Practical methods for dealing with 'not applicable' item responses in the AMC Linear Disability Score project

Background:\ud Whenever questionnaires are used to collect data on constructs, such as functional status or health related quality of life, it is unlikely that all respondents will respond to all items. This paper examines ways of dealing with responses in a 'not applicable' category to items included in the AMC Linear Disability Score (ALDS) project item bank. \ud \ud Methods:\ud The data examined in this paper come from the responses of 392 respondents to 32 items and form part of the calibration sample for the ALDS item bank. The data are analysed using the one-parameter logistic item response theory model. The four practical strategies for dealing with this type of response are: cold deck imputation; hot deck imputation; treating the missing responses as if these items had never been offered to those individual patients; and using a model which takes account of the 'tendency to respond to items'. \ud \ud Results:\ud The item and respondent population parameter estimates were very similar for the strategies involving hot deck imputation; treating the missing responses as if these items had never been offered to those individual patients; and using a model which takes account of the 'tendency to respond to items'. The estimates obtained using the cold deck imputation method were substantially different. \ud \ud Conclusions:\ud The cold deck imputation method was not considered suitable for use in the ALDS item bank. The other three methods described can be usefully implemented in the ALDS item bank, depending on the purpose of the data analysis to be carried out. These three methods may be useful for other data sets examining similar constructs, when item response theory based methods are used

Key factors in children's competence to consent to clinical research

Background: Although law is established on a strong presumption that persons younger than a certain age are not competent to consent, statutory age limits for asking children's consent to clinical research differ widely internationally. From a clinical perspective, competence is assumed to involve many factors including the developmental stage, the influence of parents and peers, and life experience. We examined potential determining factors for children's competence to consent to clinical research and to what extent they explain the variation in competence judgments. Methods: From January 1, 2012 through January 1, 2014, pediatric patients aged 6 to 18 years, eligible for clinical research studies were enrolled prospectively at various in- and outpatient pediatric departments. Children's competence to consent was assessed by MacArthur Competence Assessment Tool for Clinical Research. Potential determining child variables included age, gender, intelligence, disease experience, ethnicity and socio-economic status (SES). We used logistic regression analysis and change in explained variance in competence judgments to quantify the contribution of a child variable to the total explained variance. Contextual factors included risk and complexity of the decision to participate, parental competence judgment and the child's or parents decision to participate. Results: Out of 209 eligible patients, 161 were included (mean age, 10.6 years, 47.2 % male). Age, SES, intelligence, ethnicity, complexity, parental competence judgment and trial participation were univariately associated with competence (P∈∈0.05). Conclusions: Age is the factor that explaines most of to the variance in children's competence to consent, followed by intelligence. Experience with disease did not affect competence in this study, nor did other variables. Clinical trial registration: Development and use of a standardized instrument for assessing children's competence to consent in drug trials: Are legally established age limits valid?, NTR3918

Responsiveness: a reinvention of the wheel?

BACKGROUND: Since the mid eighties, responsiveness is considered to be a separate property of health status questionnaires distinct from reliability and validity. The aim of the study was to assess the strength of the relationship between internal consistency reliability, referring to an instrument's sensitivity to differences in health status among subjects at one point in time, and responsiveness referring to sensitivity to health status changes over time. METHODS: We used three different datasets comprising the scores of patients on the Barthel, the SIP and the GO-QoL instruments at two points in time. The internal consistency was reduced stepwise by removing the item that contributed most to a scale's reliability. We calculated the responsiveness expressed by the Standardized Response Mean (SRM) on each set of remaining items. The strength of the relationship between the thus obtained internal consistency coefficients and SRMs was quantified by Spearman rank correlation coefficients. RESULTS: Strong to perfect correlations (0.90 – 1.00) was found between internal consistency coefficients and SRMs for all instruments indicating, that the two can be used interchangeably. CONCLUSION: The results contradict the conviction that responsiveness is a separate psychometric property. The internal consistency coefficient adequately reflects an instrument's potential sensitivity to changes over time

