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Utilization of the propensity score method: an exploratory comparison of proxy-completed to self-completed responses in the Medicare Health Outcomes Survey.

BACKGROUND: This research examined the use of the propensity score method to compare proxy-completed responses to self-completed responses in the first three baseline cohorts of the Medicare Health Outcomes Survey, administered in 1998, 1999, and 2000, respectively. A proxy is someone other than the respondent who completes the survey for the respondent. METHODS: The propensity score method of matched sampling was used to compare proxy and self-completed responses. A propensity score is a value that equals the estimated probability of a given individual belonging to a treatment group given the observed background characteristics of that individual. Proxy and self-completed responses were compared on demographics, the SF-36, chronic conditions, activities of daily living, and depression-screening questions. For each individual survey respondent, logistic regression was used to calculate the probability that this individual belonged to the proxy respondent group (propensity score). Pre and post adjustment comparisons were tested by calculating effect sizes. RESULTS: Differences between self and proxy-completed responses were substantially reduced with the use of the propensity score method. However, differences were still found in the SF-36, several demographics, several impaired activities of daily living, several chronic conditions, and one depression-screening question. CONCLUSION: The propensity score method helped to reduce differences between proxy-completed and self-completed survey responses, thereby providing an approximation to a randomized controlled experiment of proxy-completed versus self-completed survey responses.

Activities of Daily Living↗

Barriers to completion of health care proxies: an examination of ethnic differences.

BACKGROUND: Advance directives have not been uniformly used by different segments of the US population and studies have consistently shown a lower prevalence of advance directives among African Americans and Hispanics compared with non-Hispanic whites. OBJECTIVE: To examine barriers to completion of health care proxies for different ethnic groups. METHODS: One hundred ninety-seven subjects aged 65 years or older self-identified as African American (n = 65), Hispanic (n = 65), or non-Hispanic white (n = 67) attending a geriatrics and internal medicine outpatient clinic of a large New York City teaching hospital were administered a questionnaire. Questionnaires were developed to examine potential barriers to completion of health care proxies. Barriers were drawn from the literature and from focus groups. RESULTS: Significant predictors of proxy completion using logistic regression analysis included knowledge of health care proxies, availability of a health care agent, exposure to mechanical ventilation, age, and self-reported health status as fair to poor. Subjects who believed that a health care agent was irrelevant in the setting of involved family were significantly less likely to have completed a health care proxy. Although there were significant differences in the baseline completion rates of health care proxies for the 3 ethnic groups, ethnicity did not predict prior appointment of a health care agent in multivariate analysis. CONCLUSIONS: Differences in health care proxy completion rates across white, African American, and Hispanic elderly individuals in this New York City population seem to be related to potentially reversible barriers such as lack of knowledge and the perceived irrelevance of advance directives in the setting of involved family. Enhanced educational efforts of both health care personnel and patients could increase the rate of formal health care proxy appointment.

Advance Care Planning↗

Proxy use of the Canadian SF-36 in rating health status of the disabled elderly.

Professionals have often depended on proxies to assess health status of elderly individuals unable to provide this information. This study set out to estimate agreement between elderly subjects and their proxies on perceptions of health status, when patients were inpatients in a rehabilitation setting or outpatients in a day hospital, and to determine if there were overestimations or underestimations by proxies. Eighty-three consenting elderly patients living in Montreal, Canada, completed a generic health-status questionnaire, the SF-36, and named a significant other and a health care provider who knew them well. These individuals completed the same questionnaire on behalf of the patients. Agreement between patient and proxy was assessed pairwise (patient/health professional and patient/significant other) using intraclass correlation coefficients. The possibility of a biased rating by type of proxy was determined via paired t-tests. When concordance within respondent pairs was examined, results indicated only poor to moderate agreement regardless of setting and type of proxy for all scales. A trend toward underestimating by proxies was found. Proxy completion of health status questionnaires did not provide similar information, but these preliminary findings need replication.

Aged↗

Survey into health problems of elderly people: a comparison of self-report with proxy information.

