate the association between patient's subjective evaluation and objective clinical evaluations on three surgical outcome measures following orofacial surgery. METHODS: Subjects were assessed at four time periods--hospital discharge, 10 days post-discharge, 1 month post-discharge and 6 months post-discharge. Three outcome measures were utilized to represent perceived health and oral health-related quality of life--General Oral Health Assessment Index (GOHAI); Mental Health Inventory (MHI-5); and a single-item self-reported health status measure. RESULTS: GOHAI scores at 1 month (mean=31.5, SD=9.5) were not substantially higher than at 10 days (mean=28.6, SD=8.8), but scores did improve substantially by 6 months (mean=42.6, SD=10.6). Mean mental health scores ranged from 17.7 at 10 days to 18.0 at 1 month and 18.6 at 6 months. Mean self-reported health status score were approximately 2.2 at all recalls, describing health as 'good.' A longitudinal growth curve analysis of GOHAI scores over four time periods indicated a significantly higher average intercept for the maxillomandibular fixation (MMF) treatment group (29.67) than in the rigid internal fixation (RIF) treatment group (25.38). Meanwhile, the increase in GOHAI scores over time was significantly greater in the RIF group than in the MMF group, resulting in scores being comparable between groups after 6 months. CONCLUSIONS: By implication, patients with MMF self-report fewer problems in the early days after placement of the intra-arch wire compared with patients with RIF.

Adolescent↗

PubMed2006

Longitudinal patterns of alcohol, drug, and mental health need and care in a national sample of U.S. adults.

OBJECTIVE: Use of longitudinal data can help clarify the extent of persistent need for services or persistent problems in gaining access to services. This study examined the level of transient and persistent need and unmet need over time among respondents to a national survey and whether need was met by provision of mental health services or resolved without treatment. METHODS: Data from the longitudinal Health Care for Communities (HCC) household telephone survey were used to produce joint distributions of need status and care for two periods (wave 1 data collected in 1997 to 1998 and wave 2 data collected in 2000 to 2001; N=6,659). Perceived need was measured as self-report of need for help with a mental or substance use problem. Probable clinical need was assessed with the Composite International Diagnostic Interview, the Alcohol Use Disorders Identification Test, and the 12-item Short Form Health Survey. RESULTS: High levels of persistent unmet need for care (44 to 52 percent) were found among respondents who had probable clinical need in wave 1. Although a majority of those with need received some care, an equal proportion (about 30 percent) of those with perceived need only or probable clinical need in wave 1 did not receive any care. A substantial portion of need (22 to 26 percent) appears to have resolved without treatment, which may suggest high levels of transient need. CONCLUSIONS: Persistent patterns of unmet need represent important targets for policy and programs that can improve utilization, including outreach, education, and improved insurance coverage.

Adolescent↗

PubMed2006

Geographic variation in alcohol, drug, and mental health services utilization: what are the sources of the variation?

BACKGROUND: Studies have documented geographic variation in health services utilization over a range of medical, surgical, and psychiatric conditions. These geographic differences are of concern to policy makers, as they may represent either excessive levels of unnecessary care or inappropriately low utilization of necessary services. However, the sources of geographic variation are not well understood, and variation may not represent a quality problem, to the extent that geographic variation is due to sampling variability or variation in case-mix across sites. AIMS OF THE STUDY: Our aim was to determine the extent to which geographic variation in assessment and treatment rates for alcohol, drug, and mental disorders (ADM) was due to variation in case-mix across sites and to quantify the amount of geographic variation after case-mix adjustment. METHODS: We analyzed data from Healthcare for Communities, a nationally representative telephone survey of ADM disorders and treatment. We utilized fixed effects and random intercept models to analyze whether individuals received a brief primary care ADM assessment, any primary care ADM treatment, any specialty ADM treatment, or any ADM treatment. Using the coefficient of variation and intra-class correlation (ICC) as summaries, we simulated reference distributions for the amount of variability in ADM assessment and treatment rates expected due to variation in case mix across 60 geographic areas. We compared this with the actual variation among our 60 sites, and the variation that remained after adjusting for ADM disorders, physical health, and socioeconomic characteristics. RESULTS: The amount of the variation in assessment and treatment rates explained by geographic area in unadjusted fixed effects and random intercepts models was statistically significant with R2 statistics ranging from 1% to 2% in fixed effects models and ICC's ranging from 0.009 to 0.043. Considerably more variation was explained in analyses that included individual level characteristics such as ADM disorders, physical health, and socioeconomic status, with R2 statistics from 10% to 19%. In random intercept models the ICC's were decreased 20 to 100% in models that adjusted for ADM disorders, physical health, and socioeconomic status. DISCUSSION: We found significant variation in ADM assessment and treatment rates across geographic sites. However, the magnitude of geographic variation was relatively modest, with 0.9 to 4.3% of the total variation in ADM assessment and treatment occurring at the geographic level. Further, it appears that a moderate amount of this geographic variation may be due to differences in case mix across sites. IMPLICATIONS FOR HEALTH POLICY: Although geographic variation in assessment and treatment rates can signal variable quality, there may be only modest potential for improving quality by reducing geographic variation. Further, the success of efforts to decrease geographic variation by focusing on provider behavior may be limited by the extent to which systematic variation is explained by individual characteristics. IMPLICATIONS FOR FURTHER RESEARCH: Future work on geographic differences in mental health care as well as in health services more generally should pay particular attention to adjusting for individual differences in morbidity, which strongly predict treatment utilization.

