Mark B. Parshall

Getting the Focus and the Group: Enhancing Analytical Rigor in Focus Group Research:

In the literature on focus groups, far more attention has been devoted to how groups are organized and conducted than to issues of analysis. Although exploitation of group dynamics is touted as a virtue of focus groups, there is very little guidance in the literature with respect to how differences between group and individual discourse impact the analysis and interpretation of focus group data. In this article, the authors describe analytical challenges inherent in the interpretation of focus group data and suggest approaches for enhancing the rigor of analysis and the reliability and validity of focus group findings.

An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea

BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

Acute Heart Failure Syndromes: Emergency Department Presentation, Treatment, and Disposition: Current Approaches and Future Aims A Scientific Statement From the American Heart Association

With a prevalence of 5 800 000 (≈2% of the entire populace) in 2009 and an estimated yearly incidence of 550 000, the burden of heart failure (HF) in the United States is tremendous.1 Although HF is largely a condition defined by chronic debility, virtually all patients experience, at some point, acute symptoms that trigger a visit to the emergency department (ED). These symptoms may vary in severity but, for the most part, they necessitate early intervention, often with intravenous medication and, less frequently, respiratory support. As shown by combined data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), this is a common occurrence; there are nearly 658 000 annual ED encounters primarily for acute HF in the United States—a figure that represents almost 20% of the total HF-specific ambulatory care delivered each year.2 It is noteworthy that few settings other than the ED can offer open access to treatment or provide the level and intensity of care required to effectively manage the acute phase of decompensation, also referred to as episodes of acute heart failure syndromes (AHFS). Nearly 80% of those treated for AHFS in the ED are ultimately admitted to the hospital and, accordingly, the ED serves as the principal portal of entry for hospitalized AHFS patients.34 The ED therefore plays a unique role in the continuum of AHFS treatment, functioning for most patients as the initial point of definitive healthcare contact, the location where primary stabilization is achieved, and the site where disposition decisions are generally made.4 Whereas the ED is a pivotal place for the vast majority of hospitalized patients with acute HF, the evidence base on which this foundation of acute care is built is astonishingly thin. The purpose of this …

Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research

There is growing awareness that dyspnoea, like pain, is a multidimensional experience, but measurement instruments have not kept pace. The Multidimensional Dyspnea Profile (MDP) assesses overall breathing discomfort, sensory qualities, and emotional responses in laboratory and clinical settings. Here we provide the MDP, review published evidence regarding its measurement properties and discuss its use and interpretation. The MDP assesses dyspnoea during a specific time or a particular activity (focus period) and is designed to examine individual items that are theoretically aligned with separate mechanisms. In contrast, other multidimensional dyspnoea scales assess recalled recent dyspnoea over a period of days using aggregate scores. Previous psychophysical and psychometric studies using the MDP show that: 1) subjects exposed to different laboratory stimuli could discriminate between air hunger and work/effort sensation, and found air hunger more unpleasant; 2) the MDP immediate unpleasantness scale (A1) was convergent with common dyspnoea scales; 3) in emergency department patients, two domains were distinguished (immediate perception, emotional response); 4) test–retest reliability over hours was high; 5) the instrument responded to opioid treatment of experimental dyspnoea and to clinical improvement; 6) convergent validity with common instruments was good; and 7) items responded differently from one another as predicted for multiple dimensions. The Multidimensional Dyspnea Profile provides a unified, reliable instrument for both clinical and laboratory research http://ow.ly/Ix8ic

