Stratum-specific likelihood ratios of the general health questionnaire in the community: help-seeking and physical co-morbidity affect the test characteristics

"Early detection of Spanish-speaking children with developmental language disorders: Concurrent validity of a short questionnaire and a screening test"

BACKGROUND

. Under-identification of Developmental Language Disorder (DLD) is a significant problem in monolingual Latin American Spanish-speaking children. We evaluated the identification utility of the sequential use of two screening tools, the "Parental Questionnaire (PQ)" and the "Screening for Language Problems (TPL)", to identify children who require confirmatory diagnosis of DLD.

METHODS

Parents of children (4 to 6 years) were contacted in schools and public health centers in Mexico. Monolingual Spanish-speaking children with no auditory and cognitive disorders were eligible. The reference diagnosis of DLD was established using BESA (Bilingual English-Spanish Assessment) or SCELF-4 (Spanish Clinical Evaluation of Language Fundamentals), combined with data from the narrative samples that yielded the percentage of ungrammaticality and the clinical judgment of two Speech-Language Pathologists (SLPs). Responses to the PQ were obtained as a parental report, and the TPL was applied by a trained SLPs.

RESULTS

. Both PQ and TPL presented a significant difference between the groups of children with DLD and typical language development (TLD). By combining the two instruments, a notable improvement in diagnostic utility was shown.

CONCLUSION

. The combination of these two procedures provides an efficient method for screening children having the risk of DLD and contributes to resolving the problem of under-identification.

Application of a stratum-specific likelihood ratio analysis in a screen for depression among a community-dwelling population in Japan

BACKGROUND

Efficient screening for depression is important in community mental health. In this study, we applied a stratum-specific likelihood ratio (SSLR) analysis, which is independent of the prevalence of the target disease, to screen for depression among community-dwelling individuals.

METHOD

The Center for Epidemiologic Studies Depression Scale (CES-D) and the Mini International Neuropsychiatric Interview (MINI) were administered to 789 individuals (19-87 years of age) who participated in the Iwaki Health Promotion Project 2011. Major depressive disorder (MDD) was assessed using the MINI.

RESULTS

For MDD, the SSLRs were 0.13 (95% CI 0.04-0.40), 3.68 (95% CI 1.37-9.89), and 24.77 (95% CI 14.97-40.98) for CES-D scores of 0-16, 17-20, and above 21, respectively.

CONCLUSION

The validity of the CES-D is confirmed, and SSLR analysis is recommended for its practical value for the detection of individuals with the risk of MDD in the Japanese community.

Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty

BACKGROUND

Increasing evidence supports the finding that patients undergoing a total knee arthroplasty with high-volume physicians and hospitals achieve better outcomes. Unfortunately, the existing definitions for high-volume surgeons and hospitals are highly variable and entirely arbitrary. The aim of this study was to identify a set of meaningful hospital and surgeon total knee arthroplasty volume thresholds.

METHODS

Using 289,976 patients undergoing primary total knee arthroplasty from an administrative database, we applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision. For hospital volume, we considered 90-day complications and 90-day mortality.

RESULTS

SSLR analysis of the ROC curves for 90-day complication and 2-year revision rates by surgeon volume identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories. Revision rates followed a similar pattern, but did not decrease between surgeons performing 60 to 145 arthroplasties per year and those performing ≥146 arthroplasties per year. SSLR analysis of 90-day complication and 90-day mortality rates by hospital volume also identified four volume categories: 0 to 89, 90 to 235, 236 to 644, and ≥645 total knee arthroplasties per year. Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories, but the rates did not decrease between hospitals performing 236 to 644 arthroplasties per year and those performing ≥645 arthroplasties per year. Mortality rates for hospitals with ≥645 total knee arthroplasties per year were significantly lower (p < 0.05) than those below the threshold.

