The Complexity of Transferring Remote Monitoring and Virtual Care Technology Between Countries: Lessons From an International Workshop.

International deployment of remote monitoring and virtual care (RMVC) technologies would efficiently harness their positive impact on outcomes. Since Canada and the United Kingdom have similar populations, health care systems, and digital health landscapes, transferring digital health innovations between them should be relatively straightforward. Yet examples of successful attempts are scarce. In a workshop, we identified 6 differences that may complicate RMVC transfer between Canada and the United Kingdom and provided recommendations for addressing them. These key differences include (1) minority groups, (2) physical geography, (3) clinical pathways, (4) value propositions, (5) governmental priorities and support for digital innovation, and (6) regulatory pathways. We detail 4 broad recommendations to plan for sustainability, including the need to formally consider how highlighted country-specific recommendations may impact RMVC and contingency planning to overcome challenges; the need to map which pathways are available as an innovator to support cross-country transfer; the need to report on and apply learnings from regulatory barriers and facilitators so that everyone may benefit; and the need to explore existing guidance to successfully transfer digital health solutions while developing further guidance (eg, extending the nonadoption, abandonment, scale-up, spread, sustainability framework for cross-country transfer). Finally, we present an ecosystem readiness checklist. Considering these recommendations will contribute to successful international deployment and an increased positive impact of RMVC technologies. Future directions should consider characterizing additional complexities associated with global transfer.

The mental health of staff working on intensive care units over the COVID-19 winter surge of 2020 in England: a cross sectional survey.

BACKGROUND: The COVID-19 pandemic generated a surge of critically ill patients greater than the capacity of the UK National Health Service (NHS). There have been multiple well-documented impacts associated with the national COVID-19 pandemic surge on ICU staff, including an increased prevalence of mental health disorders on a scale potentially sufficient to impair high-quality care delivery. We investigated the prevalence of five mental health outcomes; explored demographic and professional predictors of poor mental health outcomes; and describe the prevalence of functional impairment; and explore demographic and professional predictors of functional impairment in ICU staff over the 2020/2021 winter COVID-19 surge in England. METHODS: English ICU staff were surveyed before, during, and after the winter 2020/2021 surge using a survey which comprised validated measures of mental health. RESULTS: A total of 6080 surveys were completed, by ICU nurses (57.5%), doctors (27.9%), and other healthcare staff (14.5%). Reporting probable mental health disorders increased from 51% (before) to 64% (during), and then decreased to 46% (after). Younger, less experienced nursing staff were most likely to report probable mental health disorders. During and after the winter, >50% of participants met threshold criteria for functional impairment. Staff who reported probable post-traumatic stress disorder, anxiety, or depression were more likely to meet threshold criteria for functional impairment. CONCLUSIONS: The winter of 2020/2021 was associated with an increase in poor mental health outcomes and functional impairment amongst ICU staff during a period of peak caseload. These effects are likely to impact on patient care outcomes and the longer-term resilience of the healthcare workforce.

Engagement with protective behaviours in the UK during the COVID-19 pandemic: a series of cross-sectional surveys (the COVID-19 rapid survey of adherence to interventions and responses [CORSAIR] study).

BACKGROUND: Behaviour is key to suppressing the COVID-19 pandemic. Maintaining behaviour change can be difficult. We investigated engagement with hand cleaning, reducing the number of outings, and wearing a face covering over the course of the pandemic. METHODS: We used a series of 64 cross-sectional surveys between 10 February 2020 and 20 January 2022 (n ≈ 2000 per wave). Surveys investigated uptake of hand cleaning behaviours, out of home activity (England only, n ≈ 1700 per wave) and wearing a face covering (England only, restricted to those who reported going out shopping in the last week, n ≈ 1400 per wave). RESULTS: Reported hand cleaning has been high throughout the pandemic period (85 to 90% of participants consistently reporting washing their hands thoroughly and regularly with soap and water frequently or very frequently). Out of home activity has mirrored the easing and re-introduction of restrictive measures. Total number of outings were higher in the second national lockdown than in the first and third lockdowns. Wearing a face covering increased steadily between April to August 2020, plateauing until the end of measurement in May 2021, with approximately 80% of those who had been out shopping in the previous week reporting wearing a face covering frequently or very frequently. CONCLUSIONS: Engagement with protective behaviours increased at the start of the pandemic and has remained high since. The greatest variations in behaviour reflected changes to Government rules. Despite the duration of restrictions, people have continued to adopt personal protective behaviours that were intended to prevent the spread of COVID-19.

