Surprisingly long body length of the lungworm Parafilaroides gymnurus from common seals of the Dutch North Sea.

Lungworms of the genera Parafilaroides and Otostrongylus are responsible for parasitic bronchopneumonia, the foremost disease of eastern Atlantic common seals (EACS, Phoca vitulina vitulina) in the Dutch North Sea. Recently, there have been increased reports of lungworm cases and observations of unusually long Parafilaroides sp. adults in this location. The initial aim of this study was to confirm the identity of the Parafilaroides species infecting this population. Parafilaroides are usually small and delicate, making them difficult to extract from host tissue, and there is often difficulty accessing fresh specimens for morphological study. The large size of the Dutch worms and the accessibility of specimens from numerous animals enabled the description and measurement of many intact specimens (N = 64) from multiple host animals (N = 20). Species identity was confirmed by targeted sequencing of ribosomal and mitochondrial DNA amplicons from a subset of worms. Worm morphology was consistent with descriptions for P. gymnurus, but the mature females were 1.9-fold and 3.4-fold longer than those recovered from French EACS (P ≤ 0.001) and Canadian western Atlantic common seals (Phoca vitulina concolor; P ≤ 0.0001). They were also significantly longer than mature female P. gymnurus described from other seal species, with the exception of those from harp seals of Les Escoumins, Quebec. We suggest that intraspecific genetic differences in P. gymnurus and the environment within the host could contribute to the variation reported here. This study is the first to describe P. gymnurus using morphological and molecular methods and should serve as a reference for identification of the species.

Development and feasibility of a web-based question prompt sheet to support information provision of health-related quality of life topics after oesophageal cancer surgery.

We developed a web-based question prompt sheet (QPS) to support information provision of health-related quality of life (HRQL) topics after oesophageal cancer surgery. The QPS was evaluated and updated in three consecutive studies. In Study 1, eight patients were guided in using the QPS. Feasibility was assessed by cognitive walkthrough, questionnaire and interview. We obtained 430 notes (217 negative, 213 positive) of patients' actions and or remarks, and 91 suggestions. With minor support, most patients were able to use the QPS. In Study 2, forty patients independently used and appraised a modified version of the QPS by questionnaire. All patients deemed the QPS to be usable and useful. In Study 3, 21 patients and three surgeons used the QPS in clinical practice. Clinical feasibility was assessed by the number of QPS sent to the researcher/surgeon. Patients and surgeons were surveyed and the follow-up consultation was audio-recorded. Surgeons were additionally interviewed. Twenty/fourteen patients sent their QPS to the researcher/surgeon. Five QPSs were read by the consultation surgeon. Patients considered the QPS usable and useful. Surgeons considered the QPS of added value and helpful in informing patients, but currently not clinically feasible due to increased consultation time.

How can communication by oncologists enhance patients' trust? An experimental study.

BACKGROUND: Cancer patients need to trust their oncologist to embark in the process of oncologic treatment. Yet, it is unclear how oncologist communication contributes to such trust. The aim of this study was to investigate the effect of three elements of oncologists' communication on cancer patients' trust: conferring competence, honesty, and caring. METHODS: Eight videotaped consultations, 'vignettes', were created, reflecting an encounter between an oncologist and a patient with colorectal cancer. All vignettes were identical, except for small variations in the oncologist's verbal communication. Cancer patients (n = 345) were randomly assigned to viewing two vignettes, asked to identify with the patient and afterwards to rate their trust in the observed oncologist. The effects of competence, honesty, and caring on trust were established with multilevel analysis. RESULTS: Oncologist's enhanced expression of competence (ß = 0.17, 95% CI 0.08, 0.27; P < 0.001), honesty (ß = 0.30, 95% CI 0.20, 0.40; P < 0.001), as well as caring (ß = 0.36, 95% CI 0.26, 0.46; P < 0.001) resulted in significantly increased trust. Communication of honesty and caring also increased patients' expectation of operation success and reported willingness to recommend the oncologist. CONCLUSION(S): As hypothesized, oncologists can influence their patients' trust by enhanced conveyance of their level of competence, honesty, and caring. Caring behavior has the strongest impact on trust. These findings can be translated directly into daily clinical practice as well as in communication skills training.

