Evaluation of an online learning tool to improve medical students' clinical reasoning skills

Background: Evidence suggests that problems in clinical reasoning skills – the thought processes required to make clinical decisions – are the leading cause of diagnostic errors, which can lead to significant patient harm. Theories of learning and clinical reasoning have indicated online patient simulations (OPS) could be a novel approach to improving medical students’ clinical reasoning skills. However, little is known about their impact on clinical reasoning. Methods: I conducted a systematic literature review to explore the effectiveness of OPS. Informed by my review and theory, I co-developed eCREST (electronic Clinical Reasoning Skills Educational Simulation Tool). I assessed the feasibility, acceptability and potential impact of eCREST at three UK medical schools with a feasibility randomised controlled trial (RCT). I explored how students reasoned when using eCREST and what factors influenced reasoning, using a Think Aloud and interview approach with 16 medical students. Results: My systematic review found OPS may be effective at improving medical students’ clinical reasoning skills but the few studies available lacked methodological rigour, so these results should be treated with caution. Uptake and retention in the feasibility trial was acceptable and provided evidence to support a definitive RCT. Impact data suggested eCREST may improve clinical reasoning skills - the intervention group were significantly more likely to gather essential information from the ‘patient’ than controls (OR = 1.4; 95% CI 1.1-1.7, n = 148). Qualitative findings suggested that students use a variety of data gathering strategies and eCREST helped students to structure their data gathering and stay open-minded about diagnosis. Students’ knowledge, confidence and engagement with eCREST also influenced these strategies. Conclusions: Tools like eCREST can improve reasoning skills by helping students to gather essential information and potentially reduce future missed diagnostic opportunities. Evaluations of such tools are now needed within medical curricula, using validated outcome measures to determine effectiveness

Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment

This is the final version of the report. Available from the publisher via the DOI in this record.BACKGROUND: Available evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay. OBJECTIVES: This study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs. DATA SOURCES: We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type. METHODS: We conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England. Results: A total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings. LIMITATIONS: We only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review. CONCLUSIONS: The design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economyThe National Institute for Health Research Health Services and Delivery Research programme

Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review

IntroductionNudge-interventions aimed at health professionals are proposed to reduce the overuse and underuse of health services. However, little is known about their effectiveness at changing health professionals’ behaviours in relation to overuse or underuse of tests or treatments.ObjectiveThe aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services.Methods and analysisWe will perform a systematic review. All study designs that include a control comparison will be included. Any qualified health professional, across any specialty or setting, will be included. Only nudge-interventions aimed at altering the behaviour of health professionals will be included. We will examine the effect of choice architecture nudges (default options, active choice, framing effects, order effects) and social nudges (accountable justification and pre-commitment or publicly declared pledge/contract). Studies with outcomes relevant to overuse or underuse of health services will be included. Relevant studies will be identified by a computer-aided search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, CINAHL, Embase and PsycINFO databases. Two independent reviewers will screen studies for eligibility, extract data and perform the risk of bias assessment using the criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We will report our results in a structured synthesis format, as recommended by the Cochrane EPOC group.Ethics and disseminationNo ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature

Questioning, exploring, narrating and playing in the control room to maintain system safety

Systems whose design is primarily aimed at ensuring efficient, effective and safe working, such as control rooms, have traditionally been evaluated in terms of criteria that correspond directly to those values: functional correctness, time to complete tasks, etc. This paper reports on a study of control room working that identified other factors that contributed directly to overall system safety. These factors included the ability of staff to manage uncertainty, to learn in an exploratory way, to reflect on their actions, and to engage in problem-solving that has many of the hallmarks of playing puzzles which, in turn, supports exploratory learning. These factors, while currently difficult to measure or explicitly design for, must be recognized and valued in design

Urban Expressway Removal in Buffalo: The Historical Context

The policy brief summarizes the history of transportation infrastructure in Buffalo and some of the thinking behind its development. It sheds light on some of the positive and negative impacts of urban expressways in Buffalo and provides suggestions for how our city should think about moving forward, avoid repeating the mistakes of the past, and repair some of the harms caused

Urban Transportation Policy: A Guide and Road Map

The main transportation issues facing cities today fall into familiar categories--congestion and public transit. For congestion, there is now a far richer menu of options that are understood, technically feasible, and perhaps politically feasible. One can now contemplate offering roads of different qualities and prices. Many selected road segments are now operated by the private sector. Road pricing is routinely considered in planning exercises, and field experiments have made it more familiar to urban voters. Concerns about environmental effects of urban trucking have resulted in serious interest in tolled truck-only express highways. As for public transit, there is a need for political mechanisms to allow each type of transit to specialize where it is strongest. The spread of “bus rapid transit†has opened new possibilities for providing the advantages of rail transit at lower cost. The prospect of pricing and privatizing highway facilities could reduce the amount of subsidy needed to maintain a healthy transit system. Privately operated public transit is making a comeback in other parts of the world. The single most positive step toward better urban transportation would be to encourage the spread of road pricing. A second step, more speculative because it has not been researched, would be to use more environmentally-friendly road designs that provide needed capacity but at modest speeds, and that would not necessarily serve all vehicles.Transportation policy; Road pricing; Privatization; Product differentiation

