Effect of an integrated teaching intervention on clinical decision analysis: a randomized, controlled study of undergraduate medical students.

A four-hour integrated teaching session on clinical decision analysis has been developed and introduced as part of the Life Long Learning Skills course for medical students at The Chinese University of Hong Kong. The feasibility and effectiveness of teaching the principles and practice of clinical decision analysis to final-year undergraduate medical students was evaluated. One hundred and thirty-two students were randomly assigned to medical (intervention) and surgical rotations (control) and were assessed two weeks before and three weeks following a teaching session. The students' performance was assessed in response to 10 A-type multiple choice question items that incorporated various clinical scenarios requiring decision making and interpreting cost-effectiveness ratios and sensitivity analysis graphs. More students in the intervention group improved their overall performance scores compared with those in the control group (23.4% vs. 7.4%; 16.1% difference; 95% confidence interval [CI], 3.8-28.5%; p = 0.01). Improvements were in interpretation of decision making (22.2% difference; 95% CI, 10.1-34.4%; p < 0.001). No improvements were seen for calculating cost-effectiveness ratios or interpreting sensitivity analysis graphs. The overall educational intervention was well received by students and effective in improving students' clinical decision analysis skills under simulated conditions.

How to minimize inappropriate utilization of Accident and Emergency Departments: improve the validity of classifying the general practice cases amongst the A&E attendees.

Studies have found that one-third to two-thirds of all patients attending Accident and Emergency (A and E) Departments could be managed appropriately by general practitioners (GPs). There is also evidence that referral to GPs can be acceptable to patients. The question of primary concern is screening non-urgent cases with high degrees of sensitivity (S), specificity (SP), and positive predictive value (PPV). This paper reports the findings of the validity (S, SP and PPV) of nurses and patients in triaging A and E visitors. A cross sectional study was conducted over a 1 year period and subjects were randomly selected from four A and E Departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. S, SP and PPVs were computed for both non-weighted and weighted conditions. The gold standard for defining the true urgency status of each selected patient was based on a review of the patient's record 3-21 days (or longer if necessary) following the A and E visit. The record review in each A and E was blinded and done independently by a panel of two (and if disagreement existed, three) senior emergency physicians who did not practice in the same hospital. The greatest weights would be for incorrect decisions with greatest impact on patients' well being. The most accurate unweighted nurses' triage classification had an average sensitivity of 87.8%, specificity of 83.9%, and a PPV of 70.1%. When weighted, the average sensitivity reduced to 75%, specificity to 65.7%, and PPV to 54%. The most accurate unweighted patients' self-triage classification yielded a sensitivity of 62.5%, specificity of 69.2%, and a PPV of 58.1%, and correspondingly reduced to 43.3, 49.2 and 38.6% if weights were applied. Validity of the derived patients' self-classifications was too inaccurate for practical use. Hong Kong's current use of a five-point urgency scale by nurses would be further refined for identifying non-urgent visitors. If a mechanism was put in place for additional screening on visitors with a borderline semi-urgent or non-urgent status, the nurses could safely reassign non-urgent patients to GP care. If implemented, a significant impact on hospital costs could be realized.

Validation of an instrument to assess patient attitudes towards prescribing of pharmaceuticals by doctors.

OBJECTIVES: To establish the reliability and validity of a questionnaire designed to assess Chinese patients' attitudes towards pharmaceuticals that may influence the prescribing behaviours of their doctors. STUDY DESIGN: A draft questionnaire of 48 items was designed in English, translated into Chinese, and then back-translated into English. After establishing for content and face validity, it was administered to a convenience sample of patients. Responses were factor analysed to establish construct validity and to reduce the questionnaire's length. POPULATION: Hong Kong Chinese patients (n = 387) who visited one of 24 primary care doctors. OUTCOMES MEASURED: Derived factor score means were compared among various age, gender and education groupings. RESULTS: A final 21-item questionnaire was produced. Spearman's rank correlations indicated the instrument was relatively stable over repeated applications. Patients' attitudes were found to be multidimensional. The three-factor solution achieved a simple structure and accounted for 40% of the variance among the 21 items. Items loading heavily on each construct were internally consistent. Nine items measured patients' attitudes towards careful use of medications. Six questions measured a preference for information exchanges between patients and doctors. Six items measured patients' scepticism concerning the need for pharmaceuticals to hasten recovery from most illnesses. The three factors yielded factor score means that discriminated among the patients as expected. CONCLUSIONS: The questionnaire met adequate standards for reliability and validity. It is suitable for further use in investigating Chinese patients' attitudes concerning pharmaceuticals and how these attitudes might influence their physicians' prescribing behaviours.