Physical Activity Behavior Before, During, and After COVID-19 Restrictions: Longitudinal Smartphone-Tracking Study of Adults in the United Kingdom.

BACKGROUND: The COVID-19 pandemic led to the implementation of worldwide restrictive measures to reduce social contact and viral spread. These measures have been reported to have a negative effect on physical activity (PA). Studies of PA during the pandemic have primarily used self-reported data. The single academic study that used tracked data did not report on demographics. OBJECTIVE: This study aimed to explore patterns of smartphone-tracked activity before, during, and immediately after lockdown in the United Kingdom, and examine differences by sociodemographic characteristics and prior levels of PA. METHODS: Tracked longitudinal weekly minutes of PA were captured using the BetterPoints smartphone app between January and June 2020. Data were plotted by week, demographics, and activity levels at baseline. Nonparametric tests of difference were used to assess mean and median weekly minutes of activity at significant points before and during the lockdown, and as the lockdown was eased. Changes over time by demographics (age, gender, Index of Multiple Deprivation, baseline activity levels) were examined using generalized estimating equations (GEEs). RESULTS: There were 5395 users with a mean age of 41 years (SD 12) and 61% (n=3274) were female. At baseline, 26% (n=1422) of users were inactive, 23% (n=1240) were fairly active, and 51% (n=2733) were active. There was a relatively even spread across deprivation deciles (31% [n=1693] in the least deprived deciles and 23% in the most [n=1261]). We found significant changes in PA from the week before the first case of COVID-19 was announced (baseline) to the week that social distancing restrictions were relaxed (Friedman test: χ22=2331, P<.001). By the first full week of lockdown, the median change in PA was 57 minutes less than baseline. This represents a 37% reduction in weekly minutes of PA. Overall, 63% of people decreased their level of activity between baseline and the first week of COVID-19 restrictions. Younger people showed more PA before lockdown but the least PA after lockdown. In contrast, those aged >65 years appeared to remain more active throughout and increased their activity levels as soon as lockdown was eased. Levels of PA among those classed as active at baseline showed a larger drop compared with those considered to be fairly active or inactive. Socioeconomic group and gender did not appear to be associated with changes in PA. CONCLUSIONS: Our tracked PA data suggests a significant drop in PA during the United Kingdom's COVID-19 lockdown. Significant differences by age group and prior PA levels suggests that the government's response to COVID-19 needs to be sensitive to these individual differences and the government should react accordingly. Specifically, it should consider the impact on younger age groups, encourage everyone to increase their PA, and not assume that people will recover prior levels of PA on their own.

A Virtual Reality Exergame to Engage Adolescents in Physical Activity: Mixed Methods Study Describing the Formative Intervention Development Process.