BACKGROUND: This study was conducted as part of the Medical Research Council Cognitive Function and Ageing Study. OBJECTIVE: To compare information given by elderly people on their past and current health and family history of illness with similar information obtained from a relative, friend or carer. DESIGN: Screening and assessment stages of a prevalence study. SETTING: Three urban and two rural areas of England and Wales. PARTICIPANTS: A subsample weighted by age and cognitive status of random population samples of people >/=65 years, living in their own home or in a residential or nursing home, interviewed between 1991 and 1994. A relative, friend or carer identified by each elderly person to provide proxy information. INTERVIEW: Computerized schedules including items on demographic details, cognitive function, lifetime illnesses, current health problems and family history of illness. RESULTS: The rate of proxy 'don't know' responses and the agreement between the elderly person and their proxy were calculated for each item, both for the overall sample and for subgroups based on characteristics of the respondent and of the proxy and on the relationship between them. Higher 'don't know' rates were found to be particularly associated with more distant relationships, questions on family history, a shorter length of time known and a lack of co-residence. Agreement was strongly related to the nature of the question and less to co-residence, with other factors such as relationship having much smaller effects. CONCLUSIONS: Proxy information on past and current health problems can be almost complete and in good agreement with self-report, particularly where the proxy lives with the respondent. On family history of illness, history of head injury or boxing and current sleep problems, proxy information is likely to be less complete and show poor agreement. A proxy who is not a close relative is likely to give less complete information but agreement will not be substantially lower.

Aged↗

Proxy respondents in reproductive research: a comparison of self- and partner-reported data.

The quality of proxy reporting was assessed among 136 prenatal patients and their spouse/partners recruited from the obstetric services of a New Jersey hospital between 1985 and 1987. The concordance, sensitivity, and specificity of proxy reports about partners' occupation, smoking, and drinking were examined in relation to self-reports. Overall, private patients provided better proxy data than did clinic patients, and women provided better data than did men. No consistent effects on the quality of proxy reports were found in relation to age, level of education, marital status, or length of cohabitation. Partners' recent job titles appeared to be quite accurately reported, whereas partners' smoking and drinking patterns were less well-reported. For alcohol use in particular, there was evidence of considerable misclassification resulting from proxy reports even when kappa statistics and intraclass correlation coefficients suggested good agreement. Use of proxy respondents is unnecessary in reproductive studies and should be avoided when it may produce misleading results. Our data indicate that private prenatal patients and their partners can give reasonable proxy reports about job titles and smoking, but not about alcohol use. The high proportion of clinic patients who did not refer a partner (or whose partners could not be contacted) limits the generalizability of our results for this group and gives cause for concern about collecting proxy information from clinic populations.

Adolescent↗

The validity of proxy-generated scores as measures of patient health status.

This study examines the validity of proxy assessments as substitutes for patient assessments of patient physical and psychosocial health status. Data were obtained from 275 patient-proxy pairs who were enrolled in a national study of Adult Day Health Care. Patients and proxies (informal caregivers such as spouses) were asked to complete the Sickness Impact Profile (SIP) based on the patients health status. Findings showed that patient-generated and proxy-generated physical scores were highly correlated, although proxies rated patients as slightly more impaired than the patient's rated themselves. The correlation between psychosocial scores was not high enough to consider proxy responses as valid substitutes for patient responses. We explored these differences in response by comparing regression equations predicting patient-generated and proxy-generated physical and psychosocial SIP dimension scores. Variance in the patient-generated psychosocial score was explained by physical function, psychological distress, cognitive status and patient age. Proxy-generated psychosocial scores were primarily explained by the caregiver's psychological distress and perceived burden. These findings point out the importance of considering the source of patient health status estimates when interpreting the results of research studies.

Activities of Daily Living↗

Comparing proxy and patients' perceptions of patients' functional status: results from an outpatient geriatric clinic.

