The criterion-related validity of the Northwick Park Dependency Score as a generic nursing dependency instrument for different rehabilitation patient groups

Objective: To investigate the criterion or concurrent validity of the Northwick Park Dependency Score (NPDS) for determining nursing dependence in different rehabilitation groups, with the Barthel Index (BI) and the Care Dependency Scale (CDS).

Design: Cross-sectional study.

Setting: Centre for Rehabilitation of the University Medical Center Groningen, The Netherlands.

Subjects: Patients after stroke, spinal cord injury, multitrauma, head injury, amputation, rheumatoid arthritis, diabetes mellitus, lung diseases, tuberculosis and coronary artery disease. One hundred and fifty-four patients were included.

Measures: The Northwick Park Dependency Score (NPDS), the Barthel Index (BI) and the Care Dependency Scale (CDS).

Results: The correlation (rho) between the NPDS and the BI for all groups was -0.87; R2=0.76 ( n=154). Per patient group rho varied from -0.70 ( R2=0.49) to -0.93 ( R2=0.86). The overall correlation between the NPDS and CDS was larger than the criterion of rho=0.60 ( r=-0.74; R2=0.55) but was <0.60 in the rheumatoid arthritis and tuberculosis group. The overall correlation between BI and CDS exceeded the criterion ( r=0.75; R2=0.56).

Conclusions: The NPDS is a generic nursing dependency instrument that can be used as a valid measure across various patient groups in rehabilitation.

[Embrace, a model for integrated elderly care]

Ongoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care.

METHODS

The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program - combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period.

DISCUSSION

This study could provide evidence for the effectiveness of Embrace.

Validation of the ICF core set for neuromuscular diseases

BACKGROUND

Understanding of the consequences of a neuromuscular disease (NMD) can improve when a valid sample of disease-specific categories based on the International Classification of Functioning, Disabilities, and Health (ICF) is available.

OBJECTIVE

To examine the content validity of the initial ICF Core Set for neuromuscular diseases (NMDs). The initial ICF Core Set was developed for three chronic neurological diseases.

DESIGN

A qualitative method.

METHODS

To examine the content validity of the initial ICF Core Set for NMD, concepts in established disease-specific health-related Quality of Life Questionnaires (HRQOL) were compared with ICF categories. Next, the selected ICF categories were linked to the ICF categories in the initial ICF Core Set.

RESULTS

All concepts in the HRQOL questionnaires, except one body function concept, were covered by the initial ICF Core Set. However, the NMD Core Set reflects a broader scope concerning health problems than the concepts in the HRQOL questionnaires do, especially concerning the "Participation" and "Environmental Factors" components.

CONCLUSION

The NMD Core Set, as well as a measurement based on this Core Set, can contribute to a better understanding of the consequences of NMDs and can also serve as a basis for clinical practice, research, social security systems, and educational programs.

CLINICAL REHABILITATION IMPACT

The newly developed NMD Core Set can be a basis for enhancing the development of rehabilitation interventions and improving overall health care for patients with a NMD.

Effective and efficient learning in the operating theater with intraoperative video-enhanced surgical procedure training

BACKGROUND

INtraoperative Video Enhanced Surgical procedure Training (INVEST) is a new training method designed to improve the transition from basic skills training in a skills lab to procedural training in the operating theater. Traditionally, the master-apprentice model (MAM) is used for procedural training in the operating theater, but this model lacks uniformity and efficiency at the beginning of the learning curve. This study was designed to investigate the effectiveness and efficiency of INVEST compared to MAM.

METHODS

Ten surgical residents with no laparoscopic experience were recruited for a laparoscopic cholecystectomy training curriculum either by the MAM or with INVEST. After a uniform course in basic laparoscopic skills, each trainee performed six cholecystectomies that were digitally recorded. For 14 steps of the procedure, an observer who was blinded for the type of training determined whether the step was performed entirely by the trainee (2 points), partially by the trainee (1 point), or by the supervisor (0 points). Time measurements revealed the total procedure time and the amount of effective procedure time during which the trainee acted as the operating surgeon. Results were compared between both groups.

RESULTS

Trainees in the INVEST group were awarded statistically significant more points (115.8 vs. 70.2; p < 0.001) and performed more steps without the interference of the supervisor (46.6 vs. 18.8; p < 0.001). Total procedure time was not lengthened by INVEST, and the part performed by trainees was significantly larger (69.9 vs. 54.1 %; p = 0.004).

