Effect of the prehospital trauma life support program (PHTLS) on prehospital trauma care

BACKGROUND

Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement.

METHODS

All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post-PHTLS data by chi 2 analysis with a p value < or = 0.05 being considered statistically significant.

RESULTS

The frequency (%) increased in the post-PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post-PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%).

CONCLUSIONS

Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS.

The burden of waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project Team

The objectives of this study were to assess the impact of major joint replacements in reducing pain and disability and to describe the burden of pain and disability that could be avoided by ordering the queues with respect to severity of disease. A secondary goal was to compare the uses of a general health status measure, the Short Form Health Survey (SF-36), and a disease-specific measure, the Western Ontario McMaster Osteoarthritis Index (WOMAC), for accomplishing the objectives. The results are based on interviews with 209 patients before and after they had surgery. Only 15.9% of the patients had surgery within 3 months' waiting time, 19.2% waited 4-6 months, 30.7% waited 7-9 months, and the remaining 34.1% waited a year or more. The waiting times were unrelated to the severity of pain or disability reported in the initial interview. Following surgery, there were large reductions in the WOMAC scores for pain, stiffness and difficulty in functioning. The SF-36 showed substantial improvements in relief from pain and in physical functioning, and reductions in role limitation due to physical problems, but not for scores related to mental health. The WOMAC scores were more responsive to the benefits of surgery than the SF-36 scores. Queuing systems keyed on burden of symptoms could reduce the burden of pain and disability suffered by patients awaiting surgery. The improvements from hip and knee replacements suggest that equitable access for these procedures should be a priority in Ontario.

Predictive validity and internal consistency of the pre-hospital index measured on-site by physicians

Physiological measures of injury are used as triage tools to identify patients that require treatment in trauma centres. The Pre-Hospital Index (PHI) is based on systolic blood pressure, pulse, respiratory rate, (level of) consciousness, and presence of penetrating injury. The present study evaluated the validity and internal consistency of the PHI. The study was based on 628 patients assessed by physicians at the scene. Mean age was 38.7 years (SD = 24.8), and 65% were male. Motor vehicle collisions caused the injury for 45%. The majority had head/neck (56%) and extremity (45%) injuries. Mean PHI was 4.62 (SD = 5.77), 40% had a PHI of zero, 6% between 1 and 3, 32% between 4 and 7, and 21% greater than 7. The associations between PHI and rates of hospital admission, surgery, ICU treatment, mortality, duration of hospitalization, and length of ICU stay were significant (p < 0.001). A total of 260 (41.4%) patients had major trauma requiring treatment at a trauma centre. A PHI > 3 had 83% sensitivity and 67% specificity for identifying these patients. Internal consistency of the PHI variables was above the acceptable limits. This study has shown that the PHI is a valid and reliable physiological measure of injury severity and field triage tool.

The context of measuring disability: does it matter whether capability or performance is measured?

This study assesses the differences between two methods of conceptually framing physical disability questions, using two scenarios (capability and performance). The relationship between capability and performance was explored on the basis of the literature and empirically tested by administering two versions of the Activities Scale for Kids (ASK) to 28 physically disabled children. The capability version asked children what they "could do," whereas the performance version asked what they "did do." Capability was found to exceed performance (p < 0.001) by approximately 18%. The difference may relate to a difference in environmental contexts between the two versions, with performance reflecting abilities in usual (or real life) circumstances and capability reflecting abilities in a defined situation apart from real life. Researchers must, therefore, consider carefully the environmental circumstances in which they wish to evaluate outcomes, and use this information to decide whether to measure capability, performance, or both.

