The Pioneer Schools of Occupation: Reflections for Current Practice

Abstract

The Pioneer Schools of Occupation: Can They Teach Us Anything Today?

This study reviews the development of the pioneer schools of occupation and their curriculum or program design between 1906 and 1923. The purposes are to document the existence of the schools, to explore the issues in establishing the schools, and to compare and contrast concepts stated in early curriculum models with those in current models of practice. The dates were selected to examine ideas before the passage of the Minimum Standards for Courses of Training in Occupational Therapy by the American Occupational Therapy Association (AOTA) outlining a consensus course of study.     

Risk of febrile seizure after measles–mumps–rubella–varicella vaccine: A systematic review and meta-analysis

BackgroundConsidering the febrile seizure rate, there is no longer a clear preference for use of measles–mumps–rubella–varicella (MMRV) vaccine over separate measles–mumps–rubella (MMR) and varicella (V) vaccine. This work was undertaken to assess the risk of febrile seizure after MMRV vaccine in children.MethodsWe searched PubMed, Embase, BIOSIS Previews, Scopus, Web of Science, Cochrane Library and other databases through 12 December 2014. Meta-analysis was conducted using R version 3.1.2 and Stata version 12.0.ResultsA total of thirty-nine studies were included. Thirty-one published or unpublished clinical trials involving about 40,000 subjects did not show significant differences in incidence of febrile seizure or vaccine related febrile seizure between MMRV and MMR with or without varicella vaccine after any doses, in the risk windows of 0–28, 0–42 or 0–56 days and 7–10 days. In addition, these studies showed that the receipt of concomitant use of MMRV and other pediatric vaccines was not a significant predictor of febrile seizure. Eight post-marketing observations involving more than 3,200,000 subjects were included. No evidence suggested elevated risk of febrile seizure associated with MMRV vaccine among children aged 4–6 years old during 7–10 days or 0–42 days after vaccination. However, an approximately 2-fold increase in risk of seizure or febrile seizure during 7–10 days or 5–12 days after MMRV vaccination was found among children aged 10–24 months, although the highest incidence of seizure was still lower than 2.95‰.ConclusionsFirst MMRV vaccine dose in children aged 10–24 months was associated with an elevated risk of seizure or febrile seizure. Further post-marketing restudies based on more rigorous study design are needed to confirm the findings.     

The Validity of Occupational Performance Assessments: A Validity Generalization Meta-Analysis

ABSTRACT

The purpose of this meta-analysis was to determine sample weighted mean validity effect sizes for occupational performance assessments, and their generalizability from research to clinical settings. The bare-bones Validity Generalization (VG) guidelines developed by Hunter and Schmidt () augmented by Maximum Likelihood (ML) procedures were used to complete the meta-analysis. The sample consisted of 27 studies in which convergent, divergent, and predictive validity estimates of occupational performance assessments were investigated. The mean coefficients of assessments validated in the studies constituting the sample for this meta-analysis ranged from medium to large. Further meta-analysis with complete dis-attenuation of observed mean validity coefficients is indicated.     

Does consecutive influenza vaccination reduce protection against influenza: A systematic review and meta-analysis

IntroductionVaccination against influenza on an annual basis is widely recommended, yet recent studies suggest consecutive vaccination may reduce vaccine effectiveness (VE).PurposeTo assess whether when examining the entirety of existing data consecutive influenza vaccination reduces VE compared to current season influenza vaccination.Data sourcesMEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 26, 2017; citations of included studies.Study selectionRandomized, controlled trials (RCTs) and observational studies of children, adults and/or the elderly that reported laboratory-confirmed influenza infection over 2 or more consecutive influenza seasons were eligible.Data extractionData related to study characteristics, participant demographics, cases of influenza infection by vaccination group and risk of bias assessment was extracted in duplicate.Data synthesisFive RCTs involving 11,987 participants did not show a significant reduction in VE when participants vaccinated in two consecutive seasons (VE 71%, 95% CI 62–78%) were compared to those vaccinated in the current season (VE 58%, 95% CI 48–66%) (odds ratio [OR] 0.88, 95% CI 0.62–1.26, p = 0.49, I² = 39%). Twenty-eight observational studies involving 28,627 participants also did not show a reduction (VE for two consecutive seasons 41%, 95% CI 30–51% compared to VE for current season 47%, 95% CI 39–54%; OR 1.14, 95% CI 0.98–1.32, p = 0.09, I² = 63%). Results from subgroup analyses by influenza type/subtype, vaccine type, age, vaccine match and co-morbidity support these findings; however, dose–response results were inconsistent. Certainty in the evidence was assessed to be very low due to unexplained heterogeneity and imprecision.LimitationsThe inclusion of studies with relatively small sample sizes and low event rates contributed to the imprecision of summary VE and OR estimates, which were based on unadjusted data.ConclusionAvailable evidence does not support a reduction in VE with consecutive influenza vaccination, but the possibility of reduced effectiveness cannot be ruled out due to very low certainty in this evidence.Funding sourceCIHR Foundation Grant (PROSPERO: CRD42017059893).     

