Ensuring the "health" of a curricular program evaluation: Alignment and analytic quality of two instruments for use in evaluating the effectiveness of an interprofessional collaboration curriculum

To cultivate competencies in interprofessional collaboration (IPC) for patient-centered, team-based care, a multi-faceted training enhancement initiative was implemented at our academic primary care residency site. Evaluation of the activities from previously collected survey data occurred upon a 2-year review. First, the evaluation team scrutinized the instruments for alignment and appropriateness with planned IPC educational learning and behavior objectives. We found the two instruments were well supported by the literature and with appropriate evidence for validation, but were not well aligned to the objectives of this IPC training initiative, reducing appropriateness of potential inferences of the findings for this context. Second, the team assessed the analytic quality of survey results in item difficulty distribution and item fit to the requirements of a Rasch measurement model. This revealed low person separation due to high overall item agreement. Most residents agreed with most items, so the measures lacked the precision necessary to capture change in residents' IPC competency. Our instrument review serves as a reminder of the need to gather validity evidence for the use of any existing tool within a new context, and offers a generalizable strategy to evaluate data sources for appropriateness and quality within a specific program.

Measuring Gatekeeper Instructor Comfort to Inform Suicide Prevention Train-The-Trainer Recruitment & Training in Agricultural Communities

Farmers experience psychological distress and suicide at consistently higher rates than workers in other industries. A gatekeeper is an individual who has been trained to recognize warning symptoms of possible suicidal ideations in others. Gatekeeper programs are recognized by the federal Substance Abuse and Mental Health Services Administration as a best practice for suicide prevention. While gatekeeper programs offer promise to addressing the increasing worldwide suicide rate, how to develop these networks in communities with largely ingrained stigma and taboo related to mental health and suicide remains unanswered. Three of this study's researchers were part of the development and pilot of an agricultural community gatekeeper program and questioned how gatekeeper instructor psychological comfort could be conceptualized and operationalized for the purpose of informing gatekeeper instructor recruitment and training. After a thorough review of the literature, the researchers constructed a conceptual developmental model of gatekeeper instructor comfort and created a Gatekeeper Instructor Comfort Measure instrument which was then piloted with Kentucky K-12 and university agricultural educators. The researchers of this study employed the Rasch model to determine whether the developmental model of gatekeeper instructor comfort held together empirically. Infit and outfit mean squares (0.73 to 1.33) indicate that the items measure one construct, or are unidimensional, while person reliability and separation statistics indicate that the Gatekeeper Instructor Comfort Measure is composed of enough items to differentiate respondents into almost four strata of gatekeeper comfort. The Gatekeeper Instructor Comfort Measure's fit to the Rasch model indicates that the instrument meets the requirements of invariant measurement and should serve as a useful measure for other researchers. The instrument's item difficulty hierarchy also serves as a guide for those training gatekeepers on how to target different gatekeeper outcomes sequentially or developmentally. Researchers recommend restructuring item responses to enable greater discrimination between categories and then piloting the instrument again with a more diverse sample. The revised measure could be used pre- and post-gatekeeper instructor training to determine the impact of training on gatekeeper comfort.

Evaluating an Agricultural Community Suicide Prevention Program: Instrumentation and Impact

Highlights

Abstract. In this study, researchers detail an evaluation of a pilot community-based farmer suicide prevention program that used QPR-based training customized for the agricultural community. Community-based mental health programs have been cited as key to addressing the worldwide suicide rate, but evidence of their execution and utility is not well documented, particularly within the agricultural community context. Researchers used Kirkpatrick's (1998) training evaluation model and a pre-post one-group design (Eseryel, 2002) of consenting training participants to conduct a preliminary assessment of programmatic impact. Using a revised Willingness to Intervene Against Suicide Questionnaire (Aldrich et al., 2014), which treated the questionnaire as an interval level scale suitable for parametric analysis, researchers found statistically significant differences in pre-training willingness to intervene between male and female respondents as well as those who work in agriculture and those who do not. An analysis of those respondents who completed both pre- and post-training surveys indicated statistically significant growth of 0.21 logits in the willingness to intervene variable, as well as remarkable growth for male participants in comparison to female participants. Keywords: . Evaluation of suicide prevention program, Farmer suicide prevention, Rasch analysis, Willingness to intervene.

809 USE OF NEW MOBILITY SCORE AND A TRANS-DISCIPLINARY APPROACH TO REDUCE HOSPITAL LOS, RETURN TO ORIGINAL RESIDENCE, AND MORTALITY

Introduction

The National Hip Fracture Database indicated Guy’s and St Thomas’ Trust ranked in the fourth quartile nationally with reference to hospital length of stay (LOS), return to original residence (ROR), and mortality in hip fracture patients in 2018. This quality improvement project aimed to improve and maintain these key factors via a two-stage process.

