Keumhee C. Carriere

Agreement Between Patient and Proxy Assessments of Health-Related Quality of Life After Stroke Using the EQ-5D and Health Utilities Index

Background and Purpose— Proxy informants can provide information on patients who are limited in ability to self-assess health-related quality of life (HRQL) after stroke. One alternative is to exclude assessments of such patients and attenuate generalizability. The purpose of this study was to examine patient-proxy agreement on the domains and summary scores of the EQ-5D and Health Utilities Index Mark 3 (HUI3) after stroke. Methods— An observational longitudinal cohort of 124 patients hospitalized after ischemic stroke and their family caregivers completed the HRQL measures at baseline and were followed up for 6 months. Patient and proxy agreement was assessed by use of weighted &kgr; or the intraclass correlation coefficient (ICC). Results— At baseline, the more observable domains of HRQL demonstrated greater agreement than the more subjective components. Cross-sectional point estimates of agreement were generally acceptable (ICC >0.70) for the EQ-5D Index and HUI3 summary scores when assessed ≥1 month after baseline. Agreement between change scores was generally poor to fair (ICC <0.60), but systematic bias was not observed for the indirect preference-based summary scores between baseline and 6 months. Conclusions— Results suggest that proxy assessments obtained 6 months after stroke are more reliable than those obtained within 2 to 3 weeks after stroke. Although proxy-assessed change scores for indirect preference-based summary scores of the EQ-5D and HUI3 provided suboptimal agreement with patient assessment, limited systematic bias may support their consideration as alternatives to missing data or statistical imputation. Further research into the validity and reliability of proxy assessments is suggested.

Functional dependence after hip fracture.

Cree M, Carriere KC, Soskolne CL, Suarez-Almazor M: Functional dependence after hip fracture. Am J Phys Med Rehabil 2001;80:736–743. Objectives: To identify patients at high risk of functional dependence and examine the progression of disability after a hip fracture. Design: This was a population-based prospective inception cohort study of all patients aged 65+ yr who fractured a hip between July 1996 and August 1997. Demographic, socioeconomic, social support, and health status information was assessed in the hospital and 3 mo postfracture. Results: The analysis included 367 patients. Almost all patients with cognitive impairment were functionally dependent postfracture, with new disabilities frequently occurring in transferring. Among patients of high mental status, increased risk of functional dependence was associated with advanced age, more co-morbidities, hip pain, poor self-rated health, and previous employment in a prestigeous occupation. Bathing disability was most likely in those who functioned independently prefracture; a disability in dressing was most common otherwise. Conclusion: Hip pain is amenable to treatment and may improve chances of functional recovery. Patients can be assisted in regaining prefracture function if they are targeted for rehabilitation on the basis of mental status. The focus should be on bathing and dressing among patients of high cognition and transferring among those patients with mental impairment.

Mortality and morbidity associated with osteoporosis drug treatment following hip fracture

This study examined post-fracture osteoporosis drug treatment in hip fracture patients and the association of treatment with mortality and morbidity. Pre- and post-fracture demographic/health information was collected on a cohort of hip fracture patients aged 65+ years. Post-fracture administrative data on prescription drug use and health care utilization was linked to the cohort data. Five classes of osteoporosis drugs were available during the study period: hormone replacement therapy (HRT), bisphosphonates (BSP), calcitonin, selective estrogen receptor modulators (SERMs) and vitamin D3 (Rocaltrol). Pre-fracture, 38 of 449 patients (8%) were on osteoporosis medications. Post-fracture, 81 of 356 patients (23%) were treated; 63 of these patients were untreated prior to fracture. Both treated and untreated patients had similar rates of subsequent hip fracture (6% and 4%, respectively) and Colles fracture (2%). Regardless of treatment status, patients were also equally likely to be hospitalized, both in the short-term (28% in treated, 27% in untreated) and in the long-term (43% versus 37%). However, mortality was significantly lower in the treated group. The lower mortality in the treated group, combined with the knowledge that antiresorptive drugs reduce fractures and increase bone density, merit undertaking a randomized trial to confirm our findings that antiresorptive therapy should be considered in all patients post-hip fracture.

