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PubMed1998

Assessment of management in general practice: validation of a practice visit method.

BACKGROUND: Practice management (PM) in general practice is as yet ill-defined; a systematic description of its domain, as well as a valid method to assess it, are necessary for research and assessment. AIM: To develop and validate a method to assess PM of general practitioners (GPs) and practices. METHOD: Relevant and potentially discriminating indicators were selected from a systematic framework of 2410 elements of PM to be used in an assessment method (VIP = visit instrument PM). The method was first tested in a pilot study and, after revision, was evaluated in order to select discriminating indicators and to determine validity of dimensions (factor and reliability analysis, linear regression). RESULTS: One hundred and ten GPs were assessed with the practice visit method using 249 indicators; 208 of these discriminated sufficiently at practice level or at GP level. Factor analysis resulted in 34 dimensions and in a taxonomy of PM. Dimensions and indicators showed marked variation between GPs and practices. Training practices scored higher on five dimensions; single-handed and dispensing practices scored lower on delegated tasks, but higher on accessibility and availability. CONCLUSION: A visit method to assess PM has been developed and its validity studied systematically. The taxonomy and dimensions of PM were in line with other classifications. Selection of a balanced number of useful and relevant indicators was nevertheless difficult. The dimensions could discriminate between groups of GPs and practices, establishing the value of the method for assessment. The VIP method could be an important contribution to the introduction of continuous quality improvement in the profession.

Family Practice↗
PubMedDate not supplied

Benchmarking physician performance, Part 1.

The performance of 16 primary care physicians in the same medical specialty and university clinic is compared using data envelopment analysis (DEA) efficiency scores. DEA is capable of modeling multiple criteria and automatically determines the relative weights of each performance measure. In this research, the performance measures include physician work relative value units (RVUs) as an input variable and patient satisfaction and total billable charges as the two output variables. The results provide insights into: 1. Who are the best-performing physicians? 2. Who are the underperforming physicians? 3. How can underperforming physicians improve? 4. What are the underperformers' performance targets? 5. How do you deal with full- and part-time physicians in a university setting? This research also provides a preliminary framework for how work measurement and DEA analysis can be used as a basis for a medical team or physician compensation system.

Benchmarking↗
PubMed1995

Towards fully automated genotyping: use of an X linked recessive spastic paraplegia family to test alternative analysis methods.

Advances in dinucleotide-based genetic maps open possibilities for large scale genotyping at high resolution. The current rate-limiting steps in use of these dense maps is data interpretation (allele definition), data entry, and statistical calculations. We have recently reported automated allele identification methods. Here we show that a 10-cM framework map of the human X chromosome can be analyzed on two lanes of an automated sequencer per individual (10-12 loci per lane). We use this map and analysis strategy to generate allele data for an X-linked recessive spastic paraplegia family with a known PLP mutation. We analyzed 198 genotypes in a single gel and used the data to test three methods of data analysis: manual meiotic breakpoint mapping, automated concordance analysis, and whole chromosome multipoint linkage analysis. All methods pinpointed the correct location of the gene. We propose that multipoint exclusion mapping may permit valid inflation of LOD scores using the equation max LOD-(next best LOD).

Alleles↗
PubMed1997

Developing a foundation for the evaluation of expanded-scope EMS: a window of opportunity that cannot be ignored.

EMS systems are about to undergo a major transformation. Not only will the scope of EMS change, but many experts believe that it will dramatically expand. Some see the "expanded scope" as entailing relatively limited changes, whereas others consider them to be more broad. Although no agreement is evident about the definition for expanded-scope EMS, it is hoped that all EMS professionals can agree that it must be implemented in a manner that can be carefully evaluated to determine its effects on patients and EMS systems. We present a framework for evaluating the effect of expanded-scope EMS in the various types of systems that currently exist. Special consideration must be given to the indirect effects that system changes may have on survival from out-of-hospital cardiac arrest. Numerous issues will affect our ability to properly assess expanded-scope EMS. The basic research models necessary to assess the impact of system change are lacking. Few EMS systems consistently produce significant volumes of good systems research ... that is, there are few "EMS laboratories." Cost-effectiveness and issues surrounding the "societal value" of EMS remain essentially unstudied. Reliable scoring methods, severity scales, and outcome measures are lacking: and, it is ethically and logistically difficult to justify withholding the "standard of care" in an effort to understand the impact of EMS interventions. Despite all of these barriers, it is time to pay the price of doing methodologically sound evaluations that ensure the most optimal societal impact by the EMS systems of the future.

