Exploring the Value of Improvisational Theater in Medical Education for Advancing the Doctor-Patient Relationship and Health Equity.

PURPOSE: Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication; build trustworthy relationships with patients; and address bias, racism, oppressive systems, and structural inequities. METHOD: Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their experience. RESULTS: Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of patients with experiences different than their own. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity. CONCLUSIONS: Improv theater exercises can complement traditional communication curricula to advance health equity.

Signal-To-Noise Ratio Calculations to Validate Sensor Positioning for Facial Muscle Assessment Using Noninvasive Facial Electromyography.

The evaluation of neuromodulator treatment outcomes can be performed by noninvasive surface-derived facial electromyography (fEMG) which can detect cumulative muscle fiber activity deep to the skin. The objective of the present study is to identify the most reliable facial locations where the motor unit action potentials (MUAPs) of various facial muscles can be quantified during fEMG measurements. The study population consisted of five males and seven females (31.0 [12.9] years, body mass index of 22.15 [1.6] kg/m2). Facial muscle activity was assessed in several facial regions in each patient for their respective muscle activity utilizing noninvasive surface-derived fEMG. Variables of interest were the average root mean square of three performed muscle contractions (= signal) (µV), mean root mean square between those contraction with the face in a relaxed facial expression (= baseline noise) (µV), and the signal to noise ratio (SNR). A total of 1,709 processed fEMG signals revealed one specific reliable location in each investigated region based on each muscle's anatomy, on the highest value of the SNR, on the lowest value for the baseline noise, and on the practicability to position the sensor while performing a facial expression. The results of this exploratory study may help guiding future researchers and practitioners in designing study protocols and measuring individual facial MUAP when utilizing fEMG. The locations presented herein were selected based on the measured parameters (SNR, signal, baseline noise) and on the practicability and reproducibility of sensor placement.

2015 Young Investigator Award Winner: Cervical Nerve Root Displacement and Strain During Upper Limb Neural Tension Testing: Part 1: A Minimally Invasive Assessment in Unembalmed Cadavers.

STUDY DESIGN: A cross-sectional cadaveric examination of displacement and strain measured at the level of the cervical nerve roots during upper limb neural tension testing (ULNTT) with median nerve bias. OBJECTIVE: To determine the displacement and strain of cervical nerve roots C5-C8 during ULNTT with minimal disruption of surrounding tissues. SUMMARY OF BACKGROUND DATA: Clinical examination of neural pathology involving cervical nerve roots is difficult because of the transient nature of pathologies, such as cervical radiculopathy, entrapment neuropathies, and thoracic outlet syndrome. Cadaveric studies have demonstrated significant displacement and strain in lumbosacral nerve roots during neurodynamic testing of the lower extremity. Examination into the biomechanical behaviors of cervical nerve roots during ULNTT has not been performed. METHODS: Eleven unembalmed cadavers were positioned supine as though undergoing ULNTT. Radiolucent markers were implanted into cervical nerve roots C5-C8. Posteroanterior fluoroscopic images were captured at resting and ULNTT positioning. Images were digitized and displacement and strain were calculated. RESULTS: ULNTT resulted in significant inferolateral displacement (average, 2.16 mm-4.32 mm, P < 0.001) of cervical nerve roots C5-C8. There was a significant difference in inferolateral displacement between the C5 and C6 nerve roots (3.15 mm vs. 4.32 mm, P = 0.009). ULNTT resulted in significant strain (average, 6.80%-11.87%, P < 0.001) of cervical nerve roots C5-C8. There was a significant difference in strain between the C5 and C6 nerve roots (6.60% vs. 11.87%, P = 0.03). CONCLUSION: ULNTT caused significant inferolateral displacement and strain in cervical nerve roots C5-C8. These results provide the mechanical foundation for the use of ULNTT in clinical evaluation of pathology in the cervical region, such as in cervical radiculopathy, entrapment neuropathies, and thoracic outlet syndrome. LEVEL OF EVIDENCE: 2.

Disability-free life expectancy: comparison of sources and small area estimates in England, 2006-08.

