Der klinische und radiologische Verlauf von intrazerebralen Blutungen unter den Nicht-Vitamin-K-Abhängigen oralen Antikoagulanzien

Background: Clinical outcome and mortality in intracerebral haemorrhage (ICH) associated with anticoagulant treatment is poor. Novel direct oral anticoagulant drugs (NOACs) are increasingly prescribed. Management of NOAC-associated ICH might be more challenging. The aim of this study was to compare the clinical and radiological course of ICH patients being treated with different forms of oral anticoagulant drugs. Method: The study is a retrospective observational study. Haemorrhage in other intracranial compartments except the ventricular system were explicitly excluded. Four groups were categorised and compared with regard to their clinical and radiological course (NOACs, vitamin K antagonists [VKAs], platelet inhibitors and patients without anticoagulant/antiplatelet drugs). Clinical as well as radiological parameters were analysed. Results: Overall, 182 patients were included (2011 to early 2016). Twenty-five patients with NOAC-associated ICH were included (47 with VKAs, 50 with platelet inhibitors and 60 patients without anticoagulant/antiplatelet drugs). The frequency of NOAC-associated ICH increased over the years. Diabetes was found significantly more often in the NOAC patients (p = 0.05). The clinical and radiological courses in the three different patient groups with impaired coagulation were similar. Mortality was significantly higher in patient groups with impaired coagulation (p = 0.04) compared to those without anticoagulant/antiplatelet drugs. Multivariate analysis revealed the Glasgow Coma Scale (GCS) score as a strong predictor for worse outcome and mortality. Conclusions: The frequency of NOAC-associated ICH increased in the last 5 years. Diabetes might be a risk factor for ICH when receiving NOACs. Clinical outcome in NOAC-associated ICH is poor and mortality is as high as in patients with other oral anticoagulant/antiplatelet drugs

Assessing Sustained and Differential Impacts of North Carolina’s Medicaid "Lock-In" Program

Between 2000 and 2015, half a million people died from a drug overdose in the U.S., and most of these deaths involved an opioid. Medicaid beneficiaries are a particularly high-risk population. One strategy that nearly all states use to address potential misuse of prescription opioids, and other controlled substances (CS), are Medicaid “lock-in” programs (MLIPs). MLIPs identify beneficiaries demonstrating potential overutilization of CS and control their access. In North Carolina (NC), beneficiaries enrolled in the MLIP are required to use a single prescriber and pharmacy to obtain specific CS for a 12-month period. There has been little research examining the impact of MLIPs. In this dissertation, we 1) examined the sustained impact of the NC MLIP on dispensed CS and dosages of opioids dispensed (in terms of morphine milligram equivalents (MMEs)) and 2) examined whether trajectories of MMEs differed across time prior to, during, and following release from the MLIP for different strata of the population. Data included NC Medicaid claims linked to records from NC’s Prescription Drug Monitoring Program from October 2009 through June 2013. We found that compared to a period of stable CS dispensing prior to MLIP enrollment, the MLIP reduced the average numbers of CS dispensed both during lock-in and following release. However, the program was also associated with increased acquisition of dispensed CS using non-Medicaid payment (e.g., out-of-pocket) both during lock-in and following release. Moreover, beneficiaries acquired greater MMEs of dispensed opioids from both Medicaid and non-Medicaid payment sources during lock-in and following release. Considerable heterogeneity existed in trajectories of MMEs of dispensed opioids across time prior to, during, and following release from the MLIP. Five trajectory patterns appeared to sufficiently describe this underlying heterogeneity. All patterns demonstrated a spike in MMEs in the six months prior to lock-in, constituting a trigger for MLIP enrollment; however, patterns were dissimilar in overall starting values and slopes. While the trajectories indicated that the MLIP may have had little influence on MME patterns across time, strong associations between trajectory patterns and beneficiary characteristics were evident. Findings from this dissertation thus provide a foundation for informing future MLIP improvements.Doctor of Philosoph

The assessment partnership –assessing student readiness to practice

Assessment is a critical component of the educational paradigm. Teaching, learning and assessment need to be aligned to optimise learning outcomes (Boud, 1995), and ensure graduates are safe and competent to practice in their professions (Eva, 2007; Holmboe et al. 2010; Van der Vleuten, 1996). In this session we will present and critically evaluate the roles of the student, the University, clinical supervisor/s, and the professional body in ensuring graduates' readiness to practice. In order to maximise their learning, students need to take active roles in the learning process. We will report on research on the use of ePortfolios in which students collected and presented evidence that demonstrated their competency. Embedded in this research were students' reflections around their learning. Assessment of clinical competency in the university environment has been criticised for lacking fidelity (ie: not being real, believable, or reflecting the work environment). Clinical employers want to be assured that graduates are "work ready". We will explore several creative, innovative, evidence-based strategies to increase the fidelity of university assessments so that assessors can be more assured of students' preparedness to enter the workplace. Clinical placements offer excellent opportunities to assess students' performance in the environments in which they will eventually work. Although having greater fidelity than the university setting, significant threats to the validity of assessment remain in these environments. Particularly concerning are: variability between supervisors' judgments, and the unpredictability of clinical workplaces such that we cannot ensure that all students experience placements of the same difficulty of challenge. In this section we will present and critically evaluate a range of workplace assessments, allowing participants to consider what might work in different environments. We will further discuss ways in which assessments might be changed to manage threats to validity

