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1.  Measuring relational aspects of hospital care in England with the ‘Patient Evaluation of Emotional Care during Hospitalisation’ (PEECH) survey questionnaire 
BMJ Open  2013;3(1):e002211.
Objectives
To first, validate in English hospitals the internal structure of the ‘Patient Evaluation of Emotional Care during Hospitalisation’ (PEECH) survey tool which was developed in Australia and, second, to examine how it may deepen the understanding of patient experience through comparison with results from the Picker Patient Experience Questionnaire (PPE-15).
Design
A 48-item survey questionnaire comprising both PEECH and PPE-15 was fielded. We performed exploratory factor analysis and then confirmatory factor analysis using a number of established fit indices. The external validity of the PEECH factor scores was compared across four participating services and at the patient level, factor scores were correlated with the PPE-15.
Setting
Four hospital services (an Emergency Admissions Unit; a maternity service; a Medicine for the Elderly department and a Haemato-oncology service) that contrasted in terms of the reported patient experience performance.
Participants
Selection of these acute service settings was based on achieving variation of the following factors: teaching hospital/district general hospital, urban/rural locality and high-performing/low-performing organisations (using results of annual national staff and patient surveys). A total of 423 surveys were completed by patients (26% response rate).
Results
A different internal structure to the PEECH instrument emerged in English hospitals. However, both the existing and new factor models were similar in terms of fit. The correlations between the new PEECH factors and the PPE-15 were all in the expected direction, but two of the new factors (personal interactions and feeling valued) were more strongly associated with the PPE-15 than the remaining two factors (feeling informed and treated as an individual).
Conclusions
PEECH can help to build an understanding of complex interpersonal aspects of quality of care, alongside the more transactional and functional aspects typically captured by PPE-15. Further testing of the combined instrument should be undertaken in a wider range of healthcare settings.
doi:10.1136/bmjopen-2012-002211
PMCID: PMC3563120  PMID: 23370012
Patient-centred care; surveys; Patient satisfaction; Quality improvement; Audit and feedback
2.  Evaluation of the acceptability of Peer Physical Examination (PPE) in medical and osteopathic students: a cross sectional survey 
BMC Medical Education  2013;13:111.
Background
Peer physical examination (PPE) is a method of training in medical and osteopathic curricula. The aim of this study was to compare the acceptability of PPE in two classes of medical and osteopathic students after their first experience, to obtain comparative information useful for an understanding of the different professional approaches. The leading hypothesis was that osteopathic students enter the curriculum with a more positive attitude to bodily contact.
As a secondary aim, this study validated the new version of a questionnaire to assess the acceptability of PPE.
Methods
A new version of a previously validated questionnaire and an instrument from the literature (the Examining Fellow Student [EFS] questionnaire) were used for a cross-sectional survey in a class of 129 3rd year medical students and in two parallel classes of 1st year osteopathic students (total of 112 students).
Results
The mean score of the new questionnaire was significantly higher for the osteopathic students than for the medical students (53.4 ± 6.3 vs. 43.4 ± 8.9; p < 0.01). The only independent variables that were significantly predictive of the score in a linear regression analysis were gender and the condition of medical or osteopathic student. The EFS mean score also showed a significant difference between the osteopathic and medical students (30.76 ± 2.9 vs. 27.85 ± 4.3; p < 0.01).
Factor analysis of the new questionnaire identified three factors (appropriateness and usefulness, sexual implications and passive role) accounting for 62.8% of the variance. Criterion validity was assessed by correlation with the EFS (Pearson’s r coefficient = 0.61). Reliability was expressed in terms of Cronbach’s alpha coefficient, which equals 0.86.
Conclusions
These quantitative results are consistent with previous qualitative research on the process of embodiment both in medicine and osteopathy. The new questionnaire proved to be valid and reliable. The objective assessment of the acceptability of PPE is a way to determine differences in students’ attitudes towards contact with the body and can be used for counselling students regarding career choice. This study can also highlight differences between students from different professions and serve as a basis for reflection for improved mutual interprofessional understanding and future interprofessional education.
doi:10.1186/1472-6920-13-111
PMCID: PMC3846411  PMID: 23968312
Peer physical examination; Embodiment; Medical student; Osteopathic student; Cross sectional survey
3.  Self-Reported Use of Personal Protective Equipment among Chinese Critical Care Clinicians during 2009 H1N1 Influenza Pandemic 
PLoS ONE  2012;7(9):e44723.
Background
Critically ill patients with 2009 H1N1 influenza are often treated in intensive care units (ICUs), representing significant risk of nosocomial transmission to critical care clinicians and other patients. Despite a large body of literature and guidelines recommending infection control practices, numerous barriers have been identified in ICUs, leading to poor compliance to the use of personal protective equipment (PPE). The use of PPE among critical care clinicians has not been extensively evaluated, especially during the pandemic influenza. This study examined the knowledge, attitudes, and self-reported behaviors, and barriers to compliance with the use of PPE among ICU healthcare workers (HCWs) during the pandemic influenza.
Methodology/Principal Findings
A survey instrument consisting of 36 questions was developed and mailed to all HCWs in 21 ICUs in 17 provinces in China. A total of 733 physicians, nurses, and other professionals were surveyed, and 650 (88.7%) were included in the analysis. Fifty-six percent of respondents reported having received training program of pandemic influenza before they cared for H1N1 patients, while 77% reported to have adequate knowledge of self and patient protection. Only 18% of respondents were able to correctly identify all components of PPE, and 55% reported high compliance (>80%) with PPE use during patient care. In multivariate analysis, vaccination for 2009 H1N1 influenza, positive attitudes towards PPE use, organizational factors such as availability of PPE in ICU, and patient information of influenza precautions, as well as reprimand for noncompliance by the supervisors were associated with high compliance, whereas negative attitudes towards PPE use and violation of PPE use were independent predictors of low compliance.
Conclusion/Significance
Knowledge and self-reported compliance to recommended PPE use among Chinese critical care clinicians is suboptimal. The perceived barriers should be addressed in order to close the significant gap between perception and knowledge or behavior.
doi:10.1371/journal.pone.0044723
PMCID: PMC3434157  PMID: 22957101
4.  Validation of the care transition measure in multi-ethnic South-East Asia in Singapore 
Background
The 15-item Care Transition Measure (CTM-15) is a measure for assessing the quality of care during transition from the patients’ perspective. The purpose of this study was to test the psychometric properties of the CTM-15 and CTM-3 (a 3-item version of the CTM-15) in Singapore, a multi-ethnic urban state in South-east Asia.
Methods
A consecutive sample of patients was recruited from two tertiary hospitals. The subjects or their proxies were interviewed 3 weeks after discharge from hospital to home in English or Chinese using the CTM-15 questionnaire. Information about patients’ visit to emergency department (ED), non-elective rehospitalisation for the condition of index hospitalisation, and care experience after discharge was also collected from respondents. Psychometric properties of CTM-15 and CTM-3 based on the five-point response scale (i.e. strongly disagree, disagree, neutral, agree, and strongly agree) and the three-point response scale (i.e. [strongly] agree, neutral, and [strongly] disagree) were tested for English and Chinese versions separately. Internal consistency reliability was assessed using Cronbach’s alpha and construct validity was tested with T-test or Pearson’s correlation by examining hypothesised association of CTM scores with ED visit, rehospitalisation, and experience with care after discharge. Exploratory factor analysis was performed to examine latent dimensions of CTM-15.
