Biomedical subjects

Kimberly J O'Malley

Publications and source records attributed to Kimberly J O'Malley.

16 recordsLinked to original sources

PubMed2005

Measuring diagnoses: ICD code accuracy.

OBJECTIVE: To examine potential sources of errors at each step of the described inpatient International Classification of Diseases (ICD) coding process. DATA SOURCES/STUDY SETTING: The use of disease codes from the ICD has expanded from classifying morbidity and mortality information for statistical purposes to diverse sets of applications in research, health care policy, and health care finance. By describing a brief history of ICD coding, detailing the process for assigning codes, identifying where errors can be introduced into the process, and reviewing methods for examining code accuracy, we help code users more systematically evaluate code accuracy for their particular applications. STUDY DESIGN/METHODS: We summarize the inpatient ICD diagnostic coding process from patient admission to diagnostic code assignment. We examine potential sources of errors at each step and offer code users a tool for systematically evaluating code accuracy. PRINCIPLE FINDINGS: Main error sources along the "patient trajectory" include amount and quality of information at admission, communication among patients and providers, the clinician's knowledge and experience with the illness, and the clinician's attention to detail. Main error sources along the "paper trail" include variance in the electronic and written records, coder training and experience, facility quality-control efforts, and unintentional and intentional coder errors, such as misspecification, unbundling, and upcoding. CONCLUSIONS: By clearly specifying the code assignment process and heightening their awareness of potential error sources, code users can better evaluate the applicability and limitations of codes for their particular situations. ICD codes can then be used in the most appropriate ways.

Data Collection↗

PubMed2005

Integrating validity theory with use of measurement instruments in clinical settings.

OBJECTIVE: To present validity concepts in a conceptual framework useful for research in clinical settings. PRINCIPAL FINDINGS: We present a three-level decision rubric for validating measurement instruments, to guide health services researchers step-by-step in gathering and evaluating validity evidence within their specific situation. We address construct precision, the capacity of an instrument to measure constructs it purports to measure and differentiate from other, unrelated constructs; quantification precision, the reliability of the instrument; and translation precision, the ability to generalize scores from an instrument across subjects from the same or similar populations. We illustrate with specific examples, such as an approach to validating a measurement instrument for veterans when prior evidence of instrument validity for this population does not exist. CONCLUSIONS: Validity should be viewed as a property of the interpretations and uses of scores from an instrument, not of the instrument itself: how scores are used and the consequences of this use are integral to validity. Our advice is to liken validation to building a court case, including discovering evidence, weighing the evidence, and recognizing when the evidence is weak and more evidence is needed.

Data Collection↗

PubMed2005

Dynamic assessment of health outcomes: time to let the CAT out of the bag?

BACKGROUND: The use of item response theory (IRT) to measure self-reported outcomes has burgeoned in recent years. Perhaps the most important application of IRT is computer-adaptive testing (CAT), a measurement approach in which the selection of items is tailored for each respondent. OBJECTIVE: To provide an introduction to the use of CAT in the measurement of health outcomes, describe several IRT models that can be used as the basis of CAT, and discuss practical issues associated with the use of adaptive scaling in research settings. PRINCIPAL POINTS: The development of a CAT requires several steps that are not required in the development of a traditional measure including identification of "starting" and "stopping" rules. CAT's most attractive advantage is its efficiency. Greater measurement precision can be achieved with fewer items. Disadvantages of CAT include the high cost and level of technical expertise required to develop a CAT. CONCLUSIONS: Researchers, clinicians, and patients benefit from the availability of psychometrically rigorous measures that are not burdensome. CAT outcome measures hold substantial promise in this regard, but their development is not without challenges.

Health Services Research↗

PubMed2005

Development of a multidimensional measure for recurrent abdominal pain in children: population-based studies in three settings.

