Standardized Patient Assessment Research Articles

Clinical Efficacy of Serum-Derived Bovine Immunoglobulin in Patients With Refractory Inflammatory Bowel Disease

BackgroundInflammatory bowel disease (IBD) can have autoimmunity and/or intestinal barrier dysfunction as part of pathophysiology and may be refractory to all available treatment options. Serum-derived bovine immunoglobulin (SBI) binds microbial components with postulated downstream effects of normalized gut immune and barrier function, which may be useful for managing IBD. The purpose of our study was to evaluate the effectiveness of SBI in the management of refractory IBD, particularly symptoms of chronic diarrhea and loose stools. MethodsWe retrospectively analyzed charts for patients diagnosed with IBD (n = 40) who were refractory to standard treatment. Patients received oral SBI 5 g daily for a period of at least 6 weeks. Twelve patients with IBD fulfilled study inclusion criteria. Each patient graded the severity and frequency of gastrointestinal symptoms before starting SBI and at 6 weeks of treatment using a standardized patient assessment form. Means and standard deviations for all symptom scores at baseline and week 6 of treatment were analyzed. ResultsMean symptom scores decreased significantly for nausea (P = 0.02 for severity and P = 0.03 for mean symptom score) and diarrhea (P = 0.0006, P = 0.0001 and P = 0.0001 for severity, frequency and mean symptom score, respectively). ConclusionsTherapy with SBI alleviated some refractory gastrointestinal symptoms in patients with IBD, including nausea and diarrhea. Increased duration, dosage and/or frequency of SBI might provide additional symptom improvement and could be tested through controlled clinical trials with larger sample sizes and longer follow-up.

An Interprofessional Approach to Teaching Nutrition Counseling to Medical Students.

Many physicians do not feel competent providing nutritional counseling to patients. A minimum of 25 hours dedicated to nutrition is recommended in preclinical years, but only 40% of U.S. medical schools achieve this goal. Nutrition counseling is best done when physicians work collaboratively with registered dietitians (RDs). We sought to introduce this interprofessional approach in our preclinical curriculum. In our first-year doctoring course, students viewed a nutrition lecture from a physician and RD. Teams of two to three medical students and one dietetics student were formed. The medical students took a history and performed nutrition counseling on the dietetics student role-playing a patient. The RD student provided feedback and reviewed clinical questions pertaining to the nutrition case. Medical students presented answers to their assigned case to the whole group. Medical students completed pre-/postsurveys assessing satisfaction and perceived confidence with nutrition counseling and were formally assessed using a standardized patient. The scores were compared to students from the year before who received the lecture but not the RD student activity. Eighty-one medical students participated. After the activity, there was an increase in confidence with nutrition counseling (p < .001), and 74% found working with dietetics students to be helpful or extremely helpful. The nutrition counseling mean score increased from 68% (historical control, n = 76) to 84% (n = 75; p < .001) on the standardized patient assessment. This format is an effective method of teaching nutrition counseling and promoting interprofessional behavior among rising physicians and RDs.

Training for Medical Oncologists on Shared Decision-Making About Palliative Chemotherapy: A Randomized Controlled Trial.

Systemic treatment for advanced cancer offers uncertain and sometimes limited benefit, while the burden can be high. This study examines the effect of shared decision-making (SDM) training for medical oncologists on observed SDM in standardized patient assessments. A randomized controlled trial comparing training with standard practice was conducted. Medical oncologists and oncologists-in-training (n = 31) participated in a video-recorded, standardized patient assessment at baseline (T0) and after 4 months (T1, after training). The training was based on a four-stage SDM model and consisted of a reader, two group sessions (3.5 hours each), a booster session (1.5 hours), and a consultation card. The primary outcome was observed SDM as assessed with the Observing Patient Involvement scale (OPTION12) coded by observers blinded for arm. Secondary outcomes were observed SDM per stage, communication skills, and oncologists' satisfaction with communication. The training had a significant and large effect on observed SDM in the simulated consultations (Cohen's f = 0.62) and improved observed SDM behavior in all four SDM stages (f = 0.39-0.72). The training improved oncologists' information provision skills (f = 0.77), skills related to anticipating/responding to emotions (f = 0.42), and their satisfaction with the consultation (f = 0.53). Training medical oncologists in SDM about palliative systemic treatment improves their performance in simulated consultations. The next step is to examine the effect of such training on SDM in clinical practice and on patient outcomes. Systemic treatment for advanced cancer offers uncertain and sometimes limited benefit, while the burden can be high. Hence, applying the premises of shared decision-making (SDM) is recommended. SDM is increasingly advocated based on the ethical imperative to provide patient-centered care and the increasing evidence for beneficial patient outcomes. Few studies examined the effectiveness of SDM training in robust designs. This randomized controlled trial demonstrated that SDM training (10 hours) improves oncologists' performance in consultations with standardized patients. The next step is to examine the effect of training on oncologists' performance and patient outcomes in clinical practice.