OBJECTIVE: To compare ratings of patients referred for geriatric evaluation and their proxies with respect to patients' ability to perform activities of daily living. DESIGN: Retrospective chart audit. SETTING: University-based Outpatient Geriatric Clinic. PATIENTS: Elderly medicine patients referred to a university-based outpatient geriatrics clinic for the first time. MAIN OUTCOME MEASURES: Modified Katz Physical Activities of Daily Living (PADL) and Instrumental Activities of Daily Living (IADL). RESULTS: With regard to PADLs, patients were generally rated as independent by both patients (91%) and proxies (87%); for IADLs, ratings of independence by both patients (68%) and proxies (51%) were significantly lower. Concordance between patient and proxy ratings was significantly (P less than 0.001) greater for PADLs (92%) than for IADLs (82%). When disagreement occurred, patients consistently rated themselves as more independent than their proxies, especially for IADLs. Moreover, concordance between patients and proxies regarding IADLs was significantly (P less than 0.001) worse for patients who had scores below 24 on the Folstein Mini-Mental State Examination (72%) compared with those scoring 24 or higher (95%). CONCLUSIONS: Patient and proxy ratings were concordant when rating patients' ability to perform PADLs. Moreover, concordance was extremely high on IADLs when patients' Folstein scores were 24 or higher. Concordance with respect to IADLs was relatively poor only among patients with Folstein scores below 24. In that case, patients had a more optimistic view of their independence, compared with their proxies.

Activities of Daily Living↗

The structure of physical health status. Comparing proxies and self-respondents.

Because gerontological studies often need to rely on the use of proxy respondents, the comparability of proxy and self-respondents is of particular interest. However, it is often impossible to evaluate response agreement between proxy and self-respondents because the necessary data are not available. This study addresses the problem by using a model of health status to evaluate differences between proxy and self-respondents regarding the conceptualization of health status. The model included three dimensions of physical health: chronic illness, functional limitations, and subjective health. Three groups of respondents who differ regarding proxy status and/or physical health status were compared. A subset of matched self-respondents (n = 146) was selected to be comparable in objective health status to respondents who have proxies (n = 140). The third group consisted of physically healthier self-respondents (n = 1,425). Data came from the Study of Well-Being of Older People in Cleveland, OH. No support was found for the expectation that proxies and self-respondents would weight objective health information differently when providing summary statements of subjective health. The results suggest that proxies rely on a conceptualization similar to self-respondents when providing information about another person's health.

Activities of Daily Living↗

Proxy reporting and the increasing prevalence of arthritis in Canada.

BACKGROUND: Analyses of the 1994/95 to 1998/99 Canadian National Population Health Surveys (NPHS) reveal significant, and greater than projected, increases in the reported arthritis in the household population aged 15+ years, from 13.4 to 16.0%. The objectives of this study were to determine whether the increasing prevalence of arthritis can be explained by a) changes in the age and sex structure of the population, or b) the variation in the proportion of proxy respondents and whether proxy reporting affects the overall prevalence estimate. METHODS: Overall analyses of 1994/95, 1996/97 and 1998/99 cycles of the NPHS, for arthritis or rheumatism reported as a long-term health problem diagnosed by a health professional. Stratified analyses, by respondent type, to account for the decreasing proportion of proxy respondents over time (33% to 16%). RESULTS: Overall age-sex standardized prevalence estimates were similar to crude estimates. The crude prevalence of arthritis in proxy respondents was stable (approximately 8.5%), whereas in self-respondents it increased from 15.8 to 17.4% over the 3 cycles. Adjustment for the lower prevalence in proxy respondents increased the estimated overall prevalence of arthritis by at least 1 percentage point for each cycle year. The disparity between self- and proxy reporting was higher for younger people and females. CONCLUSION: Significant disparity exists in age- and sex-specific prevalence estimates between self- and proxy respondents. The increase in prevalence of arthritis over time is a result of increased reporting by self-respondents. Proxy reporting affects overall prevalence. The findings have implications for the use of NPHS data.

Adolescent↗

Proxy consent to medical treatment: implications for rehabilitation.

When a patient is unable to give an informed consent to a proposed therapeutic intervention, the principal health care provider is legally bound to secure a consent to treatment from the patient's legally authorized guardian or proxy. The appointment of a proxy decision-maker is a legal rather than a medical process, and health care providers risk a law suit if it is circumvented. Furthermore, the nature of the proxy appointment, which varies from state to state, is complicated by an absence of well-defined guidelines relating to the conditions under which a proxy is needed, who may serve as a proxy, how the proxy should be selected, and the scope of the proxy's authority. Because rehabilitation serves many incompetent patients, its providers should be intimately acquainted with the laws on appointing proxies so as to protect patient rights and to avoid personal liability.

Ethics, Medical↗

Promoting completion of health care proxies following hospitalization. A randomized controlled trial in a community hospital.