Information gain in patients using a multimedia website with tailored information on anaesthesia.

BACKGROUND: The preoperative visit is an appropriate time to educate the patient on anaesthesia. The aim of this study was to determine if a website, as an information source for anaesthesia before the visit to the preoperative assessment clinic (PAC), increases patients' knowledge on anaesthesia. METHODS: A multimedia website was developed containing specific information about anaesthesia relevant to the patient. A questionnaire was developed to measure knowledge gain. Patients were divided into three groups: (i) those who read the existing brochure; (ii) those who looked at the new website; and (iii) a cluster of non-brochure and non-website users: those who did not read the brochure or website but had completed the questionnaire. An anaesthesiologist also informed all three groups during the preoperative visit at the PAC. RESULTS: Patients visiting the website had a higher educational level than others. A significant increase in knowledge was observed after using the website information compared with the other two groups (P<0.001). The group with higher education levels had higher knowledge gains, and the website independently contributed to the knowledge gain. CONCLUSIONS: A patient-tailored multimedia website is an effective way to support the information provided by the anaesthesiologist in order to inform patients about their upcoming anaesthetic procedure. The use of such a website gives a significant increase in knowledge compared with only spoken information, or spoken information combined with a brochure.

Under what conditions do patients want to be informed about their risk of a complication? A vignette study.

BACKGROUND: Discussing treatment risks has become increasingly important in medical communication. Still, despite regulations, physicians must decide how much and what kind of information to present. OBJECTIVE: To investigate patients' preference for information about a small risk of a complication of colonoscopy, and whether medical and personal factors contribute to such preference. To propose a disclosure policy related to our results. DESIGN: Vignettes study. SETTING: Department of Gastroenterology, Academic Medical Centre, the Netherlands. PATIENTS: 810 consecutive colonoscopy patients. INTERVENTION: A home-sent questionnaire containing three vignettes. Vignettes varied in the indication for colonoscopy, complication severity and level of risk. Patients were invited to indicate their wish to be informed and the importance of such information. In addition, sociodemograhic, illness-related and psychological characteristics were assessed. MAIN OUTCOME MEASUREMENTS: Wish to be informed and importance of information. RESULTS: Of 810 questionnaires, 68% were returned. Patients generally wished to be informed about low-risk complications, regardless of the indication for colonoscopy or the severity of the complication. The level of risk did matter, though (OR = 2.48, SE = 0.28, p = 0.001). The information was considered less important if done for population screening purposes or diagnosis of colon cancer, if the complication was less severe (bleeding) and if the risk was smaller (0.01% and 0.1%). Patients' information preference was also related to age, mood and coping style. LIMITATIONS: Difficulty of vignettes. CONCLUSIONS: Patients generally wish to be informed about all possible risks. However, this might become uninformative. A stepwise approach is suggested.

How long do I have? Observational study on communication about life expectancy with advanced cancer patients.

OBJECTIVE: To examine how communication about life expectancy is initiated in consultations about palliative chemotherapy, and what prognostic information is presented. METHODS: Patients with advanced cancer (n=41) with a median life expectancy <1year and oncologists (n=6) and oncologists-in-training (n=7) meeting with them in consultations (n=62) to discuss palliative chemotherapy were included. Verbatim transcripts of audio-recorded consultations were analyzed using MAXqda10. RESULTS: Life expectancy was addressed in 19 of 62 of the consultations. In all cases, patients took the initiative, most often through direct questions. Estimates were provided in 12 consultations in various formats: the likelihood of experiencing a significant event, point estimates or general time scales of "months to years", often with an emphasis on the "years". The indeterminacy of estimates was consistently stressed. Also their potential inadequacy was regularly addressed, often by describing beneficial prognostic predictors for the specific patient. Oncologists did not address the reliability or precision of estimates. CONCLUSION: Oncologists did not initiate talk about life expectancy, they used different formats, emphasized the positive and stressed unpredictability, yet not ambiguity of estimates. PRACTICE IMPLICATIONS: Prognostic communication should be part of the medical curriculum. Further research should address the effect of different formats of information provision.

