How should health status measures be assessed? Cautionary notes on procrustean frameworks.
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Epidemiologic Methods↗
Biomedical subjects
J I Williams
Publications and source records attributed to J I Williams.
Standardized mortality ratio analysis on a sample of severely injured patients from a large Canadian city without regionalized trauma care.
Flora's Z statistic and standardized mortality ratios (SMRs) as indicators of excess mortality were calculated for a sample of 355 patients with major trauma. A statistically significant overall excess mortality was observed in this sample (Z = 6.77, SMR = 1.81, p less than 0.05). Advanced life support provided by physicians at the scene (MD-ALS) was not associated with reduced excess mortality. A significant trend toward lower excess mortality was associated with a higher level of trauma care at the receiving hospital (p less than 0.05). Total prehospital time over 60 minutes was associated with a significant increase in excess mortality (p less than 0.001). These results support regionalization of trauma care and failed to show any benefit associated with MD-ALS.
Adolescent↗
Cytochemical detection of superoxide in cerebral inflammation and ischemia in vivo.
We used a cytochemical technique for the detection of superoxide in cerebral inflammation and ischemia-reperfusion in anesthetized cats. The technique is based on the oxidation of Mn2+ to Mn3+ by superoxide; Mn3+, in turn, oxidizes diaminobenzidine. The oxidized diaminobenzidine forms an osmiophilic electron-dense product that is detected by electron microscopy. The reagents, manganese chloride (2 mM) and diaminobenzidine (2 mg/ml), were placed topically on the brain surface of anesthetized cats equipped with cranial windows. Inflammation was induced by topical carrageenan with or without phorbol 12-myristate 13-acetate to activate leukocytes. In inflammation, superoxide was detected in the plasma membrane and in the phagocytic vacuoles of leukocytes. In ischemia-reperfusion, superoxide was identified in the meninges in association with blood vessels. It was located primarily in the extracellular space and occasionally in endothelial and vascular smooth muscle cells. In both inflammation and ischemia, the reaction product was eliminated by superoxide dismutase or by the omission of either manganese or diaminobenzidine. It was unaffected by sodium azide, which inhibits peroxidases. No superoxide was detected in the brain parenchyma. The findings confirm the generation of superoxide is cerebral ischemia-reperfusion and show that it is produced in cerebral vessels.
Animals↗
Clinical and laboratory measures of postural balance in an elderly population.
The objective of this cross-sectional study was to compare scores on the Balance Scale with laboratory measures of postural sway and other clinical measures of balance and mobility. Thirty-one elderly subjects were assessed on the clinical measures and the laboratory tests of postural sway while standing still and in response to pseudorandom movements of the platform. The average correlation between the Balance Scale and the spontaneous sway measures was -.55. It was slightly lower (r = -.38) for the same parameters measured during the pseudorandom tests. There were high correlations between the Balance Scale and the Balance Sub-Scale developed by Tinetti (r = .91), Barthel Mobility sub-scale (r = .67), and timed "Up and Go" (r = -.76). The Balance Scale was the most efficient measure (effect size > 1) to statistically discriminate between subjects according to their use of each type of mobility aide (walker, cane, no aids). These data contribute to existing information on the performance of the Balance Scale and supports the validity of the Balance Scale in this geriatric population.
Activities of Daily Living↗
Testing various methods of introducing health charts into medical records in family medicine units.
OBJECTIVE: To test three methods of introducing health charts into the medical records of six family medicine units. DESIGN: Quasi-experiment. PARTICIPANTS: The staff physicians and family medicine residents in all six units and the nurses in two units. INTERVENTIONS: Group 1 (minimal intervention): health charts, a user's guide and one training session. Group 2 (intermediate intervention): same intervention as for group 1 plus two feedback sessions at 3 and 6 months. Group 3 (maximum intervention): same intervention as for group 2 plus promotion of the team concept (nurses were included). The intervention phase lasted from September 1987 to August 1988. OUTCOME MEASURES: The frequency with which the health charts were used, the item scores of each preventive care activity and the overall unit scores. Data were gathered through chart audits at baseline and at the end of the intervention phase. RESULTS: The frequency with which the health charts were used varied from 3.9% to 26.9%. The greatest increases in item scores were observed in the use of mammography (20.0%), counselling on lifestyle (19.4%) and breast examination (17.2%). Although the overall improvement in the unit scores was statistically significant (p less than 0.05) the hypothesis of an increasing gradient of effect across the three intervention groups could not be tested because of the variation in scores across the units. CONCLUSION: Health charts and other similar tools are useful; however, they are not sufficient to change practice behaviours. The support of a "champion" on the health care team might well be a determining factor of success for the delivery of preventive services in primary care practice.