Adolescent↗

PubMed2005

Outcomes from the Moving Beyond Cancer psychoeducational, randomized, controlled trial with breast cancer patients.

PURPOSE: Evidence suggests that the re-entry phase (ie, early period after medical treatment completion) presents distinct challenges for cancer patients. To facilitate the transition to recovery, we conducted the Moving Beyond Cancer (MBC) trial, a multisite, randomized, controlled trial of psychoeducational interventions for breast cancer patients. METHODS: Breast cancer patients were registered within 6 weeks after surgery. After medical treatment, they completed baseline measures and were randomly assigned to standard National Cancer Institute print material (CTL); standard print material and peer-modeling videotape (VID); or standard print material, videotape, two sessions with a trained cancer educator, and informational workbook (EDU). Two primary end points were examined: energy/fatigue and cancer-specific distress. Secondary end points were depressive symptoms and post-traumatic growth. Perceived preparedness for re-entry was analyzed as a moderator of effects. RESULTS: Of 558 women randomly assigned to treatment, 418 completed the 6-month assessment and 399 completed the 12-month assessment. In analyses controlling for study site and baseline depressive symptoms, VID produced significant improvement in energy/fatigue at 6 months relative to CTL, particularly among women who felt less prepared for re-entry at baseline. No significant main effect of the interventions emerged on cancer-specific distress, but EDU prompted greater reduction in this outcome relative to CTL at 6 months for patients who felt more prepared for re-entry. Between-group differences in the primary outcomes were not significant at 12 months, and no significant effects emerged on the secondary end points. CONCLUSION: A peer-modeling videotape can accelerate the recovery of energy during the re-entry phase in women treated for breast cancer, particularly among those who feel less prepared for re-entry.

Adult↗

PubMed2005

A comparison of imputation methods in a longitudinal randomized clinical trial.

It is common for longitudinal clinical trials to face problems of item non-response, unit non-response, and drop-out. In this paper, we compare two alternative methods of handling multivariate incomplete data across a baseline assessment and three follow-up time points in a multi-centre randomized controlled trial of a disease management programme for late-life depression. One approach combines hot-deck (HD) multiple imputation using a predictive mean matching method for item non-response and the approximate Bayesian bootstrap for unit non-response. A second method is based on a multivariate normal (MVN) model using PROC MI in SAS software V8.2. These two methods are contrasted with a last observation carried forward (LOCF) technique and available-case (AC) analysis in a simulation study where replicate analyses are performed on subsets of the originally complete cases. Missing-data patterns were simulated to be consistent with missing-data patterns found in the originally incomplete cases, and observed complete data means were taken to be the targets of estimation. Not surprisingly, the LOCF and AC methods had poor coverage properties for many of the variables evaluated. Multiple imputation under the MVN model performed well for most variables but produced less than nominal coverage for variables with highly skewed distributions. The HD method consistently produced close to nominal coverage, with interval widths that were roughly 7 per cent larger on average than those produced from the MVN model.

Aged↗

PubMed2005

Depression prevalence in disadvantaged young black women--African and Caribbean immigrants compared to US-born African Americans.

