Challenges in engaging patients in feedback conversations for health care professionals' workplace learning.

INTRODUCTION: Patient feedback is relevant information for improvement of health care professionals' performance. Engaging patients in feedback conversations can help to harness patient feedback as a powerful tool for learning. However, health care settings may prevent patients and health care professionals to effectively engage in a feedback dialogue. To advance our understanding of how feedback conversations may support learning in and from practice, we sought to explore patients' and health care providers' perspectives on engaging patients in feedback conversations as informal learning opportunities. METHODS: For this qualitative study, we used a pragmatic approach and conducted semi-structured interviews with 12 health care providers and 10 patient consultants. We applied an inductive approach to thematic analysis to understand interviewees' perceptions regarding patient feedback for workplace learning. RESULTS: Participants attributed importance to patient feedback and described how the feedback may improve treatment relationships, professionals' performance and care processes on the team level and the organisational level. Participants experienced conflicting roles as patient and educator or expert and learner, respectively. Changing relationships, feelings of vulnerability and perceived power dynamics in treatment relationships would affect participants' engagement in feedback conversations. Patients and professionals alike saw a role for themselves in giving or inviting feedback but often missed the tools for engaging in feedback conversations. DISCUSSION: Patient feedback can contribute to professionals' practice-based learning but requires navigating tensions around conflicting roles and power dynamics in the treatment relationship. Both patients and health care professionals need to embrace vulnerability and may need facilitation and guidance to use patient feedback effectively. Attention to power dynamics, if not a shift towards collaborative relationships, is however crucial to engage patients in feedback conversations, thereby capitalising the power patients posses.

The ASGLOS Study: A global survey on how predatory journals affect scientific practice.

Predatory journals and conferences are an emerging problem in scientific literature as they have financial motives, without guaranteeing scientific quality and exposure. The main objective of the ASGLOS project is to investigate the predatory e-email characteristics, management, and possible consequences and to analyse the extent of the current problem at each academic level. To collect the personal experiences of physicians' mailboxes on predatory publishing, a Google Form® survey was designed and disseminated from September 2021 to April 2022. A total of 978 responses were analysed from 58 countries around the world. A total of 64.8% of participants indicated the need for 3 or fewer emails to acquire a criticality view in distinguishing a real invitation from a spam, while 11.5% still have doubt regardless of how many emails they get. The AGLOS Study clearly highlights the problem of academic e-mail spam by predatory journals and conferences. Our findings signify the importance of providing academic career-oriented advice and organising training sessions to increase awareness of predatory publishing for those conducting scientific research.

Adjunctive treatment with oral dexamethasone in non-ICU patients hospitalised with community-acquired pneumonia: a randomised clinical trial.

BACKGROUND: Adjunctive intravenous corticosteroid treatment has been shown to reduce length of stay (LOS) in adults hospitalised with community-acquired pneumonia (CAP). We aimed to assess the effect of oral dexamethasone on LOS and whether this effect is disease severity dependent. METHODS: In this multicentre, stratified randomised, double-blind, placebo-controlled trial, immunocompetent adults with CAP were randomly assigned (1:1 ratio) to receive oral dexamethasone (6 mg once daily) or placebo for 4 days in four teaching hospitals in the Netherlands. Randomisation (blocks of four) was stratified by CAP severity (pneumonia severity index class I-III and IV-V). The primary outcome was LOS. RESULTS: Between December 2012 and November 2018, 401 patients were randomised to receive dexamethasone (n=203) or placebo (n=198). Median LOS was shorter in the dexamethasone group (4.5 days, 95% CI 4.0-5.0 days) than in the placebo group (5.0 days, 95% CI 4.6-5.4 days; p=0.033). Within both CAP severity subgroups, differences in LOS between treatment groups were not statistically significant. The secondary ICU admission rate was lower in the dexamethasone arm (5 (3%) versus 14 (7%); p=0.030); 30-day mortality did not differ between groups. In the dexamethasone group the rate of hospital readmission tended to be higher (20 (10%) versus 9 (5%); p=0.051) and hyperglycaemia (14 (7%) versus 1 (1%); p=0.001) was more prevalent. CONCLUSION: Oral dexamethasone reduced LOS and ICU admission rate in adults hospitalised with CAP. It remains unclear for which patients the risk-benefit ratio is optimal.

