Reliability and validity of the evidence-based practice confidence (EPIC) scale.

INTRODUCTION: The reliability, minimal detectable change (MDC), and construct validity of the evidence-based practice confidence (EPIC) scale were evaluated among physical therapists (PTs) in clinical practice. METHODS: A longitudinal mail survey was conducted. Internal consistency and test-retest reliability were estimated using Cronbach's alpha and the intraclass correlation coefficient (ICC), respectively. The ICC was used to compute the MDC. We evaluated construct validity by testing hypotheses that EPIC scores would be positively associated with education level and frequency of searching, reading, and using research literature in clinical decision making. RESULTS: At baseline, 275 PTs completed the EPIC scale and validity questionnaire and 187 completed the scale at retest (mean retest interval = 16 days). Internal consistency was 0.89 (95% confidence interval 0.86 to 0.91; N = 275). The ICC for test-retest reliability was 0.89 (95% confidence interval 0.85 to 0.91; N = 187). The MDC95 was 4.1 percentage points meaning that a change in an individual's score must be greater than 4.1 percentage points to exceed the limits of measurement error. The mean EPIC score was significantly higher among PTs holding a Masters or doctoral degree compared to those holding a bachelor's degree or diploma, and among PTs reporting searching online, reading, and using the research literature in clinical decision making 6 or more times compared to 0 to 5 times in a typical month. DISCUSSION: Results provide evidence of excellent test-retest reliability and acceptable construct validity and minimal measurement error on repeated administration of the EPIC scale. The scale is recommended for use among PTs in clinical practice. Validation of the EPIC scale in other health professional groups is warranted.

Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures.

BACKGROUND: The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures. METHODS: We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] >/= 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and chi(2) tests, followed by logistic regression analysis. RESULTS: Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12.9%; overall mortality 15.1%). The laparotomy group had higher mean ISS (36.9 v. 24.9), higher mean abbreviated injury scores (AIS) for the abdomen (2.6 v. 0.9) and chest (3.4 v. 1.6), lower mean initial hemoglobin levels (105.2 v. 127.0 g/L), higher mean crystalloid (4249 v. 3436 mL) and blood transfusion volumes over 4 hours (12.1 v. 3.9 units), more frequent hypotension (44.6 v. 18.0%) and a higher percentage of positive CT scans (67.9% v. 28.4%) and FAST examination results (42.9% v. 3.3%) than the nonlaparotomy group. Age (mean 53.7 v. 41.5 yr); ISS (mean 39.0 v. 24.4); AIS for the head (mean 3.2 v. 1.7), abdomen (mean 1.6 v. 1.1), chest (mean 2.7 v. 1.8) and pelvis (mean 3.1 v. 2.6); crystalloid (mean 5157.3 v. 3266.4 mL) and blood transfusion volumes over 4 hours (mean 13.1 v. 3.7) and initial hypotension (61% v. 14.8%) were all greater among patients who died than those who survived. Mean initial hemoglobin levels were lower among patients who died than among those who survived (111.1 v. 126.2 g/L). Age, the AIS for the head, initial hypotension and low initial hemoglobin levels were highly predictive of mortality, whereas low initial hemoglobin levels, a positive FAST examination and high AIS for the abdomen and chest were all highly predictive of laparotomy. CONCLUSION: Among the polytrauma patients with pelvic fractures, 14.3% underwent laparotomy, and mortality was higher among these patients than among those who did not have the procedure. The predictors of laparotomy and mortality are similar to those anticipated in patients without pelvic fractures.

Youth and young adults with cerebral palsy: their use of physician and hospital services.

