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1.
Paediatr Anaesth ; 27(3): 228-239, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28109052

RESUMO

BACKGROUND: Continuous opioid infusion therapy is commonly utilized in the pediatric intensive care setting to treat pain and facilitate tolerance of invasive therapies. Transitioning to methadone is one common strategy for weaning from continuous opioid infusions, but in practice this transition can be challenging, and many children still experience iatrogenic withdrawal. AIM: We reviewed the literature to evaluate the best available evidence to guide methadone therapy in this setting, and to summarize associated adverse events. METHODS: We included all studies of methadone used to facilitate weaning from continuous opioid infusions in pediatric critical care patients, including medical, cardiac, and surgical patients, excluding case reports and studies treating neonatal abstinence syndrome, or acute or chronic pain. Medline, Embase, and CINAHL databases from inception to May 2015 were queried; references of included works and conference proceedings were also reviewed. Two authors independently extracted data from each study. Meta-analysis with fixed- and random-effects models was used to pool results of studies when applicable. RESULTS: Twelve studies involving 459 patients met criteria for inclusion. A wide variety of methadone dosing and taper strategies were reported. Mean inpatient methadone taper times varied widely, from 4.3 to 26.2 days. Excessive sedation was the most frequently reported adverse event, occurring in up to 16% of patients. Withdrawal occurred in 27% of patients among studies reporting this outcome. In three of three studies in which a new methadone protocol was introduced, a decreased proportion of patients experienced withdrawal (standardized mean difference, SMD = -0.60, 95% CI = -0.998 to -0.195, P = 0.004). CONCLUSION: We did not identify sufficient evidence to recommend any particular methadone weaning strategy, or to recommend methadone over other medications or prescribed infusion weaning, for successful weaning of continuous opioid infusions in the pediatric intensive care setting.


Assuntos
Analgésicos Opioides/uso terapêutico , Cuidados Críticos/métodos , Metadona/uso terapêutico , Dor/tratamento farmacológico , Síndrome de Abstinência a Substâncias/prevenção & controle , Criança , Humanos
2.
Cochrane Database Syst Rev ; 10: CD004398, 2012 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-23076904

RESUMO

BACKGROUND: Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. OBJECTIVES: To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes. SEARCH METHODS: For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register. SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS: Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. MAIN RESULTS: The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness. AUTHORS' CONCLUSIONS: The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.


Assuntos
Disseminação de Informação/métodos , Manuais como Assunto , Avaliação de Processos e Resultados em Cuidados de Saúde , Prática Profissional , Análise de Variância , Difusão de Inovações , Publicações Periódicas como Assunto , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
3.
J Health Commun ; 17(3): 294-302, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22188207

RESUMO

American Indian and Alaska Native people suffer extreme health disparities and remain underrepresented in health research. This population needs adequate numeracy skills to make informed decisions about health care and research participation, yet little is known about their numeracy skills. Participants were 91 American Indian and Alaska Native elders who completed an anonymous survey that measured numeracy and the correlation between framing of risk and comprehension of risk. The authors measured numeracy by a previously developed 3-item scale that assessed basic probability skills and the ability to manipulate percentages and proportions. Risk comprehension was measured by 3 items on treatment benefits, which were variously framed in terms of relative risk reduction, absolute risk reduction, and number needed to treat. Framing in terms of relative risk was associated with higher odds of correct interpretation compared to absolute risk (OR=1.8, 95% CI=1.2-2.9) and number needed to treat (OR=2.0, 95% CI=1.2-3.5). This association persisted after adjusting for covariates, including baseline numeracy skills. Our results underscore the need for clinicians to consider how health information is framed and to check carefully for understanding when communicating risk information to patients.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde/etnologia , Letramento em Saúde , Indígenas Norte-Americanos/psicologia , Conceitos Matemáticos , Idoso , Alaska/etnologia , Compreensão , Escolaridade , Feminino , Humanos , Indígenas Norte-Americanos/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Washington
4.
J Organ End User Comput ; 23(4): 17-30, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-24729759

