Reference bias: presentation of extreme health states prior to eq-vas improves health-related quality of life scores. a randomised cross-over trial

Background: Clinical practice and clinical research has made a concerted effort to move beyond the use of clinical indicators alone and embrace patient focused care through the use of patient reported outcomes such as healthrelated quality of life. However, unless patients give consistent consideration to the health states that give meaning to measurement scales used to evaluate these constructs, longitudinal comparison of these measures may be invalid. This study aimed to investigate whether patients give consideration to a standard health state rating scale (EQ-VAS) and whether consideration of good and poor health state descriptors immediately changes their selfreport. Methods: A randomised crossover trial was implemented amongst hospitalised older adults (n = 151). Patients were asked to consider descriptions of extremely good (Description-A) and poor (Description-B) health states. The EQ-VAS was administered as a self-report at baseline, after the first descriptors (A or B), then again after the remaining descriptors (B or A respectively). At baseline patients were also asked if they had considered either EQVAS anchors. Results: Overall 106/151 (70%) participants changed their self-evaluation by ≥5 points on the 100 point VAS, with a mean (SD) change of +4.5 (12) points (p < 0.001). A total of 74/151 (49%) participants did not consider the best health VAS anchor, of the 77 who did 59 (77%) thought the good health descriptors were more extreme (better) then they had previously considered. Similarly 85/151 (66%) participants did not consider the worst health anchor of the 66 who did 63 (95%) thought the poor health descriptors were more extreme (worse) then they had previously considered. Conclusions: Health state self-reports may not be well considered. An immediate significant shift in response can be elicited by exposure to a mere description of an extreme health state despite no actual change in underlying health state occurring. Caution should be exercised in research and clinical settings when interpreting subjective patient reported outcomes that are dependent on brief anchors for meaning. Trial Registration: Australian and New Zealand Clinical Trials Registry (#ACTRN12607000606482) http://www.anzctr. org.a

