Questionnaire surveys in medical research

Measurement of Pain and Related Symptoms in Irritable Bowel Syndrome: The Use of Validated Pain Measurement Tools

This paper reviews the tools available to assess outcomes of treatment in irritable bowel syndrome, especially the effect on abdominal pain. Tools were identified through a wide-ranging scrutiny of PubMed and Google Scholar, together with a review of further references quoted in those publications. It critically considers their development, relevance and reliability. The Irritable Bowel Severity Scoring System (IBS-SSS) was the first simple method of monitoring the progress of the disease and its treatment. It led on to other instruments, such as The Irritable Bowel Syndrome Quality of Life (IBS-QOL). It is easier to read and faster to complete than the IBS-SSS., However, these and other tools were developed for English speaking populations. This review considers the impact of ethnicity and gender, together with the lack of information on the effect of age on the potential validity of these tools in other populations. Issues with the adequacy and appropriateness of translations of such tools are discussed. The overall conclusion is that there are few tools which meet the criteria necessary to place confidence in their validity as appropriate measures of patient outcomes.

Cross-sectional UK survey of advanced practice physiotherapy: characteristics and perceptions of existing roles

Background/aims

Few studies have investigated the characteristics of advanced practice physiotherapy in the UK to evaluate current context and implementation. The aim of this study was to understand how advanced practice physiotherapy is implemented in the UK.

Methods

A cross-sectional online descriptive national questionnaire was developed, using a previous survey and literature, comprising 33 closed, Likert-scale and open questions. Data analysis was undertaken using frequencies and thematic analysis. All 646 members of the Advanced Practice Physiotherapy Network were invited to participate.

Results

A total of 142 (22% response) reported 13 job titles; 40% had experienced ≥1 title change; most (50.7%) preferred ‘advanced practice physiotherapist’. High level job satisfaction was identified but barriers prevent fulfilment of the four advanced practice physiotherapy pillars: clinical practice, leadership and management, education and research. High level clinical skills and facilitating patient pathways were key to role differentiation. Problems included lack of support, inconsistency between responsibility and reward, and no consistent framework for advanced practice physiotherapy roles.

Conclusions

Advanced practice physiotherapists are largely satisfied, but significant variation exists in titles and implementation of roles. A consistent advanced practice physiotherapy framework is required.

Current and future perspectives on lumbar degenerative disc disease: a UK survey exploring specialist multidisciplinary clinical opinion

OBJECTIVES

Despite lumbar degenerative disc disease (LDDD) being significantly associated with non-specific low back pain and effective treatment remaining elusive, specialist multidisciplinary clinical stakeholder opinion remains unexplored. The present study examines the views of such experts.

DESIGN

A reliable and valid electronic survey was designed to establish trends using theoretical constructs relating to current assessment and management practices. Clinicians from the Society of Back Pain Research (SBPR) UK were invited to take part. Quantitative data were collated and coded using Bristol Online Surveys (BOS) software, and content analysis was used to systematically code and categorise qualitative data.

SETTING

Specialist multidisciplinary spinal interest group in the UK.

PARTICIPANTS

38/141 clinically active, multidisciplinary SBPR members with specialist spinal interest participated. Among them, 84% had >9 years postgraduate clinical experience.

INTERVENTIONS

None.

OUTCOME MEASURES

Frequency distributions were used to establish general trends in quantitative data. Qualitative responses were coded and categorised in relation to each theme and percentage responses were calculated.

RESULTS

LDDD symptom recurrence, in the absence of psychosocial influence, was associated with physical signs of joint stiffness (26%), weakness (17%) and joint hypermobility (6%), while physical factors (21%) and the ability to adapt (11%) were postulated as reasons why some experience pain and others do not. No one management strategy was supported exclusively or with consensus. Regarding effective modalities, there was no significant difference between allied health professional and medic responses (p=0.1-0.8). The future of LDDD care was expressed in terms of improvements in patient communication (35%), patient education (38%) and treatment stratification (24%).

