Biomedical subjects

M Abrahamowicz

Publications and source records attributed to M Abrahamowicz.

At least 55 records · Page 3Linked to original sources

PubMed1998

Development of a model for training and evaluation of laparoscopic skills.

BACKGROUND: Interest in the training and evaluation of laparoscopic skills is extending beyond the realm of the operating room to the use of laparoscopic simulators. The purpose of this study was to develop a series of structured tasks to objectively measure laparoscopic skills. This model was then used to test for the effects of level of training and practice on performance. METHODS: Forty-two subjects (6 each of surgical residents PGY1 to PGY5, 6 surgeons who practice laparoscopy and 6 who do not) were evaluated. Each subject viewed a 20-minute introductory video, then was tested performing 7 laparoscopic tasks (peg transfers, pattern cutting, clip and divide, endolooping, mesh placement and fixation, suturing with intracorporeal or extracorporeal knots). Performance was measured using a scoring system rewarding precision and speed. Each candidate repeated all 7 tasks and was rescored. Data were analyzed by linear regression to assess the relationship of performance with level of residency training for each task, and by ANOVA with repeated measures to test for effects of level of training, of repetition, and of the interaction between level of training and repetition on overall performance. Student's t test was used to evaluate differences between laparoscopic and nonlaparoscopic surgeons and between each of these groups and the PGY 5 level of surgical residents. RESULTS: Significant predictors of overall performance were (a) level of training (P = 0.002), (b) repetition (P < 0.0001), and (c) interaction between level of training and practice (P = 0.001). There was also a significant interaction between level of training and the specific task on performance scores (P = 0.006). When each task was evaluated individually for the 30 residents, 4 of the 7 tasks (tasks 1, 2, 6, 7) showed significant correlation between PGY level and score. A significant difference in performance scores between laparoscopic and nonlaparoscopic surgeons was seen for tasks 1, 2, and 6. CONCLUSIONS: A model was developed to evaluate laparoscopic skills. Construct validity was demonstrated by measuring significant improvement in performance with increasing residency training, and with practice. Further validation will require correlation of performance in the model with skill in vivo.

Education, Medical, Continuing↗

PubMed1998

Prognostic factors for mortality in nasopharyngeal cancer: accounting for time-dependence of relative risks.

BACKGROUND: Few studies have assessed the role of prognostic factors for mortality from nasopharyngeal cancer and even fewer used multivariable methods. Most of these studies relied on the Cox model without testing the proportional hazards assumption. METHODS: A cohort of 76 cases of nasopharyngeal cancer recorded in the Rhône, France, between 1980 and 1985, was followed until 1995. Proportional hazards assumption was tested for each putative prognostic factor. Two multivariable models were built using forward selection of prognostic factors: the Cox model and a flexible model in which variables not meeting the proportional hazards assumption were represented by a time-varying hazard ratio. RESULTS: Only Epstein Barr Virus Nuclear Antigen (EBNA) serology, a marker of infection by the Epstein-Barr virus, and tumoral extent were selected in the analysis based on the Cox model. In contrast, four prognostic factors were significant at alpha = 0.05 level in the flexible model: initial EBNA serology, tumoral histology, age and tumoral extent, the last two not verifying the proportional hazards assumption. The relative risk of age increases with duration of follow-up whereas the effect of tumoral extent changes in a non-monotonic pattern. CONCLUSION: We showed the importance of taking into account the non-proportionality of hazards which can influence results and yield new insights about the role of prognostic factors in nasopharyngeal cancer. Because of the small size of our cohort, our results have to be confirmed in an independent study.

Adult↗

PubMed1998

Impact of disease activity and cumulative damage on the health of lupus patients.

