Search

This is a very grown-up book. Encomiums on the cover welcome it as ‘masterful … at the crossroads of neuroscience, obstetrics, neonatology and psychoanalysis … a panoply of rich case reports and de...

Health professions education and practice have seen renewed calls to restore compassion to care. However, because of the ways evidence-based practice (EBP) has been implemented in health care, wherein research-based knowledge is privileged, the dominance of EBP may silence clinician and patient experience-based knowledge needed for compassionate care. This study explored what happens when the discourses of compassionate care and EBP interact in practice.Chronic pain management in Canada was selected as the context for the study. Data collection involved compiling an archive of 458 chronic pain texts, including gray literature from 2009-2015 (non-peer-reviewed sources, e.g., guidelines), patient blog posts from 2013-2015, and transcripts of study interviews with 9 clinicians and postgraduate trainees from local pain clinics from 2015-2016. The archive was analyzed using an interpretive qualitative approach informed by critical discourse analysis.Four manifestations of the discourse of compassionate care were identified: curing the pain itself, returning to function, alleviating suffering, and validating the patient experience. These discourses produced particular subject positions, activities, practices, and privileged forms of knowledge. They operated in response, partnership, apology, and resistance, respectively, to the dominant discourse of EBP. These relationships were mediated by other prevalent discourses in the system: patient safety, patient-centered care, professional liability, interprofessional collaboration, and efficiency.Medical education efforts to foster compassion in health professionals and systems need to acknowledge the complex web of discourses-which carry with them their own expectations, material effects, and roles-and support people in navigating this web.

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.Women with an unintended first trimester pregnancy.Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion careIntroduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

This chapter explores the role of arts and humanities in promoting interprofessional learning and patient-centered collaborative practice. This chapter addresses the importance of collaborative competencies in postgraduate training and healthcare practice as situated within the principles of relational-centered care. Case studies of learning activities which can be adapted for use in postgraduate medical education and specific consideration for interprofessional facilitation provide a practical guide on how to incorporate the arts into postgraduate education. Additionally, components of a certificate program for learners focusing on the development of collaborative competencies through engagement in the arts and humanities are discussed.

In this article I build on Stanley Witkin’s ideas about ‘relational poetry’ to explore the meaning(s) of a clinical encounter. Drawing on social constructionist approaches to inquiry, and notions of the ‘relational-poetic’ which invite us to pay specific attention to resonance, I present a poetic dialogue between Ronna Bloom and myself. Reflecting on this process, I discuss the role of poetic writing in creating possibilities for new conversations on the everyday meanings of practice.

Poetry has been used in professional practice and education to highlight clients' experiences, explore ethics and professionalism, and illuminate practice tensions. In this Ideas in Action paper I weave together a story from my own practice, a poetic account of an ethical dilemma written by a practitioner/scholar and reflections on the place of poetry in social work education. I invite practitioners and educators to consider the unique role of poetry in social work training to honour the relational aspects of practice and explore the complexity and ambiguity of day-to-day practice.

BACKGROUND Axillary dissection for the evaluation and treatment of patients with breast carcinoma often is not performed in older women. The objective of this study was to examine patient, clinical, and surgeon characteristics associated with the use of axillary dissection after breast-conserving surgery (BCS). METHODS A cohort of 464 women age ≥ 67 years who were newly diagnosed with Stage I–II breast carcinoma and who underwent BCS were surveyed along with their 158 surgeons, and their medical records were reviewed. Patient, tumor, and provider characteristics were examined for association with the omission of axillary dissection. RESULTS The majority of women (63.4%) underwent axillary lymph node dissection after BCS. Increasing age was associated strongly with decreasing odds of undergoing axillary lymph node dissection, even after considering patient health and preferences, clinical factors, and provider factors (odds ratio [OR], 0.11; 95% confidence interval [95%CI], 0.05–0.27). Independent of age and other factors, women in the lowest quartile of physical functioning were 37% less likely to undergo axillary lymph node dissection compared with women in the highest quartile (OR, 0.63; 95%CI, 0.62–0.64). Patients who were cared for by surgeons with subspecialty training in oncology were 60% less likely to undergo axillary lymph node dissection compared with patients who were cared for by other surgeons, even after considering other factors (OR, 0.41; 95%CI, 0.25–0.68). CONCLUSIONS The results of this study demonstrated a correlation between lower use of axillary dissection and advancing age, lower functional status, and greater surgeon training. These findings suggest that simple, age-based considerations are important but are not the sole determinants of variations in treatment. Cancer 2002;94:2534–41. © 2002 American Cancer Society. DOI 10.1002/cncr.10540