Educational interventions for the management of cancer-related fatigue in adults

Background: Cancer-related fatigue is reported as the most common and distressing symptom experienced by patients with cancer. It can exacerbate the experience of other symptoms, negatively affect mood, interfere with the ability to carry out everyday activities, and negatively impact on quality of life. Educational interventions may help people to manage this fatigue or to cope with this symptom, and reduce its overall burden. Despite the importance of education for managing cancer-related fatigue there are currently no systematic reviews examining this approach. Objectives: To determine the effectiveness of educational interventions for managing cancer-related fatigue in adults. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), and MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, OTseeker and PEDro up to 1st November 2016. We also searched trials registries. Selection criteria: We included randomised controlled trials (RCTs) of educational interventions focused on cancer-related fatigue where fatigue was a primary outcome. Studies must have aimed to evaluate the effect of educational interventions designed specifically to manage cancer-related fatigue, or to evaluate educational interventions targeting a constellation of physical symptoms or quality of life where fatigue was the primary focus. The studies could have compared educational interventions with no intervention or wait list controls, usual care or attention controls, or an alternative intervention for cancer-related fatigue in adults with any type of cancer. Data collection and analysis: Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. Trial authors were contacted for additional information. A third independent person checked the data extraction. The main outcome considered in this review was cancer-related fatigue. We assessed the evidence using GRADE and created a 'Summary of Findings' table. Main results: We included 14 RCTs with 2213 participants across different cancer diagnoses. Four studies used only 'information-giving' educational strategies, whereas the remainder used mainly information-giving strategies coupled with some problem-solving, reinforcement, or support techniques. Interventions differed in delivery including: mode of delivery (face to face, web-based, audiotape, telephone); group or individual interventions; number of sessions provided (ranging from 2 to 12 sessions); and timing of intervention in relation to completion of cancer treatment (during or after completion). Most trials compared educational interventions to usual care and meta-analyses compared educational interventions to usual care or attention controls. Methodological issues that increased the risk of bias were evident including lack of blinding of outcome assessors, unclear allocation concealment in over half of the studies, and generally small sample sizes. Using the GRADE approach, we rated the quality of evidence as very low to moderate, downgraded mainly due to high risk of bias, unexplained heterogeneity, and imprecision. There was moderate quality evidence of a small reduction in fatigue intensity from a meta-analyses of eight studies (1524 participants; standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.52 to -0.04) comparing educational interventions with usual care or attention control. We found low quality evidence from twelve studies (1711 participants) that educational interventions had a small effect on general/overall fatigue (SMD -0.27, 95% CI -0.51 to -0.04) compared to usual care or attention control. There was low quality evidence from three studies (622 participants) of a moderate size effect of educational interventions for reducing fatigue distress (SMD -0.57, 95% CI -1.09 to -0.05) compared to usual care, and this could be considered clinically significant. Pooled data from four studies (439 participants) found a small reduction in fatigue interference with daily life (SMD -0.35, 95% CI -0.54 to -0.16; moderate quality evidence). No clear effects on fatigue were found related to type of cancer treatment or timing of intervention in relation to completion of cancer treatment, and there were insufficient data available to determine the effect of educational interventions on fatigue by stage of disease, tumour type or group versus individual intervention. Three studies (571 participants) provided low quality evidence for a reduction in anxiety in favour of the intervention group (mean difference (MD) -1.47, 95% CI -2.76 to -0.18) which, for some, would be considered clinically significant. Two additional studies not included in the meta-analysis also reported statistically significant improvements in anxiety in favour of the educational intervention, whereas a third study did not. Compared with usual care or attention control, educational interventions showed no significant reduction in depressive symptoms (four studies, 881 participants, SMD -0.12, 95% CI -0.47 to 0.23; very low quality evidence). Three additional trials not included in the meta-analysis found no between-group differences in the symptoms of depression. No between-group difference was evident in the capacity for activities of daily living or physical function when comparing educational interventions with usual care (4 studies, 773 participants, SMD 0.33, 95% CI -0.10 to 0.75) and the quality of evidence was low. Pooled evidence of low quality from two of three studies examining the effect of educational interventions compared to usual care found an improvement in global quality of life on a 0-100 scale (MD 11.47, 95% CI 1.29 to 21.65), which would be considered clinically significant for some. No adverse events were reported in any of the studies. Authors' conclusions: Educational interventions may have a small effect on reducing fatigue intensity, fatigue's interference with daily life, and general fatigue, and could have a moderate effect on reducing fatigue distress. Educational interventions focused on fatigue may also help reduce anxiety and improve global quality of life, but it is unclear what effect they might have on capacity for activities of daily living or depressive symptoms. Additional studies undertaken in the future are likely to impact on our confidence in the conclusions. The incorporation of education for the management of fatigue as part of routine care appears reasonable. However, given the complex nature of this symptom, educational interventions on their own are unlikely to optimally reduce fatigue or help people manage its impact, and should be considered in conjunction with other interventions. Just how educational interventions are best delivered, and their content and timing to maximise outcomes, are issues that require further research

Same-level peer-assisted learning in medical clinical placements: a narrative systematic review

BACKGROUND: Peer-assisted learning (PAL) is increasingly used in medical education, and the benefits of this approach have been reported. Previous reviews have focused on the benefits of peer tutoring of junior students by senior students. Forms of PAL such as discussion groups and role-playing have been neglected, as have alternative teacher-learner configurations (e.g. same-level PAL) and the effects on other stakeholders, including clinician educators and patients. This review examines the benefits of same-level PAL for students, clinician educators and patients in pre-registration clinical medical education. METHODS: Medline, PsycINFO, CINAHL and ERIC were searched in March 2014. A total of 1228 abstracts were retrieved for review; 64 full-text papers were assessed. Data were extracted from empirical studies describing a same-level PAL initiative in a clinical setting, focusing on effects beyond academic performance and student satisfaction. Qualitative thematic analysis was employed to identify types of PAL and to cluster the reported PAL effects. RESULTS: Forty-three studies were included in the review. PAL activities were categorised into role-play, discussion, teaching and assessment. Only 50% of studies reported information beyond self-report and satisfaction with the PAL intervention. Benefits for students (including development of communication and professional skills) and clinician educators (developing less-used facilitation skills) were reported. Direct patient outcomes were not identified. Caveats to the use of PAL emerged, and guidelines for the use of PAL were perceived as useful. CONCLUSION: Many student-related benefits of PAL were identified. PAL contributes to the development of crucial skills required for a doctor in the workplace. Vertical integration of learning and teaching skills across the curriculum and tools such as feedback checklists may be required for successful PAL in the clinical environment. Benefits for patients and educators were poorly characterised within the included studies. Future work should evaluate the use of PAL with regards to student, clinician educator and patient outcomes

