37 research outputs found
Research on patients with multiple health conditions: different constructs, different views, one voice
Technological advances, improvements in medical care and public health policies have resulted in a growing proportion of patients with multiple health conditions. The prevalence of multiple health conditions among individuals increases with age, is substantial among older adults, and will increase dramatically in coming years. This phenomenon has received growing interest in the most recent literature and has led to several â and often differing â conceptualizations.<p></p>
The term âcomorbidityâ was originally defined by Feinstein as âany distinct additional clinical entity that has existed or may occur during the clinical course of a patient who has the index disease under studyâ. This definition places one disease in a central position and all other condition(s) as secondary, in that they may or may not affect the course and treatment of the index disease. Feinsteinâs principle has been applied all too readily as if the effect of comorbidity was secondary or indeed negligible. In clinical research, individuals with a narrowly defined index condition and no major comorbidities are usually enrolled, leaving the majority of the patients seen in a typical family practice out in the cold. In clinical practice, management of the index condition invariably takes priority, with disjointed â if any â treatment plans developed for each of the comorbidities. This model of care is typical of delivery systems constructed around specialized care, where areas of expertise are defined around specific conditions and bodily systems [11]. Not surprisingly, clinical practice guidelines arising from that model of care lack pertinence for patients with multiple health conditions
FilosofĂa de la biologĂa, papel intermediario entre ciencia y teologĂa
TeologĂa y ciencia encuentran
en la filosofĂa un dominio comĂșn de
acercamiento. Lo mismo la teologĂa
que la ciencia son racionales, que se
guĂan por criterios metodolĂłgicos compartidos
en cierto grado. En efecto, el
pensamiento racional presenta cierta
estructuraciĂłn: un nivel se halla mĂĄs
prĂłximo a los datos empĂricos (la ciencia),
otro a las cosmovisiones (tal, la filosofĂa
de la naturaleza). Ese nivel superior
es el que plantea las cuestiones que
interesan en teologĂa. En particular, si
se trata de la filosofĂa de la biologĂa. No
importa que la disciplina carezca de leyes
âen buena medida es una disciplina
histĂłricaâ y por tanto parezca menos
sĂłlida que la fĂsica. Sus cuestiones
tienen que ver con el hombre. De ahĂ
que, desde los tratados biolĂłgicos de
AristĂłteles, cientĂficos, filĂłsofos y teĂłlogos
se hayan ocupado de la singularidad
de los organismos y del reto que implica
una interpretaciĂłn reduccionista
Mariano Artigas: 1979â1987
Durante casi un decenio, de 1979 a 1987 Mariano Artigas fue depurando y profundizando en aspectos de historia y filosofĂa de la ciencia que serĂĄn determinantes en la configuraciĂłn de sus intereses intelectuales. Fuera del campo propio de la fĂsica, ahondĂł en filosofĂa de la mente, influido por John Eccles, y en la fiabilidad de la ciencia.The period 1979 to 1987 was critical in the development of the intellectual interests of Mariano Artigas. He focused on the analysis and critique of scientism and its forms, particularly because of its impact on the debate on science and theology. In the field of meta-theory of consciousness he was influenced by John Eccles. He studied the properties of science, its limitations and, above all, its reliability
Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D
Background
Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondentsâ outcomes in the acute frailty setting.
Methods
People aged 65â+âwith Clinical Frailty Scale (CFS) 5â8 were recruited from eight UK hospitalsâ emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity.
Results
The 232 participants were aged 65â102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1â1.3) and internal consistency (Cronbachâs alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (pâ=â0.010) and negatively with CFS (pâ<â0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities.
