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Biomedical subjects

R M Kaplan

Publications and source records attributed to R M Kaplan.

At least 91 records · Page 5Linked to original sources
PubMed1995

Reliability and validity of dyspnea measures in patients with obstructive lung disease.

Dyspnea, the clinical term for shortness of breath, is the primary symptom and an important outcome measure in evaluations of patients with lung disease. It is a subjective symptom that has proved difficult to quantify. Many dyspnea measures are available, yet it is difficult, based on the existing literature, to determine the most reliable and valid. In this study, we evaluated 6 measures of dyspnea for reliability and validity: (a) Baseline Dyspnea Index (BDI) and Transition Dyspnea Index, (b) UCSD Shortness of Breath Questionnaire (SOBQ),(c) American Thoracic Society Dyspnea Scale, (d) Oxygen Cost Diagram, (e) Visual Analog Scale, and (f) Borg Scale. Subjects were 143 patients (74 women) and 69 men) with obstructive lung disease, ages 40 to 86, FEV(1.0) 0.36 to 3.53 L, FVC 1.07 to 5.74 L. Dyspnea measures were assessed for test-retest reliability internal consistency, interrater reliability, and construct validity (i.e., correlations among dyspnea measures and correlations of dyspnea measures with exercise tolerance, health-related quality of life, lung function, anxiety, and depression). Results suggest that the SOBQ and BDI demonstrated the highest levels of reliability and validity among the dyspnea measures examined.

Journal Article↗
PubMed1995

Treatment of dyspnea in COPD. A controlled clinical trial of dyspnea management strategies.

We conducted a randomized clinical trial to evaluate a limited pulmonary rehabilitation program focused on coping strategies for shortness of breath but without exercise training. Eighty-nine patients with COPD were randomly assigned to either 6-week treatment or general health education control groups. Treatment consisted of instruction and practice in techniques of progressive muscle relaxation, breathing retraining, pacing, self-talk, and panic control. Tests of 6-min walk distance, quality of well-being, and psychological function as well as six dyspnea measures were administered at baseline, posttreatment, and 6 months after the intervention. Baseline pulmonary function tests also were obtained. At the end of the 6-week treatment, there were no significant differences between the treatment and control groups on any outcome measure. At the 6-month follow-up, a significant group difference was seen on only one variable, Mahler's transition dyspnea index. The results of this evaluation suggest that a treatment program of dyspnea management strategies, without structured exercise training or other components of a comprehensive pulmonary rehabilitation program, is not sufficient to produce significant improvement in dyspnea, exercise tolerance, health-related quality of well-being, anxiety, or depression.

Aged↗
PubMed1995

Comparing the quality-adjusted life-year output of two treatment arms in a randomized trial.

The quality-adjusted life year (QALY) is an outcome measure with two dimensions: wellness and time. It is difficult to compare the QALY output of two groups when subjects are observed for varying time periods, because both elements of the two-dimensional outcome measure vary in all subjects. This paper evaluates the strengths and weaknesses of five approaches for making these comparisons. These approaches are: a subject-based approach, the elimination of time, calculation of the mean of available data, use of quality-adjusted survival analysis, and calculation of a maximum likelihood estimation. It is concluded that the maximum likelihood estimation offers significant advantages over the other methods.

Female↗
PubMed1995

Por La Vida intervention model for cancer prevention in Latinas.

Our goal was to describe the development and implementation of an intervention on cancer prevention for Latinas in San Diego, Calif. Thirty-six lay community workers ("consejeras") were recruited and trained to conduct educational group sessions. Each consejera recruited approximately 14 peers from the community to participate in the program (total number = 512). Half of the consejeras were randomly assigned to a control group, in which they participated in an equally engaging program entitled "Community Living Skills." Implementation of the intervention was assessed by qualitative and quantitative methods. Preintervention and postintervention self-report information was obtained from project participants on access to health care services, cancer knowledge, preventive measures, and previous cancer-screening examinations. Base-line data suggest that lack of knowledge, costs of cancer-screening tests, and the lack of a regular health care provider are the major obstacles against obtaining cancer-screening tests. Predisposing factors, such as fear and embarrassment, also constitute barriers to getting regular cervical cancer screening. Preliminary analysis indicates that the Por La Vida intervention increases use of cancer-screening tests in comparison to a community living skills control group. Universal access to health care would remove some of the major financial barriers to cancer screening. The Por La Vida program attempts to overcome the substantial barriers by reaching out to low-income Latinas and by providing information regarding the availability, acceptability, and preventive nature of cancer-screening tests.