Adult↗
Structured abstracts of proposals for clinical and epidemiological studies.
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Abstracting and Indexing↗
Prescription drug policy: a Canadian perspective.
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Health Policy↗
Measuring the impact of trauma care on survival: rates of preventable death, effectiveness, and efficacy.
This paper focuses on the appropriateness of outcome measures to evaluate trauma care. The preventable death rate (PDR), based on the study of deceased patients only, has been the traditional measure of the impact of trauma care on improving the survival of patients with severe trauma. Another measure frequently used in other ares of evaluation research is the effectiveness rate--i.e. the survival rate in the total population of severe trauma patients. Because both the PDR and the effectiveness rate vary with the proportion of patients who would die even under conditions of optimal care, these two measures can be misleading. We illustrate their inadequacy by using published data on the impact of regionalization of trauma care. We propose the use of a third outcome measure of the impact of trauma care on survival, the efficacy rate--i.e. the survival rate among severe trauma patients with a potential for survival. Evaluation of trauma care should also measure outcomes other than survival and need not be restricted to patients with the most severe trauma. Evaluation of trauma care therefore requires outcome measures, such as the efficacy rate, which are based on the population at risk of manifesting the outcome of interest.
Emergency Medical Services↗
Examining outcome measures in a clinical study of stroke.
We investigated the relation between outcome and sample size for six selected stroke outcome measures to assist investigators in selecting end points for stroke studies. Data from a clinical trial of 167 stroke patients assessed shortly after admission to the hospital and 5 weeks later provided information on clinical, motor, and functional outcomes measured using a neurologic status scale, a stroke severity scale, the Fugl-Meyer Scale, the Barthel Index, and the activities of daily living and cognition subscales of the Level of Rehabilitation Scale. Data were examined using Pearson correlation coefficients and power analyses. All measures were significantly correlated. There was also substantial congruency between the subscales of a measure and its total score. The measures had variable efficiencies; the Barthel Index was the most efficient and therefore required the fewest subjects to identify a significant effect. These data suggest that careful consideration must be given to the choice of stroke outcome measures in terms of their numbers, interrelationships, and statistical properties, as these factors have important implications for the design, analysis, and conduct of clinical stroke studies.
Cerebrovascular Disorders↗
Arthritis impact measurement scales: reliability of a French version and validity in adult Still's disease.
The Arthritis Impact Measurement Scales (AIMS) questionnaire was administered to 57 patients with adult Still's disease (ASD) and 104 controls. Six of the 9 scales were consistent for both groups (Cronbach's alpha greater than or equal to 0.70). Two scales, Mobility and Dexterity, were consistent for ASD only (alpha greater than or equal to 0.70). The reliability of a French version of the AIMS was similar to the standard AIMS. Of the 13 associations evaluating criterion related validity of the AIMS in ASD, 11 were statistically significant. We conclude that the French and standard AIMS are comparable and that this questionnaire is reliable and valid for assessing outcome in ASD.
Adolescent↗
Cloning and expression of a collagen-analog-encoding synthetic gene in Escherichia coli.
A family of totally synthetic genes coding for multiple tandem repeats of the amino acid sequence (Gly-Pro-Pro) has been prepared and inserted into the ClaI cloning site of the expression vector pJL6. A representative recombinant plasmid, pAC1, with an insert of about 340 bp was established in an Escherichia coli strain bearing a defective lambda prophage, to study expression of the CII-collagen analog fusion protein produced from pAC1 upon heat induction. Authentic fusion protein production was demonstrated by nucleotide sequencing, Northern-blot analysis, and in vivo synthesis. Conversion of a wild-type rpoH allele to the rpoH165 mutation was shown to suppress proteolysis of the unstable fusion protein.
Amino Acid Sequence↗
Quality of care in family practice: does residency training make a difference?
As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.
Adult↗
An integrative framework for health-related research.
Research on the manifold aspects of health and health-care delivery, economics and administration has expanded rapidly in recent years and now engages a number of disciplines. The array of theories, methods, and analytical strategies derived from such diverse sources frequently impedes effective communication between investigators and sometimes renders it impossible. We propose a conceptual framework that encompasses all health-related research and demonstrates the relationships and interfaces between the various disciplines involved. The framework emerges from a classification of health-related research into studies of health states or health interventions followed by consideration of the level of analysis (e.g. cell, individual, community) employed and the purpose of each study (development, description, explanation, or evaluation).
Delivery of Health Care↗
Recruiting family physicians as participants in research.