Development of a measure of physical function for patients with bone and soft tissue sarcoma

Patients undergoing limb salvage surgery for bone and soft tissue sarcoma of the extremities experience significant physical disability as a result of life-preserving treatment. The existing health status measures do not adequately evaluate physical function from the patient's perspective. This paper presents the developmental studies (item selection, reduction, reliability, validity and responsiveness) of a new measure, The Toronto Extremity Salvage Score (TESS). Patients with bone and soft tissue sarcoma (76 upper and 83 lower extremity) were randomly selected and mailed the TESS. Patients rated the severity and importance of physical disabilities; the response options included a 'not applicable' category and open-ended questions that allowed patients to suggest additional items for inclusion in the questionnaire. Therefore, patient perceptions were used to determine item content. Difficulty and importance frequencies were calculated and items rated 'totally unimportant' or 'not applicable' by 30% of the sample were eliminated. Extra items identified 30% of the time were added to the questionnaire. Internal consistency was evaluated by Cronbach's alpha. Test-retest reliability and validity were evaluated on subsequent patient samples. The intraclass correlation coefficient (ICC) was calculated for test-retest reliability and correlations with The Musculoskeletal Tumour Society Rating Scale (MSTS) were calculated for construct validity. Standardized effect sizes were calculated as a measure of responsiveness. Fifty upper extremity and sixty-six lower extremity patients responded to the mailed questionnaire. No items were eliminated based on importance or not applicable ratings. Sporting activities were identified as additional items in both the upper and lower extremity questionnaire. High internal consistency was demonstrated: 0.94 for the lower and 0.92 for the upper extremity questionnaires respectively. Test-retest reliability was evaluated at multiple time-points and the intraclass correlation coefficient was greater than 0.87 in all instances. Construct validity was shown by a moderate correlation with the MSTS. The effect sizes were large demonstrating responsiveness. The use of patients' perceptions in determining the content of the TESS has resulted in a reliable and valid measure that is able to detect change over time.

Devolution of hip and knee replacement surgery?

The objectives of this study were to assess trends in referral patterns for joint replacements (JRs) in Ontario between the fiscal year 1988/89 and the fiscal year 1993/94; to assess the redistribution of financial resources if services were provided to residents in the region where they reside; and to estimate the financial implications of the devolution of primary JRs from tertiary-care hospitals to community hospitals. Despite rapid growth in the provision of JRs, there was no significant change in their regional distribution. Community hospitals have increased their share of JRs at the expense of teaching hospitals. For hospitals located in Central east Ontario, the cost of providing JRs to nonresidents increased from $ 5.9 million in 1988/89 to $8.3 million in 1993/94. Devolution of primary JRs requires a minimum reallocation sum of $25.1 million, with potential cost savings of $4.3 million. Many obstacles limit the devolution and local provision of health care services, including modifications to referral patterns and the availability of provider expertise, especially when a substantial redistribution of resources is required. Better clinical data to evaluate outcomes and better patient-specific costing data are required. Devolution of services should be addressed in the context of appropriate institutional compensation for medical education.

Appropriateness of primary total hip and knee replacements in regions of Ontario with high and low utilization rates

OBJECTIVE

To compare the appropriateness of case selection for primary hip and knee replacements between two regions in Ontario: one with a high population-based utilization rate and one with a low rate.

DESIGN

Random audit of medical records sampled from hospital discharge abstracts, with subsequent implicit and explicit criteria-based assessments of the appropriateness of surgery.

STUDY POPULATION

People aged 60 years or over who underwent elective, single-joint, non-fracture-related, primary hip or knee replacement between Apr. 1, 1992, and Mar. 31, 1993, at one of seven hospitals in a high-rate region (comprising Brant, Huron and Oxford countries) or one of eight hospitals in a low-rate region (comprising the cities of Scarborough and Toronto).

INTERVENTIONS

Structured review of hospital medical records, with additional review of information from surgeons and family physicians' office charts if necessary. Three physicians reviewed patient data and rated the preoperative pain level and functional status of patients, with agreement among at least two reviewers. The proportion of inappropriate cases was then assessed according to explicit criteria defined by a multidisciplinary panel using the delphi process. Profiles of each case were also subjected to independent implicit review by two rheumatologists and two orthopedic surgeons.