Reliability and Validity of the Multidimensional Dyspnea Profile

BACKGROUND Most measures of dyspnea assess a single aspect (intensity or distress) of the symptom. We developed the Multidimensional Dyspnea Profile (MDP) to measure qualities and intensities of the sensory dimension and components of the affective dimension. The MDP is not indexed to a particular activity and can be applied at rest, during exertion, or during clinical care. We report on the development and testing of the MDP in patients with a variety of acute and chronic cardiopulmonary conditions. METHODS One hundred fifty-one adults admitted to the ED with breathing symptoms completed the MDP three times in the ED, twice at least 1 h apart (T1, T2), and near discharge from the ED (T3). Measures were repeated in 68 patients twice in a follow-up session 4 to 6 weeks later (T4-T5). The ED sample was 56% men with a mean age of 53 ± 15 years; the follow-up sample was similar. RESULTS Factor analysis resulted in a two-factor solution with a total explained variance of 63%, 74%, and 72% at T1, T2, and T3, respectively. One domain related to primary sensory qualities and immediate unpleasantness, and the second encompassed emotional response. For the two domains, Cronbach α ranged from 0.82 to 0.95, and the intraclass correlation coefficient ranged from 0.91 to 0.98. Repeated-measures analysis was significant for change (T1, T3, T4), showing responsiveness to change in MDP domains with treatment (F([2,66]) = 19.67, P > .001). CONCLUSIONS These analyses support the reliability, validity, and responsiveness to clinical change of the MDP with two domains in an acute care and follow-up setting.

Test–retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study

BackgroundDyspnea is among the most common reasons for emergency department (ED) visits by patients with cardiopulmonary disease who are commonly asked to recall the symptoms that prompted them to come to the ED. The reliability of recalled dyspnea has not been systematically investigated in ED patients.MethodsPatients with chronic or acute cardiopulmonary conditions who came to the ED with dyspnea (N = 154) completed the Multidimensional Dyspnea Profile (MDP) several times during the visit and in a follow-up visit 4 to 6 weeks later (n = 68). The MDP has 12 items with numerical ratings of intensity, unpleasantness, sensory qualities, and emotions associated with how breathing felt when participants decided to come to the ED (recall MDP) or at the time of administration (“now” MDP). The recall MDP was administered twice in the ED and once during the follow-up visit. Principal components analysis (PCA) with varimax rotation was used to assess domain structure of the recall MDP. Internal consistency reliability was assessed with Cronbach’s alpha. Test–retest reliability was assessed with intraclass correlation coefficients (ICCs) for absolute agreement for individual items and domains.ResultsPCA of the recall MDP was consistent with two domains (Immediate Perception, 7 items, Cronbach’s alpha = .89 to .94; Emotional Response, 5 items; Cronbach’s alpha = .81 to .85). Test–retest ICCs for the recall MDP during the ED visit ranged from .70 to .87 for individual items and were .93 and .94 for the Immediate Perception and Emotional Response domains. ICCs were much lower for the interval between the ED visit and follow-up, both for individual items (.28 to .66) and for the Immediate Perception and Emotional Response domains (.72 and .78, respectively).ConclusionsDuring an ED visit, recall MDP ratings of dyspnea at the time participants decided to seek care in the ED are reliable and sufficiently stable, both for individual items and the two domains, that a time lag between arrival and questionnaire administration does not critically affect recall of perceptual and emotional characteristics immediately prior to the visit. However, test–retest reliability of recall over a 4- to 6-week interval is poor for individual items and significantly attenuated for the two domains.

Predictive validity of short-form health survey [36 items] scales for chronic obstructive pulmonary disease exacerbation

OBJECTIVE We evaluated whether any short-form health survey [36 items] (SF-36) domain scale or component scores would predict exacerbations of chronic obstructive pulmonary disease (COPD) during a 1-year period. METHODS In this prospective longitudinal study, the sample included 127 patients with spirometrically confirmed COPD who completed baseline assessments and > 80% of daily diary card entries during 1 year. Exacerbations were defined as >or= 2 days of worsened respiratory symptoms or as new use of corticosteroids or antibiotics. The predictive validity of baseline SF-36 scores was assessed by receiver operating characteristic analysis. RESULTS The general health, mental health, and role-physical domain scales and mental component summary score discriminated between those with any versus no exacerbations. The general health domain score was the best predictor overall based on multiple criteria. CONCLUSIONS The SF-36 general health scale is potentially a reliable and valid predictor of exacerbation for up to 1 year in community-residing patients with COPD.

The need to research refractory breathlessness.

