Distant peer-tutoring of clinical skills, using tablets with instructional videos and Skype: A pilot study in the UK and Malaysia

OBJECTIVES

To assess the feasibility and impact of using low-cost Android tablets to deliver video tutorials and remote online peer-tutoring for clinical skills between two countries.

METHODS

Nine junior medical students from Malaysia were paired with five senior medical students from the UK, who played the role of peer-tutors. Students from Malaysia were given a low-cost Android tablet from which they could access instructional video tutorials. At the end of each week, the peer-tutors would observe their peer-learners as they performed a clinical examination. Tutors would then provide individual feedback using a videoconferencing tool. Outcomes were assessed using Observed Structured Clinical Examination (OSCE) scores, post-study questionnaires and semi-structured interviews with participants.

RESULTS

Peer-learners reported an increased confidence in clinical examination of 8.4 (±1.0) on a 10-point scale and all nine said they would recommend the scheme to their peers. Both peer-tutors and peer-learners were able to establish a strong rapport over video, rating it as 8.4 (±0.6) and 8.4 (±0.9), respectively. Peer-learners' rated the sound and video quality of the tablet as 7.0 (±1.1) but were less satisfied with the screen resolution of the tablet, rating this as 4.0 (±1.5).

CONCLUSION

This preliminary pilot study presents an innovative, low cost approach to international medical education with significant potential for future development.

Government health care spending and child mortality

BACKGROUND

Government health care spending (GHS) is of increasing importance to child health. Our study determined the relationship between reductions in GHS and child mortality rates in high- and low-income countries.

METHODS

The authors used comparative country-level data for 176 countries covering the years 1981 to 2010, obtained from the World Bank and the Institute for Health Metrics and Evaluation. Multivariate regression analysis was used to determine the association between changes in GHS and child mortality, controlling for differences in infrastructure and demographics.

RESULTS

Data were available for 176 countries, equating to a population of ∼ 5.8 billion as of 2010. A 1% decrease in GHS was associated with a significant increase in 4 child mortality measures: neonatal (regression coefficient [R] 0.0899, P = .0001, 95% confidence interval [CI] 0.0440-0.1358), postneonatal (R = 0.1354, P = .0001, 95% CI 0.0678-0.2030), 1- to 5-year (R = 0.3501, P < .0001, 95% CI 0.2318-0.4685), and under 5-year (R = 0.5207, P < .0001, 95% CI 0.3168-0.7247) mortality rates. The effect was evident up to 5 years after the reduction in GHS (P < .0001). Compared with high-income countries, low-income countries experienced greater deteriorations of ∼ 1.31 times neonatal mortality, 2.81 times postneonatal mortality, 8.08 times 1- to 5-year child mortality, and 2.85 times under 5-year mortality.

CONCLUSIONS

Reductions in GHS are associated with significant increases in child mortality, with the largest increases occurring in low-income countries.

Surgical learning curves and operative efficiency: a cross-specialty observational study

OBJECTIVES

To evaluate the learning curves of three high-volume procedures, from distinct surgical specialties.

SETTING

Tertiary care academic hospital.

PARTICIPANTS

A prospectively collected database comprising all medical records of patients undergoing isolated coronary artery bypass grafting (CABG), total knee replacement (TKR) and bilateral reduction mammoplasty (BRM) at the Brigham and Women's Hospital, USA, 1996-2010. Multivariate generalised estimating equation (GEE) regression models were used to adjust for patient risk and clustering of procedures by surgeon.

PRIMARY OUTCOME MEASURE

Operative efficiency.

RESULTS

A total of 1052 BRMs, 3254 CABGs and 3325 TKRs performed by 30 surgeons were analysed. Median number of procedures per surgeon was 61 (range 11-502), 290 (52-973) and 99 (10-1871) for BRM, CABG and TKR, respectively. Mean operative times were 134.4 (SD 34.5), 180.9 (62.3) and 101.9 (30.3) minutes, respectively. For each procedure, attending surgeon experience was associated with significant reductions in operative time (p<0.05). After 15 years of experience, BRM operative time decreased by 69.8 min (38.3%), CABG operative time decreased by 17.5 min (7.8%) and TKR operative time decreased by 94.4 min (48.4%).