Results
A total of 414 (proxy: 96.1%) and 165 (proxy: 84.8%) subjects completed the interviews in English and Chinese, respectively. Cronbach’s alpha values of the different CTM-15 versions ranged from 0.81 to 0.87. In contrast, Cronbach’s alpha values of the CTM-3 ranged from 0.42 to 0.63. Both CTM-15 and CTM-3 were correlated with care experience after discharge regardless of survey language or response scale (Pearson’s correlation coefficient: 0.36 to 0.46). Among the English-speaking respondents, the CTM-15 and CTM-3 scores based on both the three- and five-point response scales discriminated well between patients with and without ED visits or rehospitalisation for their index condition. Among Chinese-speaking respondents, no difference in CTM scores was observed between patients with and without ED visits or patients with and without rehospitalisation. The English and Chinese versions of the CTM-15 items demonstrated a similar 4-factor structure representing general care plan, medication, agreement on care plan, and specific care instructions.
Conclusions
The care transition measure is a valid and reliable measure for quality of care transition in Singapore. Moreover, the care transition measure can be administered to proxies using a simpler response scale. The discriminatory power of the Chinese version of this instrument needs to be further tested in future studies.
doi:10.1186/1472-6963-12-256
PMCID: PMC3496595  PMID: 22897804
5.  Appropriate use of personal protective equipment among healthcare workers in public sector hospitals and primary healthcare polyclinics during the SARS outbreak in Singapore 
Chia, S | Koh, D | Fones, C | Qian, F | Ng, V | Tan, B | Wong, K | Chew, W | Tang, H | Ng, W | Muttakin, Z | Emmanuel, S | Fong, N | Koh, G | Lim, M
Background: Singapore was affected by an outbreak of severe acute respiratory syndrome (SARS) from 25 February to 31 May 2003, with 238 probable cases and 33 deaths.
Aims: To study usage of personal protective equipment (PPE) among three groups of healthcare workers (HCWs: doctors, nurses, and administrative staff), to determine if the appropriate PPE were used by the different groups and to examine the factors that may determine inappropriate use.
Methods: A self-administered questionnaire survey of 14 554 HCWs in nine healthcare settings, which included tertiary care hospitals, community hospitals, and polyclinics, was carried out in May–July 2003. Only doctors, nurses, and clerical staff were selected for subsequent analysis.
Results: A total of 10 236 valid questionnaires were returned (70.3% response); 873 doctors, 4404 nurses, and 921 clerical staff were studied. A total of 32.5% of doctors, 48.7% of nurses, and 77.1% of the administrative staff agreed that paper and/or surgical masks were "useful in protecting from contracting SARS". Among this group, 23.6% of doctors and 42.3% of nurses reported working with SARS patients. The view that a paper and/or surgical mask was adequate protection against SARS was held by 33.3% of doctors and 55.9% of nurses working at the A&E unit, 30.5% of doctors and 49.4% of nurses from medical wards, and 27.5% of doctors and 37.1% of nurses from intensive care units. Factors which predicted for agreement that paper and/or surgical masks were protective against SARS, included HCW's job title, reported contact with SARS patients, area of work, and Impact Events Scale scores.
Conclusion: A variety of factors determine appropriate use of personal protective equipment by HCWs in the face of a major SARS outbreak.
doi:10.1136/oem.2004.015024
PMCID: PMC1741057  PMID: 15961624
6.  Quality of care and investment in property, plant, and equipment in hospitals. 
Health Services Research  1994;28(6):713-727.
OBJECTIVE. This study explores the relationship between quality of care and investment in property, plant, and equipment (PPE) in hospitals. DATA SOURCES. Hospitals' investment in PPE was derived from audited financial statements for the fiscal years 1984-1989. Peer Review Organization (PRO) Generic Quality Screen (GQS) reviews and confirmed failures between April 1989 and September 1990 were obtained from the Massachusetts PRO. STUDY DESIGN. Weighted least squares regression models used PRO GQS confirmed failure rates as the dependent variable, and investment in PPE as the key explanatory variable. DATA EXTRACTION. Investment in PPE was standardized, summed by the hospital over the six years, and divided by the hospital's average number of beds in that period. The number of PRO reviewed cases with one or more GQS confirmed failures was divided by the total number of cases reviewed to create confirmed failure rates. PRINCIPAL FINDINGS. Investment in PPE in Massachusetts hospitals is correlated with GQS confirmed failure rates. CONCLUSIONS. A financial variable, investment in PPE, predicts certain dimensions of quality of care in hospitals.
PMCID: PMC1069977  PMID: 8113054
7.  Psychometric Evaluation of the Chinese Version of the Patient Perceptions of Empowerment Scale (PPES) 
BioMed Research International  2014;2014:867451.
Objectives. To evaluate the psychometric properties of the Chinese version of the Patient Perceptions of Empowerment Scale (PPES) and to perform a cross-cultural validity assessment. Methods. In this cross-sectional survey, 554 inpatients in three general hospitals in northern Taiwan were recruited. Principal component analysis was used to examine the factor structure of the scale. Confirmatory factor analyses were conducted on the measurement model of the Chinese version of the PPES. Results. Confirmatory factor analyses supported the presence of a second-order four-factor model (information, decision, individual, and self-management) of the Chinese version of the PPES when used with a Taiwanese inpatient population. The results indicate that the 11-item, second-order, four-factor Chinese version of the PPES provided best goodness-of-fit for the data in this study. Conclusion. The 11-item four-factor Chinese version of the PPES is a self-completion scale. This study demonstrated that the Chinese version of the PPES is a reliable and valid self-report instrument for the assessment of patient perceptions of empowerment in clinical practice. Further adaptation and evaluation of the scale will hopefully stimulate further studies on PPES in the fields of psychometrics in Taiwan.
doi:10.1155/2014/867451
PMCID: PMC4058164  PMID: 24971354
8.  THE PREPARTICIPATION EVALUATION FOR ATHLETES WITH DISABILITY 
Background:
Athletes are routinely assessed medically prior to competition. Although standardized preparticipation examinations (PPEs) are available for able‐bodied athletes, the literature lacks any validated equivalent for the athlete with disability (AWD). Since participation and level of competition is increasing in this population, evidence‐based tools such as a standardized PPE form should be available for health professionals to assess AWD health and safety.
Aim of the study:
To develop an AWD‐targeted standardized preparticipation history evaluation (PPE history) using consensus‐based expert recommendations.
Methods:
Researchers developed a PPE history for critical evaluation of its content validity. Structured Delphi method for collecting and interpreting contributions from an expert panel using a series of questionnaires with controlled feedback was performed. Opinions based on the experience of related experts ‐ physiotherapists, sports medicine physicians and physiatrists ‐ were studied during each of the three survey rounds. The process was terminated once adequate consensus relating to the proposed PPE history document was reached.
Results:
Majority consensus was reached for forty‐nine of fifty‐four items to create a refined ten section AWD‐specific document to supplement the current standardized PPE. Modifications were made by researchers to accommodate the five items that did not reach statistical consensus.
Conclusion:
Consensus was reached on a variety of AWD‐specific PPE items, including the disability‐related history and functional review. Equipment issues represent a complex area of evaluation, worthy of future research and discussion. The current proposed PPE history tool is considered comprehensive and ready for application in a clinical setting as an adjunct to existing PPE tools. Injury research in the AWD population will provide guidance for refinement and further validation of this PPE history document.