To test if lupus activity and damage predict physical function and general health in lupus was the objective of this study. Ninety-six patients with lupus were seen at baseline and monthly for 4 months. Sociodemographic characteristics and lupus damage (SLICC/ACR DI), were collected at baseline while lupus activity (SLAM-R, SLEDAI), health status measures (HAQ, SF-36) and immunological tests were collected at each visit. Associations of lupus activity and damage with general health and physical function were evaluated. Baseline health status measures were greatly impaired and comparable to those of severe medical illnesses. In cross-sectional analyses, baseline activity score measured by SLAM-R, but not by SLEDAI, correlated with most subscales of SF-36. Baseline damage score SLICC/ACR DI correlated only with the HAQ and the physical function subscale of SF-36. Differences in both activity measures (SLAM-R and SLEDAI) over time correlated with change in health status measures while baseline cumulative damage (SLICC/ACR DI) correlated with the average level of physical function only. Lupus activity measures, SLAM-R and SLEDAI, although differing cross-sectionally, both reflected patients' health status performance over time and lupus damage measure, SLICC/ACR DI, performed well in assessing physical function. Lupus patients scores for health are poor and comparable to those found in severe medical illnesses.

Activities of Daily Living↗

PubMed1998

The relationship between disease activity and expert physician's decision to start major treatment in active systemic lupus erythematosus: a decision aid for development of entry criteria for clinical trials.

OBJECTIVE: To explore the relationship between patients' systemic lupus erythematosus (SLE) activity and physicians' decision to treat with steroids or alternative medication. METHODS: Baseline information and clinical status was extracted from case histories of 30 patients with lupus and represented in clinical vignettes. These vignettes were then mailed to 60 physicians (rheumatologists and immunologists with experience in the treatment of lupus), asking them in each case whether they would initiate treatment or not. The relationship between the 38 complete responses and the SLE Activity Measure (SLAM-R) and SLE Disease Activity Index (SLEDAI) lupus activity scores was analyzed using a general additive model. RESULTS: SLE disease activity measured by SLAM-R or SLEDAI is a significant predictor (p < 0.0001) of physicians' decision to initiate treatment for patients with lupus. Variation between physicians was observed but was mostly due to a few outliers. Some other variations remained unexplained by patients' SLE disease activity, damage, or by specific organ involvement. CONCLUSION: We present reference tables and curves for research that may be used as a basis to derive standardized quantitative criteria for entry in clinical trials. More research is needed on how these tools can be used by clinicians to guide them in their decision to treat or not.

Allergy and Immunology↗

PubMed1997

Use of standardized patients to assess between-physician variations in resource utilization.

CONTEXT: As medical costs are increasingly being scrutinized, there is heightened interest in defining variations in physician behavior in clinical settings. OBJECTIVE: To evaluate if standardized patient (SP) technology is a reliable and feasible method of studying interphysician variations in test ordering, referral requests, prescribing behavior, and visit costs. DESIGN: The study was conducted with blinded SP visits to family medicine and internal medicine residents, university-affiliated family physicians, and community-based family physicians. Resource utilization and visit costs were assessed using test requisitions, consult requests, and prescriptions that were collected by the SPs. SETTING: Physicians' offices in ambulatory care, hospital-based clinics and in the community. PARTICIPANTS: Four persons (aged 57-77 years) trained to simulate having osteoarthritis of the hip. In one simulation, the patient had gastropathy due to nonsteroidal anti-inflammatory drug use, and in the other, the patient sought therapy for hip discomfort. MAIN OUTCOME MEASURES: Reliability of cost estimates of physician services, tests, consultations, prescriptions, and total visits and test-ordering behavior for nonsteroidal anti-inflammatory gastropathy. RESULTS: Overall, 112 (63%) of the physicians who were sent invitations to the study agreed to participate. Of 312 total SP visits conducted over a 1-year period, unblinding due to SP detection occurred on 36 occasions (11.5%). Reliable cost estimates of physician services, tests, and consultations, and moderately reliable estimates of total visit costs, were obtained with 4 visits per practicing physician and with 2 visits per resident. There were extreme variations in total visit costs generated by the study physicians. A small number of physicians had a major impact on this variability. CONCLUSION: Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.

Diagnosis-Related Groups↗

PubMed1997

Predictive power of duplex ultrasonography in asymptomatic carotid disease.

