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Performed a comparative analysis of Activities of Daily Living (ADL) items administered to 4,430 older adults and Instrumental Activities of Daily Living administered to 605 people with rheumatoid arthritis scoring both with Likert and Rasch measurement models. Findings show the superiority of the Rasch approach over the Likert method. (SLD)

The theoretical model of medical student performance begins with 38 measures, reduced to 18 without loss of information. These measures are shown to reflect five underlying theoretical interrelated variables: medical knowledge; clinical performance; science aptitude; college achievement; and attitudes and values. Results should be useful in assessing candidates for medical school admission. (Author/MSE)

This study determined factors associated with an increased risk of ending Medicare home health care because of hospitalization and examined specific types of and reasons for hospitalization. Sample members (N = 922) were followed from admission to discharge as they received home care from Ohio Medicare-certified home care agencies between December 1999 and March 2002. Potential patient-level risk factors were predisposing, enabling, or need variables, and an agency-level variable denoting hospital affiliation or freestanding status was examined as a second-level risk factor. Among those hospitalized (18.3%), more than 80.0% experienced emergency hospitalizations, mostly for acute exacerbations of chronic diseases. Statistically significant risk factors for hospitalization included dyspnea severity, functional disability level, skin or wound problems, diabetes, case mix score, and guarded rehabilitation prognosis. Home care agencies might reduce hospitalizations by using clinical prognosis as a key resource for team communication and by helping patients and families anticipate potential acute exacerbations of chronic diseases and manage these events at home. Keywords: Medicare home health care; hospitalization; rehospitalization; OASIS data

Abstract Background The aims of this study were to determine if observed geographic variations in colorectal cancer incidence are simply random or are statistically significant deviations from randomness, whether statistically significant excesses are temporary or persistent, and whether they can be explained by risk factors such as socioeconomic status (SES) or the percent of the population residing in an urban area rather than a rural area. Between 1995 and 1998, 6360 male and 6628 female invasive colorectal cancer cases were diagnosed in Massachusetts residents. Cases were aggregated to Census tracts and analyzed for deviations from random occurrence with respect to both location and time. Results Six geographic areas that deviated significantly from randomness were uncovered in the age-adjusted analyses of males: three with higher incidence rates than expected and eight lower than expected. In the age-adjusted analyses of females, one area with a higher incidence rate, and one area with a lower incidence rate than expected, were found. After adjustment for SES and percent urban, some of these areas were no longer significantly different. Conclusion Public health practitioners can use the results of this study to focus their attention onto areas in Massachusetts that need to increase colorectal screening or have elevated risk of colorectal cancer incidence.

Abstract Background The aims of this study were to determine whether observed geographic variations in melanoma cancer incidence in both gender groups are simply random or are statistically significant, whether statistically significant excesses are temporary or persistent, and whether they can be explained by risk factors such as socioeconomic status (SES) or the percent of the population residing in an urban rather than a rural area. Between 1990 and 1999, 4774 female and 5688 male melanomas were diagnosed in Massachusetts residents. Cases were aggregated to census tracts and analyzed for deviations from random occurrence with respect to both spatial location and time. Results Thirteen geographic areas that deviated significantly from randomness were uncovered in the age-adjusted analyses of males: five with higher incidence rates than expected and eight lower than expected. In the age-adjusted analyses of females, six areas with higher incidence rates and eight areas with lower than expected incidence rates were found. After adjustment for SES and percent urban, several of these areas were no longer significantly different. Conclusion These analyses identify geographic areas with invasive melanoma incidence higher or lower than expected, the times of their excess, and whether or not their status is affected when the model is adjusted for risk factors. These surveillance findings can be a sound starting point for the shoe-leather epidemiologist.

Abstract Background Early detection is the best way to control breast cancer. This observational epidemiologic study uses ten years of data, 1988–1997, to determine whether the observed variations in the proportion of breast cancers diagnosed at late stage are simply random or are statistically significant with respect to both geographical location and time. Results A total of three spatial-temporal areas were found to deviate significantly from randomness in the unadjusted analysis; one of the three areas contained statistically significant excesses in proportion of late stage, while two areas were identified as significantly lower than expected. The area of excess spanned the first three years of the study period, while the low areas spanned the last five years of the study period. Some of these areas were no longer statistically significant when adjustments were made for SES and urban/rural status. Conclusion Although there was an area of excess in eastern Massachusetts, it only spanned the first three years of the study period. The low areas were fairly consistent, spanning the last five years of the study period.

Faculty committees wrote educational objectives for all 23 courses in their undergraduate medical school curriculum. The objectives were used for evaluation of curriculum, student knowledge, and attitudes. (CP)

A comprehensive program evaluation designed to encourage active participation by the faculty, residents, and staff members involved in a residency program in primary care pediatrics is described. The evaluation was based on an approach in which continual review of instructional objectives and learning experiences ensured continual monitoring of program goals. (MLW)

Acute care hospitalization during or immediately following a Medicare home health care (HHC) episode is a major adverse outcome, but little has been published about HHC patient-level risk factors for hospitalization. The authors determined risk factors at HHC admission associated with subsequent acute care hospitalization in a nationally representative Medicare patient sample (N = 374,123). Hospitalization was measured using Medicare claims data; risk factors were measured using Outcome Assessment and Information Set data. Seventeen percent of sample members were hospitalized. Multivariate logistic regression analysis found that the most influential risk factors (all p < .001) were skin wound as primary HHC diagnosis, clinician-judged guarded rehabilitation prognosis, congestive heart failure as primary HHC diagnosis, presence of depressive symptoms, dyspnea severity, and Black, compared to White. HHC initiatives that minimize chronic condition exacerbations and actively treat depressive symptoms might help reduce Medicare patient hospitalizations. Unmeasured reasons for higher hospitalization rates among Black HHC patients deserve further investigation. [ABSTRACT FROM PUBLISHER]

