Successes and failures: what are we measuring?

In telemedicine and telehealth, the perception of success is complex, varies according to time and context, and depends on the perspective of the observer. Several reviews of the evaluation literature have been undertaken in recent years. These reviews identify common methodological shortcomings. Telehealth services continue to be funded as short-term projects. While it is essential to address methodology issues, it is important to understand that studies of pilot projects provide only interim findings about the feasibility of such applications, not how well they operate as mature applications. This represents something of a conundrum: evaluation is expected to establish the long-term value of telehealth using criteria which are specific to short-term projects. A useful approach would be to develop frameworks enabling all similar studies (e.g. diabetic home care) to be examined in order to extract commonalities and differences. This would enable us to draw conclusions about where telehealth is effective, as well as what variables demonstrate 'success'.     

Dietary intake assessments in epidemiology: can we know what we are measuring?

PURPOSE: We discuss fundamental assumptions required for the validation of dietary questionnaire assessments, using latent variable models. METHODS: We discuss some methodological aspects of latent variable modelling in terms of the triad method, for comparisons between questionnaire assessments, food consumption records and/or biomarkers. In particular, we address the recent proposal (Frazer et al) that biases due to correlated random errors between different measurement types could be overcome by using two biomarkers as instrumental variables, as recently proposed by. RESULTS: The instrumental variable approach proposed by Frazer et al, but also other validation models proposed so far, require the assumption that questionnaire measurements are specific for a defined type of food or nutrient intake (latent variable of interest) - that is, conditionally on the true intake levels of this food or nutrient the questionnaire measurements should have no association with intakes of any other dietary component. CONCLUSION: More methodological research is needed on the design of multivariate validation studies that might allow the examination of measurement specificity in practice.     

Validating MMI scores: are we measuring multiple attributes?

The multiple mini-interview (MMI) used in health professional schools’ admission processes is reported to assess multiple non-cognitive constructs such as ethical reasoning, oral communication, or problem evaluation. Though validation studies have been performed with total MMI scores, there is a paucity of information regarding how well MMI scores differentiate the constructs being measured, the relationship between MMI scores (construct or total) and personality characteristics, and how well MMI scores (construct or total) predict future performance in practice. Results from these studies could assist with MMI station development, rater training, score interpretation, and resource allocation. The purpose of this study was to investigate the validity of MMI construct scores (oral communication and problem evaluation), and their relationship to personality measures (emotionality and extraversion) and specific scores from standardized clinical communications interviews (building the relationship and explaining and planning). Confirmatory factor analysis results support a two factor MMI model, however the correlation between these factors was .87. Oral communication MMI scores significantly correlated with extraversion (r _c  = .25, p < .05), but MMI scores were not related to emotionality. Scores for building a relationship were significantly related to MMI oral communication scores, (r _c  = .46, p < .001) and problem evaluation scores (r _c  = .43, p < .001); scores for explaining and planning were significantly related to MMI problem evaluation scores (r _c  = .36, p < .01). The results provide validity evidence for assessing multiple non-cognitive attributes during the MMI process and reinforce the importance of developing MMI stations and scoring rubrics for attributes identified as important for future success in school and practice.     

Are we measuring what matters in health technology assessment of disease management? Systematic literature review

OBJECTIVES: An overview was produced of indicators currently used to assess disease management programs and, based on these findings, provide a framework regarding sets of indicators that should be used when taking the aims and types of disease management programs into account. METHODS: A systematic literature review was performed. RESULTS: Thirty-six studies met the inclusion criteria. It appeared that a link between aims of disease management and evaluated structure, process, as well as outcome indicators does not exist in a substantial part of published studies on disease management of diabetes and asthma/chronic obstructive pulmonary disease, especially when efficiency of care is concerned. Furthermore, structure indicators are largely missing from the evaluations, although these are of major importance for the interpretation of outcomes for purposes of decision-making. Efficiency of disease management is mainly evaluated by means of process indicators; the use of outcome indicators is less common. Within a framework, structure, process, and outcome indicators for effectiveness and efficiency are recommended for each type of disease management program. CONCLUSIONS: The link between aims of disease management and evaluated structure, process, and outcome indicators does not exist in a substantial part of published studies on disease management. The added value of this study mainly lies in the development of a framework to guide the choice of indicators for health technology assessment of disease management.     

Antidepressants for mothers: what are we prescribing?

Prescribing in the perinatal period is based on a risk-benefit analysis, in the context of a limited evidence base, composed primarily of case series and reports. Mothers with depressive illness often present first in the community and effective treatment is paramount for the wellbeing of both mother and child. We aimed at investigating current prescribing practices among general practitioners (GPs) of antidepressants to mothers presenting in first trimester of pregnancy and during breastfeeding. This qualitative study was conducted by way of postal survey to 78 GPs within South Central Edinburgh catchment area. All responses were anonymous and confidential. We discovered inconsistent prescribing patterns among GPs to both pregnant and breastfeeding mothers. Only one GP suggested consulting clinical guidelines when making prescribing choices. There was no mention of the continuation of an antidepressant from pregnancy into breastfeeding as a reason of choice. Inconsistent prescribing patterns among GPs could have implications for the wellbeing of mother and child, and may be reflective of an underlying educational need among GPs.     

