Important parameters for cost-effective implementation of lung cancer screening.

It is now widely accepted that lung cancer screening through low-dose computed tomography (LDCT) results in fewer diagnoses at a late stage, and decreased lung cancer mortality. Whilst reducing deaths from lung cancer is an essential prerequisite, this must be balanced against the considerable economic costs accumulated in screening. Multiple health economic models have shown substantial variation in cost per Quality-Adjusted Life Year (QALY), partly driven by the healthcare costs in the country concerned and partly by other modifiable programme components. Recent modelling using UK costs and a targeted approach suggest that most scenarios are within the willingness to pay threshold for the UK. However, identifying the most clinically and cost-effective programme is a priority to minimise the total financial impact. Programme components that influence cost-effectiveness include the method of selection of the eligible population, the participation rate, the interval between rounds of screening, the method of pulmonary nodule management, and the approach to clinical work up. Future research will clarify if a personalised approach to screening, using baseline and subsequent risk to define screening intervals is more cost-effective. The burden of LDCT screening on the medical infrastructure and workforce has to be quantified and carefully managed during implementation.

Collaboration in interprofessional teams: A needs assessment of factors that impact new resident physicians.

Many resident physicians struggle with effective interprofessional collaboration (IPC), but characterization of their challenges is not well known. This study examines gaps in IPC skills for graduating medical students entering residency. A needs assessment was completed to evaluate factors that impact resident physicians' ability to effectively collaborate with other healthcare professionals. This study included online surveys of 123 recent medical school graduates, 21 semi-structured interviews of residency program directors, and 3 focus groups of healthcare professionals who interacted with residents. Survey results were analyzed for means and narratives from surveys, interviews, and focus groups were analyzed for themes. We found that graduates felt they did not have a strong understanding of other providers' roles and did not feel well prepared to handle conflict with other providers or navigate interprofessional team dynamics. Themes emerging from narrative data generally aligned with the Interprofessional Education Collaborative core competencies including understanding team roles, communicating effectively, and working effectively in a team, but these interviews also elucidated an additional theme, overcoming system barriers. Data from this work can inform curricula in preparation for the transition to residency. The authors also offer an educational framework for learning effective IPC as a new team member.

The time is now: addressing implicit bias in obstetrics and gynecology education.

Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.

Improving the Medical School to Residency Transition: Narrative Experiences From First-Year Residents.

OBJECTIVES: We sought to identify first-year obstetrics and gynecology residents' perceptions of both support needed at the medical school to residency transition and readiness to address structural racism and bias at the start of residency training. STUDY DESIGN: Residents were recruited by email and social media for 1:1 interviews from March to June 2021. All interviews were completed by a first-year resident or fourth-year medical student using an interview guide created by the authorship team. Recorded interviews were anonymously transcribed and independently reviewed for themes by two authors. SETTING: Virtual interviews on the Zoom platform. PARTICIPANTS: First-year obstetrics and gynecology residents. RESULTS: Interviews were performed with 26 residents, and six themes for support emerged from their narratives: 1) Establishing a residency program community; 2) Relocation resources; 3) Residency preparation content in medical school and residency; 4) Preparedness to address racism and bias; 5) Connecting with peers with similar lived experiences across institutions; and 6) More proactive intentional touchpoints from program leadership early in residency. CONCLUSIONS: Resident narratives described multiple crucial opportunities to improve learners' transition to residency. These findings can help define a roadmap of resources and support that residency programs can provide for learners from Match Day through the first few months of residency.

Episcissors-60 for Mediolateral Episiotomy: Evaluation of Clinical and Economic Evidence to Inform NICE Medical Technologies Guidance.

Obstetric anal sphincter injury (OASI) occurs in 2.9% of all vaginal births in the UK and can result in faecal incontinence. Where there is a clinical need for episiotomy, OASI can be minimised by accurate selection of the optimum angle of mediolateral episiotomy. Episcissors-60 are adapted surgical scissors incorporating a guide-limb to help achieve an accurate angle of mediolateral episiotomy. The ability of Episcissors-60 to reduce OASI by preventing inaccurate visual estimates of episiotomy angles was considered by the National Institute of Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme (MTEP). NICE concluded that Episcissors-60 shows promise for mediolateral episiotomy both in terms of clinical effectiveness and potential cost savings, but that there was not enough evidence to support routine adoption into the NHS at this time. NICE MTG47 recommends that key gaps in the evidence including patient-reported outcomes and the addition of Episcissors-60 to care bundles be addressed through research with specific focus on potential equality considerations.

