4-stage Approach Research Articles

An Approach for Combining Clinical Judgment with Machine Learning to Inform Medical Decision Making: Analysis of Nonemergency Surgery Strategies for Acute Appendicitis in Patients with Multiple Long-Term Conditions.

Machine learning (ML) methods can identify complex patterns of treatment effect heterogeneity. However, before ML can help to personalize decision making, transparent approaches must be developed that draw on clinical judgment. We develop an approach that combines clinical judgment with ML to generate appropriate comparative effectiveness evidence for informing decision making. We motivate this approach in evaluating the effectiveness of nonemergency surgery (NES) strategies, such as antibiotic therapy, for people with acute appendicitis who have multiple long-term conditions (MLTCs) compared with emergency surgery (ES). Our 4-stage approach 1) draws on clinical judgment about which patient characteristics and morbidities modify the relative effectiveness of NES; 2) selects additional covariates from a high-dimensional covariate space (P > 500) by applying an ML approach, least absolute shrinkage and selection operator (LASSO), to large-scale administrative data (N = 24,312); 3) generates estimates of comparative effectiveness for relevant subgroups; and 4) presents evidence in a suitable form for decision making. This approach provides useful evidence for clinically relevant subgroups. We found that overall NES strategies led to increases in the mean number of days alive and out-of-hospital compared with ES, but estimates differed across subgroups, ranging from 21.2 (95% confidence interval: 1.8 to 40.5) for patients with chronic heart failure and chronic kidney disease to -10.4 (-29.8 to 9.1) for patients with cancer and hypertension. Our interactive tool for visualizing ML output allows for findings to be customized according to the specific needs of the clinical decision maker. This principled approach of combining clinical judgment with an ML approach can improve trust, relevance, and usefulness of the evidence generated for clinical decision making. Machine learning (ML) methods have many potential applications in medical decision making, but the lack of model interpretability and usability constitutes an important barrier for the wider adoption of ML evidence in practice.We develop a 4-stage approach for integrating clinical judgment into the way an ML approach is used to estimate and report comparative effectiveness.We illustrate the approach in undertaking an evaluation of nonemergency surgery (NES) strategies for acute appendicitis in patients with multiple long-term conditions and find that NES strategies lead to better outcomes compared with emergency surgery and that the effects differ across subgroups.We develop an interactive tool for visualizing the results of this study that allows findings to be customized according to the user's preferences.

DELIVERING SUSTAINABLE CHANGE OF POSTOPERATIVE CARE DOCUMENTATION PRACTICES IN SPINAL SURGERY THROUGH QUALITY IMPROVEMENT FRAMEWORKS

AbstractINTRODUCTIONIn the NHS the structure of a “regular healthcare team” is no longer the case. The NHS is facing a workforce crisis where cross-covering of ward-based health professionals is at an all-time high, this includes nurses, doctors, therapists, pharmacists and clerks. Comprehensive post-operative care documentation is essential to maintain patient safety, reduce information clarification requests, delays in rehabilitation, treatment, and investigations. The value of complete surgical registry data is emerging, and in the UK this has recently become mandated, but the completeness of post-operative care documentation is not held to the same importance, and at present there is no published standard. This project summarises a 4-stage approach, including 6 audit cycles, >400 reviewed operation notes, over a 5 year period.OBJECTIVETo deliver a sustainable change in post operative care documentation practices through quality improvement frameworks.METHODSStage 1: Characterise the problem and increase engagement through: SMART aims, process mapping, hybrid action-effect and driver diagram and stakeholder analysis. Multi disciplinary stakeholders were involved in achieving a consensus of evidence-based auditable criteria. Stage 2: Baseline audit to assess current practice. Stage 3: Intervention planning by stakeholders. Stage 4: Longitudinal monitoring through run charts and iterative refinement.RESULTSStage 1: Process mapping identified numerous downstream effects of the absence of critical information from operation notes, and the action-effect diagram highlighted the multiple unnecessary mitigating actions performed by ward staff. An MDT consensus was achieved on 15 essential criteria for complete documentation, including important negative fields. Interest-influence matrix identified stakeholder groups with high influence but low interest who needed engagement to deliver change. Stage 2: Baseline audit demonstrated unexpectedly poor documentation: >75% compliance in 4 criteria, and <50% compliance in 10 criteria, which elevated the interest of key stakeholders. Stage 3: A post-operative care template based on the 15 criteria was embedded within the existing IT software. It allowed use of existing operative templates, with a non-overwriting suffix requiring only two mouse clicks. Stage 4: Re-audit at 3 and 12 months showed improved and sustained compliance. At 24 months compliance had declined. Questionnaire of template usage identified problems of criteria response options, and lack of awareness of template by newly appointed staff. Template update improved compliance over the next 6 months (>75% compliance in 11 criteria). Finally, a further reaudit conducted 12 months after the template update (5 years post baseline audit) showed a sustained improvement in compliance (>75% compliance in 13 criteria).CONCLUSIONSSimple innovation through quality improvement frameworks has changed documentation practices by 1) achieving a consensus from stakeholders, 2) a “shock and awe” moment to highlight existing poor documentation and increase engagement 3) implementing change which fit easily into existing systems, 4) respecting autonomy rather than enforcing change and 5) longitudinal monitoring using run charts and an iterative process to ensure the template remains fit for purpose. This model has now successfully been translated to other subspecialities within the orthopaedic department.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Participatory needs assessment and action planning for a clinical and translational research network.