OUTCOME MEASURES

Proportion of joint replacements deemed inappropriate in the high- and low-rate regions according to either the explicit criteria or the implicit review, as well as preoperative pain levels and functional status of patients in the high- and low-rate regions.

RESULTS

Hip replacements were more common among patients sampled in the low-rate region than among those in the high-rate region (57.3% v. 39.3%; p < 0.002), although the patients' baseline characteristics, including severity of preoperative pain and dysfunction, were otherwise similar between the regions. Inappropriate surgery, determined by explicit criteria, was equally uncommon in the two regions (6.4% and 6.1%). On implicit review, the two rheumatologists rated fewer cases as appropriate than did the two orthopedic surgeons (63.0% v. 80.0%; p < 0.001); however, the proportion of cases rated as inappropriate by the subspecialists was similar in the high- and low-rate regions (11.4% and 11.0%, respectively, by the rheumatologists, and 6.3% and 10.4%, respectively, by the orthopedic surgeons).

CONCLUSIONS

Patients selected for primary hip or knee replacement are similar in the high- and low-rate regions of Ontario. Inappropriate use of this procedure does not account for the high rate of surgery in some areas. Further studies will be required to determine which other factors account for the regional variations in the utilization rates and whether there is underservicing in low-rate areas.

Using a trade-off technique to assess patients' treatment preferences for benign prostatic hyperplasia

The probability-tradeoff technique may be used to assess treatment preferences in dichotomous choices. In this feasibility study, it was used to elicit benign prostatic hyperplasia (BPH) patients' attitudes towards three different treatments. Eighty-seven male outpatients used rating scales and the standard gamble to indicate the extents to which they were free of BPH symptoms. Paired descriptions of "watchful waiting" (WW), treatment with an alpha blocker (AB), and transurethral resection of the prostate (TURP) were presented, and the probability-tradeoff technique was used to obtain treatment-preference scores. The tradeoff task identified six internally consistent preference-order subgroups. The majority (n = 55; 63.2%) were in the two subgroups in which TURP was the least-preferred treatment. Compared with the other respondents, the members of these two subgroups reported significantly higher utilities for their BPH symptom status (89 vs 79; t = 2.87; p < 0.0005). Within each subgroup, preference scores for the middle- and top-ranked treatments were computed relative to the bottom-ranked treatment; for both WW and AB, significant across-subgroup differences were observed. In this preliminary study the probability-tradeoff technique was feasible, able to identify unique preference-order subgroups, and able to generate apparently meaningful preference scores in a clinical situation involving three alternative treatments. Further development of tradeoff tasks as the value-clarification component of decision aids for individual patients seems warranted.

Hospital volume, calendar age, and short term outcomes in patients undergoing repair of abdominal aortic aneurysms: the Ontario experience, 1988-92

OBJECTIVE

To determine, for abdominal aortic aneurysm surgery, whether a previously reported relationship between hospital case volume and mortality rate was observed in Ontario hospitals and to assess the potential impact of age on the mortality rate for elective surgery.

DESIGN

Population based observational study using administrative data.

SETTING

All Ontario hospitals where repair of abdominal aortic aneurysm as a primary procedure was performed during 1988-92.

PATIENTS

These comprised 5492 patients with unruptured abdominal aortic aneurysms and 1203 patients with ruptured abdominal aortic aneurysms admitted to hospital between 1988-92 for repair of abdominal aortic aneurysm as a primary procedure.

MAIN OUTCOMES

In-hospital death and length of in-hospital stay.

