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PubMed2004

Assessing simulated patients in an educational setting: the MaSP (Maastricht Assessment of Simulated Patients).

CONTEXT: For more than two decades the Medical School in Maastricht, the Netherlands, has used simulated patients (SPs) to provide students with opportunities to practise their skills in communication and physical examination. In this educational setting a student meets a SP in a videotaped session. Feedback by the SP to the student at the end of the session is considered an important educational feature. We found no instruments to assess individual SP performance during those sessions. OBJECTIVE: To develop a valid, reliable and feasible instrument to evaluate the performance of SPs. METHODS: The content of the instrument was validated through interviews with students, teachers and experts who are involved with SPs. They were asked to indicate key features of good SP performance. Based on the interviews, a written checklist was developed to measure individual SP performance. The instrument was evaluated in a regular SP session at the medical school, involving 152 students and their teachers. MAIN OUTCOMES: All interviewees considered the scale to be satisfactory and the instrument to be valid. The feasibility and reliability of the checklists were investigated using the data of 398 returned checklists. Cronbach's alpha was found to be 0.73. Generalizability analysis showed that 12 completed checklists were required to obtain a reliable assessment of one SP. CONCLUSIONS: The Maastricht Assessment of Simulated Patients (MaSP) appears to be a valid, reliable and feasible tool to assess the performance of SPs in an educational setting.

Attitude of Health Personnel↗
PubMed1999

The validity of nutritional status as a marker for future disability and depressive symptoms among high-risk older adults.

OBJECTIVE: To measure the validity of the DETERMINE Checklist as a marker for future functional disability, depressive symptoms, and mortality among high-risk older adults. DESIGN: A Cohort study. SETTING: An Urban-suburban Midwestern community. PARTICIPANTS: Community-dwelling Medicare beneficiaries at high risk for hospital admission who received geriatric evaluation and management (GEM) (n = 251). MEASUREMENTS: Demographic, health-related, functional, psychosocial, survival, and nutritional data were collected through telephone and in-home interviews. RESULTS: GEM recipients with baseline Checklist scores of four or higher were found to be significantly more likely than those with lower scores to have functional disability or high levels of depressive symptoms a year later. Checklist scores did not predict mortality. CONCLUSIONS: The 10-item Checklist could be used as a secondary screen to identify older persons who, without treatment, are at especially high-risk to have disability or depression a year later.

Activities of Daily Living↗
PubMed1999

Interobserver variability among faculty in evaluations of residents' clinical skills.

OBJECTIVE: To describe interobserver variability among emergency medicine (EM) faculty when using global assessment (GA) rating scales and performance-based criterion (PBC) checklists to evaluate EM residents' clinical skills during standardized patient (SP) encounters. METHODS: Six EM residents were videotaped during encounters with SPs and subsequently evaluated by 38 EM faculty at four EM residency sites. There were two encounters in which a single SP presented with headache, two in which a second SP presented with chest pain, and two in which a third SP presented with abdominal pain, resulting in two parallel sets of three. Faculty used GA rating scales to evaluate history taking, physical examination, and interpersonal skills for the initial set of three cases. Each encounter in the second set was evaluated with complaint-specific PBC checklists developed by SAEM's National Consensus Group on Clinical Skills Task Force. RESULTS: Standard deviations, computed for each score distribution, were generally similar across evaluation methods. None of the distributions deviated significantly from that of a Gaussian distribution, as indicated by the Kolmogorov-Smirnov goodness-of-fit test. On PBC checklists, 80% agreement among faculty observers was found for 74% of chest pain, 45% of headache, and 30% of abdominal pain items. CONCLUSIONS: When EM faculty evaluate clinical performance of EM residents during videotaped SP encounters, interobserver variabilities are similar, whether a PBC checklist or a GA rating scale is used.

Clinical Competence↗
PubMed1984

A stress and arousal mood scale for low vocabulary subjects: a reworking of Mackay et al. (1978).