CONCLUSIONS

INVEST enhances effectiveness and training efficiency for procedural training inside the operating theater without compromising operating theater time efficiency.

Change in disability profile and quality of life in multiple sclerosis patients: a five-year longitudinal study using the Multiple Sclerosis Impact Profile (MSIP)

Background: Evidence on the progress of disease severity in Multiple Sclerosis (MS) is generally limited in scope.

Objectives: To examine the course of a broad spectrum of MS-related disabilities and quality of life (QOL) in relation to disease severity, and responsiveness of the Multiple Sclerosis Impact Profile (MSIP).

Methods: The mortality rate was calculated after checking the national population register for vital status of the initial cohort. We performed a longitudinal study among 245 patients with MS attending the Groningen MS Center in the Netherlands. We assessed these patients in 2004 and 2009 using a postal survey including the MSIP to evaluate disabilities, the World Health Organization Quality of Life-Abbreviation version (WHOQOL-BREF) to evaluate QOL, and the ambulation question of the Expanded Disability Status Scale (EDSS) to evaluate disease severity. Responsiveness of the MSIP was estimated using standardized response mean (SRM).

Results: Increase of disability in the MSIP disability domains and loss of QOL were most prevalent and pronounced in patients with EDSS 0 to < 4.5 in 2004. MSIP and QOL scores were remarkably stable in the higher disease severity groups. Mortality rates were highest (24%) in patients with EDSS ≥ 7 to < 10 in 2004. SRM indices for the MSIP ranged between 0.26 and 0.56.

Conclusions: Prominent increases in multiple aspects of disability and loss of QOL occur especially in the early stages in MS. Health care interventions may lead to health and QOL gains, in particular when offered to patients in the first stage of the MS process. Responsiveness was sufficient for nine of the 11 MSIP domains.

[Enlargement of the gingiva during treatment with fixed orthodontic appliances]

Gingival enlargement commonly occurs in patients treated with fixed orthodontic appliances. In a study, 25 patients were monitored during and after treatment with fixed orthodontic appliances. The extent of the enlargement of the gingiva was determined by means of intra-oral photographs made shortly before the placement of the appliances, immediately after their removal and at 3 and 6 months after the appliances had been removed. The enlargement of the gingival was determined using a Visual Analogue Scale. During orthodontic treatment the average degree of gingival enlargement increased significantly. After removal of the appliances a significant decrease in the degree of gingival enlargement occurred. Within 3 months after debonding the gingival enlargement was at the same level as before starting the orthodontic treatment. The conclusion was that the enlargement of the gingiva that takes place during treatment with fixed orthodontic appliances was reversible.

Stability and relative validity of the Multiple Sclerosis Impact Profile (MSIP)

OBJECTIVE

To examine the stability and relative validity of the Multiple Sclerosis Impact Profile (MSIP) in criterion-related groups. The MSIP is a disease-targeted health impact measure based on a selection of International Classification of Functioning, Disability and Health (ICF) aspects selected by 98 patients and medical and non-medical health professionals.

METHOD

Data were obtained from a postal survey of 377 individuals with Multiple Sclerosis (MS) attending the MS centre of the University Medical Center Groningen (UH) and 153 subjects from the MS patients' association. Stability was tested with t-tests for paired samples and intraclass correlation coefficients for repeated measures in a sample of 251 individuals from the UH sample. The Relative Validity (RV) was estimated using the Short Form Questionnaire (SF-36), the World Health Organization Quality of Life-BREF (WHOQOL-BREF), the Disability and Impact Profile (DIP), the Impact on Autonomy Questionnaire (IPAQ) and the Groningen Activity Restriction Scale (GARS).

RESULTS

These indicate that the MSIP is a stable measure in time. MSIP scales showed satisfactory and strong RV. In general, the domain-specific activities and participation measures (GARS and IPAQ) performed equally or slightly better than the comparable MSIP-scales, while the MSIP performed better than the multidimensional health impact measures (SF-36, DIP and WHOQOL-BREF).

CONCLUSION

The MSIP demonstrated good stability and RV compared to generic health impact and domain-specific measures.

EuroSCORE predicts poor health-related physical functioning six month postcoronary artery bypass graft surgery

AIM

The objectives of this study are to test whether the European system of cardiac-operative risk evaluation score (EuroSCORE) is associated with preoperative health-related quality of life (HRQoL), and whether it is a predictor of mental and physical health-related quality of life six months after coronary artery bypass grafting (CABG).

