Understanding pathways to e-cigarette use across sexual identity: A multi-group structural equation model.

This study explored the relationships between sexual violence, smoking behaviors, suicidality and past 30-day e-cigarette use under the theoretical framework of Minority Stress Theory. The 2017 National Youth Risk Behavioral Survey was utilized to study a nationally representative sample of sexual minority (lesbian, gay, bisexual, and unsure) and heterosexual high school students (N = 7882). Multi-group structural equation modeling (SEM) was employed to examine whether sexual violence and suicidality had a direct effect on e-cigarette use, after controlling for prior smoking behaviors (cigarette, cigar, and marijuana use). Suicidality and smoking behaviors were examined as mediators of the relationship between sexual violence and e-cigarette use, and suicidality was examined as a mediator of the relationship between sexual violence and smoking behaviors. This model was tested for invariance across sexual minority and heterosexual students. For both groups, smoking behaviors had significant direct effects on e-cigarette use, yet suicidality revealed no significant direct effects. Both suicidality and sexual violence had significant indirect effects on e-cigarette use through their effects on smoking behaviors. Sexual violence had a significant direct effect on e-cigarette use for sexual minority students, but not for heterosexual students. Despite this notable difference, the model was found to be invariant across the two groups. These findings suggest that students who report sexual violence may experience suicidality and victimization may lead to smoking behaviors and e-cigarette use. Students' mental health and substance use behaviors should continue to be targeted in schools, particularly among sexual minority youths.

Correlation of health-related quality of life in children with inflammatory bowel disease, their parents, and physician as measured by a visual analog scale.

BACKGROUND AND AIMS: Inflammatory bowel disease has been shown to affect children's health-related quality of life (HRQOL) through the use of lengthy questionnaires. We examined whether a pediatric patient's HRQOL, measured by a rapid visual analog scale ("feeling thermometer"), correlates with the perceptions of the HRQOL as determined by the patient's pediatric gastroenterologist and parent(s). Additionally, we attempted to determine whether the HRQOL correlates with the patient's disease activity as determined by validated activity indices. METHODS: A cross-sectional study of pediatric patients (ages 7-21 years) who were diagnosed as having Crohn disease, ulcerative colitis, or indeterminate colitis was conducted from January 2011 to May 2011. Each participant (patient, parent(s), and treating pediatric gastroenterologist) completed feeling thermometers to determine the symptom burden as well as therapeutic burden of the patient. The parent(s) and doctor were blinded to the patient's results. Pediatric Ulcerative Colitis Activity Index or a Short Pediatric Crohn Disease Activity Index (S-PCDAI) was calculated. Correlations between the participant's perceived burdens as well as their calculated disease activity were determined. RESULTS: Sixty-seven children and their families participated, resulting in 101 visits. Patients had a mean age of 15.0 years, and there were 38 boys. There was a strong significant correlation between the patient's perceived symptom burden and that of the parent's (ρ 0.59, P < 0.001) and physician (ρ 0.48, P < 0.001). Similarly, there was a strong significant correlation between patient's perceived treatment burden and that of the parent treatment burden (ρ 0.49, P < 0.001) and, to a lesser degree, the physician (ρ 0.29, P < 0.003). The correlation coefficient was strongest between the physician's perception of the patient's symptom burden against the standard disease activity indices Pediatric Ulcerative Colitis Activity Index (ρ 0.69, P < 0.001) and Short Pediatric Crohn Disease Activity Index (ρ 0.65, P < 0.001). CONCLUSIONS: The patient's HRQOL was highly correlated to both the physician's and parent's perceptions as well as their disease activity. The feeling thermometer is a quick, easy-to-use, visual analog scale that can be implemented in everyday practice to measure a pediatric patient's HRQOL.

Job satisfaction of program directors in radiology: a survey of current program directors.