The goal of this study was to assess the utility of participatory needs assessment processes for continuous improvement of developing clinical and translational research (CTR) networks. Our approach expanded on evaluation strategies for CTR networks, centers, and institutes, which often survey stakeholders to identify infrastructure or resource needs, using the case example of the Great Plains IDeA-CTR Network. Our 4-stage approach (i.e., pre-assessment, data collection, implementation of needs assessment derived actions, monitoring of action plan) included a member survey (n = 357) and five subsequent small group sessions (n = 75 participants) to better characterize needs identified in the survey and to provide actionable recommendations. This participatory, mixed-methods needs assessment and strategic action planning process yielded 11 inter-related recommendations. These recommendations were presented to the CTR steering committee as inputs to develop detailed, prioritized action plans. Preliminary evaluation shows progress towards improved program capacity and effectiveness of the network to respond to member needs. The participatory, mixed-methods needs assessment and strategic planning process allowed a wide range of stakeholders to contribute to the development of actionable recommendations for network improvement, in line with the principles of team science.

A Toolbox of Surgical Techniques for Palatal Fistula Repair.

To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type. A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses. Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals. A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting. This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

An adaptation of Peyton's 4-stage approach to deliver clinical skills teaching remotely

This article was migrated. The article was not marked as recommended. In March 2020 the UK government enforced a nationwide 'lockdown' to curb the spread of Covid-19, which has resulted in medical schools having to close and deliver teaching remotely through online platforms. This presents a number of challenges, especially for clinical and practical skills teaching which is usually very 'hands-on'. At St Georges, we have adapted Peytons '4-stage approach' to devise a tool that can be used to structure and deliver clinical skills teaching to small groups, with the help of online videos. This framework preserves the most important aspects of the '4 stage process' and allows the continuation of teaching in a way that replicates conventional face-to-face teaching practices as closely as can be possible under the current constraints.

A Consensus-Based Set of Measures for Oral Health Care

Increasingly more responsive and accountable health care systems are demanded, which is characterized by transparency and explicit demonstration of competence by health care providers and the systems in which they work. This study aimed to establish measures of oral health for transparent and explicit reporting of routine data to facilitate more patient-centered and prevention-oriented oral health care. To accomplish this, an intermediate objective was to develop a comprehensive list of topics that a range of stakeholders would perceive as valid, important, and relevant for describing oral health and oral health care. A 4-stage approach was used to develop the list of topics: 1) scoping of literature and its appraisal, 2) a meeting of experts, 3) a 2-stage Delphi process (online), and 4) a World Café discussion. The aim was to create consensus through structured conversations via a range of stakeholders (general dental practitioners, patients, insurers, and policy makers) from the Netherlands, Germany, the United Kingdom, Ireland, Hungary, and Denmark. The study was part of the ADVOCATE project, and it resulted in a list of 48 topics grouped into 6 clusters: 1) access to dental care, 2) symptoms and diagnosis, 3) health behaviors, 4) oral treatments, 5) oral prevention, and 6) patient perception. All topics can be measured, as they all have a data source with defined numerators and denominators. This study is the first to establish a comprehensive and multiple-stakeholder consented topic list designed for guiding the implementation of transparent and explicit measurement of routine data of oral health and oral health care. Successful measurement within oral health care systems is essential to facilitate learning from variation in practice and outcomes within and among systems, and it potentiates improvement toward more patient-centered and prevention-oriented oral health care.