BACKGROUND: Early adolescence (13-17 years) is a critical developmental stage for physical activity promotion. Virtual reality (VR) exergaming is a promising intervention strategy to engage adolescents in physical activity. OBJECTIVE: The vEngage project aims to develop a physical activity intervention for adolescents using VR exergaming. Here, we describe the formative intervention development work and process of academic-industry collaboration. METHODS: The formative development was guided by the Medical Research Council framework and included recruiting an adolescent user group to provide iterative feedback, a literature review, a quantitative survey of adolescents, qualitative interviews with adolescents and parents, inductive thematic analysis of public reviews of VR exergames, a quantitative survey and qualitative interviews with users of the augmented reality running app Zombies, Run!, and building and testing a prototype with our adolescent user group. RESULTS: VR exergaming was appealing to adolescents and acceptable to parents. We identified behavior change techniques that users would engage with and features that should be incorporated into a VR exergame, including realistic body movements, accurate graphics, stepped levels of gameplay difficulty, new challenges, in-game rewards, multiplayer options, and the potential to link with real-world aspects such as physical activity trackers. We also identified some potential barriers to use, such as cost, perceived discomfort of VR headsets, and motion sickness concerns. A prototype game was developed and user-tested with generally positive feedback. CONCLUSIONS: This is the first attempt to develop a VR exergame designed to engage adolescents in physical activity that has been developed within a public health intervention development framework. Our formative work suggests that this is a very promising avenue. The benefit of the design process was the collaborative parallel work between academics and game designers and the involvement of the target population in the game (intervention) design from the outset. Developing the game within an intervention framework allowed us to consider factors, such as parental support, that would be important for future implementation. This study also serves as a call to action for potential collaborators who may wish to join this endeavor for future phases and an example of how academic-industry collaboration can be successful and beneficial.

An Evaluation Service for Digital Public Health Interventions: User-Centered Design Approach.

BACKGROUND: Digital health interventions (DHIs) have the potential to improve public health by combining effective interventions and population reach. However, what biomedical researchers and digital developers consider an effective intervention differs, thereby creating an ongoing challenge to integrating their respective approaches when evaluating DHIs. OBJECTIVE: This study aims to report on the Public Health England (PHE) initiative set out to operationalize an evaluation framework that combines biomedical and digital approaches and demonstrates the impact, cost-effectiveness, and benefit of DHIs on public health. METHODS: We comprised a multidisciplinary project team including service designers, academics, and public health professionals and used user-centered design methods, such as qualitative research, engagement with end users and stakeholders, and iterative learning. The iterative approach enabled the team to sequentially define the problem, understand user needs, identify opportunity areas, develop concepts, test prototypes, and plan service implementation. Stakeholders, senior leaders from PHE, and a working group critiqued the outputs. RESULTS: We identified 26 themes and 82 user needs from semistructured interviews (N=15), expressed as 46 Jobs To Be Done, which were then validated across the journey of evaluation design for a DHI. We identified seven essential concepts for evaluating DHIs: evaluation thinking, evaluation canvas, contract assistant, testing toolkit, development history, data hub, and publish health outcomes. Of these, three concepts were prioritized for further testing and development, and subsequently refined into the proposed PHE Evaluation Service for public health DHIs. Testing with PHE's Couch-to-5K app digital team confirmed the viability, desirability, and feasibility of both the evaluation approach and the Evaluation Service. CONCLUSIONS: An iterative, user-centered design approach enabled PHE to combine the strengths of academic and biomedical disciplines with the expertise of nonacademic and digital developers for evaluating DHIs. Design-led methodologies can add value to public health settings. The subsequent service, now known as Evaluating Digital Health Products, is currently in use by health bodies in the United Kingdom and is available to others for tackling the problem of evaluating DHIs pragmatically and responsively.

Interorganizational Knowledge Sharing to Establish Digital Health Learning Ecosystems: Qualitative Evaluation of a National Digital Health Transformation Program in England.