METHODS

A longitudinal observational study was carried out among 181 patients who underwent CABG. Physical and mental domains of quality of life were measured using SF-36 and risk stratification was estimated using the EuroSCORE. A post hoc test (with Bonferroni correction) was used to determine whether EuroSCORE was associated with preoperative HRQoL, LOS and postoperative rate of complications. Hierarchical regression analysis was performed to explore the associations between EuroSCORE, postoperative events and postoperative HRQoL.

RESULTS

EuroSCORE is associated with physical functioning before and after CABG and a higher EuroSCORE is a predictor of poor physical functioning and not a predictor of the mental domains of quality of life, while smoking predicted bodily pain after CABG. Furthermore, readmission within six weeks after discharge was a predictor of poor physical functioning, physical role and general health. Moreover, post hoc tests showed statistically significant and clinically relevant differences in physical functioning between low-risk and high-risk EuroSCORE classes, and between medium and high classes at baseline and six months after CABG. High-risk patients had more perioperative complications and longer lengths of stay, as compared to low-risk patients.

CONCLUSION

EuroSCORE is a predictor of poor self-reported physical functioning six months after CABG and is not a predictor of mental functioning.

The impact of disabilities on quality of life in people with multiple sclerosis

Objective

People with Multiple Sclerosis (MS) experience lower levels of quality of life (QOL) than people from the general population. We examined the relative impact of MS-related disabilities on QOL.

Method

Data were obtained from a sample of 530 patients who completed the Multiple Sclerosis Impact Profile (MSIP), a disability measure based on the International Classification of Functioning,Disabilities and Health (ICF) and two generic health-related QOL measures, the Medical Outcome study Short Form Questionnaire (SF-36) and the World Health Organization Quality Of Life-BREF (WHOQOL-BREF). The impact of disabilities on QOL was estimated using hierarchical multiple regression analyses after controlling for the clinical course of MS.

Results

Disabilities contributed to a unique and substantial extent to QOL variance. “Impairments in mental functions” was the most important QOL predictor. “Fatigue” showed the highest prevalence and severity scores, while the impact on QOL was limited. The estimated impact on QOL appeared to be dependent on the applied QOL measure: the WHOQOL-BREF was sensitive to disabilities related to all four ICF components, while the SF-36 was only sensitive to disabilities belonging to the 'body functions' and ‘activities’ components.

Conclusion

Treatment programmes should target impairments in cognitive functioning, emotional functioning and sleep. Interventions are best evaluated using the WHOQOL-BREF.

[Health-related fitness of sedentary elderly in the Netherlands]

The assessment of fitness is a component of a national project aimed at the enhancement of physical avtivity among sedentary older adults, aged 55-65 year in the Netherlands. Deterioration in physical functioning may be improved through an exercise programme. Research showed that enhancement of physical activity results in improved fitness, increased functional ability and health-related quality of life. Scientific results of the association between exercise and physical fitness in older adults is not sufficiently evidence-based in the Netherlands. In order to support health policy interventions 5.584 fitness tests of sedentary older adults were analyzed. The fitness was assessed by the Groninger Fitnesstest for Elderly (GFE). The analysis of physical fitness in sedentary older adults showed a lower fitness status among the age group 55-65 of age and women. Health risk factors such as overweight and having a chronic disease explained 88% of the variance between a low fitness and a high fitness profile.

An international comparative study on the reliability and validity of the attitudes towards aggression scale

One of the factors known to be associated with the management of patient aggression is the attitude of staff members towards the aggressive behaviour of patients. The construct validity of an instrument measuring the attitudes of staff towards inpatient aggression in psychiatry was evaluated in this international multi-centre study. Factor analysis and simultaneous component analysis were performed with data from a convenience sample of 1769 psychiatric nurses working in psychiatric hospitals and student nurses from nursing schools. The samples were recruited by fellow researchers in their home country. The original 32-item version (POAS) was reduced to 18 items comprising five attitude scales with solid psychometric properties. The types of attitudes were labelled offensive, communicative, destructive, protective and intrusive. The format of the correlations between the types of attitudes suggested the existence of two basic underlying divergent domains in the scale. The 'communication' and 'protection' scale components on the one hand, and the 'offence', 'destruction' and 'intrusion' components on the other. The five types of attitude proved to be invariant across samples from five European countries. The Aggression Scale (ATAS) is a reliable and valid measure that will enable researchers to perform international comparative research on attitudes and aggression.