RESUMO

In this paper, the authors present the results of a qualitative case-study seeking to characterize data discovery needs and barriers of principal investigators and research support staff in clinical translational science. Several implications for designing and implementing translational research systems have emerged through the authors' analysis. The results also illustrate the benefits of forming early partnerships with scientists to better understand their workflow processes and end-user computing practices in accessing data for research. The authors use this user-centered, iterative development approach to guide the implementation and extension of i2b2, a system they have adapted to support cross-institutional aggregate anonymized clinical data querying. With ongoing evaluation, the goal is to maximize the utility and extension of this system and develop an interface that appropriately fits the swiftly evolving needs of clinical translational scientists.

5.
BMC Med Inform Decis Mak ; 9: 7, 2009 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-19159472

RESUMO

BACKGROUND: The purpose of this study is to identify publication output, and research areas, as well as descriptively and quantitatively characterize the field of medical informatics through publication trend analysis over a twenty year period (1987-2006). METHODS: A bibliometric analysis of medical informatics citations indexed in Medline was performed using publication trends, journal frequency, impact factors, MeSH term frequencies and characteristics of citations. RESULTS: There were 77,023 medical informatics articles published during this 20 year period in 4,644 unique journals. The average annual article publication growth rate was 12%. The 50 identified medical informatics MeSH terms are rarely assigned together to the same document and are almost exclusively paired with a non-medical informatics MeSH term, suggesting a strong interdisciplinary trend. Trends in citations, journals, and MeSH categories of medical informatics output for the 20-year period are summarized. Average impact factor scores and weighted average impact factor scores increased over the 20-year period with two notable growth periods. CONCLUSION: There is a steadily growing presence and increasing visibility of medical informatics literature over the years. Patterns in research output that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline, and highlight specific journals in which the medical informatics literature appears most frequently, including general medical journals as well as informatics-specific journals.


Assuntos
Informática Médica , Medical Subject Headings/estatística & dados numéricos , Publicações/tendências , Bibliometria , MEDLINE
6.
Ethn Dis ; 18(2): 210-7, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-18507276

RESUMO

OBJECTIVES: American Indians/Alaska Natives are underrepresented in clinical trials. Therefore, they must participate in large-scale cancer clinical trials to ensure the generalizability of trial results and improve their access to high-quality treatment. Our goal was to identify factors that influenced participation in cancer clinical trials among American Indians/Alaska Natives. METHODS: An anonymous survey that assessed willingness to participate in a hypothetical cancer clinical trial and how 37 factors influenced their willingness to participate was administered to 112 older American Indian/Alaska Native adults at an annual social event honoring elders. Responses ranged from one (definitely would not participate) to five (definitely would participate). Data were analyzed with ordinal logistic regression. RESULTS: Factors that most strongly increased willingness to participate were having a lead researcher of Native descent, having a study physician with experience treating American Indians/Alaska Natives, personal experience with the cancer being studied, family support for participation, and belief/hope that the study would result in new treatments. Factors that decreased willingness to participate most strongly were living far from the study site and a high risk that confidentiality could be breached. CONCLUSIONS: Our results identify conventional and culturally unique barriers to research participation among older American Indians/Alaska Natives. These data emphasize the need to establish partnerships with Native communities and include American Indian/Alaska Native and culturally competent professionals in research efforts. Of equal importance are disseminating information about clinical trials and recognizing the role of family in decisionmaking in this group.