High-Value, Cost-Conscious Care Attitudes in the Graduate Medical Education Learning Environment: Various Stakeholder Attitudes That Residents Misjudge.

BACKGROUND: Training residents in delivering high-value, cost-conscious care (HVCCC) is crucial for a sustainable healthcare. A supportive learning environment is key. Yet, stakeholders' attitudes toward HVCCC in residents' learning environment are unknown. OBJECTIVE: We aimed to measure stakeholders' HVCCC attitudes in residents' learning environment, compare these with resident perceptions of their attitudes, and identify factors associated with attitudinal differences among each stakeholder group. DESIGN: We conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018. PARTICIPANTS: Participants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals. MAIN MEASURES: Respondents completed the Maastricht HVCCC Attitude Questionnaire (MHAQ), containing three subscales: (1) high-value care, (2) cost incorporation, (3) perceived drawbacks. Additionally, resident respondents estimated the HVCCC attitudes of other stakeholders, and answered questions on job demands and resources. Univariate and multivariate analyses were used to analyze data. KEY RESULTS: Attitudes differed on all subscales: faculty and administrators reported more positive HVCCC attitudes than residents (p ≤ 0.05), while the attitudes of patients were less positive (p ≤ 0.05). Residents underestimated faculty's (p < 0.001) and overestimated patients' HVCCC attitudes (p < 0.001). Increasing age was, among residents and faculty, associated with more positive attitudes toward HVCCC (p ≤ 0.05). Lower perceived health quality was associated with less positive attitudes among patients (p < 0.001). The more autonomy residents perceived, the more positive their HVCCC attitude (p ≤ 0.05). CONCLUSIONS: Attitudes toward HVCCC vary among stakeholders in the residency learning environment, and residents misjudge the attitudes of both faculty and patients. Faculty and administrators might improve their support to residents by more explicitly sharing their thoughts and knowledge on HVCCC and granting residents autonomy in clinical practice.

Time-saving opportunities in knee osteoarthritis: T2 mapping and structural imaging of the knee using a single 5-min MRI scan.

OBJECTIVES: To assess the discriminative power of a 5-min quantitative double-echo steady-state (qDESS) sequence for simultaneous T2 measurements of cartilage and meniscus, and structural knee osteoarthritis (OA) assessment, in a clinical OA population, using radiographic knee OA as reference standard. METHODS: Fifty-three subjects were included and divided over three groups based on radiographic and clinical knee OA: 20 subjects with no OA (Kellgren-Lawrence grade (KLG) 0), 18 with mild OA (KLG2), and 15 with moderate OA (KLG3). All patients underwent a 5-min qDESS scan. We measured T2 relaxation times in four cartilage and four meniscus regions of interest (ROIs) and performed structural OA evaluation with the MRI Osteoarthritis Knee Score (MOAKS) using qDESS with multiplanar reformatting. Between-group differences in T2 values and MOAKS were calculated using ANOVA. Correlations of the reference standard (i.e., radiographic knee OA) with T2 and MOAKS were assessed with correlation analyses for ordinal variables. RESULTS: In cartilage, mean T2 values were 36.1 ± SD 4.3, 40.6 ± 5.9, and 47.1 ± 4.3 ms for no, mild, and moderate OA, respectively (p < 0.001). In menisci, mean T2 values were 15 ± 3.6, 17.5 ± 3.8, and 20.6 ± 4.7 ms for no, mild, and moderate OA, respectively (p < 0.001). Statistically significant correlations were found between radiographic OA and T2 and between radiographic OA and MOAKS in all ROIs (p < 0.05). CONCLUSION: Quantitative T2 and structural assessment of cartilage and meniscus, using a single 5-min qDESS scan, can distinguish between different grades of radiographic OA, demonstrating the potential of qDESS as an efficient tool for OA imaging. KEY POINTS: • Quantitative T2values of cartilage and meniscus as well as structural assessment of the knee with a single 5-min quantitative double-echo steady-state (qDESS) scan can distinguish between different grades of knee osteoarthritis (OA). • Quantitative and structural qDESS-based measurements correlate significantly with the reference standard, radiographic degree of OA, for all cartilage and meniscus regions. • By providing quantitative measurements and diagnostic image quality in one rapid MRI scan, qDESS has great potential for application in large-scale clinical trials in knee OA.

