Development of explicit criteria to measure adherence to hypertension guidelines.

Measures of adherence to hypertension guidelines have historically been based on prescription data or physician survey data regarding treatment practices. These methods have limitations that decrease their accuracy. As part of a randomized controlled study testing the effects of pharmacist/physician collaboration on adherence to hypertension guidelines, the investigators and an expert panel developed a JNC 7 measurement tool. The final guideline adherence measurement tool includes 22 explicit criteria in four domains of care. An exploratory factor analysis, conducted to assess the structure of the tool, suggests three underlying treatment dimensions in hypertension care. The adherence measurement tool will allow researchers to link specific elements of care to improved blood pressure control. In addition, use of the tool will provide clinicians with a taxonomy for evaluating practice and describing the effect of improved patient care on patient outcomes.

Examining the generalizability of ratings across clerkships using a clinical evaluation form.

It is necessary to average multiple clinical evaluation form (CEF) observations to obtain a reliable score. Combining CEF observations across clerkships will provide more observations per student, but it is unknown how an across-clerkship generalization affects reliability. The authors conducted generalizability studies on balanced stratified random samples to examine the impact of averaging across clerkships. The study detected a student by clerkship interaction. Although the interaction magnitude was small, it had a large negative impact on the reliability of the mean score. The authors conclude that averaging across clerkships for the purpose of evaluating global clinical skills will produce a less reliable measure for a fixed number of observations than averages calculated within a clerkship for evaluating clerkship specific skills. The content specificity of clinical skills as measured by the CEF may resemble that found using other measurement methods.

Student attitudes toward same-gender versus mixed-gender partnering in practicing physical examination skills.

Students were surveyed to assess perceptions with regard to the use of same-gender and mixed-gender partnering in practicing physical examinations. There was support for this arrangement, with students reporting that the practice provided an important learning experience with reasonable levels of comfort and no loss of thoroughness and rigor. Students did express some concerns. Females tended to have lower comfort levels, particularly when they were in the role of patient. Many of the concerns expressed could be addressed with procedural changes during the assignment of partners, and the benefits of continuing this practice seem to outweigh any negative aspects.

Interinstitutional study to compare the effectiveness of a radiology-anatomy module of instruction.

RATIONALE AND OBJECTIVES: The purpose of this study was to validate the effectiveness of a proven radiology-anatomy instructional module during I st-year gross anatomy courses at Emory University College of Medicine and the University of Iowa College of Medicine. MATERIALS AND METHODS: This prospective study involved 108 Emory students and 177 Iowa students. The instructional content was the same at both institutions. Each student was randomly assigned into one of three groups at each institution, and each group received a unique, randomized, five-item pretest. All students were posttested as part of their gross anatomy laboratory examination, and the posttests consisted of all 15 items used in the three five-item pretests. RESULTS: No statistically significant pretest effects were demonstrated by t tests. Posttest performances across items ranged from 73% to 96% correct for Emory students and 67% to 98% for Iowa students. Performance levels on the posttests were significantly higher than on pretests, and few significant differences were found in the performance of the two populations. CONCLUSION: The radiology-anatomy instructional module integrated into the gross anatomy courses for 1st-year Emory University and University of Iowa students was not instructor or institution dependent.

Pulsed-dye laser versus conventional therapy in the treatment of warts: a prospective randomized trial.