Quality of Postoperative Pain Management After Maxillofacial Fracture Repair.

Effective pain management is an essential component in the perioperative care of surgical patients. However, postoperative pain after maxillofacial fracture repair and its optimal therapy has not been described in detail. In a prospective cohort study, 95 adults rated their pain on the first postoperative day after maxillofacial fracture repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. Quality Improvement in Postoperative Pain Management allowed for a standardized assessment of patients' characteristics and pain-related parameters. Overall, the mean maximal pain and pain on activity (numeric rating scales) were significantly higher in patients with mandibular fractures than in patients with midface fractures (P = 0.002 and P = 0.045, respectively). In patients with mandibular fractures, a longer duration of surgery was significantly associated with higher satisfaction with pain intensity (P = 0.015), but was more frequently associated with postoperative vomiting (P = 0.023). A shorter duration of surgery and an absence of preoperative pain counseling in these patients were significantly correlated to desire for more pain medication (P = 0.049 and P = 0.004, respectively). Patients with mandibular fractures that received opioids in the recovery room had significantly higher strain-related pain (P = 0.017). In patients with midface fractures, a longer duration of surgery showed significantly higher levels of decreased mobility (P = 0.003). Patients receiving midazolam for premedication had significantly less minimal pain (P = 0.021). Patients with mandibular fractures seem to have more postoperative pain than patients with midface fractures. Monitoring of postsurgical pain and a procedure-specific pain-treatment protocol should be performed in clinical routine.

Comparing student self-assessments of global communication with trained faculty and standardized patient assessments

Background and purposeAssess the reliability of first year pharmacy student assessments completed by faculty members in comparison with a standardized patient (SP), and student self-assessments during a structured educational module on communication. Educational activity and settingPharmacy students completed four stations focused on communication with an SP. During each encounter, students completed a self-assessment and were evaluated by a faculty member and a trained SP. A five point Likert scale was used to evaluate student performance. Faculty assessments were compared against all others. A Pearson correlation coefficient for total scores was used and a Cohen's kappa was used to compare inter-rater reliability. Agreement and correlation was performed with student results categorized into poor, adequate, and exceptional performance based on faculty evaluation. FindingsTwenty-four students participated. In all stations, student self-assessments were graded higher than corresponding faculty and SP assessments. Agreement between faculty, SP, and self-assessment was fair to slight (k < 0.4) for all comparisons but only significant (p < 0.05) between the faculty and self-assessment. After categorization, there was a small, non-significant correlation between faculty and self-assessment (r = 0.13, p = 0.21) and moderate and significant correlation between faculty and SP (r = 0.32, p = 0.001). Categorized inter-rater agreement was fair for all comparisons (k < 0.2) and only significant (p < 0.05) between faculty and SP assessment. DiscussionPharmacy students in their first professional year assess their communication skills more positively than other evaluators. Further instruction for students and reflection may be required to build understanding of global assessment in communication. SummaryThere is high incongruity between student self-assessment and faculty appraisal.