BACKGROUND: The English Global Digital Exemplar (GDE) program is one of the first concerted efforts to create a digital health learning ecosystem across a national health service. OBJECTIVE: This study aims to explore mechanisms that support or inhibit the exchange of interorganizational digital transformation knowledge. METHODS: We conducted a formative qualitative evaluation of the GDE program. We used semistructured interviews with clinical, technical, and managerial staff; national program managers and network leaders; nonparticipant observations of knowledge transfer activities through attending meetings, workshops, and conferences; and documentary analysis of policy documents. The data were thematically analyzed by drawing on a theory-informed sociotechnical coding framework. We used a mixture of deductive and inductive methods, supported by NVivo software, to facilitate coding. RESULTS: We conducted 341 one-on-one and 116 group interviews, observed 86 meetings, and analyzed 245 documents from 36 participating provider organizations. We also conducted 51 high-level interviews with policy makers and vendors; performed 77 observations of national meetings, workshops, and conferences; and analyzed 80 national documents. Formal processes put in place by the GDE program to initiate and reinforce knowledge transfer and learning have accelerated the growth of informal knowledge networking and helped establish the foundations of a learning ecosystem. However, formal networks were most effective when supported by informal networking. The benefits of networking were enhanced (and costs reduced) by geographical proximity, shared culture and context, common technological functionality, regional and strategic alignments, and professional agendas. CONCLUSIONS: Knowledge exchange is most effective when sustained through informal networking driven by the mutual benefits of sharing knowledge and convergence between group members in their organizational and technological setting and goals. Policy interventions need to enhance incentives and reduce barriers to sharing across the ecosystem, be flexible in tailoring formal interventions to emerging needs, and promote informal knowledge sharing.

What should medical students be taught about abortion? An evaluation of student attitudes towards their abortion teaching and their future involvement in abortion care.

BACKGROUND: One in three women in the United Kingdom (UK) will have an abortion before age 45, making abortion provision an essential aspect of reproductive healthcare. Despite this, abortion remains ethically contested and stigmatised, with variable teaching in UK medical schools and concerns about falling numbers of doctors willing to participate in abortion care. University College London Medical School (UCLMS) has designed practical, inclusive, teaching that aims to give students an understanding of the importance of abortion care and prepare them to be competent practitioners in this area. This study aimed to determine students' opinions of this teaching and their wider attitudes towards abortion. METHODS: We invited all 357 final-year UCL medical students to complete an online survey consisting of closed-ended questions, exploring their opinions on their abortion teaching, their personal beliefs about abortion and their future willingness to be involved in abortion care. We analysed responses using non-parametric tests. RESULTS: One hundred and forty-six questionnaires (41% response rate) showed 83% of students identified as pro-choice (agree with the right to choose an abortion). Fifty-seven percent felt they received the right amount of abortion teaching, 39% would have liked more and 4% stated they received too much. There was no correlation between students' attitudes to abortion and the rating of teaching; both pro-choice and pro-life (opposed to the right to choose an abortion) students generally rated the teaching as important and valued the range of methods used. Students requested more simulated practice speaking to patients requesting an abortion. Students with pro-life beliefs expressed lower willingness to discuss, refer, certify and provide future abortions. Students interested in careers in specialties where they may encounter abortion were more likely to be pro-choice than pro-life. CONCLUSIONS: The majority of participating UCL medical students were pro-choice and willing to be involved in future abortion care. Efforts to make teaching on abortion practical, engaging, sensitive and inclusive were appreciated. As well as preparing students to be competent and caring practitioners, the teaching appears to contribute towards them viewing abortion as an essential aspect of women's healthcare, and may contribute to destigmatising abortion.

Thought-feeling discrimination in people with dementia: adaptation and preliminary validation of the first dementia-specific measure.

OBJECTIVE: There is emerging evidence that cognitive behavioral therapy (CBT) can be effective for treating anxiety and depression in people living with dementia (PLWD). Discriminating between thoughts and feelings is a critical element of CBT and also of relevance to emotional understanding more generally. The aim of the present study was the structured adaptation and preliminary validation of an existing measure of thought-feeling discrimination for use in PLWD. METHODS/DESIGN: The Behavior Thought Feeling Questionnaire (BTFQ) was adapted via expert and service-user consultation for use in PLWD. One hundred two PLWD and 77 people aged over 65 years who did not have measurable cognitive impairments completed the adapted measure along with two measures of emotional recognition and reasoning. The factor structure of this measure was examined and the measure reduced. RESULTS: Factor analysis suggested a two-factor solution with thought and feeling items loading on separate factors. The behavior items were not included in scoring due to high cross-loading and ceiling effects, leaving a 14-item measure with two subscales. Thus, an adapted measure was created (named the BTFQ-D), which showed moderate convergent validity in the PLWD but not the older adult sample. Both thought and feeling subscales showed good internal consistency. CONCLUSIONS: The BTFQ-D showed preliminary validity as a measure of thought-feeling discrimination in PLWD. It may have utility in measuring readiness for CBT as part of clinical assessment. Further validation is required.

