Pragmatic randomised controlled trial of a personalised intervention for carers of people requiring home oxygen therapy.

We used a pragmatic randomised controlled trial to evaluate a behavioural change strategy targeting carers of chronically hypoxaemic patients using long-term home oxygen therapy. Intervention group carers participated in personalised educational sessions focusing on motivating carers to take actions to assist patients. All patients received usual care. Effectiveness was measured through a composite event of patient survival to hospitalisation, residential care admission or death to 12 months. Secondary outcomes at baseline, 3, 6 and 12 months included carer and patient emotional and physical well-being. No difference between intervention (n = 100) and control (n = 97) patients was found for the composite outcome (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 0.89, 1.68; p = 0.22). Improved fatigue, mastery, vitality and general health occurred in intervention group patients (all p values < 0.05). No benefits were seen in carer outcomes. Mortality was significantly higher in intervention patients (HR = 2.01, 95% CI = 1.00, 4.14; p = 0.05; adjusted for Australia-modified Karnofsky Performance Status), with a significant diagnosis-intervention interaction (p = 0.028) showing higher mortality in patients with COPD (HR 4.26; 95% CI = 1.60, 11.35) but not those with interstitial lung disease (HR 0.83; 95% CI = 0.28, 2.46). No difference was detected in the primary outcome, but patient mortality was higher when carers had received the intervention, especially in the most disabled patients. Trials examining behavioural change interventions in severe disease should stratify for functionality, and both risks and benefits should be independently monitored. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000177459).

Medical student selection criteria and junior doctor workplace performance.

BACKGROUND: Medical school selection decisions have consequences beyond graduation. With generally low attrition rates, most medical students become junior doctors. Universities are therefore not just selecting students into a medical course; they are choosing the future medical workforce. Understanding the relationship between selection criteria and outcomes beyond the successful completion of a medical degree may inform approaches to student selection. METHODS: A retrospective data matching study was conducted involving 39 interns employed by a South Australian local health network in 2017 who had originally entered Flinders University's medical school through a graduate pathway. Student selection data were matched with internship workplace performance scores (measured by supervising consultants' reports across five clinical rotations using a standardised assessment). Correlational analyses then examined associations between these two sets of variables. RESULTS: An overall selection rank (equal thirds of weighted Grade Point Average from a prior degree, a panel interview, and a national selection test) was moderately associated with all performance measures, accounting for up to 25% of variance. Both weighted Grade Point Average and the interview had multiple and mostly moderate correlations with performance. An increasing number of years taken to complete the course was associated with poorer workplace performance across multiple outcome measures (moderate to strong negative associations with 31 to 62% of shared variance), as was age to a lesser extent (7 to 14%). The national selection test contributed a single and small relationship accounting for 5% of variance with one outcome measure. CONCLUSIONS: Selection into medicine is a critical assessment given that most students become doctors. This study found multiple associations between selection scores and junior doctor workplace performance measures in the internship year, with weighted Grade Point Average from a prior degree and an interview appearing more important than the national selection test. Future collaborative research should map desired workplace performance outcomes to initial student selection and explore the impact of changes to selection which focus on assessment of these domains. The association between slower course progression and poorer workplace performance should also be examined.

Interventions to improve diagnostic decision making: A systematic review and meta-analysis on reflective strategies.

Aims: To identify, appraise and describe studies of cognitive interventions to improve diagnostic decision making (DDM) amongst medical professionals, assess their effectiveness and identify methodological limitations in existing studies. Methods: We systematically searched for studies (publication date 2000-2016) in multiple databases including Cochrane Controlled Trials, EMBASE, ERIC, Medline, PubMed and PsycINFO, and used additional strategies such as hand searching and snowballing. Included studies evaluated cognitive interventions to enhance DDM amongst medical professionals, using defined outcomes such as diagnostic accuracy. A meta-analysis assessed the impact of "reflection". Results: Forty-four studies out of 10,114 screened citations, involving 4380 medical professionals, were included. Studies evaluated reasoning workshops/curricula, de-biasing workshops, checklists, reflection, feedback, and instructions to induce analytical thinking. Guided reflection was demonstrated to improve DDM [effect size 0.38(95%CI 0.23-0.52), p < 0.001]. Immediate feedback and modeling reflection using contrasting examples also appeared to improve diagnostic accuracy, however underlying methodological issues prevented a quantitative assessment of any strategies other than reflection. Conclusions: Educational interventions incorporating practising deliberate reflection on a formulated diagnosis, modeled reflection on contrasting examples and immediate feedback are promising strategies for improving DDM. The effectiveness of other strategies is unknown, with more methodological refinements required in future research.

