Showing papers by "Gordon H. Guyatt published in 1997"
TL;DR: An alternative model is presented that evaluates the differences between treatment and placebo in two sets of clinical trials, and preserves the randomization of the originally assigned patient groups.
1,690 citations
TL;DR: It is suggested that differences in functional status can be statistically significant but below the threshold at which patients notice a difference in themselves relative to others; an awareness of the smallest difference in walking distance that is noticeable to patients may help clinicians interpret the effectiveness of symptomatic treatments for COPD.
Abstract: Functional status measurements are often difficult to interpret because small differences may be statistically significant but not clinically significant. How much does the Six Minute Walk test (6MW) need to differ to signify a noticeable difference in walking ability for patients with chronic obstructive pulmonary disease (COPD)? We studied individuals with stable COPD (n = 112, mean age = 67 yr, mean FEV1 = 975 ml) and estimated the smallest difference in 6MW distances that was associated with a noticeable difference in patients' subjective comparison ratings of their walking ability. We found that the 6MW was significantly correlated with patients' ratings of their walking ability relative to other patients (r = 0.59, 95% confidence interval [CI]: 0.54 to 0.63). Distances needed to differ by 54 m for the average patient to stop rating themselves as "about the same" and start rating themselves as either "a little bit better" or "a little bit worse" (95% CI: 37 to 71 m). We suggest that differences in functional status can be statistically significant but below the threshold at which patients notice a difference in themselves relative to others; an awareness of the smallest difference in walking distance that is noticeable to patients may help clinicians interpret the effectiveness of symptomatic treatments for COPD.
1,050 citations
TL;DR: In children under 11, clinicians can gain complementary information from questioning children and parents' assessment of children's asthma, and for children over 11, parents can provide little if any information beyond that obtained through questioning the child.
Abstract: Objective. To explore children9s and parents9 assessment of children9s asthma. Design. Prospective 2-month cohort study in which children and parents were reviewed at baseline and 1-month intervals. Setting. Mid-sized, English-speaking, industrial community serving an urban and regional rural population. Patients or Participants. Fifty-two children, 7 to 17 years old, with a wide range of asthma severity, and their parents. Interventions. We offered patients with inadequately controlled asthma additional inhaled steroid. Main Outcome Measures. Children and parents provided global ratings of change in childhood symptoms and children completed spirometry and the Paediatric Asthma Quality of Life Questionnaire at clinic visits. Patients recorded peak flow rates, symptoms, and medication use in a daily diary. The diary symptom report, medication use, and spirometry were combined to form an asthma control score. Results. In children younger than 11, children9s global rating of change in symptoms correlated strongly with changes in quality of life (0.54 to .67) but not with measures of airway caliber or asthma control, while parents9 global ratings did not correlate with children9s quality of life but showed moderate correlations with airway caliber (0.29 to .48) and asthma control (0.50). In children over the age of 11, correlations with all clinical variables were higher for their own than their parents9 global ratings. Conclusions. In children under 11, clinicians can gain complementary information from questioning children and parents. For children over 11, parents can provide little if any information beyond that obtained through questioning the child.
338 citations
TL;DR: A physician following a 35-year-old man who has had active Crohn disease for 8 years is impressed by both the methods and results of a recent articledocumenting that such patients benefit from oral methotrexate and suggests to the patient that he consider this medication.
Abstract: CLINICAL SCENARIO You are a physician following a 35-year-old man who has had active Crohn disease for 8 years. The symptoms were severe enough to require resectional surgery 4 years ago, and despite treatment with sulfasalazine and metronidazole, the patient has had active disease requiring oral steroids for the last 2 years. Repeated attempts to decrease the prednisone have failed, and the patient has required doses of greater than 15 mg per day to control symptoms. You are impressed by both the methods and results of a recent article1documenting that such patients benefit from oral methotrexate and suggest to the patient that he consider this medication. When you explain some of the risks of methotrexate, particularly potential liver toxicity, the patient is hesitant. How much better, he asks, am I likely to feel while taking this medication? INTRODUCTION There are 3 reasons we offer treatment to our patients.