Clinical Trials as Topic↗
PubMed2006

[Evolution of functional autonomy in geriatric medium-term care units: a reliable performance indicator?].

The objective of this study was to compare the evolution of the level of functional dependence of patients between the time of their hospital admission and release following treatment received in the geriatric medium-term care units, in order to propose this variable as a clinical performance indicator for this type of service. The differential score of physical dependence observed was determined for each hospital stay, and the adjusted significant functional improvement rate (SFI) was calculated for every unit. This adjusted SFI rate was then compared to the overall rate of all of the units combined. The overall SFI rates were 23% in 2004. Seven of the 49 units studied present an adjusted rate significantly inferior to the average rate of the total number of units combined. This study constitutes one of the first performance analyses in the medium-term sector, and the adjusted SFI rate seems to be a pertinent and reliable indicator within this framework.

Activities of Daily Living↗
PubMed2006

Activity limitations in the lower extremities in patients with osteoarthritis: the modifying effects of illness perceptions and mental health.

OBJECTIVES: Using the International Classification of Functioning, Disability and Health as framework, we evaluated modifying effects of illness perceptions and mental health on the association between impairments in body structures and functions due to osteoarthritis (OA) and limitation in activities in the lower extremities. METHODS: Self-reported limitation in activities was assessed by the Western Ontario and McMaster Universities OA index (WOMAC) function subscale in 316 patients with knee or hip pain or evidence of OA on knee or hip radiographs. Body structures and functions were evaluated during clinical and radiological assessments. Illness perceptions and mental health were assessed with the revised Illness Perception Questionnaire (IPQ-R) and the mental component summary score of the RAND 36-item Health Survey, respectively. For each patient an expected WOMAC function score was calculated, using an equation based on a multivariate model of the association of body structures and functions with limitation in activities. RESULTS: The median (interquartile) self-reported WOMAC function score was 22.2 (9.6-43.5). Ninety-one patients reported more and 120 patients reported less limitation in activities than expected. Patients with lumbar spine degeneration, physical or exercise therapy and high IPQ-R identity, consequences and chronic timeline scores had an increased risk to report more limitation in activities than the expected range. Low IPQ-R identity, consequences and emotional representation scores and better mental health were associated with reporting less limitation in activities than the expected range. CONCLUSION: Illness perceptions and mental health modify the association between self-reported limitation in activities and calculated limitation in activities based on impairments in body structures and functions due to OA.

Adult↗
PubMed1988

Eco-systemic analysis of anorexia nervosa.

Aspects of the eco-systemic approach were used to provide a framework for the understanding of anorexia nervosa and were empirically tested by comparing 30 anorexics and their parents to 34 matched control subjects and their parents. The theoretical model employed was an adaptation of Conger's Ecological-Systems approach which was based on the principles of Bronfenbrenner's theory of human development. The subjects were compared on selected variables arising from the individual, parent, family, and community systems using (a) the California Psychological Inventory (CPI), (b) the Structural Analysis of Social Behavior (SASB), (c) the Family Environment Scale (FES), and (d) the Pattison Psychological Inventory (PPI). Discriminant analysis revealed that the Affiliation score (SASB) for the anorexic and the control subjects and the Psychopathic Deviancy score (CPI-Clinical) of the mothers of the anorexics and the controls were the variables which contributed most to the discrimination between the groups. With the Affiliation and the Psychopathic Deviancy scores alone, it was possible to correctly classify 87.5 per cent of the research subjects. Analyses also showed statistically significant results at the individual, parent, and family levels. Interactions within the family, as perceived by the anorexics, were characterized by overprotection and control by the mothers, while the anorexics themselves responded with significantly less affiliation to both their mothers and their fathers. The mothers of the anorexics also viewed their daughters as being less friendly in the relationship. The families of the anorexics were less supportive, helpful, and committed to each other than were the families of the control subjects as measured by the FES.

Adolescent↗
PubMed2006

Bioplastique injection laryngoplasty: voice performance outcome.