RESULTS

The case fatality rate was 3.8% for unruptured abdominal aortic aneurysms and 40.0% for ruptured abdominal aortic aneurysms. For unruptured cases, after adjustment for patient and hospital covariates, each 10 case per year increase in hospital volume was related to a 6% reduction in relative odds of death (odds ratio (OR) 0.94, 95% confidence intervals 0.88, 0.99) and 0.29 days reduction (95% CI -0.22, -0.35) in postoperative in-hospital stay. Female sex (OR 1.53, 95% CI 1.08, 2.18) and transfer from another acute care hospital (OR 4.37, 95% CI 2.62, 7.29) were associated with increased case fatality rates among patients in the unruptured category. For ruptured cases, neither the case fatality rate nor postoperative in-hospital stay were significantly related to hospital volume. The case fatality rates increased linearly and substantially with advancing age both for unruptured and ruptured aneurysms, and the excess risk of postoperative death in ruptured as compared to unruptured aneurysms was substantially higher in older patients.

CONCLUSION

The relationship between hospital volume and mortality or morbidity was very modest and observed only for elective surgery. Case fatality rates in patients with ruptured abdominal aortic aneurysms remained 10 times higher than for patients with unruptured abdominal aortic aneurysms, despite improvements in overall mortality in comparison to previously published data. More effective detection of aneurysms, including elective repair for those once considered "high risk" older patients, might further reduce the toll from ruptured aortic aneurysms.

Postpartum safety and satisfaction following early discharge

Two Ontario sites were involved in the evaluation of an obstetrical discharge program. Before program implementation a group of eligible women were enrolled as the preprogram control group (n = 542). During the program, eligible women who agreed to early discharge (ED) became the ED group (n = 319), and those opting not to go home early but consenting to participate in the evaluation became the concurrent group (n = 456). All groups were mailed a self-administered postpartum questionnaire. On demographic characteristics, safety and satisfaction, the ED group was comparable to the concurrent group. Hospital readmission rates did not differ across groups after stratification by site or hospital. Multiple classification analyses revealed a similar pattern for overall satisfaction levels. This unique ED program, which allowed pre- or postnatal enrollment and did not require an initial home assessment, appears to be a safe, effective and flexible approach to obstetrical care.

Utilization of health care services by immigrants and other ethnic/cultural groups in Ontario

OBJECTIVES

This study assesses the accessibility of health care services by immigrants and other ethnic/cultural groups in Ontario, using the 1990 Ontario Health Survey.

METHODS

The population sample of 38,519 adults aged 16-64 is weighted to represent the entire non-institutionalized population of the province. Outcome measures were whether the study participants visited a general practitioner's office, a specialist's office, or a hospital's emergency department during the past 12 months.

RESULTS

The results showed that while the percentages of participants who ever visited a general practitioner's office during the past 12 months were slightly higher in immigrants and other ethnic/cultural groups, the rates of visits to the specialist's office were quite similar, and the rates of hospital emergency department's visits were often lower (except for aboriginals), than for Canadians. These differences in the utilization of health services across different immigrant and ethnic/cultural groups remained unchanged after controlling for health status (as measured by self-reported health problems) and age differences. However, because the sample sizes in some immigrant and ethnic/cultural groups were small, many of the differences were not statistically significant.

CONCLUSIONS

We conclude that while immigrants and other ethnic/cultural groups in Ontario usually had equal access to regular services (e.g., visits to general practitioner's office), they often had lower utilization of hospital emergency departments. However, general purpose surveys have limited utility in assessing reasons of health care utilization amongst different ethnic/cultural groups.

Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority

OBJECTIVES

To develop, from simple clinical factors, criteria to identify appropriate patients for referral to a surgeon for consideration for arthroplasty, and to rank them in the queue once surgery is agreed.

DESIGN

Delphi process, with a panel including orthopaedic surgeons, rheumatologists, general practitioners, epidemiologists, and physiotherapists, who rated 120 case scenarios for appropriateness and 42 for waiting list priority. Scenarios incorporated combinations of relevant clinical factors. It was assumed that queues should be organised not simply by chronology but by clinical and social impact of delayed surgery. The panel focused on information obtained from clinical histories, to ensure the utility of the guidelines in practice. Relevant high quality research evidence was limited.

