Integrating PROMIS Measures in a Treat to Target (T2T) Approach to Standardize Patient-Centered Treatment of Rheumatoid Arthritis

OBJECTIVE

To evaluate the impact of a patient-centered rheumatoid arthritis (RA) treat to target (T2T) disease management approach on patient outcomes and patient satisfaction with care.

METHODS

In this longitudinal, observational pilot study, rheumatologists implemented a modified T2T approach that integrated PROMIS measures for depression, fatigue, pain interference, physical function, and social function into RA care. Study participants selected one PROMIS domain to target treatment and completed quarterly follow-up assessments. Participants were classified as improved if their Clinical Disease Activity Index (CDAI) changed by > 5 points. Change in PROMIS T-scores was examined for the group with improved CDAI, compared to those with unchanged or worsened CDAI. Satisfaction with care was assessed using multiple measures, including the FACIT Treatment Satisfaction - Patient Satisfaction Scale.

RESULTS

The analytic sample (N = 119, median age = 57 years, 90.8% female) was split between those with CDAI > 10 (n = 63) and CDAI ≤ 10 (n = 53). At 1 year, there was improvement in CDAI by > 5 points in 66% and 13% of individuals with baseline CDAI > 10 and baseline CDAI ≤ 10, respectively. Across all participants, improvement in CDAI by > 5 points correlated with improvements in the five PROMIS domains. Satisfaction with RA treatment also increased.

CONCLUSION

The integration of PROMIS measures into the T2T approach for RA care was associated with improvements in disease activity, and improvement in disease activity was associated with improvements in PROMIS measures.

A SUCCESSFUL MODEL FOR AMPLIFYING THE VOICES OF OLDER ADULTS IN LONG-TERM CARE AND SERVICES AND SUPPORT RESEARCH

The experiential voice of older adults receiving long term services and supports (LTSS) is largely absent from health research hampering the development of effective interventions. While many have the capacity to participate in the design, development, and delivery of research, researchers traditionally do not recognize such capacity, may be unsure how to seek input, or may not appreciate the extent to which such input can improve the research enterprise. But the participation of these older adults can ensure that patient-centered research meaningfully addresses their care preferences and desired health outcomes, and can improve the effectiveness of care and patients’ quality of life. Through three PCORI-funded projects, we developed a successful model for addressing barriers to amplify these voices. We outline barriers to the dissemination and implementation of this model, and suggest next steps to test strategies to amplify the voices of older adults in long-term care.

A Community-Engaged Stroke Preparedness Intervention in Chicago

Background

We evaluated a community‐engaged stroke preparedness intervention that aimed to increase early hospital arrival and emergency medical services (EMS) utilization among patients with stroke in the South Side of Chicago, Illinois.

Methods and Results

We compared change in early hospital arrival (<3 hours from symptom onset) and EMS utilization before and after our intervention among patients with confirmed ischemic stroke at an intervention hospital on the South Side of Chicago with concurrent data from 6 hospitals in nonintervention communities on the North Side of Chicago and 17 hospitals in St Louis, Missouri. We assessed EMS utilization for suspected stroke secondarily, using geospatial information systems analysis of Chicago ambulance transports before and after our intervention. Among 21 497 patients with confirmed ischemic stroke across all sites, early arrival rates at the intervention hospital increased by 0.5% per month (95% CI, −0.2% to 1.2%) after intervention compared with the preintervention period but were not different from North Side Chicago hospitals (difference of −0.3% per month [95% CI, −0.12% to 0.06%]) or St Louis hospitals (difference of 0.7% per month [95% CI, −0.1% to 1.4%]). EMS utilization at the intervention hospital decreased by 0.8% per month (95% CI, −1.7% to 0.2%) but was not different from North Side Chicago hospitals (difference of 0.004% per month [95% CI, −1.1% to 1.1%]) or St Louis hospitals (difference of −0.7% per month [95% CI, −1.7% to 0.3%]). EMS utilization for suspected stroke increased in the areas surrounding the intervention hospital (odds ratio [OR], 1.4; 95% CI, 1.2–1.6) and in the South Side (OR, 1.2; 95% CI, 1.1–1.3), but not in the North Side (OR, 1.0; 95% CI, 0.9–1.1).

