Achieving Equity in Diagnostic Excellence McDonald, Kathryn M
JAMA : the journal of the American Medical Association,
05/2022, Letnik:
327, Številka:
20
Journal Article
Recenzirano
This Viewpoint highlights some of the ways in which common practices in health care perpetuate inequitable treatment of marginalized populations and summarizes ways in which systems thinking could ...reduce these gaps.
Background
Approximately 60% to 80% of people with Parkinson's disease (PD) experience cognitive impairment that impacts on their quality of life. Cognitive decline is a core feature of the disease ...and can often present before the onset of motor symptoms. Cognitive training may be a useful non‐pharmacological intervention that could help to maintain or improve cognition and quality of life for people with PD dementia (PDD) or PD‐related mild cognitive impairment (PD‐MCI).
Objectives
To determine whether cognitive training (targeting single or multiple domains) improves cognition in people with PDD and PD‐MCI or other clearly defined forms of cognitive impairment in people with PD.
Search methods
We searched the Cochrane Dementia and Cognitive Improvement Group Trials Register (8 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO. We searched reference lists and trial registers, searched relevant reviews in the area and conference proceedings. We also contacted experts for clarifications on data and ongoing trials.
Selection criteria
We included randomised controlled trials where the participants had PDD or PD‐MCI, and where the intervention was intended to train general or specific areas of cognitive function, targeting either a single domain or multiple domains of cognition, and was compared to a control condition. Multicomponent interventions that also included motor or other elements were considered eligible.
Data collection and analysis
Two review authors independently screened titles, s, and full‐text articles for inclusion in the review. Two review authors also independently undertook extraction of data and assessment of methodological quality. We used GRADE methods to assess the overall quality of the evidence.
Main results
Seven studies with a total of 225 participants met the inclusion criteria for this review. All seven studies compared the effects of a cognitive training intervention to a control intervention at the end of treatment periods lasting four to eight weeks. Six studies included people with PD living in the community. These six studies recruited people with single‐domain (executive) or multiple‐domain mild cognitive impairment in PD. Four of these studies identified participants with MCI using established diagnostic criteria, and two included both people with PD‐MCI and people with PD who were not cognitively impaired. One study recruited people with a diagnosis of PD dementia who were living in long‐term care settings. The cognitive training intervention in three studies targeted a single cognitive domain, whilst in four studies multiple domains of cognitive function were targeted. The comparison groups either received no intervention or took part in recreational activities (sports, music, arts), speech or language exercises, computerised motor therapy, or motor rehabilitation combined with recreational activity.
We found no clear evidence that cognitive training improved global cognition. Although cognitive training was associated with higher scores on global cognition at the end of treatment, the result was imprecise and not statistically significant (6 trials, 178 participants, standardised mean difference (SMD) 0.28, 95% confidence interval (CI) −0.03 to 0.59; low‐certainty evidence). There was no evidence of a difference at the end of treatment between cognitive training and control interventions on executive function (5 trials, 112 participants; SMD 0.10, 95% CI −0.28 to 0.48; low‐certainty evidence) or visual processing (3 trials, 64 participants; SMD 0.30, 95% CI −0.21 to 0.81; low‐certainty evidence). The evidence favoured the cognitive training group on attention (5 trials, 160 participants; SMD 0.36, 95% CI 0.03 to 0.68; low‐certainty evidence) and verbal memory (5 trials, 160 participants; SMD 0.37, 95% CI 0.04 to 0.69; low‐certainty evidence), but these effects were less certain in sensitivity analyses that excluded a study in which only a minority of the sample were cognitively impaired. There was no evidence of differences between treatment and control groups in activities of daily living (3 trials, 67 participants; SMD 0.03, 95% CI −0.47 to 0.53; low‐certainty evidence) or quality of life (5 trials, 147 participants; SMD −0.01, 95% CI −0.35 to 0.33; low‐certainty evidence). There was very little information on adverse events. We considered the certainty of the evidence for all outcomes to be low due to risk of bias in the included studies and imprecision of the results.
We identified six ongoing trials recruiting participants with PD‐MCI, but no ongoing trials of cognitive training for people with PDD.
Authors' conclusions
This review found no evidence that people with PD‐MCI or PDD who receive cognitive training for four to eight weeks experience any important cognitive improvements at the end of training. However, this conclusion was based on a small number of studies with few participants, limitations of study design and execution, and imprecise results. There is a need for more robust, adequately powered studies of cognitive training before conclusions can be drawn about the effectiveness of cognitive training for people with PDD and PD‐MCI. Studies should use formal criteria to diagnose cognitive impairments, and there is a particular need for more studies testing the efficacy of cognitive training in people with PDD.
Abstract Trust and confidence are critical to the success of health care models. There are two main methods for achieving this: transparency (people can see how the model is built) and validation ...(how well the model reproduces reality). This report describes recommendations for achieving transparency and validation developed by a taskforce appointed by the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making. Recommendations were developed iteratively by the authors. A nontechnical description—including model type, intended applications, funding sources, structure, intended uses, inputs, outputs, other components that determine function, and their relationships, data sources, validation methods, results, and limitations—should be made available to anyone. Technical documentation, written in sufficient detail to enable a reader with necessary expertise to evaluate the model and potentially reproduce it, should be made available openly or under agreements that protect intellectual property, at the discretion of the modelers. Validation involves face validity (wherein experts evaluate model structure, data sources, assumptions, and results), verification or internal validity (check accuracy of coding), cross validity (comparison of results with other models analyzing the same problem), external validity (comparing model results with real-world results), and predictive validity (comparing model results with prospectively observed events). The last two are the strongest form of validation. Each section of this article contains a number of recommendations that were iterated among the authors, as well as among the wider modeling taskforce, jointly set up by the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making.
