Six-Month Prostate Cancer Empowerment Program (PC-PEP) Improves Urinary Function: A Randomized Trial.

Purpose: This is a secondary analysis examining a six-month home-based Prostate Cancer-Patient Empowerment Program (PC-PEP) on patient-reported urinary, bowel, sexual, and hormonal function in men with curative prostate cancer (PC) against standard of care. Methods: In a crossover clinical trial, 128 men scheduled for PC surgery (n = 62) or radiotherapy with/without hormones (n = 66) were randomized to PC-PEP (n = 66) or waitlist-control and received the standard of care for 6 months, and then PC-PEP to the end of the year. PC-PEP included daily emails with video instructions, aerobic and strength training, dietary guidance, stress management, and social support, with an initial PFMT nurse consultation. Over 6 months, participants in the PC-PEP received optional text alerts (up to three times daily) reminding them to follow the PFMT video program, encompassing relaxation, quick-twitch, and endurance exercises; compliance was assessed weekly. Participants completed baseline, 6, and 12-month International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC) questionnaires. Results: At 6 months, men in the PC-PEP reported improved urinary bother (IPSS, p = 0.004), continence (EPIC, p < 0.001), and irritation/obstruction function (p = 0.008) compared to controls, with sustained urinary continence benefits at 12 months (p = 0.002). Surgery patients in the waitlist-control group had 3.5 (95% CI: 1.2, 10, p = 0.024) times and 2.3 (95% CI: 0.82, 6.7, p = 0.11) times higher odds of moderate to severe urinary problems compared to PC-PEP at 6 and 12 months, respectively. Conclusions: PC-PEP significantly improves lower urinary tract symptoms, affirming its suitability for clinical integration alongside established mental health benefits in men with curative prostate cancer.

Integrating health geography and behavioral economic principles to strengthen context-specific behavior change interventions.

The long-term economic viability of modern health care systems is uncertain, in part due to costs of health care at the end of life and increasing health care utilization associated with an increasing population prevalence of multiple chronic diseases. Control of health care spending and sustaining delivery of health care services will require strategic investments in prevention to reduce the risk of disease and its complications over an individual's life course. Behavior change interventions aimed at reducing a range of harmful and risky health-related behaviors including smoking, physical inactivity, excess alcohol consumption, and excess weight, are one approach that has proven effective at reducing risk and preventing chronic disease. However, large-scale efforts to reduce population-level chronic diseases are challenging and have not been very successful at reducing the burden of chronic diseases. A new approach is required to identify when, where, and how to intervene to disrupt patterns of behavior associated with high-risk factors using context-specific interventions that can be scaled. This paper introduces the need to integrate theoretical and methodological principles of health geography and behavioral economics as opportunities to strengthen behavior change interventions for the prevention of chronic diseases. We discuss how health geography and behavioral economics can be applied to expand existing behavior change frameworks and how behavior change interventions can be strengthened by characterizing contexts of time and activity space.

Behavior change interventions are challenged by lack of information about the contexts influencing decisions patients make as part of their daily routine such as when, where, and how health behaviors occur. A new approach is required to strengthen behavior change interventions by integrating contexts of time and activity space so that strategies can be scaled across populations to influence how individuals make decisions about improving their health behaviors. Incorporating ideas from health geography and behavioral economics into the design of behavior change interventions provides an opportunity to collect and investigate individual-level health information characterizing contexts of individuals' activities across space, connections to place, time management, and patterns in behavior over time. By visualizing and characterizing key spatiotemporal contexts about an individual's day-to-day routine, insight can be gained about where and for how long activities occur and what opportunities exist for adapting day-to-day routines. This paper will discuss how theory from health geography could be applied to understand contexts influencing behaviors and how spatiotemporal information could be applied for the purpose of tailoring behavioral economic strategies to strengthen the design of behavior change interventions.

Disparities in access to primary care are growing wider in Canada.

