Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Phase I trial of alpelisib in combination with concurrent cisplatin-based chemoradiotherapy in patients with locoregionally advanced squamous cell carcinoma of the head and neck

BACKGROUND

Deregulation of the PI3K signalling pathway is frequent in squamous cell carcinoma of the head and neck (SCCHN) and may be implicated in radioresistance. We report on the results from a phase I 3 + 3 dose escalation study of alpelisib, a class I α-specific PI3K inhibitor in combination with concurrent cisplatin-based chemoradiation (CRT) in patients with locoregionally advanced SCCHN (LA-SCCHN).

METHODS

Eligible patients had previously untreated LA-SCCHN and were candidates for CRT. The primary objective was to evaluate safety and determine the recommended phase II dose (RP2D). Alpelisib was given orally once daily at two dose levels: 200 mg and 250 mg. CRT consisted of cisplatin 100 mg/m² IV every three weeks and standard fractionation radiotherapy (IMRT) 70 Gy in 35 fractions.

RESULTS

Nine patients were enrolled (six alpelisib 200 mg, three 250 mg). Oropharynx was the primary site in all patients (seven p16-positive; five T1-2N2M0, four T3-4N2-3M0 [AJCC 7th edition]). All patients completed CRT within seven weeks. Grade 3 alpelisib-related toxicities occurred in four patients. No dose-limiting toxicity (DLT) was observed at 200 mg among three DLT-evaluable patients. Two of two DLT-evaluable patients treated at 250 mg experienced DLTs (inability to complete ≥75% alpelisib secondary to radiation dermatitis and febrile neutropenia). Thus, RP2D was declared at 200 mg. After median follow-up of 39.7 months, two patients developed pulmonary metastases despite locoregional control. Three-year overall survival was 77.8% (95% CI 36.5%-93.9%).

CONCLUSION

Alpelisib at 200 mg has a manageable safety profile in combination with cisplatin-based CRT in LA-SCCHN.

Biomechanical evaluation of nursing tasks in a hospital setting

A field study was conducted to investigate spinal kinematics and loading in the nursing profession using objective and subjective measurements of selected nursing tasks observed in a hospital setting. Spinal loading was estimated using trunk motion dynamics measured by the lumbar motion monitor (LMM) and lower back compressive and shear forces were estimated using the three-dimensional (3D) Static Strength Prediction Program. Subjective measures included the rate of perceived physical effort and the perceived risk of low back pain. A multiple logistic regression model, reported in the literature for predicting low back injury based on defined risk groups, was tested. The study results concluded that the major risk factors for low back injury in nurses were the weight of patients handled, trunk moment, and trunk axial rotation. The activities that required long time exposure to awkward postures were perceived by nurses as a high physical effort. This study also concluded that self-reported perceived exertion could be used as a tool to identify nursing activities with a high risk of low-back injury.

Impact of school-based health centers on children with asthma

PURPOSE

To quantitatively assess the impact of school-based health centers (SBHCs) on hospitalization and emergency department (ED) visits for children with asthma.

METHODS

The study was conducted at four SBHC intervention school districts and two comparable non-SBHC school districts in Greater Cincinnati, Ohio. A longitudinal quasi-experimental time-series repeated measures design was used with a study period from 1997 to 2003. Children with asthma with at least 2 years of continuous enrollment who had medical claims for asthma diagnosis and antiasthmatic medications were selected. The primary data sources were student enrollment data from the schools and the Ohio Medicaid claims database. Generalized estimating equation (GEE) analysis and analysis of covariance were used to assess the intervention effect before and after the SBHC program.

