Self-reported chronic conditions and COVID-19 public health measures among Canadian adults: an analysis of the Canadian longitudinal study on aging

OBJECTIVES

During the COVID-19 pandemic, public health measures were used to reduce the spread of COVID-19; it is unknown whether people with chronic conditions differentially adhered to public health measures. The objectives of this study were to evaluate the association between chronic conditions and adherence and to explore effect modification by sex, age, and income.

STUDY DESIGN

An analysis of data from the Canadian Longitudinal Study on Aging COVID-19 Questionnaires (from April to September 2020) was conducted among middle-aged and older adults aged 50-96 years (n = 28,086).

METHODS

Self-reported chronic conditions included lung disease, diabetes, heart disease, cancer, obesity, anxiety, and depression. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between chronic conditions and low, medium, and high levels of adherence. Effect modification was evaluated using statistical interaction and stratification.

RESULTS

Most people (n = 17,435; 62%) had at least one chronic condition, and 2866 (10%) had three to seven chronic conditions. Among those with high adherence to public health measures, 69% had one or more chronic condition (n = 2266). Having three to seven chronic conditions, compared with none, was associated with higher adherence to public health measures (OR: 2.14; 95% CI: 1.12-1.42). Higher adherence was also noted across chronic conditions, for example, those with diabetes had higher adherence (OR: 1.72; 95% CI: 1.53-1.93). There was limited evidence of effect modification by sex, age, or income.

CONCLUSIONS

Canadians with chronic conditions were more likely to adhere to public health measures; however, future research is needed to understand whether adherence helped to prevent adverse COVID-19 outcomes and if adherence had unintended consequences.

Developing common metrics of mechanical exposures across aetiological studies of low back pain in working populations for use in meta-analysis

OBJECTIVES

One of the challenges of conducting meta-analyses on the relationship between workplace mechanical exposures and low back pain is that mechanical exposures are reported in a wide variety of ways. We aimed to develop common metrics to apply in the translation of literature-based workplace mechanical exposures for use in meta-analyses, and to test the metrics' measurement properties.

METHODS

We developed a set of 7-point scales to capture the intensity of important aspects of mechanical exposures that may be related to the development of low back pain in workers. The scales represented three dimensions of mechanical exposures at work: (1) trunk posture, (2) weight lifted or force exerted and (3) spinal loading, and estimated both peak and cumulative loads. Measurement properties of the scales were tested through a survey of experts in biomechanics and ergonomics who were asked to rate literature-based workplace exposure definitions using the scales and provide estimates of their confidence in their ratings.

RESULTS

For each dimension the ratings for peak loads tended to be higher than the cumulative load ratings. The inter-rater reliability for the scales ranged from 0.3 to 0.5; we would need to average the ratings of at least four expert raters to have an acceptable level of reliability (>0.7). Inter-expert reliability was positively related to the experts' level of confidence in their ratings. In most cases the ranking of intensity ratings from the experts matched the ranking of exposure intensity from the original articles.

CONCLUSIONS

This study provides insight into estimating the intensity of literature-based mechanical exposure metrics using a common set of scales which can be applied across epidemiologic studies. These metrics may be useful to quantify the relationship between workplace mechanical exposure and low back pain in a systematic review and meta-analysis.

A randomised trial to evaluate the self-administered standardised chronic respiratory questionnaire

The original chronic respiratory questionnaire (CRQ), one of the most widely used measures of health-related quality of life (HRQL) in chronic respiratory disease (CRD), is traditionally interviewer administered (IA) and includes an individualised dyspnoea domain. The present authors studied the impact of self-administered (SA) and standardised dyspnoea questions on CRQ measurement properties. In a factorial design multicentre trial, 177 patients with CRD (mean age 67.7 yrs; mean forced expiratory volume in one second per cent predicted 44.6%) were randomised to CRQ-IA (n = 86) or CRQ-SA (n = 91), and to initially complete the standardised or individualised items before and after respiratory rehabilitation. While maintaining validity, the CRQ-SA proved more responsive to changes in HRQL than the CRQ-IA in all domains. Compared with the standardised dyspnoea domain, the individualised dyspnoea domain indicated greater responsiveness. The correlations of baseline scores and change scores with other HRQL instruments indicated good validity of the CRQ-SA. In conclusion, self-administration and standardisation of the chronic respiratory questionnaire maintains validity and responsiveness relative to the interviewer-administered chronic respiratory questionnaire. These results challenge the assumption that interviewer-administered questionnaires are superior to self-administered questionnaires in older patients with chronic respiratory disease.

Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients

OBJECTIVE

Predicting patients who are harboring asymptomatic deep venous thrombosis (DVT), or who are at particular risk of developing DVT, is a desirable clinical goal since prevention or early treatment of DVT might reduce the risk of fatal pulmonary embolism. Thus validation of simple laboratory tests that reliably predict venous thromboembolism (VTE) would be clinically very important. Tests that might be useful for these applications include markers of hypercoagulability (predicting patients at risk of DVT) and D-dimer (predicting which patients may have acute DVT).

METHODS

In a prospective cohort study we measured a panel of hypercoagulability markers at the time of ICU admission, and six commercial D-dimer assays were performed serially during the ICU stay in medical-surgical ICU patients who were screened for DVT with biweekly lower limb compression ultrasonography. Ultrasonography was also performed at the time of any clinically suspected DVT events. We matched cases with DVT with controls without DVT for length of stay in the ICU to generate receiver operating characteristics (ROC) curves.

RESULTS

One hundred ninety-seven patients were enrolled. Blood was collected on a total of 763 occasions (median number of occasions per patient: 3, range 1-21). None of the assays predicted DVT, as indicated by the areas under the ROC curves, that did not differ significantly from 50%.

CONCLUSION

In critically ill patients, neither tests of hypercoagulability nor D-dimer levels predict patients at risk of DVT and thus they should not be used to guide diagnostic testing for DVT.

The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients

OBJECTIVE

To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients.