OBJECTIVE: Informal conversations and anecdotal evidence suggest that the job turnover rate among radiology residency program directors is disproportionately high. The purpose of our study was to assess the characteristics of current program directors and determine factors that may be affecting overall job satisfaction and job turnover rate. SUBJECTS AND METHODS: A survey that combined facet-specific measurements and global assessment was sent to current program directors in Accreditation Council for Graduate Medical Education (ACGME)-approved diagnostic radiology programs. An optional free response section was included. Results were collected over 4 weeks. RESULTS: Most of the program directors responded. The mean tenure of current program directors was 6.9 ± 6.7 years (range, 0.5-30 years). Fifty-three percent rated global job satisfaction high, and 6% reported low satisfaction. Sixty-four percent of the respondents were not considering resignation, compared with 13% who were definitely resigning. Program directors in larger programs reported a higher level of satisfaction. Positive interactions with residents and feeling valued by colleagues increased job satisfaction. The greatest source of dissatisfaction from all respondents seemed to be ACGME regulations, which were considered excessive and to change too frequently. The changing format of the board examination and structure of a residency were not the major factors in determining job satisfaction. CONCLUSION: The job satisfaction rate among current program directors is high, likely owing to feelings of fulfillment in working with residents and feeling valued by colleagues. The major source of dissatisfaction appears to stem from ACGME oversight, which is perceived as excessive and having requirements that change too frequently.

Residents' engagement in quality improvement: a systematic review of the literature.

PURPOSE: Residents are being asked to participate in quality improvement (QI) initiatives in hospitals and clinics with increasing frequency; however, the effectiveness of improving patient care through residents' participation in QI initiatives is unknown. METHOD: A thorough, systematic review of the English-language medical literature published between 1987 and October 2008 was performed to identify clinical QI initiatives in which there was active engagement of residents. Multiple search strategies were employed using PubMed, EMBASE, CINAHL, and ERIC. Articles were excluded in which residents played a passive or peripheral role in the QI initiative. RESULTS: Twenty-eight articles were identified that documented residents' active leadership, development, or participation in a clinical QI initiative, such as curriculum change, clinical guideline implementation, or involvement with a clinical QI team. The role and participation of residents varied widely. Measures of patient health are described as outcomes in the QI initiatives of 5 of the 28 articles. Twenty-three articles described process improvements in patient care or residents' education as the outcome measure. CONCLUSION: There are few articles that describe the clinical or educational effectiveness of residents' participation in QI efforts; the authors describe barriers that may be partly responsible. They conclude that there is a great need for additional research on the effectiveness of residents' participation in QI initiatives, particularly as they affect patient health outcomes.

"Renters" or "owners"? Residents' perceptions and behaviors regarding error reduction in teaching hospitals: a literature review.

PURPOSE: Residents' attitudes, practices, and behaviors vary in response to medical error within the context of the culture of their institutions. The purpose of this study was to conduct a systematic review of the literature focused on residents' attitudes and behaviors regarding medical errors in teaching hospitals, including a qualitative review of barriers and proposed countermeasures related to residents' engagement in patient safety. METHOD: The electronic literature databases of MEDLINE, CINAHL, and ERIC were searched for articles published between January 1988 and June 2008. The search strategy yielded 124 articles. A scoring system was developed to assess the quality of the overall literature. RESULTS: Nineteen studies met eligibility criteria, with 17 published since 2005. There were 12 cross-sectional, 5 qualitative, 1 cohort and 1 pre-post intervention study. Quality assessment scores ranged from 5.5 to 12.5 (possible range 1.0-16.0). Three studies obtained a score of < or = 8.0, 5 obtained scores of 8.5 to 10.5, and 11 studies had scores of 11.0 to 12.5. Personal, environmental, and system barriers, and environmental and system countermeasures, were identified. CONCLUSIONS: Although the published literature on this topic is limited, those articles that exist identify barriers that make residents reluctant to engage in institutional error identification and/or reduction. Key factors identified included a fear of retribution and the perception of residents as transient care providers. Whereas several countermeasures have been promulgated, the literature reveals scant evidence of their effectiveness. Institutions should recognize and capitalize on the unique experiences of residents and their potential to become owners in patient safety initiatives.

Residents' and attending physicians' handoffs: a systematic review of the literature.

PURPOSE: Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective. METHOD: The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors. RESULTS: Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness. CONCLUSIONS: Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Obesity is related to multiple functional abdominal diseases.

Analysis of the body mass index of pediatric patients with gastrointestinal complaints as a whole and by disease subgroup revealed a greater percentage of obese patients with constipation, gastroesophageal reflux, irritable bowel syndrome, encopresis, and functional abdominal pain compared with local and New Jersey control populations.

The written clinical diagnosis board examination: survey of program director and resident opinions.