323 citations
TL;DR: Two philosophically different methods for selecting items for a disease-specific quality of life questionnaire are compared, the impact method selects items that are most frequently perceived as important by patients whereas the psychometric method (factor analysis) selects items primarily according to their relationships with one another.
293 citations
Journal Article•
TL;DR: Canadian physicians, although generally positive about guidelines and confident in those developed by clinicians, have not yet integrated the use of guidelines into their practices to a large extent and the results suggest that respected organizations and opinion leaders should be involved in the development of guidelines.
Abstract: OBJECTIVE: To assess Canadian physicians' confidence in, attitudes about and preferences regarding clinical practice guidelines. DESIGN: Cross-sectional, self-administered mailed survey. PARTICIPANTS: Stratified random sample of 3000 Canadian physicians; 1878 (62.6%) responded. SETTING: Canada. OUTCOME MEASURES: Physicians' use of various information sources; familiarity with and confidence in guidelines; attitudes about guidelines and their effect on medical care; rating of importance of guidelines and other sources of information in clinical decision-making; rating of importance of various considerations in deciding whether to adopt a set of guidelines; and rating of usefulness of different formats for presenting guidelines. MAIN RESULTS: In all, 52% of the respondents reported using guidelines at least monthly, substantially less frequently than traditional information sources. Most of the respondents expressed confidence in guidelines issued by various physician organizations, but 51% to 77% were not confident in guidelines issued by federal or provincial health ministries or by health insurance plans. The respondents were generally positive about guidelines (e.g., over 50% strongly agreed that they are a convenient source of advice and good educational tools); however, 22% to 26% had concerns about loss of autonomy, the rigidity of guidelines and decreased satisfaction with medical practice. Endorsement by respected colleagues or major organizations was identified as very important by 78% and 62% of the respondents respectively in deciding whether to adopt a set of guidelines in their practice. User friendliness of the guidelines format was thought to be very important by 62%; short pamphlets, manuals summarizing a number of guidelines, journal articles and pocket cards summarizing guidelines were the preferred formats (identified as most useful by 50% to 62% of the respondents). CONCLUSIONS: Canadian physicians, although generally positive about guidelines and confident in those developed by clinicians, have not yet integrated the use of guidelines into their practices to a large extent. Our results suggest that respected organizations and opinion leaders should be involved in the development of guidelines and that the acceptability of any proposed format and medium for guidelines presentation should be pretested.
268 citations
260 citations
TL;DR: The aim of this study was to determine the minimum age and reading skills required by children to complete competently the Paediatric Asthma Quality of Life Questionnaire, the Health Utilities Index, the Feeling Thermometer and the Standard Gamble, and to evaluate the validity of each for measuring HRQL in children with asthma.
Abstract: To gain a complete picture of a child's health-status, measurement of health-related quality of life (HRQL) is necessary. Since parents do not accurately perceive children's HRQL, information must be obtained from the children themselves. The aim of this study was to determine the minimum age and reading skills required by children to complete competently the Paediatric Asthma Quality of Life Questionnaire (PAQLQ), the Health Utilities Index (HUI), the Feeling Thermometer and the Standard Gamble, and to evaluate the validity of each for measuring HRQL in children with asthma. Fifty two children (age 7-17 yrs) with symptomatic asthma participated in a 9 week single cohort study with HRQL and clinical asthma control assessed every 4 weeks. All children provided very reliable data for the PAQLQ and the HUI but they needed > or = grade 6 reading skills to complete the Standard Gamble and > or = grade 2 skills for the Feeling Thermometer. In those children who were able to provide reliable data, the PAQLQ had the best discriminative and evaluative measurement properties, followed closely by the Feeling Thermometer. Measurement properties in the Standard Gamble were weaker and although the HUI was very reliable it was not actually measuring asthma-specific HRQL. The Paediatric Asthma Quality of Life Questionnaire may be used with confidence in clinical studies and practice to provide a profile of children's day-to-day experiences. In those children with adequate skills to complete the test reliably, the Feeling Thermometer provides a good estimate of the value that children place on their asthma health status.
