Exploring the Needs and Concerns of Women with Early Breast Cancer during Chemotherapy: Valued Outcomes during a Course of Traditional Acupuncture.

Women diagnosed with breast cancer experience symptom clusters in addition to existential issues from a life-threatening diagnosis during chemotherapy. A complementary therapy, such as traditional acupuncture (TA) with its whole-person orientation, may help to modify these effects, alongside inducing other patient benefits. Exploring the needs and concerns of women and perceived benefits of TA would add to knowledge about its integrative treatment potential. Methods. A longitudinal qualitative study recruited fourteen women to receive up to ten sessions of TA during chemotherapy. They were interviewed before, during, and after chemotherapy. Two practitioners of TA delivered treatment and were interviewed before and after the study, and kept treatment logs and diaries. Interviews were recorded and transcribed, and the data were analysed using grounded theory. Findings. Both broad and specific benefits were reported by the women; a highly valued outcome was enabling coping through the alleviation of symptoms and increased well-being. Practitioners dealt with the presented symptom clusters facilitating outcome patterns, including and beyond individual symptom changes. Further research on TA as a flexible intervention able to respond to the changing needs and concerns of woman during chemotherapy along with the measure of such outcome patterns is warranted.

"It's hard to tell": the challenges of scoring patients on standardised outcome measures by multidisciplinary teams: a case study of neurorehabilitation.

BACKGROUND: Interest is increasing in the application of standardised outcome measures in clinical practice. Measures designed for use in research may not be sufficiently precise to be used in monitoring individual patients. However, little is known about how clinicians and in particular, multidisciplinary teams, score patients using these measures. This paper explores the challenges faced by multidisciplinary teams in allocating scores on standardised outcome measures in clinical practice. METHODS: Qualitative case study of an inpatient neurorehabilitation team who routinely collected standardised outcome measures on their patients. Data were collected using non participant observation, fieldnotes and tape recordings of 16 multidisciplinary team meetings during which the measures were recited and scored. Eleven clinicians from a range of different professions were also interviewed. Data were analysed used grounded theory techniques. RESULTS: We identified a number of instances where scoring the patient was 'problematic'. In 'problematic' scoring, the scores were uncertain and subject to revision and adjustment. They sometimes required negotiation to agree on a shared understanding of concepts to be measured and the guidelines for scoring. Several factors gave rise to this problematic scoring. Team members' knowledge about patients' problems changed over time so that initial scores had to be revised or dismissed, creating an impression of deterioration when none had occurred. Patients had complex problems which could not easily be distinguished from each other and patients themselves varied in their ability to perform tasks over time and across different settings. Team members from different professions worked with patients in different ways and had different perspectives on patients' problems. This was particularly an issue in the scoring of concepts such as anxiety, depression, orientation, social integration and cognitive problems. CONCLUSION: From a psychometric perspective these problems would raise questions about the validity, reliability and responsiveness of the scores. However, from a clinical perspective, such characteristics are an inherent part of clinical judgement and reasoning. It is important to highlight the challenges faced by multidisciplinary teams in scoring patients on standardised outcome measures but it would be unwarranted to conclude that such challenges imply that these measures should not be used in clinical practice for decision making about individual patients. However, our findings do raise some concerns about the use of such measures for performance management.

The MS Symptom and Impact Diary (MSSID): psychometric evaluation of a new instrument to measure the day to day impact of multiple sclerosis.

OBJECTIVES: This study aimed to develop further a diary originally devised to measure the impact of multiple sclerosis (MS) as part of a cost utility study of beta interferon, and to evaluate its reliability, validity, and responsiveness in an outpatient sample of people with MS. METHODS: The original diary was further developed using qualitative and quantitative methods to ensure that it addressed the views of people with MS. The psychometric properties of the MS Symptom and Impact Diary (MSSID) were evaluated in a sample of 77 people who completed the MSSID daily for 12 weeks. Internal and test-retest reliability, discriminant and convergent validity, and responsiveness were assessed using traditional psychometric methods. RESULTS: The MSSID formed three, internally consistent scales that measured mobility, fatigue, and the overall impact of MS. The test-retest reliability of the mobility scale was adequate for individual comparisons (ICC>0.90) and the fatigue and overall impact scales were adequate for group comparisons (ICC>0.70). The MSSID was able to distinguish between clinical groups depending on clinical course, indoor ambulation status, and relapse status. It demonstrated associations with other single point instruments in the expected direction. Compared with single point instruments, its responsiveness was similar or better, especially in detecting short term improvements in functioning. CONCLUSIONS: The MSSID may provide a useful complement to currently available instruments to measure the outcomes of MS within clinical trials. Further research is needed to explore its feasibility in the context of a randomised controlled trial and its utility for clinicians.