CONCLUSIONS

Common trends in surgical learning exist. Dependent on the procedure, experience can serve as a powerful driver of improvement or have clinically insignificant impacts on operative time.

Unemployment, public-sector health care expenditure and HIV mortality: An analysis of 74 countries, 1981-2009

Background

The global economic downturn has been associated with increased unemployment and reduced public–sector expenditure on health care (PSEH). We determined the association between unemployment, PSEH and HIV mortality.

Methods

Data were obtained from the World Bank and the World Health Organisation (1981–2009). Multivariate regression analysis was implemented, controlling for country–specific demographics and infrastructure. Time–lag analyses and robustness–checks were performed.

Findings

Data were available for 74 countries (unemployment analysis) and 75 countries (PSEH analysis), equating to 2.19 billion and 2.22 billion people, respectively, as of 2009. A 1% increase in unemployment was associated with a significant increase in HIV mortality (men: 0.1861, 95% CI: 0.0977 to 0.2744, P = 0.0000, women: 0.0383, 95% CI: 0.0108 to 0.0657, P = 0.0064). A 1% increase in PSEH was associated with a significant decrease in HIV mortality (men: –0.5015, 95% CI: –0.7432 to –0.2598, P = 0.0001; women: –0.1562, 95% CI: –0.2404 to –0.0720, P = 0.0003). Time–lag analysis showed that significant changes in HIV mortality continued for up to 5 years following variations in both unemployment and PSEH.

Interpretation

Unemployment increases were associated with significant HIV mortality increases. PSEH increases were associated with reduced HIV mortality. The facilitation of access–to–care for the unemployed and policy interventions which aim to protect PSEH could contribute to improved HIV outcomes.

Redistributing prostheses – from Britain to Sri Lanka

How used British mobility devices are being turned into brand new limbs for Sri Lankans.

Unemployment, government healthcare spending, and cerebrovascular mortality, worldwide 1981-2009: an ecological study

BACKGROUND

The global economic downturn has been associated with unemployment rises, reduced health spending, and worsened population health. This has raised the question of how economic variations affect health outcomes.

AIM

We sought to determine the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality globally.

METHODS

Data were obtained from the World Bank and World Health Organization. Multivariate regression analysis was used to assess the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Country-specific differences in infrastructure and demographics were controlled for. One- to five-year lag analyses and robustness checks were conducted.

RESULTS

Across 99 countries worldwide, between 1981 and 2009, every 1% increase in unemployment was associated with a significant increase in cerebrovascular mortality (coefficient 187, CI: 86.6-288, P = 0.0003). Every 1% rise in government healthcare expenditure, across both genders, was associated with significant decreases in cerebrovascular deaths (coefficient 869, CI: 383-1354, P = 0.0005). The association between unemployment and cerebrovascular mortality remained statistically significant for at least five years subsequent to the 1% unemployment rise, while the association between government healthcare expenditure and cerebrovascular mortality remained significant for two years. These relationships were both shown to be independent of changes in gross domestic product per capita, inflation, interest rates, urbanization, nutrition, education, and out-of-pocket spending.

CONCLUSIONS

Rises in unemployment and reductions in government healthcare expenditure are associated with significant increases in cerebrovascular mortality globally. Clinicians may also need to consider unemployment as a possible risk factor for cerebrovascular disease mortality.

The association between government healthcare spending and maternal mortality in the European Union, 1981-2010: a retrospective study

OBJECTIVE

To determine the association between reductions in government healthcare spending (GHS) on maternal mortality in 24 countries in the European Union (EU) over a 30-year period, 1981-2010.

DESIGN

Retrospective study.

SETTING AND POPULATION

Twenty-four EU countries (a total population of 419 million as of 2010).

METHODS

We used multivariate regression analysis, controlling for country-specific differences in healthcare, infrastructure, population size and demographic structure. GHS was measured as a percentage of gross domestic product. Five-year lag-time analyses were performed to estimate longer standing effects.

MAIN OUTCOME MEASURES

Maternal mortality rates.