Background Currently, there is no easy-to-use and comprehensive questionnaire that measures the effectiveness of treatment of rhinitis-related symptoms in a private practice setting. Objective To validate a brief, effective, self-administered rhinitis symptoms questionnaire that can easily be used in a private practice setting for tracking treatment outcomes. Methods One hundred seventy-five patients were randomly chosen from three private practices nationwide and were surveyed regarding systemic problems, nasal, eye, and chest symptoms, as well as medical treatment obtained. This survey was administered twice in one sitting with the first administration a recall of symptoms before immunotherapy, and the second administration an evaluation of current symptoms. Appropriate statistical methods were used to evaluate the validity, reliability, and responsiveness of the questionnaire presented. The validation of this instrument included content, statistical, construct, and predictive validity. Results Both the content and statistical validity were very good in that the questionnaire was easily understood and covered required domains. Construct validity revealed that the items were sensibly related to the domains that contained them and had less association with items from different domains. The reliability of the scales was very good (Cronbach's α = 0.80) to outstanding (Cronbach's α = 0.92). Conclusions Functionality was established for the rhinitis outcomes questionnaire (ROQ) for use in a private practice setting. This allows private practice allergists to collect reliable data with the ROQ.

BACKGROUND Older women have high rates of breast carcinoma, and there are substantial variations in the patterns of care for this population group. METHODS The authors studied 718 breast carcinoma patients age 67 years and older who were diagnosed with localized disease between 1995 and 1997 from 29 hospitals in 5 regions. Data were collected from patients, charts, and surgeons. Logistic regression analysis was used to evaluate determinants of treatment. RESULTS Women who were concerned about body image were 1.8 times more likely (95% confidence interval [95% CI], 1.1–2.8) to receive breast conservation surgery and radiotherapy than women without this preference, controlling for other factors. In contrast, women who preferred receiving no therapy beyond surgery were 3.9 times more likely (95% CI, 2.9–6.1) to undergo mastectomy than other women, after considering other factors. Radiotherapy was omitted after breast conservation 3.4 times more often (95% CI, 2.0–5.6) among women age 80 years and older than among women ages 67–79 years, controlling for covariates. Black women tended to have radiotherapy omitted after breast conservation surgery 2.0 times more often (95% CI, 0.9–4.4) than white women (P = 0.09). Women age 80 years and older also were 70% less likely (odds ratio = 0.3; 95% CI, 0.1–0.8) to receive chemotherapy than women ages 67–79 years, controlling for health, functional status, and other covariates. CONCLUSIONS After considering other factors, patient preferences and age were found to be associated with breast carcinoma treatment patterns in older women. Further research and training are needed to provide care for the growing population of older women that is both clinically appropriate and consonant with a woman's preferences. Cancer 2000;89:561–73. © 2000 American Cancer Society.