BACKGROUND: Duplex ultrasonography is considered a valid measure of stenosis of the carotid arteries, but the prognostic value of repeated ultrasonographic examinations is unknown. OBJECTIVE: To determine the ability of serial ultrasonographic measurements to predict cerebrovascular events in patients with asymptomatic carotid disease. DESIGN: Secondary analysis of data from a natural history study of asymptomatic carotid disease. PATIENTS: Asymptomatic patients with cervical bruits. MEASUREMENTS: Duplex ultrasonography of the carotid arteries was done at study enrollment and biannually thereafter. Multivariable Cox proportional hazards models with fixed and time-dependent covariates were used for analysis. RESULTS: 61 transient ischemic attacks (TIAs) and 38 strokes occurred in 715 participants over a mean follow-up period of 3.2 years; 4 strokes were disabling, and no deaths from stroke occurred. Sixty percent of strokes occurred in persons who did not have severe stenosis. One fifth of participants had stenosis progression. Baseline carotid stenosis was a significant predictor of the outcome "TIA or stroke" (relative risk, 1.5 [95% CI, 1.2 to 1.7]) and retained its predictive ability for more than 3 years. Progression of stenosis to 80% or more significantly increased the risk for cerebrovascular events and death. The sensitivity and positive predictive value of progression as an independent predictor of TIA or stroke were low. CONCLUSION: Severe carotid stenosis is associated with a higher risk for cerebrovascular events, but the power of repeated ultrasonography to predict ischemic events is limited by low incidence rates and low rates of progression. The evidence does not support the routine use of serial ultrasonography to determine the risk for stroke in unselected patients with asymptomatic carotid disease.

Adult↗

PubMed1997

Flexible modeling of the effects of serum cholesterol on coronary heart disease mortality.

Current understanding of the impact of lipids and other risk factors on coronary heart disease is largely based on the results of parametric multiple regression analyses of large prospective studies. To assess the potential impact of the a priori assumption of linearity of continuous risk factors on the results of parametric analyses, the authors completed a secondary analysis of the Lipid Research Clinics Prevalence and Follow-up Studies (1972-1987) data using an assumption-free nonparametric modeling approach. The effects of total serum cholesterol and the ratio of total serum cholesterol to high density lipoprotein cholesterol, adjusted for common risk factors, were estimated using a smoothing spline method available in the generalized additive model extension of the multiple logistic regression. The data set included 2,512 men in the random sample of the Lipid Research Clinics study who did not take lipid-lowering medications. During the median follow-up of 12.6 years, 94 coronary heart disease deaths occurred. The generalized additive model fits the effects of total serum cholesterol (p < 0.01) and the ratio of total serum cholesterol to high density lipoprotein cholesterol (p < 0.02) significantly better than the parametric logistic regression. Validation studies confirmed that, among new observations arising from the same population, generalized additive model estimates predicted outcomes better than the parametric estimates. Nonlinear effects of both lipid measures were robust and may be clinically important. The authors conclude that the linearity assumption inherent in parametric models may result in biased estimates of the effects of total serum cholesterol on coronary heart disease mortality and recommend that their findings be verified in a nonparametric analysis of data from another large prospective study.

Cholesterol↗

PubMed1997

Outcome of asymptomatic patients with carotid disease. Asymptomatic Cervical Bruit Study Group.

Asymptomatic cervical atherosclerosis carries a variable risk of vascular events. We sought to identify patients with asymptomatic cervical bruits who may be at increased risk of developing ischemic events. We conducted a prospective multicenter cohort study of neurologically asymptomatic patients presenting a cervical bruit. Patients had biannual neurologic and carotid duplex evaluation. Association between ultrasonographic findings and vascular events, adjusting for common risk factors, was evaluated. Seven hundred fifteen patients were followed on average for 3.6 years. Mean age was 65 years. At initial visit, 357 subjects had a > or = 50% stenosis. Overall, 237 events occurred in 177 patients. Annual rate of all primary vascular events in patients with > or = 50% stenosis was 11.0% versus 4.2% in those with < 50% stenosis (p < 0.001). Annual rate of stroke and vascular death was 5.5% in the > or = 50% group compared with 1.9% in the < 50% group (p < 0.001). Yearly rate of unheralded ischemic stroke was 4.2% in subjects with > or = 80% stenosis and 1.4% in those with stenosis < 80% (p < 0.001). A stroke or TIA was ipsilateral to a > or = 80% stenosis in 66% of patients. Progression of carotid stenosis particularly to more than 80% was associated both with a higher rate of ipsilateral neurologic events and overall combined vascular events. Our data suggest that severity of carotid stenosis is the main risk factor predicting occurrence of neurologic and other vascular events. Yearly rate of ipsilateral stroke with > or = 50% carotid stenosis is low (1.4%) and most are nondisabling. Progression to > or = 80% or occlusion is associated with worse outcome.

