Assessment methods in medical specialist assessments in the DACH region - overview, critical examination and recommendations for further development.

Introduction: Specialist medical assessments fulfil the task of ensuring that physicians have the clinical competence to independently represent their field and provide the best possible care to patients, taking into account the current state of knowledge. To date, there are no comprehensive reports on the status of specialist assessments in the German-speaking countries (DACH). For that reason, the assessment methods used in the DACH region are compiled and critically evaluated in this article, and recommendations for further development are described. Methods: The websites of the following institutions were searched for information regarding testing methods used and the organisation of specialist examinations: Homepage of the Swiss Institute for Medical Continuing Education (SIWF), Homepage of the Academy of Physicians (Austria) and Homepage of the German Federal Medical Association (BAEK). Further links were considered and the results were presented in tabular form. The assessment methods used in the specialist assessments are critically examined with regard to established quality criteria and recommendations for the further development of the specialist assessments are derived from these. Results: The following assessment methods are already used in Switzerland and Austria: written examinations with multiple choice and short answer questions, structured oral examinations, the Script Concordance Test (SCT) and the Objective Structured Clinical Examination (OSCE). In some cases, these assessment methods are combined (triangulation). In Germany, on the other hand, the oral examination has so far been conducted in an unstructured manner in the form of a 'collegial content discussion'. In order to test knowledge, practical and communicative competences equally, it is recommended to implement a triangulation of methods and follow the further recommendations described in this article. Conclusion: While there are already accepted approaches for quality-assured and competence-based specialist assessments in Switzerland and Austria at present, there is still a long way to go in Germany. Following the recommendations presented in this article, a contribution could be made to improving the specialist assessments in the DACH region according to the specialist assessments objectives.

Association between medical student debt and choice of specialty: a 6-year retrospective study.

BACKGROUND: The effect of rapidly increasing student debt on medical students' ultimate career plans is of particular interest to residency programs desiring to enhance recruitment, including primary care specialties. Previous survey studies of medical students indicate that amount of student debt influences choice of medical specialty. Research on this topic to date remains unclear, and few studies have included the average income of different specialties in analyses. The purpose of this study is to observe whether empirical data demonstrates an association between debt of graduating medical students and specialties into which students match. METHODS: This was a retrospective cross-sectional study of a public institution including data from graduation years 2010-2015. For each included student, total educational debt at graduation and matched specialty were obtained. Average income of each specialty was also obtained. Statistical hypothesis testing was performed to analyze any differences in average debt among specialties; subanalysis was performed assessing debt for primary care (PC) versus non-primary care (NPC) specialties. Correlation between student debt and average specialty income was also evaluated. RESULTS: One thousand three hundred ten students met the inclusion criteria and 178 were excluded for a final study population of 1132 (86%). The average debt was $182,590. Average debt was not significantly different among the different specialties (P = 0.576). There was no significant difference in average debt between PC and NPC specialties (PC $182,345 ± $64,457, NPC $182,868 ± $70,420, P = 0.342). There was no correlation between average specialty income and graduation debt (Spearman's rho = 0.021, P = 0.482). CONCLUSIONS: At our institution, student indebtedness did not appear to affect matched medical specialty, and no correlation between debt and average specialty income was observed. Different subspecialties and residency programs interested in recruiting more students or increasing diversity may consider addressing alternative factors which may have a stronger influence on student choices.

Private Practice Radiologist Subspecialty Classification Using Medicare Claims.