Topic search filters: a systematic scoping review.

BACKGROUND: Searching for topics within large biomedical databases can be challenging, especially when topics are complex, diffuse, emerging or lack definitional clarity. Experimentally derived topic search filters offer a reliable solution to effective retrieval; however, their number and range of subject foci remain unknown. OBJECTIVES: This systematic scoping review aims to identify and describe available experimentally developed topic search filters. METHODS: Reports on topic search filter development (1990-) were sought using grey literature sources and 15 databases. Reports describing the conception and prospective development of a database-specific topic search and including an objectively measured estimate of its performance ('sensitivity') were included. RESULTS: Fifty-four reports met inclusion criteria. Data were extracted and thematically synthesised to describe the characteristics of 58 topic search filters. DISCUSSION: Topic search filters are proliferating and cover a wide range of subjects. Filter reports, however, often lack clear definitions of concepts and topic scope to guide users. Without standardised terminology, filters are challenging to find. Information specialists may benefit from a centralised topic filter repository and appraisal checklists to facilitate quality assessment. CONCLUSION: Findings will help information specialists identify existing topic search filters and assist filter developers to build on current knowledge in the field.

A longitudinal study of empathy in pre-clinical and clinical medical students and clinical supervisors.

BACKGROUND: Although appropriate empathy in health professionals is essential, a loss of empathy can occur during medical education. The structure of clinical learning may be one factor that is implicated in a loss of empathy. This study examines student and doctor empathy, and possible associations between empathy and the structure of clinical learning. METHODS: There were three groups of participants: medical students (n = 281), who completed a longitudinal survey consisting of the Jefferson Scale of Empathy and an open question about empathy at the beginning and end of the 2013 academic year; private doctors (medical practitioners) in South Australia (n = 78) who completed a survey consisting of the Jefferson Scale of Empathy and an open question about empathy at the end of the students' academic year; and doctors (medical practitioners) from public teaching hospitals (n = 72) in southern Adelaide, South Australia who completed a survey consisting of the Jefferson Scale of Empathy at the end of the students' academic year . RESULTS: Year one students' empathy scores at the end of the year (102.8 ± 17.7) were significantly lower than at the start of the year (112.3 ± 9.6) p < .05). There were no other significant differences in students' empathy scores by year groups or across the two time points. Empathy scores were almost identical for private and hospital clinicians and higher than average scores for students. Free-text comments highlighted the importance students and doctors place on empathy. Students described issues that adversely affected their empathy, including specific incidents, systemic issues, and course structure, but also described some positive role models. Doctors' comments focused on the importance of empathy but qualified its meaning in the therapeutic setting. CONCLUSION: Medical students and practitioners alike ascribe importance to empathy in clinical practice, yet its developmental course remains poorly understood with possible decrement across the course of medical education. A more sophisticated understanding of empathy in medical students is needed, with attention to issues that might adversely impact on this crucial aspect of their development. TRIAL REGISTRATION: This was not undertaken as the research did not involve a health care intervention on human participants.

Predicting success in medical school: a longitudinal study of common Australian student selection tools.

