Incentive and Reminder Strategies to Improve Response Rate for Internet-Based Physician Surveys: A Randomized Experiment

Evaluating recruitment strategies for AUSPICE, a large Australian community-based randomised controlled trial

OBJECTIVES

To examine the effectiveness of different strategies for recruiting participants for a large Australian randomised controlled trial (RCT), the Australian Study for the Prevention through Immunisation of Cardiovascular Events (AUSPICE).

DESIGN, SETTING, PARTICIPANTS

Men and women aged 55-60 years with at least two cardiovascular risk factors (hypertension, hypercholesterolaemia, overweight/obesity) were recruited for a multicentre placebo-controlled RCT assessing the effectiveness of 23-valent pneumococcal polysaccharide vaccine (23vPPV) for preventing cardiovascular events.

METHODS

Invitations were mailed by the Australian Department of Human Services to people in the Medicare database aged 55-60 years; reminders were sent 2 weeks later. Invitees could respond in hard copy or electronically. Direct recruitment was supplemented by asking invitees to extend the invitation to friends and family (snowball sampling) and by Facebook advertising.

MAIN OUTCOME

Proportions of invitees completing screening questionnaire and recruited for participation in the RCT.

RESULTS

21 526 of 154 992 invited people (14%) responded by completing the screening questionnaire, of whom 4725 people were eligible and recruited for the study. Despite the minimal study burden (one questionnaire, one clinic visit), the overall participation rate was 3%, or an estimated 10% of eligible persons. Only 16% of eventual participants had responded within 2 weeks of the initial invitation letter (early responders); early and late responders did not differ in their demographic or medical characteristics. Socio-economic disadvantage did not markedly influence response rates. Facebook advertising and snowball sampling did not increase recruitment.

CONCLUSIONS

Trial participation rates are low, and multiple concurrent methods are needed to maximise recruitment. Social media strategies may not be successful in older age groups.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12615000536561.

Altruistic donation to improve survey responses: a global randomized trial

Objective

Web-based platforms have revolutionized the ability for researchers to perform global survey research. Methods to incentivize participation have been singularly focused on European and North American participants with varied results. With an ever increasing proportion of biomedical research being performed in non-western countries, assessment of novel methods to improve global survey response is timely and necessary. To that end, we created a three-arm nested randomized control trial (RCT) within a prospective cohort study to assess the impact of incentives on survey responsiveness in a global audience of biomedical researchers.

Results

Email invitations were sent to authors and editors involved in online publishing totaling 2426 participants from 111 countries. Overall we observed a 13.0% response rate: 13.3% for the control group, 14.4% for a group entered to win a gift card, and 11.1% for a group whose participation lead to donation to charity (p = 0.17). Year of publication nor country impacted response rate. Within subgroups, editors were significantly less likely to respond to the survey as compared to authors (6.5% vs. 18.9%; p-value < 0.01). With power to detect a 4.8% difference among groups, we could not detect an impact of incentives on global survey response.

The New/Novel Oral Anticoagulants and Their Impact on Patients Being Considered for Shockwave Lithotripsy: The Findings of an International Survey of the Endourological Society

INTRODUCTION

Although general guidelines exist directing the management of new/novel oral anticoagulants (NOACs) in the perioperative period for open/endoscopic procedures, no consensus exists for those patients being considered for shockwave lithotripsy (SWL). To gauge current practice, we administered a survey to the international endourologic community.

METHODS

A web-based survey was sent to current Endourological Society members. Respondents were asked whether they would consider SWL in patients receiving NOACs, and if they used SWL how these agents were managed perioperatively. Respondents were also asked which physicians in the patients' circle of care managed the discontinuation and reinstitution of the drugs.

RESULTS

There were 165 respondents from 27 countries. Approximately 92.7% of urologists had access to SWL but only 53.4% indicated they would offer SWL to patients receiving NOACs. Among these urologists, 63.3% relied on internal medicine/hematology/cardiology colleagues to counsel patients on the discontinuation of NOACs pretreatment, whereas the majority (64%) handled the resumption guidance themselves. There was wide variability in the management of NOACs before lithotripsy, with discontinuation varying from 2 to 7 days. Resumption was more consistent, ranging from 1 to 2 days or when hematuria resolved. None of the respondents reported knowledge of adverse effects such as perinephric hematomas or cardiovascular morbidity.

CONCLUSIONS

A large percentage of globally surveyed endourologists do not offer SWL to patients who are taking NOACs. Among those that do offer SWL, there seems to be a absence of consensus on optimal duration of discontinuation, suggesting a need to establish evidence-based guidance to optimize patient outcomes.

