Achieved Significance Level Research Articles

Impact on healthcare costs of adding telemedicine to a multidisciplinary disease management program for heart failure: a sub-analysis of the iCOR trial

Abstract Background Impact of telemedicine on heart failure outcomes has shown conflicting results. Little is known about the effect of these programs on mid-term healthcare costs. Purpose To evaluate the cost-efficacy of a comprehensive telemonitoring program within the vulnerable post-discharge period after an acute heart failure admission. Methods The insuficiència cardiaca Optimizació Remota (iCOR) trial was a single-centre, randomized, open-label study designed to evaluate the efficacy of the addition of telemonitoring and teleintervention to a specialized multidisciplinary nurse-led heart failure (HF) program. Adult patients with a recent hospital admission for acute HF and an acceptable social support and cognitive ability were recruited. This sub-analysis evaluates the effect of telemedicine on mid-term healthcare costs, including clinical events, drugs and devices, technology purchase and maintenance, outpatient care, days of hospitalization, procedures and complementary tests. t-test via bootstrap estimation is used to compare differences between the telemedicine (TM) and the usual care (UC) groups. Results 81 patients were assigned to the TM group and 97 patients to the UC group. Mean age was 74 years, more than 50% had HF with preserved ejection fraction and 25% were frail. Baseline characteristics were well-balanced between groups. Among the TM subgroup, adherence was very high (< 1% of missed biometric daily transmissions). During 6 months of follow-up, mean total healthcare cost per patient was 7949 euros (€) in the UC cohort and 4383 € in the TM cohort (relative risk reduction [RRR] of 45%; between-group differences 3546 €, 95% confidence interval 627-6464 €, bootstrap achieved significance level 0.022). This result was consistent across several subgroups (age, sex, frailty, left ventricular ejection fraction, educational level) and mainly driven by a 63% RRR in costs of hospitalization (which accounted for two-thirds of the total costs) in the TM cohort. 20 patients required HF admissions in the TM group, compared to 51 patients in the TM group (p < 0.001). This was associated with a 59% RRR in the need for diagnostic procedures. Total number of days of hospitalization per patient decreased from 12.2 in the UC group to 4.2 days in the TM group (p = 0.003), impelled by a reduction in HF and cardiovascular days of hospital stay. On the contrary, ambulatory care costs increase two-fold in the TM group compared to UC group. Nevertheless, these costs only accounted for a 19% of the total costs. Cost of devices needed to implement TM supposed 698 € per patient. Use of TM was associated with a 355 € increase in the cost of ambulatory neurohormonal treatment for HF. Conclusions TM implementation during the vulnerable phase after an acute HF admission was associated to a 45% RR reduction in mean total healthcare cost per patient. This result was driven by an almost two-thirds decrease in costs of hospitalization.UC and TM total healthcare costs

MTest: una Prueba bootstrap para Multicolinealidad

A nonparametric test based on bootstrap for detecting multicollinearity is proposed: MTest. This test gives statistical support to two of the most famous methods for detecting multicollinearity in applied work: Klein’s rule and Variance Inflation Factor (VIF for essential multicollinearity). As part of the procedure, MTest generates a bootstrap distribution for the coefficient of determination which: i) lets the researcher assess multicollinearity by setting a statistical significance "alfa", or more precisely, an achieved significance level (ASL) for a given threshold, ii) using a pairwise Kolmogorov-Smirnov (KS) test, establishes a guide for an educated removal of variables that are causing multicollinearity. In order to show the benefits of MTest, the procedure is computationally implemented in a function for linear regression models. This function is tested in numerical experiments that match the expected results. Finally, this paper makes an application of MTest to real data known to have multicollinearity problems and successfully detects multicollinearity with a given ASL.