SETTING

Ontario, Canada.

MAIN MEASURES

Appropriateness ratings on a 7-point scale, and urgency rankings on a 4-point scale keyed to specific waiting times.

RESULTS

Despite incomplete evidence panellists agreed on ratings in 92.5% of appropriateness and 73.8% of urgency scenarios versus 15% and 18% agreement expected by chance, respectively. Statistically validated algorithms in decision tree form, which should permit rapid estimation of urgency or appropriateness in practice, were compiled by recursive partitioning. Rating patterns and algorithms were also used to make brief written guidelines on how clinical factors affect appropriateness and urgency of surgery. A summary score was provided for each case scenario; scenarios could then be matched to chart audit results, with scoring for quality management.

CONCLUSIONS

These algorithms and criteria can be used by managers or practitioners to assess appropriateness of referral for hip or knee replacement and relative rankings of patients in the queue for surgery.

The Quebec Back Pain Disability Scale: conceptualization and development

The Quebec Back Pain Disability Scale is a new measure of functional disability for patients with back pain. Functional disability was operationalized in terms of perceived difficulty associated with simple physical activities. The content of the scale was developed in several stages, including a literature review, two studies seeking the opinions of patients and experts, pilot testing, and a large, longitudinal study of back pain patients. Forty-eight disability items were extensively studied using standard methods such as test-retest reliability, item-total correlations, and factor analysis, as well as modern techniques based on item response theory. Items that were highly effective in discriminating between different levels of disability were selected for the final, reduced scale. The scale has 20 items, representing six empirically derived categories of activities affected by back pain. Measurement properties of this instrument have been previously discussed.

The role of children in reporting their physical disability

OBJECTIVE

To explore the contributions of children during the development of a disability scale, and their competence using the new scale.

DESIGN

A new self-report measure of pediatric physical performance, the Activities Scale for Kids (ASK), was developed based on interviews and pilot testing with children. The ASK was then filled out by children on two occasions 2 weeks apart to assess the reliability of child self-report. Validity was assessed by comparison of interview data and ASK scores from children with similar data collected from their parents, and to clinician and family global ratings of disability.

SETTING

The study was conducted at a pediatric tertiary care hospital and its affiliated rehabilitation center.

PATIENTS

All subjects, 5 to 15 years of age, experienced activity limitations because of musculoskeletal disorders and were free of cognitive impairment. Thirty children (mean age, 11.5 years) participated in the development of the ASK, and 28 children (mean age, 11.4 years) participated in testing of reliability and validity.

RESULTS

Children generated items similar to those generated by parents (85% agreement) and identified 10 items not obtained from parents or the literature. Children demonstrated excellent test-retest reliability (intraclass correlation coefficient [ICC] = .97) using the ASK, and their scores were highly concordant with parent-reported ASK scores (ICC = .96). Validity was ascertained by comparison of ASK scores across different levels of disability based on global ratings of families and clinicians (p = .0023).

CONCLUSION

Children are able to play an important role in pediatric physical disability evaluation.

Fetal tissue transplantation and abortion decisions: a survey of urban women

OBJECTIVE

To describe women's attitudes and predicted behaviour regarding the potential for fetal tissue transplantation (FTT) to influence abortion decisions.

DESIGNS

Self-administered questionnaire survey by mail.

SETTING

Academic family practice in Toronto.

PARTICIPANTS

Random sample of 475 women 18 to 40 years of age selected from the family practice registry of an urban teaching hospital. Family physicians were blind to their patients' participation, and investigators were blind to the subjects' identity. Forty questionnaires were undeliverable. Of the remaining 435, 272 (62.5%) were completed. Six of the women were over 40 years of age or did not indicate their age and were excluded, which left 266 (61.1%) questionnaires for analysis.

