Are there valid proxy measures of clinical behaviour?

Background: Accurate measures of health professionals' clinical practice are critically important to guide health policy decisions, as well as for professional self-evaluation and for research-based investigation of clinical practice and process of care. It is often not feasible or ethical to measure behaviour through direct observation, and rigorous behavioural measures are difficult and costly to use. The aim of this review was to identify the current evidence relating to the relationships between proxy measures and direct measures of clinical behaviour. In particular, the accuracy of medical record review, clinician self-reported and patient-reported behaviour was assessed relative to directly observed behaviour. Methods: We searched: PsycINFO; MEDLINE; EMBASE; CINAHL; Cochrane Central Register of Controlled Trials; science/social science citation index; Current contents (social & behavioural med/clinical med); ISI conference proceedings; and Index to Theses. Inclusion criteria: empirical, quantitative studies; and examining clinical behaviours. An independent, direct measure of behaviour (by standardised patient, other trained observer or by video/audio recording) was considered the 'gold standard' for comparison. Proxy measures of behaviour included: retrospective self-report; patient-report; or chart-review. All titles, abstracts, and full text articles retrieved by electronic searching were screened for inclusion and abstracted independently by two reviewers. Disagreements were resolved by discussion with a third reviewer where necessary. Results: Fifteen reports originating from 11 studies met the inclusion criteria. The method of direct measurement was by standardised patient in six reports, trained observer in three reports, and audio/video recording in six reports. Multiple proxy measures of behaviour were compared in five of 15 reports. Only four of 15 reports used appropriate statistical methods to compare measures. Some direct measures failed to meet our validity criteria. The accuracy of patient report and chart review as proxy measures varied considerably across a wide range of clinical actions. The evidence for clinician self-report was inconclusive. Conclusion: Valid measures of clinical behaviour are of fundamental importance to accurately identify gaps in care delivery, improve quality of care, and ultimately to improve patient care. However, the evidence base for three commonly used proxy measures of clinicians' behaviour is very limited. Further research is needed to better establish the methods of development, application, and analysis for a range of both direct and proxy measures of behaviour

The Effect of Mobility Device Use on Strength, Fatigue and Quality of Life in Persons with Multiple Sclerosis

Abstract: The variability of symptoms in persons with multiple sclerosis (MS) leads to dilemmas in clinical decision-making related to mobility device prescription. When is a good time to consider a switch to wheeled mobility? What is the best type of wheeled mobility? What are the changes one can expect as they transition? Three studies addressed these questions. First, we investigated the characteristics of individuals with MS who are about to transition to wheeled mobility. Seven ambulatory individuals with MS performed the timed 25-foot walk test (T25FW), and completed questionnaires measuring quality of life (QoL), self-reported fatigue, and participation. These individuals were not able to ambulate at functional speeds and had "sedentary" activity levels. They also had QoL below that of the general population. Next, we investigated changes that accompany a transition in primary means of mobility. Eleven individuals with MS or other chronic conditions leading to a decline in mobility function participated. We collected strength, fatigue, participation and QoL data at baseline, and after mobility intervention. Substantive results revealed that individuals may not experience the expected declines in strength and endurance as they transition. Furthermore, they experienced improvements in QoL concomitant with amount of daily device use. Methodological results revealed difficulties in conducting longitudinal mobility studies, and addressed research design barriers. Finally, we investigated whether a difference exists in the type of wheeled mobility issued to veterans with MS when compared to veterans with a spinal cord injury (SCI). Using the National Prosthetic Patient Database, we isolated all veterans with MS or an SCI who received a wheelchair or scooter in 2000 and 2001. We found that the quality of wheeled mobility devices issued to individuals with MS was inferior to those issued to individuals with SCI. These studies provide preliminary evidence that individuals with MS may be waiting too long to transition to the use of wheeled mobility. When they do receive a wheelchair, veterans with MS tend to receive a lower quality of wheelchair. Finally, we made suggestions for conducting longitudinal mobility research in this population, and emphasized the need for future studies

Prevalence, drivers and surveillance of antibiotic resistance and antibiotic use in rural China: Interdisciplinary study