Temporal patterns and short-term progression of paroxysmal atrial fibrillation: data from RACE V.

AIMS: Atrial fibrillation (AF) often starts as a paroxysmal self-terminating arrhythmia. Limited information is available on AF patterns and episode duration of paroxysmal AF. In paroxysmal AF patients, we longitudinally studied the temporal AF patterns, the association with clinical characteristics, and prevalence of AF progression. METHODS AND RESULTS: In this interim analysis of the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF (RACE V) registry, 202 patients with paroxysmal AF were followed with continuous rhythm monitoring (implantable loop recorder or pacemaker) for 6 months. Mean age was 64 ± 9 years, 42% were women. Atrial fibrillation history was 2.1 (0.5-4.4) years, CHA2DS2-VASc 1.9 ± 1.3, 101 (50%) had hypertension, 69 (34%) heart failure. One-third had no AF during follow-up. Patients with long episodes (>12 hours) were often men with more comorbidities (heart failure, coronary artery disease, higher left ventricular mass). Patients with higher AF burden (>2.5%) were older with more comorbidities (worse renal function, higher calcium score, thicker intima media thickness). In 179 (89%) patients, 1-year rhythm follow-up was available. On a quarterly basis, average daily AF burden increased from 3.2% to 3.8%, 5.2%, and 6.1%. Compared to the first 6 months, 111 (62%) patients remained stable during the second 6 months, 39 (22%) showed progression to longer AF episodes, 8 (3%) developed persistent AF, and 29 (16%) patients showed AF regression. CONCLUSIONS: In paroxysmal AF, temporal patterns differ suggesting that paroxysmal AF is not one entity. Atrial fibrillation burden is low and determined by number of comorbidities. Atrial fibrillation progression occurred in a substantial number. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov identifier NCT02726698.

The usefulness of preoperative exercise therapy in patients scheduled for lung cancer surgery; a survey among Dutch pulmonologists and cardiothoracic surgeons.

BACKGROUND: Preoperative exercise training (PET) studies show promising results in various patient populations. However, the lack of standardised programmes and uniformity in practice guidelines are barriers for implementation. Aim of this study was to assess the current opinions of pulmonologists and cardiothoracic surgeons on the clinical applicability of PET in patients scheduled for lung cancer surgery. METHODS: Dutch pulmonologists and cardiothoracic surgeons were asked to complete a 29-question survey regarding PET as an additional option to further optimise the health status of patients scheduled for lung cancer surgery. RESULTS: In total, 47 respondents (63% response rate), including 30 pulmonologists and 11 cardiothoracic surgeons and 6 residents in training completed the survey. A vast majority of the respondents had a positive attitude towards PET. Home-based exercise was considered less useful, as well as unsupervised exercise. Patient's motivation, improvements in physical capacity and quality of life, and lifestyle adjustments are important factors for the success of PET. The programme should at least contain inspiratory muscle training (95.7%), lifestyle interventions (95.7%), and supervised exercise training (91.5%). Cardiac and pulmonary risk assessment and medication assessment and optimisation were found less important. CONCLUSION: Among pulmonologists and cardiothoracic surgeons, there is a tendency that PET can be a valuable addition to the perioperative care of lung surgery patients. Points of discussion are the contents of PET programmes, and there seems to be a lack of awareness among chest physicians.

Learning in the workplace: Use of informal feedback cues in doctor-patient communication.