CONCLUSIONS

Results suggest that multidisciplinary expert spinal clinicians appear to follow UK-based assessment guidelines with regard to recurrent LDDD; there are, however, inconsistencies in the management approaches supported. This reflects the current literature and the lack of specific, formalised guidance. LDDD treatment stratification and further research are explicitly supported.

Developing and testing a measure of consultation-based reassurance for people with low back pain in primary care: a cross-sectional study

Background

Reassurance from physicians is commonly recommended in guidelines for the management of low back pain (LBP), but the process of reassurance and its impact on patients is poorly researched.

We aimed to develop a valid and reliable measure of the process of reassurance during LBP consultations.

Methods

Items representing the data-gathering stage of the consultation and affective and cognitive reassurance were generated from literature on physician-patient communication and piloted with expert researchers and physicians, a Patient and Public Involvement group, and LBP patients to form a questionnaire. Patients presenting for LBP at 43 General Practice surgeries were sent the questionnaire. The questionnaire was analysed with Rasch modelling, using two samples from the same population of recent LBP consultations: the first (n = 157, follow-up n = 84) for exploratory analysis and the second (n = 162, follow-up n = 74) for confirmatory testing. Responses to the questionnaire were compared with responses to satisfaction and enablement scales to assess the external validity of the items, and participants completed the questionnaire again one-week later to assess test-retest reliability.

Results

The questionnaire was separated into four subscales: data-gathering, relationship-building, generic reassurance, and cognitive reassurance, each containing three items. All subscales showed good validity within the Rasch models, and good reliability based on person- and item-separations and test-retest reliability. All four subscales were significantly positively correlated with satisfaction and enablement for both samples. The final version of the questionnaire is presented here.

Conclusions

Overall, the measure has demonstrated a good level of validity and generally acceptable reliability. This is the first measure to focus specifically on reassurance for LBP in primary care settings, and will enable researchers to further understanding of what is reassuring within the context of low back pain consultations, and how outcomes are affected by different types of reassurance. Additionally, the measure may provide a useful training and audit tool for physicians. The new measure requires testing in prospective cohorts, and would benefit from further validation against ethnographic observation of consultations in real time.

Do Treatment Policies for Proximal Humerus Fractures Differ among Three Nordic Countries and Estonia? Results of a Survey Study

BACKGROUND AND PURPOSE

Proximal humerus fractures are common fragility injuries. The incidence of these fractures has been estimated to be 82-105 per 105 person-years. Treatment of this fracture, especially in the elderly, is controversial. Our study group published a systematic review of the available literature and concluded that non-operative methods are favored over operative methods in three- and four-part fractures. The aim of this multinational study was to compare treatment policies for proximal humerus fractures among the Nordic countries and Estonia.

MATERIALS AND METHODS

The study was conducted as a questionnaire-based survey, using the Internet-based program, Webropol(®) (webropol.com). The questionnaire link was sent to the surgeons responsible for treating proximal humerus fractures in major public hospitals in Estonia, Finland, Norway, and Sweden. Questionnaire included questions regarding the responder's hospital, patient characteristics, and examinations taken before decision making. Clinical part included eight example patient cases with treatment options.

RESULTS

Of the 77 recipients of the questionnaire, 59 responded; consequently, the response rate was 77%. Based on the eight presented displaced fracture examples, in both Estonia and Norway and in Finland, 41% and 38%, respectively, preferred surgical treatment with locking plate. In Sweden, the percentage was 28%. The pre- and post-operative protocols showed a similarity in all participant countries.

CONCLUSION

Our survey revealed a remarkable uniformity in the current practice of operative treatments and rehabilitation for proximal humerus fractures in the participant countries.

Participation and factors associated with late or non-response to an online survey in primary care

RATIONALE, AIMS AND OBJECTIVES

Online surveys have several advantages, but a low response rate is common and it is uncertain how results are affected. Response inducement techniques can be used to overcome this problem. The objectives of this study were to describe the percentage of change in the response rate after reminders and to analyse the characteristics associated with non-response and late response based on the survey results, as well as by applying archival and extrapolation techniques.