Canadian provinces and territories have undertaken varied reforms to how primary care is funded, organized, and delivered, but equity impacts of reforms are unclear. We explore disparities in access to primary care by income, educational attainment, dwelling ownership, immigration, racialization, place of residence (metropolitan/non-metropolitan), and sex/gender, and how these have changed over time, using data from the Canadian Community Health Survey (2007/08 and 2015/16 or 2017/18). We observe disparities by income, educational attainment, dwelling ownership, recent immigration, immigration (regular place of care), racialization (regular place of care), and sex/gender. Disparities are persistent over time or increasing in the case of income and racialization (regular medical provider and consulted with a medical professional). Primary care policy decisions that do not explicitly consider existing inequities may continue to entrench them. Careful study of equity impacts of ongoing policy reforms is needed.

A Comprehensive 6-mo Prostate Cancer Patient Empowerment Program Decreases Psychological Distress Among Men Undergoing Curative Prostate Cancer Treatment: A Randomized Clinical Trial.

BACKGROUND: Although survival rates for newly diagnosed prostate cancer patients are very high, most of them will likely suffer significant treatment-related side effects, depression, or anxiety, affecting their quality of life. OBJECTIVE: The aim of this study was to examine the effects of a 6-mo online home-based physical, mental, and social support intervention, the Prostate Cancer Patient Empowerment Program (PC-PEP), on preventing psychological distress among men undergoing curative prostate cancer treatment. DESIGN, SETTING, AND PARTICIPANTS: In a crossover randomized clinical trial of 128 men aged 50-82 yr scheduled for curative prostate cancer surgery or radiotherapy (± hormone treatment), 66 received the 6-mo PC-PEP intervention and 62 were randomized to a waitlist-control arm and received the standard of care for 6 mo, and then PC-PEP to the end of the year. The PC-PEP intervention consisted of daily e-mails with video instructions providing education, patient activation, and empowerment on healthy living including physical and mental health, dietary recommendations, social support, physical and pelvic floor fitness, stress reduction using a biofeedback device, social connection and intimacy, and social support. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was nonspecific psychological distress (clinical cutoff ≥20) measured at baseline, and at 6 and 12 mo using the Kessler Psychological Distress Scale (K10). RESULTS AND LIMITATIONS: At 6 mo, patients in the waitlist-control group had 3.59 (95% confidence interval: 1.12-11.51) times higher odds for nonspecific psychological distress and need for psychological treatment than men who received the PC-PEP intervention. At 12 mo, the wait-list control group that received the intervention at 6 mo had higher psychological distress than the early group. CONCLUSIONS: PC-PEP delivered early following diagnosis significantly prevented the burden of psychological distress in men undergoing curative prostate cancer treatment compared with standard of care, or late (6 mo later) intervention. PATIENT SUMMARY: In this report, we looked at the effectiveness of a program (Prostate Cancer Patient Empowerment Program: PC-PEP) developed with patients' engagement on the mental distress of patients awaiting curative treatment for their prostate cancer. The PC-PEP program lasted for 6 mo, and it prescribed, described, and demonstrated daily aerobic and strength training, kegels (pelvic floor training to help with urinary and sexual function), dietary changes that have been shown to be helpful in the prevention of prostate cancer and prostate cancer progression, stress reduction using a biofeedback device, as well as social and emotional support. All patients in the PC-PEP program were invited to a monthly video conference with the leads of the program who appeared in the 6 mo of daily videos prescribing the activities the patients were asked to watch and follow. The leads were a prostate cancer oncologist and a scientist in prostate cancer quality of life research. Half of the patients in this study received PC-PEP daily for the first 6 mo and were re-assessed at the end of the year. The other half received standard of care for 6 month and then received the intervention to the end of the year. The results of the study show that, at 6 mo, this intervention was effective at reducing the mental distress that accompanies a prostate cancer diagnosis and treatment compared with the standard of care. Mental distress was significantly reduced when the intervention was received early, compared with that received late (6 mo after scheduled curative treatment). We conclude that multi-faceted patient education and empowerment programming of this kind that is developed with patient engagement from the start is crucial to the care of patients diagnosed with prostate cancer and should be implemented in the standard of care. While treatment for prostate cancer is highly successful, side effects that accompany most treatments significantly affect the quality of life of patients. Here, we describe PC-PEP, a patient education and activation program that is cost effective, highly enforced by patients, and successful at reducing the impact of prostate cancer active treatment-related side effects on their psychological state. To learn more about this project, please visit www.pcpep.org. The program is now being tested in a phase 4 implementation trial throughout Canada and internationally (New Zealand), and is being expanded and tested for other types of cancer.