Methods

Stage one involved implementation of four key interventions through a trans-disciplinary focus group, comprising ortho-geriatricians, orthopaedic surgeons, physiotherapists (PT), occupational therapists (OT), nursing staff, and a transfer of care navigator (TCN). Firstly, the New Mobility Score (NMS) was employed as a tool to guide estimated length of stay. Secondly, use of preoperative OT assessment allowed early evaluation of patient expectations concerning discharge planning. Third, facilitation of the discharge process was optimised by the recruitment of a TCN. Lastly, attendance of a senior orthogeriatrician during the daily board round was established. Stage two involved education of new members of the trans-disciplinary team to ensure that the key interventions listed above were maintained on hip fracture patients.

Results

Following stage one, average acute hospital LOS and overall LOS decreased from 20.1 to 15.1 days and 22.4 to 18.3 days, respectively. Rate of ROR within 120 days of discharge improved from 72.4% to 86.9%, while mortality rates fell from 7.1 to 3.4. Following stage two, overall LOS improved to 17.1 days, while acute LOS and mortality were maintained at 15.6 and 3.9 days, respectively. While ROR fell to 82.8%, this remained higher than the national average at 69.9%.

Conclusions

Utilisation of NMS and multi-disciplinary input effectively improved ROR, while reducing length of hospital stay and mortality rates in hip fracture patients. Education of new members of the trans-disciplinary team allowed sustained improvement despite challenges faced during the COVID-19 pandemic.

Tobacco-Free Ambassador Partnership: Empowering Youth Advocates in Appalachian Communities

Kentucky youth (14.3%) smoke more cigarettes as compared to the U.S. average (8.8%), and Appalachian communities suffer disproportionately from tobacco-related diseases such as lung cancer. Training youth to become advocates is an effective strategy to improve health equity. This article describes the development and impact of a youth advocacy program to promote tobacco control policies in Appalachian Kentucky. Phase I (2017-2018): two ½-day trainings followed by monthly meetings with one high school (n = 20 youth). Trainings provided information on tobacco use, consequences, industry tactics, evidence-based tobacco control, and advocacy skills. Results provided support for expansion to Phase II (2018-20119): A 1-day training followed by monthly information sharing implemented in three counties (N = 80). Youth were surveyed before and 6-months posttraining during both phases. Phase I: At posttraining, 85% of youth believed they could reduce the amount of tobacco use in their community versus 66% at baseline. More students tried at least once to convince school or government officials to be more concerned about tobacco use (77% vs. 47%). Phase II: More students supported tobacco policies at posttraining survey and realized policies are an effective strategy to reduce tobacco use. At posttraining survey, students reported greater interpersonal confidence talking with others about tobacco-related issues, with a 24% increase in confidence talking with adults in their communities, as well as greater advocacy self-efficacy. Youth in Appalachia demonstrate desire to influence tobacco use and policy to improve health equity. Findings reinforce the need for collaborative public health interventions to promote ongoing training and support for youth living in high-risk communities.

Competing Roles and Expectations: Preliminary Data from an Agricultural Extension Survey on COVID-19 Impacts

Agricultural Extension professionals play a critical role in outreach and translation of research to practice. Extension has not only been an audience for Agricultural Safety and Health Center work, but also an essential partner in promoting evidence-based farm health and safety in communities. This commentary stems from a collaborative effort among Center leaders across the nation who developed a set of surveys to explore the ways COVID-19 has affected Extension professionals. Preliminary data gathered from across the nation suggest that while many Extension professionals feel prepared to address challenges from the pandemic and are well supported by their State and Center's resources, over half also reported moderate to great difficulty in balancing personal and professional needs and, to a lesser extent, balancing remote work and family needs. Because Extension professionals act as connectors between Agricultural Safety and Health Centers and farmers and their families, they serve in a role similar to first-responders. COVID-19 has exacerbated the potential for anxiety, stress, and other mental health concerns among this group. With COVID-19 numbers rising at an especially fast rate among agricultural workers, it is important to attend to the wellbeing of the professionals who work with them.

Tweeting links to Cochrane Schizophrenia Group reviews: a randomised controlled trial

OBJECTIVE

To assess the effects of using health social media on web activity.

DESIGN

Individually randomised controlled parallel group superiority trial.

SETTING

Twitter and Weibo.

PARTICIPANTS

170 Cochrane Schizophrenia Group full reviews with an abstract and plain language summary web page.

INTERVENTIONS

Three randomly ordered slightly different 140 character or less messages, each containing a short URL to the freely accessible summary page sent on specific times on one single day. This was compared with no messaging.