Using traditional or flipped classrooms to teach “Geriatrics and Gerontology”? Investigating the impact of active learning on medical students’ competences

Background: The present study aims to investigate the effect of two educational strategies to teach geriatrics (flipped classroom-FL and traditional lectures-TR) in relation to a control group (no intervention) on students’ competences.Method: An intervention study was conducted during the third year of medicine. Two different educational strategies (flipped classroom and traditional lectures) were incorporated into a theoretical–practical discipline of geriatrics. Students were evaluated about their attitudes towards older persons (Maxwell–Sullivan, UCLA geriatric attitudes), empathy (Maxwell–Sullivan), knowledge (Palmore and cognitive knowledge), skills (standardized patient assessment), and satisfaction with the activities.Results: A total of 243 students were assessed. The FL group demonstrated greater gains in knowledge among students and improved attitude compared to the TR. We found no differences in the skills using a standardized patient. In addition, students exposed to FL felt more prepared to treat older people, believed they had more knowledge, were more satisfied, and evaluated the discipline’s format better in relation to the traditional group.Conclusions: Strategies in teaching geriatrics can impact students’ knowledge, attitudes, and satisfaction with the course. We found that the way this teaching is delivered can influence students’ learning, since there were differences between active and traditional strategies.

A randomized controlled trial of a skills training for oncologists and a communication aid for patients to stimulate shared decision making about palliative systemic treatment (CHOICE): study protocol

BackgroundSystemic treatment for advanced cancer offers uncertain and sometimes little benefit while the burden can be high. Hence, treatment decisions require Shared Decision Making (SDM). The CHOICE trial examines the separate and combined effect of oncologist training and a patient communication aid on SDM in consultations about palliative systemic treatment.MethodsA RCT design with four parallel arms will be adopted. Patients with metastatic or irresectable cancer with a median life expectancy <12 months who meet with a medical oncologist to discuss the start or continuation of palliative systemic treatment are eligible. A total of 24 oncologists (in training) and 192 patients will be recruited. The oncologist training consists of a reader, two group sessions (3.5 h; including modelling videos and role play), a booster feedback session (1 h) and a consultation room tool. The patient communication aid consists of a home-sent question prompt list and a value clarification exercise to prepare patients for SDM in the consultation. The control condition consists of care as usual. The primary outcome is observed SDM in audio-recorded consultations. Secondary outcomes include patient and oncologist evaluation of communication and decision-making, the decision made, quality of life, potential adverse outcomes such as anxiety and hopelessness, and consultation duration. Patients fill out questionnaires at baseline (T0), before (T1) and after the consultation (T2) and at 3 and 6 months (T3 and T4). All oncologists participate in two standardized patient assessments (before-after training) prior to the start of patient inclusion. They will fill out a questionnaire before and after these assessments, as well as after each of the recorded consultations in clinical practice.DiscussionThe CHOICE trial will enable evidence-based choices regarding the investment in SDM interventions targeting either oncologists, patients or both in the advanced cancer setting. The trial takes into account the immediate effect of the interventions on observed communication, but also on more distal and potential adverse patient outcomes. Also, the trial provides evidence regarding the assumption that SDM about palliative cancer treatment results in less aggressive treatment and more quality of life in the final period of life.Trial registrationNetherlands Trial Registry number NTR5489 (prospective; 15 Sep 2015).

Student Perception of Preparedness for Clinical Management of Adults With Lifelong Disability Using a Standardized Patient Assessment

Background and Purpose. A need exists to increase entry-level Doctor of Physical Therapy student exposure to adults with lifelong disability using novel educational methods. The purpose of this project was to determine whether student perception of preparedness with the knowledge, skills, and attitudes required for the management of lifelong disability was enhanced by the use of a standardized patient (SP) assessment experience with actors trained as adults with cerebral palsy (CP). Method/Model Description and Evaluation. An SP case about a young adult with CP was developed, and an assessment was implemented by a team of faculty members in a neuromuscular management track. Entry-level physical therapy students in their fifth of 7 semesters completed a survey about their perception of preparedness in the 3 learning domains at 3 time points, before (time 1) and after (time 2) the SP assessment and after a 10-week clinical education experience (time 3). Outcomes. Fifty-one students completed a series of 3 surveys. There was no change in student perception of preparation with the knowledge required for physical therapist management of an adult with CP at the 3 time points. Student perception of preparation with skills was increased significantly at time 2 and was maintained at time 3. Student perception of preparation with attitudes was also significantly increased at time 2, but returned to original levels at time 3. Discussion and Conclusion. Use of an SP experience was an educational assessment method that resulted in enhanced student perception of preparedness with the skills and attitudes necessary to work with adults with CP. Physical therapy programs may consider this method to address the need for creative educational strategies to address physical therapist management of lifelong disability.

