Integrating Validity Evidence to Revise a Child Abuse Knowledge Test for Early Childhood Education Providers: A Mixed Methods Approach

Knowledge tests used to evaluate child protection training program effectiveness for early childhood education providers may suffer from threats to construct validity given the contextual variability inherent within state-specific regulations around mandated reporting requirements. Unfortunately, guidance on instrument revision that accounts for such state-specific mandated reporting requirements is lacking across research on evaluation practices. This study, therefore, explored how collection and integration of validity evidence using a mixed methods framework can guide the instrument revision process to arrive at a more valid program outcome measure.

Effects of using an abdominal simulator to develop palpatory competencies in 3rd year medical students

BACKGROUND

Medical school faculty are hard pressed to provide clerkship students with sufficient opportunity to develop and practice their capacity to perform a competent clinical examination, including the palpatory examination of the abdomen. We evaluated the impact of training with an abdominal simulator, AbSim, designed to monitor the depth, location, and thoroughness of their palpation and to provide concurrent and summative feedback regarding their performance.

METHODS

All third-year medical students were given the opportunity to develop their palpatory skills with the AbSim simulator during the family medicine rotation. The performance of those who studied with the simulator was measured by its sensors, before and after a training session that included visual feedback regarding the depth and coverage of the student's manual pressure. Additionally, all students reported their confidence in their evolving abdominal palpation skills at the beginning and end of the rotation.

RESULTS

119 (86.9%) of 137 students filled out the initial questionnaire, and 73 (61.3%) studied with the abdominal simulator. The training produced a highly significant improvement in their overall performance (4 measures, p's < 0.001). Pre-training performance (depth calibration and thoroughness of coverage) was not related to the number of months of previous clinical rotations nor to previous internal medicine or surgery rotations. There was little relation between students' confidence in their abdominal examination skills and objective measures of their palpatory performance; however, students who chose the training started with less confidence, and became more confident after training.

CONCLUSIONS

Guided abdominal simulator practice increased medical students' capacity to perform an abdominal examination with more appropriate depth and thoroughness of palpation. Interpretation of changes in confidence are uncertain, because confidence was unrelated to objectively measured performance. However, students with low initial confidence in their abdominal examination seemed to be more likely to choose to study with the abdominal simulator.

Generalizing findings from a randomized controlled trial to a real-world study of the iLookOut, an online education program to improve early childhood care and education providers' knowledge and attitudes about reporting child maltreatment

In recent years, real-world studies (RWS) are gaining increasing interests, because they can generate more realistic and generalizable results than randomized controlled clinical trials (RCT). In 2017, we published a RCT in 741 early childhood care and education providers (CCPs). It is the Phase I of our iLookOut for Child Abuse project (iLookOut), an online, interactive learning module about reporting suspected child maltreatment. That study demonstrated that in a RCT setting, the iLookOut is efficient at improving CCPs’ knowledge of and attitudes towards child maltreatment reporting. However, the generalizability of that RCT’s results in a RWS setting remains unknown. To address this question, we design and conduct this large RWS in 11,065 CCPs, which is the Phase II of the iLookOut. We hypothesize replication of the earlier RCT findings, i.e., the iLookOut can improve CCPs’ knowledge of and attitudes toward child maltreatment reporting in a real world setting. In addition, this RWS also explores whether demographic factors affect CCPs’ performance. Results of this RWS confirmed the generalizability of the previous RCT’s results in a real world setting. It yielded similar effect sizes for knowledge and attitudes as were found in the earlier RCT. Cohen’s d for knowledge improvement was 0.95 in that RCT, 0.96 in this RWS; Cohen’s d for attitude improvement was 0.98 in that RCT, 0.80 in this RWS. Also, we found several significant differences in knowledge and attitude improvement with regard to age, race, education, and employment status. In conclusion, iLookOut improves knowledge and attitudes of CCPs about child maltreatment prevention and reporting in a real-world setting. The generalizability of the initial RCT findings to this RWS provides strong evidence that the iLookout will be effective in other real world settings. It can be a useful model for other interventions aimed at preventing child maltreatment.

Clinical trial registration for the original RCT: NCT02225301 (ClinicalTrials.gov Identifier)

Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial

Background

Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians’ adherence to biopsychosocial guidelines is low.

Objective

The current study examined the effects of a flags approach–based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients.

Design

Randomized controlled trial (trial registration number: ISRCTN53670726).

Setting

University classroom.

Subjects

Medical students and GP trainees.

Methods

Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31).

Results

Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research.

Conclusions

Short flags approach–based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues.

Alternative Lens Model Equations for Dichotomous Judgments about Dichotomous Criteria

Objective

The Brunswik lens model typically represents a judge's accuracy using parameters derived from linear regression. This is not optimal if the judgment or the ecological criterion is dichotomous. Alternative approaches, modeling dichotomies using logistic regression, or linearizing judgments with confidence ratings, have not been compared with the same data.