OBJECTIVE: The purpose of our study was to assess the perceived value of the American Board of Radiology written clinical diagnosis board examination. MATERIALS AND METHODS: Two online surveys were distributed to diagnostic radiology programs approved by the Accreditation Council for Graduate Medical Education. Program directors were asked about the importance of the examination, and residents were asked about the importance and composition (proportion of repeated questions, known as recalls) of the examination and about preparation strategies. RESULTS: Most of the program directors (122 of 178, 69%) responded. Most of the respondents believed that the examination correlated with their assessment of residents' knowledge, that passing was indicative of a qualified radiologist, and that the examination should not be eliminated. Although most of the program directors believed preparation increased residents' knowledge, they also believed that preparation detracted from reading assignments. Opinion was divided whether the examination should be continued in its present form. The majority of the 171 resident respondents spent most of their time studying recalls, which they believed made up 40-60% of the examination. One half of the residents believed that preparing helped in mastering the body of radiology knowledge, although most believed that core material made up only 20-60% of the examination. A minority of the residents considered passing the examination indicative of a qualified radiologist. Opinion was divided on continuing the examination in its present form. CONCLUSION: Program directors and residents perceived value in the written clinical diagnosis board examination. The American Board of Radiology may need to reevaluate question content when restructuring the new examination.

Preliminary radiology resident interpretations versus final attending radiologist interpretations and the impact on patient care in a community hospital.

OBJECTIVE: At academic institutions, overnight emergency radiology examinations are interpreted by the on-call radiology resident and are reviewed by an attending radiologist in the morning. The objective of our study was to determine the rate of discrepancies between the two interpretations and the possible effect, if any, on patient care. MATERIALS AND METHODS: The preliminary reports for 11,908 emergency diagnostic imaging examinations interpreted after hours by residents over a 3-year period (January 2002-January 2005) were reviewed retrospectively for any discrepancy with the attending radiologist's final interpretation. A discrepancy was noted if verbal notification of the ordering physician was required. The medical charts of the cases for which there was a major discrepancy between the two interpretations were reviewed. The discrepancies were categorized as to the effect on patient morbidity. The resident discrepancy rates were also compared with RADPEER data from our institution. RESULTS: The overall major discrepancy rate was 2.6%. This rate is comparable to RADPEER data, which found a misinterpretation rate of 2.1%. The technique most commonly involved in cases with discrepant interpretations was contrast-enhanced CT of the abdomen and pelvis, with the most common diagnosis related to acute appendicitis (total of 21 cases). The rate of discrepancy was highest for residents who were in their third year of training. The indications for these examinations varied; however, the effect on patient management was no significant effect in 92.8%, some negative effect in 6.9%, and significant negative effect in 0.3%. CONCLUSION: The results of this investigation highlight the minimal discrepancy rate that occurs with overnight resident coverage. Thus, there is no detrimental effect on the quality of patient care from relying on preliminary interpretations made by radiology residents.

Inaccuracy of stated versus measured parental heights.

Routine measurement of children's height is essential in monitoring for deviations in normal growth velocity. Target adult height of children is estimated by determining an adjusted midparental height. Such determinations are dependent on the accurate acquisition of parental height. Incorrect assessment of parental height will result in inaccurate expectations for the child's height. To observe the difference between stated and measured parental heights within a United States subspecialty setting, prospective acquisition of parental stated and measured heights during the summer months of 2000 and 2001 was examined. Two hundred and thirty-eight parents, 185 mothers and 53 fathers, were measured. The mean values of the stated heights for mothers and fathers were 163.7 cm +/- 6.3 cm and 177.1 cm +/- 8.6 cm, respectively. The corresponding measured heights were 163.0 cm +/- 5.9 cm and 175.2 cm +/- 6.6 cm, respectively. The mean height difference for mothers was 0.69 cm (p<0.001) while the mean height difference for fathers was 1.90 cm (p<0.001). Parents significantly overestimate their height in a clinical setting. Fathers overestimate to a greater degree than mothers. These findings emphasize the need to obtain height measurement of parents along with that of their children in assessing for linear growth delay.

Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.