BACKGROUND: Research with Mexican Americans suggests that immigrants have lower rates of mental disorders than U. S.-born Mexican Americans. We examine the prevalence of depression, somatization, alcohol use and drug use among black American women, comparing rates of disorders among U. S.-born, Caribbean-born, and African-born subsamples. METHODS: Women in Women, Infants and Children (WIC) programs, county-run Title X family planning clinics, and low-income pediatric clinics were interviewed using the PRIME-MD. In total, 9,151 black women were interviewed; 7,965 were born in the U. S., 913 were born in Africa, and 273 were born in the Caribbean. RESULTS: Controlling for other predictors, U.S.-born black women had odds of probable depression that were 2.94 times greater than the African-born women (p<0.0001, 95% CI: 2.07, 4.18) and 2.49 times greater than Caribbean-born women (p<0.0016, 95% CI: 1.41, 4.39). Likelihood of somatization did not differ among women who were U. S. born, African born, or Caribbean born. Rates of alcohol and drug problems were exceedingly low among all three groups, with less than 1% of the women reporting either alcohol or drug problems. CONCLUSIONS: These results mirror similar findings for Mexican immigrant as compared with American-born Mexican Americans. The findings suggest that living in the U. S. might increase depression among poor black women receiving services in county entitlement clinics. Further research with ethnically validated instruments is needed to identify protective and risk factors associated with depression in immigrant and U. S.-born poor black women.

Adult↗

PubMed2005

A qualitative report of patient problems and postoperative instructions.

PURPOSE: While surgery related stress may interfere with the patient's ability to concentrate on instructions, language difficulty or low health literacy may also impede appropriate doctor/patient communication. The purpose of this study is to understand from a sample of minority patients the types of problems encountered during healing and the level of information regarding elements of postoperative instructions they recalled receiving at an inner-city safety net hospital. We initiated a qualitative study to understand the care sequence process and provision of informed consent and postoperative instruction. METHODS: African American or Latino patients, 18 years of age or older, who had third molars removed under general anesthesia or received treatment for a mandibular fracture were recruited to participate in a focus group to discuss their treatment. Patients described their problem and any informed consent given about treatment risks and benefits and postoperative information they recalled. RESULTS: A total of 137 former patients were approached, 57 agreed to participate (42%) and 34 of those (60%) completed the interview. Subjects included 14 females and 20 males. Five categories of patient problems were reported: physical, eating, treatment-related, psychosocial, and other problems. People reported 5 categories of coping strategies: medication use, physical treatments, dietary solutions, rest, and clinical assistance. Twenty people recalled being given informed consent, and 5 participants recalled no elements of informed consent. Overall, 14 participants recalled elements of postoperative instruction. CONCLUSION: Gaps in patient understanding of postoperative care suggest room for improvement in postoperative instructions. Additional research is necessary to design and test high-quality postoperative instructions for surgical treatment and recovery in populations with limited health related literacy.

Adaptation, Psychological↗

PubMed2005

Imputation and variable selection in linear regression models with missing covariates.

Across multiply imputed data sets, variable selection methods such as stepwise regression and other criterion-based strategies that include or exclude particular variables typically result in models with different selected predictors, thus presenting a problem for combining the results from separate complete-data analyses. Here, drawing on a Bayesian framework, we propose two alternative strategies to address the problem of choosing among linear regression models when there are missing covariates. One approach, which we call "impute, then select" (ITS) involves initially performing multiple imputation and then applying Bayesian variable selection to the multiply imputed data sets. A second strategy is to conduct Bayesian variable selection and missing data imputation simultaneously within one Gibbs sampling process, which we call "simultaneously impute and select" (SIAS). The methods are implemented and evaluated using the Bayesian procedure known as stochastic search variable selection for multivariate normal data sets, but both strategies offer general frameworks within which different Bayesian variable selection algorithms could be used for other types of data sets. A study of mental health services utilization among children in foster care programs is used to illustrate the techniques. Simulation studies show that both ITS and SIAS outperform complete-case analysis with stepwise variable selection and that SIAS slightly outperforms ITS.

Algorithms↗

PubMed2005

Comparison of psychiatrists' and other physicians' assessments of their ability to deliver high-quality care.