Waiting times for surgical procedures.

OBJECTIVES Polls show that nearly two thirds of Canadians believe that waiting times prior to surgery have increased in recent years. A study was undertaken in Manitoba to determine whether public perceptions about long and increasing waits were valid. RESEARCH DESIGN Using administrative data, waiting times for 10 types of surgery-ranging from coronary artery bypass surgery and mastectomy to cataract surgery and hernia repairs-were studied over a 5-year period. RESULTS Using each patients preoperative visit to the surgeon as the beginning of the waiting time, median waiting times for most of the procedures studied were found to have, in fact, remained stable or fallen slightly over the period studied. CONCLUSIONS Further, an examination of waiting times for cataract surgery demonstrated that allowing surgeons to practice in both public and private arenas seems to be counterproductive to providing good public service.

Testing Repeated Measures Hypotheses When Covariance Matrices are Heterogeneous

For balanced designs, degrees of freedom-adjusted univariate F tests or multivariate test statistics can be used to obtain a robust test of repeated measures main and interaction effect hypotheses even when the assumption of equality of the covariance matrices is not satisfied. For unbalanced designs, however, covariance heterogeneity can seriously distort the rates of Type I error of either of these approaches. This article shows how a multivariate approximate degrees of freedom procedure based onWelch (1947 , 1951)-James (1951 , 1954), as simplified byJohansen (1980), can be applied to the analysis of unbalanced repeated measures designs without assuming covariance homogeneity. Through Monte Carlo methods, we demonstrate that this approach provides a robust test of the repeated measures main effect hypothesis even when the data are obtained from a skewed distribution. The Welch-James approach also provides a robust test of the interaction effect, provided that the smallest of the unequal group sizes is five to six times the number of repeated measurements minus one or provided that a reduced level of significance is employed.

Long-Term Outcome of Endoscopic Resection vs. Surgery for Early Gastric Cancer: A Non-inferiority-Matched Cohort Study

OBJECTIVES:Few studies have compared the long-term outcomes of endoscopic resection and surgery. The aim of this study was to compare the long-term outcomes of endoscopic resection with those of surgery for early gastric cancer (EGC).METHODS:We reviewed prospectively collected data of patients who had undergone endoscopic resection (1,290 patients) or surgery (1,273 patients) for EGC. To reduce the effect of selection bias, we performed a propensity score-matching analysis between the two groups. The primary outcome was overall survival (OS). The secondary outcomes were disease-specific survival, disease-free survival (DFS), recurrence-free survival (RFS), occurrence of metachronous gastric cancer, treatment-related complications, length of hospital stay, and 30-day outcomes. The study was designed as a non-inferiority study and tested in an intention-to-treat analysis.RESULTS:In a propensity-matched analysis of 611 pairs, the 10-year OS proportion was 96.7% in the endoscopic resection group and 94.9% in the surgery group (P=0.120) (risk difference −1.8%, 95% confidence interval (CI) −4.04–0.44, Pnon-inferiority=0.014), which met the non-inferiority criterion. In contrast, the 10-year RFS proportion was 93.5% in the endoscopic resection group and 98.2% in the surgery group (P<0.001) (risk difference 4.7%, 95% CI 2.50–6.97, Pnon-inferiority=0.820), which did not meet the non-inferiority criterion, mainly because of metachronous recurrence in the endoscopic resection group. The rate of early complications was higher in the endoscopic resection group than in the surgery group (9.0 vs. 6.6%, P=0.024), whereas the rate of late complications was higher in the surgery group than in the endoscopic resection group (0.5 vs. 2.9%, P<0.001). In the multiple Cox regression analysis, patient’s age, the comorbidity index, the performance index, sex, tumor morphology, and depth of invasion were predictors of OS in patients with EGC.CONCLUSIONS:Endoscopic resection might not be inferior to surgery with respect to OS in patients with EGC lesions that meet the absolute or expanded criteria. However, DFS, RFS, and metachronous RFS might be lower after endoscopic resection than after surgery.