Medical students perform basic life support skills in a simulated scenario better using a 4-stage teaching approach compared to conventional training

Introduction. Cardiopulmonary resuscita-tion is influenced by the quality of basic life support (BLS). The primary objective of our study was to compare efficiency in the acquisition of BLS skills using conven-tional training and the 4-stage approach as a teaching method for BLS training. Methods. In a prospective, randomised, 2-parallel group study, 266 first year medi-cal students were randomised to either conventional training or the 4-stage ap-proach using 2000 and 2005 ERC (Euro-pean Resuscitation Council) guidelines. The students were tested immediately after receiving training. Three ERC-certified instructors assessed BLS skills using video recordings.Results. The students who were taught according to the 4-stage approach using 2000 guidelines preformed significantly better in the following steps: calls for help (p<0.01), opens the airway (p<0.01), plac-es hands for chest compression correctly (p<0.01) and performs chest compressions correctly (p<0.01), while using 2005 guide-lines, only chest compression hand posi-tion improved significantly in the 4-stage teaching group (p<0.01).Conclusions. The 4-stage approach im-proved the efficiency of several steps of the BLS algorithm and the ability to follow the algorithm in the correct sequence us-ing 2000 ERC guidelines, while in students using the 2005 ERC guidelines only chest compression hand position improved significantly. Students who were taught according to 2000 ERC guidelines had significantly better hand position than students who were taught according to 2005 guidelines, independent of teaching method used.

Cross-cultural Adaptation of the Pelvic Girdle Questionnaire for the French-Canadian Population

ObjectiveThe Pelvic Girdle Questionnaire (PGQ) is the only condition-specific tool assessing activity limitations and symptoms for those with pelvic girdle pain (PGP). It is simple to administer and can be used in research and clinical settings during pregnancy and postpartum periods; however, there currently is no version for the French-Canadian population. The aim of this study was to translate and culturally adapt the PGQ for the French-Canadian population. MethodsThe French-Canadian translation and adaptation of the PGQ was completed following a 4-stage approach: (1) forward translation, (2) synthesis, (3) expert committee review, and (4) testing of the prefinal version of the questionnaire. The testing stage was conducted with a cohort of 34 women, aged 18 to 45 years, who experienced PGP over the span of pregnancy or during the first year postpartum. ResultsThe global understanding of the PGP concept was rated as either “Fair” (41.2%) or “Good” (32.4%) by the majority of participants, which led to the consensual decision to add an illustration of the pelvic girdle region to the final version of the French-Canadian PGQ. Only 1 item (“Has your leg/have your legs given way?”) was reported as unclear by 12 participants (35.3%). The expert committee unanimously agreed to add a brief explanation of the term “given way” to the final version to ensure proper understanding of the question. ConclusionsThe current study yielded a satisfactory French-Canadian translation of the PGQ.

From research to practice: dissemination of the Contraceptive CHOICE Project.

Unintended pregnancy is a public health problem with societal consequences. The Contraceptive CHOICE Project (CHOICE) demonstrated a reduction in teen pregnancy and abortion by removing barriers to effective contraception. The purpose of the study was to describe the dissemination approach used to create awareness of and promote desire to adopt the CHOICE model among selected audiences. We used a 4-stage approach and detail the work completed in the first 2 stages. We describe stakeholder involvement in the first stage and the process of undertaking core strategies in the second stage. We examine insights gained throughout the process. Through our dissemination approach, we reached an estimated 300,000 targeted individuals, not including the population reached through media. We were contacted by 141 entities for technical assistance. The completion and reporting of dissemination processes is an important component of research. There is a need to fully document and disseminate strategies that can help facilitate practice change.