Adult↗
PubMed1994

Relationship of advance directives to physician-patient communication.

BACKGROUND: Although advance medical directives, such as living wills and durable powers of attorney for health care, are by themselves imperfect instruments for expressing patients' treatment preferences, a possible benefit of these documents is that they will enhance patient-physician communication, especially when end-of-life treatment decisions have to be made. METHOD: Structured interviews were completed for 115 seriously ill cancer patients and 22 of their physicians. The questions dealt with various aspects of advance directives, including communications between the two parties regarding general and specific treatment wishes. Responses were compared in 37 physician-patient pairs for patients who had executed advance directives and in 31 physician-patient pairs for patients who had not executed advance directives. RESULTS: Physicians were frequently unaware of their patients' advance directives. Although patients with advance directives were marginally more likely than patients without advance directives to report discussions about end-of-life treatment decisions, only 34 (30%) out of the total of 115 patients claimed that they had any discussion of treatment decisions with their physicians. Such discussions tended to be about general life attitudes and feelings rather than specific treatments, such as use of artificial nutrition or ventilation. CONCLUSION: Despite public enthusiasm for the use of advance directives and great efforts to promote them, we found little evidence that these documents are associated with enhanced communication between patients and physicians about end-of-life treatment decisions.

Advance Directives↗
PubMed1994

Effects of offering advance directives on quality adjusted life expectancy and psychological well-being among ill adults.

Two hundred and four patients from various clinical services at the San Diego Veterans' Administration Medical Center and the University of California, San Diego Medical Center were randomly assigned to either experimental (offered the opportunity to execute an Advance Directive regarding the level of care they wanted to receive if incapacitated) or control (no Advance Directive offered) conditions. Patients were given a baseline interview and re-interviewed at specific intervals (3 months, 6 months, 1 year and 2 years after baseline, and every 6 months thereafter). Outcome measures included the Qualitty of Well-being Scale, a measure of health status, and the General Well-being Index, a measure of psychological well-being. All differences between the health status and psychological well-being of experimental and control groups 3.5 years after the randomization were non-significant. Methodological implications of including mortality as part of the outcomes are discussed.

Adult↗
PubMed1994

Self-efficacy expectations predict survival for patients with chronic obstructive pulmonary disease.

The validity of self-efficacy expectations as predictors of mortality was evaluated for 119 patients with chronic obstructive pulmonary disease (COPD). Patients completed 4 physiological measures that represent common clinical indicators of disease severity: (a) forced expiratory volume in 1 s (FEV1.0), (b) arterial blood gas measurement of resting partial pressure of oxygen (PaO2), (c) single-breath diffusing capacity (DLCO), and (d) maximum oxygen uptake (VO2max) during exercise. In addition, self-reported self-efficacy expectation for walking on a treadmill was measured. Self-efficacy was a significant univariate predictor of 5-year survival. However, when controlling for FEV1.0 in multivariate survival analysis, self-efficacy had only a marginal effect. We concluded that simple self-report scales could provide significant information about health status.

Activities of Daily Living↗
PubMed1994

The Ziggy theorem: toward an outcomes-focused health psychology.

The purpose of health care is twofold: to make people live longer and to enhance quality of life in the years before death. These goals are consistent with a Ziggy cartoon that emphasized that the meaning of life was "doin' stuff." "Doin' stuff" requires being alive (survival) and having the capability to perform activities. These objectives are quantifiable and can be represented in indices that combine life expectancy with health-related quality of life. This article emphasizes patient-oriented outcomes as a focal point for health care. This outcomes orientation is referred to as the Ziggy theorem. Examples demonstrate that emphasis on patient-oriented outcomes may redirect conceptualizations of public health indicators and may change the way medical subspecialists make clinical decisions. Furthermore, the Ziggy Theorem may suggest new approaches to the allocation of public health resources.