AIM: To compare voice performance following Bioplastique injection with that following Isshiki thyroplasty. MEASURES: A 12 item, self-reported voice performance questionnaire was completed and observer-rated perceptual voice analysis scores were also measured, before and after Bioplastique injection, for 14 patients. Results were compared with our previously reported outcomes for 28 thyroplasty patients. RESULTS: Only 14 of 30 patients had complete datasets. For these patients, the mean pre-operative voice performance questionnaire score improved significantly, from 40.3 to 18.9 (p=0.002, Wilcoxon test). All perceptual analysis parameters showed significant improvement. These results compare favourably with the thyroplasty cohort (mean voice performance questionnaire score: pre-operative 35; post-operative 18; p<0.001). One Bioplastique patient developed contralateral paresis, requiring partial removal of the material 18 months later. Two thyroplasty patients experienced complications and three required revision. CONCLUSIONS: Both Bioplastique injection and Isshiki thyroplasty resulted in a significant improvement in both subjective and perceptual voice performance. Our data suggest that the effect size of the two interventions is approximately similar (in nonrandomised cohorts of surviving patients). As in many similar studies, the incomplete follow-up data reflect severe comorbidity. Bioplastique injection is a quicker procedure associated with fewer complications, and thus appears superior to framework surgery in patients with limited life expectancy.

Aged↗
PubMed1998

Assessment of rehabilitation needs in cancer patients.

In Germany and the United States cancer patients are admitted to rehabilitation programmes after anti-cancer treatment. Such programmes do not exist in the Netherlands. This leads to the question of whether in the Dutch health care situation certain problems (impairments-disabilities-handicaps) exist in (ex)cancer patients that can be dealt with by a rehabilitation programme. Using theories on the development of health care needs of chronic patients and the WHO approach of Impairment, Disability and Handicap, a framework for a questionnaire was developed. This questionnaire used quality of life items, functional health items and items mainly from specific cancer-orientated instruments. One hundred and forty seven patients participated in the study. After the results of this phase were clear, a focus group approach combined with in-depth interviews was used to present patients with possible rehabilitation programmes. Questions were formulated verifying the nature of prior results, inquiring about specific elements and desired outcomes and about practical aspects concerning post-cancer rehabilitation. The population consisted mostly of breast cancer (69.4%) and bowel cancer patients (23.8%). Quality of life scored averagely moderate, not indicating large problems. About 26% of all respondents wanted to receive professional help; this was largely determined by perceived quality of life and level of social support. The desire for professional help concentrated significantly on role performance, cognition, control, family relations, psychologic and somatic aspects. The focus group discussion and interviews revealed that patients would prefer a rehabilitation programme focusing on reducing fatigue, reinforcing loadability, coping with social aspects, dietary aspects and finding new life targets. Quality of life seemed to be relatively high and only 26% of post-cancer patients indicated the need of rehabilitation. Related to a significantly lower quality of life score, improved physical loadability and psychosocial functioning (coping) should be the main outcomes of such a programme. Specific elements such as dietary advice and finding new life targets should, from the patients' perspective, be included.

Adult↗
PubMed2000

Benchmarks of fairness for health care reform: a policy tool for developing countries.

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political and cultural differences.

Benchmarking↗
PubMed1999

Method for constructing confidently ordered linkage maps.

We describe a method for identifying, from a comprehensive genetic map, the most dense framework of confidently ordered markers. The approach uses the number of observed recombination events between each pair of markers, and finds the largest subset of markers for which adjacent loci are separated by at least one recombination. We illustrate the approach using a short region of chromosome 7p.

Algorithms↗
PubMed2003

The feasibility of applying item response theory to measures of migraine impact: a re-analysis of three clinical studies.

BACKGROUND: Item response theory (IRT) is a powerful framework for analyzing multiitem scales and is central to the implementation of computerized adaptive testing. OBJECTIVES: To explain the use of IRT to examine measurement properties and to apply IRT to a questionnaire for measuring migraine impact--the Migraine Specific Questionnaire (MSQ). METHODS: Data from three clinical studies that employed the MSQ-version 1 were analyzed by confirmatory factor analysis for categorical data and by IRT modeling. RESULTS: Confirmatory factor analyses showed very high correlations between the factors hypothesized by the original test constructions. Further, high item loadings on one common factor suggest that migraine impact may be adequately assessed by only one score. IRT analyses of the MSQ were feasible and provided several suggestions as to how to improve the items and in particular the response choices. Out of 15 items, 13 showed adequate fit to the IRT model. In general, IRT scores were strongly associated with the scores proposed by the original test developers and with the total item sum score. Analysis of response consistency showed that more than 90% of the patients answered consistently according to a unidimensional IRT model. For the remaining patients, scores on the dimension of emotional function were less strongly related to the overall IRT scores that mainly reflected role limitations. Such response patterns can be detected easily using response consistency indices. Analysis of test precision across score levels revealed that the MSQ was most precise at one standard deviation worse than the mean impact level for migraine patients that are not in treatment. Thus, gains in test precision can be achieved by developing items aimed at less severe levels of migraine impact. CONCLUSIONS: IRT proved useful for analyzing the MSQ. The approach warrants further testing in a more comprehensive item pool for headache impact that would enable computerized adaptive testing.