OBJECTIVES: We expect physicians to be lifelong learners. Participation in clinical practice is an important potential source of that learning. To support physicians in this process, a better understanding of how they learn in clinical practice is necessary. This study investigates how physicians recognise and use informal feedback from interactions with patients in outpatient settings as learning cues to adjust their communication behaviours in daily practice. METHODS: To understand physicians' use of informal feedback, we combined non-participant observations with semi-structured interviews. We enrolled 10 respiratory physicians and observed 100 physician-patient interactions at two teaching hospitals in the Netherlands. Data collection and analysis were performed iteratively according to the principles of constructivist grounded theory. RESULTS: Following stages of open, axial and selective coding, we were able to conceptualise how physicians use cues to reflect on and adjust their communication. In addition to vast variations within and across patient encounters, we observed recurring adjustments in physicians' communication behaviours in response to specific informal feedback cues. Physicians recognised and used these cues to self-monitor communication performance. They had established 'communication repertoires' based on multiple patient interactions, which many saw as learning opportunities contributing to the development of expertise. Our findings, however, show differences in physicians' individual levels of sensitivity in recognising and using learning opportunities in daily practice, which were further influenced by contextual, personal and interpersonal factors. Whereas some described themselves as having little inclination to change, others used critical incidents to fine-tune their communication repertoires, and yet others constantly reshaped them, seeking learning opportunities in their daily work. CONCLUSIONS: There is large variation in how physicians use learning cues from daily practice. To enhance learning in and from daily practice, we propose turning workplace learning into a collaborative effort with the aim of increasing awareness and the use of informal performance-relevant feedback.

Perceptions of people with respiratory problems on physician performance evaluation-A qualitative study.

BACKGROUND: Despite increasing calls for patient and public involvement in health-care quality improvement, the question of how patient evaluations can contribute to physician learning and performance assessment has received scant attention. OBJECTIVE: The objective of this study was to explore, amid calls for patient involvement in quality assurance, patients' perspectives on their role in the evaluation of physician performance and to support physicians' learning and decision making on professional competence. DESIGN: A qualitative study based on semi-structured interviews. SETTING AND PARTICIPANTS: The study took place in a secondary care setting in the Netherlands. The authors selected 25 patients from two Dutch hospitals and through the Dutch Lung Foundation, using purposive sampling. METHODS: Data were analysed according to the principles of template analysis, based on an a priori coding framework developed from the literature about patient empowerment, feedback and performance assessment. RESULTS: The analysis unearthed three predominant patient perspectives: the proactive perspective, the restrained perspective and the outsider perspective. These perspectives differed in terms of perceived power dynamics within the doctor-patient relationship, patients' perceived ability, and willingness to provide feedback and evaluate their physician's performance. Patients' perspectives thus affected the role patients envisaged for themselves in evaluating physician performance. DISCUSSION AND CONCLUSION: Although not all patients are equally suitable or willing to be involved, patients can play a role in evaluating physician performance and continuing training through formative approaches. To involve patients successfully, it is imperative to distinguish between different patient perspectives and empower patients by ensuring a safe environment for feedback.

A new instrument to measure high value, cost-conscious care attitudes among healthcare stakeholders: development of the MHAQ.

BACKGROUND: Residents have to learn to provide high value, cost-conscious care (HVCCC) to counter the trend of excessive healthcare costs. Their learning is impacted by individuals from different stakeholder groups within the workplace environment. These individuals' attitudes toward HVCCC may influence how and what residents learn. This study was carried out to develop an instrument to reliably measure HVCCC attitudes among residents, staff physicians, administrators, and patients. The instrument can be used to assess the residency-training environment. METHOD: The Maastricht HVCCC Attitude Questionnaire (MHAQ) was developed in four phases. First, we conducted exploratory factor analyses using original data from a previously published survey. Next, we added nine items to strengthen subscales and tested the new questionnaire among the four stakeholder groups. We used exploratory factor analysis and Cronbach's alphas to define subscales, after which the final version of the MHAQ was constructed. Finally, we used generalizability theory to determine the number of respondents (residents or staff physicians) needed to reliably measure a specialty attitude score. RESULTS: Initial factor analysis identified three subscales. Thereafter, 301 residents, 297 staff physicians, 53 administrators and 792 patients completed the new questionnaire between June 2017 and July 2018. The best fitting subscale composition was a three-factor model. Subscales were defined as high-value care, cost incorporation, and perceived drawbacks. Cronbach's alphas were between 0.61 and 0.82 for all stakeholders on all subscales. Sufficient reliability for assessing national specialty attitude (G-coefficient > 0.6) could be achieved from 14 respondents. CONCLUSIONS: The MHAQ reliably measures individual attitudes toward HVCCC in different stakeholders in health care contexts. It addresses key dimensions of HVCCC, providing content validity evidence. The MHAQ can be used to identify frontrunners of HVCCC, pinpoint aspects of residency training that need improvement, and benchmark and compare across specialties, hospitals and regions.