Factors associated with the occurrence of sentinel events during transition from hospital to home for individuals with traumatic brain injury

Objective: To describe the timing and factors associated with the occurrence of sentinel events (financial strain, difficulty accessing therapy, return to work, accommodation change and independent transport use) during transition to the community for individuals with traumatic brain injury. Design: Longitudinal cohort design with data collected pre discharge and at 1, 3 and 6-month follow-ups. Subjects: Individuals with moderate to severe traumatic brain injury (n = 127), discharged home from acute care and inpatient rehabilitation. Methods: Data were collected using self-report questionnaires (sentinel events questionnaire, Mayo Portland Adaptability Inventory-4, Sydney Psychosocial Reintegration Scale, Depression Anxiety Stress Scale). Logistic regression was used to identify factors associated with sentinel events. Results: The most commonly reported events were independent transport use and return to work, reported on 104 and 90 occasions, respectively. A longer hospital stay and poorer community integration were related to negative events (e.g. reduced therapy). The inverse relationship was seen for positive events. Links existed between sentinel events (e.g. previous financial strain increased the likelihood of this event in transition). Conclusion: This paper highlights the interplay between personal and environmental factors and life events in shaping transition experiences. Individualised service planning and monitoring of sentinel events is important to promote successful community transition

Response shift, recall bias and their effect on measuring change in health-related quality of life amongst older hospital patients

Background: Assessments of change in subjective patient reported outcomes such as health-related quality of life (HRQoL) are a key component of many clinical and research evaluations. However, conventional longitudinal evaluation of change may not agree with patient perceived change if patients' understanding of the subjective construct under evaluation changes over time (response shift) or if patients' have inaccurate recollection (recall bias). This study examined whether older adults' perception of change is in agreement with conventional longitudinal evaluation of change in their HRQoL over the duration of their hospital stay. It also investigated this level of agreement after adjusting patient perceived change for recall bias that patients may have experienced. Methods: A prospective longitudinal cohort design nested within a larger randomised controlled trial was implemented. 103 hospitalised older adults participated in this investigation at a tertiary hospital facility. The EQ-5D utility and Visual Analogue Scale (VAS) scores were used to evaluate HRQoL. Participants completed EQ-5D reports as soon as they were medically stable (within three days of admission) then again immediately prior to discharge. Three methods of change score calculation were used (conventional change, patient perceived change and patient perceived change adjusted for recall bias). Agreement was primarily investigated using intraclass correlation coefficients (ICC) and limits of agreement. Results: Overall 101 (98%) participants completed both admission and discharge assessments. The mean (SD) age was 73.3 (11.2). The median (IQR) length of stay was 38 (20-60) days. For agreement between conventional longitudinal change and patient perceived change: ICCs were 0.34 and 0.40 for EQ-5D utility and VAS respectively. For agreement between conventional longitudinal change and patient perceived change adjusted for recall bias: ICCs were 0.98 and 0.90 respectively. Discrepancy between conventional longitudinal change and patient perceived change was considered clinically meaningful for 84 (83.2%) of participants, after adjusting for recall bias this reduced to 8 (7.9%). Conclusions: Agreement between conventional change and patient perceived change was not strong. A large proportion of this disagreement could be attributed to recall bias. To overcome the invalidating effect of response shift (on conventional change) and recall bias (on patient perceived change) a method of adjusting patient perceived change for recall bias has been described

Physiotherapists have accurate expectations of their patients’ future health-related quality of life after first assessment in a subacute rehabilitation setting

