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Using CATs in Clinical Practice 在临床实践中应用 CATs Herbert Fliege Genius 译

Using CATs in Clinical Practice 在临床实践中应用 CATs Herbert Fliege Genius 译. Psychosomatic Medicine. Clinical Setting 医疗设施配备. Charité University Medicine, Berlin 卡瑞特大学医学院 , 柏林 founded 1710 创立于 1710 年 2,600 beds 2600 张床 All medical faculties 全部是医学专家组成. Clinical Setting 医疗设施配备.

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Using CATs in Clinical Practice 在临床实践中应用 CATs Herbert Fliege Genius 译

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  1. Using CATs in Clinical Practice 在临床实践中应用CATs Herbert Fliege Genius 译 Psychosomatic Medicine

  2. Clinical Setting医疗设施配备 • Charité University Medicine, Berlin • 卡瑞特大学医学院,柏林 • founded 1710 • 创立于1710年 • 2,600 beds • 2600张床 • All medical faculties • 全部是医学专家组成

  3. Clinical Setting医疗设施配备 • Charité University Medicine, Berlin • 卡瑞特大学医学院,柏林 • founded 1710 • 创立于1710年 • 2,600 beds • 2600张床 • All medical faculties • 全部是医学专家组成 Breast Cancer Center 胸部肿瘤中心 Transplantation Medicine 器官移植医学 Clinic for Internal Medicine 内科门诊 Psycho-Gynecology 妇科心理学 Psychosomatic Medicine /Psychotherapy 心理医学/精神疗法 Diabetes Outpatient Center 糖尿病门诊中心 Sexual Medicine 性医学 Pain Center 伤害中心 Inpatients ~ 1000 cases/yr 住院病人 ~1000例/年 Emergency Room 急诊室 Rheumatology 风湿病 Outpatients ~ 1500 cases/yr 门诊病人 1500例/年 Consultation-Liaison~ 2400 cases/yr 会诊病人 ~2400例/年

  4. Main Diagnoses ICD-10 F 主要诊断 ICD-10 F 躯体功能失调Somatoform Disorders F45 抑郁焦虑性功能失调Depressive & Anxiety DisordersF32, F34, F40-43 药物依赖和饮食紊乱Substance Dependence & Eating DisordersF10, F50, F55 Organic Disease only 仅器官性疾病

  5. Somatic Conditions 躯体情况 其它原因2% 传染学2% Infectiological 2% ExternalCauses 2% 妇产科学1% Gynecological 1% 肿瘤学3% Oncological 3% 血液学2% Hematological 2% 沁尿科学4% Urological 4% 营养和代谢19% 风湿整形科学21% Rheumatologic Nutritional/Metabolic 19% Orthopedic 21% 皮肤病学4% Dermatological 4% 神经学9% Neurological 9% 眼科学2% Ophtalmological2% 肠胃病学10% Gastroenterological 10% 耳鼻喉科学3% Oto-rhino-laryngological 3% 心血管18% Cardiovascular 18%

  6. Using CATs in Clinical Practice 在临床实践中应用CATs     secretary or nurse gives the PDA to the patient 秘书或护士将PDA交给患者 patient answers a set of questionnaires in the waiting area / in bed 患者在等候区或在床上回答一系列问题

  7. Using CATs in Clinical Practice 在临床实践中应用CATs   Immediate report 即时报表    datatransfer to the main systemvia cable or WLAN 数据通过电缆或无线网传输到中心计算机系统 secretary or nurse gives the PDA to the patient 秘书或护士将PDA交给患者 patient answers a set of questionnaires in the waiting area / in bed 患者在等候区或在床上回答一系列问题

  8. Using CATs in Clinical Practice 在临床实践中应用CATs Self Reported Health Status Bodily Complaints 健康状态自我评价报告   Daisy Miller Immediate report    datatransfer to the main systemvia cable or WLAN secretary or nurse gives the PDA to the patient 秘书或护士将PDA交给患者 patient answers a set of questionnaires in the waiting area / in bed 患者在等候区或在床上回答一系列问题

  9. Using CATs in Clinical Practice 在临床实践中应用CATs Questionnaires used to inform clinical decision making 问卷用于指导临床决策 12000 number of questionnaires per year 每年的问卷数量 10000 introduction of a PDA based system 引入基于 PDA的系统 Development of CATs to be used on PDA 开发基于PDA的CATs 8000 Tests of 3 CATs in dailyroutines 以三项CATs测试作为日常工作 experiments with PC and scannersystems 试验使用电脑和扫描仪 6000 systematic useof paper-pencilquestionnaires 纸笔方式问卷体系 4000 2000 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