PURPOSE: The aim of this study was to assess both existing Medicare provider code assignments and a new claims-based system for subspecialty classification of private practice radiologists. METHODS: Websites of the 100 largest US radiology private practices were used to identify 1,476 radiologists self-identified with a single subspecialty ([1] abdominal, [2] breast, [3] cardiothoracic, or [4] musculoskeletal imaging; [5] nuclear medicine; [6] interventional radiology; [7] neuroradiology). Concordance of existing Medicare radiology subspecialty provider codes (present only for nuclear medicine and interventional radiology) was first assessed. Next, using a classification approach based on Neiman Imaging Types of Service (NITOS) piloted among academic practices, the percentage of subspecialty work relative value units (wRVUs) from 2012 to 2014 Medicare claims were used to assign each radiologist a unique subspecialty. RESULTS: Existing Medicare provider codes matched only 8.0% of nuclear medicine physicians and 10.7% of interventional radiologists to their self-reported subspecialties. The NITOS-based system mapped a median 51.9% of private practice radiologists' wRVUs to self-identified subspecialties (range, 23.3% [nuclear medicine] to 73.6% [neuroradiology]). The 50% NITOS-based wRVU threshold previously established for academic radiologists correctly assigned subspecialties to 48.8% of private practice radiologists but incorrectly categorized 2.9%. Practice patterns of the remaining 48.3% were sufficiently varied such that no single subspecialty assignment was possible. CONCLUSIONS: Existing Medicare provider codes poorly mirror subspecialty radiologists' own practice website-designated subspecialties. Actual payer claims data permit far more granular and accurate subspecialty identification for many radiologists. As new payment models increasingly focus on subspecialty-specific performance measures, claims-based identification methodologies show promise for reproducibly and transparently matching radiologists to practice-relevant metrics.

[Clinical competence certification for advanced heart failure: an emerging need also in Italy?]. / La certificazione di "clinical competence" per l'insufficienza cardiaca avanzata: un'esigenza anche in Italia?

Advanced heart failure (HF) is a deadly condition. Fortunately, an increasing array of effective (but often expensive) therapies has become available. The management of patients with advanced HF is complex and requires a high level of expertise. The American Board of Internal Medicine was the first regulatory board to recognize the need for a subspecialty in Advanced HF and Transplant Cardiology. More recently, the HF Association of the European Society of Cardiology has proposed a curriculum for HF specialists that includes the optional module of advanced HF therapy. However, the successful completion of such a curriculum does not result in a European Certification in Heart Failure, because no European Board of Medicine does exist. While in some European countries the secondary specialty of HF has been implemented, no country has a subspecialty in advanced HF. The ANMCO HF Area has proposed a survey to 25 Italian centers with accredited programs for heart transplant or ventricular assist device implant as destination therapy with the aim to assess the actual need of a certification of clinical competence in advanced HF and a certification of institutional competence for the centers with the highest expertise in advanced HF management. The survey indicated that there is a perceived need. A first step towards education of advanced HF specialists could be the implementation of CME courses by Scientific Societies. As regards certification of institutional competence for the centers with the highest expertise in advanced HF management, the government appears to be the only entity that can grant it.

An investigation of the effect of nurses' technology readiness on the acceptance of mobile electronic medical record systems.

BACKGROUND: Adopting mobile electronic medical record (MEMR) systems is expected to be one of the superior approaches for improving nurses' bedside and point of care services. However, nurses may use the functions for far fewer tasks than the MEMR supports. This may depend on their technological personality associated to MEMR acceptance. The purpose of this study is to investigate nurses' personality traits in regard to technology readiness toward MEMR acceptance. METHODS: The study used a self-administered questionnaire to collect 665 valid responses from a large hospital in Taiwan. Structural Equation modeling was utilized to analyze the collected data. RESULTS: Of the four personality traits of the technology readiness, the results posit that nurses are optimistic, innovative, secure but uncomfortable about technology. Furthermore, these four personality traits were all proven to have a significant impact on the perceived ease of use of MEMR while the perceived usefulness of MEMR was significantly influenced by the optimism trait only. The results also confirmed the relationships between the perceived components of ease of use, usefulness, and behavioral intention in the Technology Acceptance Model toward MEMR usage. CONCLUSIONS: Continuous educational programs can be provided for nurses to enhance their information technology literacy, minimizing their stress and discomfort about information technology. Further, hospital should recruit, either internally or externally, more optimistic nurses as champions of MEMR by leveraging the instrument proposed in this study. Besides, nurses' requirements must be fully understood during the development of MEMR to ensure that MEMR can meet the real needs of nurses. The friendliness of user interfaces of MEMR and the compatibility of nurses' work practices as these will also greatly enhance nurses' willingness to use MEMR. Finally, the effects of technology personality should not be ignored, indicating that hospitals should also include more employees' characteristics beyond socio-demographic profiles in their personnel databases.

The discriminatory cost of ICD-10-CM transition between clinical specialties: metrics, case study, and mitigating tools.

