Companion Question Research Articles

Development and application of the RE-AIM QuEST mixed methods framework for program evaluation.

To increase the likelihood of successful implementation of interventions and promote dissemination across real-world settings, it is essential to evaluate outcomes related to dimensions other than Effectiveness alone. Glasgow and colleagues' RE-AIM framework specifies four additional types of outcomes that are important to decision-makers: Reach, Adoption, Implementation (including cost), and Maintenance. To further strengthen RE-AIM, we propose integrating qualitative assessments in an expanded framework: RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST), a mixed methods framework. RE-AIM QuEST guides formative evaluation to identify real-time implementation barriers and explain how implementation context may influence translation to additional settings.RE-AIM QuEST was used to evaluate a pharmacist-led hypertension management intervention at 3 VA facilities in 2008–2009. We systematically reviewed each of the five RE-AIM dimensions and created open-ended companion questions to quantitative measures and identified qualitative and quantitative data sources, measures, and analyses.To illustrate use of the RE-AIM QuEST framework, we provide examples of real-time, coordinated use of quantitative process measures and qualitative methods to identify site-specific issues, and retrospective use of these data sources and analyses to understand variation across sites and explain outcomes. For example, in the Reach dimension, we conducted real-time measurement of enrollment across sites and used qualitative data to better understand and address barriers at a low-enrollment site.The RE-AIM QuEST framework may be a useful tool for improving interventions in real-time, for understanding retrospectively why an intervention did or did not work, and for enhancing its sustainability and translation to other settings.

Oncologist, patient, and companion questions during pretreatment consultations about adjuvant cancer treatment: a shared decision-making perspective

To assess the occurrence of questions that foster shared decision making, in particular cancer patients' understanding of treatment decisions and oncologists' understanding of patients' priorities, during consultations in which preference-sensitive decisions are discussed. Specifically, (a) regarding patient understanding, do oncologists ask about patients' preexisting knowledge, information preferences, and understanding and do patients and companions ask about the disease and treatment, and (b) regarding patient priorities, do oncologists ask about patients' treatment- and decision-related preferences and do patients and companions ask about the decision? Audiotaped pretreatment consultations of 100 cancer patients with 32 oncologists about (neo)adjuvant treatment were coded and analyzed to document question type, topic, and initiative. The oncologists ascertained prior knowledge in 50 patients, asked 24 patients about preferred (probability) information, and invited questions from 56 patients. The oncologists asked 32 patients about treatment preferences and/or for consent. Respectively, one-third and one-fifth of patients and companions asked about treatment benefits compared with three-quarters of them who asked about treatment harms and/or procedures. It would be helpful to patients if oncologists more often assessed patients' existing knowledge to tailor their information provision. Also, patients could receive treatment recommendations that better fit their personal situation if oncologists collected information on patients' views about treatments. Moreover, by educating patients to ask about treatment alternatives, benefits, and harms, patients may gain a better understanding of the choice they have.

Asking questions during breast cancer consultations: Does being alone or being accompanied make a difference?

Companions often accompany patients to cancer consultations. The number of questions asked by patients and companions is an indicator of their active participation. The present study aims to provide first descriptive evidence on the characteristics of unaccompanied and accompanied Italian breast cancer patients that attend the first consultation after surgery and to analyse companions contribution to the type and quantity of questions asked during the consultation. Seventy consultations of female patients with breast cancer were audio taped. Questions were transcribed and coded by content. Companion's questions were also classified in terms of function. Socio-demographic and clinical data, patients' role preference and confidence in decision making measures were gathered for each patient. Post consultation satisfaction with decision and the perceived level of shared decision making were collected either for the patient and the companion. 69% of patients were accompanied, usually by one close family member, either husband or adult child. Non employed or retired patients and those with a preference for passive role in decision making were more likely to be accompanied. Unaccompanied patients and accompanied patients had comparable levels of anxiety, emotional distress and depression and were equally active in asking questions. These levels were far greater than those reported for other cancer patients in the literature. Companions did not increase significantly the number of questions per consultation. Accompanied and non accompanied patients differed more in socio-demographic than clinical characteristics. Companions sustained the patient and shared information without reducing the level of patient involvement.