Why do high-volume hospitals achieve better outcomes? A systematic review about intermediate factors in volume–outcome relationships

ObjectiveTo assess the role of process and structural factors in volume–outcome relationships.Data sourcesPubmed electronic database, until March 2014.Study designSystematic review. Based on a conceptual framework, peer-reviewed publications were included that presented evidence about explanatory factors in volume–outcome associations.Data collectionTwo reviewers extracted information about study design, study population, volume and outcome measures, as well as explanatory factors. Included publications were appraised for methodological quality.Principal findingsAfter screening 1756 titles, 27 met our inclusion criteria. Three main categories of explanatory factors could be identified: 1. Compliance to evidence based processes of care (n = 7). 2. Level of specialization (n = 11). 3. Hospital level factors (n = 10). In ten studies, process and/or structural characteristics partly explained the established volume–outcome association. The median quality score of the 27 studies was 8 out of a possible 18 points.ConclusionsThe vast majority of volume–outcome studies do not focus on the underlying mechanism by including process and structural characteristics as explanatory factors in their analysis. The methodological quality of studies is also modest, which makes us question the available evidence for current policies to concentrate care on the basis of volume.     

The Perceive,Recall, Plan and Perform (PRPP) system for persons with Parkinson’s disease: a psychometric study

Background: The Perceive, Recall, Plan &; Perform (PRPP) system of task analysis might be feasible to evaluate occupational performance and information processing strategies for persons with Parkinson’s disease (PD).

Aim: To evaluate: (1) the random error between raters (inter-rater study), (2) the random error within raters (intra-rater study), and (3) the internal consistency of the PRPP.

Materials and methods: (1) video-recorded performance of meaningful activities of 13 Dutch persons with PD, scored independently by 38 Dutch PRPP trained occupational therapists were included in the analysis. The random error between raters was analyzed with two-way random Intraclass Correlation Coefficients (ICC). (2) Four videos were scored twice by 30 raters (6 week time interval). The random error within raters was analyzed using one-way random ICC’s. (3) Internal consistency study: data of 190 persons with PD were analyzed using Cronbach’s alpha (α).

Results: Inter-rater reliability ranged from slight to moderate (ICC=?0.06–0.43). The mean intra-rater reliability ranged from moderate to almost perfect (ICC=?0.60–0.83). Internal consistency is good (α?=?0.60–0.86).

Conclusion: The limited inter-rater reliability but adequate intra-rater reliability and internal consistency show the feasibility of the PRPP when used for persons with PD. Implications for reliable clinical use are discussed.     

Gender differences in quality of schoolwork task performance among typically developing students and students at risk of or with mild disabilities

Abstract

Aim: As no studies have examined for gender differences in quality of schoolwork task performance, the purpose of this study was to examine whether there is a gender difference in quality of schoolwork task performance among students at risk of or with mild disabilities, and to compare any identified differences to those that might exist among their typically developing peers. Methods: The participants were 2510 students (typically developing = 412 girls, 422 boys; at risk = 147 girls, 379 boys; mild = 242 girls, 901 boys), 4–10 years of age. Schoolwork task performance was measured using the School Version of the Assessment of Motor and Process Skills (School AMPS). Results: Regression analyses revealed no significant gender or age-by-gender interaction effects for any of the three groups (typically developing, at risk, mild). Interpretation: The results, focused on occupational performance, complement prior research that has focused on examining for gender differences in behaviour, academic achievement, and coordination among students with mild disabilities. These results also suggest that current School AMPS normative values, based on combined gender means, are valid.     

