The effects of graduate competency-based education and mastery learning on patient care and return on investment: a narrative review of basic anesthetic procedures.

BACKGROUND: Despite the widespread implementation of competency-based education, evidence of ensuing enhanced patient care and cost-benefit remains scarce. This narrative review uses the Kirkpatrick/Phillips model to investigate the patient-related and organizational effects of graduate competency-based medical education for five basic anesthetic procedures. METHODS: The MEDLINE, ERIC, CINAHL, and Embase databases were searched for papers reporting results in Kirkpatrick/Phillips levels 3-5 from graduate competency-based education for five basic anesthetic procedures. A gray literature search was conducted by reference search in Google Scholar. RESULTS: In all, 38 studies were included, predominantly concerning central venous catheterization. Three studies reported significant cost-effectiveness by reducing infection rates for central venous catheterization. Furthermore, the procedural competency, retention of skills and patient care as evaluated by fewer complications improved in 20 of the reported studies. CONCLUSION: Evidence suggests that competency-based education with procedural central venous catheterization courses have positive effects on patient care and are both cost-effective. However, more rigorously controlled and reproducible studies are needed. Specifically, future studies could focus on organizational effects and the possibility of transferability to other medical specialties and the broader healthcare system.

Flexible competency based medical education: More time efficient, higher costs.

The financing of postgraduate medical education (PGME) becomes an important topic. PGME is costly, and in most western countries is partly paid by public funding. One of the models that can help to reduce costs is time-variable PGME. Moving to true outcome-based education can lead to more efficient training programs while maintaining educational quality. We analyzed the financial effects of time-variable PGME by identifying the educational activities of PGME programs and comparing the costs and revenues of these activities in gynecology training as an example. This resulted in a revenue-cost balance of PGME activities in gynecology. As gynecology consists of both surgical and non-surgical parts, this specialty is a good starting point for a training cost analysis that can be used for a more general discussion. Shortening PGME programs without losing educational quality appears to be possible with time-variable structures. However, shortening is only safely possible on those areas in which residents have already obtained the desired level of competence. This means that time can be gained at the expense of those educational activities in which residents generate the highest revenues. We therefore conclude that shorter education with the help of time-variable training schemes leads to overall higher costs at the hospital level.

A Cost-Effectiveness Analysis of Blended Versus Face-to-Face Delivery of Evidence-Based Medicine to Medical Students.

BACKGROUND: Blended learning describes a combination of teaching methods, often utilizing digital technologies. Research suggests that learner outcomes can be improved through some blended learning formats. However, the cost-effectiveness of delivering blended learning is unclear. OBJECTIVE: This study aimed to determine the cost-effectiveness of a face-to-face learning and blended learning approach for evidence-based medicine training within a medical program. METHODS: The economic evaluation was conducted as part of a randomized controlled trial (RCT) comparing the evidence-based medicine (EBM) competency of medical students who participated in two different modes of education delivery. In the traditional face-to-face method, students received ten 2-hour classes. In the blended learning approach, students received the same total face-to-face hours but with different activities and additional online and mobile learning. Online activities utilized YouTube and a library guide indexing electronic databases, guides, and books. Mobile learning involved self-directed interactions with patients in their regular clinical placements. The attribution and differentiation of costs between the interventions within the RCT was measured in conjunction with measured outcomes of effectiveness. An incremental cost-effectiveness ratio was calculated comparing the ongoing operation costs of each method with the level of EBM proficiency achieved. Present value analysis was used to calculate the break-even point considering the transition cost and the difference in ongoing operation cost. RESULTS: The incremental cost-effectiveness ratio indicated that it costs 24% less to educate a student to the same level of EBM competency via the blended learning approach used in the study, when excluding transition costs. The sunk cost of approximately AUD $40,000 to transition to the blended model exceeds any savings from using the approach within the first year of its implementation; however, a break-even point is achieved within its third iteration and relative savings in the subsequent years. The sensitivity analysis indicates that approaches with higher transition costs, or staffing requirements over that of a traditional method, are likely to result in negative value propositions. CONCLUSIONS: Under the study conditions, a blended learning approach was more cost-effective to operate and resulted in improved value for the institution after the third year iteration, when compared to the traditional face-to-face model. The wider applicability of the findings are dependent on the type of blended learning utilized, staffing expertise, and educational context.

