William L. Cats-Baril

The North American spine society lumbar spine outcome assessment Instrument: reliability and validity tests.

Study Design A cross‐sectional study of a convenience sample of lumbar spine patients, with a subsample followed for retest reliability. Objectives To assess the instruments reliability, validity, and acceptability to patients. Summary of Background Data Patients with eight diagnoses, four before surgery and four after surgery, were recruited from six orthopedic practices to test the questionnaire. Methods One hundred sixty‐seven patients were approached through the physicians office, yielding 136 usable questionnaires (84%) and 24‐hour retests on 64 patients. Results The questionnaire took about 20 minutes to administer and was acceptable to patients. The lumbar spine pain and disability and neurogenic symptoms subscales discriminated among patient groups as hypothesized and showed significantly better scores for patients independently judged successful by their physicians after surgery. Test‐retest reliability and internal reliability were high (range, 0.85‐0.97). Sample sizes of 20‐37 would be needed to detect a 20% difference between two groups (alpha, 0.05; beta, 0.20). Conclusions The questionnaire should be considered for monitoring of individual patients progress in treatment and for clinical trials.

Identifying patients at risk of becoming disabled because of low-back pain : the Vermont rehabilitation engineering center predictive model

A predictive risk model of low-back pain (LBP) disability was developed by a panel of six experts in the fields of chronic pain and disability. It comprised 28 factors organized into eight categories: job, psychosocial, injury, diagnostic, demographic, medical history, health behaviors, and anthropometric characteristics and was administered as a 15-minute written questionnaire. The model was tested prospectively on 250 patients (age range, 18-65 years) attending two secondary-care low-back clinics. Disability, as predicted by the model, was compared with 1) actual disability assessed 3 and 6 months later; 2) predictions of disability made by the attending physicians; and 3) predictions obtained from an empirically derived model. These results showed that 1) the expert-generated risk model had a predictive accuracy of 89% and did better in predicting disability than the physicians across all samples and 2) the empirically weighted model did best of all (91% predictive accuracy), suggesting that the expert model used appropriate factors but that the weights assigned to these factors by the panel of experts could be improved.

The validity of the SRS-22 instrument in an adult spinal deformity population compared with the Oswestry and SF-12: a study of response distribution, concurrent validity, internal consistency, and reliability.

Study Design. Prospective analysis of a consecutive cohort of adult spinal deformity patients queried over a 12-month period. Objectives. To assess the SRS-22 instrument compared with the SF-12 and Oswestry. Summary of Background Data. Very few reports in the literature have applied the SRS-22 to adult spinal deformity patients. Methods. Consecutive adult spinal deformity patients were applied the SRS-22, SF-12, and Oswestry. Four analyses were done: 1) floor/ceiling effect; 2) Pearson’s correlation coefficients between the SRS-22, SF-12, and Oswestry; 3) Cronbach’s alpha analysis for internal consistency within the SRS-22; and 4) test/retest. Results. Floor/ceiling range for the SRS-22 compared favorably with the SF-12 and Oswestry. The Pearson’s coefficients correlating the two questionnaires relative to the SRS-22 were > 0.7. The Cronbach’s alpha within each domain for the SRS-22 were > 0.7, except for pain (0.67). Test/retest correlation coefficients ranged from 0.84 to 0.95 for the subscales. Conclusions. The SRS-22 is a disease-specific instrument with the capacity to demonstrate change in health status more effectively than the SF-12 and in more domains than the Oswestry. The SRS-22 showed high criterion validity with the SF-12 and Oswestry based on Pearson’s coefficients. High Cronbach’s alpha scores suggested a high internal consistency within each domain of the SRS-22, except for pain (0.67). Test/retest reliability was excellent.