Machine Learning–Based Prediction Models for Delirium: A Systematic Review and Meta-Analysis

ObjectiveTo critically appraise and quantify the performance studies by employing machine learning (ML) to predict delirium.DesignA systematic review and meta-analysis.Setting and ParticipantsArticles reporting the use of ML to predict delirium in adult patients were included. Studies were excluded if (1) the primary goal was only the identification of various risk factors for delirium; (2) the full-text article was not found; and (3) the article was published in a language other than English/Chinese.MethodsPubMed, Embase, Cochrane Library database, Web of Science, Grey literature, and other relevant databases for the related publications were searched (from inception to December 15, 2021). The data were extracted using a standard checklist, and the risk of bias was assessed through the prediction model risk of bias assessment tool. Meta-analysis with the area under the receiver operating characteristic curve, sensitivity, and specificity as effect measures, was performed with Metadisc software. Cochran Q and I² statistics were used to assess the heterogeneity. Meta-regression was performed to determine the potential effect of adjustment for the key covariates.ResultsA total of 22 studies were included. Only 4 of 22 studies were quantitatively analyzed. The studies varied widely in reporting about the study participants, features and selection, handling of missing data, sample size calculations, and the intended clinical application of the model. For ML models, the overall pooled area under the receiver operating characteristic curve for predicting delirium was 0.89, sensitivity 0.85 (95% confidence interval 0.84?0.85), and specificity 0.80 (95% confidence interval 0.81–0.80).Conclusions and ImplicationsWe found that the ML model showed excellent performance in predicting delirium. This review highlights the potential shortcomings of the current approaches, including low comparability and reproducibility. Finally, we present the various recommendations on how these challenges can be effectively addressed before deploying these models in prospective analyses.     

Psychometric evaluation of the Finnish translation of the assessment of communication and interaction skills (ACIS-FI)

Abstract

Background: The Model of Human Occupation (MOHO) is a widely used conceptual practice model in Finland. Therefore, Finnish translations of valid and reliable MOHO assessments are needed.

Objective: The primary objective of this study was to examine the psychometric properties of the Finnish translation of the Assessment of Communication and Interaction Skills (ACIS-FI) using the many-facet Rasch model approach.

Methods and Materials: Twenty-eight occupational therapists completed an in-person training workshop on the ACIS-FI and participated as raters in this study. One hundred and forty-eight clients were rated using the ACIS-FI. Rating scale functioning, unidimensionality, person validity and rater severity, item targeting, and item and person separation statistics were examined.

Results: The rating scales demonstrated adequate functioning; the rating category ‘deficit’ was infrequently adopted by the raters. The ACIS-FI had satisfactory construct validity, as confirmed by all items exhibiting unidimensionality within a single construct (i.e. communication and interaction skills), and appropriate item fit. Validity was further confirmed through low person misfit (6%) and low rater misfit (3.6%). No ceiling or floor effects were found. The ACIS-FI was able to separate clients into four levels of communication and interaction skills.

Conclusions: This study offers evidence for the validity of the ACIS-FI as a measure of communication and interaction skills in occupational therapy.

Significance: The ACIS-FI offers Finnish practitioners and researchers a valid tool to measure communication and interactions skills that is theoretically grounded in the MOHO.     

Intensive client-centred occupational therapy in the home improves older adults’ occupational performance. Results from a Danish randomized controlled trial

Background: There is growing interest in enabling older adults’ occupational performance. We tested whether 11 weeks of intensive client-centred occupational therapy (ICC-OT) was superior to usual practice in improving the occupational performance of home-dwelling older adults.

Methods: An assessor-masked randomized controlled trial among adults 60?+?with chronic health issues, who received or applied for homecare services. Recruitment took place September 2012 to April 2014. All participants received practical and personal assistance and meal delivery as needed. In addition, they were randomized to receive either a maximum 22 sessions of occupation-based ICC-OT (N?=?59) or to receive usual practice with a maximum three sessions of occupational therapy (N?=?60). The primary outcome was self-rated occupational performance assessed with the Canadian Occupational Performance Measure (COPM).

Results: No important adverse events occurred. ICC-OT was accepted by 46 participants (88%), usual practice by 60 (100%). After 3 months, the ICC-OT-group had improved 1.86 points on COPM performance; the Usual-Practice group had improved 0.61 points. The between-group difference was statistically significant (95% confidence interval 0.50 to 2.02), t-test: p?=?0.001.