RESULTS

Asthma was one of the major diseases for SBHC encounters. Major prescription drugs that SBHC staff managed for children with asthma included albuterol, montelukast, fluticasone, budesonide, and triamcinolone. Of 273 children (196 in SBHC schools and 77 in non-SBHC schools), 42% were female, 41.7% African-Americans, and the average age was 8.2 years. After the opening of the SBHC, relative risks of hospitalization and ED visits in the SBHC group decreased 2.4-fold and 33.5%, respectively. The cost of hospitalization per child decreased significantly over time for children in SBHC schools (F = 4.115, p = .044). After SBHCs opened, cost of hospitalization decreased for African-American children (F = 5.198, p = .023). Costs of ED visits for children in SBHC schools were significantly lower than children in non-SBHC schools (F = 19.8, p < .0001).

CONCLUSIONS

The risk of hospitalization and ED visits for children with asthma decreased significantly with SBHC programs. The potential cost-savings for hospitalization was estimated as 970 dollars per child.

Interpretation of three-dimensional structure from two-dimensional endovascular images: implications for educators in vascular surgery

PURPOSE

Endovascular therapy has had a major effect on vascular surgery; surgeons perform tasks in three dimensions (3D) while viewing two-dimensional (2D) displays. This fundamental change in how surgeons perform operations has educational implications related to learning curves and patient safety. We studied the effects of experience, training, and visual-spatial ability on 3D perception of 2D angiographic images of abdominal aortic aneurysms (AAA).

METHODS

A novel computer-based method was developed to produce 3D depth maps based on subjects' interpretations of 2D images. Seven experts (certified vascular surgeons) and 20 novices (medical or surgical trainees) were presented with a 2D AAA angiographic image. With software specifically designed for this study, a depth map representing each subject's 3D interpretation of the 2D angiogram was produced. The novices were then randomized into a control group and a treatment group, who received a 5-minute AAA anatomy educational session. All subjects repeated the exercise on a second AAA image. Finally, all novices were given tests of visual-spatial ability, including the Surface Development Test and the Mental Rotations Test. Comparisons between experts and novices were made with depth map comparison, a subject's perception of overall object contour.

RESULTS

The depth maps were significantly different (depth map comparison, P <.001) between the expert and both novice groups for the first image. After the educational intervention, the control group and the treatment group exhibited significantly different depth maps (depth map comparison, P <.001), with treatment group depth maps more similar to those of the expert group. There were no significant correlations between the visual-spatial tests and the novice depth map comparison with the expert group.

CONCLUSIONS

This is the first study to examine perception of endovascular images in an educational context. Perception of overall surface contour of 3D structures from 2D angiographic images is affected by experience and training. With application of methods of vision science to an important problem in surgery, this research represents a first step in understanding the nature of visual perceptual processes involved in execution of an increasingly common clinical task. These results have implications for understanding and studying the endovascular learning curve.

CLINICAL RELEVANCE

This research represents a unique collaboration in an effort to understand and solve one of the greatest problems facing surgical educators and surgeons. This research uses applied tools in vision science to understand the perceptual constraints involved in minimally invasive surgery. Specifically, we examined the mental three-dimensional maps experts use when viewing two-dimensional displays. Furthermore, we compared experts with novices in an effort to assist surgical trainees.

Time and cost analysis of repacking medications in unit-of-use containers

OBJECTIVES

To evaluate the effects of repacking drugs in unit-of-use containers in community pharmacies. The purpose of this study was to examine whether unit-of-use repacking reduces routine mechanical "counting and pouring" to allow more time for pharmaceutical care.

DESIGN

Simulation pilot study to evaluate the differences between the existing and proposed systems. Based on the literature, four variables--optimum pack size, time savings, packaging costs, and shelving requirements--were selected for evaluation. Historical prescription data from a chain were used in determining the sample drugs and their optimum pack sizes. Workflow analysis and time study were used to estimate the time savings. Manufacturer bottles, repack bottles, and shelves were measured to determine the impact of using unit-of-use containers on storage requirements.

SETTING

Three community pharmacies in a major drugstore chain in Cincinnati, Ohio.

