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Results for “multilevel analysis”

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At least 505 records · Page 28Linked to original sources
PubMed1999

Do better quality consultations result in better health? Relationship between quality of consultations and health status of patients with non-acute abdominal complaints in general practice.

BACKGROUND: In theory, a positive relationship is expected between the quality of a consultation and a patient's subsequent health status. However, such a relationship has not yet been firmly established in daily practice. OBJECTIVE: We aimed to study the relationship between the quality of the first consultation in a new episode of non-acute abdominal complaints and subsequent health status of patients in general practice. METHODS: Quality scores for 743 consultations were calculated on the basis of review criteria developed by expert panels. Functional health status was measured by the SIP (Sickness Impact Profile) at baseline, and at 1 and 6 months after the consultation. Multilevel regression analysis was used to examine the relationship between the quality of consultations and health status, and to identify factors of influence on this relationship. RESULTS: In the majority of these patients (97%) health status improved regardless of consultation quality. In patients with malignant disease, and chronic colitis, however, an association between consultation quality and subsequent health status was found: in those with a high consultation quality score (>66-percentile) the health status deteriorated in the first month but improved over the following 5 months; in those with a low consultation quality score (<33-percentile) it deteriorated continuously. CONCLUSION: For the great majority of patients we found no relation between the quality of consultation and health status. However, for a very small subgroup of patients there is proof of benefit from better quality consultations.

Abdominal Pain↗
PubMed2003

Communication in general practice: differences between European countries.

BACKGROUND: Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies. OBJECTIVES: Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice. METHODS: Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis. RESULTS: Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication. CONCLUSION: The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.

Adult↗
PubMed2001

A longitudinal study of the relationship between levels of depression among persons with Alzheimer's disease and levels of depression among their family caregivers.

The purpose of this study was to examine the effects, over time, of depressive symptoms in persons with Alzheimer's disease on depression in their family caregivers. In a sample of 353 patients and caregivers, multilevel longitudinal analysis was used to accommodate an observational design in which the number of observation points and the intervals between points varied across caregivers. The rate of change (increase) in caregiver depression was predicted by the rate of change (increase) in patient depressive symptoms and by increase in patient dependency in instrumental activities of daily living (ADLs). Acceleration of the increase in caregiver depression was predicted by acceleration in patient dependency in instrumental and basic ADLs but not by acceleration in patient depressive symptoms. These findings indicate the importance of measuring the rate and acceleration of change in patient characteristics in order to understand caregiver depression. They also support early interventions for caregivers.

Activities of Daily Living↗
PubMed2005

The effects of sleep loss on medical residents' emotional reactions to work events: a cognitive-energy model.

STUDY OBJECTIVES: This study investigated the relationship between sleep loss and emotional reactivity in medical residents. We hypothesized that this relationship is shaped by the effect of sleep loss on cog-nitive-energy resources required for coping with goal-disruptive events or for capitalizing on new opportunities offered by goal-enhancing events. SETTINGS: 15 medical wards in 4 large hospitals in Israel. PARTICIPANTS: 78 medical residents, 67% men, aged 26 to 39 years. DESIGN: Actigraphic sleep-wake cycles were measured for 5- to 7-day periods, surrounding nightshifts, every 6 months, covering the first 2 years of residency. During each study period, emotional reactivity was investigated using the experience-sampling methodology by which residents received 3 phone calls at random times during their working day for 3 consecutive days. These calls reminded them to fill out brief questionnaires concerning change of circumstances over the previous 15 minutes and to rate their emotional response to these circumstances using the Positive Affect and Negative Affect Scales. Fatigue at those times was measured by a subscale of the Profile of Mood States. MEASUREMENTS AND RESULTS: Multilevel regression analysis was used to determine the influence of sleep duration and sleep fragmentation on the emotional reactions to goal-disruptive and goal-enhancing daytime events. We found that sleep loss intensified negative emotions and fatigue following daytime disruptive events, while positive emotion was mitigated following goal-enhancing events. Sleep loss also resulted in an overall elevated baseline for positive emotion. CONCLUSIONS: Sleep loss amplifies the negative emotive effects of disruptive events while reducing the positive effect of goal-enhancing events. Methodologically, the study highlights the utility and advantages of event-level analysis as opposed to the current practice of random sampling of emotion states during waking hours, disregarding contextual factors associated with purposeful, goal-oriented behavior episodes.