CONCLUSIONS

Our study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons and hospitals. This should help patients, surgeons, hospitals, and policymakers to make decisions with regard to the optimal delivery of total knee arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using an accumulation of deficits approach to measure frailty in a population of home care users with intellectual and developmental disabilities: an analytical descriptive study

Background

The aging population of adults with intellectual and developmental disabilities (IDD) is growing. In the general aging population, frailty is commonly used to predict adverse health outcomes, including hospital use, death, and admission to long-term care. However, existing frailty measures are less appropriate for aging persons with IDD, given their pre-existing conditions and limitations. An accumulation of deficits approach, which is now widely used to describe frailty in the general population, may be more suitable for persons with IDD. Frailty measures specific to persons with IDD have not been widely studied.

Methods

Using pre-determined criteria, a frailty index (FI) specific to persons with IDD was developed based on items in the Resident Assessment Instrument - Home Care (RAI-HC), and using the assessments of 7,863 individuals with IDD in Ontario (aged 18–99 years) admitted to home care between April 1^st, 2006 and March 31^st, 2014. FI scores were derived by dividing deficits present by deficits measured, and categorized into meaningful strata using stratum-specific likelihood ratios. A multinomial logistic regression model identified associations between frailty and individual characteristics.

Results

The resulting FI is comprised of 42 deficits across five domains (physiological, psychological, cognitive, social and service use). The mean FI score was 0.22 (SD = 0.13), equivalent to 9 deficits. Over half of the cohort was non-frail (FI score < 0.21), while the remaining were either pre-frail (21 %, FI score between 0.21 and 0.30) or frail (27 %, FI score > 0.30). Controlling for individual characteristics, women were more likely to be frail compared to men (OR = 1.39, 95 % CI: 1.23–1.56). Individuals who were frail were significantly more likely to have a caregiver who was unable to continuing caring (OR = 1.86, 95 % CI: 1.55–2.22) or feeling distressed (OR = 1.54, 95 % CI: 1.30–1.83). Living with a family members was significantly protective of frailty (OR = 0.35, 95 % CI: 0.29–0.41), compared to living alone.

Conclusions

Using the FI to identify frailty in adults with IDD is feasible and can be incorporated into existing home care assessments. This could offer case managers assistance in identifying at-risk individuals. Future analyses should evaluate this measure’s ability to predict future adverse outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0170-5) contains supplementary material, which is available to authorized users.

Quantifying diagnostic uncertainty using item response theory: the Posterior Probability of Diagnosis Index

Using traditional Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (American Psychiatric Association, 2000) diagnostic criteria, clinicians are forced to make categorical decisions (diagnosis vs. no diagnosis). This forced choice implies that mental and behavioral health disorders are categorical and does not fully characterize varying degrees of uncertainty associated with a particular diagnosis. Using an item response theory (latent trait model) framework, we describe the development of the Posterior Probability of Diagnosis (PPOD) Index, which answers the question: What is the likelihood that a patient meets or exceeds the latent trait threshold for a diagnosis? The PPOD Index is based on the posterior distribution of θ (latent trait score) for each patient's profile of symptoms. The PPOD Index allows clinicians to quantify and communicate the degree of uncertainty associated with each diagnosis in probabilistic terms. We illustrate the advantages of the PPOD Index in a clinical sample (N = 321) of children and adolescents with oppositional defiant disorder.

Psychometric validation of the Growth and Empowerment Measure (GEM) applied with Indigenous Australians

OBJECTIVE

Empowerment is a complex process of psychological, social, organizational and structural change. It allows individuals and groups to achieve positive growth and effectively address the social and psychological impacts of historical oppression, marginalization and disadvantage. The Growth and Empowerment Measure (GEM) was developed to measure change in dimensions of empowerment as defined and described by Aboriginal Australians who participated in the Family Well Being programme.

METHOD

The GEM has two components: a 14-item Emotional Empowerment Scale (EES14) and 12 Scenarios (12S). It is accompanied by the Kessler 6 Psychological Distress Scale (K6), supplemented by two questions assessing frequency of happy and angry feelings. For validation, the measure was applied with 184 Indigenous Australian participants involved in personal and/or organizational social health activities.

