Association of day-case rates with post COVID-19 recovery of elective laparoscopic cholecystectomy activity across England.

INTRODUCTION: The aim of this study was to investigate the safety of day-case laparoscopic cholecystectomy, and the association between day-case rates and, post the COVID-19 pandemic, recovery of activity to prepandemic levels for integrated care boards (ICBs) in England. METHODS: This was a retrospective observational study of the Hospital Episodes Statistics (HES) data set. Elective laparoscopic cholecystectomies for the period 1 January 2019 to 31 December 2022 were identified. Activity levels for 2022 were compared with those for the whole of 2019 (baseline). Day-case activity was identified where the length of stay recorded in the HES was zero days. RESULTS: Data were available for 184,252 patients across the 42 ICBs in England, of which 120,408 (65.3%) were day-case procedures. By December 2022, activity levels for the whole of England had returned to 88.2% of prepandemic levels. The South West region stood out as having recovered activity levels to the greatest extent, with activity at 97.3% of prepandemic levels during 2022. The South West also had the highest postpandemic day-case rate at 74.9% of all patients seen as a day-case during 2022; this compares with an England average of 65.3%. At an ICB level, there was a significant correlation between day-case rates and postpandemic activity levels (r = 0.362, p = 0.019). There was no strong or consistent evidence that day-case surgery had poorer patient outcomes than inpatient surgery. CONCLUSIONS: Recovery of elective laparoscopic cholecystectomy activity has been better in South West England than in other regions. Increasing day-case rates may be important if ICBs in other regions are to increase activity levels up to and beyond prepandemic levels.

Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data.

PURPOSE: Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery have to stay in hospital for at least one night. The aim of this study was to identify the factors associated with conversion from day-case to in-patient management for elective inguinal hernia repair surgery. METHODS: This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified. The exposure of interest was discharged on the day of admission (day-case) or requiring overnight stay. The primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level. RESULTS: A total of 351,528 planned day-case elective primary inguinal hernia repairs were identified over the eight-year study period. Of these, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and be operated on by a low-annual volume surgeon. Post-procedural complications were strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 3.3% to 21.3%. CONCLUSIONS: There was considerable variation in conversion to in-patient stay rates for inguinal hernia repair across ICBs in England. Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates.

Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint.

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes.

PURPOSE: Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, in England there is evidence of wide variation in day-case rates across hospitals. Reducing the extent of this variation has the potential to support more efficient use of resources (e.g., clinician time, hospital beds) and help the recovery of elective surgical activity following the COVID-19 pandemic. The aims of this study were to explore the extent of variation in day-case rates across healthcare providers in England and to evaluate the safety of day-case elective primary inguinal hernia repair surgery. METHODS: This was an exploratory, retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 were identified. The exposure of interest was day-case or in-patient stay, and the primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level. RESULTS: A total of 413,059 elective primary inguinal hernia repairs were identified over the 8-year study period. Of these, 326,833 (79.1%) were day-case procedures. During the most recent financial year (2021-22), the highest day-case rate for an ICB was 93.8% and the lowest 66.1%. After adjusting for covariates, day-case surgery was associated with significantly lower rates of 30-day emergency readmission (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.58-0.64, p < 0.001) and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge. Rates of 30-day emergency readmission were significantly lower in ICBs with high rates of day-case surgery (OR 0.84, 95% CI 0.74-0.96, p < 0.001) than in ICBs with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates (OR 1.20, 95% CI 1.04-1.40, p = 0.015). CONCLUSIONS: For the outcomes studied, we found no consistent evidence that day-case elective inguinal hernia repair was unsafe for selected patients. Currently, there is substantial variation between ICBs in terms of delivering day-case surgery. Reducing this variability may help address the current pressures on the NHS in elective surgery.

Social Participation's Association with Falls and Frailty in Malaysia: A Cross-Sectional Study.