BACKGROUND: Medical student selection and assessment share an underlying high stakes context with the need for valid and reliable tools. This study examined the predictive validity of three tools commonly used in Australia: previous academic performance (Grade Point Average (GPA)), cognitive aptitude (a national admissions test), and non-academic qualities of prospective medical students (interview). METHODS: A four year retrospective cohort study was conducted at Flinders University Australia involving 382 graduate entry medical students first enrolled between 2006 and 2009. The main outcomes were academic and clinical performance measures and an indicator of unimpeded progress across the four years of the course. RESULTS: A combination of the selection criteria explained between 7.1 and 29.1 % of variance in performance depending on the outcome measure. Weighted GPA consistently predicted performance across all years of the course. The national admissions test was associated with performance in Years 1 and 2 (pre-clinical) and the interview with performance in Years 3 and 4 (clinical). Those students with higher GPAs were more likely to have unimpeded progress across the entire course (OR = 2.29, 95 % CI 1.57, 3.33). CONCLUSIONS: The continued use of multiple selection criteria to graduate entry medical courses is supported, with GPA remaining the single most consistent predictor of performance across all years of the course. The national admissions test is more valuable in the pre-clinical years, and the interview in the clinical years. Future selections research should develop the fledgling research base regarding the predictive validity of the Graduate Australian Medical School Admissions Test (GAMSAT), the algorithms for how individual tools are combined in selection, and further explore the usefulness of the unimpeded progress index.

LIt.search: fast tracking access to Aboriginal and Torres Strait Islander health literature.

OBJECTIVE: To develop and validate a PubMed search filter, LIt.search, that automatically retrieves Aboriginal and Torres Strait Islander health literature and to make it publicly accessible through the Lowitja Institute website. METHODS: Search filter development phases included: (1) scoping of the publication characteristics of Aboriginal and Torres Start Islander literature; (2) advisory group input and review; (3) systematic identification and testing of MeSH and text word terms; (4) relevance assessment of the search filter's retrieved items; and (5) translation for use in PubMed through the web. RESULTS: Scoping study analyses demonstrated complexity in the nature and use of possible search terms and publication characteristics. The search filter achieved a recall rate of 84.8% in the full gold standard test set. To determine real-world performance, post-hoc assessment of items retrieved by the search filter in PubMed was undertaken with 87.2% of articles deemed as relevant. The search filter was constructed as a series of URL hyperlinks to enable one-click searching. CONCLUSION: LIt.search is a search tool that facilitates research into practice for improving outcomes in Aboriginal and Torres Strait Islander health and is publicly available on the Lowitja Institute website. WHAT IS KNOWN ABOUT THIS TOPIC?: Health professionals, researchers and decision makers can find it difficult to retrieve published literature on Aboriginal and Torres Strait Islander health easily, effectively and in a timely way. WHAT DOES THIS PAPER ADD?: This paper describes a new web-based searching tool, LIt.search, which facilitates access to the relevant literature. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Ready access to published literature on Aboriginal and Torres Strait Islander health reduces a barrier to the use of this evidence in practice. LIt.search encourages the use of this evidence to inform clinical judgement and policy and service decision-making as well as reducing the burdens associated with searching for community practitioners, academics and policy makers.

OvidSP Medline-to-PubMed search filter translation: a methodology for extending search filter range to include PubMed's unique content.

BACKGROUND: PubMed translations of OvidSP Medline search filters offer searchers improved ease of access. They may also facilitate access to PubMed's unique content, including citations for the most recently published biomedical evidence. Retrieving this content requires a search strategy comprising natural language terms ('textwords'), rather than Medical Subject Headings (MeSH). We describe a reproducible methodology that uses a validated PubMed search filter translation to create a textword-only strategy to extend retrieval to PubMed's unique heart failure literature. METHODS: We translated an OvidSP Medline heart failure search filter for PubMed and established version equivalence in terms of indexed literature retrieval. The PubMed version was then run within PubMed to identify citations retrieved by the filter's MeSH terms (Heart failure, Left ventricular dysfunction, and Cardiomyopathy). It was then rerun with the same MeSH terms restricted to searching on title and abstract fields (i.e. as 'textwords'). Citations retrieved by the MeSH search but not the textword search were isolated. Frequency analysis of their titles/abstracts identified natural language alternatives for those MeSH terms that performed less effectively as textwords. These terms were tested in combination to determine the best performing search string for reclaiming this 'lost set'. This string, restricted to searching on PubMed's unique content, was then combined with the validated PubMed translation to extend the filter's performance in this database. RESULTS: The PubMed heart failure filter retrieved 6829 citations. Of these, 834 (12%) failed to be retrieved when MeSH terms were converted to textwords. Frequency analysis of the 834 citations identified five high frequency natural language alternatives that could improve retrieval of this set (cardiac failure, cardiac resynchronization, left ventricular systolic dysfunction, left ventricular diastolic dysfunction, and LV dysfunction). Together these terms reclaimed 157/834 (18.8%) of lost citations. CONCLUSIONS: MeSH terms facilitate precise searching in PubMed's indexed subset. They may, however, work less effectively as search terms prior to subject indexing. A validated PubMed search filter can be used to develop a supplementary textword-only search strategy to extend retrieval to PubMed's unique content. A PubMed heart failure search filter is available on the CareSearch website (http://www.caresearch.com.au) providing access to both indexed and non-indexed heart failure evidence.

