Cost-utility analysis of prenatal diagnosis of congenital cardiac diseases using deep learning.

BACKGROUND: Deep learning (DL) is a new technology that can assist prenatal ultrasound (US) in the detection of congenital heart disease (CHD) at the prenatal stage. Hence, an economic-epidemiologic evaluation (aka Cost-Utility Analysis) is required to assist policymakers in deciding whether to adopt the new technology. METHODS: The incremental cost-utility ratios (CUR), of adding DL assisted ultrasound (DL-US) to the current provision of US plus pulse oximetry (POX), was calculated by building a spreadsheet model that integrated demographic, economic epidemiological, health service utilization, screening performance, survival and lifetime quality of life data based on the standard formula: CUR = Increase in Intervention Costs - Decrease in Treatment costs Averted QALY losses of adding DL to US & POX US screening data were based on real-world operational routine reports (as opposed to research studies). The DL screening cost of 145 USD was based on Israeli US costs plus 20.54 USD for reading and recording screens. RESULTS: The addition of DL assisted US, which is associated with increased sensitivity (95% vs 58.1%), resulted in far fewer undiagnosed infants (16 vs 102 [or 2.9% vs 15.4%] of the 560 and 659 births, respectively). Adoption of DL-US will add 1,204 QALYs. with increased screening costs 22.5 million USD largely offset by decreased treatment costs (20.4 million USD). Therefore, the new DL-US technology is considered "very cost-effective", costing only 1,720 USD per QALY. For most performance combinations (sensitivity > 80%, specificity > 90%), the adoption of DL-US is either cost effective or very cost effective. For specificities greater than 98% (with sensitivities above 94%), DL-US (& POX) is said to "dominate" US (& POX) by providing more QALYs at a lower cost. CONCLUSION: Our exploratory CUA calculations indicate the feasibility of DL-US as being at least cost-effective.

[CASE REPORT: LEGAL, PSYCHOLOGICAL AND ETHICAL ASPECTS OF THE DYING PATIENT ACT].

INTRODUCTION: We present a patient with amyotrophic lateral sclerosis (ALS), dependent on noninvasive ventilation, whose advance directives precluded life-prolonging measures. The patient was found in cardiac arrest and in accordance with the directives of her surrogate decision maker, underwent intubation and mechanical ventilation. Later, an additional surrogate decision maker disapproved of ventilation and when the ventilator was disconnected for bronchial suctioning, she asked the nurse not to reconnect the patient to the ventilator. We discuss the legal, psychological and ethical aspects of implementation of Israeli law in this complex patient.

Patient Self-Assessment of Surgical Site Infection is Inaccurate.

BACKGROUND: Availability of surgical site infection (SSI) surveillance rates challenges clinicians, healthcare administrators and leaders and the public. The purpose of this report is to demonstrate the consequences patient self-assessment strategies have on SSI reporting rates. METHODS: We performed SSI surveillance among patients undergoing general surgery procedures, including telephone follow-up 30 days after surgery. Additionally we undertook a separate validation study in which we compared patient self-assessments of SSI with surgeon assessment. Finally, we performed a meta-analysis of similar validation studies of patient self-assessment strategies. RESULTS: There were 22/266 in-hospital SSIs diagnosed (8.3%), and additional 16 cases were detected through the 30-day follow-up. In total, the SSI rate was 16.8% (95% CI 10.1-18.5). In the validation survey, we found patient telephone surveillance to have a sensitivity of 66% (95% CI 40-93%) and a specificity of 90% (95% CI 86-94%). The meta-analysis included five additional studies. The overall sensitivity was 83.3% (95% CI 79-88%), and the overall specificity was 97.4% (95% CI 97-98%). Simulation of the meta-analysis results divulged that when the true infection rate is 1%, reported rates would be 4%; a true rate of 50%, the reported rates would be 43%. CONCLUSION: Patient self-assessment strategies in order to fulfill 30-day SSI surveillance misestimate SSI rates and lead to an erroneous overall appreciation of inter-institutional variation. Self-assessment strategies overestimate SSIs rate of institutions with high-quality performance and underestimate rates of poor performance. We propose such strategies be abandoned. Alternative strategies of patient follow-up strategies should be evaluated in order to provide valid and reliable information regarding institutional performance in preventing patient harm.

