Steven Hanna

AGREE II: advancing guideline development, reporting and evaluation in health care

Clinical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions,[1][1],[2][2] frequently vary widely in quality.[3][3],[4][4] A strategy was needed to differentiate among guidelines and ensure that those

Patterns of participation in recreational and leisure activities among children with complex physical disabilities

Children with physical disabilities are at increased risk of limitations to participation in everyday activities. This study describes research examining the participation of children in day‐to‐day formal and informal activities (excluding mandated academic schooling). Using the Childrens Assessment of Participation and Enjoyment (CAPE) measure, data on participation patterns were collected from 427 children (229 males, 198 females; mean age 10y [SD 2y 4mo]; range 6–14y) with physical limitations and from their families. The primary types of physical disability in the sample included cerebral palsy, spina bifida, acquired brain injury, and musculoskeletal limitations. Findings indicate a broad range of diversity and intensity of participation, with proportionately greater involvement in informal rather than formal activities. Significant differences in participation and enjoyment were found between males and females, and for children more than 12 years of age. Childrens participation was less diverse in families reporting lower income, single‐parent status, and lower respondent parent education. These findings provide a foundation for an improved understanding of the participation of children with physical disabilities, which can assist families and service providers in planning activities that fit with their childs preferences and ensure active participation.

Stability and Decline in Gross Motor Function among Children and Youth with Cerebral Palsy Aged 2 to 21 Years

This paper reports the construction of gross motor development curves for children and youth with cerebral palsy (CP) in order to assess whether function is lost during adolescence. We followed children previously enrolled in a prospective longitudinal cohort study for an additional 4 years, as they entered adolescence and young adulthood. The resulting longitudinal dataset comprised 3455 observations of 657 children with CP (369 males, 288 females), assessed up to 10 times, at ages ranging from 16 months to 21 years. Motor function was assessed using the 66‐item Gross Motor Function Measure (GMFM‐66). Participants were classified using the Gross Motor Function Classification System (GMFCS). We assessed the loss of function in adolescence by contrasting a model of function that assumes no loss with a model that allows for a peak and subsequent decline. We found no evidence of functional decline, on average, for children in GMFCS Levels I and II. However, in Levels III, IV, and V, average GMFM‐66 was estimated to peak at ages 7 years 11 months, 6 years 11 months, and 6 years 11 months respectively, before declining by 4.7, 7.8, and 6.4 GMFM‐66 points, in Levels III, IV, and V respectively, as these adolescents became young adults. We show that these declines are clinically significant.

Development of the AGREE II, part 1: performance, usefulness and areas for improvement

Background: We undertook research to improve the AGREE instrument, a tool used to evaluate guidelines. We tested a new seven-point scale, evaluated the usefulness of the original items in the instrument, investigated evidence to support shorter, tailored versions of the tool, and identified areas for improvement. Method: We report on one component of a larger study that used a mixed design with four factors (user type, clinical topic, guideline and condition). For the analysis reported in this article, we asked participants to read a guideline and use the AGREE items to evaluate it based on a seven-point scale, to complete three outcome measures related to adoption of the guideline, and to provide feedback on the instrument’s usefulness and how to improve it. Results: Guideline developers gave lower-quality ratings than did clinicians or policy-makers. Five of six domains were significant predictors of participants’ outcome measures (p < 0.05). All domains and items were rated as useful by stakeholders (mean scores > 4.0) with no significant differences by user type (p > 0.05). Internal consistency ranged between 0.64 and 0.89. Inter-rater reliability was satisfactory. We received feedback on how to improve the instrument. Interpretation: Quality ratings of the AGREE domains were significant predictors of outcome measures associated with guideline adoption: guideline endorsements, overall intentions to use guidelines, and overall quality of guidelines. All AGREE items were assessed as useful in determining whether a participant would use a guideline. No clusters of items were found more useful by some users than others. The measurement properties of the seven-point scale were promising. These data contributed to the refinements and release of the AGREE II.

A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies

ContextSignificant resources and time are invested in the production of research knowledge. The primary objective of this randomized controlled trial was to evaluate the effectiveness of three knowledge translation and exchange strategies in the incorporation of research evidence into public health policies and programs.MethodsThis trial was conducted with a national sample of public health departments in Canada from 2004 to 2006. The three interventions, implemented over one year in 2005, included access to an online registry of research evidence; tailored messaging; and a knowledge broker. The primary outcome assessed the extent to which research evidence was used in a recent program decision, and the secondary outcome measured the change in the sum of evidence-informed healthy body weight promotion policies or programs being delivered at health departments. Mixed-effects models were used to test the hypotheses.FindingsOne hundred and eight of 141 (77%) health departments participated in this study. No significant effect of the intervention was observed for primary outcome (p < 0.45). However, for public health policies and programs (HPPs), a significant effect of the intervention was observed only for tailored, targeted messages (p < 0.01). The treatment effect was moderated by organizational research culture (e.g., value placed on research evidence in decision making).ConclusionThe results of this study suggest that under certain conditions tailored, targeted messages are more effective than knowledge brokering and access to an online registry of research evidence. Greater emphasis on the identification of organizational factors is needed in order to implement strategies that best meet the needs of individual organizations.Trial RegistrationThe trial registration number and title are as follows: ISRCTN35240937 -- Is a knowledge broker more effective than other strategies in promoting evidence-based physical activity and healthy body weight programming?

Development of the AGREE II, part 2: assessment of validity of items and tools to support application.