Conclusions

Following a community stroke preparedness intervention, early hospital arrival and EMS utilization for confirmed ischemic stroke did not increase. However, ambulance transports for suspected stroke increased in the intervention community compared with other regions.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02301299.

Improving the Relationship of Medicaid Home and Community-Based Services Home Care Aides and Clients Through Health Interviewing

Medicaid home and community-based services (HCBS) care plans should be person-centered, yet there is little research on how to ascertain this information in practice. The purpose of this study was to investigate the feasibility of a home care aide (HCA)-led health interview with clients during usual HCBS. We provided interview training, and HCAs (n = 21) conducted five interviews with one client each using a card sort methodology to elicit client care preferences. HCAs audio-recorded interviews and photographed card sorts for analysis. We used a mixed-methods approach of semistructured interviews and focus groups with clients and HCAs to evaluate the health interviewing experience and client surveys of Your Health Orientation, Willingness to Communicate, and PROMIS (Patient-Reported Outcomes Measurement Information System) global health and HCA surveys of the Active Empathetic Listening Scale. We used t tests to investigate changes in survey outcomes pre and post interviews. Results show HCAs can conduct health interviews, and doing so contributes new knowledge on client preferences for care. Clients desire HCAs who provide empathy, compassion, and motivation, and HCAs felt interviewing clients helped them to better understand their care recipient's needs.

Abstract 170: Paramedic-Suspected Stroke Increased after Implementing a Community-Engaged Stroke Preparedness Intervention in Chicago

Introduction: Emergency medical services (EMS) utilization for acute stroke is associated with improved stroke care and outcomes. We evaluated whether a community-engaged stroke preparedness intervention would increase EMS use for suspected stroke.

Methods: The Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS) study was conducted in a South Side Chicago neighborhood with proximity to a primary stroke center. In early 2016, CEERIAS implemented a community-engaged stroke preparedness intervention delivered by trained laypersons from the target community who taught peers about the importance of calling 9-1-1 for acute stroke. Paramedic impressions of all EMS calls were obtained from the municipal EMS provider agency serving the study neighborhood. Using ArcGIS 10.5.1 and ArcGIS Pro 2.1.2 (Esri Inc., Redlands, CA), EMS run locations were geolocated, and Getis-Ord Gi* analysis was used to identify hot spots for EMS-suspected stroke. Statistical hot and cold spots are defined as areas where there is <1% chance of case clusters occurring by chance.

Results: A total of 274,773 EMS runs were successfully geolocated in the 13.5 month pre-CEERIAS intervention period, and 267,061 in the 12.5 month post-CEERIAS intervention period. The study hospital’s neighborhood changed from a cold spot to a hot spot for EMS-suspected stroke (Figure). In the hot spot region adjacent to the study hospital, EMS use for suspected stroke increased 2.2-fold (p<0.001) post-CEERIAS compared to pre-CEERIAS. Overall EMS utilization and EMS utilization for stroke were similar pre- and post-CEERIAS elsewhere in the city.

Conclusions: A community-engaged stroke preparedness intervention was associated with an increase in EMS use for suspected stroke in targeted neighborhoods of Chicago. Further studies should investigate the effect on stroke outcomes and dissemination strategies to broaden the impact of this intervention.

Abstract WP240: Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS): Exploring Stroke Knowledge, Self-Efficacy, and Trust in the Healthcare System in Chicago

Introduction: In a segregated city like Chicago with distinct neighborhood characteristics, a discrepancy between neighborhoods in stroke knowledge, self-efficacy, and trust in the medical system could impact stroke outcomes.

Methods: As part of a study which implemented a culturally-tailored stroke preparedness intervention targeting South (S) Side Chicago communities, individuals attending community health events were recruited in S neighborhoods and North (N) Side neighborhoods pre- and one-year post-intervention to assess stroke knowledge, self-efficacy, and trust. Independent stand-alone pre- and post-sample cohorts were purposefully recruited to match demographics. Survey outcomes included knowledge (assessed via Stroke Action Test, STAT), self-efficacy (Likert scale), trust (Health Care Trust Survey), and stress (Likert). Zip codes divided subjects into S/N neighborhoods. Two-sample t-tests compared cohorts, and interactions between race/ethnicity-time and neighborhood-time were tested, with multivariable linear regression when statistically (p<0.05) significant.

