Implementation of entrustable professional activities in multiple surgical residencies: A quality improvement approach.

BACKGROUND: The COVID-19 pandemic decreased the operative case volume for surgical residents. Our institution implemented Entrustable Professional Activities (EPAs) in all core surgical training programs to document the competency of graduating residents. Continuation of this project aimed to improve implementation. METHODS: This project occurred at a large academic center with eight surgical specialties during the 2020-21 (Year 1) and 2021-22 (Year 2) academic years. Each specialty chose five EPAs, and residents were asked to obtain three micro-assessments per EPA. After the initial pilot year, program directors were surveyed regarding perceptions of EPA utility and barriers to implementation. RESULTS: Seventy senior residents completed 732/906 (80.8%) micro-assessments. Of these, 99.6% were deemed practice ready. Total micro-assessment completion rates in four specialties, four specific EPAs (including one EPA identified "at risk" due to the COVID-19 pandemic), and overall were significantly higher in Year 2 than Year 1 (p â€‹< â€‹0.05) CONCLUSIONS: Implementing EPAs in all core surgical specialties at an institution is achievable, though expectedly initially imperfect. An ongoing quality collaborative initiative focused on barriers to implementation can improve completion rates.

Implementation of a deidentified federated data network for population-based cohort discovery.

OBJECTIVE: The Cross-Institutional Clinical Translational Research project explored a federated query tool and looked at how this tool can facilitate clinical trial cohort discovery by managing access to aggregate patient data located within unaffiliated academic medical centers. METHODS: The project adapted software from the Informatics for Integrating Biology and the Bedside (i2b2) program to connect three Clinical Translational Research Award sites: University of Washington, Seattle, University of California, Davis, and University of California, San Francisco. The project developed an iterative spiral software development model to support the implementation and coordination of this multisite data resource. RESULTS: By standardizing technical infrastructures, policies, and semantics, the project enabled federated querying of deidentified clinical datasets stored in separate institutional environments and identified barriers to engaging users for measuring utility. DISCUSSION: The authors discuss the iterative development and evaluation phases of the project and highlight the challenges identified and the lessons learned. CONCLUSION: The common system architecture and translational processes provide high-level (aggregate) deidentified access to a large patient population (>5 million patients), and represent a novel and extensible resource. Enhancing the network for more focused disease areas will require research-driven partnerships represented across all partner sites.

Using RxNorm for cross-institutional formulary data normalization within a distributed grid-computing environment.

Within the CTSA (Clinical Translational Sciences Awards) program, academic medical centers are tasked with the storage of clinical formulary data within an Integrated Data Repository (IDR) and the subsequent exposure of that data over grid computing environments for hypothesis generation and cohort selection. Formulary data collected over long periods of time across multiple institutions requires normalization of terms before those data sets can be aggregated and compared. This paper sets forth a solution to the challenge of generating derived aggregated normalized views from large, distributed data sets of clinical formulary data intended for re-use within clinical translational research.

The Biomedical Resource Ontology (BRO) to enable resource discovery in clinical and translational research.

The biomedical research community relies on a diverse set of resources, both within their own institutions and at other research centers. In addition, an increasing number of shared electronic resources have been developed. Without effective means to locate and query these resources, it is challenging, if not impossible, for investigators to be aware of the myriad resources available, or to effectively perform resource discovery when the need arises. In this paper, we describe the development and use of the Biomedical Resource Ontology (BRO) to enable semantic annotation and discovery of biomedical resources. We also describe the Resource Discovery System (RDS) which is a federated, inter-institutional pilot project that uses the BRO to facilitate resource discovery on the Internet. Through the RDS framework and its associated Biositemaps infrastructure, the BRO facilitates semantic search and discovery of biomedical resources, breaking down barriers and streamlining scientific research that will improve human health.

Compliance with the American Academy of Ophthalmology Preferred Practice Pattern for Diabetic Retinopathy in a resident ophthalmology clinic.

PURPOSE: The purpose of this study was to evaluate compliance with the American Academy of Ophthalmology Diabetic Retinopathy (DR) Preferred Practice Pattern for an initial DR examination in a resident ophthalmology clinic. METHODS: Adult patients with diabetes were included if seen in the resident ophthalmology clinic at a Veterans Affairs Medical Center for an initial DR examination between July 2006 and June 2007. Medical records were reviewed for compliance with the 29 applicable elements from the American Academy of Ophthalmology DR Preferred Practice Pattern. RESULTS: Of 451 diabetic patient visits in the ophthalmology clinic in the study period, 70 met inclusion criteria. The overall mean compliance rate was 52%. Compliance was best in the categories of examination (mean = 87%), diagnosis (mean = 82%), and treatment (mean = 74%). Compliance was lowest in the categories of medical history (mean = 11%) and counseling/referral (mean = 34%). CONCLUSION: Compliance with both practice and documentation of American Academy of Ophthalmology DR Preferred Practice Pattern guidelines at a resident ophthalmology clinic should be monitored, especially in the areas of medical history, patient education, and referrals. A target level of compliance should be set and maintained in all the DR Preferred Practice Pattern categories, especially in a teaching hospital where residents are developing their approach to quality care.