Background: We established a program of research to improve the development, reporting and evaluation of practice guidelines. We assessed the construct validity of the items and user’s manual in the β version of the AGREE II. Methods: We designed guideline excerpts reflecting high-and low-quality guideline content for 21 of the 23 items in the tool. We designed two study packages so that one low-quality and one high-quality version of each item were randomly assigned to each package. We randomly assigned 30 participants to one of the two packages. Participants reviewed and rated the guideline content according to the instructions of the user’s manual and completed a survey assessing the manual. Results: In all cases, content designed to be of high quality was rated higher than low-quality content; in 18 of 21 cases, the differences were significant (p < 0.05). The manual was rated by participants as appropriate, easy to use, and helpful in differentiating guidelines of varying quality, with all scores above the mid-point of the seven-point scale. Considerable feedback was offered on how the items and manual of the β-AGREE II could be improved. Interpretation: The validity of the items was established and the user’s manual was rated as highly useful by users. We used these results and those of our study presented in part 1 to modify the items and user’s manual. We recommend AGREE II (available at www.agreetrust.org) as the revised standard for guideline development, reporting and evaluation.

Predictors of the Leisure and Recreation Participation of Children With Physical Disabilities: A Structural Equation Modeling Analysis

Structural equation modeling was used to test a theoretically based model of environmental, family, and child factors as determinants of the leisure and recreation participation of children with physical disabilities. Participants were 427 families and children (229 boys and 198 girls) with physical functional limitations, in 3 age groups (6-8, 9-11, and 12-14 years). Data were collected via home interviews and self-administered standardized questionnaires. The significant direct predictors of childrens participation intensity in both formal and informal activities were child functional ability, family participation in social and recreational activities, and child preferences for formal and informal activities. Family cohesion, unsupportive environments, and supportive relationships for the child had significant indirect effects on participation. The findings indicate the vital role played by families and the importance of multifaceted approaches to supporting participation.

Health status of school-aged children with cerebral palsy: information from a population-based sample.

In this study parents’systematic accounts of the health status of 408 school‐aged children with cerebral palsy (CP) are reported (221 males, 187 females; mean age 8 years 5 months, SD 1 year 11 months; range 5 to 13 years), as are relations between severity of functional motor impairment and eight functional health status domains. Data were collected as part of a longitudinal study of the motor development of a population‐based, stratified, random sample of children with CP from across Ontario, Canada. The Gross Motor Function Classification System (GMFCS) was used to classify severity of CP and functional health status was described with the eight‐level Health Utilities Index ‐ Mark 3. Rates of functional limitations in Mobility, Dexterity, Speech, and Vision were statistically significantly associated with GMFCS levels (all p<0.01), with correlation values (tau‐b) of 0.82,0.58,0.46, and 0.36, respectively. Functional limitations in hearing (tau‐b=0.16; p=0.04) and cognition (tau‐b=0.27;p<0.01) were both statistically significantly associated with GMFCS levels, though correlations were low. Neither emotion (tau‐b=0.03;p=0.24) nor pain (tau‐b=0.07;p=0.37) was associated with degree of functional limitation as described by the GMFCS. Clinical and epidemiological implications of findings are discussed.

Participation of children with physical disabilities: relationships with diagnosis, physical function, and demographic variables

The primary goal of occupational therapy intervention for children with disabilities is enabling participation in the daily activities of childhood. The World Health Organization conceptualizes chronic health conditions and disability as two distinct aspects of health, with the primary concern on the level of health condition being with diagnosis rather than function. Participation, within the International Classification of Functioning, Disability and Health (ICF), is characterized by the interactions between a child, its family, and other personal and environmental factors. Few studies have examined the relationships between diagnosis, function, and participation in children with disabilities. Using the results of a study of the participation of 427 children with physical disabilities in activities outside mandated school, the authors examined the relative influence of diagnostic category on participation. When adjusted for age, sex, and physical function, diagnostic category does not significantly affect the intensity and diversity of participation. The results of this study confirm and highlight the limitations in using diagnostic information in childrens rehabilitation in the absence of other information. Participation is a complex phenomenon so it is important to understand more clearly how personal, environmental, and family factors influence the childs involvement in everyday activities. There is a need to move beyond diagnosis to focus on other personal and environmental factors as major predictors of participation.

Effect of environmental setting on mobility methods of children with cerebral palsy.

The aim of this study was to: (1) describe the usual mobility methods of children with cerebral palsy (CP) at home, school, and outdoors or in the community and (2) examine whether children with CP are more dependent on adult assistance for mobility in certain settings. The participants were a stratified random sample of 636 children with CP (355 males and 281 females; 2 to 12 years of age, mean 6.8 years SD 2.7), receiving rehabilitation services in Ontario, Canada. Children were grouped by age and Gross Motor Function Classification System (GMFCS) level. Among the five levels of the GMFCS, there were 185 children classified at level I, 81 children at level II, 113 children at level III, 132 children at level IV, and 125 children at level V. Information on childrens usual mobility was obtained by parent report. The results of logistic regression indicated that compared with the school setting, children were more dependent on adult assistance for mobility when outdoors/in the community and less dependent at home. The majority of children aged from 4 to 12 years at levels III to V used wheelchair mobility at school and outdoors or in the community, however, only a small percentage self-propelled their wheelchair or used powered mobility. Of the children aged 4 to 12 years at level V, 39% were carried at home. The findings suggest that environmental setting is an important consideration for assessment and intervention to improve mobility of children with CP. For children who do not walk, attention should be given to the needs of caregivers and factors that are important for successful powered mobility.