Care Coordination Between Family Physicians and Palliative Care Physicians for Patients With Cancer: Results of a Quality Improvement Initiative.

PURPOSE: At our institution's cancer palliative care (PC) clinic, new referrals from oncologists were scheduled for consultation and ongoing follow-up by PC physicians without input from the patients' family physicians (FPs). FPs reported that they felt out of the loop. We implemented a quality improvement (QI) initiative aimed at systematically facilitating care coordination between FPs and PC physicians. METHODS: A coordination toolkit was sent from the PC physician to the FP whenever the PC physician received a consultation request from an oncologist. The toolkit included an introduction to the PC physician team; an opportunity for the FP to choose how best to collaborate with PC physicians to meet the patient's PC needs; and contact information for access to 24/7 PC physician support. Responses from FPs regarding their preferred level of engagement with PC determined further care planning in the clinic. We measured feasibility, response rate, and qualitative surveys of FPs about the usefulness of the intervention. RESULTS: Two hundred fourteen new consultations were eligible for a standardized letter over the 6-month implementation period. Feasibility for sending the toolkit was 90.0% and response rate for collaborative care preference from FPs was 86.0%, with median response time of 3-4 days. 78.9% of FPs indicated they would prefer ongoing consultative care by the PC physician, while 18.6% indicated that PC physician consultation was not needed, or that the FP would provide primary PC after a one-time PC physician consultation. CONCLUSION: We successfully implemented a QI initiative to improve care coordination between FPs and PC physicians for patients with cancer. The coordination toolkit can protect the patient-FP primary PC relationship and optimize specialist PC resource utilization for complex patients.

Use of Machine Learning to Assess Cataract Surgery Skill Level With Tool Detection.

Purpose: To develop a method for objective analysis of the reproducible steps in routine cataract surgery. Design: Prospective study; machine learning. Participants: Deidentified faculty and trainee surgical videos. Methods: Consecutive cataract surgeries performed by a faculty or trainee surgeon in an ophthalmology residency program over 6 months were collected and labeled according to degrees of difficulty. An existing image classification network, ResNet 152, was fine-tuned for tool detection in cataract surgery to allow for automatic identification of each unique surgical instrument. Individual microscope video frame windows were subsequently encoded as a vector. The relation between vector encodings and perceived skill using k-fold user-out cross-validation was examined. Algorithms were evaluated using area under the receiver operating characteristic curve (AUC) and the classification accuracy. Main Outcome Measures: Accuracy of tool detection and skill assessment. Results: In total, 391 consecutive cataract procedures with 209 routine cases were used. Our model achieved an AUC ranging from 0.933 to 0.998 for tool detection. For skill classification, AUC was 0.550 (95% confidence interval [CI], 0.547-0.553) with an accuracy of 54.3% (95% CI, 53.9%-54.7%) for a single snippet, AUC was 0.570 (0.565-0.575) with an accuracy of 57.8% (56.8%-58.7%) for a single surgery, and AUC was 0.692 (0.659-0.758) with an accuracy of 63.3% (56.8%-69.8%) for a single user given all their trials. Conclusions: Our research shows that machine learning can accurately and independently identify distinct cataract surgery tools in videos, which is crucial for comparing the use of the tool in a step. However, it is more challenging for machine learning to accurately differentiate overall and specific step skill to assess the level of training or expertise. Financial Disclosures: The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Evaluation of ophthalmology residents' self-assessments and peer assessments in simulated surgery.

OBJECTIVE: To evaluate the accuracy of ophthalmology residents' self-assessment and peer assessment of surgical skills in a simulation setting. DESIGN: Simulation laboratory assessment. PARTICIPANTS: Ophthalmology residents novice to cataract surgery. METHODS: A modified International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric: Phacoemulsification structured assessment tool for simulated cataract surgery was established by conventional Delphi method. Residents completed 10 independent simulated surgeries that were video-recorded. Two experts graded the videos using the assessment tool. Participants performed self-assessment of their own 10 videos, and peer assessment of 10 of their peers' videos. RESULTS: Nine cataract surgery experts provided feedback and modifications for the assessment tool. Agreement for the first round of the Delphi method ranged from 55.56% to 100%. Second round agreement was 80% or greater for all answers. The final assessment tool comprised (i) 4 procedural items scored from 0 (not performed) to 7 (competent), and (ii) a global rating scale (GRS) requiring yes/no answers to 4 performance-related questions. Eight residents participated in the study. There was excellent expert inter-rater reliability intraclass correlation ((ICC) = 0.844, 0.875, 0.809, 0.844) and fair to excellent inter-rater reliability between expert and peer scores (ICC = 0.702, 0.831, 0.521, 0.423), but systematic disagreement (ICC = -0.428, -0.038) or poor inter-rater reliability (ICC = 0.298, 0.362) between expert and self-scores. There was poor agreement for all GRS questions (κ statistic < 0.40) except 2 comparisons. CONCLUSIONS: In the simulation setting, experts were able to reliably assess trainees' performance using the assessment tool. Participants demonstrated inconsistency in assessing their own skills; however, they were adequate at assessing their peers' overall performance.

Ear Disease Knowledge and Otoscopy Skills Transfer to Real Patients: A Randomized Controlled Trial.