A Population-Based Health Information System

The authors introduce the Population Health Information System, its conceptual framework, and the data elements required to implement such a system in other jurisdictions. Among other innovations, the Population Health Information System distinguishes between indicators of health status (outcomes measures) and indicators of need for health care (socioeconomic measures of risk for poor health). The system also can be used to perform needs-based planning and challenge delivery patterns.

Mortality during hospitalisation for pneumonia in Alberta, Canada, is associated with physician volume

The association of mortality with patient factors (severity of illness, comorbidity), physician factors (specialty training, prehospitalisation visit, in-hospital consultation, volume of patients seen per physician) and healthcare organisation factors (patient-travel distances, regional beds per capita, admitting hospital-bed occupancy, admitting hospital-bed turnover, hospital location, volume of pneumonia cases per hospital) after hospital admission with community-acquired pneumonia was investigated using administrative data from Alberta, Canada from April 1, 1994–March 31, 1999. During the 5‐yr study period there were 43,642 pneumonia hospitalisations, with an 11% in-hospital and 26% 1‐yr mortality. Patient severity of illness and comorbidity were the strongest predictors of increased mortality. Physicians with the highest in-hospital pneumonia patient volume (>27 patients·yr−1) cared for patients with greater severity/comorbidity, but with decreased odds of in-hospital mortality, compared with the lowest volume physicians (less than seven patients per year). The effects of internal medicine specialist or subspecialist care were mixed, with a reduction in deaths for the first 72 h and an increase in in-hospital deaths. Pre-hospitalisation visit by a physician was associated with decreased mortality. Healthcare organisation factors were the least strong predictor of mortality, demonstrating an effect only for 1‐yr mortality in those discharged alive from hospital. Admissions to larger volume or metropolitan hospitals were associated with a decrease in mortality. Severity of illness and comorbidity had the strongest association with mortality. The first association of high-volume physician and pre-hospital care with decreased in-hospital mortality for community-acquired pneumonia is reported.

Factors Associated with Death among Adults <55 Years of Age Hospitalized for Community-Acquired Pneumonia

An administrative database was used to study death occurring among adults aged 18-55 years who were hospitalized during the period from 1 April 1994 through 31 March 1999 for treatment of community-acquired pneumonia. In-hospital case-fatality rates for the first 10 days of hospitalization and overall were 2.1% and 3.2%, respectively, for 11,684 patient hospitalizations. Patient factors (age, sex, and comorbidity) were the most important associations with death. Aspiration provided the largest explanation of variance in deaths occurring during the first 10 days of hospitalization (odds ratio, 5.0; 95% confidence interval, 3.7-6.8). Busy hospitals (higher occupancy and higher number of daily admissions) were not associated with higher case-fatality rates. Bigger hospitals (metropolitan hospitals) had higher case-fatality rates, but this was more likely related to greater comorbidity and severity of pneumonia. Death due to community-acquired pneumonia among young and middle-aged adults is infrequent and is more related to the severity of pneumonia and to such risk factors as aspiration than to the manner in which the provision of care is organized.

Robust and Powerful Nonorthogonal Analyses.

Numerous types of analyses for factorial designs having unequal cell frequencies have been discussed in the literature. These analyses test either weighted or unweighted marginal means which, in turn, correspond to different model comparisons. Previous research has indicated, however, that these analyses result in biased (liberal or conservative) tests when cell variances are heterogeneous. We show how to obtain a generally robust and powerful analysis with any of the recommended nonorthogonal solutions by adapting a modification of the Welch-James procedure for comparing means when population variances are heterogeneous.