IMPORTANCE: There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions. ...OBJECTIVE: To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty. DATA SOURCES: Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016. STUDY SELECTION: Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses. MAIN OUTCOMES AND MEASURES: Postoperative pain and consumption of opioids and analgesics. RESULTS: Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, −3.50; 95% CI, −5.90 to −1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, −1.14; 95% CI, −1.90 to −0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, −0.13; 95% CI, −0.26 to −0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, −0.51; 95% CI, −1.00 to −0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were −0.05 (95% CI, −0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, −6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was −0.14 (95% CI, −1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%). CONCLUSIONS AND RELEVANCE: In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.
Diagnostic errors receive less attention than medical error though correct diagnosis remains fundamental to a patient seeking health care. Committee by the Institution of Medicine (IOM) of the ...National Academics of Sciences, Engineering, and Medicine identifies five purposes for measuring diagnostic errors.
Objectives
In the context of validating a measure of patient report specific to diagnostic accuracy in emergency department or urgent care, this study investigates patients’ and care partners’ ...perceptions of diagnoses as accurate and explores variations in how they reason while they assess accuracy.
Methods
In February 2022, we surveyed a national panel of adults who had an emergency department or urgent care visit in the past month to test a patient-reported measure. As part of the survey validation, we asked for free-text responses about why the respondents indicated their (dis)agreement with 2 statements comprising patient-reported diagnostic accuracy: 1) the explanation they received of the health problem was true and 2) the explanation described what to expect of the health problem. Those paired free-text responses were qualitatively analyzed according to themes created inductively.
Results
A total of 1,116 patients and care partners provided 982 responses coded into 10 themes, which were further grouped into 3 reasoning types. Almost one-third (32%) of respondents used only corroborative reasoning in assessing the accuracy of the health problem explanation (alignment of the explanation with either test results, patients’ subsequent health trajectory, their medical knowledge, symptoms, or another doctor’s opinion), 26% used only perception-based reasoning (perceptions of diagnostic process, uncertainty around the explanation received, or clinical team’s attitudes), and 27% used both types of reasoning. The remaining 15% used general beliefs or nonexplicated logic (used only about accurate diagnoses) and combinations of general reasoning with perception-based and corroborative.
Conclusions
Patients and care partners used multifaceted reasoning in their assessment of diagnostic accuracy.
Implications
As health care shifts toward meaningful diagnostic co-production and shared decision making, in-depth understanding of variations in patient reasoning and mental models informs use in clinical practice.
Highlights
An analysis of 982 responses examined how patients and care partners reason about the accuracy of diagnoses they received in emergency or urgent care.
In reasoning, people used their perception of the process and whether the diagnosis matched other factual information they have.
We introduce “patient reasoning” in the diagnostic measurement context as an area of further research to inform diagnostic shared decision making and co-production of health.
Care coordination has increasingly been recognized as an important aspect of high-quality health care delivery. Robust measures of coordination processes will be essential tools to evaluate, guide ...and support efforts to understand and improve coordination, yet little agreement exists among stakeholders about how to best measure care coordination. We aimed to review and characterize existing measures of care coordination processes and identify areas of high and low density to guide future measure development.
We conducted a systematic review of measures published in MEDLINE through April 2012 and identified from additional key sources and informants. We characterized included measures with respect to the aspects of coordination measured (domain), measurement perspective (patient/family, health care professional, system representative), applicable settings and patient populations (by age and condition), and data used (survey, chart review, administrative claims).
Among the 96 included measure instruments, most relied on survey methods (88%) and measured aspects of communication (93%), in particular the transfer of information (81%). Few measured changing coordination needs (11%). Nearly half (49%) of instruments mapped to the patient/family perspective; 29% to the system representative and 27% to the health care professionals perspective. Few instruments were applicable to settings other than primary care (58%), inpatient facilities (25%), and outpatient specialty care (22%).
New measures are needed that evaluate changing coordination needs, coordination as perceived by health care professionals, coordination in the home health setting, and for patients at the end of life.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Model Transparency and Validation Eddy, David M.; Hollingworth, William; Caro, J. Jaime ...
Medical decision making,
09/2012, Letnik:
32, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Trust and confidence are critical to the success of health care models. There are two main methods for achieving this: transparency (people can see how the model is built) and validation (how well it ...reproduces reality). This report describes recommendations for achieving transparency and validation, developed by a task force appointed by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the Society for Medical Decision Making (SMDM). Recommendations were developed iteratively by the authors. A nontechnical description should be made available to anyone—including model type and intended applications; funding sources; structure; inputs, outputs, other components that determine function, and their relationships; data sources; validation methods and results; and limitations. Technical documentation, written in sufficient detail to enable a reader with necessary expertise to evaluate the model and potentially reproduce it, should be made available openly or under agreements that protect intellectual property, at the discretion of the modelers. Validation involves face validity (wherein experts evaluate model structure, data sources, assumptions, and results), verification or internal validity (check accuracy of coding), cross validity (comparison of results with other models analyzing same problem), external validity (comparing model results to real-world results), and predictive validity (comparing model results with prospectively observed events). The last two are the strongest form of validation. Each section of this paper contains a number of recommendations that were iterated among the authors, as well as the wider modeling task force jointly set up by the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making.
Abstract Purpose “Diagnostic excellence,” as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We ...aimed to explore the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains. Methods We conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains’ diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples. Results We identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges. Conclusion The multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients’ well-being.
PDF