Item selection, scaling and construct validation of the Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC) measurement tool in adults.

PURPOSE: To select and scale items for the seven domains of the Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC) and assess its construct validity. METHODS: Using an online survey, data on 100 potential items, and other variables for assessing construct validity, were collected from 1055 adults with one or more chronic health conditions. Based on a validated conceptual model, confirmatory factor analysis (CFA) and item response models (IRT) were used to select and scale potential items and assess the internal consistency and structural validity of the PRISM-CC. To further assess construct validity, hypothesis testing of known relationships was conducted using structural equation models. RESULTS: Of 100 potential items, 36 (4-8 per domain) were selected, providing excellent fit to our hypothesized correlated factors model and demonstrating internal consistency and structural validity of the PRISM-CC. Hypothesized associations between PRISM-CC domains and other measures and variables were confirmed, providing further evidence of construct validity. CONCLUSION: The PRISM-CC overcomes limitations of assessment tools currently available to measure patient self-management of chronic health conditions. This study provides strong evidence for the internal consistency and construct validity of the PRISM-CC as an instrument to assess patient-reported difficulty in self-managing different aspects of daily life with one or more chronic conditions. Further research is needed to assess its measurement equivalence across patient attributes, ability to measure clinically important change, and utility to inform self-management support.

Predicting COVID-19 mortality risk in Toronto, Canada: a comparison of tree-based and regression-based machine learning methods.

BACKGROUND: Coronavirus disease (COVID-19) presents an unprecedented threat to global health worldwide. Accurately predicting the mortality risk among the infected individuals is crucial for prioritizing medical care and mitigating the healthcare system's burden. The present study aimed to assess the predictive accuracy of machine learning methods to predict the COVID-19 mortality risk. METHODS: We compared the performance of classification tree, random forest (RF), extreme gradient boosting (XGBoost), logistic regression, generalized additive model (GAM) and linear discriminant analysis (LDA) to predict the mortality risk among 49,216 COVID-19 positive cases in Toronto, Canada, reported from March 1 to December 10, 2020. We used repeated split-sample validation and k-steps-ahead forecasting validation. Predictive models were estimated using training samples, and predictive accuracy of the methods for the testing samples was assessed using the area under the receiver operating characteristic curve, Brier's score, calibration intercept and calibration slope. RESULTS: We found XGBoost is highly discriminative, with an AUC of 0.9669 and has superior performance over conventional tree-based methods, i.e., classification tree or RF methods for predicting COVID-19 mortality risk. Regression-based methods (logistic, GAM and LASSO) had comparable performance to the XGBoost with slightly lower AUCs and higher Brier's scores. CONCLUSIONS: XGBoost offers superior performance over conventional tree-based methods and minor improvement over regression-based methods for predicting COVID-19 mortality risk in the study population.

Nurse Navigators' Views on Patient and System Factors Associated with Navigation Needs among Women with Breast Cancer.

Coordinating breast cancer treatment is a complex task that can overwhelm patients and their support networks. Though the Cancer Patient Navigator (CPN) program in Nova Scotia (NS) provides professional assistance to patients, certain groups of patients may still face barriers to accessing its services. Employing interviews and a modified Delphi approach with CPN participants, this study sought to identify factors associated with the need for navigation to help better target CPN program referrals among breast cancer patients. Six CPNs were recruited directly through the CPN program manager for interviews and surveys. The CPNs identified 27 different factors, which were divided into 4 categories: sociodemographic, psychological, clinical and health systems. While these patient factors (particularly sociodemographic) are not directly modifiable, awareness of their association with the need for navigation could be used to better target patients with a high need for navigation for referral to CPN services.

Potential of community-based risk estimates for improving hospital performance measures and discharge planning.