Residents' identification of learning moments and subsequent reflection: impact of peers, supervisors, and patients.

BACKGROUND: The clinical workplace offers residents many opportunities for learning. Reflection on workplace experiences drives learning and development because experiences potentially make residents reconsider existing knowledge, action repertoires and beliefs. As reflective learning in the workplace cannot be taken for granted, we aimed to gain a better insight into the process of why residents identify experiences as learning moments, and how residents reflect on these moments. METHODS: This study draws on semi-structured interviews with 33 medical residents. Interviews explored how residents identified learning moments and how they reflected on such moments, both in-action and on-action. Aiming for extensive explanations on the process of reflection, open-ended questions were used that built on and deepened residents' answers. After interviews were transcribed verbatim, a within-case and cross-case analysis was conducted to build a general pattern of explanation. RESULTS: The data analysis yielded understanding of the crucial role of the social context. Interactions with peers, supervisors, and patients drive reflection, because residents want to measure up to their peers, meet supervisors' standards, and offer the best patient care. Conversely, quality and depth of reflection sometimes suffer, because residents prioritize patient care over learning. This urges them to seek immediate solutions or ask their peers or supervisor for advice, rather than reflectively deal with a learning moment themselves. Peer discussions potentially enhance deep reflection, while own supervisor involvement sometimes feels unsafe. DISCUSSION: Our results adds to our understanding of the social-constructivist nature of reflection. We suggest that feelings of self-preservation during interactions with peers and supervisors in a highly demanding work environment shape reflection. Support from peers or supervisors helps residents to instantly deal with learning moments more easily, but it also makes them more dependent on others for learning. Since residents' devotion to patient care obscures the reflection process, residents need more dedicated time to reflect. Moreover, to elaborate deeply on learning moments, a supportive and safe learning climate with peers and supervisors is recommended.

Completing the Maternal Care Team: OB/GYN Expertise at Rural District Hospitals in Ghana, a Qualitative Study.

Introduction To provide a qualitative perspective on the changes that occurred after newly placed OB/GYNs began working at district hospitals in Ashanti, Ghana. Methods Structured interviews of healthcare professionals were conducted at eight district hospitals located throughout the Ashanti district of Ghana, four with and four without a full-time OB/GYN on staff. Individuals interviewed include: medical superintendents, medical officers, district hospital administrators, OB/GYNs (where applicable), and nurse-midwives. Interviews were transcribed verbatim and content analysis was performed to identify common themes. Characteristics quotes were identified to illustrate principal interview themes. Quotes were verified in context by researchers for accuracy. Results Interviews with providers revealed four areas most impacted by an OB/GYN's leadership and expertise at district hospitals: patient referral patterns, obstetric protocol and training, facility management and organization, and hospital reputation. Discussion OB/GYNs are uniquely positioned to add clinical capacity and care quality to established maternal care teams at district hospitals-empowering district hospitals as reliable care centers throughout rural Ghana for women's health. Coordinated efforts between government, donors and OBGYN training institutions to provide complete obstetric teams is the next step to achieve the global goal of eliminating preventable maternal mortality by 2030.

Box-ticking and Olympic high jumping - Physicians' perceptions and acceptance of national physician validation systems.