BACKGROUND: Health expectancies (HEs) at sub-national geographies or by clusters of areas defined by relative deprivation are important tools to monitor inequalities in health. Previously, analyses have had limited usefulness due to a lack of timeliness or local relevance caused by limitations on the frequency or coverage of survey data. Here we explore the potential of the Annual Population Survey (APS) to provide robust estimates of disability-free life expectancy (DFLE) for men and women by clusters of area deprivation, English regions and local authority districts (LAs) in the period 2006-08. METHODS: DFLE estimates for the UK were compared using the prevalence of limiting long-standing illness (LLSI) calculated using data from the APS and from the General Lifestyle Survey (GLF) covering Great Britain and equivalent data from the Continuous Household Survey (CHS) covering Northern Ireland, aggregated over the period 2006-08. The further use of APS data for England enabled the calculation of estimates of DFLE at age 16 and at age 65 for men and women by area deprivation quintiles (each quintile comprises a fifth of areas ranked according to their relative deprivation), English regions and LAs in order to measure inequality in DFLE between these population groupings. RESULTS: The prevalence of LLSI and estimates of DFLE at national level were broadly comparable using APS and GLF/CHS data. Substantial inequality in DFLE was present between clusters of areas defined by relative deprivation and between English regions and LAs. The scale of inequality increased markedly with each finer geographical scale analysed. CONCLUSION: The APS is a viable data source to provide LLSI data for use in DFLE estimation across a range of areas and clusters of area deprivation. While increasingly fine-grained analysis decreases statistical precision, it is possible to detect clear differences between areas within regions and in making comparisons with the England average. The estimates presented here provide scope to set benchmarks for assessing the impact of interventions designed to reduce inequality in DFLE beyond the period 2006-08.

Inequalities in disability-free life expectancy by area deprivation: England, 2001-04 and 2005-08.

BACKGROUND: The reduction of health inequalities is a long-standing public health priority. Accurate and timely measurement of the magnitude of health inequalities over time is complex, often relying on data available from a decennial census to conduct detailed analyses of social and geographical inequalities. While inequalities in mortality rates and life expectancy are well-established, the scale of inequality in health expectancies has been reported to be even greater. This study examines changes in inequality in disability-free life expectancy (DFLE) over time between Lower Super Output Areas (LSOAs) in England, grouped into quintiles of an area-based measure of relative deprivation. METHODS: Life expectancy (LE) and DFLE for males and females at birth and at age 65 were estimated using a combination of survey, mortality and population data; survey data provided an estimate of the prevalence of limiting long-standing illness or disability (LLSI) used in the DFLE metric. An estimate of the inequality in DFLE between area-based quintiles of relative deprivation (using the Index of Multiple Deprivation 2007) in the periods 2001-04 and 2005-08 enabled the measurement of change in equality over time between advantaged and disadvantaged areas. RESULTS: The prevalence of LLSI among males and females rose incrementally with increasing levels of deprivation in both periods. Males and females in the most deprived areas were more than 1.5 times more likely to report LLSI compared to those in the least deprived areas. There were also large inequalities in LE and DFLE in a similar pattern to LLSI. The extent of inequality in DFLE between the most and least deprived quintiles was approximately twice that of LE. Although LE and DFLE generally increased over time, this improvement varied across quintiles, causing the gap between the most and least deprived quintiles to increase. In comparison with more advantaged areas, people experiencing the greatest deprivation spent the greatest proportion of their lives with a limiting illness or disability, and this proportion increased over time. CONCLUSIONS: Males and females at birth and at age 65 in the less deprived areas could expect longer, healthier lives than their counterparts in more deprived areas in both 2001-04 and 2005-08. This analysis suggests that the inequality in DFLE between deprived and affluent area clusters has increased during the first decade of the 21st century.

Life expectancy and disability-free life expectancy estimates for Middle Super Output Areas; England, 1999-2003.

BACKGROUND: In recent years, there has been increasing demand for health indicators at small area level to support monitoring and planning. This study investigates the use of a small area geography, Middle Layer Super Output Areas (MSOAs) for the estimation and comparison of disability-free life expectancy (DFLE) in England. METHODS: Using death registrations from 1999 to 2003 and data on limiting long-term illness from the Census 2001, life expectancy and DFLE are estimated for English MSOAs and Government Office Regions. Figures are presented for quintiles based on MSOA DFLE values, and quintiles of relative deprivation using the Index of Multiple Deprivation 2004. Health inequalities are assessed at regional level and between quintile extremes for both measures. RESULTS: The distribution of DFLE across MSOAs was characterised by a north-south geographical divide: the highest DFLE at birth for males was in Kensington and Chelsea 016 (73.9 years) and lowest was in Manchester 013 (44.1 years). For females the highest value was in Kensington and Chelsea 012 (74.4 years) and the lowest in Liverpool 039 (48.2 years). Over 40 per cent of MSOAs in the South East, but only about 3 per cent of those in the North East, were in the quintile with the highest DFLE values at birth. Conversely, the equivalent proportions in the quintile with the lowest values were approximately 4 per cent and 50 per cent respectively.At birth, males in the most affluent areas could expect to spend an additional 12.6 years without a disability compared to those in the most deprived areas. For females this inequality was 10.9 years. At age 65 inequalities persisted but the differences were narrower. CONCLUSIONS: This is the first use of MSOAs in estimating DFLE, and the results highlight the substantial inequalities between quintile groupings based on DFLE values as well as between the least and most deprived MSOAs in England. These findings provide useful health outcomes information to planners at the local level, for benchmarking purposes and to assist in resource allocation through the identification of differences in relative need between local populations.