OBJECTIVE: Recurrent abdominal pain (RAP) is a common problem in children and adolescents. Evaluation and treatment of children with RAP continue to challenge physicians because of the lack of a psychometrically sound measure for RAP. A major obstacle to progress in research on RAP has been the lack of a biological marker for RAP and the lack of a reliable and valid clinical measure for RAP. The objectives of this study were (1) to develop and test a multidimensional measure for RAP (MM-RAP) in children to serve as a primary outcome measure for clinical trials, (2) to evaluate the reliability of the measure and compare its responses across different populations, and (3) to examine the reliabilities of the measure scales in relation to the demographic variables of the studied population. METHODS: We conducted 3 cross-sectional studies. Two studies were clinic-based studies that enrolled children with RAP from 1 pediatric gastroenterology clinic and 6 primary care clinics. The third study was a community-based study in which children from 1 elementary and 2 middle schools were screened for frequent episodes of abdominal pain. The 3 studies were conducted in Houston, Texas. Inclusion criteria for the clinic-based studies were (1) age of 4 to 18 years; (2) abdominal pain that had persisted for 3 or more months; (3) abdominal pain that was moderate to severe and interfered with some or all regular activities; (4) abdominal pain that may or may not be accompanied by upper-gastrointestinal symptoms; and (5) children were accompanied by a parent or guardian who was capable of giving informed consent, and children over the age of 10 years were capable of giving informed assent. The community-based study used standardized questionnaires that were offered to 1080 children/parents from the 3 participating schools; 700 completed and returned the questionnaires (65% response rate). The questionnaire was designed to elicit data concerning the history of abdominal pain or discomfort. A total of 160 children met Apley's criteria and were classified as having RAP. Inclusion criteria were identical to those criteria for the clinic-based studies. Participating children in the 3 studies received a standardized questionnaire that asked about socioeconomic variables, abdominal pain (intensity; frequency; duration; nature of abdominal pain, if present, and possible relationships with school activities; and other upper gastrointestinal symptoms). We used 4 scales for the MM-RAP: pain intensity scale (3 items), nonpain symptoms scale (12 items), disability scale (3 items), and satisfaction scale (2 items). Age 7 was used as a cutoff point for the analysis as the 7-year-olds have been shown to exhibit more sophisticated knowledge of illness than younger children. RESULTS: A total of 295 children who were aged 4 to 18 years participated in the study: 155 children from the pediatric gastroenterology clinics, 82 from the primary care clinics, and 58 from the schools. The interitem consistency (Cronbach's coefficient alpha) for the pain intensity items, nonpain symptoms items, disability items, and satisfaction items were 0.75, 0.81, 0.80, and 0.78, respectively, demonstrating good reliability of the measure. The internal consistencies of the 4 scales did not significantly differ between younger (< or =7 years) and older (>7 years) children. There was also no significant variation in the coefficient alpha of each of the 4 scales in relation to gender or the level of the parent's education. Reliability was identical for the pain-intensity items (0.74) among children who sought medical attention from primary care or pediatric gastroenterology clinics. The intercorrelations of factor scores among the 4 scales showed a strong relationship among the factors but not high enough that correlations would be expected to be measuring the same items. The results of the factor analysis identified 5 components instead of 4 components representing the 4 scales. The 12 items of the nonpain symptoms scale were classified into 2 components; 1 component included heartburn, burping, passing gas, bloating, problem with ingestion of milk, bad breath, and sour taste (nonpain symptoms I), and the other included nausea/vomiting, diarrhea, and constipation (nonpain symptoms II). The program ordered the 5 components on the basis of the percentage of the total variance explained by each component and consequently by the strength of each components in the following order: nonpain symptoms I, pain intensity, pain disability, satisfaction, and nonpain symptoms II. Of the 20 items that composed the MM-RAP, 17 met the inclusion criteria of having a correlation of > or =0.40 on the primary factor analyses. The 3 items that assessed pain intensity met the inclusion criteria as well as the 2 items that assessed satisfaction. Two of the 3 items that assessed disability met the inclusion criteria; however, the missed school item did not. The sleep problem and the loss of appetite items in the nonpain items also did not meet the inclusion criteria in both components of the nonpain symptoms scale. However, the loss of appetite item met the inclusion criteria in the disability scale with a correlation of 0.6. The 2 items that did not meet the inclusion criteria (missed school days and sour taste) will be eliminated in the revised measure for RAP. CONCLUSION: The MM-RAP demonstrated good reliability evidence in population samples. Children who have RAP and are seen at pediatric gastroenterology or primary care pediatric clinics have similar responses, showing that the measure performed well across several populations. Age did not affect the reliability of responses. The MM-RAP included 4 dimensions, each with several items that may identify disease-specific dimensions. In addition, dividing the nonpain symptoms scale into 2 components instead of 1 component could assist in creating a disease-specific measure. The present study focused exclusively on developing the multidimensional measure for RAP in children that could assist physicians in evaluating the efficacy of RAP treatment independent of psychological evaluations. In addition, the measure was designed for use in clinical trials that evaluate the efficacy of RAP treatment and to allow comparison between intervention studies. In conclusion, we were able to identify 4 dimensions of RAP in children (pain intensity, nonpain symptoms, pain disability, and satisfaction with health). We demonstrated that these dimensions can be measured in a reliable manner that is applicable to children who experience RAP in various settings.