Level of evidence:
5
PMCID: PMC3924614  PMID: 24567861
Delphi; disabled athlete; paralympic; preparticipation evaluation; sledge
9.  Psychometric properties of the hospital survey on patient safety culture, HSOPSC, applied on a large Swedish health care sample 
Background
A Swedish version of the USA Agency for Healthcare Research and Quality “Hospital Survey on Patient Safety Culture” (S-HSOPSC) was developed to be used in both hospitals and primary care. Two new dimensions with two and four questions each were added as well as one outcome measure. This paper describes this Swedish version and an assessment of its psychometric properties which were tested on a large sample of responses from personnel in both hospital and primary care.
Methods
The questionnaire was mainly administered in web form and 84215 forms were returned (response rate 60%) between 2009 and 2011. Eleven per cent of the responses came from primary care workers and 46% from hospital care workers. The psychometric properties were analyzed using both the total sample and the hospital and primary care subsamples by assessment of construct validity and internal consistency. Construct validity was assessed by confirmatory (CFA) and exploratory factor (EFA) analyses and internal consistency was established by Cronbachs’s α.
Results
CFA of the total, hospital and primary care samples generally showed a good fit while the EFA pointed towards a 9-factor model in all samples instead of the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable with Cronbach’s α values above 0.7 in a major part of the dimensions.
Conclusions
The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome measures, is used both in hospitals and in primary care settings in Sweden for different purposes. This version of the original American instrument has acceptable construct validity and internal consistency when tested on large datasets of first-time responders from both hospitals and primary care centres. One common instrument for measurements of patient safety culture in both hospitals and primary care settings is an advantage since it enables comparisons between sectors and assessments of national patient safety improvement programs. Future research into this version of the instrument includes comparing results from patient safety culture measurements with other outcomes in relation to safety improvement strategies.
doi:10.1186/1472-6963-13-332
PMCID: PMC3765335  PMID: 23964867
Patient safety culture; Hospital Survey on Patient Safety Culture; S-Hospital Survey on Patient Safety Culture; Primary care; Psychometric properties; Construct validity; Internal consistency
10.  Point-of-Care International Normalized Ratio (INR) Monitoring Devices for Patients on Long-term Oral Anticoagulation Therapy 
Executive Summary
Subject of the Evidence-Based Analysis
The purpose of this evidence based analysis report is to examine the safety and effectiveness of point-of-care (POC) international normalized ratio (INR) monitoring devices for patients on long-term oral anticoagulation therapy (OAT).
Clinical Need: Target Population and Condition
Long-term OAT is typically required by patients with mechanical heart valves, chronic atrial fibrillation, venous thromboembolism, myocardial infarction, stroke, and/or peripheral arterial occlusion. It is estimated that approximately 1% of the population receives anticoagulation treatment and, by applying this value to Ontario, there are an estimated 132,000 patients on OAT in the province, a figure that is expected to increase with the aging population.
Patients on OAT are regularly monitored and their medications adjusted to ensure that their INR scores remain in the therapeutic range. This can be challenging due to the narrow therapeutic window of warfarin and variation in individual responses. Optimal INR scores depend on the underlying indication for treatment and patient level characteristics, but for most patients the therapeutic range is an INR score of between 2.0 and 3.0.
The current standard of care in Ontario for patients on long-term OAT is laboratory-based INR determination with management carried out by primary care physicians or anticoagulation clinics (ACCs). Patients also regularly visit a hospital or community-based facility to provide a venous blood samples (venipuncture) that are then sent to a laboratory for INR analysis.
Experts, however, have commented that there may be under-utilization of OAT due to patient factors, physician factors, or regional practice variations and that sub-optimal patient management may also occur. There is currently no population-based Ontario data to permit the assessment of patient care, but recent systematic reviews have estimated that less that 50% of patients receive OAT on a routine basis and that patients are in the therapeutic range only 64% of the time.
Overview of POC INR Devices
POC INR devices offer an alternative to laboratory-based testing and venipuncture, enabling INR determination from a fingerstick sample of whole blood. Independent evaluations have shown POC devices to have an acceptable level of precision. They permit INR results to be determined immediately, allowing for more rapid medication adjustments.
POC devices can be used in a variety of settings including physician offices, ACCs, long-term care facilities, pharmacies, or by the patients themselves through self-testing (PST) or self-management (PSM) techniques. With PST, patients measure their INR values and then contact their physician for instructions on dose adjustment, whereas with PSM, patients adjust the medication themselves based on pre-set algorithms. These models are not suitable for all patients and require the identification and education of suitable candidates.
Potential advantages of POC devices include improved convenience to patients, better treatment compliance and satisfaction, more frequent monitoring and fewer thromboembolic and hemorrhagic complications. Potential disadvantages of the device include the tendency to underestimate high INR values and overestimate low INR values, low thromboplastin sensitivity, inability to calculate a mean normal PT, and errors in INR determination in patients with antiphospholipid antibodies with certain instruments. Although treatment satisfaction and quality of life (QoL) may improve with POC INR monitoring, some patients may experience increased anxiety or preoccupation with their disease with these strategies.
Evidence-Based Analysis Methods
Research Questions
1. Effectiveness
Does POC INR monitoring improve clinical outcomes in various settings compared to standard laboratory-based testing?
Does POC INR monitoring impact patient satisfaction, QoL, compliance, acceptability, convenience compared to standard laboratory-based INR determination?
Settings include primary care settings with use of POC INR devices by general practitioners or nurses, ACCs, pharmacies, long-term care homes, and use by the patient either for PST or PSM.
2. Cost-effectiveness
What is the cost-effectiveness of POC INR monitoring devices in various settings compared to standard laboratory-based INR determination?
Inclusion Criteria
English-language RCTs, systematic reviews, and meta-analyses
Publication dates: 1996 to November 25, 2008
Population: patients on OAT
Intervention: anticoagulation monitoring by POC INR device in any setting including anticoagulation clinic, primary care (general practitioner or nurse), pharmacy, long-term care facility, PST, PSM or any other POC INR strategy
Minimum sample size: 50 patients Minimum follow-up period: 3 months
Comparator: usual care defined as venipuncture blood draw for an INR laboratory test and management provided by an ACC or individual practitioner
Outcomes: Hemorrhagic events, thromboembolic events, all-cause mortality, anticoagulation control as assessed by proportion of time or values in the therapeutic range, patient reported outcomes including satisfaction, QoL, compliance, acceptability, convenience
Exclusion criteria
Non-RCTs, before-after studies, quasi-experimental studies, observational studies, case reports, case series, editorials, letters, non-systematic reviews, conference proceedings, abstracts, non-English articles, duplicate publications
Studies where POC INR devices were compared to laboratory testing to assess test accuracy
Studies where the POC INR results were not used to guide patient management
Method of Review
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database) was undertaken to identify evidence published from January 1, 1998 to November 25, 2008. Studies meeting the inclusion criteria were selected from the search results. Reference lists of selected articles were also checked for relevant studies.
Summary of Findings
Five existing reviews and 22 articles describing 17 unique RCTs met the inclusion criteria. Three RCTs examined POC INR monitoring devices with PST strategies, 11 RCTs examined PSM strategies, one RCT included both PST and PSM strategies and two RCTs examined the use of POC INR monitoring devices by health care professionals.
Anticoagulation Control
Anticoagulation control is measured by the percentage of time INR is within the therapeutic range or by the percentage of INR values in the therapeutic range. Due to the differing methodologies and reporting structures used, it was deemed inappropriate to combine the data and estimate whether the difference between groups would be significant. Instead, the results of individual studies were weighted by the number of person-years of observation and then pooled to calculate a summary measure.