METHOD

In the Autonomous Community of Madrid, an online questionnaire about cancer prevention was sent to a random sample of primary care health professionals (3586 physicians and nurses). Two reminders were sent later. The percentage of change in response rates after reminders, global and by demographic and health care characteristics of participants; and factors associated with non-response and late response were analysed using response rates and odds ratios (ORs).

RESULTS

After the reminders, the response rate increased from 22.6% to 32.9% and to 39.4%. Non-response was associated with age [OR: 3.14; confidence interval (CI) 95%: 2.23-4.42 for aged >60 years], gender and functional area. Further, a higher response rate after reminders was observed in professionals with heavier workloads (OR: 1.46; CI 95%: 1.08-1.97) and in those who stated a lower relevance of cancer prevention in primary care.

CONCLUSIONS

After electronic reminders, the response rate increased, especially among professionals with the highest workloads and a minor interest in the survey topic. However, possible bias associated with non-response remains and the factors behind this should be examined in future research.

Characteristics in response rates for surveys administered to surgery residents

BACKGROUND

Surveys are important research tools that permit the accumulation of information from large samples that would otherwise be impractical to collect. Resident surveys have been used frequently to monitor the quality of postgraduate training. Low response rates threaten the utility of this research tool. The purpose of this study was to determine the standard response rate of surveys administered to surgery residents and identify characteristics associated with achieving greater response rates.

METHODS

A search of peer-reviewed literature published between September 2003 and June 2011 was performed with the use of PubMed with Medical Subject Headings: "internship and residency," "surgery," "data collection," and "questionnaires." For inclusion, articles must have described a survey given to active surgery residents within the United States. Surveys were evaluated based on the following criteria: population size, response rate, incentive use, follow-up use, survey format (online vs paper), and institution versus national.

RESULTS

Of 433 initial results, 47 met inclusion criteria with a mean response rate of 65.3%. Surveys administered in paper format had a greater response rate compared with those given electronically (mean 78.6% vs 36.4%, respectively, P < .001). Greatest mean response rates were seen for institutional surveys compared with those given nationally (83.1% vs 42% respectively, P < .001).

CONCLUSION

Our review demonstrated that paper surveys administered at the institutional level and during assemblies integrated into residents' schedules demonstrated enhanced response rates. The validity and generalizability of data collected through such surveys will improve as the aspects which dictate response rate are better understood and implemented.

A prospective, multicenter study of complementary/alternative medicine (CAM) utilization during definitive radiation for breast cancer

PURPOSE

Although complementary and alternative medicine (CAM) utilization in breast cancer patients is reported to be high, there are few data on CAM practices in breast patients specifically during radiation. This prospective, multi-institutional study was conducted to define CAM utilization in breast cancer during definitive radiation.

MATERIALS/METHODS

A validated CAM instrument with a self-skin assessment was administered to 360 Stage 0-III breast cancer patients from 5 centers during the last week of radiation. All data were analyzed to detect significant differences between users/nonusers.

RESULTS

CAM usage was reported in 54% of the study cohort (n=194/360). Of CAM users, 71% reported activity-based CAM (eg, Reiki, meditation), 26% topical CAM, and 45% oral CAM. Only 16% received advice/counseling from naturopathic/homeopathic/medical professionals before initiating CAM. CAM use significantly correlated with higher education level (P<.001), inversely correlated with concomitant hormone/radiation therapy use (P=.010), with a trend toward greater use in younger patients (P=.066). On multivariate analysis, level of education (OR: 6.821, 95% CI: 2.307-20.168, P<.001) and hormones/radiation therapy (OR: 0.573, 95% CI: 0.347-0.949, P=.031) independently predicted for CAM use. Significantly lower skin toxicity scores were reported in CAM users vs nonusers, respectively (mild: 34% vs 25%, severe: 17% vs 29%, P=.017).