Theoretical and methodological considerations in evaluating large-scale health information technology change programmes.

BACKGROUND: Attempts to achieve digital transformation across the health service have stimulated increasingly large-scale and more complex change programmes. These encompass a growing range of functions in multiple locations across the system and may take place over extended timeframes. This calls for new approaches to evaluate these programmes. MAIN BODY: Drawing on over a decade of conducting formative and summative evaluations of health information technologies, we here build on previous work detailing evaluation challenges and ways to tackle these. Important considerations include changing organisational, economic, political, vendor and markets necessitating tracing of evolving networks, relationships, and processes; exploring mechanisms of spread; and studying selected settings in depth to understand local tensions and priorities. CONCLUSIONS: Decision-makers need to recognise that formative evaluations, if built on solid theoretical and methodological foundations, can help to mitigate risks and help to ensure that programmes have maximum chances of success.

Engagement With a Behavior Change App for Alcohol Reduction: Data Visualization for Longitudinal Observational Study.

BACKGROUND: Behavior change apps can develop iteratively, where the app evolves into a complex, dynamic, or personalized intervention through cycles of research, development, and implementation. Understanding how existing users engage with an app (eg, frequency, amount, depth, and duration of use) can help guide further incremental improvements. We aim to explore how simple visualizations can provide a good understanding of temporal patterns of engagement, as usage data are often longitudinal and rich. OBJECTIVE: This study aims to visualize behavioral engagement with Drink Less, a behavior change app to help reduce hazardous and harmful alcohol consumption in the general adult population of the United Kingdom. METHODS: We explored behavioral engagement among 19,233 existing users of Drink Less. Users were included in the sample if they were from the United Kingdom; were 18 years or older; were interested in reducing their alcohol consumption; had a baseline Alcohol Use Disorders Identification Test score of 8 or above, indicative of excessive drinking; and had downloaded the app between May 17, 2017, and January 22, 2019 (615 days). Measures of when sessions begin, length of sessions, time to disengagement, and patterns of use were visualized with heat maps, timeline plots, k-modes clustering analyses, and Kaplan-Meier plots. RESULTS: The daily 11 AM notification is strongly associated with a change in engagement in the following hour; reduction in behavioral engagement over time, with 50.00% (9617/19,233) of users disengaging (defined as no use for 7 or more consecutive days) 22 days after download; identification of 3 distinct trajectories of use, namely engagers (4651/19,233, 24.18% of users), slow disengagers (3679/19,233, 19.13% of users), and fast disengagers (10,903/19,233, 56.68% of users); and limited depth of engagement with 85.076% (7,095,348/8,340,005) of screen views occurring within the Self-monitoring and Feedback module. In addition, a peak of both frequency and amount of time spent per session was observed in the evenings. CONCLUSIONS: Visualizations play an important role in understanding engagement with behavior change apps. Here, we discuss how simple visualizations helped identify important patterns of engagement with Drink Less. Our visualizations of behavioral engagement suggest that the daily notification substantially impacts engagement. Furthermore, the visualizations suggest that a fixed notification policy can be effective for maintaining engagement for some users but ineffective for others. We conclude that optimizing the notification policy to target both effectiveness and engagement is a worthwhile investment. Our future goal is to both understand the causal effect of the notification on engagement and further optimize the notification policy within Drink Less by tailoring to contextual circumstances of individuals over time. Such tailoring will be informed from the findings of our micro-randomized trial (MRT), and these visualizations were useful in both gaining a better understanding of engagement and designing the MRT.

Technological Capabilities to Assess Digital Excellence in Hospitals in High Performing Health Care Systems: International eDelphi Exercise.