A self-management approach using self-initiated action plans for symptoms with ongoing nurse support in patients with Chronic Obstructive Pulmonary Disease (COPD) and comorbidities: the COPE-III study protocol.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) frequently coexists with other diseases. Whereas COPD action plans are currently part of usual care, they are less suitable and potentially unsafe for use in the presence of comorbidities. This study evaluates whether an innovative treatment approach directed towards COPD and frequently existing comorbidities can reduce COPD exacerbation days. We hypothesise that this approach, which combines self-initiated action plans and nurse support, will accelerate proper treatment actions and lead to better control of deteriorating symptoms. METHODS: In this multicenter randomised controlled trial we aim to include 300 patients with COPD (GOLD II-IV), and with at least one comorbidity (cardiovascular disease, diabetes, anxiety and/or depression). Patients will be recruited from hospitals in the Netherlands (n = 150) and Australia (n = 150) and will be assigned to an intervention or control group. All patients will learn to complete daily symptom diaries for 12-months. Intervention group patients will participate in self-management training sessions to learn the use of individualised action plans for COPD and comorbidities, linked to the diary. The primary outcome is the number of COPD exacerbation days. Secondary outcomes include hospitalisations, quality of life, self-efficacy, adherence, patient's satisfaction and confidence, health care use and cost data. ANALYSES: Intention-to-treat analyses (random effect negative binomial regression and random effect mixed models) and cost-effectiveness analyses will be performed. DISCUSSION: Prudence should be employed before extrapolating the use of COPD specific action plans in patients with comorbidities. This study evaluates the efficacy of tailored action plans for both COPD and common comorbidities.

Searching MEDLINE for Aboriginal and Torres Strait Islander health literature: questionable sensitivity.

OBJECTIVE: The extent to which existing and future research can impact on reducing health disparities relates not only to the evidence available, but the ability to find that evidence. Our objective is to quantify experts' literature searching effectiveness with respect to Aboriginal and Torres Strait Islander people's health. METHODS: Nine journals were dual reviewed, and a 'gold standard' set of relevant articles was identified. Health librarians (n = 25) completed a standardised searching task using OVID MEDLINE, and results were compared with the gold standard. Sensitivity, specificity and precision rates were calculated. RESULTS: The gold standard comprised 136 of 1469 (9.3%) records from nine journals. Searches achieved a mean sensitivity of 53.2% (median = 64.7%, range 0.0-93.4%), specificity of 97.4% (median = 99.4%, range 52.6-100%) and precision of 83.3% (median = 91.0%, range 16.7-100%). Self-estimates of search sensitivity (post hoc) were significantly higher than observed (M = 78.9%, t = 4.812, P < 0.001). CONCLUSIONS: Even expert searchers struggle to find the relevant peer-reviewed literature in MEDLINE. IMPLICATIONS: A search filter may improve searching effectiveness for Aboriginal and Torres Strait Islander health literature. Assessment of health librarians' searching competencies warrants further professional debate and consideration.

Shoulder pain at the workplace.