Results: We recruited 364 subjects pre-intervention (S=199, N=165) and 363 subjects post-intervention (S=198, N=165) who were well-matched in race/ethnicity, sex, and education, though the post-group was slightly younger (p=0.04). Unadjusted analysis revealed increases post-intervention in stroke knowledge (p=0.07), self-efficacy (p<0.0001), trust (p<0.0001), and stress scores (p<0.0001). After adjusting for race/ethnicity, gender, and age, the N post-group had greater gains in knowledge (N: 4.0, p=0.02 vs. S: 0.7, p=0.69), self-efficacy (N: 2.3, p<0.0001 vs. S: 0.7, p<0.0001), trust (N: 0.8, p<0.0001 vs. S: -0.1, p=0.20) and stress (N: -0.3, p<0.0001 vs. S: -0.1, p=0.04).

Conclusions: The observed gains in stroke knowledge, self-efficacy, trust, and stress, greater in the North Side of Chicago, could signal overall improved public health messaging around stroke recognition and treatment, but could also point to socioeconomic factors that may have disproportionately benefited North Side residents. Further focused research to understand neighborhood factors which influence stroke awareness and action is necessary.

Abstract TMP73: The Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS) Study: Primary Results

Introduction: Early hospital arrival after stroke increases access to proven treatments and improves outcomes. We hypothesized that a community-engaged stroke preparedness intervention to overcome barriers to early activation of 9-1-1 would increase early hospital arrival and emergency medical services (EMS) use after stroke in high-risk neighborhoods in Chicago.

Methods: We partnered with stakeholders in a South Side Chicago community with a high stroke incidence and in close proximity to a primary stroke center to develop a community stroke preparedness intervention. The intervention was delivered by “stroke promoters”, trained lay persons from the target neighborhood who utilized in-person discussions to overcome barriers and obtain stroke preparedness pledges as measured by “Pacts to Act FAST”. We applied an interrupted time-series analysis at the target hospital to study the effects of the intervention on EMS utilization and hospital arrival within 3 hours of symptom onset among patients with confirmed ischemic stroke. We compared these results to 6 North Side Chicago stroke centers and 17 St. Louis stroke centers as concurrent controls.

Results: During a 12-month period, 242 stroke promoters distributed >110,000 educational materials, participated in 167 community events, and registered 39,975 Pacts to Act FAST, reaching 19.4% of residents in the target South Side neighborhoods. Early arrival increased (0.5%/month post-intervention; p=0.124 for slope change) at the target hospital but was not different compared to North Side hospitals (p=0.560) or St. Louis hospitals (p=0.072). The effect on early arrival was significant among patients <66 years old (0.8%/month increase; p=0.036), men (1.2%/month increase; p=0.026), and African-Americans (0.9%/month increase; p=0.037). No effect was observed on EMS use.

Conclusions: Using a community-engaged approach to deliver a stroke preparedness intervention in Chicago, we observed a modest increase in early hospital arrival after confirmed stroke, which was more pronounced in younger, male, and African-Americans patients. Future efforts should consider improving message penetration and sustainability using novel personal approaches such as social media.

Abstract TP167: Race-ethnic Differences in Barriers To 9-1-1 Use for Acute Stroke in Chicago

Introduction: Racial/ethnic minority and lower income communities are disproportionately affected by stroke. Earlier recognition and treatment after stroke onset improves outcomes. The goal of this study was to understand the barriers to and facilitators of stroke recognition and subsequent action in multi-ethnic, high-risk communities in Chicago to inform a culturally relevant intervention for increasing early hospital arrival after stroke.

Methods: This qualitative research study, funded by PCORI, engaged community members and stakeholders in development of a focus group guide about stroke recognition and action, participant recruitment, and analysis and interpretation of results. Six (4 in English, 2 in Spanish) focus groups (51 participants) were conducted with African-American (n=26), Caucasian (n=12), and Hispanic adults (n=13) in two communities. Analysis of focus group transcripts was done by 4 team members using constant comparative methods in which initial thematic codes were derived from the focus group guide. Initial codes were applied, results compared, and codes revised until agreement was reached among coders.