Assuntos
Ensaios Clínicos como Assunto/psicologia , Tomada de Decisões , Indígenas Norte-Americanos/psicologia , Inuíte/psicologia , Neoplasias , Participação do Paciente/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Alaska , Atitude Frente a Saúde/etnologia , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/etnologia , Neoplasias/psicologia , Neoplasias/terapia , Razão de Chances , Participação do Paciente/estatística & dados numéricos , Relações Médico-Paciente , Washington
7.
BMC Med Educ ; 8: 1, 2008 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-18194533

RESUMO

BACKGROUND: New technologies that emerge at the interface of computational and biomedical science could drive new advances in global health, therefore more training in technology is needed among health care workers. To assess the potential for informatics training using an approach designed to foster interaction at this interface, the University of Washington and the Universidad Peruana Cayetano Heredia developed and assessed a one-week course that included a new Bioinformatics (BIO) track along with an established Medical/Public Health Informatics track (MI) for participants in Peru. METHODS: We assessed the background of the participants, and measured the knowledge gained by track-specific (MI or BIO) 30-minute pre- and post-tests. Participants' attitudes were evaluated both by daily evaluations and by an end-course evaluation. RESULTS: Forty-three participants enrolled in the course - 20 in the MI track and 23 in the BIO track. Of 20 questions, the mean % score for the MI track increased from 49.7 pre-test (standard deviation or SD = 17.0) to 59.7 (SD = 15.2) for the post-test (P = 0.002, n = 18). The BIO track mean score increased from 33.6 pre-test to 51.2 post-test (P < 0.001, n = 21). Most comments (76%) about any aspect of the course were positive. The main perceived strength of the course was the quality of the speakers, and the main perceived weakness was the short duration of the course. Overall, the course acceptability was very good to excellent with a rating of 4.1 (scale 1-5), and the usefulness of the course was rated as very good. Most participants (62.9%) expressed a positive opinion about having had the BIO and MI tracks come together for some of the lectures. CONCLUSION: Pre- and post-test results and the positive evaluations by the participants indicate that this first joint Bioinformatics and Medical/Public Health Informatics (MI and BIO) course was a success.


Assuntos
Biologia Computacional/educação , Currículo , Conhecimentos, Atitudes e Prática em Saúde , Internacionalidade , Informática Médica/educação , Saúde Pública/educação , Adulto , Coleta de Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Educacionais , Peru , Fatores de Tempo , Estados Unidos
8.
Diabetes Technol Ther ; 9(1): 52-9, 2007 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17316098

RESUMO

BACKGROUND: The emergence of the World Wide Web in the last decade has made it feasible for the Internet to be a vehicle for chronic disease management. METHODS: A randomized controlled trial (n = 62) testing the effects of a 6-month web-based intervention plus usual care, compared with usual care alone, among adults 60 years of age and older with diabetes. The outcomes were hemoglobin A1c (HbA1c), blood pressure, weight, cholesterol, and high-density lipoprotein (HDL) levels. RESULTS: A multivariate analysis of covariance controlling for all baseline outcome variables, age, gender, and number of years with diabetes showed significant (P = 0.001) reductions in HbA1c, weight, and cholesterol level and significant improvement in HDL levels in the intervention versus the control group. CONCLUSIONS: Findings show a web-based intervention was effective in improving HbA1c, weight, cholesterol, and HDL levels at a 6-month follow-up. Future research is needed to investigate the long-term effectiveness of web-based interventions.


Assuntos
Diabetes Mellitus/terapia , Internet , Idoso , Pressão Sanguínea , Peso Corporal , Colesterol/sangue , HDL-Colesterol/sangue , Diabetes Mellitus/sangue , Diabetes Mellitus/fisiopatologia , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
9.
J Bone Joint Surg Am ; 89(2): 244-54, 2007 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17272436