Resource requirements for a quality Doctor of Nursing Practice program.

Fundamental to planning, implementing, and sustaining a quality Doctor of Nursing Practice (DNP) program is access to the resources needed to foster a learning environment that prepares nurses for advanced practice and leadership in the future redesigned health care system. This creates formidable challenges for schools and colleges of nursing as they endeavor to address the nation's need for an increased supply of advanced practice nurses to provide access to high-quality, cost-effective care for an aging population. This article describes the essential resources needed to support the delivery of a DNP program and the proposed strategies needed to address the resource challenges.

Assessment of surgical residents in a vascular anastomosis laboratory.

BACKGROUND: We designed a simple, low-cost workshop to teach surgical residents the basic skills of vascular anastomosis. We studied our ability to identify objective procedural and end-product metrics that could be used to measure improvement in vascular anastomotic skill before and after training. MATERIALS AND METHODS: Ten postgraduate year 2 residents without previous vascular surgery experience and four attending surgeons (expert) performed end-to-side anastomosis using a synthetic graft. The residents were taught the basic skills of vascular anastomosis during three didactic workshops. The objective metrics included volume leakage after saline perfusion (leak) and the time needed to complete the anastomosis. Penalty points were assigned for broken sutures, air knots, locking sutures, and failure to maintain an outside-in to inside-out technique. The leak, time, and penalties before and after training were compared. RESULTS: The mean leak was 70.4 ± 13.7 mL and the mean completion time was 18.7 ± 3 min for the pretraining group versus 45.3 ± 10.6 mL (P < 0.01) and 8.5 ± 1 min (P < 0.001), respectively, for the attending group. After training, significant improvement was seen in resident leak (46.7 ± 6.8 mL; P < 0.001) and completion time (14.4 ± 3 min; P < 0.01). Leak was similar between the post-training and expert groups (46.7 ± 6.8 mL and 45.3 ± 10.6 mL, respectively; P = 0.77); however, a significant difference for the completion time remained (14.4 ± 3.0 min and 8.5 ± 1 min, respectively; P < 0.01). The mean number of technical errors improved from 2.7 in the pretraining group to zero for the post-training group after completing the workshop. CONCLUSIONS: We have reported an easy to implement workshop for teaching surgical residents the basic skills of performing vascular anastomosis.

A cost-effectiveness analysis of the Incredible Years parenting programme in reducing childhood health inequalities.

Early onset of behavioural problems has lasting negative effects on a broad range of lifetime outcomes, placing large costs on individuals, families and society. A number of researchers and policy makers have argued that early interventions aimed at supporting the family is the most effective way of tackling child behaviour problems. This study forms the economic component of a randomised evaluation of the Incredible Years programme, a programme aimed at improving the skills and parenting strategies of parents of children with conduct problems. Our results show that the programme provides a cost-effective way of reducing behavioural problems. Furthermore, our cost analysis, when combined with a consideration of the potential long-run benefits, suggests that investment in such programmes may generate favourable long-run economic returns.

Opportunity costs of gastrointestinal endoscopic training in Canada.

