William B. Carter

The sickness impact profile : development and final revision of a health status measure.

The final development of the Sickness Impact Profile (SIP), a behaviorally based measure of health status, is presented. A large field trial on a random sample of prepaid group practice enrollees and smaller trials on samples of patients with hyperthyroidism, rheumatoid arthritis and hip replacements were undertaken to assess reliability and validity of the SIP and provide data for category and item analyses. Test-retest reliability (r = 0.92) and internal consistency (r = 0.94) were high. Convergent and discriminant validity was evaluated using the multitrait–multimethod technique. Clinical validity was assessed by determining the relationship between clinical measures of disease and the SIP scores. The relationship between the SIP and criterion measures were moderate to high and in the direction hypotheszed. A technique for describing and assessing similarities and differences among groups was developed using profile and pattern analysis. The final SIP contains 136 items in 12 categories. Overall, category, and dimension scores may be calculated.

Screening for Depression in Well Older Adults: Evaluation of a Short Form of the CES-D

We derived and tested a short form of the Center for Epidemiologic Studies Depression Scale (CES-D) for reliability and validity among a sample of well older adults in a large Health Maintenance Organization. The 10-item screening questionnaire, the CESD-10, showed good predictive accuracy when compared to the full-length 20-item version of the CES-D (kappa = .97, P < .001). Cutoff scores for depressive symptoms were > or = 16 for the full-length questionnaire and > or = 10 for the 10-item version. We discuss other potential cutoff values. The CESD-10 showed an expected positive correlation with poorer health status scores (r = .37) and a strong negative correlation with positive affect (r = -.63). Retest correlations for the CESD-10 were comparable to those in other studies (r = .71). We administered the CESD-10 again after 12 months, and scores were stable with strong correlation of r = .59.

Problems and prospects for health services research on provider-patient communication.

The effectiveness of medical practice is largely dependent on the quality of provider-patient communication. Inputs to the provider-patient encounter include prior experience with medical care, patient objectives for the visit, patient age, type of medical problem, the number of patient concerns, and characteristics of the physicians practice setting. Outcomes linked to the communication process include patient knowledge, provider-patient congruence on problems or recommendations, patient satisfaction, patient compliance with provider recommendations, and resolution of patient concerns or symptoms. The development of interactional analysis systems for the description of provider-patient communication processes in medical encounters should permit reasonably detailed descriptive research on these phenomena. Among the problems in this area have been the lack of a theoretical base for taxonomic categories of behavior, overlapping categories, the arcane nature of many disciplinary taxonomies, and lack of rigorous operational definitions for measurements. Given the rudimentary state of development of this field, descriptive designs for research will continue to be appropriate. However, interactional analysis systems will require additional development so that provider-patient encounters can be understood as episodes of information transfer through several channels. The development of hypotheses for experimental testing of efficacy of clinical strategies for communication requires measurement of pre to postencounter change.

Symptomatic depression in elderly medical outpatients. I. Prevalence, demography, and health service utilization

The authors assessed the prevalence and demography of depressive symptoms, their association with specific chronic diseases, and their influence on health service use in a large sample of elderly men seen in a primary care setting. Twenty‐four percent of respondents reported clinically significant depressive symptoms; the prevalence of major depressive disorders was estimated at 10%, but only 1 % reported receiving mental health treatment by a specialist. Self‐reported marital separation or divorce and physical disability affecting employment were strongly associated with high depression scores, whereas the normative stresses of aging (widowhood, retirement, social isolation) were not. Only chronic lung disease was differentially associated with high depression scores, and this effect was weak. The authors discuss the implications of these findings for the design of comprehensive health services for the elderly with chronic disease.

Emergency CPR instruction via telephone.

We initiated a program of telephone CPR (cardiopulmonary resuscitation) instruction provided by emergency dispatchers to increase the percentage of bystander-initiated CPR for out-of-hospital cardiac arrest. Cardiac arrests in King County, Washington were studied for 20 months before and after the telephone CPR program began. Bystander-initiated CPR increased from 86 of 191 (45 per cent) cardiac arrests before the program to 143 of 255 (56 per cent) cardiac arrests after the program. During the after period, 58 patients received CPR as a result of telephone instruction, 12 of whom were discharged. We estimate that four lives may have been saved by the program. A review of hospital records revealed no excess morbidity in the group of patients receiving dispatcher-assisted CPR.

Outcome-based doctor-patient interaction analysis: II. Identifying effective provider and patient behavior.

Three interactional analysis (IA) systems (Bales’, Roter’s modified Bales and Stiles’ “Verbal response modes”) were used to characterize behavioral elements of provider–patient dialogues of 101 new-patient visits in a general medical clinic. In a previous article,1 the explanatory power of these IA systems was compared. In this article, specific provider and patient behaviors within segments of the encounter (introduction–history, physical examination and conclusion), which were shown to be related to encounter outcomes of knowledge, compliance and satisfaction, were examined. Review of interactional behaviors entering regression analysis with a significant F-to-enter (p≤0.05) and supplementary contextual analyses suggested the importance of several categories of physician and patient behavior. Behaviors manifesting tension bear important and complex relationships to encounter outcomes. For example, patient and physician expressions of tension generally bear strong negative relationships to patient satisfaction, while patient expressions interpreted as tension release are positively related to both satisfaction and compliance. The timing of other behaviors appears to be critical to subsequent outcomes. If patient requests for medication occur early in the encounter, this behavior is positively related to subsequent patient satisfaction. However, if they occur in the concluding segment, a negative relationship results. Finally, several relationships taken together indicate that physician teaching in the concluding segment may be important. While useful observations may emerge from application of currently available IA techniques, the resulting information is best characterized as hypothesis-generating. These IA systems have many limitations, and research is needed to derive more clinically oriented systems that may permit more consistent demonstrations of critical process-outcome relationships.