DESIGN

Three strategies were used to estimate the mortality attributable to bleeding in two multicentre databases. The first method matched patients who bled with those who did not (matched cohort), using duration of ICU stay prior to the bleed, each of six domains of the Multiple Organ Dysfunction Score (MODS) measured 3 days prior to the bleed, APACHE II score, age, admitting diagnosis, and duration of mechanical ventilation. The second approach employed Cox proportional hazards regression to match bleeding and non-bleeding patients (model-based matched cohort). The third method, instead of matching, derived estimates based on regression modelling using the entire population (regression method). Three parallel analyses were conducted for the length of ICU stay attributable to clinically important bleeding.

SETTING

Sixteen Canadian university-affiliated ICUs.

PATIENTS

A total of 1666 critically ill patients receiving mechanical ventilation for at least 48 hours.

MEASUREMENTS

We prospectively collected data on patient demographics, APACHE II score, admitting diagnosis, daily MODS, clinically important bleeding, length of ICU stay, and mortality. Independent adjudicators determined the occurrence of clinically important gastrointestinal bleeding, defined as overt bleeding in association with haemodynamic compromise or blood transfusion.

RESULTS

Of 1666 patients, 59 developed clinically important gastrointestinal bleeding. The mean APACHE II score was 22.9 +/- 8.6 among bleeding patients and 23.3 +/- 7.7 among non-bleeding patients. The risk of death was increased in patients with bleeding using all three analytic approaches (matched cohort method: relative risk [RR]= 2.9, 95% confidence interval (CI)= 1.6-5.5; model-based matched cohort method: RR = 1.8, 95% CI = 1.1-2.9; and the regression method: RR = 4.1, 95% CI = 2.6-6.5). However, this was not significant for the adjusted regression method (RR = 1.0, 95% CI = 0.6-1.7). The median length of ICU stay attributable to clinically important bleeding for these three methods, respectively, was 3.8 days (95% CI = -0.01 to 7.6 days), 6.7 days (95% CI = 2.7-10.7 days), and 7.9 days (95% CI = 1.4-14.4 days).

CONCLUSIONS

Clinically important upper gastrointestinal bleeding has an important attributable morbidity and mortality, associated with a RR of death of 1-4 and an excess length of ICU stay of approximately 4-8 days.

Comparison of open and closed questionnaire formats in obtaining demographic information from Canadian general internists

The objective of this study was to compare the impact of closed- versus open-ended question formats on the completeness and accuracy of demographic data collected in a mailed survey questionnaire. We surveyed general internists in five Canadian provinces to determine their career satisfaction. We randomized respondents to receive versions of the questionnaire in which 16 demographic questions were presented in a closed-ended or open-ended format. Two questions required respondents to make a relatively simple computation (ensuring that three or four categories of response added to 100%). The response rate was 1007/1192 physicians (80.0%). The proportion of respondents with no missing data for all 16 questions was 44.7% for open-ended and 67.0% for closed-ended formats (P < 0.001). The odds of having missing items remained higher for open-ended response options after adjusting for a number of respondent characteristics (2.67, 95% confidence interval 2.01 to 3.55). For the two questions requiring computations focused on professional activity and income, there were more missing data (P = 0.02, 0.02, respectively) but fewer inaccurate responses (P = 0.009, 0.20, respectively) for the open-ended compared to the closed-ended format. Investigators can achieve higher response rates for demographic items using closed format response options, but at the risk of increasing inaccuracy in response to questions requiring computation.

Surgeons' assessment of symptoms suggesting extrathoracic metastases in patients with lung cancer. Canadian Lung Oncology Group

BACKGROUND

In patients with apparently operable non-small cell lung cancer (NSCLC), clinicians often omit investigation for M disease in asymptomatic patients. Previous investigations have not specified in detail what is meant by "symptomatic," and this could differ between surgeons. We have investigated the extent to which surgeons' criteria differ for presence of symptoms.

METHODS

Participating surgeons from seven centers, enrolled patients they judged "asymptomatic" in a randomized trial of investigational strategies for NSCLC. Patients completed a structured questionnaire describing symptoms of the central nervous system (CNS). In 685 patients, we documented CNS symptom recurrence after resectional surgery over 1 year of follow-up.

RESULTS

Two centers enrolled only patients without even the mildest symptoms. Three centers took an intermediate approach, occasionally classifying patients with mild symptoms as "asymptomatic" and thus enrolling them in the trial. Two centers classified an appreciable number of patients with minimal symptoms, and occasionally with more than minimal symptoms, as "asymptomatic." Patients with even mild CNS symptoms were more likely to subsequently present with CNS metastases.

CONCLUSIONS

Thoracic surgeons differ in their ideas of what may constitute the symptoms of M disease. Patients with structured questionnaire results that suggest symptoms of CNS disease are more likely to have CNS symptom recurrence after resectional surgery.

Isoniazid prophylaxis for tuberculosis in HIV infection: a meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the efficacy of isoniazid for the prevention of tuberculosis in tuberculin skin test-positive and negative individuals with HIV infection.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Seven trials from Mexico, Haiti, the United States, Zambia, Uganda and Kenya.

PATIENTS

Individuals free from tuberculosis, 2367 persons in the intervention and 2162 in the control groups.

INTERVENTION

Comparison of isoniazid with placebo or no prophylaxis.

METHODS

A systematic search of the literature was carried out from 1985 to October 1997 for randomized controlled trials of isoniazid prophylaxis in HIV-infected persons. Two reviewers evaluated the relevance of each candidate study and the validity of eligible trials. Studies were pooled using a random effect model, conducting secondary analyses for tuberculin skin test-positive and negative persons.

RESULTS

Mean follow-up in trials varied between 0.4 and 3.2 years. Pooling all seven trials, a risk ratio was found for persons treated with isoniazid for developing tuberculosis of 0.58 [95% confidence interval (CI), 0.43-0.80] and 0.94 (95% CI, 0.83-1.07) for death. In groups of tuberculin skin test-positive and negative persons, the risk ratio of tuberculosis was 0.40 (95% CI, 0.24-0.65) and 0.84 (95% CI, 0.54-1.30), respectively, and the difference in the effectiveness of isoniazid versus placebo between these groups was statistically significant (P = 0.03, for the difference of summary estimates). Consistency of results was found across trials (P > 0.10, heterogeneity value) for all comparisons.