BACKGROUND: No data exist to define the opportunity costs related to instruction in endoscopic procedures in Royal College of Physicians and Surgeons of Canada-accredited teaching centres. Academic and institutional administrators expect staff to achieve acceptable performance standards. There is a need to measure some of the effects of training activity in the establishment of such standards. OBJECTIVE: To measure the effect of resident training in colonoscopy on real procedure times and, as a secondary goal, to estimate procedural losses related to the process of training. METHODS: Real procedure times for ambulatory colonoscopy in a single academic, hospital-based endoscopy unit were documented. Times for certified endoscopy instructors functioning solo were compared with times for procedures involving trainees at several levels of colonoscopic experience. Procedural reductions associated with resident training were estimated based on the parameters derived from the results. The analysis was executed retrospectively using prospectively collected data. RESULTS: Resident training prolonged procedure times for ambulatory colonoscopy by 50%. The trainee effect was consistent, although variable in degree, among a variety of endoscopy instructors. Such increased procedure times have the potential to reduce case throughput and endoscopist remuneration. CONCLUSIONS: Resident training in colonoscopy in a Canadian certified training program has significant negative effects on case throughput and endoscopist billings. These factors should be considered in any assessment of performance in similar training environments.

Using technology in resource limited countries for competency based education and training.

Competency based education and training (CBET) helps to prepare graduates of medical laboratory science programs for the specific needs of the workforce. This is especially important in resource-limited countries where shortage of laboratory personnel creates a large demand for skilled graduates. Internet and other technology can be useful to teach specific tasks in CBET. Even in resource-limited countries, technology can be used in the implementation of competency based education and training curricula in medical laboratory programs.

The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship--a response to the economic pressures facing academic medicine today.

BACKGROUND: In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship. METHODS: Sixty-three medical students participated in a skills training laboratory. The first part of the laboratory taught basic suturing skills, and the second involved a cadaver with pig skin grafted to different anatomic locations. Clinical scenarios were simulated, and students performed essential procedural skills. RESULTS: Students learned most of their suturing skills in the laboratory skills sessions, compared with the emergency room or the operating room (P = .01). Students reported that the laboratory allowed them greater opportunity to participate in the emergency room and operating room. Students also felt that the suture laboratory contributed greatly to their skills in wound closure. Finally, 90% of students had never received instruction on suturing, and only 12% had performed any procedural skills before beginning the surgery rotation. CONCLUSIONS: The laboratory described is an effective way of insuring that necessary technical skills are imparted during the surgery rotation.

Pretraining on Southwestern stations decreases training time and cost for proficiency-based fundamentals of laparoscopic surgery training.

BACKGROUND: We previously reported a proficiency-based Fundamentals of Laparoscopic Surgery (FLS) curriculum that uniformly resulted in passing the technical skills certification criteria. We hypothesized that pretraining using the Southwestern (SW) videotrainer stations would decrease costs and training time and maintain benefits. STUDY DESIGN: Group I (2nd-year medical student, n = 10) underwent FLS pretesting (Pretest 1), SW station proficiency-based training, repeat FLS testing (Pretest 2), FLS proficiency-based training, and final FLS testing (Posttest). These data were compared with a historic control, group II (2nd-year medical student, n = 10), which underwent FLS pretesting (Pretest 1), proficiency-based training, and final FLS testing (Posttest). RESULTS: During training, group I achieved proficiency (85.4 + or - 26.2 repetitions) for all SW tasks. For both groups, proficiency was achieved for 96% of the FLS tasks, with substantial differences detected for group I and group II repetitions (100.5 + or - 15.9 versus 114 + or - 25.5) and training time (6.0 + or - 1.5 versus 9.2 + or - 2.2 hours), respectively. Per-person material costs were considerably different for groups I and II ($827 + or - 116 versus $1,108 + or - 393). Group I demonstrated significant improvement from Pretest 1 (149 + or - 39; 0% FLS pass rate) to Pretest 2 (293 + or - 83; p < 0.001; 60% FLS pass rate), and to Posttest (444 + or - 60; p < 0.001; 100% FLS pass rate). Group II demonstrated significant improvement from Pretest 1 (158 + or - 78; 0% FLS pass rate) to Posttest (469.7 + or - 12.0; p < 0.001; 100% FLS pass rate). CONCLUSIONS: Pretraining on SW stations decreases training time for FLS skill acquisition and maintains educational benefits. This strategy decreases costs associated with using consumable materials for training.