Method

Four techniques for deriving lens model equation parameters were compared: 1) linear and 2) logistic regression applied to dichotomous patient outcomes and judgments; 3) linear regression with confidence-adjusted judgments but dichotomous patient outcomes; and 4) a hybrid with a linear model of the confidence-adjusted judgments and a logistic model of the patient outcomes.

Results

Judgment accuracy (r_a) was slightly higher with confidence adjustment of the categorical judgments. The logistic lens model accounted for a higher proportion of r_a than the linear lens model; the confident-linear and hybrid lens models were intermediate. For up to a quarter of participants, different methods identified different cues as most important. Display condition differences in achievement r_a and in lens model components are similar with all lens model methods.

Conclusion

Each of the three alternative lens model equation methods improves on the linear lens model equation's decomposition of the accuracy of dichotomous judgments. Confidence adjustment improves achievement although it requires additional work from the subjects. The logistic lens model equation explains the highest proportion of achievement, but with a small stimulus set it is more vulnerable to cue intercorrelations than either the linear or the confident linear lens model equation.

In patients suspected of cognitive decline, what is the most accurate in-office screening instrument to determine if there is dementia needing further evaluation and management?

While screening for dementia in patients without symptoms is not recommended by the United States Preventative Services Task Force (USPSTF), screening in those presenting with symptoms may help patients and caregivers prepare for the future. When selecting which screening tool to use in a primary care office, one needs to consider practicality, feasibility, applicability, and psychometric properties. The MIS, MiniCog, PhotoTest, and GPCOG have been found to have short administration times, good accuracy, and applicability for a broad range of patient education and backgrounds. The BAS, MiniCog, PhotoTest and MAT have been found to be the most accurate tests. However, the evidence is limited and more studies need to be done to accurately answer the presented question.

Explanations for Common Responses to the Blue/Green Cab Probabilistic Inference Word Problem

Three explanations have been advanced to explain the most popular error on probabilistic inference word problems, which is the use of the reliability of the evidence p(E/H) as the response when p(H/E) is requested. Production system simulations of each explanation are applied to data from a study in which 265 subjects judged the probability of an hypothesis after receiving each of three pertinent pieces of information—the evidence, the baserate, and the reliability of the evidence—in all possible combinations. The explanation that subjects consider the baserate to be irrelevant is rejected. Data are consistent with both the explanation that 265 subjects confuse p(E/H) with p(H/E) and the explanation that they interpolate between the baserate probability and 1.0 and then select their response from among nearby numbers that are available in the word problem.

Theory about Heuristic Strategies Based on Verbal Protocol Analysis: The Emperor Needs a Shave

A research report in the present issue of Medical Decision Making raises questions about the definition of heuristic strategies, the validity of conclusions drawn from the analysis of verbal protocols, and the tradeoff between rigor and relevance in research on the psychology of patient decision making.

The Relationships among Constructs in the Health Belief Model and the Transtheoretical Model among African-American College Women for Physical Activity

Purpose.

Health Belief Model (HBM) and Transtheoretical Model concepts were used to investigate possible differences in perceptions of physical activity among African-American college women categorized by their stage of physical activity behavior.

Methods.

A survey was administered to 233 participants to assess their stage of physical activity behavior and HBM perceptions. Analysis of variance was used to investigate possible differences among HBM constructs for each behavior stage.

Results.

Perceived barriers were significantly higher (p < .05), and perceived severity, cues to action, and self-efficacy were significantly lower in the inactive group than in the active group. For example, perceived barriers were significantly higher in the inactive (mean = 2.3) stage than in the preparation (mean = 2.1), action (mean = 1.9), and maintenance (mean = 1.7) stages of physical activity behavior.

Discussion.

The results suggest that many perceptions of physical activity differ significantly among stages of behavior in this sample of African-American college women. A limitation was that some scales were modified specifically for this population and were not validated.

Effectiveness of a biopsychosocial e-learning intervention on the clinical judgements of medical students and GP trainees regarding future risk of disability in patients with chronic lower back pain: study protocol for a randomised controlled trial

INTRODUCTION

Chronic lower back pain (CLBP) is a major healthcare problem with wide ranging effects. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions that identify biopsychosocial barriers to recovery have been observed to lead to successfully reduced pain-related work absences and increased return to work for individuals with CLBP. Modern conceptualisations of pain adopt a biopsychosocial approach, such as the flags approach. Biopsychosocial perspectives have been applied to judgements about future adjustment, recovery from pain and risk of long-term disability; and provide a helpful model for understanding the importance of contextual interactions between psychosocial and biological variables in the experience of pain. Medical students and general practitioner (GP) trainees are important groups to target with education about biopsychosocial conceptualisations of pain and related clinical implications.