Quality of life in goserelin-treated versus cyclophosphamide + methotrexate + fluorouracil-treated premenopausal and perimenopausal patients with node-positive, early breast cancer: the Zoladex Early Breast Cancer Research Association Trialists Group.

PURPOSE: To compare quality of life (QoL) in premenopausal and perimenopausal patients with node-positive, early breast cancer treated with the endocrine agent goserelin (Zoladex; AstraZeneca Pharmaceuticals LP, Wilmington, DE) or cyclophosphamide + methotrexate + fluorouracil (CMF). PATIENTS AND METHODS: Patients from 86 centers worldwide were randomly assigned to receive either goserelin (3.6 mg every 28 days for 2 years; n = 514) or CMF (six 28-day cycles; n = 496), and were included in the QoL study. QoL was assessed using a self-administered patient questionnaire that consisted of 39 items from the Rotterdam Symptom Checklist, including dimensions evaluating physical and psychological symptom distress, activities of daily living, hormonal effects, and an assessment of overall QoL. RESULTS: Early benefits were noted during months 3 to 6 of treatment, for goserelin compared with CMF. Significant differences were found for changes in overall QoL (eg, 6.96 +/- 0.88 v 0.69 +/- 0.92 at 6 months; P <.0001) and for physical symptom distress, activity levels, and "effort to cope with illness" dimensions. At 1, 2, and 3 years, there were no significant differences in overall QoL or specific QoL dimensions. Scores for hormonal symptoms were worse with goserelin during the 2-year goserelin treatment period; however, this trend was reversed at 3 years. CONCLUSION: Goserelin offers improved overall QoL during the first 6 months of therapy compared with CMF chemotherapy in premenopausal and perimenopausal patients with early breast cancer. Coupled with equivalent efficacy in estrogen receptor-positive patients, these data support the use of goserelin as an alternative to CMF in premenopausal and perimenopausal patients with estrogen receptor-positive, node-positive early breast cancer.

Decision support for patients with early-stage breast cancer: effects of an interactive breast cancer CDROM on treatment decision, satisfaction, and quality of life.

PURPOSE: To investigate the effects of the Interactive Breast Cancer CDROM as a decision aid for breast cancer patients with a choice between breast conserving therapy (BCT) and mastectomy (MT). PATIENTS AND METHODS: Consecutive patients with stage I and II breast cancer were enrolled. A quasi-experimental, longitudinal, and pretest/posttest design was used. Follow-up was scheduled 3 and 9 months after discharge from the hospital. Control patients (n = 88) received standard care (oral information and brochures). The CDROM was provided to patients in the experimental condition (n = 92) as a supplement to standard procedures. Outcome variables were treatment decision, satisfaction, and quality of life (QoL). RESULTS: No effect on treatment decision was found. CDROM patients expressed more general satisfaction with information at 3 and 9 months (95% confidence interval for the difference (d) between the means (d: 4.1 to 12.5 and 5.7 to 14.2 respectively). CDROM patients were also more satisfied with their treatment decision at 3 and at 9 months (d: 0.1 to 0.4; 0.2 to 0.5). Moreover, at 9 months, CDROM patients were more satisfied with breast cancer-specific information (d: 0.9 to 16.5), the decision-making process (d: 0.1 to 0.4), and communication (d: 0.2 to 11.0). At 3 and 9 months, a positive effect was found on general health (d: 0.2 to 14.5 and 0.3 to 15.0). Moreover, at 9 months, CDROM patients reported better physical functioning (d: 5.1 to 19.8), less pain (d: -17.9 to -4.5), and fewer arm symptoms (d: -14.1 to -0.5). CONCLUSION: The Interactive Breast Cancer CDROM improved decision making in patients with early-stage breast cancer with a choice between BCT and MT, as evaluated in terms of patients' satisfaction and QoL.