237 citations
TL;DR: Respiratory rehabilitation is likely to improve functional exercise capacity and HRQL if it includes exercise training and psychosocial support as well as the influence of respiratory muscle training and patient education.
166 citations
TL;DR: Comparisons with the same method are necessary to determine whether the improvements in HRQL that follow inpatient rehabilitation are cheap or expensive, and a consideration of cost-effectiveness from the perspective of NNT may be useful in the evaluation of health-care programs.
128 citations
TL;DR: Evidence-based Emergency Medicine summarizes the published evidence available for the diagnosis and treatment of common emergency health care problems in adults using evidence from systematic reviews, RCTs, and prospective observational studies to provide conclusions and practical recommendations.
TL;DR: Although current evidence does not allow a definitive recommendation, administration of trimethoprim-sulfamethoxazole for prophylaxis of P. carinii pneumonia and toxoplasmosis in patients with HIV infection is consistent with the available data.
Abstract: In a meta-analysis, we examined the efficacy of aerosolized pentamidine, trimethoprim-sulfamethoxazole, and dapsone or dapsone/pyrimethamine for the prevention of Pneumocystis carinii pneumonia and toxoplasma encephalitis in patients with HIV infection. Of 22 trials, 13 compared trimethoprim-sulfamethoxazole with aerosolized pentamidine, nine compared dapsone alone or in combination with pyrimethamine with aerosolized pentamidine, and eight compared trimethoprim-sulfamethoxazole with dapsone/pyrimethamine. In total, 1484 patients were treated with trimethoprim-sulfamethoxazole, 1548 patients with dapsone/pyrimethamine or dapsone, and 1800 patients with aerosolized pentamidine. For dapsone/pyrimethamine versus aerosolized pentamidine, the risk ratio for P. carinii pneumonia was 0.90 (95% confidence interval [CI], 0.71-1.15), and for toxoplasma encephalitis it was 0.72 (95% CI, 0.54-0.97). For trimethoprim-sulfamethoxazole versus aerosolized pentamidine, the risk ratio of P. carinii pneumonia was 0.59 (95% CI, 0.45-0.76), and for toxoplasma encephalitis it was 0.78 (95% CI, 0.55-1.11). For trimethoprim-sulfamethoxazole versus dapsone/pyrimethamine, the risk ratio of P. carinii pneumonia was 0.49 (95% CI, 0.26-0.92), and for toxoplasma encephalitis it was 1.17 (95% CI, 0.68-2.04). Although current evidence does not allow a definitive recommendation, administration of trimethoprim-sulfamethoxazole for prophylaxis of P. carinii pneumonia and toxoplasmosis in patients with HIV infection is consistent with the available data.
TL;DR: Clinicians can use the data from high quality studies of diagnostic tests in the form of specificity and specificity, as well as likelihood ratios, which indicate the direction and magnitude of the change in probability of a target condition from pretest to posttest.
Abstract: Medical diagnosis involves generating a set of hypotheses and obtaining information that modifies these hypotheses. Sources of this information include the history, physical examination, and laboratory investigations, all of which function as diagnostic tests. Studies of diagnostic tests are useful when a) the population under study is representative of those to whom we would like to apply the results; b) when an independent, blind comparison is made of the test results with a reference standard; and c) when the reference standard is performed on all patients, rather than restricted to those patients with particular test results. Clinicians can use the data from such high quality studies in the form of sensitivity and specificity, as well as likelihood ratios, which indicate the direction and magnitude of the change in probability of a target condition from pretest to posttest. Study results will be more easily applicable to practice when the performance and interpretation of the test is similar in study and clinical settings. We conduct diagnostic tests primarily to improve the process of patient care and patient outcome, and test ordering behavior ideally reflects these goals.