AIM

The current study will compare the effects of an e-learning intervention that focuses on a biopsychosocial model of pain, on the clinical judgements of medical students and trainees.

METHODS AND ANALYSIS

Medical student and GP trainee participants will be randomised to 1 of 2 study conditions: (1) a 20 min e-learning intervention focused on the fundamentals of the flags approach to clinical judgement-making regarding risk of future pain-related disability; compared with a (2) wait-list control group on judgement accuracy and weighting (ie, primary outcomes); flags approach knowledge, attitudes and beliefs towards pain, judgement speed and empathy (ie, secondary outcomes). Participants will be assessed at preintervention and postintervention.

ETHICS AND DISSEMINATION

The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee. The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN53670726; Pre-results.

Rationality, practice variation and person-centred health policy: a threshold hypothesis

Variation in practice of medicine is one of the major health policy issues of today. Ultimately, it is related to physicians' decision making. Similar patients with similar likelihood of having disease are often managed by different doctors differently: some doctors may elect to observe the patient, others decide to act based on diagnostic testing and yet others may elect to treat without testing. We explain these differences in practice by differences in disease probability thresholds at which physicians decide to act: contextual social and clinical factors and emotions such as regret affect the threshold by influencing the way doctors integrate objective data related to treatment and testing. However, depending on a theoretical construct each of the physician's behaviour can be considered rational. In fact, we showed that the current regulatory policies lead to predictably low thresholds for most decisions in contemporary practice. As a result, we may expect continuing motivation for overuse of treatment and diagnostic tests. We argue that rationality should take into account both formal principles of rationality and human intuitions about good decisions along the lines of Rawls' 'reflective equilibrium/considered judgment'. In turn, this can help define a threshold model that is empirically testable.

When is rational to order a diagnostic test, or prescribe treatment: the threshold model as an explanation of practice variation

BACKGROUND

The threshold model represents an important advance in the field of medical decision-making. It is a linchpin between evidence (which exists on the continuum of credibility) and decision-making (which is a categorical exercise - we decide to act or not act). The threshold concept is closely related to the question of rational decision-making. When should the physician act, that is order a diagnostic test, or prescribe treatment? The threshold model embodies the decision theoretic rationality that says the most rational decision is to prescribe treatment when the expected treatment benefit outweighs its expected harms. However, the well-documented large variation in the way physicians order diagnostic tests or decide to administer treatments is consistent with a notion that physicians' individual action thresholds vary.

METHODS

We present a narrative review summarizing the existing literature on physicians' use of a threshold strategy for decision-making.

RESULTS

We found that the observed variation in decision action thresholds is partially due to the way people integrate benefits and harms. That is, explanation of variation in clinical practice can be reduced to a consideration of thresholds. Limited evidence suggests that non-expected utility threshold (non-EUT) models, such as regret-based and dual-processing models, may explain current medical practice better. However, inclusion of costs and recognition of risk attitudes towards uncertain treatment effects and comorbidities may improve the explanatory and predictive value of the EUT-based threshold models.

CONCLUSIONS

The decision when to act is closely related to the question of rational choice. We conclude that the medical community has not yet fully defined criteria for rational clinical decision-making. The traditional notion of rationality rooted in EUT may need to be supplemented by reflective rationality, which strives to integrate all aspects of medical practice - medical, humanistic and socio-economic - within a coherent reasoning system.

For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL)care such as ICU admission, feeding tube placement, CPR, or intubation?

CLINICAL QUESTION

For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation?

ANSWER

Inconclusive. Existing evidence does not provide a conclusive answer to this particular question. While multiple prospective, randomized, controlled trials demonstrate an association between increased patient-provider contact time and decreased aggressive EOL care, interventions in those studies contain multiple confounding elements that preclude isolation of the time factor from the other elements in the interventions. There is a need for research focusing on physician-patient communication time and EOL care.

LEVEL OF EVIDENCE FOR THE ANSWER

A

SEARCH TERMS

Terminal care, palliative care, terminal illness, communication, patient-provider relations, time factors, life support care, resuscitation orders, enteral nutrition

INCLUSION CRITERIA

Systematic reviews, meta-analyses, and comparative studies published between 2008 and the current date comparing EOL care or EOL care preferences of patients who spend more face-to-face time with a healthcare provider to those of patients who spend less face-to-face time with a healthcare provider.

EXCLUSION CRITERIA

Studies that do not report the primary outcome of interest (EOL care or EOL care preferences) or that do not measure discussion time or provide interventions that include face-to-face discussion.