Importance of n-3 PUFA consumption during pregnancy: perception discrepancies between pregnant women and gynaecologists-obstetricians in Belgium

OBJECTIVE

n-3 PUFA during pregnancy have been subject to intense research interest, but also much controversy, creating a situation of confusion among patients and health-care providers. The present study was carried out to explore knowledge, attitude and practices regarding n-3 PUFA in two independent populations of pregnant women and gynaecologists-obstetricians in Belgium and to assess the relationship between the pregnant women's attributes and their n-3 PUFA status measured by the omega-3 index.

DESIGN

Cross-sectional study. Knowledge, attitude and practices were collected by self-administered questionnaires while laboratory data were available for each pregnant woman.

SETTING

During the first antenatal hospital appointment (for the pregnant women) and by email (for the gynaecologists-obstetricians).ParticipantsWomen in early pregnancy (n 122) and gynaecologists-obstetricians (n 67).

RESULTS

Marked discrepancies in perception were evidenced between the pregnant women and health-care providers. While 82 % of the women attached high importance to n-3 PUFA during pregnancy, only a third of the gynaecologists-obstetricians did. About 35 % of the women declared paying particular attention to their consumption of n-3 PUFA. After adjusting for sociodemographic characteristics, these positive dietary practices were significantly associated with higher omega-3 index (P=0·04). Overall, 43·3 % of professionals did not provide any information about n-3 PUFA to their pregnant patients and 46·3 % did not take any preventive actions.

CONCLUSIONS

Evidence-based guidelines, refreshment training and communication tools are needed to improve awareness and clinical practices among caregivers regarding n-3 PUFA to benefit both mothers and their children.

Spinal cord stimulator education during pain fellowship: unmet training needs and factors that impact future practice

Background and objectives

With a growing need for non-opioid chronic pain treatments, pain physicians should understand the proper utilization of neuromodulation therapies to provide the most comprehensive care. We aimed to identify the unmet training needs that deter physicians from using spinal cord stimulation (SCS) devices.

Methods

Internet-based surveys were fielded to fellows enrolled in pain fellowships during the 2016–2017 academic year accredited by the Accreditation Council for Graduate Medical Education and past pain fellows identified through pain medicine societies and SCS manufacturers.

Results

Current fellows were more likely to have received SCS training during fellowship compared with past fellows (100.0% vs 84.0%), yet there was variability in fellows’ SCS experiences with a wide range of trials and implants performed. Forty-six percent of current fellows felt there was an unmet training need regarding SCS. Deficiency in SCS case volume was the most common barrier that was noted (38.5%), followed by lack of SCS curriculum (30.8%) and lack of faculty with SCS expertise (23.1%). Lack of training was a predominant reason for past fellows choosing not to use SCS devices postfellowship. The majority of current and past fellows (79.5% and 55.4%, respectively) strongly supported direct training of fellows by SCS manufacturers.

Conclusions

While SCS training during pain fellowship has become more universal, the experiences that fellows receive are highly variable, and most rely on industry-sponsored programs to supplement training deficiencies. Standardization of SCS procedures may also enable less experienced providers to navigate the SCS treatment algorithm.

Health Care Provider Perceptions of Consumer-Grade Devices and Apps for Tracking Health: A Pilot Study

Background

The use of Web- or mobile phone–based apps for tracking health indicators has increased greatly. However, provider perceptions of consumer-grade devices have not been widely explored.

Objective

The purpose of this study was to determine primary care physicians’ and advanced practice registered nurses’ perceptions of consumer-grade sensor devices and Web- or mobile phone–based apps that allow patients to track physical activity, diet, and sleep.

Methods

We conducted a cross-sectional mailed survey with a random sample of 300 primary care physicians and 300 advanced practice registered nurses from Michigan, USA. Providers’ use and recommendation of these types of technologies, and their perceptions of the benefits of and barriers to patients’ use of the technologies for physical activity, diet, and sleep tracking were key outcomes assessed.

Results

Most of the respondents (189/562, 33.6% response rate) were advanced practice registered nurses (107/189, 56.6%). Almost half of the sample (93/189, 49.2%) owned or used behavioral tracking technologies. Providers found these technologies to be helpful in clinical encounters, trusted the data, perceived their patients to be interested in them, and did not have concerns over the privacy of the data. However, the providers did perceive patient barriers to using these technologies. Additionally, those who owned or used these technologies were up to 6.5 times more likely to recommend them to their patients.

Conclusions

Our study demonstrated that many providers perceived benefits for their patients to use these technologies, including improved communication. Providers’ concerns included their patients’ access and the usability of these technologies. Providers who encountered data from these technologies during patient visits generally perceive this to be helpful. We additionally discuss the barriers perceived by the providers and offer suggestions and future research to realize the potential benefits to using these data in clinical encounters.