Promoting Diversity, Equity, and Inclusion in the Selection of Obstetrician-Gynecologists.

In the setting of long-standing structural racism in health care, it is imperative to highlight inequities in the medical school-to-residency transition. In obstetrics and gynecology, the percentage of Black residents has decreased in the past decade. The etiology for this troubling decrease is unknown, but racial and ethnic biases inherent in key residency application metrics are finally being recognized, while the use of these metrics to filter applicants is increasing. Now is the time for action and for transformational change to rectify the factors that are detrimentally affecting the racial diversity of our residents. This will benefit our patients and learners with equitable health care and better outcomes.

Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes: Systematic review (CHIMES) protocol.

INTRODUCTION: The mental health and well-being of children and young people who have been in care (ie, care-experienced) are a priority. There are a range of interventions aimed at addressing these outcomes, but the international evidence-base remains ambiguous. There is a paucity of methodologically robust systematic reviews of intervention effectiveness, with few considering the contextual conditions under which evaluations were conducted. This is important in understanding the potential transferability of the evidence-base across contexts. The present systematic review will adopt a complex systems perspective to synthesise evidence reporting evaluations of mental health and well-being interventions for care-experienced children and young people. It will address impact, equity, cost-effectiveness, context, implementation and acceptability. Stakeholder consultation will prioritise a programme theory, and associated intervention, that may progress to further development and evaluation in the UK. METHODS AND ANALYSIS: We will search 16 bibliographic databases from 1990 to June 2020. Supplementary searching will include citation tracking, author recommendation, and identification of evidence clusters relevant to included evaluations. The eligible population is children and young people (aged ≤25 years) with experience of being in care. Outcomes are (1) mental, behavioural or neurodevelopmental disorders; (2) subjective well-being; (3) self-harm; suicidal ideation; suicide. Study quality will be appraised with methodologically appropriate tools. We will construct a taxonomy of programme theories and intervention types. Thematic synthesis will be used for qualitative data reporting context, implementation and acceptability. If appropriate, meta-analysis will be conducted with outcome and economic data. Convergent synthesis will be used to integrate syntheses of qualitative and quantitative data. ETHICS AND DISSEMINATION: We have a comprehensive strategy for engagement with care-experienced children and young people, carers and social care professionals. Dissemination will include academic and non-academic publications and conference presentations. Ethical approval from Cardiff University's School of Social Sciences REC will be obtained if necessary. PROSPERO REGISTRATION NUMBER: CRD42020177478.

Effectiveness, Acceptability, and Feasibility of Digital Health Interventions for LGBTIQ+ Young People: Systematic Review.

BACKGROUND: Young people (aged 12-25 years) with diverse sexuality, gender, or bodily characteristics, such as those who identify as lesbian, gay, bisexual, transgender, intersex, or queer (LGBTIQ+), are at substantially greater risk of a range of mental, physical, and sexual health difficulties compared with their peers. Digital health interventions have been identified as a potential way to reduce these health disparities. OBJECTIVE: This review aims to summarize the characteristics of existing evidence-based digital health interventions for LGBTIQ+ young people and to describe the evidence for their effectiveness, acceptability, and feasibility. METHODS: A systematic literature search was conducted using internet databases and gray literature sources, and the results were screened for inclusion. The included studies were synthesized qualitatively. RESULTS: The search identified 38 studies of 24 unique interventions seeking to address mental, physical, or sexual health-related concerns in LGBTIQ+ young people. Substantially more evidence-based interventions existed for gay and bisexual men than for any other population group, and there were more interventions related to risk reduction of sexually transmitted infections than to any other health concern. There was some evidence for the effectiveness, feasibility, and acceptability of these interventions overall; however, the quality of evidence is often lacking. CONCLUSIONS: There is sufficient evidence to suggest that targeted digital health interventions are an important focus for future research aimed at addressing health difficulties in LGBTIQ+ young people. Additional digital health interventions are needed for a wider range of health difficulties, particularly in terms of mental and physical health concerns, as well as more targeted interventions for same gender-attracted women, trans and gender-diverse people, and people with intersex variations. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020128164; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=128164.

Trainees' Perceptions of the Transition From Medical School to Residency.