Adult↗
PubMedDate not supplied

Motivational interviewing to increase physical activity in long-term cancer survivors: a randomized controlled trial.

BACKGROUND: Physical activity can confer many benefits on cancer survivors, including relief of persistent symptoms related to cancer treatment. OBJECTIVES: To evaluate the effect of a motivational interviewing (MI) intervention on increasing physical activity (Community Healthy Activities Model Program for Seniors questionnaire) and improving aerobic fitness (6-minute walk), health (Medical Outcomes Study Short-Form 36), and fatigue (Schwartz Cancer Fatigue Scale) in cancer survivors. A secondary purpose was to evaluate whether the effect of MI on physical activities depended on self-efficacy. METHODS: Fifty-six physically inactive adult cancer survivors (mean=42 months since completion of treatment) were assigned randomly to intervention and control groups. The MI intervention consisted of one in-person counseling session followed by two MI telephone calls over 6 months. Control group participants received two telephone calls without MI content. Outcomes were measured at baseline, 3 months, and 6 months, and were analyzed using multilevel modeling. RESULTS: The results of the MI intervention explained significant group differences in regular physical activities (measured in caloric expenditure per week), controlling for time since completion of cancer treatment (p<.05). Aerobic fitness, physical and mental health, and fatigue were not different between groups. In the intervention group, individuals with high self-efficacy for exercise at baseline increased their physical activity more than those with low self-efficacy (p<.05). In the control group, increases in physical activity did not depend on self-efficacy. DISCUSSION: Use of MI may increase physical activity in long-term cancer survivors, especially in persons with high self-efficacy for exercise. Multilevel modeling analysis revealed individual changes that would not have been shown by analysis of group means. Future studies with larger samples or more intense MI interventions may show changes in aerobic fitness, physical and mental health, and fatigue.

Adult↗
PubMedDate not supplied

Cortisol responses to daily events in major depressive disorder.

OBJECTIVE: Abnormal responses of the hypothalamic-pituitary-adrenal (HPA) axis to stress are thought to be involved in the pathophysiology of major depressive disorder (MDD). The aim of the present study was to determine whether cortisol responses to negative and positive daily events in depressed participants (N= 47) differed from such responses in healthy participants (N= 39). We also examined the influence of clinical characteristics and possible gender differences in cortisol responses to events. Finally, the role of mood changes in mediating cortisol responses was assessed. METHODS: Experience sampling methodology (self-reports of mood and events, with simultaneous saliva samples, 10 times each day for 6 consecutive days) and multilevel regression analysis were used to examine the relationship between events in daily life and salivary cortisol levels. RESULTS: In contrast to healthy participants, depressed participants showed no increase in cortisol following negative events. Responses were even more blunted in depressed participants with a family history of mood disorders. Although the effects of negative events on cortisol responses appeared to be mediated by changes in mood, negative affect tended to be less closely associated with cortisol levels in depressed participants. Depressed women showed larger cortisol responses to negative events than depressed men. Positive events had no effect on cortisol levels in either group. CONCLUSIONS: These results suggest that responses of the HPA axis to negative daily events and mood changes are blunted in MDD. Future studies will need to address whether these abnormalities disappear after clinical recovery.

Adaptation, Physiological↗
PubMed2005

Effects of variation in posture and respiration on RSA and pre-ejection period.

The extent to which variation in posture and respiration can confound pre-ejection period and respiratory sinus arrhythmia (RSA) as indices of cardiac sympatho-vagal activity was examined. Within-subjects changes in these measures were assessed in 36 subjects during different postures and (paced) respiratory frequencies. Changes from supine to sitting to standing led to reduced RSA values and longer pre-ejection periods, reflecting the known decrease in vagal but not the increase of sympathetic activity. Multilevel path analysis showed that within-subjects changes in sympatho-vagal balance were faithfully reflected by changes in interbeat interval, but imperfectly by changes in RSA and pre-ejection period. It was concluded that pre-ejection period should be stratified for posture and RSA for respiratory frequency to reliably index changes in sympatho-vagal balance when these factors are prone to change (e.g., during 24-h ambulatory recording).