Adolescent↗
PubMed2001

Monitoring and evaluation of contracts for health service delivery in Costa Rica.

The Costa Rican Social Security Fund (CCSS) has been purchasing primary health care services from the Costa Rican Cooperative, COOPESALUD. The CCSS has made significant progress in establishing performance indicators and conducting evaluations of progress against those indicators. After laying out a general framework for developing performance indicators, this paper analyzes the CCSS's evaluation of its 1998 contract with COOPESALUD in terms of objectives, performance indicators, evaluation results, and use of the evaluation results. The objectives of the COOPESALUD contract, as they are stated within the body of the contract, are to increase coverage, improve quality and increase efficiency. Contract performance is measured through three categories of indicators: organization, service delivery and quality. Service delivery targets are set in terms of volume of services based upon geographic population. A 'yes' or a 'no' rating to indicate whether a particular system is in place is used for scoring organization and quality targets. While the CCSS contract is one of the most advanced in the region, many aspects could be improved. By setting indicator targets based upon population estimates, it is difficult for the CCSS to accurately assess COOPESALUD's performance. Although the CCSS conducts periodic evaluations through formal mechanisms, and some data on volume of service delivery are available, the data gathered in all three categories do not provide the purchaser with information directly related to all of the contract objectives nor to contractor performance. The indicators spelled out in the contract, and the evaluation of those indicators, do not seek to measure quantifiable results or impact through numerical data. There are no process or result indicators in place. The evaluation results could therefore tend to be fairly superficial - based upon population coverage and not on effectiveness of treatment, quality of treatment or efficient resource use.

Community Health Planning↗
PubMedDate not supplied

Retrieval feedback in MEDLINE.

OBJECTIVE: To investigate a new approach for query expansion based on retrieval feedback. The first objective in this study was to examine alternative query-expansion methods within the same retrieval-feedback framework. The three alternatives proposed are: expansion on the MeSH query field alone, expansion on the free-text field alone, and expansion on both the MeSH and the free-text fields. The second objective was to gain further understanding of retrieval feedback by examining possible dependencies on relevant documents during the feedback cycle. DESIGN: Comparative study of retrieval effectiveness using the original unexpanded and the alternative expanded user queries on a MEDLINE test collection of 75 queries and 2,334 MEDLINE citations. MEASUREMENTS: Retrieval effectivenesses of the original unexpanded and the alternative expanded queries were compared using 11-point-average precision scores (11-AvgP). These are averages of precision scores obtained at 11 standard recall points. RESULTS: All three expansion strategies significantly improved the original queries in terms of retrieval effectiveness. Expansion on MeSH alone was equivalent to expansion on both MeSH and the free-text fields. Expansion on the free-text field alone improved the queries significantly less than did the other two strategies. The second part of the study indicated that retrieval-feedback-based expansion yields significant performance improvements independent of the availability of relevant documents for feedback information. CONCLUSIONS: Retrieval feedback offers a robust procedure for query expansion that is most effective for MEDLINE when applied to the MeSH field.

Feedback↗
PubMed2004

A watershed-scale model for predicting nonpoint pollution risk in North Carolina.

The Southeastern United States is a global center of freshwater biotic diversity, but much of the region's aquatic biodiversity is at risk from stream degradation. Nonpoint pollution sources are responsible for 70% of that degradation, and controlling nonpoint pollution from agriculture, urbanization, and silviculture is considered critical to maintaining water quality and aquatic biodiversity in the Southeast. We used an ecological risk assessment framework to develop vulnerability models that can help policymakers and natural resource managers understand the impact of land cover changes on water quality in North Carolina. Additionally, we determined which landscape characteristics are most closely associated with macroinvertebrate community tolerance of stream degradation, and therefore with lower-quality water. The results will allow managers and policymakers to weigh the risks of management and policy decisions to a given watershed or set of watersheds, including whether streamside buffer protection zones are ecologically effective in achieving water quality standards. Regression analyses revealed that landscape variables explained up to 56.3% of the variability in benthic macroinvertebrate index scores. The resulting vulnerability models indicate that North Carolina watersheds with less forest cover are at most risk for degraded water quality and steam habitat conditions. The importance of forest cover, at both the watershed and riparian zone scale, in predicting macrobenthic invertebrate community assemblage varies by geographic region of the state.

