[IMPROVING THE ORGANIZATION OF LABOR AND THE QUALITY OF MEDICAL CARE AT PARAMEDIC AND OBSTETRIC STATIONS]

In the provision of primary health care to the rural population, the role of paramedic and obstetric stations (FAP) is great. The purpose of the study is to develop a system of measures aimed at improving the quality of medical care provided at paramedic and obstetric stations. The study was conducted in 2019-2020 on the basis of 26 FAP of 12 central district hospitals (CRH) of the Republic of Dagestan. The organization of labor of 26 paramedics and 26 midwives during 1740 hours was studied by the method of time-lapse observation. The content of 16511 visits by the FAP population was analyzed. The expert evaluation method studied the quality of medical care to 445 patients on 7 FAP. The main work of FAP paramedics accounts for 74.5%, and for midwives - 76.3% of all labor costs. A significant share in the cost structure is occupied by preventive (22.9% for paramedics and 27.8% for midwives) and diagnostic and therapeutic activities (17% and 15.6%). There are high costs for transitions and relocations (17.3% and 14.1%) and for working with documentation (13.7% and 14.5%). In the structure of visits by the population of paramedics and midwives of FAP, for reasons of the greatest proportion are visits with therapeutic and diagnostic purposes (37%), followed by visits for medical appointments (32.8%) and preventive (23.9%). The quality of medical care provided by paramedics to patients with therapeutic diseases was inadequate in 23.8% of cases. Every third (35.7%) patient was treated with FAP unreasonably. Out of the total number of patients who were treated unreasonably on FAP, according to experts, 62.5% had to be treated in the CRH, 34.8% - in the district hospital (outpatient clinic).

Concordance of Occupational Exposure Assessment between the Canadian Job-Exposure Matrix (CANJEM) and Expert Assessment of Jobs Held by Women

OBJECTIVES

To compare the exposure data generated by using the Canadian job-exposure matrix (CANJEM) with data generated by expert assessment, for jobs held by women.

METHODS

We selected 69 occupational agents that had been assessed by experts for each of 3403 jobs held by 998 women in a population-based case-control study of lung cancer. We then assessed the same agents among the same jobs by linking their occupation codes to CANJEM and thereby derived probability of exposure to each of the agents in each job. To create binary exposure variables, we dichotomized probability of exposure using two cutpoints: 25 and 50% (referred to as CANJEM-25% and CANJEM-50%). Using jobs as units of observation, we estimated the prevalence of exposure to each selected agent using CANJEM-25% and CANJEM-50%, and using expert assessment. Further, using expert assessment as the gold standard, for each agent, we estimated CANJEM's sensitivity, specificity, and kappa.

RESULTS

CANJEM-based prevalence estimates correlated well with the prevalences assessed by the experts. When comparing CANJEM-based exposure estimates with expert-based exposure estimates, sensitivity, specificity, and kappa varied greatly among agents, and between CANJEM-25% and CANJEM-50% probability of exposure. With CANJEM-25%, the median sensitivity, specificity, and kappa values were 0.49, 0.99, and 0.46, respectively. Analogously, with CANJEM-50%, the corresponding values were 0.26, 1.00, and 0.35, respectively. For the following agents, we observed high concordance between CANJEM- and expert-based assessments (sensitivity ≥0.70 and specificity ≥0.99): fabric dust, cotton dust, synthetic fibres, cooking fumes, soldering fumes, calcium carbonate, and tin compounds. We present concordance estimates for each of 69 agents.

CONCLUSIONS

Concordance between CANJEM and expert assessment varied greatly by agents. Our results indicate which agents provide data that mimic best those obtained with expert assessment.