On Graduation from Default, Inflation, and Banking Crises: Elusive or Illusion?

This paper uses a data set of over two hundred years of sovereign debt, banking and inflation crises to explore the question of how long it takes a country to "graduate" from the typical pattern of serial crisis that most emerging markets experience. We find that for default and inflation crises, twenty years is a significant market, but the distribution of recidivism has extremely fat tails. In the case of banking crises, it is unclear whether countries ever graduate. We also examine the more recent phenomenon of IMF programs, which sometimes result in "near misses" but sometimes end in default even after a program is instituted. The paper raises the important theoretical question of why countries experience serial default, and how they might graduate.

Information seeking during “bad news” oncology interactions: Question asking by patients and their companions

Previous research has investigated patient question asking in clinical settings as a strategy of information seeking and as an indicator of the level of active patient participation in the interaction. This study investigates questions asked by patients and their companions during stressful encounters in the oncology setting in the USA. We transcribed all questions patients and companions asked the oncologist during 28 outpatient interactions in which "bad news" was discussed (n = 705) and analyzed them for frequency and topic. Additionally, we analyzed the extent to which personal and demographic characteristics and independently obtained ratings of the oncologist-patient/companion relationships were related to question asking. Findings demonstrated that at least one companion was present in 24 (86%) of the 28 interactions and companions asked significantly more questions than patients. The most frequently occurring topics for both patients and companions were treatment, diagnostic testing, diagnosis, and prognosis. In general, personal and demographic characteristics were unrelated to question asking, but older patients asked fewer questions, while more educated patients asked more questions. With regard to ratings of the quality of the dyadic relationships, results showed that "trust" between the physician and companions was positively correlated and "conversational dominance by physician" was negatively correlated with the frequency of companion questions. Additionally, positive ratings of the relationship between physicians and companions were correlated with fewer patient questions. This study demonstrates that companions are active participants in stressful oncology interactions. Future research and physician training in communication would benefit from expanding the focus beyond the patient-physician dyad to the roles and influence of multiple participants in medical interactions.

Age and Attitudes

THIS EDITION of Pulse of the Public probes the relationship between age and attitudes by comparing the responses of 18- to 29-year-olds with those of people 50 and older. Of course, we cannot establish causation beyond doubt, but one would suspect that the differences identified are related, to some extent, to the recency of the respondents' contact with schools. The Biggest Problem When asked to identify the biggest problem facing local schools, those 50 and older place discipline at the top of the list. Discipline is mentioned by 23% of this older group, as compared to just 7% of 18- to 29-year-olds. If discipline and fighting/violence/gangs are taken to be synonymous terms, then the difference shrinks, as 15% of the younger group mention fighting/violence/gangs, while just 6% of those 50 and older do so. The top problem for the younger group is finance, mentioned by 20%, but the difference between the two groups is not great, since finance is also mentioned by 18% of those 50 and older. Overcrowding is mentioned by 15% of 18- to 29-year-olds, as compared to just 8% of those 50 and older. Regarding use of drugs and getting and keeping good teachers -- the last two of the top six problems noted by the entire sample -- there is little difference between the groups. They attract a smaller but uniform number of mentions from both groups. Grading the Public Schools The two groups assign similar grades to the public schools. The percentage giving A's and B's is 47% for the younger group and 44% for those 50 and older. The breakout of specific grades is reflected in Table 1. These high grades may help explain why, when asked to indicate whether improvement should come by reforming the existing public school system or through finding an alternative to that system, reform of the existing system is the strong choice of both age groups. Among those 50 and older, 68% choose reforming the existing system, while 25% would seek an alternative. The corresponding figures for those 18 to 29 are 60% and 38%. Asked to choose between strengthening the existing public schools and offering vouchers for parents to use in having their children attend private or church-related schools, 72% of 18- to 29- year-olds and 70% of those 50 and older choose strengthening the existing schools. The percentages favoring the voucher option are 26% and 28% respectively. Propensity for Change The fact that both groups favor improvement through the existing public schools should not be allowed to mask the fact that those in the 18- to 29-year-old group are more receptive to change. In the poll question asking about permitting parents to send their children to private schools at public expense, a majority of both groups express opposition, but 46% of 18- to 29-year-olds favor this option, while only 31% of those 50 and older do so. And in the companion question, in which choosing a public school is an option along with private and church-related schools, 58% of those in the 18- to 29-year-old group are in favor, compared to just 37% of those 50 and older. …