Abdominal Pain↗

PubMed2005

Associations between the impact of terrorism and health perceptions of patients.

OBJECTIVE: Previous studies have demonstrated the effects of the September 11th 2001 terrorist attacks on anxiety and anxiety-related conditions in Americans. However, data regarding associations between the attacks and patients' health perceptions are lacking. The objective of this study was to explore associations between the personal impact of the September 11th attacks and patients' perceptions of health and illness. METHOD: We performed a cross-sectional survey of 303 adult African-American, Caucasian, and Hispanic patients at primary care clinics in Houston, Texas. Data were collected between October 15, 2001 and March 1, 2002. We developed items to measure the impact of the September 11th attacks and patients' quality of life. Previously validated scales were used to measure health status, health locus of control, preferences regarding the patient-physician relationship, and patients' explanatory models of illness. RESULTS: Twenty-two percent of patients reported no impact from the attacks, 41% reported mildly negative impact, 22% reported moderately negative impact, and 15% reported extremely negative impact in their lives. In multivariate analysis, demographic characteristics were not associated with impact from the attacks. However, patients who perceived a more external locus of control with respect to health and patients who reported greater meaning of illness in their lives also reported more negative impact from the September 11th attacks. CONCLUSIONS: The September 11th terrorist attacks had at least a somewhat negative impact for a majority of patients far from the site of the nearest attack, and regardless of their demographic backgrounds. The amount of negative impact that patients perceived as a result of the terrorist attacks correlates with certain illness perceptions, including an external health locus of control and a perception of greater meaning of illness in one's life. Such correlations may indicate an effect of terrorism on patients' illness behaviors. Further research is needed to better understand effects of the threat of terrorism on the general health and illness behaviors of patients.

Attitude to Health↗

PubMed2005

Determinants of treatment adherence in ethnically diverse, economically disadvantaged patients with rheumatic disease.

OBJECTIVE: To explore the determinants of adherence to medical recommendations, including drug therapy and appointment-keeping, among ethnically diverse and economically disadvantaged patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). METHODS: Patients with RA and SLE were identified through chart review and were invited to participate in focus groups to examine their attitudes and beliefs regarding adherence to treatment and medical appointments. Eight focus groups (4 RA, 4 SLE) were conducted, with a total of 40 participants (22 SLE patients and 18 RA patients). Transcripts were analyzed using grounded theory techniques and qualitative analysis software to facilitate coding interpretation. RESULTS: The majority of participants reported experiencing difficulty in adhering to their treatment at least occasionally. Both SLE and RA patients reported similar barriers to treatment adherence: fear of side effects, financial problems, difficulty in navigating the public health system, and perceived treatment inefficacy. RA and SLE patients also revealed barriers to appointment keeping, including difficulties in scheduling, financial costs, transportation, and functional impairment limiting their ability to attend the clinic. CONCLUSION: Patients' perceptions of and experiences with the health system, physicians, medication effectiveness, and side effects influence their adherence to treatment and other medical recommendations. Strategies to improve adherence could include the following: attempting to modify patients' beliefs and perceptions regarding medication effectiveness, promoting realistic expectations about risk/benefit ratios, and improving access to health care by reducing barriers that limit the interaction between patients and the health system.

