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<TD BGCOLOR="#CCCCFF" ALIGN="LEFT"><a name="skipnav"></A><DIV CLASS="main"><font face="arial,sans-serif" size="3" color="#000000"><B>Validated Questionnaires Available for Use</B>
<P>
<B>A. Primary Care Assessment Survey (PCAS)</B>
<P>
The Primary Care Assessment Survey (PCAS) is a validated, 51-item, patient-completed questionnaire designed to operationalize formal definitions of primary care, including the definition recently suggested by the Institute of Medicine Committee on the Future of Primary Care. The survey, developed in 1993 and widely used in a decade of research, is intended for performance measurement and quality improvement at the individual physician, group practice, health plan, or delivery system level. The PCAS measures 7 defining characteristics of primary care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (knowledge of patient, preventive counseling), integration of care, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Extensive psychometric testing and evaluation has been conducted on the PCAS scales. All scales exceed established standards for excellent instrumentation, and perform consistently well across population subgroups defined according to age, sex, education, race, household income, and health status.
<P>
The PCAS is a copyrighted document, made freely available to those who wish to use it in research or practice. For further information, please contact Angela Li at The Health Institute, 617-636-8619 (<A HREF="MAILTO:[email protected]">[email protected]</a>).
<P>
<B>B. Ambulatory Care Experiences Survey (ACES).</B>
<P>
The Ambulatory Care Experiences Survey (ACES) is a brief, patient-completed questionnaire that evaluates patients' experiences with their primary care physician, specialist physicians and health plan. The survey was designed for practical applications, particularly quality monitoring and improvement initiatives that require physician-level performance assessment. The survey emphasizes content that is highly �actionable� at the individual physician and practice level. The survey includes a primary care module (PCP-ACES) that can be used as a stand-alone instrument to evaluate patients� experiences with their primary care physician and the physician�s practice. This module of the survey builds upon and extends beyond the measures contained in the Primary Care Assessment Survey (PCAS) � including both previously validated measures as well as new items developed with advice and input from a National Advisory Committee. The Institute of Medicine definition of primary care forms the conceptual basis for the content areas addressed by the primary care module. The PCP module yields 11 summary scales as follows: relationship duration, communication quality, health promotion, whole-person orientation, interpersonal treatment, trust, access, visit-based continuity, integration of care, office staff, and other clinical staff. All measures from the PCP module exceed established criteria for Likert scales and demonstrate high internal consistency reliability (Cronbach's alpha range: .75-.93) and meet additional criteria relevant to physician-level measurement (physician-level reliability, discrimination among physicians, substantial variance explained by physician). Sample sizes of 45 patients per physician yielded physician-level reliability greater than 0.70 for all scales, and many scales exceeded 0.80. A short-form version of PCP-ACES is currently being administered and tested in several large-scale demonstration projects in diverse markets nationwide.
<P>
For more information, please contact, Angela Li, The Health Institute, 617-636-8619 (<A HREF="MAILTO:[email protected]">[email protected]</a>).
<P>
<!-- -->
<B>C. Depression Screening using the PC-SAD©</B>
<P>
The PC-SAD© is a Patient Administered Depression Screening Instrument
<P>
As many as 50% of patients with major depression seen in primary care clinics are not diagnosed. To facilitate efficient identification of primary care patients with depression, we developed a new patient- administered depression screening instrument (PC-SAD©) that produces a DSM-IV diagnosis. The PC-SAD consists of 37 items: a three item pre-screen, a 26-item MDD section, and an eight-item dysthymia section. The 26-item MDD section includes five questions from the Short Form-36 (SF-36). Questions are laid out in grid formats. The three-item pre-screener consists of two depression questions that are closely related to the WHO depression screener, and one dysthymia question that we introduced. The two pre-screener questions were posed in terms of 1-week recall period. The pre-screen questions become part of the scorning algorithm if a patient�s reply is yes. Otherwise, this reduces respondent burden by terminating the screener when all are negative.
