Kitty S. Chan

The PedsQL: reliability and validity of the short-form generic core scales and Asthma Module.

Objective:We sought to assess the reliability and validity of the PedsQL™ 4.0 SF15, a shortened version of the 23-item PedsQL™ 4.0 Generic Core Scales, which is a pediatric health-related quality of life (HRQoL) instrument, and the PedsQL™ 3.0 SF22 Asthma Module, a short-form of the PedsQL™ 3.0 Asthma Module. Methods:The PedsQL™ 4.0 SF15 and the PedsQL™ 3.0 SF22 Asthma Module were administered by telephone to 125 adolescents (aged 12–18) and 338 parents of children with asthma (aged 2–11). Healthy (n = 451) and chronically ill (n = 422) children, matched by age, respondent status, and ethnicity to the asthma sample, provided data for selected validity tests. Results:The Total Score from the PedsQL™ 4.0 SF15 and the Asthma Symptoms scale and Treatment Problems scale from the PedsQL™ 3.0 SF22 Asthma Module were sufficiently reliable for group comparisons (alpha ≥ 0.70 across all age groups) in the asthma sample. The PedsQL™ 4.0 SF15 and the PedsQL™ 3.0 SF22 Asthma Module were able to distinguish between children of different clinical status and correlated as expected with measures of productivity and family functioning in the asthma sample. The psychometric properties of the PedsQL™ 4.0 SF15 were generally comparable to those of the original instrument. Conclusion:The Total Score of the PedsQL™ 4.0 SF15 and the Asthma Symptoms scale of the PedsQL™ 3.0 SF22 Asthma Module demonstrated the best reliability and validity and should be suitable for group-level comparisons of generic and asthma-specific HRQoL in clinical research studies of children with asthma.

Review: Electronic Health Records and the Reliability and Validity of Quality Measures: A Review of the Literature

Previous reviews of research on electronic health record (EHR) data quality have not focused on the needs of quality measurement. The authors reviewed empirical studies of EHR data quality, published from January 2004, with an emphasis on data attributes relevant to quality measurement. Many of the 35 studies reviewed examined multiple aspects of data quality. Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging. Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. Finally, factors associated with poor or variability in data quality need to be better understood and effective interventions developed.

“e-Iatrogenesis”: The Most Critical Unintended Consequence of CPOE and other HIT

In the September/October 2006 issues of JAMIA, Campbell et al.s article “Types of Unintended Consequences Related to Computerized Provider Order Entry”1 lays out an innovative and comprehensive framework for categorizing the things that can go wrong when CPOE systems are implemented. We commend the authors for helping to move forward our collective understanding of this important area. As CPOE and other components of health information technology (HIT) logarithmically diffuse across the U.S. health care system, it is clear they will eventually become the standard all-encompassing platform for the delivery of medical care. As has been the case for all previous medical and non-medical technologies, HIT dissemination carries with it both positive and negative consequences. All nine types of “unintended consequences” outlined by Campbell et al. in their article should be …

Residential segregation and disparities in health care services utilization

Using data from the 2006 Medical Expenditure Panel Survey and the 2000 Census, the authors explored whether race/ethnic disparities in health care use were associated with residential segregation. They used five measures of health care use: office-based physician visits, outpatient department physician visits, visits to nurses and physician’s assistants, visits to other health professionals, and having a usual source of care. For each individual, the authors controlled for age, gender, marital status, insurance status, income, educational attainment, employment status, region, and health status. The authors used the racial–ethnic composition of the zip code to control for residential segregation. The findings suggest that disparities in health care utilization are related to both individuals’ racial and ethnic identity and the racial and ethnic composition of their communities. Therefore, efforts to improve access to health care services and to eliminate health care disparities for African Americans and Hispanics should not only focus on individual-level factors but also include community-level factors.

Evaluation of a Quality Improvement Collaborative in Asthma Care: Does it Improve Processes and Outcomes of Care?

PURPOSE We wanted to examine whether a collaborative to improve asthma care influences process and outcomes of care in asthmatic adults. METHOD We undertook a preintervention-postintervention evaluation of 185 patients in 6 intervention clinics and 3 matched control sites that participated in the Institute for Healthcare Improvement Breakthrough Series (BTS) Collaborative for asthma care. The intervention consisted of 3, 2-day educational sessions for teams dispatched by participating sites, which were followed by 3 action periods during the course of a year. RESULTS Overall process of asthma care improved significantly in the intervention compared with the control group (change of 10% vs 1%, P = .003). Patients in the intervention group were more likely to attend educational sessions (20% vs 5%, P = .03). Having a written action plan, setting goals, monitoring peak flow rates, and using long-term asthma medications increased between 2% and 19% (not significant), but asthma-related knowledge was unchanged for the 2 groups. Patients in the BTS Collaborative were significantly more likely to be satisfied with clinician and lay educator communication (62% vs 39%, P = .02). Health-related quality of life, asthma-specific quality of life, number of bed days caused by asthma-related illness, and acute care service use were not significantly different between the 2 groups. CONCLUSIONS The intervention was associated with improved process-of-care measures that have been linked with better outcomes. Patients benefited through increased satisfaction with communication. Follow-up of patients who participated in the intervention may have been too brief to be able to detect significant improvement in health-related outcomes.