Across most studies, patients in the intervention groups tended to have a higher percentage of time and values in the therapeutic target range in comparison to control patients. When the percentage of time in the therapeutic range was pooled across studies and weighted by the number of person-years of observation, the difference between the intervention and control groups was 4.2% for PSM, 7.2% for PST and 6.1% for POC use by health care practitioners. Overall, intervention patients were in the target range 69% of the time and control patients were in the therapeutic target range 64% of the time leading to an overall difference between groups of roughly 5%.
Major Complications and Deaths
There was no statistically significant difference in the number of major hemorrhagic events between patients managed with POC INR monitoring devices and patients managed with standard laboratory testing (OR =0.74; 95% CI: 0.52- 1.04). This difference was non-significant for all POC strategies (PSM, PST, health care practitioner).
Patients managed with POC INR monitoring devices had significantly fewer thromboembolic events than usual care patients (OR =0.52; 95% CI: 0.37 - 0.74). When divided by POC strategy, PSM resulted in significantly fewer thromboembolic events than usual care (OR =0.46.; 95% CI: 0.29 - 0.72). The observed difference in thromboembolic events for PSM remained significant when the analysis was limited to major thromboembolic events (OR =0.40; 95% CI: 0.17 - 0.93), but was non-significant when the analysis was limited to minor thromboembolic events (OR =0.73; 95% CI: 0.08 - 7.01). PST and GP/Nurse strategies did not result in significant differences in thromboembolic events, however there were only a limited number of studies examining these interventions.
No statistically significant difference was observed in the number of deaths between POC intervention and usual care control groups (OR =0.67; 95% CI: 0.41 - 1.10). This difference was non-significant for all POC strategies. Only one study reported on survival with 10-year survival rate of 76.1% in the usual care control group compared to 84.5% in the PSM group (P=0.05).
Summary Results of Meta-Analyses of Major Complications and Deaths in POC INR Monitoring Studies
Patient Satisfaction and Quality of Life
Quality of life measures were reported in eight studies comparing POC INR monitoring to standard laboratory testing using a variety of measurement tools. It was thus not possible to calculate a quantitative summary measure. The majority of studies reported favourable impacts of POC INR monitoring on QoL and found better treatment satisfaction with POC monitoring. Results from a pre-analysis patient and caregiver focus group conducted in Ontario also indicated improved patient QoL with POC monitoring.
Quality of the Evidence
Studies varied with regard to patient eligibility, baseline patient characteristics, follow-up duration, and withdrawal rates. Differential drop-out rates were observed such that the POC intervention groups tended to have a larger number of patients who withdrew. There was a lack of consistency in the definitions and reporting for OAT control and definitions of adverse events. In most studies, the intervention group received more education on the use of warfarin and performed more frequent INR testing, which may have overestimated the effect of the POC intervention. Patient selection and eligibility criteria were not always fully described and it is likely that the majority of the PST/PSM trials included a highly motivated patient population. Lastly, a large number of trials were also sponsored by industry.
Despite the observed heterogeneity among studies, there was a general consensus in findings that POC INR monitoring devices have beneficial impacts on the risk of thromboembolic events, anticoagulation control and patient satisfaction and QoL (ES Table 2).
GRADE Quality of the Evidence on POC INR Monitoring Studies
CI refers to confidence interval; Interv, intervention; OR, odds ratio; RCT, randomized controlled trial.
Economic Analysis
Using a 5-year Markov model, the health and economic outcomes associated with four different anticoagulation management approaches were evaluated:
Standard care: consisting of a laboratory test with a venipuncture blood draw for an INR;
Healthcare staff testing: consisting of a test with a POC INR device in a medical clinic comprised of healthcare staff such as pharmacists, nurses, and physicians following protocol to manage OAT;
PST: patient self-testing using a POC INR device and phoning in results to an ACC or family physician; and
PSM: patient self-managing using a POC INR device and self-adjustment of OAT according to a standardized protocol. Patients may also phone in to a medical office for guidance.
The primary analytic perspective was that of the MOHLTC. Only direct medical costs were considered and the time horizon of the model was five years - the serviceable life of a POC device.
From the results of the economic analysis, it was found that POC strategies are cost-effective compared to traditional INR laboratory testing. In particular, the healthcare staff testing strategy can derive potential cost savings from the use of one device for multiple patients. The PSM strategy, however, seems to be the most cost-effective method i.e. patients are more inclined to adjust their INRs more readily (as opposed to allowing INRs to fall out of range).
Considerations for Ontario Health System
Although the use of POC devices continues to diffuse throughout Ontario, not all OAT patients are suitable or have the ability to practice PST/PSM. The use of POC is currently concentrated at the institutional setting, including hospitals, ACCs, long-term care facilities, physician offices and pharmacies, and is much less commonly used at the patient level. It is, however, estimated that 24% of OAT patients (representing approximately 32,000 patients in Ontario), would be suitable candidates for PST/PSM strategies and willing to use a POC device.
There are several barriers to the use and implementation of POC INR monitoring devices, including factors such as lack of physician familiarity with the devices, resistance to changing established laboratory-based methods, lack of an approach for identifying suitable patients and inadequate resources for effective patient education and training. Issues of cost and insufficient reimbursement strategies may also hinder implementation and effective quality assurance programs would need to be developed to ensure that INR measurements are accurate and precise.
Conclusions
For a select group of patients who are highly motivated and trained, PSM resulted in significantly fewer thromboembolic events compared to conventional laboratory-based INR testing. No significant differences were observed for major hemorrhages or all-cause mortality. PST and GP/Nurse use of POC strategies are just as effective as conventional laboratory-based INR testing for thromboembolic events, major hemorrhages, and all-cause mortality. POC strategies may also result in better OAT control as measured by the proportion of time INR is in the therapeutic range and there appears to be beneficial impacts on patient satisfaction and QoL. The use of POC devices should factor in patient suitability, patient education and training, health system constraints, and affordability.
Keywords
anticoagulants, International Normalized Ratio, point-of-care, self-monitoring, warfarin.
PMCID: PMC3377545  PMID: 23074516
11.  Patient satisfaction in an acute medicine department in Morocco 
Background
Patients' satisfaction is an important indicator for quality of care. Measuring healthcare quality and improving patient satisfaction have become increasingly prevalent, especially among healthcare providers and purchasers of healthcare. This is mainly due to the fact that consumers are becoming increasingly more knowledgeable about healthcare. No studies of inpatients' satisfaction with hospital care have been conducted in Morocco. The first objective of the present study was to confirm the reliability and validity of the Arabic version of the EQS-H (Echelle de Qualité des Soins en Hospitalisation). The second objective was to evaluate patient satisfaction in an acute medicine department in Morocco by using the EQS-H questionnaire; and also to assess the influence of certain demographics, socioeconomics, and health characteristics in patient satisfaction.
Methods
it was a patient survey conducted in an acute medicine department of a Moroccan University Hospital. We surveyed their socio demographic status, and health characteristics at admission. We performed structured face to face interviews with patients who were discharged from hospital. The core of the EQS-H questionnaire was translated to Arabic, adapted to the present setting, and then used to measure patient satisfaction with quality of care. The internal consistency of the EQS-H scale was assessed by Chronbach's coefficient alpha. Validity was assessed by factor analysis. Factors influencing inpatients' satisfaction were identified using multiple linear regression.