Aged↗

PubMed1997

Factors associated with growth of extremely premature infants during initial hospitalization.

OBJECTIVE: To quantify the factors associated with growth of very small premature infants during initial hospitalization. POPULATION: Study patients were 109 infants who were appropriate for gestational age, weighed <1000 g at birth, and were fed intravenous hyperalimentation then calcium-supplemented 81-kcal preterm formula according to a protocol. ANALYSIS: Multiple regression analysis was performed for periods of 0 to 56, 0 to 14, and 15 to 56 days of age. Growth was determined as change in weight during the period. Variables assessed in the initial model were caloric intake, protein intake, respiratory support duration, patent ductus arteriosus, dexamethasone use, infection, birth weight ratio (weight divided by expected intrauterine weight for gestation), gestational age, sex, calendar time from study start, maternal betamethasone administration, and necrotizing enterocolitis. For the 0 to 14-day period, maximum oxygen requirement for respiratory distress syndrome replaced respiratory support duration, and 5-minute Apgar score was added, whereas dexamethasone and necrotizing enterocolitis were deleted. RESULTS: Mean change in weight was 785 g for 0 to 56 days, -16 g for 0 to 14 days, and 770 g for 15 to 56 days. Mean weight was 94% (13 SD) of mean intrauterine at birth, 73% (10 SD) at 14 days, and 73% (12 SD) at 56 days. Regression models explained 85%, 43%, and 80%, respectively, of variation in growth. Of the initial variables assessed, the following were the independent prognostic determinants of growth. There was a positive association with caloric intake at 0 to 56 days and 15 to 56 days, and with protein intake at 0 to 14 days. Negative associations were found for birth weight ratio and gestational age at 0 to 56 and 0 to 14 days. Respiratory support duration was negatively associated at 15 to 56 days, and dexamethasone was negatively associated at 0 to 56 and 15 to 56 days. Formulas to predict growth were established from the final regression models. CONCLUSION: The growth failure in appropriate-for-gestational-age, <1000-g birth weight infants can be related in part to dexamethasone use and respiratory support duration. Increasing caloric intake and early protein intake improves growth. However, for the majority of these patients, early losses are not corrected completely by 56 days using currently recommended intakes.

Dexamethasone↗

PubMed1996

Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations.

OBJECTIVES: To determine (a) whether the risk of a potentially inappropriate drug combination (PIDC) increases with the number of physicians involved in the medical management of an elderly patient and (b) whether the risk of a PIDC is reduced if a patient has a single primary care physician or a single dispensing pharmacy, or both. DESIGN: Cross-sectional retrospective provincial database study. PARTICIPANTS: A regionally stratified random sample of 51,587 elderly medicare registrants in Quebec who (a) visited at least one physician in 1990, (b) were not living in a health care institution for the entire year and (c) had been dispensed at least one prescription for a cardiovascular drug, a psychotropic drug or a nonsteroidal anti-inflammatory drug (NSAID). OUTCOME MEASURES: Information on all physician visits and drugs dispensed during 1990. Physician claims were used to identify the number of physicians involved in a patient's management and whether the patient had one primary care physician. Prescription claims were used to identify the number of PIDCs, prescribing physicians and dispensing pharmacies. RESULTS: The prevalence of PIDCs ranged from 4.0% (among those in the NSAID group) to 20.3% (among those in the psychotropic drug group). Of the PIDCs identified, 17.6% to 25.8% resulted from contemporaneous prescribing by different physicians. The number of prescribing physicians was the most important risk factor for a PIDC in all drug groups (odds ratio [OR] 1.44 to 1.71). The presence of a single primary care physician lowered the risk for cardiovascular and psychotropic PIDCs (OR 0.70 and 0.79 respectively) but not for NSAID PIDCs (OR 0.94). The use of a single dispensing pharmacy lowered the risk of a PIDC in all drug groups (OR 0.68 to 0.79). CONCLUSION: The greater the number of physicians prescribing medications for an elderly patient, the greater is the risk that the patient will receive a PIDC. A single primary care physician and a single dispensing pharmacy may be "protective" factors in preventing PIDCs.