The influence of spinopelvic relationships on late dislocation of the prosthetic femoral head after total hip arthroplasty

Objective. To analyze the influence of sagittal balance parameters on the risk of dislocations of the head of the femoral component of the hip joint endoprosthesis.Material and Methods. A retrospective analysis of medical records of 113 patients with idiopathic coxarthrosis who underwent unilateral total hip arthroplasty was performed. The study assessed the parameters characterizing the sagittal balance in patients without prosthetic femoral head dislocation in the postoperative period (Group 1; n = 60) and in patients treated for prosthetic femoral head dislocation (Group 2; n = 53). Comparison of indicators was carried out by non-parametric Mann – Whitney U-test, and identification of dislocation predictors – by building single- and multi-factor logistic regression models. Differences were considered statistically significant at the achieved significance level p < 0.05.Results. In Group 1, the type 3 sagittal balance according to Roussouly prevailed (48 %), in Group 2 – types 1, 2 and 4 (75 %). In patients with types 1 and 2 sagittal balance, the dislocations of the prosthetic femoral head occured 1.84 times more often than in patients with type 3, and that in patients with type 4 – 1.66 times more often.Conclusion. Patients with Roussouly type 3 sagittal balance have significantly lower risks of postoperative dislocation of the prosthetic femoral head, as compared with those with types 1, 2 and 4.

Effects of Forbush decreases on clouds determined from PATMOS-x

This study examines the relationship between cosmic rays and clouds during Forbush decreases (FDs) to understand the cause-effect relationships between cloud microphysics, cloud condensation nuclei (CCN), and ionisation in the atmosphere. The results of a Monte Carlo analysis of cloud parameters during FDs, which were obtained using newly calibrated satellite data (Pathfinder Atmospheres Extended (PATMOS-x)) from 1978 to 2018, show the connections between some cloud parameters and FDs. For context, FD is the event where the number of cosmic rays arriving in the atmosphere decreases and recovers over several days. Other studies have shown that FDs impacted the cloud fraction, aerosol optical depth, CCN, water content, and cloud effective radius (reff) in the atmosphere. Using the Monte Carlo analysis, nine atmospheric parameters from the dataset were evaluated and exhibited a significant response to FDs. Each added FD event (after the first event) reduces the noise, but only the strongest events add a significant signal (exceptionally when the 2nd and 5th rank FD data are added, the signal/noise ration dropped due to a change in the satellite version). We found that cloud fraction shows statistically significant signals following FDs at an achieved significance level of 0.33%. Cloud emissivity also showed highly significant signals from the analysis; however, these cannot be classified as physical causes of FDs since the response starts a week before the FDs. In contrast, the cloud optical depth, integrated total cloud water over the entire column, and reff did not show any significant signals in the frameworks of the applied methods. The top of the atmosphere brightness temperatures (TABTs) at nominal wavelengths of 3.75, 11.0, and 12.0 μm were analysed again along with surface BTs and showed significant signals. The estimated changes in the BT were determined using a radiative transfer model (Fu-Liou model) and showed consistent results with the observed changes in cloud parameters during FD events. Among the analysed several atmospheric/cloud/aerosol parameters, cloud fraction and TABT at nominal wavelengths of 3.75, 11.0, and 12.0 μm are the only parameters depicting a statistically significant and correct-phase response to FDs.

Peripheral Quantitative Computed Tomography Derived Muscle Density Is Associated With Physical Performance in Older Adults

PurposeThe assessment of body composition is an integral part in diagnosing sarcopenia. The purpose of this study was to determine the relationships between peripheral quantitative computed tomography (pQCT)-derived measures of body composition and measures of physical performance in older adults. MethodsMuscle density, muscle area, and fat area of 168 patients aged 65 years and older (76.3±6.5) were measured with pQCT at the distal forearm additionally to clinical assessment consisting of medical history, physical examination and physical assessment including hand grip strength, gait speed and chair rise tests. Regression analyses assessed associations between patients’ physical performance and pQCT derived data. ResultsAmong the three pQCT parameters, especially muscle density was significantly correlated with all of the three measures of physical performance even after adjusting for sex, age, BMI, vitamin D serum level and the level of physical activity. The same analysis for muscle area achieved significance level only for handgrip strength but not for gait speed nor for chair rise time. Fat area was significantly correlated only with gait speed after adjusting for sex and age. The association of muscle density with physical performance held up in an additional subanalysis stratified by body mass index. ConclusionMuscle density, a proxy for muscle fat infiltration, seems to be better than muscle area or fat area at assessing muscle quality and physical performance in older adults. This association seems to be independent of the body mass index.