CONCLUSIONS

Prophylaxis with isoniazid reduces the risk of tuberculosis in persons with HIV infection. The effect is restricted to tuberculin skin test-positive persons.

Development of a questionnaire to measure quality of life in patients with irritable bowel syndrome

OBJECTIVE

To develop a questionnaire for measuring health-related quality of life (HRQL) in patients with Irritable Bowel Syndrome (IBS).

METHODS

We surveyed the existing literature, and interviewed patients and clinicians, to develop a list of 182 potential problems for IBS patients. One hundred patients with IBS completed a questionnaire in which they told us whether each of the 182 items was a problem for them, and if so the magnitude of their importance in their lives.

RESULTS

Patients identified four major problem areas: bowel symptoms, fatigue, activity limitations, and emotional dysfunction. On the basis of these findings, we constructed a 26-item questionnaire which, in pre-testing, 16 patients found clear and easy to complete.

CONCLUSION

We have developed a questionnaire that measures HRQL in IBS patients and is suitable for use as an outcome measure in clinical trials in IBS.

Systematic review on the risk and benefit of different cholesterol-lowering interventions

Meta-analyses have investigated the efficacy of cholesterol-lowering interventions in relation to the underlying risk of coronary heart disease and the extent and duration of cholesterol reduction. We systematically reviewed the efficacy of antilipidemic interventions on major mortality outcomes in relation to drug classes. We searched MEDLINE and EMBASE from 1966 through October 1996 for randomized, controlled trials of any cholesterol-lowering interventions reporting mortality data. We included 59 trials involving 85 431 participants in the intervention and 87 729 participants in the control groups. We pooled these trials into 7 pharmacological categories of cholesterol-lowering interventions: statins (13 trials), fibrates (12 trials), resins (8 trials), hormones (8 trials), niacin acid (2 trials), n-3 fatty acids (3 trials), and dietary interventions (16 trials). Of the cholesterol-lowering interventions, only statins showed a large and statistically significant reduction in mortality from coronary heart disease (risk ratio, 0.66; 95% confidence interval [CI], 0.54 to 0. 79) and from all causes (risk ratio, 0.75; 95% CI, 0.65 to 0.86). For both all-cause and cardiovascular mortality, the difference between statins and the combined estimate of the other classes of agents was unlikely to be due to chance (P<0.02 for both comparisons). Meta-regression analysis demonstrated that variability in results across trials could be largely explained on the basis of differences in the magnitude of cholesterol reduction. Statins have the largest effect on the reduction of cardiovascular and all-cause mortality, and this result recommends their use in preference to other antilipidemic agents. The greater effect of statins is likely due to the larger reduction in cholesterol.

Development and validation of the mini-osteoporosis quality of life questionnaire (OQLQ) in osteoporotic women with back pain due to vertebral fractures. Osteoporosis Quality of Life Study Group

The objective of the study was to evaluate a shortened osteoporosis quality of life questionnaire (OQLQ) in osteoporotic women with back pain due to vertebral fractures. From the longer 30-item OQLQ (four to nine items per domain) we created the mini-OQLQ by choosing the two items with the highest impact in each of five domains (symptoms, physical function, activities of daily living, emotional function, leisure). We administered the OQLQ, the Sickness Impact Profile, the SF-36 and the Brief Pain Index to patients at baseline, after 2 weeks and after 6 months. The intraclass correlations between baseline and the 2-week follow-up for the five mini-OQLQ domains ranged from 0.72 to 0.86. Cross-sectional correlations between the domains of the mini-OQLQ and other health instruments were moderate to large (0.35-0.80) and greater than predicted. The mini-OQLQ items showed moderate to large correlations with items omitted from the shortened questionnaire (0. 44-0.88). Correlations between the OQLQ domains and the other three instruments were greater than those of the mini-OQLQ, and partial correlations between OQLQ items omitted from the mini-OQLQ and the other three instruments after considering mini-OQLQ items were substantial (0.19-0.71) and statistically significant. Sample sizes of less than 200 per group should be required to detect minimally important differences in parallel-group clinical trials. Longitudinal correlations between the mini-OQLQ and the other measures were often significant but generally lower than predicted (0.10-0.49). The partial correlations revealed that the omitted items explained a significant portion of the longitudinal variance in each domain. We conclude that in a selected group of patients with back pain caused by vertebral fractures, the mini-OQLQ demonstrated good discriminative and adequate evaluative properties. The mini-questionnaire should be useful in clinical settings.

The influence of dietary and nondietary calcium supplementation on blood pressure: an updated metaanalysis of randomized controlled trials

We updated our previous systematic review of the effect of supplemental calcium on blood pressure. We extended our previous searches on MEDLINE and EMBASE to May 1997 and examined citations from relevant articles. We contacted the authors of eligible trials to ensure the accuracy and completeness of data, and to identify unpublished trials. We included any study in which investigators randomized hypertensive or normotensive people to calcium supplementation or alternative therapy and measured blood pressure for at least 2 weeks. In addition to 32 trials included in the prior metaanalysis, 10 new trials contributed to this metaanalysis. Two pairs of independent reviewers abstracted data and assessed the validity of the study data according to six quality criteria. We calculated the differences in blood pressure change between the calcium supplementation and control groups and pooled the estimates with each trial weighted with the inverse of the variance using a random effects model. The predictors of blood pressure reduction that we examined included method of supplementation, baseline blood pressure, and the methodologic quality of the studies. The pooled analysis shows a reduction in systolic blood pressure of -1.44 mm Hg (95% confidence interval -2.20 to -0.68; P < .001) and in diastolic blood pressure of -0.84 mm Hg (95% confidence interval -1.44 to -0.24; P < .001). We found statistically significant heterogeneity of results across trials (P < or = .02), which persisted when we looked at the nondietary trials alone, but not when we restricted our analysis to dietary trials. Although there was a trend toward larger effects with dietary interventions, none of the possible mediators of blood pressure reduction explained differences in treatment effect. We conclude that calcium supplementation leads to a small reduction in systolic and diastolic blood pressure. The effect of supplemental calcium in the diet is at least as great as nondietary supplementation.

Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients

BACKGROUND

Understanding the risk factors for ventilator-associated pneumonia can help to assess prognosis and devise and test preventive strategies.

OBJECTIVE

To examine the baseline and time-dependent risk factors for ventilator-associated pneumonia and to determine the conditional probability and cumulative risk over the duration of stay in the intensive care unit.

DESIGN

Prospective cohort study.

SETTING

16 intensive care units in Canada.

PATIENTS

1014 mechanically ventilated patients.

MEASUREMENTS

Demographic and time-dependent variables reflecting illness severity, ventilation, nutrition, and drug exposure. Pneumonia was classified by using five methods: adjudication committee, bedside clinician's diagnosis, Centers for Disease Control and Prevention definition, Clinical Pulmonary Infection score, and positive culture from bronchoalveolar lavage or protected specimen brush.

RESULTS

177 of 1014 patients (17.5%) developed ventilator-associated pneumonia 9.0 +/- 5.9 days (median, 7 days [interquartile range, 5 to 10 days]) after admission to the intensive care unit. Although the cumulative risk increased over time, the daily hazard rate decreased after day 5 (3.3% at day 5, 2.3% at day 10, and 1.3% at day 15). Independent predictors of ventilator-associated pneumonia in multivariable analysis were a primary admitting diagnosis of burns (risk ratio, 5.09 [95% CI, 1.52 to 17.03]), trauma (risk ratio, 5.00 [CI, 1.91 to 13.11]), central nervous system disease (risk ratio, 3.40 [CI, 1.31 to 8.81]), respiratory disease (risk ratio, 2.79 [CI, 1.04 to 7.51]), cardiac disease (risk ratio, 2.72 [CI, 1.05 to 7.01]), mechanical ventilation in the previous 24 hours (risk ratio, 2.28 [CI, 1.11 to 4.68]), witnessed aspiration (risk ratio, 3.25 [CI, 1.62 to 6.50]), and paralytic agents (risk ratio, 1.57 [CI, 1.03 to 2.39]). Exposure to antibiotics conferred protection (risk ratio, 0.37 [CI, 0.27 to 0.51]). Independent risk factors were the same regardless of the pneumonia definition used.

CONCLUSIONS

The daily risk for pneumonia decreases with increasing duration of stay in the intensive care unit. Witnessed aspiration and exposure to paralytic agents are potentially modifiable independent risk factors. Exposure to antibiotics was associated with low rates of early ventilator-associated pneumonia, but this effect attenuates over time.

Effect of HMGcoA reductase inhibitors on stroke. A meta-analysis of randomized, controlled trials

BACKGROUND

Stroke is a leading cause of death in the industrialized world, and hypercholesterolemia may be a risk factor for stroke.

OBJECTIVE

To determine whether reducing cholesterol levels with HMGcoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors or other antilipidemic interventions reduces risk for nonfatal and fatal stroke.

DATA SOURCES

A systematic search in the MEDLINE and EMBASE databases of the English-language and non-English-language literature published from 1966 through October 1996.

STUDY SELECTION

All randomized, controlled trials of any cholesterol-lowering intervention that reported data on nonfatal and fatal strokes, on death from coronary heart disease, and on overall mortality were included. Whether treatment effects differed according to the type of cholesterol-lowering intervention used was investigated.

DATA EXTRACTION

Trials were reviewed for methods, inclusion and exclusion criteria, and outcomes.

DATA SYNTHESIS

28 trials (for a total of 49,477 study participants in the intervention group and 56,636 participants in the control group) were included. The risk ratio for nonfatal and fatal stroke with HMGcoA reductase inhibitors was 0.76 (95% CI, 0.62 to 0.92; test of heterogeneity, P > 0.2). The risk ratios for nonfatal and fatal stroke with fibrates, resins, and dietary interventions were all close to 1.0, and the difference between the HMGcoA reductase inhibitor effect and the pooled estimate for all other interventions would, under the null hypothesis, be unlikely to occur by chance (P = 0.01). Trials with HMGcoA reductase inhibitors also showed reductions in rates of death from coronary heart disease and overall mortality.

CONCLUSION

This meta-analysis of randomized, controlled trials suggests that in hyperlipidemic patients who have not previously had stroke, HMGcoA reductase inhibitors reduce the incidence of stroke.

Documenting life-support preferences in hospitalized patients

PURPOSE

The purpose of this article was to determine the extent to which patients at high risk of hospital death who undergo cardiopulmonary resuscitation (CPR) have previously had their life support preferences addressed and documented.

MATERIALS AND METHODS

We conducted a retrospective chart review of all patients older than 18 years of age hospitalized for more than 24 hours who sustained a cardiac arrest with attempted CPR at our tertiary care university teaching hospital during 1994 (n = 71). We searched all hospital charts specifying ICD-9 codes: Cardiac arrest, ventricular fibrillation, ventricular tachycardia, asystole, electromechanical dissociation, defibrillation, or CPR. Patients were selected if (1) they had a true cardiac arrest (abrupt cessation of spontaneous circulation) and (2) had attempted CPR or defibrillation. Patients were classified as "high risk" if they satisfied at least one of the following: modified prearrest morbidity index > or = 7, moderate/severe dementia, day 1 APACHE II score > 24 or > or = 4 dysfunctional organ systems.

RESULTS

We searched 147 charts; of 71 patients meeting inclusion criteria, 53 were high risk. Of patients at high risk of sustaining a cardiopulmonary arrest during the index hospital admission, 3 (6%) had preferences addressed within the first 24 hours of hospitalization, 7 (13%) had delayed discussion of preferences before arrest, 23 (43%) had preferences addressed post arrest, and 20 (38%) had no documented discussions. Of the 23 high-risk patients initially surviving cardiac arrest, all were subsequently given "do not resuscitate" orders. Univariate analysis of factors associated with life-support discussion before cardiac arrest were previous cardiac arrest (OR, 5.9) and APACHE II score > 24 (OR, 1.1), although neither reached statistical significance. None of the 32 patients with a modified PAM index > or = 7 (32 of 71) survived hospitalization. Only 3 patients survived to hospital discharge.

