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Objective To compare the performance of risk adjustment models using the Elixhauser and Charlson comorbidity scores in predicting in-hospital outcomes of ACS patients from a nationwide administrative database. Study Design and Setting All hospitalizations for ACS in the United States between 2004 and 2014 (n = 7,201,900) were retrospectively analyzed. We used ECS and CCI score based on ICD-9 codes to define comorbidity variables. Logistic regression models were fitted to three in-hospital outcomes, including mortality, Major Acute Cardiovascular & Cerebrovascular Events (MACCE) and bleeding. The prognostic values of ECS and CCI after adjusting for known confounders, were compared using the C-statistic, Akaike information criterion (AIC), and Bayesian information criterion (BIC). Results The statistical performance of models predicting all in-hospital outcomes demonstrated that the ECS had superior prognostic value compared to the CCI, with higher C-statistics and lower AIC and BIC values associated with the former. Conclusion This is the first study that compared the prognostic value of the ECS and CCI scores in predicting multiple ACS outcomes, based on their scoring systems. Better discrimination and goodness of fit was achieved with the Elixhauser method across all in-hospital outcomes studied.

Objective\ud To establish the association between prior knee-pain consultations and early diagnosis of knee osteoarthritis (OA) by weighted cumulative exposure (WCE) models.\ud \ud Study Design and Setting\ud Data were from an electronic health care record (EHR) database (Consultations in Primary Care Archive). WCE functions for modeling the cumulative effect of time-varying knee-pain consultations weighted by recency were derived as a predictive tool in a population-based case-control sample and validated in a prospective cohort sample. Two WCE functions ([i] weighting of the importance of past consultations determined a priori; [ii] flexible spline-based estimation) were comprehensively compared with two simpler models ([iii] time since most recent consultation; total number of past consultations) on model goodness of fit, discrimination, and calibration both in derivation and validation phases.\ud \ud Results\ud People with the most recent and most frequent knee-pain consultations were more likely to have high WCE scores that were associated with increased risk of knee OA diagnosis both in derivation and validation phases. Better model goodness of fit, discrimination, and calibration were observed for flexible spline-based WCE models.\ud \ud Conclusion\ud WCE functions can be used to model prediagnostic symptoms within routine EHR data and provide novel low-cost predictive tools contributing to early diagnosis.

Objective Measurement error in predictor variables may threaten the validity of clinical prediction models. We sought to evaluate the possible extent of the problem. A secondary objective was to examine whether predictors are measured at the intended moment of model use. Methods A systematic search of Medline was used to identify a sample of articles reporting the development of a clinical prediction model published in 2015. After screening according to a predefined inclusion criteria, information on predictors, strategies to control for measurement error, and intended moment of model use were extracted. Susceptibility to measurement error for each predictor was classified into low and high risks. Results Thirty-three studies were reviewed, including 151 different predictors in the final prediction models. Fifty-one (33.7%) predictors were categorized as high risk of error; however, this was not accounted for in the model development. Only 8 (24.2%) studies explicitly stated the intended moment of model use and when the predictors were measured. Conclusion Reporting of measurement error and intended moment of model use is poor in prediction model studies. There is a need to identify circumstances where ignoring measurement error in prediction models is consequential and whether accounting for the error will improve the predictions.

Background and objectives Clinical history and examination remain the cornerstones of diagnosis, prognosis, estimates of severity, and treatment selection in primary care for older adults presenting with knee pain. In this study we investigated the extent and cause of inter- and intraobserver variability of the clinical history using a structured, quantitative, clinical interview (KNE-SCI). Methods 58 patients aged 50 years and over with current knee pain were independently interviewed by two trained observers and again by one of these observers a month later. Results Interobserver and intraobserver variability were found to be generally low [median agreement beyond chance (kappa) = 0.71 (range: −0.03–1.00) and 0.58 (range: −0.03–1.00), respectively]. However, 9 of the 57 items demonstrated high inter- and intraobserver variability: notably subjective reports of swelling and specific aspects of pain experience and functional limitation. Conclusion Structured interview can reliably quantify certain clinically relevant aspects of the clinical history in older adults with knee pain, including those felt to be indicative of osteoarthritis. Its usefulness requires further investigation.