PURPOSE: National physician validation systems aim to ensure lifelong learning through periodic appraisals of physicians' competence. Their effectiveness is determined by physicians' acceptance of and commitment to the system. This study, therefore, sought to explore physicians' perceptions and self-reported acceptance of validation across three different physician validation systems in Europe. MATERIALS AND METHODS: Using a constructivist grounded-theory approach, we conducted semi-structured interviews with 32 respiratory specialists from three countries with markedly different validation systems: Germany, which has a mandatory, credit-based system oriented to continuing professional development; Denmark, with mandatory annual dialogs and ensuing, non-compulsory activities; and the UK, with a mandatory, portfolio-based revalidation system. We analyzed interview data with a view to identifying factors influencing physicians' perceptions and acceptance. RESULTS: Factors that influenced acceptance were the assessment's authenticity and alignment of its requirements with clinical practice, physicians' beliefs about learning, perceived autonomy, and organizational support. CONCLUSIONS: Users' acceptance levels determine any system's effectiveness. To support lifelong learning effectively, national physician validation systems must be carefully designed and integrated into daily practice. Involving physicians in their design may render systems more authentic and improve alignment between individual ambitions and the systems' goals, thereby promoting acceptance.

Analysis of nocturnal actigraphic sleep measures in patients with COPD and their association with daytime physical activity.

BACKGROUND: Sleep disturbances are common in patients with chronic obstructive pulmonary disease (COPD) with a considerable negative impact on their quality of life. However, factors associated with measures of sleep in daily life have not been investigated before nor has the association between sleep and the ability to engage in physical activity on a day-to-day basis been studied. AIMS: To provide insight into the relationship between actigraphic sleep measures and disease severity, exertional dyspnoea, gender and parts of the week; and to investigate the association between sleep measures and next day physical activity. METHODS: Data were analysed from 932 patients with COPD (66% male, 66.4±8.3 years, FEV1% predicted=50.8±20.5). Participants had sleep and physical activity continuously monitored using a multisensor activity monitor for a median of 6 days. Linear mixed effects models were applied to investigate the factors associated with sleep impairment and the association between nocturnal sleep and patients' subsequent daytime physical activity. RESULTS: Actigraphic estimates of sleep impairment were greater in patients with worse airflow limitation and worse exertional dyspnoea. Patients with better sleep measures (ie, non-fragmented sleep, sleeping bouts ≥225 min, sleep efficiency ≥91% and time spent awake after sleep onset <57 min) spent significantly more time in light (p<0.01) and moderate-to-vigorous physical activity (p<0.01). CONCLUSIONS: There is a relationship between measures of sleep in patients with COPD and the amount of activity they undertake during the waking day. Identifying groups with specific sleep characteristics may be useful information when designing physical activity-enhancing interventions.

Community-based surveillance of maternal deaths in rural Ghana.

OBJECTIVE: To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records. METHODS: In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13-49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes-no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes-no question. A mortality review committee established the cause of death. FINDINGS: Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes-no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records. CONCLUSION: The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.

Fracture prevention in COPD patients; a clinical 5-step approach.

Although osteoporosis and its related fractures are common in patients with COPD, patients at high risk of fracture are poorly identified, and consequently, undertreated. Since there are no fracture prevention guidelines available that focus on COPD patients, we developed a clinical approach to improve the identification and treatment of COPD patients at high risk of fracture. We organised a round-table discussion with 8 clinical experts in the field of COPD and fracture prevention in the Netherlands in December 2013. The clinical experts presented a review of the literature on COPD, osteoporosis and fracture prevention. Based on the Dutch fracture prevention guideline, they developed a 5-step clinical approach for fracture prevention in COPD. Thereby, they took into account both classical risk factors for fracture (low body mass index, older age, personal and family history of fracture, immobility, smoking, alcohol intake, use of glucocorticoids and increased fall risk) and COPD-specific risk factors for fracture (severe airflow obstruction, pulmonary exacerbations and oxygen therapy). Severe COPD (defined as postbronchodilator FEV1 < 50% predicted) was added as COPD-specific risk factor to the list of classical risk factors for fracture. The 5-step clinical approach starts with case finding using clinical risk factors, followed by risk evaluation (dual energy X-ray absorptiometry and imaging of the spine), differential diagnosis, treatment and follow-up. This systematic clinical approach, which is evidence-based and easy-to-use in daily practice by pulmonologists, should contribute to optimise fracture prevention in COPD patients at high risk of fracture.