CONCLUSION

This is the first prospective study to assess CAM practices in breast patients during radiation, with definition of these practices as the first step for future investigation of CAM/radiation interactions. These results should alert radiation oncologists that a large percentage of breast cancer patients use CAM during radiation without disclosure or consideration for potential interactions, and should encourage increased awareness, communication, and documentation of CAM practices in patients undergoing radiation treatment for breast cancer.

Listening to patients: using verbal data in the validation of the Aberdeen Measures of Impairment, Activity Limitation and Participation Restriction (Ab-IAP)

BACKGROUND

The purpose of the study was to evaluate the validity of the self-administered Aberdeen Measures of Impairment, Activity Limitation and Participation Restriction (Ab-IAP): by investigating how participants interpret and respond to questions using the cognitive interviewing technique.

METHODS

Twenty patients with osteoarthritis of the knee or hip participated in a cognitive interview whilst completing the Ab-IAP. Interviews were conducted using the concurrent 'think aloud' design. All interviews were audio recorded and transcribed verbatim and analysed (i) using a standardised classification scheme to identify four types of response problems and (ii) thematically using the constant comparative technique.

RESULTS

Participants used various response strategies when answering questions about impairment, activity limitations and participation restriction. Problems were judged to be present in 3.1% of participants' responses for the item Ab-IAP. Thematic analysis provided insight into the type and nature of problems people experienced when completing the Ab-IAP measures. The problems identified were mainly comprehension and response problems.

CONCLUSIONS

Participants had minimal difficulties completing the Ab-IAP; however those difficulties identified have prompted suggestions for improving the measures. The cognitive interviews produced results that were compatible with statistical analysis of the measures.. Cognitive interviewing was beneficial for testing the validity and acceptability of new Ab-IAP measures. The results demonstrates that the Ab-IAP, in addition to being theoretically-based and having good psychometric properties, elicits appropriate responses.

Cognitive testing of PAINReportIt in adult African Americans with sickle cell disease

PAINReportIt, a computerized version of the McGill Pain Questionnaire (Pain. 1975, 1:277-299), presents pain measurement items to responders in serial display screens accompanied by pop-up screens. In this study, we used cognitive interviews to examine further validity of PAINReportIt with 25 African Americans with sickle cell disease. The specific aims were to determine if the questions in the PAINReportIt program were relevant to and understood by African Americans with sickle cell disease and to describe the nature of the pain they experienced. Most study participants were enthusiastic and able to use the tool as intended and appreciated the comprehensiveness, detail, and multidimensionality of its pain data. For some screens, two to six participants' responses suggested some question understanding and interpretation issues, inability to retrieve the requested information, or technical issues. Their responses indicated that screens lacked sufficient specificity for the temporal nature of pain recurrence over a lifetime. The program captured both nociceptive and neuropathic aspects of sickle cell pain and provided detailed information on the location, intensity, quality, and pattern of pain experienced by participants. We recommend that future revisions to the PAINReportIt program address the temporal issues of measuring recurrent pain, resolve technological issues related to pop-ups, and simplify difficult words to better match the typical health literacy levels of patients. These revisions could further enhance the technological aspects, usability, and cultural appropriateness of the tool for African Americans with sickle cell disease.

When and why do subfertile couples discontinue their fertility care? A longitudinal cohort study in a secondary care subfertility population

BACKGROUND

A substantial number of subfertile couples discontinues fertility care before achieving pregnancy. Most studies on dropouts are related to IVF. The aim here is to examine dropout rates at all stages of fertility care.

METHODS

We analysed a consecutive cohort of 1391 couples, referred to our secondary care hospital between January 2002 and December 2006. Discontinuation rates were studied at six stages. Stage I: immediately after first visit, Stage II: during diagnostic workup, Stage III: after finishing diagnostic workup but before treatment, Stage IV: during or after non-IVF treatment, Stage V: during IVF, Stage VI: after at least 3 cycles of IVF. Reasons to discontinue and spontaneous pregnancy rates after discontinuation were secondary outcomes.