TL;DR: In previous editorials in this series, it was described a path that leads from health care research evidence to evidence-based health care and the steps include getting the evidence straight, developing evidence- based clinical policy, and then applying the policy.
Abstract: In previous editorials in this series (1, 2), we described a path that leads from health care research evidence to evidence-based health care. The steps include getting the evidence straight, developing evidence-based clinical policy, and then applying the policy.
TL;DR: An introduction to evidence-based nursing is provided as well as a description of the process in two separate undergraduate nursing programs to help future healthcare providers manage the explosion of new literature and technology.
Abstract: Nurse educators face many challenges in the current healthcare environment. Educational methods, philosophies, and the content of curricula need to be reexamined to meet the needs of professional nurses who will practice in the next millennium. Evidence-based nursing is one approach that may enable future healthcare providers to manage the explosion of new literature and technology and ultimately may result in improved patient outcomes. The authors provide an introduction to evidence-based nursing as well as a description of the process in two separate undergraduate nursing programs.
Journal Article•
TL;DR: This editorial focuses on the final step, applying evidence-based policy in the right way at the right place and time, as a precondition for justified application efforts.
Abstract: In the 3 preceding essays in this series (1–3), we described a path that leads from health care research evidence to evidence-based health care. The steps include getting the evidence straight, developing evidence-based clinical policy, and then applying the policy. In this editorial, we focus on the final step, applying evidence-based policy in the right way at the right place and time. As a precondition, application efforts are only justified if the evidence on which they are based is up to date and has been accurately incorporated and if the policy to be applied achieves a workable balance between both the evidence from research and the circumstances in which the evidence must be applied.
TL;DR: Assessment of health-related quality of life of patients with chronic lung disease has become an important aspect of many clinical investigations, and the measurement properties of a disease-specific HRQL questionnaire, the Chronic Respiratory Questionnaire, are examined.
Abstract: BACKGROUND: Assessment of health-related quality of life (HRQL) of patients with chronic lung disease has become an important aspect of many clinical investigations. The authors examined the measurement properties of a disease-specific HRQL questionnaire, the Chronic Respiratory Questionnaire (CRQ), when used by independent investigators in clinical trials and observational studies.
TL;DR: A simple model for evidencebased clinical decision making that included 3 components: clinical expertise, patient preferences, and evidence from research was considered.
Abstract: In Part 1 of this series (1), we considered a simple model for evidencebased clinical decision making that included 3 components: clinical expertise, patient preferences, and evidencefrom research.
Journal Article•
TL;DR: There is little difference in the therapeutic benefit between the 2 approaches for the treatment of ragweed pollen hay fever, and the approach to treatment should be based on patient preference, convenience and cost.
Abstract: OBJECTIVE: To determine whether better health-related quality of life (HRQL) is achieved by initiating treatment of seasonal (ragweed) rhinoconjunctivitis (hay fever) with a nasal steroid (fluticasone) backed up by a nonsedating antihistamine (terfenadine) or whether it is better to start with the antihistamine and add the nasal steroid when necessary. DESIGN: Randomized, nonblind, parallel-group management study during the 6 weeks of the ragweed pollen season in 1995. PATIENTS: Sixty-one adults with ragweed pollen hay fever recruited from patients who had participated in previous clinical studies and from those who responded to notices in the local media. SETTING: Southern Ontario. INTERVENTIONS: Nasal steroid group: 200 micrograms of fluticasone nasal spray when needed (up to 400 micrograms/d) starting about 1 week before the ragweed pollen season and continued throughout, with 1 to 2 tablets of terfenadine daily (maximum 120 mg/d) if needed. Antihistamine group: 1 60-mg tablet of terfenadine when needed (maximum 120 mg/d) starting about 1 week before the ragweed pollen season and continued throughout, with 200-400 micrograms/d of fluticasone nasal spray (maximum 400 micrograms/d) if needed. OUTCOME MEASURES: HRQL before, at the height of and toward the end of the ragweed pollen season; HRQL was measured using the Rhinoconjunctivitis Quality of Life Questionnaire. RESULTS: Overall, HRQL tended to be better in the group of patients whose first-line treatment was with fluticasone (p = 0.052), but the difference between the 2 groups was small and not clinically important. Just over half (52% [16/31]) of the patients in the fluticasone group did not need additional help with terfenadine, whereas only 13% (4/30) of those in the terfenadine group did not need additional help with fluticasone (p = 0.002). CONCLUSIONS: There is little difference in the therapeutic benefit between the 2 approaches for the treatment of ragweed pollen hay fever. Therefore, the approach to treatment should be based on patient preference, convenience and cost. Regardless of the treatment, at least 50% of patients will need to take both types of medication in combination to control symptoms adequately.