Adult↗

PubMed2004

NOPPAIN: a nursing assistant-administered pain assessment instrument for use in dementia.

The Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN) is a nursing assistant-administered instrument for assessing pain behaviors in patients with dementia. This study investigated the validity of the NOPPAIN. Twenty-one nursing assistants (NAs) with no prior training in using the NOPPAIN watched six videos, each portraying a bed-bound patient with severe dementia receiving personal care from a nursing assistant and responding with a different level of pain intensity. The NAs completed a NOPPAIN rating for each video. The NAs were also presented with each possible pair of videos and asked to identify the video showing the most pain. Results indicated the NAs were quite accurate in their ratings of the videos, providing excellent preliminary evidence on the use of the NOPPAIN for detecting pain in nursing home patients with dementia.

Adult↗

PubMed2004

A Spanish translation of the Walking Impairment Questionnaire was validated for patients with peripheral arterial disease.

OBJECTIVES: Walking impairment is a common manifestation of peripheral arterial disease (PAD). In this study we present evidence for the validity of our Spanish translation of the Walking Impairment Questionnaire (WIQ). METHODS: The WIQ was translated into Spanish by our team of researchers. Spanish-speaking patients in the Houston, TX, area completed Spanish versions of the WIQ and the SF-36. Evidence for convergent and discriminant validity of the WIQ was obtained from correlations between the WIQ and other measures. Spanish or English as the primary language defined language-speaking status. RESULTS: Among 403 patients, convergent validity evidence was strong for both English- and Spanish-speaking patients. For patients with PAD, the correlation between walking distance and physical functioning was 0.55 (P < .01) for English-speaking patients and 0.85 (P < .01) for Spanish-speaking patients. The correlations of walking impairment with emotional health measures ranged from 0.26 to 0.44 for English-speaking patients (P < .01) and from 0.34 to 0.78 for Spanish-speaking patients. CONCLUSIONS: The WIQ scores correlated well with SF-36 components for both English- and Spanish-speaking patients. Our findings suggested that our translation process did not limit our ability to capture good-quality data. Further research is needed to determine what specific items in the WIQ or the SF-36 questionnaire warrant restructuring to increase their validity for use in diverse populations.

Aged↗

PubMed2004

Empowering communication: a community-based intervention for patients.

The "How to Talk to Your Doctor" community education forums operate under the assumption that information exchange and consumer involvement in healthcare can empower communities in need. We report on the development and preliminary evaluation of this community-based intervention designed to activate and enhance patients' communicative abilities in the medical encounter. We review evidence supporting the feasibility of and benefits that can be expected from improving patients' communication competency. Our intervention is simple and flexible so, therefore, can be portable to a large number of communities. Our preliminary evaluation suggests that the intervention is well-received and produces improved self-perceptions of communication competence across diverse settings and participants. We describe our intervention and its development and dissemination as a model for improving patients' communicative abilities through a community-based, active learner approach. By sharing our experiences, the barriers we encountered, and our ongoing efforts to improve patient communication in the medical encounter, we hope to empower patients to communicate better with their physicians.

Communication↗

PubMed2004

Outcome expectancies, functional outcomes, and expectancy fulfillment for patients with shoulder problems.

OBJECTIVES: This study was conducted to evaluate the relationship among patient outcome expectancies, perceived shoulder function changes, and perceptions of expectancy fulfillment. METHODS: Patients (n = 199) treated for shoulder problems at one orthopedic surgeon's office completed a baseline survey comprised of measures of outcome expectancies, shoulder function, health status, and demographics. At 1 month, 2 months, and 3 months, patients completed a mailed follow-up survey comprised of all baseline measures except demographic variables. At 3 months, a measure of expectancy fulfillment was added. A general linear modeling approach was used to assess the significance and effect size of 1) outcome expectancies on changes in shoulder function; and (2) outcome expectancies, shoulder function changes, and their interaction on perceptions of expectancy fulfillment. RESULTS: Outcome expectancies significantly predicted changes in shoulder function and accounted for 10% of the variance in functional improvement. The improvement difference between patients with high expectancies compared with those with low expectancies was clinically relevant (4.57 points), as it was greater than the minimal clinically important difference (3.02 points). Outcome expectancies and shoulder function changes significantly predicted patients' perceptions of fulfilled expectancies, but their interaction was not statistically significant. CONCLUSIONS: Results highlight the importance of patient expectancy in medical encounters. The findings suggest the need for interventions targeting patient expectancies such as including discussions about expectancy in patient-physician negotiations of therapeutic plans. Results also underscore the need for the development of better measures of outcome expectancies and expectancy fulfillment.