Perspectives on the DNR decision process: A survey of nurses and physicians in hematology and oncology

INTRODUCTION

In cancer care, do-not-resuscitate (DNR) decisions are made frequently; i.e., decisions not to start the heart in the event of a cardiac arrest. A DNR decision can be a complex process involving nurses and physicians with a wide variety of experiences and perspectives. Previous studies have shown different perceptions of the DNR decision process among nurses and physicians, e.g. concerning patient involvement and information. DNR decisions have also been reported to be unclear and documentation inconsistent.

OBJECTIVE

The aim was to investigate how important and how likely to happen nurses and physicians considered various aspects of the DNR decision process, regarding participation, information and documentation, as well as which attributes they found most important in relation to DNR decisions.

METHODS

A descriptive correlational study using a web survey was conducted, including 132 nurses and 84 physicians working in hematology and oncology.

RESULTS

Almost half of the respondents reported it not likely that the patient would be involved in the decision on DNR, and 21% found it unimportant to inform patients of the DNR decision. Further, 57% reported that providing information to the patient was important, but only 21% stated that this was likely to happen. There were differences between nurses and physicians, especially regarding participation by and information to patients and relatives. The attributes deemed most important for both nurses and physicians pertained more to medical viewpoints than to ethical values, but a difference was found, as nurses chose patient autonomy as the most important value, while physicians rated non-maleficence as the most important value in relation to DNR decisions.

CONCLUSION

Nurses and physicians need to be able to talk openly about their different perspectives on DNR decisions, so that they can develop a deeper understanding of the decisions, especially in cases where they disagree. They should also be aware that what they think is important is not always likely to happen. The organization needs to support such discussions through providing an environment that allows ethical discussions on regular basis. Patients and relatives will also benefit from receiving the same information from all caregivers.

Parental emotion regulation and preschoolers' prosocial behavior: The mediating roles of parental warmth and inductive discipline

The potential mediating roles of parental warmth and inductive discipline on the relations of parental emotion regulation strategies to children's prosocial behavior were examined in this study. Sixty-four parents of preschoolers (50% girls) completed questionnaires assessing their own regulation practices (i.e., cognitive reappraisal, expressive suppression), parenting behaviors (i.e., parental warmth/nurturance, inductive discipline), and children's prosocial behavior (voluntary behavior intended to benefit another). The authors hypothesized that cognitive reappraisal would be positively and expressive suppression would be negatively related to parenting behaviors and children's prosocial behavior. They further hypothesized that parental warmth and inductive discipline would mediate the relations between parents' own regulation strategies and children's prosocial behavior. Results demonstrated that parental cognitive reappraisal was positively associated with warmth, and expressive suppression was negatively associated with inductive discipline and children's prosocial behavior. Parental warmth, but not inductive discipline, mediated the relations between cognitive reappraisal and children's prosocial behavior. The results highlight adults' own regulatory strategies as predictors of socialization behaviors and the potential processes for socialization of children's moral emotions and positive social development.

The Implementation Gap in Laparoscopic Simulation Training

BACKGROUND AND AIMS

Simulation-based training in laparoscopy can improve patient safety and efficiency of care, but it depends on how it is used. Research in medical education has moved from demonstrating transferability of simulation training to the operating room to how to best implement it. This study aims to investigate how simulation-based training in laparoscopy has been implemented Scandinavia.

MATERIAL AND METHODS

An online survey was sent out to medical doctors at surgical, gynecological, and urological departments at 138 hospitals in Denmark, Norway, and Sweden. The questionnaire included questions on respondents' baseline characteristics, opinions, access, and actual use of simulation-based training in laparoscopy.

RESULTS

In total, 738 respondents completed the survey. Of these, 636 (86.2%) of respondents agreed or strongly agreed that simulation-based training in laparoscopy should be mandatory. A total of 602 (81.6%) had access to simulation-based training in laparoscopy. Of the total 738 respondents, 141 (19.1%) were offered structured training courses, 129 (17.5%) were required to reach a predefined level of competency, and 66 (8.9%) had mandatory courses in laparoscopy. In all, 72 (9.8%) had never used simulation-based training in laparoscopy.

CONCLUSION

An implementation gap in laparoscopic simulation-based training still exists in Scandinavia. Simulation equipment is generally available, but there is a lack of structured simulation-based training.

Improving outcomes in the treatment of opioid dependence (IOTOD): reflections on the impact of a medical education initiative on healthcare professionals' attitudes and clinical practice

Since 2011, the annual improving outcomes in the treatment of opioid dependence (IOTOD) meeting has brought together a broad range of primarily European healthcare professionals as part of an ongoing effort to promote best practice for this particularly vulnerable patient population. IOTOD, a comprehensive educational initiative, includes the annual Continuing Medical Education (CME)-accredited IOTOD conference, which is dedicated to measuring practice change and outcomes resulting from attendance at its educational sessions. Following each session, delegates are asked to vote for or against incorporating specified changes into their clinical practice. These "commitments to change" have formed one measure of the effectiveness and impact of the IOTOD conference. Here, we look at why educational initiatives like the IOTOD conference are valuable, examine our methods for conducting a CME-accredited event, and highlight individualised treatment plans and delivery. We examine this approach - increasingly seen as best practice - as an example of how it may be changing attitudes and eventually affecting clinical applications in the field of opioid dependence. The measured commitments to change offer insight into HCPs' attitudes towards opioid dependence management and show that attitudes towards individualised treatment plans seem to be progressively positive, with a general consensus to incorporate psychosocial interventions.