Bayesian Hierarchical Modelling of Individual Expert Assessments in the Development of a General-Population Job-Exposure Matrix

The CANJEM job-exposure matrix compiles expert evaluations of 31 673 jobs from four population-based case-control studies conducted in Montreal. For each job, experts had derived indices of intensity, frequency, and probability of exposure to 258 agents. CANJEM summarizes the exposures assigned to jobs into cells defined by occupation/industry, agent, and period. Some cells may, however, be less populated than others, resulting in uncertain estimates. We developed a modelling framework to refine the estimates of sparse cells by drawing on information available in adjacent cells. Bayesian hierarchical logistic and linear models were used to estimate the probability of exposure and the geometric mean (GM) of frequency-weighted intensity (FWI) of cells, respectively. The hierarchy followed the Canadian Classification and Dictionary of Occupations (CCDO) classification structure, allowing for exposure estimates to be provided across occupations (seven-digit code), unit groups (four-digit code), and minor groups (three-digit code). The models were applied to metallic dust, formaldehyde, wood dust, silica, and benzene, and four periods, adjusting for the study from which jobs were evaluated. The models provided estimates of probability and FWI for all cells that pulled the sparsely populated cells towards the average of the higher-level group. In comparisons stratified by cell sample size, shrinkage of the estimates towards the group mean was marked below 5 jobs/cell, moderate from 5 to 9 jobs/cell, and negligible at ≥10 jobs/cell. The modelled probability of three-digit cells were slightly smaller than their descriptive estimates. No systematic trend in between-study differences in exposure emerged. Overall, the modelling framework for FWI appears to be a suitable approach to refine CANJEM estimates. For probability, the models could be improved by methods better adapted to the large number of cells with no exposure.

Relating characteristics of global biodiversity targets to reported progress

To inform governmental discussions on the nature of a revised Strategic Plan for Biodiversity of the Convention on Biological Diversity (CBD), we reviewed the relevant literature and assessed the framing of the 20 Aichi Biodiversity Targets in the current strategic plan. We asked international experts from nongovernmental organizations, academia, government agencies, international organizations, research institutes, and the CBD to score the Aichi Targets and their constituent elements against a set of specific, measurable, ambitious, realistic, unambiguous, scalable, and comprehensive criteria (SMART based, excluding time bound because all targets are bound to 2015 or 2020). We then investigated the relationship between these expert scores and reported progress toward the target elements by using the findings from 2 global progress assessments (Global Biodiversity Outlook and the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services). We analyzed the data with ordinal logistic regressions. We found significant positive relationships (p < 0.05) between progress and the extent to which the target elements were perceived to be measurable, realistic, unambiguous, and scalable. There was some evidence of a relationship between progress and specificity of the target elements, but no relationship between progress and ambition. We are the first to show associations between progress and the extent to which the Aichi Targets meet certain SMART criteria. As negotiations around the post-2020 biodiversity framework proceed, decision makers should strive to ensure that new or revised targets are effectively structured and clearly worded to allow the translation of targets into actionable policies that can be successfully implemented nationally, regionally, and globally.

"Reflection-Before-Practice" Improves Self-Assessment and End-Performance in Laparoscopic Surgical Skills Training

OBJECTIVE

To establish whether a systematized approach to self-assessment in a laparoscopic surgical skills course improves accordance between expert- and self-assessment.

DESIGN

A systematic training course in self-assessment using Competency Assessment Tool was introduced into the normal course of evaluation within a Laparoscopic Surgical Skills training course for the test group (n = 30). Differences between these and a control group (n = 30) who did not receive the additional training were assessed.

SETTING

Catharina Hospital, Eindhoven, The Netherlands (n = 27), and GSL Medical College, Rajahmundry, India (n = 33).

PARTICIPANTS

Sixty postgraduate year 2 and 3 surgical residents who attended the 2-day Laparoscopic Surgical Skills grade 1 level 1 curriculum were invited to participate.

RESULTS

The test group (n = 30) showed better accordance between expert- and self-assessment (difference of 1.5, standard deviation [SD] = 0.2 versus 3.83, SD = 0.6, p = 0.009) as well as half the number (7 versus 14) of cases of overreporting. Furthermore, the test group also showed higher overall mean performance (mean = 38.1, SD = 0.7 versus mean = 31.8, SD = 1.0, p < 0.001) than the control group (n = 30). The systematic approach to self-assessment can be viewed as responsible for this and can be seen as "reflection-before-practice" within the framework of reflective practice as defined by Donald Schon.

CONCLUSION

Our results suggest that "reflection-before-practice" in implementing self-assessment is an important step in the development of surgical skills, yielding both better understanding of one's strengths and weaknesses and also improving overall performance.