Everyday Strangeness: Robert Ripley's International Oddities as Documentary Attractions

My alternative title is Everyday Estrangement, emphasiz ing a very particular aspect of everyday life theory having to do with the critical capacity of the strange. While most theorists of everyday life are concerned with the ordinary and its uses, not all visit the problem of critique; if, like Michel de Certeau, they are interested in critique from below, at the level of ordinary people and ordinary practices, this outburst is diffuse and often undetectable. For my purposes, I find in a combination of Bertolt Brecht and Henri Lefebvre an edge and a sharper d?finition. In both, the critique is spatialized as proximity or juxtaposition. Here, the problematic juxtaposition is that of the ordinary and the extraordinary, or the strange as it contributes to estrangement, where estrangement means distance and disillusionment. The reader will note my interest in suggesting that under some circumstances the ordinary verges on the extraordinary. Conversely, the odd thing can be made common or familiar. But what arises from this consideration is a new problem, the politics of determining what is strange, which carries with it a companion question: what is at stake in the separation of the ordinary from the extraordinary? Here, in my consideration of everyday life theory as it parallels documentary film theory, I suggest that although there is an ideological need for the separation between the norm and the aberration, in popular culture, since the early part of this century, there has been a fascination with the problem of the difference between ordinary and extraordinary.

Finding the Key to Reform in End-of-Life Care

We conducted an observational cohort study to determine if hospital-based, reinforcing regulatory and educational interventions could encourage physicians to discuss end-of-life (EOL) care with their patients. Specifically, we measured the effect of (1) administrative prompts to encourage discussions about EOL care and (2) a mandatory educational seminar focusing on EOL issues. Study subjects were patients consecutively admitted to the medicine service who faced an anticipated 3-year mortality rate of at least 50%. The main study endpoint was the frequency of documented EOL discussions between physicians and patients. In the inception cohort of 184 patients, physicians discussed EOL care with 64 patients (34.8%), and in the follow-up cohort of 121 patients, 41 individuals (33.9%) had documented discussions regarding EOL issues (P = 0.90). Actual Do Not Resuscitate(DNR) orders were written for 53 patients (28.8%) in the inception cohort and for 33 persons (27.3%) in the follow-up cohort (P = 0.71), We conclude that enhanced, mutually reinforcing regulatory and educational efforts focusing on EOL care proved ineffectual at promoting either discussions about EOL issues or the use of DNR orders.

PERIODONTAL TRAUMA AND MOBILITY: Diagnosis and Treatment Planning

With the dearth of well-controlled human clinical studies, it is still impossible to answer the question of whether occlusal trauma modifies the progression of attachment loss resulting from inflammatory periodontal disease and the companion questions related to the treatment of occlusal trauma and mobility. Teeth with stable mobility are apparently at no greater risk of attachment loss than nonmobile teeth. Increasing mobility is a concern that must be addressed by inflammatory control, occlusal adjustment, and perhaps some type of stabilization or splinting of the tooth in question. In addition, greater attachment gains have been noted when occlusal adjustment was included as part of surgical therapy. There is no question that aspects of occlusal therapy have an empiric base. It is incumbent on the clinician to examine for, diagnose, and treat trauma from occlusion to stabilize the dentition. Proper occlusal management assists in maintaining the patient's natural dentition in a state of health and comfortable function.