Quality and extent of informed consent for invasive procedures: a pilot study at the institutional level in Turkey.

OBJECTIVE: To assess the quality of informed consent for patients undergoing invasive procedures and to reveal patient preferences for being informed about the potential risks of treatment and alternatives to treatment. DESIGN: This study was planned as a pilot study. Hospitalized patients' perceptions and expectations about the informed-consent process were explored in a general surgery department. The prepared questionnaire was completed by patients via interview. SETTING: Inpatient services of the general surgery department of a large academic hospital in Istanbul, Turkey. PARTICIPANTS: The study population consisted of hospitalized patients in a general surgery department who underwent invasive procedures in March 2013. MAIN OUTCOME MEASURES: Recognition of consent forms by the patients, rate of patients' recall of risks, rate of patients who were willing to be involved in decision making, and rate of patients who were satisfied with the whole decision-making process were measured. RESULTS: All patients signed consent forms. Most patients did not properly read the consent form since they trusted their physician. Potential exposure to risk seemed to be important for patient expectations. CONCLUSIONS: Paternalism seemed to dominate our clinical setting. The informed-consent process was definitely a separate issue from signing the consent forms. We conclude that the informed-consent process should be modified to be more functional and appropriate to human psychology. We suggest that education is necessary for informed consent to promote better quality and safety in health care.

Disclosure following a medical error: lessons learned from a national initiative of workshops with patients, healthcare teams, and executives.

BACKGROUND: Despite the increase in disclosures of medical errors, transparency remains a challenge. Recognized barriers include shame, fear of litigation, disciplinary actions, and loss of patient trust. In 2018, the Israeli Ministry of Health initiated a series of workshops about disclosure of medical errors. The workshops involved medical center executives, healthcare providers, patients, and family members of patients who had previously been harmed by a medical error. This study presents the lessons learned about perceived challenges in disclosure of errors in 15 such workshops. METHODS: Data collection included participant observations in 15 workshops, full audio recordings of all of the workshops, and documentation of detailed field notes. Analysis was performed under thematic analysis guidelines. RESULTS: We identified four main themes: "Providers agree on the value of disclosure of a medical error to the patient"; "Emotional challenges of disclosure of medical error to patients"; "The medico-legal discourse challenges transparency"; and "Providers and patients call for a change in the culture regarding disclosure of medical errors". Participant observations indicated that the presence of a patient who had experienced a tragedy in another hospital, and who was willing to share it created an intimate atmosphere that enabled an open conversation between parties. CONCLUSION: The study shows the moral, human, and educational values of open discourse in a protective setting after the occurrence of a medical error. We believe that workshops like these may help foster a culture of institutional disclosure following medical errors. We recommend that the Ministry of Health extend such workshops to all healthcare facilities, establish guidelines and mandate training for skills in disclosure for all providers.

[The effect of an intervention on rates of central vascular catheter-related bloodstream infection in intensive care units at the Hadassah Medical Center].

INTRODUCTION: Catheter-related bloodstream infection (CR-BSI) is a significant source for morbidity and mortality in addition to increased hospital costs. Patients in intensive care units (ICUs) have a greater risk for CR-BSI. Continuous monitoring and control of intravascular central catheters insertion (CCI) by using checklists have a key role in reducing the rate of infections and improving patient health care quality and safety. OBJECTIVES: To determine the rate of CR-BSI, and to evaluate the adherence of ICU teams to infection control guidelines during CCI prior to and following an intervention program in ICU patients. METHODS: The present study was conducted in six ICUs at the Hadassah Medical Center, during a period of 15 months. The rate of CR-BSI was determined in 320 patients with central catheters during the first period of the study. Assessment of adherence to infection control guidelines during CCI was carried out by observations. Educational intervention consisted of the introduction of physician guidelines for CCI, implementing a checklist to ensure adherence to the guidelines and lectures for the teams, beginning in the second period of the study. During the third period of the study, the rate of CR-BSI was determined in 336 patients with central catheters in the same ICUs, by the same research methods. RESULTS: Following the intervention, a significant reduction in the rate of CR-BSI was observed in the study population from 9.66 to 3.63 infections per 1000 catheter days, with 62.4% risk reduction for CR-BSI, (P < 0.001). Improvements were also recorded in the CCI process and the rate of compliance of the ICUs team with infection control guidelines. CONCLUSIONS: The implementation of a simple and inexpensive intervention reduced the rate of CR-BSI, leading to improved process of insertion of these catheters. DISCUSSION: The continuous monitoring of the rate of CR-BSI and using checklists in every CCI process may reduce the morbidity, mortality, hospital stay, and lower hospital costs associated with centrally placed vascular catheters.