Wishful Thinking? Inside the Black Box of Exposure Assessment

BACKGROUND

Decision-making processes used by experts when undertaking occupational exposure assessment are relatively unknown, but it is often assumed that there is a common underlying method that experts employ. However, differences in training and experience of assessors make it unlikely that one general method for expert assessment would exist. Therefore, there are concerns about formalizing, validating, and comparing expert estimates within and between studies that are difficult, if not impossible, to characterize. Heuristics on the other hand (the processes involved in decision making) have been extensively studied. Heuristics are deployed by everyone as short-cuts to make the often complex process of decision-making simpler, quicker, and less burdensome. Experts' assessments are often subject to various simplifying heuristics as a way to reach a decision in the absence of sufficient data. Therefore, investigating the underlying heuristics or decision-making processes involved may help to shed light on the 'black box' of exposure assessment.

METHODS

A mixed method study was conducted utilizing both a web-based exposure assessment exercise incorporating quantitative and semiqualitative elements of data collection, and qualitative semi-structured interviews with exposure assessors. Qualitative data were analyzed using thematic analysis.

RESULTS

Twenty-five experts completed the web-based exposure assessment exercise and 8 of these 25 were randomly selected to participate in the follow-up interview. Familiar key themes relating to the exposure assessment exercise emerged; 'intensity'; 'probability'; 'agent'; 'process'; and 'duration' of exposure. However, an important aspect of the detailed follow-up interviews revealed a lack of structure and order with which participants described their decision making. Participants mostly described some form of an iterative process, heavily relying on the anchoring and adjustment heuristic, which differed between experts.

CONCLUSION

In spite of having undertaken comparable training (in occupational hygiene or exposure assessment), experts use different methods to assess exposure. Decision making appears to be an iterative process with heavy reliance on the key heuristic of anchoring and adjustment. Using multiple experts to assess exposure while providing some form of anchoring scenario to build from, and additional training in understanding the impact of simple heuristics on the process of decision making, is likely to produce a more methodical approach to assessment; thereby improving consistency and transparency in expert exposure assessment.

Bladder cancer and occupational exposure to diesel and gasoline engine emissions among Canadian men

The International Agency for Research on Cancer has classified diesel exhaust as a carcinogen based on lung cancer evidence; however, few studies have investigated the effect of engine emissions on bladder cancer. The purpose of this study was to investigate the association between occupational exposure to diesel and gasoline emissions and bladder cancer in men using data from the Canadian National Enhanced Cancer Surveillance System; a population‐based case–control study. This analysis included 658 bladder cancer cases and 1360 controls with information on lifetime occupational histories and a large number of possible cancer risk factors. A job‐exposure matrix for engine emissions was supplemented by expert review to assign values for each job across three dimensions of exposure: concentration, frequency, and reliability. Odds ratios (OR) and their corresponding 95% confidence intervals were estimated using logistic regression. Relative to unexposed, men ever exposed to high concentrations of diesel emissions were at an increased risk of bladder cancer (OR = 1.64, 0.87–3.08), but this result was not significant, and those with >10 years of exposure to diesel emissions at high concentrations had a greater than twofold increase in risk (OR = 2.45, 1.04–5.74). Increased risk of bladder cancer was also observed with >30% of work time exposed to gasoline engine emissions (OR = 1.59, 1.04–2.43) relative to the unexposed, but only among men that had never been exposed to diesel emissions. Taken together, our findings support the hypothesis that exposure to high concentrations of diesel engine emissions may increase the risk of bladder cancer.

Validity of expert assigned retrospective estimates of occupational polychlorinated biphenyl exposure