The impact of informed self-assessment on the development of medical students’ learning goals

Purpose: This study investigates the contributions of self-assessment (SA) and external feedback on the development of learning goals (LG) and the influence on LG recall and implementation in medical students.Methods: Following a standardized patient (SP) assessment, 168 pre-clinical medical students completed a SA, received SP feedback and created a LG. LG were categorized by source. Two weeks later, students recalled LG and described implementation. Chi-squared analyses were used to test the associations.Results: SA influenced LG for 82.8% of students whereas SP feedback influenced LG for 45.9%. Students rarely generated LG based on SA when they received discordant feedback (5.4%), but sometimes incorporated feedback discordant from their SA into LG (14.9%). Students who created LG based on SP feedback were more likely to recall LG than those who created LG based on SA, 89.7 versus 67.6%, p < 0.05 and implement their LG, 72.4 versus 48.9%, χ2(1) = 5.3, p = 0.017. Students who reported receiving effective feedback were more likely to implement their LG than those reporting adequate feedback, 60.9 versus 37.9%, χ2(1) = 8.0, p = 0.01.Conclusions: SA is an essential part of goal setting and subsequent action. Perception of feedback plays a crucial role in LG implementation.

Gastric ultrasound to guide anesthetic management in elective surgical patients non-compliant with fasting instructions: a retrospective cohort study.

Perioperative aspiration leads to significant morbidity and mortality. Standard fasting periods are used to ensure an empty stomach in patients. Anesthesiologists are frequently confronted with cases of dubious adherence to these guidelines. Point-of-care gastric ultrasound is a diagnostic tool that offers information on the type and volume of gastric contents. We performed a retrospective analysis of a departmental database containing clinical and sonographic information on elective surgical patients who had been non-compliant to the fasting guidelines. Primary outcome was the incidence of changes in aspiration risk stratification and anesthetic management when a point-of-care gastric ultrasound examination was added to a standard history-based clinical assessment. Secondary outcomes included type of changes (timing of the surgical procedure or change in anesthetic technique) and the incidence of aspiration. Differences in the management plan (history-based versus gastric ultrasound) were tested with McNemar-Bowker's Exact Test of symmetry. Thirty-seven patients met the inclusion criteria. Aspiration risk assessment and anesthetic management changed in 24 cases (64.9%) following gastric ultrasound. Additionally, there was a non-significant difference in the distribution of the pre- and post-test changes in timing (delay, cancel, proceed) (P=0.074) with a trend towards a lower number of surgical cancellations and a higher number of proceeds. No aspirations were documented. This retrospective study suggests that gastric ultrasound may be a useful diagnostic addition to standard patient assessment in cases of non-compliance to fasting guidelines. It allows to personalize aspiration risk assessment and to tailor anesthetic management to the individual patient.

Performance of an Annular Closure Device in a 'Real-World', Heterogeneous, At-Risk, Lumbar Discectomy Population.

Study design/settingRetrospective analysis of single-center registry outcomes data.ObjectiveAssess the utility of an annular closure device (ACD) as an adjunct to limited discectomy for lumbar disc herniation (LDH).BackgroundRecurrent lumbar disc herniation (rLDH) following limited discectomy persists at clinically significant rates, especially in large annular defect (at least 6 mm width) patients. While the etiology of reherniation is often multifactorial, inadequate annular occlusion remains one of the foremost considerations. Accordingly, annular closure has emerged as a promising technique and is the focus of this analysis.MethodsThis was a retrospective analysis of 171 patients who underwent limited lumbar discectomy with an ACD for LDH. Standardized patient assessment was performed preoperatively, three months postoperatively, and 12 months postoperatively, in addition to self-presented visits. No minimum last follow-up was required for inclusion. Oswestry Disability Index (ODI) and Visual Analog Scale (VAS Leg/Back) pain scores were collected at all visits. Plain radiographs were obtained at all visits, with magnetic resonance imaging (MRI) scans performed annually and/or when patients presented as symptomatic. ACD-related complications due to partial or complete mesh detachment from the titanium anchor were reported. All secondary surgical interventions were also reported. The Wilcoxon Rank-sum test was used to compare outcomes and events between sub-groups (p < 0.05).ResultsMean last follow-up for all patients was 15 months. Large annular defects were present in 154 patients (90%). Symptomatic reherniations were observed in six patients (3.5%; five were present in the large annular defect subpopulation). All patients demonstrated clinically meaningful improvement in clinical outcome scores at both follow-up intervals. ACD mesh detachment was observed in 15 patients (8.8%; two underwent a subsequent surgical intervention). No symptomatic reherniations were observed in secondary herniation patients compared to six (4.1%) in the primary herniation group (p = 0.60).ConclusionsAnnular closure with the ACD results in clinically meaningful improvements in both primary and secondary LDH patients, with decreased rates of reherniation in high-risk patients compared to previous discectomy reports.