Results: Themes relating to risk factors, symptoms, knowledge of stroke mechanisms, experience of acute stroke, help seeking, stroke education, recovery, and treatment were identified. Though there was a general understanding of stroke treatments such as “tPA” among all participants, Hispanics frequently discussed folk treatments including "smoothies" and "linseed oil." Specific barriers to calling 9-1-1 included fears about immigration status and fatalism among Hispanics and financial costs and fear/embarrassment of being wrong among African-Americans. Suggestions for stroke education and dissemination included offering resources for low-cost care and treatment among Hispanics and emphasizing neighborhood-level prevalence of stroke among African-Americans.

Conclusions: This study identified differences in knowledge of treatments and attitudes and specific barriers to acute stroke care in minority and lower income communities in Chicago. These findings underscore the importance of engaging communities to tailor interventions and messages to racial/ethnic barriers and needs.

Abstract TP288: Development and Preliminary Results of a Community Partnered Stroke Preparedness Intervention in Chicago

Objective: Delayed recognition and hospital arrival after acute stroke leads to worse outcomes. Given multi-level barriers to calling 9-1-1 for stroke, we sought to develop a community-partnered stroke preparedness intervention in Chicago’s underserved communities (where EMS use is low, despite high stroke incidence and mortality) tailored to neighborhood and cultural needs and barriers.

Methods: As part of the CEERIAS study, we recruited local laypersons to serve as community promoters for a training program that sought to instruct them on delivering targeted messages to their communities. Each half-day training session was facilitated by CEERIAS study investigators, and consisted of a mix of didactic material on stroke statistics relevant to South Side communities, hospital-based tours of the “stroke patient journey,” role playing and tailored strategies for community messaging based on aim 1 focus group findings, and distribution of stroke education materials, “Pact to Act FAST” pledge cards, and website (www.ceerias.com) instructions.

Results: We conducted 21 training sessions for 242 community promoters (81 African-American [AA] males, 133 AA females, 4 Hispanic males, 5 Hispanic females, 3 Caucasian males, 16 Caucasian females) between October 2015 and May 2016. Since training, these community promoters have distributed >110,000 educational materials including FAST cards and magnets and participated in 167 community events. A total of 38,221 Pact to Act FAST pledges have been registered (Figure), 80.3% of which registered in South Side Chicago zip codes (Figure).

Conclusions: A community-partnered stroke preparedness campaign was effective in increasing stroke awareness in underserved minority communities, as noted by the high volume of Pact to Act FAST pledges. Data on 9-1-1 calls for stroke and early arrival after stroke at neighborhood hospitals will be analyzed to assess effect of the intervention.

Abstract WP175: Neighborhood Differences in Stroke Knowledge, Self-efficacy, and Barriers to Calling 9-1-1 in Chicago

Introduction: Differences in self-efficacy, stroke knowledge, and symptom recognition during acute stroke may affect calling 9-1-1, time to hospital arrival, and stroke outcomes. In a segregated city like Chicago, with significant disparities in stroke outcomes, comparing differences between geographic neighborhoods could reveal important areas for focused interventions.

Methods: The ongoing Community Engagement in Early Recognition and Immediate Action in Stroke (CEEERIAS) study is a community- and patient-partnered intervention to improve early hospital arrival for stroke patients in Chicago. As part of study analysis, we conducted surveys of a sample of Chicago residents to assess stroke knowledge, self-efficacy, and barriers to calling 9-1-1. Subjects, recruited at community events, were separated into North Side (N) and South Side (S) groups by subject zip code. Surveys included the validated Stroke Action Test (STAT) for knowledge, self-efficacy scales for willingness to call 9-1-1 for stroke, and the Health Care Trust Survey for trust.

Results: A total of 364 subjects participated (199 in N group and 165 in S group; 55% female [S: 63.6% vs. N: 48.3%]). The N group was more educated while the S group had greater interest in participating in the CEERIAS study, more health problems, and more recent hospital visits. Though stroke knowledge using the STAT was similar, the N group felt more confident recognizing a stroke (p<0.0001). The S group was less likely to believe that immediate hospital care improved post-stroke survival and more likely to believe doctors treated that black patients differently than whites, that hospitals covered up mistakes, and that hospitals experimented on people without consent. The S group was more likely to not call 9-1-1 for fear of financial costs, compared to the N group (23.5% vs. 4.5%, p<0.001).