Results
The Arabic version of EQS-H demonstrated an excellent internal consistency for the two dimensions studied (0.889 for 'quality of medical information' (MI) and 0.906 for 'Relationship with staff and daily routine' (RS)). The principal component analysis confirmed the bidimensional structure of the questionnaire and explained 60% of the total variance. In the univariate analysis, urban residence, higher income, better perceived health status compared to admission, better perceived health status compared to people of the same age, and satisfaction with life in general were related to MI dimension; Otherwise, mal gender, urban residence, higher income, staying in double room, better perceived health status compared to admission, and satisfaction with life in general were related to RS dimension. The multiple linear regression showed that four independent variables were associated with higher satisfaction in MI: More than 2 prior hospitalizations, a longer length of stay (10-14 days) (P = 0.002), staying in double room (P = 0.022), and better perceived health status compared to admission (P = 0.036). Three independent variables were associated with higher satisfaction in RS: a longer length of stay (10-14 days) (P = 0.017), better perceived health status compared to admission day (P = 0.013), and satisfaction with life in general (P = 0.006).
Conclusions
Our current data assessing patient satisfaction with acute health care by the Arabic version of the EQS-H showed that the satisfaction rate was average on MI dimension; and good on RS dimension of the questionnaire. The majority of participants were satisfied with the overall care. Demographic, socioeconomic, and health characteristics may influence in-patients satisfaction in Morocco, a low/middle income country. An appreciation and understanding of these factors is essential to develop socio culturally appropriate interventions in order to improve satisfaction of patients.
doi:10.1186/1472-6963-10-149
PMCID: PMC2900260  PMID: 20525170
12.  Assessing Safety Culture in Pharmacies: The psychometric validation of the Safety Attitudes Questionnaire (SAQ) in a national sample of community pharmacies in Sweden 
Background
Safety culture assessment is increasingly recognized as an important component in healthcare quality improvement, also in pharmacies. One of the most commonly used and rigorously validated tools to measure safety culture is the Safety Attitudes Questionnaire; SAQ. This study presents the validation of the SAQ for use in Swedish pharmacies. The psychometric properties of the translated questionnaire are presented
Methods
The original English language version of the SAQ was translated and adapted to the Swedish context and distributed by e-mail. The survey was carried out on a national basis, covering all 870 Swedish community pharmacies. In total, 7,244 questionnaires were distributed. Scale psychometrics were analysed using Cronbach alphas and intercorrelations among the scales. Multiple group confirmatory factor analysis (CFA) was conducted.
Results
SAQ data from 828 community pharmacies in Sweden, including 4,090 (60.22%) pharmacy personnel out of 6,683 eligible respondents, were received. There were 252 (28.97%) pharmacies that met the inclusion criteria of having at least 5 respondents and a minimum response rate of 60% within that pharmacy.
The coefficient alpha value for each of the SAQ scales ranged from .72 to .89. The internal consistency results, in conjunction with the confirmatory factor analysis results, demonstrate that the Swedish translation of the SAQ has acceptable to good psychometric properties. Perceptions of the pharmacy (Teamwork Climate, Job Satisfaction, Perceptions of Management, Safety Climate, and Working Conditions) were moderately to highly correlated with one another whereas attitudes about stress (Stress Recognition) had only low correlations with other factors. Perceptions of management showed the most variability across pharmacies (SD = 26.66), whereas Stress Recognition showed the least (SD = 18.58). There was substantial variability ranging from 0% to 100% in the percent of positive scores for each of the factors across the 252 pharmacies.
Conclusions
The Swedish translation of the SAQ demonstrates acceptable construct validity, for capturing the frontline perspective of safety culture of community pharmacy staff. The psychometric results reported here met or exceeded standard guidelines, which is consistent with previous studies using the SAQ in other healthcare settings and other languages.
doi:10.1186/1472-6904-10-8
PMCID: PMC2868807  PMID: 20380741
13.  The Consumer Quality Index Hip Knee Questionnaire measuring patients' experiences with quality of care after a total hip or knee arthroplasty 
Background
The Dutch Consumer Quality Index Hip Knee Questionnaire (CQI Hip Knee) was used to assess patients' experiences with and evaluations of quality of care after a total hip (THA) or total knee arthroplasty (TKA). The aim of this study is to evaluate the construct validity and internal consistency reliability of this new instrument and to assess its ability to measure differences in quality of care between hospitals.
Methods
Survey data of 1,675 subjects who underwent a THA or TKA were used to evaluate the psychometric properties. Exploratory factor analyses were performed and item-total correlations and inter-factor correlations were calculated to assess the construct validity of the instrument. Reliability analyses included tests of internal consistency (Cronbach's alpha coefficients). Finally, multilevel analyses were performed to assess the ability of the instrument to discriminate between hospitals in quality of care.
Results
Exploratory factor analyses indicated that the survey consisted of 21 items measuring five aspects of care (i.e. communication with nurses, communication with doctors, communication with general practitioner, communication about new medication, and pain control). Cronbach's alpha coefficients ranged from 0.76 to 0.90 indicating good internal consistency. The survey's ability to discriminate between hospitals was partly supported by multilevel analysis. Two scales (i.e. communication with nurses and communication with doctors) were able to measure differences between hospitals with respect to patients' experiences with quality of care. Logistic multilevel analyses indicated that hospitals explained part of the variation between patients in receiving information.
Conclusion
These findings suggest that the CQI Hip Knee is reliable and valid for use in Dutch health care. Health care providers or health plans can use this survey to measure patients' experiences with hospital care and to identify variations in care between hospitals.
doi:10.1186/1472-6963-7-60
PMCID: PMC1876799  PMID: 17462084
14.  Development of a Brief Instrument for Assessing Healthcare Employee Satisfaction in a Low-Income Setting 
PLoS ONE  2013;8(11):e79053.
Background
Ethiopia is one of 57 countries identified by the World Health Report 2006 as having a severely limited number of health care professionals. In recognition of this shortage, the Ethiopian Federal Ministry of Health, through the Ethiopian Hospital Management Initiative, prioritized the need to improve retention of health care workers. Accordingly, we sought to develop the Satisfaction of Employees in Health Care (SEHC) survey for use in hospitals and health centers throughout Ethiopia.
Methods
Literature reviews and cognitive interviews were used to generate a staff satisfaction survey for use in the Ethiopian healthcare setting. We pretested the survey in each of the six hospitals and four health centers across Ethiopia (98% response rate). We assessed content validity and convergent validity using factor analysis and examined reliability using the Cronbach alpha coefficients to assess internal consistency. The final survey was comprised of 18 questions about specific aspects of an individual's work and two overall staff satisfaction questions.
Results
We found support for content validity, as data from the 18 responses factored into three factors, which we characterized as 1) relationship with management and supervisors, 2) job content, and 3) relationships with coworkers. Summary scores for two factors (relationship with management and supervisors and job content) were significantly associated (P-value, <0.001) with the two overall satisfaction items. Cronbach's alpha coefficients showed good to excellent internal consistency (Cronbach alpha coefficients >0.70) for the items in the three summary scores.