In an experiment investigating patient mood in an out-patient setting, a Mood Adjective Checklist (Mackay et al., 1978) was administered to 189 patients before and after their consultations, obtaining 366 completed questionnaires. Both the stress and arousal scales in the Mackay et al. checklist contain unequal numbers of positive and negative items, and are thus subject to response bias. When the results were analysed, it was noted that some items in the checklist led to large numbers of question mark responses, and it was discovered that word frequency, used as an estimate of word unfamiliarity, was correlated with the use of the question mark. Furthermore, when question mark responses were treated as missing data, as recommended by Meddis (1972), the factor analytic distinction between stress and arousal disappeared. Next, items giving rise to 15 per cent or more question mark responses were omitted from analysis, and the remaining items factor analysed. The resulting checklist comprised nine high stress items, nine low stress items, four high arousal items and four low arousal items. Mackay et al.'s stress and arousal scales were reconstructed using these items; they were no longer subject to response bias, and were more accessible to low vocabulary subjects.

Adult↗
PubMed2003

Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.

OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy, to allow readers to assess the potential for bias in a study, and to evaluate a study's generalisability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organisations shortened this list during a two day consensus meeting, with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25 item checklist, by using evidence, whenever available. A prototype of a flow diagram provides information about the method of patient recruitment, the order of test execution, and the numbers of patients undergoing the test under evaluation and the reference standard, or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the STARD checklist and flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of clinicians, researchers, reviewers, journals, and the public.

Algorithms↗
PubMed2001

Burns and scalds in pre-school children attending accident and emergency: accident or abuse?

OBJECTIVES: To assess how frequently and adequately information relating to the possibility of non-accidental injury (NAI) is documented and considered by doctors assessing pre-school children with burns and scalds in the accident and emergency (A&E) department, and to determine the effect of introducing a routine reminder mechanism into the A&E notes, coupled with an improved programme of NAI education and awareness. METHODS: The records of 100 pre-school children attending an A&E department with a burn or scald were reviewed against nine pre-determined standards. Changes in policy were instituted, through a programme of education and the use of a reminder checklist, and the next 100 cases re-audited against the same checklist. RESULTS: Groups one and two were similar in their demographic characteristics. The reminder checklist was included in 60% of group two notes, and when included was completed in 97%. The child protection register was rarely consulted. There was a statistically significant increase in recording the following: time that the injury had occurred, the consistency of the history, the compatibility of the injury with the history given, the consideration of the possibility of NAI, the general state and behaviour of the child and the presence or absence of any other injuries. The rate of referral for a further opinion regarding the possibility of NAI increased from 0 to 3%, but failed to reach statistical significance. CONCLUSIONS: Prevailing awareness and documentation regarding the possibility of NAI was found to be poor, but a programme of intervention combining education and the use of a reminder checklist improved both awareness and documentation of NAI, as well as referral rates for further assessment. This strategy may prove applicable to children of all ages and injury types, reducing the number of cases of child abuse that are overlooked in the A&E department.

Burns↗
PubMed2000

Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: development of a guideline.

Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients. The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians (step 3), the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a "checklist of considerations" (step 4). Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline (step 5). The accordingly adapted "checklist of considerations" was tested in a pilot study (step 6), after which all experts endorsed the checklist (step 7). The resulting "checklist of considerations" structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest (see annex at end of paper).

Advance Directive Adherence↗
PubMed2005

Real time patient safety audits: improving safety every day.

BACKGROUND: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety. OBJECTIVE: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU). METHODS: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003. RESULTS: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected >or=1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4). CONCLUSIONS: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free "culture of patient safety" involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Delphi Technique↗
PubMed2005

Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit.