Adolescent↗

PubMed2004

Ethnic differences in health preferences: analysis using willingness-to-pay.

OBJECTIVE: Racial and ethnic differences in health services utilization are well recognized, but the explicit contribution of access to care, physician bias, and patient preferences to these disparities remains unclear. We investigated whether preferences for improvements in health vary among ethnic groups. We chose to assess preferences for osteoarthritis (OA) of the knee because significant differences have been observed in the utilization of total knee arthroplasty among ethnic groups, and because it is an elective procedure, where individual preferences have a major role in decision-making. METHODS: A survey using willingness-to-pay (WTP) methodology was conducted to elicit preferences for improvement in severe and mild OA and for 5 non-health items; data were collected from 193 white, African American, and Hispanic individuals over the age of 20 years. Multivariate regression analyses were used to determine whether WTP varied across racial/ethnic groups. RESULTS: WTP as a percentage of income for each of the 3 scenarios was highest for whites, intermediate for Hispanics, and lowest for African Americans (e.g., 32.9%, 26.4%, and 16.7% for mild OA). Controlling for income, differences in log WTP between African Americans and whites were significant in multivariate regression analyses, whereas values for Hispanics and whites did not differ significantly. Race/ethnic group variables explained a relatively large (21-30%) part of the variation in log WTP. CONCLUSION: The findings suggest that ethnic differences in health valuation and preferences contribute to the observed disparities in health services utilization of elective procedures such as total knee arthroplasty.

Adult↗

PubMed2003

Validation of an observation instrument for measuring student engagement in health professions settings.

Documenting student engagement has received increased emphasis in medical schools, as teaching strategies are changing to include more student-to-student interactions. The purpose of this study was to develop and evaluate a measure of student engagement completed by independent observers that would not interfere with student learning time. Data from 3,182 observations completed by nine observers in 32 educational classroom settings with 23 different instructors were used to evaluate the interobserver reliability and gather validity evidence for our observational instrument, named the STROBE. Results indicated that interobserver agreement was good to excellent when observations were conducted simultaneously on randomly selected students in the same classroom (84% average agreement and 0.79 average kappa coefficient) and when observations were conducted on different randomly selected students (79% average agreement). Results also provided strong evidence for validity. Overall, findings indicate that the STROBE demonstrates promise for educational research and evaluation by documenting student engagement in medical education settings.

Health Occupations↗

PubMed2003

Joint-specific multidimensional assessment of pain (J-MAP): factor structure, reliability, validity, and responsiveness in patients with knee osteoarthritis.

OBJECTIVE: To develop a reliable and valid instrument for measuring and monitoring joint-specific pain. METHODS: Developed using patient interviews, reviews of pain literature, and expert input from orthopedic surgeons, the final Joint-Specific Multidimensional Assessment of Pain (J-MAP) includes the 6-item Pain Sensory and the 4-item Pain Affect subscales. Scores on the J-MAP Pain Sensory and Affect subscales range from 0 to 100, with higher scores indicating more pain intensity and worse pain distastefulness, respectively. Following the assessment of the factor structure, patients' scores (n = 180) on the J-MAP subscales were converted to equal interval scores using Rasch analyses. A psychometric evaluation of the items and Rasch-calibrated scores was conducted and included an assessment of reliability, validity, and responsiveness for use with patients with radiographic knee osteoarthritis. RESULTS: Evidence from the factor analyses showed that the J-MAP Pain Sensory and Affect items made up 2 distinct factors. Internal consistency estimates for the J-MAP subscales exceeded 0.85. The J-MAP subscales showed evidence for validity and were shown to be internally and externally responsive, demonstrating greater responsiveness than the Arthritis Impact Measurement Scale or the Medical Outcome Study Short Form-36 pain subscales. Finally, evidence was found supporting the J-MAP subscales' ability to distinguish target joint pain from pain emanating from other musculoskeletal conditions. CONCLUSION: The J-MAP is a reliable, valid, and responsive measure for assessing joint-specific pain at a single time point, or changes over time for one or a group of patients with knee osteoarthritis. With this initial evidence of its psychometric rigor, further testing of the measurement properties of the J-MAP in other joints and in other populations should be undertaken.