CONCLUSIONS

Early communication regarding life-support preferences is important in high-risk patients so that inappropriate or unwanted treatment is not implemented. Given that optimal care includes addressing and documenting life-support preferences in high-risk patients early in their hospitalization, this standard was infrequently met.

Minimum skills required by children to complete health-related quality of life instruments for asthma: comparison of measurement properties

To gain a complete picture of a child's health-status, measurement of health-related quality of life (HRQL) is necessary. Since parents do not accurately perceive children's HRQL, information must be obtained from the children themselves. The aim of this study was to determine the minimum age and reading skills required by children to complete competently the Paediatric Asthma Quality of Life Questionnaire (PAQLQ), the Health Utilities Index (HUI), the Feeling Thermometer and the Standard Gamble, and to evaluate the validity of each for measuring HRQL in children with asthma. Fifty two children (age 7-17 yrs) with symptomatic asthma participated in a 9 week single cohort study with HRQL and clinical asthma control assessed every 4 weeks. All children provided very reliable data for the PAQLQ and the HUI but they needed > or = grade 6 reading skills to complete the Standard Gamble and > or = grade 2 skills for the Feeling Thermometer. In those children who were able to provide reliable data, the PAQLQ had the best discriminative and evaluative measurement properties, followed closely by the Feeling Thermometer. Measurement properties in the Standard Gamble were weaker and although the HUI was very reliable it was not actually measuring asthma-specific HRQL. The Paediatric Asthma Quality of Life Questionnaire may be used with confidence in clinical studies and practice to provide a profile of children's day-to-day experiences. In those children with adequate skills to complete the test reliably, the Feeling Thermometer provides a good estimate of the value that children place on their asthma health status.

The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials

When little or no data directly comparing two treatments are available, investigators often rely on indirect comparisons from studies testing the treatments against a control or placebo. One approach to indirect comparison is to pool findings from the active treatment arms of the original controlled trials. This approach offers no advantage over a comparison of observational study data and is prone to bias. We present an alternative model that evaluates the differences between treatment and placebo in two sets of clinical trials, and preserves the randomization of the originally assigned patient groups. We apply the method to data on sulphamethoxazole-trimethoprim or dapsone/pyrimethamine as prophylaxis against Pneumocystis carinii in HIV infected patients. The indirect comparison showed substantial increased benefit from the former (odds ratio 0.37, 95% CI 0.21 to 0.65), while direct comparisons from randomized trials suggests a much smaller difference (risk ratio 0.64, 95% CI 0.45 to 0.90; p-value for difference of effect = 0.11). Direct comparisons of treatments should be sought. When direct comparisons are unavailable, indirect comparison meta-analysis should evaluate the magnitude of treatment effects across studies, recognizing the limited strength of inference.

First-line treatment of seasonal (ragweed) rhinoconjunctivitis. A randomized management trial comparing a nasal steroid spray and a nonsedating antihistamine

OBJECTIVE

To determine whether better health-related quality of life (HRQL) is achieved by initiating treatment of seasonal (ragweed) rhinoconjunctivitis (hay fever) with a nasal steroid (fluticasone) backed up by a nonsedating antihistamine (terfenadine) or whether it is better to start with the antihistamine and add the nasal steroid when necessary.

DESIGN

Randomized, nonblind, parallel-group management study during the 6 weeks of the ragweed pollen season in 1995.

PATIENTS

Sixty-one adults with ragweed pollen hay fever recruited from patients who had participated in previous clinical studies and from those who responded to notices in the local media.

SETTING

Southern Ontario.

INTERVENTIONS

Nasal steroid group: 200 micrograms of fluticasone nasal spray when needed (up to 400 micrograms/d) starting about 1 week before the ragweed pollen season and continued throughout, with 1 to 2 tablets of terfenadine daily (maximum 120 mg/d) if needed. Antihistamine group: 1 60-mg tablet of terfenadine when needed (maximum 120 mg/d) starting about 1 week before the ragweed pollen season and continued throughout, with 200-400 micrograms/d of fluticasone nasal spray (maximum 400 micrograms/d) if needed.

OUTCOME MEASURES

HRQL before, at the height of and toward the end of the ragweed pollen season; HRQL was measured using the Rhinoconjunctivitis Quality of Life Questionnáire.

RESULTS

Overall, HRQL tended to be better in the group of patients whose first-line treatment was with fluticasone (p = 0.052), but the difference between the 2 groups was small and not clinically important. Just over half (52% [16/31]) of the patients in the fluticasone group did not need additional help with terfenadine, whereas only 13% (4/30) of those in the terfenadine group did not need additional help with fluticasone (p = 0.002).

CONCLUSIONS

There is little difference in the therapeutic benefit between the 2 approaches for the treatment of ragweed pollen hay fever. Therefore, the approach to treatment should be based on patient preference, convenience and cost. Regardless of the treatment, at least 50% of patients will need to take both types of medication in combination to control symptoms adequately.

Children and adult perceptions of childhood asthma

OBJECTIVE

To explore children's and parents' assessment of children's asthma.

DESIGN

Prospective 2-month cohort study in which children and parents were reviewed at baseline and 1-month intervals.

SETTING

Mid-sized, English-speaking, industrial community serving an urban and regional rural population.

PATIENTS OR PARTICIPANTS

Fifty-two children, 7 to 17 years old, with a wide range of asthma severity, and their parents.

INTERVENTIONS

We offered patients with inadequately controlled asthma additional inhaled steroid.

MAIN OUTCOME MEASURES

Children and parents provided global ratings of change in childhood symptoms and children completed spirometry and the Paediatric Asthma Quality of Life Questionnaire at clinic visits. Patients recorded peak flow rates, symptoms, and medication use in a daily diary. The diary symptom report, medication use, and spirometry were combined to form an asthma control score.

RESULTS

In children younger than 11, children's global rating of change in symptoms correlated strongly with changes in quality of life (0.54 to .67) but not with measures of airway caliber or asthma control, while parents' global ratings did not correlate with children's quality of life but showed moderate correlations with airway caliber (0.29 to .48) and asthma control (0.50). In children over the age of 11, correlations with all clinical variables were higher for their own than their parents' global ratings.