Aged↗

PubMed1996

Laboratory tests as predictors of disease exacerbations in systemic lupus erythematosus. Why some tests fail.

OBJECTIVE: To evaluate whether changes in laboratory test values are either simultaneous with or precede disease exacerbations in patients with systemic lupus erythematosus (SLE). METHODS: At 9, 6, and 3 months preceding a flare in disease activity (defined as a rise of > or = 6 points in the modified SLE Disease Activity Index), laboratory tests were performed to measure patients' hematocrit levels, white blood cell, lymphocyte, and platelet counts, erythrocyte sedimentation rate, C1q binding, DNA binding, and levels of C3 and C4. Flares were classified as either present or absent, and were divided into renal, vasculitic, central nervous system, skin, serosal, and musculoskeletal subgroups. The predictive patterns were 1) the simultaneous change in the test value from the mean of 9, 6, and 3 months preceding a flare to the time of the flare; 2) the gradual change, following a linear time trend, in test results for the same time points; and 3) the change from the mean of 9 and 6 months to 3 months preceding a flare, as a measure of predictive ability. These analyses used repeated-measures analysis of variance models. Multiple linear regression was used to study the cross-sectional association of average-over-time differences in test results with patients' flare subgroup. RESULTS: Among 202 patients with SLE (median followup 86.5 months), 83 flares occurred in 53 patients. Of 189 statistical contrasts performed, only 14 were significant (versus 10 expected), and the differences were of minor importance. Nonetheless, evaluation of all test results over each patient's observed disease course revealed significant differences between selected test values in association with specific types of flare. CONCLUSION: Fluctuations in laboratory test values are poor predictors of disease exacerbations in SLE. Cross-sectional evaluation of some test results revealed differences at the time of flare for those patients who were destined to have different types of flares, because these values differed over the entire study period. This pattern explains the frequent cross-sectional association of disease activity with laboratory test results, and the inconsistent association of flares with recent changes in test values.

Adolescent↗

PubMed1996

The Quebec Back Pain Disability Scale: conceptualization and development.

The Quebec Back Pain Disability Scale is a new measure of functional disability for patients with back pain. Functional disability was operationalized in terms of perceived difficulty associated with simple physical activities. The content of the scale was developed in several stages, including a literature review, two studies seeking the opinions of patients and experts, pilot testing, and a large, longitudinal study of back pain patients. Forty-eight disability items were extensively studied using standard methods such as test-retest reliability, item-total correlations, and factor analysis, as well as modern techniques based on item response theory. Items that were highly effective in discriminating between different levels of disability were selected for the final, reduced scale. The scale has 20 items, representing six empirically derived categories of activities affected by back pain. Measurement properties of this instrument have been previously discussed.

Activities of Daily Living↗

PubMed1996

Incidence of and risk factors for delirium among psychiatric inpatients.

OBJECTIVE: The presence and effects of delirium among psychiatric patients are not well understood. This study investigated incidence rates and risk factors for delirium among hospitalized psychiatric patients. METHODS: The charts of 199 patients admitted over a one-year period to a tertiary care teaching hospital were retrospectively reviewed. Demographic and medication variables were analyzed using multiple logistic regression. Delirium was diagnosed retrospectively using DSM-III-R criteria. RESULTS: The overall incidence of delirium in the study sample was 14.6 percent. Delirium was most common among patients with schizophrenia and bipolar disorder; patients with bipolar disorder had the highest incidence (35.5 percent). Only 48 percent of delirious patients were actually recognized as having delirium at the time it occurred. Antiparkinsonian medications were the only medications significantly associated with delirium; lithium was not an independent risk factor. Older age was the only significant demographic risk variable. The hospital stays of patients with delirium were 62.1 percent longer than those of patients without delirium. CONCLUSIONS: Patients with bipolar disorder appeared to be at higher risk for developing delirium, whether or not lithium was used in treatment. This finding may reflect an inherent predisposition to delirium among these patients. Alternatively, the combination of medications used in treating patients with bipolar disorder may be a risk factor.