OUTCOME

The primary outcome was web page visits at 1 week. Secondary outcomes were other metrics of web activity at 1 week.

RESULTS

85 reviews were randomised to each of the intervention and control arms. Google Analytics allowed 100% follow-up within 1 week of completion. Intervention and control reviews received a total of 1162 and 449 visits, respectively (IRR 2.7, 95% CI 2.2 to 3.3). Fewer intervention reviews had single page only visits (16% vs 31%, OR 0.41, 0.19 to 0.88) and users spent more time viewing intervention reviews (geometric mean 76 vs 31 s, ratio 2.5, 1.3 to 4.6). Other secondary metrics of web activity all showed strong evidence in favour of the intervention.

CONCLUSIONS

Tweeting in this limited area of healthcare increases 'product placement' of evidence with the potential for that to influence care.

TRIAL REGISTRATION NUMBER

ISRCTN84658943.

Electroconvulsive therapy is equally effective in unipolar and bipolar depression

OBJECTIVE

To determine the relative efficacy of electroconvulsive therapy (ECT) in the treatment of bipolar (BP) and unipolar (UP) depressive illness and clarify its role in BP depression.

METHOD

Patients referred for ECT with both UP and BP depressions. [classified by Structured Clinical Interview for DSM (SCID-I) criteria for history of mania] were included in a multi-site collaborative, double-masked, randomized controlled trial of three electrode placements - right unilateral, bifrontal or bitemporal - in a permutated block randomization scheme.

RESULTS

Of 220 patients, 170 patients (77.3%) were classified as UP and 50 (22.7%) as BP depression in the intent-to-treat sample. The remission and response rates and numbers of ECT for both groups were equivalent.

CONCLUSION

Both UP and BP depressions remit with ECT. Polarity is not a factor in the response rate. In this sample ECT did not precipitate mania in depressed patients. Treatment algorithms for UP and BP depression warrant re-evaluation.

Faith communities and HIV/AIDS prevention in New York State: results of a statewide survey

OBJECTIVES

The authors surveyed religious congregations in New York State to document the extent to which HIV/AIDS-related education and prevention services were being offered; to identify barriers to offering services; and to assess respondents' willingness to meet with HIV/AIDS service providers in their communities.

METHODS

In October 1997, a questionnaire was mailed to all congregations in New York State. Due to an initially poor response rate, follow-up telephone interviews were made to a random sample of non-respondents. Survey responses were weighted to represent all congregations across New York State.

RESULTS

Just 16.7% of congregations provided or facilitated HIV/AIDS-related prevention services. Respondents cited both attitudinal and resource-related reasons for not offering services. There was a striking discordance between respondents' perceptions of the need for HIV/AIDS prevention services in their communities and an objective measure of need created by the Health Department. Approximately half of survey respondents expressed willingness to meet with HIV/AIDS service providers.

CONCLUSION

Follow-up efforts to increase the number of religious congregations providing, facilitating, or offering referrals to HIV/AIDS-related education and prevention services are warranted.

DNA fingerprinting and molecular epidemiology of tuberculosis: use and interpretation in an epidemic setting

Tuberculosis (TB) is still a major cause of morbidity and mortality. It is clear that control requires more than simple availability of antibiotics. In order to gain insight into the disease, DNA fingerprinting has been applied to the study of bacterial population structure. This technology has been used to quantitate various components of the disease in a high-incidence community, viz. recent transmission (RT) and reactivation (RA) and to monitor these over time as a tool to quantitate changes in the epidemic. In our high-incidence community, we find unexpectedly high strain diversity, lower than predicted RT, and that reactivation disease dominates. This technology can be used to examine and challenge traditional dogmas. Quantitative measure of RT varies over time, using a two-year sliding window for estimation as a useful period. The results show that the "epidemic" consists of subepidemics characterized by strain families that wax and wane in the community of TB patients. The technology is shown to be a useful and quantitative tool to assess disease status and can therefore be used to monitor intervention strategies and refine and monitor results of new control measures.

Standardized screening of elderly patients' needs for social work assessment in primary care: use of the SF-36

Fewer hospitalizations and decreased lengths of stay in the hospital have resulted in an increased need for extensive support services and continuing care planning for elderly people in primary care. Early identification of elderly patients needing community and hospital nonmedical services is necessary so that timely appropriate services can be delivered. This study addresses the issue of whether a standardized health-related quality of life questionnaire, the SF-36, can be used independently as a screen predicting primary care elderly patients' needs for social work assessment. In addition, the question of what scales on the SF-36 a social worker would use to screen patients in need of assessment is explored.