CONCLUSIONS

In children under 11, clinicians can gain complementary information from questioning children and parents. For children over 11, parents can provide little if any information beyond that obtained through questioning the child.

Multidisciplinary education for oxygen prescription. A continuous quality improvement study

OBJECTIVES

To examine the oxygen-prescribing habits and monitoring patterns on a medical teaching ward and to review the literature in this area.

DESIGN

A continuous quality improvement study.

SETTING

A 29-bed medical clinical teaching unit in a 453-bed university-affiliated tertiary care hospital.

PATIENTS

We studied 50 consecutive patients who required 79 oxygen treatments.

METHODS

We recorded the indication, prescriber, documentation of prior hypoxemia, method and mode of delivery, oxygenation assessment after initiation, and duration of therapy.

RESULTS

Patients received oxygen for a mean (+/- SD) of 4.7 +/- 4.5 days. Oxygen therapy was ordered on a continuous basis 60.3% of the time. It was ordered by house staff in 54 cases (68%); nurses initiated oxygen therapy in 14 cases (18%) but discontinued it more often than any other health care workers. The most common indications for starting oxygen therapy were dyspnea and tachypnea. In 15 patients (30%), none of the American College of Chest Physicians and National Heart, Lung, and Blood Institute criteria for starting oxygen therapy were fulfilled. For 16 patients (32%), arterial blood gas values were measured within 1 hour of oxygen administration; for 29 patients, oximetry was performed. For 9 patients (18%), no testing of adequate oxygenation was performed within 24 hours. Oxygenation status was assessed daily for 23 patients (46%).

CONCLUSIONS

Oxygen prescribing and monitoring practices were suboptimal on our busy medical teaching ward. Practice guidelines based on best available evidence are needed to increase the efficiency of oxygen use. A physiologic, multidisciplinary educational focus on the benefits and hazards of supplemental oxygen is necessary, and randomized trials of such educational interventions should be conducted.

Residents' experiences of abuse, discrimination and sexual harassment during residency training. McMaster University Residency Training Programs

OBJECTIVE

To assess the prevalence of psychological abuse, physical assault, and discrimination on the basis of gender and sexual orientation, and to examine the prevalence and impact of sexual harassment in residency training programs.

DESIGN

Self-administered questionnaire.

SETTING

McMaster University, Hamilton, Ont.

PARTICIPANTS

Residents in seven residency training programs during the academic year from July 1993 to June 1994. Of 225 residents 186 (82.7%) returned a completed questionnaire, and 50% of the respondents were women.

OUTCOME MEASURES

Prevalence of psychological abuse, physical assault and discrimination on the basis of gender and sexual orientation experienced by residents during medical training, prevalence and residents' perceived frequency of sexual harassment.

RESULTS

Psychological abuse was reported by 50% of the residents. Some of the respondents reported physical assault, mostly by patients and their family members (14.7% reported assaults by male patients and family members, 9.8% reported assaults by female patients and family members), 5.4% of the female respondents reported assault by male supervising physicians. Discrimination on the basis of gender was reported to be common and was experienced significantly more often by female residents than by male residents (p < 0.01). Ten respondents, all female, reported having experienced discrimination on the basis of their sexual orientation. Most of the respondents experienced sexual harassment, especially in the form of sexist jokes, flirtation and unwanted compliments on their dress or figure. On average, 40% of the respondents, especially women (p < 0.01), reported experiencing offensive body language and receiving sexist teaching material and unwanted compliments on their dress. Significantly more female respondents than male respondents stated that they had reported events of sexual harassment to someone (p < 0.001). The most frequent emotional reactions to sexual harassment were embarassment (reported by 24.0%), anger (by 23.4%) and frustration (20.8%).

CONCLUSION

Psychological abuse, discrimination on the basis of gender and sexual harassment are commonly experienced by residents in training programs. A direct, progressive, multidisciplinary approach is needed to label and address these problems.

Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses

PURPOSE

To resolve discrepancies in previous systematic overviews and provide estimates of the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality in critically ill patients.

DATA IDENTIFICATION

Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files, and conference abstract reports.

STUDY SELECTION

Independent review of 269 articles identified 63 relevant randomized trials for inclusion.

DATA ABSTRACTION

We made independent, duplicate assessment of the methodologic quality, population, intervention, and outcomes of each trial.

RESULTS

The source of discrepancies between prior meta-analyses included incomplete identification of relevant studies, differential inclusion of non-English language and nonrandomized trials, different definitions of bleeding, provision of additional information through direct correspondence with authors, and different statistical methods. The current overview demonstrates that prophylaxis with histamine2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.42 to 0.79) and clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88). There is a trend toward decreased overt bleeding when antacids are compared with no therapy (OR, 0.66; 95% CI, 0.37 to 1.17). Histamine2-receptor antagonists and antacids are associated with a trend toward lower clinically important bleeding rates than sucralfate is. There is a trend toward an increased risk of pneumonia associated with histamine2-receptor antagonists as compared with no prophylaxis (OR, 1.25; 95% CI, 0.78 to 2.00). Sucralfate is associated with a lower incidence of nosocomial pneumonia when compared with antacids (OR, 0.80; 95% CI, 0.56 to 1.15) and histamine2-receptor antagonists (OR, 0.77; 95% CI, 0.60 to 1.01). Sucralfate is also associated with a reduced mortality rate (OR, 0.73; 95% CI, 0.54 to 0.97) relative to antacids and to histamine2-receptor antagonists (OR, 0.83; 95% CI, 0.63 to 1.09).

CONCLUSIONS

Our results emphasize the need for registries to include all randomized trials and demonstrate the importance of explicit methodology for systematic reviews. There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists. Sucralfate may be as effective in reducing bleeding as gastric pH-altering drugs and is associated with lower rates of pneumonia and mortality. However, the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis.