Assessment of Children's Health-Related Quality of Life in the United States With a Multidimensional Index

OBJECTIVE. Using nationally representative data, we examined biological, medical system, and sociodemographic factors that are associated with health-related quality of life as measured by a multidimensional index that accounts for a wide range of child health domains. METHODS. Children aged ≥6 years (N = 69031) were drawn from the 2003/2004 National Survey of Childrens Health. A random 25% sample was used to create a 12-item index of health-related quality of life with a range of 0 to 100, based on the conceptual framework of the Child Health and Illness Profile. Bivariate and multivariable regression analyses were conducted to identify the unadjusted and independent associations of key biological, medical system, and sociodemographic variables with health-related quality of life. RESULTS. The index mean was 72.3 (SD: 14.5), median value was 73.7, and range was 11.1 to 99.9. Only 0.2% of children had a score at the ceiling. In multivariable regression analysis, the following variables were independently associated with lower health-related quality of life: biological factors (greater disease burden, severe asthma, and overweight status); medical system factors (unmet medical needs, lack of a regular health care provider, Medicaid insurance, or being uninsured previously during the year); and sociodemographic factors (older age groups, lower family education, single-mother family, having a smoker in the household, black race, and poverty). CONCLUSIONS. Health-related quality of life in the United States is poorest for children and youth in lower socioeconomic status groups, those with access barriers, adolescents compared with children, and individuals with medical conditions. A multidimensional health-related quality-of-life index is an alternative to conventional measures (eg, mortality) for national monitoring of child health.

The Interview Mode Effect on the Center for Epidemiological Studies Depression (ces-d) Scale: An Item Response Theory Analysis

BackgroundEvidence of a mode effect has raised concerns about the comparability and validity of self- versus interviewer-administered versions of the Center for Epidemiological Studies Depression (CES-D) scale. Response anonymity has been proposed to explain this effect. However, the factors that contribute to this mode effect are not well understood. We used item response theory (IRT) to examine the nature of the CES-D mode effect. MethodsA sample of depressed primary care patients from the Partners-in-Care Study were randomized to receive either a phone interview (N = 139) or a mail survey (N = 139) of the CES-D. We used likelihood ratio tests to identify differentially functioning items in the 2 groups. Category response curves are used to describe these effects. ResultsTwelve items manifested differential functioning. Category response curves consistently indicate that phone respondents had a lower probability of endorsing the third of 4 response categories than mail respondents, suggesting a possible cognitive effect. ConclusionAlthough response anonymity could be important in mode effects observed in surveys of sensitive topics, cognitive factors appear more important to the mode effect in the CES-D.

Retention of court-referred youths in residential treatment programs: client characteristics and treatment process effects.

The juvenile justice system relies heavily on residential treatment services for adolescents. Because treatment dropout limits the likely effectiveness of these services, in this study we examine the client and program characteristics associated with program retention among a sample of adolescent probationers referred to residential rehabilitation by the Juvenile Court in Los Angeles. Participants in the present study (n=291) are a subset of those in the Adolescent Outcomes Project, conducted within RANDs Drug Policy Research Center, to examine the outcomes of youths entering treatment at seven residential treatment programs. Three months after a preadmission interview, youths were asked about their perceptions of counselors at the program, other residents, and their feelings of safety in the program. In addition, they were asked whether they needed and had received various services (e.g., job training, legal advice, family counseling). Results of a multivariate survival analysis revealed that pretreatment characteristics including motivation and substance use severity, as well as treatment program factors including safety, and perceived over- and underprovision of services, contribute significantly to the prediction of retention. Pretreatment environmental risk factors and ratings of program counselor and resident support were marginally significant. These results imply that changes in adolescent residential program delivery may serve to increase retention rates, thus improving long-term outcomes.

Residential segregation, geographic proximity and type of services used: Evidence for racial/ethnic disparities in mental health

Residential characteristics influence opportunities, life chances and access to health services in the United States but what role does residential segregation play in differential access and mental health service utilization? We explore this issue using secondary data from the 2006 Medical Expenditure Panel Survey, 2006 American Medical Association Area Research File and the 2000 Census. Our sample included 9737 whites, 3362 African Americans and 5053 Latinos living in Metropolitan Statistical Areas. Using logistic regression techniques, results show respondents high on Latino isolation and Latino centralization resided in psychiatrist shortage areas whereas respondents high on African American concentration had access to psychiatrists in their neighborhoods. Predominant race of neighborhood was associated with the type of mental health professional used where respondents in majority African American neighborhoods were treated by non-psychiatrists and general doctors whereas respondents in majority Latino neighborhoods saw general doctors. Respondents high on Latino Isolation and Latino Centralization were more likely to utilize non-psychiatrists. These findings suggest that living in segregated neighborhoods influence access and utilization of mental health services differently for race/ethnic groups which contradicts findings that suggest living in ethnic enclaves is beneficial to health.

Measurement Equivalence in ADL and IADL Difficulty Across International Surveys of Aging: Findings From the HRS, SHARE, and ELSA

OBJECTIVE To examine the measurement equivalence of items on disability across three international surveys of aging. METHOD Data for persons aged 65 and older were drawn from the Health and Retirement Survey (HRS, n = 10,905), English Longitudinal Study of Aging (ELSA, n = 5,437), and Survey of Health, Ageing and Retirement in Europe (SHARE, n = 13,408). Differential item functioning (DIF) was assessed using item response theory (IRT) methods for activities of daily living (ADL) and instrumental activities of daily living (IADL) items. RESULTS HRS and SHARE exhibited measurement equivalence, but 6 of 11 items in ELSA demonstrated meaningful DIF. At the scale level, this item-level DIF affected scores reflecting greater disability. IRT methods also spread out score distributions and shifted scores higher (toward greater disability). Results for mean disability differences by demographic characteristics, using original and DIF-adjusted scores, were the same overall but differed for some subgroup comparisons involving ELSA. DISCUSSION Testing and adjusting for DIF is one means of minimizing measurement error in cross-national survey comparisons. IRT methods were used to evaluate potential measurement bias in disability comparisons across three international surveys of aging. The analysis also suggested DIF was mitigated for scales including both ADL and IADL and that summary indexes (counts of limitations) likely underestimate mean disability in these international populations.