Remote assessment via video evaluation (RAVVE): a pilot study to trial video-enabled peer feedback on clinical performance.

BACKGROUND: Video review processes for evaluation and coaching are often incorporated into medical education as a means to accurately capture physician-patient interactions. Compared to direct observation they offer the advantage of overcoming many logistical challenges. However, the suitability and viability of using video-based peer consultations for professional development requires further investigation. This study aims to explore the acceptability and feasibility of video-based peer feedback to support professional development and quality improvement in patient care. METHODS: Five rheumatologists each provided four videos of patient consultations. Peers evaluated the videos using five-point scales, providing annotations in the video recordings, and offering recommendations. The rheumatologists reviewed the videos of their own four patient interactions along with the feedback. They were asked to document if they would make practice changes based on the feedback. Focus groups were conducted and analysed to explore the effectiveness of video-based peer feedback in assisting physicians to improve clinical practice. RESULTS: Participants felt the video-based feedback provided accurate and detailed information in a more convenient, less intrusive manner than direct observation. Observations made through video review enabled participants to evaluate more detailed information than a chart review alone. Participants believed that reviewing recorded consultations allowed them to reflect on their practice and gain insight into alternative communication methods. CONCLUSIONS: Video-based peer feedback and self-review of clinical performance is an acceptable and pragmatic approach to support professional development and improve clinical care among peer clinicians. Further investigation into the effectiveness of this approach is needed.

The effect of magnesium infusion on rest cramps: randomized controlled trial.

BACKGROUND: Rest cramps (also known as nocturnal leg cramps) are very common in a geriatric population. Oral magnesium supplements are marketed for prophylaxis of such cramps but clinical trials exploring the efficacy of oral magnesium conflict. A therapeutic trial of intravenous magnesium overcomes the limited oral bioavailability of magnesium and better assesses its therapeutic potential. METHODS: A double blind, placebo controlled randomized controlled trial was conducted on 46 community-dwelling older adult (69.3 ± 7.7 years) rest cramp sufferers to determine whether 5 consecutive days infusion of 20-mmol (5 g) magnesium sulfate would reduce the frequency of leg cramps per week in the 30 days immediately pre and post infusions. It was also determined whether the response to treatment varied with the extent to which infused magnesium was retained (as measured by 24-hour urinary magnesium excretion). RESULTS: The study population averaged 8.0 cramps per week at baseline. The mean change in number of cramps per week, magnesium versus placebo arms, was -2.4 versus -1.7, p = .51, 95% confidence interval of the difference -3.1 to 1.7. Magnesium retention did not correlate with treatment response. CONCLUSIONS: Intravenous magnesium infusion did not reduce the frequency of leg cramps in a group of older adult rest cramp sufferers regardless of the extent to which infused magnesium was retained. Although oral magnesium is widely marketed to older adults for the prophylaxis of leg cramps, our data suggest that magnesium therapy is not indicated for the treatment of rest cramps in a geriatric population.

Test of Memory Malingering (TOMM) scores are not affected by chronic pain or depression in patients with fibromyalgia.

Neuropsychologists routinely give effort tests, such as the Test of Memory Malingering (TOMM). When a person fails one of these tests, the clinician must try to determine whether the poor performance was due to suboptimal effort or to chronic pain, depression, or other problems. Participants were 54 community-dwelling patients who met American College of Rheumatology criteria for fibromyalgia (FM). In addition to the TOMM, they completed the Beck Depression Inventory-Second Edition, Multidimensional Pain Inventory-Version 1, Oswestry Disability Index-2.0, British Columbia Cognitive Complaints Inventory, and the Fibromyalgia Impact Questionnaire. The majority endorsed at least mild levels of depressive symptoms (72%), and 22% endorsed "severe" levels of depression. The average scores on the TOMM were 48.8 (SD = 1.9, range = 40-50) for Trial 1, 49.8 (SD = 0.5, range = 48-50) for Trial 2, and 49.6 (SD = 0.9, range = 45-50) for Retention. Despite relatively high levels of self-reported depression, chronic pain, and disability, not a single patient failed the TOMM. In this study, the TOMM was not affected by chronic pain, depression, or both.