Voiding diary: proposal and assessment of a tool

ABSTRACTCan voiding diary be a primary tool to assess urinary symptoms, being accessible and easier to fit into patients' lives and their family or caregiver? The nursing care to neurogenic bladder patients reveals the daily need for standardized patient assessment tools that support the treatment process. The aim of this study is to propose and assess a voiding diary for use with intermittent bladder catheter users and their caregivers. Voiding diary is important tool for patients and their caregivers to use to help both parties understand the functioning of the urinary tract and identify urinary symptoms. Research developed at a Rehabilitation Center of a university hospital. After characterizing the population, the voiding diary was constructed based on the literature review and then subject to expert face and content validation. Each participant received a diary, a graded plastic flask and a data collection instrument, between June and October 2013. The data were analysed using descriptive statistics. Among the 44 (100.0%) participants, 28 (63.6%) were caregivers and 16 (36.4%) patients. The best assessed items regarding the diary were ‘Importance of the tool,’, ‘Explanation of the orientations’ and ‘Clarity of the Figures.’ The good adherence level to the tool was highlighted, as well as the importance of appropriate orientations before completing the diary.

Using Jazz as a Metaphor to Teach Improvisational Communication Skills.

Metaphor helps humans understand complex concepts by “mapping” them onto accessible concepts. The purpose of this study was to investigate the effects of using jazz as a metaphor to teach senior medical students improvisational communication skills, and to understand student learning experiences. The authors designed a month-long course that used jazz to teach improvisational communication. A sample of fourth-year medical students (N = 30) completed the course between 2011 and 2014. Evaluation consisted of quantitative and qualitative data collected pre- and post-course, with comparison to a concurrent control group on some measures. Measures included: (a) Student self-reports of knowledge and ability performing communicative tasks; (b) blinded standardized patient assessment of students’ adaptability and quality of listening; and (c) qualitative course evaluation data and open-ended interviews with course students. Compared to control students, course students demonstrated statistically significant and educationally meaningful gains in adaptability and listening behaviors. Students’ course experiences suggested that the jazz components led to high engagement and creativity, and provided a model to guide application of improvisational concepts to their own communication behaviors. Metaphor proved to be a powerful tool in this study, partly through enabling increased reflection and decreased resistance to behaviors that, on the surface, tended to run counter to generally accepted norms. The use of jazz as a metaphor to teach improvisational communication warrants further refinement and investigation.

The Association of Electrocardiographic Abnormalities and Acute Coronary Syndrome in Emergency Patients With Chest Pain.

The electrocardiograph (ECG) is an essential tool in initial management and risk stratification of patients with suspected acute coronary syndrome (ACS). A six-point reporting criterion has been proposed to facilitate standardized clinical assessment of patients presenting to the emergency department (ED) with suspected ACS. We set out to evaluate the efficacy of these criteria in identifying patients with major adverse cardiac events (MACE), Type 1 myocardial infarction (T1MI), Type 2 myocardial infarction (T2MI), and 1-year mortality in a cohort of emergency patients with chest pain. This was an analysis of data from 2,349 patients who presented to the ED with chest pain between 2008 and 2013. Data were collected as part of two prospective trials. ECGs were recorded at presentation and categorized according to the six-point criteria by local cardiologists blinded to all clinical information. The primary outcome was 30-day MACE, including T1MI, T2MI, unstable angina pectoris, revascularization, and 30-day mortality. The outcome was adjudicated by cardiologists on the basis of all clinical information and test results. Likelihood ratios and odds ratios for 30-day MACE were reported for each ECG category. Major adverse cardiac events were diagnosed in 264 (11.3%) patients. Increasing ischemic abnormalities in ECGs, as categorized by the standardized reporting criteria, were associated with increasing rates of MACE. Within 30 days, T1MI occurred in 148 (6.3%) patients and T2MI occurred in 59 (2.5%) patients. Risk for T1MI increased with higher classification of ECG abnormalities. T2MI rates were highest in patients with ECGs of nonspecific changes. The rates of MACE, T1MI, and 1-year death can be stratified according to standardized ECG criteria in patients presenting to the ED with chest pain. The ECG findings in patients with T2MI are variable, and the ECG is less helpful in defining risk in this group.