The balance beam metaphor: a perspective on clinical diagnosis

Understanding the impact of clinical findings in discriminating between possible causes of a patient's presentation is essential in clinical judgment. A balance beam is a natural physical analogue that can accurately represent the combination of several pieces of evidence with varying ability to discriminate between disease hypotheses. Calculation of Bayes' theorem using log(posterior odds) as a function of log(prior odds) and the logarithms of the evidence's likelihood ratios maps onto the physical forces affecting objects placed on a balance beam. We describe the rules governing the functioning of tokens representing clinical findings in the comparison of 2 competing diseases. The likelihood ratios corresponding to positive (LR+) or negative (LR-) observations for each symptom determine the lateral position at which the symptom's token is placed on the beam, using a weight if the finding is present and a helium balloon if it is absent. We discuss how a balance beam could represent concepts of dynamic specificity (due to changes in competitor diseases' probabilities) and dynamic sensitivity (due to class-conditional independence). Utility-based thresholds for acting on a diagnosis could be represented by moving the balance beam's fulcrum. It is suggested that a balance beam can be a useful aid for students learning clinical diagnosis, allowing them to build on existing intuitive understanding to develop an appreciation of how evidence combines to influence degree of belief. The balance beam could also facilitate exploration of the potential impact of available questions or investigations.

A balance beam aid for instruction in clinical diagnostic reasoning

We describe a balance beam aid for instruction in diagnosis (BBAID) and demonstrate its potential use in supplementing the training of medical students to diagnose acute chest pain. We suggest the BBAID helps students understand the process of diagnosis because the impact of tokens (weights and helium balloons) attached to a beam at different distances from the fulcrum is analogous to the impact of evidence to the relative support for 2 diseases. The BBAID presents a list of potential findings and allows students to specify whether each is present, absent, or unknown. It displays the likelihood ratios corresponding to a positive (LR+) or negative (LR-) observation for each symptom, for any pair of diseases. For each specified finding, a token is placed on the beam at a location whose distance from the fulcrum is proportional to the finding's log(LR): a downward force (a weight) if the finding is present and a lifting force (a balloon) if it is absent. Combining the physical torques of multiple tokens is mathematically identical to applying Bayes' theorem to multiple independent findings, so the balance beam is a high-fidelity metaphor. Seven first-year medical students and 3 faculty members consulted the BBAID while diagnosing brief patient case vignettes. Student comments indicated the program is usable, helpful for understanding pertinent positive and negative findings' usefulness in particular situations, and welcome as a reference or self-test. All students attended the effect of the tokens on the beam, although some stated they did not use the numerical statistics. Faculty noted the BBAID might be particularly helpful in reminding students of diseases that should not be missed and identifying pertinent findings to ask for.

Figure and ground in physician misdiagnosis: metacognition and diagnostic norms

Meta-cognitive awareness, or self reflection informed by the “heuristics and biases” theory of how experts make cognitive errors, has been offered as a partial solution for diagnostic errors in medicine. I argue that this approach is not as easy nor as effective as one might hope. We should also promote mastery of the basic principles of diagnosis in medical school, continuing medical education, and routine reflection and review. While it may seem difficult to attend to both levels simultaneously, there is more to be gained from attending to both than from focusing only on one.

Interpreting the psychometric properties of the components of primary care instrument in an elderly population

Objective:

To determine the psychometric properties of the Components of Primary Care Instrument (CPCI) in a patient population aged 65 or older.

Materials and Methods:

795 participants in the OKLAHOMA Studies, a longitudinal population-based study of predominantly Caucasian, elderly patients, completed the CPCI. Reliability analysis and confirmatory factor analysis were done to provide psychometric properties for this elderly sample. Models were constructed and tested to determine the best fit for the data including the addition of a method factor for negatively worded items.

Results:

Cronbach's alphas were comparable to values reported in prior studies. The confirmatory factor analysis with factor inter-correlations and a method factor each improved the fit of the factor model to the data. The combined model's fit approached the level conventionally recognized as adequate.

Conclusion:

CPCI appears to be a reliable tool for describing patient perceptions of the quality of primary care for patients over age 65.

A decision aid for teaching limitations of prostate cancer screening

There is minimal research regarding men's knowledge of the limitations of prostate cancer screening. This study measured knowledge of prostate cancer screening based on exposure to one of two decision aids that were related to prostate cancer screening (enhanced versus usual care). The sample consisted primarily of low income (54%) African-American men (81%) (n=230). The enhanced decision aid was compared against the usual care decision aid that was developed by the American Cancer Society. The enhanced decision aid was associated with higher post-test knowledge scores, but statistically significant differences were observed only in the men who reported having had a previous DRE (p = 0.013) in the multivariable analyses. All the men were screened, regardless of which decision aid they received. This study highlights the impact of previous screening on education of the limitations of prostate screening, and challenges the assumption that increased knowledge of the limitations of prostate cancer screening will lead to decreased screening.