RESUMO

BACKGROUND: Both arthroscopic and open surgical repairs are utilized for the management of anterior glenohumeral instability. To determine the evidence supporting the relative effectiveness of these two approaches, we conducted a rigorous and comprehensive analysis of all reports comparing arthroscopic and open repairs. METHODS: A systematic analysis of eighteen published or presented studies was performed to determine if there were significant differences between the two approaches with regard to recurrence (recurrent dislocation, subluxation, and/or apprehension and/or a reoperation for instability), return to work and/or sports, and Rowe scores. We also performed subgroup analysis to determine if the quality of the study or the arthroscopic technique influenced the results. RESULTS: We identified four randomized controlled trials, ten controlled clinical trials, and four other comparative studies. Results were influenced both by the quality of the study and by the arthroscopic technique. Meta-analysis revealed that, compared with open methods, arthroscopic repairs were associated with significantly higher risks of recurrent instability (p < 0.00001, relative risk = 2.37, 95% confidence interval = 1.66 to 3.38), recurrent dislocation (p < 0.0001, relative risk = 2.74, 95% confidence interval = 1.75 to 4.28), and a reoperation (p = 0.002, relative risk = 2.32, 95% confidence interval = 1.35 to 3.99). When considered alone, arthroscopic suture anchor techniques were associated with significantly higher risks of recurrent instability (p = 0.01, relative risk = 2.25, 95% confidence interval = 1.21 to 4.17) and recurrent dislocation (p = 0.004, relative risk = 2.57, 95% confidence interval = 1.35 to 4.92) than were open methods. Arthroscopic approaches were also less effective than open methods with regard to enabling patients to return to work and/or sports (p = 0.03, relative risk = 0.87, 95% confidence interval = 0.77 to 0.99). On the other hand, analysis of the randomized clinical trials indicated that arthroscopic repairs were associated with higher Rowe scores (p = 0.002, standardized mean difference = 0.43, 95% confidence interval = 0.16 to 0.70) than were open methods. Similarly, analysis of the arthroscopic suture anchor techniques alone showed the Rowe scores to be higher (p = 0.04, standardized mean difference = 0.29, 95% confidence interval = 0.01 to 0.56) than those associated with open methods. CONCLUSIONS: The available evidence indicates that arthroscopic approaches are not as effective as open approaches in preventing recurrent instability or enabling patients to return to work. Arthroscopic approaches resulted in better function as reflected by the Rowe scores in the randomized clinical trials. The study design and the arthroscopic technique had substantial effects on the results of the analysis.


Assuntos
Artroscopia , Instabilidade Articular/cirurgia , Luxação do Ombro/cirurgia , Articulação do Ombro/cirurgia , Recidiva , Técnicas de Sutura , Resultado do Tratamento
10.
J Bone Joint Surg Am ; 89(5): 1010-8, 2007 May.
Artigo em Inglês | MEDLINE | ID: mdl-17473138

RESUMO

BACKGROUND: Prior studies implying associations between receipt of commercial funding and positive (significant and/or pro-industry) research outcomes have analyzed only published papers, which is an insufficiently robust approach for assessing publication bias. In this study, we tested the following hypotheses regarding orthopaedic manuscripts submitted for review: (1) nonscientific variables, including receipt of commercial funding, affect the likelihood that a peer-reviewed submission will conclude with a report of a positive study outcome, and (2) positive outcomes and other, nonscientific variables are associated with acceptance for publication. METHODS: All manuscripts about hip or knee arthroplasty that were submitted to The Journal of Bone and Joint Surgery, American Volume, over seventeen months were evaluated to determine the study design, quality, and outcome. Analyses were carried out to identify associations between scientific factors (sample size, study quality, and level of evidence) and study outcome as well as between non-scientific factors (funding source and country of origin) and study outcome. Analyses were also performed to determine whether outcome, scientific factors, or nonscientific variables were associated with acceptance for publication. RESULTS: Two hundred and nine manuscripts were reviewed. Commercial funding was not found to be associated with a positive study outcome (p = 0.668). Studies with a positive outcome were no more likely to be published than were those with a negative outcome (p = 0.410). Studies with a negative outcome were of higher quality (p = 0.003) and included larger sample sizes (p = 0.05). Commercially funded (p = 0.027) and United States-based (p = 0.020) studies were more likely to be published, even though those studies were not associated with higher quality, larger sample sizes, or lower levels of evidence (p = 0.24 to 0.79). CONCLUSIONS: Commercially funded studies submitted for review were not more likely to conclude with a positive outcome than were nonfunded studies, and studies with a positive outcome were no more likely to be published than were studies with a negative outcome. These findings contradict those of most previous analyses of published (rather than submitted) research. Commercial funding and the country of origin predict publication following peer review beyond what would be expected on the basis of study quality. Studies with a negative outcome, although seemingly superior in quality, fared no better than studies with a positive outcome in the peer-review process; this may result in inflation of apparent treatment effects when the published literature is subjected to meta-analysis.