PROBLEM: Measuring a process of care in real time is essential for continuous quality improvement (CQI). Our inability to measure the process of central venous catheter (CVC) care in real time prevented CQI efforts aimed at reducing catheter related bloodstream infections (CR-BSIs) from these devices. DESIGN: A system was developed for measuring the process of CVC care in real time. We used these new process measurements to continuously monitor the system, guide CQI activities, and deliver performance feedback to providers. SETTING: Adult medical intensive care unit (MICU). KEY MEASURES FOR IMPROVEMENT: Measured process of CVC care in real time; CR-BSI rate and time between CR-BSI events; and performance feedback to staff. STRATEGIES FOR CHANGE: An interdisciplinary team developed a standardized, user friendly nursing checklist for CVC insertion. Infection control practitioners scanned the completed checklists into a computerized database, thereby generating real time measurements for the process of CVC insertion. Armed with these new process measurements, the team optimized the impact of a multifaceted intervention aimed at reducing CR-BSIs. EFFECTS OF CHANGE: The new checklist immediately provided real time measurements for the process of CVC insertion. These process measures allowed the team to directly monitor adherence to evidence-based guidelines. Through continuous process measurement, the team successfully overcame barriers to change, reduced the CR-BSI rate, and improved patient safety. Two years after the introduction of the checklist the CR-BSI rate remained at a historic low. LESSONS LEARNT: Measuring the process of CVC care in real time is feasible in the ICU. When trying to improve care, real time process measurements are an excellent tool for overcoming barriers to change and enhancing the sustainability of efforts. To continually improve patient safety, healthcare organizations should continually measure their key clinical processes in real time.

Adult↗
PubMed2003

Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD Initiative.

OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy, to allow readers to assess the potential for bias in the study and to evaluate its generalisability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering group searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organisations shortened this list during a two-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines regarding diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25-item checklist, using evidence, whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution and the numbers of patients undergoing the test under evaluation, the reference standard or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of the clinicians, researchers, reviewers, journals, and the public.

Algorithms↗
PubMed2000

Improving the Quality of Reports of Meta-Analyses of Randomised Controlled Trials: The QUOROM Statement.

BACKGROUND: The Quality of Reporting of Meta-analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs). METHODS: The QUOROM group consisted of 30 clinical epidemiologists, clinicians, statisticians, editors, and researchers. In conference, the group was asked to identify items they thought should be included in a checklist of standards. Whenever possible, checklist items were guided by research evidence suggesting that failure to adhere to the item proposed could lead to biased results. A modified Delphi technique was used in assessing candidate items. FINDINGS: The conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes our preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It is organised into 21 headings and subheadings regarding searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with < >, study characteristics, and quantitative data synthesis; research documentation was identified for eight of the 18 items. The flow diagram provides information about both the numbers of RCTs identified, included, and excluded and the reasons for exclusion of trials. INTERPRETATION: We hope this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement. Copyright 2000 S. Karger GmbH, Freiburg

Journal Article↗
PubMed2000

Reliability and validity of a simple measure for assessing the social skills of people with schizophrenia necessary for seeking and securing a job.

The literature shows that social and vocational impairments are common problems among people with schizophrenia. However, assessment instruments available for measuring social competence of people with schizophrenia in the workplace are limited. This article describes a two-part measure developed and validated based on a model (Tsang & Pearson, 1996) for assessing social skills necessary for seeking and maintaining a job for people with schizophrenia. The measure consists of a 10 item self-administered checklist and a role-play exercise. The self-administered checklist measures clients' perceived competence in handling work-related social situations. The role-play exercise assesses the social skills necessary for job acquisition and maintenance in two simulated situations (participating in a simulated job interview and requesting urgent leave from work). Cronbach alpha coefficients (self-administered checklist: .80 (n = 140); role-play test: .96 (n = 60)) show that both parts had good internal consistency. In addition, correlation coefficients show that the self-administered checklist has acceptable test-retest reliability (.35 to .78), and the role-play exercise has good interrater reliability (.77 to .90). The concurrent validity is also shown to be good for both parts of the measure using the method of contrasted groups. It is suggested that this measure is suitable for use by clinicians, rehabilitation administrators and researchers. Application of the instrument in other countries is discussed. Finally, further research is suggested.

Adult↗
PubMed1989

Predicting suicide behaviours in incarcerated settings.