RESULTS

In our cohort 319 couples dropped out of fertility care, 76.8%, [95% confidence interval (CI): 72.2-81.4] on their own initiative and 23.2% (95% CI: 18.6-27.8) on doctor's advice. Percentage (95% CI) of couples discontinuing per stage were: Stage I 6.0% (3.4-8.6), Stage II 3.4% (1.5-5.5), Stage III 35.7% (30.5-41.0), Stage IV 23.5% (18.9-28.2), Stage V 17.9% (13.7-22.1) and Stage VI 13.5% (9.7-17.2). Main reasons for dropout (%, 95% CI) were 'emotional distress' (22.3%, 17.7-26.8), 'poor prognosis' (18.8%, 14.5-23.1) and 'reject treatment' (17.2%, 13.1-21.4). The spontaneous ongoing pregnancy rate after discontinuation was 10% (6.7-13.3).

CONCLUSION

About half of the couples stopped before any fertility treatment was started and one-third stopped after at least one IVF cycle. The main reasons for withdrawal were emotional distress and poor prognosis. This insight may help to improve quality of patient care by making care more responsive to the needs and expectations of subfertile couples.

Optimum survey methods when interviewing employed women

BACKGROUND

While survey studies have examined bias much is unknown regarding specific subpopulations, especially women workers.

METHODS

A population based phone, Internet, and mail survey of workplace falls during pregnancy was undertaken. Participation by industry and occupation and survey approach and bias, reliability, and incomplete data were examined.

RESULTS

Of the 3,997 women surveyed, 71% were employed during their pregnancy. Internet responders were most likely to be employed while pregnant and to report a workplace fall at 8.8% compared to 5.8% and 6.1% for mail and phone respondents. Internet responders had the most missing employment data with company name missing for 17.9% compared to 1.3% for phone responders. Mail surveys were best for recruiting those employed in eight of nine industries, and this was especially true for service occupations.

CONCLUSIONS

To decrease bias and increase participation, mixed approaches may be useful with particular attention for collecting occupational data. Am. J. Ind. Med. 52:105-112, 2009. (c) 2008 Wiley-Liss, Inc.

SURGEONS? ATTITUDES TOWARDS AND USAGE OF EVIDENCE-BASED MEDICINE IN SURGICAL PRACTICE: A PILOT STUDY

BACKGROUND

Within surgery the debate about the place of evidence-based medicine (EBM) has focused on the nature and compatibility of EBM with surgical practice with an inevitable polarization of opinion. However, EBM techniques are being embedded into undergraduate medical curricula and surgical training programs across Australia. The Monash University Department of Surgery at Monash Medical Centre implemented a pilot study to explore current knowledge, attitudes and behaviours of practising surgeons towards EBM techniques.

METHODS

Descriptive survey of surgeons based in a tertiary care environment.

RESULTS

The results from the surgeons surveyed suggest that (i) they believe that EBM marginalizes patient involvement in decision-making; (ii) they believe that EBM-generated knowledge is useful and is commonly used in daily clinical decision-making--however, not using EBM does not adversely affect their daily clinical decision-making; (iii) they have high confidence in their own judgement compared with low confidence in clinical practice guidelines and other sources of evidence; and (iv) journal summaries of the latest research related to a subject are the most useful resources in clinical practice above clinical practice guidelines.

CONCLUSION

The importance of incorporating concepts of the 'culture' of surgery as an important factor in understanding and developing new ways to mobilize Australian surgeons to adopt EBM into their practice is discussed.

Identification of pain indicators for infants at risk for neurological impairment: a Delphi consensus study

BACKGROUND

A number of infant pain measures have been developed over the past 15 years incorporating behavioural and physiologic indicators; however, no reliable or valid measure exists for infants who are at risk for neurological impairments (NI). The objective of this study was to establish consensus about which behavioural, physiologic and contextual indicators best characterize pain in infants at high, moderate and low levels of risk for NI.