Comparison of bibliographic databases for information on the rehabilitation of people with severe mental illness.

OBJECTIVE: The research sought to examine the overlap in coverage between several health-related databases, thus enabling the identification of the most important sources for searching for information on the rehabilitation of people with severe mental illness. METHODS: The literature was searched within a systematic review. Several health-related databases were retrieved (Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, MEDLINE, PsycLIT, Sociofile, and Social Science Citation Index), noting their source and comparing results retrieved from each database. FINDINGS: The total number of studies retrieved from each database varied. Almost a third of the papers retrieved from each database were unique to that source. Forty-two percent of the papers were only found in one database. Restricting a search to one database alone would miss many papers and could affect the results of a systematic review. PsycLIT was the most useful database for this topic area, containing 44% of the papers. MEDLINE, the database of first choice for many health professionals, held only 29%. CONCLUSIONS: No database was determined to be significantly more useful than any other--each warranted inclusion in the study. Reliance cannot be placed on one database alone, and other methods such as hand searching should also be used. Although this may not be new information for information professionals, it is likely to be new for health professionals and researchers who are increasingly performing their own literature searches. Information professionals have an important role to play in conveying this message to those outside their profession.

Assessment, re-design and evaluation of changes to the driver's cab in a suburban electric train.

A new type of electric train, called the Tangara, began replacing older trains on the Sydney city and suburban network in 1990. Shortly afterwards, some of the train drivers began reporting pain in the arms while driving the new train. The Ergonomics Unit of Worksafe Australia was then engaged to identify and assess ergonomic problems in the driver's cab. This process included direct observation of drivers at work, distribution of a self-administered questionnaire to all drivers, and analysis of anthropometric problems using a computer-aided design package. The analysis of 193 completed questionnaires and the problems shown by the design study were used in developing an improved design. A mock-up of the modified cab was made and tried out by 134 drivers whose comments led to further changes. The modified design was applied to new production, and existing cabs were modified during major maintenance. By 1996, 96% of the driver's cabs were to the new design. An evaluation of the new design was undertaken using written questionnaires, which were completed by 227 drivers. The results were strongly in favour of the new design, showing the effectiveness of the ergonomic modifications.

Developing a tool to measure holistic practice: a missing dimension in outcomes measurement within complementary therapies.

Despite the wide and continuing debate over the relevance of particular research methods to evaluate complementary therapies, less attention has been given to what outcome criteria and measures to use and/or whether these have a sufficient breadth in perspective. While complementary and alternative medicine researchers have paid heed to the importance of measuring the subjective experience of therapy users, they have left unmeasured the notion of holism, in particular, the measurement of the effect of the interaction between therapist and therapy user, and its underlying philosophy of health and healing. This paper reports on an exploratory, qualitative study aimed at developing a measure of holism and holistic practice. It draws out some key features requiring measurement and provides insight into the emerging measure. Further development work is needed before the measure can be used within research or routine practice.

Searching for information on outcomes: do you need to be comprehensive?

The concepts of evidence-based practice and clinical effectiveness are reliant on up to date, accurate, high quality, and relevant information. Although this information can be obtained from a range of sources, computerised databases such as MEDLINE offer a fast, effective means of bringing up to date information to clinicians, as well as health service and information professionals. Common problems when searching for information from databases include missing important relevant papers or retrieving too much information. Effective search strategies are therefore necessary to retrieve a manageable amount of relevant information. This paper presents a range of strategies which can be used to locate information on MEDLINE efficiently and effectively.

Audit activity and uptake of postgraduate dental education among general dental practitioners in Yorkshire.

The aim of this study was to assess the involvement of general dental practitioners in Yorkshire in clinical audit activity and in postgraduate dental education and to compare the results with those of a previous survey undertaken in 1989. There is a need to find ways of encouraging all general dental practitioners to become actively involved in continuing professional development and in improving the quality of general dental practice through the use of clinical audit.

Reviewing and selecting outcome measures for use in routine practice.