Long term effect (more than five years) of intrathecal baclofen on impairment, disability, and quality of life in patients with severe spasticity of spinal origin

OBJECTIVES

To evaluate long term change in impairment, disability, and health related functional status in patients with severe spasticity who received intrathecal baclofen.

METHODS

A long term (more than five years) observational longitudinal follow up study assessing 21 patients who received intrathecal baclofen given by programmable pump. Patients had chronic disabling spasticity which did not respond to oral antispasmolytic agents. Clinical efficacy was assessed by the Ashworth scale and spasm score; disability by the expanded disability status scale (EDSS), ambulation index (AI), and incapacity status scale (ISS); and health related quality of life by the sickness impact profile (SIP) and the Hopkins symptom checklist (HSCL).

RESULTS

Compared with pretreatment values, there was a significant improvement in clinical efficacy (Ashworth scale and spasm score, p<0.05) but a small but significant worsening of disability (EDSS, AI, and ISS, p<0.05). Comparing pretreatment with 26 weeks after pump implantation, a worsening was observed in disability (EDSS and ISS, p<0.05) and perceived health status (SIP, psychosocial dimension, p<0.05).

CONCLUSIONS

Long term administration of intrathecal baclofen delivered by an implanted programmable pump resulted in improved clinical efficacy but not in improvement in disability or perceived health status.

Cryopreservation of porcine fetal ventral mesencephalic tissue for intrastriatal transplantation in Parkinson's disease

In this study we examined the efficacy of cryopreserving porcine fetal mesencephalic tissue. After microscopical dissection of the ventral mesencephalon (VM) from E28 pig fetuses, the collection of explants was randomly divided into two equal parts. One part was directly prepared as cell suspension. The other part was stored in hibernation medium for less than 2 days and then cryopreserved as tissue fragments and stored in liquid nitrogen. After 2 weeks up to 1 year, these tissue fragments were thawed and processed as cell suspensions. After cell counting and assessment of viability, these cell suspensions were used to examine survival, morphology, and neurite formation of the dopaminergic neurons in cell culture as well as after intrastriatal implantation in 6-OHDA-lesioned rats. Comparison of cryopreserved with fresh VM cell suspensions showed no significant difference with respect to cell viability and the average number of living cells per VM explant. The morphology of cultured dopaminergic neurons after cryopreservation was identical to that of fresh cells. After intrastriatal implantation, survival and outgrowth of cryopreserved dopaminergic neurons as well as functional effects did not differ from those of fresh cells. In conclusion, the cryopreservation technique we used proves to be a reliably effective method for storing porcine fetal VM tissue.

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

Some clinical trials perform repeated measurement over time and estimate clinically relevant change in an instrument's score with global ratings of perceived change or so-called transition questions. The conceptual and methodological difficulties in estimating the magnitude of clinically relevant change over time in health-related functional status (HRFS) are discussed. This paper investigates the concordance between the amount of serially assessed change with effect size estimates (the researcher's perspective) and global ratings of perceived change (the patient's perspective). A total of 217 patients who were scheduled for diagnostic examination were included, and the Minnesota Living with Heart Failure Questionnaire, extended with MOS-20 items, was assessed before and after medical intervention (percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or pharmaco-therapy). Global questions were applied to assess perceived change over time for every item from domains of physical and emotional functioning and used as the external criterion of relevant change in the analysis of items. Global questions corresponding with overall change in these domains were used in the comparison of change in physical and emotional functioning scales. Two effect size indices were used: (i) ES (mean change/SDpooled) and (ii) ES (mean change/SDchange). A method is described to calculate a value indicating the extent of discordance between the researcher's interpretation of magnitude of change and the external criterion (the patient's perspective). Findings suggest that effect size (ES) (mean change/SDpooled) was in keeping with the magnitude of change indicated by patients' judgements, or their category of subjective meaning, for all scales. Furthermore, in cases in which the magnitude of change estimated with the SRM (mean change/SDchange) was not confirmed empirically by the external criterion ratings, the discordance could be interpreted as a trivial discordance.

Psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q)

OBJECTIVE

To evaluate the psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q) in patients with atrial fibrillation.

DESIGN

A prospective study of the patients who underwent DC electrical cardioversion.