Assuntos
Bibliometria , Revisão da Pesquisa por Pares , Publicações Periódicas como Assunto/normas , Apoio à Pesquisa como Assunto/métodos , Artroplastia de Quadril , Artroplastia do Joelho , Comércio , Setor de Assistência à Saúde , Humanos , Ortopedia , Revisão da Pesquisa por Pares/normas , Apoio à Pesquisa como Assunto/economia , Resultado do Tratamento , Estados Unidos
11.
Eval Health Prof ; 30(1): 3-21, 2007 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-17293605

RESUMO

Tools to examine the effects of teaching interventions across a variety of studies are needed. The authors perform a meta-analysis of 24 randomized controlled trials evaluating the effects of teaching on medical students' patient communication skills. Study quality is rated using a modified Jadad score, and standardized mean difference effect size (d) measures are calculated. Fifteen of 24 studies have sufficient data for analysis. Students' ability to establish rapport improves after teaching. The effects are large when the teaching intervention was small group discussion (n = 5) or giving structured feedback on a student-patient interview (n = 6). A similar effect of teaching is seen on student data gathering skills (n = 5). Teaching medical students patient communication skills using small group discussion or providing feedback on a student-patient interview results in improvement in student performance.


Assuntos
Comunicação , Relações Médico-Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudantes de Medicina , Ensino/métodos , Retroalimentação , Humanos , Educação de Pacientes como Assunto/métodos
12.
J Gen Intern Med ; 20(4): 334-9, 2005 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15857490

RESUMO

OBJECTIVE: This study explores the alignment between physicians' confidence in their diagnoses and the "correctness" of these diagnoses, as a function of clinical experience, and whether subjects were prone to over-or underconfidence. DESIGN: Prospective, counterbalanced experimental design. SETTING: Laboratory study conducted under controlled conditions at three academic medical centers. PARTICIPANTS: Seventy-two senior medical students, 72 senior medical residents, and 72 faculty internists. INTERVENTION: We created highly detailed, 2-to 4-page synopses of 36 diagnostically challenging medical cases, each with a definitive correct diagnosis. Subjects generated a differential diagnosis for each of 9 assigned cases, and indicated their level of confidence in each diagnosis. MEASUREMENTS AND MAIN RESULTS: A differential was considered "correct" if the clinically true diagnosis was listed in that subject's hypothesis list. To assess confidence, subjects rated the likelihood that they would, at the time they generated the differential, seek assistance in reaching a diagnosis. Subjects' confidence and correctness were "mildly" aligned (kappa=.314 for all subjects, .285 for faculty, .227 for residents, and .349 for students). Residents were overconfident in 41% of cases where their confidence and correctness were not aligned, whereas faculty were overconfident in 36% of such cases and students in 25%. CONCLUSIONS: Even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them. Medical decision support systems, and other interventions designed to reduce medical errors, cannot rely exclusively on clinicians' perceptions of their needs for such support.