Canadian Studies and the Canadian University in the Twenty-First Century

The organizers of the University in the Twenty-First Century conference have invited me to speak on the Symons Report and its aftermath, and I am glad to do so.(f.1) However, I would like to do this in a future-oriented way in order to consider more broadly something of the role and condition of Canadian universities in the increasingly continentalist environment in which we now find ourselves. In particular, and in keeping with the theme of this conference, I would like to develop the argument that the study of Canadian higher education is a key area of Canadian studies that is still surprisingly neglected, despite the good work of a small handful of scholars some of whom are attending this gathering, including some from the University of Manitoba's Centre for Higher Education Research and Development, which has made such an important contribution in the field. But few universities are paying sustained or adequate attention to this subject, and I fear that Canadian universities will place them-selves in peril if they continue this neglect. In his thoughtful address opening this conference, Bernard Shapiro posed the question, does the university have a future? I would put to you, as a companion question, does Canada have a future? and I would suggest to you that it won't, unless our universities devote sufficient attention to fostering knowledge and understanding about our country in their teaching and research. Throughout the conference, in every session and in the corridors, participants have laid stress on the need for our universities to prepare and to rethink, in order to meet the challenge of the next century. An important part of that challenge for Canadian universities is to meet the particular needs of this country. To do so, they must both have and offer a knowledge and an understanding of Canada. Thus, teaching and research about Canada is a central facet of the challenge facing Canadian universities in the 21st century. What, then, is the present state of Canadian studies? It would, I suppose, be possible to answer that question by reviewing and enumerating--and perhaps even relishing--the remarkable growth in teaching and research about Canada in the last 15 or 20 years. One possible approach along these lines would be to take you back to the findings presented in To Know Ourselves: The Report of the Commission on Canadian Studies (1976), and to contrast the situation described there with the situation that exists today. For example, there were then less than 10 programmes or centres for Canadian studies in universities and community colleges across the country, appreciably more in the United States. Today, there are three dozen such programmes or centres listed by the 80-plus universities of Canada. It is, apparently, a dramatic improvement. Similarly, outside Canada, there has been a dramatic change. Then, there were associations for Canadian studies abroad in three countries or groups of countries. Today, there are 15 such associations with more on the way. Then, there were programmes or centres for Canadian studies abroad in half a dozen countries. Today, there are over 150 programmes or centres for Canadian studies outside Canada, located in more than two dozen countries, and more are on the way. It is certainly clear that there has been an enormous development, one of great significance in the field of Canadian studies, both within Canada and abroad. Yet, while it is true that the past 20 years apparently have been in many ways a success story for Canadian studies--a period of growth and achievement--this is not a line that I care to take. Such figures, as is so often the case, do not give a true picture. They are useful numbers, but they tell us nothing about the health or quality of these programmes, whether in Canada or abroad. The numbers are, indeed, impressive; the health and quality, less so. Amongst the three dozen Canadian studies programmes at Canadian universities, there are indeed some that are excellent: lively, diverse, and academically strong--even distinguished. …

Believing the axioms. I

§0. Introduction. Ask a beginning philosophy of mathematics student why we believe the theorems of mathematics and you are likely to hear, “because we have proofs!” The more sophisticated might add that those proofs are based on true axioms, and that our rules of inference preserve truth. The next question, naturally, is why we believe the axioms, and here the response will usually be that they are “obvious”, or “self-evident”, that to deny them is “to contradict oneself” or “to commit a crime against the intellect”. Again, the more sophisticated might prefer to say that the axioms are “laws of logic” or “implicit definitions” or “conceptual truths” or some such thing.Unfortunately, heartwarming answers along these lines are no longer tenable (if they ever were). On the one hand, assumptions once thought to be self-evident have turned out to be debatable, like the law of the excluded middle, or outright false, like the idea that every property determines a set. Conversely, the axiomatization of set theory has led to the consideration of axiom candidates that no one finds obvious, not even their staunchest supporters. In such cases, we find the methodology has more in common with the natural scientist's hypotheses formation and testing than the caricature of the mathematician writing down a few obvious truths and preceeding to draw logical consequences.The central problem in the philosophy of natural science is when and why the sorts of facts scientists cite as evidence really are evidence. The same is true in the case of mathematics. Historically, philosophers have given considerable attention to the question of when and why various forms of logical inference are truth-preserving. The companion question of when and why the assumption of various axioms is justified has received less attention, perhaps because versions of the “self-evidence” view live on, and perhaps because of a complacent if-thenism.