Conclusions
Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL
Patient-Reported Morbidity Instruments: A Systematic Review
Objectives: Although comorbidities play an essential role in risk adjustment and outcomes measurement, there is little consensus regarding the best source of this data. The aim of this study was to identify general patient-reported morbidity instruments and their measurement properties. Methods: A systematic review was conducted using multiple electronic databases (Embase, Medline, Cochrane Central, and Web of Science) from inception to March 2018. Articles focusing primarily on the development or subsequent validation of a patient-reported morbidity instrument were included. After including relevant articles, the measurement properties of each morbidity instrument were extracted by 2 investigators for narrative synthesis. Results: A total of 1005 articles were screened, of which 34 eligible articles were ultimately included. The most widely assessed instruments were the Self-Reported Charlson Comorbidity Index (n = 7), the Self-Administered Comorbidity Questionnaire (n = 3), and the Disease Burden Morbidity Assessment (n = 3). The most commonly included conditions were diabetes, hypertension, and myocardial infarction. Studies demonstrated substantial variability in item-level reliability versus the gold standard medical record review (Îș range 0.66-0.86), meaning that the accuracy of the self-reported comorbidity data is dependent on the selected morbidity. Conclusions: The Self-Reported Charlson Comorbidity Index and the Self-Administered Comorbidity Questionnaire were the most frequently cited instruments. Significant variability was observed in reliability per comorbid condition of patient-reported morbidity questionnaires. Further research is needed to determine whether patient-reported morbidity data should be used to bolster medical records data or serve as a stand-alone entity when risk adjusting observational outcomes data
Co-creation of a patient-reported outcome measure for older people living with frailty receiving acute care (PROM-OPAC)
Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (âPROM-OPACâ). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation
What matters most in acute care: an interview study with older people living with frailty
Background
Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty.
Methods
Healthcare outcome goals were explored using semi-structured patient interviews. Participants aged over 65 with Clinical Frailty Score 5-8 (mild to very severe frailty) were recruited during their first 72 hours in a UK hospital. Purposive, maximum variation sampling was guided by lay partners from a Patient and Public Involvement Forum specialising in ageing-related research. Qualitative analysis used a blended approach based on framework and constant comparative methodologies for the identification of themes. Findings were validated through triangulation with participant, lay partner, and technical expert review.
Results
The 22 participants were aged 71 to 98 and had mild to very severe frailty. One quarter were living with dementia. Most participants had reflected on their situation and considered their outcome goals. Theme categories (and corresponding sub-categories) were âAutonomyâ (information, control, and security) and âFunctioningâ (physical, psychosocial, and relief). A novel âsecurityâ theme was identified, whereby participants sought to feel safe in their usual living place and with their health problems. Those living with milder frailty were concerned to maintain ability to support loved ones, while those living with most severe frailty were concerned about burdening others.
Conclusions
Outcome goals for acute care among older participants living with frailty were influenced by the insecurity of their situation and fear of deterioration. Patients may be supported to feel safe and in control through appropriate information provision and functional support
One-year risk of stroke after transient ischemic attack or minor stroke in Hunter New England, Australia (INSIST Study)
Background: One-year risk of stroke in transient ischemic attack and minor stroke (TIAMS) managed in secondary care settings has been reported as 5â8%. However, evidence for the outcomes of TIAMS in community care settings is limited. Methods: The INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study was a prospective inception cohort community-based study of patients of 16 general practices in the HunterâManning region (New South Wales, Australia). Possible-TIAMS patients were recruited from 2012 to 2016 and followed-up for 12 months post-index event. Adjudication as TIAMS or TIAMS-mimics was by an expert panel. We established 7-days, 90-days, and 1-year risk of stroke, TIA, myocardial infarction (MI), coronary or carotid revascularization procedure and death; and medications use at 24 h post-index event. Results: Of 613 participants (mean age; 70 ñ 12 years), 298 (49%) were adjudicated as TIAMS. TIAMS-group participants had ischemic strokes at 7-days, 90-days, and 1-year, at Kaplan-Meier (KM) rates of 1% (95% confidence interval; 0.3, 3.1), 2.1% (0.9, 4.6), and 3.2% (1.7, 6.1), respectively, compared to 0.3, 0.3, and 0.6% of TIAMS-mimic-group participants. At one year, TIAMS-group-participants had twenty-five TIA events (KM rate: 8.8%), two MI events (0.6%), four coronary revascularizations (1.5%), eleven carotid revascularizations (3.9%), and three deaths (1.1%), compared to 1.6, 0.6, 1.0, 0.3, and 0.6% of TIAMS-mimic-group participants. Of 167 TIAMS-group participants who commenced or received enhanced therapies, 95 (57%) were treated within 24 h post-index event. For TIAMS-group participants who commenced or received enhanced therapies, time from symptom onset to treatment was median 9.5 h [IQR 1.8â89.9]. Conclusion: One-year risk of stroke in TIAMS participants was lower than reported in previous studies. Early implementation of antiplatelet/anticoagulant therapies may have contributed to the low stroke recurrence
The case for an international patient-reported outcomes measurement information system (PROMISÂź) initiative.