Conclusion: Though both neighborhoods had similar levels of stroke knowledge, the subjects living on the South Side had higher mistrust of hospitals and were less likely to call 9-1-1 due to financial costs. Understanding neighborhood-level perceptions of healthcare and barriers allows for development and implementation of targeted, nuanced community-partnered interventions to reduce disparities in stroke outcomes.

A method to create a standardized generic and condition-specific patient-reported outcome measure for patient care and healthcare improvement

PURPOSE

Patient-reported outcome measures (PROMs), which are generic or condition-specific, are used for a number of reasons, including clinical care, clinical trials, and in national-level efforts to monitor the quality of health care delivery. Creating PROMs that meet different purposes without overburdening patients, healthcare systems, providers, and data systems is paramount. The objective of this study was to test a generalizable method to incorporate condition-specific issues into generic PROM measures as a first step to producing PROMs that efficiently provide a standardized score. This paper outlines the method and preliminary findings focused on a PROM for osteoarthritis of the knee (OA-K).

METHODS

We used a mixed-methods approach and PROMIS^® measures to test development of a combined generic and OA-K-specific PROM. Qualitative methods included patient focus groups and provider interviews to identify impacts of OA-K important to patients. We then conducted a thematic analysis and an item gap analysis: identified areas covered by existing generic PROMIS measures, identified "gap" areas not covered, compared gap areas to legacy instruments to verify relevance, and developed new items to address gaps. We then performed cognitive testing on new items and drafted an OA-K-specific instrument based on findings.

RESULTS

We identified 52 existing PROMIS items and developed 24 new items across 14 domains.

CONCLUSIONS

We developed a process for creating condition-specific instruments that bridge gaps in existing generic measures. If successful, the methodology will create instruments that efficiently gather the patient's perspective while allowing health systems, researchers, and other interested parties to monitor and compare outcomes over time, conditions, and populations.

The Impact of Strong for Life on the Physical Functioning and Health of Older Adults Receiving Home and Community-Based Services

BACKGROUND/OBJECTIVES

To test the effects of Strong for Life (SFL) on the physical performance and self-rated health of older adults receiving Home and Community-Based Services (HCBS).

DESIGN

Randomized, two-group trial with pre-post measures.

SETTING

In-home exercise program.

PARTICIPANTS

Clients aged 65-95 (n=42) and their Home Care Aide (HCA) (n=32) were randomly assigned to a usual care and SFL intervention or usual care control group.

INTERVENTION

Clients were instructed in SFL by their HCA and completed SFL 3 times per week for 12-weeks.

MEASUREMENTS

Outcomes included grip and quadriceps strength, Timed Up and Go, gait speed, Self-Efficacy for Exercise, pain, and PROMIS-global health measured at baseline and immediately following the intervention. Clients completed opened ended survey items on SFL program evaluation.

RESULTS

Effect sizes were moderate for grip strength (d= .38), pain (d= .34), and PROMIS-global health (d= .27). Small effect sizes were found for all other measures. Median quadriceps and TUG scores differentially improved among intervention participants versus controls. No adverse health events and high program satisfaction were reported. Frailty prevalence in the control group increased between baseline and post-test while frailty prevalence in the intervention group decreased during the same time period.

CONCLUSION

Strong for Life has the potential to improve the strength, mobility, health, and frailty of older adults receiving HCBS. This study provides initial evidence of the impact of SFL for older adults receiving HCBS, as well as the safety of the intervention evidenced by the lack of reported adverse events.

Effect of Moderate to Vigorous Physical Activity Intervention on Improving Dementia Family Caregiver Physical Function: A Randomized Controlled Trial

OBJECTIVE

Alzheimer's disease and related dementias (ADRD) affect more than five million Americans and their family caregivers. Caregiving creates challenges, may contribute to decreased caregiver health and is associated with $9.7 billion of caregiver health care costs. The purpose of this 12 month randomized clinical trial (RCT) was to examine if the Enhancing Physical Activity Intervention (EPAI), a moderate to vigorous physical activity (MVPA) treatment group, versus the Caregiver Skill Building Intervention (CSBI) control, would have greater: (1) MVPA adherence; and (2) physical function.