Self-Assessment Scores Improve After Simulation-Based Palliative Care Communication Skill Workshops.

We conducted a randomized trial of a simulation-based multisession workshop to improve palliative care communication skills (Codetalk). Standardized patient assessments demonstrated improved communication skills for trainees receiving the intervention; however, patient and family assessments failed to demonstrate improvement. This article reports findings from trainees' self-assessments. To examine whether Codetalk resulted in improved self-assessed communication competence by trainees. Trainees were recruited from the University of Washington and the Medical University of South Carolina. Internal medicine residents, medicine subspecialty fellows, nurse practitioner students, or community-based advanced practice nurses were randomized to Codetalk, a simulation-based workshop, or usual education. The outcome measure was self-assessed competence discussing palliative care needs with patients and was assessed at the start and end of the academic year. We used robust linear regression models to predict self-assessed competency, both as a latent construct and as individual indicators, including randomization status and baseline self-assessed competency. We randomized 472 trainees to the intervention (n = 232) or usual education (n = 240). The intervention was associated with an improvement in trainee's overall self-assessment of competence in communication skills ( P < .001). The intervention was also associated with an improvement in trainee self-assessments of 3 of the 4 skill-specific indicators-expressing empathy, discussing spiritual issues, and eliciting goals of care. Simulation-based communication training was associated with improved self-assessed competency in overall and specific communication skills in this randomized trial. Further research is needed to fully understand the importance and limitations of self-assessed competence in relation to other outcomes of improved communication skill.

Definitions and Assessment Approaches for Emergency Medical Services for Children.

Pediatric Life Support (PLS) courses and instructional programs are educational tools developed to teach resuscitation and stabilization of children who are critically ill or injured. A number of PLS courses have been developed by national professional organizations for different health care providers (eg, pediatricians, emergency physicians, other physicians, prehospital professionals, pediatric and emergency advanced practice nurses, physician assistants). PLS courses and programs have attempted to clarify and standardize assessment and treatment approaches for clinical practice in emergency, trauma, and critical care. Although the effectiveness of PLS education has not yet been scientifically validated, the courses and programs have significantly expanded pediatric resuscitation training throughout the United States and internationally. Variability in terminology and in assessment components used in education and training among PLS courses has the potential to create confusion among target groups and in how experts train educators and learners to teach and practice pediatric emergency, trauma, and critical care. It is critical that all educators use standard terminology and patient assessment to address potential or actual conflicts regarding patient evaluation and treatment. This article provides a consensus of several organizations as to the proper order and terminology for pediatric patient assessment. The Supplemental Information provides definitions for terms and nomenclature used in pediatric resuscitation and life support courses.

A Process for Curricular Improvement Based on Evaluation of Student Performance on Milestone Examinations

Objective. To identify and address areas for curricular improvement by evaluating student achievement of expected learning outcomes and competencies on annual milestone examinations. Design. Students were tested each professional year with a comprehensive milestone examination designed to evaluate student achievement of learning outcomes and professional competencies using a combination of multiple-choice questions, standardized patient assessments (SPAs), and objective structured clinical examination (OSCE) questions. Assessment. Based on student performance on milestone examinations, curricular changes were instituted, including an increased emphasis on graded comprehensive cases, OSCE skills days, and use of patient simulation in lecture and laboratory courses. After making these changes, significant improvements were observed in second and third-year pharmacy students' grades for the therapeutic case and physician interaction/errors and omissions components of the milestone examinations. Conclusion. Results from milestone examinations can be used to identify specific areas in which curricular improvements are needed to foster student achievement of learning outcomes and professional competencies.