Managing Information Technology Projects in the Public Sector

Public sector organizations are being scrutinized and held accountable for their use of funds, now more than ever. Further, taxpayers are increasingly comparing the public sector to the private sector, demanding better customer service. As an added dimension, public organizations find themselves spending more on information technology (IT), even as their budgets come under pressure. In a situation similar to the private sector, public organizations find a large number of IT projects that are over budget, behind schedule, and producing fewer benefits than expected. The trend in computing is to migrate from mainframe-based systems to smaller computer platforms, frequently employing Graphical User Interface (GUI) software. Such migrations are proving difficult for private sector and public sector managers alike. The problem is more acute in the public sector, however, because the bulk of the IT management experience in the public sector is with mainframe-based systems. Such experience does not translate readily to the skills needed for Local Area Networks (LANs) and client-server architectures. Project management frameworks have been developed in the private sector that can provide guidelines, but blindly adopting such frameworks to the public sector can be misleading. What is needed is a workable project management framework that addresses the common elements of risk assessment and project management, while taking into account the unique needs of public organizations. Our purpose in this article is to suggest a framework that will address the needs of managing large-scale IT projects in the public sector. We first discuss the differences between public and private organizations, with emphasis on IT project management. Next a discussion is offered of trends in human resource management systems (HRMS), providing an introduction to the case. The case describes a specific attempt to implement an HRMS in a state government. The case is followed by the presentation of an IT project management framework. We close with a discussion of the lessons learned. Information Technology in the Public Sector The role of IT in public organizations has been the subject of numerous research efforts, including a major research program at the University of California at Irvine (Northrop et al., 1990). The Irvine group argued that many of the intended benefits of IT, such as better information for planning and managerial control, had not been realized. A long-term, longitudinal study found that most payoffs from computerization were in the areas of fiscal control, cost avoidance, and better interactions with the public. However, those payoffs were not immediate, and the prospects for future payoffs in these areas were mixed. Other research has focused on the control of information resources (including IT) at the state level. A national study of state governments investigated new organizational structures, planning processes, and policy formulation activities relating to the acquisition, use, and management of IT (Caudle, 1990). The study concluded that although the focus remained on IT management, public sector management was increasingly considering information itself as an important resource to be managed. Another study was designed to test the basic premise that management of IT in public organizations differs from that carried out in private sector firms (Bretschneider, 1990). Using a sample of slightly more than 1,000 public and private sector organizations, the study presented a list of potential differences between public and private organizations that could affect the capacity of an organization to manage IT effectively. The differences identified by Bretschneider included the following (MIS stands for the management information systems function in the private sector, and PMIS for the public management information systems in the public sector): 1 .PMIS managers must contend with greater levels of interdependence across organizational boundaries than do private MIS managers. …

Analysis of patient and parent assessment of deformity in idiopathic scoliosis using the Walter Reed Visual Assessment Scale.

Objectives. This study evaluates the Walter Reed Visual Assessment Scale (WRVAS) compared with clinical parameters and written descriptions of the deformity from idiopathic scoliosis patients and their parents. Summary of Background Data. The WRVAS demonstrates seven visible aspects of spinal deformity in an analogue scale. Higher scores reflect worsening deformity. Materials and Methods. The WRVAS was administered to 182 idiopathic scoliosis patients at four centers in conjunction with open-ended questions about patients’ and their parents’ perceptions of their spinal deformity. The open-ended responses were categorized as either “deformity noted” or “no deformity noted.” Results. WRVAS scores strongly correlate with curve magnitude (P = 0.01) and clearly differentiates curves of 30° or more from lesser curves. Among treatment groups, patients with surgery recommended had significantly higher scores than that of other patients. The instrument differentiated those noting no deformity from those noting a deformity. The correlation between patients’ and parents’ scores was high (Spearman’s rho = 0.8). When a deformity was noted, parents gave higher scores than did their children for rib prominence, shoulder level, scapular rotation, and the total score, but not for the other dimensions. Conclusions. Increasing scores of the WRVAS are strongly correlated with curve magnitude lending construct validity to this type of assessment tool. Patients with “surgery recommended” report more visible deformity on the scale than observed, braced, and postoperative patients, supporting the hypothesis that surgery improves the perceived appearance. Parents perceive more deformity of the ribs and shoulders more than did the patients, but other aspects of the deformity are identified equally. WRVAS scores correlate significantly with curve magnitude and treatment. Parents and patients have similar scores, but with parents perceiving more deformity of the ribs and shoulders than patients.

International Consensus on Periprosthetic Joint Infection: Description of the Consensus Process

William Cats-Baril PhD, Thorsten Gehrke MD,Katherine Huff BA, Daniel Kendoff MD,Mitchell Maltenfort PhD, Javad Parvizi MD, FRCSBackgroundPeriprosthetic joint infection (PJI),with all its disastrous consequences,continues to pose a challenge to theorthopaedic community. Practicingorthopaedic surgeons have investedgreat efforts to implement strategiesthat may minimize surgical site infec-tion (SSI). While new discoveries inorthopaedic research allow us toanswer more questions each year onthe basis of high-level evidence, thereremain numerous topics—includingmany important ones—for which theevidence is limited, contradictory, orabsent. For these clinical issues, itsometimes is helpful to know whethergeneral consensus on diagnosis ortreatment exists among individualswho specialize in these areas.Toward that end, we convened ameeting of an international panel ofexperts during 2 days (July 31 andAugust 1, 2013) in Philadelphia, PA,USA. The meeting was the penulti-mate step of a 10-month-long processto generate a set of best practices formanagement of PJI through engage-ment of experts in the field. More than300 experts from various disciplinesincluding orthopaedic surgery, infec-tious disease, musculoskeletalpathology, microbiology, anesthesiol-ogy, dermatology, nuclear medicine,rheumatology, musculoskeletal radiol-ogy, veterinary surgery, and pharmacy,as well as numerous scientists withinterest in orthopaedic infectionsattended. Delegates from 52 countriescovering all major regions of the globeparticipated, representing 160 medicalinstitutions and research centers, hav-ing memberships in more than 100medical societies and boards, andsharing a collective experience ofmany thousands of cases. The panelundertook this consensus effort to helpthe global medical communityimprove the efficacy, lower the com-plication rates, and move towardadoption of standardized measures andtechniques for management of PJI.As mentioned, the lack of evidencefor many aspects of clinical practice

