Arlene Fink

Consensus methods: characteristics and guidelines for use.

Consensus methods are being used increasingly to solve problems in medicine and health. Their main purpose is to define levels of agreement on controversial subjects. Advocates suggest that, when properly employed, consensus strategies can create structured environments in which experts are given the best available information, allowing their solutions to problems to be more justifiable and credible than otherwise. This paper surveys the characteristics of several major methods (Delphi, Nominal Group, and models developed by the National Institutes of Health and Glaser) and provides guidelines for those who want to use the techniques. Among the concerns these guidelines address are selecting problems, choosing members for consensus panels, specifying acceptable levels of agreement, properly using empirical data, obtaining professional and political support, and disseminating results.

The UCLA Prostate Cancer Index: development, reliability, and validity of a health-related quality of life measure.

OBJECTIVES The need for accurate measures of health-related quality of life (HRQOL) in men treated for prostate cancer is of paramount importance because patients may survive for many years after their diagnosis. Hence, interest has increased in choosing treatments that optimize both the quality and quantity of life in patients with this disease. This study sought to develop and evaluate a self-administered, multiitem, disease-specific instrument to capture the health concerns central to the quality of life of men treated for early stage prostate cancer. METHODS After focus group analysis and pilot testing, the instrument was tested with a large retrospective, cross-sectional survey. Exploratory factor analysis and multitrait scaling analysis were used to facilitate the formation of six scales containing 20 disease-targeted items that address impairment in the urinary, bowel, and sexual domains. The psychometric properties of the new scales were assessed by measuring test-retest reliability, internal consistency reliability, and construct validity. Performance on the new scales was compared with scores on other established cancer-related health-related quality of life instruments. Two hundred fifty-five long-term survivors of prostate cancer treatment and 273 age-matched and ZIP code-matched comparison subjects without prostate cancer from a large managed care population in California were studied. Mean age was 72.7 years. In addition to the new scales, the RAND 36-Item Health Survey (SF-36) was used as a generic core measure, and a cancer-related health-related quality of life instrument (the Cancer Rehabilitation System-Short Form) was used to provide construct validity. RESULTS For the new scales, test-retest reliability ranged from 0.66 to 0.93, and internal consistency ranged from 0.65 to 0.93. Disease-targeted measures of function and bother in the three domains correlated substantially with one another. Scale scores correlated well with related, established scales. Men undergoing prostatectomy or pelvic irradiation demonstrated the expected differences in performance on the disease-specific health-related quality of life scales when compared with each other or with comparison subjects. Age was inversely related to sexual and bowel function. CONCLUSIONS The UCLA Prostate Cancer Index performed well in this population of older men with and without prostate cancer. It demonstrated good psychometric properties and appeared to be well understood and easily completed. The high response among patients suggests that these men especially are interested in addressing both the general and disease-specific concerns that impact their daily quality of life.

A method for the detailed assessment of the appropriateness of medical technologies.

The standard way to assess medical technologies is to conduct a randomized clinical trial. Patients are randomly assigned to groups receiving alternative treatments, and outcomes are monitored over a long period of time. For example, some victims of left main coronary artery disease may undergo coronary artery bypass surgery, and others may receive medical treatment with nitroglycerine and beta blockers. Comparison of five-year mortality and morbidity in the two groups helps to determine the relative appropriateness of the two procedures. In addition, information about quality of life and cost can also be collected and compared.

Variations in the Use of Medical and Surgical Services By the Medicare Population

We measured geographic differences in the use of medical and surgical services during 1981 by Medicare beneficiaries (age greater than or equal to 65) in 13 large areas of the United States. The average number of Medicare beneficiaries per site was 340,000. We found large and significant differences in the use of services provided by all medical and surgical specialties. Of 123 procedures studied, 67 showed at least threefold differences between sites with the highest and lowest rates of use. Use rates were not consistently high in one site, but rates for procedures used to diagnose and treat a specific disease varied together, as did alternative treatments for the same condition. These results cannot be explained by the actions of a small number of physicians. We do not know whether physicians in high-use areas performed too many procedures, whether physicians in low-use areas performed too few, or whether neither or both of these explanations are accurate. However, we do know that the differences are too large to ignore and that unless they are understood at a clinical level, uninformed policy decisions that have adverse effects on the health of the elderly may be made.

Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures

We convened three panels of physicians to rate the appropriateness of a large number of indications for performing a total of six medical and surgical procedures. The panels followed a modified Delphi process. Panelists separately assigned initial ratings, then met in Santa Monica, California where they received reports showing their initial ratings and the distribution of the other panelists ratings. They discussed the indications and revised the indications lists, then individually assigned final ratings. There was generally better agreement on the final ratings than on the initial ratings. Based on reasonable criteria for agreement and disagreement, and excluding one outlying procedure, the panelists agreed on ratings for 42 to 56 per cent of the indications, and disagreed on 11 to 29 per cent.

The functional status questionnaire

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients’ functional status. In this study, the FSQ was administered to 497 regular users of Boston’s Beth Israel Hospital’ Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

How to sample in surveys

How to Sample in Surveys: Learning Objectives Ch 1. Target Populations and Samples Checklist for Obtaining a Sample That Represents the Target Probability Sampling Simple Random Sampling Stratified Random Sampling Systematic Sampling Cluster Sampling Nonprobability Sampling Convenience Sampling Snowball Sampling Quota Sampling Focus Groups Commonly Used Probability and Nonprobability Sampling Methods Ch 2. Statistics and Samples Sampling Error Estimating the Standard Error for Simple Random Samples Sample Size: How Much Is Enough? Checklist of Factors to Consider When Calculating Sample Size Calculating Sample Size Checklist of Questions to Ask When Determining Sample Size Help With Sample Size and Power Sampling Units and the Unit of Analysis Acceptable Response Rate Guidelines for Promoting Responses and Minimizing Response Bias Calculating the Response Rate Exercises Answers Suggested Readings Glossary About the Author

Physician and Patient Satisfaction as Factors Related to the Organization of Internal Medicine Group Practices

The present study compares patient satisfaction scores with job satisfaction scores of the physicians providing their care in 16 general internal medicine teaching hospital group practices. Practice sites with more satisfied patients were also more likely to have more satisfied housestaff and faculty physicians. Additionally, higher satisfaction scores for both physician groups and patients were consistently associated with a greater percentage of patients experiencing continuity of care, lower patient no-show rates, more efficient use of ancillary staff in providing direct patient care, and more reasonable charges for a routine follow-up visit. These findings suggest that improving physician and patient satisfaction may have economic as well as psychological and social benefits.

Violence Exposure, Posttraumatic Stress Disorder, and Depressive Symptoms Among Recent Immigrant Schoolchildren

OBJECTIVE Many recent immigrant children are at risk for violence exposure and related psychological distress resulting from experiences before, during, and after immigration. This study examines the rates of violence exposure and associated symptoms among recent immigrant children in Los Angeles. METHOD 1,004 recent immigrant schoolchildren (aged 8-15 years) were surveyed about their prior exposure to violence and symptoms of posttraumatic stress disorder (PTSD) and depression. Participants included children whose native language was Spanish, Korean, Russian, or Western Armenian. RESULTS Participants reported high levels of violence exposure, both personal victimization and witnessing violence, in the previous year and in their lifetimes. Thirty-two percent of children reported PTSD symptoms in the clinical range, and 16% reported depressive symptoms in the clinical range. Although boys and older children were more likely to have experienced violence, girls reported more PTSD and depressive symptoms. Linear multiple regressions revealed that PTSD symptoms were predicted by both recent and lifetime violence exposure (p values < .001 and p < .05, respectively), when depressive symptoms and gender were controlled. On the other hand, depressive symptoms were predicted by recent victimization only (p < .001) when PTSD and gender were controlled. CONCLUSION These findings document the need for interventions addressing the psychological sequelae of violence exposure in immigrant children.

Stigma and depression among primary care patients

We assessed stigma affecting employment, health insurance, and friendships in 1,187 depressed patients from 46 U.S. primary care clinics. We compared stigma associated with depression, HIV, diabetes, and hypertension. Finally, we examined the association of depression-related stigma with health services use and unmet need for mental health care during a 6-month follow-up. We found that 67% of depressed primary care patients expected depression related stigma to have a negative effect on employment, 59% on health insurance, and 24% on friendships. Stigma associated with depression was greater than for hypertension or diabetes but not HIV. Younger men reported less stigma affecting employment. Women had more employment-related stigma but this was somewhat mitigated by social support. Other factors associated with stigma included ethnicity (associated with health insurance stigma) and number of chronic medical conditions (associated with health insurance and friendship related stigma). Stigma was not associated with service use, but individuals with stigma concerns related to friendships reported greater unmet mental health care needs. In summary, stigma was common in depressed primary care patients and related to age, gender, ethnicity, social support and chronic medical conditions. The relationship between stigma and service use deserves further study in diverse settings and populations.