The AMC Linear Disability Score project in a population requiring residential care: psychometric properties

BACKGROUND: Currently there is a lot of interest in the flexible framework offered by item banks for measuring patient relevant outcomes, including functional status. However, there are few item banks, which have been developed to quantify functional status, as expressed by the ability to perform activities of daily life. METHOD: This paper examines the psychometric properties of the AMC Linear Disability Score (ALDS) project item bank using an item response theory model and full information factor analysis. Data were collected from 555 respondents on a total of 160 items. RESULTS: Following the analysis, 79 items remained in the item bank. The remaining 81 items were excluded because of: difficulties in presentation (1 item); low levels of variation in response pattern (28 items); significant differences in measurement characteristics for males and females or for respondents under or over 85 years old (26 items); or lack of model fit to the data at item level (26 items). CONCLUSIONS: It is conceivable that the item bank will have different measurement characteristics for other patient or demographic populations. However, these results indicate that the ALDS item bank has sound psychometric properties for respondents in residential care settings and could form a stable base for measuring functional status in a range of situations, including the implementation of computerised adaptive testing of functional status

Multidimensional treatment foster care for preschoolers: early findings of an implementation in the Netherlands

Multidimensional Treatment Foster Care (MTFC) has been shown to be an evidence based alternative to residential rearing and an effective method to improve behavior and attachment of preschool foster children in the US. This preliminary study investigated an application of MTFC for preschoolers (MTFC-P) in the Netherlands focusing on behavioral outcomes in course of the intervention. To examine the following hypothesis: “the time in the MTFC-P intervention predicts a decline in problem behavior, as this is the desired outcome for children assigned to MTFC-P”, we assessed the daily occurrence of 38 problem behaviors via telephone interviews. Repeated measures revealed significant reduced problem behavior in course of the program. MTFC-P promises to be a treatment model suitable for high-risk foster children, that is transferable across centres and countries

The Academic Medical Center Linear Disability Score (ALDS) item bank: item response theory analysis in a mixed patient population

BACKGROUND: Currently, there is a lot of interest in the flexible framework offered by item banks for measuring patient relevant outcomes. However, there are few item banks, which have been developed to quantify functional status, as expressed by the ability to perform activities of daily life. This paper examines the measurement properties of the Academic Medical Center linear disability score item bank in a mixed population. METHODS: This paper uses item response theory to analyse data on 115 of 170 items from a total of 1002 respondents. These were: 551 (55%) residents of supported housing, residential care or nursing homes; 235 (23%) patients with chronic pain; 127 (13%) inpatients on a neurology ward following a stroke; and 89 (9%) patients suffering from Parkinson's disease. RESULTS: Of the 170 items, 115 were judged to be clinically relevant. Of these 115 items, 77 were retained in the item bank following the item response theory analysis. Of the 38 items that were excluded from the item bank, 24 had either been presented to fewer than 200 respondents or had fewer than 10% or more than 90% of responses in the category 'can carry out'. A further 11 items had different measurement properties for younger and older or for male and female respondents. Finally, 3 items were excluded because the item response theory model did not fit the data. CONCLUSION: The Academic Medical Center linear disability score item bank has promising measurement characteristics for the mixed patient population described in this paper. Further studies will be needed to examine the measurement properties of the item bank in other populations

Emergency department crowding in The Netherlands: managers’ experiences

__Abstract__ __Background__ In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding. __Methods__ A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow. __Results__ Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using a fasttrack with treatment of patients by trained nurse practitioners. __Conclusions__ Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding

Feasibility of an Assessment Tool for Children\u27s Competence to Consent to Predictive Genetic Testing: a Pilot Study

