Conducting Health Outcomes Research Book

Preface

Acknowledgments

About the Authors

Chapter 1 Introduction to Outcomes Research 1

An Outcomes Approach 8

Risk Adjustment 9

Treatment 10

Types of Study Designs 11

Measuring Outcomes 15

Conceptual Modeling 16

Organization of the Book 21

References 21

Chapter 2 Models and Causal 'Thinking 25

Causation 25

Conceptual Models 29

Explanatory Models 33

Summary 35

References 36

Chapter 3 Outcomes Research Study Designs 39

Isolating the Effect of the Intervention 39

Threats to Validity 41

Threats to Internal Validity 41

Basic Research Designs 43

Potential Biases in Implementing a Study 46

References 47

Chapter 4 Measurement 49

The Nature of Measurement 50

Scaling 52

Nominal Measurement 52

Ordinal Measurement 54

Interval Measurement 55

Ratio Measurement 56

Scaling Methods 56

Rating Scales 57

Comparative Methods 58

Econometric Methods 60

Item Response Theory 61

Strategic Questions in the Selection of Health Outcomes Measures 61

Sensibility 62

Reliability 63

Validity 70

The Three C's of Validity 71

Responsiveness 74

Burden 77

Design 78

Final Thoughts About Outcomes Measures 78

Advantages of Multiple-Item Versus Single-Item Measures 78

Other Useful Terms to Describe Measures 79

Summary 80

References 80

Chapter 5 Generic Health Outcomes Measures 85

Why Use Generic Measures? 86

Advantages and Disadvantages of Using Generic Health Outcomes Measures 88

Health Outcome Domains 89

Physical Functioning 91

Psychologic Well-Being 93

Social Functioning 93

Pain 94

Cognitive Functioning 94

Vitality 95

Overall Well-Being 95

Practical Considerations 96

Choosing a Measure 98

Conclusion 99

References 100

Chapter 6 Health-Related Quality of Life 105

Applications for Health-Related Quality of Life Measures 108

Condition-Specific HRQL 108

Examples of HRQL Measures 109

Karnofsky Scale 109

COOP Charts for Primary Care Practices 112

Medical Outcomes Studies Short-Form Measures 114

Sickness Impact Profile 115

Quality of Well-Being Index 118

EuroQol 120

World Health Organization Quality of Life-BREF 121

Health Utilities Index 121

QOL Coverage 123

Utility Assessment 123

References 129

Chapter 7 Condition-Specific Measures 133

Condition-Specific Measures Versus Generic Health Status Measures 133

Why Not Generic Health Status Measures? 134

Condition-Specific Health Status Measures 136

Physiologic Measures 137

Case Definition Disease Does Not Equal Disease 140

Other Alternatives 140

The Choice of a Condition-Specific Measure 143

The Conceptual Model 143

Hierarchy of Measurement 146

The Role of Condition-Specific Versus Generic Measures 148

Choosing a Measure 151

Conclusion 153

References 154

Chapter 8 Satisfaction With Care 159

The Importance of Patient Satisfaction 159

Theoretic Models of Satisfaction 160

Interpreting Satisfaction Ratings 161

Expectations and Psychosocial Determinants 161

Dimensions of Satisfaction 163

Process of Care and Satisfaction 166

Outcomes and Satisfaction 166

Methodology of Measuring Satisfaction 167

Measurement Methods 167

Methodological Issues 169

Psychometric Testing 170

Utilization Patterns, Survey Timing and Reference Group 172

Reporting Versus Rating 173

Importance of Satisfaction Elements 173

Existing Satisfaction Measures 175

Health Plan 174

Hospital 178

Ambulatory Care 180

Long-Term Care 183

Literature Reviews 188

Summary 188

References 189

Chapter 9 Demographic, Psychologic, and Social Factors 199

Demographic Factors 201

Age 202

Residence 202

Race 203

Marital Status 204

Social Economic Status 205

Psychologic Factors 206

Mind Body Connection 206

Well-Being 210

Locus of Control 210

Pain 211

Stress 212

Other 212

Affect 213

Depression 216

Anxiety 216

Cognitive Function 218

Social Function 218

Social Support 219

Social Function/Adjustment 219

Summary 223

References 223

Chapter 10 Treatment and Interventions 235

Importance of Understanding Treatment 235

What is a Treatment? 235

Components of Treatment 237

Diagnosis Versus Treatment 241

Treatment Components 241

Medications 242

Procedures 242

Counseling/Education 243

Understanding the Components of Treatment 244

Does the Type of Physician Matter? 245

Isolating the Treatment of Interest 246

Statistically Isolating the Effect of Treatment 247

Variation in Treatment 248

Quality Improvement 254

Summary 254

References 255

Chapter 11 Risk Adjustment 261

Severity and Comorbidity 262

Diagnosis-Specific Severity 263

Generic Comorbidity Measures 264

Why Should We Measure Comorbidity (or the Severity of Illness)? 270

Control for Selection Bias 270

Improve Prediction of Outcomes 271

Form a Basis for Subgroup Analysis 271

Data Sources 272

Considerations in Selecting a Risk-Adjustment Strategy 273

Statistical Performance: How Do You Evaluate the Performance of a Risk Model? 275

Summary 277

References 277

Chapter 12 Methods for Collecting Health Outcomes and Related Data 281

Self-Report 282

Tailored Design 287

Designing a Survey Implementation System 288

Pretesting 288

Clinical Data 289

Administrative Data 291

Summary 294

References 294

Chapter 13 Analysis and Visual Display of Health Outcomes Research Data 297

Considerations for Analyzing Health Outcomes Data 297

Select the Analytic Method 298

Threats to Validity 302

Low Statistical Power 302

Fishing and Error Rate Problems 306

Employ Acceptable Methods for Handling Missing Data 308

Create a Database and a Data Dictionary 311

Operationalize Study Variables and Structure Data for Analysis 313

Visual Display of Health Outcomes Information 315

Regulatory Demands Accompanying Health Outcomes Research 316

Summary 318

References 319

Chapter 14 Making Sense of It All: Interpreting the Results 323

Organizing One's Thinking 323

The Search for Simple Measures 325

Adjusting for Case Mix 326

Data Quality 327

Getting Follow-up Data 329

Using Extant Data Sources 331

Basic Analysis Issues 332

Ethics 335

Disease Management 336

Quality Improvement 337

Operational Steps 337

Summary 340

References 341

Index 343