BACKGROUND: Risk-adjusted rates of hospital readmission are a common indicator of hospital performance. There are concerns that current risk-adjustment methods do not account for the many factors outside the hospital setting that can affect readmission rates. Not accounting for these external factors could result in hospitals being unfairly penalized when they discharge patients to communities that are less able to support care transitions and disease management. While incorporating adjustments for the myriad of social and economic factors outside of the hospital setting could improve the accuracy of readmission rates as a performance measure, doing so has limited feasibility due to the number of potential variables and the paucity of data to measure them. This paper assesses a practical approach to addressing this problem: using mixed-effect regression models to estimate case-mix adjusted risk of readmission by community of patients' residence (community risk of readmission) as a complementary performance indicator to hospital readmission rates. METHODS: Using hospital discharge data and mixed-effect regression models with a random intercept for community, we assess if case-mix adjusted community risk of readmission can be useful as a quality indicator for community-based care. Our outcome of interest was an unplanned repeat hospitalisation. Our primary exposure was community of residence. RESULTS: Community of residence is associated with case-mix adjusted risk of unplanned repeat hospitalisation. Community risk of readmission can be estimated and mapped as indicators of the ability of communities to support both care transitions and long-term disease management. CONCLUSION: Contextualising readmission rates through a community lens has the potential to help hospitals and policymakers improve discharge planning, reduce penalties to hospitals, and most importantly, provide higher quality care to the people that they serve.

Managing everyday life: Self-management strategies people use to live well with neurological conditions.

OBJECTIVE: This paper uses the Taxonomy of Everyday Self-management Strategies (TEDSS) to provide insight and understanding into the complex and interdependent self-management strategies people with neurological conditions use to manage everyday life. METHODS: As part of a national Canadian study, structured telephone interviews were conducted monthly for eleven months, with 117 people living with one or more neurological conditions. Answers to five open-ended questions were analyzed using qualitative content analysis. A total of 7236 statements were analyzed. RESULTS: Findings are presented in two overarching patterns: 1) self-management pervades all aspects of life, and 2) self-management is a chain of decisions and behaviours. Participants emphasized management of daily activities and social relationships as important to maintaining meaning in their lives. CONCLUSION: Managing everyday life with a neurological condition includes a wide range of diverse strategies that often interact and complement each other. Some people need to intentionally manage every aspect of everyday life. PRACTICE IMPLICATIONS: For people living with neurological conditions, there is a need for health providers and systems to go beyond standard advice for self-management. Self-management support is best tailored to each individual, their life context and the realities of their illness trajectory.

The Team Assessment of Self-Management Support (TASMS): A new approach to uncovering how teams support people with chronic conditions.

Canadian and other healthcare systems are adopting primary care models founded on multidisciplinary, team-based care. This paper describes the development and use of a new tool, the Team Assessment of Self-Management Support (TASMS), designed to understand and improve the self-management support teams provide to patients with chronic conditions. Team Assessment of Self-Management Support captures the time providers spend supporting seven different types of self-management support (process strategies, resources strategies, disease controlling strategies, activities strategies, internal strategies, social interactions strategies, and healthy behaviours strategies), their referral patterns and perceived gaps in care. Four unique features make TASMS user-friendly: it is patient-centred, it uses provider-level data to create a team profile, it has the ability to be tailored to needs (diagnosis and visit type), and visual presentation of results are quickly and intuitively understood by both providers and planners. Currently being used by providers and planners in Nova Scotia, scaling up will allow more widespread use.

Protocol for development, calibration and validation of the Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC).

INTRODUCTION: Assessing and measuring patients' chronic condition self-management needs are critical to quality health care and to related research. One in three adults around the world live with multiple chronic conditions. While many patient-reported measures of self-management have been developed, none has emerged as the gold standard, and all have one or more of the following limitations: (1) they fail to measure the different domains of self-management important to patients, (2) they lack sufficient specificity to support patient-centred care or identify the specific components of self-management interventions that work and/or (3) they lack suitability for patients with multiple chronic conditions. METHODS AND ANALYSIS: The Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC) is being developed to overcome these shortcomings. It will measure respondents' perceived success (or difficulty) in self-managing seven domains important to patients. The protocol has three phases. Phase 1 is conceptual model development and item generation. Phase 2 is assessment of the relevance and understanding of items by people with chronic conditions. Phase 3 is item analysis, dimensionality assessment, scaling and preliminary validation of the PRISM-CC using an online survey of people with chronic conditions (n~750). The expected completion date is early 2021. ETHICS AND DISSEMINATION: This study will adhere to the Canadian Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans. Ethics approval for all phases has been obtained from the Nova Scotia Health Authority Research Ethics Board. Once completed, the PRISM-CC will be made available for research and healthcare at minimal to no cost.