Theoretically and empirically-informed narrative descriptions of competency development

Background: Determining whether a student has demonstrated readiness to enter their profession, particularly in professions where semi-autonomous practice is required on graduation, is challenging. Discourse regarding performance assessment has moved from measurement and psychometric validity towards the value of qualitative approaches and narratives to support sound judgement of readiness for practice. The objective of this study was to develop narrative descriptions of competency development. The research questions were: (i) how do experienced clinicians describe students who are developing their clinical competency, and (ii) how do they describe a student who is ready for semi-autonomous professional practice? We investigated these questions within the profession of clinical exercise physiology (CEP). CEP is a role emerging health profession in Australia and therefore is in the early stages of articulating its understanding of readiness for practice and related assessment of performance. Summary of Work: A social constructivist theoretical perspective informed the methodology. Across three focus groups, 17 CEP clinicians with clinical educator experience were asked to describe (i) what students who are developing their clinical competency 'look like' and (ii) what students who were ready for professional practice 'look like'. Data saturation was reached at the third focus group. A thematic analysis identified the behavioural constructs describing competency development which were then used to write three narrative descriptions of points along a competency continuum. These narrative descriptions were further evaluated and refined through semi-structured interviews. Summary of Results: The behavioural constructs which informed the narrative descriptions included: consistency, managing complexity, flexibility, safe practice, independence and insight into own performance. Participants considered the narrative descriptions to accurately describe the continuum of competency development and a student who is ready for professional practice. Discussion and Conclusions: The narrative descriptions fit with contemporary discourse on assessment in clinical workplace settings. The narrative descriptions may be useful in providing support for quality judgements of students' performances in the workplace setting. That is, the narrative descriptions could be used as reference points by those constructing their judgements of student performances. Take-home Messages: The broad behavioural constructs in the narratives may be relevant to other health professionals' practice

Determination of clinical competencies for exercise physiology students

Introduction: Clinical placements and assessment are a key part of health professional education. However, quality assessment in a clinical environment is difficult to achieve without a clear picture of what constitutes competence. The aim of this study was to establish a set of competencies that describe the attributes considered critical to ensuring an entry-level exercise physiologist (EP) can practice safely and effectively with a client-centred philosophy. Methods: This study used a mixed methods, multiphase approach. The competencies, which are organised into units of competency with underlying elements, were developed following online surveys and focus groups involving those with expertise in the area, with additional refinement provided by the project team. A first-stage validation was conducted via electronic survey where (i) participants rated the importance of each unit of competency to practice as an entry-level EP; and (ii) those participants who were recently graduated EPs rated the extent to which they perceived they were competent in each unit. Results: The final set of competencies is described as 19 elements organised into 6 units. The units are: (i) Communication, (ii) Professionalism, (iii) Assessment and Interpretation, (iv) Planning and delivery of an exercise and/or physical activity intervention, (v) Lifestyle Modification and (vi) Risk Management. The majority of survey participants (93-97%) considered each unit of competency as being important to practice successfully as an entry-level EP. The majority (78-95%) of the sub-group who identified as new EPs considered themselves competent in each unit, suggesting the competencies are articulated at the level of a new EP. Conclusion: The competencies resulted from an extensive, iterative process involving those with expertise in the area followed by initial validation. The competencies will have a range of applications, including informing the development of a student placement assessment tool

Determination of clinical competencies for exercise physiology students

Introduction: Clinical placements and assessment are a key part of health professional education. However, quality assessment in a clinical environment is difficult to achieve without a clear picture of what constitutes competence. The aim of this study was to establish a set of competencies that describe the attributes considered critical to ensuring an entry-level exercise physiologist (EP) can practice safely and effectively with a client-centred philosophy. Methods: This study used a mixed methods, multiphase approach. The competencies, which are organised into units of competency with underlying elements, were developed following online surveys and focus groups involving those with expertise in the area, with additional refinement provided by the project team. A first-stage validation was conducted via electronic survey where (i) participants rated the importance of each unit of competency to practice as an entry-level EP; and (ii) those participants who were recently graduated EPs rated the extent to which they perceived they were competent in each unit. Results: The final set of competencies is described as 19 elements organised into 6 units. The units are: (i) Communication, (ii) Professionalism, (iii) Assessment and Interpretation, (iv) Planning and delivery of an exercise and/or physical activity intervention, (v) Lifestyle Modification and (vi) Risk Management. The majority of survey participants (93-97%) considered each unit of competency as being important to practice successfully as an entry-level EP. The majority (78-95%) of the sub-group who identified as new EPs considered themselves competent in each unit, suggesting the competencies are articulated at the level of a new EP. Conclusion: The competencies resulted from an extensive, iterative process involving those with expertise in the area followed by initial validation. The competencies will have a range of applications, including informing the development of a student placement assessment tool