Assuntos
Competência Clínica , Técnicas de Apoio para a Decisão , Medicina Interna/normas , Julgamento , Sistemas de Apoio a Decisões Clínicas , Humanos , Internato e Residência , Modelos Lineares , Erros Médicos/prevenção & controle , Estudos Prospectivos , Estudantes de Medicina
13.
J Bone Joint Surg Am ; 87(5): 1031-7, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15866966

RESUMO

BACKGROUND: Many complex new procedures involve a learning curve, and patients treated by individuals who are new to a procedure may have more complications than those treated by a practitioner who has performed the intervention more frequently. Still, at some point on the learning curve, each individual must decide that he or she is qualified to perform a procedure, presumably on the basis of his or her level of confidence, background, education, and skill. To evaluate the interrelationship of these factors, we designed a study in which we assessed the performance of a simulated knee joint injection. METHODS: Ninety-three practitioners attending a continuing medical education session on knee injection were randomized to receive skills instruction through the use of a printed manual, a video, or hands-on instruction; each performed one injection before and after instruction. The participants completed pre-instruction and post-instruction questionnaires gauging confidence and also provided self-assessments of their performances of injections before and after instruction. Self-assessments were compared with objective performance standards measured by custom-designed knee models with electronic sensors that detected correct needle placement. RESULTS: Before instruction, the participants' confidence was significantly but inversely related to competent performance (r = -0.253, p = 0.02); that is, greater confidence correlated with poorer performance. Both men and physician-practitioners displayed higher pre-instruction confidence (p < 0.01), which was not correlated with better performance. After instruction, performance improved significantly in all three training groups (p < 0.001), with no significant differences in efficacy detected among the three groups (p = 0.99). After instruction, confidence correlated with objective competence in all groups (r = 0.24, p = 0.04); however, this correlation was weaker than the correlation between the participants' confidence and their self-assessment of performance (r = 0.72, p = 0.001). CONCLUSIONS: Even low-intensity forms of instruction improve individuals' confidence, competence, and self-assessment of their skill in performing the fairly straightforward psychomotor task of simulated knee injection. However, men and physicians disproportionately overestimated their skills both before and after training, a finding that worsened as confidence increased. The inverse relationship between confidence and competence that we observed before the educational intervention as well as the demographic differences that we noted should raise questions about how complex new procedures should be introduced and when self-trained practitioners should begin to perform them.


Assuntos
Competência Clínica , Educação Médica Continuada , Injeções Intra-Articulares , Humanos , Articulação do Joelho , Profissionais de Enfermagem/educação , Ortopedia/educação , Medicina Osteopática/educação , Análise e Desempenho de Tarefas , Gravação em Vídeo
14.
Acad Med ; 79(10): 1007-11, 2004 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-15383366

RESUMO

Faculty in the Department of Medical Education and Biomedical Informatics at the University of Washington School of Medicine received over $1.2 million in direct grant and contract support in 2003. In this case study, the authors provide some of the history and background of the evolution of the department's structure and its role in providing leadership in medical education research at the university, as well as regionally, nationally, and internationally. The authors offer their observations and reflections on what has helped and hindered the department's success, and end with some predictions on medical education research in the future. The University of Washington's five-state regional WWAMI educational program, establishing a single medical school for the states of Washington, Wyoming, Alaska, Montana, and Idaho, has been an important environmental influence on the direction of the department's educational and research activities. External support has helped the department to create the Northwest Consortium for Clinical Performance Assessment, the Center for Medical Education Research, the Teaching Scholars Program, and a Biomedical and Health Informatics graduate and fellowship training program, as well as a number of international programs.


Assuntos
Educação Médica/organização & administração , Educação Médica/tendências , Informática Médica/educação , Pesquisa/organização & administração , Faculdades de Medicina/organização & administração , Bolsas de Estudo , Humanos , Estudos de Casos Organizacionais , Washington
15.
BMC Med Res Methodol ; 4: 17, 2004 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-15248899