Strength in Numbers: A National Monthly Case Conference Series for Fellows

Small fellowship programs face challenges in providing learners with sufficiently diverse experiences and patient populations. The Fellows Most Difficult Case Conference is designed to broaden geriatric medicine fellows' exposure to cases and to faculty and fellows from around the country through a monthly telephone conference. We describe this innovative approach to a national monthly complex case conference that fellows from almost one-third of geriatrics fellowship programs attend, including its value to geriatric fellows and faculty and administrative costs. Once per month, a fellow presents a case, a moderator leads the discussion, and 2 faculty members provide teaching points during the 60-minute session. Participants rated the conference's value using an 11-item on-line survey followed by a debriefing held during a regularly scheduled 2017 monthly conference. Thirty-six percent of eligible participants responded to the survey (67/186), with 75% of respondents reporting that they applied knowledge gained from the conferences to their patient care at least 1 or 2 times per month and 41% that they applied it at least once per week. Participants appreciated the inclusion of multiple programs, the duration of the conference, and the interactive approach. Our administration time was less than 5 hours per month, plus a few additional hours annually to create the academic year schedule. We believe that this national case conference, the first of its kind in the country, involving almost one-third of geriatrics fellowship programs, is an innovative and valuable way for fellows to explore complex cases and variations in regional perspectives and to connect with additional colleagues.

Metrics for quantifying antibiotic use in the hospital setting: results from a systematic review and international multidisciplinary consensus procedure

Background

Quantifying antibiotic use is an essential element of antibiotic stewardship since it allows comparison between different settings and time windows, and measurement of the impact of interventions. However, quantity metrics (QMs) and methods have not been standardized.

Objectives

To propose a set of QMs for antibiotic use in inpatients (IQMs) that are accepted globally by professionals in a range of disciplines. The study was conducted within the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project.

Methods

A systematic literature review using MEDLINE identified articles on measuring inpatient antibiotic use, published up to 29 January 2015. A consensually selected list of national and international web sites was screened for additional IQMs. IQMs were classified according to the type of numerator used and presented to a multidisciplinary panel of stakeholders. A RAND-modified Delphi consensus procedure, which consisted of two online questionnaires and a face-to-face meeting, was performed.

Results

The systematic literature review and web site search identified 168 eligible articles from which an initial list of 20 IQMs, composed of 20 different numerators and associated denominators was developed. The consensus procedure resulted in a final set of 12 IQMs. Among this final set, DDDs per 100(0) patient-days and days of therapy per patient-days were most frequently found in the review. The panel recommended that antibiotic use should be expressed in at least two metrics simultaneously.

Conclusions

Our consensus procedure identified a set of IQMs that we propose as an evidence-based global standard.

The Culture of Carbapenem Overconsumption: Where Does It Begin? Results of a Single-Center Survey

Purpose: The United States has seen an increased consumption of carbapenem antibiotics in recent years. The increased utilization of these agents has potential negative consequences, including the increasing incidence of carbapenem-resistant Enterobacteriaceae. Reasons for the rise in carbapenem use among providers in acute care hospitals are not well elucidated in literature. The objectives of this study were to identify factors that influence empiric carbapenem use among providers in a single academic medical center, and to assess therapeutic knowledge pertaining to carbapenem use. Methods: A cross-sectional, single-center, 9-item electronic research survey was developed independently and validated by an infectious diseases pharmacist and infectious diseases physician. The survey was distributed to email accounts of providers at a single academic medical center. Demographic data, factors affecting carbapenem prescription, and baseline therapeutic knowledge were assessed. Results: Ninety-five of 416 providers responded to the survey (response rate of 22.8%). Respondents were well distributed across all levels of training with primary roles in internal medicine and surgery. The most important factors influencing empiric carbapenem use were suspected pathogens at the site of infection, drug allergies, history of multidrug resistant organisms, severity of illness, type of infection, and local resistance rates. A recommendation from a pharmacist was selected as the most likely factor for deterring carbapenem use. Misconceptions pertaining to penicillin drug allergy and beta-lactam cross reactivity, knowledge of local resistance rates according to the institutional antibiogram, and comparative efficacy data for carbapenems were apparent across all levels of training. Conclusions: Provider misconceptions regarding several factors appear to contribute to unnecessary use of carbapenems. An opportunity exists for hospital pharmacists to improve the prescribing patterns of carbapenems by correcting provider misconceptions through education.

