Longitudinal employment outcomes of an early intervention vocational rehabilitation service for people admitted to rehabilitation with a traumatic spinal cord injury.

STUDY DESIGN: Longitudinal cohort design. OBJECTIVES: First, to explore the longitudinal outcomes for people who received early intervention vocational rehabilitation (EIVR); second, to examine the nature and extent of relationships between contextual factors and employment outcomes over time. SETTING: Both inpatient and community-based clients of a Spinal Community Integration Service (SCIS). METHODS: People of workforce age undergoing inpatient rehabilitation for traumatic spinal cord injury were invited to participate in EIVR as part of SCIS. Data were collected at the following three time points: discharge and at 1 year and 2+ years post discharge. Measures included the spinal cord independence measure, hospital anxiety and depression scale, impact on participation and autonomy scale, numerical pain-rating scale and personal wellbeing index. A range of chi square, correlation and regression tests were undertaken to look for relationships between employment outcomes and demographic, emotional and physical characteristics. RESULTS: Ninety-seven participants were recruited and 60 were available at the final time point where 33% (95% confidence interval (CI): 24-42%) had achieved an employment outcome. Greater social participation was strongly correlated with wellbeing (ρ=0.692), and reduced anxiety (ρ=-0.522), depression (ρ=-0.643) and pain (ρ=-0.427) at the final time point. In a generalised linear mixed effect model, education status, relationship status and subjective wellbeing increased significantly the odds of being employed at the final time point. Tertiary education prior to injury was associated with eight times increased odds of being in employment at the final time point; being in a relationship at the time of injury was associated with increased odds of being in employment of more than 3.5; subjective wellbeing, while being the least powerful predictor was still associated with increased odds (1.8 times) of being employed at the final time point. CONCLUSIONS: EIVR shows promise in delivering similar return-to-work rates as those traditionally reported, but sooner. The dynamics around relationships, subjective wellbeing, social participation and employment outcomes require further exploration.

Enhancement of clinicians' diagnostic reasoning by computer-based consultation: a multisite study of 2 systems.

CONTEXT: Computer-based diagnostic decision support systems (DSSs) were developed to improve health care quality by providing accurate, useful, and timely diagnostic information to clinicians. However, most studies have emphasized the accuracy of the computer system alone, without placing clinicians in the role of direct users. OBJECTIVE: To explore the extent to which consultations with DSSs improve clinicians' diagnostic hypotheses in a set of diagnostically challenging cases. DESIGN: Partially randomized controlled trial conducted in a laboratory setting, using a prospective balanced experimental design in 1995-1998. SETTING: Three academic medical centers, none of which were involved in the development of the DSSs. PARTICIPANTS: A total of 216 physicians: 72 at each site, including 24 internal medicine faculty members, 24 senior residents, and 24 fourth-year medical students. One physician's data were lost to analysis. INTERVENTION: Two DSSs, ILIAD (version 4.2) and Quick Medical Reference (QMR; version 3.7.1), were used by participants for diagnostic evaluation of a total of 36 cases based on actual patients. After training, each subject evaluated 9 of the 36 cases, first without and then using a DSS, and suggested an ordered list of diagnostic hypotheses after each evaluation. MAIN OUTCOME MEASURE: Diagnostic accuracy, measured as the presence of the correct diagnosis on the hypothesis list and also using a derived diagnostic quality score, before and after consultation with the DSSs. RESULTS: Correct diagnoses appeared in subjects' hypothesis lists for 39.5% of cases prior to consultation and 45.4% of cases after consultation. Subjects' mean diagnostic quality scores increased from 5.7 (95% confidence interval [CI], 5.5-5.9) to 6.1 (95% CI, 5.9-6.3) (effect size: Cohen d = 0.32; 95% CI, 0.23-0.41; P<.001). Larger increases (P = .048) were observed for students than for residents and faculty. Effect size varied significantly (P<.02) by DSS (Cohen d = 0.20; 95% CI, 0.08-0.32 for ILIAD vs Cohen d = 0.45; 95% CI, 0.31-0.59 for QMR). CONCLUSIONS: Our study supports the idea that "hands-on" use of diagnostic DSSs can influence diagnostic reasoning of clinicians. The larger effect for students suggests a possible educational role for these systems.