Dynamics of the epidemic process and the course of the COVID-19 in pregnant women of the Far Eastern and Siberian Federal Districts

The objective of the study was to evaluate an epidemiological characteristic and the course of COVID-19 in pregnant women from the Far East and Siberian Federal Districts of Russia.
 Materials and methods. The analysis of operational information on the incidence of COVID-19 and the its features in pregnant women and after childbirth provided by the chief obstetrician-gynecologists of the Far Eastern Federal District and Siberian Federal District on May 25, 2020 and August 25, 2020 is carried out. Mathematical analysis included descriptive statistics methods, analysis of contingency tables, where the 2 value, the achieved significance level (p)
 Results. On August 25, 2020, 2010 cases of COVID-19 in pregnant women were detected in two subjects, including 134 active cases. In the population, the proportion of pregnant women among cases of COVID-19 was 1.45%. Pneumonia in pregnant women was registered in 44.8% of cases, severe course of the disease - in 3.7%, hospitalization in RAW - in 1.9% of cases, mechanical ventilation - 0. In the population, pneumonia was registered in 24.4% of cases, hospitalized in RAW - 2.1%, on mechanical ventilation - 0.77%. The incidence in pregnant women was 1464.7 per 100000 (in the population - 591.8 per 100 000). 23 (1.76%) COVID-19 (+) newborns were identified, despite preventive measures and separation of mother and child immediately after childbirth, which does not exclude vertical transmission of the disease. Maternal mortality was 2 cases (0.1%) vs population mortality 1.49%. Perinatal mortality was 7 cases (0.35%). There were 5 (0.25%) stillbirths. Early neonatal mortality was 2 (0.1%) cases.
 Conclusion. The incidence of COVID-19 in pregnant women in the Far East and Siberia is higher than in the general population with a higher incidence of pneumonia, but a milder course: less need for ICU, mechanical ventilation and mortality. 23 cases of SARSCoV-2-positive newborns, despite the separation of mother and child, do not exclude the possibility of vertical transmission of infection.
 Keywords: COVID-19, pregnancy, epidemiology, incidence, pneumonia, mortality

Comparative clinical and epidemiological characteristics and cytokine profile of viral diarrhea in adults

The aim of the work is to determine the clinical and pidemiological features and indicators of the cytokine profile in patients with viral diarrhea in the adult population, to establish the influence of inflammatory mediators on the course of the disease. Materials and methods -we analyzed the patient’s hospital records, as well as the blood serum of patients diagnosed with viral diarrhea. The experimental group consisted of 29 patients aged 23,2 ±8,4, with an equal distribution among men and women. The 1 experimental group included 22 patients with norovirus infection, the 2 comparison group consisted of 7 people with rotavirus gastroenteritis. The control group consisted of 20 somatically healthy people of the appropriate age (23,3±1,4). The concentration of proinflammatory and anti-inflammatory cytokines in blood serum was determined by ELISA using reagents from Vector-best LLC (Novosibirsk). Statistical processing of the obtained data was carried out using electronic programs Microsoft Excel 2010, Statistica 6.0, with the determination of the statistical significance of differences at the achieved significance level p ≤ 0.05 using the Mann – Whitney test (U-test). When calculating correlations, we used Spearman’s coefficient, r = -1+1 (r=0-0, 3 – weak connection, r= 0,3–0,7 – medium strength connection, r= 0,7–1 – strong connection; «+» – direct connection, «–» – feedback). The distribution of features was evaluated using the Shapiro – Wilkes W test. Results : in the course of work, the prevalence of norovirus infection among adult patients with viral diarrhea was established. Among the ways of infection, the food and water routes predominated, contact and household was noted, mainly, when caring for children with intestinal infection. In the clinical picture, all patients had a moderate intoxication syndrome. With rotavirus infection, catarrhal and pronounced gastroenteritis syndromes were determined, while for norovirus gastroenteritis, catarrhal syndrome was not characteristic, and patients also had a tendency to constipation. When assessing the cytokine status, an increase in the concentration of IL-2, IL-6, TNF- α , IL-10 was found, regardless of the etiological factor, at normal levels of IL-1 β and low IL-4, as well as a strong direct dependence of the severity of feverish intoxication syndrome on the level of IL-2, IL-1 β and IL-4. The effect of Pro-inflammatory and anti-inflammatory cytokine production on the duration of individual syndromes and on the duration of the disease as a whole has not been established. Conclusion – norovirus infection, in contrast to rotavirus infection, occurs without an obvious respiratory catarrhal syndrome, with the predominance of intoxication over gastroenteritis, while in rotavirus infection, the syndrome of intoxication and gastroenteritis are expressed equally. In viral diarrhea, there is an increase in IL-2, IL-6, TNF-a, and IL-10, which play an important role in the development of feverintoxication syndrome and the formation of antiviral protection.