International survey on high- and low-dose synacthen test and assessment of accuracy in preparing low-dose synacthen

OBJECTIVE

The short synacthen test (SST) is widely used to assess patients for adrenal insufficiency, but the frequency and protocols used across different centres for the low-dose test (LDT) are unknown. This study aimed to survey centres and test the accuracy of ten different synacthen preparation strategies used for the LDT.

METHODS

Members of 6 international endocrine societies were surveyed regarding diagnostic tests used for adrenal insufficiency, and in particular the SST. Synacthen was diluted for the LDT and concentrations measured using a synacthen ELISA.

RESULTS

Survey responses were received from 766 individuals across 60 countries (52% adult, 45% paediatric endocrinologists). The SST is used by 98% of centres: 92% using high-dose (250 μg), 43% low-dose and 37% both. Ten low-dose dilution methods were assessed and variation in synacthen concentration was demonstrated with intramethod coefficients of variation (CV) ranging from 2.1% to 109%. The method using 5% dextrose as a diluent was the least variable (CV of 2.1%). The variation in dilution methods means that the dose of synacthen administered in a LDT may vary between 0.16 and 0.81 μg.

CONCLUSIONS

The high-dose SST is the most popular diagnostic test of adrenal insufficiency, but up to 72% of paediatric endocrinologists use a LDT. There is considerable variation observed both within and between low-dose synacthen dilution methods creating considerable risk of inaccurate dosing and thereby invalid results.

Effect of Recruitment Methods on Response Rate in a Web-Based Study for Primary Care Physicians: Factorial Randomized Controlled Trial

Background

Low participation rates are one of the most serious disadvantages of Web-based studies. It is necessary to develop effective strategies to improve participation rates to obtain sufficient data.

Objective

The objective of this trial was to investigate the effect of emphasizing the incentive in the subject line of the invitation email and the day of the week of sending the invitation email on the participation rate in a Web-based trial.

Methods

We conducted a 2×2 factorial design randomized controlled trial. We contacted 2000 primary care physicians from members of the Japan Primary Care Association in January 2017 and randomly allocated them to 1 of 4 combinations of 2 subject lines (presence or absence of an emphasis on a lottery for an Amazon gift card worth 3000 yen or approximately US $30) and 2 delivery days (sending the invitation email on Tuesday or Friday). The primary outcome was the response rate defined as the number of participants answering the first page of the questionnaire divided by the number of invitation emails delivered. All outcomes were collected between January 17, 2017, and February 8, 2017.

Results

We analyzed data from 1943 out of 2000 participants after excluding those whose email addresses were invalid. The overall response rate was 6.3% (123/1943). There was no significant difference in the response rates between the 2 groups regarding incentive in the subject line: the risk ratio was 1.12 (95% CI 0.80 to 1.58) and the risk difference was 0.7% (95% CI –1.5% to 2.9%). Similarly, there was no significant difference in the response rates between the 2 groups regarding sending the email on Tuesday or Friday: the risk ratio was 0.98 (95% CI 0.70 to 1.38) and the risk difference was –0.1% (95% CI –2.3% to 2.1%).

Conclusions

Neither emphasizing the incentive in the subject line of the invitation email nor varying the day of the week the invitation email was sent led to a meaningful increase in response rates in a Web-based trial with primary care physicians.

Trial Registration

University Hospital Medical Information Network Clinical Trials Registry UMIN000025317; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000029121 (Archived by WebCite at http://www.webcitation. org/6wOo1jl9t)

Retrospective Analysis of Physician-based Surveys Published in OPRS

PURPOSE

To review physician-based clinical surveys published in Ophthalmic Plastic and Reconstructive Surgery.

METHODS

Complementary Ovid and PubMed searches of Ophthalmic Plastic and Reconstructive Surgery journal content were performed for the term "survey." Results were narrowed to studies that specifically addressed physicians' clinical practices. This search resulted in 162 articles, and after dual-investigator independent screening, 13 surveys met inclusion criteria.

RESULTS

Of the 13 surveys published from 2007 to January 2017, 6 were published since 2015, showing an increased trend in survey-based publications. Topics included assessing practice patterns regarding eyelid disorders, thyroid eye disease, optic nerve sheath fenestration, anophthalmic socket, and diagnosing lacrimal disorders. Average response rate was 38.7% (range 17.5-60%), with 201 average number of replies (range 72-310). Nine out of 13 surveys included some form of statistical analysis with the remainder presenting data in percentages.