OBJECTIVES: To examine patterns of health care utilization among youth and young adults who have cerebral palsy (CP) and to provide information to guide the development of health services for adults who have CP. DESIGN: This study analyzed health insurance data for outpatient physician visits and hospital admissions for a 4-year period. SETTING: Six children's treatment centers in Ontario, Canada. PARTICIPANTS: The sample included 587 youth and 477 adults with CP identified from health records. Youths were 13 to 17 years of age, and adults were 23 to 32 years of age at the end of the data range. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We computed the annual rates of outpatient physician visits and hospitalizations per 1000 persons and compared these with rates for the general population. RESULTS: Annual rates of outpatient physician visits were 6052 for youth and 6404 for adults with CP, 2.2 times and 1.9 times higher, respectively, than rates for age-matched peers (P<.01). Specialists provided 28.4% of youth visits but only 18.8% of adult visits. Annual hospital admission rates were 180 for youth and 98 for adults with CP, 4.3 times and 10.6 times higher, respectively, than rates for age-matched peers (P<.01). CONCLUSIONS: It appears that youth and adults with CP continue to have complex care needs and rely heavily on the health care system. Comprehensive services are essential to support their health as they move into youth and adulthood. However, there appear to be gaps in the adult health care system, such as limited access to specialist physicians.

A prospective population-based study of the predictors of undergoing total joint arthroplasty.

OBJECTIVE: To examine prospectively the predictors of time to total joint arthroplasty (TJA). METHODS: This was a prospective cohort study with a median followup time of 6.1 years. We included participants from an existing population-based cohort of 2,128 individuals, ages 55 years and older with disabling hip and/or knee arthritis and no prior TJA, from 2 regions of Ontario, Canada, 1 urban with low TJA rates and 1 rural with high rates. The main outcome measure was the occurrence of a TJA based on procedure codes in the hospital discharge abstract database. RESULTS: At baseline, the mean age of the patients was 71.5 years, 67.9% had a high school education or higher, 73.4% were women, the mean arthritis severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) score was 41.1 (maximum possible score 100), and 20.0% were willing to consider TJA. Greater probability of undergoing TJA was associated with higher (worse) baseline WOMAC scores (hazard ratio [HR] 1.22 per 10-unit increase, P < 0.001), age (compared with age or=82 years; P < 0.05 for all), better health (HR 1.14 per 10-unit increase in Short Form 36 general health survey score, P < 0.001), and willingness to consider TJA (HR 4.92, P < 0.001). When willingness was excluded from the model, education level, but not sex or income, became a significant predictor of TJA receipt. CONCLUSION: Willingness to consider TJA was the strongest predictor of the time to first TJA. Given that previous research indicates that willingness is largely explained by perceptions of the indications for and risks associated with TJA and not disease severity, this finding supports the need for population education about arthritis treatments, including TJA.

Determinants of survival in children with congenital abnormalities: a long-term population-based cohort study.

BACKGROUND: Today more children with birth defects survive early childhood because of improved medical care; however, little information is available about patterns of long-term mortality and survival in this population. In particular, it is not clear whether other birth characteristics, apart from birth defects, have any role in their mortality. METHODS: Two large cohorts of children with and without birth defects were followed for up to 17 years. More than 45,000 children with birth defects, and 45,000 matched children without birth defects born in Ontario between 1979 and 1986 were followed. Throughout the study period long-term survival rates and the risk of death were compared between the 2 cohorts. Birth characteristics were also examined to determine their effect on the risk of death. RESULTS: During the study the deaths of 3620 and 301 children with and without birth defects, respectively, were recorded, indicating that those with birth defects had a 13 times higher rate of mortality (relative risk [RR], 12.9, 95% confidence interval [CI], 12.1-13.7). Mortality rates in the birth-defects cohort remained higher even after 10-15 years. In both groups children of low gestational age and low birth weight had a higher risk of death. There was a strong dose-response relationship between the number of defects and the risk of death. CONCLUSIONS: Children born with abnormalities face many challenges throughout their lifetimes. If they survive the high mortality risk of the first year of life, they still have to face the considerably higher risk of death in the years to come. In addition to birth defects, other birth characteristics play an independent role in their mortality. These indicators could be used to identify high-risk children.

Socioeconomic status and mortality after acute myocardial infarction.