OBJECTIVE: This study compared psychiatrists' assessments of their ability to deliver high-quality care with those of other physicians. METHODS: Data were used from the Community Tracking Study Physician Survey, a national survey of 12,528 physicians. Linear regression models were used to investigate the effects of type of physician (psychiatrist or other physician), managed care involvement, and ability to obtain inpatient care on four measures of physicians' assessments of quality. RESULTS: In models that did not control for difficulty in obtaining inpatient services, assessments of quality were significantly lower among psychiatrists than among other physicians. Furthermore, although managed care involvement was associated with lower assessments of quality for all physicians in these models, the effects were stronger for psychiatrists than for other physicians. However, after difficulty in obtaining inpatient services was controlled for, psychiatrists' and other physicians' assessments of quality were similar. CONCLUSIONS: Compared with other physicians, psychiatrists' assessments of the quality of care that they provide were lower and their assessments were more influenced by involvement with managed care. These differences may be mediated by difficulty in obtaining inpatient services. When designing and administering behavioral health benefits packages, clinical policy makers should consider the possible effects of reduction in inpatient services on quality of care.

Attitude of Health Personnel↗

PubMed2005

Depression among Latina immigrant mothers separated from their children.

OBJECTIVE: Latinas who immigrate to the United States and leave their children in their homelands may experience psychological consequences of this separation. This study examined whether immigrant Latinas who were separated from their children differed in rates of probable major depression from those who lived with their children and from those who did not have any children. METHODS: Data were obtained between March 1997 and May 2002 from women in Women, Infants, and Children programs that target low-income pregnant and postpartum women and their children (up to five years of age), women in county-run Title X family planning clinics, women in pediatric clinics for low-income families, and women who were living in a subsidized-housing project or attending programs for county welfare recipients. Latinas in this study were all immigrants to the United States. The women were screened for major depressive disorders with the Primary Care Evaluation of Mental Disorders. RESULTS: A total of 5,122 Latina immigrants were screened. Overall, 11.7 percent of the sample screened positive for major depression. The rates of depression were 11.4 percent for women who lived with their children, 10.9 percent for those who did not have children, and 18.1 for those who were not living with their children. When the analyses controlled for demographic differences, the odds of depression for immigrant Latinas who were separated from their children were 1.52 times as great as the odds for those whose children were currently living with them (p=.02). Odds of depression were similar among women who lived with their children and those who did not have children. CONCLUSIONS: Separation from children during immigration may lead to increased risk of depression for immigrant Latinas. Health care clinicians who treat young immigrant women should pay close attention to signs of depression among women who have left children with relatives in their homelands.

Adult↗

PubMed2005

Do specialist self-referral insurance policies improve access to HIV-experienced physicians as a regular source of care?

Health insurance policies that require prior authorization for specialty care may be detrimental to persons with HIV, according to evidence that having a regular physician with HIV expertise leads to improved patient outcomes. The objective of this study is to determine whether HIV patients who can self-refer to specialists are more likely to have physicians who mainly treat HIV. The authors analyze cross-sectional survey data from the HIV Costs and Services Utilization Study. At baseline, 67 percent of patients had insurance that permitted self-referral. In multivariate analyses, being able to self-refer was associated with an 8-12 percent increased likelihood of having a physician at a regular source of care that mainly treats patients with HIV. Patients who can self-refer are more likely to have HIV-experienced physicians than are patients who need prior authorization. Insurance policies allowing self-referral to specialists may result in HIV patients seeing physicians with clinical expertise relevant to HIV care.

Adult↗

PubMed2004

Imputation for incomplete high-dimensional multivariate normal data using a common factor model.

It is common in applied research to have large numbers of variables measured on a modest number of cases. Even with low rates of missingness on individual variables, such data sets can have a large number of incomplete cases. Here we present a new method for handling missing continuously scaled items in multivariate data, based on extracting common factors to reduce the number of covariance parameters to be estimated in a multivariate normal model. The technique is compared in several simulation settings to available-case analysis and to a multivariate normal model with a ridge prior. The method is also illustrated on a study with over 100 variables evaluating an emergency room intervention for adolescents who attempted suicide.

Humans↗

PubMed2004

Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial.