Four-year experience with a regional program providing simulation-based endovascular training for vascular surgery fellows.

PURPOSE: High-fidelity procedure simulation has been found useful for training vascular surgery residents in endovascular procedures, but the costs of acquiring, maintaining, and operating simulators represent a barrier to routine use of endovascular simulation in vascular surgery programs. Providing simulation training opportunities through regional centers may make simulation more cost effective, but the costs and benefits of this approach have not been reported previously. We reviewed participation costs in a regional simulation program to provide a benchmark for comparison with other training options. METHODS: Simulation-based training was offered annually from 2004 to 2007 to the 11 vascular surgery fellowships in Washington, Oregon, California, Arizona, and Utah. Participation was at the discretion of the program directors and fellows. Sessions were designed to offer individualized, hands-on training with 2-4 participants per 2-day session. SimSuite (Medical Simulation Corporation, Denver, Colorado) simulators were used. RESULTS: During the 4-year period, participation by invited programs averaged 75%. Ten of 11 programs in the western United States region participated, with 34 fellows participating during the 4 years of the program. In addition, 2 program directors or faculty attended sessions to participate as learners, and 8 other individuals were allowed to participate (including 7 senior surgery residents and 1 vascular surgery fellow from out of the region). The average participant costs for travel, which include transportation, lodging, and meals, were $571. Simulation facility expenses, which included use of the simulator, computer-based training modules, and instructional support by an educational specialist, averaged $1055 per participant. Surgical faculty spent 12 hours per 2-day session instructing and in other direct educational activities. Costs for this time were not calculated separately. CONCLUSIONS: Vascular surgery fellows' participation in simulation training at regional centers offers program directors a lower cost alternative for providing high-fidelity simulation training, compared with acquiring and operating an endovascular procedure simulator at their individual institutions.

A cost-effective approach to establishing a surgical skills laboratory.

BACKGROUND: Recent studies comparing inexpensive low-fidelity box trainers to expensive computer-based virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. METHODS: Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. RESULTS: Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 2003-2004, $1,049; and 2004-2005, $982). CONCLUSIONS: Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources.

Correlación entre presión intraocular, paquimetría y queratometría en una población normal / Correlation between intraocular pressure paquimetry and keratometry in a normal population

Objetivo: Estudiar la distribución de la presión intraocular (PIO), paquimetría y queratometría en una población normal. Establecer las relaciones existentes entre estas variables y conocer la influencia de la edad y el estado refractivo. Métodos: En una muestra de 545 ojos de 273 sujetos, sin patología ocular previa, se ha evaluado el estado refractivo, curvatura corneal, grosor corneal central, PIO mediante tonometría de no contacto (TNC) y tonometría Goldman (TG). Resultados: La media de edad de la población fue de 49,34 DE 7,23 años (27-68). La paquimetría media fue de 544,3 DE 33 Ìm en mujeres y de 543,1 DE 29 Ìm en hombres. No se ha encontrado una asociación relevante entre paquimetría y edad. Se ha obtenido una correlación leve, pero significativa entre la paquimetría y la cifra de PIO para ambos métodos r = 0,316 (p < 0,001) y r = 0,264 (p < 0,001), con TNC Y TG respectivamente. No encontramos relación de la paquimetría ni con el estado refractivo ni con la K media. En nuestro modelo de regresión múltiple la paquimetría y la K media aparecieron como variables predictoras del cálculo de la PIO: R = 0,341 (p < 0,001). Conclusiones: La medida de espesor corneal central fue similar a la obtenida por otros estudios sobre población latina. Existe una paquimetría significativamente menor en el grupo de mayores de 54 años. Se ha definido la relación del grosor y la curvatura corneal con la PIO mediante un análisis de regresión lineal