Patient-reported outcomes (PROs) play an increasingly important role in clinical practice and research. Modern psychometric methods such as item response theory (IRT) enable the creation of item banks that support fixed-length forms as well as computerized adaptive testing (CAT), often resulting in improved measurement precision and responsiveness. Here we describe and discuss the case for developing an international core set of PROs building from the US PROMISÂź network.PROMIS is a U.S.-based cooperative group of research sites and centers of excellence convened to develop and standardize PRO measures across studies and settings. If extended to a global collaboration, PROMIS has the potential to transform PRO measurement by creating a shared, unifying terminology and metric for reporting of common symptoms and functional life domains. Extending a common set of standardized PRO measures to the international community offers great potential for improving patient-centered research, clinical trials reporting, population monitoring, and health care worldwide. Benefits of such standardization include the possibility of: international syntheses (such as meta-analyses) of research findings; international population monitoring and policy development; health services administrators and planners access to relevant information on the populations they serve; better assessment and monitoring of patients by providers; and improved shared decision making.The goal of the current PROMIS International initiative is to ensure that item banks are translated and culturally adapted for use in adults and children in as many countries as possible. The process includes 3 key steps: translation/cultural adaptation, calibration, and validation. A universal translation, an approach focusing on commonalities, rather than differences across versions developed in regions or countries speaking the same language, is proposed to ensure conceptual equivalence for all items. International item calibration using nationally representative samples of adults and children within countries is essential to demonstrate that all items possess expected strong measurement properties. Finally, it is important to demonstrate that the PROMIS measures are valid, reliable and responsive to change when used in an international context.IRT item banking will allow for tailoring within countries and facilitate growth and evolution of PROs through contributions from the international measurement community. A number of opportunities and challenges of international development of PROs item banks are discussed
A systematic review and recommendations for prom instruments for older people with frailty in emergency care
Introduction
The current service metrics used to evaluate quality in emergency care do not account for specific healthcare outcome goals for older people living with frailty. These have previously been classified under themes of âAutonomyâ and âFunctioningâ. There is no person-reported outcome measure (PROM) for older people with frailty and emergency care needs. This study aimed to identify and co-produce recommendations for instruments potentially suitable for use in this population.
Methods
In this systematic review, we searched six databases for PROMs used between 2010 and 2021 by older people living with frailty receiving acute hospital care. Studies were reviewed against predefined eligibility criteria and appraised for quality using the COSMIN Risk of Bias checklist. Data were extracted to map instrument constructs against an existing framework of acute healthcare outcome goals. Instrument face and content validity were assessed by lay collaborators. Recommendations for instruments with potential emergency care suitability were formed through co-production.
Results
Of 9392 unique citations screened, we appraised the full texts of 158 studies. Nine studies were identified, evaluating nine PROMs. Quality of included studies ranged from âdoubtfulâ to âvery goodâ. Most instruments had strong evidence for measurement properties. PROMs mainly assessed âFunctioningâ constructs, with limited coverage of âAutonomyâ. Five instruments were considered too burdensome for the emergency care setting or too specific for older people living with frailty.
Conclusions
Four PROMs were recommended as potentially suitable for further validation with older people with frailty and emergency care needs: COOP/WONCA charts, EuroQol, McGill Quality of Life (Expanded), and Palliative care Outcome Scale