Cardiovascular disease in women--challenges deserving a comprehensive translational approach.

Heart disease in women is associated with high levels of morbidity and mortality. Although many of the underlying causes are similar for both genders, cardiovascular disease among women has some unique features, including higher coronary heart disease mortality, higher frequency of sudden cardiac death without previous symptoms, and increased mortality among older women compared to men following a myocardial infarction. During recent years, increasing efforts have been placed on identifying preventive measures, but translation of knowledge from epidemiological studies and clinical trials remain incomplete, particularly in women. The recent launch of the National Institutes of Health's Clinical and Translational Science Award program offers opportunities to address these gaps and represent a unique opportunity to foster a new generation of researchers familiar with important issues regarding women's cardiovascular health.

Evidence-based management of resident-performed cataract surgery: an investigation of compliance with a preferred practice pattern.

PURPOSE: To evaluate compliance with the American Academy of Ophthalmology (AAO) Cataract in the Adult Eye Preferred Practice Pattern (PPP) in a resident ophthalmology clinic. DESIGN: Retrospective chart review. PARTICIPANTS: All patients undergoing first-eye cataract surgery by ophthalmology residents with attending supervision at a Veterans Affairs Medical Center between January 1, 2006, and July 31, 2007. METHODS: Electronic medical records (EMRs) were reviewed for compliance with the AAO Cataract in the Adult Eye PPP. MAIN OUTCOME MEASURES: Frequency of resident compliance with all 39 elements of the AAO Cataract in the Adult Eye PPP. RESULTS: A total of 129 patients met the inclusion criteria. The mean compliance with the PPP was 81%, with 62% of the elements having 90% or greater compliance. Compliance was below the mean for those PPP elements requiring patient input or assessment, including 0% for considering patient preference in the determination of anesthesia management, 73% for patient assessment of preoperative functional status, and 66% for patient assessment of postoperative vision. CONCLUSIONS: Compliance with the AAO Cataract in the Adult Eye PPP in this resident ophthalmology clinic can be improved by increasing the documentation of patient input about their visual function both preoperatively and postoperatively. Further study of compliance with evidence-based guidelines is needed in ophthalmology, particularly in teaching hospitals where new providers are developing their approach to care.

U-Scores for Multivariate Data in Sports.

In many sport competitions athletes, teams, or countries are evaluated based on several variables. The strong assumptions underlying traditional 'linear weight' scoring systems (that the relative importance, interactions and linearizing transformations of the variables are known) can often not be justified on theoretical grounds, and empirical 'validation' of weights, interactions and transformations, is problematic when a 'gold standard' is lacking. With µ-scores (u-scores for multivariate data) one can integrate information even if the variables have different scales and unknown interactions or if the events counted are not directly comparable, as long as the variables have an 'orientation'. Using baseball as an example, we discuss how measures based on µ-scores can complement the existing measures for 'performance' (which may depend on the situation) by providing the first multivariate measures for 'ability' (which should be independent of the situation). Recently, µ-scores have been extended to situations where count variables are graded by importance or relevance, such as medals in the Olympics (Wittkowski 2003) or Tour-de-France jerseys (Cherchye and Vermeulen 2006, 2007). Here, we present extensions to 'censored' variables (life-time achievements of active athletes), penalties (counting a win more than two ties) and hierarchically structured variables (Nordic, alpine, outdoor, and indoor Olympic events). The methods presented are not restricted to sports. Other applications of the method include medicine (adverse events), finance (risk analysis), social choice theory (voting), and economy (long-term profit).

Fungal keratitis caused by Paecilomyces lilacinus associated with a retained intracorneal hair.

OBJECTIVE: To report a case of fungal keratitis caused by Paecilomyces lilacinus (P. lilacinus) associated with a retained intracorneal hair. METHODS: A 61-year-old man developed pain, decreased vision, hyperemia, and corneal infiltrates in his right eye without any predisposing factor. An intracorneal hair had migrated superiorly in the corneal stroma, giving rise to 3 separate stromal infiltrates. The patient demonstrated a waxing and waning course over several months despite antimicrobial and steroid therapy. RESULTS: Histopathologic examination of a corneal biopsy specimen disclosed the presence of fungal elements, and intensive antifungal therapy was initiated. Verticillium sp. was initially identified as the causative organism, but after failure to improve on topical natamycin, subsequent investigations demonstrated the pathogen to be P. lilacinus that was resistant to routine antifungal agents. The patient was then initiated on systemic voriconazole and terbinafine. He responded well to treatment and ultimately recovered a best-corrected visual acuity of 6/15 in the affected eye. CONCLUSION: This is the first case of P. lilacinus keratitis associated with a retained intracorneal hair. Hair in the cornea could be a predisposing factor for this infection. Early corneal biopsy should be considered to properly diagnose and manage atypical keratitis and to prevent further complications.