The resident assessment instrument-minimum data set 2.0 quality indicators : a systematic review

Background
The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. These data have been used to compute indicators of care quality. Use of the quality indicators to inform quality improvement initiatives is contingent upon the validity and reliability of the indicators. The purpose of this review was to systematically examine published and grey research reports in order to assess the state of the science regarding the validity and reliability of the RAI-MDS 2.0 Quality Indicators (QIs).

Methods
We systematically reviewed the evidence for the validity and reliability of the RAI-MDS 2.0 QIs. A comprehensive literature search identified relevant original research published, in English, prior to December 2008. Fourteen articles and one report examining the validity and/or reliability of the RAI-MDS 2.0 QIs were included.

Results
The studies fell into two broad categories, those that examined individual quality indicators and those that examined multiple indicators. All studies were conducted in the United States and included from one to a total of 209 facilities. The number of residents included in the studies ranged from 109 to 5758. One study conducted under research conditions examined 38 chronic care QIs, of which strong evidence for the validity of 12 of the QIs was found. In response to these findings, the 12 QIs were recommended for public reporting purposes. However, a number of observational studies (n=13), conducted in "real world" conditions, have tested the validity and/or reliability of individual QIs, with mixed results. Ten QIs have been studied in this manner, including falls, depression, depression without treatment, urinary incontinence, urinary tract infections, weight loss, bedfast, restraint, pressure ulcer, and pain. These studies have revealed the potential for systematic bias in reporting, with under-reporting of some indicators and over-reporting of others.

Conclusion
Evidence for the reliability and validity of the RAI-MDS QIs remains inconclusive. The QIs provide a useful tool for quality monitoring and to inform quality improvement programs and initiatives. However, caution should be exercised when interpreting the QI results and other sources of evidence of the quality of care processes should be considered in conjunction with QI results.

Predicting time trade-off health state valuations of adolescents in four Pacific countries using the assessment of quality-of-life (AQoL-6D) instrument

Objectives: Pacific Obesity Prevention in Communities (OPIC) is a community-based intervention project targeting adolescent obesity in Australia, New Zealand, Fiji, and Tonga. The Assessment of Quality of Life Mark 2 (AQoL-6D) instrument was completed by 15,481 adolescents to obtain a description of the quality of life associated with adolescent overweight and obesity, and a corresponding utility score for use in a cost–utility analysis of the interventions. This article describes the recalibration of this utility instrument for adolescents in each country.

Methods: The recalibration was based on country-specific time trade-off (TTO) data for 30 multiattribute health states constructed from the AQoL-6D descriptive system. Senior secondary students, in a classroom setting, responded to 10 health state scenarios each. These TTO interviews were conducted for 24 groups, comprising 279 students in the four countries resulting in 2790 completed TTO scores. The TTO scores were econometrically transformed by regressing the TTO scores upon predicted scores from the AQoL-6D to produce country-specific algorithms. The latter incorporated country-specific “corrections” to the Australian adult utility weights in the original AQoL.

Results: This article reports two methodological elements not previously reported. The first is the econometric modification of an extant multi-attribute utility instrument to accommodate cultural and other group-specific differences in preferences. The second is the use of the TTO technique with adolescents in a classroom group setting. Significant differences in utility scores were found between the four countries.

Conclusion: Statistical results indicate that the AQoL-6D can be validly used in the economic evaluation of both the OPIC interventions and other adolescent programs.

Sexual and violent recidivism by offender type and actuarial risk : reoffending rates for rapists, child molesters and mixed-victim offenders

The current study examines sexual and violent reoffence rates for a sample of 2474 sexual offenders over an average of 15 years following release from prison. Reoffence rates are reported as a function of the offenders' victim type and level of risk as assessed by the Automated Sexual Recidivism Scale, a computer scored measure of relevant historical risk factors. Observed sexual recidivism rates for offenders with child victims, adult victims, and mixed victims were quite similar. Results indicate that offenders with exclusively female child victims not only showed a lower rate of sexual reoffending, but that the reoffence rates were relatively low across all levels of actuarial risk. In contrast, those with male child victims and adult victims showed a pronounced escalation of reoffence rates as actuarial risk increased. Results also indicated that adult victim offenders are less consistent in the victim type of their reoffences, with 37% sexually reoffending against child victims. Finally, combined rates of sexual and violent reoffending were particularly high for those with adult victim sexual offence histories. Risk assessment and public policy implications are discussed.