[Challenges and barriers in the promotion of quality in health care services].

The promotion of quality and safety in health care faces many challenges and barriers including lack of cooperation by physicians. Complexity and uncertainty in measuring quality raise methodological difficulties. Lack of sufficient awareness about these limitations, also among those who measure quality, contributes to physicians lack of interest, suspicion and mistrust. Strategic issues associated with quality assessment in the Israeli health care system derive from lack of regulation and evasiveness about the accountability of executives and governing bodies regarding the quality of the services provided to patients in hospitals and clinics. Some of these challenges relate to the intrusion of market forces into the world of medicine without needed adaptations, so that reimbursement is often conveniently linked to the quantity of services and not to their quality. Efficiency, which characterizes competitive markets, is not easily translated in the clinical world where empathy, listening skills, and capability of explaining are critical physician attributes. This clinical world values giving beyond monetary compensation, and cooperation between institutions--rather than competition--all crucial for the continuity of patient's care. The interface between economics and health care calls for creative thinking, with a novel definition for the social value of medical and nursing care according to their quality and not their quantity.

Vulnerability of health to market forces.

OBJECTIVES: This article reviews adverse influences of for-profit enterprises on health care and public health, and examines significance for public policy. RESEARCH DESIGN: Narrative review. RESULTS: For-profit health-care industries may increase costs and reduce quality, leading to market failure and contributing to the USA's unflattering position in international comparisons of health-care efficiency. Drug and device corporations use strategies such as making biased inferences, influencing scientists and physicians, marketing rather than informing the public, and lobbying to control their own industry regulations to create market advantage. Successful marketing leads to the increased use of costly profit-making drugs and procedures over cheaper, nonpatented therapies. Because resources are limited, the overuse of costly modalities contributes to expensive health care, which presents a challenge to universal coverage. The free market also fosters the proliferation of industries, such as tobacco, food, and chemicals, which externalize costs to maximize profits, seek to unduly influence research by paying experts and universities, and attempt to control the media and regulatory agencies. Most vulnerable to the cumulative harm of these tactics are children, the poor, the sick, and the least educated. CONCLUSIONS: The free market can harm health and health care. The corporate obligation to increase profits and ensure a return to shareholders affects public health. Such excesses of capitalism pose formidable challenges to social justice and public health. The recognition of the health risks entailed by corporation-controlled markets has important implications for public policy. Reforms are required to limit the power of corporations.

Discordant views of experts and laypersons on the adoption of new fertility technology.

BACKGROUND: Healthcare costs are increased by the adoption of novel technologies before solid evidence on efficacy and risks. Oocyte cryopreservation for preserving fertility raises special ethical challenges. We compared opinions of professionals for assisted reproductive technology (ART), bioethicists, medical students and the general population toward the questions: do you support access to oocyte cryopreservation to preserve fertility for personal reasons and who should bear the costs? METHODS: The surveys conducted for this study were carried out in Israel included the following: (1) survey of 21 ART unit directors; (2) interviews with 23 bioethics experts; (3) survey of 196 medical students from 2 universities; (4) random digit-dial population-based survey of the public (N=600). RESULTS: Nearly 80% of ART and bioethics experts and 56% of students thought that oocyte cryopreservation should be allowed even for personal reasons. While expressing concerns about social consequences, bioethicists emphasized individuals' rights. In contrast, among the public, only 40% supported the use of this technology for personal reasons (ranging from 24% among Ultra-orthodox Jews and Arabs, to 51% among seculars or with academic education). Of note, 15% were undecided (vs. <2% among students, P<0.001). Most experts suggested private financing of the procedure for personal reasons, whereas the public preferred national or private insurance coverage. CONCLUSIONS: Nonexperts present a greater level of ambivalence than experts toward the use of a novel fertility technology for nonmedical reasons. Experts' preferences and interests may facilitate adoption of novel technologies with yet unclear effectiveness and safety, potentially contributing to increased healthcare costs.