Shoulder pain is among the most common of regional musculoskeletal complaints in the work environment. It is also a very common problem in the broader community. A challenge to health professionals working in this area is that only a small proportion of shoulder pain at work can be explained by conditions that are readily identifiable (such as rotator cuff disease) and can be adequately managed in a medical model. A greater proportion of shoulder pain at work cannot be understood in this way, and standard medical management is unlikely to offer the best chance of recovery. Furthermore, current research suggests that traditional work-related associations and risk factors only explain a minor part of the total problem and that ergonomic approaches focusing on primary prevention are also unlikely to adequately address the problem. This article examines recent research in the area of work-associated shoulder pain. It focuses on the recent literature examining classification of shoulder pain, and the assessment, management and prognosis of this challenging, regional musculoskeletal pain problem and argues for a more encompassing approach to its management.

Development of a heart failure filter for Medline: an objective approach using evidence-based clinical practice guidelines as an alternative to hand searching.

BACKGROUND: Heart failure is a highly debilitating syndrome with a poor prognosis primarily affecting the elderly. Clinicians wanting timely access to heart failure evidence to provide optimal patient care can face many challenges in locating this evidence. This study developed and validated a search filter of high clinical utility for the retrieval of heart failure articles in OvidSP Medline. METHODS: A Clinical Advisory Group was established to advise study investigators. The study set of 876 relevant articles from four heart failure clinical practice guidelines was divided into three datasets: a Term Identification Set, a Filter Development Set, and a Filter Validation Set. A further validation set (the Cochrane Validation Set) was formed using studies included in Cochrane heart failure systematic reviews. Candidate search terms were identified via word frequency analysis. The filter was developed by creating combinations of terms and recording their performance in retrieving items from the Filter Development Set. The filter's recall was then validated in both the Filter Validation Set and the Cochrane Validation Set. A precision estimate was obtained post-hoc by running the filter in Medline and screening the first 200 retrievals for relevance to heart failure. RESULTS: The four-term filter achieved a recall of 96.9% in the Filter Development Set; 98.2% in the Filter Validation Set; and 97.8% in the Cochrane Validation Set. Of the first 200 references retrieved by the filter when run in Medline, 150 were deemed relevant and 50 irrelevant. The post-hoc precision estimate was therefore 75%. CONCLUSIONS: This study describes an objective method for developing a validated heart failure filter of high recall performance and then testing its precision post-hoc. Clinical practice guidelines were found to be a feasible alternative to hand searching in creating a gold standard for filter development. Guidelines may be especially appropriate given their clinical utility. A validated heart failure filter is now available to support health professionals seeking reliable and efficient access to the heart failure literature.

Do doctors, nurses and managers have different thinking styles?

A study of the preferred thinking styles among senior health professionals is reported. A total of 49 medical consultants, 50 senior nurses and 53 health managers from two public teaching hospitals in Adelaide, Australia, were invited via a personal letter to complete a questionnaire comprising measures of thinking style (the Rational Experiential Inventory) and cognitive style (two dimensions of the Myers-Briggs Type Indicator). Managers reported a higher preference for 'rational' reasoning than nurses, whereas medical consultants reported a lower preference for 'experiential' reasoning than both managers and nurses. Cognitive style was largely homogenous. Although generalisation of the findings may be limited due to small sample sizes and the self-selection of participants, an understanding of the thinking styles of senior health professionals will likely inform the design and evaluation of future change strategies.

Applying evidence in the real world: a case study in library and information practice.

BACKGROUND/OBJECTIVES: Methodological decisions made during the research process can influence generalizability of findings to real world practice. The aims of this study were to explore the impact of decisions made in the development of a palliative care search filter and to consider the implications for implementation. METHODS: Three elements of the original study methodology were explored: (i) choice of OVID medline field delimiters; (ii) use of the general medical literature to evaluate the filter's performance; and (iii) use of the OVID interface. Sensitivity, specificity, accuracy and precision rates of variant search strategies were compared to consider each issue. RESULTS: The delimiter .af. outperformed the alternatives of .tw. or .mp. in OVID medline, improving sensitivity from 45.4 to 46.2%. Applying the filter in the specialist palliative literature resulted in 87.5% (692/791) of articles being retrieved using either .tw. or .mp., increasing to 100% (791/791) with the .af. delimiter. Finally, a PubMed version of the filter was successfully validated. CONCLUSIONS: Reviewing three methodological decisions that preserved validity in an original study led to the improved utility of a search filter in practice. Generating high-quality evidence is only part of evidence-based practice: consideration of generalizability issues can inform further research and effective evidence implementation.