Knocking at the wrong door: insured workers' inadequate psychiatric care and workers' compensation claims

OBJECTIVE

To describe the prevalence of inadequately evaluated and treated psychopathology among insured workers making workers' compensation claims for psychiatric disability whose cases were reviewed by one forensic psychiatrist. To assess the relationship of inadequate evaluation and treatment to the outcomes of these workers' compensation claims.

METHODS

Records of a series of 185 workers' compensation cases reviewed in 1998 and 1999 by a California forensic psychiatrist were abstracted. Patient factors (gender, Axis II pathology, psychosocial circumstances, substance abuse), case factors (psychiatric injury secondary to physical injury, or secondary to psychological stresses), type of provider (mental health, or other), adequacy of evaluation and treatment, forensic psychiatrist's recommendation, and claim outcome were categorized. The relationships between case characteristics, adequacy of care, and claim outcome were described.

RESULTS

22% of cases had adequate evaluation, 48% superficial, and 30% had no evaluation. 11% had adequate treatment, 67% superficial, and 22% had no treatment. Compared to claims for psychiatric disability related to a physical injury, claims related to psychosocial stresses more often had superficial diagnostic evaluations and treatments. Those with superficial treatment were less likely to have their claim granted (19.3%) than those with no treatment (47.5%) or those with adequate treatment (36.8%). Success of claim was not related to provider type.

CONCLUSIONS

The majority of the studied workers with employer-provided health insurance who sought workers' compensation for disability due to mental illness did so inappropriately, in that the workplace did not cause the psychopathology. Their seeking workers' compensation was plausibly due to the observed inadequate evaluation and treatment available through their employer-provided health insurance. The adequacy of their care influenced the likelihood their claim would be granted. The relations observed here merit further research to establish their generality and to determine their causes.

Exploring beliefs about prostate cancer and early detection in men and women of three ethnic groups

OBJECTIVES

Practice guidelines support informed or shared decision-making about prostate cancer screening. To compare beliefs across three racial/ethnic categories concerning prostate cancer etiology and risk, screening routines, and shared decision-making, we conducted 12 focus groups.

METHODS

Participants were recruited in primary care settings and included 33 African Americans, 35 Hispanics, and 22 non-Hispanic Whites. Of the 90 participants, 53% were male.

RESULTS

Groups identified heredity, age, race, sexual activity, and other lifestyle influences as risk factors. Few were aware that prostate cancer is asymptomatic in early stages. Confidence in knowledge of screening routines was high, but included misconceptions supporting initiation of screening at earlier ages and at shorter intervals than professional recommendations. Females encouraged screening of male relatives to protect their health.

DISCUSSION AND CONCLUSION

While racial/ethnic groups had similar views and knowledge about screening, African Americans wanted to organize to address the threat of prostate cancer in their communities. Hispanics had awakening awareness of the health risks of prostate cancer. Non-Hispanic Whites were aware of the health threat of prostate cancer, but their approach to health protection was more individual and less community focused than that of African Americans. Participants were not aware of controversy about screening.

PRACTICE IMPLICATIONS

Developers of educational materials to support informed or shared decision-making should be aware that initial views of prostate cancer screening are positive.

Does secondary smoke exposure increase the incidence and/or severity of asthma in children?

Pediatric asthma is a significant health problem in the United States. Up to 26,000 new asthma cases are identified every year. Seventeen percent of all pediatric emergency department visits are attributable to asthma. There are no universally agreed upon diagnostic criteria for asthma. Because no single agent has been identified as causing asthma and because no pathologic feature is entirely unique to asthma, the disease can more easily be described than defined. Asthma is diagnosed clinically based upon recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night in the absence of other causes. Asthma is considered a chronic inflammatory disorder associated with airflow obstruction, which is often reversible either spontaneously or with treatment. This inflammation exacerbates bronchial hyper-responsiveness to a variety of environmental stimuli including allergens and irritants. Due to inconsistency of diagnostic criteria for asthma, it is easier to measure asthma severity or to study events such as hospitalizations or deaths, rather than to measure incidence. Since a randomized controlled trial of the effect of cigarette exposure on asthma would be unethical, we must rely on either randomized trials of reduction of cigarette exposure or epidemiological studies to determine associations between secondary exposure to cigarette smoke and asthma.