Ethical practice in sex offender assessment : consideration of actuarial and polygraph methods

The current generation of community protection laws represents a shift in priorities that may see the individual rights of sex offenders compromised for the goal of public safety. At the center of many judicial decisions under these laws are the risk assessment reports provided by mental health practitioners. The widespread enactment of laws allowing for additional sanctions for sex offenders, and a burgeoning research literature regarding the methods used to assess risk have served to heighten rather than resolve the ethical concerns associated with professional practice in this area. This article examines ethical issues inherent in the use of two assessment methods commonly used with sex offenders in the correctional context, focusing on actuarial measures and polygraph tests. Properly conducted and adequately reported actuarial findings are considered to provide useful information of sufficient accuracy to inform rather than mislead judicial decision makers, although careful consideration must be given to the limitations of current measures in each individual case. Despite its increasing use, polygraph testing is considered controversial, with little consensus regarding its accuracy or appropriate applications. On the basis of the current state of the professional literature regarding the polygraph, its use with sex offenders raises unresolved ethical concerns.

Recent research (N=9,305) underscores the importance of using age-stratified actuarial tables in sex offender risk assessments

A useful understanding of the relationship between age, actuarial scores, and sexual recidivism can be obtained by comparing the entries in equivalent cells from “agestratified” actuarial tables. This article reports the compilation of the first multisample age-stratified table of sexual recidivism rates, referred to as the “multisample age-stratified table of sexual recidivism rates (MATS-1),” from recent research on Static-99 and another actuarial known as the Automated Sexual Recidivism Scale. The MATS-1 validates the “age invariance effect” that the risk of sexual recidivism declines with advancing age and shows that age-restricted tables underestimate risk for younger offenders and overestimate risk for older offenders. Based on data from more than 9,000 sex offenders, our conclusion is that evaluators should report recidivism estimates from age-stratified tables when they are assessing sexual recidivism risk, particularly when evaluating the aging sex offender.

The factor structure of the Chinese family assessment instrument adapted for parent report

This article reports on a confirmatory factor analytic study of an adapted version of an instrument designed to assess family functioning of Chinese families. The Chinese Family Assessment Instrument, originally designed for completion by adolescents, was adapted for completion by parents. A sample of 700 parent dyads of elementary school children (382 girls and 318 boys) completed the adapted questionnaire. Initial factor analyses showed that the existing five-factor structure used for adolescents’ responses was not a good fit for these data. Instead, a four-factor solution emerged where the factors were positive family functioning, negative family functioning, tolerance for family members, and parental understanding. This structure was the same for both mothers and fathers. Further studies of the Chinese Family Assessment Instrument parent adaptation are required to test the factor structure that emerged. Following such studies, validation studies will be required.

Construction of the descriptive system for the assessment of quality of life AQoL-6D utility instrument

Background
Multi attribute utility (MAU) instruments are used to include the health related quality of life (HRQoL) in economic evaluations of health programs. Comparative studies suggest different MAU instruments measure related but different constructs. The objective of this paper is to describe the methods employed to achieve content validity in the descriptive system of the Assessment of Quality of Life (AQoL)-6D, MAU instrument.

Methods
The AQoL program introduced the use of psychometric methods in the construction of health related MAU instruments. To develop the AQoL-6D we selected 112 items from previous research, focus groups and expert judgment and administered them to 316 members of the public and 302 hospital patients. The search for content validity across a broad spectrum of health states required both formative and reflective modelling. We employed Exploratory Factor Analysis and Structural Equation Modelling (SEM) to meet these dual requirements.

Results and Discussion
The resulting instrument employs 20 items in a multi-tier descriptive system. Latent dimension variables achieve sensitive descriptions of 6 dimensions which, in turn, combine to form a single latent QoL variable. Diagnostic statistics from the SEM analysis are exceptionally good and confirm the hypothesised structure of the model.

Conclusions
The AQoL-6D descriptive system has good psychometric properties. They imply that the instrument has achieved construct validity and provides a sensitive description of HRQoL. This means that it may be used with confidence for measuring health related quality of life and that it is a suitable basis for modelling utilities for inclusion in the economic evaluation of health programs.