Purpose: To study the intraocular pressure (IOP), the corneal thickness and the corneal curvature distribution in a normal population. To investigate the relation between these variables, and to determine if the IOP and the paquimetry will be modified by the refractive error and age. Methods: A population of 273 subjects, 545 eyes, without ocular pathology was selected. The refractive error, the corneal curvature, the corneal thickness and the IOP [with a non-contact tonometer (NCT) and with a Goldmann tonometer (GT)] were evaluated. Results: The average age of the population was 49.34 (SD 7.23) years (27-68). The average corneal thickness was 544.3 (SD 33) mm in females and 543.1 (SD 29) mm in males. An inverse correlation was found between corneal thickness and age but this was not significant statistically. A mildly statistically significant correlation was found between corneal thickness and intraocular pressure with both methods of measurement of IOP: r = 0.316 (p < 0,001) and r = 0.264 (p < 0,001), with NCT and GT respectively. No correlation was found between corneal thickness and refractive error, or with mean corneal curvature. In the regression model, corneal thickness and mean corneal curvature were significant in the IOP prediction: R = 0.341 (p < 0.001). Conclusion: Mean corneal thickness was very similar to that reported in other studies of a latin population. A statistically significant inferior corneal thickness has been found in people older than 54 years. The relationship between the corneal thickness and the corneal curvature with the IOP has been calculated by linear regression analyses

The new formal competency-based curriculum and informal curriculum at Indiana University School of Medicine: overview and five-year analysis.

There is growing recognition in the medical community that being a good doctor requires more than strong scientific knowledge and excellent clinical skills. Many key qualities are essential to providing comprehensive care, including the abilities to communicate effectively with patients and colleagues, act in a professional manner, cultivate an awareness of one's own values and prejudices, and provide care with an understanding of the cultural and spiritual dimensions of patients' lives. To ensure that Indiana University School of Medicine (IUSM) graduates demonstrate this range of abilities, IUSM has undertaken a substantial transformation of both its formal curriculum and learning environment (informal curriculum). The authors provide an overview of IUSM's two-part initiative to develop and implement a competency-based formal curriculum that requires students to demonstrate proficiency in nine core competencies and to create simultaneously an informal curriculum that models and supports the moral, professional, and humane values expressed in the formal curriculum. The authors describe the institutional and curricular transformations that have enabled and furthered the new IUSM curricular goals: changes in education administration; education implementation, assessment, and curricular design; admissions procedures; performance tracking; and the development of an electronic infrastructure to facilitate the expanded curriculum. The authors address the cost of reform and the results of two progress reviews. Specific case examples illustrate the interweaving of the formal competency curriculum through the students' four years of training, as well as techniques that are being used to positively influence the IUSM informal curriculum.

Professional development in the youth development field: issues, trends, opportunities, and challenges.

This chapter reviews key issues in professional development in the youth development field, describing important work done over the past two decades and lessons learned from major philanthropic investments in capacity building both nationally and locally.

An evaluation of the cost of designing, delivering and assessing an undergraduate communication skills module.

Communication skills courses are considered expensive to run in terms of time, human resource and finance. This paper reports on the financial cost of designing, delivering and assessing a communication skills module delivered to fifth-year medical students. Costs are classified into three categories: personnel, standardized patients and administrative. The total cost attributable to the design and delivery of the Communication Skills Module was 8987 Euros, comprising 7900 Euros personnel costs, 960 Euros standardized patient costs and 127 Euros administrative costs. The total cost for assessing communication skills by an OSCE was 7223 Euros. This comprised 5309 Euros personnel costs, 1600 Euros standardized patient costs and 314 Euros administrative costs. As communication skills are often taught by smaller faculty departments, such as that of general practice, justification of financial outlay is crucial. As doctor-patient communication is a generic skill, consideration needs to be given to reducing the burden of cost borne by the individual department providing the teaching.