BACKGROUND: Gradients that link socioeconomic status and cardiovascular mortality have been observed in many populations, including those of countries that provide publicly funded comprehensive medical coverage. The intermediary causes of such gradients remain poorly elucidated. OBJECTIVE: To examine the relationships among socioeconomic status, other health factors, and 2-year mortality rates after acute myocardial infarction (MI). DESIGN: Prospective cohort study. SETTING: Ontario, Canada. PATIENTS: 3407 patients who were hospitalized for acute MI in 53 large-volume hospitals in Canada from December 1999 to February 2003. MEASUREMENTS: The authors obtained self-reported measures of income and education and developed profiles of the patients' prehospitalization cardiac risks and comorbid conditions. To create these profiles, the authors used the patients' self-reports and retrospectively linked no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, ethnicity, social support, cardiovascular history and risk, comorbid conditions, and selected in-hospital process factors. RESULTS: Income was strongly and inversely correlated with 2-year mortality rate (crude hazard ratio for high-income vs. low-income tertile, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, after adjustment for age and preexisting cardiovascular events or conventional vascular risk factors, the effect of income was greatly attenuated (adjusted hazard ratio for high-income vs. low-income tertile, 0.77 [CI, 0.54 to 1.10]; P = 0.150). Noncardiovascular comorbid conditions and in-hospital process factors had negligible explanatory effect. LIMITATIONS: Previous cardiovascular risks were ascertained through self-report or retrospectively through the longitudinal tracking of the hospitals' administrative databases. The study began with a cohort of patients who had an index cardiac event rather than with asymptomatic individuals. CONCLUSIONS: Age, past cardiovascular events, and current vascular risk factors accounted for most of the income-mortality gradient after acute MI. This observation suggests that the "wealth-health gradient" in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factors among less affluent persons. *For a list of members of the SESAMI Study Group, see the Appendix.

Trauma base knowledge and the effect of the trauma evaluation and management program among senior medical students in seven countries.

BACKGROUND: We compared base trauma knowledge and the impact of the Trauma Evaluation and Management (TEAM) program among senior medical students in seven countries. METHODS: We compared pre- and post-TEAM multiple choice question scores of fourth-year students in Jamaica (n = 32), Trinidad (n = 32), Costa Rica (n = 64), Australia (n = 35), United Arab Emirates (n = 68), Toronto (n = 29) and Pennsylvania (n = 34). Means and degree of improvement were compared by analysis of variance (p < 0.05 for statistical significance). Percentage pass (based on 70% or 60% pass mark), student's perception of instruction level, and grading of TEAM (based on the percentage of students grading 1-5 for each category) were assessed by chi2 analysis. [table: see text]. RESULTS: Only 31.4% of students achieved the borderline pass mark of 60%, and 5.4% achieved a clear pass mark of 70%. The performance before and after TEAM was quite variable among medical schools. A grade of > or = 4 was assigned by 74% to 100% for objectives, knowledge improvement, satisfaction, and recommending TEAM for the curriculum. TEAM was rated "just right" by 70.3% to 92.7%, "too simple" by 1.6% to 21.6%, and "too advanced" by 3.3% to 13.5% of students. CONCLUSION: Base trauma knowledge in these students, though variable, was generally very low and improved with TEAM. Our data suggest a need for greater undergraduate emphasis in trauma education.

Trauma evaluation and management: who benefits among medical students?