BACKGROUND: The global population is ageing rapidly, with the most dramatic increases in developing countries like Malaysia. Older people are at increased risk of multimorbidity, frailty and falls. OBJECTIVES: In this study we aimed to determine the relationship between social participation, frailty and falls in Malaysia. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study of individuals aged 55 years and above selected from the electoral rolls of three Klang Valley parliamentary constituencies through stratified random sampling. They were invited to take part in a questionnaire and physical assessment as part of the Malaysian Elders Longitudinal Research (MELoR) study. MEASUREMENTS: Fallers were individuals who had fallen in the previous year. Frailty was defined as meeting ≥3 of: low body mass index, reduced cognition, low physical activity, low hand-grip strength, and slow walking speed. Social participation was determined from employment status, social network, and community activity. Binomial logistic regression multivariant analysis was performed to identify links between the measures of social participation and falls and frailty. RESULTS: The mean age of the 1383 participants was 68.5 years, with 57.1% female. Within the population, 22.9% were fallers and 9.3% were frail. Social isolation (OR= 2.119; 95% CI=1.351-3.324), and non-engagement in community activities (OR=2.548; 95% CI=1.107-5.865) were associated with increased frailty. Falls increased with social isolation (OR=1.327; 95% CI=1.004-1.754). CONCLUSIONS: Previous studies have shown social participation to be linked to frailty and falls risk, and social isolation to be a predictor of falls. In this study frailty was associated with all three social participation measures and history of falls was associated with social isolation.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme.

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Volume-outcome relationship for adrenalectomy: analysis of an administrative dataset for the Getting It Right First Time Programme.

BACKGROUND: A minimum volume threshold of at least six procedures per annum per surgeon has been set in UK and European guidelines for adrenal surgery. The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume. METHODS: Data were extracted from the Hospital Episodes Statistics database for England. A 6-year period (January 2013 to December 2018 inclusive) for all adult admissions for unilateral adrenal surgery was used. The primary outcome measure was an emergency readmission within 30 days of discharge following surgery. Procedures were categorized as open or minimally invasive surgery for analysis. Multilevel modelling was used to adjust for hierarchy and potential confounders. RESULTS: Data for 4189 adrenalectomies were identified. Only one third of surgeons (who operated on just over a half of all patients) performed at least six procedures in the year prior to the index procedure. For open surgery, emergency readmission rates fell significantly from 15.2 to 6.4 per cent for surgeons and from 13.2 to 6.1 per cent for trusts between the lowest- and highest-volume categories. Significant, but less dramatic falls were also seen for minimally invasive surgery. CONCLUSION: A volume-outcome effect was identified for adrenal surgery in England. Minimum volume thresholds should be set, although these may need to be more ambitious than the current threshold if outcomes are to be optimized. LAY SUMMARY: Surgery for disease of the adrenal gland can be complex. In many cases the skill and experience of the surgeon and the wider surgical team is thought to be important in determining the success of the procedure. The relative rarity of adrenal surgery means that there is little evidence to support this view. This study looked at outcomes for all 4189 patients who underwent adrenal surgery in England over a 6-year period. There was evidence that outcomes were better for patents when the surgeon and hospital trust had performed a larger number of adrenal surgery procedures in the year prior to the procedure. This was, however, dependent on which patient outcomes were studied and the type of procedure. These findings will inform the ongoing debate as to whether adrenal surgery in England should only be performed in regional centres by experienced teams.

Surgery for disease of the adrenal gland can be complex. In many cases the skill and experience of the surgeon and the wider surgical team is thought to be important in determining the success of the procedure. The relative rarity of adrenal surgery means that there is little evidence to support this view. This study looked at outcomes for all 4189 patients who underwent adrenal surgery in England over a 6-year period. There was evidence that outcomes were better for patents when the surgeon and hospital trust had performed a larger number of adrenal surgery procedures in the year prior to the procedure. This was, however, dependent on which patient outcomes were studied and the type of procedure. These findings will inform the ongoing debate as to whether adrenal surgery in England should only be performed in regional centres by experienced teams.

Can elective surgery for mandibular and zygomatic complex fractures reduce overall hospital stay without compromising outcomes? Analysis of administrative datasets by the GIRFT programme.