From PLOS via Jisc Publications RouterHistory: received 2022-10-06, collection 2023, accepted 2023-05-22, epub 2023-08-09Acknowledgements: The authors acknowledge the multidisciplinary study team for their help and guidance in conducting this research. In particular, we thank Tao Jiang, Xuemeng Dong, Maomao Xie and AMU graduate students for data collection, and Melissa Cole for support with coordination. This work could only be accomplished through the active involvement of many health professionals and patients in the study sites and we are very grateful for their willingness to participate in this study. We also thank the anonymous reviewers whose comments helped us to improve the manuscript.Publication status: PublishedFunder: Newton Fund; funder-id: http://dx.doi.org/10.13039/100010897; Grant(s): MR/P00756/1Funder: Natural Science Foundation of China; Grant(s): 81661138001Paul Kadetz - ORCID: 0000-0002-2824-1856 https://orcid.org/0000-0002-2824-1856This study aimed to characterise antibiotic prescribing and dispensing patterns in rural health facilities in China and determine the community prevalence of antibiotic resistance. We investigated patterns and drivers of antibiotic use for common respiratory and urinary tract infections (RTI/UTI) in community settings, examined relationships between presenting symptoms, clinical diagnosis and microbiological results in rural outpatient clinics, and assessed potential for using patient records to monitor antibiotic use. This interdisciplinary mixed methods study included: (i) Observations and exit interviews in eight village clinics and township health centres and 15 retail pharmacies; (ii) Urine, throat swab and sputum samples from patients to identify potential pathogens and test susceptibility; (iii) 103 semi-structured interviews with doctors, patients, pharmacy workers and antibiotic-purchasing customers; (iv) Assessment of completeness and accuracy of electronic patient records through comparison with observational data. 87.9% of 1123 recruited clinic patients were prescribed antibiotics (of which 35.5% contained antibiotic combinations and >40% were for intravenous administration), most of whom had RTIs. Antibiotic prescribing for RTIs was not associated with presence of bacterial pathogens but was correlated with longer duration of infection (OR = 3.33) and presence of sore throat (OR = 1.64). Fever strongly predicted prescription of intravenous antibiotics (OR = 2.87). Resistance rates in bacterial pathogens isolated were low compared with national data. 25.8% of patients reported antibiotics use prior to their clinic visit, but only 56.2% of clinic patients and 53% of pharmacy customers could confirm their prescription or purchase included antibiotics. Diagnostic uncertainty, financial incentives, understanding of antibiotics as anti-inflammatory and limited doctor-patient communication were identified as key drivers of antibiotic use. Completion and accuracy of electronic patient records were highly variable. Prevalence of antibiotic resistance in this rural population is relatively low despite high levels of antibiotic prescribing and self-medication. More systematic use of e-records and in-service training could improve antibiotic surveillance and stewardship in rural facilities. Combining qualitative and observational anthropological methods and concepts with microbiological and epidemiological investigation of antibiotic resistance at both research design and analytic synthesis stages substantially increases the validity of research findings and their utility in informing future intervention development.The Newton Fund supported this study under the UK-China AMR Partnership Initiative through UK Research & Innovation (UKRI) grant number MR/P00756/1 (grant recipient: Helen Lambert) and National Natural Science Foundation of China (NSFC) grant number 81661138001 (grant recipient: Debin Wang). The funding source had no role in study design, analysis or in the decision to submit the manuscript for publication. RK, CC, MH and IO all acknowledge support from the NIHR Health Protection Research Unit in Evaluation of Interventions at the University of Bristol.pubpu

Antibiotic Overuse in the Geriatric Population

The Centers for Medicare and Medicaid are requiring long-term care facilities (LTCFs) to implement antibiotic stewardship programs (ASPs) to alleviate overuse of antibiotics in the nursing home population. Current research shows that the benefits of ASPs include improved patient outcomes, reduced adverse events related to Clostridium difficile (C-diff) infection, improvement in rates of antibiotic susceptibilities, and optimized resource utilization. This project addressed the problem of antibiotic overuse and misuse in the geriatric population and whether the implementation of an ASP reduced the overuse of antibiotics, C-diff infection, and resistance rates in the LTCF. Application of the Johns Hopkins nursing model and Centers for Disease Control framework informed this project. An ASP was implemented by the organization. This project evaluated the program preASP and postASP over a 10-month period. A descriptive analysis was used to compare the number of new antibiotic starts, C-diff cases, and resistant cases before and after ASP implementation. The total number of cases of resistance declined from 12 to 10 cases after the ASP was implemented, which was a 16.67% decline. The number of monthly new antibiotic orders for the time period evaluated declined from 120 to 110 respectively, which was an 8.3% change. There was no change in the number of C-diff infections. The results demonstrated that implementing the ASP led to a decline in antibiotic misuse, overuse, and resistance cases. This project supports social change by expanding the healthcare team\u27s knowledge regarding the project problem and informing future interventions to be implemented to help reduce antibiotic overuse and misuse in the geriatric population