Believing the axioms. I

§0. Introduction. Ask a beginning philosophy of mathematics student why we believe the theorems of mathematics and you are likely to hear, “because we have proofs!” The more sophisticated might add that those proofs are based on true axioms, and that our rules of inference preserve truth. The next question, naturally, is why we believe the axioms, and here the response will usually be that they are “obvious”, or “self-evident”, that to deny them is “to contradict oneself” or “to commit a crime against the intellect”. Again, the more sophisticated might prefer to say that the axioms are “laws of logic” or “implicit definitions” or “conceptual truths” or some such thing.Unfortunately, heartwarming answers along these lines are no longer tenable (if they ever were). On the one hand, assumptions once thought to be self-evident have turned out to be debatable, like the law of the excluded middle, or outright false, like the idea that every property determines a set. Conversely, the axiomatization of set theory has led to the consideration of axiom candidates that no one finds obvious, not even their staunchest supporters. In such cases, we find the methodology has more in common with the natural scientist's hypotheses formation and testing than the caricature of the mathematician writing down a few obvious truths and preceeding to draw logical consequences.The central problem in the philosophy of natural science is when and why the sorts of facts scientists cite as evidence really are evidence. The same is true in the case of mathematics. Historically, philosophers have given considerable attention to the question of when and why various forms of logical inference are truth-preserving. The companion question of when and why the assumption of various axioms is justified has received less attention, perhaps because versions of the “self-evidence” view live on, and perhaps because of a complacent if-thenism.

Can One See the Shape of a Surface?

Some ten years ago Professor Mark Kac published in these pages an article [3] entitled Can one hear the shape of a Drum?. Under this provocative title Kac raised a fascinating question: To what extent is the shape of a smooth closed surface (a drum) determined by the eigenvalues of the classical Dirichlet problem for the interior? Since these eigenvalues are just the resonance frequencies for the acoustic wave motion in the interior, the question asks: to what extent is the shape of a surface determined by the sound of its interior? This problem is a representative example of a class of problems, called inverse problems, which are quite different in character from the more familiar direct problems of partial differential equations. Generally speaking, direct problems ask us to develop a solution from the data, Whereas inverse problems ask us to recover the data from the solution. Inverse problems have attracted a consideKable and increasing interest in recent years because of their many immediate practical applications in our physical world. A splendid introduction may be found in Prof. Keller's recent article [20]. Typically they are very hard problems; Kac's problem, for example, remains unsolved today, though it has given rise to a considerable literature. Here we should like to raise a companion question: To what extent is the shape of a surface determined by the eigenfunctions of the classical Dirichlet problem for the exterior? We must note first of all that information about the shape of the drum is not to be found in the eigenvalues of the exterior problem, since, as we shall see, these consist of all negative real numbers, no matter what the shape. So whatever information about the shape can be recovered from the solution must be somehow contained in the eigenfunctions of the exterior problem. In particular, we expect on the basis of pract,ical experience that this information should be available in the asymptotic behavior of these eigenfunctions at great distances from the surface, since it is this behavior that determines what we when the surface is illuminated by a given source of light, radar, or sonar waves. That is, we expect to find that the shape of a surface is determined by the sight of its exterior. Thus we can see the shape of a drum, even if we can't hear it.

Perspectives on MS Applications—All Around the Model

Recently, I was asked for my opinion on whether, since the management sciences have applied to industrial problems since the early 1950s, more than twenty years, I perceived any substantial tangible effect of the management sciences in our current economy. This question seems particularly pertinent in view of the recession we have just been through, its depth, its duration and the speed with which we climb out of it. Obviously it is difficult to answer any such question since one must ask the companion question, “Compared to what?” In other words, we can't really know what might have been had the management sciences not been around at all. Nevertheless some observations may be possible, and, in this column, I shall select one small area for examination to determine whether management science has truly had its effect, and determine what we can do to make ourselves more effective.