Evaluating Aesthetics: The Major Issues and a Bibliography

There is a growing need for a more informed and consistent approach to evaluating aesthetics. This need is due to a heightened awareness of environmental impacts and the utility of conservation practices. The integration of methodological approaches from various fields of expertise is essential in addressing the complex problems facing planners and developers in dealing with landscape aesthetics. The rationale behind this study was to facilitate such an integration by identifying the major issues in, and the most helpful bibliographic sources for, the assessment of landscape aesthetics. Forty-nine practitioners and academicians from various backgrounds agreed to participate in the study. The participants interacted through a Delphi process. They identified five major issues regarding the assessment of scenery aesthetics, and they generated and prioritized a bibliography consisting of eighty-five sources. There was little correspondence between the issues and the bibliography suggesting that the issues identified in this study constitute fertile research topics.

Creating an Academy of Medical Educators: How and Where to Start

BackgroundWhile most faculty members want to improve as teachers, they neither know where their educational strengths and weaknesses lie nor where or how to begin to effect a change in their teaching abilities. The lack of actionable, directed and specific feedback, and sensible and sensitive metrics to assess performance and improvement complicates the attainment of educational excellence.PurposeThe purpose of this article was to outline a series of specific steps that medical education programs can take to enhance the quality of teaching, promote teaching excellence, elevate the status and value of medical educators, and stimulate the creation of innovative teaching programs and curricula.MethodsTo achieve these goals at the Hospital for Special Surgery, the Academy of Rheumatology Medical Educators was formed. The academy had the following goals: (1) create within our institution a mission which advances and supports educators, (2) establish a membership composed of distinguished educators, (3) create a formal organizational structure with designated leadership, (4) dedicate resources that fund mission-related initiatives and research, and (5) establish a plan for promoting teachers as well as enhancing and advancing educational scholarship.ResultsThe Hospital for Special Surgery Academy of Rheumatology Medical Educators was recently formed to address these goals by promoting teaching and learning of musculoskeletal skills in an environment that is supportive to educators and trainees and provides much needed resources for teachers.SummaryThe development of a pilot academy of medical educators represents one of the high-priority goals of those institutions that wish to elevate and enrich their teaching through a structured, proven approach.

Evaluating landscape aesthetics: A multi-attribute utility approach

Abstract Regulatory functions require subjective judgments which are sometimes inconsistently and arbitrarily applied. Aesthetic assessments of land-use proposals is such a situation. The research presented here involved developing a multi-attribute utility model to measure the aesthetic impact of proposed land developments. It was hypothesized that such a model would help in the process of reviewing land-use permit applications by increasing the consistency and comprehensiveness of the evaluation; while at the same time increasing the efficiency of the process. A panel of 11 experts with backgrounds in architecture, historical preservation, law, art, planning and government was convened to construct the model. The panel met seven times for 2.5 hours each time over a 6-month period. The resulting instrument, called the Aesthetic Impact Model (AIM), consists of 34 attributes. AIM has been used on a variety of examples and has proved to be an excellent framework for discussing the aesthetic impact of proposed development projects. AIM has also been used very successfully in public gatherings of 20–30 people to discuss landscape aesthetics. Specifically, AIM has shown five strong points: it increases communication among interested parties by providing a common lexicon and clear and detailed feedback; it clarifies disagreements by narrowing them to specific attributes; it facilitates discussion of aesthetics by lay people; it rates projects on a systematic and consistent scale; it allows the performance of sensitivity (or “what-if”) analyses to determine the effect of changing the scores on specific attributes of a project. Some of the disadvantages of AIM are a false sense of objectivity and a verbalization of priorities by the regulating bodies that may have political ramifications and affect the chances of implementing the model.

Building a Rheumatology Education Academy: Insights from Assessment of Needs During a Rheumatology Division Retreat

Objective. To implement a rheumatology department education retreat to systematically identify and address the key factors necessary to improve medical education in our division in preparation for developing a rheumatology academy. Methods. The Hospital for Special Surgery organized a retreat for the Rheumatology Department aimed at (1) providing formal didactics and (2) assessing participants’ self-reported skills and interest in education with the goal of directing this information toward formalizing improvement. In a mixed-methods study design, faculty and fellows in the Division of Rheumatology were surveyed online pre- and post-retreat regarding various aspects of the current education program, their teaching abilities, interest and time spent in teaching, divisional resources allocated, and how education is valued. Results. Enthusiasm for teaching was high before and rose further after the retreat. Confidence in abilities was higher than expected before but fell afterward. Many noted that the lack of specific feedback on teaching skills and useful metrics to assess performance prevented the achievement of educational excellence. Most responding felt lack of time, knowledge of how to teach well, and resources prevented them from making greater commitments to educational endeavors and participating fully and effectively in the department’s teaching activities. Conclusion. While most rheumatology faculty members want to improve as teachers, they know neither where their educational strengths and weaknesses lie nor where or how to begin to change their teaching abilities. The key elements for an academy would thus be an educational environment that elevates the quality of teaching throughout the division and promotes teaching careers and education research, and raises the importance and quality of teaching to equivalence with clinical care and research.