Transitioning to Full Field Digital Mammography in Nova Scotia: Using Interrupted Time Series Methods to Study the Impact of Technology Change on Mammography Volumes.

BACKGROUND: Over the past decade, mammography has transitioned from film to digital media with promises of increased productivity and time savings. Between 2007 and 2010 in Nova Scotia, 10 mammography sites transitioned from analog to digital, providing a natural experiment to evaluate the transition (full-field digital mammography) on mammography with respect to changes in throughput volumes in a "real-world" setting. METHODS: Study data consisted of aggregate, monthly, site-specific counts of screening and diagnostic mammograms for the period 2006 to 2014, which were obtained from an information system that supports central booking, clinical reporting, and patient management for all breast imaging in Nova Scotia. A multigroup interrupted time series design using segmented regression with site-month data assessed pre-to post-transition changes in screening throughput volumes and the proportion of diagnostic mammograms performed. RESULTS: The overall mean monthly number of mammograms per machine per full-time equivalent increased by 17% from 192.9 (95% confidence interval: 182.7-203.1) to 225.7 (95% CI 218.3-233.0); however, there was marked heterogeneity across these sites. A pooled analysis for all sites revealed that there was no statistically significantly change in the proportion of diagnostic mammograms performed after transition. CONCLUSIONS: Increases in throughput volumes were observed only in some sites, suggesting unmeasured site-specific factors may have limited the potential for improvement. Interrupted time series methods are an appropriate and meaningful approach for evaluating technology and procedure changes in diagnostic imaging.

The Taxonomy of Everyday Self-management Strategies (TEDSS): A framework derived from the literature and refined using empirical data.

OBJECTIVE: To extend our understanding of self-management by using original data and a recent concept analysis to propose a unifying framework for self-management strategies. METHODS: Longitudinal interview data with 117 people with neurological conditions were used to test a preliminary framework derived from the literature. Statements from the interviews were sorted according to the predefined categories of the preliminary framework to investigate the fit between the framework and the qualitative data. Data on frequencies of strategies complemented the qualitative analysis. RESULTS: The Taxonomy of Every Day Self-management Strategies (TEDSS) Framework includes five Goal-oriented Domains (Internal, Social Interaction, Activities, Health Behaviour and Disease Controlling), and two additional Support-oriented Domains (Process and Resource). The Support-oriented Domain strategies (such as information seeking and health navigation) are not, in and of themselves, goal focused. Instead, they underlie and support the Goal-oriented Domain strategies. Together, the seven domains create a comprehensive and unified framework for understanding how people with neurological conditions self-manage all aspects of everyday life. CONCLUSIONS: The resulting TEDSS Framework provides a taxonomy that has potential to resolve conceptual confusion within the field of self-management science. PRACTICE IMPLICATIONS: The TEDSS Framework may help to guide health service delivery and research.

The structural and convergent validity of three commonly used measures of self-management in persons with neurological conditions.

PURPOSE: Self-management ability is commonly assessed in chronic disease research and clinical practice. The purpose of this study was to assess the structural and convergent validity of three commonly used self-management outcome measures in a sample of persons with neurological conditions. METHODS: We used data from a Canadian survey of persons with neurological conditions, which included three commonly used self-management measures: the Partners in Health Scale (PIH), the Patient Activation Measure (PAM), and the Self-Efficacy for Managing a Chronic Disease Scale (SEMCD). Confirmatory factor analysis was used to assess the structural and convergent validity of the three measures. RESULTS: When treated as single-factor constructs, none of the measurement models provided a good fit to the data. A four-domain version of the PIH was the best fitting model. Confirmatory factor analysis suggests that the three tools measure different, but correlated constructs. CONCLUSIONS: While the PAM, PIH and SEMCD scales are all used as measures of patient self-management, our study indicates that they measure different, but correlated latent variables. None, when treated as single, uni-dimensional construct, provides an acceptable fit to our data. This is probably because self-management is multi-dimensional, as is consistently shown by qualitative evidence. While these measures may provide reliable summative measures, multi-dimensional scales are needed for clinical use and more detailed research on self-management.

How adults with cardiac conditions in Singapore understand the Patient Activation Measure (PAM-13) items: a cognitive interviewing study.