TL;DR: It is already clear that comprehensive assessment of HR-QOL requires more than 1 type of instrument, and the alternatives to generic measures, instruments that are specific to a function or a health problem, are more responsive than generic measures.
Abstract: Investigators use 2 fundamental approaches to the measurement of health-related quality of life (HR-QOL). Generic instruments include health profiles that tap into the full range of HR-QOL issues and are widely applicable, but may lack responsiveness to small but important changes in HR-QOL. Utility measures summarise HR-QOL in a single number between 0 (death) and 1 (full health) and are useful for economic analysis, but may lack responsiveness. Accumulating data suggest the alternatives to generic measures, instruments that are specific to a function or a health problem, are more responsive than generic measures. While direct comparison of the validity and responsiveness of alternative approaches remains limited and should be extended, it is already clear that comprehensive assessment of HR-QOL requires more than 1 type of instrument.
TL;DR: Generic questionnaires should not be used alone in clinical trials as evaluative instruments because of their inability to detect change over time, and further validation and improved interpretability of existing instruments would be of greater benefit to clinicians and scientists than the development of new questionnaires.
Abstract: Chronic obstructive pulmonary disease (COPD) is associated with primary respiratory impairment, disability and handicap, as well as with secondary impairments not necessarily confined to the respiratory system. Because the primary goals of managing patients with COPD include relief of dyspnea and the improvement of health-related quality of life (HRQL), a direct measurement of HRQL is important. Fourteen disease-specific and nine generic questionnaires (four health profiles and five utility measures) most commonly used to measure health status in patients with COPD were reviewed. The measures were classified according to their domain of interest, and their measurement properties - specifications, validity, reliability, responsiveness and interpretability - were described. This review suggests several findings. Currently used health status instruments usually refer to the patients’ perception of performance in three major domains of HRQL - somatic sensation, physical and occupational function, and psychological state. The choice of a questionnaire must be related to its purpose, with a clear distinction being made between its evaluative and discriminative function. In their evaluative function, only a few instruments fulfilled the criteria of responsiveness, and the interpretability of most questionnaires is limited. Generic questionnaires should not be used alone in clinical trials as evaluative instruments because of their inability to detect change over time. Further validation and improved interpretability of existing instruments would be of greater benefit to clinicians and scientists than the development of new questionnaires.
TL;DR: This approach may aid in the interpretation of an article on therapy or prevention; in it, a strategy designed to prevent ventilator associated pneumonia in critically ill patients is discussed.
Abstract: Evidence based critical care medicine involves integrating clinical experience, expertise, and patient preferences with explicit, systematic, and judicious use of current best evidence in making medical decisions. Published evidence has many sources: research from the basic sciences of medicine, and from patient-centered clinical research on the accuracy of diagnostic tests, the power of prognostic markers, and the effectiveness and safety of preventive, therapeutic, rehabilitative, and palliative interventions. When critically appraising a clinical article for potential use in intensive care unit (ICU) practice, the first question we ask ourselves is: Is this study valid? If examination of the study methods reveals that the design is rigorous, we can turn to the two other key questions: What are the results? and, Will the results help me care for my patients? This approach may aid in the interpretation of an article on therapy or prevention; in it we discuss a strategy designed to prevent ventilator associated pneumonia in critically ill patients.