Conclusions
The introduction of consistent and reliable measures of staff satisfaction is crucial to understand and improve employee retention rates, which threaten the successful achievement of the Millennium Development Goals in low-income countries. The use of the SEHC survey in Ethiopian healthcare facilities has ample leadership support, which is essential for addressing problems that reduce staff satisfaction and exacerbate excessive workforce shortages.
doi:10.1371/journal.pone.0079053
PMCID: PMC3818514  PMID: 24223878
15.  Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers 
Summary
The aim of this study was to determine the validity of the Italian translation of the Tinnitus Handicap Inventory (THI) by Newman et al. in order to make this self-report measure of perceived tinnitus handicap available both for clinical and research purposes in our country and to contribute to its cross-cultural validation as a self-report measure of perceived severity of tinnitus. The Italian translation of the Tinnitus Handicap Inventory (THI) was administered to 100 outpatients suffering from chronic tinnitus, aged between 20 and 82 years, who attended the audiological tertiary centres of the University Hospital of Modena and the Regional Hospital of Treviso. No segregation of cases was made on audiometric results; patients suffering from vertigo and neurological diseases were excluded. Pyschoacoustic characteristics of tinnitus (loudness and pitch) were determined and all patients also completed the MOS 36-Item Short Form Health Survey to assess self-perceived quality of life and the Hospital Anxiety and Depression Scale as a measure of self-perceived levels of anxiety and depression. The THI-I showed a robust internal consistency reliability (Cronbach’s alpha = 0.91) that was only slightly lower than the original version (Tinnitus Handicap Inventory-US; Cronbach’s alpha = 0.93) and its Danish (Cronbach’s alpha = 0.93) and Portuguese (Cronbach’s alpha = 0.94) translations. Also its two subscales (Functional and Emotional) showed a good internal consistency reliability (Cronbach’s alpha = 0.85 and 0.86, respectively). On the other hand, the Catastrophic subscale showed an unacceptable internal consistency reliability as it is too short in length (5 items). A confirmatory factor analysis failed to demonstrate that the 3 subscales of the THI-I correspond to 3 different factors. Close correlations were found between the total score of the Italian translation of the Tinnitus Handicap Inventory and all the subscales of the MOS 36-Item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale scores indicating a good construct validity. Moreover, these statistically significant correlations (p < 0.005) confirmed that the self-report tinnitus handicap is largely related to psychological distress and a deterioration in the quality of life. On the other hand, it was confirmed that the tinnitus perceived handicap is totally independent (p > 0.05) from its audiometrically-derived measures of loudness and pitch thus supporting previous studies that focused on the importance of non-auditory factors, namely somatic attention, psychological distress and coping strategies, in the generation of tinnitus annoyance. Finally the results of the present study suggest that the THI-I maintains its original validity and should be incorporated, together with other adequate psychometric questionnaires, in the audiological examination of patients suffering from tinnitus and that psychiatric counselling should be recommended for the suspected co-morbidity between tinnitus annoyance and psychological distress.
PMCID: PMC2644986  PMID: 18646574
Tinnitus; Anxiety; Depression; Quality of life
16.  Swedish translation and psychometric testing of the safety attitudes questionnaire (operating room version) 
Background
Tens of millions of patients worldwide suffer from avoidable disabling injuries and death every year. Measuring the safety climate in health care is an important step in improving patient safety. The most commonly used instrument to measure safety climate is the Safety Attitudes Questionnaire (SAQ). The aim of the present study was to establish the validity and reliability of the translated version of the SAQ.
Methods
The SAQ was translated and adapted to the Swedish context. The survey was then carried out with 374 respondents in the operating room (OR) setting. Data was received from three hospitals, a total of 237 responses. Cronbach’s alpha and confirmatory factor analysis (CFA) was used to evaluate the reliability and validity of the instrument.
Results
The Cronbach’s alpha values for each of the factors of the SAQ ranged between 0.59 and 0.83. The CFA and its goodness-of-fit indices (SRMR 0.055, RMSEA 0.043, CFI 0.98) showed good model fit. Intercorrelations between the factors safety climate, teamwork climate, job satisfaction, perceptions of management, and working conditions showed moderate to high correlation with each other. The factor stress recognition had no significant correlation with teamwork climate, perception of management, or job satisfaction.
Conclusions
Therefore, the Swedish translation and psychometric testing of the SAQ (OR version) has good construct validity. However, the reliability analysis suggested that some of the items need further refinement to establish sound internal consistency. As suggested by previous research, the SAQ is potentially a useful tool for evaluating safety climate. However, further psychometric testing is required with larger samples to establish the psychometric properties of the instrument for use in Sweden.
doi:10.1186/1472-6963-13-104
PMCID: PMC3618303  PMID: 23506044
Patient safety; Operating room; Safety climate; Psychometrics; Translation; Safety attitudes questionnaire
17.  Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale 
Background
Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff.
Methods
The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach’s alpha on total and on subscale levels; temporal stability was assessed through Pearson’s product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit.
Results
The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC.
Conclusions
POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.
doi:10.1186/1472-6963-13-327
PMCID: PMC3751919  PMID: 23958295
Person-centred care; Nursing; Older people; Cognitive impairment; Scale; Measurement; Intervention
18.  Risser patient satisfaction scale: a validation study in Greek cancer patients 
BMC Nursing  2012;11:27.
Background
The current healthcare climate is characterized by a constant battle for the provision of quality care with limited resources and with patient satisfaction receiving increased attention, there is a need for reliable and valid assessment measures. This study describes the adaptation, testing and validation of the Risser Patient satisfaction Scale in an oncology care setting in Greece. The rationale for this study lies in the scarcity of such measures in the Greek language.
Methods
This is a test retest validation study in Greece. Data were collected from 298 hospitalized cancer patients. The validation methodology included the assessment of the item internal consistency, using the Cronbach alpha coefficient. The test-retest reliability was tested by the Kappa correlation coefficient.
Results
The scale demonstrated very good psychometric properties. The internal consistency of the instrument was good, Cronbach’s alpha was found to be 0.78 (p<0.001) and Kappa coefficient for reproducibility was found to be K=0.89 (95% CI: 0.83-0.91 p<0.0001).
Conclusion
The findings demonstrated strong agreement of the scale, suggesting that the Greek version offers substantial reliability. This study provides a valid and reliable tool to assess patient satisfaction in oncology settings. Means to monitor patient satisfaction, a key aspect of the policy agenda for quality care remain important for nurse leaders to develop better care in oncology settings.
doi:10.1186/1472-6955-11-27
PMCID: PMC3531274  PMID: 23190625
Nursing care; Patient satisfaction; Validation; Risser patient satisfaction scale; Cancer settings; Cancer patients
19.  Patients' experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care 
Quality & safety in health care  2002;11(4):335-339.
Objective: To determine what aspects of healthcare provision are most likely to influence satisfaction with care and willingness to recommend hospital services to others and, secondly, to explore the extent to which satisfaction is a meaningful indicator of patient experience of healthcare services.
Design: Postal survey of a sample of patients who underwent a period of inpatient care. Patients were asked to evaluate their overall experience of this episode of care and to complete the Picker Inpatient Survey questionnaire on specific aspects of their care.
Sample: Patients aged 18 and over presenting at five hospitals within one NHS trust in Scotland.
Method: 3592 questionnaires were mailed to patients' homes within 1 month of discharge from hospital during a 12 month period. Two reminders were sent to non-responders; 2249 (65%) questionnaires were returned.
Results: Almost 90% of respondents indicated that they were satisfied with their period of inpatient care. Age and overall self-assessed health were only weakly associated with satisfaction. A multiple linear regression indicated that the major determinants of patient satisfaction were physical comfort, emotional support, and respect for patient preferences. However, many patients who reported their satisfaction with the care they received also indicated problems with their inpatient care as measured on the Picker Inpatient Survey; 55% of respondents who rated their inpatient episode as "excellent" indicated problems on 10% of the issues measured on the Picker questionnaire.