Objective: There is no consensus on the best method to determine the minimal important change (MIC) of patient-reported outcomes. Recent publications recommend the use of multiple methods. Our aim was to assess whether different methods lead to consistent values for the MIC. Study Design and Setting: We used two commonly used anchor-based methods and three commonly used distribution-based methods to determine the MIC of the subscales: pain and physical functioning of the Western Ontario and McMaster University Osteoarthritis Index questionnaire in five different studies involving patients with hip or knee complaints. We repeated the anchor-based methods using relative change scores, to adjust for baseline scores. Results: We found large variation in MIC values by the same method across studies and across different methods within studies. We consider it unlikely that this variation can be explained by differences between disease groups, disease severity, or lengths of follow-up. The variation persisted when using relative change scores. It was not possible to conclude whether this variation is because of true differences in MIC values between populations or to conceptual and methodological problems of the MIC methods. Conclusion: To better disentangle these two possible explanations, the MIC methodology should be improved and standardized. In the meantime, caution is needed when interpreting and using published MIC values. (C) 2010 Elsevier Inc. All rights reserved..

Objective To investigate the effect of font size and paper thickness on the response to, and completion of, a self-completion postal questionnaire among older people with joint pain. Study Design and Setting Randomized trial. People aged 50 years and older with joint pain who consulted a general practitioner at one of five general practices in Central Cheshire were sent a postal questionnaire. Questionnaire format (large or small font size, thick or thin paper) was randomly allocated using a 2 × 2 factorial design. Results Questionnaires were received from 502 out of 650 participants (crude response 77%). Response was significantly higher for participants receiving questionnaires with a larger font size (79.3% vs. 75.2%; hazard ratio 1.26, 95% confidence interval: 1.02, 1.56). Paper thickness had no significant effect on response. Completion (measure by assessing double-page turnover error) was increased in participants receiving questionnaires printed on thicker paper (3.2% vs. 7.1%; P = 0.049) but was not affected by font size. Conclusion This study demonstrates that questionnaires in larger font and on thicker paper may produce higher and more complete responses than surveys using standard size font and standard thickness paper, and should therefore be considered in studies among older people.

Background and Objective To review current practice in the assessment of the quality of original observational studies included in systematic reviews. Materials and Methods Examination of all systematic reviews identified by a basic PubMed search for the years 1999–2000 (32 reviews) and 2003–2004 (98 reviews). English language systematic reviews published in peer-reviewed journals was the setting. Each review was evaluated for the use of quality assessment of original observational studies and if quality assessment occurred, what type of assessment was used. Results Quality assessment occurred in 22% of systematic reviews identified in 1999–2000 compared with 50% of reviews identified from 2003–2004. All earlier reviews devised their own quality assessment criteria, whereas in 2003–2004 10 different quality assessment techniques were identified. Conclusions Quality assessment does not routinely occur in systematic reviews of observational studies. Where it does occur, there is no clear consensus in the method used.

Objective This study estimated the inter- and intraobserver reliability of a set of noninstrumented physical examination measures for knee pain in older adults. Study Design and Setting Forty-five patients from primary care, and 13 patients from secondary care, were each examined by two out of a team of three physical therapists, and were reexamined by one of these observers 1 month later. The examination items were standardized and included dichotomous, ordinal and continuous variables considered relevant to a primary care context. Results For individual dichotomous items, median interobserver and intraobserver agreement (κ) was 0.22 (interquartile range IQR = 0.12–0.35) and 0.41 (IQR = 0.28–0.56) respectively. For ordinally rated variables, weighted kappa ranged from −0.08 to 0.43 for interobserver agreement, and from 0.00 to 0.79 for intraobserver agreement. The median intraclass correlation coefficient for continuous examination variables was 0.80 (range 0.68–0.89) for interobserver agreement, and 0.84 (range 0.67–0.95) for intraobserver agreement. Conclusion For trained but nonexpert examiners, agreement was generally poor for dichotomous and ordinal examination items; however, κ-values are liable to be depressed by the low prevalence of clinical signs in this sample. Agreement on continuous variables was notably better.

Clinical history and examination remain the cornerstones of diagnosis, prognosis, estimates of severity, and treatment selection in primary care for older adults presenting with knee pain. In this study we investigated the extent and cause of inter- and intraobserver variability of the clinical history using a structured, quantitative, clinical interview (KNE-SCI).58 patients aged 50 years and over with current knee pain were independently interviewed by two trained observers and again by one of these observers a month later.Interobserver and intraobserver variability were found to be generally low [median agreement beyond chance (kappa)=0.71 (range: -0.03-1.00) and 0.58 (range: -0.03-1.00), respectively]. However, 9 of the 57 items demonstrated high inter- and intraobserver variability: notably subjective reports of swelling and specific aspects of pain experience and functional limitation.Structured interview can reliably quantify certain clinically relevant aspects of the clinical history in older adults with knee pain, including those felt to be indicative of osteoarthritis. Its usefulness requires further investigation.