TL;DR: Need was expressed for the majority of the 35 educational topics identified, including the role of the palliative care team, management of physical symptoms, pharmacological and non-pharmacological management of pain, stress management, spiritual needs, culture and death, and counseling.
Abstract: Health care providers in three nursing homes in Ontario were surveyed to determine educational needs, barriers to meeting these needs, and the preferred format for education. Of the 415 health care providers asked to participate, 225 completed the questionnaire. Need was expressed for the majority of the 35 educational topics identified, including the role of the palliative care team, management of physical symptoms, pharmacological and non-pharmacological management of pain, stress management, spiritual needs, culture and death, and counseling. Group discussions and seminars were favored over traditional lectures. The primary factors influencing attendance at a palliative care workshop were loss of pay and time and location of the workshop.
TL;DR: Self- or interviewer-administered questionnaires can be used to measure cross-sectional differences in quality of life among patients at a point in time or longitudinal changes in HRQL within patients over time (evaluative instruments).
Abstract: Clinicians and policy makers recognize the importance of measuring health-related quality of life (HRQL) to make informed patient management and policy decisions. Self- or interviewer-administered questionnaires can be used to measure cross-sectional differences in quality of life among patients at a point in time (discriminative instruments) or longitudinal changes in HRQL within patients over time (evaluative instruments). Both discriminative and evaluative instruments must be valid (ie, measure what they are supposed to measure) and have a high ratio of signal to noise (reliability and responsiveness for the two instruments, respectively). Reliable discriminative instruments are able to differentiate reproducibly among persons. Responsive evaluative measures are able to detect important changes in HRQL over time, even if those changes are small. HRQL should also be interpretable B that is, clinicians and policy makers must be able to identify differences in scores that correspond to trivial, small, moderate and large differences.
Journal Article•
TL;DR: This randomized control trial examined the proportion of chronically ill elders receiving Victorian Order of Nurses services in the home who would complete an advance directive, factors associated with directive completion, treatment choices, and satisfaction with care.
Abstract: In Canada, advance directives have been developed to ensure individual's decisions about health care are known in the event of mental incapacity. This randomized control trial examined the proportion of chronically ill elders receiving Victorian Order of Nurses (VON) services in the home who would complete an advance directive, factors associated with directive completion, treatment choices, and satisfaction with care. The participants consisted of 163 elders with a chronic illness residing within the Hamilton-Wentworth and Haldimand-Norfolk regions in South Central Ontario. Seventy percent of the experimental group completed the directive. Younger patients (p = 0.01) and patients with particular nurses (p = 0.04) were more likely to complete a directive. Psychosocial variables such as mood, depression, and uncertainty in illness did not influence directive completion. Satisfaction with involvement in health care decisions was not changed by this intervention (p = 0.576).
TL;DR: A study to examine how well the 36-item Short Form of the Medical Outcomes Study (SF-36) performs and simultaneously how quality-of-life evolves after three different surgical procedures illustrates the evolution of health status measurement and its limitations and potential for providing important information to clinicians.
