A qualitative study on the impact of long-distance travel for gynecologic cancer care.

BACKGROUND: Women with gynecologic malignancies experience improved clinical outcomes when they are treated by gynecologic oncologists and in high-volume cancer centers. However, geography is a major barrier to high-volume care for patients. This qualitative study was undertaken to identify facilitators and barriers to patients traveling long distances for gynecologic cancer care. METHODS: Semi-structured interviews were conducted with 19 women with gynecologic malignancies traveling >50 miles for treatment at Wake Forest Comprehensive Cancer Center. Eight interviews included caregivers. Four interview domains focused on personal challenges and coping strategies related to accessing cancer care. RESULTS: Mean distance traveled for care was 87 miles (range: 54-218). Most participants reported that recommendations from physicians, friends, and family motivated travel. 10/19 participants were aware of closer sites for cancer care; 5 had unfavorable experiences elsewhere. Barriers to travel included time, cost, childcare, difficulty navigating, and physical discomfort. Social support was an important facilitator of travel for care; some patients utilized loaned money or vehicles. Participants reported significant energy expenditure scheduling travel, coordinating time off work, and arranging overnight stays near the cancer center. Suggestions for care improvement included travel vouchers, transportation assistance, signage and personnel to help with navigation, and appointments later in the day. Participants supported in-person oncologist outreach to rural areas and appointments via telemedicine; few preferred the current infrastructure. CONCLUSION: Patients who travel long distances for gynecologic cancer care encounter significant burdens and rely heavily on social and financial support. Interventions should be developed and evaluated to reduce the burden of long-distance travel and develop efficient methods of outreach, including telemedicine.

Validation and Testing of an E-Learning Module Teaching Core Urinary Incontinence Objectives in a Randomized Controlled Trial.

OBJECTIVES: To evaluate the efficacy of a urinary incontinence (UI) e-learning module (ELM) in undergraduate medical education. METHODS: An ELM was developed and validated to teach on UI learning objectives. A 21-item assessment was developed to test knowledge gained. A randomized-controlled trial and parallel nested-cohort study were performed to test the effectiveness of the validated UI-ELM compared with standard methods of UI learning. Students were recruited and enrolled at the onset of their obstetrics and gynecology clerkship. Assignments to either a week-long rotation of gynecologic (GYN) or urogynecologic (UroGyn) surgery were made independent of the study protocol. On the GYN rotation, students were randomly assigned to the UI-ELM intervention or no intervention (control group). The nested-cohort comprised students assigned to the UroGyn rotation. Parametric statistics were applied assessing score changes between the UI-ELM versus control/UroGyn groups. RESULTS: Eighty-three students rotated between June 2015 and February 2016. Fifty-five were assigned to GYN and randomized: 35 UI-ELM versus 20 no intervention; 28 were assigned to UroGyn. Students randomized to the UI-ELM had greater score improvement compared with controls (between group difference of +2.73; 95% confidence interval, 0.53-4.93; P = 0.02). Knowledge improvement was similar between students exposed to the UI-ELM compared with those with UroGyn exposure (between group difference, +0.91; 95% confidence interval, -1.05 to 2.88; P = 0.35). CONCLUSIONS: The UI-ELM resulted in greater improvement in UI knowledge among third year medical students compared with traditional methods of learning and similar to those exposed to a UroGyn rotation.

Optimizing the amount of simulation training used to teach vaginal delivery skills to medical students.

OBJECTIVE: To determine the amount of simulation training required for students to attain minimal competence and mastery of a vaginal delivery. METHODS: An observational study was conducted at a US medical school between May 11, 2015, and May 8, 2016. Using a modified Angoff method, 10 members of the Obstetrics and Gynecology faculty evaluated a vaginal delivery procedural checklist and established cutoff scores for minimal competence and mastery. During a 5-week period, all third-year students received between two and five 45-minute vaginal delivery simulation sessions; performance was assessed during week 6. Performance according to the checklist was compared. RESULTS: The cutoff score was 20 and 26 out of 30 for minimal competence and mastery, respectively. Among 115 students, mean checklist scores in final assessment rose with increasing number of simulations: 23.6, 25.1, 27.5, and 27.6 points for two, three, four, and five training sessions, respectively (P<0.001). The proportion of patients achieving mastery also increased with number of simulations: 34%, 59%, 73%, and 93% for two, three, four, and five training sessions, respectively (P<0.001). Two or three training sessions were sufficient to attain minimal competence in most students; however, no significant between-group difference was found. CONCLUSION: Simulation training exerts an increasing effect on performance with each additional session that students receive.

The Maternal Quality Improvement Program: A Clinical Data-Driven National Registry for Maternity Care.

Advancing the quality and safety of maternity care should be data-driven. Defining a standard set of clinical data elements, across electronic health record platforms and facilities, could accelerate performance measurement, benchmarking, and identification of better practices. In 2014, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists launched the Maternal Quality Improvement Program, a data-driven national clinical registry for maternity care. Having an agreed-on set of discrete data elements related to labor and delivery will set the stage for analysis of this care. Through the use of clinical performance measures and data quality metrics, the Maternal Quality Improvement Program will provide an opportunity for health care providers to better understand the overall quality and safety of the maternity care provided within their institution.