Developing questionnaires for educational research: AMEE Guide No. 87

In this AMEE Guide, we consider the design and development of self-administered surveys, commonly called questionnaires. Questionnaires are widely employed in medical education research. Unfortunately, the processes used to develop such questionnaires vary in quality and lack consistent, rigorous standards. Consequently, the quality of the questionnaires used in medical education research is highly variable. To address this problem, this AMEE Guide presents a systematic, seven-step process for designing high-quality questionnaires, with particular emphasis on developing survey scales. These seven steps do not address all aspects of survey design, nor do they represent the only way to develop a high-quality questionnaire. Instead, these steps synthesize multiple survey design techniques and organize them into a cohesive process for questionnaire developers of all levels. Addressing each of these steps systematically will improve the probabilities that survey designers will accurately measure what they intend to measure

New approaches to selection system design in healthcare: The practical and theoretical relevance of a modular approach

This chapter presents a modular approach to healthcare selection system design. Contrary to the traditional holistic view on selection procedures, a modular approach highlights the components underlying selection procedures. Our framework identifies seven key design components of selection procedures (The stimulus format, contextualization, stimulus presentation consistency, the response format, response evaluation consistency, information source, and instructions) and reviews studies in the healthcare selection literature that compared the effect of these components on key selection outcomes. A modular approach allows (1) gaining insights into how the different components underlying selection procedures affect selection outcomes and (2) drawing conceptual similarities between components of different selection procedures. At a practical level, a modular approach permits developing a myriad of new selection procedures by "mixing and matching" different building blocks. We present two case studies and future research avenues to further illustrate these merits of a modular approach

Epidemiology of psychiatric disorders sustained by a U.S. Army brigade combat team during the Iraq War

The article of record as published may be found at http://dx.doi.org/10.1016/j.genhosppsych.2010.10.007This study was designed to describe the epidemiology of psychiatric illnesses experienced by soldiers in a combat environment, which has been previously underreported.Approved for public release; distribution is unlimited

Medical education in the United States of America

This article was written to provide a brief history of the medical educational system in the USA, the current educational structure, and the current topics and challenges facing USA medical educators today. The USA is fortunate to have a robust educational system, with over 150 medical schools, thousands of graduate medical education programs, well-accepted standardized examinations throughout training, and many educational research programs. All levels of medical education, from curriculum reform in medical schools and the integration of competencies in graduate medical education, to the maintenance of certification in continuing medical education, have undergone rapid changes since the turn of the millennium. The intent of the changes has been to involve the patient sooner in the educational process, use better educational strategies, link educational processes more closely with educational outcomes, and focus on other skills besides knowledge. However, with the litany of changes have come increased regulation without (as of yet) clear evidence as to which of the changes will result in better physicians. In addition, the USA governmental debt crisis threatens the current educational structure. The next wave of changes in the USA medical system needs to focus on what particular educational strategies result in the best physicians and how to fund the system over the long term. © 2012 Informa UK Ltd

Factors associated with early failure of infrainguinal lower extremity arterial bypass

Objectives: We analyzed the Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP), a large clinical database, to investigate which factors, other than technical, were associated with a higher incidence of early graft failure in infrainguinal bypass. Methods: Data are prospectively collected in NSQIP from 123 participating VA Medical Centers. All patients from 1995 to 2003 in the NSQIP database who underwent infrainguinal arterial bypass were identified by Current Procedural Terminology (CPT) codes (CPT is a registered trademark of the American Medical Association, Chicago, Ill, Copyright 2007). Data for 30-day graft failure were evaluated by univariate analysis, and multivariate logistic regression was used to control for possible confounders. Results: The NSQIP database identified 14,788 patients who underwent infrainguinal lower extremity arterial bypasses during the study period, and 723 acute graft failures (4.9%) occurred. On multivariate analysis, compared with patients aged \u3e70 years, patient ages of \u3c50 and 51 to 60 years were significantly associated with early graft failure (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.6-3.0; P \u3c .001; OR, 1.4; 95% CI, 1.2-1.6, P \u3c .001; respectively); age range of 61 to 70 years was not significantly associated with early graft failure. African American race was also associated with early graft failure, and diabetes mellitus had a negative association with early graft failure (OR, 1.4; 95% CI, 1.3-1.5; P \u3c .001; OR, 0.72; 95% CI, 0.58-0.89; P = .002; respectively). Although smoking was a significant factor for acute graft failure on univariate analysis, it was not significant on multivariate analysis. Multivariate analysis of the type of procedure performed revealed that femoral to popliteal bypass with vein or prosthetic graft was associated with better early graft patency than any of the tibial vessel bypass procedures except for popliteal to tibial bypass with autogenous vein. Conclusion: These data suggest that factors other than technique have an effect on the 30-day graft failure rates of infrainguinal bypasses. These results help the vascular surgeon to predict more accurately early bypass failure rates while planning the procedure and counseling patients about its prognosis. © 2008 The Society for Vascular Surgery