Abstract: In this issue of JGIM, Mangione and colleagues report a study designed to examine how well the 36-item Short Form of the Medical Outcomes Study (SF-36) performs and simultaneously how quality-of-life evolves after three different surgical procedures1 The competing nature of these goals illustrates the evolution of health status measurement and its limitations and potential for providing important information to clinicians
The appropriateness of the term health-related quality of life (HRQL), which Mangione and colleagues use to describe what they are measuring, remains controversial The key instrument they have chosen, the SF-36, focuses to a large extent on how patients are functioning, including their ability to take care of themselves and carry out their usual roles in life Although this pragmatic view of HRQL seems to have gained ascendancy, there remain those who argue that unless investigators tap into individual patient values they are measuring only health status—they are not measuring HRQL2
This issue can be clarified by thinking of a woman with posttraumatic quadriplegia who, despite her limitations, is happy and fulfilled and values her life highly (more, for instance, than most people, and more than she did before she developed quadriplegia) Most of this woman's SF-36 results would suggest a poor HRQL, despite the high value she places on her health state My own view is that HRQL is an appropriate label for what Mangione and her colleagues have measured because there is a consensus of values both within and between cultures for the basic human functions included in the SF-36
It is more difficult, however, to determine whether the SF-36 really measures HRQL Because there is no criterion or “gold standard” for HRQL, it is a challenge to determine whether any HRQL measure is tapping into the intended aspect of peoples’ experience The most convincing approach to establishing whether an instrument is really measuring what it is designed to measure (the technical term is “validity”) is for investigators to make predictions about the results they expect before they collect the data Without such predictions, it is easy for investigators to rationalize their findings, whatever the results
Although some of the predictions made by Mangione and colleagues proved accurate, others did not For instance, their results did not show the deterioration in emotional function or health perceptions that the investigators anticipated 1 month postoperatively in lung cancer patients Also, correlations between change in the Specific Activity Scale, which is a measure of cardiovascular physical function, and change in several SF-36 domains related to physical functioning were lower than predicted We might interpret these findings as reflecting limitations in the validity of the SF-36 Alternatively, we might interpret them as limitations in the investigators’ understanding of the course of emotional function in lung cancer and problems with the validity of the Specific Activity Scale To put the dilemma more vividly: Have the investigators discovered something we didn’t know about how lung cancer patients feel after surgery, or have they discovered a limitation in the SF-36's ability to measure emotional function?
Because most of the investigators’ predictions proved accurate, I am inclined to share their view that the study's results provide strong support for the validity of the SF-36 Nevertheless, the discrepancy between predictions and findings highlights the challenges of measurement in an area without a criterion standard for HRQL
In their investigation, the authors focused on the ability of the SF-36 to measure change—what we have called its evaluative function3 This contrasts with the discriminative function of the instrument, which is its ability to differentiate between those with a better and those with a worse quality of life at a point in time Therefore, in studying the instrument's validity, the investigators have correlated changes in the SF-36 with changes in other measures but have not calculated correlations between different measures at a single point in time
The second key property of an evaluative measure is its ability to pick up important changes in HRQL, even if those changes are small Although Mangione and colleagues report the ability of the SF-36 to detect change (the technical term is “relative responsiveness”), they provide little information about the size of the changes they observed Thus, whether the SF-36 can pick up small but important changes in physical or emotional function in these populations remains uncertain
The responsiveness to small but important changes would be important if investigators used HRQL measures in the context suggested by the final paragraph of Mangione's discussion: randomized trials of surgery versus alternative treatments The SF-36 is an example of a generic measure that tries to cover all important areas of HRQL In contrast, specific measures focus on groups of patients with similar issues and explore areas of particular relevance in more detail4 For example, a specific instrument for patients with hip osteoarthritis would focus on pain and mobility, while one for lung cancer patients might focus on dyspnea and fatigue
Theoretically, specific HRQL measures are more responsive than generic HRQL measures, and accumulating data from head-to-head comparisons in randomized trials suggest that this is the case5–10 Responsiveness to small but important changes is likely to matter if we compare different types of hardware for hip arthroplasty or different resection strategies in lung cancer Indeed, investigators have chosen a disease-specific measure of HRQL as the primary outcome in several ongoing randomized trials of lung volume reduction surgery
Because the area of HRQL measurement is relatively new, clinicians may find it difficult to interpret studies in which HRQL is an important outcome To help them, we have suggested a set of guidelines for evaluating HRQL studies11 Mangione's report meets most of our criteria The investigators measured aspects of patients’ lives that patients consider important, and their instruments worked as intended They have shown that the SF-36 is able to detect changes as patients go through surgery (whether the SF-36 can detect the change patients would experience with alternative management remains uncertain) The investigators have not omitted any important areas of HRQL They did not attempt an economic assessment, which would have required other measurement instruments
We are left, however, with some uncertainty about the size of the HRQL changes that patients experienced Mangione and colleagues correctly point out that population norms help us understand the impact of surgery on HRQL as measured by the SF-36 Still, the meaning of the deterioration in, for instance, role physical function at 1 month after surgery is not evident Full understanding of whether the observed changes in SF-36 scores represent trivial changes in HRQL, small but important changes in HRQL, or large changes in HRQL (the technical term is “interpretability”)4 remains a research challenge
TL;DR: Effective treatment of dysfunctional behaviors requires their description and identification, evaluation of their frequency and impact on the caregiver, identification of causes, development of a treatment plan, and evaluation of the effects of treatment.