Association between primary care physicians' evidence-based medicine knowledge and quality of care.

OBJECTIVE: Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care. DESIGN: A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire. SETTING: One region of the largest Health Maintenance Organization in Israel. PARTICIPANTS: Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients. MAIN OUTCOME MEASURES: Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval. RESULTS: Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores. CONCLUSIONS: Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.

[Why do good drugs disappear?].

Old drugs, with proved efficacy and safety, are disappearing from the market. For instance, nitrofurantoin, an inexpensive effective agent for urinary tract infections with low incidence of bacterial resistance in comparison to other antibiotics, is becoming unavailable. Alpha-methyldopa and hydraLazine, drugs of choice for pregnancy hypertension, are no longer available. Chlorthalidone, a Long acting thiazide with best evidence on efficacy, is no Longer marketed in Israel. Switching to newer agents increases costs and is often associated with relative uncertainty about safety and efficacy. The reason for the disappearance of old drugs is a combination of market failures and failures in production and regulatory processes. System revisions are needed to allow continued availability of old, safe and effective drugs.

[Additional remedies for the failing departments of internal medicine].

An evolving crisis within the departments of internal medicine in Israel reflects increase in the number of patients, age and morbidity, with a concomitant shortage of appointed personnel, the outcome of anachronistic manpower standards. Consequently, the extremely high occupancy rate and work burden are among the leading causes of growing dissatisfaction among the medical personnel and the evolving shortage of recruited trainees in internal medicine. In addition to the unequivocal necessity to adjust manpower standards to the growing needs, the authors critically review processes involved in hospital admissions and patients' discharge that intensify the growing crisis. Among such processes are economic incentives that limit the evaluation capabilities within the emergency rooms, with ensuing unnecessary admissions, erroneous decisions that lead to unselected referral of dying patients from chronic care facilities and forces that retard and limit the discharge of disabled patients at the conclusion of their hospitalization course. More efficient and rational control of patients' influx and discharge is clearly needed for the failing wards of internal medicine.

[Oocytes cryopreservation: in which circumstances? Who should pay? Approaches amongst attending IVF physicians and researchers in the field of bioethics and health regulation].

BACKGROUND: In recent years there have been significant advances in the process of oocyte cryopreservation. Advanced techniques including vitrification have seen increasing success rates of fertilization. These successes warrant renewed public consideration and debate on several issues: In what circumstances? Who should pay? How should the process be regulated? STUDY QUESTION: Our goals were to examine the approach to oocyte cryopreservation amongst attending in-vitro fertilization (IVF) physicians and amongst researchers in the field of bioethics and health regulation. METHODS: Questionnaires regarding egg freezing were given to physicians heading IVF departments in Israel, and to bioethics researchers / health care administrators. RESULTS: Among the two groups questioned, there is strong support (80%) for the freezing of oocytes for personal circumstances, which may not be purely medical. Despite this support, there appears to be a difference in reasoning for this support. While most physicians see no reason to inhibit using the technology, bioethicists attend to the conflict between personal liberties and potentially troubling ethical consequences on society when utilizing these technologies. There is an additional discrepancy between the groups concerning regulation. Physicians prefer regulation by administrative means, while bioethicists would prefer regulation by Laws. CONCLUSIONS: Despite widespread support of oocyte cryopreservation for personal reasons among the two groups questioned, their views arise from different rationales. implementation of egg freezing technologies requires careful interdisciplinary discussion in order to consider the various medical, ethical, and sociological factors that these technologies will incur.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills.

BACKGROUND: Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences. METHODS: The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM. RESULTS: We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills. CONCLUSIONS: We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

Is an exercise tolerance test indicated before beginning regular exercise? A decision analysis.