Burden of disease and economic evaluation of healthcare interventions: are we investigating what really matters?

Background  

The allocation of limited available healthcare resources demands an agreed rational allocation principle and the consequent priority setting. We assessed the association between economic evaluations of healthcare interventions published in Spain (1983-2008) and the disease burden in the population.     

Educating adolescents about puberty: what are we missing?

Adolescents undergo significant physical and cognitive changes during their pubertal development. These changes contribute to and impact their future development. Educating adolescents at an early age about their expected development decreases the possible anxiety associated with this period of life and also helps adolescents make better choices in regards to their sexuality. In order to assess the degree of education regarding pubertal development and sexuality, we conducted a survey of late adolescents (Median age 19 years) and parents of adolescents. A total of 409 adolescents (237 females, 172 males) and 124 parents completed the survey. 14.4% of teens (36.6% of males and 2% of females) reported that no one spoke to them prior or during puberty about pubertal development or sexuality issues. Teens receiving some form of puberty/sexuality education did so at a median age of 13 for girls and 15 for boys. More than one source of information was the most common (49%) followed by mother only (20%). 85% of parents reported talking to their teens about pubertal development and sexuality. There were several differences between areas reported covered by parents but not by teens, for example 72% of parents reported talking to their teens about gender differences in growth but only 31% of teens reported being spoken to about that. Areas that are very poorly covered are breast development in boys and sexual assault/date rape in girls at 5% and 26% respectively. In summary, it appears that we continue to do a relatively poor job in educating our kids about their development and sexuality and we do it late. Boys are even less likely than girls to be talked to about many areas of pubertal development and sexuality and when that is done, it is done at a later age.     

But what are we trying to prove?

Chaplaincy and Clinical Pastoral Education (CPE) in the health care setting can and should approach their ministries more scientifically, primarily by incorporating the methods and results of quantitative and qualitative research. Such an approach, however, should have a carefully considered rationale. Proponents of a scientific approach should avoid associating their advocacy with dubious notions of health care "reform." They should attend to the perceptions--and fears--that chaplains may have of "science" and research as these affect pastoral care. In particular, fears for professional and programmatic survival should be recognized for their potential to predispose chaplains either favorably or unfavorably toward a scientific approach. Ultimately, chaplains should increase their openness to scientific methods in order to learn more about their ministry and improve their practice, without expecting that the adoption of research methods will be a magical solution to the problems posed by the current environment.     

Markers of increased cardiovascular risk: are we measuring the most appropriate parameters?

The vital task of evaluating cardiovascular disease risk in individual patients is challenging in light of the ever-growing list of risk factors. Some of the traditional measures of cardiovascular risk, such as blood lipid levels, have been further refined to provide better risk assessments. Certain specific parameters, such as lipoprotein buoyancy, seem to be better predictors of cardiovascular disease than total lipoprotein levels. Furthermore, as the contribution of systemic inflammation to the pathogenesis of atherosclerosis is increasingly recognized, several inflammatory markers have become associated with disease risk. Consequently, many studies have attempted to determine the individual merits of these factors in predicting cardiovascular risk.     

Provitamin a carotenoid bioavailability:what really matters?

Micronutrient malnutrition, or ?hidden hunger,? afflicts a large part of the world?s population, with vitamin A deficiency among the most prevalent public health problems. Provitamin A carotenoids in plant foods are a source of vitamin A for humans; however, several factors, including species of carotenoids, host status, and effectors of absorption can negatively, positively, or in yet undetermined ways affect the bioavailability of these compounds. Staple foods biofortified with provitamin A carotenoids have shown more efficient bioconversion to retinol than generally observed for vegetables (e. g., 3 - 6 versus 10 - 80 beta-carotene to 1 μg retinol). Staple foods such as maize, rice, and cassava, are generally more accessible than meat or vegetable sources of retinol or provitamin A carotenoids to poor consumers, who are most likely to suffer micronutrient malnutrition. Interdisciplinary teamwork, including plant breeders, nutritionists, government and local agencies, seed companies, and communities, is needed to avail biofortified crops to needy populations. Key steps include developing, validating the nutritional effects of, providing nutrition education concerning, and promoting the use of biofortified crops. Provitamin A carotenoid biofortification of sweet potato, maize, cassava, and rice are at different stages along this continuum. Close linkages between agriculture, nutrition, and health, are essential in the quest to eradicate hunger among the poor.     

Rising mental health costs: what are we getting for our money?

This synthesis of recent epidemiological and service use data concludes that, in aggregate, rising mental health spending since the early 1990s appear to be purchasing improvements in access to care and to represent a good value for society. However, there is also evidence of continuing waste and quality deficits. Although mental health faces some unique challenges, these patterns are more similar to than different from those seen in all of health care. These parallels suggest the importance of learning from and working with the broader health care system in improving the returns on U.S. mental health spending.