OUTCOME MEASURES

Number of women who would (a) be more likely to have an abortion if they could donate tissue for FTT and (b) feel better or worse about choosing abortion if FTT were an option, and open-ended comments about the potential for FTT to influence abortion decisions.

RESULTS

Of the 266 respondents 32 (12.0%) reported that they would be more likely to have an abortion if they could donate tissue for FTT, 178 (66.9%) stated that they would not be more likely to do so, and 56 (21.1%) were uncertain. Of the 122 who indicated that they would consider an abortion if they were pregnant, 21 (17.2%) stated that they would be more likely to have an abortion if they could donate tissue for FTT, 77 (63.1%) replied that they would not be more likely to do so, and 24 (19.7%) were uncertain. The women 25 to 33 years of age were more likely to be influenced by FTT than the younger or older women, and the women 18 to 24 years were more uncertain about the influence of FTT on abortion decisions than the older women. In written responses some of the women felt that FTT might make abortion decisions easier; many were troubled that FTT might be used to justify a morally problematic abortion decision and felt that FTT should not be used to justify abortion.

CONCLUSION

The data, the first of their kind gathered from from women, suggest that some women's abortion decisions may be influenced by the option to donate tissue for FTT. Further research is necessary to explore the mechanism of influence.

Canadian Medicare: prognosis guarded

Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making across-the-board cuts. (3) Replace blame with praise:give health care professionals and institutions credit for their contributions. (4) Learn from the successful programs and policies already in place across the country. (5) Foster horizontal and vertical integration of services. (6) Promote physician leadership by rewarding efforts to promote the efficient use of resources. (7) Monitor the effects of cutbacks: physician groups should cooperate with government in maintaining a national "report card" on services, costs and the health status of Canadians.

The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke

The objective of this study was to assess the reliability of the Balance Scale. Subjects were chosen from a larger group of 113 elderly residents and 70 stroke patients participating in a psychometric study. Elderly residents were examined at baseline, and at 3, 6 and 9 months, and the stroke patients were evaluated at 2, 4, 6 and 12 weeks post onset. The Cronbach's alphas at each evaluation were greater than 0.83 and 0.97 for the elderly residents and stroke patients respectively, showing strong internal consistency. To assess inter-rater reliability, therapists treating 35 stroke patients were asked to administer the Balance Scale within 24 hours of the independent evaluator. Similarly, caregivers at the Residence were asked to test the elderly residents within one week of the independent evaluator. To assess intra-rater reliability, 18 residents and 6 stroke patients were assessed one week apart by the same rater. The agreement between raters was excellent (ICC = 0.98) as was the consistency within the same rater at two points in time (ICC = 0.97). The results support the use of the Balance Scale in these groups.

Gastrointestinal Quality of Life Index: development, validation and application of a new instrument

At present, an instrument for measuring the quality of life, specifically for patients with gastrointestinal disease, is not available. A new instrument for gastrointestinal disorders that is system-specific has been developed in three phases. In the first phase, questions were collated and then tested on 70 patients with gastrointestinal diseases and those that worked well were retained. In the second phase, the questions were modified and tested on 204 patients and the results verified by international experts. The instrument was also validated against other generic measures of quality of life. During the third phase, the instrument was validated with 168 normal individuals. Reproducibility was tested on 25 patients with stable gastrointestinal disease and responsiveness was tested on 194 patients undergoing laparoscopic cholecystectomy. The result is a bilingual (German and English) questionnaire containing 36 questions each with five response categories. The responses to questions are summed to give a numerical score. It is concluded that the Gastrointestinal Quality of Life Index (GIQLI) is ready to be used in clinical practice and research.

The Quebec Back Pain Disability Scale. Measurement properties

STUDY DESIGN

The Quebec Back Pain Disability Scale is a 20-item self-administered instrument designed to assess the level of functional disability in individuals with back pain. The scale was administered as part of a larger questionnaire to a group of 242 back pain patients. Follow-up data were obtained after several days and after 2 to 6 months.

