Judy A. Shea

The Functional Independence Measure: Tests of Scaling Assumptions, Structure, and Reliability Across 20 Diverse Impairment Categories

OBJECTIVE The analysis presented here evaluated the psychometric properties of the Functional Independence Measure (FIM) as a summated rating scale within context of the 20 impairment categories of the FIM-Function Related Group (FIM-FRG) system. DESIGN This study involved a cross-sectional analysis of patient records, utilizing factor analysis and techniques of multitrait scaling to verify the summative properties of the motor and cognitive dimensions of the FIM and to study the statistical properties of admission FIM scores. PATIENTS Included were a total of 93.829 patients discharged from 252 freestanding rehabilitation hospitals and units during calendar year 1992. Cases were excluded that had missing or out-of-range values or atypical lengths of stay. These criteria were developed previously in conjunction with an expert clinical panel and confirmed through statistical analyses. RESULTS Factor analyses supported the motor and cognitive dimensions across all 20 impairment categories. The resulting subscales exceeded minimum criteria for item internal consistency in 96.9% of tests and item discriminant validity in 100% of tests. Reliability coefficients for each impairment category for both subscales ranged from .86 to .97. There were no major ceiling effects, but patients in certain impairment categories were unable to climb stairs at admission. CONCLUSION The psychometric properties of the summated FIM compare favorably to most standardized health measures used in medical practice. Findings provide support for the motor and cognitive subscales as used in the FIM-FRGs. As a unidimensional scale, the FIM quantifies care burden. Split into the motor and cognitive (as used in the FIM-FRGs) it distinguishes physical disabilities from those arising from communication or cognitive difficulties.

Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis.

OBJECTIVE The purpose of this study was to perform a meta-analysis of large laparoscopic cholecystectomy case-series and compare results concerning complications, particularly bile duct injury, to those reported in open cholecystectomy case-series. SUMMARY BACKGROUND DATA Since the introduction of laparoscopic cholecystectomy in the United States, hundreds of reports about the technique have been published, many including statements about the advantages of laparoscopic cholecystectomy compared with those of open cholecystectomy. There is an unevenness in scope and quality of the studies. Nevertheless, enough data have accumulated from large series to permit analyses of data regarding some of the most important issues. METHODS Articles identified via a MEDLINE (the National Library of Medicines computerized database) search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes of cholecystectomy were abstracted and summarized across studies. RESULTS Outcomes of laparoscopic cholecystectomy are examined for 78,747 patients reported on in 98 studies and compared with outcomes of open cholecystectomy for 12,973 patients reported on in 28 studies. Laparoscopic cholecystectomy appears to have a higher common bile duct injury rate and a lower mortality rate. Estimated rates of other types of complications after laparoscopic cholecystectomy generally were low. Most conversions followed operative discoveries (e.g., dense adhesions) and were not the result of injury. CONCLUSIONS There is wide variability in the amount and type of data reported within any single study, and patient populations may not be comparable across studies. Except for a higher common bile duct injury rate, laparoscopic cholecystectomy appears to be at least as safe a procedure as that of open cholecystectomy.

Validation of the questionnaire for impulsive-compulsive disorders in Parkinson's disease.

As no comprehensive assessment instrument for impulse control disorders (ICDs) in Parkinsons disease (PD) exists, the aim of this study was to design and assess the psychometric properties of a self‐administered screening questionnaire for ICDs and other compulsive behaviors in PD. The Questionnaire for Impulsive‐Compulsive Disorders in Parkinsons Disease (QUIP) has 3 sections: Section 1 assesses four ICDs (involving gambling, sexual, buying, and eating behaviors), Section 2 other compulsive behaviors (punding, hobbyism, and walkabout), and Section 3 compulsive medication use. For validation, a convenience sample of 157 PD patients at 4 movement disorders centers first completed the QUIP, and then was administered a diagnostic interview by a trained rater blinded to the QUIP results. A shortened instrument (QUIP‐S) was then explored. The discriminant validity of the QUIP was high for each disorder or behavior (receiver operating characteristic area under the curve [ROC AUC]: gambling = 0.95, sexual behavior = 0.97, buying = 0.87, eating = 0.88, punding = 0.78, hobbyism = 0.93, walkabout = 0.79). On post hoc analysis, the QUIP‐S ICD section had similar properties (ROC AUC: gambling = 0.95, sexual behavior = 0.96, buying = 0.87, eating = 0.88). When disorders/behaviors were combined, the sensitivity of the QUIP and QUIP‐S to detect an individual with any disorder was 96 and 94%, respectively. Scores on the QUIP appear to be valid as a self‐assessment screening instrument for a range of ICDs and other compulsive behaviors that occur in PD, and a shortened version may perform as well as the full version. A positive screen should be followed by a comprehensive, clinical interview to determine the range and severity of symptoms, as well as need for clinical management.