Methodologic issues in effectiveness research on palliative cancer care: a systematic review.

BACKGROUND: The objective of this report is to explore methodologic issues on the basis of a systematic review of the literature of effectiveness research on palliative cancer care with regard to selection and characteristics of a study population, interventions, and outcome assessment. METHODS: A systematic review was performed of randomized clinical trials on comprehensive palliative care with quality assessment of the studies by three independent observers, using predefined quality criteria. RESULTS: In the literature search, 11 relevant studies were identified. Without exception, methodologic problems were experienced. In two studies, the problems were so severe that no results were reported. Problems were associated with the recruitment of a study population in 10 studies, its homogeneity in six, patient attrition in four, defining and maintaining the contrast between the strategies in six, and selection of the outcome variables in four. CONCLUSION: Effectiveness research in palliative care is complex and has many pitfalls. To enhance the quality of future palliative care trials and the validity of their results, we particularly stress the importance of careful case finding, strict eligibility criteria, precise documentation of the process of care, and comprehensive outcome measurement. The relation of structure, process, and outcome variables in comprehensive palliative care should be further explored. It is a challenge for future research to link patient outcomes to the quality of care, independent from the autonomous course of the disease and from personal characteristics.

The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study.

PURPOSE: To construct a breast cancer-specific quality-of-life questionnaire (QLQ) module to be used in conjunction with the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and to test its reliability and validity cross-culturally. PATIENTS AND METHODS: Module construction took place after the EORTC guidelines for module development. The module--the QLQ-BR23--consists of 23 items covering symptoms and side effects related to different treatment modalities, body image, sexuality, and future perspective. This module was tested in 170 Dutch, 168 Spanish, and 158 American cancer patients at two points in time. The timing for the Dutch and Spanish patients was before and during treatment with radiotherapy or chemotherapy. For the American patients, the questionnaire was administered at admission at the breast clinic and 3 months after the first assessment. RESULTS: Multitrait scaling analysis confirmed the hypothesized structure of four of the five scales. Cronbach's alpha coefficients were, in general, lowest in Spain (range; .46 to .94) and highest in the United States (range; .70 to .91). On the basis of known-groups comparisons, selective scales distinguished clearly between patients differing in disease stage, previous surgery, performance status, and treatment modality, according to expectation. Additionally, selective scales detected change over time as a function of changes in performance status and treatment-induced change. CONCLUSION: These results lend support to the clinical and cross-cultural validity of the QLQ-BR23 as a supplementary questionnaire for assessing specific quality-of-life issues relevant to patients with breast cancer.

Quality of survival after cardiopulmonary resuscitation.

BACKGROUND: Outcome of cardiopulmonary resuscitation (CPR) can be poor, in terms of life expectancy and quality of life. OBJECTIVES: To determine the impact of patient characteristics before, during, and after CPR on these outcomes, and to compare results of the quality-of-life assessment with published studies. METHODS: In a cohort study, we assessed by formal instruments the quality of life, cognitive functioning, depression, and level of dependence of survivors after inhospital CPR. Follow-up was at least 3 months after discharge from the hospital (tertiary care center). RESULTS: Of 827 resuscitated patients, 12% (n = 101) survived to follow-up. Of the survivors, 89% participated in the study. Most survivors were independent in daily life (75%), 17% were cognitively impaired, and 16% had depressive symptoms. Multivariate regression analysis showed that quality of life and cognitive function were determined by 2 factors known before CPR-the reason for admission and age. Factors during and after resuscitation, such as prolonged cardiac arrest and coma, did not significantly determine the quality of life or cognitive functioning of survivors. The quality of life of our CPR survivors was worse compared with a reference group of elderly individuals, but better than that of a reference group of patients with stroke. The quality of life did not importantly differ between the compared studies of CPR survivors. CONCLUSIONS: Cardiopulmonary resuscitation is frequently unsuccessful, but if survival is achieved, a relatively good quality of life can be expected. Quality of life after CPR is mostly determined by factors known before CPR. These findings may be helpful in informing patients about the outcomes of CPR.