Objective. The aim of this study was to evaluate the relationships between age, health status, access to care, and breast and cervical cancer screening among multiethnic elderly and nonelderly women. Methods. A structured telephone survey of a quota sample of 1,420 New York City women from four Hispanic groups (Columbian, Dominican, Puerto Rican, Ecuadorian) and three black groups (U.S., Caribbean, and Haitian) was performed. Outcome measures included “ever” and “recent” self-reported use of mammography, clinical breast examination (CBE), and Pap smears. Logistic regression models assessed the predictors of screening use. Results. Having a regular source of care significantly predicted all screening use for both elderly and nonelderly, controlling for ethnicity, sociodemographics, health status, access to care, proportion of life in the United States, and cancer attitudes. Elderly women (≥65 years) were significantly less likely to have ever had (OR = 0.79, 95% CI 0.65–0.96) and to have recently had (OR = 0.67, 95% CI 0.57–0.79) Pap smears than younger women, controlling for the other variables; being elderly also tended to be an independent predictor of ever and recent mammography and CBE use. Interestingly, there was a trend for health status to act differently in predicting Pap smear use for the two age groups. For younger women, being in poor health increased the odds of Pap smear screening, while for elderly women, being in good health increased the odds of screening. Conclusions. Elderly women reported being screened less than younger women; interactions between health status and age need further exploration.

Background: Magnetic resonance imaging (MRI) of the breast has been proposed as a noninvasive diagnostic test for evaluation of suspicious (index) lesions noted on mammography and/or clinical breast examination (CBE). However, women may have incidental (serendipitous) lesions detected by MRI that are not found on mammography or CBE. To understand better whether or not biopsy procedures should be performed to evaluate serendipitous lesions, we estimated the breast cancer risk for women with this type of lesion. Methods: A decision analysis model was used to estimate the positive predictive value (i.e., the chance that a woman with a serendipitous lesion has cancer) of MRI for serendipitous lesions in women who had an abnormal mammogram and/or CBE suspicious for cancer (where a biopsy procedure is recommended). We restricted the analysis to data from women whose index lesions were noncancerous and used meta-analysis of published medical literature to determine the likelihood ratios (measures of how test results change the probability of having cancer) for MRI and the combination of CBE and mammography. The positive predictive value of MRI was calculated using the U.S. population prevalence of cancer (derived from registry data) and the likelihood ratios of the diagnostic tests. Results: Under a wide variety of assumptions, the positive predictive value of MRI was extremely low for serendipitous lesions. For instance, assuming sensitivity and specificity values for MRI of 95.6% and 68.6%, respectively, approximately four of 1000 55- to 59-year-old women with serendipitous lesions would be expected to have cancer (positive predictive value = 0.44%, 95% confidence interval = 0.24%-0.67%). Conclusion : In women with a suspicious lesion discovered by mammography and/or CBE that is found to be benign, serendipitous breast lesions detected by MRI are extremely unlikely to represent invasive breast cancer. Immediate biopsy of such serendipitous lesions may, therefore, not be required.

Historically, women have used creative expression and art activities to express the unspeakable, to soothe the self and to connect to other women. This connection to self and community through creative activities is the basis for a group model that the authors have developed for women who are dealing with the effects of childhood sexual abuse. This model draws on women's historic use of the creative arts for healing, on current feminist practice in the area of violence, and on the existential art therapy movement.

OBJECTIVES: This study assessed the cost-effectiveness of cervix and breast cancer screening in a public hospital emergency room. METHODS: Age-eligible women with nonurgent conditions and without recent screening were offered screening by a nurse. A decision analysis compared the costs and outcomes of emergency room screening and standard hospital screening efforts. RESULTS: The undiscounted cost-effectiveness results for establishing new programs were $4050 (cervical cancer), $403,203 (breast cancer), and $4375 (joint cervix and breast cancer) per year of life saved. If screening is added to an existing program, results are more favorable ($429, $21,324, and $479 per year of life saved for cervix, breast, and joint screening, respectively). Results were most sensitive to volume and probability of receiving treatment after an abnormal screen. CONCLUSIONS: Emergency room screening was cost-effective for cervical cancer; breast cancer screening was relatively expensive given the low number of women reached. More intensive recruitment and follow-up strategies are needed to maximize the cost-effectiveness of such programs.

Background: The measurement of health outcomes has become a priority for assessing and containing health care costs. Objective: To develop and fully validate a simple symptom scale assessing both asthma and rhinoconjunctivitis, two interdependent conditions. Methods: A self-administered questionnaire of 31 items was tested in 102 patients with asthma and rhinoconjunctivitis between September 1992 and December 1994. The items were rated on a six-point Likert scale ranging from none to extremely severe and included commonly recorded symptoms of inflammation such as irritation, congestion, and discharge in the skin, eyes, nose, sinus, pharynx, and chest. Results: Validation included (1) responsiveness: scores for 18 patients evaluated during an emergency room visit were statistically significantly different from those recorded after recovery and in a control group of 24 patients with asthma; (2) reliability: external consistency was 0.8 at 1 week, and internal consistency was 0.8 for individual organs and 0.7 for individual symptoms; (3) validity: a five-point scale better captured the distribution of values; irrelevant and redundant items were eliminated. The optimal questionnaire included 21 items. Conclusions: The symptom score was applicable, responsive, reliable, and valid. Used with existing validated tools such as treatment needs and quality of life assessment, it may provide a comprehensive picture of allergic airway disease for quality assurance or research purposes. (J Allergy Clin Immunol 1997;100:16-22)

Polycyclic Aromatic Hydrocarbons (PAHs) are a group of chemicals that are formed during the incomplete burning of coal, oil, gas, wood, garbage, or other organic substances, such as tobacco and charbroiled meat. There are more than 100 PAHs. PAHs generally occur as complex mixtures (for example, as part of products such as soot), not as single compounds. PAHs are found throughout the environment in the air, water, and soil. As part of its mandate, the Agency for Toxic Substances and Disease Registry (ATSDR) prepares toxicological profiles on hazardous chemicals, including PAHs (ATSDR, 1995), found atfacilities on the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) National Priorities List (NPL) and which pose the most significant potential threat to human health, as determined by ATSDR and the Environmental Protection Agency (EPA). These profiles include information on health effects of chemicals from different routes and durations of exposure, their potential for exposure, regulations and advisories, and the adequacy of the existing database. Assessing the health effects of PAHs is a major challenge because environmental exposures to these chemicals are usually to complex mixtures of PAHs with other chemicals. The biological consequences of human exposure to mixtures of PAHs depend on the toxicity, carcinogenic and noncarcinogenic, of the individual components of the mixture, the types of interactions among them, and confounding factors that are not thoroughly understood. Also identified are components of exposure and health effects research needed on PAHs that will allow estimation of realistic human health risks posed by exposures to PAHs. The exposure assessmentcomponent of research should focus on (1 ) development of reliable analytical methods for the determination of bioavailable PAHs following ingestion, (2) estimation of bioavailable PAHs from environmental media, particularly the determination of particle-bound PAHs, (3) data on ambient levels of PAHs metabolites in tissueslfluids of control populations, and (4) the need for a critical evaluation of current levels of PAHs found in environmental media including data from hazardous waste sites. The health effects component should focus on obtaining information on (1) the health effects of mixtures of PAHs particularly their noncarcinogenic effects in humans, and (2) their toxicokinetics. This report provides excerpts from the toxicological profile of PAHs (ATSDR, 1995) that contains more detailed information.

Evaluating texts is an important activity associated with teaching statistics. Surprisingly, the statistical education literature offers little guidance on how these evaluations should be conducted. This lack of guidance may be at least partly responsible for the fact that published evaluations of statistics texts almost invariably employ evaluation criteria that lack any theory-based rationale. This failing is typically compounded by a lack of empirical evidence supporting the usefulness of the criteria. This article describes the construction and piloting of instruments for evaluating statistics texts that are grounded in the statistical education and text evaluation literatures. The study is an initial step in a line of research which we hope will result in the establishment and maintenance of a database of evaluations of statistical texts. Evaluative information of this kind should assist instructors wrestling with text selection decisions and individuals charged with performing evaluations, such as journal reviewers, and should ultimately benefit the direct consumers of these texts—the students.