RESULTS

The 25 fastest-moving solid oral dosage forms, representing 21.6% of all drugs dispensed by the chain, were selected as the sample drugs for the study. The workflow analysis and time study revealed that 0.79 minutes could be saved per prescription if repacked drugs were used. There was an increased cost of approximately $0.05 for every repack bottle used in place of a prescription vial. It was calculated that repacking in unit-of-use containers would increase storage requirements in the pharmacy by 2.5 times if current inventory levels were maintained.

CONCLUSION

Repacking drugs in unit-of-use containers is potentially an inexpensive method to increase usable time in the pharmacy that does not require an increase in personnel or the purchase of additional technology at the store level.

Re-engineering a pharmacy work system and layout to facilitate patient counseling

The development and evaluation of a new work system and facility design for a chain of community pharmacies are described. A new work system was developed to optimize utilization of pharmacist and technician time and allow the pharmacy to increase patient counseling without adding personnel. In the new system, pharmacists would review prescriptions, check technicians' work, and dispense prescriptions, counseling patients as needed; technicians would enter prescriptions into the pharmacy computer and fill them. The existing work system and design were evaluated in June and July of 1992 by observing, classifying, and recording activities of pharmacy personnel three days per week at six pharmacies in the chain. Pharmacy designs that would work with the new work system were created by a university design class after consultation with representatives of the pharmacy chain and the university's college of pharmacy. The pharmacy chain selected one design, and a detailed floor plan and specifications were created. To test how the new design and system would work at each of the six test pharmacies, a computer simulation program was developed and verified by using the data collected on the existing pharmacy operations. Computer simulation showed that, with the new design and system, increasing patient counseling would increase patient waiting time slightly but would not require additional personnel. The layout and work system in a chain of community pharmacies were redesigned to facilitate patient counseling and make the best use of employee time.

Factors affecting practice-area choices by pharmacy students in the Midwest

The results of a survey to determine the first-choice practice intentions of midwestern pharmacy students and to describe and quantify the factors affecting their decisions are reported. Questionnaires were sent to 12 pharmacy schools in American Association of Colleges of Pharmacy District IV and distributed during November 1988 to January 1989. The questionnaires were given to entry-level pharmacy students who were in their final year of study. The students were asked to indicate their preferred practice setting upon graduation and to rate the importance of 21 factors that a pharmacist might consider when selecting a first position. A total of 715 usable responses were received (response rate, 6.75%). OF the respondents, 83.2% were enrolled in B.S. degree programs and 16.8% in entry-level Pharm.D. degree programs. The distribution of first choices of a practice area was as follows: chain community pharmacy, 33.1%; hospital pharmacy, 27.6%; independent community pharmacy, 12.4%; industry, 8.4%; "other," 5.5%; ambulatory-care clinic, 5.2%; graduate school, 3.8%; department store, discount store, or grocery store, 1.7%; home health care, 1.5%; and nursing home, 0.8%. The three factors ranked as most important in affecting the choice of a practice area were personal fulfillment, salary, and the opportunity to use one's abilities and education. The ranking of the factors varied depending on the practice area chosen. Midwestern pharmacy students were most interested in chain community and hospital pharmacy practice settings. Retail-oriented students placed salary concerns first, whereas clinically oriented students emphasized personal fulfillment. These findings have implications for recruitment strategies.

Biochemical measurement in cord blood as an indicator of neonatal maturity

Neonates were categorized by gestational scoring (G. Score) using physical and neurological signs, into two groups: TERM and preterm (PRE) using a score corresponding to approximately 38 weeks of gestation as the dividing point. Cord blood concentrations of alphafetoprotein (AFP), fetal hemoglobin (HGF), prealbumin (PALB), creatinine (CRE), and pseudocholinesterase (PC) were determined. The CRE, AFP, and HGF were divided by birthweight in grams (WT) to give three additional markers: CRE/WT, AFP/WT and HGF/WT. Strong Pearsonian correlations between CRE/WT, AFP/WT, and HGF/WT, and G. Scores in the PRE group were obtained. Histograms of AFP/WT and HGF/WT values gave non-Gaussian distributions and resulted in the clear separation of a group of extremely premature infants from the rest of the population. The plots also revealed substantial separation between the TERM and PRE groups. The CRE/WT was predominantly Gaussian, with separation of a group of neonates including the six very preterm infants. It is concluded that CRE/WT, AFP/WT, and HGF/WT have the greatest potential as maturity markers, while PC and PALB have little if any potential.