Improving Warfarin Management Within the Medical Home: A Health-System Approach

BackgroundAnticoagulation clinics have been considered the optimal strategy for warfarin management with demonstrated improved patient outcomes through increased time in therapeutic international normalized ratio (INR) range, decreased critical INR values, and decreased anticoagulation-related adverse events. However, not all health systems are able to support a specialized anticoagulation clinic or may see patient volume exceed available anticoagulation clinic resources. The purpose of this study was to utilize an anticoagulation clinic model to standardize warfarin management in a primary care clinic setting. MethodsA warfarin management program was developed that included standardized patient assessment, protocolized warfarin-dosing algorithm, and electronic documentation and reporting tools. Primary care clinics were targeted for training and implementation of this program. ResultsThe warfarin management program was applied to over 2000 patients and implemented at 39 clinic sites. A total of 160 nurses and 15 pharmacists were trained on the program. Documentation of warfarin dose and date of the next INR increased from 70% to 90% (P <.0001), documentation occurring within 24 hours of the INR result increased from 75% to 87% (P <.0001), and monitoring the INR at least every 4 weeks increased from 71% to 83% (P <.0001) per patient encounter. Time in therapeutic INR range improved from 65% to 75%. ConclusionIncorporating a standardized approach to warfarin management in the primary care setting significantly improves warfarin-related documentation and time in therapeutic INR range.

Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices

BackgroundThe unique needs of homebound adults receiving home-based medical care (HBMC) (ie, home-based primary care and home-based palliative care services) are ideally provided by interdisciplinary care teams (IDTs) that provide coordinated care. The composition of team members from an array of organizations and the unique dimension of providing care in the home present specific challenges to timely access and communication of patient care information. The objective of this work was to develop a conceptual framework and corresponding quality indicators (QIs) that assess how IDT members for HBMC practices access and communicate key patient information with each other. MethodsA systematic review of peer-reviewed and gray literature was performed to inform a framework for care coordination in the home and the development of candidate QIs to assess processes by which all IDT members optimally access and use patient information. A technical expert panel (TEP) participated in a modified Delphi process to assess the validity and feasibility of each QI and to identify which would be most suitable for testing in the field. ResultsThematic analysis of literature revealed 4 process themes for how HBMC practices might engage in high-quality care coordination: using electronic medical records, conducting interdisciplinary team meetings, sharing standardized patient assessments, and communicating via secure e-messaging. Based on these themes, 9 candidate QIs were developed to reflect these processes. Three candidate QIs were assessed by the TEP as valid and feasible to measure in an HBMC practice setting. These indicators focused on use of IDT meetings, standardized patient assessments, and secure e-messaging. ConclusionTranslating the complex issue of care coordination into QIs will improve care delivered to vulnerable home-limited adults who receive HBMC. Guided by the literature, we developed a framework to reflect optimal care coordination in the home setting and identified 3 candidate QIs to field-test in HBMC practices.

Pilot Evaluation of a Communication Skills Training Program for Psychiatry Residents Using Standardized Patient Assessment.

Mental health clinicians can experience difficulties communicating diagnostic information to patients and their families/carers, especially about distressing psychiatric disorders such as schizophrenia. There is evidence for the effectiveness of communication skills training (CST) for improving diagnostic discussions, particularly in specialties such as oncology, but only limited evidence exists about CST for psychiatry. This study evaluated a CST program specifically developed for psychiatry residents called ComPsych that focuses on conveying diagnostic and prognostic information about schizophrenia. The ComPsych program consists of an introductory lecture, module booklets for trainees, and exemplary skills videos, followed by small group role-plays with simulated patients (SPs) led by a trained facilitator. A standardized patient assessment (SPA) was digitally recorded pre- and post-training with a SP using a standardized scenario in a time-limited (15min) period. Recorded SPAs were independently rated using a validated coding system (ComSkil) to identify frequency of skills used in five skills categories (agenda setting, checking, questioning, information organization, and empathic communication). Thirty trainees (15 males and 15 females; median age = 32) undertaking their vocational specialty training in psychiatry participated in ComPsych training and pre- and post-ComPsych SPAs. Skills increased post-training for agenda setting (d = -0.82), while questioning skills (d = 0.56) decreased. There were no significant differences in any other skills grouping, although checking, information organization, and empathic communication skills tended to increase post-training. A dose effect was observed for agenda setting, with trainees who attended more CST sessions outperforming those attending fewer. Findings support the generalization and translation of ComPsych CST to psychiatry.