Conclusions: ICC-OT improved older adults’ occupational performance more effectively than usual practice. This result may benefit older adults and support programmatic changes.     

Evaluating the Consistency Between Conceptual Frameworks and Factors Influencing the Safe Behavior of Iranian Workers in the Petrochemical Industry: Mixed Methods Study

BackgroundUnsafe worker behavior is often identified as a major cause of dangerous incidents in the petrochemical industry. Behavioral safety models provide frameworks that may help to prevent such incidents by identifying factors promoting safe or unsafe behavior. We recently conducted a qualitative study to identify factors affecting workers'' unsafe behaviors in an Iranian petrochemical company.ObjectiveThe aims of this study were to (1) conduct a review of the relevant research literature between the years 2000 and 2019 to identify theoretical models proposed to explain and predict safe behavior in the workplace and (2) to select the model that best reflects our qualitative findings and other evidence about the factors influencing safe behaviors among petrochemical workers.MethodsThis research used mixed methods. Initially, we conducted a qualitative study of factors that Iranian petrochemical workers believed affected their safety behavior. Four themes emerged from the semistructured interviews: (1) poor direct safety management and supervision; (2) unsafe workplace conditions; (3) workers’ perceptions, skills, and training; and (4) broader organizational factors. Electronic databases, including PubMed, Embase, Scopus, Google Scholar, EBSCOhost, and Science Direct, were then searched for eligible studies on models to explain and predict safe behaviors, which were published between the years 2000 and 2019. Medical subject headings were used as the primary analytical element. Medical subject headings and subheadings were then extracted from the literature. One researcher conducted the search and 3 researchers performed screening and data extraction. Then, constructs described in each study were assessed to determine which were the most consistent with themes derived from our qualitative analysis.ResultsA total of 2032 publications were found using the search strategy. Of these, 142 studies were assessed and 28 studies met the inclusion criteria and were included in the review. The themes identified in the qualitative study most closely matched 3 scales included in Wu et al''s model that measured safety behavior and performance, safety leadership, and safety climate in petrochemical industries. Poor direct safety management and supervision matched with safety leadership and its subscales; unsafe workplace conditions matched with safety climate and its subscales; workers'' perceptions, skills, and training matched with safety performance and its subscales; and broader organizational factors matched with some subscales of the model.ConclusionsThis is the first literature review to identify models intended to explain and predict safe behavior and select the model most consistent with themes elicited from a qualitative study. Our results showed that effective safety leadership and management and safety climate and culture systems are the most frequently identified factors affecting safe behaviors in the petrochemical industry. These results can further help safety researchers and professionals design effective behavior-based safety interventions, which can have a more sustainable and persistent impact on workers’ safety behaviors.Trial RegistrationIranian Registry of Clinical Trials IRCT20170515033981N2; https://www.irct.ir/trial/26107International Registered Report Identifier (IRRID)RR2-10.1186/s12889-019-7126-1     

Teaching Ill-Structured Problem Solving Using Occupational Therapy Practice Epistemology

ABSTRACT

Epistemic and ontological cognition (EOC) have to do with an individual's beliefs about knowledge and knowing. Research has shown that EOC have an influence on learning and achievement. EOC may be discipline-specific with a profession being defined by its practice epistemology. If an individual's EOC is inconsistent with the profession's practice epistemology, the student or practitioner may struggle with effectively solving ill-structured occupational performance problems. The purpose of this paper is to increase awareness of the constructs of EOC, to describe its importance to occupational therapy education and practice, and to provide recommendations for educators and researchers. Specific examples are detailed and recommendations for future research are proposed.     