Abstract: A dysfunctional behavior can be defined as “an inappropriate action or response, other than an activity of daily living, in a given social milieu that is a problem for the caregiver.” Dysfunctional behaviors commonly accompany cognitive impairment and are a significant source of burden to caregivers. Dysfunctional behaviors may be the first sign of a dementing illness, even before caregivers perceive changes in the patient's cognitive abilities. However, unlike cognitive impairment, dysfunctional behaviors are amenable to medical treatment. Effective treatment of these behaviors requires their description and identification, evaluation of their frequency and impact on the caregiver, identification of causes, development of a treatment plan, and evaluation of the effects of treatment.
TL;DR: The necessary measurement qualities of instruments used to measure health-related quality of life in the elderly are described and some examples of measurement approaches with which researchers and health workers are familiar are provided.
Abstract: The elderly are a heterogeneous population group who range from well and completely independent individuals to a smaller proportion who are frail, require help and are high users of the healthcare system. Since health is a state of well-being which includes the domains of social, spiritual, psychological and physical function, each of these domains must be evaluated when we are measuring the health of older adults. In this article, we discuss some of the more important aspects of these domains. If we focus exclusively on the diseases which occur in older adults we will miss important aspects of their health status. We may miss the interactions of several different disease processes occurring in 1 individual, and the impact of those diseases on the individual's ability to live independently and his or her quality of life. In this article, we not only justify the measurement of function, cognition, affect and quality of life in the elderly but we also describe the necessary measurement qualities of instruments used to measure health-related quality of life in the elderly. We provide some examples of measurement approaches with which we as researchers and health workers are familiar.
Journal Article•
TL;DR: Postgraduate medical trainees' attitudes toward the use of gender-inclusive language may provide an index of underlying attitudes that may create hostile environments for female trainees.
Abstract: Objective: To explore postgraduate medical trainees’ attitudes toward the use of gender-inclusive language. Design: Self-administered questionnaire. Setting: Seven residency training programs at McMaster University, Hamilton, Ont., from July 1993 to June 1994. Participants: Of 225 residents in the programs, 186 responded to the survey, for a response rate of 82.7%. Men and women were equally represented among the respondents. Outcome measures: Categorization of attitudes about the use of language as gender-inclusive or gender-exclusive; characteristics predicting a gender-inclusive attitude. Results: Factor analysis and Cronbach’s α (0.90) supported the existence of a construct related to attitudes about language use, the poles of which were categorized as gender-inclusive and gender-exclusive. The authors classified residents with respect to their attitudes to language use from their responses to the questionnaire. In univariate analyses, sex, residency program and country of graduation significantly predicted a gender-inclusive attitude (p < 0.01). Only the first 2 variables were significant in a multivariate model; residency program explained 18% of the variance and sex 3%. Residents in obstetrics and gynecology and psychiatry had the most gender-inclusive attitudes, whereas residents in surgery and anesthesia had the most gender-exclusive attitudes. Conclusions: Residents’ values are reflected in the language they choose to use. Language use may provide an index of underlying attitudes that may create hostile environments for female trainees. Resume Objectif : Explorer les attitudes des stagiaires en medecine au niveau postdoctoral