Acute bacterial rhinosinusitis in adults: part I. Evaluation

Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory practice. Although often caused by viruses, it sometimes is caused by bacteria, a condition that is called acute bacterial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which makes accurate clinical diagnosis difficult. Because two thirds of patients with acute bacterial rhinosinusitis improve without antibiotic treatment and most patients with viral upper respiratory infection improve within seven d antibiotic therapy should be reserved for use in patients who have had symptoms for more than seven days and meet clinical criteria. Four signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis: purulent nasal discharge, maxillary tooth or facial pain (especially unilateral), unilateral maxillary sinus tenderness, and worsening symptoms after initial improvement. Sinus radiography and ultrasonography are not recommended in the diagnosis of uncomplicated acute bacterial rhinosinusitis, although computed tomography has a role in the care of patients with recurrent or chronic symptoms.

Acute bacterial rhinosinusitis in adults: part II. Treatment

Although most cases of acute rhinosinusitis are caused by viruses, acute bacterial rhinosinusitis is a fairly common complication. Even though most patients with acute rhinosinusitis recover promptly without it, antibiotic therapy should be considered in patients with prolonged or more severe symptoms. To avoid the emergence and spread of antibiotic-resistant bacteria, narrow-spectrum antibiotics such as amoxicillin should be used for 10 to 14 days. In patients with mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are options. Second-line antibiotics should be considered if the patient has moderate disease, recent antibiotic use (past six weeks), or no response to treatment within 72 hours. Amoxicillin-clavulanate potassium and fluoroquinolones have the best coverage for Haemophilus influenzae and Streptococcus pneumoniae. In patients with beta-lactam hypersensitivity who have moderate disease, a fluoroquinolone should be prescribed. The evidence supporting the use of ancillary treatments is limited. Decongestants often are recommended, and there is some evidence to support their use, although topical decongestants should not be used for more than three days to avoid rebound congestion. Topical ipratropium and the sedating antihistamines have anticholinergic effects that maybe beneficial, but there are no clinical studies supporting this possibility. Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and has no serious adverse effects. Nasal corticosteroids also may be beneficial in treating chronic sinusitis. Mist, zinc salt lozenges, echinacea extract, and vitamin C have no proven benefit in the treatment of acute bacterial rhinosinusitis.

Reimbursement for pediatric diabetes intensive case management: a model for chronic diseases?

OBJECTIVE

Current reimbursement policies serve as potent disincentives for physicians who provide evaluation and management services exclusively. Such policies threaten nationwide availability of care for personnel-intensive services such as pediatric diabetes. This report describes an approach to improving reimbursement for highly specialized, comprehensive pediatric diabetes management through prospective contracting for services. The objective of this study was to determine whether pediatric diabetes intensive case management services are cost-effective to the payer, the patient, and a pediatric diabetes program.

METHODS

A contract with a third-party payer was created to reimburse for 3 key pediatric diabetes intensive case management components: specialty education, 24/7 telephone access to an educator (and board-certified pediatric endocrinologist as needed), and quarterly educator assessments of self-management skills. Data were collected and analyzed for 15 months after signing the contract. Within the first 15 months after the contract was signed, 22 hospital admissions for diabetic ketoacidosis (DKA) occurred in 16 different patients. After hospitalizations for DKA, all 16 patients were offered participation in the program. All were followed during the subsequent 1 to 15 months of observation. Ten patients elected to participate, and 6 refused participation. Frequency of rehospitalization, emergency department visits, and costs were compared between the 2 groups.

RESULTS

Among the 10 participating patients, there was only 1 subsequent DKA admission, whereas among the 6 who refused participation, 5 were rehospitalized for DKA on at least 1 occasion. The 10 patients who participated in the program had greater telephone contact with the team compared with those who did not (16 crisis-management calls vs 0). Costs (education, hospitalization, and emergency department visits) per participating patient were approximately 1350 dollars less than those for nonparticipating patients. Differences between participating and nonparticipating groups included age (participants were of younger age), double-parent households (participants were more likely to be from double parent households), and number of medical visits kept (participants kept more follow-up visits). No differences in duration of diabetes, months followed in the program, sex, or ethnicity were observed.

CONCLUSIONS

Contracting with third-party payers for pediatric diabetes intensive case management services reduces costs by reducing emergency department and inpatient hospital utilizations, likely a result of intensive education and immediate access to the diabetes health care team for crisis management. Such strategies may prove to be cost saving not only for diabetes management but also for managing other costly and personnel-intensive chronic diseases.

Do perceptions of risk and quality of life affect use of hormone replacement therapy by postmenopausal women?

BACKGROUND

Although the understanding of the health impact of hormone replacement therapy (HRT) is incomplete, even less is known about the attitudes, perceptions, and motivations of women faced with the decision to use HRT. The purpose of this study was to evaluate the relation between HRT use and women's perceptions of the risk and benefits associated with HRT use.

METHODS

A written questionnaire was administered to 387 women, aged 45 years and older, responding to a health plan invitation for free bone mineral density screening. Women were asked to estimate the lifetime probability of developing breast cancer, uterine cancer, osteoporosis, and myocardial infarction when taking HRT and when not taking HRT. Women rated their quality of life in their current state of health, with breast cancer, with uterine cancer, with osteoporosis, and after myocardial infarction.