Attempts to predict suicide behaviours have produced a number of useful clinical tools. Unfortunately, these have been largely designed with a specific psychiatric population or institutional setting in mind and are not easily transferred to an incarcerated setting. In 1983 the authors developed a suicide checklist which could be used to aid screening of new admissions to Remand Centres in the Province of Alberta. Studies completed to date have revealed this checklist to be a practical and reliable method of standardizing the suicide screening process. This paper presents findings from a study designed to evaluate the predictive power (discriminant validity) of the checklist. A stepwise multivariate framework is used to assess the overall ability of checklist items to discriminate a high risk group. As well, the relative importance of specific socio-demographic, clinical and historical variables is assessed. Data were collected on a cohort of consecutive admissions to the Edmonton Remand Centre during 1986. Findings reveal that marital status is the only direct statistical predictor of suicide risk. Inmates who had divorced or separated from a spouse were more likely to be active suicide risks at some time during their remand than those who were married or single. Symptom score was found to be generally predictive, however, closer assessment revealed this relationship to be heterogeneous across subgroups defined on the basis of certain criminological variables. The model which allowed for the interaction of clinical with criminological variables correctly discriminated 100% of the active suicide risks and 63% of inmates who had a prior history of suicide behaviours. The practical implications of these findings for suicide screening are discussed.

Adult↗
PubMed2006

Behavioral and emotional problems in children with epilepsy.

The principal purpose of this study was to assess behavioral and emotional problems in children with epilepsy to investigate if specific behavioral and emotional problems are associated with specific medical epilepsy-related factors. The Child Behavior Checklist (CBCL) was used to assess parent-reported behavioral and emotional problems in 108 5- to 18-year-old children with various epilepsy syndromes. Specific medical epilepsy-related factors, such as etiology, age at onset, seizure symptoms, prognosis, seizure frequency, electroencephalography (EEG), and anticonvulsive therapy, were recorded during a regular follow-up examination in our pediatric outpatient epilepsy clinic, and 22.2% of our patients showed moderate to severe behavioral or emotional problems as measured by the Child Behavior Checklist total score. Higher Child Behavior Checklist scores were associated with such specific medical epilepsy-related factors as etiology, age at onset, and polypharmacy. Higher scores on the Social Problem scale were associated with symptomatic epilepsy syndromes and an earlier age at onset. Higher scores on the Social Problems, Attention Problems, and Aggressive Behavior scales were associated with anticonvulsive polytherapy. There were no statistically significant associations between the Child Behavior Checklist scores and seizure symptoms and frequency and EEG at the time of evaluation. The demonstrated frequency of behavioral and emotional problems in children with epilepsy suggests the necessity to address psychosocial issues during the course of clinical treatment.

Adolescent↗
PubMed2005

Health measurement using the ICF: test-retest reliability study of ICF codes and qualifiers in geriatric care.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization (WHO) to standardize descriptions of health and disability. Little is known about the reliability and clinical relevance of measurements using the ICF and its qualifiers. This study examines the test-retest reliability of ICF codes, and the rate of immeasurability in long-term care settings of the elderly to evaluate the clinical applicability of the ICF and its qualifiers, and the ICF checklist. METHODS: Reliability of 85 body function (BF) items and 152 activity and participation (AP) items of the ICF was studied using a test-retest procedure with a sample of 742 elderly persons from 59 institutional and at home care service centers. Test-retest reliability was estimated using the weighted kappa statistic. The clinical relevance of the ICF was estimated by calculating immeasurability rate. The effect of the measurement settings and evaluators' experience was analyzed by stratification of these variables. The properties of each item were evaluated using both the kappa statistic and immeasurability rate to assess the clinical applicability of WHO's ICF checklist in the elderly care setting. RESULTS: The median of the weighted kappa statistics of 85 BF and 152 AP items were 0.46 and 0.55 respectively. The reproducibility statistics improved when the measurements were performed by experienced evaluators. Some chapters such as genitourinary and reproductive functions in the BF domain and major life area in the AP domain contained more items with lower test-retest reliability measures and rated as immeasurable than in the other chapters. Some items in the ICF checklist were rated as unreliable and immeasurable. CONCLUSION: The reliability of the ICF codes when measured with the current ICF qualifiers is relatively low. The result in increase in reliability according to evaluators' experience suggests proper education will have positive effects to raise the reliability. The ICF checklist contains some items that are difficult to be applied in the geriatric care settings. The improvements should be achieved by selecting the most relevant items for each measurement and by developing appropriate qualifiers for each code according to the interest of the users.