METHODS

A 39- item, self-administered electronic survey that included infant physiologic, behavioral and contextual pain indicators was used in a two round Delphi consensus exercise. Fourteen pediatric pain experts were polled individually and anonymously on the importance and usefulness of the pain indicators for the 3 differing levels of risk for NI.

RESULTS

The strength of agreement between expert raters was moderate in Round 1 and fair in Round 2. In general, pain indicators with the highest concordance for all three groups were brow bulge, facial grimace, eye squeeze, and inconsolability. Increased heart rate from baseline in the moderate and severe groups demonstrated high concordance. In the severe risk group, fluctuations in heart rate and reduced oxygen saturation were also highly rated.

CONCLUSION

These data constitute the first step in contributing to the development and validation of a pain measure for infants at risk for NI. In future research, we will integrate these findings with the opinions of (a) health care providers about the importance and usefulness of infant pain indicators and (b) the pain responses of infants at mild, moderate and high risk for NI.

Long-term prognosis in Crohn's disease: factors that affect quality of life

BACKGROUND

There are many studies investigating quality of life in recently diagnosed patients and following surgery for Crohn's disease, but there are none investigating quality of life changes with disease duration. The response shift model suggests quality of life improves with time following diagnosis.

AIM

To assess how well the model applies to patients with Crohn's disease.

METHODS

The Cardiff Crohn's disease database contains data on all patients diagnosed there since 1934. Three hundred and ninety four patients diagnosed before 1 January 1985 were traced and the mortality status on 31 December 2004 established. Two hundred and eleven still living were sent quality of life questionnaires. Two hundred and eighty five questionnaires were sent to patients with varying disease duration attending out-patient clinics in Leicester.

RESULTS

Eighty-nine valid replies were received from Cardiff, 63 from Leicester patients diagnosed over 20 years, 69 from Leicester patients diagnosed <10 years. There was no difference in quality of life between newly diagnosed and established patients. Of greatest concern was possible need for ostomy, uncertain nature of disease, and lack of energy. Stepwise regression showed that increased disease severity, older age and smoking adversely affect quality of life.

DISCUSSION

Quality of life is equally poor in patients with established disease as in those newly diagnosed, and directly correlates with disease severity. The response shift model may not be applicable in Crohn's disease.

A hybrid qualitative method for pretesting questionnaires: The example of a questionnaire to caregivers of Alzheimer disease patients

A hybrid method based on cognitive interviewing and consensus panels was developed to pretest a questionnaire for caregivers of persons with Alzheimer disease (AD). The objective of the questionnaire was to elicit caregivers' attitudes and opinions on the use of medications to treat the disease. Thirty-one caregivers were divided into five pretest groups, within which each participant was asked to comment on questionnaire wording and design. The comments from participants in the first three groups were used to revise the questionnaire, and the revised version was given to participants in the remaining two groups. Overall, 81% (118/146) of the participants' comments were implemented. The number of comments made in the last two groups decreased relative to the number of comments made in the first three groups. The hybrid method enhanced the user-friendliness of the questionnaire and can serve as an alternative to common ad hoc pretest approaches that have little basis in theory.

Phoning logistics in a longitudinal follow-up of batterers and their partners

More needs to be known about the phoning logistics of interviewing subjects for longitudinal follow-up studies in the domestic violence field. Using phoning logs from a 4-year follow-up of batterer intervention, the authors calculated the number, results, and costs of phone calls from a subsample of 100 men and 138 women. The number of calls is high (5.5 per man and 7.1 per woman), locators play a substantial role (for 25% of the men and women), and mailed questionnaires are a useful supplement (increasing response rate 5% for men and 11% for women). On average, about half of the subjects were interviewed at each interval. The main obstacle is not refusals but no response and not being able to locate a subject. Strategies to address "no response" are considered.