BACKGROUND: The wider use of written advance directives is popular but problematic. We have shown previously that acute hospitalization in the era of the Patient Self-Determination Act can facilitate directive discussions and documentation. We investigated whether a simple educational intervention following hospitalization would increase patients' execution of durable health care proxies. METHODS: We studied a consecutive series of patients (n = 162) recently discharged from the acute care medical service of a community hospital where they had been interviewed about advance directives. The intervention group was randomized to receive an educational brochure and encouragement to execute durable health care proxies. The primary outcome was the proportion of patients in each group with completed durable health care proxies on file in their primary physicians' offices. RESULTS: Overall, only 20 (12.3%) of 162 patients had documented proxies, 17 of whom (85%) were 65 years of age or older, with no difference between the intervention and control groups (11 [13.3%] of 83 vs nine [11.4%] of 79, respectively). Subgroup analysis of elderly patients also revealed no intervention effect. Univariate analysis revealed three significant predictors of patients' proxy completion: patient age, whether patients had discussed directives in hospital with their physicians, and whether patients' physicians completed proxies for themselves. Multiple logistic regression analysis showed that these three variables interact to predict the probability of patients' executing proxies. CONCLUSIONS: Simple educational interventions, like those mandated by the Patient Self-Determination Act, are unlikely to increase patients' completion of durable healthcare proxies. Multidimensional interventions that target both elderly patients and their personal physicians should be tested in the future. Discussion in hospital about advance directives can be a useful component of such efforts.

Adolescent↗

Proxy ratings of health related quality of life in patients with hepatocellular carcinoma.

The present study prospectively assessed consistency of ratings of health-related quality of life between patients with hepatocellular carcinoma and two types of proxy raters, family caregivers and oncologist care providers. Patients and proxies completed the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) at baseline prior to treatment (82 patients plus proxies), at 3-months (32 patients plus proxies), and 6-months follow up (16 patients plus proxies) after diagnosis. Patient and proxy demographic data and patient medical data were also collected. At baseline, significant intra-class correlations (ICC) were found for patient--caregiver ratings of physical, social/family, and functional well-being, additional concerns (symptoms, side effects), and overall health related quality of life (HRQL); for patient--care provider ratings of physical well-being; and for caregiver--care provider ratings of physical and emotional well-being. At 3-months follow-up, the most significant number of ICCs were recorded across all three rater pairs. Significant consistencies were found for overall HRQL, and all subscale scores except for social and family well-being. The fewest significant ICCs were found at the 6-month follow-up, and were for patient--caregiver ratings of physical and functional well-being, and additional concerns; and for caregiver--care provider ratings on overall HRQL. These results suggest that family caregivers are adequate proxies of patient physical and functional well-being and additional concerns throughout the patient's illness, more so than oncologist care providers. Further research is warranted with larger samples.

Adult↗

Validation of the European proxy KIDSCREEN-52 pilot test health-related quality of life questionnaire: first results.

PURPOSE: The KIDSCREEN project aims to develop a European cross-cultural generic self-administered Health-Related Quality of Life (HRQoL) instrument for children and adolescents. Proxy measures HRQoL should be a useful and practical alternative to assess children's HRQoL. The KIDSCREEN pilot study involved 3988 children and 2526 child-proxy pairs in seven European countries (Austria, Switzerland, Germany, Spain, France, United Kingdom, and The Netherlands). The proxy instrument is based on the model developed from the children and adolescents reports. The aim of this study is to assess the psychometric properties of the proxy measure in terms of reliability and construct and external validity. METHODS: Confirmatory factor analysis (CFA) of the parent's data allows testing of the multidimensional structure of the proxy measure. Rasch analysis evaluates the scalability of each dimension. The mutltitrait-multimethod (MTMM) model assesses the trait validity through CFA. The agreement between children and proxies reports has been assessed using the Intraclass Correlation Coefficient (ICC). RESULTS: CFA indicates that the children's model is adequate to the parents' data. Reliability is satisfactory for every dimension (CFI = .957). For every dimension, Rasch analysis indicates that items form a unidimensional continuum. MTMM results confirm the trait validity of the instrument. Higher agreement was found for the physical well being dimension (ICC=.52) and school/cognitive functioning (ICC=.52). Adolescents showed higher agreement than the children, and girls higher than boys. Children with physical chronic health conditions showed higher agreement for several domains: physical and psychological well-being, social support, and school environment. CONCLUSIONS: Exploring different facets of validity showed satisfactory results. This new instrument provides a promising measure to further assess the relationships between youth and proxy reports.