Activities of Daily Living↗

PubMed2002

An initial experience with "team learning" in medical education.

Team learning is an approach to large-group teaching that combines the strengths of small-group interactive learning with teacher-driven content delivery. Team learning has been used successfully in professional disciplines other than medicine. The authors describe a field test of team learning in the setting of an internal medicine residency noontime lecture in the spring of 2000 at Baylor College of Medicine. They surveyed residents on their attitudes toward the usefulness of the lecture content before and after the session and surveyed them on their engagement in learning. Residents reported their engagement as high and demonstrated favorable changes in their attitudes about the usefulness of the lecture content to their daily medical practice. The authors describe their adaptation of the team-learning approach and conclude that team learning may be a useful new pedagogic tool in medical education.

Attitude of Health Personnel↗

PubMedDate not supplied

The relationship among strength and mobility measures and self-report outcome scores in persons after rotator cuff repair surgery: impairment measures are not enough.

In the past, measures of active range of motion and strength testing were deemed sufficient to "prove" the efficacy of treatment interventions. In the current outcomes milieu, however, the focus has shifted to patient-centered assessment (ie, patients' ability to perform activities that are personally relevant). We report results from a study with patients in the private practice of a shoulder surgeon. In this study we evaluated the relationship between impairment measures and scores from several shoulder outcome scales. In addition, we examined transcripts of interviews with shoulder patients regarding the impact of shoulder problems on their lives. One hundred eight persons participated in a randomized trial of home exercise instruction after arthroscopic repair of rotator cuff tears. Two impairment measures were used-strength estimates obtained by use of a Nicholas electronic dynamometer and range of motion in the standing position. Self- reported outcomes were measured by use of the Shoulder Pain and Disability Index (SPADI) and the University of Pennsylvania (UPenn) Shoulder Scale. Pearson correlation coefficients were calculated to estimate the associations between scores on impairment measures and self-report measures. R 2 values were calculated to estimate the proportion of variance shared by impairment and self-report scores. We found that the linear relationship between impairment scores and patient-reported outcomes was quite low, explaining as little as 8% of the total variance. Qualitative analysis of patient interviews suggests that patients distinguish between their impairment and their status on personally relevant outcomes. Future research should evaluate the nature of patient judgments of shoulder health outcomes.

Exercise Therapy↗

PubMedDate not supplied

Development of a Flexilevel Scale for use with computer-adaptive testing for assessing shoulder function.

In a 5-year study, a self-report measure of shoulder function-the Flexilevel Scale of Shoulder Function (FLEX-SF)-was developed by use of item response theory. A large pool of candidate items (N = 68) was developed. A questionnaire that included the 68 items, another scale of shoulder function, and clinical and demographic questions were administered to 400 persons with shoulder complaints. Patients' responses to the 68 items were calibrated by use of Andrich's rating scale model. Thirty-three items were selected from the pool and subdivided into three overlapping testlets targeting low, medium, and high shoulder function. A table translates raw scores on testlets to a common mathematical metric. The validity and reliability of the FLEX-SF was evaluated in a longitudinal study of 199 patients. The FLEX-SF scores were highly reliable and exhibited excellent validity (including responsiveness). We report on a simulation of a computer-adaptive test of shoulder function. This simulation is based on the developmental items we tested for use in the FLEX-SF. The results indicate that greater measurement efficiency can be achieved with a computer-adaptive test format.

Computer Simulation↗