The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study.

PURPOSE: To answer the question whether a single fraction of radiotherapy that is considered more convenient to the patient is as effective as a dose of multiple fractions for palliation of painful bone metastases. PATIENTS: 1171 patients were randomised to receive either 8 Gy x 1 (n = 585) or 4 Gy x 6 (n = 586). The primary tumour was in the breast in 39% of the patients, in the prostate in 23%, in the lung in 25% and in other locations in 13%. Bone metastases were located in the spine (30%), pelvis (36%), femur (10%), ribs (8%), humerus (6%) and other sites (10%). METHOD: Questionnaires were mailed to collect information on pain, analgesics consumption, quality of life and side effects during treatment. The main endpoint was pain measured on a pain scale from 0 (no pain at all) to 10 (worst imaginable pain). Costs per treatment schedule were estimated. RESULTS: On average, patients participated in the study for 4 months. Median survival was 7 months. Response was defined as a decrease of at least two points as compared to the initial pain score. The difference in response between the two treatment groups proved not significant and stayed well within the margin of 10%. Overall, 71% experienced a response at some time during the first year. An analysis of repeated measures confirmed that the two treatment schedules were equivalent in terms of palliation. With regard to pain medication, quality of life and side effects no differences between the two treatment groups were found. The total number of retreatments was 188 (16%). This number was 147 (25%) in the 8 Gy x 1 irradiation group and 41 (7%) in the 4 Gy x 6 group. It was shown that the level of pain was an important reason to retreat. There were also indications that doctors were more willing to retreat patients in the single fraction group because time to retreatment was substantially shorter in this group and the preceding pain score was lower. Unexpectedly, more pathological fractures were observed in the single fraction group, but the absolute percentage was low. In a cost-analysis, the costs of the 4 Gy x 6 and the 8 Gy x 1 treatment schedules were calculated at 2305 and 1734 Euro respectively. Including the costs of retreatment reduced this 25% cost difference to only 8%. The saving of radiotherapy capacity, however, was considered the major economic advantage of the single dose schedule. CONCLUSION: The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A more detailed analysis of the study is in progress.

Which chronic conditions are associated with better or poorer quality of life?

The objective of the present study is to compare the QL of a wide range of chronic disease patients. Secondary analysis of eight existing data sets, including over 15,000 patients, was performed. The studies were conducted between 1993 and 1996 and included population-based samples, referred samples, consecutive samples, and/or consecutive samples. The SF-36 or SF-24 were employed as generic QL instruments. Patients who were older, female, had a low level of education, were not living with a partner, and had at least one comorbid condition, in general, reported the poorest level of QL. On the basis of rank ordering across the QL dimensions, three broad categories could be distinguished. Urogenital conditions, hearing impairments, psychiatric disorders, and dermatologic conditions were found to result in relatively favorable functioning. A group of disease clusters assuming an intermediate position encompassed cardiovascular conditions, cancer, endocrinologic conditions, visual impairments, and chronic respiratory diseases. Gastrointestinal conditions, cerebrovascular/neurologic conditions, renal diseases, and musculoskeletal conditions led to the most adverse sequelae. This categorization reflects the combined result of the diseases and comorbid conditions. If these results are replicated and validated in future studies, they can be considered in addition to information on the prevalence of the diseases, potential benefits of care, and current disease-specific expenditures. This combined information will help to better plan and allocate resources for research, training, and health care.

How response shift may affect the measurement of change in fatigue.

If patients experience extreme fatigue during treatment, they may judge the level of fatigue following this experience differently from how they would have judged it before. This change in internal standard is referred to as a response shift. We explored whether a response shift might have occurred in patients receiving radiotherapy (n = 199). Fatigue was assessed before and after radiotherapy. Following completion of the post-test, a thentest was administered where patients had to provide a renewed judgment of their pre-treatment level of fatigue. Response shift was assessed by the mean difference between the pre-test and thentest scores. Comparing the thentest with the pretest scores, patients retrospectively minimized their pre-treatment level of fatigue. The thentest-post-test difference was significant, whereas the conventional pretest-post-test difference was not. These results are in line with the occurrence of a response shift. Additional hypotheses regarding response shift were partially supported. It is concluded that the potentially large implications of response shift justify further research.