RESULTS

Psychometric analyses of the new instruments support their validity and reliability and indicate two-component structures for both the EES (Self-capacity; Inner peace) and the 12S (Healing and enabling growth, Connection and purpose). Strong correlations were observed across the scales and subscales. Participants who scored higher on the newly developed scales showed lower distress on the K6, particularly when the two additional questions were included. However, exploratory factor analyses demonstrated that GEM subscales are separable from the Kessler distress measure.

CONCLUSION

The GEM shows promise in enabling measurement and enhancing understanding of both process and outcome of psychological and social empowerment within an Australian Indigenous context.

Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative

Data are reported on the background and performance of the K6 screening scale for serious mental illness (SMI) in the World Health Organization (WHO) World Mental Health (WMH) surveys. The K6 is a six-item scale developed to provide a brief valid screen for Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) SMI based on the criteria in the US ADAMHA Reorganization Act. Although methodological studies have documented good K6 validity in a number of countries, optimal scoring rules have never been proposed. Such rules are presented here based on analysis of K6 data in nationally or regionally representative WMH surveys in 14 countries (combined N = 41,770 respondents). Twelve-month prevalence of DSM-IV SMI was assessed with the fully-structured WHO Composite International Diagnostic Interview. Nested logistic regression analysis was used to generate estimates of the predicted probability of SMI for each respondent from K6 scores, taking into consideration the possibility of variable concordance as a function of respondent age, gender, education, and country. Concordance, assessed by calculating the area under the receiver operating characteristic curve, was generally substantial (median 0.83; range 0.76-0.89; inter-quartile range 0.81-0.85). Based on this result, optimal scaling rules are presented for use by investigators working with the K6 scale in the countries studied.

Suicidal Ideation

Background. Suicidal ideation is an important risk factor for suicide attempts and completions, and early identification of the likely presence of self-harm cognitions would benefit clients and clinicians alike. This study examined the clinical utility of the Kessler K10 psychological distress score as an indicator of suicidal ideation. Methods. Suicidal ideation was assessed on the basis of four relevant questions contained in the General Health Questionnaire (GHQ-28), and these were subsequently analyzed against the K10 scores. The data were collected using a monthly risk-factor surveillance system where each month a representative random sample of South Australians over the age of 16 years is interviewed. The cumulative data covered the period 2002 to 2007 (n = 12,884). Results. Psychological distress and suicidal ideation were reported by 9.9% and 5.1% of the participants, respectively. Univariate analysis demonstrated a positive linear relationship between the K10 score and suicidal ideation. Participants scoring in the very high range of the K10 were more likely to report suicidal ideation and this was experienced with greater frequency than by those who were less distressed. A logistic regression analysis revealed that even those in the moderate category were four times more likely to experience suicidal ideation than those in the low category, and those in the high and very high categories were 21 and 77 times more likely, respectively. Separate models based on sex and using odds-ratios based on very high vs. low K10 scores showed that males were 104 times more likely to report suicidal ideation compared to a 63 times higher rate for females. Both sexes had a 52% probability of experiencing suicidal ideation if they fell into the very high distress group. Conclusions. The K10 score is a clinically useful indicator of the presence of suicidal ideation.

Identifying PTSD in primary care: comparison of the Primary Care-PTSD screen (PC-PTSD) and the General Health Questionnaire-12 (GHQ)

The aim of this study was to compare the PC-PTSD and GHQ-12 in detecting new cases of PTSD among primary care patients. Data on the PC-PTSD, GHQ-12 and psychiatric diagnoses was extracted from clinical databases for 11,230 VA primary care patients. Signal detection analyses and likelihood ratios were used to compare screens. Logistic regression analysis was used to examine the prediction of PTSD by the PC-PTSD after controlling for the GHQ. The PC-PTSD had a higher positive predictive value than the GHQ (41 percent vs. 31 percent). Combining positive results on the two screens in predicting PTSD yielded the highest likelihood ratio (LR=17.3) compared to a positive result on the PC-PTSD only (LR=8.3) or the GHQ only (LR=4.6). The PC-PTSD performed slightly better than the GHQ and provided unique information in identifying PTSD, suggesting that disorder specific screens are important to use in primary care settings.