A Comparative Study of the Power of Parametric and Permutation Tests for a Multidimensional Two-sample Location Problem

Objective: A comparison of multidimensional populations is a very interesting and common statistical problem. It most often involves verifying a hypothesis about the equality of mean vectors in two populations. The classical test for verification of this hypothesis is the Hotelling’s T 2 test. Another solution is to use simulation and randomization methods to test the significance of differences between the studied populations. Permutation tests are to enable statistical inference in situations where it is not possible to use classical parametric tests. These tests are supposed to provide comparable power to parametric tests with a simultaneous reduction of assumptions, e.g. regarding the sample size taken or the distribution of the tested variable in the population. The purpose of this study is a comparative analysis of the parametric test, the (usual) permutation test, and the nonparametric permutation procedure using two-stage ASL determination. Research Design & Methods: The study considered the analysis of multivariate data. The paper presents theoretical considerations and refers to the Monte Carlo simulation. Findings: The article presents a permutational, complex procedure for assessing the overall ASL (achieved significance level) value. The applied nonparametric statistical inference procedure uses combining functions. A simulation study was carried out to determine the size and power of the test under normality. A Monte Carlo simulation made it possible to compare the empirical power of this test with that of Hotelling’s T 2 test. The most powerful test was the permutation test based on a two-stage ASL determination method using the Fisher combining function. Implications/Recommendations: The advantage of the proposed method is that it can be used even when samples are taken from any type of continuous distributions in a population. Contribution: The proposed test can be used in the analysis of multidimensional economic phenomena.

Структура неоперированных врожденных пороков сердца у детей Забайкальского края

The aim of the research is to study the morbidity by appealability and some characteristics of congenital heart diseases in children of Zabaikalsky Territory. Material and methods. A retrospective clinical and anamnestic analysis of children with congenital heart diseases without surgical treatment, who were hospitalized, was carried out. The analysis included 3 year-observation. CHD diagnosed is an inclusion criterion; while surgical treatment of heart diseases is exclusion criterion. Statistical data processing was carried out using Microsoft Excel 2007, Statistica v.10.0 software package. χ2 test (Pearson) was used to compare two independent groups by qualitative characteristics. The results were considered statistically significant (reliable) at the achieved significance level of p <0.05. Results. In Zabaikalsky Territory, approximately 200 children with congenital heart disease without surgical treatment are hospitalized annually; the average age is 3 years. Fifty-three per cent of children applied for inpatient care for the first time, 44% of them were children at their first year. Gender distribution indicates the highest incidence of the pathology in girls. In CHD structure, atrial septal defects are on the first place, while interventricular septal defects are on the second. Combination of ASD and IVSD was observed with approximately equal frequency. Chronic heart failure associated with CHD was registered in 77% of children. In most cases CHF, stage 1, was diagnosed (63%). In 2/3 of cases, pulmonary hypertension of various severity was detected. Analysis of place of residence of children with CHD in the Zabaikalsky Territory shows that children from areas with the highest population density are hospitalized more often. Conclusion. The problem of congenital heart diseases in children of Zabaikalsky Territory is of current importance due to the widespread prevalence and high specific gravity among all internal organ defects in children of this region.

ON PERMUTATION LOCATION–SCALE TESTS

Abstract Statisticians are constantly looking for methods of statistical inference that would be both effective and would require meeting as few assumptions as possible. Permutation tests seem to fit here, as using them makes it possible to perform statistical inference in situations where classical parametric tests do not work. Permutation tests appear to be comparably powerful to parametric tests, but require meeting fewer assumptions, e.g. regarding the size of the sample or the from of distribution of the tested variable in a population. The presented tests make it possible to verify the overall hypothesis about the identity of both location and scale parameters in the studied populations. In literature, the Lepage test and the Cucconi test are most often referred to in this context. The paper considers various forms of test statistics, and presents a simulation study carried out to determine the size and power of the tests under normality. As the study demonstrated, the advantage of the proposed method is that it can be applied to small-size samples. A nonparametric, complex procedure was used to assess the overall ASL (achieved significance level) value by applying the permutation principle. For comparative purposes, the results for the permutation Lepage test and the permutation Cucconi test are also presented.