  10. Development of three German CATs 开发了三套德语版的CATs Depression抑郁 D-CAT Anxiety焦虑 A-CAT Perceived Stress压力感知 S-CAT

  11. Patient Samples 病例样本 N=1.092, 2.348, 3.270 in- and outpatients门诊和住院病人Department of Psychosomatic Medicine Charité, University Medicine Berlin 卡瑞特大学柏林医学院心理医学系 Diagnoses ICD 10诊断 9% Somatic Diseases身体疾病 21% Depressive Disorders抑郁性功能紊乱13% Anxiety Disorders焦虑性功能紊乱19% Somatization Disorders躯体功能紊乱10% Eating Disorders饮食紊乱 Age年龄41.112.5 years(岁) Gender性别65% female女性35% male男性

  12. Steps CAT Development CAT开发步骤 探索性因素分析(exploratory factor analysis, EFA) 验证性因素分析(confirmatory factor analysis, CFA) • 1Unidimensionality and local independence线性和局部独立性EFA with factor loading  .40CFA with residual correlations  .25(RMSEA .070) • 2Item characteristics条目特性response curvesslope parameters  .70differential item function (DIF) R2.03(logistic regression for age / gender) • 3IRT modeling IRT建模Generalized Partial Credit Model (Muraki)item-fit • 4CAT Programming CAT编程EAP and WML Mplus TestGraf SAS Parscale in house softwareOtto B. Walterwalterob@psy.uni-muenster.de Fliege et al. Qual Life Res 2005, Walter et al. Diagnostica 2005

  13. Current Item Banks 当前条目池 -38% -55% -48% -26% most items deleted due to multidimensionality of the construct 许多条目因为其结构多维而被删除了 Anxiety 焦虑 Depression 抑郁 Stress 压力 Demands命令 Reaction反馈 N of Itemsconsidered 成熟的条目数 81 items 144 items 62 items 42 items poster …Kocalevent et al. N of Itemsfulfilled allquality criteria 满足质量要求的条目数 50 items 64 items 38 items 31 items Fliege et al. Qual Life Res 2005, Walter et al. Diagnostica 2005

  14. CAT simulation CAT模拟 n=2,900 simulees Stopping rule SE<.32 (r>.90) Anxiety焦虑 Depression抑郁 numberof itemsneededfor scoreestimation 分值估计所需的条目数 Latent TraitTheta Latent TraitTheta 潜在特质θ值

  15. CAT simulation CAT模拟 n=2.348/3.270 patients Stopping rule SE<.32 (r>.90) Anxiety焦虑 Depression抑郁 ThetaIRT scoreestimationusing all itemsin the bank θ IRT分值估计时用到库中的条目数量 A-CAT D-CAT r=.97 r=.95 -3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3 Theta CAT score estimation  7 ± 2 items θ CAT分值估计 7 ± 2个条目

  16. CAT simulation CAT模拟 n=2.348/3.270 patients Stopping rule SE<.32 (r>.90) Anxiety焦虑 Depression抑郁 STAIstate STAIstate CES-D r=.88 r=.85 A-CAT A-CAT D-CAT -3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3 Theta CAT score estimation  7 ± 2 items

  17. Real CAT application: Leading questions CAT实际应用:首要的问题 Are they accepted by the patients? 它们是否能被患者所接受? Do they perform as they should? 它们是否能实现预期的功能?

  18. Real CAT Applications CAT实际应用 N=772 adults 成人 n=114 Psychosomatic in-patients with additional Composite International Diagnostic Interview (CIDI) Diagnosis 114例精神相关疾病的住院病人复合其它国际会诊结果疾病的诊断: n=423 Psychosomatic in-patients Clinical diagnoses: 423例精神相关疾病的住院病人的临床诊断: Depression抑郁 Adjustment Disorder调节紊乱 Anxiety Disorder焦虑性紊乱 Somatoform Disorder躯体功能紊乱Eating Disorder饮食紊乱 Other ICD-10 其它F-disorder F-紊乱 No ICD-10 F diagnosis (Wittchen & Pfister 1997) n=35 Students 35例学生 n=200 General Population 200例普通人口