RESULTS

HRT users perceived a greater risk reduction using HRT compared with HRT nonusers for osteoporosis (-34.9% vs -17.8%, P <.001) and myocardial infarction (-20.7% vs -8.4%, P <.001). HRT nonusers perceived a greater risk increase using HRT compared with HRT nonusers for breast cancer (16.5% vs 3.3%, P <.001) and uterine cancer (9.2% vs 0.6%, P =.004). HRT users estimated a greater quality-of-life reduction compared with HRT nonusers for osteoporosis (-31.0 vs -24.5, P =.006).

CONCLUSIONS

Regardless of whether they used HRT, women in this study overestimated their risk for all four diseases. HRT users perceived greater benefit and less risk using HRT than nonusers. The results of our study show that continuing efforts are needed to help women understand the risks and benefits of HRT.

Interpretation of prostate cancer screening events and outcomes: a focus group study

Professional guidelines call for physicians to provide patients with information to permit informed decision making. We conducted focus groups to obtain reactions to numerical information about events and outcomes related to prostate cancer screening (prevalence, natural history, accuracy of screening, and treatment outcomes). The focus groups were used to help develop a balance sheet, a decision aid that explicitly compares likelihood and value of outcomes. In all, 90 persons participated in 12 focus groups homogeneous in ethnicity (African American, White, Hispanic) and gender. Discussions were transcribed and analyzed using qualitative methods. The view of screening derived by participants from the numerical information was less positive than initial opinions based on the media and confidence in medicine. Participants suggested shorter screening intervals, regular screening, and different treatment methods. No single topic was seen as sufficient for the screening decision. The balance sheet should cover prevalence and outcomes of screening and treatment.

Measuring academic production

BACKGROUND

The entire academic medical community is under increasing pressure to define and measure its activities. Previous relative value-based systems to measure research, teaching, administration, and patient care share several features that threaten their acceptability and validity. Using a bottom-up approach, our academic family medicine department attempted to develop a measurement system that avoided some of the flaws of the earlier systems.

METHODS

The system was developed in two phases. In the first phase, faculty members were invited to submit lists of all their professional activities. In the second phase, the faculty rated the relative value of a comprehensive list of academic activities using an unbounded ratio scale and indicated how many times a year they did each activity.

RESULTS

Phase One resulted in a list of 96 academic activities. The activity rated in Phase Two as having the greatest relative value was principal investigator of a funded grant (relative value=30.23), followed by sole author of a book (relative value=28.25). The activity with the smallest relative value was attending a faculty meeting (relative value=.36). A half-day clinic session had a relative value of 1.08. The department's annual production, measured in relative value units, was 5,764 units of administration, 5,702 units of clinical activities, 5,480 units of teaching, and 4,401 units of scholarly activities.

CONCLUSIONS

Overall, the process efficiently produced relative value measures for a large number of faculty activities using a process in which most of the faculty participated. Problems with internal coherence, face validity, and inconsistencies in estimation suggest it would be premature to use such estimates of relative value to quantify individuals 'productivity as a basis for budgetary decisions.

Screening for microalbuminuria to prevent nephropathy in patients with diabetes: a systematic review of the evidence

OBJECTIVE

Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is effective according to the criteria developed by Frame and Carlson and those of the US Preventive Services Task Force.

STUDY DESIGN

We searched the MEDLINE database (1966-present) and bibliographies of relevant articles.

OUTCOMES MEASURED

We evaluated the impact of MA screening using published criteria for periodic health screening tests. The effect of the correlation between repeated tests on the accuracy of a currently recommended testing strategy was analyzed.

RESULTS

Quantitative tests have reported sensitivities from 56% to 100% and specificities from 81% to 98%. Semiquantitative tests for MA have reported sensitivities from 51% to 100% and specificities from 21% to 100%. First morning, morning, or random urine sampling appear feasible. Assuming an individual test sensitivity of 90%, a specificity of 90%, and a 10% prevalence of MA, the correlation between tests would have to be lower than 0.1 to achieve a positive predictive value for repeated testing of 75%.

CONCLUSIONS

Screening for MA meets only 4 of 6 Frame and Carlson criteria for evaluating screening tests. The recommended strategies to overcome diagnostic uncertainty by using repeated testing are based on expert opinion, are difficult to follow in primary care settings, do not improve diagnostic accuracy sufficiently, and have not been tested in a controlled trial. Although not advocated by the American Diabetes Association, semiquantitative MA screening tests using random urine sampling have acceptable accuracy but may not be reliable in all settings.