METHODS

Caregivers were randomly assigned to EPAI or CSBI (N=211). MVPA was assessed using a self-report measure; and physical function was objectively assessed using two measures. Intention-to-treat analyses used descriptive, categorical and generalized estimating equations (GEE), with an exchangeable working correlation matrix and a log link, to examine main effects and interactions in change of MVPA and physical function over time.

RESULTS

At 12 months, EPAI significantly increased MVPA (p=<0.001) and number of steps (p=< .01); maintained stable caregiving hours and use of formal services; while CSBI increased hours of caregiving (p=<0.001) and used more formal services (p=<0.02). Qualitative physical function data indicated that approximately 50% of caregivers had difficulties completing physical function tests.

CONCLUSION

The EPAI had a stronger 12 month effect on caregiver MVPA and physical function, as well as maintaining stability of caregiving hours and formal service use; while CSBI increased caregiving hours and use of formal services. A study limitation included greater EPAI versus CSBI attrition. Future directions are proposed for dementia family caregiver physical activity research.

Sustaining Chicago's Informal Caregivers: an Age-Friendly Approach

The concept of age-friendliness has been globally coined by the World Health Organization (WHO) to give value to the physical, social, and environmental factors that can promote or hinder older residents' ability to age in place in cities. The initiative has been very successful in raising awareness among public health policy makers about the generic needs of older adults and urban features that promote active aging. However, the movement has been less focused on highlighting divergent needs of different older adult populations and their informal caregivers. The objective of this mixed method study is to analyze the ratings of 397 caregivers of urban age-friendly features relative to the ratings of 1737 noncaregivers collected as part of a baseline assessment of the age-friendliness of the city of Chicago. Using the approved WHO Vancouver Protocol, the research team also conducted six mixed caregiver/noncaregiver focus groups (n = 84) and three caregiver-only focus groups (n = 21). Survey findings show that informal caregivers rate all eight age-friendly domains with less satisfaction than do noncaregivers. Discussion in focus groups highlighted some of the reasons for these less favorable ratings and foregrounded the domains and themes that mattered most to caregivers. In conclusion, while our study revealed few systematic differences between caregiver and noncaregiver survey satisfaction ratings, caregivers report significantly poorer health than do noncaregivers. In addition, caregiver-only focus groups foregrounded "missing" priority issues specific to caregivers such as respite and the quality of training and flexibility of home help care. Results suggest that one productive next step for researchers would be to widen the usual range of factors considered essential for maintaining the well-being of informal caregivers of community-dwelling older adults. The age-friendly domains provide a starting point for this. Another would be to develop integrated support and improve service responsiveness to particular caregiver/care recipient dyad's physical, psychological, and social needs.

Impact of an Individualized Physical Activity Intervention on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomized Controlled Trial

PURPOSE

This study examined secondary benefits of an individualized physical activity intervention on improving dementia family caregivers' subjective burden, depressive symptoms and positive affect.

DESIGN AND METHODS

A community-based randomized controlled trial (RCT) was implemented with family caregivers of persons with dementia (N = 211) who received the Enhanced Physical Activity Intervention (EPAI: treatment intervention, n = 106) or the Caregiver Skill Building Intervention (CSBI: control intervention, n = 105). Interventions were delivered over 12 months, including a baseline home visit and regularly spaced telephone calls. Data were collected in person at baseline, 6 and 12-months; and telephonically at 3 and 9-months. The EPAI integrated physical activity and caregiving content while the CSBI focused only on caregiving content. Descriptive, bivariate and intention-to-treat analyses using generalized estimating equations (GEE) were performed to examine secondary benefits of the EPAI on family caregiver burden, depressive symptoms and positive affect.

RESULTS

Compared to caregivers in the CSBI group, caregivers in the EPAI significantly increased their overall and total moderate physical activity and showed a positive interaction between the intervention and time for positive affect at both six (p = 0.01) and 12-months (p = 0.03). The EPAI was significantly associated with improving burden at 3 months (p = 0.03) but had no significant effect on depressive symptoms.