Monitoring inequalities in health expectancies in England - small area analyses from the Census 2001 and General Household Survey 2001-05.

BACKGROUND: Deprivation and ill health are intimately linked. Monitoring this relationship in detail and with sufficient frequency is key in attempts to reduce health inequalities through more efficient targeting of healthcare resources. This study explores the potential of the General Household Survey (GHS) to provide an inter-censal measure of health expectancies in small areas experiencing differing degrees of deprivation. METHODS: The prevalence of health status and the health expectancy of males and females at birth and at age 65 by quintiles of small area deprivation are estimated. Comparisons are made between census 2001 and GHS 2001-05 to inform the suitability of the latter as an inter-censal measure of health expectancy across small areas. Comparisons are also made between the health expectancies of people living in more and less deprived areas. RESULTS: Reports of 'good' and 'fairly good' health fell and health expectancies declined as deprivation increased. Consistency between census and GHS data indicates that the latter is a suitable source for the inter-censal measurement of health expectancies across quintiles of deprivation. At birth, people living in the least deprived areas can expect more than 12 additional years of life in good or fairly good health than those in the most deprived areas, at age 65 the difference was more than four years. In terms of the proportion of life spent in favourable health states; at birth, those living in the least deprived areas could expect to spend around 91 per cent or more of their lives in good or fairly good health compared to 82 per cent for those in the most deprived areas. At age 65, people in the least deprived areas could expect to spend around 82 per cent of their remaining life in good or fairly good health compared to 69 per cent or less for those in the most deprived areas. CONCLUSIONS: This study represents the first use of the Index of Multiple Deprivation (IMD) 2004 in the measurement of health expectancy across small areas. Both the census and GHS highlighted substantial differences in the health status and health expectancies of people experiencing differing degrees of ecological deprivation. These findings serve as a useful measure and benchmark in the targeting and assessment of interventions designed to ameliorate health inequalities.

Update to the methodology used to calculate health expectancies for the UK and constituent countries.

BACKGROUND: Changes to the design of the General Household Survey (GHS) risk a discontinuity in the ONS Health Expectancy (HE) series. This report compares methodological approaches to ensure consistency of this important National Statistic and reports improvements to the methodology surrounding standard error (SE) estimation. METHODS: A comparison of the use of cross-sectional and longitudinal GHS data in estimating health state prevalence and HE in the UK, GB and constituent countries for the period 2005-07. Incorporation of the GHS sampling design effect into the calculation of standard errors surrounding estimates of HE backdated to 2000-02. RESULTS: The prevalence of favourable health states was significantly higher in the longitudinal compared to the cross-sectional sample of the GHS. Compared to established trends, the inclusion of longitudinal data in estimates of healthy life expectancy (HLE) led to implausible increases in this metric. However, the prevalence of limiting long-standing illness and estimates of disability-free life expectancy (DFLE) using longitudinal data were broadly comparable and in line with recent trends.Inclusion of the design effect had only a minor impact on the estimation of current and historic HE standard errors. On three occasions, increases in HLE over time were no longer significant using this enhanced method of SE estimation and in a single instance differences in DFLE between countries were no longer significant. CONCLUSIONS: Attrition in the GHS longitudinal dataset introduces significant bias into estimates of health state prevalence and a discontinuity in the established trend of HLE. Utilising the cross-sectional GHS sample alone in 2005-07 represents the most reliable approach to maintain the consistency of this important series. Incorporation of the design effect enhances the precision of estimates of HE.

High-throughput operating room system for joint arthroplasties durably outperforms routine processes.

BACKGROUND: Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput. METHODS: The high-throughput parallel processing strategy included neuraxial anesthesia performed in an "induction room" adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time. RESULTS: There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 +/- 0.7 (mean +/- SD) to 3.4 +/- 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%. CONCLUSION: Reorganizing the perioperative work process for total joint replacements sustainably increased OR throughput. Because joint arthroplasties generated a positive margin greater than the incremental cost, the high-throughput system improved financial performance.