Background. Expectations held by health professionals and their patients are likely to affect treatment choices in subacute inpatient rehabilitation settings for older adults. There is a scarcity of empirical evidence evaluating whether health professionals expectations of the quality of their patients’ future health states are accurate. Methods. A prospective longitudinal cohort investigation was implemented to examine agreement (kappa coefficients, exact agreement, limits-of-agreement, and intraclass-correlation coefficients) between physiotherapists’ (n=23) prediction of patients’ discharge health-related quality of life (reported on the EQ-5D-3L) and the actual health-related quality of life self-reported by patients (n=272) at their discharge assessment (using the EQ-5D-3L). The mini-mental state examination was used as an indicator of patients’ cognitive ability. Results. Overall, 232 (85%) patients had all assessment data completed and were included in analysis. Kappa coefficients (exact agreement) ranged between 0.37–0.57 (58%–83%) across EQ-5D-3L domains in the lower cognition group and 0.53–0.68 (81%–85%) in the better cognition group. Conclusions. Physiotherapists in this subacute rehabilitation setting predicted their patients’ discharge health-related quality of life with substantial accuracy. Physiotherapists are likely able to provide their patients with sound information regarding potential recovery and health-related quality of life on discharge. The prediction accuracy was higher among patients with better cognition than patients with poorer cognition

Subjective evaluations of integer cosine transform compressed Galileo solid state imagery

This paper describes a study conducted for the Jet Propulsion Laboratory, Pasadena, California, using 15 evaluators from 12 institutions involved in the Galileo Solid State Imaging (SSI) experiment. The objective of the study was to determine the impact of integer cosine transform (ICT) compression using specially formulated quantization (q) tables and compression ratios on acceptability of the 800 x 800 x 8 monochromatic astronomical images as evaluated visually by Galileo SSI mission scientists. Fourteen different images in seven image groups were evaluated. Each evaluator viewed two versions of the same image side by side on a high-resolution monitor; each was compressed using a different q level. First the evaluators selected the image with the highest overall quality to support them in their visual evaluations of image content. Next they rated each image using a scale from one to five indicating its judged degree of usefulness. Up to four preselected types of images with and without noise were presented to each evaluator

Comparison Of Finnish, American, And New Zealand Franchisee Satisfaction

Franchising is growing as a business model in many countries.  We test a model of franchisee satisfaction across three countries to examine the model’s predictive and measure reliability.  The multi-dimensional franchisee satisfaction model is a significant and reliable predictor of general franchisee satisfaction in different cultures.  Franchise systems looking for an efficient method of measuring and predicting franchisee satisfaction can rely on the model to aid their efforts of managing the franchisor-franchisee relationship.  In the future the model should be tested in other industries, cultures, and with larger samples

Setting Research Priorities Within Allied Health: What Do Clinicians Think?

Background: Research activity among allied health clinicians working in publicly funded health care organisations is growing, yet little attention has been paid to how these activities are prioritised. Without a specific framework to guide research direction, it is likely that research will be conducted in areas that are prioritised by individual clinicians. However, it is presently unknown what areas are prioritised by clinicians and the reasoning behind their prioritisation. Purpose: The aims of this study were to identify what clinicians identify to be the highest priority research across personal, department, and health service levels, and the reasons why. It also sought to identify barriers and enablers to conducting this research. Methods: Qualitative, cross-sectional survey with n=95 allied health clinician respondents within one organisation. Survey items relating to research priority were structured across three levels. Survey format consisted of open-ended questions and thematic content analysis was used to categorise responses. Results: The highest priority research across personal, departmental and organisational levels were related to areas of personal work, departmental service and models of care evaluation respectively. The top three priorities in all levels combined were “testing solutions”, “understanding problems or developing solutions” and “implementing evidence-based approaches in real life”. The primary reason provided as to why the research was considered to be of the highest priority was related to the anticipated effectiveness of intervention on patient outcomes and the efficiency of service delivery models being investigated. Time shortages/workload/competing priorities were the most frequently identified barriers to conducting this research, while mentoring /access to university partners/organisational culture/leadership and priorities that favoured research were the most frequently identified enablers. Conclusions: Considerations can be taken from our findings to guide the development of a framework or system to prioritise research projects in the publicly funded health care organisation