For the successful achievement of evidence-based practice, clinicians, managers and purchasers need evidence on whether a particular intervention works and ways to judge the appropriateness of the outcome criteria and measures used. Guidance is needed on what outcome measure to use, especially within routine clinical care settings. Beginning with a reclarification of the difference between a health status and an outcome measure, the paper presents an evaluative checklist for use by clinical audit and research staff to review outcome measures for use in routine care settings. Central features include the user-centredness of the measure, its psychometric properties, feasibility of use and utility. The applicability of the checklist is illustrated for outcome measurement in diabetes and stroke care. A modified form of the checklist is proposed for use by the busy clinician as an aid to the critical review of research papers within the context of evidence-based practice and to aid health care practitioners' choice of which outcome measure(s) to use within routine clinical care.

Key issues in outcomes measurement.

Exploring and monitoring outcomes within routine clinical practice is central to high quality patient care. It is however a complex and challenging task. Multiple interests in outcomes information are apparent and different perspectives on what counts as an 'effective' intervention or 'successful' outcome. The paper provides insight into ways to explore and monitor the desired outcomes of key participants to the health care process. In particular, it outlines the approach of the outcomes grid, and applies this to services for genitourinary medicine.

Measuring the outcomes of disease management.

Discusses measuring outcomes in the context of disease management and provides a single framework in the form of a key question checklist. Identifies key stakeholders. Outlines levels of outcome monitoring, measurement and date type and source. The development of an evaluative culture is essential to successful outcome measurements.

Monitoring outcomes in routine practice: defining appropriate measurement criteria.

With the development of an internal market for health care, 'purchasing for outcomes' has become an important if somewhat rhetorical catchphrase. While there is emerging understanding about how it can be pursued, doubts are being expressed over an outcomes rather that a process emphasis. This debate has been confused by a failure to differentiate the role and importance of monitoring outcomes at an individual patient care level from those at an aggregate population/purchaser level. The clinical need to collect outcomes data on individual patient care within routine care settings places additional requirements on measurement development and selection. Traditional measurement criteria, stressing reliability, validity and responsiveness to change, must be supplemented by criteria of feasibility of use, clinical utility and acceptability. One option is to select domains or items of interest from longer instruments initially designed for research, carefully selected in relation to the purposes of measurement. Further measurement criteria must be addressed which stress the relevance of the proposed instrument to the condition and to the participants in the clinical interaction: in particular, patient-centredness and sensitivity to the setting. Monitoring the outcomes of individual patient care within routine clinical practice poses considerable challenges to researchers who are developing instruments and to clinicians who collect and use the data. A shift in emphasis is required towards more context-specific tests, addressing relevance to lay perceptions, to clinical use and to the condition and setting under review. The content validity, the responsiveness to patient-relevant and clinically relevant change and, of course, reliability must have greater primacy. In this way, outcome data which measure the quality of clinical practice and which provide appropriate criteria for research into effectiveness can be generated.

The value of an outcomes information resource. An evaluation of the UK Clearing House on Health Outcomes.

Reports on the first phase of an evaluation of the UK Clearing House on Health Outcomes (UKCHHO) undertaken by a sample survey of purchasers and providers on its mailing list and users of its enquiry service. Explores user satisfaction with the services and publications of the project, uses made of the information provided and perceptions of the future role of a UKCHHO. Reports overwhelming satisfaction with the enquiry service and agreement about the usefulness of Outcomes Briefing. States that the main areas of use for the information provided were within clinical audit, guidelines and the exploration of outcomes within routine clinical practice. Also that the findings provide evidence of the need for an expanded brief for a UKCHHO, to include the provision of an enquiry service on study design and demonstrations of the value of the collection of outcomes data. Notes there is an urgent need to show that the systematic collection and use of outcomes data makes a difference to the quality of care provided to patients and to the purchase of services.

The evaluation of three computer-assisted learning packages for general dental practitioners.

Two studies were undertaken to determine the acceptability of computer-assisted learning (CAL) to general dental practitioners. The first was a single programme in two parts designed to give experience in orthodontic cases assessment and treatment planning, developed at the Bristol Dental School. The second contained two modules, one on the planning and management of dental biopsy and the other on surgical endodontics, developed within the Leeds Dental Institute. An identical self-administered questionnaire was completed by participants in the evaluation study. Knowledge and skill gains were indicated following study of the modules. The modules were also found to be easy to use and useful. The CAL approach was rated positively compared to audio tapes, books and journals, but a less consistent pictures when CAL was compared with videotapes. The study provides evidence for the acceptability and potential of the CAL approach to general dental practitioners.

Guidelines, protocols and outcomes.

Clinical guidelines are being widely advocated. Discusses the agenda for outcomes in a context of both purchasing and providing and from user and clinical perspectives. Debates the question of whether practitioners will change their behaviour and act on research evidence.