The development of a locus of control measure predictive of injured athletes' adherence to treatment.

The Sports Rehabilitation Locus of Control (SRLC) scale was developed to facilitate study of the behaviour of athletes recovering from injury. The SRLC was built specifically to assess locus of control in injured athletes by adapting selected items from the Multidimensional Health Locus of Control (MHLC) questionnaire developed by Wallston, Wallston, & DeVellis (1978), and in accordance with their rationale for the construction of domain-specific LOC scales. The resultant locus of control measures (internal, powerful others, and chance) were administered (along with the MHLC) to a sample of 145 sports-injured athletes. Good internal consistency (alphas ranged from .72 to .79) and test-retest reliability (correlations ranged from .75 to .85) was shown by the SRLC scales, and the pattern of inter-scale correlations supported the three-factor conceptualisation of locus of control on which the SRLC was based. In the subsequent initial validation study, the relationship between SRLC scale scores and adherence to treatment was tested with a sample of injured athletes. Encouragingly, internality was positively associated p<.05 with treatment adherence.

Utility of relaxation training with children in school settings: a plea for realistic goal setting and evaluation.

BACKGROUND: School-based relaxation training programmes are a popular means of helping children with anxiety problems such as headaches and test anxiety. AIMS: Our major objective is to evaluate the empirical status of school-based relaxation training programmes. CONTENTS: Focusing on progressive muscle relaxation training, we show how this adult training procedure has been modified for use with children. Several training issues are discussed including the questions of live versus recorded instruction and individual versus group instruction. We also discuss the evaluation of relaxation training programmes in school settings, highlighting issues of reliability and validity. CONCLUSIONS: Our review of studies examining the efficacy of school-based relaxation training shows that improvements are usually modest and of dubious clinical or educational significance. Consequently we suggest that when relaxation training is used with school children treatment goals should be more modest or, that if improvements in specific performance areas are sought, then more comprehensive treatment packages be developed which can influence the successful performance of children in target areas and reduce anxiety to normal levels.

Spinal cord injury rehabilitation outcomes: a comparison of agricultural and non-agricultural workers.

This study of Victorian workers who sustained a spinal cord injury aimed to: (i) define the proportion of this population who were employed in an agricultural setting prior to sustaining their injury; (ii) explore the preinjury characteristics and postinjury vocational achievements of agricultural workers; and (iii) compare these with those of non-agricultural workers. Respondents were sampled from patients presenting for review at the participating spinal unit over the 9 months study period (N = 150 with a participation rate of 71%). Results indicated that while those working in agricultural occupations account for between 4 and 4.5% of Victorian workers, 13.3% of respondents reported working in agricultural occupations at the time of their injury. In spite of the physically demanding nature of their workplace many agricultural workers returned to farming postinjury. The rehabilitation experiences and return to work outcomes achieved by the agricultural workers were found to be very similar to those of other workers, despite the additional barriers they were expected to have encountered.

Assessment of childhood phobias.

Childhood phobias can be successfully treated using a variety of behavioral strategies, provided there has been a psychometrically sound assessment. Measures are also important for the evaluation of treatment efficacy and the testing of hypotheses generated by new ideas and theories of children's phobias. This paper outlines broad-based assessment procedures used in the evaluation of children's phobias, including the behavioral or problem-focused interview, the diagnostic interview, self-report inventories, caregiver completed instruments, behavioral observations, self-monitoring and physiological assessment. Reflecting recent theoretical and clinical advances in the study of childhood internalizing disorders, we also explore laboratory-based measures and family assessment measures. Particular attention is given to psychometric issues and developmental sensitivity in our discussion of these assessment procedures.

Locus of control of smokers, nonsmokers, and nonpracticing smokers.

In this survey, score analyses of 123 male and female respondents, ages 21 to 33 years, yielded no significant differences between either sex and smokers versus nonsmokers on Rotter's locus of control scale. Of particular interest was that nonpracticing smokers (quitters) scored more internal than either smokers or nonsmokers.

Test-retest reliability of information about employment provided in surveys by people with spinal cord injuries.

Agreement was examined between the answers to an employment survey administered to discharged patients with spinal cord injury on two occasions 6 mo. apart. Analysis suggested reasonable test-retest reliability, with kappas ranging from .65 to .87 for the categorical data, e.g., current employment information and amount of time before respondents achieved any return to work.