CONCLUSIONS

There has been an increased rate of survey-type publications in Ophthalmic Plastic and Reconstructive Surgery over the past 10 years. The low response rate and frequent lack of statistical analysis raise concerns regarding the validity and usefulness of such studies. The authors believe that survey studies can be improved through better standardization and the use of author guidelines. They have made specific recommendations to improve the impact of survey papers in the future.

Antibiotic use patterns in endoscopic sinus surgery: a survey of the American Rhinologic Society membership

BACKGROUND

There is a paucity of data supporting antibiotic use in endoscopic sinus surgery (ESS). The objective of this study is to determine perioperative antibiotic use patterns and factors which influence use in ESS.

METHODS

An online-based survey was distributed to members of the American Rhinologic Society (ARS). Outcomes included timing of perioperative antibiotic use, practice environment, years of experience, and patient factors that influenced antibiotic use.

RESULTS

There were 204 responses (response rate 18.3%); 36.8% of respondents were in academic positions, 32.8% were in private practice, and 30.4% were in academic-affiliated private practice; 20.6% routinely gave preoperative antibiotics, most commonly to reduce bacterial burden (59.5%) and mucosal inflammation (59.5%); 54.4% routinely gave intraoperative antibiotics, most commonly to reduce the risk of postoperative infection (63.1%); 62.3% routinely gave postoperative antibiotics, citing the need to reduce the risk of postoperative infection (75.6%). Diagnosis influenced postoperative antibiotic use in 63.0%. Preoperative antibiotics were more likely to be prescribed by respondents with more than 5 years of experience (odds ratio [OR] 2.97; 95% confidence interval [CI], 1.04 to 8.54; p = 0.043). Compared to private practitioners, academicians were more likely to give intraoperative antibiotics (OR 2.68; 95% CI, 1.39 to 5.17; p = 0.003), but not preoperative or postoperative antibiotics. Use of nonabsorbable packing was significantly associated with use of postoperative antibiotics (OR 2.01; 95% CI, 1.07 to 3.77; p = 0.031).

CONCLUSION

This study demonstrates the significant variation in perioperative antibiotic use among otolaryngologists. These results provide support for the establishment of evidence-based practice guidelines for perioperative antibiotic use in ESS.

International Elective Opportunities in United States Anesthesia Residency Programs

BACKGROUND

Global health is a recognized component of medical education and is increasingly included in residency programs. International electives have the potential to improve global health training by providing exposure to different populations and the challenges of health disparities. The objective of this study was to describe international elective opportunities in US anesthesiology residency training programs, including an assessment the types of programs offered and the obstacles to providing this type of training.

METHODS

An electronic survey was sent to 122 anesthesiology programs. The survey defined an international experience as "a time in which a current US anesthesiology resident traveled outside of the US to pursue a healthcare-related experience." Details describing international opportunities were collected. Responses were stratified by geographic region, program size, and by the availability of international electives. The websites of all surveyed programs were then reviewed to determine specific mention of international or global health programs. These results were compared to the survey responses.

RESULTS

In the website review, 33.6% of programs' websites described international electives for residents. Among all surveyed programs, 56 (45.9%) completed surveys were returned, with 39 (69.6%) of these programs offering international electives. Not all programs with electives described the offering on their websites. There was no relationship between program size or location and the availability of an elective. At most programs with international electives, at least 4 residents participated annually. Funding was the primary barrier to providing international electives. Perceptions of international electives were generally positive.

CONCLUSIONS

A large proportion of US anesthesia residency programs offer international electives, and perceptions of global health in anesthesiology are positive. This is consistent with developments in global health in other subspecialty fields.

Factors influencing healthcare provider respondent fatigue answering a globally administered in-app survey

Background

Respondent fatigue, also known as survey fatigue, is a common problem in the collection of survey data. Factors that are known to influence respondent fatigue include survey length, survey topic, question complexity, and open-ended question type. There is a great deal of interest in understanding the drivers of physician survey responsiveness due to the value of information received from these practitioners. With the recent explosion of mobile smartphone technology, it has been possible to obtain survey data from users of mobile applications (apps) on a question-by-question basis. The author obtained basic demographic survey data as well as survey data related to an anesthesiology-specific drug called sugammadex and leveraged nonresponse rates to examine factors that influenced respondent fatigue.

Methods

Primary data were collected between December 2015 and February 2017. Surveys and in-app analytics were collected from global users of a mobile anesthesia calculator app. Key independent variables were user country, healthcare provider role, rating of importance of the app to personal practice, length of time in practice, and frequency of app use. Key dependent variable was the metric of respondent fatigue.

Results

Provider role and World Bank country income level were predictive of the rate of respondent fatigue for this in-app survey. Importance of the app to the provider and length of time in practice were moderately associated with fatigue. Frequency of app use was not associated. This study focused on a survey with a topic closely related to the subject area of the app. Respondent fatigue rates will likely change dramatically if the topic does not align closely.