Adult↗

PubMed1996

Randomized controlled trial of artesunate plus tetracycline versus standard treatment (quinine plus tetracycline) for uncomplicated Plasmodium falciparum malaria in Brazil.

A triple-blind, randomized, clinical trial was undertaken in a Brazilian Amazon region to compare the effectiveness of oral artesunate (seven days, total dose = 0.75 g) plus tetracycline (seven days, total dose = 10.5 g) (AT) and oral quinine (three days, total dose = 6 g) plus tetracycline (seven days, total dose = 10.5 g) (QT) against uncomplicated Plasmodium falciparum malaria. Effectiveness was assessed by cure rates (World Health Organization [WHO]) and parasite clearance at day 2. Patients were randomized, 88 to each group. The groups had similar baseline clinical characteristics. The incidence of side effects was much higher in the QT group (82%) than in the AT group (50%) (P < 0.001). Cure rates were similar: 80% in the AT group and 77% in the QT group (P = 0.68). Parasitemia (by day 2) cleared faster in the AT group than in the QT group (98.5% versus 47.6%, respectively; P < 0.001). These results indicate that the combination of artesunate plus tetracycline is effective in the treatment of uncomplicated falciparum malaria and may provide a useful alternative to other treatment regimens.

Adolescent↗

PubMed1996

Routine immunologic tests in systemic lupus erythematosus: is there a need for more studies?

OBJECTIVE: To evaluate the sensitivity, specificity, and likelihood ratios of anti-dsDNA, C3, C4, and Clq binding tests for predicting flares in systemic lupus erythematosus (SLE) and to evaluate the conflicting results reported in the recent literature. METHODS: Test results from 9 to 3 months preceding 83 flares among 53 patients from a cohort study of 202 patients with SLE were assessed for their ability to predict renal and nonrenal flares and all flares combined. A flare was defined as a 6 point rise in a modified SLE Disease Activity Index. RESULTS: For all 4 tests, sensitivity approximated 50% and specificity was less than 75%. For anti-dsDNA, Clq binding, and C4, both positive and negative likelihood ratios were close to 1.0, suggesting little clinical value for routine testing. For C3, likelihood ratios for a positive test approximated 2.0, meeting the minimal level for clinical significance. Review of previous studies suggested that sample size, the use of a standardized disease activity measure to define a flare, the severity of the flare, and the study duration could not explain the discrepant results among studies. The 2 studies with testing every 4 to 6 weeks found that a rising anti-dsDNA predicted flares, while those with less frequent testing did not. CONCLUSION: While our study provided no major support for routine testing with anti-dsDNA, C3, C4, or Clq binding, additional longitudinal studies are needed to assess monthly testing of anti-dsDNA as a predictor of flare in SLE.

Adult↗

PubMed1995

Lack of effect of aspirin in asymptomatic patients with carotid bruits and substantial carotid narrowing. The Asymptomatic Cervical Bruit Study Group.

