Care that Matters: Quality Measurement and Health Care

Barry Saver and colleagues caution against the use of process and performance metrics as health care quality measures in the United States

Validation of a non-linear model of health

Purpose: The purpose of this study was to evaluate the veracity of a theoretically derived model of health that describes a non-linear trajectory of health from birth to death with available population data sets. Methods: The distribution of mortality by age is directly related to health at that age, thus health approximates 1/mortality. The inverse of available all-cause mortality data from various time periods and populations was used as proxy data to compare with the theoretically derived non-linear health model predictions, using both qualitative approaches and quantitative one-sample Kolmogorov–Smirnov analysis with Monte Carlo simulation. Results: The mortality data's inverse resembles a log–normal distribution as predicted by the proposed health model. The curves have identical slopes from birth and follow a logarithmic decline from peak health in young adulthood. A majority of the sampled populations had a good to excellent quantitative fit to a log–normal distribution, supporting the underlying model assumptions. Post hoc manipulation showed the model predictions to be stable. Conclusions: This is a first theory of health to be validated by proxy data, namely the inverse of all-cause mortality. This non-linear model, derived from the notion of the interaction of physical, environmental, mental, emotional, social and sense-making domains of health, gives physicians a more rigorous basis to direct health care services and resources away from disease-focused elder care towards broad-based biopsychosocial interventions earlier in life

For every complex problem, there is an answer that is clear, simple and wrong: and other aphorisms about medical statistical fallacies

Rationale, Method: This essay examines the notions of knowledge, truth and certainty as they apply to medical research and patient care. The human body does not behave in mechanistic but rather complex adaptive ways; thus, its behaviour to challenges is non-deterministic. This insight has important ramifications for experimental studies in health care and their statistical interrogation that are described in detail. Results and Conclusions: Four implications are highlighted: one, there is an urgent need to develop a greater awareness of uncertainties and how to respond to them in clinical practice, namely, what is important and what is not in the context of this patient; two, there is an equally urgent need for health professionals to understand some basic statistical terms and their meanings, specifically <i>absolute risk</i>, its reciprocal, <i>numbers needed to treat</i> and its inverse, <i>index of therapeutic impotence</i>, as well as seeking out the <i>effect size</i> of an intervention rather than blindly accepting <i>P</i>-values; three, there is an urgent need to accurately present <i>the known</i> in comprehensible ways through the use of visual tools; and four, there is a need to overcome the perception, that <i>errors of commission</i> are less troublesome than <i>errors of omission</i> as neither's consequences are predictable

Health: A Systems- and Complexity-Based Definition

The previous three chapters have explored the dimensions of health through different lenses - the multiplicative agents of one's health potential , the subjective experience arising from sense-making, and a functional state that a11ows for survival and reproduction-the struggle for life. Together, they provide the basis for a congruent systems-based definition of health. Human health is a balanced state between physical, emotional, social and cognitive/sense-making domains. Within any local environmental context, a health state exists within a multidimensional phase space of physical integrity, functional performance and subjective experience producing an entropic state most consistent with viability

Translation to German and linguistic validation of the Rapid Assessment of Physical Activity (RAPA) questionnaire

Abstract Purpose To produce a culturally adapted translation of the Rapid Assessment of Physical Activity (RAPA) questionnaire for German speaking Austrians and to conduct a linguistic validation of the new language version. Methods The original English RAPA questionnaire was translated into German for Austria and underwent an independent forward and back translation, followed by cognitive debriefing interviews with older adults aged 55 to 78 years with and without health conditions (n = 13), for linguistic validation. Results Several distinct choices were made in the translation of the RAPA questionnaire to German, including the use of colloquial terms for ‘physical activity’ and ‘intensity’; and the decision to keep to the original examples and images of different physical activities for illustrating the intensity levels (light, moderate, vigorous) of physical activity. In cognitive debriefing, interviewees commented that some example activities for the respective intensity levels could – depending on the individual – also represent a higher or lower intensity level; and that the wording of RAPA items 4 and 5, which describe the category ‘under-active regular’ aerobic activity, was difficult to understand. Both issues were addressed and resolved through minor iterative modifications made during the cognitive debriefing process. Conclusions A new version of the RAPA questionnaire in German for Austria has been produced by forward and back translation and linguistic validation. The questionnaire may now undergo psychometric evaluation

Comparison of typical performance measures and author recommendations.

<p>* NNT: number needed to treat; NNH: number needed to harm; NNS: number needed to screen</p><p>Comparison of typical performance measures and author recommendations.</p

Associations of self-reported physical activity types and levels with quality of life, depression symptoms, and mortality in hemodialysis patients: the DOPPS.

BACKGROUND AND OBJECTIVES Physical activity has been associated with better health status in diverse populations, but the association in patients on maintenance hemodialysis is less established. Patient-reported physical activities and associations with mortality, health-related quality of life, and depression symptoms in patients on maintenance hemodialysis in 12 countries were examined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 5763 patients enrolled in phase 4 of the Dialysis Outcomes and Practice Patterns Study (2009-2011) were classified into five aerobic physical activity categories (never/rarely active to very active) and by muscle strength/flexibility activity using the Rapid Assessment of Physical Activity questionnaire. The Kidney Disease Quality of Life scale was used for health-related quality of life. The Center for Epidemiologic Studies Depression scale was used for depression symptoms. Linear regression was used for associations of physical activity with health-related quality of life and depression symptoms scores. Cox regression was used for association of physical activity with mortality. RESULTS The median (interquartile range) of follow-up was 1.6 (0.9-2.5) years; 29% of patients were classified as never/rarely active, 20% of patients were classified as very active, and 20.5% of patients reported strength/flexibility activities. Percentages of very active patients were greater in clinics offering exercise programs. Aerobic activity, but not strength/flexibility activity, was associated positively with health-related quality of life and inversely with depression symptoms and mortality (adjusted hazard ratio of death for very active versus never/rarely active, 0.60; 95% confidence interval, 0.47 to 0.77). Similar associations with aerobic activity were observed in strata of age, sex, time on dialysis, and diabetes status. CONCLUSIONS The findings are consistent with the health benefits of aerobic physical activity for patients on maintenance hemodialysis. Greater physical activity was observed in facilities providing exercise programs, suggesting a possible opportunity for improving patient outcomes