Assessment of retrospective exposures based on expert judgment in case-control studies is usually of unknown validity because of the difficulty in finding gold standards for comparison. We investigated the relationship between expert-assigned retrospective occupational polychlorinated biphenyl (PCB) exposure estimates and serum PCB concentrations. Analyses were conducted on a subset of cases (n = 94) and controls (n = 96) in the multi-center National Cancer Institute, Surveillance, Epidemiology, and End Results Case-Control Study of non-Hodgkin lymphoma. Based on the subjects' lifetime work histories, an industrial hygienist assigned each job a probability of PCB exposure [<5% (unexposed), 5-<50% (possibly exposed), ≥50% (probably exposed)]. Ordinary least squares regression was used to investigate associations between the probability rating and log-transformed lipid-adjusted serum levels of 14 PCB congeners and total PCBs (ΓPCBs). Compared to unexposed participants (n = 163), those with a probably exposed job (n = 7) had serum levels that were 87% higher for ΓPCBs (95% confidence interval: 1.33-2.62) and 38% of serum level variability was explained by the probability rating. Statistically significant associations between probability ratings and serum levels for 12 of 14 individual congeners were also observed. In summary, the observed contrast in PCB serum levels by probability rating provides support for the occupational PCB exposure assessment.

Reliability and validity of expert assessment based on airborne and urinary measures of nickel and chromium exposure in the electroplating industry

The reliability and validity of six experts' exposure ratings were evaluated for 64 nickel-exposed and 72 chromium-exposed workers from six Shanghai electroplating plants based on airborne and urinary nickel and chromium measurements. Three industrial hygienists and three occupational physicians independently ranked the exposure intensity of each metal on an ordinal scale (1-4) for each worker's job in two rounds: the first round was based on responses to an occupational history questionnaire and the second round also included responses to an electroplating industry-specific questionnaire. The Spearman correlation (r(s)) was used to compare each rating's validity to its corresponding subject-specific arithmetic mean of four airborne or four urinary measurements. Reliability was moderately high (weighted kappa range=0.60-0.64). Validity was poor to moderate (r(s)=-0.37-0.46) for both airborne and urinary concentrations of both metals. For airborne nickel concentrations, validity differed by plant. For dichotomized metrics, sensitivity and specificity were higher based on urinary measurements (47-78%) than airborne measurements (16-50%). Few patterns were observed by metal, assessment round, or expert type. These results suggest that, for electroplating exposures, experts can achieve moderately high agreement and (reasonably) distinguish between low and high exposures when reviewing responses to in-depth questionnaires used in population-based case-control studies.

Agreement of experts and non-experts in a desktop exercise evaluating exposure to asthmagens in the cotton and textile, and other industries

In the absence of personal exposure measurements, expert assessment, generally on a case-by-case basis, is often used to estimate exposures. However, the decision processes of individual experts when making assessments are unknown, making it difficult to assess the quality of these assessments or to compare different assessments to each other. We conducted a study in primarily the textile and cotton industries, but also in baking, metal work, and agriculture industries in which we assessed agreement between experts assessing intensity and probability of exposure in the absence of exposure measurements to compare how well their performance compares to agreement of non-desktop-based exercises reported in literature. In addition, agreement was compared with that of non-experts undertaking the same exercise, and results were further stratified to assess the impact of factors expected of affected assessments. Intraclass correlation coefficients of absolute agreement (ICC1) and consistency (ICC3) between raters were calculated. Sensitivity and specificity were estimated using a probabilistic simulation methodology developed previously. Fourteen occupational hygienists and exposure assessors with complete data for all 48 job descriptions and 8 non-experts participated. Although confidence intervals about correlation-coefficient differences are not reported, the individual limits were found to be so broad as to suggest that no statistically significant comparisons can be made. Nevertheless, preliminary observations are presented here as suggested by the computed means. Absolute agreement between expert raters was fair-good, but was somewhat better for intensity (ICC1 = 0.61) than for probability (ICC1 = 0.44) of exposure and was better for experts than non-experts. Estimated sensitivity was 0.95 and specificity 0.82 for intensity, and 0.91 and 0.78 for probability of exposure, respectively. Stratification for factors hypothesized to affect agreement did not show statistically significant differences, but consistent patterns of point estimates indicated that agreement between raters (both expert on non-experts) dropped for medium levels of information compared with little or extensive information. Inclusion of a photo or video generally improved agreement between experts but not between non-experts, whereas the year of the job description had no influence on the assessments. These data indicate that the desktop exposure assessment exercise was of similar quality to previously reported levels of agreement. Agreements between experts' assessments were independent of the time period of the job and can be improved by inclusion of visual material. Agreement between experts as well as the non-experts does not increase with the detail of provided job information.