Adolescent↗
PubMed2006

Explaining differences between hospitals in number of organ donors.

The shortage of donor organs calls for a careful examination of all improvement options. In this study, 80 Dutch hospitals were compared. They provided 868 donors in a 5-year period, constituting 91% of all donors in that period in The Netherlands. Multilevel regression analysis was used to explain the differences between hospitals. Potential explanatory variables were hospital-specific mortality statistics, donor policy and structural hospital characteristics. Of all donors, 81% came from one quarter of the hospitals, mainly larger hospitals. A strong relationship was found between the number of donors and hospital-specific mortality statistics. Hospitals with a neurosurgery department had additional donors. Seven hospitals systematically underperformed over a period of 5 years. If these hospitals were to increase their donor efficiency to their expected value, it would lead to an increase of 10% in the number of donors. Most donors are found in large hospitals, implying that resources to improve donor-recruitment should be channelled to larger hospitals. This study presents an efficient strategy toward a benchmark for hospitals of their organ donation rates. Some larger hospitals performed less well than others. This suggests that there is still room for improvement. There is no evidence for large undiscovered and unused pools of donor organs.

Hospitals↗
PubMed2006

Physical activity among elderly people in a city population: the influence of neighbourhood level violence and self perceived safety.

STUDY OBJECTIVE: To study the associations between neighbourhood level violence/fear of violence and physical activity among elderly people, accounting for somatic health. DESIGN: Self reported data from the Oslo health study, a cross sectional study conducted in 2000, were linked with sociodemographic and social security data from Statistics Norway. A multilevel regression analysis was conducted by MlwiN using contextual level variables provided by the Oslo City Council. SETTING: Oslo, Norway. PARTICIPANTS: 3499 inhabitants aged 74/5 (53.2% of all invitees). MAIN RESULTS: 20.5% of the elderly were physically active less than one hour a week. Somatic health was clearly associated with physical activity among both men and women. Neighbourhood level violence was associated with physical activity only for men, while fear of violence was only associated with physical activity for women. Differences in somatic health did not explain differences in physical activity between neighbourhoods. These differences were explained by socioeconomic variables, and neighbourhood level violence/fear of violence. CONCLUSIONS: In a sample of presumably healthy 75/76 year olds in Oslo, the associations between neighbourhood level violence and physical activity (among men), and fear of violence and physical activity (among women), are of the same sizes as those between somatic health and physical activity. These two dimensions of violence have, in contrast with somatic health, an explanatory function in exploring differences in physical activity between neighbourhoods in Oslo.

Aged↗
PubMed2006

Inequity in access to dental care services explains current socioeconomic disparities in oral health: the Swedish National Surveys of Public Health 2004-2005.

OBJECTIVE: To analyse the effects of socioeconomic disadvantage on access to dental care services and on oral health. Design, setting and outcomes: Cross-sectional data from the Swedish National Surveys of Public Health 2004 and 2005. Outcomes were poor oral health (self-rated oral health and symptoms of periodontal disease) and lack of access to dental care services. A socioeconomic disadvantage index (SDI) was developed, consisting of social welfare beneficiary, being unemployed, financial crisis and lack of cash reserves. PARTICIPANTS: Swedish population-based sample of 17 362 men and 20 037 women. RESULTS: Every instance of increasing levels of socioeconomic disadvantage was associated with worsened oral health but, simultaneously, with decreased utilisation of dental care services. After adjusting for age, men with a mild SDI compared with those with no SDI had 2.7 (95% confidence interval (CI) 2.5 to 3.0) times the odds for self-rated poor oral health, whereas odds related to severe SDI were 6.8 (95% CI 6.2 to 7.5). The corresponding values among women were 2.3 (95% CI 2.1 to 2.5) and 6.8 (95% CI 6.3 to 7.5). Nevertheless, people with severe socioeconomic disparities were 7-9 times as likely to refrain from seeking the required dental treatment. These associations persisted even after controlling for living alone, education, occupational status and lifestyle factors. Lifestyle factors explained only 29% of the socioeconomic differences in poor oral health among men and women, whereas lack of access to dental care services explained about 60%. The results of the multilevel regression analysis indicated no additional effect of the administrative boundaries of counties or of municipalities in Sweden. CONCLUSIONS: Results call for urgent public health interventions to increase equitable access to dental care services.