PURPOSE: Validation studies of the PAM-13 have found differences in scale performance, suggesting that health beliefs embedded in different cultures and/or self-management needs of different client groups influence how people respond to the items. The purpose of this study was to examine how adults with cardiac conditions in Singapore interpreted and responded to the PAM-13, to investigate possible reasons for differences in responses and to propose solutions to overcome them. METHODS: We conducted retrospective cognitive interviews with 13 participants in an out-patient heart center. Interviews were transcribed and analyzed based on the framework approach to qualitative analysis. The four stages from Tourangeau's cognitive model were used as a framework to index the data from each item. RESULTS: There was variation in comprehension of questions leading to variation in responses. Comprehension issues were due to terms perceived by participants to be vague and the use of English terms uncommon in Singapore. Cultural influences impacted decision processes and problems with response processes of the self-rating Likert scale surfaced. CONCLUSIONS: This study reinforces the need to culturally adapt the tool, even when language translation is not necessary. Providing Likert scales with a larger number of may widen the relevance of PAM-13 in Singapore. Implications for rehabilitation Need to culturally adapt assessment tool, even when language translation is not necessary. Consider using Likert scales with a larger number of categories when using in Asian countries such as Singapore. Caution must be taken when using PAM-13 levels to decide interventions for each individual.

What we know about the purpose, theoretical foundation, scope and dimensionality of existing self-management measurement tools: A scoping review.

OBJECTIVES: To identify self-report, self-management measures for adults with chronic conditions, and describe their purpose, theoretical foundation, dimensionality (multi versus uni), and scope (generic versus condition specific). METHODS: A search of four databases (8479 articles) resulted in a scoping review of 28 self-management measures. RESULTS: Although authors identified tools as measures of self-management, wide variation in constructs measured, purpose, and theoretical foundations existed. Subscales on 13 multidimensional tools collectively measure domains of self-management relevant to clients, however no one tool's subscales cover all domains. CONCLUSIONS: Viewing self-management as a complex, multidimensional whole, demonstrated that existing measures assess different, related aspects of self-management. Activities and social roles, though important to patients, are rarely measured. Measures with capacity to quantify and distinguish aspects of self-management may promote tailored patient care. PRACTICE IMPLICATIONS: In selecting tools for research or assessment, the reason for development, definitions, and theories underpinning the measure should be scrutinized. Our ability to measure self-management must be rigorously mapped to provide comprehensive and system-wide care for clients with chronic conditions. Viewing self-management as a complex whole will help practitioners to understand the patient perspective and their contribution in supporting each individual patient.

Discordance in Utility Measurement in Persons with Neurological Conditions: A Comparison of the SF-6D and the HUI3.

OBJECTIVES: To examine the extent of disagreement in estimated utility between the six-dimensional health state short form (SF-6D) and the Health Utilities Index-Mark 3 (HUI3) in Canadians with neurological conditions and how discordance varied by participant and neurological condition attributes. METHODS: The study analyzed cross-sectional survey data from the Living with and Managing the Impact of a Neurological Condition Study. Self-reported data were collected on the burden and impact of neurological conditions on participants' everyday lives. Disagreement was examined by comparing utility distributions, paired t tests of the means, Spearman ρ correlations, intraclass correlations, and Bland-Altman plots. Associations between participant and neurological condition attributes and utility differences were assessed using multiple regression models. RESULTS: Disagreement between the SF-6D and the HUI3 was substantial, with a mean utility difference of 0.15 (95% confidence interval 0.13-0.17). An intraclass correlation coefficient of 0.41 suggests only marginal agreement. The Bland-Altman plot and regression analysis showed systematic variation in utility difference associated with level of utility. Depending on the level of utility, utility differences between the SF-6D and the HUI3 shift in magnitude and direction. The pattern of disagreement did not vary substantially by participant or neurological condition characteristics. CONCLUSIONS: The SF-6D and the HUI3 provide inconsistent evaluations of utility in persons with neurological conditions. The magnitude and direction of differences in estimated utility are strongly associated with level of utility. Depending on the health status of the sample, the SF-6D and the HUI3 could provide widely contradictory utility estimates. A concern is that utility scores, and hence potential evaluations and health care decisions, may vary simply according to the choice of instrument.