Tapping employee insights with the Nominal Group Technique

In our scenario, we brought together the manager, pharmacist, full-time and part-time sales people, the delivery person, and the stock person, to give a perspective from every possible area of operation. We have found that input from all employees often generates ideas that they would not have thought of on their own. We suggest that NGT, used on a quarterly basis, for instance, would be an excellent means of developing team spirit, employee participation, and meaningful and effective solutions to problems. NGT is much better than trying to "go it alone," especially in today's competitive environment. NGT helps us realize that the potential contribution of employees is great, but generally untapped. The process requires planning but little time; yet it can produce astounding results, both in encouraging team spirit and in protecting profitability. The process fosters effective use of a participative style of management. It forces us, in effect, to use our most valuable resource: the people we manage.

Hemoglobin F: relationship to maturity measures in the neonate

The maturity of organ functioning is a key to predicting neonatal prognosis, particularly in preterm babies, and laboratory tests have the potential for providing better information than external exams. This approach was examined utilizing the fetal protein, HGB F. While HGB F itself does not correlate well with current measures of maturity, HGB F/WT was found to correlate very strongly, in a linear relationship with the gestational score (G. Score) obtained from a physical and neurological assessment of the neonate. This relationship was not affected by sex or race in our population. A cut-off value for HGB F/WT of 0.025 was chosen as the difference between mature and immature neonates and the value of the test using that cut-off was determined. Infants were classified as preterm or term based upon G. Score and gestational age (from the mother's last menstrual period) and were further classified depending upon whether the HGB F/WT value indicated a mature or premature infant. Utilizing predictive theory, the test was found to have a predictive value of 0.914 with an overall test efficiency of 0.967. These results indicate that this measurement has potential as a maturity marker in neonates.

Medicaid formularies: a critical review of the literature

Studies on the impact of restricted Medicaid formularies were reviewed to assess whether other drugs on the formulary were substituted for restricted drugs, the cost of the substitutes, whether the substitutes were therapeutically appropriate, whether restricted drugs continued to be prescribed, what incremental administrative costs accompanied restrictions, what indirect costs occurred and how the cost-effectiveness of pharmaceuticals impinged on the total cost of illness. The assumption that restriction of specific drugs results in savings in the drug costs proportional to prior usage was shown to be questionable, numerous studies found alternate formulary drugs to the restricted drugs being prescribed, or patients were paying out-of-pocket for denied drugs. There was a tendency for alternate drugs to be more expensive. Little information exists as to the incremental administrative costs of restricted formularies or the therapeutic appropriateness of substituted drugs. One study suggests that major shifts in costs occur due to restrictive formularies through substitution of more expensive services such as hospitalization in lieu of pharmaceuticals. It is concluded that restricting formularies leads to dynamic changes in the total Medicaid program of a complex and often costly nature. Plans to implement formulary restrictions require considerable careful thought.

General purpose of research designs

The purposes and criteria for formulating a design of research, conditions for judging causality, and use of research design as a control of variance are discussed. The purpose of a research design is to provide a plan of study that permits accurate assessment of cause and effect relationships between independent and dependent variables. The classic controlled experiment is an ideal example of good research design. Factors that jeopardize the evaluation of the effect of experimental treatment (internal validity) and the generalizations derived from it (external validity) are identified. Sources of variance can be controlled by eliminating a variable, randomization, matching, or including a variable as part of the design. A research project should be so designed that (1) it answers the questions being investigated, (2) extraneous factors are controlled, and (3) the degree of generalization that can be made is valid.