Genotyping of Mycobacterium tuberculosis with additional markers enhances accuracy in epidemiological studies

Two highly polymorphic Mycobacterium tuberculosis genomic domains, characterized by hybridization to the oligonucleotide (GTG)5, were identified as potential DNA fingerprinting probes. These domains were cloned [pMTB484(1) and pMTB484(2K4), respectively] and shown to be useful for genotype analysis by Southern blotting. These probes were used to genotype geographically linked strains of M. tuberculosis previously shown to have identical IS6110 fingerprints. Subsequent DNA fingerprints generated with MTB484(1) and MTB484(2K4) showed a high degree of polymorphism, allowing subclassification of IS6110-defined clusters into composites of smaller clusters and unique strains. Correlation of the molecular data with patient interviews and clinical records confirmed the sensitivity of these probes, as contacts were established only within subclusters. These findings demonstrate the requirement for multiple probes to accurately classify M. tuberculosis strains, even those with high copy numbers of IS6110. The enhanced accuracy of strain typing should, in turn, further our understanding of the epidemiology of tuberculosis.

An analysis of surveillance for stage I combined teratoma--seminoma of the testis

We analysed 973 patients with stage I testicular tumours presenting between 1983 and 1994. The median ages at presentation for non-seminomatous germ cell tumour (teratoma) were 27 years, seminoma 36 years and combined tumour 33 years. These differences were statistically significant (Mann-Whitney P < 0.05), suggesting that combined tumours may have a separate natural history. We, therefore, analysed all stage I patients managed with surveillance (530 in total) post orchidectomy. The actuarial 5 year relapse-free survival and anatomical patterns of relapse were identical for non-seminomatous germ cell tumour (NSGCT) and combined tumour and both were statistically distinct from seminoma (P = 0.01, log-rank test, chi-square test P = 0.001). The association of seminoma within a histologically confirmed NSGCT has no influence on the clinical outcome.

Ambulatory elderly patients of primary care physicians: functional, psychosocial and environmental predictors of need for social work care management

With increasing numbers of elderly people, and the escalating costs of health care, screening becomes increasingly important for identifying those older people with social health care needs who appear in their primary care physicians' offices. Many people are not aware of available social services. Families with serious social problems are not finding the help they need. The aim of this study was to develop and refine a questionnaire as a screening tool to identify elderly outpatients in primary care settings who are at high risk for psychological, social or environmental needs. This study identified those ten factors at each site which were most indicative that further intervention was needed. There were consistencies among the coordinators across sites in terms of what factors triggered intervention. Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) were more likely to be predictive of the coordinator's intervention than were other factors.

Myths and biases related to cancer in the elderly

Advances in medical science have led to effective treatments for cancer; however, there are myriad myths and biases related to older people and cancer that pervade both patients' and professionals' ideas on causation, course of illness, treatment, and recovery, and act as hindrances to early detection, treatment, and rehabilitation. The geriatric population is comprised of a heterogeneous group of persons who are not categorized easily according to chronologic age. Health care professionals are particularly susceptible to ageist stereotyping and negative attitudes toward the elderly because they lack training in caring for older people. In the future, the elderly will be better educated, expect greater participation in decision-making, and be less likely to postpone entry into the medical care system. There is a need to educate both health care professionals and the elderly population about the myths and realities of cancer detection and treatment.

Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results

Fifty consecutive patients with intractable sciatic pain, positive root tension signs, correlative myelography, and neurological impairment were treated by percutaneous lateral discectomy (PLD). Under local anesthesia and C-arm fluoroscopy control, an 18-gauge needle, introduced into the intervertebral disc dorsolaterally, entered the skin at approximately 9 cm from the midline. A Kirschner wire replaced the stylet of the needle, and the needle was withdrawn. The introduction of a specially designed cannulated trocar over the K-wire facilitated precisional insertion of the instruments. This step was followed by the introduction of a sheath with an internal diameter of 4.9 mm over the trocar. The sheath was held against the annulus fibrosis, and the cannulated trocar was removed. The annulus was windowed and the herniated disc material evacuated by instruments and suction. Evaluations were made with Macnab's criteria. Excellent and good results were obtained in 88% of patients. The mean length of hospital stay after operation was 2.3 days. The operative time, blood loss, and morbidity were minimal, and no serious complications were encountered. In carefully selected patients, PLD appears to be safe, effective, and cost-efficient.