BACKGROUND: Hospitals worldwide are developing ambitious digital transformation programs as part of broader efforts to create digitally advanced health care systems. However, there is as yet no consensus on how best to characterize and assess digital excellence in hospitals. OBJECTIVE: Our aim was to develop an international agreement on a defined set of technological capabilities to assess digital excellence in hospitals. METHODS: We conducted a two-stage international modified electronic Delphi (eDelphi) consensus-building exercise, which included a qualitative analysis of free-text responses. In total, 31 international health informatics experts participated, representing clinical, academic, public, and vendor organizations. RESULTS: We identified 35 technological capabilities that indicate digital excellence in hospitals. These are divided into two categories: (a) capabilities within a hospital (n=20) and (b) capabilities enabling communication with other parts of the health and social care system, and with patients and carers (n=15). The analysis of free-text responses pointed to the importance of nontechnological aspects of digitally enabled change, including social and organizational factors. Examples included an institutional culture characterized by a willingness to transform established ways of working and openness to risk-taking. The availability of a range of skills within digitization teams, including technological, project management and business expertise, and availability of resources to support hospital staff, were also highlighted. CONCLUSIONS: We have identified a set of criteria for assessing digital excellence in hospitals. Our findings highlight the need to broaden the focus from technical functionalities to wider digital transformation capabilities.

A theory-based study of doctors' intentions to engage in professional behaviours.

BACKGROUND: The Theory of Planned Behaviour (TPB) has been proposed as an appropriate model for creating a theory-driven approach to teaching medical professionalism. However, there is a lack of empirical evidence into its efficacy. This study explores if the TPB can assess UK medical doctors' professional behaviours and explores if there are differences in the TPB's efficacy depending on doctors' primary medical qualification (UK or outside). METHODS: Three hundred fourteen doctors in England at 21 NHS Trusts completed a questionnaire about reflective practice, using the General Medical Council's confidentiality guidance, and raising a patient safety concern. The majority of participants were male (52%), white (68%), consultants (62%), and UK medical graduates (UKGs) (71%). RESULTS: The TPB variables of attitudes, subjective norms, and perceived behavioural control were predictive of intention to engage in raising concerns (R2 = 35%), reflection (R2 = 52%), and use of confidentiality guidance (R2 = 45%). Perceived behavioural control was the strongest predictor of intentions to raise a concern (ß = 0.44), while attitude was the strongest predictor of intentions to engage in reflective practice (ß = 0.61) and using confidentiality guidance (ß = 0.38). The TBP constructs predicted intention for raising concerns and reflecting for both UKGs and non-UKGs (Fs ≥ 2.3; ps ≤ .023, ßs ≥ 0.12). However, only perceived behaviour control was predictive of intentions to use guidance for both UKGs and non-UKGs (ß = 0.24) while attitudes and norms were just predictive for UKGs (ßs ≥ 0.26). CONCLUSIONS: This study demonstrates the efficacy of the TPB for three professional behaviours. The implications for medical educators are to use the variables of the TPB (attitudes, subjective norms, and perceived behavioural control) in the education of professionalism, and for medical education researchers to further our understanding by employing the TPB in more empirical studies of non-clinical behaviours.

What Players of Virtual Reality Exercise Games Want: Thematic Analysis of Web-Based Reviews.