Cost effectiveness of human immunodeficiency virus postexposure prophylaxis for healthcare workers

OBJECTIVE

The United States Public Health Service (USPHS) published recommendations for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) of healthcare workers in May 1998. The aim of this study was to analyse the cost effectiveness of the USPHS PEP guidelines.

DESIGN AND SETTING

This was a modelling study in the setting of the US healthcare system in 1989. The analysis was performed from the societal perspective; however, only HIV healthcare costs were considered and health-related losses of productivity were not included.

METHODS

A decision tree incorporating a Markov model was created for 4 PEP strategies: the current USPHS recommendations, triple drug therapy, zidovudine monotherapy or no prophylaxis. A probabilistic sensitivity analysis using a Monte Carlo simulation was performed. Confidence intervals (CIs) around cost-effectiveness estimates were estimated by a bootstrapping method.

RESULTS

The costs (in 1997 US dollars) per quality-adjusted life-year (QALY) save by each strategy were as follows: monotherapy $US688 (95% CI: $US624 to $US750); USPHS recommendations $US5211 (95% CI: $US5126 to $US5293); and triple drug therapy $US8827 (95% CI: $US8715 to $US8940). The marginal cost per year of life saved was: USPHS recommendations $US81 987 (95% CI: $US80 437 to $US83 689); triple drug therapy $US970 451 (95% CI: $US924 786 to $US 1 014 429). Sensitivity testing showed that estimates of the probability of seroconversion for each category of exposure were most influential, but did not change the order of strategies in the baseline analysis. With the prolonged HIV stage durations and increased costs associated with recent innovations in HIV therapy, the marginal cost effectiveness of the USPHS PEP strategy was decreased to $US62 497/QALY saved. All 3 intervention strategies were cost effective compared with no postexposure prophylaxis.

CONCLUSIONS

Current USPHS PEP recommendations are marginally cost effective compared with monotherapy, but the additional efficacy of triple drug therapy for all risk categories is rewarded by only a small reduction in HIV infections at great expense. For the foreseeable future, assuming innovations in therapy that employ expensive drug combinations earlier in the HIV disease course to extend life expectancy and the increasing prevalence of HIV drug resistance, our model supports the use of the USPHS PEP guidelines.

Population-based time preferences for future health outcomes

CONTEXT

Time preference (how preference for an outcome changes depending on when the outcome occurs) affects clinical decisions, but little is known about determinants of time preferences in clinical settings.

OBJECTIVES

To determine whether information about mean population time preferences for specific health states can be easily assessed, whether mean time preferences are constant across different diseases, and whether under certain circumstances substantial fractions of the patient population make choices that are consistent with a negative time preference.

DESIGN

Self-administered survey.

SETTING

Family physician waiting rooms in four states.

PATIENTS

A convenience sample of 169 adults.

INTERVENTION

Subjects were presented five clinical vignettes. For each vignette the subject chose between interventions maximizing a present and a future health outcome. The options for individual vignettes varied among the patients so that a distribution of responses was obtained across the population of patients.

MAIN OUTCOME MEASURE

Logistic regression was used to estimate the mean preference for each vignette, which was translated into an implicit discount rate for this group of patients.

RESULTS

There were marked differences in time preferences for future health outcomes based on the five vignettes, ranging from a negative to a high positive (116%) discount rate.

CONCLUSIONS

The study provides empirical evidence that time preferences for future health outcomes may vary substantially among disease conditions. This is likely because the vignettes evoked different rationales for time preferences. Time preference is a critical element in patient decision making and cost-effectiveness research, and more work is necessary to improve our understanding of patient preferences for future health outcomes.

The effect of labeling on perceived ability to recover from acute illnesses and injuries

BACKGROUND

The process of giving a patient a diagnosis may cause harm. The adverse effects of labeling, best documented for the diagnosis of hypertension, include increased absenteeism from work and lower earnings, increased depressive symptoms, and reduced quality of life. We tried to determine whether the diagnosis of hypertension affects perceptions about the time required to recover from common acute medical problems.

METHODS

In an academic family practice clinic, equal numbers of patients with and without hypertension were asked to estimate how long it would take them to recover from an upper respiratory tract infection (URI), a urinary tract infection (UTI), and an ankle sprain now and 5 years ago (before the diagnosis of hypertension).

RESULTS

Compared with patients who did not have hypertension, patients with hypertension estimated that it would take them twice as long, on average, to recover from a URI now (11.7 vs 6.0 days, P=.002) and in the past (10 vs 5.5 days, P=.02). These differences persisted after controlling for age, sex, race, and education. No significant differences were found for estimated recovery times for UTI or ankle sprain.

CONCLUSIONS

The diagnosis of hypertension may affect patients' perceptions of their ability to recover from unrelated acute illnesses. This may have implications for the way physicians choose to present information to patients.