Intermediate Outcome Measures Research Articles

Measurements, Instruments, Scales, and Tests: The Helping Alliance Questionnaire: Psychometric Properties in Patients with Substance Dependence

Psychometric properties of the Helping Alliance Questionnaire (HAQ) are analyzed in a population of 340 substance-dependent patients of an addiction clinic in the Netherlands. Factor analysis yields a two-factor structure: Cooperation and Helpfulness. The scales show fair correlations with three out of seven scales from the Barrett-Lennard Relationship Inventory. Length of Stay in Detox is predicted by scores on the Helpfulness scale and noncompliance by scores on the Cooperation scale. Besides this, intermediate outcome measures are correlated with HAQ scores. The HAQ seems to be a “quick scan” instrument to give a quick and global impression of the patients' perception of the quality of the working alliance with the therapist.

Pharmacological intervention in older patients with rheumatoid arthritis. Quality of life aspects.

Despite the rather pessimistic outlook regarding the long term effects of pharmacological treatment of patients with rheumatoid arthritis (RA), there is no doubt that drug interventions can affect quality of life (QOL). The disease has a significant impact upon physical, psychological and social function, and QOL optimisation should cover all these dimensions. Swelling of joints and pain are important manifestations in assessing RA since these may result in sleep disturbances as well as depressed mood. This might be particularly significant for older persons with RA. Outcome parameters of RA can be divided into short, intermediate and long term. The long term results are quite disappointing with regard to disability and premature death. However, more intermediate outcome measures related to QOL might improve after pharmacological interventions. Patient preferences and expectations with regard to the outcome of pharmacological interventions are important parameters to assess. When assessing older patients with RA with QOL instruments, it is recommended that questionnaires are fairly short and easy to complete. Adverse effects of pharmacological interventions are important factors to monitor in QOL assessment in older patients with reduced remaining life span.

Greater toxicity in overdose of dothiepin than of other tricyclic antidepressants

Epidemiological studies have implicated dothiepin in a greater number of self-poisoning deaths than would be expected from its use. We have prospectively assessed the clinical toxicity of dothiepin and other tricyclic antidepressants (TCAs) in overdose. We followed-up consecutively admitted patients with TCA poisoning managed by our department between January, 1987, and August, 1992. 75 patients had taken dothiepin, 101 amitriptyline, 83 doxepin, and 61 other TCAs. Death after TCA poisoning is rare nowadays, so we used intermediate outcome measures—general seizures, tachyarrhythmias, sedation, and QRS width on the electrocardiogram. 15 patients had seizures and 7 tachyarrhythmias. When we excluded patients who had taken more than one TCA, general seizures were more likely after dothiepin than after other TCAs (9/67 vs 5/220) as were arrhythmias (4/67 vs 3/220). Rates of other complications were similar. The dothiepin group had ingested a larger dose, attributable to the larger average tablet strength, than patients who took other TCAs. The odds ratio for seizures with dothiepin versus other TCAs was 6·7 (95% Cl 2·2-20·7) unadjusted and 7 1 (2·2-23 2) after adjustment for sex, age, and ingested dose. The corresponding odds ratios for arrhythmias were 4 6 (1·0-21·1) and 3·4 (0 7-16·3). Dothiepin in overdose seems to be proconvulsant. Patients with only minor sedation and normal limb-lead QRS width may still have major complications. Consideration should be given to the use of other antidepressants in patients at risk of seizures or suicide. Regulatory authorities should review the need for a 75 mg strength tablet of any TCA.

The challenge of outcome evaluation in homeless services: Engagement as an intermediate outcome measure

Evaluating treatment outcomes for programs serving individuals who are homeless and mentally ill presents many challenges in terms of measures available and timeframes for data collection and analysis. These difficulties pose significant obstacles in terms of responsiveness to the need for short-term justification of program funding and for program modifications to improve operations. Information is presented from a two-site intervention in Michigan, providing outreach and in vivo services to individuals who are homeless and mentally ill, which measured client engagement with project services. The project's use of engagement as an intermediate outcome measure is described. Data is presented supporting the validity of the measure. Documentation is provided on the measure's utility in evaluating program performance and in improving project operations. Discussion follows on interpretation of program-level and individual client differences in engagement status.