RESUMO

BACKGROUND: Meta-analysis can be used to pool rate measures across studies, but challenges arise when follow-up duration varies. Our objective was to compare different statistical approaches for pooling count data of varying follow-up times in terms of estimates of effect, precision, and clinical interpretability. METHODS: We examined data from a published Cochrane Review of asthma self-management education in children. We selected two rate measures with the largest number of contributing studies: school absences and emergency room (ER) visits. We estimated fixed- and random-effects standardized weighted mean differences (SMD), stratified incidence rate differences (IRD), and stratified incidence rate ratios (IRR). We also fit Poisson regression models, which allowed for further adjustment for clustering by study. RESULTS: For both outcomes, all methods gave qualitatively similar estimates of effect in favor of the intervention. For school absences, SMD showed modest results in favor of the intervention (SMD -0.14, 95% CI -0.23 to -0.04). IRD implied that the intervention reduced school absences by 1.8 days per year (IRD -0.15 days/child-month, 95% CI -0.19 to -0.11), while IRR suggested a 14% reduction in absences (IRR 0.86, 95% CI 0.83 to 0.90). For ER visits, SMD showed a modest benefit in favor of the intervention (SMD -0.27, 95% CI: -0.45 to -0.09). IRD implied that the intervention reduced ER visits by 1 visit every 2 years (IRD -0.04 visits/child-month, 95% CI: -0.05 to -0.03), while IRR suggested a 34% reduction in ER visits (IRR 0.66, 95% CI 0.59 to 0.74). In Poisson models, adjustment for clustering lowered the precision of the estimates relative to stratified IRR results. For ER visits but not school absences, failure to incorporate study indicators resulted in a different estimate of effect (unadjusted IRR 0.77, 95% CI 0.59 to 0.99). CONCLUSIONS: Choice of method among the ones presented had little effect on inference but affected the clinical interpretability of the findings. Incidence rate methods gave more clinically interpretable results than SMD. Poisson regression allowed for further adjustment for heterogeneity across studies. These data suggest that analysts who want to improve the clinical interpretability of their findings should consider incidence rate methods.


Assuntos
Asma/epidemiologia , Asma/prevenção & controle , Metanálise como Assunto , Educação de Pacientes como Assunto , Autocuidado , Absenteísmo , Adolescente , Criança , Pré-Escolar , Análise por Conglomerados , Interpretação Estatística de Dados , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Incidência , Distribuição de Poisson , Avaliação de Programas e Projetos de Saúde
16.
Ethn Dis ; 12(3): 404-10, 2002.
Artigo em Inglês | MEDLINE | ID: mdl-12148713

RESUMO

The purpose of this study was to evaluate the need for, and efficacy of, community-based culturally specific eye disease screening clinics for urban African Americans with diabetes. The study employed a variety of culturally specific methods in the design and performance of 43 community-based eye disease screening clinics in southeastern Michigan. One thousand, thirty-seven subjects were recruited for the study. Of that number, 817 identified themselves as African Americans and are the focus of this report. Of the 817 African-American patients screened, 84 (10%) needed to be examined by an ophthalmologist immediately (< 30 days), and 180 (22%) needed to be examined soon (within 1 to 3 months), while 544 (67%) were advised to return for another exam a year later. The project demonstrated that it was possible to use culturally specific techniques to identify a significant number of urban African Americans with diabetes in need of eye screening and treatment. However, lack of health insurance proved to be the primary barrier to receiving needed treatment. Although the project was successful, it is not a solution to what is essentially a health systems problem, ie, inadequate access to appropriate diabetes care for a significant number of our population.