Six-minute walk distance in patients with chronic obstructive pulmonary disease: Which reference equations should we use?

The use of different 6-min walk distance (6MWD) reference equations probably results in different predicted 6MWD reference values. We wished to investigate the impact of several 6MWD reference equations for adults in patients with chronic obstructive pulmonary disease (COPD) and factors accountable for different 6MWD% predicted values. Twenty-two 6MWD reference equations were applied to a data set of 2757 patients with COPD. The predicted 6MWD reference value of Troosters and colleagues was used as the point of reference. Four out of 21 remaining equations resulted in comparable 6MWD% predicted, 16 equations resulted in significantly higher 6MWD% predicted and 1 equation resulted in a significantly lower 6MWD% predicted. Similar differences in 6MWD% predicted were observed after stratification by sex. Body mass index and global initiative for chronic obstructive lung disease (GOLD) stage classification demonstrated varying results within and between the groups; 9 out of 21 equations resulted in comparable 6MWD% predicted in underweight patients but only 1 equation demonstrated comparable result in obese. Eight equations in GOLD I, whilst 5 out of 21 equations in GOLD IV resulted in comparable 6MWD% predicted. Existing 6MWD reference equations will give varying results. The choice of 6MWD reference equation should consider the consistency of 6-min walk test operating procedures and at least be specific for the country/region of origin.

The public health impact of training physicians to become obstetricians and gynecologists in Ghana.

OBJECTIVES: We assessed the public health effect of creating and sustaining obstetrics and gynecology postgraduate training in Ghana, established in 1989 to reverse low repatriation of physicians trained abroad. METHODS: All 85 certified graduates of 2 Ghanaian university-based postgraduate training programs from program initiation in 1989 through June 2010 were identified and eligible for this study. Of these, 7 were unable to be contacted, inaccessible, declined participation, or deceased. RESULTS: Of the graduates, 83 provide clinical services in Ghana and work in 33 sites in 8 of 10 regions; 15% were the first obstetrician and gynecologist at their facility, 25% hold clinical leadership positions, 50% practice in teaching hospitals, and 14% serve as academic faculty. CONCLUSIONS: Creating capacity for university-based postgraduate training in obstetrics and gynecology is effective and sustainable for a comprehensive global approach to reduce maternal and neonatal morbidity and mortality. Policies to support training and research capacity in obstetrics and gynecology are an integral part of a long-term national plan for maternal health.

Should I stay or should I go home? A latent class analysis of a discrete choice experiment on hospital-at-home.

OBJECTIVES: This study aimed 1) to quantify the strength of patient preferences for different aspects of early assisted discharge in The Netherlands for patients who were admitted with a chronic obstructive pulmonary disease exacerbation and 2) to illustrate the benefits of latent class modeling of discrete choice data. This technique is rarely used in health economics. METHODS: Respondents made multiple choices between hospital treatment as usual (7 days) and two combinations of hospital admission (3 days) followed by treatment at home. The latter was described by a set of attributes. Hospital treatment was constant across choice sets. Respondents were patients with chronic obstructive pulmonary disease in a randomized controlled trial investigating the cost-effectiveness of early assisted discharge and their informal caregivers. The data were analyzed using mixed logit, generalized multinomial logit, and latent-class conditional logit regression. These methods allow for heterogeneous preferences across groups, but in different ways. RESULTS: Twenty-five percent of the respondents opted for hospital treatment regardless of the description of the early assisted discharge program, and 46% never opted for the hospital. The best model contained four latent classes of respondents, defined by different preferences for the hospital and caregiver burden. Preferences for other attributes were constant across classes. Attributes with the strongest effect on choices were the burden on informal caregivers and co-payments. Except for the number of visits, all attributes had a significant effect on choices in the expected direction. CONCLUSIONS: Considerable segments of respondents had fixed preferences for either treatment option. Applying latent class analysis was essential in quantifying preferences for attributes of early assisted discharge.