Adolescent↗

The use of proxies in community integration research.

OBJECTIVE: To assess the level of agreement between persons with various disabilities and their proxies in reporting community integration outcomes using the Craig Handicap Assessment and Reporting Technique (CHART). DESIGN: Reliability study. SETTING: Participants living in the community for a minimum of 6 months after onset of disability or completion of inpatient rehabilitation. PARTICIPANTS: Persons (n = 983) with disability resulting from amputation, burn, multiple sclerosis, spinal cord injury (SCI), stroke, or traumatic brain injury and their self-selected proxies. INTERVENTIONS: Telephone interview of subjects (FIM instrument, CHART); proxies (CHART). FIM instrument assesses the degree of assistance with physical and cognitive subscales; CHART measures community integration in 6 subscales: physical, cognitive, and economic independence, and mobility, social integration, and occupation. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs) were used to assess participant-proxy agreement, and stepwise multiple regressions were used to identify patterns of difference in agreement based on disability type and demographic variables. RESULTS: Thirty-seven of the 38 items examined for the entire sample yielded moderate to strong ICCs. Multiple regression analyses indicated that proxies overrated participants with severe functional cognitive disabilities on the mobility subscale (p < .001), overrated participants with less than a high school education on the total CHART score (p < .01), and underrated participants with SCIs on the occupation subscale (p < .01). Differences in all cases, however, were less than 6 points out of a possible score of 100 per subscale. CONCLUSIONS: Participant-proxy agreement across the 6 disability groups provided evidence in support of the inclusion of proxy data for persons with various types of disabilities in community integration research.

Adult↗

The effects of retention intervals on self- and proxy reports of purchases.

Two studies explored underlying differences between self- and proxy reports and determining whether proxy reporters process and retrieve information the same way self-reporters do. In both studies, participants recorded their own and a target person's incidental purchases for two weeks and then returned, either immediately or one-week after the diary-keeping period, for two recall tests. These tests pertained to self- and proxy purchases. The reported items were scored against the recorded ones. In Study 1, the data indicate that proxies tend to recall more typical events than do self-reporters immediately following the diary-keeping period. However, after a delay of one week, both proxy and self-reporters tended to report typical items. These findings suggest that, at least initially, self- and proxy reporters process the information differently but that after one week they process it similarly. Study 2 employed a method that was identical to that of Study 1 except that participants were given a recognition test. The verbal protocols from the recognition test indicate that participants used different strategies to determine who made the purchase. Whereas participants focused on perceptual details surrounding the event when identifying their own purchases, proxies engaged in various strategies to identify their spouses' purchases.

Adult↗

Smoking status by proxy and self report: rate of agreement in different ethnic groups.

OBJECTIVE: To examine the rate of agreement between proxy and self report of smoking status in Hispanics compared with other ethnic groups. DESIGN: Data source is the 1990 California Tobacco Survey (CTS) which includes proxy and self reported smoking status. The CTS is a random digit dialed survey conducted in 57,244 households. A sample of 10,011 adults was included in the analyses. MAIN OUTCOME MEASURE: Percentages of agreement and disagreement between self report and report by other member of the household on smoking status. RESULTS: Cohen's kappa coefficients of agreement on smoking status between self report and proxy report was highest in non-Hispanic whites and African Americans (kappa = 0.91), followed by Asian Americans (kappa = 0.82) and Hispanics (kappa = 0.76). Among adults identified as current smokers by proxy, a lower percentage of Hispanics compared with non-Hispanics indicated that they were current smokers (odds ratio (OR) = 3.74, 95% confidence intervals (CI) = 3.28 to 4.20). Furthermore, agreement between proxy and self report was also lower in Hispanics of low acculturation compared with Hispanics with a high level of acculturation (OR = 0.40, 95% CI = 0 to 0.94). CONCLUSIONS: The agreement between self reported and proxy reported smoking status is higher among non-Hispanics compared with Hispanics. Smoking rates in different ethnic groups that are estimated by telephone surveys including proxy and self report might not be comparable.

Adolescent↗

Factors influencing agreement between child self-report and parent proxy-reports on the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales.