Changes in the quantity and level of evidence of palliative and hospice care literature: the last century.

PURPOSE: To objectively quantify the literature and the clinical trial basis for palliative and hospice practice given a perception that its evidence base is not well developed. METHODS: Using Ovid Medline, the study looked at cumulative and absolute numbers of articles in the general medical literature and the palliative and hospice care literature. The same comparisons were made exploring clinical trials from 1902 to 2005. Data were collated in five year groups from 1970 onward using a highly specific search phrase. RESULTS: The proportion of all Ovid Medline publications relating to palliative and hospice care rose from 0.08% in 1970 to 0.38% of the literature in 2005. In the same time, clinical trials increased from 0.96% to 7.22% of the palliative care literature published. By 2005, one in every 122 clinical trials published in the literature as a whole was in palliative or hospice care. The rate of growth in palliative care clinical trials as a proportion of all palliative and hospice publications was on average 1.4 times greater than in the corresponding general literature. More than one half of these studies were reported in just 43 journals, most of which were not specialist palliative and hospice care journals. DISCUSSION: Given the diversity of journals in which clinical studies related to hospice and palliative care appear, there is a key challenge for clinicians in finding ways that will allow currency of practice in a broad and rapidly changing field.

Why don't doctors wash their hands? A correlational study of thinking styles and hand hygiene.

BACKGROUND: The World Health Organization has identified cognitive determinants of hand hygiene as an outstanding research question. This study investigated whether doctors' preferences for a rational thinking style or an experiential thinking style are associated with hand hygiene compliance. METHODS: This was an observational study of hand hygiene practices of 32 doctors in 2 teaching hospitals in South Australia. Compliance rates were correlated with self-reported thinking styles. The doctors were observed by a trained observer during a ward round or outpatient clinic and were unaware that hand hygiene was under observation. The main outcome measures were hand hygiene compliance (hand hygiene compliance tool) and thinking style (Rational-Experiential Inventory). RESULTS: An overall mean compliance rate of 7.6% (standard deviation +/- 7.2%) was found. Compliance was significantly positively correlated with experiential/automatic thinking (r = .46; P = .004) and the observational setting of ward rounds (vs clinics) (r = -.47; P = .003). No significant relationship was found between compliance and a rational/deliberate thinking style (r = -.01; P = .472). CONCLUSIONS: Hand hygiene is more experiential than rational. Findings suggest that certain promotional strategies appealing to the experiential thinking mode may improve compliance, and that traditional approaches based on logic and reasoning alone probably will not work.

Measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM).

BACKGROUND: Understanding how doctors think may inform both undergraduate and postgraduate medical education. Developing such an understanding requires valid and reliable measurement tools. We examined the measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM), designed to tap this domain with specific reference to medicine, but with previously questionable measurement properties. METHODS: First year postgraduate entry medical students at Flinders University, and trainees (postgraduate doctors in any specialty) and consultants (N = 348) based at two teaching hospitals in Adelaide, Australia, completed the ICBM and a questionnaire measuring thinking styles (Rational Experiential Inventory). RESULTS: Questions with the lowest item-total correlation were deleted from the original 22 item ICBM, although the resultant 17 item scale only marginally improved internal consistency (Cronbach's alpha = 0.61 compared with 0.57). A factor analysis identified two scales, both achieving only alpha = 0.58. Construct validity was assessed by correlating Rational Experiential Inventory scores with the ICBM, with some positive correlations noted for students only, suggesting that those who are naïve to the knowledge base required to "successfully" respond to the ICBM may profit by a thinking style in tune with logical reasoning. CONCLUSION: The ICBM failed to demonstrate adequate content validity, internal consistency and construct validity. It is unlikely that improvements can be achieved without considered attention to both the audience for which it is designed and its item content. The latter may need to involve both removal of some items deemed to measure multiple biases and the addition of new items in the attempt to survey the range of biases that may compromise medical decision making.