BACKGROUND: There is emerging evidence that learners may be suboptimally prepared for the expectations of residency. In order to address these concerns, many medical schools are implementing residency preparation courses (RPCs). OBJECTIVE: We aimed to determine trainees' perceptions of their transition to residency and whether they felt that they benefited from participation in an RPC. METHODS: All residents and fellows at the University of Michigan (n = 1292) received an electronic survey in July 2018 that queried respondents on demographics, whether medical school had prepared them for intern year, and whether they had participated in an RPC. RESULTS: The response rate was 44% (563 of 1292) with even distribution across gender and postgraduate years (PGYs). Most (78%, 439 of 563) felt that medical school prepared them well for intern year. There were no differences in reported preparedness for intern year across PGY, age, gender, or specialty. Overall, 28% (156 of 563) of respondents participated in an RPC and endorsed feeling prepared for intern year, which was more than RPC non-participants (85% [133 of 156] vs 70% [306 of 439], P = .029). Participation in longer RPCs was also associated with higher perceived preparedness for residency. CONCLUSIONS: This study found that residents from multiple specialties reported greater preparedness for residency if they participated in a medical school fourth-year RPC, with greater perceptions of preparedness for longer duration RPCs, which may help to bridge the medical school to residency gap.

iFuse Implant System for Treating Chronic Sacroiliac Joint Pain: A NICE Medical Technology Guidance.

Treatment and management of sacroiliac joint pain is often non-surgical, involving packages of care that can include analgesics, physiotherapy, corticosteroid injections and radiofrequency ablation. Surgical intervention is considered when patients no longer respond to conservative management. The iFuse Implant System is placed across the sacroiliac joint using minimally invasive surgery, stabilising the joint and correcting any misalignment or weakness that can cause chronic pain. The iFuse system was evaluated in 2018 by the UK National Institute for Health and Care Excellence (NICE) as part of the Medical Technologies Evaluation Programme (MTEP). Clinical evidence for iFuse suggests improved pain, Oswestry disability index (ODI) and quality of life compared to non-surgical management. The company (SI-Bone®) submitted two cost models indicating that iFuse was cost saving compared with open surgery and non-surgical management. Clinicians advised that non-surgical management was the most appropriate comparator and Cedar (a health technology research centre) made changes to the model to test the impact of higher acquisition and procedure costs. Cedar found iFuse to be cost incurring by approximately £560 per patient at 7 years. During the consultation period, the company reduced the cost of some iFuse consumables, and Cedar extended the time horizon to test the assumption that iFuse would become cost saving over time. These changes indicated that iFuse becomes cost saving at 8 years (approximately £129 per patient), after which the cost saving continues to increase. NICE published guidance in October 2018 recommending that the case for adoption of the iFuse system in the UK National Health Service (NHS) was supported by the evidence.

Moving Toward Summative Competency Assessment to Individualize the Postclerkship Phase.

In the move toward competency-based medical education, leaders have called for standardization of learning outcomes and individualization of the learning process. Significant progress has been made in establishing defined expectations for the knowledge, skills, attitudes, and behaviors required for successful transition to residency training, but individualization of educational processes to assist learners in reaching these competencies has been predominantly conceptual to date. The traditional time-based structure of medical education has posed a challenge to individualization within the curriculum and has led to more attention on innovations that facilitate transition from medical school to residency. However, a shift of focus to the clerkship-to-postclerkship transition point in the undergraduate curriculum provides an opportunity to determine how longitudinal competency-based assessments can be used to facilitate intentional and individualized structuring of the long-debated fourth year.This Perspective demonstrates how 2 institutions-the University of Virginia School of Medicine and the University of Michigan Medical School-are using competency assessments and applying standardized outcomes in decisions about individualization of the postclerkship learning process. One institution assesses Core Entrustable Professional Activities for Entering Residency, whereas the other has incorporated Accreditation Council for Graduate Medical Education core competencies and student career interests to determine degrees of flexibility in the postclerkship phase. Individualization in addition to continued assessment of performance presents an opportunity for intentional use of curriculum time to develop each student to be competently prepared for the transition to residency.

Thopaz+ Portable Digital System for Managing Chest Drains: A NICE Medical Technology Guidance.