Inflammatory Bowel Disease Questionnaire: cross-cultural adaptation and further validation.

OBJECTIVES: The Inflammatory Bowel Disease Questionnaire (IBDQ) is a disease-specific quality of life instrument. We translated and adapted the questionnaire and tested its reliability and (cross-cultural) validity. METHODS: We surveyed 271 patients with inflammatory bowel disease. The inflammatory Bowel Disease Questionnaire and its dimensional scores (bowel, systemic, social and emotional) were correlated with disease activity, health care use, medication and three other indices of quality of life. RESULTS: The reliability coefficient of the Inflammatory Bowel Disease Questionnaire was high (0.93). Patients with higher disease activity had significantly lower quality of life on all Inflammatory Bowel Disease Questionnaire dimensions (P < 0.001). Inflammatory Bowel Disease Questionnaire scores were significantly correlated with health care use (P < 0.01) but not with medication. Almost all Inflammatory Bowel Disease Questionnaire dimensions correlated highly (0.43-0.79, P < 0.001) with the corresponding scales of the standard quality of life indices, except for the bowel dimension. Modified Dutch Inflammatory Bowel Disease Questionnaire scores were consistent with Canadian Inflammatory Bowel Disease Questionnaire norms. CONCLUSIONS: These results support the Inflammatory Bowel Disease Questionnaire as a reliable and valid measure of the quality of life of inflammatory bowel disease patients in multicultural research settings.

Predictors of health care utilization in patients with inflammatory bowel disease: a longitudinal study.

OBJECTIVES: To predict health care utilization in patients with inflammatory bowel disease (IBD). METHODS: The health care utilization of 222 consecutive IBD patients was studied twice over the course of one year. Utilization consisted of medical care, including visits to the gastroenterologist and the general practitioner, and non-medical care, including use of a psychotherapist, a dietitian or home care nurse in the last six months. Prior and concurrent socio-demographic, disease-related and psychosocial factors were measured and their association with patient health care utilization was determined. RESULTS: Poor quality of life, disease burden experienced and depression were significantly (P < 0.01) associated with more visits to both gastroenterologist and GP. Disease activity was found to be significantly correlated to gastroenterologist visits, while female gender was associated with GP visits. Other socio-demographic and disease-related factors were not related to medical care utilization. Results of regression analysis indicated that prior disease burden experienced, social functioning and female sex are the best predictors of physician visits a year later. Of the concurrent factors, the best predictors were disease activity, emotional and social functioning, and disease burden experienced. Psychotherapy and home care were significantly correlated (P < 0.01) with co-morbidity, disease activity, quality of life and depression. Non-medical care utilization was not related to the majority of sociodemographic factors. CONCLUSION: Psychosocial factors, such as poor quality of life and disease burden experienced, are important predictors of health care utilization in IBD patients. Addressing these problems should not only increase the patient's quality of life, but also minimize health care utilization.

Test-retest reliabilities of two treatment-preference instruments in measuring utilities.

The authors assessed the test-retest reliabilities of two treatment-preference instruments recently applied to the measurement of the utilities of health states after different treatment modalities for cancer. The first instrument measures the strengths of preferences concerning a choice between a wait-and-see policy, and treatment with radiotherapy after an initial surgical breast-conserving procedure for early breast cancer. The second measures the strengths of preferences concerning a choice between two hypothetical surgical treatment outcomes in cancer of the rectum with different probabilities of expected five-year survival. Both measure the strength of a subject's treatment preference given probabilities of treatment-related costs and benefits. The subjects were radiotherapy technicians (n = 20) and cancer patients (n = 20) who were interviewed in weeks 2 and 4 of radiotherapy. The test-retest reliabilities of both instruments were inconsistent and moderately high, with Spearman's rank correlations ranging from 0.38 to 0.81 and weighted kappas ranging from 0.38 to 0.69. To investigate whether the start of treatment with radiotherapy influenced the utilities that patients assigned to health states, the same procedure was applied in another, comparable, group of patients with cancer (n = 20). For this group, the first assessment was made prior to the start of treatment and the second during the second week of radiation therapy. The scores of this group of patients indeed appeared to be less stable than the scores of the patients assessed in weeks 2 and 4 of radiotherapy. However, the instability of the scores could have been the result of test bias.