This study presents a structural equation model describing the influence of stressful life experiences on low birth weight. Data were gathered prospectively in two waves from 5295 inner-city women as part of a city-wide preterm birth prevention project. Using interviews and the medical record, over 200 measures were gathered on each mother and her infant, where each measure was included because of its relevance documented in the risk factor literature. Seventeen of these measures reflected real life stressful experiences and through measurement modeling, eleven of these measures were chosen to represent three underlying measures of stress: economic stress, family stress, and the lack of social support. This study incorporates these psychosocial stressors into a full structural equation model to show their influence on addictive behavior and low birth weight. The full model emerged from tests of alternative causal conceptualizations of how these stressors influence each other and low birth weight - whether their influence on low birth weight in simple and direct, or whether their influence is mediated by addictive behaviors. The model was tested on the first wave, a sample of 3205, and cross-validated on the second wave, a sample of 2090. The model shows that economic stress influences both social support and family stress, but has no direct influence on low birth weight: that social support, or its absence, influences addictive behavior, but has no direct influence on low birth weight, and that family stress influences addictive behavior, and consistent with 30 years of research on humans, has no direct influence on low birth weight. Finally, the mother's history of medical risks shows an independent influence on low birth weight, while her age does not. Age, however, shows a strong influence on addictive behavior. The study demonstrates how structural equation modeling can be used to create and test alternative conceptualizations of how stress affects low birth weight. There are strong implications for planners of prenatal care programs. Key words - low birth weight, preterm birth, stress, structural equation modeling

Background: The aims of this study were to determine whether observed geographic variations in melanoma cancer incidence in both gender groups are simply random or are statistically significant, whether statistically significant excesses are temporary or persistent, and whether they can be explained by risk factors such as socioeconomic status (SES) or the percent of the population residing in an urban rather than a rural area. Between 1990 and 1999, 4774 female and 5688 male melanomas were diagnosed in Massachusetts residents. Cases were aggregated to census tracts and analyzed for deviations from random occurrence with respect to both spatial location and time. Results: Thirteen geographic areas that deviated significantly from randomness were uncovered in the age-adjusted analyses of males: five with higher incidence rates than expected and eight lower than expected. In the age-adjusted analyses of females, six areas with higher incidence rates and eight areas with lower than expected incidence rates were found. After adjustment for SES and percent urban, several of these areas were no longer significantly different. Conclusion: These analyses identify geographic areas with invasive melanoma incidence higher or lower than expected, the times of their excess, and whether or not their status is affected when the model is adjusted for risk factors. These surveillance findings can be a sound starting point for the shoe-leather epidemiologist. [ABSTRACT FROM AUTHOR]

Background: The aims of this study were to determine whether observed geographic variations in breast cancer incidence are random or statistically significant, whether statistically significant excesses are temporary or time-persistent, and whether they can be explained by covariates such as socioeconomic status (SES) or urban/rural status? Results: A purely spatial analysis found fourteen geographic areas that deviated significantly from randomness: ten with higher incidence rates than expected, four lower than expected. After covariate adjustment, three of the ten high areas remained statistically significant and one new high area emerged. The space-time analysis identified eleven geographic areas as statistically significant, seven high and four low. After covariate adjustment, four of the seven high areas remained statistically significant and a fifth high area also identified in the purely spatial analysis emerged. Conclusions: These analyses identify geographic areas with invasive breast cancer incidence higher or lower than expected, the times of their excess, and whether or not their status is affected when the model is adjusted for risk factors. These surveillance findings can be a sound starting point for the epidemiologist and has the potential of monitoring time trends for cancer control activities. [ABSTRACT FROM AUTHOR]

In order to identify and explain those aspects of clinical performance related to moral reasoning, 39 family medicine residents were studied as they interacted with each of two simulated patients. Residents were interviewed to assess their performance with each patient, elicit their general philosophy of being a doctor, and measure their moral reasoning. General performance as residents was rated by three faculty supervisors. Scoringprotocols were developedfor each measure to ensure objectivity. Factor analysis of each measure guided selection of the most meaningful variablefrom each instrument. Based upon general models relating attitude to behavior, structural equations were used to explicate the relationship between moral reasoning, performance on the simulated cases, performance as a resident, attitude, and intention. Chi-square goodness offit indicates that the general attitude-behavior models adequatelyfit the data. These models would suggest that moral reasoning and physician attitudes have more of an influence on behavior than physician intentions. [ABSTRACT FROM PUBLISHER]

In order to see if the problem oriented record could be used to measure a student's facility at data collection, data recording, and clinical problem solving, the problem oriented record (POR) was divided into 14 sections, each of which was graded for structure and completeness. Maximum possible score was 162 points. Seven faculty members and a teaching resident at two institutions graded a single work-up, with a coefficient of variation of 2.8%. In two observed work-ups, there was a high correlation between observed and recorded data. Three clerkship groups of 9 to 16 students each, some of whom were taught by a teaching resident, handed in at different times during the clerkship a total of 66 PORs, with a mean score of 101.75 points (range, 10 to 152 points). It was concluded that the graded POR could objectively measure facility at data collection, data recording, and problem solving, and that students were taught these skills by grading a work-up themselves. [ABSTRACT FROM AUTHOR]