The Thopaz+ portable digital system was evaluated by the Medical Technologies Advisory Committee (MTAC) of the National Institute for Health and Care Excellence (NICE). The manufacturer, Medela, submitted a case for the adoption of Thopaz+ that was critiqued by Cedar, on behalf of NICE. Due to a lack of clinical evidence submitted by the manufacturer, Cedar carried out its own literature search. Clinical evidence showed that the use of Thopaz+ led to shorter drainage times, a shorter hospital stay, lower rates of chest drain re-insertion and higher patient satisfaction compared to conventional chest drainage when used in patients following pulmonary resection. One comparative study of the use of Thopaz+ in patients with spontaneous pneumothorax was identified and showed shorter drainage times and a shorter length of hospital stay compared to conventional drainage. No economic evidence was submitted by the manufacturer, but a simple decision tree model was included. The model was improved by Cedar and showed a cost saving of £111.33 per patient when Thopaz+ was used instead of conventional chest drainage in patients following pulmonary resection. Cedar also carried out a sub-group analysis of the use of Thopaz+ instead of conventional drainage in patients with pneumothorax where a cost saving of £550.90 was observed. The main cost driver for the model and sub-group analysis was length of stay. The sub-group analysis was based on a single comparative study. However, the MTAC received details of an unpublished audit of Thopaz+ which confirmed its efficacy in treating patients with pneumothorax. Thopaz+ received a positive recommendation in Medical Technologies Guidance 37.

Peristeen Transanal Irrigation System to Manage Bowel Dysfunction: A NICE Medical Technology Guidance.

The Peristeen transanal irrigation system is intended to allow people with bowel dysfunction to flush out the lower part of the bowel as part of their bowel management strategy. Peristeen was the subject of an evaluation by the National Institute for Health and Care Excellence, through its Medical Technologies Evaluation Programme, for the management of bowel dysfunction. The company, Coloplast, submitted a case for adoption of the technology, claiming that the technology improves the severity of chronic constipation or faecal incontinence and improves quality of life for people with bowel dysfunction. Other claimed benefits included reduced frequency of UTIs, stoma surgery and hospitalisation rates, as well as reduced costs. The submission was critiqued by Cedar. The clinical evidence assessed included one randomised controlled trial, and 12 observational studies for adults and 11 studies for children. Although there are limitations in the evidence, the assessed studies show some improvement in outcomes for patients who choose to continue using Peristeen. The committee heard from patient experts that Peristeen had improved their lives and allowed them increased independence. The submitted economic evidence had numerous flaws, however following Cedar's changes to the model, and additional sensitivity analysis, the use of Peristeen was judged unlikely to be cost incurring compared with standard bowel care. The Peristeen transanal irrigation system received a positive recommendation in Medical Technologies Guidance 36.

ENDURALIFE-Powered Cardiac Resynchronisation Therapy Defibrillator Devices for Treating Heart Failure: A NICE Medical Technology Guidance.

ENDURALIFE™-powered cardiac resynchronisation therapy defibrillator (CRT-D) devices were the subject of an evaluation by the National Institute for Health and Care Excellence, through its Medical Technologies Evaluation Programme, for the treatment of heart failure. Boston Scientific (manufacturer) submitted a case for the adoption of the technology, claiming that it has a longer battery life resulting in a longer time to CRT-D replacement. Other claimed benefits were fewer complications associated with replacement procedures, fewer hospital admissions, less time spent in hospital and reduced demand on cardiology device implantation rooms. The submission was critiqued by Cedar, an external assessment centre. The submitted clinical evidence showed that ENDURALIFE-powered devices implanted during the period 2008-2010 were superior, in terms of longevity, to other devices at that time. Submitted economic evidence indicated that, because of a reduction in the need for replacement procedures, ENDURALIFE-powered devices were cost saving when compared to comparator devices. Cedar highlighted uncertainty of the applicability of the clinical evidence to devices marketed today. The Medical Technologies Advisory Committee noted that this was unavoidable due to the follow-up time required to study battery life. Clinical experts noted that increased battery life is an important patient benefit. However, centres use devices from multiple manufacturers to negate pressure on clinical services in the event of a major device recall. The clinical and economic evidence showed benefits to the patient, and further analysis requested by the committee suggested that ENDURALIFE-powered CRT-Ds may save between £2120 and £5627 per patient over 15 years through a reduction in the need for replacement procedures. ENDURALIFE-powered CRT-D devices received a positive recommendation in Medical Technologies Guidance 33.