Goodness‐of‐fit testing in sparse contingency tables when the number of variables is large

AbstractThe Pearson and likelihood ratio statistics are commonly used to test goodness of fit for models applied to data from a multinomial distribution. When data are from a table formed by the cross‐classification of a large number of variables, the common statistics may have low power and inaccurate Type I error level due to sparseness. One approach to finding a valid approximation to the achieved significance level (ASL) is to use a bootstrap distribution for the test statistic. For a composite null hypothesis with unknown parameters, the parametric bootstrap has been employed. The parametric bootstrap can be computationally demanding, but a recent development provides a method for computationally efficient calculation of the Pearson–Fisher statistic for very large sparse tables. Another approach employs orthogonal components of the Pearson–Fisher statistic obtained from lower‐order marginal distributions of a large cross‐classified table rather than the joint distribution. These statistics are used essentially for focused tests and have mostly been applied to latent variable models. They have very good performance for Type I error rate and power, even when applied to a sparse table. However, there are limitations when the number of variables becomes larger than 20. Some related statistics also employ lower‐order marginals, but they are not components of the Pearson–Fisher statistic. The performance of these approaches is compared for obtaining a valid ASL for a goodness‐of‐fit test applied to a very large multi‐way contingency table. The approaches are compared with a small simulation study.This article is categorized under: Types and Structure > Categorical Data Statistical and Graphical Methods of Data Analysis > Bootstrap and Resampling Statistical Models > Fitting Models

Long-Term Outcome of Bodily Distress Syndrome in Primary Care: A Follow-Up Study on Health Care Costs, Work Disability, and Self-Rated Health.

The upcoming International Classification of Diseases, 11th Revision for primary care use suggests inclusion of a new diagnostic construct, bodily (di)stress syndrome (BDS), for individuals with medically unexplained symptoms. We aimed to explore the long-term outcome of BDS in health care costs, work disability, and self-rated health. Consecutive patients consulting their family physician for a new health problem were screened for physical and mental symptoms by questionnaires (n = 1785). A stratified subsample was examined with a standardized diagnostic interview (n = 701). Patients with single-organ BDS (n = 124) and multiorgan BDS (n = 35), and a reference group with a family physician-verified medical condition (n = 880) were included. All included patients completed a questionnaire at 3, 12, and 24 months of follow-up. Register data on health care costs and work disability were obtained after 2 and 10 years of follow-up, respectively. Patients with BDS displayed poorer self-rated health and higher illness worry at index consultation and throughout follow-up than the reference group (p ≤ .001). The annual health care costs were higher in the BDS groups (2270 USD and 4066 USD) than in the reference group (1392 USD) (achieved significance level (ASL) ≤ 0.001). Both BDS groups had higher risk of sick leave during the first 2 years of follow-up (RRsingle-organ BDS = 3.0; 95% confidence interval [CI] = 1.8-5.0; RRmultiorgan BDS = 3.4; 95% CI = 1.5-7.5) and substantially higher risk of newly awarded disability pension than the reference group (HRsingle-organ BDS = 4.9; 95% CI = 2.8-8.4; HRmultiorgan BDS = 8.7; 95% CI = 3.7-20.7). Patients with BDS have poor long-term outcome of health care costs, work disability, and subjective suffering. These findings stress the need for adequate recognition and management of BDS.

IMPLEMENTASI METODE BOOTSTRAP UNTUK PENGUJIAN HIPOTESIS MENGENAI DUA MEAN POPULASI

This paper examines the problem of testing hypotheses about two population means. Most testing hypotheses about two population means, based on the assumption that each random sample drawn from a normal population. In this paper studied the problem of testing hypotheses about two population means are not using the assumption of normality and homogeneity. The method used to test hypotheses about two population means are the bootstrap method. The basic idea of the bootstrap method of repeated sampling with replacement from the sample data. Replication of samples used to determine the point estimator of Achieved Significance Level (ASL). Performance of the bootstrap method was tested using simulated data. The test results show that the bootstrap method to test the hypothesis of two population means well. Furthermore bootstrap method implemented on real data.