The present study examined the cognitive-behavioral linkages between depressed mood and level of nicotine dependence in smokers seeking smoking cessation treatment. Prior to treatment, 202 subjects completed validated self-report measures of smoking history, depressive symptomatology, "self medication" processes, "learned helplessness" processes, and nicotine dependence. Results revealed that 48% of the study population scored in the "depressed" range on the Center for Epidemiologic Studies (CESD) depression scale. Further, these smokers reported significantly higher levels of nicotine dependence than other nondepressed smokers. Depressed and nondepressed smokers did not differ with respect to several cognitions related to learned helplessness theory. However, depressed smokers were more likely to report "self medication" processes (i.e., negative affect reduction smoking and stimulation smoking). In addition, multivariable regression and path analyses suggested that negative affect reduction smoking and stimulation smoking are sequential mediators of the depression-nicotine dependence relationship. These results underscore the need to screen for depressive symptomatology among smokers seeking treatment, and to develop cessation treatments that are tailored to the needs of depressed smokers.

When anesthetizing children with congenital heart disease for diagnostic cardiac catheterization, anesthesiologists and cardiologists seek to use anesthetic regimens that yield minimal hemodynamic changes and allow for spontaneous ventilations. Recently, dexmedetomidine has been used as an anesthesia adjunct because of its sedative and analgesic properties and minimal ventilatory depressive effects. We tested the hypothesis that the combination of sevoflurane and dexmedetomidine is non-inferior to sevoflurane alone as it refers to hemodynamic measurements during diagnostic cardiac catheterization in children with a transplanted heart, one ventricle (Fontan procedure), or normal cardiac physiology. Patients were anesthetized with inhalation of sevoflurane in nitrous oxide/oxygen and, after baseline hemodynamic measurements, successive boluses of dexmedetomidine followed by continuous infusion were administered. In this study, non-inferiority was shown when differences at steady-state (dexmedetomidine + sevoflurane) compared to baseline (sevoflurane alone) and its associated 95% confidence interval fell completely within the range of plus or minus 20%. Forty-one (26 normal physiology, 9 cardiac transplantation, and 6 Fontan) patients were enrolled. Non-inferiority of sevoflurane + dexmedetomidine compared with sevoflurane alone was shown for heart rate, but not for arterial blood pressure in patients with normal and cardiac transplant physiology. In patients with normal cardiac physiology, non-inferiority was demonstrated for bispectral index. Therefore, while the lack of depressive respiratory effects and non-inferiority for heart rate are desirable, the lack of non-inferiority of dexmedetomidine + sevoflurane combination for arterial blood pressure do not justify the routine use of this combination compared with sevoflurane alone for children with congenital heart disease undergoing cardiac catheterization.

This article describes a training project developed by a hospital-based women's health center to help service providers expand resources for survivors of incest. The project reflected a feminist social work approach based on an awareness of the connections among gender, power, and violence, as well as a commitment to social justice, empowerment of clients and service providers, and community building.

The use of the term survivor is widespread in the feminist therapy community. While the term survivor has been described in primarily positive terms in the abuse literature, this article examines some of the conflicting meanings it holds for women who have been sexually abused. Drawing from the words of clients, the authors argue that women's experiences with abuse are diverse and complex. This paper outlines the dangers of labeling in the therapeutic context, and advocates for approaches to working with women which acknowledge women's experiences of violation while not reducing women to those experiences. Finally, the authors encourage a therapeutic process which offers women an opportunity to explore language and acquire control over the naming of their realities.