Unilateral Tailored Fronto-Orbital Approach for Giant Olfactory Groove Meningiomas: Technical Nuances

Giant olfactory groove meningiomas (maximum diameter ≥6 cm) remain a surgical challenge. Historically, extensive anterior and antero-lateral approaches have been the primary approaches for removal of such large tumors with limitations and morbidity pertaining to each approach. Herein, the authors describe a minimally invasive, unilateral, tailored fronto-orbital approach for resection of these complex lesions with an emphasis on preservation of the anterior cerebral arteries and olfactory nerves. A 4-stage approach using neuronavigation is performed: 1) predefined corridor, 2) identification of the ipsilateral anterior cerebral artery, 3) postdefined corridor, and 4) tumor base. The details of this approach are described below in a stepwise fashion and supplemented by a sample of 3 cases utilizing this technique. In the 3 representative cases in which this technique was used, gross total resection was achieved without injury to any of the adjacent neurovascular structures. Significant sellar extension can be resected through a second stage endoscopic endonasal approach. Giant olfactory groove meningiomas (≥6 cm) can be safely and completely resected with this 4-stage, unilateral fronto-orbital technique. Furthermore, early identification and preservation of the adjacent critical neurovascular structures can be achieved. This technique avoids the inherent limitations and morbidity associated with the more classic pterional and bifrontal approaches respectively while minimizing normal tissue disruption.

Concept mapping: A supervision strategy for introducing case conceptualization skills to novice therapists.

Case conceptualization, a term synonymous with case formulation, is an essential psychotherapy skill. Novice therapists enter into the practice of psychotherapy with limited case conceptualization skills. Hence, an important goal when supervising novice therapists is to effectively teach these skills. Concept mapping facilitates case conceptualization skills through the process of methodically creating graphic representations of clients' problems and dynamic relationships between these problems. This article introduces a highly structured and practical 4-stage approach to supervision that effectively introduces case formulation skills to novice therapists using concept mapping. It is assumed that concept maps, when shared with clients, function as an intervention to facilitate insight and change.

A prospective, blinded evaluation of a video-assisted '4-stage approach' during undergraduate student practical skills training.

BackgroundThe 4-stage approach (4-SA) is used as a didactic method for teaching practical skills in international courses on resuscitation and the structured care of trauma patients. The aim of this study was to evaluate objective and subjective learning success of a video-assisted 4-SA in teaching undergraduate medical students.MethodsThe participants were medical students learning the principles of the acute treatment of trauma patients in their multidiscipline course on emergency and intensive care medicine. The participants were quasi- randomly divided into two groups. The 4-SA was used in both groups. In the control group, all four steps were presented by an instructor. In the study group, the first two steps were presented as a video. At the end of the course a 5-minute objective, structured clinical examination (OSCE) of a simulated trauma patient was conducted. The test results were divided into objective results obtained through a checklist with 9 dichotomous items and the assessment of the global performance rated subjectively by the examiner on a Likert scale from 1 to 6.Results313 students were recruited; the results of 256 were suitable for analysis. The OSCE results were excellent in both groups and did not differ significantly (control group: median 9, interquantil range (IQR) 8–9, study group: median 9, IQR 8–9; p = 0.29). The global performance was rated significantly better for the study group (median 1, IQR 1–2 vs. median 2, IQR 1–3; p < 0.01). The relative knowledge increase, stated by the students in their evaluation after the course, was greater in the study group (85% vs. 80%).ConclusionIt is possible to employ video assistance in the classical 4-SA with comparable objective test results in an OSCE. The global performance was significantly improved with use of video assistance.

Simulation-based neonatal resuscitation training of medical students: is Peyton’s 4-stage approach more effective than traditional 2-stage technique?

Resuscitation of newborns is a critical procedure and requires refined skills. The contents of resuscitation guidelines and their implementation should be crucial in education of medical students. The traditional 2-stage (“see one, do one”) instruction is theory-loaded and does not provide sufficient hands-on training needed to give trainees the necessary practical experience or confidence in clinical skills. We aimed to evaluate whether simulation-based skill training by Peyton’s 4-step approach can improve the performance of medical students in neonatal resuscitation compared to traditional front-side 2-step teaching. In a prospective trial design, 49 fourth-year medical students were randomized in traditional and 4-stage groups. According to the “see one, do one” principle in the traditional group the teacher at first explained the ERC-algorithm and demonstrated the neonatal resuscitation procedure before the practitioners could train on manikins. In the “Peyton” group students were divided in small-groups with 4 trainees each and received 4-step approach training. Three days after the initial neonatal resuscitation training all students passed a standardized simulation-based scenario with newborn manikins to assess the effect of both teaching methods by an objective structured clinical examination (OSCE) and binary checklist. We modified the OSCE with a practical (pOSCE, maximal score 118) and a theoretical part (tOSCE, maximal score 74). Students in 4-stage group scored significantly higher than traditional trained participants: 113±5 vs. 68±23 (pOSCE) and 66±5 vs. 40±23 (tOSCE), all p<0.001. In conclusion, our study demonstrates that simulation-based training by Peyton’s 4-stage approach is effective to increase the performance of medical students in neonatal resuscitation.

