The perceived behavior and barriers of community care professionals in encouraging functional activities of older adults:the development and validation of the MAINtAIN-C questionnaire

Background: Community care professionals need to encourage older adults in performing functional activities to maintain independence. However, professionals often perform functional activities on behalf of older adults. To change this, insights into the behavior and barriers of professionals in encouraging activities are required. In the current study, the MAINtAIN questionnaire, which was developed for nursing homes, was adopted. The objective was to create a modified version that is suitable for measuring behavior and barriers of community care professionals in encouraging functional activities of clients in the community care setting. The overall aims were to assess the content validity, construct validity, and internal consistency of the modified version. Methods: Data was collected by qualitative and quantitative methods in two phases. During phase one, the MAINtAIN was assessed on appropriateness and feasibility by community nurses (N = 7), and the adapted questionnaire was assessed on content validity by research experts (N = 9) and community care professionals (N = 18). During phase two, the psychometric properties of the adapted MAINtAIN-C were assessed in community care professionals (N = 80). Construct validity was evaluated by an Exploratory Factor Analysis (EFA), and internal consistency was determined by calculating Cronbach’s alpha coefficients. Results: The formulation, verbs, and wording of the MAINtAIN were adapted; some items were excluded and relevant items were added, resulting in the MAINtAIN-C with two scales, showing good content validity. The Behaviors scale (20 items) measures perceived behavior in encouraging functional activities, expressing good internal consistency (Cronbach’s alpha: .92). The Barriers scale measures barriers in encouraging functional activities related to two dimensions: 1) the clients’ context (7 items), with good internal consistency (.78); and 2) the professional, social, and organizational contexts (21 items), showing good internal consistency (.83). Conclusions: The MAINtAIN-C seems promising to assess the behavior and barriers of community care professionals in encouraging functional activities. It can be used to display a possible difference between perceived and actual behavior, to develop strategies for removing barriers in encouraging activities to foster behavioral change. The results also provide guidance for further research in a larger sample to obtain more insight into the psychometric properties

Safety and clinical utility of four clinical decision rules in the diagnostic management of acute pulmonary embolism-the prometheus diagnosis study

Background: Several clinical decision rules (CDRs) are available for the exclusion of acute pulmonary embolism (PE). This prospective multi-center study compared the safety and clinical utility of four CDRs (Wells rule, revised Geneva score, simplified Wells rule and simplified revised Geneva score) in excluding PE in combination with D-dimer testing. Methods: Clinical probability of patients with suspected acute PE was assessed using a computerized based “black box”, which calculated all CDRs and indicated the next diagnostic step. A “PE unlikely” result according to all CDRs in combination with a normal D-dimer result excluded PE, while patients with “PE likely” according to at least one of the CDRs or an abnormal D-dimer result underwent CT-scanning. Patients in whom PE was excluded were followed for three months. Results: 807 consecutive patients were included and PE prevalence was 23%. The number of patients categorized as “PE unlikely” ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal D-dimer level, the CDRs excluded PE in 22-24% of patients. The total failure rates of the CDR-D-dimer combinations were similar (1 failure, 0.5- 0.6%, upper 95% CI 2.9- 3.1%). Despite 30% of the patients had discordant CDR outcomes, PE was missed in none of the patients with discordant CDRs and a normal D-dimer result. Conclusions: All four CDRs show similar safety and clinical utility for exclusion of acute PE in combination with a normal D-dimer level. With this prospective validation, the more straightforward simplified scores are ready for use in clinical practice

Concerns in using multi-detector computed tomography for diagnosing pulmonary embolism in daily practice. A cross-sectional analysis using expert opinion as reference standard

Item does not contain fulltextMulti-detector computed tomography (MDCT) is considered to be the reference standard in diagnosing pulmonary embolism (PE). However, two concerns remain. Firstly, with the introduction of MDCT the prevalence of (sub)segmental emboli increased but the clinical implications of these small clots are uncertain. Secondly, we are not well informed about the number of false-positive CT-scans due to the lack of a gold standard.We used data from a prospective primary care study including patients suspected of pulmonary embolism. CT-scan-reading by the local radiologist in daily care was retrospectively compared with expert reading as reference standard. Final diagnosis was categorized as central/lobar, segmental or subsegmental PE.A total of 79 patients were included. In 3 of 30 patients (10\%) diagnosed with PE by the local radiologist the experts refuted the diagnosis. In 7 of 49 patients (14\%) not diagnosed with PE by the local radiologist the experts confirmed the presence of PE. The experts diagnosed 17 of 32 PE-patients (53\%) with a central or lobar PE. All these 17 patients were also diagnosed with PE by the local radiologist. The experts diagnosed 15 patients with (sub)segmental PE. In 7 of these 15 patients (47\%) the local radiologist refuted PE.Accuracy of MDCT using the expert radiologist as reference standard is not optimal. On the one hand it shows 10\% false-positives exposing patients to anticoagulant treatment unnecessarily. On the other hand small emboli seem to be missed although the clinical implications of this finding are not fully clear