BACKGROUND: This study examines whether or not the ACS ATLS Subcommittee's Trauma Evaluation and Management (TEAM) course is more appropriate for third (Y3) or fourth year (Y4) medical students. MATERIALS AND METHODS: Y3 and Y4 students were divided into control (CTL: 41 Y3, 17 Y4) and experimental (EXP: 39 Y3, 17 Y4) groups. The EXP groups had a 20-item, multiple-choice question exam before, and a similar exam after TEAM. The control CTL group took both exams prior to TEAM. Repeated measures analysis of variance was used for statistical comparison with group and year as between subject factors and with P < 0.05 being considered statistically significant. RESULTS: For the Y4 CTL, pretest was 58.8 +/- 10.5% and posttest was 54.4 +/- 11.2%. For the Y3 CTL, pretest was 53.0 +/- 11.8% and posttest was 47.6% +/- 11.4%. For the Y4 EXP, pretest was 59.4% +/- 11.5% and posttest was 69.1 +/- 8.3%. For the Y3 EXP, pretest was 49.2 +/- 11.4% and posttest was 55.0 +/- 10.9%. The difference between experimental and control groups was statistically significant (P = 0.042). The scores for Y4 were higher than Y3 in all groups (P < 0.001). The distribution of scores of Y4 control was nearly identical to Y3 experimental, suggesting that the improvement with TEAM in Y3 was equivalent to the improvement following the traditional curriculum in Y4 without TEAM. CONCLUSIONS: Y3 and Y4 students improved their performance following TEAM, but Y4 students had greater improvement. Y4 students without TEAM achieved scores similar to or greater than students who completed TEAM in Y3. TEAM appears to be more effectively directed to Y4 medical students.

Congenital abnormalities and childhood cancer.

BACKGROUND: The examination of specific characteristics of neoplasms diagnosed in children have suggested that a significant proportion can be attributed to a genetic mutation or genetic predisposition. Although the study of a genetic predisposition to cancer in children remains in the early stages, congenital abnormalities could provide essential information for mapping predisposing lesions in children with cancer. METHODS: In the current study, 2 large cohorts of children with and without congenital abnormalities were followed for the occurrence of cancer and death up to 18 years. Through this study, the risk of developing cancer by age at diagnosis, effects of birth characteristics on cancer risk, and possible associations between specific anomalies and tumor types were examined. RESULTS: Based on the follow-up of 90,400 children, the risk of developing cancer during the first year of life was found to be nearly 6 times higher in children with anomalies (rate ratio [RR] of 5.8; 95% confidence interval [95% CI], 3.7-9.1). Children with birth defects were found to be at a higher risk for developing leukemia (RR of 2.7; 95% CI, 2.1-3.6), tumors of the central nervous system (RR of 2.5; 95% CI, 1.8-3.4), sympathetic nervous system tumors (RR of 2.2; 95% CI, 1.4-3.4), and soft tissue sarcomas (RR of 1.9; 95% CI, 1.0-3.5). Among children with birth defects, children with Down syndrome, nervous system anomalies, and anomalies of the urinary system had the highest incidence rates of cancer. In the presence of birth defects, other factors such as birth weight, gestational age, age of the mother, and birth order were not found to be associated significantly with the risk of cancer. CONCLUSIONS: The significant relative risks found in the current study provided evidence of links between the presence of abnormalities and the development of cancer. Some "cancer-prone" abnormalities were identified in the current study. Such anomalies may be markers of other exposures or processes that increase the risk of developing cancer.

Provider volume and other predictors of outcome after total knee arthroplasty: a population study in Ontario.

INTRODUCTION: Because of rationing of the limited pool of health care resources, access to total knee arthroplasty (TKA) is limited, but investigation of variables that predict complications, length of hospital stay, cost and outcomes of TKA may allow us to optimize the available resources. The objective of this study was to examine the effect of various factors on complication rates after TKA in patients managed in Ontario. METHODS: Patients who had undergone an elective TKA between 1993 and 1996, as captured in the Canadian Institute for Health Information (CIHI) database, formed the study cohort. The CIHI dataset was used to obtain information regarding in-hospital complications, hospital length of stay, revision rates, infection rates and mortality. Generalized estimating linear or logistic regression equations were used to model outcomes as a function of age, gender, comorbidity, diagnosis and provider volume. RESULTS: During the study period, 14,352 patients in Ontario underwent TKA. Mortality at 3 months was associated with patient age, gender and comorbidity. There was no association between provider volume and mortality or the infection rate. Higher revision rates at 1 and 3 years were significantly associated with lower patient age and low hospital volume (p < 0.05). Hospitals in which fewer than 48 TKA procedures were done per year (< 40th percentile) had 2.2-fold greater 1-year revision rates than hospitals performing more than 113 TKAs annually (> 80th percentile). Complications during admission were associated with increased patient age and comorbidity, and higher hospital volume. Longer hospital stay was associated with female gender, increasing patient comorbidity and age, and lower provider volume. Surgeons who performed fewer than 14 TKAs annually (< 40th percentile) kept patients in hospital an average of 1.4 days longer than surgeons performing more than 42 TKAs annually (> 80th percentile). CONCLUSIONS: Patient variables significantly affect the rate of complications. Age, sex and comorbidity were significant predictors of complications, length of hospital stay and mortality after TKA. Although low surgeon volume was related to longer hospital stay, there was no association between surgeon volume and complication rates. The increased early revision rate for low-volume hospitals demands further study.