Pathways to Coastal Resiliency: the Adaptive Gradients Framework

Current and future climate-related coastal impacts such as catastrophic and repetitive flooding, hurricane intensity, and sea level rise necessitate a new approach to developing and managing coastal infrastructure. Traditional “hard” or “grey” engineering solutions are proving both expensive and inflexible in the face of a rapidly changing coastal environment. Hybrid solutions that incorporate natural, nature-based, structural, and non-structural features may better achieve a broad set of goals such as ecological enhancement, long-term adaptation, and social benefits, but broad consideration and uptake of these approaches has been slow. One barrier to the widespread implementation of hybrid solutions is the lack of a relatively quick but holistic evaluation framework that places these broader environmental and societal goals on equal footing with the more traditional goal of exposure reduction. To respond to this need, the Adaptive Gradients Framework was developed and pilot-tested as a qualitative, flexible, and collaborative process guide for organizations to understand, evaluate, and potentially select more diverse kinds of infrastructural responses. These responses would ideally include natural, nature-based, and regulatory/cultural approaches, as well as hybrid designs combining multiple approaches. It enables rapid expert review of project designs based on eight metrics called “gradients”, which include exposure reduction, cost efficiency, institutional capacity, ecological enhancement, adaptation over time, greenhouse gas reduction, participatory process, and social benefits. The framework was conceptualized and developed in three phases: relevant factors and barriers were collected from practitioners and experts by survey; these factors were ranked by importance and used to develop the initial framework; several case studies were iteratively evaluated using this technique; and the framework was finalized for implementation. The article presents the framework and a pilot test of its application, along with resources that would enable wider application of the framework by practitioners and theorists

ENVIRONMENTAL DRIVERS OF JAGUAR DISTRIBUTION, ACTIVITY, AND ABUNDANCE IN SANTA ROSA NATIONAL PARK, COSTA RICA

Jaguars (Panthera onca) are a landscape species persisting in less than 54% of their historical distribution range; thus, the understanding of abiotic and biotic environmental factors affecting ecological interactions of this top predator in seasonal ecosystems such the dry forest is crucial for their conservation. In addition to factors affecting species ecology, some methodological constraints also could affect jaguar study outcomes leading to wrong decision-making. Data gathered from available jaguar peer-reviewed literature showed that there are large number of variables and techniques used to model jaguar distribution that did not contribute substantially to descriptions of jaguar distribution. Using the variables that do correlate with distribution (or better estimates of those variables or what they represent) such as prey abundance, protection level, distance to protected areas, landcover, road variables and vegetation, would improve estimates of jaguar distribution and abundance based on intuitive predictors. Therefore, researchers should better identify and then quantify specific casual factors affecting jaguar distribution and abundance, rather than simply describe it. Camera trap data at waterholes and pathways in Santa Rosa National Park in northwestern Costa Rica were evaluated that included two camera trap designs (50 camera traps at waterholes and on pathways during both dry/wet seasons). For 10 large mammal species (including jaguars) and four large bird species in the dry forest of northwestern Costa Rica, only capuchin monkeys (Cebus capucinus), tiger herons (Trigrisoma mexicanum), white-tailed deer (Odocoileus virginianus), and tapirs (Tapirus bairdii) showed interacting effects of location and seasonality, suggesting that these species were the most influenced by waterholes during the dry season. Data from a single female jaguar equipped with a GPS unit, and seasonal sea turtle abundance data and predation rates from track count surveys at Playa Naranjo and Playa Nancite, were analyzed to assess jaguar dependency on nesting turtles. Seasonal movements of this single female were influenced by seasonal sea turtle abundance availability, an overall home range size of 89 km2 did not differ statistically across turtle and non-turtle seasons, and during turtle seasons this collared female tended to stay mostly near the coastline. With regard to camera placement and seasonality on photo rates of jaguars and nontarget species, from June 2016 to June 2017 I deployed 58 camera traps at trail and off-trail locations in a grid array. I recorded 64 species of amphibians, reptiles, birds and mammals for which I calculated and compared relative abundance indexes (RAI: no. of independent photos/100 trap nights). For jaguars, I identified a high RAI of males at trail locations and high rates of female jaguars at off trail locations. Analysis of predator and prey interactions indicated temporal avoidance at trail locations. Density estimation using spatial capture-recapture models registered 19 jaguar individuals (11 males; 8 females), and a population density of 2.6/100 km2 (95% [CI] 1.7-4.0) jaguar females and 5.0/100 km2 jaguar males (95% [CI] 3.4-7.4). Camera location placement might bias sex individual detections and subsequent estimates based on telemetry and camera trap data. Long-term studies of jaguar populations might give more realistic and useful insights to conservation if researchers paid more attention to species’ behavior and interactions that could be biasing results. Thus, it is important to continuously rethink the “what?” and “how?” of the things we are doing in conservation science to effectively understand ecological processes. Additional observations from this study suggest some large herbivores are more sensitive to changes of climate than other species; therefore, jaguar studies should continue to tackle the effects of climate variability on prey species and their relationships with large predators in a unique ecosystem such the tropical dry forest