<P>
We compared its performance to other screeners that yielded DSM-IV diagnoses. To assess validity, the diagnostic accuracy of the PC-SAD was compared with the Inventory to Diagnose Depression (ODD) and the PRIME-MD-PHQ (PHQ) in a convenience sample (n=312) of health plan members, primary care outpatients, and psychiatric patients with diagnoses. The screeners were compared with each other and with psychiatric diagnoses to assess their relative performance. Disagreement among the screeners was formally tested using a triangulation approach that incorporates a statistical likelihood model. The performance of the PC-SAD and the IDD were comparable. The PHQ was less sensitive than either of those. The PC-SAD respondent burden strikes a balance between the very short PHQ, and the longer IDD, and has the lowest (easiest) Flesch-Kincaid reading level. Investigators, clinicians, and health plans that want a DSM-IV-based depression screener can choose from any of these instruments, with known tradeoffs in sensitivity, respondent burden, and readability.
<P>
To read more about the validity, reliability, sensitivity, and specificity, consult the following publication:
<BLOCKQUOTE>
Rogers WH, Wilson IB, Bungay KM, Cynn DJ, Adler DA. Assessing the performance of a new depression screener for primary care (PC-SAD ©). Journal of Clinical Epidemiology 55 (2002) 164-175.
</BLOCKQUOTE>
<P>
For questions or to obtain the instrument, call 1-617-636-8078 or email <A HREF="MAILTO:[email protected]">[email protected]</A>
<P>
<!-- -->
<B>D. The Work Limitations Questionnaire (WLQ)</B>
<P>
Clinical researchers, the pharmaceutical industry, employers, managed care organizations, and public health professionals are all seeking accurate information concerning the work and productivity impact of employee health problems. The pharmaceutical industry requires sensitive and specific work disability and productivity indicators for use in its clinical trials and to provide useful information to employers and other health care system stakeholders. Employers are requesting data to assess the impact of changing employee demographics on health and productivity, to evaluate the need for health and work productivity improvement strategies and, once implemented, to evaluate their impact. Managed care organizations are being asked to demonstrate "value" to customers, including purchasers, who are interested in improving employee function and limiting the indirect costs of illness. Finally, public health officials have widened their surveillance and prevention efforts to include disability due to chronic disease. The WLQ can contribute information to all of these initiatives.
<P>
The WLQ is an easy to use questionnaire, measuring the degree to which employed individuals are experiencing limitations on-the-job due to their health problems, and health-related productivity loss. The WLQ has 25 items that ask respondents to rate their level of difficulty or ability to perform specific job demands (Figure 1). The job demands, which are contained in the WLQ's items, have four defining features: 1) they occur among a variety of jobs; 2) many different physical and emotional health problems may interfere with their performance; 3) they are considered important to the job from the worker's perspective; and 4) problems performing them are frequently related to productivity.
<P>
The WLQ's 25 items are aggregated into four scales. The Time Management scale contains five items that address difficulty handling time and scheduling demands. The six-item Physical Demands scale covers a person's ability to perform job tasks that involve bodily strength, movement, endurance, coordination and flexibility. The Mental-Interpersonal Demands Scale has nine items addressing cognitive job tasks, and on-the-job social interactions. The fourth scale is the Output Demands scale and it contains five items concerning diminished work quantity and quality.
Scale score range from 0 (limited none of the time) to 100 (limited all of the time) and represent the reported amount of time in the prior two weeks respondents were limited on-the-job. Additionally, using an algorithm, WLQ scale scores can be converted into an estimate of productivity loss.
<P>
Development Process<BR>
The WLQ development process began in 1994 with a grant from Glaxo-Wellcome, Inc. WLQ research has also been supported by Pharmacia, Inc., Pfizer, Inc., and the National Institute of Mental Health. Prior to the WLQ's development, there had been a very limited amount of detailed information available on health-related work productivity loss. Much of the information was gleaned from global indicators, such as the activity limitation and disability day items appearing within the US National Health Interview Survey, and the role disability scales of health assessment questionnaires (2).