A cross-cultural comparison of health status values.

The extent to which the values attached to health states are similar in different cultures or social groups is important for understanding health and illness behaviors and for developing standardized health status measures. A cross-cultural study was conducted to compare the health status values obtained in a United States population (Seattle, Washington) with those from another English-speaking culture (London, England) on the Sickness Impact Profile, a standardized measure composed of 136 items. London judges rated the severity of dysfunction described in each item on an equal interval scale using the same methods of scaling and analysis employed in the Seattle study. A regression of English mean item values on US mean values yielded a slope of 1.00 and an intercept of -0.07, indicating that judges gave strikingly similar ratings to most items. Agreement was higher at the more severe end of the dysfunction continuum than at the least severe end, a finding consistent with the notion that what constitutes health is more difficult to define than what constitutes illness. While a universal conception of dysfunction may exist in English-speaking societies, the social and cultural determinants of health status values deserve more systematic study.

Development and implementation of emergency CPR instruction via telephone

We developed a cardiopulmonary resuscitation (CPR) message that can be given via telephone by emergency dispatchers directly to an individual reporting a cardiac arrest. The message was developed and evaluated on the basis of empirical observation of CPR performance of 203 community volunteers during simulated cardiac arrest events. The majority of volunteers were women, aged 30 to 80 years, who had not had previous CPR training. An average of five ventilation and compression cycles were given within five minutes using telephone instruction. We judged the quality of CPR to be comparable to the performance of individuals who have received formal training. The specific words used in the message directly determined adequacy of performance, and resulted in significantly better CPR performance than did impromptu instruction offered by professional dispatchers (P less than or equal to .02).

STRATEGIES FOR IMPROVING AND EXPANDING THE APPLICATION OF HEALTH STATUS MEASURES IN CLINICAL SETTINGS : A RESEARCHER-DEVELOPER VIEWPOINT

Health status instruments may be useful in clinical settings to screen for functional problems, monitor disease progression or therapeutic response, improve doctor-patient communications, assess quality of care, or provide case-mix adjustment for comparing other outcomes between patient groups. However, conceptual, practical, and attitudinal barriers have prevented their wider implementation. Aside from providing more data on how these measures influence the process and outcomes of clinical care, several strategies may help to improve and expand their application. Wider application would be promoted by training health care providers about the methods of health status assessment, their validity, and the available instruments; comparing newer functional measures and older scales with which clinicians are familiar (to make scores more meaningful); providing better data for the selection of instruments; and improving the responsiveness of these questionnaires to clinical changes. If health status measures are used in direct patient care, it is important to determine whether the goal is to screen for functional problems or to monitor patient changes over time. These different purposes may influence the selection of instruments, the types of patients targeted (e.g., based on age or diagnosis), and the frequency of patient assessment. Health status measures must be easily incorporated into the office routine, requiring that they be brief, easy to interpret, and not require complex training or scoring algorithms. In this setting, it may be helpful to provide clinicians not only with functional status scores, but with interpretations and recommendations about management or community resources to consider. The costs of health status measurement and data analysis will probably be borne by third-party payers, who must be persuaded of their utility. When health status measures are used for quality assurance, average scores for groups of patients should be adjusted for disease severity, comorbid conditions, demographic characteristics, socioeconomic status, and baseline health status. Furthermore, the sickest or most vulnerable members of a clinical population may be least able to provide valid health status information because of dementia, frailty, blindness, illiteracy, or inability to speak English. These patients may be of particular interest, and are likely to alter average health status scores for a population, so methods to assure complete ascertainment must be considered.

Novel ITGB4 Mutations in Lethal and Nonlethal Variants of Epidermolysis Bullosa with Pyloric Atresia: Missense versus Nonsense

Epidermolysis bullosa with pyloric atresia (EB-PA), an autosomal recessive genodermatosis, manifests with neonatal cutaneous blistering associated with congenital pyloric atresia. The disease is frequently lethal, but nonlethal cases have also been reported. Expression of the alpha6 beta4 integrin is altered at the dermal-epidermal basement-membrane zone; recently, mutations in the corresponding genes (ITGA6 and ITGB4) have been disclosed in a limited number of patients, premature termination codons in both alleles being characteristic of lethal variants. In this study, we have examined the molecular basis of EB-PA in five families, two of them with lethal and three of them with nonlethal variants of the disease. Mutation analysis disclosed novel lesions in both ITGB4 alleles of each proband. One of the patients with lethal EB-PA was a compound heterozygote for premature termination-codon mutations (C738X/4791delCA), whereas the other patient with a lethal variant was homozygous for a missense mutation involving a cysteine residue (C61Y). The three nonlethal cases had missense mutations in both alleles (C562R/C562R, R1281W/R252C, and R1281W/R1281W). Immunofluorescence staining of skin in two of the nonlethal patients and in one of the lethal cases was positive, yet attenuated, for alpha6 and beta4 integrins. These results confirm that ITGB4 mutations underlie EB-PA and show that missense mutations may lead to nonlethal phenotypes.