A dynamic mathematical model of red blood cell clinical demand to assess the impact of prolonged blood shortages and transfusion restriction policies.

BACKGROUND: Estimating change in clinical demand for red blood cells (RBCs) from a disaster, as well as triaging introduced in response, is essential to plan effectively for a major blood shortage. We aimed to develop a RBC demand model to assess the impact of restriction policies on RBC use and patient outcomes. STUDY DESIGN AND METHODS: A compartmental dynamic model was developed in which patients require RBCs acutely (within 1 hr), urgently (24 hr), semiurgently (1-7 days), or nonurgently; outcomes included death or remaining at or transitioning to more or less urgent categories. A mathematical model was developed with transitions governed by differential equations and calibrated to a baseline scenario of adequate blood supply (using population-based hospital data sets, registries, and RBC issues). Distribution into urgency categories was based on a prospective study of 5132 randomly selected RBC units. Scenarios when the blood supply is limited compared to baseline were investigated. Transition rates between urgency categories under these scenarios were established by clinician survey. RESULTS: In the baseline 21-day scenario, patients requiring the most RBCs were other surgery (2162, 22%), medical anemia (1916, 12%), malignant hematology (1092, 16%), and gastrointestinal hemorrhage (1115, 8%). A policy of withholding RBCs for all nonurgent indications results in an estimated reduction of only 1007 (11.2%) RBC units and, if extended to semiurgent, a reduction of 2567 (28.5%) RBC units. CONCLUSIONS: Based on this model, restrictions that withhold transfusion from nonurgent patients have minimal impact on RBC demand and may not be sufficient to address changed demand and/or decreased supply during a prolonged disaster.

Student approaches for learning in medicine: what does it tell us about the informal curriculum?

BACKGROUND: It has long been acknowledged that medical students frequently focus their learning on that which will enable them to pass examinations, and that they use a range of study approaches and resources in preparing for their examinations. A recent qualitative study identified that in addition to the formal curriculum, students are using a range of resources and study strategies which could be attributed to the informal curriculum. What is not clearly established is the extent to which these informal learning resources and strategies are utilized by medical students. The aim of this study was to establish the extent to which students in a graduate-entry medical program use various learning approaches to assist their learning and preparation for examinations, apart from those resources offered as part of the formal curriculum. METHODS: A validated survey instrument was administered to 522 medical students. Factor analysis and internal consistence, descriptive analysis and comparisons with demographic variables were completed. The factor analysis identified eight scales with acceptable levels of internal consistency with an alpha coefficient between 0.72 and 0.96. RESULTS: Nearly 80% of the students reported that they were overwhelmed by the amount of work that was perceived necessary to complete the formal curriculum, with 74.3% believing that the informal learning approaches helped them pass the examinations. 61.3% believed that they prepared them to be good doctors. A variety of informal learning activities utilized by students included using past student notes (85.8%) and PBL tutor guides (62.7%), and being part of self-organised study groups (62.6%), and peer-led tutorials (60.2%). Almost all students accessed the formal school resources for at least 10% of their study time. Students in the first year of the program were more likely to rely on the formal curriculum resources compared to those of Year 2 (p = 0.008). CONCLUSIONS: Curriculum planners should examine the level of use of informal learning activities in their schools, and investigate whether this is to enhance student progress, a result of perceived weakness in the delivery and effectiveness of formal resources, or to overcome anxiety about the volume of work expected by medical programs.

Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes.