  19. Acceptance接受性 % endorsing response option 3 or 4 median The handling of the device was … 设备掌握程度… The technology impeded my concentratingon the questions … 由于技术原因妨碍我获取问题信息 I would rather fill in a paper-pencil questionnaire … 我更愿意使用纸笔方式的问卷… Using the computer disturbed me … 电脑使用困难… I would prefer seeing all questions at once to seeing only one question at a time ... 我宁愿一次看很多问题而不是一次一个问题… easy 容易 not at all 一点也不 not at all 一点也不 not at all 一点也不 not at all 一点也不 difficult 难 very much 非常多 very much 非常多 very much 非常多 very much 非常多 5% 12% 11% 11% 10% 1 2 3 4

  20. Leading questions首要问题 Are they accepted by the patients? 它们是否能被患者所接受? Do they perform as they should? 它们是否能实现预期的功能?

  21. Number of Items needed for a precise score estimate 精确分值估计时所需的条目数量 20 average presentation of 6 items (SD=2.5) 平均显示6个条目range 4-18 items 范围为4-18个条目 18 16 14 12 Number of items administered 条目数量管理 10 8 6 4 2 0 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 Latent Trait / estimated theta 潜在特质θ值估计 n=423 patients 423例病人 Stopping rule SE<.32 (r>.90) Depression-CAT抑郁CAT

  22. Item usage: 27 Items used 条目应用:用到27个条目 Depression-CAT抑郁CAT

  23. 37 Items not used 37个条目未用到 Depression-CAT抑郁CAT

  24. Item Usage / Steps of item presentation 条目应用/条目出现的步骤(在那一步出现) Depression-CAT抑郁CAT

  25. Item Usage条目应用 Depression-CAT抑郁CAT • Only 42 % of all items in the bank were used • 在整个条目池中仅有42%的条目被用到 • 4 items accounted for 50% of all item administrations • 在所有被用到的条目中,有4个条目的使用频率达到50%

  26. Correlations with established instruments 与确定指标的相关性 n=126 patients CES-D Center for Epidemiological Studies Depression (Radloff 1977 German 15 item version) 抑郁流行病学研究 r=.77 6 ± 2.5 items

  27. Correlations with established instruments n=126 patients HADS Hospital Anxiety Depression Scale(Hermann, Buss & Snaith 1995, 7 items) 医院焦虑性抑郁量表 r=.72 6 ± 2.5 items

  28. Correlations with established instruments n=111 patients BDI Beck-Depression-Inventory (Hautzinger et al. 1995, 21 items) r=.68 6 ± 2.5 items

  29. Sensitivity and Specificity 敏感度与特异性 Depression-CAT General Population 普通人 Clinical Diagnosis Depression 临床诊断为抑郁者

  30. Sensitivity and Specificity pertaining Clinical Diagnosis 与临床诊断相关的敏感性的特异度

  31. Sensitivity and Specificity pertaining DIAX Diagnosis 与DIAX诊断相关的敏感性的特异度

  32. CIDI diagnoses and different depression instruments CIDE诊断与一些不同的抑郁指标 1,2 D-CATaverage 6 items 0,8 0,4 0 cut off -0,4 -0,8 -1,2 40 BDI21 items 30 20 cut off 10 0 40 CES-D15 items 30 cut off 20 10 0 Depression AnxietyDisorder EatingDisorders Somati-zationDisorder SomaticDiseases Students

  33. Summary总结 The use of CATs in daily clinical practice is feasible and well accepted by the patients 在临床日常业务中使用CATs是可行的,并且可以被患者接受 I The CATs we tested have equivalent discriminatory validity with established static questionnaires 经过我们的测试,CATs在辨别问题的有效性方面等同于当前已经制定的标准问卷 II III CATs are not burdensome and promise to increase the measurement precision for individual clinical decision making 使用CATs可以更轻松并且可以提高测量的精确度,对独立的临床决策有帮助

  34. Acknowledgements致谢 有关CAT软件如何使用可以与我们联系: Information how to use our CAT-Software can be obtained from: Otto B. Walterwalterob@psy.uni-muenster.deor fromwww.cibait.de Thank you!谢谢! This work was supported in part by the Deutsche Forschungsgemeinschaft (German Research Society), Grant RO 2258/2-1 (Development of Computer Adaptive Tests for Clinical Medicine using the Item Response Theory, Matthias Rose (Principal Investigator)) and different Grants from the Humboldt University (UFF 200-162, Matthias Rose (Principal Investigator)). 这项工作得到了他们的支持:德国研究协会,德国洪堡大学等

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