BACKGROUND: There is limited information concerning the risks for, and occurrence of, cardiovascular complications because of GI endoscopy. Published data are based on questionnaire surveys, which have a potential for bias. Moreover, available studies pertain exclusively to out-patients. METHODS: In-patients and day-stay patients who incurred charges for endoscopy with endoscopic procedure coding from 1999 through 2001 were identified from a financial database for all 9 hospitals in a large health care system. From these patients, those considered "at risk" for cardiovascular complications were selected based on charges for cardioactive medications, cardiac enzyme determinations, or intensive care services on the day of or the day after endoscopy. Medical records were reviewed for 25% of these patients, selected at random, noting demographics, history, and a modified Goldman score in patients with cardiovascular complications (defined as arrhythmia, chest pain or anginal equivalent, hypotension or myocardial infarction occurring within 24 hours after endoscopy). Identical information was obtained from a random sample of 0.5% of the chart records for all patients undergoing endoscopy. RESULTS: Patients who underwent endoscopy were not reliably identified for one hospital. This hospital was omitted from the calculation of the extrapolated rate of complication occurrence, but patients identified through chart review as having or not having a complication after endoscopy were included in the risk analysis. The extrapolated rate of occurrence of cardiovascular complications was 308: 95% CI [197, 457] per 100,000 procedures. Independent risk factors were: male gender, modified Goldman score, and use of propofol. CONCLUSIONS: In this study of patients undergoing hospital-based GI endoscopy, the risk of procedure-related cardiovascular complications was 2 to 70 times higher than previously reported. This finding may be ascribed to differences in the populations sampled and to a case-finding method that minimized reporting and ascertainment biases.

Assessment of a 360-degree instrument to evaluate residents' competency in interpersonal and communication skills.

OBJECTIVE: To test the reliability of the 360-degree evaluation instrument for assessing residents' competency in interpersonal and communication skills. METHOD: Ten-item questionnaires were distributed to residents and evaluators at Monmouth Medical Center in Long Branch, New Jersey, in March/April, 2002. The scoring scale was 1-5; the highest score was 50. Data were maintained strictly confidential; each resident was assigned a code. Completed data sheets were collated by category and entered into a spreadsheet. The total and mean scores by each category of evaluator were calculated for each resident and a rank order list created. Shrout-Fleiss (model 2) intraclass correlation coefficients measured reliability of ratings within each group of evaluators. Reliability/reproducibility among evaluators' scores were tested by the Pearson correlation coefficient (p <.05). RESULTS: Intraclass correlation coefficients showed a narrow range, from.85-.54. The highest ranked resident overall ranked high and the lowest was low with most evaluators. The rank order among fellow residents was markedly different from other evaluator categories. Pearson correlation coefficients showed significant correlation between faculty and ancillary staff, (p =.002). Patients as evaluators did show intraclass correlation, but did not correlate significantly with other categories. Scores from colleagues correlated negatively with all other categories of evaluators. CONCLUSIONS: The 360-degree instrument appears to be reliable to evaluate residents' competency in interpersonal and communication skills. Information from the assessment may provide feedback to residents. Areas of improvement identified by the scores would suggest areas for improvement and further ongoing assessment.

A randomized trial of initial warfarin dosing based on simple clinical criteria.

Warfarin induction is accomplished by titrating dosage to coagulation test results. Algorithms can guide this process but not identify the starting dose. We hypothesized that an initial warfarin dose approximating the maintenance value would safely enhance rapidity of induction. In a randomized trial we compared a fixed-dose to a maintenance-dose strategy for beginning warfarin therapy. To predict the maintenance dose among patients with differing warfarin requirements we performed regression analysis on clinical factors derived from chart review. Four community hospitals supplied records for retrospective analysis. The prospective trial was conducted in one, a 350-bed teaching institution. A sample of inpatients anticoagulated during 1998 formed the development set for retrospective study; a 1999 sample formed the validation set. A one year trial recruited consecutive eligible inpatients initiated on warfarin. We randomly assigned patients to a first warfarin dose calculated using our regression formula or fixed at 5 mg. All patients' subsequent doses were determined (as a percentage of initial) from coagulation testing. We compared days to anticoagulation, hospitalized hours, complications, and activity of factor II and protein C in a patient sample at intervals after induction. Weight, age, serum albumin, and presence of malignancy explained 25-30% of variance in maintenance dose. Ninety patients (44 calculated-dose and 46 standard-dose) evaluated in the clinical trial. Mean time to anticoagulation (among patients achieving anticoagulation) was 4.2 and 5.0 days, respectively (p = 0.007). We observed no significant differences in other endpoints. Individualized initial dosing may safely hasten warfarin induction.

Can computerized cost data substitute for chart review?

Identification of alternatives to manual chart review might improve efficiency in quality improvement work. This study at a large community teaching hospital in central New Jersey considered whether selected charges from a patient-level costs database could identify compliance with Sixth Scope of Work indicators in congestive heart failure (CHF). Charges resulting from specific tests, from test outcomes, and from prescribed treatments were identified from among 75 randomly chosen patients with CHF. In the sample 65% (as determined by database analysis) and 69% (as determined by chart review) complied with the principal peer review organization criterion. This difference was less than that found between review and re-review of study charts.