OBJECTIVE: Applying the science of networks to quantify the discriminatory impact of the ICD-9-CM to ICD-10-CM transition between clinical specialties. MATERIALS AND METHODS: Datasets were the Center for Medicaid and Medicare Services ICD-9-CM to ICD-10-CM mapping files, general equivalence mappings, and statewide Medicaid emergency department billing. Diagnoses were represented as nodes and their mappings as directional relationships. The complex network was synthesized as an aggregate of simpler motifs and tabulation per clinical specialty. RESULTS: We identified five mapping motif categories: identity, class-to-subclass, subclass-to-class, convoluted, and no mapping. Convoluted mappings indicate that multiple ICD-9-CM and ICD-10-CM codes share complex, entangled, and non-reciprocal mappings. The proportions of convoluted diagnoses mappings (36% overall) range from 5% (hematology) to 60% (obstetrics and injuries). In a case study of 24 008 patient visits in 217 emergency departments, 27% of the costs are associated with convoluted diagnoses, with 'abdominal pain' and 'gastroenteritis' accounting for approximately 3.5%. DISCUSSION: Previous qualitative studies report that administrators and clinicians are likely to be challenged in understanding and managing their practice because of the ICD-10-CM transition. We substantiate the complexity of this transition with a thorough quantitative summary per clinical specialty, a case study, and the tools to apply this methodology easily to any clinical practice in the form of a web portal and analytic tables. CONCLUSIONS: Post-transition, successful management of frequent diseases with convoluted mapping network patterns is critical. The http://lussierlab.org/transition-to-ICD10CM web portal provides insight in linking onerous diseases to the ICD-10 transition.

Rates of complete colonic evaluation after incomplete colonoscopy and their associated factors: a population-based study.

BACKGROUND: With the increasing use of colonoscopy there is growing concern about the quality of these procedures. OBJECTIVE: To evaluate the rates of complete colonic evaluation after an incomplete colonoscopy and their associated factors. METHODS: Men and women > or =50 years old living in Ontario on January 1, 1997 who did not have a prior history of colorectal cancer, inflammatory bowel disease, or colonic resection comprised the inception cohort. Receipt of an incomplete colonoscopy between January 1, 1997 and December 31, 2002 was determined. Individuals were followed over 1 year and the time from incomplete colonoscopy to complete colonic evaluation was estimated using Kaplan-Meier analysis. A generalized estimating equations model was used to evaluate the association between patient, physician, and setting factors and complete colonic evaluation. RESULTS: Twenty thousand one hundred sixty-six individuals had an incomplete colonoscopy, of whom 29.4% underwent complete colonic evaluation within 1 year after the procedure. Women > or =80 years were less likely to undergo complete colonic evaluation (odds ratio: 0.89; 95% confidence interval: 0.79-0.99), as were those who had their colonoscopy in a private office or clinic (odds ratio: 0.77; 95% confidence interval: 0.67-0.89). CONCLUSIONS: Only 29.4% of individuals with an incomplete colonoscopy underwent complete colonic evaluation within 1 year after the procedure. Women > or =80 years and those who had their colonoscopy in a private office or clinic were less likely to undergo complete colonic evaluation. The quality of care provided to older women and colonoscopy practice in office settings may be suboptimal.

The corporate transformation of medical specialty care: the exemplary case of neonatology.

The key to wealth in health care is the physician, who certifies to third-party payers that health care items and services are necessary for patient care. To compete more effectively for this wealth, physician specialists are organizing their practices into for-profit corporations and employing other physicians. Focusing on neonatology, this article describes the prevailing business model of these for-profit medical groups as controlling employed physicians through restrictive employment contract provisions, e.g., non-compete and mandatory arbitration clauses. With this business model and because of deficiencies in current law, for-profit medical groups eliminate competition from other physician specialists to the detriment of patients and consumers.

Economic contributions of physicians--the financial impact on their community.

This study quantifies the value that physicians bring to their local community. The physician's value is assessed in 3 economic arenas: as a major provider of health care services, as an employer, and as a generator of new jobs within the community. This is a descriptive report with data analyzed using internal documents, government statistics, research reports, and Medical Group Management Association data. The results indicate that approximately 1,800 physicians contribute $1.84 billion (or 10.8%) toward the $17 billion local economy. The conclusion is that attending physicians have a major impact on the economies in which they practice.

Benchmarking and reducing length of stay in Dutch hospitals.