BACKGROUND AND OBJECTIVE: The present study, using a decision analysis, evaluates whether an exercise tolerance test (ETT) is indicated before initiating regular physical activity to reduce the risk of sudden death during exercise training. DESIGN: The study encompasses a decision tree, Monte Carlo simulation, and utility analysis for adults at low to high risk for coronary disease, with a time horizon of five years, with or without routine ETT screening before initiating physical activity. MEASURES: Mortality in Monte Carlo simulation; expected values in utility analysis. RESULTS: Routine screening decreases mortality in intermediate to high-risk populations but not in low-risk persons. At all risk levels, the number of exercise-induced deaths prevented is less than the added number of deaths from angiography. Utility analysis indicates inferiority of routine screening, regardless of risk. Personal preferences (perceived stigma from having coronary disease and perceived benefit of regular exercise on quality of life) have a strong influence on the optimal choice. CONCLUSION: Routine screening before initiating regular exercise is not recommended for the purpose of reducing the risk of sudden death during exercise training.

Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients.

BACKGROUND: Spontaneous bacterial peritonitis is a complication of cirrhotic ascites that occurs in the absence of any intra-abdominal, surgically treatable source of infection. Antibiotic therapy is indicated and should be initiated as soon as possible to avoid severe complications that may lead to death. It has been proposed that empirical treatment should cover gram-negative enteric bacteria and gram-positive cocci, responsible for up to 90% of spontaneous bacterial peritonitis cases. OBJECTIVES: This review aims to evaluate the beneficial and harmful effects of different types and modes of antibiotic therapy in the treatment of spontaneous bacterial peritonitis in cirrhotic patients. SEARCH STRATEGY: We performed electronic searches in The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2008), MEDLINE (1950 to July 2008), EMBASE (1980 to July 2008), and Science Citation Index EXPANDED (1945 to July 2008). In addition, we handsearched the references of all identified studies and contacted the first author of each included trial. SELECTION CRITERIA: Randomised studies comparing different types of antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. DATA COLLECTION AND ANALYSIS: Data were independently extracted from the trials by at least two authors. Peto odds ratios or average differences, with their 95% confidence intervals, were estimated. MAIN RESULTS: This systematic review attempted to summarise evidence from randomised clinical trials on the treatment of spontaneous bacterial peritonitis. Thirteen studies were included; each one of them compared different antibiotics in their experimental and control groups. No meta-analyses could be performed, though data on the main outcomes were collected and analysed separately for each included trial. Currently, the evidence showing that lower dosage or short-term treatment with third generation cephalosporins is as effective as higher dosage or long-term treatment is weak. Oral quinolones could be considered an option for those with less severe manifestations of the disease. AUTHORS' CONCLUSIONS: This review provides no clear evidence for the treatment of cirrhotic patients with spontaneous bacterial peritonitis. In practice, third generation cephalosporins have already been established as the standard treatment of spontaneous bacterial peritonitis, and it is clear, that empirical antibiotic therapy should be provided in any case. However, until large, well-conducted trials provide more information, practice will remain based on impression, not evidence.

Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding.