Mood Change and Empathy Decline Persist during Three Years of Internal Medicine Training

Purpose To examine longitudinal changes in mood and empathy over the course of the internal medicine residency. Method The authors conducted a cohort study of 61 residents who completed the Profile of Mood States (POMS) and the Interpersonal Reactivity Index (IRI) at six time points during their internal medicine residency at a university-based program. (POMS was administered five times, and IRI was administered six times.) The main outcomes measured were trends in mood disturbances and multiple domains of empathy over the three-year residency, and comparisons to norms. Results Response rates varied from Time 1 to Time 6 (98%, 72%, 79%, 79%, 94%, and 95%, respectively). Interns had better scores on four POMS subscales: Depression–Dejection (p = .0031), Anger–Hostility (p < .0001), Fatigue–Inertia (p < .0001), and Vigor–Activity (p < .0001) compared with later administrations, especially midinternship. By the end of residency all POMS scores were returning towards baseline (effects sizes in the .20s), but only depression was no longer significantly different. IRI scores showed the decline in Empathic Concern remained over residency whereas Personal Distress peaked midinternship year but approached baseline at the end of residency. Compared with the general population, the graduating residents were less tense, depressed, and confused. Personal Distress was significantly lower than the norm group. Conclusions Internal medicine residency presents challenges resulting in common mood disturbances. Although graduating residents appear to be better off than the population norms, some domains of their mood disturbances and empathy never fully recover from their internship year.

Do Palliative Consultations Improve Patient Outcomes

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care.

Toward the development of an objective assessment of ego-identity status

Four investigations were completed to develop a self-report measure of ego-identity status. Following James Marcias definition of diffusion, moratorium, foreclosure, and identity achievement status, a series of Likert-type items were constructed and validated for use in the study of ego-identity formation. Convergent-divergent, concurrent, and predictive validity and test-retest reliability are documented in the reported data. Cross-sectional data suggest the measure will be sensitive to intraindividual change in identity formation. The new Objective Measure of Ego-Identity Status allows researchers to use either a “typology” or a “distribution of stage responses” in future longitudinal investigations.

A New HIV/AIDS-Targeted Quality of Life (HAT-QoL) Instrument: Development, Reliability, and Validity

OBJECTIVES The objectives of this study were to identify quality-of-life concerns, as reported by human immunodeficiency virus (HIV) seropositive individuals, and to develop a measure to assess these concerns. METHODS The HIV/acquired immunodeficiency syndrome (AIDS)-targeted measure was developed in two linked studies. In study one, group discussions with 42 HIV seropositive individuals were used to generate item content for the new measure. In study two, 201 HIV seropositive individuals were cross-sectionally studied to identify dimensions and to reduce the number of items of the quality of life questionnaire resulting from study one. RESULTS Study one subjects (76% male; 66% white; 55% gay/bisexual) identified concerns captured by 76 items. Factor analysis indicated that responses of study two subjects (78% male; 42% white; 55% gay/bisexual) could be summarized by nine dimensions. Overall function, sexual function, disclosure worries, health worries, financial worries, HIV mastery, life satisfaction, medication concerns, and provider trust dimensions were refined by removing items using methods to maximize internal consistency and to minimize item redundancy. No substantial ceiling/floor effects existed, except for the provider trust dimension (43% received the highest score possible). All internal consistency coefficients were > or = 0.70, except those for the HIV mastery (0.57) and medication concerns (0.51) dimensions, as well as the sexual function dimension (0.56) in the non-AIDS subsample. Multitrait/multiitem assessment indicated scaling success rates that were high (> or = 91%) for eight of nine dimensions (HIV mastery revealed a lower but modest success rate of 79%). Validity assessments, using self-reported HIV disease severity and sociodemographic variables, indicated expected relationships for all dimensions. CONCLUSIONS Five dimensions of the new HIV/AIDS-targeted quality of life instrument (overall function, disclosure worries, health worries, financial worries, and life satisfaction) exhibited good psychometric properties, including low ceiling/floor effects, good internal consistency, and evidence for construct validity.