SETTING

Clinics of cardiology and thoracic surgery of the University Hospital in Groningen, the Netherlands.

MAIN OUTCOME MEASURES

The disease-specific MLHF-Q and generic measures of quality of life were administered. The sensitivity to change over time was tested with effect sizes (ES). Internal consistency of MLHF-Q scales was estimated with Cronbach's alpha. To evaluate the construct validity multitrait-multimethod analysis was applied. The 'known group validity' was evaluated by the comparison of mean scores and effect sizes between two groups of the New York Heart Association (NYHA) classification (NYHA I versus II-III). Stability of MLHF-Q scales was estimated in a subgroup of patients who remained stable. Perfect congruence analysis and factor analysis were applied to confirm the a priori determined structure.

RESULTS

Cronbach's alpha was > or = 0.80 of the MLHF-Q scales. Perfect congruence analysis (PCA) showed that the results resemble quite well the a priori assumed factor structure. Multitrait-multimethod analysis showed convergent validity coefficients ranging from 0.59 to 0.73 (physical impairment dimension) and 0.39 to 0.69 (emotional dimension). The magnitude of change can be interpreted as medium (ES = 0.50). The results of a 'test-retest' analysis in a stable group can be valued as satisfactory for the MLHF-Q scales (Pearson's r > 0.60). The physical dimension and the overall score of the MLHF-Q discriminated significantly between the NYHA I and II-III groups (p < 0.001) with large effect sizes (ES > 1.0).

Increased vital exhaustion among type-D patients with ischemic heart disease

OBJECTIVE

To investigate the prevalence of the "distressed personality" (type-D) in cardiac patients and to explore the relationships between type-D, gender, vital exhaustion and angina pectoris.

METHODS

A questionnaire was completed by 171 patients scheduled for coronary angiography (CAG) at baseline and again at 6 weeks following implementation of treatment with invasive procedures or medication.

RESULTS

Women were more vitally exhausted at baseline and more likely to be classified as type-D. Type-D patients scored higher on vital exhaustion independent of all other variables. Angina was related to vital exhaustion, but improvement in angina following intervention was not associated with improvement in vital exhaustion scores.

CONCLUSION

Although medical interventions reduced angina, a concomitant decrease in vital exhaustion scores was not found. It is suggested that type-D may explain gender differences on distress. Clinical implications are discussed, including the importance of including personality factors in future research, as they have been shown to have independent prognostic value.

Effect of intrathecal baclofen delivered by an implanted programmable pump on health related quality of life in patients with severe spasticity

OBJECTIVES

To compare clinical effectiveness and health related quality of life in patients with severe spasticity who received intrathecal baclofen or a placebo.

METHODS

In a double blind, randomised, multicentre trial 22 patients were followed up during 13 weeks and subsequently included in a 52 week observational longitudinal study. Patients were those with chronic, disabling spasticity who did not respond to maximum doses of oral baclofen, dantrolene, and tizanidine. After implantation of a programmable pump patients were randomly assigned to placebo or baclofen infusion for 13 weeks. After 13 weeks all patients received baclofen. Clinical efficacy was assessed by the Ashworth scale, spasm score, and self reported pain, and health related quality of life by the sickness impact profile (SIP) and the Hopkins symptom checklist (HSCL).

RESULTS

At three months the scores of the placebo and baclofen group differed slightly for the spasm score (effect size=0.20) and substantially for the Ashworth scale (effect size=1.40) and pain score (effect size=0.94); health related quality of life showed no significant differences. Three months after implantation the baclofen group showed a significant, substantial improvement on the SIP "physical health", "mental health", "mobility", and "sleep and rest" subscales and on the HSCL mental health scale; patients receiving placebo showed no change. After one year of baclofen treatment significant (P<0.05) improvement was found on the SIP dimensions "mobility" and "body care and movement" with moderate effect sizes. Improvement on the SIP subscale "physical health" (P<0.05; effect size 0.86), the SIP overall score (without "ambulation"), and the "physical health" and overall scale of the HSCL was also significant, with effect sizes >0.80. Changes in health related behaviour were noted for "sleep and rest" and "recreation and pastimes" (P<0.01, P<0.05; effect size 0.95 and 0.63, respectively). Psychosocial behaviour showed no improvement.

CONCLUSIONS

Intrathecal baclofen delivered by an implanted, programmable pump resulted in improved self reported quality of life as assessed by the SIP, and HSCL physical health dimensions also suggest improvement.