BACKGROUND: To assess the development of and variation in lengths of stay in Dutch hospitals and to determine the potential reduction in hospital days if all Dutch hospitals would have an average length of stay equal to that of benchmark hospitals. METHODS: The potential reduction was calculated using data obtained from 69 hospitals that participated in the National Medical Registration (LMR). For each hospital, the average length of stay was adjusted for differences in type of admission (clinical or day-care admission) and case mix (age, diagnosis and procedure). We calculated the number of hospital days that theoretically could be saved by (i) counting unnecessary clinical admissions as day cases whenever possible, and (ii) treating all remaining clinical patients with a length of stay equal to the benchmark (15th percentile length of stay hospital). RESULTS: The average (mean) length of stay in Dutch hospitals decreased from 14 days in 1980 to 7 days in 2006. In 2006 more than 80% of all hospitals reached an average length of stay shorter than the 15th percentile hospital in the year 2000. In 2006 the mean length of stay ranged from 5.1 to 8.7 days. If the average length of stay of the 15th percentile hospital in 2006 is identified as the standard that other hospitals can achieve, a 14% reduction of hospital days can be attained. This percentage varied substantially across medical specialties. Extrapolating the potential reduction of hospital days of the 69 hospitals to all 98 Dutch hospitals yielded a total savings of 1.8 million hospital days (2006). The average length of stay in Dutch hospitals if all hospitals were able to treat their patients as the 15th percentile hospital would be 6 days and the number of day cases would increase by 13%. CONCLUSION: Hospitals in the Netherlands vary substantially in case mix adjusted length of stay. Benchmarking--using the method presented--shows the potential for efficiency improvement which can be realized by decreasing inputs (e.g. available beds for inpatient care). Future research should focus on the effect of length of stay reduction programs on outputs such as quality of care.

Projected acute inpatient activity in New South Wales - aIM2005.

OBJECTIVES: To describe the statewide projections of acute inpatient activity in New South Wales. METHODS: Data on acute inpatient activity in NSW for the period 1998-1999 to 2003-04 were derived from the Admitted Patient Data Collection. Regression analysis was used to project trends in utilisation and length of stay by age group, clinical specialty groups and stay type (day-only and overnight). The projected separation rates and length of stay were subject to clinical review. Projected separation rates (by age group, clinical speciality and stay type) were applied to NSW population projections to derive the projected number of separations. Bed-days were calculated by applying projected overnight average length of stay. RESULTS: Total acute inpatient activity in NSW public hospitals is projected to increase from around 1.05 million separations in 2004 to around 1.3 million separations by 2017 (24%). Same-day separations are projected to increase from around 368 000 to around 514 000 (40%). Overnight separations are projected to rise from around 690 000 in 2003-04 to around 798 000 in 2016-17 (18%). Overnight bed-days are projected to increase from around 3.7 million in 2003-04 to around 4.1 million bed-days in 2017 (12%). Differences across age groups and clinical specialties are also evident from the modelling.

Changes in the cost and management of emergency department on-call coverage: evidence from a longitudinal statewide survey.

STUDY OBJECTIVE: We measure changes in the prevalence and magnitude of stipends and other payments for taking emergency call during a 2-year period for hospitals in Oregon and evaluate the ways in which hospitals are limiting services and assessing policy options. METHODS: This was a longitudinal, standardized, e-mail-based survey of chief executive officers from all hospitals with emergency departments (EDs) in Oregon (N=56). The first wave was conducted in the summer of 2005; a follow-up survey was conducted in summer 2006. Hospitals reported on-call payments made to 8 selected specialties. RESULTS: Among 56 Oregon hospitals with EDs, 43 responded to our survey in both 2005 and 2006, representing a 77% response rate. Among 54 specialties receiving stipends in 2006, the average stipend was $18,324. Total annual stipend payments increased by 84%, from an average of $227,000 per hospital in 2005 to $487,000 per hospital in 2006. In Oregon, between 2004 and 2006, 67% of hospitals lost the ability to provide coverage for at least 1 specialty on a 24-hour, 7-day-a-week basis. Approximately half of hospitals (49%) manage this lack of coverage by transferring patients to other hospitals on a case-by-case, ad hoc basis. CONCLUSION: The cost of maintaining on-call coverage is increasing in Oregon, raising concerns about hospital financing and a degradation of the emergency services. There has not been a systematic response to on-call shortages, with patient transfers primarily managed in an ad hoc, case-by-case basis.