Discussion: The evidence suggests that patient satisfaction scores present a limited and optimistic picture. Detailed questions about specific aspects of patients' experiences are likely to be more useful for monitoring the performance of various hospital departments and wards and could point to ways in which delivery of health care could be improved.
doi:10.1136/qhc.11.4.335
PMCID: PMC1757991  PMID: 12468693
20.  Assessing the safety attitudes questionnaire (SAQ), German language version in Swiss university hospitals - a validation study 
Background
Improving patient safety has become a major focus of clinical care and research over the past two decades. An institution’s patient safety climate represents an essential component of ensuring a safe environment and thereby can be vital to the prevention of adverse events. Covering six patient safety related factors, the Safety Attitudes Questionnaire (SAQ) is a validated and widely used instrument to measure the patient safety climate in clinical areas. The objective of this study was to assess the psychometric properties of the German language version of the SAQ.
Methods
A survey was carried out in two University Hospitals in Switzerland in autumn 2009 where the SAQ was distributed to a sample of 406 nurses and physicians in medical and surgical wards. Following the American Educational Research Association guidelines, we tested the questionnaire validity by levels of evidence: content validity, internal structure and relations to other variables. Confirmatory factor analysis was used to examine factor structure. Cronbach’s alphas and inter-item correlations were calculated to examine internal consistency reliability.
Results
A total of 319 questionnaires were completed representing an overall response rate of 78.6%. For three items, the item content validity index was <0.75. Confirmatory factor analysis showed acceptable model fit (RMSEA = 0.045; CFI = 0.944) for the six-factor model. Additional exploratory factor analysis could not identify a better factor model. SAQ factor scores showed positive correlations with the Safety Organizing Scale (r = .56 - .72). The SAQ German version showed moderate to strong internal consistency reliability indices (Cronbach alpha = .65 - .83).
Conclusions
The German language version of the SAQ demonstrated acceptable to good psychometric properties and therefore shows promise to be a sound instrument to measure patient safety climate in Swiss hospital wards. However, the low item content validity and large number of missing responses for several items suggest that improvements and adaptations in translation are required for select items, especially within the perception of management scale. Following these revisions, psychometric properties should reassessed in a randomly selected sample and hospitals and departments prior to use in Swiss hospital settings.
doi:10.1186/1472-6963-13-347
PMCID: PMC3846625  PMID: 24016183
Safety attitudes questionnaire (SAQ); Patient safety; Psychometrics; Swiss hospital setting
21.  The association of access to medical care with regular source of care and sociodemographic characteristics in patients with HIV and tuberculosis. 
PURPOSE: To examine satisfaction with access to health care in two populations, one with HIV and one with TB, and examine the effect of having a regular doctor and sociodemographic characteristics. DESIGN: Cross-Sectional survey. PATIENTS: A sample of HIV inpatients hospitalized at seven Los Angeles sites (N = 217) and TB outpatients chosen randomly from the Los Angeles County TB Registry Census (N = 313). ANALYSIS: We performed bivariate and multivariate regression analyses of satisfaction with access to care on gender, race/ethnicity, age, education, income, insurance, and having a regular doctor. MAIN OUTCOME MEASURES: A six-item scale of satisfaction with access to care (range 0-100; Cronbach's alpha 0.87). RESULTS: The mean satisfaction with access score for the HIV sample was significantly lower than the TB sample (53.5 vs. 61.2, p<0.001). The HIV sample multivariate analysis (including all the variables) showed that increasing age (p<0.021 and having a regular doctor (p<0.002) were associated with better access, and that low income (p<0.005) was associated with poor access. In the TB sample analysis, only increasing age was associated with better satisfaction with access to care (p< 0.01). CONCLUSION: HIV patients receiving care in the private sector reported less satisfaction with access to care compared to TB patients receiving care in the public health sector. The traditional factors of socio-economic status and having a regular doctor were associated with satisfaction with access-to-care in the HIV sample but not the TB sample. Our findings suggest that certain characteristics of the TB public health programs may explain these differences and suggests that, perhaps, the existence of a similar public health program for vulnerable low-income populations with HIV would improve their satisfaction with access, as well.
PMCID: PMC2594297  PMID: 12126284
22.  Properties of a short questionnaire for assessing Primary Care experiences for children in a population survey 
BMC Public Health  2011;11:285.
Background
The Primary Care Assessment Tool (PCAT) is an interesting set of tools for primary care research. A very short version could inform policy makers about consumer experiences with primary care (PC) through health surveys. This work aimed to investigate the validity and reliability of a selection of items from the child short edition (CS) of the PCAT.
Methods
A 24 item questionnaire permitted the identification of a regular source of care and the assessment of the key attributes of first contact, ongoing care over time, coordination, services available and services received (comprehensiveness), and cultural competence. Structural validity, reliability, and construct validity were assessed using responses from 2,200 parents of a representative sample of the population aged 0 to 14 years in Catalonia (Spain) who participated in the 2006 Health Survey. Structural validity was analyzed using exploratory and confirmatory factor analyses and reliability was assessed using Cronbach's alpha. Construct validity was assessed using linear regression analysis between PC experience scores and a measure of overall user satisfaction with healthcare services.
Results
A total of 2,095 (95.2%) parents provided useable responses on PC. After Confirmatory Factor Analysis (CFA), the best fitting model was a 5-factor model in which the original dimensions of first contact and ongoing care were collapsed into one. The CFA also showed a second order factor onto which all domains except services available loaded (root mean square error of approximation = 0.000; comparative fit index = 1.00). Cronbach's alpha values for one of the original scales (first-contact) was poor (alpha < 0.50), but improved using the modified factor structure (alpha > 0.70). Scores on the scales were correlated with satisfaction with healthcare services (p < 0.01), thereby providing some preliminary evidence of construct validity.
Conclusions
This very short questionnaire obtained from the PCAT-CE yields information about five attributes of PC and a summary score. It has shown evidence of validity and reliability for judgments about experiences with primary care overall. If space on surveys is at a premium, the instrument could be useful as a measure of PC experiences.
doi:10.1186/1471-2458-11-285
PMCID: PMC3103459  PMID: 21554717
23.  Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and Meta-Analysis—Critical Appraisal and Commentary 
Journal of Athletic Training  2011;46(1):103-106.
Abstract
Reference/Citation:
Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396–412.
Clinical Question:
Among patients with or at risk for musculoskeletal overuse conditions, (1) do foot orthoses provide clinically meaningful improvements, and (2) are foot orthoses cost-effective?
Data Sources:
Studies published through September 28, 2005, were identified by using MEDLINE, EMBASE, CINAHL and Pre-CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, SPORTDiscus, Biological Abstracts, Web of Science, Allied Health and Complementary Medicine Database, and the full Cochrane Library. The authors did not provide the search strategy used. Reference lists of included randomized controlled trials (RCTs) and identified systematic reviews were searched by hand.
Study Selection:
Studies were included if (1) they were RCTs that included the use of foot orthoses (either custom or prefabricated) in 1 of the intervention groups, (2) the clinical problem was an overuse condition as defined by the American College of Foot and Ankle Orthopedics and Medicine guidelines for which foot orthoses were recommended, and (3) at least 1 clinically relevant outcome was measured for a minimum of 1 week. Limits were not placed on year of publication, status of publication, or language.