Despite evidence of their benefit and efforts to increase usage, anticoagulation for stroke prophylaxis in atrial fibrillation (AF) patients remains underutilized. Previous surveys have assessed reasons for underuse of anticoagulation but have limitations including non-structured approach for eliciting barriers and use of clinical vignettes and not patient-level data. The objectives of this study were to develop a questionnaire to assess barriers to anticoagulation use for stroke prophylaxis in AF patients at a patient- and physician-level and to conduct a preliminary field-test of the instrument.Barriers to warfarin use were identified from a literature review, input from clinical experts, and a physician focus group. A sample of US physicians who treat AF patients completed the questionnaire. Physicians ranked their reluctance on a 1-10 scale (10 = very reluctant) in general to prescribe warfarin if a specific barrier was present in a patient and then indicated critical barriers to prescribing warfarin in a sample of their own AF patients not receiving warfarin.Forty-one barriers to warfarin use were identified and classified into 4 groups: patient medical characteristics (n = 17), health care system factors (n = 7), patient capability (n = 12), and patient preference (n = 5). Several new items were developed (e.g., difficulty in obtaining venous access), existing items were revised (e.g., timeframe for bleeding episodes subdivided intooror= 3 months), and multi-factorial barriers (e.g., dementia, epilepsy) were explored. The factor that most strongly influenced physicians' (n = 30) decisions not to prescribe warfarin was severe bleeding3 months ago (mean +/- SD: 9.2 +/- 1.3) while the most prevalent critical barriers to prescribing warfarin in specific AF patients (n = 24) was patient unwilling to undergo repeat testing (29%).This questionnaire has the potential to assist in better understanding barriers to warfarin use with a view to addressing and then overcoming warfarin underutilization. Preliminary data suggest patient preference and capabilities are at least as important as medical characteristics as barriers to prescribing warfarin in AF patients.

BACKGROUND To evaluate associations between race and breast carcinoma treatment. METHODS Data from 984 black and 849 white Medicare beneficiaries 67 years or older with local breast carcinoma and a subset of 732 surviving women interviewed 3–4 years posttreatment were used to calculate adjusted odds of treatment, controlling for age, comorbidity, attitudes, region, and area measures of socioeconomic and health care resources. RESULTS Sixty-seven percent of women received a mastectomy and 33% received breast-conserving surgery. The odds of radiation omission were 48% higher (95% confidence interval [CI] 1.01–2.19) for blacks than for whites after considering covariates, but the absolute number of women who failed to receive this modality was small (11%). In race-stratified models, the odds of having radiation omitted were significantly higher among blacks living greater distances from a cancer center (vs. lesser) or living in areas with high poverty (vs. low), but these factors did not affect radiation use among whites. Among those interviewed, blacks reported perceiving more ageism and racism in the health care system than whites (P = 0.001). The independent odds of receiving mastectomy (vs. breast conservation and radiation) were 2.72 times higher (95% CI 1.25–5.92) among women reporting the highest quartile of perceived ageism scores, compared with the lowest, and higher perceived ageism tended to be associated with higher odds of radiation omission (P = 0.06). CONCLUSIONS Older black women with localized breast carcinoma may have a different experience obtaining treatment than their white counterparts. The absolute number of women receiving nonstandard care was small and the effects were small to moderate. However, if these patterns persist, it will be important to evaluate whether such experiences contribute to within-stage race mortality disparities. Cancer 2002;95:1401–14. © 2002 American Cancer Society. DOI 10.1002/cncr.10825