A Review of the Psychometric Performance of Selected Child and Adolescent Preference-Based Measures Used to Produce Utilities for Child and Adolescent Health

ObjectiveThis review examined the psychometric performance of 4 generic child- and adolescent-specific preference-based measures that can be used to produce utilities for child and adolescent health.MethodsA systematic search was undertaken to identify studies reporting the psychometric performance of the Child Health Utility (CHU9D), EQ-5D-Y (3L or 5L), and Health Utilities Index Mark 2 (HUI2) or Mark 3 (HUI3) in children and/or adolescents. Data were extracted to assess known-group validity, convergent validity, responsiveness, reliability, acceptability, and feasibility. Data were extracted separately for the dimensions and utility index where this was reported.ResultsThe review included 76 studies (CHU9D n = 12, EQ-5D-Y-3L n = 20, HUI2 n = 26,HUI3 n = 43), which varied considerably across conditions and sample size. EQ-5D-Y-3L had the largest amount of evidence of good psychometric performance in proportion to the number of studies examining performance. The majority of the evidence related to EQ-5D-Y-3L was based on dimensions. CHU9D was assessed in fewer studies, but the majority of studies found evidence of good psychometric performance. Evidence for HUI2 and HUI3 was more mixed, but the studies were more limited in sample size and statistical power, which was likely to have affected performance.ConclusionsThe heterogeneity of published studies means that the evidence is based on studies across a range of countries, populations and conditions, using different study designs, different languages, different value sets and different statistical techniques. Evidence for CHU9D in particular is based on a limited number of studies. The findings raise concerns about the comparability of self-report and proxy-report responses to generate utility values for children and adolescents.     

Integrating Behavior Change Theory into Geriatric Case Management Practice

ABSTRACT

Case management practices have continued to grow despite a lack of clear evidence of their efficacy. With the expanding segment of the elderly population, there is a critical need to develop and identify programs that will address the many needs of the aging. Geriatric Case Management has been the avenue selected by many health care providers to address these issues, focusing on maintaining health status and improving linkages with medical and community resources. Studies testing the effectiveness of these models have failed to demonstrate their effectiveness in reducing depression, reducing acute care service use, and improving or maintaining health status. The Geriatric Case Management models presented in these lack an evidence-based, theoretical framework that provides definition and direction for case management practice. This article introduces behavior change theories as a method of structuring and delineating the case management intervention. The Transtheoretical Model and the Theory of Planned Behavior are discussed and methods of integrating these theories into practice are discussed.     

Evaluating domains of everyday functioning in people with developmental disabilities

Objective: To examine the relationship among (a) quality of activities of daily living (ADL) task performance, (b) quality of social interaction, and (c) the extent of discrepancy between the person’s and the occupational therapist’s perspectives; and explore patterns of strengths and challenges among people with developmental disabilities (DD). Methods: Fifty-eight adults with different types of DD, living in northern Sweden, were evaluated using the Assessment of Motor and Process Skills (AMPS), the Evaluation of Social Interaction (ESI) and the Assessment of Compared Qualities – Occupational Performance (ACQ-OP) and Assessment of Compared Qualities – Social Interaction (ACQ-SI). The relationships among assessments were analysed using Pearson correlation analyses. Cluster analysis was used to group participants based on their evaluation results. Results The quality of ADL task performance and the quality of social interaction demonstrated weak to moderate positive relationships while the ACQ-OP and ACQ-SI demonstrated a strong positive relationship. The cluster analysis resulted in identifying three distinct groups that differed significantly from one another. Conclusion: The findings support the clinical use of multiple assessment tools, including observation and self-report, to evaluate different aspects of occupational performance. Comprehensive and relevant evaluation supports collaborative goal setting and intervention planning.     

Occupational problems and barriers reported by individuals with obesity

Background: Even if occupational therapists meet many people with obesity in the course of their work, a majority of them do not seem to view weight management as within their area of professional practice.

Aim: To explore the occupational problems and barriers among persons with severe obesity from an occupational therapy perspective.

Materials and methods: The study used the Canadian Model of Occupation and Engagement (CMOP-E) and Canadian Occupational Performance Measure (COPM) to identify and analyze prioritized occupational performance problems and barriers perceived by 63 individuals with obesity.

Results: The occupational problems individuals with obesity most frequently prioritized comprised playing with (grand)children, purchasing clothes, implementing regular meals and going to the swimming pool, while the barriers they most frequently described were dyspnea, musculoskeletal disorders, narrow chairs and seats, fear of glances and comments from others, and social anxiety.

Conclusion: Persons with obesity struggle with a large variety of occupational performance problems, which occur in the dynamic relationship between these individuals, their environment and their occupation. Occupational therapists have the skills to take more active role in helping persons with obesity to perform valued occupations and establish healthier everyday routines.     