The joint American Thoracic Society (ATS)/European Respiratory Society (ERS) statement “An official American Thoracic Society/European Respiratory Society statement: research questions in COPD” by Celli et al. [1] is a timely summary of the current evidence and the questions that arise directly from where that evidence reaches its limits. Such documents are crucial in framing research strategies for researchers and research funders. High-quality research is needed to improve quality of life for people with chronic refractory breathlessness in COPD http://ow.ly/Q2GDY

Ethnic Disparities in Emergency Severity Index Scores among U.S. Veteran’s Affairs Emergency Department Patients

Background The goal of these analyses was to determine whether there were systematic differences in Emergency Severity Index (ESI) scores, which are intended to determine priority of treatment and anticipate resource needs, across categories of race and ethnicity, after accounting for patient-presenting vital signs and examiner characteristics, and whether these differences varied among male and female Veterans Affairs (VA) ED patients. Methods and Findings We used a large national database of electronic medical records of ED patients from twenty-two U.S. Department of Veterans Affairs ED stations to determine whether ESI assignments differ systematically by race or ethnicity. Multi-level, random effects linear modeling was used to control for demographic characteristics and patient’s vital signs (heart rate, respiratory rate, and pain level), as well as age, gender, and experience of triage nurses. The dataset included 129,991 VA patients presenting for emergency care between 2008 and 2012 (91% males; 61% non-Hispanic White, 28% Black, 7% Hispanic, 2% Asian, <1% American Indian/Alaska Native, 1% mixed ethnicity) and 774 nurses for a total of 359,642 patient/examiner encounters. Approximately 13% of the variance in ESI scores was due to patient characteristics and 21% was due to the nurse characteristics. After controlling for characteristics of nurses and patients, Black patients were assigned less urgent ESI scores than White patients, and this effect was more prominent for Black males compared with Black females. A similar interaction was found for Hispanic males. It remains unclear how these results may generalize to EDs and patient populations outside of the U.S. VA Health Care system. Conclusions The findings suggest the possibility that subgroups of VA patients receive different ESI ratings in triage, which may have cascading, downstream consequences for patient treatment quality, satisfaction with care, and trust in the health equity of emergency care.

Patient Ethnicity Affects Triage Assessments and Patient Prioritization in U.S. Department of Veterans Affairs Emergency Departments.

AbstractEthnic minority patients receive lower priority triage assignments in Veterans Affairs (VA) emergency departments (EDs) compared to White patients, but it is currently unknown whether this disparity arises from generalized biases across the triage assessment process or from differences in how objective and/or subjective institution-level or person-level information is incorporated into the triage assessment process, thus contributing to disparate treatment.The VA database of electronic medical records of patients who presented to the VA ED from 2008 to 2012 was used to measure patient ethnicity, self-reported pain intensity (PI) levels, heart rate (HR), respiratory rate (RR), and nurse-provided triage assignment, the Emergency Severity Index (ESI) score. Multilevel, random effects linear modeling was used to control for demographic and clinical characteristics of patients as well as age, gender, and experience of triage nurses.A total of 359,642 patient/provider encounters between 129,991 VA patients and 774 nurses were included in the study. Patients were 61% non-Hispanic White [NHW], 28% African-American, 7% Hispanic, 2% Asian-American, <1% American Indian/Alaska Native, and 1% mixed ethnicity. After controlling for demographic characteristics of nurses and patients, African-American, Hispanic, and mixed-ethnicity patients reported higher average PI scores but lower HRs and RRs than NHW patients. NHW patients received higher priority ESI ratings with lower PI when compared against African-American patients. NHW patients with low to moderate HRs also received higher priority ESI scoring than African-American, Hispanic, Asian-American, and Mixed-ethnicity patients; however, when HR was high NHWs received lower priority ESI ratings than each of the minority groups (except for African-Americans).This study provides evidence for systemic differences in how patients’ vital signs are applied for determining ESI scores for different ethnic groups. Additional prospective research will be needed to determine how this specific person-level mechanism affects healthcare quality and outcomes.