Teaching effectiveness of the trauma evaluation and management module for senior medical students.

BACKGROUND: The Trauma Evaluation and Management (TEAM) module was devised by the American College of Surgeons for teaching senior medical students trauma management principles. This article reports on the teaching effectiveness of this module. METHOD: Cognitive skills (by 20 item multiple-choice question examination on trauma topics) and clinical trauma management skills performance, using the Objective Structured Clinical Examination, were compared between two groups of 16 randomly selected final year medical students who had completed the standard curriculum including trauma topics. One group had the TEAM (TEAM group) and the other did not (no-TEAM group). Objective Structured Clinical Examination score (percentage), Priority score (range, 1-7), Organized Approach score (range, 1-5), and Global Pass status were assigned at each station. The students also completed a five-part questionnaire. RESULTS: Results of the questionnaire showed that on a scale of 1 to 5, with 5 being excellent, 96.8% assigned a score of 4 or greater, indicating the objectives were met, 83.8% that trauma knowledge was improved, 51.6% that clinical skills were improved, 90.3% that the module should be mandatory, and 83.9% overall satisfaction with the program. CONCLUSION: The TEAM module is very effective in teaching trauma management principles to senior medical students, by whom the program was very well received. Consideration should be given to adopting this program more widely in our medical undergraduate curriculum.

Arthroscopic débridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario.

BACKGROUND: There is little available information regarding the effectiveness of arthroscopic knee débridement for the treatment of arthritis. The purpose of this study was to evaluate patterns of utilization of arthroscopic knee débridement and outcomes following that procedure for the treatment of degenerative arthritis in persons fifty years of age or older in the Province of Ontario. METHODS: All patients fifty years of age or older who underwent elective arthroscopic knee débridement for the treatment of degenerative arthritis between 1992 and 1996 were identified from administrative data sets. Surgical complications and subsequent knee replacements were noted. Population rates were compared across the sixteen District Health Council regions within Ontario. Outcomes were modeled as a function of patient age, gender, and comorbidity with use of multivariate regression analysis. RESULTS: We identified 14,391 eligible unilateral arthroscopic knee débridement procedures. There was a threefold difference in the population rate of arthroscopic débridement across geographic regions. Overall, 1330 (9.2%) of all patients required total knee arthroplasty within one year after the débridement. Of the 6212 patients with a minimum three-year follow-up, 1146 (18.4%) had undergone total knee replacement within three years following the débridement. Patients who were at least seventy years of age were 4.7 times more likely to have total knee arthroplasty within one year after the débridement than were those less than sixty years of age (19.0% compared with 4.0%; p < 0.05). Patients sixty years of age or older were more likely to have an early total knee replacement (within one year after the débridement) in District Health Council regions where the population rates of arthroscopic knee débridement were higher (p = 0.04). CONCLUSIONS: The higher rates of early total knee arthroplasty and the significant relationship between rates of early total knee arthroplasty and rates of utilization suggest that arthroscopic débridement for the treatment of osteoarthritis of the knee may be overutilized in elderly patients. Important clinical issues such as patient preference, risk perception, and functional outcome cannot be addressed just with the administrative data used for this study.