BACKGROUND: The clinical management of verrucae vulgaris is often challenging, and no ideal treatment currently exists. Early studies suggested that pulsed-dye laser (PDL) therapy might be highly effective in the treatment of verrucae, although more recent reports have been less optimistic. Previous studies have been retrospective or have consisted of a series of patients treated with PDL alone. OBJECTIVE: Our objective was to prospectively evaluate the efficacy of PDL therapy versus conventional therapy with liquid nitrogen cryotherapy or cantharidin in the treatment of warts. METHODS: Forty healthy adult patients with verrucae were randomized to receive either PDL (585 nm) therapy or conventional therapy. All enrollees also performed home therapy. Patients were eligible for up to 4 treatment sessions at 1-month intervals. Warts were individually counted and measured at the time of each treatment session. Complete response was defined as complete absence of verrucae with the presence of dermatoglyphics, and partial response was defined as a 50% or greater reduction in wart size. RESULTS: A total of 194 warts were evaluated by the conclusion of the study. Complete response was noted in an average of 70% of the warts treated with conventional therapy and in 66% of those in the PDL group; this was statistically insignificant. Partial response was observed in an average of 82% of the warts in patients treated with conventional therapy and 87% in the PDL group. Verruca vulgaris responded more readily than verruca plantaris in both treatment groups. The mean number of treatments to achieve success was similar in both groups. CONCLUSION: The PDL is an efficacious form of therapy for verrucae, as is conventional therapy. PDL therapy should be considered among the better established approaches in the treatment of warts, although data from this trial suggest that this approach is probably not superior.

Improving usage of pediatric information on the Internet: the Virtual Children's Hospital.

OBJECTIVE: Digital health sciences libraries (DHSLs) bring order to the chaos of the Internet by making authoritative medical information easily and conveniently available to patrons. The goal of this project was to perform a baseline usage analysis of the pediatric-related information in a general DHSL and to determine whether reorganization of the pediatric-related information into its own pediatric DHSL could increase the usage of the pediatric-related information. METHODS: From March through August 1997, a baseline analysis of a general DHSL (Virtual Hospital) was conducted using computer server log file analysis programs. The quantity of pediatric-related information in the general DHSL and its baseline usage were determined. In September 1997, the pediatric-related information was reorganized into its own pediatric DHSL (Virtual Children's Hospital), and server log file analyses were conducted of the pediatric DHSL from September 1997 to August 1998. Statistical analysis was performed by time series autoregression. RESULTS: During the baseline, the general DHSL and the pediatric-related information received a monthly average of 2 320 782 and 141 444 qualified hits, respectively. After the intervention, the general DHSL and the pediatric DHSL received a monthly average of 2 765 454 and 256 998 qualified hits, respectively. This is an increase of 19. 2% for the general DHSL and 81.7% for the pediatric DHSL. These changes were statistically significant at the P >.0001 level. The most requested pediatric-related content in the pediatric DHSL did not change substantively from preintervention to postintervention. DISCUSSION: On the Internet, as in real life, children's services must have their own distinct identity and must be differentiated from adult services. Therefore, pediatric-related information will receive increased usage if it is part of a pediatric DHSL rather than part of a general DHSL. Others can use this process and the lessons learned to develop and enhance their own pediatric-related information on the Internet. Internet, pediatrics, digital health sciences libraries, digital library, medical library.

Evaluating the usefulness of computerized adaptive testing for medical in-course assessment.

PURPOSE: This study investigated the feasibility of converting an existing computer-administered, in-course internal medicine test to an adaptive format. METHOD: A 200-item internal medicine extended matching test was used for this research. Parameters were estimated with commercially available software with responses from 621 examinees. A specially developed simulation program was used to retrospectively estimate the efficiency of the computer-adaptive exam format. RESULTS: It was found that the average test length could be shortened by almost half with measurement precision approximately equal to that of the full 200-item paper-and-pencil test. However, computer-adaptive testing with this item bank provided little advantage for examinees at the upper end of the ability continuum. An examination of classical item statistics and IRT item statistics suggested that adding more difficult items might extend the advantage to this group of examinees. CONCLUSIONS: Medical item banks presently used for incourse assessment might be advantageously employed in adaptive testing. However, it is important to evaluate the match between the items and the measurement objective of the test before implementing this format.

Teaching a screening musculoskeletal examination: a randomized, controlled trial of different instructional methods.