<P>
The WLQ itself evolved from a qualitative and quantitative research process. Early in that process, we convened multiple focus groups, consisting of employed patients with chronic disease. These interactions with working patients helped us to better understand how the work activities, associated with various jobs, were influenced by different conditions and their treatments. For example, we found that several physical and mental conditions made it difficult for individuals to perform their job tasks effectively throughout the workday according to an established or expected work schedule. Another important finding was that work productivity was a sensitive topic for many of the chronically ill workers we interviewed, and we learned how, in a non-threatening manner, to ask about work productivity. We also found that the act of recalling information about work productivity, and the effects of health problems on productivity, constituted a relatively difficult response task. These general findings helped to shape our measurement approach.
<P>
A period of cognitive testing followed, in which items and item groupings were evaluated for content validity (relevance to work and to illness), clarity, and respondent burden. Finally, a series of psychometric tests, conducted on the resulting questionnaire forms, led to the current 25-item version. Within patient and employee populations, this version of the WLQ has demonstrated excellent scaling properties, as well as construct and criterion validity.
<P>
Scale alpha's exceed the recommended level of .70 in both patient and employee populations. Construct validity tests have shown that WLQ scale scores vary with SF-36 measures of physical and mental health, type of chronic condition, and severity within condition groups, such as depression and osteoarthritis.
<P>
Criterion validity tests have been performed in several settings. For example, within a sample of private short-term disability claimants with back pain, baseline WLQ scores obtained within four weeks of the claim predicted the duration of the disability until return to work. In a study of patients with rheumatoid arthritis and in a second with a fibromyalgia sample, WLQ scores predicted patient income level. The WLQ has also been shown to correlate with adverse events in the workplace such as employee injuries.
<P>
In a work-site study involving repeat measures of approximately 900 employees, WLQ scores were significantly related to objectively-measured employee-level work productivity. Using results generated within this study, we developed and validated an approach to scoring the WLQ, which enables the user to translate scale scores into a single estimate of productivity loss. The WLQ Productivity Index Score indicates the percentage difference in output from a healthy (not limited) benchmark population.
<P>
National Benchmarking Database<BR>
In 2003, we completed our first national WLQ benchmarking survey. This survey involved a representative sample of adults in the United States and will generate high quality benchmarks for the population and important subgroups (defined by health condition, occupation and other demographic features). Data from this survey will become available to WLQ users in 2004.
<P>
WLQ Modules<BR>
WLQ users, who wish to take a comprehensive approach to measurement, may take advantage of the other survey modules we have developed. These include a Work Absence Index, a comorbidity checklist, and additional survey items for measuring multiple dimensions of health and employment.
<P>
Availability<BR>
The WLQ is available royalty-free for non-commercial applications, commercial users are charged a fee. Information about the WLQ, and copies of the instrument, are available free by request from <A HREF="mailto:[email protected]">[email protected]</A>.
<P>
Work Limitations Questionnaire, © 1998, The Health Institute; Debra Lerner, Ph.D.; Benjamin Amick III, Ph.D.; and GlaxoWellcome, Inc. All Rights Reserved.
<P>
<!-- -->
<B>E. Medical Outcomes Study Instruments</B>
<P>
The Medical Outcomes Trust is a not for profit organization dedicated to improving health and health care by promoting the science of outcomes measurement, and the development, evaluation and distribution of standardized, high quality instruments that measure health and the outcomes of medical care. The Trust supports the use of these instruments with services and publications.
<P>
The Trust was incorporated in Massachusetts in 1992 as a public service organization. It began its programs in June, 1994 with a grant from the Henry J. Kaiser Family Foundation. In 2000, the Trust became affiliated with Health Assessment Lab (HAL), a non-profit research organization based in Boston. HAL evolved from the health status assessment group at the Health Institute of the New England Medical Center.
<P>
Contact Information:
<BLOCKQUOTE>
Medical Outcomes Trust<BR>
235 Wyman Street, Suite 130<BR>
Waltham, MA 02451<BR>
Phone 781-890-4884<BR>
Fax 781-890-0922<BR>
<A HREF="mailto:[email protected]">[email protected]</A></BR>
</BOCKQUOTE>
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