Measuring quality of life in children with asthma

The Paediatric Asthma Quality of Life Questionnaire contains 23 items that children with asthma have identified as troublesome in their daily lives. The aim was to evaluate the measurement properties of the questionnaire. The study design consisted of a 9 week single cohort study with assessments at 1, 5 and 9 weeks. Patients participating in the study were fifty-two children, 7-17 years of age, with a wide range of asthma severity. At each clinic visit, a trained interviewer administered the Paediatric Asthma Quality of Life Questionnaire, the Feeling Thermometer, a clinical asthma control questionnaire and measured spirometry. For 1 week before each clinic visit, patients recorded morning peak flow rates, medication use and symptoms in a diary. The Paediatric Asthma Quality of Life Questionnaire was able to detect quality of life changes in those patients who altered their health status either as a result of treatment or natural fluctuations in their asthma (p < 0.001) and to differentiate these patients from those who remained stable (p < 0.0001). It was reproducible in patients who were stable (ICC = 0.95), which also indicates the instrument's strength to discriminate between subjects of different impairment levels. The questionnaire showed good levels of both longitudinal and cross-sectional correlations with the conventional asthma indices and with general quality of life. The results were consistent across individual domains and different age strata. The Paediatric Asthma Quality of Life Questionnaire has good measurement properties and is valid both as an evaluative and a discriminative instrument. It captures aspects of asthma most important to the patient and adds additional information to conventional clinical outcomes.

Measuring quality of life in the parents of children with asthma

Parents and primary caregivers of children with asthma are limited in normal daily activities and experience anxieties and fears due to the child's illness. We have developed the Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ) to measure these impairments. The objective of this study was to evaluate the measurement properties of the PACQLQ. A 9-week single cohort study was conducted with assessments at 1, 5 and 9 weeks. Participants in the study were primary caregivers of 52 children (age 7-17 years) with symptomatic asthma, recruited from notices in the local media and paediatric asthma clinics. Caregivers completed the PACQLQ, Impact-on-Family Scale and Global Rating of Change Questionnaires. Patients completed the Paediatric Asthma Quality of Life Questionnaire and an asthma control questionnaire. Spirometry and beta-agonist use were recorded. The PACQLQ was able to detect quality of life changes in those caregivers who changed (p < 0.001) and to differentiate these from the caregivers whose quality of life remained stable (p < 0.0001). The PACQLQ is reproducible in subjects who are stable (ICC = 0.84), and showed acceptable levels of longitudinal and cross-sectional correlations with the child's asthma status and health-related quality of life and with other measures of caregiver health-related quality of life. The PACQLQ functions well as both an evaluative and a discriminative instrument.

Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses

PURPOSE

To resolve discrepancies in previous systematic overviews and provide estimates of the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality in critically ill patients.

DATA IDENTIFICATION

Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files, and conference abstract reports.

STUDY SELECTION

Independent review of 269 articles identified 63 relevant randomized trials for inclusion.

DATA ABSTRACTION

We made independent, duplicate assessment of the methodologic quality, population, intervention, and outcomes of each trial.

RESULTS

The source of discrepancies between prior meta-analyses included incomplete identification of relevant studies, differential inclusion of non-English language and nonrandomized trials, different definitions of bleeding, provision of additional information through direct correspondence with authors, and different statistical methods. The current overview demonstrates that prophylaxis with histamine2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.42 to 0.79) and clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88). There is a trend toward decreased overt bleeding when antacids are compared with no therapy (OR, 0.66; 95% CI, 0.37 to 1.17). Histamine2-receptor antagonists and antacids are associated with a trend toward lower clinically important bleeding rates than sucralfate is. There is a trend toward an increased risk of pneumonia associated with histamine2-receptor antagonists as compared with no prophylaxis (OR, 1.25; 95% CI, 0.78 to 2.00). Sucralfate is associated with a lower incidence of nosocomial pneumonia when compared with antacids (OR, 0.80; 95% CI, 0.56 to 1.15) and histamine2-receptor antagonists (OR, 0.77; 95% CI, 0.60 to 1.01). Sucralfate is also associated with a reduced mortality rate (OR, 0.73; 95% CI, 0.54 to 0.97) relative to antacids and to histamine2-receptor antagonists (OR, 0.83; 95% CI, 0.63 to 1.09).

CONCLUSIONS

Our results emphasize the need for registries to include all randomized trials and demonstrate the importance of explicit methodology for systematic reviews. There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists. Sucralfate may be as effective in reducing bleeding as gastric pH-altering drugs and is associated with lower rates of pneumonia and mortality. However, the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis.

Discrimination and abuse experienced by general internists in Canada

OBJECTIVE

To identify the frequency of psychological and emotional abuse, gender discrimination, verbal sexual harassment, physical sexual harassment, physical assault, and homophobia experienced by general internists.

DESIGN

Cross-sectional survey.

SETTING

Canadian general internal medicine practices.

RESULTS

The overall response rate was 70.6% (984/1,393); the 501 respondents who classified themselves as general internists were studied. Three-fourths of the internists experienced psychological and emotional abuse at the hands of patients, and 38% of the women and 26% of the men experienced physical assault by patients. The majority of the female internists experienced gender discrimination by patients (67%) and by physician peers (56%). Forty-five percent of the women experienced verbal sexual harassment by patients, and 22% experienced physical sexual harassment by patients. The male internists experienced verbal sexual harassment from nurses slightly more often than the female internists did (19% vs 13%, p > 0.05). Verbal sexual harassment by male colleagues was reported by 35% of the female internists, and physical sexual harassment was reported by 11%. Approximately 40% of general internists reported homophobic remarks by both health care team members and patients.

CONCLUSIONS

Abuse, discrimination, and homophobia are prevalent in the internal medicine workplace. A direct, progressive, multidisciplinary approach is necessary to label and address these problems.

Importance of and satisfaction with work and professional interpersonal issues: a survey of physicians practicing general internal medicine in Ontario

OBJECTIVES

To explore the importance of and satisfaction with clinical responsibilities, teaching, research and interpersonal issues among general internists; to understand the barriers to satisfaction in these domains and the usefulness of potential solutions to these problems.

DESIGN

Cross-sectional survey conducted from November 1992 to June 1994.

SETTING

Ontario.