BACKGROUND: Physical activity (PA) is associated with a variety of physical and psychosocial health benefits, but levels of moderate-to-vigorous intensity PA remain low worldwide. Virtual reality (VR) gaming systems involving movement (VR exergames) could be used to engage people in more PA. OBJECTIVE: This study aimed to synthesize public reviews of popular VR exergames to identify common features that players liked or disliked to inform future VR exergame design. METHODS: We conducted a thematic analysis of 498 reviews of the 29 most popular exergames sold in the top 3 VR marketplaces: Steam (Valve Corporation), Viveport (Valve Corporation), and Oculus (Oculus VR). We categorized reviews as positive and negative as they appeared in the marketplaces and identified the most common themes using an inductive thematic analysis. RESULTS: The reviews were often mixed, reporting a wide variety of expectations, preferences, and gaming experiences. Players preferred highly realistic games (eg, closely simulated real-world sport), games that were intuitive (in terms of body movement and controls), and games that provided gradual increases in skill acquisition. Players reported feeling that they reached a high level of exertion when playing and that the immersion distracted them from the intensity of the exercise. Some preferred features included music and social aspects of the games, with multiplayer options to include friends or receive help from experienced players. There were 3 main themes in negative reviews. The first concerned bugs that rendered games frustrating. Second, the quality of graphics had a particularly strong impact on perceived enjoyment. Finally, reviewers disliked when games had overly complex controls and display functions that evoked motion sickness. CONCLUSIONS: Exergames prove to be a stimulating avenue for players to engage in PA and distract themselves from the negative perceptions of performing exercise. The common negative aspects of VR exergames should be addressed for increased uptake and continued engagement.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country.

BACKGROUND: There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise. METHODS: Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179). RESULTS: Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02). CONCLUSIONS: As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

The GP tests of competence assessment: which part best predicts fitness to practise decisions?

BACKGROUND: The General Medical Council (GMC) conducts Tests of Competence (ToC) for doctors referred for Fitness to Practise (FtP) issues. GPs take a single best answer knowledge test, an Objective Structured Clinical Examination (OSCE), and a Simulated Surgery (SimSurg) assessment which is a simulated GP consultation. The aim of this study was to examine the similarities between OSCEs and SimSurg to determine whether each assessment contributed something unique to GP ToCs. METHODS: A mixed methods approach was used. Data were collated on 153 GPs who were required to undertake a ToC as a part of being investigated for FtP issues between February 2010 and October 2016. Using correlation analysis, we examined to what degree performance on the knowledge test, OSCE, and SimSurg related to case examiner recommendations and FtP outcomes, including the unique predictive power of these three assessments. The outcome measures were case examiner recommendations (i) not fit to practise; ii) fit to practise on a limited basis; or iii) fit to practise) as well as FtP outcomes (i) erased/removed from the register; ii) having restrictions/conditions; or iii) be in good standing). For the qualitative component, 45 GP assessors were asked to rate whether they assess the same competencies and which assessment provides better feedback about candidates. RESULTS: There was significant overlap between OSCEs and SimSurg, p < 0.001. SimSurg had additional predictive power in the presence of OSCEs and the knowledge test (p = 0.030) in distinguishing doctors from different FtP categories, while OSCEs did not (p = 0.080). Both the OSCEs (p = 0.004) and SimSurg (p < 0.001) had significant negative correlations with case examiner recommendations when accounting for the effects of the other two assessments. Inductive thematic analysis of the responses to the questionnaire showed that assessors perceived OSCEs to be better suited to target specific knowledge and skills. SimSurg was thought to produce a more global picture as the scenarios more accurately portray a patient consultation. CONCLUSION: While all three assessments are strong predictors of both case examiner recommendations and FtP outcomes, our findings suggest that the efficiency of GP ToCs can be improved by removing some of this overlapping content.

Predictors of influenza vaccine uptake during the 2009/10 influenza A H1N1v ('swine flu') pandemic: Results from five national surveys in the United Kingdom.