Data Extraction:
The journal, authors, and author affiliations of included RCTs were masked from 2 of the reviewers who independently assessed the included RCTs for methodologic quality using a modified PEDro scale plus 3 additional items (justification of sample size, use of outcome measures with known validity and reliability, and reporting of adverse or side effects). Disagreements on methodologic quality were resolved with consensus or by a third reviewer. The effect sizes for the included RCTs were represented by relative risk (RR) for dichotomous outcomes and standardized mean difference (SMD) for continuous data. Confidence intervals (CIs) were reported for RR and SMD. Study data were extracted directly from each of the included studies. If provided, data from intention-to-treat analysis were extracted. Study authors were contacted when insufficient data were reported. A meta-analysis (random-effects model) was conducted using Review Manager (version 4.2; The Nordic Cochrane Centre, Copenhagen, Denmark).
Main Results:
The search identified 3192 potentially relevant studies. Full articles were retrieved for 327 studies. Twenty-two of the 327 studies met the inclusion criteria. Because the authors of 1 study used the same methods to report on 2 populations, a total of 23 RCTs were included in the systematic review. Prevention of lower limb overuse conditions with the use of foot orthoses was reported in 8 RCTs (7 studies). The effect of foot orthoses in the treatment of lower limb overuse conditions was reported in 15 RCTs. Of the 23 RCTs, the cost-effectiveness of foot orthoses was reported in 2 and the adverse effects of foot orthoses were reported in 8. Across the prevention RCTs, data were available for analysis for a range of 47 to 417 participants with 8 to 16 weeks of follow-up. Based on 4 RCTs in which the researchers examined prevention of lower limb overuse conditions with foot orthoses versus control in military personnel, the RR was 1.49 (95% CI  =  1.07, 2.08). A clinically beneficial effect size was set a priori at 1.5 or greater for the foot-orthoses group or at 0.7 or less for the comparison group. Based on 2 RCTs reported in 1 study of the use of custom versus prefabricated foot orthoses for prevention of lower limb overuse conditions, no significant difference in risk was found (RR  =  1.14, 95% CI  =  0.90, 1.44). In their calculating and reporting of RR, the authors do not appear to have followed convention. Across the treatment RCTs, data were available for analysis for a range of 18 to 133 participants with 8 to 52 weeks of follow-up. The authors of the treatment RCTs reported a variety of outcome measures. Two of these, patient-perceived treatment effect (PPE) and pain on the visual analog scale (VAS), were used to calculate an overall treatment effect (PPE as RR and VAS as SMD). Based on 2 RCTs examining foot orthoses versus control, no significant difference in PPE was found (RR  =  1.01, 95% CI  =  0.61, 1.68). Based on 2 RCTs in which custom versus prefabricated foot orthoses were examined, no significant difference in PPE was found (RR  =  0.88, 95% CI  =  0.42, 1.81). The VAS data reported in the text appear to contradict the VAS data reported in Figure 2 for foot orthoses versus control for the treatment of lower limb overuse conditions. Specifically, the lower limit of the CI in the text was negative (−0.28) and in Figure 2 was positive. Because of this apparent contradiction, we did not interpret these data. Authors of 2 RCTs reported cost-effectiveness, but the data could not be pooled. Adverse events were reported in 8 of the 22 studies. The most common adverse effect reported was discomfort, which was the main reason for discontinuing foot-orthoses use in 2 studies.
Conclusions:
The evidence supports the use of foot orthoses to prevent a first occurrence of lower limb overuse conditions and shows no difference between custom and prefabricated foot orthoses. The evidence was insufficient to recommend foot orthoses (custom or prefabricated) for the treatment of lower limb overuse conditions.
doi:10.4085/1062-6050-46.1.103
PMCID: PMC3017481  PMID: 21214358
overuse injuries; foot orthotics
24.  National survey focusing on the crucial information needs of intensive care charge nurses and intensivists: same goal, different demands 
Background
Although information technology adequately supports clinical care in many intensive care units (ICUs), it provides much poorer support for the managerial information needed to coordinate multi-professional care. To gain a general view of the most crucial multi-professional information needs of ICU shift leaders a national survey was conducted, focusing on the information needs of charge nurses and intensivists.
Methods
Based on our previous observation study an online survey was developed, containing 122 information need statements related to the decision-making of ICU shift leaders. Information need statements were divided into six dimensions: patient admission, organisation and management of work, allocation of staff and material resources, special treatments, and patient discharge. This survey involved all ICU shift leaders (n = 738) who worked in any of the 17 highest level ICUs for adults in university hospitals in Finland during the autumn of 2009. Both charge nurses’ and intensivists’ crucial information needs for care coordination were evaluated.
Results
Two hundred and fifty-seven (50%) charge nurses and 96 (43%) intensivists responded to the survey. The consistency of the survey was found to be good (Cronbach’s α scores between .87–.97, with a total explanatory power of 64.53%). Altogether, 57 crucial information needs for care coordination were found; 22 of which were shared between shift leaders. The most crucial of these information needs were related to organisation and management, patient admission, and allocation of staff resources. The associations between working experience, or shift leader acting frequencies, and crucial information needs were not statistically significant. However, a statistically significant difference was found between the number of ICU beds and the ICU experience of charge nurses with information needs, under the dimension of organisation and management of work. The information needs of charge nurses and intensivists differed. Charge nurses’ information needs related to care coordination, were more varied, and concerned issues at a unit level, whereas intensivists focused on direct patient care.
Conclusions
The reliability and validity of our survey was found to be good. Our study findings show that care coordination at an ICU is a collaborative process among ICU shift leaders with multiprofessional information needs related to organisation and management, patient admission, and allocation of staff resources. Study findings can be used to identify the most crucial information needs of ICU shift leaders when new information technology is developed to support managerial decision-making during care coordination.
doi:10.1186/1472-6947-13-15
PMCID: PMC3564892  PMID: 23360245
25.  Cross-cultural Validation of a Patient Satisfaction with Interpersonal Relationship with Navigator Measure: A Multi-site Patient Navigation Research Study. 
Psycho-oncology  2011;21(12):1309-1315.
Background
Patient Navigators are trained to help patients effectively access and utilize healthcare resources to facilitate timely completion of cancer screening and recommended treatment. Patient navigators provide logistic, instrumental and psychosocial support to cancer patients. Yet, studies that examine patient-navigator relationships are lacking.
Objective
To validate a Spanish version of the Patient Satisfaction with Interpersonal Relationship with Navigator (PSN-I-Sp).
Methods
We translated and back translated the English Patient Satisfaction with Navigator Interpersonal measure in Spanish and administered the resulting PSN-I-Sp to 165 Spanish fluent participants. Then, we conducted psychometric validation of the PSN-I-Sp using principal components analysis (PCA) for latent structural evaluation, Cronbach coefficient alpha (α) for internal consistency, and correlation analyses to examine divergence and convergence of the PSN-I-Sp with the Patient Satisfaction with Cancer-Related Care-Spanish (PSCC-Sp), the Rapid Estimate of Adult Literacy in Medicine (REALM) Long Form, and patients’ demographics.
Results
The PCA revealed a one-dimensional PSN-I-Sp measure explaining 85% of the variance. Reliability assessment revealed high internal consistency (α = 0.98). The PSN-I-Sp had good face validity, and demonstrated appropriate convergent and divergent validity as indicated by moderate correlation with score on the PSCC (all ps < 0.0001) and non-statistically significant correlations with primary language, marital status, and scores on the REALM-Long Form (all ps > 0.05).
Conclusion
The PSN-I is a valid and suitable measure of satisfaction with a patient navigator for the persons who preferred language is Spanish.
doi:10.1002/pon.2018
PMCID: PMC3634567  PMID: 21726018

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