Discussion

Although apps may serve as powerful platforms for data collection, responses rates to in-app surveys may differ on the basis of important respondent characteristics. Studies should be carefully designed to mitigate fatigue as well as powered with the understanding of the respondent characteristics that may have higher rates of respondent fatigue.

Contraceptive counseling among pediatric primary care providers in Western Pennsylvania: A survey-based study

OBJECTIVES

Data suggest that adolescents in the United States receive inadequate contraceptive counseling. This study sought to determine factors affecting pediatricians' discussion of contraception with adolescent patients, with a specific focus on long-acting reversible contraception-implantable contraception and intrauterine devices.

METHODS

A cross-sectional survey was sent via email to a convenience sample of pediatric residents and pediatric primary care providers in Western Pennsylvania. Self-reported contraceptive counseling and prescribing practices in response to clinical vignettes were assessed.

RESULTS

Of potential participants (287), 88 (31%) responded. Younger providers and providers who had received contraceptive training were significantly more likely to discuss long-acting reversible contraception methods. Discussion of contraceptive methods also varied by both the age and the sexual history of the patient.

CONCLUSION

Variation in contraceptive counseling potentially results in missed opportunities to counsel about and provide the most effective contraceptive methods. More uniform, universal provider training might alleviate some of these inconsistencies.

Professional Development Perceptions and Practices Among U.S. Physicians: A Cross-Specialty National Survey

PURPOSE

Professional development (PD)-both for-credit continuing medical education (CME) and informal self-directed or point-of-care learning-is vital to all physicians. The authors sought to understand physicians' PD perceptions and practices and how these vary by specialty and practice type.

METHOD

The authors administered an Internet and paper survey, from September 2015 to April 2016, to randomly sampled U.S. physicians. Survey items addressed perceived PD needs and barriers and how physicians identify knowledge/skills gaps.

RESULTS

Of 4,648 invitees, 988 (21.6%) responded. Respondents believed that they already know what they need to learn (mean 5.8 [1 = strongly disagree; 7 = strongly agree]), can answer clinical questions using available resources (5.9), and want credit for learning during patient care (5.1). They did not strongly desire help identifying learning gaps (4.0) or indicate difficulty accumulating CME credits (3.1). Most PD was done during personal time (5.5). Competencies regarding medical knowledge/skills, wellness, informatics, and practice/systems improvement were rated the highest priority, while research, teaching, and professionalism were rated the lowest. The most important sources used to identify knowledge/skills gaps were immediate patient care needs (4.1 [1 = not important; 5 = extremely important]), personal awareness (3.8), and practice updates (3.7). The most important barriers were time (3.5) and cost (2.9). Differences by specialty and practice type were generally small and not statistically significant.

CONCLUSIONS

Physicians feel confident in identifying their own learning needs, perceive medical knowledge/skills as their highest-priority need, and desire more credit for learning during patient care.

Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment

STUDY OBJECTIVES

Insomnia is a widespread issue among United States adults and rates of insomnia among veterans are even higher than the general population. Prior research examining primary care provider (PCP) perspectives on insomnia treatment found that: sleep hygiene and pharmacotherapy are the primary treatments offered; PCPs tend to focus on perceived causes of insomnia rather than the insomnia itself; and neither patients nor providers are satisfied with insomnia treatment options. Although insomnia complaints are typically first reported to primary care providers, little research has focused on perspectives regarding insomnia treatment among PCPs working in the largest integrated health care system in the United States-the Veterans Affairs (VA) health care system. This study was conducted to examine VA PCP perceptions of the availability of insomnia treatments, identify specific strategies offered by PCPs, and examine perceptions regarding the importance of treating insomnia and the role of comorbid conditions.

METHODS

A survey was conducted within the VA health care system. Primary care providers completed surveys electronically.

RESULTS

A high percentage of veterans (modal response = 20% to 39%) seen in VA primary care settings report an insomnia complaint to their provider. Almost half of respondents do not consistently document insomnia in the medical record (46% endorsed "sometimes," "rarely," or "never"). PCPs routinely advise sleep hygiene recommendations for insomnia (ie, avoid stimulants before bedtime [84.3%], and keep the bedroom environment quiet and dark and comfortable [68.6%]) and many are uncertain if cognitive behavioral therapy for insomnia is available at their facility (43.1%).

CONCLUSIONS

Findings point to the need for systems-level changes within health care systems, including the adoption of evidence-based clinical practice standards for insomnia and PCP education about the processes that maintain insomnia.

COMMENTARY

A commentary on this article appears in this issue on page 937.

A school-based epidemiological field survey: difficulties in collecting psychiatric outcome data in a middle-income country

BACKGROUND

Low- and middle-income countries (LMICs) face a lack of epidemiological data. The development of high-quality surveys is a key research priority in countries such as Brazil. Our aim is to discuss the difficulties in conducting a longitudinal epidemiological survey in a pilot study of a school-based sample in São Paulo.