PURPOSE: To develop and test a program to teach a rapid screening musculoskeletal examination. METHOD: In 1995, 191 medical and physician assistant students were randomized to four intervention groups: written materials only (n = 47), written materials and videotape (n = 46), written materials and small-group sessions facilitated by fourth-year medical students (n = 55), and all three methods (n = 43). Assessments, in the form of a written test and standardized patient examinations, were conducted before the interventions (n = 40 randomly selected students), seven to ten days and again three months after the interventions (n = all 191 students), and 16 months after the interventions (n = 103 students). RESULTS: While the four intervention groups' written test scores were approximately equal, their scores on the standardized patient examination differed significantly. The students taught in small groups demonstrated significantly superior examination skills compared with the students taught with written material or videotape at seven to ten days and retained this relative superiority after three and 16 months (p < .0001). CONCLUSION: Small-group instruction with hands-on supervised practice is superior to more passive instructional methods for teaching musculoskeletal examination skills and can be successfully delivered by trained senior medical student facilitators with minimal direct expenditure of faculty time.

The effects of attrition on implementing and evaluating a mental health continuing education program for nursing personnel in long-term care facilities.

BACKGROUND: The effects of attrition on a continuing education program for nursing personnel within long-term care facilities are described. METHODS: Allowing flexible participation can enhance the impact of a continuing education program designed for paraprofessional staff. Increasing the number of nursing staff who experience only a portion of the training has implications for the instructional design and the evaluation. Recommendations to improve accommodation of staff and enhance dissemination of training are offered as well as appropriate evaluation techniques. CONCLUSION: Self-contained short units of instruction allow those with minimal time to benefit from the training. Effective evaluation requires special sampling and measurement strategies. Cross-sectional methods make good use of training resources but usually yield measurable changes only in lower-level program objectives.

A generalizability study of a new standardized rating form used to evaluate students' clinical clerkship performances.

PURPOSE: To investigate the measurement characteristics of standardized clinical evaluation forms (CEFs) used to assign grades for clerkship performance. METHOD: In 1996-97, the authors reviewed 5,168 CEFs completed for 175 students in eight clerkships. Limiting their analysis to the three clerkships that produced the most CEFs, the authors conducted a generalizability study to determine the five variance components for each clerkship. A decision study then calculated the generalizability coefficients and standard errors of measurement in each clerkship for varied numbers of raters and CEF items. RESULTS: The generalizability study found large variance components attributable to rater and rating context. The decision study found that, when three or more raters completed CEFs for a student, the generalizability coefficient and standard error of measurement reached levels acceptable for grading. Increasing the number of items on the CEF had no significant effect. CONCLUSION: The reliability of assigning students clerkship grades based on single CEFs is unacceptably low. However, CEFs can accurately measure students' clerkship performances if completed by three or more raters.

Longitudinal follow-up comparison of educational interventions: multimedia textbook, traditional lecture, and printed textbook.

RATIONALE AND OBJECTIVES: The goal of this prospective, interinstitutional study was to compare the long-term instructional effectiveness of a pediatric multimedia textbook (MMTB) to that of a standard lecture and a printed textbook. MATERIALS AND METHODS: A randomized cohort of 89 3rd-year medical students from two institutions were initially evaluated from June 1992 to June 1993 and reevaluated in May 1994. Students were randomly assigned to one of four instructional groups: computer-aided instruction by means of MMTBs (n = 21), traditional lecture (n = 23), printed textbook (n = 19), and a control group (n = 26). After instruction, all groups were tested by means of a multiple choice test at the end of their pediatric clerkship; they were given this same test 11-22 months later. RESULTS: The long-term instructional effectiveness of the MMTB, printed textbook, and lecture were the same as that in the control group, as determined by analysis of variance of mean test scores. CONCLUSION: The educational advantage of MMTBs observed immediately after instruction was not detected 1 year later. Because attrition reduced statistical power, further research is necessary to determine how educational fading affects these instructional formats.