When patients attend the emergency department with facial fractures that require surgery and are immediately admitted, surgery can be delayed as theatre time is prioritised for other more urgent patients. One solution is to send the patient home and admit them as an elective patient at a later date. The aim of this study was to investigate the outcomes of patients admitted directly and those seen as elective patients following fracture of the mandible or zygomatic complex. Data were taken from the hospital episodes statistics (HES) dataset for 2011-2018, and all hospital admissions for mandibular and zygomatic complex fractures within the National Health Service (NHS) in England were extracted. Patients were categorised as those admitted on attendance at the emergency department and given definitive treatment during the admission, and those not admitted on attendance at the emergency department but discharged home and seen as elective admissions within 30 days of attendance. Data were available for 39 606 patients. For both types of fracture there was substantial variation between NHS trusts in the proportion of patients admitted electively and the proportion admitted directly as emergencies. Elective admission was independently associated with shorter overall stay and lower emergency readmission rates. We found no evidence that delays to definitive surgery through elective admission had a negative impact on emergency readmission rates. Patients admitted electively had a significantly shorter hospital stay.

Identification of delirium and dementia in older medical inpatients in Tanzania: A comparison of screening and diagnostic methods.

BACKGROUND: In sub-Saharan Africa, there are no validated screening tools for delirium in older adults. This study assesses clinical utility of two instruments, the IDEA cognitive screen and the Confusion Assessment Method (CAM) for identification of delirium in older adults admitted to medical wards of a tertiary referral hospital in Tanzania. METHOD: The IDEA cognitive screen and CAM were administered to a consecutive cohort of older individuals on admission to Kilimanjaro Christian Medical Centre using a blinded protocol. Consensus diagnosis for delirium was established against DSM-5 criteria and dementia by DSM-IV criteria. RESULTS: Of 507 admission assessments, 95 (18.7%) had DSM-5 delirium and 95 (18.7%) had DSM-IV dementia (33 (6.5%) delirium superimposed on dementia). The CAM and IDEA cognitive screen had very good diagnostic accuracy for delirium (AUROC curve 0.94 and 0.87 respectively). However, a number of participants (10.5% and 16.4% respectively) were unable to complete these screening assessments due to reduced consciousness, or other causes of reduced verbal response and were excluded from this analysis; many of whom met DSM-5 criteria for delirium. Secondary analysis suggests that selected cognitive and observational items from the CAM and IDEA cognitive screen may be as effective as the full screening tools in identifying delirium even in unresponsive patients. CONCLUSION: Both instruments appeared useful for delirium screening in this inpatient setting, but had significant limitations. The combination of assessment items identified may form the basis of a brief, simple delirium screening tool suitable for use by non-specialist clinicians. Further development work is needed.

Deriving an optimal threshold of waist circumference for detecting cardiometabolic risk in sub-Saharan Africa.

BACKGROUND: Waist circumference (WC) thresholds derived from western populations continue to be used in sub-Saharan Africa (SSA) despite increasing evidence of ethnic variation in the association between adiposity and cardiometabolic disease and availability of data from African populations. We aimed to derive a SSA-specific optimal WC cut-point for identifying individuals at increased cardiometabolic risk. METHODS: We used individual level cross-sectional data on 24 181 participants aged ⩾15 years from 17 studies conducted between 1990 and 2014 in eight countries in SSA. Receiver operating characteristic curves were used to derive optimal WC cut-points for detecting the presence of at least two components of metabolic syndrome (MS), excluding WC. RESULTS: The optimal WC cut-point was 81.2 cm (95% CI 78.5-83.8 cm) and 81.0 cm (95% CI 79.2-82.8 cm) for men and women, respectively, with comparable accuracy in men and women. Sensitivity was higher in women (64%, 95% CI 63-65) than in men (53%, 95% CI 51-55), and increased with the prevalence of obesity. Having WC above the derived cut-point was associated with a twofold probability of having at least two components of MS (age-adjusted odds ratio 2.6, 95% CI 2.4-2.9, for men and 2.2, 95% CI 2.0-2.3, for women). CONCLUSION: The optimal WC cut-point for identifying men at increased cardiometabolic risk is lower (⩾81.2 cm) than current guidelines (⩾94.0 cm) recommend, and similar to that in women in SSA. Prospective studies are needed to confirm these cut-points based on cardiometabolic outcomes.International Journal of Obesity advance online publication, 31 October 2017; doi:10.1038/ijo.2017.240.

Case-fatality and disability in the Tanzanian Stroke Incidence Project cohort.

OBJECTIVES: The burden of stroke on healthcare services in sub-Saharan Africa (SSA) is increasing. However, long-term outcomes from stroke in SSA are not well described. We aimed to investigate case-fatality and health outcomes for stroke survivors at 7- to 10-year follow-up. MATERIALS AND METHODS: The Tanzanian Stroke Incidence Project (TSIP) recruited incidence stroke cases between 2003 and 2006. We followed up cases in 2013, recording date of death in those who had died. RESULTS: Of 130 stroke cases included in this study, case-fatality and date of death data were available for 124 at 7-10 years post-stroke. Of these, 102 (82.3%) had died by 7 years post-stroke. Functional disability, as measured by the Barthel index immediately post-stroke, was a significant predictor of case-fatality at seven-year follow-up with those with severe disability having an almost four-fold increase in the odds of death compared with those with no, mild or moderate disability. CONCLUSIONS: Case-fatality rates are higher than reported in high-income countries, with post-stroke disability a significant predictor of death. Sustainable interventions to reduce post-stroke disability in this setting should be investigated.

The prevalence and burden of behavioural and psychological symptoms of dementia in rural Tanzania.

OBJECTIVES: Behavioural and psychological symptoms (BPS) in dementia are common in high-income countries, but there are few data from sub-Saharan Africa. Our aim was to estimate the prevalence and pattern of BPS and associated caregiver distress in rural Tanzania. METHODS: Prevalent cases of dementia (aged 70 and over) were identified during a community-based door-to-door study in six rural villages in Tanzania. Following cognitive screening, a stratified sample (over-sampled for people with dementia) of cases underwent a detailed clinical assessment including the brief 12 item neuropsychiatric inventory (NPI-Q), which assesses BPS and associated caregiver distress over the preceding 30 days. RESULTS: Of 78 people with dementia, at least one current BPS was reported by 69 (88.4%), with 40 (51.3%) reporting 3 or more symptoms. In 172 people with no cognitive impairment, 110 (64.0%) reported at least one symptom and 48 (27.9%) reported 3 or more. In dementia cases, the most frequent symptoms reported were anxiety (47.4%), agitation/aggression (38.5%), night-time behavioural disturbance (34.6%), irritability (33.3%) and depression (33.3%). CONCLUSION: The frequency of BPS in dementia in this rural Tanzanian population is high and comparable to that reported in prevalence studies from high income countries. Symptoms were also common, although to a lesser degree, amongst cognitively intact subjects. BPS are likely to have a significant impact on quality of life for elderly persons and their carers in low-income settings. Low-cost interventions, such as community-based therapy and education, are needed.

A comparison of caregiver burden in older persons and persons with Parkinson's disease or dementia in sub-Saharan Africa.

BACKGROUND: Caregiver burden includes the many physical, mental and socio-economic problems arising from caring for individuals with chronic and disabling diseases. Being a carer in sub-Saharan Africa (SSA), where little is known about chronic neurological conditions, may be extremely demanding. Conversely, multigenerational living may allow sharing of care among many caregivers. We wished to determine the relative burden of caring for two chronic neurodegenerative conditions (Parkinson's disease (PD) and dementia) in rural Tanzania. METHODS: All surviving patients from a PD prevalence study, newly identified people with PD from a neurological disorders study and all people with dementia from a dementia prevalence study in Hai, rural Tanzania, were invited to participate. The Zarit Burden Interview (ZBI) was used to determine level of caregiver strain (higher score reflects more strain). RESULTS: Of 25 PD patients ZBI was recorded in 20 (14 male). Five had no identifiable carer as they were largely independent. Three had PD dementia (PDD). Of 75 people with dementia (excluding 3 PDD), 43 (32 female) completed the ZBI. For the other 32, the caregivers felt the care they provided was a normal intergenerational expectation. Median ages were 78.5 and 85 years for PD and dementia, respectively. Median ZBI was 30.5 for PD and 14 for dementia (U = 166.0, z = -3.913, p < 0.001). Disease duration and disease type (PD or dementia) were univariate predictor of ZBI score, although only disease type was predictive by multivariable linear regression. CONCLUSIONS: Caring for an individual with PD may be more burdensome than caring for an individual with dementia in SSA. People with more advanced PD had higher caregiver burden.

The prevalence of neurological disorders in older people in Tanzania.

OBJECTIVES: There are few data on neurological disorders prevalence from low- and middle-income countries, particularly sub-Saharan Africa (SSA) and none specific to the African elderly. We aimed to determined the prevalence of neurological disorders in those aged 70 years and over in a rural African community. MATERIALS AND METHODS: This study was a cross-sectional two-phased community epidemiological survey set in the rural Hai district of Tanzania. Screening was performed with a validated screening questionnaire with high sensitivity and specificity. Positive responders to screening underwent full neurological history and examination to confirm or refute the presence of neurological disorders and to classify the disorder using the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). RESULTS: Of 2232 participants, there were 384 neurological diagnoses amongst 349 people. The age-adjusted prevalence of people with neurological diagnoses was 154.1 per 1000 (95% CI 139.2-169.1). The age-adjusted prevalence per 1000 of the most common neurological disorders were tremor (48.2), headache (41.8), stroke (23.0), peripheral polyneuropathy (18.6), upper limb mononeuropathy (6.5) and parkinsonism (5.9). CONCLUSIONS: This is the first published community-based neurological disorders prevalence study specifically in the elderly in SSA. It reveals a high prevalence of neurological morbidity and demonstrates the contribution neurological disorders make to the non-communicable disease epidemic. This is likely to increase as the population of low-income countries ages constituting a public health dilemma.

The high prevalence of hypertension in rural-dwelling Tanzanian older adults and the disparity between detection, treatment and control: a rule of sixths?

There are limited, reliable data on the prevalence of hypertension in East African populations. The aim of this study was to document the prevalence of hypertension in the rural Hai district of Tanzania. All consenting individuals aged 70 years and over who were living in 12 randomly-selected villages in the district underwent three consecutive sitting blood pressure (BP) measurements. An average of the last two measurements was taken. Prior diagnosis of, and treatment for, hypertension was recorded. Of the 2223 subjects, 1553 (69.9%, 95% CI 68.0-71.8) had hypertension (BP ≥140/90). Of those with hypertension 733 (47.2%) had isolated systolic hypertension. Only 586 (37.7%) hypertensives had been previously diagnosed, 94 (6.1%) were currently treated and 14 (0.9%) were adequately controlled. This is the first large-scale prevalence study of hypertension in the elderly in sub-Saharan Africa (SSA). Our results approximate to a 'rule of sixths'; 2/6 of hypertensives were previously detected, 1/6 of those previously detected were on treatment and 1/6 of those on treatment were adequately controlled. Hypertension is a large problem in the elderly population in SSA, and there are a growing number of elderly who are at risk of hypertensive sequelae owing to lack of detection and treatment.

Correlates of short- and long-term case fatality within an incident stroke population in Tanzania.

BACKGROUND: This study aimed to identify correlates of case fatality within an incident stroke population in rural Tanzania. METHODS: Stroke patients, identified by the Tanzanian Stroke Incidence Project, underwent a full examination and assessment around the time of incident stroke. Records were made of demographic data, blood pressure, pulse rate and rhythm, physical function (Barthel index), neurological status (communication, swallowing, vision, muscle activity, sensation), echocardiogram, chest X-ray and computed tomography (CT) head scan. Cases were followed up over the next 3 - 6 years. RESULTS: In 130 incident cases included in this study, speech, language and swallowing problems, reduced muscle power, and reduced physical function were all significantly correlated with case fatality at 28 days and 3 years. Age was significantly correlated with case fatality at 3 years, but not at 28 days post-stroke. Smoking history was the only significant correlate of case fatality at 28 days that pre-dated the incident stroke. All other significant correlates were measures of neurological recovery from stroke. CONCLUSIONS: This is the first published study of the correlates of post-stroke case fatality in sub-Saharan Africa (SSA) from an incident stroke population. Case fatality was correlated with the various motor impairments resulting from the incident stroke. Improving poststroke care may help to reduce stroke case fatality in SSA.

Predicting vocational aptitude of mentally retarded persons: a comparison of assessment systems.

The relationship between the AAMD Adaptive Behavior Scale (ABS), the Behavioral Characteristics Progression Scale, and the McCarron-Dial Work Evaluation System and the vocational competencies of mentally retarded clients, as typically assessed by the San Francisco Vocational Competency Scale, was examined. Results were discussed in terms of the general applicability of the McCarron-Dial Work Evaluation System in assessing vocational potential of retarded persons when compared to either the ABS or the Behavioral Characteristics Progression Scale.