BACKGROUND: During the last decade, survival rates for breast cancer have increased as a result of earlier detection and increased use of adjuvant therapy. Limited data exist on the psychosocial aspects of the transitional period between the end of primary treatment and survivorship. We investigated the baseline psychosocial status of women enrolled in a randomized trial testing two psychosocial interventions for women at the end of primary treatment. METHODS: Participants, identified within 1 month after surgery (registration), provided demographic information and limited measures of quality of life. They were followed until they finished primary treatment (enrollment), at which time they completed a mailed baseline survey that included standardized measures of quality of life (including standardized scales of physical and emotional functioning), mood, symptoms, and sexual functioning. A total of 558 patients (mean age = 56.9 years) were enrolled in the study between July 1, 1999, and June 30, 2002. Health outcomes were examined according to treatment received: mastectomy with and without chemotherapy, and lumpectomy with and without chemotherapy. All statistical tests were two-sided. RESULTS: Among all treatment groups, patients who had a mastectomy had the poorest physical functioning at registration (P<.001) and at enrollment (P=.05). At enrollment, mood and emotional functioning were similar among all patients, with no differences by type of treatment received. At enrollment, symptoms, including muscle stiffness, breast sensitivity, aches and pains, tendency to take naps, and difficulty concentrating, were common among patients in all groups and were statistically significantly associated with poor physical functioning and emotional well-being. Sexual functioning was worse for women who received chemotherapy than for those who did not, regardless of type of surgery (P<.001). CONCLUSIONS: At the end of primary treatment for breast cancer, women in all treatment groups report good emotional functioning but report decreased physical functioning, particularly among women who have a mastectomy or receive chemotherapy. Clinical interventions to address common symptoms associated with treatment should be considered to improve physical and emotional functioning at the end of primary treatment for breast cancer.

Adult↗

PubMed2004

Psychologic functioning and needs of indigent patients with facial injury: a prospective controlled study.

PURPOSE: This study sought to examine 1) temporal changes in psychologic functioning over 12 months and 2) baseline differences in mental health and social service needs between orofacial injury patients and sociodemographically comparable controls undergoing elective oral surgery. MATERIALS AND METHODS: Prospective, case-control study of patients treated at a public hospital in Los Angeles, CA. A total of 336 subjects with mandible fractures and 119 subjects undergoing elective removal of their third molars participated in structured, repeated follow-up assessments (10 days, 6 months, and 12 months after their surgical procedures). Multiple imputation was used to manage incomplete data, and propensity score analysis was used to correct for covariate imbalances between the injury and the control cohort. A series of ANOVAs, chi(2) analyses, and odds ratios was conducted. RESULTS: The injury patients continue to experience significant psychologic distress for up to 12 months following the traumatic event. Orofacial injury patients also tend to report more lifetime and current mental health and social service needs than the sociodemographically similar elective-surgery cohort. CONCLUSION: The management of facial injuries in disadvantaged individuals should integrate case management that addresses psychosocial sequelae and service needs of patients.

Adult↗

PubMed2003

Determinants of surgical decisions about mandible fractures.

PURPOSE: The study goal was to explore contextual patient- and surgeon-related characteristics that influence the perception of injury severity and treatment strategy for mandible fractures. METHODS: After reviewing plain radiographs of 22 patients with mandible fractures, 18 oral and maxillofacial surgeons were queried on summary severity ratings and treatment decisions for each injury. Subsequently, they were asked to indicate how various hypothetical fracture and patient-specific factors would alter their perception of injury severity and original treatment recommendations. The effect of the level of clinician trauma expertise on perception of injury severity and treatment choice was also assessed. RESULTS: Each of the fracture-specific characteristics-number of constituent fractures, fracture complexity, degree of displacement, and summary injury severity-influenced the choice of treatment modality. Surgeon-specific characteristics were related to both perception of injury severity and treatment choice. Although clinicians with greater trauma loads tended to provide higher summary severity ratings for the same range of injuries (P <.001), they appeared to recommend maxillomandibular fixation for a much broader spectrum of injury severity (R = -0.42). Surgeons' perception of injury severity appeared to escalate with increasing damage to the soft tissue envelope; the influence of patient-related risk factors was less distinct. More than half of the surgeons suggesting maxillomandibular fixation for a particular case changed their treatment recommendation to rigid internal fixation on learning that the patient was noncompliant. CONCLUSIONS: Clinical decision making for mandible fractures is not a precise and fully reliable activity. Contextual factors (fracture, patient, and surgeon related) appear to influence the clinical decision and may be responsible for the existing variations in practice patterns.

Analysis of Variance↗