Adolescent↗
PubMed2003

Neighbourhood socioeconomic disadvantage and behavioural problems from late childhood into early adolescence.

STUDY OBJECTIVE: This study investigates whether neighbourhood socioeconomic disadvantage may contribute to child behavioural and emotional problems, beyond the effects of parental socioeconomic status. It also examines the influence of neighbourhood disadvantage on changes in the frequency of behavioural problems from late childhood into early adolescence. DESIGN AND SETTING: The study was conducted in a large community sample in Rotterdam, the Netherlands. An index of neighbourhood socioeconomic disadvantage was calculated for each of the city's 74 neighbourhoods. Multilevel regression analysis estimated effects of neighbourhood disadvantage and individual variables (parental socioeconomic status, child's gender, and age) on behavioural problems reported by children (Youth Self-Report) and parents (Child Behavior Checklist) and on changes in these scores over a two year follow up. PARTICIPANTS: A cohort of all children born in 1978 and living in Rotterdam. Of those eligible, 73% (n=2587) participated in the first measurement (T1), at 10-12 years; 71% of the T1 respondents participated again two years later (T2), at 12-14 years. MAIN RESULTS: Neighbourhood disadvantage was associated with higher Total, Internalising, and Externalising Problems, as assessed with both the Child Behavior Checklist and the Youth Self-Report, even after controlling for parental socioeconomic status. Neighbourhood disadvantage also seemed to contribute to increases in Total Problems over the follow up. CONCLUSIONS: Living in a disadvantaged neighbourhood is associated with greater behavioural problems and may lead to an exacerbation of problems as children move from childhood into adolescence. Public health interventions to improve child mental health must take the neighbourhood environment into account.

Adolescent↗
PubMed1995

Cerebral blood flow and metabolism in children with severe head injuries. Part 2: Cerebrovascular resistance and its determinants.

It has been proposed that in children with severe head injuries the cerebral circulation does not respond appropriately to normal physiological control mechanisms, making children more susceptible than adults to low cerebrovascular resistance, increased cerebral blood flow (cerebral hyperaemia), and raised intracranial pressure. To investigate this issue, 122 serial measurements of cerebrovascular resistance in 17 children with severe head injuries have been performed and related to cerebral perfusion pressure, arterial CO2 (PaCO2), arterial oxygen content (AO2), and the cerebral metabolic rate of oxygen (CMRO2). Cerebrovascular resistance values (mean (SD) 1.54 (0.61) mm Hg.ml-1.100 g.min) were normal or raised in most cases; 71 values (58%) were within the normal range, 39 (32%) above the upper limit, and only 12 (10%) below the lower limit. There was a significant correlation between cerebral perfusion pressure and cerebrovascular resistance (r = 0.32, p = 0.0003), suggesting preservation of pressure autoregulation. This correlation was absent in four of the five children who died or survived with severe handicap. Analysis by multilevel modelling indicated that, as in normal subjects, CMRO2, CPP, AO2, PaCO2, and cerebrovenous pH were important independent determinants of cerebrovascular resistance. The results indicate that normal cerebrovascular reactivity is often preserved in children with severe head injuries but may be impaired in the most severely injured patients.

Adolescent↗
PubMed2001

Feedback of patients' evaluations of general practice care: a randomised trial.

OBJECTIVE: To assess the effects of feedback of patients' evaluations of care to general practitioners. DESIGN: Randomised trial. SETTING: General practice in the Netherlands. SUBJECTS: 55 GPs and samples of 3691 and 3595 adult patients before and after the intervention, respectively. INTERVENTIONS: GPs in the intervention group were given an individualised structured feedback report concerning evaluations of care provided by their own patients. Reference figures referring to other GPs were added as well as suggestions for interpretation of this feedback, an evidence-based overview of factors determining patients' evaluations of care, and methods to discuss and plan improvements. MAIN OUTCOME MEASURES: Patients' evaluations of nine dimensions of general practice measured with the CEP, a previously validated questionnaire consisting of 64 questions, using a six point answering scale (1= poor, 6 = very good). RESULTS: Mean scores per CEP dimension varied from 3.88 to 4.77. Multilevel regression analysis showed that, after correction for baseline scores, patients' evaluations of continuity and medical care were less positive after the intervention in the intervention group (4.60 v 4.77, p < 0.05 and 4.68 v 4.71, p < 0.05, respectively). No differences were found in the remaining seven CEP dimensions. CONCLUSIONS: Providing feedback on patients' evaluations of care to GPs did not result in changes in their evaluation of the care received. This conclusion challenges the relevance of feedback on patients' evaluations of care for quality improvement.