AIMS: To assess the relationship between patient activation for self-management and admissions to hospital or attendances at emergency departments among people with diabetes, after controlling for other known associations. METHODS: Patients were randomly selected from Australia's National Diabetes Services Scheme and invited to participate in the Living with Diabetes Study, which is a longitudinal survey providing a comprehensive examination of health care utilisation, well-being and disease progression. Data was collected for 3951 participants. RESULTS: Outcome events were defined as 1 or more hospitalization and 1 or more visits to an emergency department in the preceding 12 months. Logistic regression analyses showed six variables remained significantly associated with both outcomes: age, income, disease duration and severity, current depression and PAM stage. Patients at PAM stage 1 were 1.4 times more likely to be hospitalised (p=0.023) and 1.3 times more likely to have visited emergency (p=0.049) compared to those at stage 4. CONCLUSIONS: Low levels of activation are associated with higher utilisation of hospital resources even after controlling for relevant factors such as disease severity and co-morbid depression. Most will be gained by moving patients from PAM stage 1 to a higher level of activation.

Patterns and determinants of influenza and pneumococcal immunisation among adults with chronic disease living in Queensland, Australia.

Using findings from a random, computer assisted telephone survey of households, this paper examines influenza and pneumococcal immunisation coverage and predictors of immunisation in 2203 adults with asthma, diabetes or a cardiovascular condition living in Queensland, Australia. 47% and 31% of high-risk persons were immunised against influenza and pneumococcus respectively. Immunisation coverage varied across chronic conditions and increased with age, being significantly higher for those aged 65 years and older and consequently eligible for free vaccination. Poor self reported health status was an independent predictor of pneumococcal vaccination status for people with asthma, diabetes or a cardiovascular condition; however it was only an independent predictor of influenza immunisation status for people with diabetes. Extending free vaccination to all people at risk may increase immunisation rates for younger people with a chronic condition.

The role of patient activation in frequent attendance at primary care: a population-based study of people with chronic disease.

OBJECTIVE: This study explores a range of relevant socio-demographic, physical and psychological factors in a unique examination of the risk factors for frequent attendance at primary care. The impact of patient activation for self-management on health service utilisation is of particular interest. METHODS: A population-based sample of people with chronic disease from Queensland, Australia, was interviewed using computer assisted telephone surveying. Data were collected from a random sample of 1470 people with either diabetes or a cardiovascular condition. RESULTS: As participants became more activated they were less likely to frequently attend their main health care provider for assistance with their chronic condition. For both conditions the association was graduated and for participants with a cardiovascular condition this association remained statistically significant even after controlling for other potentially influential factors such as disease severity, length of time since diagnosis, and psychological distress. CONCLUSION: Characteristics of the individual, including patient activation and psychological functioning, as well as disease factors contribute to primary care consulting patterns among people with chronic illness. PRACTICAL IMPLICATIONS: Efforts to improve patient activation for self-management should remain a central element of chronic care.

The "pyramid of professionalism": seven years of experience with an integrated program of teaching, developing, and assessing professionalism among medical students.

The authors report on an integrated program of teaching, developing, and assessing professionalism as well as managing unprofessional behavior referrals and supporting students through the Personal and Professional Development Committee (PPDC) in the four-year, graduate-entry medical program at the School of Medicine, University of Queensland, Australia. Two thousand six hundred thirty medical students have participated in the ethics and professional practice teaching program from 2000 to 2006. They were assessed through formal examination; students who did not satisfy requirements completed supplementary examinations. One student failed a year on the basis of formal examination. Instructors referred 507 students (19% of all enrolled) during the seven-year period to the PPDC, which interviewed 142 (25%; 5% of all enrolled) at least once; 25 of these more than once. In all, 711 reports were submitted to the PPDC, 420 (55%) for unsatisfactory attendance only and 291 (45%) for other concerns. Most of these related to "responsibility/reliability" (46.7%) and "participation" (41.9%);12.4% related to "honesty/integrity [corrected] The PPDC referred four students to the board of examiners, and two students failed a year for persistent unprofessional behavior. The authors established a Pyramid of Professionalism whose foundation is a formal curriculum of medical ethics, law, and professionalism. At higher levels, the pyramid mirrors Australia's medical regulatory processes, combining nonpunitive support with the possibility of sanctions, by mediating and sometimes remediating a range of notified concerns. Students who persist in behaving unprofessionally or in seriously unacceptable ways have failed academically on professionalism grounds.