Predicting medical school and internship success: Does the quality of the research and clinical experience matter?

© Association of Military Surgeons of the U.S. All rights reserved. Objectives: This article explores specific aspects of self-reported clinical and research experience and their relationship to performance in medical training. Methods: This is a retrospective cohort study conducted at the Uniformed Services University. The American Medical College Application Service application was used to discern students’ self-reported clinical and research experience. Two authors applied a classification scheme for clinical and research experience to the self-reported experiences. Study outcomes included medical school grade point average (GPA), U.S. Medical Licensing Examination (USMLE) scores, and intern expertise and professionalism scores. A linear regression analysis was conducted for each outcome while controlling for prematriculation GPA. Results: Data were retrieved on 1,020 matriculants. There were several statistically significant but small differences across outcomes when comparing the various categories of clinical experience with no clinical experience. The technician-level experience group had a decrease of 0.1 in cumulative GPA in comparison to students without self-reported clinical experience (p = 0.004). This group also performed 5 points lower on the USMLE Step 2 than students who did not report clinical experience (p = 0.013). The various levels of self-reported research experience were unrelated to success in medical school and graduate medical education. Discussion: These findings indicate that self-reported technician-level clinical experience is related to a small reduction in typically reported outcomes in medical school

Factors associated with early failure of infrainguinal lower extremity arterial bypass

Objectives: We analyzed the Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP), a large clinical database, to investigate which factors, other than technical, were associated with a higher incidence of early graft failure in infrainguinal bypass. Methods: Data are prospectively collected in NSQIP from 123 participating VA Medical Centers. All patients from 1995 to 2003 in the NSQIP database who underwent infrainguinal arterial bypass were identified by Current Procedural Terminology (CPT) codes (CPT is a registered trademark of the American Medical Association, Chicago, Ill, Copyright 2007). Data for 30-day graft failure were evaluated by univariate analysis, and multivariate logistic regression was used to control for possible confounders. Results: The NSQIP database identified 14,788 patients who underwent infrainguinal lower extremity arterial bypasses during the study period, and 723 acute graft failures (4.9%) occurred. On multivariate analysis, compared with patients aged \u3e70 years, patient ages of \u3c50 and 51 to 60 years were significantly associated with early graft failure (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.6-3.0; P \u3c .001; OR, 1.4; 95% CI, 1.2-1.6, P \u3c .001; respectively); age range of 61 to 70 years was not significantly associated with early graft failure. African American race was also associated with early graft failure, and diabetes mellitus had a negative association with early graft failure (OR, 1.4; 95% CI, 1.3-1.5; P \u3c .001; OR, 0.72; 95% CI, 0.58-0.89; P = .002; respectively). Although smoking was a significant factor for acute graft failure on univariate analysis, it was not significant on multivariate analysis. Multivariate analysis of the type of procedure performed revealed that femoral to popliteal bypass with vein or prosthetic graft was associated with better early graft patency than any of the tibial vessel bypass procedures except for popliteal to tibial bypass with autogenous vein. Conclusion: These data suggest that factors other than technique have an effect on the 30-day graft failure rates of infrainguinal bypasses. These results help the vascular surgeon to predict more accurately early bypass failure rates while planning the procedure and counseling patients about its prognosis. © 2008 The Society for Vascular Surgery

Predictors of lower extremity arterial injury after total knee or total hip arthroplasty