Community Participation↗
PubMed1994

An outcomes-based model for directing decisions in women's health care.

Physicians have recognized for a long time that disease categories provide minimal information about the impact of illness on patient experiences. A diagnosis is important, because it can identify a course of treatment. However, there are considerable differences in how patients with similar diagnoses are affected. Multiple sclerosis, for example, may have essentially no impact on behavioral dysfunction or it could have devastating implications. The impact of the disease on the daily life of the patient may be more important than the diagnosis of the condition. Physicians need to learn to treat the patient, not the disease. There are only two health outcomes that are of importance. First, there is life expectancy. Second, there is function or quality of life. Biologic and physical events are mediators of these behavioral outcomes. We are concerned about cancer, high blood pressure, high cholesterol, and other problems because they may shorten a patient's life expectancy or make his or her life less desirable before death. There is a growing consensus that these behavioral outcomes are central in studies of health care and medicine. However, these outcomes, which can be obtained from standardized questionnaires, rarely are obtained in medical research and practice. A behavioral concept of health outcomes can suggest important new directions for research and practice.

Adult↗
PubMed1994

Value judgment in the Oregon Medicaid experiment.

Oregon proposed a unique social experiment in which combinations of medical conditions and treatments were prioritized. Under the proposed program, providers would not be reimbursed for services relevant to 17% of the condition-treatment pairs. The program was designed to expand access and allow significantly more residents to qualify for Medicaid. The original Oregon proposal used four levels of human judgment: community values assessed in town meetings; ratings of the desirability of health states; medical judgment of treatment efficacy; and subjective reordering of the list by Oregon Health Services Commissioners. In August 1992, the Department of Health and Human Services rejected Oregon's application to proceed with the experiment, objecting to the use of one of the four types of subjective data: ratings of the desirability of health states. A revised application that eliminated this one subjective component was approved in March 1993. This paper demonstrates that among the four levels of judgment, the ratings of health states were supported by the most evidence of reliability and validity. Implications for future prioritization experiments are discussed.

Community Participation↗
PubMed1994

Outcome measurement in kidney disease.

The effects of chronic kidney disease have been difficult to quantify using traditional measures of mortality and biological processes. New approaches to the quantification of outcomes in kidney disease are required. A wide variety of methods have become available and are now in use in some studies. Psychometric approaches, such as the Sickness Impact Profile and the Kidney Disease Questionnaire, have been shown to be responsive to change in some clinical studies. In order to estimate the cost-effectiveness of investments in kidney disease, decision theory approaches are required. We argue that these decision theory approaches should be given serious consideration for inclusion in clinical trials and in the US Renal Data System.

Decision Theory↗
PubMed1994

Efficacy of injectable abamectin against gastrointestinal tract nematodes and lungworms of cattle.

Efficacy of abamectin against gastrointestinal tract nematodes and lungworms of cattle was determined in 4 experiments. The first 2 experiments were controlled trials in which efficacy was determined at necropsy in calves with either experimentally induced (n = 14) or naturally acquired (n = 16) infections. Half the calves in each experiment were treated with abamectin (200 micrograms/kg of body weight, SC), and half were left untreated as controls. Efficacy was > 99% against adult stages of Dictyocaulus viviparus, Haemonchus placei, Ostertagia ostertagi, Trichostrongylus axei, Cooperia punctata, Trichuris discolor, and C oncophora, and was 92.4% against Nematodirus helvetianus. The second 2 experiments were clinical trials in which efficacy was determined by fecal egg count reduction in naturally infected yearling heifers (n = 75) or 2-year-old heifers (n = 75). Within replicates of 5, 4 heifers were assigned at random to treatment with 200 micrograms of abamectin/kg and 1 was left untreated as a control. Abamectin was 100% effective in eliminating strongylate nematode eggs from the feces of these heifers. In all experiments, adverse reactions were limited to small, clinically unimportant injection site swellings in 29% of abamectin-treated calves. Abamectin was judged to be safe and effective in these trials.

