Development of quality of care indicators for Parkinson's disease.

Parkinson's disease (PD) is a major cause of disability. To date, there have been no large-scale efforts to measure the quality of PD care because of a lack of quality indicators for conducting an explicit review of PD care processes. We present a set of quality indicators for PD care. Based on a structured review of the medical literature, 79 potential indicators were drafted. Through a two-round modified Delphi process, an expert panel of seven movement disorders specialists rated each indicator on criteria of validity, feasibility, impact on outcomes, room for improvement, and overall utility. Seventy-one quality indicators met validity and feasibility thresholds. Applying thresholds for impact on outcomes, room for improvement, and overall utility, a subset of 29 indicators was identified, spanning dopaminergic therapy, assessment of functional status, assessment and treatment of depression, coordination of care, and medication use. Multivariable analysis showed that overall utility ratings were driven by validity and impact on outcomes (P < 0.01). An expert panel can reach consensus on a set of highly rated quality indicators for PD care, which can be used to assess quality of PD care and guide the design of quality improvement projects.     

Validity and Responsiveness of Generic Preference-based HRQOL Instruments in Chronic Epilepsy

Generic, preference-based instruments are recommended for assessing health-related quality of life (HRQOL) in cost-utility analyses (CUA). We aimed to determine which instrument is the most appropriate for CUA of epilepsy care, using established psychometric criteria. We compared validity and responsiveness of EQ5D (using both UK and US preferences), visual analog scale (VAS), Health Utilities Index Mark II (HUI-2) and Mark III (HUI-3) and SF6D in 165 adults evaluated for epilepsy surgery. SF6D had the strongest or next-strongest associations with seizure severity and seizure control. It was not associated with education or IQ. Only SF6D and HUI-3 discriminated between patients with and without seizures 2 years after baseline evaluation. SF6D was most or next-most responsive to being seizure-free for 2 years, in most responsiveness analyses. VAS was also responsive, but showed less evidence of validity. The QOLIE-89, an epilepsy-targeted profile instrument, had stronger evidence for validity and responsiveness than the preference instruments. SF6D has several key psychometric advantages over four other preference instruments in CUAs of epilepsy care. This may reflect better coverage of HRQOL dimensions affected by epilepsy, greater sensitivity at the upper end of the HRQOL continuum, or both. These findings may not generalize to other chronic conditions.     

Training the future neurology workforce

OBJECTIVE: To address training demands on future neurologists, the American Academy of Neurology (AAN) surveyed its US members as to their views about training the future neurology workforce. METHODS: The survey was mailed to 575 US neurologists and 425 residents/fellows. Respondents (54%) were asked about their perceptions of current and future educational programs and settings needed to improve practice competence; issues related to subspecialization; and the role of non-neurologists in providing neurologic care. Views of neurologists were compared with those of neurology residents/fellows. RESULTS: Most respondents support additional training in outpatient, community, and staff model health maintenance organization settings. The majority of respondents oppose a required fifth year of training or a yearly competency examination, but neurologists who have a subspecialty interest and residents/fellows favor elective certification and higher fees by subspecialists. General neurologists oppose these ideas. Most neurologists feel that primary care physicians, nurse practitioners, and physician assistants can manage uncomplicated neurologic problems, although residents/fellows are less willing to accept the role of nonphysician providers for neurologic services. CONCLUSIONS: Neurology educational programs should consider addressing deficiencies that today's practitioners perceive. Increasing subspecialization, although favored by most neurologists, creates a challenge for the neurologic community as neurologists without subspecialty training see this trend as a threat to their livelihood.     