Obtaining the voluntary participation of family physicians in quality of care research is a major problem in family practice research. An innovative approach was therefore required to recruit 120 randomly selected family physicians in southern Ontario in a quality of care study by the College of Family Physicians of Canada. A network of physician recruiters oriented to the study was organized for each district. This recruitment method resulted in an 84.5% participation rate. The relationship of these physician recruiters to the candidate and the method of approach were important factors in the enrolment process: the highest participation rate (95%) was obtained when the recruiters were friends of the candidate and when a personal meeting was arranged (91%). Recruiters were given an information package to help them in the recruitment process and rated the most useful items as follows: a policy statement about confidentiality, a description of the study and reprints of a published feasibility study. These results illustrate that cooperation in research in family physicians' offices can become a reality.
Confidentiality↗
Functional outcome in pediatric trauma.
Two hundred fifty consecutive children hospitalized with severe injuries (at least one injury with an Abbreviated Injury Score [AIS] greater than or equal to 4 or two or more injuries with AIS scores greater than or equal to 2) were studied to determine their functional status at discharge and 6 months later using questions from the RAND Health Insurance Study (HIS) and the Glasgow Outcome Scale (GOS). Of the 217 surviving patients, 190 (88%) had one or more functional limitations by the HIS scale at discharge. Ten (5%) were in a vegetative state, 40 (18%) severely disabled, 97 (45%) moderately disabled, and 70 (32%) healthy by the GOS. Six-month followup was complete for 156 patients. Of these, 84 (54%) had one or more functional limitations by the HIS scale. Seven (4%) were in a vegetative state, 17 (11%) severely disabled, 50 (32%) moderately disabled, and 82 (53%) healthy by the GOS. A substantial proportion of the whole group of children hospitalized for the treatment of severe injuries had ongoing physical disabilities that limited their participation in normal activities 6 months after they were discharged. This suggests a need for greater emphasis on the rehabilitation of pediatric trauma patients.
Activities of Daily Living↗
A novel diagnostic method based on DNA strand displacement.
A novel approach for the detection of specific DNA or RNA sequences based on branch migration and DNA strand displacement is described. A partially double-stranded probe complex is prepared with a detectable label on one of the two strands and incubated with analyte molecules under hybridization conditions. The analyte molecules hybridize to the single-stranded portion of the probe complex and undergo branch migration to release the labelled DNA strand from the complex. Initial characterization of the assay indicates that both qualitative and quantitative information about analytes present in a sample can be obtained. The strand displacement assay is more sensitive to sequence alterations in the analyte than is a hybridization assay and can be promoted by rec A protein at 37 degrees C. Finally, a method for preparing probe complexes by cloning in a single-stranded DNA vector is also described.
DNA↗
Study of relation of continuing medical education to quality of family physicians' care.
A random sample of 120 physicians in Ontario was studied to assess quality of care in primary care and test an hypothesis that quality of care was related to continuing medical education (CME) activities. The quality-of-care scores were obtained by an in-office audit of a random selection of charts. The scores were global scores for charting, prevention, the use of 13 classes of drugs, and care of a two-year period for 182 different diagnoses. There were no relationships between global quality-of-care scores based on these randomly chosen charts and either the type or quantity of the physicians' CME activities. These activities were reading journals, attending rounds, attending scientific conferences, having informal consultations, using audio and video cassettes, and engaging in self-assessment. The implications of these findings are significant for future research in CME and for planners of present CME programs.
Certification↗
Evaluating a pediatric trauma program: effectiveness versus preventable death rate.
We compared effectiveness (E), the proportion of severely injured patients who were salvageable and survived, to the preventable death rate (PDR) over three consecutive 1-year periods. Severely injured patients were those with at least one injury with an Abbreviated Injury Score (AIS) of greater than or equal to 4. Those with one fatal injury (AIS greater than or equal to 6), a critical head injury (AIS greater than or equal to 5) apart from acute epidural hematoma, or massive multiple injuries (Injury Severity Score greater than 59) were considered nonsalvageable; the remainder were considered salvageable. In the first year, six of 74 salvageable patients died, in the second year five of 76, and in the third year one of 69. The PDR rates were 0.32 (6/19), 0.23 (5/22), and 0.06 (1/17), respectively. There was no significant difference in the E of our trauma program over the 3 years. The apparent improvement in PDR in the second and third years resulted from an increased number of deaths among nonsalvageable patients and fewer deaths among salvageable patients. This finding demonstrates that PDR is sensitive to case mix and not just quality of care, and confirms the superiority of E over PDR for assessing a trauma program.
Child↗