OBJECTIVES

The goal of this study was to determine whether the Quebec scale is a reliable, valid, and responsive measure of disability in back pain, and to compare it with other disability scales.

SUMMARY OF BACKGROUND DATA

A number of functional disability scales for back pain are being used, but their conceptual validity is uncertain. Unlike most published instruments, the Quebec scale was constructed using a conceptual approach to disability assessment and empirical methods of item development, analysis, and selection.

METHODS

The authors calculated test-retest and internal consistency coefficients, evaluated construct validity of the scale, and tested its responsiveness against a global index of change. Direct comparisons with the Roland, Oswestry, and SF-36 scales were carried out.

RESULTS

Test-retest reliability was 0.92, and Cronbach's alpha coefficient was 0.96. The scale correlated as expected with other measures of disability, pain, medical history, and utilization variables, work-related variables, and socio-demographic characteristics. Significant changes in disability over time, and differences in change scores between patients that were expected to differ in the direction of change, were found.

CONCLUSIONS

The Quebec scale can be recommended as an outcome measure in clinical trials, and for monitoring the progress of individual patients participating in treatment or rehabilitation programs.

Randomized trial of modified Bassini versus Shouldice inguinal hernia repair. The Cologne Hernia Study Group

Between 1986 and 1992, 265 men of mean age 51 (range 16-75) years with a primary inguinal hernia were randomized to undergo surgery by staff surgeon or surgical resident and further randomized to receive a modified Bassini operation (transversalis fascia not divided but included in the repair) or Shouldice procedure. The follow-up rate was 92.1 per cent with a mean follow-up of 3.3 years. Recurrence developed in 12 of 125 patients with a Bassini procedure and two of 119 after a Shouldice repair (9.6 versus 1.7 per cent, P = 0.006). The recurrence rate was no different for staff surgeons and trainees (5.9 versus 5.6 per cent, P not significant). Multivariate analysis identified the presence of a direct hernia (P = 0.003) as the additional main factor for the development of recurrence.

Transplantation of electively aborted human fetal tissue: physicians' attitudes

OBJECTIVE

To provide empirical data on the attitudes of Ontario family physicians and gynecologists toward the use of electively aborted fetal tissue for transplantation (FTT).

DESIGN

Cross-sectional survey.

SETTING

Ontario.

PARTICIPANTS

Random samples of 300 physicians from the membership list of the College of Family Physicians of Canada and 300 from the membership list of the Society of Obstetricians and Gynaecologists of Canada; 248 family physicians and 186 gynecologists responded, for an overall response rate of 72%.

OUTCOME MEASURES

Physicians' attitudes toward incentives to collect fetal tissue at abortion, patient-management issues, consent issues and potential conflicts in the supply and demand of fetal tissue.

RESULTS

Of those surveyed 75% agreed that there should be no incentives to collect fetal tissue at abortion, 90% believed that decisions to abort must be separate from decisions to donate fetal tissue, 94% agreed that an option to donate fetal tissue should be discussed only after a firm decision to abort has been made, and 88% stated that the demand for fetal tissue should not hinder the availability of new abortion technology such as the abortifacient pill (RU 486).

CONCLUSIONS

Results suggest that there is general approval for FTT. Apparent variations between responses to global statements and to practice-oriented statements suggest strategies for effective Canadian public policy regarding FTT.

Determinants of on-scene time in injured patients treated by physicians at the site

INTRODUCTION

The controversy surrounding the use of advanced life support (ALS) for the pre-hospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care. In Montreal, Québec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene.

HYPOTHESIS

The use of on-site ALS by physicians is associated with a significant increase in scene time.

METHODS

A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were used to analyze the data.

RESULTS

Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean = 5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (> 20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009).

CONCLUSION

This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with severe injuries.

Improving trauma care in Trinidad and Tobago

Identification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post-ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago.