Design and reliability of pediatric HealthQuiz: preliminary report of a comprehensive, computerized, self-administered child health assessment.

The time available for pediatric ambulatory visits is rarely sufficient to permit a truly comprehensive health assessment. We hypothesized that a reliable, computerized, self-administered questionnaire could be designed to screen for a full range of pediatric health issues and provide a comprehensive health database for pediatric patients. An age- and gender-specific pediatric questionnaire of 478 questions was formatted to elicit only a "Yes," "No," or "Not Sure" response and structured in a branched, decision-tree format. The initial draft was reviewed for content by pediatric experts in Canada and the United States and revised in accordance with their suggestions. The questionnaire was divided into two modules, Medical Peds, covering biomedical issues and Prevent Peds, covering prevention, psychosocial, educational, and safety topics. Cognitive interviews were carried out with 132 parents in pediatric ambulatory care centers in Chicago and Halifax, with use of scripted and nonscripted probe questions, to ensure comprehensibility among patients with widely varying educational levels and health knowledge. Reliability was tested in 100 parents of children aged 1 month to 12 years, through use of five different test-retest sequences. Respondents' impressions were surveyed on completion of the procedure. Following content reviews, and cognitive and reliability testing, the total bank of questions was reduced to 375. As a result of the use of branching logic, individual parents answered an average of 111 Prevent Peds and 144 Medical Peds questions. Average time required to complete the entire questionnaire was 13 minutes for Prevent Peds and 19 minutes for Med Peds. Retesting within 36 hours showed an overall 97% concordance of response pairs in the Medical Peds and Prevent Peds questionnaires. There were no statistically significant differences in test-retest reliability between different sequence formats used, (e.g., HealthQuiz followed by personal interview, or HealthQuiz vs. HealthQuiz). A few questions that frequently elicited "Not Sure" responses were eliminated. As a result, the majority of questions elicited either a "Yes" or "No" response. Pediatric HealthQuiz identified a wide spectrum of child health problems that are often overlooked in routine health visits. Parents completing Pediatric HealthQuiz indicated a high degree of satisfaction with the procedure. Most reported that they believed the information would improve their child's health care.

Use of electronic mail for postoperative follow-up after ambulatory surgery.

The authors report on a patient who used electronic mail to report satisfactory recovery from ambulatory surgery and anesthesia. The potential benefits and pitfalls of using electronic mail for patient follow-up and communication, as well as research purposes, are reviewed. Potential benefits include cost savings, ease in collecting quality improvement data, and the potential for increased reporting of unpleasant events. Potential pitfalls include lack of universal access (with racial and socioeconomic differentials), privacy and security concerns, and potential slow responses to messages that might require emergent responses or actions.

Improving the efficiency of survey research in postoperative patients.

STUDY OBJECTIVE: To increase the contact rate with eligible patients for quality assurance/improvement surveys by modifying survey rounds to accommodate the schedules of individual nursing units. DESIGN: Two-phase, interventional time series study. SETTING: Postoperative inpatients at a university hospital. PATIENTS: 498 adult postoperative inpatients who remained hospitalized during the second postoperative day. INTERVENTIONS: Between the first and second measurement periods, efforts were made to learn the schedule of each nursing unit and to improve the efficiency of survey rounds so that a larger proportion of patients could be contacted. MEASUREMENTS AND MAIN RESULTS: The contact rate for eligible patients was improved from 66% to 80% (p < 0.01). Improvement during the second period was attributed to fewer patients being away from the nursing unit (20% vs. 12%, p < 0.05) or otherwise occupied by attending physicians on rounds (9% vs. 4%, p < 0.05). CONCLUSION: Strategies individualized to patient care units can improve the efficiency and credibility of inpatient survey research. We describe the strategies most helpful in improving the efficiency of survey rounds at one medical center.

Assessment of satisfaction with treatment for chronic pain.

The purpose of this study was to develop an instrument to assess satisfaction with treatment of chronic pain, evaluate the reliability and validity of this instrument, and then examine predictors and consequences of satisfaction. The Pain Service Satisfaction Test (PSST) is the result of this effort. Fifty adult patients receiving services for chronic pain in a university pain clinic completed the PSST as part of a survey mailed to their homes. Findings supporting the validity of the PSST included significant positive correlations with a general measure of treatment satisfaction, patient ratings of global treatment satisfaction and effects of treatment, and physician ratings of patient satisfaction with treatment. Regression analyses of predictors of satisfaction highlighted significant contributions of confidence and trust in the provider, pain reduction, and waiting in the clinic. These predictors together accounted for 60% of satisfaction with treatment. Treatment satisfaction was negatively correlated with depression, reported number of physicians consulted, and number of physician visits for pain in the past 12 months; and there was a trend toward a negative correlation with disability. Results of the present study support the importance of satisfaction with treatment as a predictor and possible determinant of later health, function, and service utilization.

Question-induced cognitive biases in reports of dietary intake by college men and women.

In two experiments, investigated how variations in questionnaire structure influence respondents' reports of two aspects of dietary intake--the frequency with which various food items are eaten and the sizes of the portions that are eaten. In Experiment 1, approximately 400 subjects, prior to making a frequency judgment, were asked to think either about a specific occasion or about all the occasions on which they had eaten a particular food. The thoughts that preceded the frequency judgment influenced that judgment: Thinking of the range of occasions on which a food is consumed resulted in higher frequency estimates than thinking only of the most recent occasion. In Experiment 2, the same subjects made judgments about their typical portion sizes of several foods relative to described standards. For only one of eight foods were estimates properly and significantly affected by differences among the described standards. These results suggest that respondents are not particularly sensitive to portion-size definitions. We consider the implications of these phenomena for the development of a general theory of the cognitive processes that subserve health-survey responding.

Cognitive laboratory approach to designing questionnaires for surveys of the elderly.

Data from surveys of the elderly are used by policy analysts to design health services programs. Consequently, the quality of survey data on elderly respondents has important implications for this growing segment of society: improving the quality of data should result in more cost effective programs for the elderly. However, studies suggest that the quality of responses from the elderly may be less than that for other respondents. Moreover, the increasing needs of policy analysts and health researchers for data have resulted in more complex survey questions that place a high cognitive burden on respondents. New methods for improving the design of these questionnaires are needed. This project investigated whether new techniques of questionnaire design, adapted from the theories and methods of cognitive psychology, could be effectively used in interviewing older respondents. The techniques used in this study, concurrent think-aloud interviews with followup probe questions, have been shown recently to be effective with younger respondents. Problems that elderly respondents have in comprehending survey questions, retrieving relevant information from memory, and using decision processes to estimate and provide answers were investigated. Questions on functional ability and social support were taken from the 1984 Supplement on Aging to the National Health Interview Survey. Analysis of respondents' think-aloud protocols and responses to probes suggest that the cognitive interview procedures were effective in identifying problems with the survey questions that would result in data of poorer quality and in suggesting the wording of questions that would be likely to result in answers of greater validity and reliability. Implications of these results for survey design and validation studies are discussed.

Recall strategies and memory for health-care visits.

Complex questions in health surveys place heavy cognitive demands on respondents, prompting researchers to appraise how specific cognitive interventions may improve the accuracy of people's answers. Investigators in one experiment asked participants to recall visits to medical providers in forward, backward, or no particular order, and matched results with providers' records. "Free" recall proved marginally superior to forward or backward ordering, although overall respondents underreported the number of visits by 20 percent; participants' gender and self-reported health status, among other factors, also affected quality of recall. The experiment lends support to contentions that the methods of cognitive science applied to survey research better the accuracy of population survey data.