Animals↗
PubMedDate not supplied

An exploration of recurrent injury prevention in patients with trauma.

INTRODUCTION/PURPOSE: Individuals who have sustained an injury are also at an increased risk for recurrent injury. The purposes of this study were to explore perceptions of recurrent injury risk and prevention, factors associated with the initiation of behavioral and environmental injury prevention strategies, and barriers to injury prevention. The Health Belief Model provided the theoretical framework for this study. METHODS: In this descriptive cross-sectional study, subjects completed a semi-structured interview. Questions were designed to explore subjects' perceptions and behaviors regarding strategies to prevent recurrent injury and any injury prevention information they may have received since their injury event. SAMPLE: Thirty adults who had sustained a nonviolent unintentional injury, mean age 43, mean time since injury 4 months. RESULTS: The majority of subjects reported high levels of perceived susceptibility to injury, and a large degree of perceived control in injury prevention. Factors associated with initiation of environmental strategies included injury to a lower extremity, lower physical function scores, use of an assistive device, and higher perceived injury severity. Few barriers to injury prevention were identified. DISCUSSION/CLINICAL IMPLICATIONS: Previously injured individuals made a variety of environmental and behavioral changes to prevent recurrent injury. However, subjects' perceived susceptibility for recurrent injury and lack of injury prevention information support the need for nursing interventions designed to decrease the risk of recurrent injury.

Adolescent↗
PubMed1998

Algorithms for resource allocation of substance abuse prevention funds based on the estimated need: a case study on state of Florida--Part 1.

The purposes of Parts 1-3 of this article is to develop a framework for county-based prevention resource allocation algorithms based on the aggregated need for substance abuse prevention services estimated at the county level. The development of these algorithms is founded upon two databases: statewide student drug survey and a set of social indicators routinely collected and published by various agencies of the state of Florida. The resource allocation models are devised by developing several indices of prevention needs that are conceptualized in terms of: 1) county-based composite drug use index (COMDRUG), 2) the definitions of prevention target populations as envisioned by the Institute of Medicine (IOM), 3) composite risk-factor index score, and 4) a set of social indicators that are empirically related to COMDRUG observed at the county level. The first three models are based on the prevention needs estimated from the statewide student survey on substance abuse. The social indicator model, however, is presented as an alternative resource allocation model which may be used in lieu of or in the absence of statewide survey. The resource allocation algorithms found on these four conceptualizations are thought to be more equitable and appropriate to the prevention needs of various communities than may be contrived otherwise. Due to a significant amount of information leading to the development of these models, Part 1 of this series is devoted to the following three topics: 1) sampling method used, 2) poststratification weighting methods used to estimate county-based COMDRUG, and 3) the development of resource allocation models based on COMDRUG and the IOM definitions of prevention target populations.

Alcoholism↗
PubMed2002

Evaluation of indications for and outcomes of elective surgery.

BACKGROUND: Wide small-area variations in the rates of elective surgical procedures and lack of systematic outcome measurement have raised questions about the appropriateness of such surgery. Our objective was to determine the feasibility of routine evaluation of indications for and outcomes of elective surgery. METHODS: Participants consisted of 138 surgeons and 5313 patients who underwent 1 or more of 6 specific surgical procedures (for a total of 6274 operations). Surgical indications were evaluated according to published guidelines. Patients' self-reported health-related quality of life (HRQOL) before and at appropriate intervals after surgery was measured with standard, validated generic and disease-specific instruments. Patient-specific results were routinely sent to the surgeons, from whom feedback was requested. RESULTS: Surgeons provided information on the indications for surgery for 44% to 95% of the 6 procedures, and the indications matched the guidelines in 73% to 99% of cases. Completed HRQOL questionnaires were returned by 58% of the patients. Postoperative HRQOL scores were markedly improved in most patients, but in 2% to 26% of the various procedures, there was either no change or a deterioration in HRQOL. In most of the procedure groups a small proportion of patients had relatively minor symptoms and disability preoperatively, but in the cataract surgery group this proportion was large. Opinion among the participating surgeons was divided as to the potential value of this method of evaluation. The cost of the outcome evaluation program was about $12/patient. INTERPRETATION: Evaluation of indications for and outcomes of elective surgery could be implemented systematically at reasonable cost and could be included in an accountability framework for health services. Most surgeons were not enthusiastic about this kind of evaluation.

Adult↗