Animals↗
PubMed1993

Factors affecting unprescribed remedy use among people with self-reported arthritis.

OBJECTIVE: The purpose of the study is to determine the frequency and consequences of use of unprescribed remedies by people with self-reported osteoarthritis, and to find methods for predicting such use. METHODS: A random digit telephone survey was used to contact respondents. A 90-item questionnaire evaluated demographic characteristics, type of disorder, area affected, severity of problem, and symptoms encountered. RESULTS: Among 1,811 contacts, 21% had musculoskeletal complaints. Of those with self-reported musculoskeletal disorders, 84% had used at least one unprescribed remedy during the past 6 months. People with self-reported rheumatoid arthritis used more such remedies than those with self-reported osteoarthritis, and those with a greater degree of disability used more unprescribed remedies than those who were less affected. Unprescribed remedies were rated as effective as prescribed remedies. CONCLUSIONS: Unprescribed remedies are used frequently, particularly by those with painful and disabling arthritis. These remedies may be effective. Harmful and expensive remedies are used rarely.

Activities of Daily Living↗
PubMed1993

Methods for assessing relative importance in preference based outcome measures.

This paper reviews issues relevant to preference assessment for utility based measures of health-related quality of life. Cost/utility studies require a common measurement of health outcome, such as the quality adjusted life year (QALY). A key element in the QALY methodology is the measure of preference that estimates subjective health quality. Economists and psychologists differ on their preferred approach to preference measurement. Economists rely on utility assessment methods that formally consider economic trades. These methods include the standard gamble, time-trade off and person trade-off. However, some evidence suggests that many of the assumptions that underlie economic measurements of choice are open to challenge because human information processors do poorly at integrating complex probability information when making decisions that involve risk. Further, economic analysis assumes that choices accurately correspond to the way rational humans use information. Psychology experiments suggest that methods commonly used for economic analysis do not represent the underlying true preference continuum and some evidence supports the use of simple rating scales. More recent research by economists attempts integrated cognitive models, while contemporary research by psychologists considers economic models of choice. The review also suggests that difference in preference between different social groups tends to be small.

Choice Behavior↗
PubMed1993

Relationship between psychometric and utility-based approaches to the measurement of health-related quality of life.

This paper summarizes selected evidence pertaining to the relationship between psychometric health status measures and utility/preference measures of health outcome. Few studies contain measures of both health status and utility/preference. The evidence to date suggests that various health status measures are at best only moderately correlated with standard gamble (SG) and time trade-off (TTO) utilities. Results from regression analysis, predicting SG or TTO utilities from combinations of health status scales, typically have an R2 of 0.18 to 0.43. Preferences determined by rating scale methods are more strongly related to health status scores, but correlations are variable ranging from 0.17 to 0.46 and only about 27% to 34% of variance can be explained in regression models. The Quality of Well-Being Scale and other multi-attribute preference measures have low to moderate correlations with health status measures (r = 0.03 to 0.71). Health utility/preference measures and psychometric health status scores are only moderately correlated. Health utility and psychometric health status scales may measure different attributes of health. Although both approaches are useful for evaluating medical outcomes, they are not interchangeable indicators of health-related quality of life.

Choice Behavior↗
PubMed1993

Measurement of dyspnoea in chronic obstructive pulmonary disease.

This paper reviews the assessment of shortness of breath in chronic obstructive pulmonary disease (COPD). The validity criteria for evaluating measures of dyspnoea are discussed and a description and critique of current measures of shortness of breath are offered. Across studies, dyspnoea measures are moderately correlated with pulmonary function (e.g. FEV1.0 and FVC), psychological function, and walking tests (6 min walk). In addition, dyspnoea measures tend to be correlated with one another. The need for standardisation of dyspnoea measures for research and clinical practice is identified as an important objective for future work.

Activities of Daily Living↗