Adult↗
PubMed1998

Modeling developmental changes in strength and aerobic power in children.

The present study examined two contrasting multilevel model structures to describe the developmental (longitudinal) changes in strength and aerobic power in children: 1) an additive polynomial structure and 2) a multiplicative structure with allometric body size components. On the basis of the maximum log-likelihood criterion, the multiplicative "allometric" model was shown to be superior to the additive polynomial model when fitted to the data from two published longitudinal studies and to provide more plausible solutions within and beyond the range of observations. The multilevel regression analysis of study 1 confirmed that aerobic power develops approximately in proportion to body mass, m1/3. The analyses from study 2 identified a significant increase in quadriceps and biceps strength, in proportion to body size, plus an additional contribution from age, centered at about peak height velocity (PHV). The positive "age" term for boys suggested that at PHV the boys were becoming stronger in the quadriceps and biceps in relation to their body size. In contrast, the girls' age term was either negligible (quadriceps) or negative (biceps), indicating that at PHV the girls' strength was developing in proportion to or, in the case of the biceps, was becoming weaker in relation to their body size.

Adolescent↗
PubMed2004

Applications of hierarchical linear models for evaluations of health interventions: demystifying the methods and interpretations of multilevel models.

Despite the wide availability of statistical programs designed to deal with longitudinal data from a multilevel perspective, many applied researchers remain unfamiliar with the benefits of this methodology, particularly for the evaluation of interventions. The authors present an example of multilevel modeling as part of the analysis of evaluation data from an HIV intervention study. Strategies for understanding multilevel models using longitudinal (panel) data are demonstrated and discussed. The authors illustrate how multiple linear regression models provide a convenient conceptual background to understanding how hierarchical linear models can be developed and interpreted. Multilevel analysis results are compared and contrasted with typical approaches through general linear models for repeated-measures data. Analyses are presented using the SPSS and HLM 5 software.

Analysis of Variance↗
PubMed1998

Do minutes count? Consultation lengths in general practice.

OBJECTIVE: To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. DESIGN: A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. SETTING AND SUBJECTS: Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. MAIN OUTCOME MEASURES: Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. RESULTS: There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. CONCLUSIONS: The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.

Aged↗
PubMed2005

Geographical clustering of prostate cancer grade and stage at diagnosis, before and after adjustment for risk factors.

BACKGROUND: Spatial variation in patterns of disease outcomes is often explored with techniques such as cluster detection analysis. In other types of investigations, geographically varying individual or community level characteristics are often used as independent predictors in statistical models which also attempt to explain variation in disease outcomes. However, there is a lack of research which combines geographically referenced exploratory analysis with multilevel models. We used a spatial scan statistic approach, in combination with predicted block group-level disease patterns from multilevel models, to examine geographic variation in prostate cancer grade and stage at diagnosis. RESULTS: We examined data from 20928 Maryland men with incident prostate cancer reported to the Maryland Cancer Registry during 1992-1997. Initial cluster detection analyses, prior to adjustment, indicated that there were four statistically significant clusters of high and low rates of each outcome (later stage at diagnosis and higher histologic grade of tumor) for prostate cancer cases in Maryland during 1992-1997. After adjustment for individual case attributes, including age, race, year of diagnosis, patterns of clusters changed for both outcomes. Additional adjustment for Census block group and county-level socioeconomic measures changed the cluster patterns further. CONCLUSIONS: These findings provide evidence that, in locations where adjustment changed patterns of clusters, the adjustment factors may be contributing causes of the original clusters. In addition, clusters identified after adjusting for individual and area-level predictors indicate area of unexplained variation, and merit further small-area investigations.

Journal Article↗