Background. Few measures exist to assess physicians’ practice style, and there are few data on physicians’ practice styles and patterns of care. Objectives. To use clinical vignettes to measure surgeons’ “propensity” for local treatments for early-stage breast cancer and to describe factors associated with propensity. Research Design and Subjects. A cross-sectional mailed survey with telephone follow-up of a random sample of 1,000 surgeons treating Medicare beneficiaries in fee-for-service settings. Measures. Outcome measures include treatment propensity, self-reported practice, and actual treatment received by the surgeons’ patients. Results. Propensities were significantly associated with actual treatment, controlling for covariates. Area Medicare fees were the strongest predictor of propensity, followed by region, attitudes, volume, and gender. For instance, after other factors were considered, surgeons practicing in areas with the highest breast-conserving surgery (BCS) fees were 8.61 (95% CI 2.26–32.73) times more likely to have a BCS propensity than surgeons in areas with the lowest fees. Surgeons with the strongest beliefs in patient participation in treatment decisions were nearly 6 times (95% CI 1.67–20.84) more likely to have a BCS propensity than surgeons with the lowest such beliefs, controlling for covariates. Male surgeons were also independently more likely to have a mastectomy propensity than female surgeons. Conclusions. Surgeons’ propensities explain some of the observed variations in breast cancer treatment patterns among older women. Standardized scenarios provide a practical method to measure practice style and could be used to evaluate physician contributions to shared decision making, practice patterns, costs and outcomes, and adherence to guidelines.

Twenty-one asthma patients with allergic rhinitis completed a series of self-administered questionnaires (21-item symptom score for rhinosinusitis and asthma, bother scale, McMaster Asthma Quality of Life Questionnaire [MAQOL] and Euroqol) at 2-week intervals from August to November 1994. Relative responsiveness of the instruments was assessed in reference to the maximum and minimum average scores for MAQOL, with area under the curve (AUC) and correlation coefficients between the different instruments. Symptom score, MAQOL, and bother scale provided similar results for both extreme values and AUC, whereas Euroqol utilities were less responsive. These results suggest that the symptom scores and bother scales are responsive and valid, and might prove valuable in everyday practice, clinical trials, and quality assurance programs.

Objective To utilize health services research techniques in developing an episode of care using an administrative data set. This method is demonstrated for an episodic clinical condition, migraine. Data Sources Medicaid administrative data set of 3,372 patients with a diagnosis of migraine (ICD-9-CM 346.0, 346.1) in the state of Pennsylvania between May 1990 and March 1992. Study Design The duration of a migraine episode was measured by assessing the magnitude of resource utilization and the proportion of patients with charges in the period after the index migraine as compared to the period before the index migraine. A confidence interval (CI) was developed around each measure using bootstrap techniques. Data Collection Methods All charge data were extracted daily for a 113-day observation period surrounding each index migraine in order to observe the duration of impact of a migraine diagnosis on resource utilization. Principal Findings The lower limits of both the 95% and 99% CIs for the difference in charges are greater than 0 for three weeks. The lower limits of both CIs for the difference in the proportion of patients with charges are above 0 for six weeks. Conclusions Our analysis demonstrates that a health services research framework can be used to define an episode of care for a chronic disease category such as migraine. This method can be used to evaluate episodes of care for clinical studies of limited or episodic conditions and to complement clinical expertise in developing time horizons for clinical trials. Copyright © 1999 Health Research and Education Trust. Reprinted in 2001 by John Wiley & Sons, Ltd.

In this article the authors report on the short-term impact of incorporating biomarker feedback about exposure and genetic susceptibility into minimal-contact quit-smoking counseling (QSC). Four hundred and twenty-seven smokers were randomized to 1 of 3 treatments: (a) QSC, (b) QSC + exposure biomarker feedback (EBF) about carbon monoxide in exhaled breath, or (b) QSC + EBF + biomarker feedback about genetic susceptibility to lung cancer (SBF). We observed significant immediate positive effects of SBF, compared with EBF and QSC on perceived risk, perceived quitting benefits, and fear arousal. However, at the 2-month follow-up, there were no group differences in quit rates. SBF did lead to significant reductions in the number of cigarettes smoked for smokers who were in the preparation stage. Smokers in the EBF and QSC conditions showed reductions in depressive symptoms by 2 months, but smokers in the SBF condition did not. In the context of QSC, genetic feedback may heighten vulnerability and possibly promote distress, but may not immediately enhance quitting in most smokers.