Activities of Daily Living↗
PubMed1980

A methodological consideration in the construction of actuarial interpretation systems.

Several actuarial interpretive systems have been constructed utilizing medical records as the source of criterion data. The present study compared adjective frequencies tabulated on a 100-item checklist from two samples of behaviorally disturbed children and adolescents employing different data collection procedures. Frequencies for the medical record sample (n = 79) were obtained by raters who reviewed case history materials and completed the checklist. The checklist sample (n = 79) was comprised of subjects matched on sex, age, and race and on whom the checklist was completed following a diagnostic evaluation. Significant differences in adjective frequencies were obtained on more than one-third of the items. When descriptors reflected syndrome-specific behaviors, minimal or no differences were found. However, consistent under-reporting of less diagnostically specific though clinically relevant characteristics was indicated in the medical record sample. This was attributed to the lack of systematic review of potential correlates. The implications for the development of actuarial systems, conduct of retrospective investigations, and construction of empirical classification systems based on medical record data were discussed.

Adolescent↗
PubMed1989

Personality assessment with children of superior intelligence: divergence versus psychopathology.

The perceptual and cognitive functioning of children with intelligence quotients greater than 135 was examined with the Rorschach Inkblot Test. A criterion measure, the Child Behavior Checklist, was also administered so as to determine whether deviations for Rorschach variables from age-appropriate norms indicated the presence of psychopathology or were evidence of nonentrenched, novel, or creative styles of encoding and processing information. Rorschach variables indicative of intellectual sophistication, nonentrenched thinking or inaccurate reality perception, and cognitive slippage were reliably elevated for this sample versus norms. Results for the Child Behavior Checklist demonstrated that the incidence of psychopathology in the intellectually superior and average samples were comparable. There was a lack of covariance between Rorschach makers of inaccurate reality perception, cognitive slippages, and schizophrenia, and the sum of behavior problems on the Child Behavior Checklist. Results for the Rorschach and Child Behavior Checklist variables were comparable for children with intelligence quotients greater than 150 versus between 136 and 140. It was concluded that the intellectually superior children did process the Rorschach stimuli in a manner that was nonentrenched and reliably different from norms, but that these differences should not routinely be considered as indications of psychopathology.

Adolescent↗
PubMed2005

Use of "standardized examinees" to screen for standardized-patient scoring bias in a clinical skills examination.

BACKGROUND: Clinical skills examinations using standardized patients (SPs) are important in documenting the proficiency of trainees. "Standardized examinees" (SEs) are individuals trained to a specific level of performance; they can be used as internal controls in a high-stakes, clinical skills examination. PURPOSE: The purpose of this study was to determine whether SEs can be trained to portray a specified level of confidence and whether SPs' checklist scoring is affected by the personal manner of the examinee. METHODS: Eight SEs were trained as "students" and trained to achieve a failing score on six cases in an National Board of Medical Examiners (NBME) Prototype Clinical Skills Examination. Four SEs were coached to be confident in manner, and 4 were coached to be insecure. Checklist scores were compared. Seven lay reviewers scored the SEs as confident or insecure on a behavioral assessment form. RESULTS: SEs were not detected as simulations. There was no difference between the checklist scores of confident versus insecure SEs, but their manner was rated as significantly different on all scales in the behavioral assessment. CONCLUSIONS: SEs can be trained to a specified performance level and a desired level of confidence. In this small study, personal manner did not affect SPs' checklist scoring. The use of the SEs provides a mechanism to screen for bias in high-stakes SP examinations.

Baltimore↗