Whose Problem Is It? The Priority of Physician Wellness in Residency Training.

OBJECTIVE: Physician wellness is associated with improved outcomes for patients and physicians. Wellness is a priority of the Accreditation Council on Graduate Medical Education, and many residencies have programs in place to improve wellness. This study sought to understand how stakeholders in graduate medical education perceive wellness among other educational priorities and whether these programs are improving the experience and training of residents. METHODS: The Council on Resident Education in Obstetrics and Gynecology (OBGYN)/Association of Professors in Gynecology Wellness Task Force created a survey and distributed it electronically to all OBGYN residents and program directors (PDs) in 2015. The survey included demographics, questions about the priority of wellness in the educational programs, experience with wellness programming, and problems with resident wellness (burnout, depression, binge drinking, suicide/suicide attempts, drug use, or eating disorders). Data rated on a Likert scale were analyzed using Kruskal-Wallis and Mann-Whitney U tests. RESULTS: Among 248 OBGYN PDs, 149 (60%) completed the survey. Of a total 5274 OBGYN residents nationally, 838 (16%) completed the survey. Most of the residents, 737 (89.4%) reported that they or a colleague experienced some problem with wellness. Many PDs also reported problems with wellness, but 46 (33.9%) reported not being aware of problems in the previous 5 years. When asked to rate the priority of wellness in resident education, <1% (1) PD stated that this was not a priority; however, 85 residents (10%) responded that wellness should not be a priority for residency programs. Resident reports of problems were higher as year in training increased (depression χ2 = 23.6, p ≤ 0.001; burnout χ2 = 14.0, p = 0.003; suicide attempt χ2 = 15.5, p = 0.001; drug use χ2 = 9.09, p = 0.028; and binge drinking χ2 = 10.7, p = 0.013). Compared with community programs, university programs reported slightly fewer problems with wellness (χ2 = 5.4, p = 0.02) and suicide/suicide attempts (χ2 = 13.3, p = 0.001). Most PDs reported having some programming in place, although residents reported lower rates of feeling that these programs addressed wellness. CONCLUSIONS: There is a discrepancy between the perspective that residents and PDs have on resident wellness, and its priority within the residency program. PDs may not be aware of the scope of the problem of resident wellness. These problems increase with year of training, and may be more common in community programs. Current wellness programming may not be effective, and a significant minority of residents feels that wellness is beyond the scope of the training program.

Social inequality and infant health in the UK: systematic review and meta-analyses.

OBJECTIVES: To determine the association between area and individual measures of social disadvantage and infant health in the UK. DESIGN: Systematic review and meta-analyses. DATA SOURCES: 26 databases and websites, reference lists, experts in the field and hand-searching. STUDY SELECTION: 36 prospective and retrospective observational studies with socioeconomic data and health outcomes for infants in the UK, published from 1994 to May 2011. DATA EXTRACTION AND SYNTHESIS: 2 independent reviewers assessed the methodological quality of the studies and abstracted data. Where possible, study outcomes were reported as ORs for the highest versus the lowest deprivation quintile. RESULTS: In relation to the highest versus lowest area deprivation quintiles, the odds of adverse birth outcomes were 1.81 (95% CI 1.71 to 1.92) for low birth weight, 1.67 (95% CI 1.42 to 1.96) for premature birth and 1.54 (95% CI 1.39 to 1.72) for stillbirth. For infant mortality rates, the ORs were 1.72 (95% CI 1.37 to 2.15) overall, 1.61 (95% CI 1.08 to 2.39) for neonatal and 2.31 (95% CI 2.03 to 2.64) for post-neonatal mortality. For lowest versus highest social class, the odds were 1.79 (95% CI 1.43 to 2.24) for low birth weight, 1.52 (95% CI 1.44 to 1.61) for overall infant mortality, 1.42 (95% CI 1.33 to1.51) for neonatal and 1.69 (95% CI 1.53 to 1.87) for post-neonatal mortality. There are similar patterns for other infant health outcomes with the possible exception of failure to thrive, where there is no clear association. CONCLUSIONS: This review quantifies the influence of social disadvantage on infant outcomes in the UK. The magnitude of effect is similar across a range of area and individual deprivation measures and birth and mortality outcomes. Further research should explore the factors that are more proximal to mothers and infants, to help throw light on the most appropriate times to provide support and the form(s) that this support should take.