Long-term regularly inhaled salbutamol

Seventeen asthmatic patients were allocated at random to one of two treatment regimens: prophylactic (10 patients), in which salbutamol inhaler was used regularly in a dose of 200 micrograms 4-times daily; or symptomatic (7 patients), in which a placebo inhaler was used regularly as 2 actuations 4-times daily. In both regimens, an 'escape' salbutamol inhaler was given to be used for symptomatic relief if and when needed. The study lasted 12 months, after a run-in period of 1 month to accustom patients to the trial procedure. At the end of the year, 16 patients transferred to the alternative regimen for a further 3 months. Both groups were well matched except that the group starting with the prophylactic regimen had more severe airways obstruction than the symptomatic group. Patients were assessed by daily scores of their asthmatic symptoms, twice daily PEFR measurements and the amount of anti-asthmatic medication used. Acute reversibility tests were performed every month at the clinic visits. Patients treated prophylactically had less seasonal variation in PEFR and generally lower symptom scores despite a lower mean PEFR. There was no evidence to suggest tolerance was developing either by acute reversibility tests or by an escalating use of symptomatic salbutamol or other anti-asthma medication. The prophylactic use of salbutamol seemed to provide a more stable control of asthma, offering potential benefit to patients.

How accurate are medical records in detecting patient problems?

Medical records can become a book about the health and sickness of a person or a family; they should be comprehensive, orderly and reviewed by the doctor at regular intervals. They can be one of the best sources of continuing medical education. The RACGP has developed a format for recording a brief but comprehensive dossier on a patient. This study shows the case finding method is superior in the detection of most patient problems to the method of gradual accumulation of patient data over the course of several consultations. The improved method takes a modest increase in time and effort but is worthwhile for the patient and well within the organisational capabilities of the modern general practitioner.

The risk of placement in a nursing home after acute hospitalization

Using data from an urban Professional Standards Review Organization, the authors examined the pattern of discharges for persons aged 65 years and older from acute hospitals for 1979 and 1980. Of the 9% of elderly persons who were discharged to nursing homes, those older than 85 years were 10 times as likely to enter a nursing home as those aged 65; females were twice as likely as males; and those with a diagnosis of mental illness were more likely than those with a diagnosis of physical disease, but the effects were additive. Even after adjustments for patient source, patient characteristics, and therapeutic service, the university teaching hospital was less likely to discharge elderly patients to nursing homes than were the 10 community hospitals in the area.

The outcome of hospitalization for acute illness in the elderly

The use of acute-care hospitals by the elderly is rising rapidly, particularly in the age group 75 and older. Any changes that will reduce the length of stay could result in considerable savings in health care costs. It is imperative to look at present policies and explore possible changes that could reduce costs by reducing the total hospital days. A study was conducted in a 290-bed county-founded community hospital in California that serves the majority of disadvantaged and poor elderly residing in an area with a population of approximately 300,000 persons. The objective was to determine what demographic, medical, and sociologic characteristics of elderly patients recorded at admission would be of value in predicting those most likely to change their functional status. It was found that the most important predictors of deterioration of function are (1) older age, especially 85+, and (2) abnormal mental status. Patients admitted from nursing homes had a longer than average length of stay, and those who survived (80 per cent) returned to a nursing home. It was concluded that routine assessment of elderly patients admitted for acute illness or injury could facilitate discharge planning by an early prediction of the level of care that will be required after discharge. This assessment should include preadmission mental and functional status; identification of causes for, and correction of, acute confusional states; and an assessment of the impact of the present illness or injury on future level of function following rehabilitation. This could result in a reduced length of average hospital stay.

The hemostatic effect of conjugated water-soluble estrogens in rats

Estrogenic steroids have been used as hemostatic agents in various surgical procedures in humans. Their use to reduce bleeding has been based mainly on clinical observation. The present study was carried out to test experimentally whether intravenously administered Premarin reduces capillary bleeding. Skin-graft donor sites in rats served as the standard capillary bleeding source in this controlled double-blind experiment, in which Premarin was found to appreciably reduce capillary bleeding.

Adenocarcinoma of the uterine cervix in Jewish women: a distinct epidemiological entity

During an 11-year period, 532 Jewish women with invasive cancer of the uterine cervix were diagnosed in Israel. Of these, 441 (82.9%) had squamous cell carcinoma (SUC) and 52 (9.8%) had adenocarcinoma (AUC). Different characteristics were noted for these two histological categories with regard to age, ethnic distribution, and chronological time trends. The ratio between AUC and SUC differed considerably between the various ethnic groups, ranging from about 1:6 in the Asian and European born to less than 1:14 in the North African. This indicates that the relatively higher incidence of AUC in Israeli Jewish women is limited to those ethnic groups that have a low risk for cervical cancer. The different patterns of SUC and AUC in the population support the contention of a varying etiology.