Application of the stratum-specific likelihood ratio (SSLR) analysis to results of a depressive symptoms screening survey among Japanese workers

BACKGROUND

The stratum-specific likelihood ratio (SSLR) has been widely used as a convenient method to interpret the results of screening surveys. In the present paper, an SSLR analysis is applied to the results of a survey that used the Center for Epidemiologic Studies Depression Scale (CES-D) to identify depressive symptoms in a group of Japanese workers in an attempt to determine score categories that have predictive clinical values in a screening context.

METHODS

The self-reported CES-D and the Mini International Neuropsychiatric Interview (MINI) were administered to 2,219 workers (84.2% men; age 21-68 years) during a periodical medical examination. The SSLR was calculated to determine strata with optimal discrimination for major depressive disorder (MDD).

RESULTS

For MDD, the SSLR was 0.06 (95%CI: 0.02-0.18) for the CES-D score range 0-16, 1.90 (0.78-4.62) for the score range 17-19, and 12.4 (10.2-15.1) for the score above 20.

CONCLUSIONS

The SSLR shown in this study proposes score categories that guide clinicians in selecting the workers most at risks of having MDD among Japanese workers.

Screening for depression in terminally ill cancer patients in Japan

This study attempted to assess the performance of several screening instruments for adjustment disorders (ADs) and major depression (MD) among terminally ill Japanese cancer patients. Two hundred and nine consecutive patients were assessed for ADs and MD using a structured clinical interview at the time of their registration with a palliative care unit, and two single-item interviews ("Are you depressed?" and "Have you lost interest?") and the Hospital Anxiety and Depression Scale (HADS) were administered. Screening performance was investigated by calculating sensitivity, specificity, the positive predictive value, negative predictive value, likelihood ratio, and stratum-specific likelihood ratios. When the screening target included both an AD and MD, the HADS is a more useful screening method than the single-item interviews. Regarding screening for MD, both single-item interviews and the HADS possess useful screening performance. Different screening instruments may be recommended depending on the depressive disorders and specific populations.

Prospective psychosocial monitoring of living kidney donors using the Short Form-36 health survey: results at 12 months

BACKGROUND

Lack of prospective psychosocial outcome studies on living kidney donors impedes identification of risk factors for poor outcome.

METHODS

Psychiatric assessment of living kidney donors was performed preoperatively and at 4 and 12 months postoperatively using a semistructured interview, the Short Form (SF)-36 Health Survey, and Patient Health Questionnaire psychiatric assessment. A total of 48 of 51 consecutive donors (94%) over a 5-year period were available for follow-up and completed all assessments.

RESULTS

At preoperative assessment, only 1 of the 48 donors (2%) had a Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition Axis I psychiatric disorder, but 15 (31%) developed a disorder during the 12 months, a 29% incidence. Disorders were depressive (12%), anxiety (6%), and adjustment (13%). Seven donors (15%) demonstrated a disorder at 12 months (depressive 10%, anxiety 2%, adjustment 2%). There was a corresponding decline in psychosocial function as measured by the SF-36 Mental Component Summary score; it decreased at both 4 and 12 months (P<0.01, P<0.05); for 19% of donors, this was a larger decrease than would be expected for the cohort (>2 standard error of measurement units). Scores for SF-36 scales of General Health and Vitality decreased significantly (P<0.05), as did those of Bodily Pain, indicating greater impairment from pain. Psychiatric disorder at 12 months was associated with donor psychosocial function (Mental Component Summary) and psychiatric disorder at 4 months (P<0.01), physical function (SF-36 Physical Component Summary score) at 4 and 12 months (P<0.01), and recipient psychiatric disorder at 12 months (P<0.05).

CONCLUSIONS

Donors should be alerted to possible psychosocial impairment, assessed for risk factors, and monitored for at least 12 months. Treatment should be available.

Measuring outcomes in patients with depression or anxiety: an essential part of clinical practice

A wide range of instruments is available for ongoing assessment of clinical status and outcome in patients with depressive or anxiety disorders. However, few doctors use these instruments in managing their patients. As depression and anxiety are relapsing or chronic conditions and are often comorbid with other medical conditions, standard outcome measures should be incorporated into the management plans for all such patients.