Development and Testing of the Health Care System Distrust Scale

AbstractBACKGROUND: Distrust of the health care system may be a significant barrier to seeking medical care, adhering to preventive health care and treatment regimens, and participating in medical research. OBJECTIVE: To describe the development and psychometric testing of an instrument (the Health Care System Distrust Scale) to measure distrust of the health care system. METHODS: Scale development involved 2 phases. In Phase 1, a pilot instrument was developed based on a conceptual model of health care-related distrust. Draft items were created using focus group sessions with members of the general public, literature review, and expert opinion. Draft items were pilot tested with 55 individuals waiting to be assigned to jury duty at the Municipal Court of Philadelphia. A priori, candidate items for elimination or revision included those with >5% missing data, extremely low or high interitem or item-total correlations, or those having a negative effect on the scale’s internal consistency. In Phase 2, we conducted a survey of 400 prospective jurors to assess the reliability and validity of the final scale scores. RESULTS: In Phase 1, a 10-item scale was constructed that included 4 items measuring honesty, 2 items measuring confidentiality, 2 items measuring competence, and 2 items measuring fidelity. The participants in Phase 2 had a mean age of 41 years. Forty-three percent were African-American, 45% white, and 4% Hispanic. Scores on the Health Care System Distrust scale ranged from 12 to 46 with a possible range from 10 to 50. The mean score was 29.4 with a standard deviation of 6.33. No item had over 5% missing data. Internal consistency (Cronbach’s α) was 0.75. Item-total correlations ranged from 0.27 to 0.57. Principal components analysis revealed 1 general component accounting for 32% of the variance. Nine of the variables had loadings higher than 0.40. As predicted, distrust of the health care system was higher among African Americans than whites and was inversely correlated with trust in personal physicians. CONCLUSIONS: Initial testing suggests that we developed an instrument with valid and reliable scores in order to measure distrust of the health care system. Future research is needed to evaluate the validity and reliability of the Health Care System Distrust scale among diverse populations. This instrument can facilitate the investigation of the prevalence, causes, and effects of health care system distrust in the United States.

Differences in the Patterns of Health Care System Distrust Between Blacks and Whites

ContextAlthough health care-related distrust may contribute to racial disparities in health and health care in the US, current evidence about racial differences in distrust is often conflicting, largely limited to measures of physician trust, and rarely linked to multidimensional trust or distrust.ObjectiveTo test the hypothesis that racial differences in health care system distrust are more closely linked to values distrust than to competence distrust.DesignCross-sectional telephone survey.ParticipantsTwo hundred fifty-five individuals (144 black, 92 white) who had been treated in primary care practices or the emergency department of a large, urban Mid-Atlantic health system.Primary measuresRace, scores on the overall health care system distrust scale and on the 2 distrust subscales, values distrust and competence distrust.ResultsIn univariate analysis, overall health care system distrust scores were slightly higher among blacks than whites (25.8 vs 24.1, p = .05); however, this difference was driven by racial differences in values distrust scores (15.4 vs 13.8, p = .003) rather than in competence distrust scores (10.4 vs 10.3, p = .85). After adjustment for socioeconomic status, health/psychological status, and health care access, individuals in the top quartile of values distrust were significantly more likely to be black (odds ratio = 2.60, 95% confidence interval = 1.03–6.58), but there was no significant association between race and competence distrust.ConclusionsRacial differences in health care system distrust are complex with far greater differences seen in the domain of values distrust than in competence distrust. This framework may be useful for explaining the mixed results of studies of race and health care-related distrust to date, for the design of future studies exploring the causes of racial disparities in health and health care, and for the development and testing of novel strategies for reducing these disparities.

Distrust of the Health Care System and Self-Reported Health in the United States

AbstractCONTEXT: Despite theoretical concerns that health care related distrust may lead to poor health outcomes by interfering with effective health care, little is currently known about the prevalence or outcomes of distrust of the health care system in the United States. OBJECTIVE: To investigate the association between distrust of the health care system and self-reported health status among the general population in the United States. DESIGN: Random-digit-dialing telephone survey. PARTICIPANTS: Nine hundred and sixty-one adult residents of the continental U.S. PRIMARY MEASURES: Distrust of the health care system and self-reported health status. RESULTS: Distrust of the health care system is relatively high in the United States, with between 20% and 80% of respondents reporting distrust for each item on the Health Care System Distrust scale and a median scale score of 31 (potential range from 10 to 50). Distrust of the health care system is strongly associated with self-reported fair/poor health (odds ratio [OR] 1.40%, 95% confidence interval [CI] 1.12 to 1.75 for each standard deviation increase in distrust), even after adjusting for sociodemographic characteristics, access to health care and trust in primary physicians. In contrast, low trust in one’s primary physician is much lower (only 10% to 20% of respondents reported distrust for each item) and is not associated with health status. CONCLUSIONS: Distrust of the health care system is relatively high in the general population in the United States and is strongly associated with worse self-reported health. Further studies are needed to assess the direction of this association and the mechanisms involved.