Validation of the Patient Activation Measure (PAM-13) among adults with cardiac conditions in Singapore.

PURPOSE: The Patient Activation Measure (PAM-13) measures patients' knowledge, skill, and confidence in chronic condition self-management. The purpose of this study was to assess the validity of PAM-13 (English version) among English-speaking adults with cardiac conditions in Singapore. METHODS: A cross-sectional study was conducted in a convenient sample of 270 heart clinic patients. Using the unitary concept of validity, evidence of (1) internal structure via data quality, unidimensionality, differential item functioning, and internal consistency, (2) response process through item difficulty and item fit using Rasch modeling, and (3) relationship to other variables via correlations with depression and self-efficacy were examined. RESULTS: The item response was high with only one missing answer. All items had a small floor effect, but nine out of 13 items had a ceiling effect larger than 15 %. Cronbach's α was 0.86, and average inter-item correlations was 0.324. Results suggested unidimensionality; however, differences in item difficulty ranking were found. A low, negative correlation was found with depression, while a moderate, positive correlation was found with self-efficacy. CONCLUSION: Evidence in all three areas of validity were mixed. Caution should be exercised when using categorical activation "level" to inform clinical decisions.

Understanding the Effects of Competition for Constrained Colonoscopy Services with the Introduction of Population-level Colorectal Cancer Screening.

BACKGROUND: Median wait times for gastroenterology services in Canada exceed consensus-recommended targets and have worsened substantially over the past decade. Meanwhile, efforts to control colorectal cancer have shifted their focus to screening asymptomatic, average-risk individuals. Along with increasing prevalence of colorectal cancer due to an aging population, screening programs are expected to add substantially to the existing burden on colonoscopy services, and create competition for limited services among individuals of varying risk. Failure to understand the effects of operational programmatic screening decisions may cause unintended harm to both screening participants and higher-risk patients, make inefficient use of limited health care resources, and ultimately hinder a program's success. METHODS: We present a new simulation model (Simulation of Cancer Outcomes for Planning Exercises, or SCOPE) for colorectal cancer screening which, unlike many other colorectal cancer screening models, reflects the effects of competition for limited colonoscopy services between patient groups and can be used to guide planning to ensure adequate resource allocation. We include verification and validation results for the SCOPE model. RESULTS: A discrete event simulation model was developed based on an epidemiological representation of colorectal cancer in a sample population. Colonoscopy service and screening modules were added to allow observation of screening scenarios and resource considerations. The model reproduces population-based data on prevalence of colorectal cancer by stage, and mortality by cause of death, age, and sex, and attendant demand and wait times for colonoscopy services. CONCLUSIONS: The study model differs from existing screening models in that it explicitly considers the colonoscopy resource implications of screening activities and the impact of constrained resources on screening effectiveness.

Misclassification errors from postal code-based geocoding to assign census geography in Nova Scotia, Canada.

OBJECTIVES: Postal codes are often the only available geographic identifiers in many sources of health data in Canada. In order to conduct geographic analyses, postal codes are routinely geocoded to census geography to link to ecological data. Despite common use of this method, the extent of geographic misclassification errors is poorly understood. We estimated misclassification errors in the geocoding of postal codes to assign census geography in Nova Scotia, Canada. METHODS: We examined differences between counts and match rates for postal-code geocoded and actual locations of buildings in Nova Scotia at two census administrative area levels: dissemination areas (DAs) and census subdivisions (CSDs). Actual locations were based on the data collected by the provincial government containing actual latitude/longitude of buildings. Variation in misclassification by rurality, using Statistics Canada's classification, was also assessed. RESULTS: Outside two urban areas (Halifax Metro and Sydney) which had <10% differences in counts, many DAs had >30% differences. Match rates showed similar patterns, with the vast majority of non-urban DAs having <40% match rates. Even in major urban areas, 10% of DAs had large misclassification errors. Misclassification errors at the CSD level were still too great to estimate counts or rates without further area aggregation. CONCLUSION: Routine use of postal code geocoding should be replaced with geocoding of location information using additional identifiers such as civic addresses or latitude and longitude. If data holders did this in-house before providing data to researchers, the accuracy and capacity of geographic analysis would be enhanced while protecting confidentiality.