Minerals and Sarcopenia in Older Adults: An Updated Systematic Review

ObjectiveThis systematic review aims to reevaluate the role of minerals on muscle mass, muscle strength, physical performance, and the prevalence of sarcopenia in community-dwelling and institutionalized older adults.DesignSystematic review.Setting and ParticipantsIn March 2022, a systematic search was performed in PubMed, Scopus, and Web of Sciences using predefined search terms. Original studies on dietary mineral intake or mineral serum blood concentrations on muscle mass, muscle strength, and physical performance or the prevalence of sarcopenia in older adults (average age ≥65 years) were included.MethodsEligibility screening and data extraction was performed by 2 independent reviewers. Quality assessment was performed with the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Risk of bias was evaluated using the Risk Of Bias In Non-randomized Studies-of Exposure (ROBINS-E) tool.ResultsFrom the 15,622 identified articles, a total of 45 studies were included in the review, mainly being cross-sectional and observational studies. Moderate quality of evidence showed that selenium (n = 8) and magnesium (n = 7) were significantly associated with muscle mass, strength, and physical performance as well as the prevalence of sarcopenia. For calcium and zinc, no association could be found. For potassium, iron, sodium, and phosphorus, the association with sarcopenic outcomes remains unclear as not enough studies could be included or were nonconclusive (low quality of evidence).Conclusions and ImplicationsThis systematic review shows a potential role for selenium and magnesium on the prevention and treatment of sarcopenia in older adults. More randomized controlled trials are warranted to determine the impact of minerals on sarcopenia in older adults.     

宫颈癌发病风险预测模型的系统综述

目的 系统评价宫颈癌发病风险预测模型的现况,为实践工作选择最合适的模型提供证据,指导宫颈癌筛查。方法 以宫颈癌和风险预测模型相关的两组中英文关键词,分别检索中国知网、万方数据知识服务平台及PubMed、Embase、Cochrane Library,筛选截至2019年11月21日发表构建或验证宫颈癌发病模型相关文献。根据CHARMS清单制定提取表,以PROBAST工具评估偏倚风险。结果 共纳入12篇文献,涉及15个模型,其中5个模型在中国构建。预测结局包含从宫颈癌前病变到癌症发生的多个阶段宫颈涂片异常（1）、CIN的发生或复发（9）、宫颈癌发生（5）。使用较多的预测因素为HPV感染（12）、年龄（7）、吸烟（5）和文化程度（5）。有2个模型采用机器学习建模。模型表现上,区分度范围为0.53~0.87,而校准度只有2个模型正确评价。仅2个模型在中国台湾地区利用不同时间段的人群进行了外部验证。偏倚风险评价发现所有模型均为高风险,尤其分析领域,问题集中在缺失数据处理不当（13）、模型表现评价不完整（13）、内部验证使用不当（12）和样本量不足（11）。另外,预测因素和结局测量不一致（8）、结局测量盲法使用情况未报告（8）的问题较突出。相对而言,Rothberg等（2018）的模型质量较高。结论 宫颈癌发病风险预测模型有一定数量但质量较差,亟须提高预测因素与结局的测量以及缺失数据处理和模型表现评价等统计分析细节,对现有模型进行外部验证,以更好地指导筛查。     

Propensity score model overfitting led to inflated variance of estimated odds ratios

ObjectiveSimulation studies suggest that the ratio of the number of events to the number of estimated parameters in a logistic regression model should be not less than 10 or 20 to 1 to achieve reliable effect estimates. Applications of propensity score approaches for confounding control in practice, however, do often not consider these recommendations.Study Design and SettingWe conducted extensive Monte Carlo and plasmode simulation studies to investigate the impact of propensity score model overfitting on the performance in estimating conditional and marginal odds ratios using different established propensity score inference approaches. We assessed estimate accuracy and precision as well as associated type I error and type II error rates in testing the null hypothesis of no exposure effect.ResultsFor all inference approaches considered, our simulation study revealed considerably inflated standard errors of effect estimates when using overfitted propensity score models. Overfitting did not considerably affect type I error rates for most inference approaches. However, because of residual confounding, estimation performance and type I error probabilities were unsatisfactory when using propensity score quintile adjustment.ConclusionOverfitting of propensity score models should be avoided to obtain reliable estimates of treatment or exposure effects in individual studies.