The student voice: recognising the hidden and informal curriculum in medicine.

BACKGROUND: While there has been broad-based recognition of the concepts of both the informal and the hidden curriculum, these elements have been poorly described in the medical education literature from the student perspective. METHODS: The Student Voice study used focus groups to explore student views of the informal and hidden curriculum, to establish the importance of this curriculum for the students, and to identify how students perceive the role of this curriculum in aiding their learning in medical school. RESULTS: Students recognised that the informal curriculum existed to a greater degree in Medicine than in other degree programs, and that it revolved around the processes of 'being' a doctor. CONCLUSION: The students' concepts of the informal curriculum highlighted a tension between the importance of the informal curriculum in focusing their learning on what was important to know for assessment, and the extremely valuable components of the informal curriculum that remained predominantly unassessed.

Medical school selection criteria and the prediction of academic performance.

OBJECTIVE: To assess how well prior academic performance, admission tests, and interviews predict academic performance in a graduate medical school. DESIGN, SETTING AND PARTICIPANTS: Analysis of academic performance of 706 students in three consecutive cohorts of the 4-year graduate-entry medical program at the University of Queensland. MAIN OUTCOME MEASURES: Proportion of academic performance during the medical program explained by selection criteria, and correlation between selection criteria and performance. Selection criteria were grade point average (GPA), GAMSAT (Graduate Australian Medical School Admissions Test) score, and interview score. Academic performance was defined as overall total in all examinations combined, in first and fourth year examinations, and in individual written, ethics and clinical components. RESULTS: Selection criteria explained 21.9% of variation in overall total score, falling from 28.2% in Year 1 to 17.7% in Year 4. This was highest for the written examination in Year 1 (30.5%) and lowest for the clinical examination in Year 4 (10.9%). GPA was most strongly correlated with academic performance (eg, for overall score, partial Spearman's correlation coefficient [pSCC], 0.47; P < 0.001), followed by interviews (pSCC, 0.12; P = 0.004) and GAMSAT (pSCC, 0.07; P = 0.08). The association between GPA and performance waned from Year 1 to Year 4, while the association between interview score and performance increased from Year 1 to Year 4. CONCLUSION: The school's selection criteria only modestly predict academic performance. GPA is most strongly associated with performance, followed by interview score and GAMSAT score. The school has changed its selection process as a result.

IVIMEDS: a short report on an evaluation of the cardiovascular system learning module.

BACKGROUND: On-line learning technology can be used to present curricular material in a variety of formats to stimulate and support student learning in both content and potentially skills-based areas in medicine. In 2005, second-year medical students at the University of Queensland evaluated the IVIMEDS' cardiovascular module, and were given access to all learning objects in the module. AIM: The study aimed to determine the value to students of the IVIMEDS' Cardio-vascular System (CVS) module compared with existing CVS learning resources. METHOD: Research and control groups (n = 50 respectively) completed a 16-item questionnaire relating either to the IVIMEDS' CVS module or to the existing CVS resources. Responses were analysed for common themes, and the performance of the control and research groups on the mid-year summative assessment results was compared. RESULTS: Thirty-five students in the research group completed the IVIMEDS evaluation. Thirty-one-percent had difficulty learning to navigate the software, and 17% felt that they would have derived greater benefit with prior training. Students in the research group scored significantly higher on one question in the summative assessment than did students in the control group (F(66) = 2.1, p < 0.5). Qualitative data suggest that for students to fully accept the IVIMEDS' material, it will be essential to ensure that students are fully aware of its place in the medical program so they are confident that by using it, they will be able to achieve the set learning objectives. CONCLUSIONS: The students appreciated the potential of the IVIMEDS' cardiovascular module, but a full evaluation of the package would require that the module be presented at an appropriate time using an easily navigable system, after training in use of the software package.