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As our validation studies had indicated, this item was proving too difficult for people to answer and produced data of limited value.
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For example, an examination of item G12 shows that for options 1 to 7, the probability is ≤ 0.3 for the entire severity range, indicating this item does not discriminate between different levels of symptom severity.
The impact of items was calculated based on the proportion of patients who indicated each as important, multiplied by the mean importance score [ranging from 1 (least) to 5 (greatest)] indicated for this item (impact score = frequency cited × importance) [ 15].
Together with a low estimated discrimination, this indicated that this item did not contribute very much to the intended estimate of the measure.
*Proportion of events for which respondents indicated that this item influenced their decision to seek care "somewhat" or "a great deal".
*Proportion of events for which respondents indicated that this item influenced their decision to seek care for any of their concerns.
For example, the infit MNSQ value of 1.12 obtained in item 12 ('When things look hopeless, I don't give up') indicated that this item had 12%% more variation in the observed data than what was predicted by the model.
The item "loose stools" listed only in the textbook [ 2] for the diagnosis of KDS-Yang was added as a control to the KDSQ, but was not found to be grouped to the domains of KDS-Yang by the EFA indicating this control item was independent from the domains of KDS-Yang.
Factor analysis indicated this factor contained three items, which dealt with stereotypic attitudes toward working with people with a Swedish background.
*For this item the mean score for influence on dignity is lower than 2.50, and less than 25% of the nursing home residents to whom the item applied indicated this to influence their dignity quite a lot or very much (score 4 or 5); this item will therefore be removed from the instrument.
These observations indicate that this item was not well understood by patients and the formulation was changed.
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com