RESULTS

An annual 1% decrease in GHS is associated with significant rises in maternal mortality rates [regression coefficient [R] 0.0177, P = 0.0021, 95% confidence interval [95% CI] 0.0065-0.0289]. For every annual 1% decrease in GHS, we estimate 89 excess maternal deaths in the EU, a 10.6% annual increase in maternal mortality. The impact on maternal mortality was sustained for up to 1 year (R 0.0150, P = 0.0034, 95% CI 0.0050-0.0250). The associations remained significant after accounting for economic, infrastructure and hospital resource controls, in addition to out-of-pocket expenditure, private health spending and total fertility rate. However, accounting for births attended by skilled staff removed the significance of these effects.

CONCLUSIONS

Reductions in GHS were significantly associated with increased maternal mortality rates, which may occur through changes in the provision of skilled health professionals attending births. Examples of reduced GHS such as the implementation of austerity measures and budgetary reductions are likely to worsen maternal mortality in the EU.

Systematic review of perioperative outcomes following laparoscopic abdominal aortic aneurysm repair

OBJECTIVE

To collate information available in the literature regarding perioperative outcomes following elective laparoscopic abdominal aortic aneurysm repair.

MATERIALS AND METHODS

Electronic databases were searched and a systematic review was performed. In total, 1256 abstracts were screened, from which 10 studies were included for analysis. Perioperative and technical outcomes were analysed.

RESULTS

In the totally laparoscopic repair of infra-renal aneurysms (n = 302), 30-day mortality ranged between 0% and 6% and in the laparoscopic-assisted cases (n = 547) ranged between 0% and 7%. Of the former group, 5-30% of cases were converted to open repair, with 6% reintervention rate, whereas there was a 5-10% conversion and 3% reintervention rate in the latter group.

CONCLUSIONS

The outcomes from selected patients in selected centres demonstrate that elective laparoscopic repair of aortic aneurysms is feasible and comparable in safety to open repair; it remains unclear, however, whether there are substantial advantages of this method compared with open and endovascular repair.

Unemployment, public-sector healthcare spending and stomach cancer mortality in the European Union, 1981-2009

OBJECTIVES

We sought to determine the association between changes in unemployment, healthcare spending and stomach cancer mortality.

METHODS

Multivariate regression analysis was used to assess how changes in unemployment and public-sector expenditure on healthcare (PSEH) varied with stomach cancer mortality in 25 member states of the European Union from 1981 to 2009. Country-specific differences in healthcare infrastructure and demographics were controlled for 1- to 5-year time-lag analyses and robustness checks were carried out.

RESULTS

A 1% increase in unemployment was associated with a significant increase in stomach cancer mortality in both men and women [men: coefficient (R)=0.1080, 95% confidence interval (CI)=0.0470-0.1690, P=0.0006; women: R=0.0488, 95% CI=0.0168-0.0809, P=0.0029]. A 1% increase in PSEH was associated with a significant decrease in stomach cancer mortality (men: R=-0.0009, 95% CI=-0.0013 to -0.005, P<0.0001; women: R=-0.0004, 95% CI=-0.0007 to -0.0001, P=0.0054). The associations remained when economic factors, urbanization, nutrition and alcohol intake were controlled for, but not when healthcare resources were controlled for. Time-lag analysis showed that the largest changes in mortality occurred 3-4 years after any changes in either unemployment or PSEH.

CONCLUSION

Increases in unemployment are associated with a significant increase in stomach cancer mortality. Stomach cancer mortality is also affected by public-sector healthcare spending. Initiatives that bolster employment and maintain public-sector healthcare expenditure may help to minimize increases in stomach cancer mortality during economic downturns.

The NHS Five Year Forward View: implications for clinicians

The Five Year Forward View is a look at what the NHS could achieve, given the range of resources that may be available. It sets out how the health service needs to change, arguing for a more engaged relationship with patients, carers, and citizens to promote wellbeing and prevent ill health. Here, we outline how the Forward View supports clinicians to provide better, higher quality and more integrated care.New models of care are presented, including multispecialty providers, primary and acute care systems, urgent and emergency care networks, viable smaller hospitals, specialised services, modern maternity services, and enhanced care homes. The commitments to support clinicians are discussed, including specific proposals for primary care, initiatives to improve the health of NHS staff, dealing with gaps in the NHS workforce, and the use of technology and innovation to further enable clinicians.