A review of health-related quality-of-life measures in stroke

The objective of this review was to evaluate health-related quality of life (HR-QOL) measures for use with patients with stroke. HR-QOL measures are increasingly used for assessment in many health conditions; these measures may serve an important role in evaluating the impact of stroke and of stroke interventions. HR-QOL measures used in patients with stroke should: (i) cover the domains of HR-QOL that may be affected by stroke; (ii) have administration characteristics suitable for use in patients with stroke; and (iii) have undergone reliability and validity assessment in patients with stroke. The present study evaluates HR-QOL measures with reference to these requirements. A systematic literature review was conducted to identify and evaluate HR-QOL measures of potential use in studies of patients with stroke. Identified measures were assessed with regard to stroke-relevant domains covered, measure characteristics (e.g. self-administration versus administration by an interviewer, interviewer time to complete) and psychometric properties of reliability and validity. The measures evaluated vary widely on domains covered, and limited assessment of the performance of HR-QOL measures has been conducted in patients with stroke. No existing measure comprehensively covers all relevant domains or addresses fully the issues of obtaining and combining HR-QOL assessments in patients and proxies in many stroke populations. Additional psychometric testing in stroke populations is needed for existing HR-QOL measures. In addition, stroke-targeted HR-QOL measures need to be developed and evaluated with patients with stroke.     

Antimicrobial prophylaxis for urinary tract infection in persons with spinal cord dysfunction.

OBJECTIVE: To assess the benefits and harms of antimicrobial prophylaxis to prevent urinary tract infections (UTIs) in persons with neurogenic bladders caused by spinal cord dysfunction. DATA SOURCES: A broad search strategy with no language restriction was conducted of MEDLINE (1966-January 1998), EMBASE (1974-January 1998), and CINAHL (1982-July 1998) using the general search terms urinary tract, urinary tract infections, bacteriuria, paraplegia, quadriplegia, spinal cord injuries, multiple sclerosis, neurogenic bladder, and neuropathic bladder. Additional articles were identified by experts and by reviewing reference lists of articles obtained from searches. STUDY SELECTION: Criteria included human studies of adults and adolescents who had neurogenic bladder due to spinal cord dysfunction; the studies had to address antimicrobial prophylaxis of UTI and include bacteriuria or UTI as an outcome. We excluded any study that was clearly not a controlled trial or that only included children under the age of 13 years. Two reviewers independently abstracted data, and disagreements were resolved by consensus. DATA EXTRACTION: Two reviewers independently abstracted data, and disagreements were resolved by consensus. Studies were graded by 1 project investigator according to quality criteria developed by Jadad and Schulz. DATA SYNTHESIS: The sizes of the effect of antimicrobial prophylaxis on weekly infection rates from 15 trials that met the inclusion criteria were pooled by using a random effects model. Antimicrobial prophylaxis did not significantly decrease symptomatic infections. Prophylaxis was associated with a reduction in asymptomatic bacteriuria among acute patients (<90d after spinal cord injury; P <.05); 1 patient would require 3.7 weeks of treatment on average to prevent 1 asymptomatic infection. For nonacute patients, the reduction approached statistical significance (P =.06). Prophylaxis resulted in an approximately twofold increase in antimicrobial-resistant bacteria. CONCLUSIONS: The regular use of antimicrobial prophylaxis for most patients who have neurogenic bladder caused by spinal cord dysfunction is not supported. A clinically important effect, however, has not been excluded. Future research should focus on randomized trials in those patients who have recurrent UTIs that limit their daily functioning and well-being.     

Disparities of care in veterans with Parkinson's disease

BACKGROUND: Disparities of Parkinson's disease (PD) care have not been assessed. METHODS: We examined the medical records of 309 (83%) non-Hispanic White and 65 (17%) non-White Los Angeles veterans with PD from 1998 to 2004 to determine if care quality as measured by 10 PD indicators different by race/ethnicity. RESULTS: In multivariate modeling, adherence to indicators was higher among non-Hispanic Whites (71% vs. 65%, risk ratio 1.15, 95% CI [1.07-1.32]) compared to non-Whites. Differences in adherence by race/ethnicity were greatest for depression treatment (p<0.05). CONCLUSIONS: We detected disparities in quality of PD care, particularly in depression treatment. Future research should determine causes for these so that interventions can be designed to reduce such disparities.