PARTICIPANTS

General internists who were fellows of the Royal College of Physicians and Surgeons of Canada and members of the Ontario Medical Association. Of 1192 physicians, 1007 (84.5%) returned a completed questionnaire; only the 199 who devoted at least 50% of their time to the practice of general internal medicine were included in this analysis.

RESULTS

The respondents were satisfied with their primary role as clinicians dealing with complex, undifferentiated problems caring for the total patient and providing consultation. Guidelines for the referral of patients to general internists, computerization of test results, recruitment of general internal medicine fellows and more confidence in the future of general internal medicine were some of the solutions considered likely to increase professional satisfaction. The respondents involved in teaching suggested additional solutions, such as an opportunity to improve their teaching and evidence-based medicine skills and a greater recognition for their teaching efforts. Few of the general internists conducted research, barriers included lack of personal and project funding, and pressure to generate clinical earnings. In the domain of professional interpersonal issues, women were significantly more likely than men to rate having a mentor, peer support groups, ongoing career counselling, promotion and tenure guidelines for parental leave, availability of on-site day care, addressing gender discrimination and adoption of gender-neutral language as likely to improve the work environment.

CONCLUSIONS

The primary role of general internists is that of patient-centred clinician. Our findings suggest that general internists want to take responsibility for revitalizing this discipline. The potential solutions generated in this survey may help to promote action that will improve professional satisfaction in the area of clinical responsibilities, teaching, research and interpersonal issues.

Determining a minimal important change in a disease-specific Quality of Life Questionnaire

This study was carried out to determine whether the minimal important difference, in evaluative quality of life instruments which use a 7-point scale, is similar across individual domains and for both improvement and deterioration. Thirty nine adults with asthma were studied, using an 8 week cohort with assessments at 0, 4 and 8 weeks. The outcomes were the Asthma Quality of Life Questionnaire and global rating of change. For overall asthma-specific quality of life and for all individual domains (activities, emotions, symptoms), the minimal important difference of quality of life score per item was very close to 0.5 (range: 0.42-0.58); differences of approximately 1.0 represented a moderate change (range: 0.77-1.51); differences greater than 1.5 represented large changes. Changes for improvement and deterioration were very similar. The changes in quality of life score that represent a minimal important difference are very similar to those observed for other evaluative instruments. The observation that the minimal important difference is consistent across domains and for both improvement and deterioration will facilitate interpretation of results of studies examining quality of life.

A prospective study identifying risk factors for discontinuance of insulin pump therapy

OBJECTIVE

To identify characteristics of adult patients at baseline associated with duration of subsequent, continuous, subcutaneous infusion of insulin treatment (pump therapy) of type I diabetes.

RESEARCH DESIGN AND METHODS

For 6 wk, patients followed a standardized conventional therapy and kept a record of insulin dosages, capillary blood glucose concentrations, and symptomatic hypoglycemia. They were then hospitalized. Additional baseline data were obtained and pump therapy was started. Survival analysis was used to determine the relationship between baseline independent variables or risk factors and duration of pump therapy, which is the dependent variable.

RESULTS

Of the 68 participants, 33 (49%) terminated pump therapy after an average of 9.9 mo of treatment. Two models (each P < 0.00005) were developed that exhibited a high degree of consistency. Of the 6 variables, 5 were common to both models (HbA1, autonomic neuropathy, mean amplitude of glycemic excursions, frequency of symptoms of hypoglycemia when blood glucose was < 70 mg/dl, and erythema at injection sites). The sixth variable in model 1 (insulin dosage) was replaced in model 2 by a variable, Adult Self-Efficacy for Diabetes, which was obtained on the 33 more recently enrolled patients; this variable related to patient perceptions of self-care behaviors.

CONCLUSIONS

We found that, at baseline, the presence of a high concentration of HbA1 and a low estimation by the patient of their ability to treat the disease portend failure of insulin pump therapy as evidenced by its discontinuation. This effect is accentuated when clinical evidence of autonomic neuropathy is observed. These findings offer guidance in selecting patients with type I diabetes for insulin pump therapy.

Quality of life issues in women with vertebral fractures due to osteoporosis

OBJECTIVE

To learn about the physical, emotional, and social limitations experienced by postmenopausal women who have back pain due to vertebral fractures resulting from osteoporosis.

METHODS

We conducted a cross-sectional survey of female patients with persistent pain due to vertebral fractures.

RESULTS

Respondents had a mean (+/- SD) bone density of 0.87 +/- 0.13 gm/cm2 and a mean (+/- SD) of 2.84 +/- 2.18 fractures. Disability was identified in pain, movement, activities of daily living, and emotion. There was a poor correlation between quality of life and findings on radiography or densitometry.

CONCLUSION

To evaluate the effects of osteoporosis on a patient's functional status, direct questioning is required.

Measuring quality of life in asthma

The aim of this study was to evaluate the measurement properties of an Asthma Quality of Life Questionnaire. The study design was an 8-wk unblinded single cohort with assessments at 0, 4, and 8 wk. Thirty-nine adults with symptomatic asthma and a wide range of airway responsiveness and medication requirements were enrolled from previous studies and through notices in the local media. Those with inadequately controlled asthma were offered an inhaled steroid (budesonide). Asthma Quality of Life Questionnaire, spirometry, a clinical asthma control questionnaire, medication requirements, airway responsiveness to methacholine, the Sickness Impact Profile, and the Rand questionnaire were recorded at each visit. Patients kept daily diaries of peak flow rates and medications. The Asthma Quality of Life Questionnaire was able to detect changes in patients who responded to treatment or who had natural fluctuations in their asthma (p < 0.001) and to differentiate these patients from those who remained stable (p < 0.001). The Questionnaire was reproducible in patients who were stable (intraclass correlation coefficient = 0.92). There were significant longitudinal and cross-sectional correlations between asthma quality of life and other measures of both clinical asthma and generic quality of life. We conclude that the Asthma Quality of Life Questionnaire has good measurement properties and that it is valid as both an evaluative and a discriminative instrument. It measures the component of asthma most important to patients, and it should be considered for inclusion in all asthma studies.