Prescribing trends in disease modifying antirheumatic drugs for rheumatoid arthritis: a survey of practicing Canadian rheumatologists.

OBJECTIVE: To determine the prescribing and monitoring practices of disease modifying antirheumatic drugs (DMARD) for Canadian rheumatologists in their treatment of rheumatoid arthritis (RA). METHODS: A survey questionnaire was mailed to 279 rheumatologists with a 70% response rate after 2 mailings. RESULTS: Antimalarials are prescribed commonly, with the preference being hydroxychloroquine (HCQ). For antimalarials, 78% do not routinely monitor laboratory results. There was wide variability in monitoring for ocular complications. Thirty-eight percent of rheumatologists never do a baseline eye examination and 39% always do. All rheumatologists frequently use methotrexate (MTX) in RA. The reported mean maximum dose for MTX was 25.1 mg/week (range 7.5-50), with 86% routinely using folate. Ninety-eight percent prescribe sulfasalazine (SSZ) for RA. Mean maximum dose prescribed for SSZ was 2.8 g/day. Most never used oral gold, while IM gold was used by 95%. Only 9% frequently use azathioprine in RA, to a mean maximum dose of 185 mg/day. Less commonly prescribed DMARD included cyclosporine (66% frequently; 25% never) and D-penicillamine (2% frequently; 53% never). There was a wide range of what exactly was monitored with respect to laboratory tests, and at what frequency, for many of the DMARD. Nearly all (99%) used combination DMARD, the most popular combination being MTX-HCQ. There were some significant differences in treatment trends when comparing year of fellowship completion, but no sex or type of practice differences were found. Those completing fellowships prior to 1984 were more likely to prescribe azathioprine (p < 0.03), chloroquine (p < 0.01) and chronic steroids (p < 0.1) in RA. There was, however, regional variability in the use of IM gold and newer DMARD--they were most prescribed in Western Canada and least in Quebec. Cyclosporine was prescribed most frequently in Quebec compared to Western Canada and least in Ontario and the Atlantic Provinces. CONCLUSION: Canadian rheumatologists are fairly similar in their use of common DMARD and combination therapies in RA. There is variability in the use of some older medications including azathioprine and chloroquine, depending on when rheumatology training was completed, and use of some drugs varies by region.

A comparison of four indirect methods of assessing utility values in rheumatoid arthritis.

OBJECTIVES: Utility scores can be assessed indirectly using preference-based instruments and used as weightings for quality-adjusted life years in economic analyses. It is not clear whether available instruments yield similar results or what domains of health are contributing to the overall score in a sample of patients with rheumatoid arthritis (RA). SUBJECTS: Our study included 313 individuals with rheumatologist-confirmed RA. MEASURES: A self-completed survey that permitted scoring of 4 indirect utility instruments (the Health Utilities Index Mark 2 and 3 (HUI-2 and HUI-3), the EuroQoL (EQ-5D), and the Short Form 6D (SF-6D) was the basis of our study. RESULTS: Mean (standard deviation) global utility scores were 0.63 (0.24) for the SF-6D, 0.66 (0.13) for the EQ-5D, 0.71 (0.19) for the HUI-2, and 0.53 (0.29) for the HUI-3 (P = 0.02 by repeated-measures analysis of variance). The intraclass correlation across all the indices was 0.67 (95% confidence interval 0.62-0.71). Bland-Altman plots revealed that agreement among instruments was poor at lower utility values. In this elderly RA sample, all of the global utilities mostly measured functional ability and pain. CONCLUSIONS: There are significant differences in utilities obtained from different indirect methods. Agreement among the instruments was moderate but poorer at lower utilities. It is unlikely that these utility values, if used as the weightings for quality-adjusted life years, would result in comparable estimates.