The Word-of-Mouth Phenomenon: Its Presence and Impact in a Sport Setting

Word-of-mouth (WOM) marketing has the potential to effectively contribute to revenue generation as sport organizations continue to create and implement marketing strategies to build and maintain relationships with consumers. While there has been a plethora of research on WOM marketing in the general business literature, the magnitude of the phenomenon must be examined separately in a sport setting because of the uniqueness of sport fans as consumers. This study examined the effect of the transference of personal experiences through WOM activity on brand associations, team identification, and the behavioral intentions of college basketball fans. Through a 4-stage data-collection approach in which both positive and negative messages were used, it was found that WOM activity has a significant impact on some of the measured constructs. The results of the study suggest that negative WOM has a greater impact on consumers than positive WOM, providing significant theoretical and managerial implications.

Emergency skill training—A randomized controlled study on the effectiveness of the 4-stage approach compared to traditional clinical teaching

Introduction The “4-stage approach” has been widely accepted for practical skill training replacing the traditional 2 stages (“see one, do one”). However, the superior effectiveness of the 4-stage approach was never proved. Objectives To evaluate whether skill training with the 4-stage approach results in shorter performance time needed for a successful percutaneous needle-puncture cricothyroidotomy, and consequently in a reduced number of attempts needed to perform the skill in <60 s compared to traditional teaching. Trial design Randomized controlled single-blinded parallel group study at the University Hospital Bern. Methods With IRB approval and informed consent 128 undergraduate medical students were randomized in four groups: traditional teaching, no stage 2, no stage 3, and 4-stage approach for the training of cricothyroidotomy. Everyone watched a video of the cricothyroidotomy as stage 1 followed by skill training in the respective teaching group. Participants had to perform the cricothyroidotomy 10 times on skin-covered pig larynxes. Performance time was measured from skin palpation to trachea ventilation. Study participants filled out a self-rating on competency during the training. Results Performance time for each attempt was comparable in all groups and improved similarly to reach a performance time of <60 s. Self-rating revealed that all groups felt equally competent throughout. Conclusions Even if the 4-stage approach is widely accepted and used as a didactic method for skill teaching we could not find evidence that its use or omitting stage 2 or 3 results in superior learning of an emergency skill compared to traditional teaching.

Dynamics of shallow-water assemblages in the Saipan Lagoon

The Saipan Lagoon (Northern Mariana Islands) was first examined for benthic compo- sition and habitat distribution in the late 1940s. Here, we employ a 4-stage approach to evaluate and explain change in the distribution of the 9 habitats previously demarcated. We show that there have been considerable reductions in seagrass, staghorn Acropora, and Acropora palifera dominated habi- tats (-3.72, -1.26, and -1.37 km 2 , respectively) that were replaced by 6.16 km 2 of sand (~20% of the lagoon area). Multiple regressions showed that the spatial extent of Enhalus seagrass was positively related with, and best predicted by, the adjacent watershed area and lagoon width. Although the interaction was not as strong, Enhalus also increased in accordance with human development. The size of the Halodule seagrass and macroalgal habitat was negatively related to water-flow velocities and positively related to human development, while its integrity (i.e. the density of seagrass within a given habitat) decreased with human development. Taken together, the results suggest Enhalus and Halodule respond differently to proxies of watershed pollution, and contradict contemporary doctrine linking pollution with reduced seagrass density. This study found no relationship between offshore habitats and watershed characteristics, but suggests their expansion and contraction on relatively short time scales is a result of large-scale disturbances such as typhoons. We posit that, while habitat integrity can be altered by human disturbances, habitat identity is only altered under extreme condi- tions. In summary, this study advances habitat mapping by increasing resolution and accuracy, which, in turn, improves the texture at which reef ecology is used by management.