Knowledge on children\u27s capacities to consent to medical treatment is limited. Also, age limits for asking children\u27s consent vary considerably between countries. Decision-making on predictive genetic testing (PGT) is especially complicated, considering the ongoing ethical debate. In order to examine just age limits for alleged competence to consent in children, we evaluated feasibility of a standardized assessment tool, and investigated cutoff ages for children\u27s competence to consent to PGT. We performed a pilot study, including 17 pediatric outpatients between 6 and 18 years at risk for an autosomal dominantly inherited cardiac disease, eligible for predictive genetic testing. The reference standard for competence was established by experts trained in the relevant criteria for competent decision-making. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) served as index test. Data analysis included raw agreement between competence classifications, difference in mean ages between children judged competent and judged incompetent, and estimation of cutoff ages for judgments of competence. Twelve (71 %) children were considered competent by the reference standard, and 16 (94 %) by the MacCAT-T, with an overall agreement of 76 %. The expert judgments disagreed in most cases, while the MacCAT-T judgments agreed in 65 %. Mean age of children judged incompetent was 9.3 years and of children judged competent 12.1 years (p = .035). With 90 % sensitivity, children younger than 10.0 years were judged incompetent, with 90 % specificity children older than 11.8 years were judged competent. Feasibility of the MacCAT-T in children is confirmed. Initial findings on age cutoffs are indicative for children between the age of 12 and 18 to be judged competent for involvement in the informed consent process. Future research on appropriate age-limits for children\u27s alleged competence to consent is needed

Stochastic integrals for spde’s: A comparison

AbstractWe present the Walsh theory of stochastic integrals with respect to martingale measures, and various extensions of this theory, alongside of the Da Prato and Zabczyk theory of stochastic integrals with respect to Hilbert-space-valued Wiener processes, and we explore the links between these theories. Somewhat surprisingly, the end results of both theories turn out to be essentially equivalent. We then show how each theory can be used to study stochastic partial differential equations, with an emphasis on the stochastic heat and wave equations driven by spatially homogeneous Gaussian noise that is white in time. We compare the solutions produced by the different theories

Development and Validation of the EBP-Affinity Questionnaire:A Mixed-Method Study

Background: Implementation of evidence-based practice (EBP) in nursing homes is important to improve quality of care and reduce costs. These facilities primarily employ certified nurse assistants (CNAs) and vocationally-trained registered nurses (VTRNs). Although EBP is scarcely addressed in their education, these caregivers have an important role in EBP. Insight into their affinity with EBP could provide a good starting point for working according to EBP. Aims: To develop a questionnaire that measures affinity with EBP amongst CNAs and VTRNs in nursing homes. To assess the reliability and validity of the questionnaire. Design: Mixed-method design according to the COSMIN-checklist. Methods: Phase 1: the questionnaire was developed in three steps: (1) gathering items from existing questionnaires, occupational profiles and interviews; (2) compression through consensus rounds and (3) a pilot study. Phase 2: psychometric properties were assessed amongst CNAs and VTRNs in nine nursing homes. The factors extracted through principal component analysis were tested for measurement invariance using the one-parameter Rasch model. Results: Phase 1: all experts interviewed (N = 5) indicated CNAs and VTRNs can play specific and significant roles in EBP. A 26-item questionnaire was created through two consensus rounds with experts (N = 7) and a pilot study (N = 7). Phase 2: Principal component analysis revealed a two-factor structure with good internal reliability (N = 428 questionnaires). All items exhibited good fit with the Rasch model and measurement invariance for CNAs and VTRNs. Conclusion: CNAs and VTRNs can fulfil important roles in EBP in nursing homes. The ‘Evidence-Based Practice-Affinity Questionnaire’ is reliable and valid for assessing affinity with EBP amongst CNAs and VTRNs to improve practice and research, and can guide tailored training programs for CNAs and VTRNs, enhancing evidence-based practices in nursing homes. Impact: The research provides insight into the roles CNAs and VTRNs can play in EBP and how to measure their affinity with EBP, which contributes to implementation of EBP in nursing homes. Patient or Public Contribution: No patient or public contribution in the study.</p