BMC Medical Informatics and Decision Making

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The effect of improving task representativeness on capturing nurses' risk assessment judgements: a comparison of written case simulations and physical simulations.

Publication Date: 2013 May 30 PMID: 23718556
Authors: Yang, H. - Thompson, C. - Hamm, R. M. - Bland, M. - Foster, A.
Journal: BMC Med Inform Decis Mak

BACKGROUND: The validity of studies describing clinicians' judgements based on their responses to paper cases is questionable, because - commonly used - paper case simulations only partly reflect real clinical environments. In this study we test whether paper case simulations evoke similar risk assessment judgements to the more realistic simulated patients used in high fidelity physical simulations. METHODS: 97 nurses (34 experienced nurses and 63 student nurses) made dichotomous assessments of risk of acute deterioration on the same 25 simulated scenarios in both paper case and physical simulation settings. Scenarios were generated from real patient cases. Measures of judgement 'ecology' were derived from the same case records. The relationship between nurses' judgements, actual patient outcomes (i.e. ecological criteria), and patient characteristics were described using the methodology of judgement analysis. Logistic regression models were constructed to calculate Lens Model Equation parameters. Parameters were then compared between the modeled paper-case and physical-simulation judgements. RESULTS: Participants had significantly less achievement (ra) judging physical simulations than when judging paper cases. They used less modelable knowledge (G) with physical simulations than with paper cases, while retaining similar cognitive control and consistency on repeated patients. Respiration rate, the most important cue for predicting patient risk in the ecological model, was weighted most heavily by participants. CONCLUSIONS: To the extent that accuracy in judgement analysis studies is a function of task representativeness, improving task representativeness via high fidelity physical simulations resulted in lower judgement performance in risk assessments amongst nurses when compared to paper case simulations. Lens Model statistics could prove useful when comparing different options for the design of simulations used in clinical judgement analysis. The approach outlined may be of value to those designing and evaluating clinical simulations as part of education and training strategies aimed at improving clinical judgement and reasoning.

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The usability and preliminary effectiveness of a web-based physical activity intervention in patients with knee and/or hip osteoarthritis.

Publication Date: 2013 PMID: 23714120
Authors: Bossen, D. - Veenhof, C. - Dekker, J. - de Bakker, D.
Journal: BMC Med Inform Decis Mak

BACKGROUND: A large proportion of patients with knee and/or hip osteoarthritis (OA) do not meet the recommended levels of physical activity (PA). Therefore, we developed a web-based intervention that provides a tailored PA program for patients with knee and/or hip OA, entitled Join2move. The intervention incorporates core principles of the behaviour graded activity theory (BGA). The aim of this study was to investigate the preliminary effectiveness, feasibility and acceptability of Join2move in patients with knee and/or hip OA. METHODS: A non-randomized pilot study was performed among patients with knee and/or hip OA. Primary outcomes were PA (SQUASH Questionnaire), physical function (HOOS and KOOS questionnaires) and self-perceived effect (7-point Likert scale). Baseline, 6 and 12 week follow-up data were collected via online questionnaires. To assess feasibility and acceptability, program usage (modules completed) and user satisfaction (SUS questionnaire) were measured as secondary outcomes. Participants from the pilot study were invited to be interviewed. The interviews focused on users' experiences with Join2move. Besides the pilot study we performed two usability tests to determine the feasibility and acceptability of Join2move. In the first usability test, software experts evaluated the website from a list of usability concepts. In the second test, users were asked to verbalize thoughts during the execution of multiple tasks. RESULTS: Twenty OA patients with knee and/or hip OA between 50 and 80 years of age participated in the pilot study. After six weeks, pain scores increased from 5.3 to 6.6 (p=0.04). After 12 weeks this difference disappeared (p=0.5). Overall, users were enthusiastic about Join2move. In particular, performing exercise at one's own pace without time or travel restrictions was cited as convenient. However, some minor flaws were observed. Users perceived some difficulties in completing the entire introduction module and rated the inability to edit and undo actions as annoying. CONCLUSIONS: This paper outlines the preliminary effectiveness, feasibility and acceptability of a web-based PA intervention. Preliminary results from the pilot study revealed that PA scores increased, although differences were not statistically significant. Interviews and usability tests suggest that the intervention is feasible and acceptable in promoting PA in patients with knee and/or hip OA. The intervention was easy to use and the satisfaction with the program was high. TRIAL REGISTRATION: The Netherlands National Trial Register. Trial number: NTR2483.

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Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population.