Monitoring patient profiles from the pharmacy : an opportunity for the pharmacist to contribute to patient care

The literature clearly indicates that pharmacist monitoring of hospital patients by use of a patient profile is needed. The literature does not, however, describe a method of selecting the information to be included on the profile. Since monitoring needs vary from hospital to hospital, a method of identifying specific needs is necessary. Therefore, this study was undertaken in three parts to develop such a method. Part I was concerned with devising a list of the types of information which can be monitored by the pharmacist. This list included both patient information, such as age and weight, and therapeutic information, such as drug regimens and laboratory tests. Another list was then generated of all contributions a pharmacist can make to patient care. A contribution was defined as any action the pharmacist can take to insure safety of the patient's drug-related therapy and to provide for the optimal use of medications. It was then possible to identify which types of information lead to making specific contributions to patient care and which were non-productive. Part II consisted of designing the A-P-C (All-Possible-Contributions) profile. This profile contains all of the information found in part I to be useful, enabling the pharmacist to make all of the contributions possible to patient care. The third part was the application of the newly devised A-P-C profile to an actual hospital pharmacy practice. The contributions to patient care which were needed were identified on the basis of finding drug-drug interactions, adverse drug reactions, etc. occurring in the sampled patients' therapy. Once the needed contributions were identified by use of the A-P-C profile, the pharmacist was able to know which types of information he must monitor. Any extraneous information was then eliminated from the A-P-C profile, and a new profile drawn up for use thereafter. In part I, seventeen types of information were found to be useful for making the fifteen possible contributions to patient care. Application of the A-P-C profile to the actual hospital practice indicated that fourteen types of information should be monitored to make possible the twelve contributions shown to be needed. The results of the study indicate that the A-P-C profile can be used to identify the specific monitoring requirement of a given hospital pharmacy practice, which can lead to safer and more effective therapy

Three Essays on Health, Health Care, and Healthy Ageing

This thesis consists of three empirical studies focusing on the health and health care utilisation of older adults using the healthy ageing framework proposed by the World Health Organization in 2015. In Essay 1, I examine the relationships between life-course factors and intrinsic capacity, a break-through and strengths-based composite measure of ageing. I find that unfavourable early-life factors directly decrease late-life intrinsic capacities, particularly cognitive, sensory and psychological capacities rather than locomotor functioning and vitality, and these effects are exacerbated by the cumulative socioeconomic inequalities over a person’s life course. In Essay 2, I employ the method of standardised patients to identify the overuse of health care, document its patterns, and quantify its financial impact on patients in primary care in China. My findings suggest that overuse is pervasive in primary care in China and leads to a significant increase in health care expenditure. The overuse in my setting seems unlikely to be attributable to physician incompetence. My findings shed light on the cost escalation of primary care in China, which is a form of medical inefficiency that should be urgently addressed. In Essay 3, I further investigate the impact of physician over-service on the quality of care provided, since physician over-service can also contribute to physicians’ learning and therefore better health care. I report new evidence that physician over-service is associated with a significant increase in physicians’ investment in learning, such as consultation length, adherence to checklists, and patient-centred communication, but no significant change in giving a correct diagnosis, correct drug prescriptions or a referral. Moreover, over-service in drugs is associated with a significant increase in physicians’ better learning and the provision of correct drugs. However, my findings imply that physician over-service does not improve the accuracy of physicians’ decisions. The higher rate of correct drug prescriptions was mainly explained by the prescription of more drugs

Ordered Diagnosis

We propose to regard a diagnostic system as an ordered logic theory, i.e. a partially ordered set of clauses where smaller rules carry more preference