Millennial- to centennial-scale climate periodicities and forcing mechanisms in the westernmost Mediterranean for the past 20,000 yr

Cyclostratigraphic analysis conducted on a continuous high-resolution marine record from the western most Mediterranean reveals well-identified paleoclimate cycles for the last 20,000yr. The detrital proxies used (Si/Al, Ti/Al, Zr/Al, Mg/Al, K/Al, Rb/Al) are related to different sediment-transport mechanisms, including eolian dust and fluvial runoff, which involve fluctuations in the atmosphere–hydrosphere systems. These fluctuations are accompanied by changes in marine productivity (supported by Ba/Al) and bottom-water redox conditions (Cu/Al, V/Al, Zn/Al, Fe/Al, Mn/Al, U/Th). Spectral analysis conducted using the Lomb–Scargle periodogram and the achieved significance level implemented with the permutation test allowed us to establish major periodicities at 1300, 1515, 2000, and 5000yr, and secondary peaks at 650, 1087, and 3000yr. Some of these cycles also agree with those previously described in the North Atlantic Ocean and circum-Mediterranean records. The periodicities obtained at 2000 and 5000yr support a global connection with records distributed at high, mid, and low latitudes associated with solar activity, monsoonal regime and orbital forcing. The 1300- and 1515-yrcycles appear to be linked with North Atlantic climate variability and the African monsoon system. Thus, the analyzed record provides evidence of climate cycles and plausible forcing mechanisms coupled with ocean–atmosphere fluctuations.

Blood Levels of Free Fatty Acids and Energy-Rich Phosphates in Patients with Acute Acetic Acid Poisoning Complicated by Toxic Shock

Objective: to study the blood levels of free fatty acids (FFA) and adenyl nucleotides in patients with acute acetic acid poisoning (AAAP) complicated with exotoxic shock (ES). Subjects and methods. The study enrolled 33 patients with severe AAAP (with (n=10) and without (n=23) ES), of them there were 5 deaths. The patients’ age was 31.6±11.6 years. A control group comprised 16 healthy individuals. The total level of FFA and the concentration of glycerol were measured in the plasma. Red blood cells were as an object for investigation of ATP, ADP, and AMP. Hearts were morphologically studied in 5 patients died from shock. The data were statistically processed using the Mann-Whitney rank nonparametric tests. The differences were regarded as statistically significant at the achieved significance level of pConclusion. Microscopic studies of the hearts from the deceased patients revealed multiple cardiomyocyte necroses. All the patients with severe AAAP showed a considerably elevated blood level of FFAs with their impaired myocardial utilization and decreased red blood cell ATP and ADP concentrations. The most pronounced changes were found in a group of patients with AAAP and ES. Key words: acetic acid poisoning, exotoxic shock, free fatty acids, energy-rich phosphates.

Guidelines for reporting statistics in journals published by the American Physiological Society

Guidelines for reporting statistics in journals published by the American Physiological Society

Guidelines for reporting statistics in journals published by the American Physiological Society

Guidelines for reporting statistics in journals published by the American Physiological Society

Guidelines for reporting statistics in journals published by the American Physiological Society

Guidelines for reporting statistics in journals published by the American Physiological Society

Guidelines for reporting statistics in journals published by the American Physiological Society

Concepts and procedures in statistics are inherent to publications in science. Based on the incidence of standard deviations, standard errors, and confidence intervals in articles published by the American Physiological Society (APS), however, many scientists appear to misunderstand fundamental

How Might Classroom Time Be Used Given WWW‐Based Lectures?

AbstractThis paper investigates how traditional lecture time might be used given the availability of effective web‐based courseware for delivering materials typically presented in the classroom. After providing an overview of web‐based educational materials, the effectiveness of two teaching approaches is compared using a product design lecture on visual prototyping. One group of students prepared for class using web‐based materials and then received a lecture‐style second coverage of the topic in class (web+class lecture). The other group of students prepared for class using the same web‐based materials and then worked with the faculty, applying only a small portion of the subject matter, on illustrative examples (web+limited experience). The two groups then completed an assignment based on the subject matter. The average grade performance of the web+limited experience group was 10.8% higher than for the web+class lecture group. An achieved significance level of 0.001 provides very strong evidence to reject the hypothesis that the two groups performed equally. Analysis of how the two student groups used the web‐lecture resource showed that the form of class instruction had a strong influence on student motivation for independent study. The average time spent in web‐based preparation by the web+limited experience group was 1.6 times greater than the average preparation time for the web+class lecture group. Sixty percent of the web+class lecture group prepared less than the least prepared student in the web+limited experience group. These findings suggest that, if codified materials are primarily delivered using a medium such as the WWW, traditional classroom time might be liberated for potentially higher value‐added activities such as mentoring and experiential activities.