Publication Date: 2013 May 25 PMID: 23705639
Authors: Hardigan, P. C. - Schwartz, D. C. - Hardigan, W. D.
Journal: BMC Med Inform Decis Mak

BACKGROUND: Falls among the elderly are a major public health concern. Therefore, the possibility of a modeling technique which could better estimate fall probability is both timely and needed. Using biomedical, pharmacological and demographic variables as predictors, latent class analysis (LCA) is demonstrated as a tool for the prediction of falls among community dwelling elderly. METHODS: Using a retrospective data-set a two-step LCA modeling approach was employed. First, we looked for the optimal number of latent classes for the seven medical indicators, along with the patients' prescription medication and three covariates (age, gender, and number of medications). Second, the appropriate latent class structure, with the covariates, were modeled on the distal outcome (fall/no fall). The default estimator was maximum likelihood with robust standard errors. The Pearson chi-square, likelihood ratio chi-square, BIC, Lo-Mendell-Rubin Adjusted Likelihood Ratio test and the bootstrap likelihood ratio test were used for model comparisons. RESULTS: A review of the model fit indices with covariates shows that a six-class solution was preferred. The predictive probability for latent classes ranged from 84% to 97%. Entropy, a measure of classification accuracy, was good at 90%. Specific prescription medications were found to strongly influence group membership. CONCLUSIONS: In conclusion the LCA method was effective at finding relevant subgroups within a heterogenous at-risk population for falling. This study demonstrated that LCA offers researchers a valuable tool to model medical data.

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Simulating an emergency department: the importance of modeling the interactions between physicians and delegates in a discrete event simulation.

Publication Date: 2013 PMID: 23692710
Authors: Lim, M. E. - Worster, A. - Goeree, R. - Tarride, J. E.
Journal: BMC Med Inform Decis Mak

BACKGROUND: Computer simulation studies of the emergency department (ED) are often patient driven and consider the physician as a human resource whose primary activity is interacting directly with the patient. In many EDs, physicians supervise delegates such as residents, physician assistants and nurse practitioners each with different skill sets and levels of independence. The purpose of this study is to present an alternative approach where physicians and their delegates in the ED are modeled as interacting pseudo-agents in a discrete event simulation (DES) and to compare it with the traditional approach ignoring such interactions. METHODS: The new approach models a hierarchy of heterogeneous interacting pseudo-agents in a DES, where pseudo-agents are entities with embedded decision logic. The pseudo-agents represent a physician and delegate, where the physician plays a senior role to the delegate (i.e. treats high acuity patients and acts as a consult for the delegate). A simple model without the complexity of the ED is first created in order to validate the building blocks (programming) used to create the pseudo-agents and their interaction (i.e. consultation). Following validation, the new approach is implemented in an ED model using data from an Ontario hospital. Outputs from this model are compared with outputs from the ED model without the interacting pseudo-agents. They are compared based on physician and delegate utilization, patient waiting time for treatment, and average length of stay. Additionally, we conduct sensitivity analyses on key parameters in the model. RESULTS: In the hospital ED model, comparisons between the approach with interaction and without showed physician utilization increase from 23% to 41% and delegate utilization increase from 56% to 71%. Results show statistically significant mean time differences for low acuity patients between models. Interaction time between physician and delegate results in increased ED length of stay and longer waits for beds. CONCLUSION: This example shows the importance of accurately modeling physician relationships and the roles in which they treat patients. Neglecting these relationships could lead to inefficient resource allocation due to inaccurate estimates of physician and delegate time spent on patient related activities and length of stay.

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A study of general practitioners' perspectives on electronic medical records systems in NHSScotland.

Publication Date: 2013 May 21 PMID: 23688255
Authors: Bouamrane, M. M. - Mair, F. S.
Journal: BMC Med Inform Decis Mak

BACKGROUND: Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recentlybrought radical changes to the primary care computing landscape in Scotland: an informationsystem (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practiceshas now been replaced by systems provided by two approved commercial providers. The transitionto new electronic medical records had to be completed nationally across all health-boards by March2012. METHODS: We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs'perspectives on their practice information systems and collect more general information on managementprocesses in the patient surgical pathway in NHSScotland. We undertook a thematic analysis ofinterviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework. RESULTS: The majority of GPs' interviewed considered that electronic medical records are an integral and essentialelement of their work during the consultation, playing a key role in facilitating integrated andcontinuity of care for patients and making clinical information more accessible. However, GPs expresseda number of reservations about various system functionalities -- for example: in relation tousability, system navigation and information visualisation. Our study highlights that while electronicinformation systems are perceived as having important benefits, there remains substantial scope toimprove GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvementscombined with additional training in the use of technology would promote an increased understanding,familiarity and command of the range of functionalities of electronic medical records amongprimary care doctors.

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