Assuntos
Negro ou Afro-Americano , Centros Comunitários de Saúde/organização & administração , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/etnologia , Seleção Visual/organização & administração , Idoso , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Avaliação das Necessidades , Propriedade , Saúde Pública , Resultado do Tratamento , Seleção Visual/estatística & dados numéricos
17.
Ethn Dis ; 13(1): 40-6, 2003.
Artigo em Inglês | MEDLINE | ID: mdl-12723011

RESUMO

OBJECTIVE: To evaluate the effectiveness of using personalized follow-up, as compared to reminder letters, in increasing return rates at urban eye disease screening clinics for African Americans with diabetes, and to identify factors predictive of the patient's likelihood of returning for annual follow-up exams. RESEARCH DESIGN AND METHODS: All patients attending free community-based retinopathy screening clinics who were advised to return in one year for another diabetes eye evaluation (DEE) were randomized to standard or personalized follow-up interventions. Patients in the standard follow-up group received reminder letters a month before it was time to return for their next annual DEE. Patients in the intensive personalized intervention also received the letters, but those patients who did not call for an appointment within 10 days received a phone call from project staff, encouraging them to return for a DEE. RESULTS: One hundred thirty-two African Americans with diabetes were randomized to one of the 2 treatments. The return rate for the intensive, personalized follow-up group was 66%, significantly (P=.001) higher than the 35% return rate for the standard follow-up group. CONCLUSION: This study demonstrated the efficacy of personal contact by telephone in improving return rates for annual DEEs in this population of patients. This finding is consistent with one of the key design principles of the project, which was to establish credible personal relationships with community leaders and patients as a means to maximize the utilization of the eye screening clinics.


Assuntos
Negro ou Afro-Americano , Diabetes Mellitus/epidemiologia , Oftalmopatias/diagnóstico , Programas de Rastreamento/estatística & dados numéricos , Cooperação do Paciente/etnologia , Sistemas de Alerta , Adulto , Idoso , Oftalmopatias/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , População Urbana
18.
J Comp Eff Res ; 3(4): 345-57, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25275232

RESUMO

AIM: Assessing relative performance among competing interventions is an important part of comparative effectiveness research. Bayesian indirect comparisons add information to existing Cochrane reviews, such as which intervention is likely to perform best. However, heterogeneity variance priors may influence results and, potentially, clinical guidance. METHODS: We highlight the features of Bayesian indirect comparisons using a case study of a Cochrane review update in asthma care. The probability that one self-management educational intervention outperforms others is estimated. Simulation studies investigate the effect of heterogeneity variance prior distributions. RESULTS: Results suggest a 55% probability that individual education is best, followed by combination (39%) and group (6%). The intervention with few trials was sensitive to prior distributions. CONCLUSION: Bayesian indirect comparisons updates of Cochrane reviews are valuable comparative effectiveness research tools.


Assuntos
Asma/terapia , Teorema de Bayes , Pesquisa Comparativa da Efetividade , Educação de Pacientes como Assunto , Literatura de Revisão como Assunto , Humanos , Metanálise como Assunto , Autocuidado
20.
Gen Hosp Psychiatry ; 35(3): 217-25, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23415577

RESUMO

OBJECTIVES: To estimate risk of comorbid depression on all-cause mortality over time among individuals with diabetes. METHODS: The Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase and Science Direct databases were searched through September 30, 2012. We limited our search to longitudinal or prospective studies reporting all-cause mortality among those having depression and diabetes, compared with those having diabetes alone that used hazard ratios (HRs) as the main outcome. Two reviewers independently extracted primary data and evaluated the quality of studies using predetermined criteria. The pooled random effects adjusted HRs were estimated using meta-analysis. The impact of moderator variables on study effect size was examined with meta-regression. RESULTS: A total of 42,363 respondents from 10 studies were included in the analysis. Depression was significantly associated with risk of mortality (pooled HR=1.50, 95% confidence interval=1.35-1.66). Little evidence for heterogeneity was found across the studies (Cochran Q=13.52, P=.20, I(2)=26.03). No significant possibility of publication bias was detected (Egger's regression intercept=0.98, P=.23). CONCLUSION: Depression significantly increases the risk of mortality among individuals with diabetes. Early detection and treatment of depression may improve health outcomes in this population.


Assuntos
Transtorno Depressivo/epidemiologia , Diabetes Mellitus Tipo 1/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Comorbidade , Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Humanos , Fatores de Risco
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