Changes in diagnostic decision-making after a computerized decision support consultation based on perceptions of need and helpfulness: a preliminary report.

We examined the degree to which attending physicians, residents, and medical students' stated desire for a consultation on difficult-to-diagnose patient cases is related to changes in their diagnostic judgments after a computer consultation, and whether, in fact, their perceptions of the usefulness of these consultations are related to these changes. The decision support system (DSS) used in this study was ILIAD (v4.2). Preliminary findings based on 16 subjects' (6 general internists, 4 second-year residents in internal medicine, and 6 fourth-year medical students) workup of 136 patient cases indicated no significant main effects for 1) level of experience, 2) whether or not subjects indicated they would seek a diagnostic consultation before using the DSS, or 3) whether or not they found the DSS consultation in fact to be helpful in arriving at a diagnosis (p > .49 in all instances). Nor were there any significant interactions. Findings were similar using subjects or cases as the unit of analysis. It is possible that what may appear to be counter-intuitive, and perhaps irrational, may not necessarily be so. We are currently examining potential explanatory hypotheses in our ongoing current, larger study.

Vocational achievements following spinal cord injury in Australia.

This study describes the vocational achievements in a sample (n = 139) of Australian persons with spinal cord injuries. The post-accident and employment achievements (February-March 1993) were represented by significant diversity in outcomes. Around one-third of subjects went on to obtain further qualifications since their injury, and around 31% were employed full-time or part-time. The majority of subjects utilized informal means of returning to work. Around two-thirds of those employed indicated that they were in a preferred occupation and their median length of employment was 108 months. The hours of work varied greatly but were centred around a median of 38 hours (i.e. a full-time job). A model of diverse employment outcomes and achievement following spinal cord injury is proposed.

The influence of a decision support system on the differential diagnosis of medical practitioners at three levels of training.

As computer-based diagnostic consultation systems become, available, their influence and usefulness need to be evaluated. This report, based on partial data from a larger study, examines the influence of Iliad, a diagnostic consultation system, on the differential diagnosis of fourth year medical students, residents in medicine, and attendings in general internal medicine. Our results show that when faced with difficult diagnostic cases, medical students add significantly more diagnoses from Iliad's differential than do residents or attendings. However, the quality of Iliad's diagnostic advice in terms of the presence of the correct diagnosis, is no better for consultations done by students or residents compared to attendings.

Job satisfaction of and return to work by occupationally injured employees.

The job-satisfaction scores of 107 work-injured employees were correlated with return to work status at 20 weeks postinjury. There was a slight tendency for the more satisfied employees to be back at work.

Automated medical knowledge acquisition: a study of consistency.

Knowledge bases are more representative of the population of medical experts if they are constructed by a group of individuals, rather than one practitioner. However, one runs into problems with consistency when information is elicited from a group without a consistent format and terminology. This study examines the consistency of relatively unconstrained computer-elicited medical knowledge using the computer program, KSSO. The results of this study show that the group of ten general internists were somewhat consistent in the diagnoses they listed for a patient presenting with chest pain. They were much less consistent in the findings they listed to differentiate between the diagnoses they had listed. The mean number of subjects listing each diagnosis was 3.3 +/- 2.7 while the mean for findings was 2.0 +/- 1.5. The implications of these data are discussed.

General patterns of managerial approaches to work motivation: Implications for rehabilitation professionals involved in occupational rehabilitation.

Calls for rehabilitation counselors to learn more about the world of work have been recently repeated. The validity of these calls is suggested by a group of studies which indicate that the rehabilitation counseling literature has an established emphasis on matters of counseling and adjustment rather than on matters related to behavior in organizations. A survey of rehabilitation counsellors' beliefs about key topics in organizational behavior indicates that their beliefs are often discrepant with those of practicing managers and supervisors. A summary of dominant models of work motivation adopted by managerial workers is presented and some implications for occupational rehabilitation practice identified. Finally, some contemporary literature relevant to managerial approaches to employee motivation are identified and it is suggested that familiarity with this literature could assist rehabilitation practitioners move from a more narrow occupational rehabilitation role to a broader involvement in organizational life via the expansion of the disability management approach in work organizations.