OBJECTIVE: To determine the effectiveness of aspirin in preventing ischemic events in patients with asymptomatic carotid stenosis. DESIGN: Double-blind, placebo-controlled trial. SETTING: University-affiliated hospitals. PATIENTS: 372 neurologically asymptomatic patients with carotid stenosis of 50% or more in at least one artery as determined by luminal diameter reduction on duplex ultrasonography. INTERVENTION: Patients were randomly assigned to receive either enteric coated aspirin, 325 mg/d, or identically appearing placebo. Duration of therapy was 2.0 years for the aspirin recipients and 1.9 years for the placebo recipients. OUTCOME MEASURES: Patients were scheduled for a clinical examination every 6 months for assessment of the occurrence of any clinical event in the composite end point, which consisted of transient ischemic attack, stroke, myocardial infarction, unstable angina, or death. RESULTS: At baseline, the 188 patients receiving aspirin and the 184 patients receiving placebo had similar demographic, ultrasonographic, and laboratory characteristics. The median duration of follow-up was 2.3 years. The annual rate of all ischemic events and death from any cause was 12.3% for the placebo group and 11.0% for the aspirin group (P = 0.61). The Cox proportional hazards analysis yielded an adjusted hazard ratio (aspirin-placebo) of 0.99 (95% CI, 0.67 to 1.46; P = 0.95). The annual rates for vascular events only were 11% for the placebo group and 10.7% for the aspirin group (P = 0.99). The multivariate analysis yielded a hazard ratio of 1.08 (CI, 0.72 to 1.62; P = 0.71). CONCLUSION: Aspirin did not have a significant long-term protective effect in asymptomatic patients with high-grade (> or = 50%) carotid stenosis.

Aged↗

PubMed1995

Do doctors accurately assess coronary risk in their patients? Preliminary results of the coronary health assessment study.

OBJECTIVE: To evaluate the ability of doctors in primary care to assess risk patients' risk of coronary heart disease. DESIGN: Questionnaire survey. SETTING: Continuing medical education meetings, Ontario and Quebec, Canada. SUBJECTS: Community based doctors who agreed to enroll in the coronary health assessment study. MAIN OUTCOME MEASURE: Ratings of coronary risk factors and estimates by doctors of relative and absolute coronary risk of two hypothetical patients and the "average" 40 year old Canadian man and 70 year old Canadian woman. RESULTS: 253 doctors answered the questionnaire. For 30 year olds the doctors rated cigarette smoking as the most important risk factor and raised serum triglyceride concentrations as the least important; for 70 year old patients they rated diabetes as the most important risk factor and raised serum triglyceride concentrations as the least important. They rated each individual risk factor as significantly less important for 70 year olds than for 30 year olds (all risk factors, P < 0.001). They showed a strong understanding of the relative importance of specific risk factors, and most were confident in their ability to estimate coronary risk. While doctors accurately estimated the relative risk of a specific patient (compared with the average adult) they systematically overestimated the absolute baseline risk of developing coronary disease and the risk reductions associated with specific interventions. CONCLUSIONS: Despite guidelines on targeting patients at high risk of coronary disease accurate assessment of coronary risk remains difficult for many doctors. Additional strategies must be developed to help doctors to assess better their patients' coronary risk.

Clinical Competence↗

PubMed1995

The Quebec Back Pain Disability Scale. Measurement properties.

STUDY DESIGN: The Quebec Back Pain Disability Scale is a 20-item self-administered instrument designed to assess the level of functional disability in individuals with back pain. The scale was administered as part of a larger questionnaire to a group of 242 back pain patients. Follow-up data were obtained after several days and after 2 to 6 months. OBJECTIVES: The goal of this study was to determine whether the Quebec scale is a reliable, valid, and responsive measure of disability in back pain, and to compare it with other disability scales. SUMMARY OF BACKGROUND DATA: A number of functional disability scales for back pain are being used, but their conceptual validity is uncertain. Unlike most published instruments, the Quebec scale was constructed using a conceptual approach to disability assessment and empirical methods of item development, analysis, and selection. METHODS: The authors calculated test-retest and internal consistency coefficients, evaluated construct validity of the scale, and tested its responsiveness against a global index of change. Direct comparisons with the Roland, Oswestry, and SF-36 scales were carried out. RESULTS: Test-retest reliability was 0.92, and Cronbach's alpha coefficient was 0.96. The scale correlated as expected with other measures of disability, pain, medical history, and utilization variables, work-related variables, and socio-demographic characteristics. Significant changes in disability over time, and differences in change scores between patients that were expected to differ in the direction of change, were found. CONCLUSIONS: The Quebec scale can be recommended as an outcome measure in clinical trials, and for monitoring the progress of individual patients participating in treatment or rehabilitation programs.

Adolescent↗