IMPLICATIONS

Caregiver involvement in an individualized physical activity intervention was associated with increased overall and total moderate physical activity and improved positive affect from baseline to 12 months. Improved positive affect may help caregivers to feel better about themselves and their situation, and better enable them to continue providing care for their family member for a longer time at lower risk to their own mental health.

Meta-analysis provides evidence-based interpretation guidelines for the clinical significance of mean differences for the FACT-G, a cancer-specific quality of life questionnaire

Our aim was to develop evidence-based interpretation guidelines for the Functional Assessment of Cancer Therapy-General (FACT-G), a cancer-specific health-related quality of life (HRQOL) instrument, from a range of clinically relevant anchors, incorporating expert judgment about clinical significance. Three clinicians with many years' experience managing cancer patients and using HRQOL outcomes in clinical research reviewed 71 papers. Blinded to the FACT-G results, they considered the clinical anchors associated with each FACT-G mean difference, predicted which dimensions of HRQOL would be affected, and whether the effects would be trivial, small, moderate, or large. These size classes were defined in terms of clinical relevance. The experts' judgments were then linked with FACT-G mean differences, and inverse-variance weighted mean differences were calculated for each size class. Small, medium, and large differences (95% confidence interval) from 1,118 cross-sectional comparisons were as follows: physical well-being 1.9 (0.6-3.2), 4.1 (2.7-5.5), 8.7 (5.2-12); functional well-being 2.0 (0.5-3.5), 3.8 (2.0-5.5), 8.8 (4.3-13); emotional well-being 1.0 (0.1-2.6), 1.9 (0.3-3.5), no large differences; social well-being 0.7 (-0.7 to 2.1), 0.8 (-2.9 to 4.5), no large differences. Results from 436 longitudinal comparisons tended to be smaller than the corresponding cross-sectional results. These results augment other interpretation guidelines for FACT-G with information on sample size, power calculations, and interpretation of cancer clinical trials that use FACT-G.

Developing a self-report outcome measure for complementary and alternative medicine

OBJECTIVE

Our objective was to develop a pilot measure of subjective outcomes of complementary and alternative medicine (CAM). Current options for assessing subjective outcomes in CAM are either too burdensome or fail to represent diverse outcomes. A single measure specifying common, patient-reported outcomes of CAM would be of value.

DESIGN

We conducted a three-phase instrument development study. In phase I, 30 CAM-receiving patients and 12 CAM practitioners completed a battery of standardized measures. Participants identified those standardized items relevant to CAM outcome and suggested additional outcome issues. In phase II, 20 CAM-receiving patients completed a Q-sort to determine which items from phase I were most relevant to CAM outcome. In phase III, five experts reviewed the items from phase II for content validity.

SETTING

An integrative medicine clinic at a private, Midwest US hospital.

PARTICIPANTS

CAM patients, practitioners, and researchers and an outcomes measurement specialist.

RESULTS

In phase I, 30 standardized items were judged relevant to CAM outcome, and 8 additional items were suggested. In phase II, 29 of the 38 phase I items were deemed at least "moderately relevant" to CAM outcome. In phase III, experts added 15 items, dropped 9 items, and altered 3 items. The 35 resulting items were classified into content domains, forming a testable, pilot version of the instrument.

Biochemical abnormalities in patients with slipped capital femoral epiphysis and chondrolysis

A prospective clinical and laboratory study was performed in thirty-four patients (twenty-two blacks, ten Puerto Ricans, and two whites) who had slipped capital femoral epiphysis in fifty-two hips. Although the majority of the laboratory studies were normal, all patients showed significant elevations of the serum immunoglobulins and C3 component of complement, with the highest values recorded for IgA. Urinary glycosaminoglycans were elevated in the few patients studied and increased proportionally with the duration of the disease. Nine (25 per cent) of the thirty-four patients had chondrolysis in thirteen hips. The male:female ratio in these nine patients was 0.8:1, compared with the ratio of 1.4:1 in all thirty-four patients. No additional biochemical abnormality was found in the patients with chondrolysis except for a greater elevation of the IgM fraction. These preliminary and tentative data suggest either that slipping of an epiphysis produces an antigen which induces an autoimmune state or that slipping is a localized manifestation of a generalized process resembling some form of connective-tissue disorder or inflammatory state. There is presumably a genetically determined sub-group of patients with this disorder who may have chondrolysis.