Unemployment, public-sector health-care spending and breast cancer mortality in the European Union: 1990-2009

BACKGROUND

The global economic crisis has been associated with increased unemployment, reduced health-care spending and adverse health outcomes. Insights into the impact of economic variations on cancer mortality, however, remain limited.

METHODS

We used multivariate regression analysis to assess how changes in unemployment and public-sector expenditure on health care (PSEH) varied with female breast cancer mortality in the 27 European Union member states from 1990 to 2009. We then determined how the association with unemployment was modified by PSEH. Country-specific differences in infrastructure and demographic structure were controlled for, and 1-, 3-, 5- and 10-year lag analyses were conducted. Several robustness checks were also implemented.

RESULTS

Unemployment was associated with an increase in breast cancer mortality [P < 0.0001, coefficient (R) = 0.1829, 95% confidence interval (CI) 0.0978-0.2680]. Lag analysis showed a continued increase in breast cancer mortality at 1, 3, 5 and 10 years after unemployment rises (P < 0.05). Controlling for PSEH removed this association (P = 0.063, R = 0.080, 95% CI -0.004 to 0.163). PSEH increases were associated with significant decreases in breast cancer mortality (P < 0.0001, R = -1.28, 95% CI -1.67 to -0.877). The association between unemployment and breast cancer mortality remained in all robustness checks.

CONCLUSION

Rises in unemployment are associated with significant short- and long-term increases in breast cancer mortality, while increases in PSEH are associated with reductions in breast cancer mortality. Initiatives that bolster employment and maintain total health-care expenditure may help minimize increases in breast cancer mortality during economic crises.

Systematic review of methodological quality of individual performance measurement in surgery

Background

Calls for greater transparency with improved quality, safety and outcomes have led to performance tracking of individual surgeons. This study evaluated the methodology of studies investigating individual performance in surgery.

Methods

MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews (from their inception to July 2014) were searched. Two authors independently reviewed citations using predetermined inclusion and exclusion criteria; 91 data points per study were extracted.

Results

The search strategy yielded 8514 citations; 101 were eligible, comprising 1 006 037 procedures by 14 455 surgeons. Thirty-four studies were prospective and 66 were retrospective. The aim of the studies was either to assess individual performance and describe the learning curve of a procedure, to describe factors influencing performance, or to describe methods for routine performance monitoring. Some 51·5 per cent of the studies investigated 500 or fewer procedures. Most (77 of 101) were single-centre studies. Less than half of the studies (42, 41·6 per cent) employed statistical modelling or stratification to adjust performance measures. Forty studies (39·6 per cent) adjusted outcomes for case mix. Seventeen (16·8 per cent) adjusted metrics for surgeon-specific factors. Thirteen studies (12·9 per cent) considered clustering in their analyses. The most frequent outcome studied was duration of operation (59·4 per cent), followed by complication rate (45·5 per cent) and reoperation rate (29·7 per cent); 15·8 per cent of studies recorded mortality, and 4·0 per cent explored patient satisfaction. Only 48·5 per cent of studies displayed procedural learning curves using a graph.

Conclusion

There exist substantial shortcomings in methodological quality, outcome measurements and quality improvement evaluation among current studies of individual surgical performance. Methodological guidelines should be established to ensure that assessments are valid.

Surgical care in low and middle-income countries: burden and barriers

Surgically correctable pathology accounts for a sizeable proportion of the overall global burden of disease. Over the last decade the role of surgery in the public health agenda has increased in prominence and attempts to quantify surgical capacity suggest that it is a significant public health issue, with a great disparity between high-income, and low- and middle-income countries (LMICs). Although barriers such as accessibility, availability, affordability and acceptability of surgical care hinder improvements in LMICs, evidence suggests that interventions to improve surgical care in these settings can be cost-effective. Currently, efforts to improve surgical care are mainly coordinated by academia and intuitions with strong surgical and global health interests. However, with the involvement of various international organisations, policy makers, healthcare managers and other stakeholders, a collaborative approach can be achieved in order to accelerate progress towards improved and sustainable surgical care. In this article, we discuss the current burden of global surgical disease and explore some of the barriers that may be encountered in improving surgical capacity in LMICs. We go on to consider the role that international organisations can have in improving surgical care globally. We conclude by discussing surgery as a global health priority and possible solutions to improving surgical care globally.