A novel Vision Zero leadership training model to support collaboration and strategic action planning

Introduction: While collaboration and cooperation are regarded as foundational to Vision Zero (VZ) and Safe Systems initiatives, there is little guidance on structuring VZ collaboration, conducting collaborative goal setting, and aligning tangible action across organizations. As part of a larger VZ mutual learning model, we developed a VZ Leadership Team Institute to support communities in collaborative VZ strategic planning and goal setting. The purpose of this paper is to describe the development and evaluation of the Institute, which can serve as a foundation for other initiatives seeking to move VZ planning and implementation forward in a collaborative, systems-aware manner.Methods: In June 2021, eight multi-disciplinary teams of 3–6 persons each (n = 42 participants) attended the Institute, representing leaders from communities of various sizes. Surveys were administered pre, immediately post, and 6 months following the Institute. We measured confidence in a range of skills (on a 5-point scale, 1: not confident to 5: very confident). Surveys also measured coalition collaboration pre-Institute and 6 months post-Institute (on a 4-point scale, 1: strongly disagree to 4: strongly agree).Results: The largest increases in confidence from pre- to immediately post-Institute were for collaboratively drafting objectives and actions for VZ goals (pre-mean: 2.6, SD: 0.9 to post-mean: 3.8, SD: 0.9); incorporating equity into goals (pre-mean: 2.8, SD: 1.0 to post-mean: 3.9, SD: 0.8); and knowing how to keep VZ planning and implementation efforts on track (pre-mean: 2.6, SD: 1.0 to post-mean: 3.7, SD: 0.7). For all measures, average confidence in skills decreased from immediately post-Institute to 6 months post-Institute, but remained greater than average scores pre-Institute. Several measures of coalition collaboration maintained high agreement across time, and mean agreement increased for reporting that the future direction of the coalition was clearly communicated to everyone (pre-mean: .6, SD: 0.8; 6 months post-mean: 3.1, SD: 0.4). However, average scores decreased for feeling like the coalition had adequate staffing (pre-mean: 3.0, SD: 0.6; 6 months post-mean: 2.3, SD: 0.5).Discussion: The Institute utilized innovative content, tools, and examples to support VZ coalitions’ collaborative and systems-aware planning and implementation processes. As communities work toward zero transportation deaths and serious injuries, providing effective support models to aid multidisciplinary planning and action around a Safe Systems approach will be important to accelerate progress toward a safer transportation system

An assessment tool to judge exercise physiology student performance in a clinical placement setting

Introduction/background: Assessment in clinical settings has historically been problematic due to lack of standardisation and objectivity. This had led to calls to look at assessment in the clinical setting differently. Aim/objectives: The overall aim of this research is to develop a competency assessment tool for use by clinical educators to make valid judgments of exercise physiology students' performances in clinical placement settings. This presentation reports on the design of the assessment tool and considers the features that will support quality judgments. The research question is: What are the elements required in the assessment tool that will support quality judgments? Methods: An educational design based research model was used to design and develop the assessment tool. Focus groups exploring the continuum of competency development and the required design features, and educational theory were used to develop an initial prototype. Results: The prototype uses a visual analogue scale to record judgments of student performance against 19 elements related to exercise physiology professional and clinical competencies. A rich description of the developmental continuum towards entry-level competence, which draws on the language used by exercise physiologists, is designed to support clinical educators to make meaning of the multiple observations they make of student performance. Conclusions: An educational design based research model has been used to design an assessment tool prototype aimed at supporting quality judgements of student performance. The design principles generated by the focus groups and literature have led to a prototype that is less measurement focussed than traditional workplace based assessment tools

Sociodemographic and Clinical Predictors of Prescription Opioid Use in a Longitudinal Community-Based Cohort Study of Middle-Aged and Older Adults

Objectives: Identifying factors associated with opioid use in middle-aged and older adults is a fundamental step in the mitigation of potentially unnecessary opioid consumption and opioid-related harms. Methods: Using longitudinal data on a community-based cohort of adults aged 50-90 years residing in Johnston County, North Carolina, we examined sociodemographic and clinical factors in non-opioid users (n = 786) at baseline (2006-2010) as predictors of opioid use at follow-up (2013-2015). Variables included age, sex, race, obesity, educational attainment, employment status, household poverty rate, marital status, depressive symptoms, social support, pain catastrophizing, pain sensitivity, insurance status, polypharmacy, and smoking status. Results: At follow-up, 13% of participants were using prescription opioids. In the multivariable model, high pain catastrophizing (adjusted odds ratio; 95% confidence interval = 2.14; 1.33-3.46), polypharmacy (2.08; 1.23-3.53), and history of depressive symptoms (2.00; 1.19-3.38) were independent markers of opioid use. Discussion: Findings support the assessment of these modifiable factors during clinical encounters in patients ≥ 50 years old with chronic pain