Comparison of Clinical Symptoms of Human Immunodeficiency Virus Disease Between Intravenous Drug Users and Homosexual Men

To compare the prevalence of human immunodeficiency virus (HIV)-related clinical symptoms among male intravenous drug users and homosexual men stratified by HIV serostatus and CD4 cell levels. A cross-sectional sample using concurrent longitudinal studies of the natural history of HIV-1 infection among intravenous drug users (N = 539) and homosexual men (N = 932) was recruited in Baltimore, Md. Participants were administered a risk behavior interview and physical examination, and had hematologic tests evaluated in a similar calendar period. Both risk groups demonstrated an inverse relationship between frequency of symptoms and CD4 cell count. Fever, night sweats, and lymphadenopathy were not evaluated because pilot data suggested a confounding association with drug injection. Among those with mild to moderate immune suppression, intravenous drug users were significantly more likely than homosexual men to experience fatigue, weight loss, diarrhea, and shortness of breath; to have oral candidiasis, palpable spleen, and lower mean weight on physical examination; and abnormal hematocrit, platelets, and total lymphocyte counts. However, participants in either risk group with CD4 cell levels below 0.2 x 10(9)/L experienced similar frequency of all clinical symptoms. Self-reported oral candidiasis increased fourfold with HIV infection and was as likely in both groups at all CD4 cell levels. Duration and recency of intravenous drug use was not significantly associated with the higher frequency of most clinical symptoms. Social factors are an important consideration in evaluating the association between clinical symptoms and HIV immunosuppression. Except for oral candidiasis, there are limitations for the use of clinical symptoms as intermediate outcome measures for HIV infection among intravenous drug users.

Free-standing Papers: Abstracts

Possible and preferable outcome measures in primary care are increasingly discussed in Finland. An ad hoc committee of the Finnish Medical Association used a new classification of outcome measures for health care. The measures are divided into operational measures (input, process, and output); measures of medical quality; intermediate outcome measures; and true health outcome measures. In order to chart the availability of measuring instruments, their appropriateness and utilisation, a questionnaire was sent to all Finnish health centres in 1991. The response rate was 76%. Operational measures were overwhelmingly used for resource allocation (85% of criteria). Need for usable measures of medical quality was evident, while quality indicators are not used at all for resource allocation at present. The main metholodogical problems of this research concern the study design and concepts. 1) Method of eliciting knowledge. We could have used statistics of the health centre activity; an interview instead of a questionnaire; or a multiple choice instead of open questions. The nature of our primary questions led to the choice of method and much work ensued in classification. We still prefer having personal, fresh opinions to work from. Interviews would have given more answers, but the possibility of altering the opinions or giving ctrightn answers had to be avoided. Open questions have given us rich material especially in view of future needs and present problems. '2) Choice of respondent. The complexity of the process of planning and resource allocation in health' centres is obvious, and we had to narrow the point of view to only one person. We chose to send the questionnaire to the chief administrative physician. Many of them have consulted others in the health centre, and some questionnaires were answered by other personnel. Asking for a group opinion would probably have balanced the views. At the cost of generalisability, our method perhaps allows more delicate problems to be identified than a udemocratic>) process would have produced. 3) Classifying the measures used. The classification criteria were laid down in advance, but these was difficulty in sorting specific measures to one class only. Most problems were caused by the measures that could belong to either intermediate or true health outcomes, and indicators of either quality or true health outcomes. Defining criteria and concepts is a lengthy process, and the results change with time. This reflects not only a methodological problem but is a result of the study as well.

Work-load and outcomes of diabetes care in general practice.

The effect of starting a general practice diabetes clinic on practice work-load and intermediate outcome measures was studied retrospectively using patient records. The 35 diabetic patients included had been diagnosed greater than 4 years before the diabetes clinic started and were followed for 6 years in the clinic, together with a group of age- and sex-matched controls. There was a significant rise in the consultation rates of the diabetic patients, due to an increase in diabetes-related consultations, from 3.9 consultations yr-1 to 6.7 consultations yr-1 (p less than 0.001). There was a fall in HbA1c level of 0.22 (99% CI 0.13, 0.32) %Hb yr-1 over the 6 years and in body mass index of 0.37 (99% CI 0.22, 0.52) kg m-2 yr-1, suggesting an improvement in diabetes management.

A new intermediate dental outcome measure: amalgam replacement rate.

The length of time amalgam restorations last before replacement was investigated for use as an intermediate outcome measure in utilization review and quality assurance studies. Based on record data from 37 general dental practices, a determination was made of the average percentage of two- or three-surface amalgams receiving another service at 6, 12, and 24 months from the date of insertion. After 2 years, approximately 13 per cent of the amalgams were replaced, and the estimated median life time for amalgams was between 10 and 14 years. The variation in replacement rates among practices was substantial but was not explained by the technical quality of restorations or several practice characteristics.