BACKGROUND: Spontaneous bacterial peritonitis is frequent among cirrhotic patients, associated with significant morbidity and mortality. Selective intestinal decontamination employing antibiotics is a proposed prophylactic measure. While data regarding this modality among cirrhotic patients with gastrointestinal bleeding exist, there is insufficient data synthesis regarding cirrhotic patients with ascites and no gastrointestinal bleeding. OBJECTIVES: To assess whether antibiotic prophylaxis decreases spontaneous bacterial peritonitis and mortality among cirrhotic patients with ascites and no gastrointestinal bleeding. SEARCH STRATEGY: We identified relevant randomised trials by searching trial registries of The Cochrane Hepato-Biliary Group and The Cochrane Collaboration, medical literature search engines, and reviewing all literature we found on the topic until February 2009. SELECTION CRITERIA: We searched for randomised clinical trials assessing prophylactic treatment among adult cirrhotic patients with ascites and no gastrointestinal bleeding, comparing antibiotic therapy with no intervention, placebo, or with another antibiotic regimen. DATA COLLECTION AND ANALYSIS: Three independent authors searched for and collected the trials and extracted relevant data. Four other independent authors validated the findings and assessed them. The studies were assessed for design, patient and intervention characteristics, and quality. A meta-analysis was performed to estimate measures of association between antibiotic prophylaxis and spontaneous bacterial peritonitis or mortality. MAIN RESULTS: Nine trials were included in the review. Seven trials, comparing antibiotics to placebo or no treatment, were meta-analysed. Systematic bias in design or publication is suggested by trial results. The randomisation results suggest that the probability that true randomisation took place in all trials is very small and the report of most trials regarding design was poor. The proportion of participants with spontaneous bacterial peritonitis varied between the trials from 15% to 50%. The calculated relative risks (95% confidence interval) of spontaneous bacterial peritonitis and mortality among patients treated with antibiotics compared with no treatment/placebo were 0.20 (0.11 to 0.37) and 0.61 (0.43 to 0.87). There were very few reports of adverse events. AUTHORS' CONCLUSIONS: The pooled estimates suggest that antibiotic prophylaxis might be prudent among cirrhotic patients with ascites and no gastrointestinal bleeding. However, poor trial methodology and report coupled with findings suggesting systematic bias in publication and design reflect the fragility of these findings. Potential hazard to society and the patients themselves from resistant pathogens should be considered when promoting long-lasting antibiotic prophylaxis. It seems that recommending antibiotic prophylaxis is still far from being a substantiated prevention strategy. Trials of better design, well reported, and of longer follow-up are greatly needed.

Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors?

PURPOSE: Although transparency is critical for reducing medical errors, physicians feel discomfort with disclosure. We explored whether overconfidence relates to physician's reluctance to admit that an error may have occurred. METHOD: At 3 university medical centers, a survey presented a clinical vignette of a girl with urinary infection and penicillin allergy to medical students and physicians, asking them to rate their level of confidence for each step of the diagnosis and management. After anaphylaxis develops after cephalosporin administration, respondents were asked about their willingness to admit that an error might have occurred and to rate their level of discomfort in doing so. We analyzed levels of confidence, accuracy, willingness to admit mistake, and discomfort. RESULTS: Respondents reported high levels of confidence for their answers to the questions of diagnosis and management, even when wrong-indicating miscalibration of confidence and accuracy. Compared with students, physicians had significantly higher levels of confidence, lower accuracy, and lower willingness to admit mistake. Although most respondents agreed in principle that errors should be disclosed, in the presented case, significantly less agreed to admit that a mistake might have occurred or to say so explicitly to the family. An association was found between overconfidence and discomfort with disclosure. CONCLUSIONS: Our study shows overconfidence associated with clinician's training and with reluctance to admit mistake, suggesting a contributing role to the difficulty in leveraging safety events into quality improvement. Training physicians to have both knowledge and adequate self-doubt is an educational challenge.

A systematic review of interventions to increase awareness, knowledge, and folic acid consumption before and during pregnancy.

OBJECTIVE: We conducted a systematic review of studies designed to increase awareness of knowledge about, and consumption of folic acid before and during pregnancy. DATA SOURCES: Studies were identified from Cochrane Library, Medline, and the references of primary studies and reviews. STUDY INCLUSION AND EXCLUSION CRITERIA: Studies included randomized controlled trials, quasi-experimental interrupted time series studies, follow-up studies, case-control studies, and before-and-after studies, all of which were conducted between 1992 and 2005 on women ages 15 to 49 years and/or health professionals, evaluating awareness and/or knowledge and/or consumption of folic acid both before and after intervention. Studies were excluded if data were not presented both before and after intervention or were other outcomes than those mentioned here. DATA EXTRACTION: Data were extracted in relation to characteristics of studies, participants, interventions, and outcomes. DATA SYNTHESIS: Because of heterogeneity, we performed a narrative synthesis describing the direction and the size of effects. RESULTS: On average, women's awareness increased from 60% to 72%, knowledge from 21% to 45%, and consumption from 14% to 23%. CONCLUSIONS: Interventions had a positive effect on folic acid intakes before and during pregnancy, although the average usage reached less than 25%.