METHODS

Data came from a cohort of school-attending adolescents in two neighborhoods with different levels of urbanicity in São Paulo. Students born in 2002 and in the 7th grade during 2014 were recruited from nine public schools. Adolescents and caregivers were interviewed separately at baseline and at one year follow-up, using several instruments, including the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL).

RESULTS

Achieving unbiased sampling, keeping an updated register of participants' contact information, using a full clinical interview without an algorithm for its scoring, and maintaining a highly-trained research team were among the difficulties faced.

CONCLUSION

Working closely with community leaders, organizing group efforts to perform interviews, using a short, easy to understand instrument and providing some reward for participants were identified as alternatives to dealing with these difficulties, useful not only in Brazil, but also in other LMICs.

Letters of Recommendation: Association with Interviewers' Perceptions and Preferences

Objective Letters of recommendation (LORs) are an inescapable aspect of the application process. Standardized LORs (SLORs) have been developed and compared with traditional narrative LORs (NLORs). This study investigated whether there was a difference in degree of association between LOR types and face-to-face interviews. Interviewer preference for LOR was anonymously surveyed. Study Design Survey. Setting Single-institution otolaryngology residency program, 1 year before and 4 years after introduction of SLORs. Subjects and Methods Residency interviewers indicated on a visual analog scale how well their impression of an applicant compared between the LOR and the face-to-face interview. Interviewers assessed each applicant, each year, based on LOR type. Results Of 2573 assessments, 964 were collected (37.5% response rate), including 927 responses related to NLORs, 561 to SLORs, and 316 to medical student performance evaluations (ie, dean's letters). The average association of VAS scores between LORs and interviews ranged from 72 to 81 across years and LOR types. Sixty-one percent of interviewers preferred NLORs, and 13% preferred SLORs. Reasons for these preferences included more information provided in NLORs versus faster read time with SLORs. Conclusions Interviewers' perceptions of applicants based on LORs and face-to-face interviews were comparable across LOR types over the last 5 years. For many reasons, the general utility of the LOR remains questionable, and the continued need for it should be critically assessed.

Preventing delayed diagnosis of cancer: clinicians' views on main problems and solutions

Background

Delayed diagnosis is a major contributing factor to the UK’s lower cancer survival compared to many European countries. In the UK, there is a significant national variation in early cancer diagnosis. Healthcare providers can offer an insight into local priorities for timely cancer diagnosis. In this study, we aimed to identify the main problems and solutions relating to delay cancer diagnosis according to cancer care clinicians.

Methods

We developed and implemented a new priority–setting approach called PRIORITIZE and invited North West London cancer care clinicians to identify and prioritize main causes for and solutions to delayed diagnosis of cancer care.

Results

Clinicians identified a number of concrete problems and solutions relating to delayed diagnosis of cancer. Raising public awareness, patient education as well as better access to specialist care and diagnostic testing were seen as the highest priorities. The identified suggestions focused mostly on the delays during referrals from primary to secondary care.

Conclusions

Many identified priorities were feasible, affordable and converged around common themes such as public awareness, care continuity and length of consultation. As a timely, proactive and scalable priority–setting approach, PRIORITZE could be implemented as a routine preventative system for determining patient safety issues by frontline staff.

Factors Influencing Physicians' Selection of Continuous Professional Development Activities: A Cross-Specialty National Survey

INTRODUCTION

We sought to understand what influences physicians' decisions about participation in continuous professional development (CPD) activities, and how often physicians engage in specific CPD activities.

METHODS

From September 2015 to April 2016, we administered a survey to 4648 randomly sampled licensed US physicians. Survey items addressed perceived barriers to CPD, factors that might influence participation in four prototypical CPD activities (reading an article, or completing a local activity, online course, or far-away course), and frequency of CPD engagement.

RESULTS

Nine hundred eighty-eight (21.6%) physicians responded. The most important barriers were time (mean [SD] 3.5 [1.3], 1 = not important, 5 = extremely important) and cost (2.9 [1.3]). In prioritizing factors influencing participation in four prototypical CPD activities, topical relevance consistently had the highest average rank. Quality of content and time to complete the activity were also frequently selected. Over the past 3 years, most physicians reported having participated in patient-focused learning and self-directed learning on a weekly basis; quality improvement and local continuing medical education (CME) activities several times per year; online learning, on-site courses, and national board-related activities a few times per year; and interprofessional learning less than once per year. Physicians believed that they ought to engage more often in all of these activities except board-related activities. They would like CME credit for these activities much more often than currently obtained.

DISCUSSION

The reasons physicians select a given CPD activity vary by activity, but invariably include topic and quality of content. Physicians want CME credit for the CPD activities they are already doing.