Feasibility and effects of decision aids.

Decision aids for patients have recently been introduced in health care. A literature review was conducted to address the following research questions: 1) which types of decision aids have been developed?; 2) to what extent are they feasible, and acceptable to patients and health care providers?; 3) do decision aids affect the decision-making process and patients' outcomes? Thirty non-controlled (e.g., one-group-only designs) and controlled studies (e.g., randomized experimental designs) were identified. Decision aids were found to be feasible and acceptable to patients and to increase the agreement between patients' values and decisions and patients' knowledge. The effects of decision aids on decisions and on patients' outcomes, including decision uncertainty, satisfaction, and health, have rarely been addressed. When studied, the beneficial effects of decision aids on these outcomes appear to be rather modest. Implications for future development of decision aids and the design of studies are discussed.

The decisional conflict scale: further validation in two samples of Dutch oncology patients.

The importance of patient involvement in medical decision making is indisputable. Yet, decision making concerning medical treatment options is a difficult task for most patients. In order to study decision-making processes in health care, O'Connor developed the decisional conflict scale (DCS). The DCS assesses the level of 'decisional conflict' that patients experience while making health care decisions, and encompasses the following three subscales: (1) uncertainty about choosing among alternatives; (2) factors contributing to uncertainty; (3) perceived effectiveness of the decision. The aim of the present study is to investigate the reliability and validity of the Dutch version of the DCS. A written version of the DCS was administered in two samples of Dutch cancer patients. One sample consisted of cancer patients faced with the decision whether or not to undergo palliative chemotherapy (N=29). The other sample included women with early stage breast cancer who had to choose between mastectomy or lumpectomy followed by radiation therapy (N=141). The response rates were 76% and 91%, respectively. The reliability coefficients of the three subscales were 0.52, 0.80, 0.84, and 0.74, 0.83, 0.83 in the two samples, respectively. Construct validity was partly supported. Criterion validity was substantiated. In evaluating the factorial validity, it was found that the original three-factor model had to be rejected (chi(2)(87)=293, root mean square error of approximation (RMSEA)=0.137). A subsequent exploratory factor analysis suggested an alternative four-factor model. The psychometric properties of the DCS were partly confirmed in Dutch cancer patients. Improved 'wording' of certain items, e.g. to avoid double negatives, could further increase the factorial validity of the DCS. Then, this scale may be a valuable tool for studies that address the quality of medical decision making.

Predictors of health care utilization in the chronically ill: a review of the literature.

The objective of this paper is to identify predictors of health care utilization in the chronically ill. This paper reviews 53 studies on hospitalizations and physician visits, published between 1966 and 1997 and identified by MEDLINE and ClinPSYCH databases. Studies with both univariate and multivariate analyses were included. On the basis of the Andersen-Newman model of health care utilization, the effects of predisposing, enabling and need variables are examined. Most studies reviewed indicate that predisposing factors such as age, sex, and marital status are not predictors of hospital utilization in the chronically ill. The enabling factors income, insurance and social support have not been shown to affect health care utilization, but characteristics of the hospitals could have an effect. Need factors such as disease severity, symptom severity and complications adversely affected health care utilization in the chronically ill, while disease duration and comorbidity do not have such an effect. Quality of life and perceived health might affect hospital utilization and physician use. Finally, depression and psychological distress proved to be among the strongest predictors of hospitalizations and physician visits. In conclusion, both disease severity and psychological well-being are most important in health care utilization. Intervention programs to support depressed or psychologically distressed patients should be considered. These could both help the patient and reduce health care utilization costs.