OBJECTIVES: To investigate reasons underlying the low uptake of the influenza A H1N1v vaccination in the UK during the 2009/10 pandemic. METHODS: We analysed data from five national telephone surveys conducted in the UK during the latter stages of the pandemic to identify predictors of uptake amongst members of the public offered the vaccine by their primary care physician (n=1320). In addition to demographic variables, participants reported: reasons for declining the vaccination, levels of worry about the risk of catching swine flu, whether too much fuss was being made about the pandemic, whether they or a close friend or relative had had swine flu, how effective they felt the vaccine was, whether they had previously had a seasonal flu vaccination, how well prepared they felt the government was for a pandemic and how satisfied they were with information available about the pandemic. Most participants (n=734, 55.6%) reported being vaccinated against swine flu, compared to 396 who had not been vaccinated and were unlikely to be vaccinated in the future. RESULTS: The main reasons given for declining vaccination were concerns over the vaccine's safety, and being generally healthy. Controlling for demographic variables, risk factors for not being vaccinated were: being female, not having a long-standing infirmity or illness, not having been vaccinated against seasonal flu in previous years, feeling that too much fuss had been made about the pandemic and believing that the vaccine was ineffective. CONCLUSIONS: Interventions that target these factors may be effective in improving uptake in a future pandemic.

Performance of EQ-5D, howRu and Oxford hip & knee scores in assessing the outcome of hip and knee replacements.

BACKGROUND: We aimed to compare the performance of EQ-5D-3 L and howRu, which are short generic patient-reported outcome measures (PROMs), in assessing the outcome of hip and knee replacements, using the Oxford Hip Score (OHS) and the Oxford Knee Scores (OKS) for comparison. METHODS: Outcome was assessed as the difference between pre-surgery and 6-month post-surgery scores. We used a large sample from the NHS PROMs database, which used EQ-5D-3 L, and a small cohort of patients having the same operations collected by MyClinicalOutcomes (MCO), which used howRu. Both cohorts completed the OHS (hips) or the OKS (knees). RESULTS: The change (outcome) between pre-op and post-op scores as measured by howRu was greater than that measured by EQ-5D, relative to that measured by OHS or OKS. For hip replacements, the correlation for change measured by howRu and OHS was r = 0.77 (0.66-0.85). The corresponding correlation for change measured by EQ-5D Index and OHS was r = 0.64 (0.63-0.64). For knee replacements the correlation between change in howRu and OKS was r = 0.86 (0.75-0.92); between EQ-5D Index and OKS r = 0.59 (0.58-0.60). CONCLUSIONS: For hip and knee replacement, the outcome measured by howRu was more highly correlated with that measured by the condition-specific Oxford Hip and Knee Scores than were EQ-5D Index or EQ-VAS. The magnitude of change before and after surgery was also greater.

Sex differences in medico-legal action against doctors: a systematic review and meta-analysis.

BACKGROUND: The relationship between male sex and poor performance in doctors remains unclear, with high profile studies showing conflicting results. Nevertheless, it is an important first step towards understanding the causes of poor performance in doctors. This article aims to establish the robustness of the association between male sex and poor performance in doctors, internationally and over time. METHODS: The electronic databases MEDLINE, EMBASE, and PsycINFO were searched from inception to January 2015. Backward and forward citation searching was performed. Journals that yielded the majority of the eligible articles and journals in the medical education field were electronically searched, along with the conference and poster abstracts from two of the largest international medical education conferences. Studies reporting original data, written in English or French, examining the association between sex and medico-legal action against doctors were included. Two reviewers independently extracted study characteristics and outcome data from the full texts of the studies meeting the eligibility criteria. Study quality was assessed using the Newcastle-Ottawa scale. A random effect meta-analysis model was used to summarize and assess the effect of doctors' sex on medico-legal action. Extracted outcomes included disciplinary action by a medical regulatory board, malpractice experience, referral to a medical regulatory body, complaints received by a healthcare complaints body, criminal cases, and medico-legal matter with a medical defence organisation. RESULTS: Overall, 32 reports examining the association between doctors' sex and medico-legal action were included in the systematic review (n=4,054,551), of which 27 found that male doctors were more likely to have experienced medico-legal action. 19 reports were included in the meta-analysis (n=3,794,486, including 20,666 cases). Results showed male doctors had nearly two and a half times the odds of being subject to medico-legal action than female doctors. Heterogeneity was present in all meta-analyses. CONCLUSION: Male doctors are more likely to have had experienced medico-legal actions compared to female doctors. This finding is robust internationally, across outcomes of varying severity, and over time.