Objective: Lower extremity arterial injury is a rare complication following total knee (TKA) or total hip arthroplasty (THA). To date, no multi-institutional study has identified preoperative factors that may portend increased risk for these injuries. We queried a large clinical database for the incidence and predictors of arterial injury and/or compromise following lower extremity arthroplasty. Methods: Prospectively collected preoperative and postoperative data by the National Surgical Quality Improvement Program (NSQIP) of the Veterans Affairs Medical Centers were analyzed. All patients from 1996 to 2003 in the NSQIP database who underwent TKA or THA were identified via CPT codes. NSQIP defined, 30-day, postoperative outcomes were analyzed. Data were compared using bivariable analysis, as well as limited multivariable logistic regression. Results: A total of 41,633 arthroplasties (24,029 TKA, 2077 redo-TKA, 13,494 THA, 2033 redo-THA) were identified in the NSQIP database. A total of 34 (0.08%) lower extremity arterial injuries were recognized (0.08% TKA, 0.19% redo-TKA, 0.04% THA, 0.20% redo-THA). Eighteen injuries were repaired on the same day of surgery (seven intraop, 11 postop), eight between postoperative days 1 and 5, and 8 between days 6 and 30. Only two patients underwent lower extremity amputation (overall limb loss rate of 5.9% of patients who had arterial injury). Statistically significant predictors of lower extremity arterial injury identified on logistic regression analysis included redo procedure (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.0, P = .013) and African American race (OR 2.5, 95% CI 1.2-5.3, P = .02). Conclusion: Lower extremity arterial injury was exceedingly rare after total knee or total hip arthroplasty. There is an increased incidence in African American patients and those undergoing redo arthroplasty. Among patients who sustain vascular injury, excellent limb salvage rates can be achieved with close postoperative surveillance to achieve early detection and repair of injuries. © 2008 The Society for Vascular Surgery

Effect of folic acid and vitamins B6 and B12 on microcirculatory vasoreactivity in patients with hyperhomocysteinemia

Objective: Hyperhomocysteinemia (HHcy) has been identified as an independent risk factor for atherosclerotic vascular disease. The effect of high-dose folic acid or combination vitamin therapy for the treatment of HHcy on the microcirculation is unknown. The purpose of this study was to evaluate the effect of a combination of folic acid, vitamin B6, and vitamin B12 on endothelium-dependent and endothelium-independent vasoreactivity in patientswith HHcy. Methods: Baseline cutaneous microvascular vasoreactivity was measured in 20 patients with HHcy and 18 patients with normohomocysteinemia (NHcy). Laser Doppler scan imaging before and after iontophoresis of 1% acetylcholine chloride (endothelium-dependent response) and 1% sodium nitroprusside (endothelium-independent response) was performed for the measurement of forearm skin vasodilatation. Patients were then treated with 10 mg folic acid, 100 mg vitamin B6, and 1 mg vitamin B12 orally once a day for 6 months. Follow-up fasting serum homocysteine and cutaneous Laser Doppler scan imaging before and after iontophoresis were performed at 1, 2, 3, and 6 months. Statistical analysis was performed using Fisher\u27s exact test, paired t test, and Wilcoxon matched-pairs signed-ranks test, with significance set at P \u3c.05. Results: The HHcy group was older than the NHcy group (70.89 ± 1.95 vs 61.78 ± 2.73 years, P =.02). Otherwise the groups were similar in terms of race, tobacco use, comorbid diseases, and serum lipoproteins. Over the 6-month period, fasting serum homocysteine levels decreased significantly in both the NHcy group (10.40 ± 0.59 μmol/L vs 8.97 ± 0.84 μmol/L, P =.01) and the HHcy group (19.80 ± 1.06 μmol/L vs 13.40 ± 0.86 μmol/L, P =.0002). There were no statistically significant changes in endothelium-independent vasoreactivity (voltage change from baseline) in either group. Endothelium-independent vasore activity decreased over the 6-month period in the HHcy group (0.20 ± 0.04 V vs 0.11 ± 0.03 V, P =.03). Subanalysis of HHcy with diabetes or age greater than 65 years both showed worsening trends in endothelium-independent vasoreactivity (P =.05 for both groups). There were no statistically significant changes in endothelium- independent vasoreactivity in the NHcy group. Conclusions: High doses of folic acid and vitamins B6 and B12 lower fasting serum homocysteine levels in patients with HHcy. Older and diabetic patients with HHcy tend to do worse possibly because of long-term fixed microvascular insult secondary to multiple sustained comorbidities. © 2007 Sage Publications