OBJECTIVE: To determine which teaching method-otoscopy simulation (OS), web-based module (WM), or standard classroom instruction (SI)-produced greater translation of knowledge and otoscopy examination skills to real patients. DESIGN: In a prospective randomized controlled nonclinical trial, medical students were randomized to 1 of 3 interventional arms: (1) OS, (2) WM, or (3) SI. Students were assessed at baseline for diagnostic accuracy and otoscopy skills on 5 volunteer patients (total of 10 ears), followed by the intervention. Testing was repeated immediately after intervention on the same patients. Student reported confidence in diagnostic accuracy and otoscopy examination were also captured. Assessors were blinded to the intervention group, and whether students were pre- or post-intervention. SETTING: Clinical Teaching Centre, Queen's University. PARTICIPANTS: Twenty-nine participants were initially randomized. Two students were unable to attend their specific intervention sessions and withdrew. Final group sizes were: OS-10, WM-9, SI-8. Five patients with external/middle ear pathologies were voluntarily recruited to participate as testing subjects. RESULTS: Baseline diagnostic accuracy and otoscopy clinical skills did not differ across the groups. Post-intervention, there were improvements in diagnostic accuracy from all groups: OS (127.78%, 2.30 ± 1.42, p = 0.0006), WM (76.40%, 1.44 ± 1.88, p = 0.0499), and SI (100.00%, 1.50 ± 1.20, p = 0.0093). For otoscopy skills, post-intervention improvements were noted from OS (77.00%, 3.85 ± 2.55, p < 0.0001) and SI (22.20%, 1.25 ± 1.20, p = 0.0011), with no significant improvement from WM (13.46%, 0.78 ± 1.92, p = 0.1050). Students across all groups reported significantly improved confidence in diagnostic accuracy (p < 0.0001) and otoscopy skill (p < 0.0001) after the intervention. CONCLUSION: All 3 teaching modalities showed an improvement in diagnostic accuracy immediately post-intervention. Otoscopy clinical skills were found to have increased only in OS and SI, with the OS group demonstrating the largest improvement. Simulation-based medical education in Otolaryngology may provide the greatest transfer of medical knowledge and technical skills when evaluated with real patients.

The impact of psychosocial intervention on survival in cancer: a meta-analysis.

BACKGROUND: The impact of psychosocial interventions on survival remains controversial in patients with cancer. A meta-analysis of the recent literature was conducted to evaluate the potential survival benefit associated with psychosocial interventions for cancer patients. METHODS: MEDLINE, EMBASE, and Cochrane Central were searched from January 2004 to May 2015 for all randomized controlled trials (RCTs) that compared survival outcomes between cancer patients receiving a psychosocial intervention and those receiving other, or no interventions. Endpoints included one-, two-, and four-year overall survival. Subgroup analyses were performed to compare group-versus individually-delivered interventions, and to assess breast cancer-only trials. RESULTS: Of 5,080 identified articles, thirteen trials were included for analysis. There was a significant survival benefit for the intervention group at one year [risk ratio (RR) =0.82; 95% confidence interval (CI), 0.67-1.00; P=0.04] and two years (RR =0.86; 95% CI, 0.78-0.95; P=0.003). However, no significant difference was detected at four years (RR =0.94; 95% CI, 0.85-1.04; P=0.24). Among patients with breast cancer, there was a significant survival benefit of psychosocial interventions at one year (RR =0.59; 95% CI, 0.42-0.82; P=0.002), but no difference at two years (RR =0.82; 95% CI, 0.67-1.02; P=0.07) or four years (RR =0.95; 95% CI, 0.73-1.23; P=0.68). Group-delivered interventions had a significant survival benefit favouring the intervention group at one year (RR =0.57; 95% CI, 0.41-0.79; P=0.0008), but no difference at two years (RR =0.84; 95% CI, 0.68-1.02; P=0.08) or four years (RR =0.94; 95% CI, 0.75-1.20; P=0.64). Individually-delivered interventions had no significant survival benefit at one year (RR =0.92; 95% CI, 0.79-1.08; P=0.32), two years (RR =0.87; 95% CI, 0.75-1.00; P=0.05), or four years (RR =0.93; 95% CI, 0.84-1.04; P=0.21). CONCLUSIONS: For the main analysis and group-delivered treatments, psychosocial interventions demonstrated only short-term improvements in survival. Individually-delivered interventions failed to show any survival benefit. Future studies with longer follow-up are warranted to investigate long-term survival outcomes.

The accuracy of clinicians' predictions of survival in advanced cancer: a review.

The process of formulating an accurate survival prediction is often difficult but important, as it influences the decisions of clinicians, patients, and their families. The current article aims to review the accuracy of clinicians' predictions of survival (CPS) in advanced cancer patients. A literature search of Cochrane CENTRAL, EMBASE, and MEDLINE was conducted to identify studies that reported clinicians' prediction of survival in advanced cancer patients. Studies were included if the subjects consisted of advanced cancer patients and the data reported on the ability of clinicians to predict survival, with both estimated and observed survival data present. Studies reporting on the ability of biological and molecular markers to predict survival were excluded. Fifteen studies that met the inclusion and exclusion criteria were identified. Clinicians in five studies underestimated patients' survival (estimated to observed survival ratio between 0.5 and 0.92). In contrast, 12 studies reported clinicians' overestimation of survival (ratio between 1.06 and 6). CPS in advanced cancer patients is often inaccurate and overestimated. Given these findings, clinicians should be aware of their tendency to be overoptimistic. Further investigation of predictive patient and clinician characteristics is warranted to improve clinicians' ability to predict survival.