Can we improve the identification of cold homes for targeted home energy-efficiency improvements?

Objective: To investigate the extent to which homes with low indoor-temperatures can be identified from dwelling and household characteristics.Design: Analysis of data from a national survey of dwellings, occupied by low-income households, scheduled for home energy-efficiency improvements. Setting: Five urban areas of England: Birmingham, Liverpool, Manchester, Newcastle and Southampton.Methods: Half-hourly living-room temperatures were recorded for two to four weeks in dwellings over the winter periods November to April 2001-2002 and 2002-2003. Regression of indoor on outdoor temperatures was used to identify cold-homes in which standardized daytime living-room and/ or nighttime bedroom-temperatures were < 16 degrees C (when the outdoor temperature was 5 degrees C). Tabulation and logistic regression were used to examine the extent to which these cold-homes can be identified from dwelling and household characteristics.Results: Overall, 21.0% of dwellings had standardized daytime living-room temperatures < 16 degrees C and 46.4% had standardized nighttime bedroom-temperatures below the same temperature. Standardized indoor-temperatures were influenced by a wide range of household and dwelling characteristics, but most strongly by the energy efficiency (SAP) rating and by standardized heating costs. However, even using these variables, along with other dwelling and household characteristics in a multi-variable prediction model, it would be necessary to target more than half of all dwellings in our sample to ensure at least 80% sensitivity for identifying dwellings with cold living-room temperatures. An even higher proportion would have to be targeted to ensure 80% sensitivity for identifying dwellings with cold-bedroom temperatures.Conclusion: Property and household characteristics provide only limited potential for identifying dwellings where winter indoor temperatures are likely to be low, presumably because of the multiple influences on home heating, including personal choice and behaviour. This suggests that the highly selective targeting of energy-efficiency programmes is difficult to achieve if the primary aim is to identify dwellings with cold-indoor-temperatures. (c) 2006 Published by Elsevier Ltd

A systematic review of the effects of residency training on patient outcomes

<p>Abstract</p> <p>Background</p> <p>Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes.</p> <p>Methods</p> <p>The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes.</p> <p>Results</p> <p>Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design.Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained.</p> <p>Conclusions</p> <p>The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.</p

Entrustment and Mapping of Observable Practice Activities for Resident Assessment

Entrustable Professional Activities (EPAs) and the Next Accreditation System reporting milestones reduce general competencies into smaller evaluable parts. However, some EPAs and reporting milestones may be too broad to use as direct assessment tools. We describe our internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment. We created discrete OPAs for each resident rotation and learning experience. In combination, these serve as curricular foundation and tools for assessment. OPA performance is measured via a 5-point entrustment scale, and mapped to milestones and EPAs. Entrustment ratings of OPAs provide an opportunity for immediate structured feedback of specific clinical skills, and mapping OPAs to milestones and EPAs can be used for longitudinal assessment, promotion decisions, and reporting. Direct assessment and demonstration of progressive entrustment of trainee skill over time are important goals for all training programs. Systems that use OPAs mapped to milestones and EPAs provide the opportunity for achieving both, but require validation