BACKGROUND: In situations where children are unable or unwilling to respond for themselves, measurement of quality of life (QOL) is often obtained by parent proxy-report. However the relationship between child self and parent proxy-reports has been shown to be poor in some circumstances. Additionally the most appropriate statistical method for comparing ratings between child and parent proxy-reports has not been clearly established. The objectives of this study were to assess the: 1) agreement between child and parent proxy-reports on an established child QOL measure (the PedsQL) using two different statistical methods; 2) effect of chronological age and domain type on agreement between children's and parents' reports on the PedsQL; 3) relationship between parents' own well-being and their ratings of their child's QOL. METHODS: One hundred and forty-nine healthy children (5.5 - 6.5, 6.5 - 7.5, and 7.5 - 8.5 years) completed the PedsQL. One hundred and three of their parents completed these measures in relation to their child, and a measure of their own QOL (SF-36). RESULTS: Consistency between child and parent proxy-reports on the PedsQL was low, with Intra-Class correlation coefficients ranging from 0.02 to 0.23. Correlations were higher for the oldest age group for Total Score and Psychosocial Health domains, and for the Physical Health domain in the youngest age group. Statistically significant median differences were found between child and parent-reports on all subscales of the PedsQL. The largest median differences were found for the two older age groups. Statistically significant correlations were found between parents' own QOL and their proxy-reports of child QOL across the total sample and within the middle age group. CONCLUSION: Intra-Class correlation coefficients and median difference testing can provide different information on the relationship between parent proxy-reports and child self-reports. Our findings suggest that differences in the levels of parent-child agreement previously reported may be an artefact of the statistical method used. In addition, levels of agreement can be affected by child age, domains investigated, and parents' own QOL. Further studies are needed to establish the optimal predictors of levels of parent-child agreement.

Adolescent↗

Parent proxy-report of their children's health-related quality of life: an analysis of 13,878 parents' reliability and validity across age subgroups using the PedsQL 4.0 Generic Core Scales.

BACKGROUND: Health-related quality of life (HRQOL) measurement has emerged as an important health outcome in clinical trials, clinical practice improvement strategies, and healthcare services research and evaluation. While pediatric patient self-report should be considered the standard for measuring perceived HRQOL, there are circumstances when children are too young, too cognitively impaired, too ill or fatigued to complete a HRQOL instrument, and reliable and valid parent proxy-report instruments are needed in such cases. Further, it is typically parents' perceptions of their children's HRQOL that influences healthcare utilization. Data from the PedsQL DatabaseSM were utilized to test the reliability and validity of parent proxy-report at the individual age subgroup level for ages 2-16 years as recommended by recent FDA guidelines. METHODS: The sample analyzed represents parent proxy-report age data on 13,878 children ages 2 to 16 years from the PedsQL 4.0 Generic Core Scales DatabaseSM. Parents were recruited from general pediatric clinics, subspecialty clinics, and hospitals in which their children were being seen for well-child checks, mild acute illness, or chronic illness care (n = 3,718, 26.8%), and from a State Children's Health Insurance Program (SCHIP) in California (n = 10,160, 73.2%). RESULTS: The percentage of missing item responses for the parent proxy-report sample as a whole was 2.1%, supporting feasibility. The majority of the parent proxy-report scales across the age subgroups exceeded the minimum internal consistency reliability standard of 0.70 required for group comparisons, while the Total Scale Scores across the age subgroups approached or exceeded the reliability criterion of 0.90 recommended for analyzing individual patient scale scores. Construct validity was demonstrated utilizing the known groups approach. For each PedsQL scale and summary score, across age subgroups, healthy children demonstrated a statistically significant difference in HRQOL (better HRQOL) than children with a known chronic health condition, with most effect sizes in the medium to large effect size range. CONCLUSION: The results demonstrate the feasibility, reliability, and validity of parent proxy-report at the individual age subgroup for ages 2-16 years. These analyses are consistent with recent FDA guidelines which require instrument development and validation testing for children and adolescents within fairly narrow age groupings and which determine the lower age limit at which reliable and valid responses across age categories are achievable. Even as pediatric patient self-report is advocated, there remains a fundamental role for parent proxy-report in pediatric clinical trials and health services research.

Adolescent↗